CRO 38 County Borough of Croydon. ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER For the Year 1936 OSCAR M. HOLDEN, M.D., D.P.H. CROYDON: Printed by the "Croydon Times,"Ltd., 104, High Street. 2 PUBLIC HEALTH COMMITTEE. NOVEMBER, 1935—36. The Worshipful the Mayor (Alderman Arthur Peters, C.B.E., J.P.) Alderman Mrs. B. J. Roberts (Chairman). Alderman Major F. W. Rees, L.R.I.B.A. (ViceChairman). Alderman H. J. Morland, M.A., J.P. Councillor E. E. L. Arkell. Councillor W. Bennett. Councillor E. E. Constable. Councillor Mrs. Dale. Councillor F. Gardner. Councillor Miss M. H. Glazier. Councillor G. Lewin. Councillor E. S. More. Councillor H. T. Muggeridge, J.P. Councillor W. H. Parry. Councillor Major Petrie, O.B.E. Councillor H. Regan. Councillor Mrs. Squire, J.P. For purposes of Maternity and Child Welfare— Mesdames Bailey, Chalke, Green, Horn, and Southwell. 3 COUNTY BOROUGH OF CROYDON. ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER For the Year 1936. To the Chairman and Members of the Public Health Committee. Ladies and Gentlemen, 1 have the honour to present herewith my ninth Annual Report, being the thirty-seventh of the series, dealing with the health of Croydon, and the various branches of the work carried out by the Council under the various Public Health, Housing, and Mental Deficiency Acts. There is also incorporated my report to the Education Committee as School Medical Officer. lhe delay in the presentation of this report is regretted. Infortunately, the increasing number of routine duties laid upon medical officers of health under recent social legislation, and the consequently large number of supplementary reports to Committees which have been called for, have left very little time to devote to the task of compilation of the Annual Report which all medical officers of health are called upon to make. lhe form of report follows the same lines as previously. It is divided into 14 sections, including the report on the School Medical Service, each section dealing with a particular phase of the work. This has been done for the convenience of readers who, though not interested in the whole report, desire to gain information of the work upon some special subject. 4 VITAL STATISTICS. The Birth Rate (13.4) was slightly lower than in 1935, and was 1.4 per 1,000 less than that for the whole of England and Wales, whilst the Death Rate (10.7) showed a small rise upon 1935. This rise was predicted in a previous report, in view of the lower birth rate over a period of years past, and the consequent raising of the mean age of the population. It was, however, 1.4 per 1,000 less than for the whole of England and Wales. A further reduction in the Infantile Mortality was effected and the new low record of 41 per 1,000 live births was attained. This is one of the lowest among all county boroughs in England and Wales, and the lowest among towns of over 200,000 inhabitants. Through the kindness of the Medical Officer of Health of Portsmouth, a comparative table has been inserted showing various items of vital statistics, and from this table the favourable position of Croydon is noticeable. The changing character of Croydon from a mainly residential to an industrial centre will tend to be reflected in the vital statistics in coming years. This can be combated by appropriate preventive measures and expansion of the health, housing, and other social services. The commoner infectious diseases showed a further decrease in incidence and in mortality. This was especially noticeable in the case of Diphtheria. Measles showed an increase; this ailment, however, tends to occur in two-yearly cycles, so that the rise of the incidence and mortality in 1936 will probably be followed by a decline in 1937. Apart from this epidemic during the first quarter of the year, there was no undue incidence of infectious sickness. The chief causes of death were substantially the same as in 1935. Cancer, for some reason at present unascertained, showed a large increase and reached a maximum figure for the town. Diseases of the Heart and Circulatory System, Cancer and the Respiratory diseases caused 69 per cent, of the total deaths. Pulmonary and Non-pulmonary Tuberculosis showed a continuance of the slow but steady decline noticed in recent years. The section dealing with the work at Mayday Hospital demonstrates the changing character of that work. Slowly but surely the hospital is becoming more of a general hospital an less of a Poor Law Institution. When the chronic sick and infirm are accommodated at Queen's Road, Mayday will be able 5 to take on entirely the functions of a General Hospital. The extensions have proceeded slowly, but during the year the new ward block was put into use as a Maternity and Gynaecological unit, whilst the new Maternity Block was being erected; and the new Children's Block, X-ray Department and special departments block were practically completed and ready for occupation at the end of the year. These three new blocks were opened on 7th December by the Chief Medical Officer of the Ministry of Health, and are good examples of modern hospital design. A full account has been given of the Diphtheria Immunisation work, and its perusal shows that parents are coming to appreciate the value of the prevention which it demonstrably confers. No special propaganda has been employed, as it was felt that immunisation would carry its own message and that satisfied parents would constitute the best advertising medium. 1 his has proved to be right. Throughout the year the time which it was possible to allocate for this work has been fully occupied. In view of the comprehensive scheme in being for the care of women before, during, and after confinement, a considerable section has been devoted to describing this work and giving statistical details. In addition, a separate special report will be compiled dealing more fully with medical details. This report has, in the past years since it was first issued in 1933, received very favourable notice from high obstetrical authorities, and its continued issue will enable valuable information to be summarised and used to elaborate further preventive measures. Both Mayday Hospital and St. Mary's Hospital have had a very busy obstetrical year, a record being established in the number of cases dealt with. Unfortunately, the present ante-natal clinic premises at Lodge Road are quite inadequate to deal satisfactorily with such large numbers, with the result that women have been put to considerable discomfort whilst waiting their turn to see the doctor. It is hoped, when the Observation Nursery has been moved to the New Children's Ward at Mayday, that alterations ran be made at Lodge Road to make better accommodation. Owing to the overcrowding at the Infant Welfare Clinic at l odge Road, the premises, 47, St. James's Road, were adapted, and this clinic, together with the Ophthalmic and Massage Clinics, are now held there. This has resulted in a welcome increase in 'he comfort of the many persons who attend these clinics. A second session was initiated at the Lower Addiscombe Road Clinic owing to the increase in attendances. The Infant 6 Centres (16), with the exception of the Municipal, are organised by the Croydon Mothers' and Infants' Welfare Association, with the aid of a grant from the Corporation, and the supply of a doctor and nurse from the Public Health Staff. During the year the Association handed over the Home Helps Scheme which they had started, to the Corporation, and this has been continued by the Public Health Department. It is expanding, and the demands made upon it are greater than the available number of Home Helps. Every effort is being made to find suitable women to act in this capacity. The Public Health Committee also took over the distribution of dried foods, etc., at Infant Welfare Centres, and the coupon system was tried. After a few initial minor difficulties, the scheme is working very smoothly and effectively. The work of the Sanitary Inspectors is given in detail in Section XIII. New legislation has added to their multifarious duties, whilst practically half their time has been spent on housing inspections under the Housing Act, 1935, more especially with regard to overcrowding and the remedying of housing defects, The Census of Overcrowding showed that in a total of 17,549 families investigated, 650 were found to be overcrowded, and the number of individuals affected was 3,686. During the year, 108 overcrowded families were dealt with and the overcrowding relieved. The five-years plan has been pursued, surveys have been made of the Leighton Street area, and a Clearance Order been obtained for a portion of that area; also of the Wilford and Forster Road area and the rest of the Leighton Street area with a view to Redevelopment Schemes. One of the chief difficulties which will have to be overcome is overcrowding in large private houses adapted as tenements, more especially those in which the basement is let as a separate tenement. There are a large number of these houses in Croydon, and in many the basement, although it does not fall within tin definition of an underground dwelling, is unsatisfactory for use as a dwelling house on account of dampness and lack of proper light and ventilation. The new powers under the Housing Act, 1936, should be useful, used in conjunction with the Byelaws adopted by the Council on October 29th, 1936, in dealing with properties of this description. A perusal, even if only cursory, of the contents of this report, will, it is hoped, show how thoroughly the Corporation 7 endeavours to safeguard the health of its citizens. For the full attainment of success the co-operation of all citizens is necessary. All the activities undertaken are not necessitated by law, but experience and common-sense have shown they have, nevertheless, integral parts to play in making an effective whole. All the staff of the Department have carried out their duties in a satisfactory manner, and I wish to place before the Committee my indebtedness to them for the work they have done and for their loyalty. I wish to tender my thanks to the Chairmen and Members of the Public Health Committee, the Housing Committee, the Maternity and Child Welfare Committee, and the Mental Deficiency Committee for the sympathetic consideration they have given to any proposals submitted to them and for the interest they have taken in the activities of the Depatrment. I am, Yours faithfully, OSCAR M. HOLDEN. CONTENTS. A.- PUBLIC HEALTH REPORT. PAGE Acts, Adoptive 201 Ambulance Service 17 Amusement Houses 217 Animals, Keeping of 218 Ante-natal Clinic 149 Aerodrome 195 Babies Help Committee 181 Bacteriological Examination 85 Bakehouses 212,214 Births 22 Blind Persons 198 Borough Hospital 14,73 Bye-laws ami Regulations 201 Cancer 121 Cerebro-Spinal Meningitis 81 Children Acts 183 Chicken Pox 55 Closet Accommodation 13 Contacts, Tuberculosis 106 Committee 2 Cowkeepers214 Croydon Nursing Service 106 Children Acts 183 Convalescence 181 Coombe Cliff Convalescent Hosp. 14 Creche 182 Dairies, Cowsheds and Milkshops 214 Deaths 27 Dental Treatment—M. & C.W. 176 Diphtheria 53, 60, 77 Disinfection 219 Disinfestation 219 Dispensary, Tuberculosis 89 Dried Milk 172 Drainage and Sewage 13 Encephalitis Lethargica 81 Enteric Fever 80 Erysipelas 81 Expectant Mothers 149 Factories & Workshops Acts 211 Fertilisers & Feeding Stuffs Act 218 Foods, Inspection of 222, 227 Food & Drugs Acts 240, 245 Foster-Mothers 184 : Foster-Children 183 Gynaecological Clinic 162 Health Visitors, Work of 171 Home Nursing 106 Homework 213 Hospitals 12 Hospital, St. Mary's (Maternity) 14, 148 Houses Let in Lodgings 214, 215 Housing 208 Housing Act, 1930 209 Immunisation Clinic 61 PAGE Infant Welfare Clinics, Municipal 166 „ „ „ Voluntary 166 Infant Mortality 137 Infectious Diseases 52 Laboratory Work 83,85,151 Lighthouse Mission 182 Local Acts 201 Local Government Act 21 Lodging Houses, Common 214,215 Marriages 22 Massage Clinic 175,194 Maternity Homes 146 Maternity Homes, Registration 146 Mayday Hospital 15,33 Measles 54,81 Meat Inspection 225 Medical Help Records 144 Meteorology32 Mental Deficiency 185 Midwives 143 Midwives Act, Section 14 1411 Milk, Provision of 172 Milk, Examination of 86,228 Milk, Tuberculous 233 Milkshops 230 Mortality in Child-birth 131,164 Mothers' and Infants' Welfare Association 166 Mumps 56 Municipal Lodging House 214 Neo-natal Deaths 137 Notification of Births Acts 131 Nuisances 204 Nursing Arrangements 106 Nursing Homes 146 N.S.P.C.C 17 Observation Nursery 14,175 Obstetrical Unit 147 Occupation Centre (Grange Wood) 189 Offensive Trades 214,216 Ophthalmia Neonatorum 86,136 Orthopaedic Department 191 Overcrowding 201 Parrots (Prohibition of Imports) Reg.221 Poisons & Pharmacy Act 218 Poliomyelitis 81 Poor Law Relief 19 Population 31 Post-natal Clinic 162 Public Laboratory 85 Puerperal Sepsis and Pyrexia 80,133,164 Queen's Road Homes 17 Rag Flock Acts 217 Rats & Mice (Destruction) Act 221 Rescue Home 182 Rent Restriction Acts 208 PAGE Rivers and Streams 13,218 Sanatorium, Cheam 111 Sanatoria, Treatment in 103 Sanitary Administration 201 Sanitary Certificates 208 Sanitary Inspectors, Work of 202 Scavenging 13 Scarlet Fever 52, 59, 75 Schools 218 St. Christopher's Special School 188 Shop Hours Acts 214 Slaughterhouses 214, 223 Social Conditions 12 Small Pox 14 Smoke Observations 217 Sputum, Examination 85,101 Staff 8 Still-births 135 St. Mary's Maternity Hospital 14, 148 Swimming Pool 245 Tuberculosis—Care Committee 110 „ Cheam Sanatorium 111 „ Contacts 106 „ Deaths 93 PAGE Tuberculosis—Dental Treatment 113 „ Notifications 89 „ Home Nursing 106 „ Home Visits 106 „ Housing 108 Tables 117 „ Pregnancy 150 „ Pneumothorax 112 „ Institutional Treatment 103 Unmarried Mothers 17, 134, 182 Ultra-Violet Light 196 Vaccination 87 Venereal Diseases 125, 150 Verminous Persons 221 Vital Statistics 10, 22 Watercourses 218 Water Supply 12 Whooping Cough 53, 81 Workplaces 211 Workshops 211 X-ray Examination 101, 112, 151, 193 B.-SCHOOL MEDICAL REPORT. PAGE I Accommodation 258 Adenoids 267,281 Blind Children 299 Cleansing of Children 262 Clinics 247, 280 Clothing and Footgear 262 Committee 246 Cost 257 Crippling Defects 283 Deaf Children 268,299,300 Defective Children 274 Detective Hearing 268 Deformities 269 Dental Disease 270 Dental Treatment 284 Domestic Subjects 308 Ear Clinic 293 Ear Disease. 268 Epileptic Children 299, 300 Exclusions 276 Eye Clinic 283 Eye Disease 269 Following up 279 Health Visitors, Work of 279 Heart Defects 266 Heights and Weights 263,310 Infectious Diseases 278 Inspection Clinic 282 Inspections, Routine 258 Inspections, Special 258 juvenile Employment 303 PAGE Lungs, Diseases of 266 Malnutrition 262 Massage Clinic 283 Meals, Provision of 303 Mentally Defective Children 301, 304 Milk, etc., Provision of 257, 263, 303 Minor Ailments 280 Nutrition 262 Orthopaedic Work 283 Orthodontic Service 290 Physical Training 305 Physically Defective Children 301 Remedial Exercises 283 Rheumatism Clinic 294 Sanitary Accommodation 252 School Camps 302 Schools, Special 257,284, 300 Secondary Schools 309 Skin Affections 269 Speech 268,301 Staff 246 Statistical Tables 312 Surveys, Uncleanliness 262 St. Christopher's 304 St. Giles 284 St. Luke's 300 Throat and Nose 267, 281 Treatment 275,280 Tuberculosis 266 Uncleanliness 262 Vision, Defective 269,283 8 STAFF OF THE HEALTH DEPARTMENT. The staff of the Public Health Department on the 31st December, 1936, was as follows:— Medical Staff.— (a) Whole-time:— Oscar M. Holden, M.D., D.P.H., Medical Officer of Health, School Medical Officer, and Medical Officer under the Mental Deficiency Acts, etc. Wm. B. Watson, L.R.C.P., L.R.C.S., D.P.H., Deputy Medical Officer of Health, Deputy School Medical Officer and Medical Officer under the Mental Deficiency Acts. J. C. McMillan, M.B., Ch.B., B.A.O., B.Sc., D.P.H., Assistant Medical Officer of Health for Tuberculosis. A. L. Gunn, M.D., F.R.C.S. (Ed.), B.Sc., M.C.O.G., Assistant Medical Officer of Health for Obstetrics. (Left 1st December, Dr. Rufus C. Thomas appointed.) Rnfns C. Thomas. M.R.C.S., L.R.C.P., F.R.C.S.(Ed.), M.C.O.G., Assistant Medical Officer of Health for Obstetrics. (Commenced 18th December 1936.) W. R. Martine, M.B.E., M.B., Ch.B., D.P.H.. Assistant Medical Officer of Health and Assistant School Medical Officer. G. B. Matthews, M.R.C.S., L.R.C.P., Assistant Medical Officer of Health and Assistant School Medical Officer. (Temporary.) Iris A. Jenkin-Lloyd, M.R.C.S., L.R.C.P., D.P.H., Assistant Medical Officerof Health, Maternity and Child Welfare, and School Medical Officer. Aileen I. McMahon, M.R.C.S., L.R.C.P., D.P.H.. Assistant Medical Officer of Health, Maternity and Child Welfare, and School Medical Officer. Rosa Morrison, M.B., Ch.B., D.P.H., Assistant Medical Officer of Health (Maternity and Child Welfare) and Assistant School Medical Officer. J. Todesco, M.D., M.R.C.S., L.R.C.P., D.P.H., Resident Medical Superintendent, Borough (Fever) Hospital. R. C. Poyser, M.R.C.S., L.R.C.P., Resident Medical Superintendent, Croydon Borough Sanatorium. H. W. Southgate, M.B., B.S.. B.Sc., Pathologist. (b) Part-time:— J. R Draper, B.A., M.B., Medical Inspector of Aliens (Croydon Air Port*. J. S. Bookless, B.A., M.B., F.R.C.S.—Ophthalmic Surgeon (School Medical Service). Rota of 4 local medical practitioners for 6urgical 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., G. M. Davie, L.M W. A. Sowden Hills, L.D.S. Inspectors.— R. J. Jackson, M.R.S.T., A.M.T.S.E., M.S.T.A., Chief Sanitary Inspector, F. F. Fulker, A.R.S.I., A.T.S.E., M.S.T.A., Deputy Chief Inspector. 17 District Sanitary Inspectors. In addition, there are 7 disinfectors, 1 rat-catcher, and 5 assistants to the Sanitary Inspectors. Health Visiting Staff.— 22 District Health Visitors; 2 Special Visitors; 1 Tuberculosis Nurse, Almoners and 4 Dental Attendants. Also 2 whole-time Masseuses and Remedial Gymnasts. 9 Clerical Staff.— Twenty-seven full-time clerks. Veterinary Inspector(Part-time).— Peter R. A. Thrale, O.B.E., M.R.C.V.S. Analyst(Part-time).— Edward Hinks, B.Sc., F.I.C., F.C.S. Transferred Officers under Local Government Act, 1929.— MAYDAY HOSPITAL— Arnold Gilray, M.B., Ch.B. (N.Z.), Medical Superintendent. John Joseph Walsh, M.D., F.R.C.S. (Eng.), Assistant Medical dent. John Ewart Edson, M.B.. Ch.B.. M.R.C.P., M.Sc., Assistant Medical Officer. Fredk W. J. Thomas, M.R.C.S.. L.R.C.P., B.Sc., Assistant Medical Officer. Herbert L. R. Sargant, M.B., Ch.B., Assistant Medical Officer. Dental Surgeon.— Eric Herbert Laurence, L.D.S. District Medical Officers.— William Vaudrey Braddon, M.B., Ch.B., L.S.A. 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., Tj.R.C.P. Austin Stafford, L.R.C.P.L & L.M., L.R.C.S.I. & L.M Panel of medical practitioners appointed for Addiscombe, Central, East and Thornton Heath Wards. Public Vaccinators.— William Vaudrey Braddon, M.B., Ch.B., L.S.A. Patrick Francis O'Hagan, L.R.C.P., L.R.C.8. 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, Observation Nursery, Coombe Cliff Convalescent Home. Nursing and Domestic Staffs. Consultants to the Public Health Department.— Thomas Warwick Preston, M.P., M.R.C.P., Physician. Ernest Marshall Cowell, D.S.O., M.D., F.R.C.S., Surgeon. Alan Herapath Todd, M.S., F.R.C.S., Orthopaedic Surgeon. John Smeed Bookless, B.A., M.B., F.R.C.S., Ophthalmic Surgeon. Archer Ryland, F.R.C.S., Ear, Nose and Throat Surgeon. David Low Greig, M.R.C.S., L.R.C.P., D.M.R.E., Radiologist. 10 SUMMARY OF VITAL STATISTICS FOR 1936. Area 12,617 acres. Population (Census 1931), 233,115. Population (estimated middle of 1936), 241,739. Number of Inhabited Houses (1931 Census), 56,429. Overcrowding Census (1936), 65,550. Rateable Value (1st April, 1936), £2,287,851. Product of a Penny Rate (1936), £8,864. Rate in the £ (1935-36), 10/-. Gross expenditure on Health Services (administered by Medical Officer of Health) £154,013 5 1 Income on Health Services (excluding transfers) 12,858 8 9 Net expenditure on Health Services £141,154 16 4 Expressed as a Penny Rate, 15.92d. pence in the pound. Live Births— M. F. Total. Legitimate 1,590 1,478 3,068 Illegitimate 85 95 180 Birth-rate per 1.000 of the estimated resident population, 13.4. Still Births—125. Rate per 1,000 total (live and still) births, 37.1. Deaths—2,590. Death-rate per 1,000 of the estimated resident population, 10.7. Deaths from diseases and accidents of pregnancy and childbirth : From sepsis, 5; other causes, 8. Maternal mortality: 3.85 per 1,000 total live and still births. 11 Death-rate of Infants under one year of age— All infants per 1,000 live births 41 Legitimate infants (122 deaths) per 1,000 legitimate live births 40 Illegitimate infants (12 deaths) per 1,000 illegitimate live births 67 Deaths from Measles (all ages) 21 ,, ,, Whooping Cough (all ages) 15 „ ,, Diarrhoea (under 2 years of age) 22 „ ,, Diphtheria (all ages) 8 Per 1,000 of the population. Deaths from diseases of Cardiac and Circulatory System (including Cerebral Haemorrhage) 4.01 ,, ,, disease of the Respiratory System (including Tuberculosis) 1.59 ,, ,, diseases of Renal System 0.37 ,, ,, diseases of Digestive System 0.61 ,, ,, Suicide and Accidents 0.47 „ „ Old Age 0.95 12 SECTION I. SOCIAL CONDITIONS, HOSPITAL ACCOMMODATION AND VITAL STATISTICS. Croydon, though still a dormitory town for London, is rapidly developing industries and trades of its own. A considerable factory area is being developed on the "West side of Purley Way in proximity to the gas and electricity undertakings. The chief industries are iron foundries, bell foundries, engineering and building. The London Terminal Aerodrome is within the County Borough boundary. The population has been growing rapidly. The increase of population revealed in the 1931 census was 21.8% on that for 1921. This was 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 as at the middle of 1935 was 242,100. For the middle of 1936 the population is given as 241,739 (R.-G.). 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 Beard. 1 am indebted to the Borough Engineer, Mr. C. E. Boast, 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, 11.7 deg. ,, Permanent, 4.0 deg. No B. Coli in 100 c.c. No Streptococci in 100 c.c. No Acid Organisms in 100 c.c. The supply during the year was from the Corporation's Wells 2,001,156,913 Metropolitan Water Board in Bulk 667,765,000 2,668,921,913 gallons. 13 This works out, on an average population basis of 248,000 (1935), at a consumption of 29.4 gallons per diem per head, an increase upon the consumption in 1935. Rivers and Streams. There are ouly small streams or ditclies. These have been kept in a good state. Drainage and Sewage. Extensions of the system have been made to keep pace with the growth of the Borough and the outside areas draining into the Borough. About £48,000 has been expended in maintenance and laying of new main sewers and surface water drains and a loan for 121,150 has been sanctioned by the Ministry of Health for further extensions. At the sewage disposal works at Bedding ton, three Activated Sludge plants are in operation dealing with 3½ to 5 million gallons per day. A Sludge Digestion Tank at South Norwood will be brought into use early in 1937. Six similar tanks are in course of construction at Beddington. 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. 94 beds are provided for the treatment of early, intermediate and advanced cases in adults. 14 (2) Maternity. St. Mary's Maternity 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 £1,499. This hospital, so far as administration and general conduction is concerned, was transferred to the Council on April 1st, 1937. (3) Children. (a) Observation Nursery, Lodge Road. These premises occupy the upper storey of the buildiugs 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. This Nursery was closed and the patients transferred lo the new children's ward at Mayday Hospital, on the completion of the latter. This transference was made on 8/2/1937. (b) Coombe Cliff Convalescent Hospital. This Home is for the reception of infants and children convalescing after acute illnesses. The majority of the cases are referred from the Public Health and School Medical Departments, but cases are also admitted from Mayday and other Hospitals and at the request of private medical practitioners. There are 34 beds and cots. (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 tubeiculosis. (5) Small Pox. The Croydon and District Joint Small Pox Hospital Boards Hospital is now used as the Borough Sanatorium. Arrangement have been made with the Surrey County Council to receive into their Clandon Hospital cases of small pox arising in Croydon. 15 General Hospitals. Mayday Hospital—Local Authority's General Hospital. During the year a Maternity Block of 48 beds, a Special Departments Block, and a Children's Block of 20 were completed. In addition a new nurses' home to accommodate 74 nurses was practically finished. Owing to the dislocation of accommodation caused by alterations and additions to other parts of the hospital, it has not yet been possible to use the E Block, which was completed in 1935, for the purposes intended, viz., for acute medical and surgical cases. Owing to the vacation of the old Maternity Block, Ward Block E was used as a Lying-in and Gynaecological unit until the new Maternity Block was ready for occupation. During the whole of the year the X-ray plant was out of action. Minor work was done by means of a portable apparatus, whilst major work was done at the Radiologist's rooms. No. of beds provided for sick, maternity and mental cases at 31.12.36. (a) For Men 160 (b) For Women 258 (c) For Children (under 16 years of age) 70 Total 488 No. of Wards. Men. Women. Children. Total. Provided. Occupied. Provided. Occupied. Provided. Occupied. Provided. Occupied. Medical 2 32 35 32 33 — — 64 68 Surgical 2 32 30 32 35 — — 64 65 Ch. Sick 3 32 33 64 69 — — 96 102 Children 2 — — — — 70 63 70 63 Tuberculosis 2 32 34 32 34 - 64 68 Gynaecl. 1 — — 22 32 - - 22 32 Maternity 2 — — 44 48 — — 44 48 Mental 2 32 27 32 30 - - 64 57 16 160 159 258 281 70 63 488 503 16 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)Orthopaedic Clinic; (c) Venereal Diseases Clinic; (d) Ultra-Violet Eay 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 52 surgical 22 medical Female Beds 51 surgical 22 medical Children's Beds 30 Private Beds 23 A total of 200 beds. The number of in-patients treated during 1936 was 3,231; the average stay of each in hospital being 19.1 days. The number of out-patient attendances, including casualties, was 153,634. 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,7 beds ; together with 6 Private Wards ; a total of 51 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. 17 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 Maternity Hospital, as well as to a maternity home at Upper Norwood, established by the Free Church Council. One other Voluntary Institution also offers facilities for unmarried mothers, namely, The Mission of Hope, Birdhurst Lodge. 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 Nalional 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 13 cases were dealt with. The reasons for reference were: general neglect, 11; other causes, 2. These cases affected the welfare of 20 children, and entailed 49 visits by the Inspector. AMBULANCE FACILITIES. (1) Two Motor Ambulances are provided by the Council for tlie removal of infectious cases from the Borough and Penge. (2) For non-infectious, surgical or medical cases— (a) One motor ambulance provided by the Council for the removal of cases to the Mayday Hospital and operating from the hospital. (b) Four motor ambulances provided by the Council operating from the Chief Fire Station, Park Lane. (c) Three motor ambulances operating from the Addiscombe Division of the St. John Ambulance Brigade. (d) One motor ambulance provided by the Public Assistance Committee and operating from Queen's Road Homes. 18 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 59 (b) For Women 92 (c) For Children (under 16 years of age) 6 157 Table I. Table showing the classification of the accommodation and the number of beds occupied on the 31st December, 1936. Classification. Number of Wards. Men. Women. Children under 16yrs. of age. Total vided. pied. vided. Occu- pied. vided. pied. vided. pied. Chronic Sick 4 50 49 50 50 – – 100 99 Mental (Lunacy Act, 1890) 2 8 8 42 31 – – 50 39 Mental Defectives 1 1 1 - - 6 6 7 7 Aged and Infirm 12 95 88 94 91 - — 189 179 Totals 19 154 146 186 172 6 6 346 324 IN-PATIENTS. Total number of admissions (including infants born in hospital): 62. Total number of deaths: 39. Total number of discharges (including infants born in hospital): 23. Duration of stay of patients— (a) Four weeks or less: 9. (b) Exceeding four weeks but under thirteen weeks: 21. (c) Thirteen weeks or more: 32. Number of beds occupied— (а) Average during the year: 97. (б) Highest : 100 (on 3/4/36). (c) Lowest: 93 (on 15/6/36). 19 Classification of In-Patients who were discharged from or who died in the Institution during the year ended 31st December, 1936— Disease Groups. Men and Women. Discharged. Died. Acute Infectious Disease 2 - Influenza - - Tuberculosis (non-pulmonary) - - Malignant disease 1 2 Rheumatism— Chronic Arthritis - - Venereal Disease - - Mental Diseases- Senile Dementia 7 - Senile Decay 3 12 Accidental Injury and Violence 2 — Disease of the Nervous System and Sense Organs 1 3 „ „ Respiratory System 1 6 „ „ Circulatory System — 15 „ ,, Digestive System 3 — „ „ Genito Urinary System — 1 „ „ Skin 2 — Other Diseases 1 — Totals 23 39 POOR LAW RELIEF. No. of residents in Croydon County Borough Area in receipt if outdoor poor relief on the 1st January, 1936 5,651 persons; 2,209 cases (including able1st July, 1936 4,718 „ 2,041 „ „ bodied). 1st January, 1937 5,253 „ 2,289 „ „ Number of Croydon poor persons relieved in the Mayday Hospital on 1st January, 1937, and in the Queen's Road Homes on the same date- Mayday Hospital 95 Queen's Road Homes 410 Expenditure on Out-relief to Croydon cases during the 12 months ended 30th September, 1936. Half-year ended 31st March, 1936 £45,320 2 4 Half-year ended 30th Sept., 1936 £42,628 2 9 During the year the District Medical Officer for No. 2 Medical District resigned, and a Panel Medical Service Scheme, similar to that already operating in No. 3 Medical District, was evolved to take his place. This scheme commenced on May 1st, 1936. 20 The following is a summary of the work done in the two panel districts:— Average number of separate patients attended during each quarter No. 3 District. Year to 31/3/1937. No. 2 District. Eleven months to 31/3/1937. 209 174 Particulars of services rendered: Attendances at patients' homes 1,087 3,343 583 2,626 Attendances on a second person in the same house at the same visit 156 22 Attendances on patients at the surgery 1,786 1,719 Medical Certificates issued 314 302 Total number of prescriptions written 3,045 2,679 (1936) 2,211 (1936) Total number issued during corresponding period of previous year 1,700 Estimated cost of drugs, dressings and dispensing £101 £88 (1936) £74 (1936) Estimated cost for corresponding period of previous year £56 Estimated amount of per capita payment to doctors in respect of patients actually attended 2/5 2/3 Estimated average payment per service point 1.1 pence 1.2 pence NUMBER 3 DISTRICT. NUMBER 2 DISTRICT. Previous Arrangement. Panel Medical Scheme. Previous Arrangement. Panel Medical Scheme. £ £ £ £ D.M.O.'s Salary 150 Pool for payment of PracDrugs, Dressings and Dis- titioners 200 D.M.O.'s Salary 120 Pool for Payment of Practitioners 150 Drugs, Dressings and Dispensing (year to 31/3/1936) pensing 62 Drugs, Dressings and Dispensing 104 51 Drugs, Dressings and Dispensing 74 £212 £301 £171 £224 21 LOCAL GOVERNMENT ACT, 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 grants made to Voluntary Associations by the Council under the Local Government Act, 1928, during 1936-7 were as follows:— Croydon Mothers' and Infants' Welfare Association— 1936/7 £ (a) Maternity 4,500 (b) Infant Welfare Centres 850 (c) Convalescence 650 (d) Care-work (Unmarried Mothers) 150 £6,150t Other Grants— 1936/7 £ The Retreat, Ross Road 650 Wilford Road Creche 175 Croydon Association of Moral Welfare 100 Children's Aid Society 230 £7,305 †Less Hospital Contributions. 22 SECTION II. VITAL STATISTICS. Marriages.—The number of marriages solemnised was 2,1% compared with 2,132 in 1935; 2,125 in 1934; 2,244 in 1933; 2,134 in 1932; 2,212 in 1931; and 2,112 in 1930. The marriage rate was 9.0 per 1,000 of the population; 1,177 were solemnised in Established Churches, 285 in other places of worship, 735 in the Register Office; 1 ceremony was performed under Jewish ritual. Births.—The births registered were 3,068 legitimate and 180 illegitimate. The birth-rate consequently was 13.4. For England and Wales the rate was 14.8, and in the Great Towns it was 14.9. The illegitimate births in Croydon were 5.5% of the total, compared with 4.4% in 1935, 4.7% in 1934, 4.2% in 1933, 4.9% in 1932, and 4.8% in 1931. The live male births numibered 1,675, the female 1,573, being a proportion of 1,065 males to 1,000 females. The subjoined table gives the vital statistics for the Wards in the Town. It is seen that the Wards with the highest birth-rates were Waddon (19.5), South Norwood (18.4), and Thornton Heath (16.8). Those with the lowest were: Norbury (6.6), Upper Norwood (6.7), and Central (8.4). Deaths.—The deaths numbered 2,590, compared with 2,453 in 1935. For 1936 the death-rate was 10.7. For 1935 it was 10.1. The death-rate for England and Wales was 12.1, and for the Great Towns 12.3. For London the death-rate was 12.5. The male death-rate was 11.2, the female 10.3 for the Borough. There were 150 inquests held by Coroners in respect of Croydon residents during 1936, and 146 findings by Coroners after postmortem examination without inquest. Wards with the highest death-rates were: South Norwood (14.6), Thornton Heath, Addiscombe, and Central (12.1): lowest in Addington (3.1), Upper Norwood (7.9), West Thornton (9.8). and Norbury (9.9). Natural Increase.—The excess of births over deaths was 658, or 2.7 per 1,000 of the population. 23 Table 1. WARDS. Estimitod 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 Irom Diarrhoca. Death Rate from Bronchitis and Pneumonia. Death Rate from Pulmonary Tuberculosis. Death Rate from Non-Pulmonary Tuberculosis. Death Rate from Heart and Circulation Diseases. Death Rate from Nervous Diseases. Death Rate from Cancer. Estimated persons per acre. Natural Increase or Decrease of Population. Upper Norwood 22152 171 176 7.7 7.9 53 0.09 0.14 0.86 0.54 0.05 3.02 0.23 1.22 20 —5 Norbury 15713 103 155 6.6 9.9 19 0.19 — 0.64 0.57 0.06 3.44 0.57 1.78 29 -52 West Thornton 19822 208 194 10.5 9.8 58 0.10 0.15 1.26 0.55 0.10 3.23 0.35 1.41 42 14 Bensham Manor 15813 196 176 12.4 11.1 20 0.19 — 1.01 0.38 — 5.19 0.32 1.77 50 20 Thornton Heath 15330 258 186 16 8 12.1 62 0.39 0.20 1.44 0.65 — 4.05 0.26 1.89 51 72 South Norwood 17450 321 254 18.4 14.6 47 0.51 0.17 1.78 0.52 0.29 5 47 0.46 2.18 29 67 Woodside 15370 148 153 9.6 10.0 68 0.20 0.66 1.30 0.78 — 3.77 0.33 1.43 37 —5 East 17772 174 192 9.8 10.8 40 0.06 0.23 0.73 0.73 — 3.49 0.56 2.25 10 —18 Addiscombe 14163 181 172 12.8 12.1 44 0.14 0.07 1.69 0.42 0.07 3.88 0.84 2.19 49 9 Whitehorse Manor 16479 260 175 15.8 10.6 62 0.49 0.24 0.97 0.85 0 0 3.09 0.06 2.06 63 85 Broad Green 15084 225 172 14.9 11.4 40 0.33 0.20 1.33 0.26 0.20 4.84 0.40 1.33 69 53 Central 11894 100 144 8.4 12.1 60 0.08 0.25 1.35 0.25 — 5.21 0.67 1.68 33 -44 Waddon 21609 421 236 19.5 10.9 26 0.42 0.09 0.93 0.56 0.09 4.26 0.32 1.76 23 185 South 14611 146 163 10 0 11.2 55 0.14 0.14 0.89 0.34 — 4.24 0.48 2.40 13 -17 Addington 8477 93 26 11.0 3.1 11 0.12 — 0.59 0.24 — 1.06 0.12 0.35 1 67 The Borough 241739 3248* 2590* 13.4 10.7 41 0.24 0.13 1.11 — — 4.01 0 39 1.78 19 658 * These are the corrected figures. 24 Comments on Table I. 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 Woodside (68), Thornton Heath and Whitehorse Manor (62), and Central (60); lowest in Addington (11), Norbury (19), and Bensham Manor ('20). The Infantile Mortality rate was above the average for the whole Borough in the following Wards: Upper Norwood, West Thornton, Thornton Heath, South Norwood, Woodside, Addiscombe, Whitehorse Manor, Central, and South. Birth-rates were highest in Waddon, South Norwood, and Thornton Heath ; lowest in Norbury, Upper Norwood, and Central. The general death-rate was highest in South Norwood, Thornton Heath, Addiscombe, and Central; lowest in Addington, Upper Norwood, West Thornton, and Norbury. The death-rate was above the average for the whole Borough in the following Wards: Bensham Manor, Thornton Heath, South Norwood, East, Addiscombe, Broad Green, Central, Waddon, and South. The death-rate from Diarrhoea was highest in Woodside, Central, and Whitehorse Manor; from Bronchitis and Pneumonia in South Norwood, Addiscombe, and Thornton Heath; from Pulmonary Tuberculosis in Whitehorse Manor, Woodside, and East; from Non-Pulmonary Tuberculosis in South Norwood and Broad Green; from Diseases of the Heart and Circulation in South Norwood, Central, and Bensham Manor; from Nervous Diseases in Addiscombe and Central; from Cancer in South, East, Addiscombe, and South Norwood. Through the kindness of the Medical Officer of Health of Portsmouth I am able to include the following Table, showing comparative vital statistics for 20 of the large towns in England and Wales. They are arranged—taking Croydon with the basic comparability factor of 1., as it has the lowest crude death-rate (10.7)—in order of their death-rate as adjusted by the factor. Croydon shows (a) the lowest death-rate, (b) the lowest infant mortality rate, (c) the lowest Tuberculosis rate, (d) the lowest birth-rate: :(e) it is bracketed with Portsmouth 2nd Leicester in having the lowest Diphtheria incidence rate. It is not so favourably placed as some of the other towns with regard to the Maternal Mortality rate. 25 Showing the Population, Birth-rates, Zymotic Death-rates, Maternal Mortality, etc., In 20 Large Towns for the year 1936. Name of Town Population as estimated by the Registrar General Mid1936 Compara bility Factor Per 1,000 Population Death Rate as adjusted by Factor Rates per 1,000 Population from : Infantile Mortality Rate Maternal Mortality (per 1,000 Total Births) Birth Rate Crude Death Rate Smallpox Measles Scarlet Fever Whooping Cough Diphtheria Typhoid and Paraty phoid Diarrhoea (under 2 years) Influ enza Tuberculosis From Sepsis From Other Causes Total Pulmon ary Other Forms 1. CROYDON 241,739 13.4 - 10.7 - 0.09 0.01 0.06 0.03 0.02 0.09 0.16 0.55 0.08 41 1.48 2.08 3.56 2. PORTSMOUTH 251,400 0.99 15.56 11.81 11.69 — 0.05 0.00 0.00 0.03 0.00 0.06 0.13 0.68 0.13 49 0.73 1.47 2.21 3. LEICESTER 261,800 1.02 14.46 11.57 11.80 — — — 0.04 0.03 0.00 0.08 0.13 0.78 0.11 58 2.3 1.0 3.3 4. BRISTOL 413,900 0.98 14.24 12.27 12.02 0.00 0.10 0.01 0.04 0.04 0.00 0.06 0.11 0.71 0.10 48 1.46 1.64 3.10 5. SHEFFIELD 518,200 1.13 15.21 10.81 12.22 — 0.08 0.01 0.08 0.17 0.00 0.09 0.10 0.58 0.10 59 1.34 2.56 3.90 6. PLYMOUTH 206,400 0.98 14.8 12.5 12.25 — 0.01 0.00 0.09 0.19 0.01 0.06 0.02 0.60 0.13 56 1.57 1.25 2.82 7. BIRMINGHAM 1,038,000 1.10 15.8 11.3 12.4 — 0.04 0.01 0.10 0.06 0.00 0.08 0.13 0.71 0.07 62 1.47 2.06 3.53 8. LONDON 4,141,100 1.02 13.59 12.35 12.60 — 0.14 0.01 0.07 0.05 0.01 0.20 0.13 0.69 0.09 66 0.72 1.14 1.86 9. WEST HAM 265,800 1.15 15.7 11.6 13.3 — 0.18 0.01 0.06 0.05 0.00 0.27 0.11 0.70 0.10 70 0.7 1.1 1.8 10. CARDIFF 221,500 1.06 15.1 12.6 13.3 — 0.01 0.01 0.05 0.07 0.02 0.09 0.18 0.87 0.18 55 2.60 1.15 3.75 11. NOTTINGHAM 279,400 1.03 15.20 13.21 13.61 — 0.08 0.02 0.09 0.09 0.00 0.15 0.09 0.83 0.10 89 1.13 3.38 4.51 12. HULL 321,500 1.10 18.4 12.7 14.0 — 0.21 0.01 0.02 0.39 — 0.18 0.12 0.79 0.16 65 1.30 1.95 3.25 13. SUNDERLAND 184,179 1.12 19.6 12.8 14.3 0.00 0.01 0.02 0.06 0.16 0.02 0.34 0.17 0.78 0.13 72 1.38 2.22 3.60 14. LEEDS 489,800 1.07 14.99 13.61 14.56 — 0.10 0.02 0.06 0.07 — 0.14 0.13 0.71 0.13 65 1.30 1.83 3.13 15. NEWCASTLE 290,400 1.13 15.6 13.1 14.8 — 0.06 0.03 0.02 0.12 0.01 0.36 0.13 0.90 0.14 90 2.12 3.81 5.92 16. LIVERPOOL 867,110 1.15 20.07 12.90 14.83 0.00 0.20 0.00 0.12 0.16 0.00 0.15 0.08 0.82 0.14 75 1.10 2.43 3.53 17. BRADFORD 290,500 1.00 13.42 14.92 14.92 — 0.05 0.02 0.04 0.18 0.01 0.13 0.19 0.52 0.14 82 1.46 3.18 4.64 18. Stoke-on-Trent 273,100 1.22 16.8 12.4 15.1 0.00 0.13 0.02 0.06 0.07 0.01 0.16 0.13 0.73 0.12 74 1.03 2.28 3.31 19. MANCHESTER 759,058 1.14 14.71 13.50 15.39 — 0.16 0.01 0.06 0.12 0.00 0.09 0.17 0.87 0.14 77 1.69 3.29 4.98 20. SALFORD 206,000 1.18 15.0 14.0 16.5 - 0.24 0.03 0.11 0.15 - 0.21 0.12 0.98 0.14 90 1.5 3.7 5.2 26 Table II. Year. Population estimated to Middle of each Year. Births. Total Deaths Reg. in the District. Transferable Deaths. Nett deaths belonging to the District. of Non-residents registered in the District. of Residents not registered in the District. Under 1 Year of Age. At all Ages. Uncorrected Number. Nett. Number. Rate. Number. Rate. Number. Rate per 1,000 Nett Births. Number. Rate. 1925 199,300 3521 3406 17.1 2262 11.4 336 243 187 55 2169 10.9 1926 205,900 3569 3477 16.9 2340 11.4 318 247 211 61 2269 11.0 1927 211,700 3329 3174 15.0 2542 12.1 384 294 176 55 2452 11.6 1928 214,800 3501 3374 15.7 2439 11.4 389 301 178 53 2354 11.0 1929 222,300 3553 3399 15.3 2954 13.3 463 301 221 65 2792 12.5 1930 222,300 3703 3514 15.8 2407 10.8 364 294 171 48 2337 10.5 1931 233,800 3601 3400 14.5 2719 11.6 331 300 196 58 2674 11.4 1932 237,186 3607 3311 14.0 2500 10.5 242 298 161 49 2556 10.8 1933 239,950 3391 3147 13.2 2612 10.9 257 366 148 47 2721 11.3 1934 240,600 3508 3185 13.2 2451 10.2 219 339 145 46 2571 10.7 1935 242,100 3576 3288 13.6 2413 10.0 256 296 147 45 2453 10.1 1936 241,739 3357 3248 13.4 2515 10.6 245 320 134 41 2590 10.7 27 Table III. REGISTRAR GENERAL'S TABLE OF DEATHS ACCORDING TO CAUSE, AGE AND SEX. Causes of Death. Sex All Ages. 0— 1— 2— 5- 15— 25— 35— 45— 55— 5— All Causes M 1248 75 25 14 37 44 51 71 111 227 282 311 F 1342 59 11 8 14 29 49 58 117 179 302 516 1 Typhoid and paratyphoid fevers M 1 ... ... ... ... ... ... ... ... 1 ... ... F 3 ... ... ... ... 2 ... ... ... 1 ... ... 2 Measles M 12 1 4 2 5 ... ... ... ... ... ... ... F 9 1 4 3 ... 1 ... ... ... ... ... ... 3 Scarlet fever M 2 ... ... ... ... 1 ... 1 ... ... ... ... F ... ... ... ... ... ... ... ... ... ... ... ... 4 Whooping cough M 10 2 5 2 1 ... ... ... ... ... ... ... F 5 4 1 ... ... ... ... ... ... ... ... ... 5 Diphtheria M 3 ... ... 1 2 ... ... ... ... ... ... ... F 5 1 ... 1 2 ... ... ... ... ... ... ... 6 Influenza M 19 ... ... 1 ... 1 2 3 ... 5 4 3 F 20 ... ... ... ... ... ... 1 2 4 6 7 7 Encephalitis lethargica M 2 ... ... ... ... 1 1 ... ... ... ... ... F ... ... ... ... ... ... ... ... ... ... ... ... 8 Cerebro-spinal fever M ... ... ... ... ... ... ... ... ... ... ... ... F ... ... ... ... ... ... ... ... ... ... ... ... 9 Tuberculosis of respiratory system M 77 ... ... ... 1 12 14 13 13 19 5 ... F 55 1 ... 1 1 11 15 9 5 6 4 2 10 Other tuberculous diseases M 13 1 1 2 1 4 1 1 1 1 ... ... F 6 ... ... 1 1 1 1 ... ... ... 2 ... 11 Syphilis M 4 ... ... ... ... ... 1 1 ... 2 ... F ... ... ... ... ... ... ... ... ... ... ... ... 12 General paralysis of the insane, tabes dorsalis M 5 ... ... ... ... ... ... ... 1 4 ... ... F 2 ... ... ... ... ... ... ... ... 2 ... ... 13 Cancer, malignant disease M 191 ... ... ... ... ... 7 10 24 58 58 34 F 237 ... ... ... ... 1 1 16 42 54 69 54 14 Diabetes M 16 ... ... ... ... ... ... 3 1 3 6 3 F 21 ... ... ... ... 2 ... ... ... 4 7 8 15 Cerebral haemorrhage, etc. M 30 ... ... ... ... ... ... ... 2 6 10 12 F 63 ... ... ... ... ... 1 1 4 4 20 33 16 Heart Disease M 336 ... ... ... 1 1 7 10 21 46 106 144 F 413 ... ... ... 1 1 2 6 16 41 99 247 17 Aneurysm M 9 ... ... ... ... ... 1 1 2 2 ... 3 F 6 ... ... ... ... ... ... 1 ... 1 1 3 18 Other circulatory diseases M 53 ... ... ... ... ... ... ... 5 13 15 20 F 59 ... ... ... ... ... ... ... 3 5 20 31 19 Bronchitis M 19 ... ... ... ... ... ... ... 2 3 7 6 F 25 2 ... ... ... ... 1 ... ... 2 5 15 20 Pneumonia (all forms) M 101 10 9 ... 3 1 2 5 13 16 17 23 F 84 10 4 ... 1 1 4 1 4 16 13 30 21 Other respiratory diseases M 12 1 ... ... 1 ... ... 1 3 1 2 3 F 11 ... ... ... ... ... 2 ... 2 1 2 4 22 Peptic ulcer M 17 ... ... ... ... ... 1 5 2 4 5 ... F 6 ... ... ... ... ... ... ... 2 1 2 1 23 Diarrhoea, etc. M 16 11 ... ... 1 ... ... ... ... 1 1 1 F 15 10 ... ... ... ... ... 1 3 ... 1 ... 24 Appendicitis M 12 ... ... ... 3 3 1 1 2 1 1 ... F 6 ... ... ... ... ... ... ... 1 2 2 ... 25 Cirrhosis of liver M 4 ... ... ... ... ... ... ... ... 2 1 1 F 4 ... ... ... ... 1 ... ... ... 2 1 ... 26 Other diseases of liver, etc M 3 ... ... ... ... ... ... ... ... 1 1 1 F 12 ... ... ... ... ... 1 ... ... 3 3 5 27 Other digestive diseases M 24 1 ... ... 1 2 ... 2 3 2 6 6 F 23 2 ... ... ... 1 4 2 1 3 5 10 28 Acute and chronic nephritis M 37 ... ... ... 2 3 ... ... 5 10 6 11 F 52 ... ... ... ... ... 2 3 10 9 15 13 29 Puerperal sepsis F 5 ... ... ... ... ... 3 2 ... ... ... ... 30 Other puerperal causes F 7 ... ... ... ... 1 4 2 ... ... ... ... 31 Congenital debility, premature birth, malformation, etc. M 40 40 ... ... ... ... ... ... ... ... ... ... F 23 23 ... ... ... ... ... ... ... ... ... ... 32 Suicide M 7 ... ... ... ... ... ... ... ... ... ... 7 F 16 ... ... ... ... ... ... ... ... ... ... 16 32 Suicide M 15 ... ... ... ... 3 2 3 2 5 ... ... F 14 ... ... ... ... ... 3 2 6 2 ... ... 34 Other violence M 52 4 ... ... 6 7 7 3 2 10 5 6 F 33 ... ... ... 2 4 1 1 ... 5 7 13 35 Other defined diseases M 106 4 3 2 9 5 5 8 6 13 24 27 F 97 5 1 1 6 2 4 10 16 11 18 23 36 Causes ill-defined, or unknown M ... ... ... ... ... ... ... ... ... ... ... ... F ... ... ... ... ... ... ... ... ... ... ... ... 28 Comments on the Registrar-General's Table of Total Deaths by Cause and Age and Sex. The chief cause of death, both in males and females, was Heart Disease, and its heaviest incidence was in ages over 45 years. The next important cause of death was Cancer, which resembled Heart Disease in causing most deaths in females and in its highest incidence after 45 years. Pneumonia also exacted a heavy toll with a higher incidence in males. The age period 5-25 showed the lowest number of deaths from this cause. The fatality of Pneumonia during the first year of life should be noted. With the exception of the group of conditions, Congenital Debility, Premature Birth, Malformation, etc., it was the greatest cause of death at this age. Other illuminating and important causes of death are Other Circulatory Diseases, which fell particularly heavily on women over 55 years. Tuberculosis, which was more fatal in the male sex, and which, in both sexes, caused the highest number of deaths in the young adult age period of 15-35 years, more specially in women, was, with the exception of Pneumonia, the greatest cause of death among the young adult population. Deaths from violence were more numerous in men. Cerebral Haemorrhage and Nephritis were a more usual cause of death in women than men, whilst Digestive diseases, fell more heavily on men. Deaths from Zymotic diseases were insignificant in number after the 2nd year of life. To sum up, the most dangerous time of life up to the 45th year is the first year: from 45 years onward the incidence of death rises, fairly slowly at first, but rapidly after the 55th year. Comparisons with 1935. There was a rise in the deaths from the Zymotic diseases. In 1935, no deaths were recorded from Measles or Scarlet Fever. In 1936 there were 21 deaths from Measles and 2 from Scarlet Fever. Whooping Cough caused 15 deaths (2 in 1935), and Diphthena 8 deaths (12 in 1935). The deaths from Pulmonary Tuberculosis decreased by 16. There was an increase in the number of deaths attributed to Cancer, from 326 in 1935 to 428 in 1936. Deaths from Heart Disease, however, decreased by 31. Pneumoniadea; showed an increase of 65, and those due to Bronchitis a decline of 1. Deaths from Digestive diseases, including Appendicitis, decreased by 31. Deaths from Suicide and Violence increased from 111 to 114. 29 The percentage of deaths under 1 year of age to total deaths was 5.2%. Deaths under 15 years, 9.4%; deaths under 65 years, 45.5%; deaths over 65 years, 54.5%. The corresponding figures for 1935 were 6.0 ; 9.1; 46.1; and 53.9. Table IV. CLASSIFICATION OF DEATHS ACCORDING TO DISEASE OVER A PERIOD OF 12 YEARS. Cause of Death. 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 Total Deaths total Deaths. Total Deaths. Total Deaths. Total Deaths. Total Deaths. Total Deaths. Total Deaths. total Deaths. Total Deaths Total Deaths. Total Heaths Death Rate. Enteric Fever ... 1 2 ... 1 ... ... 2 ... 1 ... 4 0016 Malaria 1 1 ... ... ... ... ... ... ... ... ... ... ... Small Pox ... ... ... ... ... ... ... ... ... ... ... ... ... Measles 7 13 6 30 1 22 ... 2 13 14 ... 21 0.087 Scarlet Fever 1 ... 3 5 4 2 3 ... ... 3 ... 2 0.008 Whooping Cough 9 9 21 14 24 3 9 12 3 18 2 15 0.062 Diphtheria and Croup 8 32 10 32 23 14 5 11 17 24 12 8 0.033 Influenza (including Influenzal pneumonia) 63 44 118 38 199 32 84 100 103 28 25 39 0.161 Dysentery ... ... ... ... ... 1 1 ... ... ... ... ... ... Erysipelas 5 5 5 3 8 7 4 3 8 5 2 6 0.025 Uerebro-Spinal Fever ... ... ... 2 ... 2 3 2 2 3 3 ... ... Pulmonay Tuberculosis 131 171 165 167 170 154 155 144 162 144 148 132 0.546 Tuberculous Meningitis 17 17 10 13 10 7 11 9 10 6 9 19 0.079 Other Tuberculous Disease 13 20 28 26 19 14 11 13 12 V 14 Cancer, Malignant Disease 319 330 344 327 330 339 342 341 374 371 321 428 1.776 Kheumatic Fever 8 11 6 6 5 4 7 4 4 6 9 6 0.025 Meningitis 6 2 9 11 17 14 15 9 7 9 14 4 0.016 Organic Heart Disease 273 281 346 405 308 375 490 469 627 591 780 749 3.098 Bronchitis, Acute and Chronic 130 100 92 92 226 125 200 145 130 93 45 44 0.182 Pneumonia 140 138 200 158 272 199 258 238 210 199 120 135 0.765 Other Diseases of the Respiratory Organs 32 34 33 33 21 16 20 15 22 24 29 23 0.095 Diarrhoea and Enteritis 36 34 24 28 45 32 15 25 26 18 29 31 0.128 Appendicitis and Typhlitis 20 14 17 16 27 23 23 28 44 23 48 18 0.074 Cirrhosis of Liver 12 3 9 11 10 5 5 8 6 5 2 8 0.033 Alcoholism 1 2 3 3 4 3 1 1 ... 5 2 ... ... Nephritis and Bright s Disease 65 81 77 79 117 45 60 81 75 75 66 89 0.368 Paerperal Fever 5 11 4 2 6 1 8 2 7 5 7 5 0.021 Other Diseases and Accidents of Piegminy & Parturition 8 13 5 11 5 6 14 5 5 8 1 7 0.029 Congenitil Debility and Malformation . 36 52 30 26 42 42 49 27 19 33 87 63 0.261 Premature Birth 42 40 48 32 47 40 49 46 47 34 Viol deaths (cxclding 6.5 71 83 75 64 74 92 75 70 91 85 85 0.352 Suicide 23 33 30 35 29 19 33 43 30 37 26 29 0.120 Other defined Diseases 672 703 720 664 748 713 706 684 677 688 567 570 2.358 Diseases Ill-defined or unknown 1 3 4 10 10 4 1 10 8 3 ... ... ... Total 2169 2269 22452 2354 2792 2337 2674 2556 2721 2571 2453 2590 10.7 30 1936 showed an increase in the general death-rate, a slight decrease in the birth-rate and a still further decline in the infant mortality rate, which reached the lowest yet recorded in Croydon. Taking diseases of bodily systems and group diseases to which deaths were definitely assigned by the Registrar General, we find:— Circulatory System (including Atheroma and Cerebral Haemorrhage) 969 per 1,000 population. or 4.01 Cancer 428 1.78 Respiratory System (not Tubercular) 252 1.04 Tuberculosis (all forms) 151 0.62 Diseases of the Digestive System (excluding Cancer and Tuberculosis) 147 0.61 Diseases of the Nervous System (not Tubercular) 95 0.39 Diseases of Renal System 89 0.37 Infectious Diseases (excluding Tuberculosis but including Influenza) 91 0.37 Suicides and Violent Deaths 114 0.47 Old Age 23 0.95 Congenital Debility, Prematurity and Malformation 63 0.26 The greatest single group of causes of death as in 1935 was diseases of the Circulatory system, and of this group Organic Heart disease was the most prominent member (749 deaths). Rheumatism in childhood is indubitably a cause of cardiac breakdown latrte in life, more particularly if the original attack of rheumatism tobeen overlooked or disregarded. Arterio-sclerosis (250 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, 69 deaths, is one of the sequelae of Arterio-sclerosis combined with excessive blood pressure. Arterio-sclerosis and Cerebral Haemorrhage between them caused 319 deaths. Populatiorn (thoryandss) 31 POPULATION. I 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 1936 the estimated population is 241,739. 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 a rapid increase of population gives rise to its own public health problems, in as much as facilities available do not always keep pace with the demand, resulting in overcrowding of Clinics and a straining of the organisation. The estimated population as put forward by the RegistrarGeneral shows a decrease in population of 361. It is difficult to think that this is in fact tha case when the number of new houses erected, and the degree of the conversion of large single dwellings into flats, is remembered. Although there is only a slight natural increase in the population, the actual increase is swollen by immigration of families into the town. 32 Table V. METEOROLOGICAL RECORD. Months. Air Temperature in Degrees Fahrenheit. Rainfall Total. Bright Sunshine. Hrs. per day. Percentage. Means o† Mean of A. & B. A. Max. B. Min. Daily Mean January OF. 44.6 OF. 37.8 °F. 41.2 in. 5.05 mm. 128 hrs. 0.88 11 February 43.5 32.7 38.1 2.15 55 2.98 30 March 51.5 39.8 45.7 1.18 30 2.60 22 April 50.7 38.2 44.5 1.81 46 3.66 27 May 63.3 45.5 54.4 0.45 11 5.52 36 June 68.4 52.8 60.6 2.50 63 5.95 36 July 67.3 54.9 61.1 4.12 105 4.85 30 August 70.7 54.4 62.5 0.98 25 5.74 40 September 65.8 53.8 59.8 2.76 70 2.98 24 October 56.1 43.6 49.9 2.11 54 2.85 27 November 48.0 40.3 44.1 3.97 101 1.11 12 December 46.4 38.6 42.5 3.09 78 1.87 24 Means and Totals for Year 56.4 44.4 50.4 30.17 766 3.42 29 33 SECTION III. MAYDAY HOSPITAL. The Staff consists of the Medical Superintendent, 4 other resident Medical Staff. 8 Visiting Consultant Staff. Specialised Services:—Orthopaedic, Gynaecological, Dental, X-Rays, Ultra Violet Light, Massage, Ophthalmic, Ear, Nose and Throat. No. of Trained Nurses 58 (plus X-Ray and Massage 4). Probationer Nurses 79 Assistant Nurses 7 Male Attendants 7 Table I. Summary of Statistics. 1936. 1935. 1.—Total number of admissions (including infants born in hospital) 5623 4872 2.—Number of women confined in hospital 760 647 3.—Number of live births 724 616 4.—Number of deaths among the newly born (i.e. under 4 weeks of age) 16 27 5.—Total number of deaths among children under 1 year (including those given under 4) 29 52 6.—Number of stillbirths 44 37 7.—Number of maternal deaths among women admitted to hospital for confinement 6 1 8.—Total number of deaths 771 726 9.—Total number of discharged (including infants born in hospital) 4764 4125 10.—Duration of stay of patients included in 8 and 9 above: (a) Under four weeks 3875 3296 (b) Four weeks and under thirteen weeks 1331 1248 (c) Thirteen weeks or more 329 307 11.—Number of beds occupied: (a) average during year 473 478 (b) highest 518 on 11/2/36; (c) lowest 422 on 25/7/36 and 4/1/36. 12.- Number of surgical operations under general anaesthetics (excluding dental operations) 947 706 13.—Number of abdominal sections 357 316 34 Table IF. Classification of In-Patients who were Discharged from or who Died in the Institution during the year ended 31st December, 1936. Children (under 16) Men and Women. Discharged. Died. Discharged. Died. A.—Acute infectious disease 24 — 11 - B.—Influenza 5 — 15 - C.—Tuberculosis : Pulmonary 10 2 59 38 Non-Pulmonary 3 1 12 6 D.—Malignant Disease — — 65 127 E.—Rheumatism, Acute rheumatism (rheumatic fever) together with sub-acute rheumatism and chorea 9 - 19 7 Non-articular manifestations of so called "rheumatism" (muscular rheumatism, fibrositis, lumbago, and sciatica) 2 - 5 - Chronic Arthritis 5 - 30 3 F.—Venereal Disease 1 - 13 1 G.—Puerperal pyrexia — — 20 - 11.—Puerperal fever (a) Women confined in hospital - - 2 - (b) Other cases - - - - I.—Other diseases and accidents connected with Pregnancy and childbirth - - 402 7 J.—Mental disease (Senile Dementia) 8 — 267 8 (Other) — — — - K.—Senile Decay — — 68 32 L.—Accidental injury and violence 86 3 218 22 M.—Diseases of the Nervous System and Sense organs 17 9 116 62 N. „ „ Respiratory System 110 17 221 75 O. „ „ Circulatory System 9 4 148 197 P. „ „ Digestive System 203 10 462 51 Q. „ „ Genito-Urinary System 30 1 184 44 R. „ ,, Skin 67 1 93 it S.—Other Diseases 91 7 107 17 T.—Mothers and infants discharged from Maternity Wards and not ( Mothers - - 754 - included in above figures (Infants 708 — - - U.—Any persons not falling under any of the above headings 51 17 34 - Totals 1439 72 3325 699 35 Patients Discharged During the Year. 1936. 1935. Cured 3383 2900 Relieved 921 867 Unrelieved. 460 358 Died 771 726 5535 4851 36 Table III. Diagnoses in Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Alimentary. Appendicitis - - - - 130 16 3 8 157 Ischio rectal abscess — — — — 6 1 — - 7 Intestinal obstruction — — — — 6 1 — 13 20 Pancreatitis - - - - - - - 3 3 Stomatitis 3 1 - - - - - - 4 Cholelithiasis — — — — 3 11 I 1 16 Peritonitis - - - - - 2 — 5 7 Pyorrhoea — - - — 5 3 3 - 11 Gastric ulcer 17 - 4 4 3 4 — - 32 Duodenal ulcer 15 3 1 1 4 1 — - 25 Cholecystitis — — — — 11 10 1 5 27 Gastritis 13 2 - - - - - - 15 Constipation 12 8 2 - - - - - 22 Hernia — — — — 20 16 7 3 46 Colitis 7 — 1 3 — — — - 11 Dyspepsia 7 - - - - - - - 7 Peritonsillar abscess - - - - - 1 — — 1 Alveolar abscess — — — — 3 - — - 3 Intestinal colic 14 2 - - - - - - 16 Diverticulitis of colon — — — — 1 3 — - 4 Adhesions — — — — 3 1 1 - 5 Visceroptosis — 5 — — — - - - 5 Threadworms 1 - - - - - - - 1 Intussusception — — — — 1 — — - 1 Submaxillary calculus — — — — 2 — — — 2 Cirrhosis of liver — 12 — 3 — - — — 15 Pyloric stenosis - - - - - 1 — — 1 Ascites - - - - - 2 - - 2 37 Diagnoses In Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Jaundice 5 3 — — — — — — 8 Enteritis 12 2 1 4 — — — — 19 Haemorrhoids 11 — — — 2 — — — 13 Fissure in Ano 2 — 1 — — — — — 3 Cyst of liver 1 1 — — — — — — 2 Volvulus of sigmoid — — — — 1 — — — 1 512 Bones, Joints and Muscles. Arthritis 8 23 4 3 — — — — 38 Osteoarthritis 1 1 3 — — — — — 5 Bursitis 4 — — — — — — — 4 Acute rheumatism 22 7 — 7 — — — — 36 Osteomyelitis — — — — 3 3 — — 6 Synovitis — — — — 4 1 — — 5 Fibrositis 1 3 — — — — — — 4 Lumbago 2 1 — — — — — — 3 Pott's disease of spine — — 1 — — — — — 1 Perthe's disease of hip — — — — — 1 — — 1 Rigid finger after TenoSynovitis — — — — 1 — — — 1 Pleurodynia 1 — — — — — — — 1 105 Carcinoma. Stomach — — — — — 3 6 23 32 Cervix Uteri — — — — — 6 7 7 20 Ovary — — — — — — — 1 1 38 Diagnoses in Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died0 Vagina — — — — — — — 1 1 Rectum — — — — — 6 5 11 22 Colon — — — — — 6 — 11 17 Breast — — — — 1 3 1 19 24 Spine — — — — — — — 1 1 Lung — — — — — — 1 10 11 Parotid Gland — — — — — — — 1 1 Maxilla — — — — — — 1 — 1 Bronchus — — — — — — 1 — 1 Larynx — — — — — 1 — 3 4 Face — — — — — — — 2 2 Tongue and floor of mouth — — — — — 1 2 4 7 Pancreas — — — — — 1 — 2 3 Caecum — — — — — 1 — — 1 Liver — — — — — — 1 3 4 Oesophagus — — — — — — — 2 2 Bladder — — — — — — — 3 3 Prostate — — — — — — 1 9 10 Sarcoma of Femur — — — — — 1 3 — 4 172 Circulatory (Blood) Anaemia 3 1 — 1 — — — — 5 Septicaemia — — — 2 — — — _ 2 Pyaemia 1 1 — 5 — — — — 7 Leukaemia — — — 1 — — — — 1 15 39 Diagnoses in Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Circulatory (Heart and Vessels). Varicose veins 2 12 — — — — — — 14 Gangrene 1 — — — — — — — 1 Epistaxis 2 4 — — — — — — 6 Phlebitis 15 — — 1 — — — — 16 Thrombosis 1 1 — 2 — — — — 4 Myocarditis — 15 1 15 — — — — 31 Endocarditis 2 7 2 2 — — — — 13 Auricular fibrillation — 11 10 — — — — — 21 Ruptured heart — — — 1 — — — — 1 Aortic incompetence — 1 — 7 — — — — 8 Arterio sclerosis — 8 2 8 — — — — 18 Congenital heart disease — — 1 — — — — — 1 Aortic aneurysm — — — 1 — — — — 1 Myocardial degeneration — 29 15 152 — — — — 196 Hyperpiesia — 29 — — — — — — 29 Pericarditis — — — 2 — — — — 2 Mitral stenosis — 17 1 2 — — — — 20 Lymphangitis — 1 — — — — — — 1 Heart Block — 1 — — — — — — 1 384 Constitutional. Debility 17 16 — — — — — — 33 Nutritional disorders 11 12 — 2 — — — — 25 Obesity 1 — — — — — — — 1 Marasmus 11 — — — — — — — 11 Rickets 1 — — — — — — — 1 Amyloid disease — — — 1 — — — — 1 40 Diagnoses in Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Diabetes mellitus 3 16 1 10 — — — — 30 Gout — 1 — — — — — — 1 Scurvy 1 — — — — — — — 1 104 Eye. Keratitis — 1 — — — — — — 1 Corneal ulcers — — — — — 1 1 — 2 Blepharitis 1 — — — — — — — 1 Cataract — 2 — — — — — — 2 Glaucoma 3 — — — — — — — 3 9 Genito Urinary. Prostate enlargement — — — — 17 11 — 7 35 Uraemia — — — 17 — — — — 17 Orchitis — — 1 — — — — — 1 Renal colic 2 — — — — — — — 2 Haematuria 5 2 — — — — — — 7 Nephritis 15 15 1 15 — — — — 46 Pyelitis 11 3 — — — — — — 14 Semenuria — 1 — — — — — — 1 Urethral stricture — — — — — — — 1 1 Epididymo-orchitis 2 1 — — 1 — — — 4 Addisons disease — — — 1 — — — — 1 Undescended testicle — — 1 — — — — — 1 Urinary incontinence 1 — 1 1 1 — — — 4 Cystitis 3 1 1 — — — — — 5 41 Diagnoses in Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Renal tumour — — — — — — — 1 1 Renal calculus — — — 1 5 5 2 — 13 Phimosis — — — — 8 — — — 8 Renal mobility — — — — — 1 — — 1 Umbilical urethral fistula — — — — 1 — — — 1 Albuminuria 2 1 — — — — — — 3 Congenital cystic kidneys — — 1 — — — — 1 2 Papilloma of bladder — 1 — — — — — — 1 Hydronephrosis — — — — 1 — — — 1 170 Glands. Adentitis 9 — — — 1 — — — 10 Glandular fever 1 — — — — — — — 1 Hodgkin's disease — — — — — 1 1 — 2 Hyperthyroidism 1 — — — — — — — 1 14 Gynaecological. Abortion — — — — 132 6 1 1 140 Ovarian cyst — — — — 7 — 1 — 8 Fibrosis uteri — — — — 11 3 — — 14 Uterine haemorrhage — — — — 16 1 — — 17 Investigation — — — — 13 — 1 — 14 Abscess of breast — — — — 6 1 — — 7 Sterility — — — — 2 — 1 — 3 Menorrhagia — — — — 3 5 — — 8 Vaginitis — — — — 2 — — — 2 42 Diagnoses in Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Metrorrhagia — — — — 1 — — — 1 Bartholin's abscess — — — — 1 — — — 1 Puerperal abscess — — — — 1 — — — 1 Dysmenorrhoea — — — — 2 5 — — 7 Uterine polypus — — — — 5 — — — 5 Erosion of cervix — — — — 3 — — — 3 Toxaemia — — — — 2 1 — — 3 Chr. Cervicitis — — — — 10 1 1 — 12 Deficient Pelvic floor — — — — 15 — — — 15 Sub involution — — — — 2 — — — 2 263 Maternity. Deliveries — — — — 755 — — 5 760 Live births — — — — 704 — — 12 716 Delivered before admission — — — — 22 — — — 22 Maternity cases undelivered — — — — — — — 1 1 For version — — — — 7 1 3 — 11 Pyelitis of pregnancy — — — — 13 11 1 — 25 Albuminuria do. — — — — 43 3 2 — 48 False labour pains — — — — 36 12 9 — 57 Pseudocyesis — — — — — — 1 — 1 Ante partum haemorrhage — — — — 20 16 — — 36 Vesicular mole — — — — 1 — — — 1 Ectopic gestation — — — — 7 — — — 7 H.B.P. of Pregnancy — — — — 22 — — — 22 Vomiting of do. — — — — 30 3 — — 33 Puerperal sepsis — — — — 2 — — — 2 1742 43 Diagnoses in Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Infectious. Influenza 17 1 1 — — — — — 19 Scarlet Fever 1 1 3 — — — — — 5 Measles — — 4 — — — — — 4 Croup — 1 — — — — — — 1 Diphtheria — — 5 — — — — — 5 Whooping cough — — 1 — — — — — 1 Chicken-pox — 1 13 — — — — — 14 Typhoid fever — 3 1 — — — — — 4 Erysipelas — — 5 — — — — — 5 Ophthalmia 1 — — — — — — — 1 59 Ear, Nose and Throat. Otitis media — — — — 36 10 1 1 48 Mastoiditis — — — — 18 10 — 3 31 Sinusitis — — — — 2 — — — 2 Empyema of antrum — — — — 1 — — — 1 Quinsey — — — — 2 — — — 2 Tonsillitis 28 — — — 88 — 1 — 117 Rhinitis sicca — — — — — 1 — — 1 202 Mental. Certified — — 127 — — — — — 127 Uncertified 24 27 31 1 — — — — 83 Epilepsy 3 19 11 1 — — — — 34 44 Diagnoses in Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Congenital idiocy — — — 1 — — — — 1 Dipsomania — 1 — — — — — — 1 Dementia — 8 12 1 — — — — 21 G.P.I. — 1 1 — — — — — 2 Mongolism — — — 1 — — — — 1 M.D. — 2 — — — — — — 2 272 Nervous. Chorea — 3 3 — — — — — 6 Hemiplegia — 23 2 13 — — — — 38 Neurasthenia — 14 4 — — — — — 18 Neurosis 1 16 4 — — — — — 21 Neuritis 2 1 — — — — — — 3 Cerebral thrombosis — 2 — 6 — _ — — 8 Meningitis 1 1 1 7 — — — — 10 Cerebral tumour — 1 2 4 — — — — 7 Neuralgia 1 — — — — — — — 1 Disseminated sclerosis — 2 1 — — — — — 3 Paralysis agitans — 1 1 5 — — — — 7 Post encephalitis 2 1 3 — — — — — 6 Tabo paresis — — — 1 — — — — 1 Hysteria 5 3 — — — — — — 8 Spinal paraplegia — 2 1 — — — — — 3 Spina bifida — — — 2 — — — — 2 Cerebral arterio sclerosis — 1 — — — — — — 1 Tabes dorsalis — 2 1 — — — — — 3 Cerebral haemorrhage — 18 1 43 — — — — 62 Sciatica 8 4 — — — — — — 12 Muscular dystrophy — — 1 — — — — — l 45 Diagnoses in Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Poliomyelitis 1 — 1 — — — — — 2 Coxalgia 1 — — — — — — — 1 Convulsions — — — 1 — — — — 1 225 Poisoning 4 1 — 3 — — — — 8 Alcoholism 8 4 — 2 — — — — 14 Tuberculosis (Pulmonary) — 49 17 40 — — — — 106 Pleural effusion 2 2 1 — — — — — 5 111 Tuberculosis (Non Pulmonary). Hip — — — — — — 1 — 1 Joints — — — — 1 2 — — 3 Salpingitis — — — — 2 — — — 2 Kidneys — — — — — — 1 2 3 Adenitis — — — — 2 3 — — 5 Peritoneum — — — — — 1 — — 1 Lupus — — — — — — 3 — 3 Meningitis — — — — — — — 1 1 Spine — — — — — 1 — — 1 20 46 Diagnoses in Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Respiratory. Pneumonia 96 4 — 85 — — — — 185 Bronchitis 70 59 — 15 — — — — 144 Pleurisy 11 — — — — — — — 11 Asthma 6 7 3 — — — — — 16 Pulmonary embolism — — — 3 — — — — 3 Bronchiectasis — 6 — — — — — — 6 Fibroid lung 1 1 — — — — — — 2 Bronchial catarrh 2 1 2 — — — — — 5 Empyema 11 2 2 3 — — — — 18 Pleural effusion 3 2 1 — — — — — 6 Emphysema — — 1 — — — — — 1 Congestion of lungs 2 — — — — — — — 2 399 Senility — 24 44 32 — — — — 100 Skin. Dermatitis 6 3 — — — — — — 9 Impetigo 20 4 1 — — — — — 25 Boils and abscesses — — — — 38 3 — 1 42 Ulceration — — — — 7 7 2 4 20 Burns and scalds — — — — 8 1 — 3 12 Eczema 4 3 — 1 — — — — 8 Vaccinia — — — — 1 — — — 1 Cellulitis — — — — 5 — — 2 7 Whitlow — — — — 1 — — — 1 Septic spots 3 2 — — — — — — 5 Seborrhoea corporis — — 2 — — — — — 2 Scabies 3 — — — — — — — 3 Lipoma — — — — 1 — — — l Carbuncle — — — — 6 1 — — 7 47 Diagnoses in Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Urticaria 3 1 — — — — — — 4 Herpes zoster 4 — — — — — — — 4 Sycosis barbae — 1 — — — — — — 1 Naevus on chest — — — — 1 — — — 1 Sinuses in operation scars — — — — 1 — — — 1 154 Miscellaneous. Collapse 3 3 — — — — — — 6 Teething — 1 — — — — — — 1 Admitted with mother 46 — — — — — — — 46 No abnormality detected 37 — — — — — — — 37 90 Violence. Bruises — — — — 21 3 — — 24 Dislocations — — — 5 1 — — 6 Wounds — — — — 44 2 — 1 47 Fractured Limbs — — — — 89 27 4 22 142 Fractured clavicle — — — — 1 1 — — 2 Fractured patella — — — — 3 — — — 3 Fractured skull — — — — 4 1 — 1 6 Fractured ribs — — — — — — — 1 1 Concussion — — — — 50 8 1 1 60 Minor injuries — — — — 57 2 1 — 60 Sprains — — — — — — — 1 1 48 Diagnoses in Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Amputations — — — — 3 — — — 3 Lacerations — — — — 16 1 — — 17 372 Venereal. Syphilis — — — — — 13 2 1 16 Gonorrhoea — — — — — 2 1 — 3 19 Table Operations Performed. Number. abdominal. Suture of perforated duodenal ulcer 8 Suture of perforated gastric ulcer 3 Appendicectomy l66 Drainage of appendix abscess 6 Caecostomy 6 Gastrectomy 1 Resection of Colon 5 Cholecystectomy 11 Cholecystostomy 5 Reduction of Intussusception 1 Excision of fistula 2 Colostomy 6 Drainage for General peritonitis 1 Gastro-jejunostomy 5 Sigmoidoscopy 17 Excision of haemorrhoids 5 Herniotomy 28 For acute obstruction 11 Excision Meckel's diverticulum 1 Enterectomy 1 Laparotomy (Carcinatomosis, etc.) 25 Fistula-in-ano 1 315 49 bones and joints. Number. Reduction of joints 18 Application of plasters 33 For Osteo-myelitis 8 Wiring of bones 27 Plating of fracture 1 Manipulation of Limbs 21 Fixing of caliper 3 Resection of rib 12 Removal of sequestra 2 Amputation of limbs 7 Arthrotomy 1 For hammer toes 1 134 ear, nose and throat. Tonsillectomy 88 Mastoidectomy 29 Puncture and irrigation of antrum 2 Incision of mastoid 4 Removal of odontone 1 124 Operation Performed. gynaecological. Plastic hymenectomy 3 Excision of Bartholin's cyst 4 Incision of Bartholin's abscess 1 Evacuation of vesicular mole 2 Anterior and posterior colpo-perineorrhaphy 7 Amputation of cervix 7 Cauterization of cervix 8 Drainage of para vaginal haematoma 1 Removal of tissue for section 1 For twisted ovarian cyst 4 Dilatation and curettage 7 Exploration of uterus 15 Myomectomy 2 Wertheim's hysterectomy 1 Total hysterectomy 18 Subtotal hysterectomy 6 Salpingectomy 4 Salpingo-oophorectomy 4 Oophorectomy 2 Laparotomy for ovarian carcinoma 1 Ovariotomy 4 Incision of mammary abscess 5 Examination under anaesthesia 10 Excision of coccyx 1 Uterine tampionage 2 Cauterisation of urethral caruncle 4 Blood transfusion (for gynaecological reasons) 43 167 50 obstetrical. Number. Forceps delivery 36 Breech extraction 3 Internal version 11 Manual removal of placenta 9 Vaginal packing 2 Anaesthesia for examination (external version, etc.) 19 Induction of abortion 4 For ectopic gestation 8 Caesarean section 15 Surgical induction of labour 23 Drainage for pelvic peritonitis 4 Suture of perineum 5 Evacuation of uterus and glycerine drainage 86 Episiotomy 5 Perforation of foetal skull 2 Examination in theatre without anaesthetic (external version : for bacteriological purposes, etc.) 28 260 Operations Performed. genito-urinary. Pyelography 11 Pyelolithotomy 1 Cystoscopy 40 Dilatation of urethral stricture 7 Supra pubic prostatectomy 19 Orchidectomy 1 Cystostomy 21 Circumcision 14 Epididymectomy 1 Catheterization of ureters 2 Passing of urethral bougies 5 Removal of calculi 11 Irrigation of bladder 1 Nephrectomy 2 Urethrotomy 1 Left Haematocele 1 138 miscellaneous. Aspiration of chest 59 Incisions: Abscesses, whitlows, cellulitis, etc. 115 Lumbar punctures 75 Excision of sinuses 2 Excision of glands 6 Excision of naevus 1 Avulsion of nails 5 Bronchoscopy 1 Excision of varicose veins 1 Application of tannic acid 12 Removal of semilunar cartilage 1 Thiersch skin graft 3 Suture of wounds 41 Removal of breast 3 Excision of ganglion left foot 1 Injection of Saline for sciatica 3 329 Total 1,467 No. of patients who had teeth extracted at Mayday Hospital 342 No. of patients who had teeth extracted at Queen's Road Homes 35 51 NUMBER OF X-RAY FILMS TAKEN 1936. 1935. Spine 161 113 Long bones 936 790 Pelvis 32 20 Skull 163 155 Chest (including lungs) 405 385 Barium meals 129 199 Barium enemata 18 26 Urinary tract 176 196 Gall-bladder 55 105 Teeth 118 140 Abdominal ? F.B. 10 16 Maternity cases 164 226 Total 2,367 2,371 Actual number of cases treated 1,382 968 1936. 1935. massage 7,345 7,764 Exercises 7,892 7,033 Radiant Heat 1,922 1,673 Electrical 963 542 Diathermy 476 463 Ultra violet light 283 446 Total 18,881 17,921 Actual number of patients treated 998 827 mental patients dealt with during the year. Male. Female. Admitted 231 234 Certified and sent to C.M.H 54 73 Discharged not certified 120 124 174 197 Deaths: Male 60, Female 29. number of patients seen by the oculist during the year 286 number of specimens sent to the council's laboratory during the year 2,201 number of post mortems ordered by the coroner and performed at mayday hospital during the year. Outside cases 236 Hospital 67 Total 303 number of post mortems not ordered by the coroner 85 52 SECTION IV. PREVALENCE AND CONTROL OF INFECTIOUS DISEASE, Table I. gives the figures for ages and Wards. Scarlet Fever was less prevalent than in 1935; the largest incidence has been in West Thornton, Waddon, and Norbury Wards. Based on the estimated ward populations, the case rate for these wards was respectively 520, 356, and 465 per 100,000 of the population. The age group 6-15 years, as usual, suffered most; cases in this group comprising 54.8 per cent. of the total. Diphtheria was also less prevalent than in 1935; most cases occurred in Waddon (36) and West Thornton (27). Once again the age group 5-15 years gives the highest figures, constituting 53 per cent, of the total. No cases of Small Pox occurred during the year. There were 14 cases of Puerperal Fever and 48 of Puerperal Pyrexia; 28 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 thirteen 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 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 begininng of May, when the incidence fell rapidly and remained low until the beginning of a new wave in November. Tn 1933 the incidence remained fairly steady throughout the year. In 1934 there were two peaks of incidence, the first and smaller came in the second week in 53 March following a steady rise from the beginning of the year; the incidence then dropped rapidly and remained constant until the second peak was reached, following a rapid rise, the third week in November. Throughout 1935 there was a steady incidence with no epidemic waves, and this has continued during 1936. September and October had the lowest incidence of cases, and May the highest. The average weekly number of cases was 12.6, being 2.45 lower than in 1935. Diphtheria.—During 1924 there was a small but steady incidence throughout the year; in 1925 a trough occurred in the curve and verv 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 trend became upwards once more, reaching its apex in January, 1928; this was followed by a slight fall, followed by a slight rise until December, 1928, when another fall commenced, reaching its minimum in July, 1929, from when the curve rose steadily to its maximum in November. In 1930 Diphtheria was not troublesome, though there was a small rise in the number of cases in October, reaching a maximum of 22 during the week ending October 18th. In 1931 the highest number of cases arose in February and the last two weeks of March. 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; a small wave of increased incidence spread over the first half of the year and was succeeded by a more intense wave covering October, November and December. In 1934, there was a minor wave of increased incidence during February, March and April, with a minimum incidence at the end of July. A fairly sharp rise took place during October, November and December, and persisted until the end of the year. In 1935 the incidence was low throughout the year and there were no pronounced waves of incidence. During 1936 the incidence remained exceptionally low. The weekly average of cases was 3.5 as compared with 5.86 in 1935. 11 hooping 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 54 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. In 1934 two waves were also experienced ; the first with its peak at the end of January, and the second with its peak at the middle of April. From then a moderate incidence was present until the beginning of August, when the numbers dropped rapidly, the incidence remaining very low for the rest of the year. In 1935 the incidence of Whooping Cough rose in a series of sharp waves throughout the year. In 1936, this zymotic maintained an average of some 20 cases brought to the notice of the Department each week. There was a slight decline in incidence towards 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, 192-5, to May, 1926. During 1927 there was very little Measles in Croydon; a small rise in October, November and December, however, heralded a very big incidence of cases—the highest during the period under review—during the first six months of 1928, Practically no cases occurred after this exacerbation, until March, 1929, but during this month, and April, May and June, 1929, a number of cases occurred from when the incidence dropped awav 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 in the second week in April which readied 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 55 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; the 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. Measles was again prevalent during the first half of 1934 with peak incidences in February and May. A very rapid decline at the end of July was followed by a low incidence for the rest of the year. In 1935 a minor wave occurred during February and March, and then declined until early in November, when there was a sudden sharp rise which reached its maximum at the end of the year. This foretold the severe epidemic which swept over Croydon during the first quarter of 1936. This epidemic came to an abrupt end in the middle of April, and throughout the rest of the year practically no cases arose. The highest number of cases brought to our notice in a week was the week ending January 13th, namely, 298. 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 ithe last quarter. During 1927 and 1928 there was a fairly high and steady incidence with a peak in October and N'ovember, 1927. Another wave came during the latter half of 1920 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 1933 to reach a maximum early in July. It then dropped rapidly and did not show any signs of recrudescence until the end of November. In 1934 a moderate wave of incidence covered January to the end of March, and was followed by a sudden rise during May. The incidence then dropped, but a small rise was manifest in December. Chicken Pox showed a minor wave during May, June and July, and a major wave during November and December, the 56 incidence remaining high till the end of the year. This high incidence carried over into 1936, but dropped towards the end of March and remained at a comparatively low level until the end of November, when there was a transitory rise. 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 thoughout the year, and in 1932 the incidence was very low. The very low incidence of Mumps continued during 1933 and until November, 1934; a rise then commenced and continued during December, indicating the onset of a major incidence in 1935. 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. The major incidence foretold in 1934, occurred in 1935. The peak was reached in March, when the high number of 317 cases during the week ending March 30th was reached. The epidemic continued until the end of July. After the schools summer holidays, the cases dropped very markedly, and the rest of the year showed the usual low incidence. During 1936, Mumps incidence remained very low until the end of November, when the cases rose slightlv and continued raised for the remainder of the year. 57 Table I. CASES OF NOTIFIED INFECTIOUS DISEASE, 1936. 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. 1936. At all Ages. At ages–years. Upper Norwood. Nor bury. West Thornton. Ben sham Manor. Thornton Heath. South Norwood. Woodside. East. Addiscombe. Whitehorse Manor. Broad Green. Central. Waddon. South. Addington. Under 1 year. 1–5. 6–15. 16–25. 26–45. 46–65. 66 and up. M F Small Pox Cholera • •• Diphtheria (inc. Membranous Croup) 183 57 97 17 12 11 5 27 9 13 10 11 12 4 16 13 4 36 8 4 164 8 141 163 Erysipelas 59 1 2 2 3 14 26 11 6 13 3 5 7 3 5 1 1 4 1 4 5 1 29 6 29 41 Scarlet Fever 655 2 183 359 51 52 7 1 45 73 103 37 23 34 24 54 27 41 55 17 77 19 26 610 2 334 441 Typhus Fever . . Enteric Fever (including Paratyphoid) 16 1 4 5 3 3 6 2 4 1 1 1 1 9 4 6 7 Puerperal Fever 14 3 11 1 4 1 1 3 1 3 7 5 18 Puerperal Pyrexia 48 25 23 2 25 1 1 7 1 3 8 9 47 Cerebro-Spinal Meningitis 4 2 2 3 1 3 3 1 Ophthalmia Neonatorum. 20 20 1 10 1 2 1 2 6 1 8 5 Poliomyelitis 2 1 1 1 1 2 1 Encephalitis Lethargica 1 2 Dysentery Malaria Ac. Primary and Ac. Inf. Pneumonia 53 9 6 7 11 13 7 6 8 5 2 7 1 6 2 3 7 5 1 16*† 38 17 Polio Encephalitis * Influenzal Pneumonia only.† Not accommodated at Borough Hospital. 58 Table II. 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. 1936 1935 Small Pox - — — - — — - Diphtheria 0.75 1.25 3 140 19 21 183 Erysipelas 0.24 0.29 1 30 8 20 59 Scarlet Fever 2.709 3.201 17 468 93 77 655 Enteric Fever (inc. Paratyphoid) 0.066 0.053 — 5 4 7 16 Puerperal Fever 0.058 0.074 — 4 — 10 14 Puerperal Pyrexia 0.198 0.194 — 9 — 39 48 Cerebro-Spinal Meningitis 0.014 0.016 — — — 4 4 Ophthalmia Neonatorum 0.070 0.05 — 11 — 9 20 Poliomyelitis 0.007 0.004 — 1 — 1 2 Encephalitis Lethargica - - - - - - — Acute Primary or Acute Influenzal Pneumonia 0.22 0.22 — 41 7 5 53 Dysentery - - - - - - Polio-encephalitis - - - - - - - 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.% 59 TABLE III. 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 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 iS6 1 † .23 387 1 0.26 1933 633 264 599 1 0..17 1934 1003 416 3 .29 968 5 0 .51 1935 775 320 755 1 0 .1 1936 655 271 2 631 2 0 .3 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 a decrease in the number of cases notified and admitted to Hospital in 1936 as compared with 1935. The type mild and the case mortality was 0.31. The attack rate (Col. 3) for England and Wales was 253. Croydon shows a rather higher figure. 60 Table IV. 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 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 7.0 329 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 1934 524 217 24 4.5 546 19 3.4 1935 304 125 12 3.9 465 12 2.6 1936 183 76 8 4.4 282 6 2.1 * Cases from Penge are included in Cols. 6 to 8. The incidence of Diphtheria showed a decrease in 1936, and the mortality was 4.4%. The type of the disease was moderately severe. Ninety-two cases of bacteriological Diphtheria were admitted but these are not included in columns 2-4 as Diphtheria as they exhibited no clinical symptoms. The case rate (Col. 3) for England and Wales was 139. Croydon's rate was therefore lower than for the whole country. 61 DIPHTHERIA IMMUNISATION CLINIC. I am indebted to Dr. W. R. Martine, an Assistant Medical Officer of Health, who has done the clinical work of this Clinic, for the following particulars. The demand for Immunisation against Diphtheria has been more than maintained at the high level reached towards the close of 1935. As in former years, no widespread propaganda has been employed, and the principle of immunising those requesting treatment, without in any way attempting to convert those antagonistic or apathetic, has been adhered to. Leaflets are distributed to parents at School Medical Examinations, at School Clinics, and at Infant Welfare Centres. At 5 Schools in the Borough informal meetings were held, at which the Assistant School Medical Officer concerned explained the procedure to those parents who were sufficiently interested to attend. In three areas this had a considerable reaction upon the waiting list; by October this had reached 585, and there were still 486 waiting to commence treatment at the end of the year. It has been gratifying to note the number of families introduced to the Clinic by friends and neighbours who have previously had treatment, and also of children sent for a Schick Test after treatment carried out through another local authority or by a private practitioner. The effects of, and results from, Immunisation are clearly explained to each parent on first attendance at the Clinic, and, on Schick Test after Immunisation, parents are given definitely to understand that it is impossible to guarantee that any individual, immunised and found thereafter to be Schick negative, will never contract Diphtheria, but that, should this occur, the attack will be mild in character, without risk to the individual of those grave complications which render the disease such a serious one. An acquired immunity may slowly be lost or reduced, and the resistance of the individual may subsequently be inadequate in the face of an especially virulent infection, yet the attack is mild by comparison with that in the Schick positive or unprotected child. It may be said here that little or no difficulty has been experienced in gaining the co-operation of parents and children, so ensuring completion of the treatment, once begun. The policy of allowing Immunisation to conduct, for the most part, its own Propaganda, continues to justify itself. The current year's work commenced with 624 children still under treatment. Three sessions per week were again held; two, 62 to begin with, at Lodge Load Clinic, and one at Selhurst Road. In view, however, of a sadden large increase in the waiting list— from Thornton Heath and Norbury for the most part—one session was temporarily transferred to the Winterbourne Road School. As the demand in this area still exists on a scale unrivalled in any other, this branch of the main Clinic was retained at the end of the year. During July and August, two weekly sessions only were held, both at Lodge Road, but on the re-opening of Schools on 31st August, the three sessions were continued as previously. The following details give a summary of the attendance:— Total attendances throughout the year 8,774 Total number of sessions held during the year 145 Highest attendance at any one session 94 Lowest attendance at any one session 18 Average attendance per session 60.5 During the year 2,167 children and 10 adults attended for treatment—see Table I. While no parents or teachers have been offered Immunisation, those asking for a Schick Test have had this carried out, and, if found susceptible, have been immunised thereafter. Of the children who attended, 1,620 were school children, a Table showing their distribution throughout the Schools of the Borough being incorporated in this report—Table IV. ; while 547 children, under the age of 5 years and not yet attending School, came under treatment. Many parents who had previously brought older children, have returned with the latest toddler of their own accord, but the number of children under 5 is still disappointingly small, even in the Thornton Heath and Norbury area where there has been most demand. It is definitely advantageous for a child to be protected before reaching School age ; the opportunities of contact with infection becomes greater then, and it is felt that if it were Possible to immunise the greater proportion of pre-school children and entrants in the infant departments of Elementary Schools, Diphtheria would become of very minor importance as an infection of School life. Treatment Given at Clinic. 1,215 Primary Schick Tests were carried out (see Table II while this test was dispensed with in the case of 446 younger children. In all, 1,369 completed an immunising course of Toxoidantitoxin mixture (T.A.M.), while 76 (adults and older children underwent a similar series of injections of Toxoid-antitoxin Floccules (T.A.F.), 4,003 injection of T.A.M., and 254 of T.A.F. being given during the year. 63 As it is felt that such treatment without subsequent Schick Testing is of no proved value, and perhaps even a source of danger, an effort has been made to carry this out in the case of everyone treated at the Clinic. Such tests were performed at an interval of 3 months or more after the last injection of T.A.M. or T.A.F., 1,224 and 40 respectively. The latter all proved to be negative, while of the former, 1,214 were negative and 10 positive. All tests so carried out were actually read, or a reliable report received as to the result; this was made possible by visiting 39 children in thenhomes during the year, when, by reason of reported illness, they were unable to attend for final reading. Of the 10 children Schick positive after treatment, 4 were retested after a further interval of from 3-5 months, and all proved to have become Schick negative. One gave a weak positive reaction on two subsequent occasions, at 2 and then at a further 6 months interval, when the child received one extra injection of T.A.M. The Schick Test has not been repeated again so far in the case of this child. The remaining 5 received extra injections of T.A.M., four receiving 1, and one 2, injections on account of their apparent degree of susceptibility as shown by the Schick Test subsequent to their course of T.A.M. All gave a negative reaction to a further test. Three children, retested after extra injections of T.A.M. given in 1935, all prove to be Schick negative. In view of the number of children on the waiting list, it was found to be impossible to arrange any systematic repeat Schick Tests among children previously immunised, or naturally immune. Out of 54 carried out, 50 were confirmatory in children originally found to be Schick negative, while 4 were repeats in original Schick positives whose treatment had rendered them Schick negative at 3 months. These latter repeats were carried out at 3 months, 15 months and 2 years (2 cases) after the development of the Schick negative state, and in all the result was satisfactory. The Immunisation course employed was one of 3 infra-muscular or subcutaneous injections of 1.0 T.A.M. (or T.A.F.) into the left arm near the shoulder, and with due aseptic technique. In older children injections were given at fortnightly or weekly intervals, while in younger children, with presumably a lower degree\ of basal immunity, there was frequently an interval of 3 or more between injections. Gentle rotatory massage was employed in all cases after injection, to prevent, if possible, the development of any tender swelling after an injection, by early dissipation of the injected material throughout the tissues. 64 Reactions reported during course of treatment were few—0.59 per cent. to T.A.M. and 0.39 per cent. to T.A.F. They, are summarised as follows:— Local Reactions to T.A.M.—9 after 1st injection (one severe) and 6 after 2nd. The severe case showed redness with swelling and tenderness from shoulder to elbow, commencing after 48 hours, and lasting for 5 days; child, however, never confined to bed. There was no reaction to later injections. The remaining 14 cases were very mild, with symptoms in no way corresponding with the physical signs. Focal Reactions to T.A.M.—Two cases of Axillary Adenitis in children of same family, one to 1st, and one to 2nd injection, and one case of " sore throat " after 2nd injection. General Reactions to T.A.M.—One case of headache after first injection accompanied by malaise and anorexia ; and one characterised by the appearance of a scarlatiniform rash 4 to 5 days after 2nd injection, transient in nature and with no systemic disturbance. Local and General Reactions to T.A.M.—All subsequent to 1st injection, and none dangerous or alarming. 1.—Slight local effects with urticarial rash and cervical adenitis. An asthmatic history was admitted at the next attendance, and no complaint was made after subsequent injections (T.A.F. given in this case). 2.—Nausea same evening, with vomiting and temperature of 101° F. next day and later redness of arm; had completely recovered by 3rd day, and had no ill-effects from subsequent injections of T.A.M. 3.—Following a pseudo positive reaction to primary Schick Test, on day after 1st injection complained of dry throat, headache and vomiting, with slight tenderness and localised redness, temperature 102° F. Next day temperature still 102° F, but tongue moist and clean, appetite good, sleeping well and not complainingHe had fully recovered by the end of 3 days. Further treatment was cautiously given and injections of 0.3 cc, 0.6 cc, and 0.8 cc with only a slight transient local reaction to the last sufficed to produce a Schick negative response after 3 months. 65 4.—Slight localised redness with squeamishness after 1st injection, followed by more severe local but no general reaction to 2nd injection. 5.—Temperature 101° F. on 2nd day after 1st injection, settling within -24 hours, and localised redness and tenderness lasting to 4th day. Local Reactions to T.A.F.—One adult complained of a severe local reaction after 1st injection, with stiffness persisting for 4 days, and leaving slight redness at the end of 7 days. Reactions to Primary Schick Test.—One boy had an Epileptiform attack, with cyanosis and rigidity two minutes after test; always a highly strung boy but no definite previous history. He completed course of T.A.F. and subsequent Schick Test without further mishap. Another boy fainted on leaving the Clinic, but mother gave a history of frequent similar collapses. One complained of slight general malaise and feeling out of sorts for 24 hours. In another child a transient Scarlatiniform rash appeared, and in one child who showed an extremely strong positive reaction there was an acute cervical adenitis, subsiding in 3-4 days. Pseudo Reactions to Schick Test.—By reading tests at the end of 7 days, it was not possible to note all pseudo reactions occurring, and only 24 were recorded during the year. Of these, 2 occurred in children under 5 years of age ; 10 between the ages of 5 and 10 years, and 12 at ages over 10 years. In one case, aged 10 years, the reaction appeared in less than 24 hours, arm swollen, throat dry, and, within 3 days, an urticarial rash of extremities, with temperature up to 100° F. and slight cervical adenitis. The temperature was still 99° F. at the end of 7 days, but there was at that time no evidence of any local reaction to the Schick Test. A history of asthma and hay fever was elicited from the parent. Co-operation with General Practitioners.—Three children, unable to attend by reason of Infectious Disease at home, received doses of T.A.M. from their private practitioner. Eleven children were Schick Tested following upon 3-injection immunisation elsewhere or privately, and all were found to be Schick negative. Of 9 children treated privately with one injection of Alum Precipitated Toxoid (A.P.T.) (brand unspecified) at varying times during the previous 12 months, 8 were Schick negative. Of these 8, 66 however, one, aged 7 years, was retested after a further 6 months and found to have reverted to a strong Schick positive. She was given 2 injections of 1.0 cc T.A.M. and after a further 2 months was found to be Schick negative. She is to be kept under observation. Another of the negative reactors, aged 6 years, was 8 months later admitted to hospital with Clinical Diphtheria. The remaining one of the 9 children retested after one injection of A.P.T. was very definitely Schick positive, and received two injections of 1.0cc T.A.M. She had not attended for a further Schick Test by the end of the year. Two children, Schick negative to primary test, were reported as having received antitoxin (dose unknown) 4 weeks previous to test. On another test being carried out 6 months later, both were positive and were duly immunised. One child, aged 5, who gave a Schick negative reaction when submitted to a test gave the following history:—She received one injection of A.P.T. in April, 1935, was never Schick Tested subsequently, and developed Clinical Diphtheria in November, 1935. She was stated at the time to have been seriously ill. Previous, Intercurrent and Subsequent Diphtheria.—Of 31 children giving a history of previous Clinical Diphtheria, and treatment therefor in hospital, 25 were Schick negative, and 6 Schick positive. Of 7 who gave a history of previous isolation as carriers, 0 were Schick negative and 1 Schick positive. One child, aged 5 years, became a carrier during the course of immunisation. Schick Tested 3.2.36, she gave a moderately positive reaction ; she received 1.0 cc T.A.M. and on 20.2.30 was removed to hospital as a result of a positive nasal swab. She was discharged after 10 days and later completed her treatment. A second child, aged 7 years, developed Clinical Diphtheria 7 weeks after her 3rd injection of T.A.M. The history was as follows:—27.4.36 Schick positive, received 3 x 1.0 cc T.A.M. at weekly intervals. An aunt, living in same house, was removed hospital 3.7.36, suffering from Diphtheria. The child was excluded from School, apparently quite well, and nose and throat swabs taken, both being reported positive 4.7.36. She was admitted to hospital, still apparently well, and a Virulence Test carried out after admission proved to be positive, the guinea pig dying 67 24 hours. At no time did the child exhibit any clinical signs other than the positive swab results. Her throat swab was still positive 15.7.36; tonsils and adenoids were removed 21.7.36 and all swabs taken after 30.7.36 were negative. She was discharged 7.8.36, after 34 days in hospital, fit and well. In this child, while sufficient time had not elapsed to allow of a full degree of immunity being obtained, the treatment did, in view of the positive Virulence Test and the complete absence of clinical symptoms, afford the child a considerable degree of protection. A third child, aged 5 years, developed a mild attack of Diphtheria, subsequent to a negative Schick reaction after treatment at the Clinic. History was as follows:—Received 3 injections of 1.0 cc T.A.M., one week elapsing between injections. Schick Tested at 8 weeks, he proved to be Schick positive, and received 2 further injections of 1.0 cc, at an interval of a fortnight. After a long wait of 13 months owing to intercurrent illness, he gave a Schick negative reaction on 31.3.36. On 7.9.36 he complained of sore throat, and was found to have a small patch of membrane on one tonsil; swab positive ; removed to hospital 9.9.36, having had 16,000 units of antitoxin before admission. Swabs continued to remain positive until 2.10.36, but apart from a persistent sore on the lip, convalescence was uneventful and he was discharged well on 17.10.36. Defaulters.—Of 16 children who failed to complete treatment, 11 left the district before completion (8 having had full course of 3 injections but no retest), 1 died following an operation before due for retest, and 4 discontinued attendance (3 having had 3 injections, and one 1 injection only). Not Completed at End of Year.—Six hundred and eight whose treatment is at various stages have been carried over to 1937. Summary.—There is sufficient demand, as shown by the numbers on the waiting list, to justify the continuance of the Clinic. The relative absence of defaulters and the satisfactory results in regard to (a) immunity developed, (b) small percentage of fractions, suggest that the work should be continued on the present lines: further that, in view of the lack of certainty in results of "one shot immunisation," and the fact that two shot treatment with A.P.T. has not been sufficiently employed as yet to allow of a reliable comparison of results, it would be unwise, meantime, to "lake any change. 68 There has again been a relatively high percentage of positive reactions to the primary Schick Test, but this is fully explained by the fact that the big majority of children attending still come from homes that may be classed as above average. Though many injections in older children have been given at weekly intervals, it has been thought advisable to spread out the course to fortnightly and even 3-weekly attendances in the youngest children where the basic immunity is lowest and the response to immunisation slowest. Again it is only by Schick Test subsequent to Immunisation that it can be ascertained that the state of immunity has been reached, and such testing has been a routine measure in all cases. It has, moreover, been welcomed by all parents, when the situation has been explained to them. The interest of the Head Teacher in certain Schools appears to exert a marked effect on the attitude of parents towards this branch of preventive medicine, and where the Medical Officer or Health Visitor attending a particular School have gained the confidence of the Head Teacher, leading to an understanding of the advantages of closing the door to Diphtheria, the demand by parents has invariably increased. Small School epidemics have added to the numbers brought forward from these particular Schools, in two cases this demand arising after two years of almost complete apathy. Finally the impression that children under 5 years are too young to be immunised appears to die hard. The sooner immunisation is effected after about the second year of life the better as the risk of reaction is less, whilst between 2 and 12 years of age is the most susceptible period of a child's life to infection. Table III gives a summary of the results obtained. Classification of those attending the Immunisation Clinic. Definite School Cases 1,620 Definite Welfare Centre Cases 310 Under 5 years, but not sent from I.W. Centres 232 Nursery School 5 Adults 10 Summary of Results of 1,215 Primary Schick Tests. Age Group. Positive. Percentage. Negative. Percentage. Total.[##/#] Under 5 46 94 3 6 49 Over 5, under 6 140 88 20 12 160 Over 6, under 7 130 90 14 10 144 Over 7, under 8 143 85 24 15 167 Over 8, under 9 141 83 30 17 171 Over 9, under 10 105 71 43 29 148 Over 10 all ages 240 64 136 36 376 Total 945 78 270 22 1215 IMMUNISATION CLINIC —SUMMARY OF TREATMENT No. Attending 1/1/36. No. Given Primary Schick Test. No. Positive on Primary Schick Test. % Positive on Primary Schick Test. No. Not given Primary Schick Test. No. completed Treatment (T.A.M. and T.A.F.). 624 1215 945 64 446 1445 No. Retested after Treatment. (T.A.M. and T.A.F.) No. Negative on Retest after Treatment. (T.A.M. and T.A.F.) % Negative on Retest after Treatment. (T.A.M. and T.A.F.) No. Uncompleted at 31/12/36. No. left District or Defaulted during year 1264 1254 99.2 608 16 12 completed. 4 uncompleted. 69 70 Distribution of School Children who have attended the Immunisation Clinic since its Inauguration. School. Completed Treatment during Attended Clinic during 1936. Total attended Clinic to end 1936. School. Completed Treatment during Attended Clinic during 1936. Total attended Clinic to end 1936. 1934. 1935. 1934. 1935. Ashburton 4 8 53 65 All Saints 53 33 57 143 Benson 1 5 — 6 Tenison's 1 2 2 5 Beulah 10 28 38 76 Christ Church 2 15 9 26 British 2 1 2 5 Holy Trinity — 4 13 17 Davidson 1 7 11 19 Parish Church 3 18 11 32 Duppas — 14 11 25 St. Andrew's 1 5 4 10 St. George's — 2 - 2 St. Joseph's — - 3 3 Ecclesboturne — 9 34 43 St. Mark's 1 4 12 17 Elmwood 2 5 34 41 Addington — — - - Gonville 8 41 37 86 St. Mary's 3 8 3 14 Howard - 1 11 12 St. Peter's — 3 6 9 Ingram 8 14 29 51 St. Saviour's — 4 9 13 Kensington 1 13 126 140 Shirley 2 2 4 Kingsley 14 52 49 115 Lanfranc 2 9 8 19 John Ruskin — 10 10 Norbury Manor 2 14 65 81 Lady Edridge 1 3 6 10 Oval 2 23 29 54 Heath Clark — 6 24 30 Portland 10 67 77 St. Michael's — — 4 4 Ptirley Oaks 2 3 26 31 Selhurst Gram. 4 3 17 24 Rockmonnt 1 5 66 72 Croydon High S. — 8 3 11 South Norwood 3 10 43 56 Coloma — 5 7 12 Suffolk Road 1 3 7 11 Old Palace 9 3 4 16 Sydenham 1 2 16 19 Whitgift — 2 5 7 Tavistock — 3 20 23 Polytechnics 1 2 3 Waddon 12 26 19 57 W. Thornton 3 33 34 70 Private 6 17 27 50 Whitehorse Man. 1 5 8 14 Winterbourne 1 45 442 488 Unknown 4 33 8 45 Woodsidc 10 15 85 110 St. Christopher's 1 2 1 4 Total 183 586 1620 2380 St. Luke's — — - - St. Giles 1 - 1 2 71 IMMUNISATION AT RESIDENTIAL SCHOOLS AND HOMES. Prior to October only one injection of Alum Precipitated Toxoid was given to all Schick positive reactions. Since, however, the results—as in the latter part of 1935—showed a higher percentage of non-immunes after this treatment than after treatment with Toxoid Anti-toxin Mixture, or Toxoid Anti-toxin Floccules, either in the various institutions or at the Clinic, it was decided in October to give 2 doses of A.P.T. 0.1 cc followed a week later by 0.5 cc. As, however, this method of treatment was only commenced after 20th October, 1936, it has been impossible so far to retest and make any reliable comparison with the results already obtained after only one injection, as shown in Table below. No reactions were reported, but where only one injection was given, the children were not seen again for 3 or more months if at all, and thus reactions were not investigated. Other Treatment prior to 20th October, 1936, included the following:— Fidelis Convent, Central Hill, Upper Norwood.—4 who had completed course of T.A.M. (3 x 1.0 cc) were retested and found to he Schick negative. 1 primary Schick Test was repeated because of uncertainty and result was negative. Children's Infirmary, Central Hill Convent, Upper Norwood.— 3 who had completed course of T.A.M. (3 x 1.0 cc) were retested and found to be Schick negative. P.A.C. (Queen's Road) Homes.—4 children were reschicked after completion of course of T.A.M. (3 x 1.0 cc) and all were negative. P.A.C. (London Road) Homes.—3 children transferred from Brighton P.A.C. Homes completed course of T.A.F. and have not\ yet been reschicked. 3 received a 2nd reschick test after the injecI'on of A.P.T., and one proved to be negative and two positive. St. Jude s Homes for Girls, Dagnall Park.—3 primary Schick Test were repeated because of doubt of result of original test— these were all negative. 72 Boys' Home, 106, Beulah Hill, Upper Norwood.—3 boys, previously Schick positive after treatment, were given 1 extra injection of A.P.T. but have not yet been retested. Russell School, Ballards.—4 primary Schick Tests were repeated—all negative. 15 were retested after previous course of T.A.M. and all proved to be negative. 23 reschick positives, following one injection A.P.T., received an extra injection of A.P.T.—4 of these so far having been retested with 3 showing a negative Schick reaction. Since 20th October, when the 2-injection method of Immunisation with A.P.T. was started, the following treatment has been given:— P.A.C. (London Road) Homes.—25 received 2 injections of A.P.T. (0.1 cc and 0.5 cc) and have not yet fallen due for retest. Russell School, Ballards.—2 Schick positives out of 7 boys tested received 2 injections of A.P.T. (as above) and have not yet been retested. Treatment given to those in Institutions other than those mentioned above:— Gordon Boys' Home, Morland Road.—7 boys were Schick Tested and found to be Schick positive. They were treated at the Clinic (Selhurst Road) as also were subsequent admissions to the Home, at the request of the Head Tearher of the School attended (Woodside). They are included in the annual report of the Immunisation Clinic. Cases of Diphtheria or Positive Swab occurring in the various Institutions during the year:— Not immunised. Queen Road Homes 2 cases Not immunised. Not fully Convent and Convent Infirmary 1 case immunised 4 positive swabs (One positive swab. One London Road Homes other case not immunised. Boys' Home, Beulah Hill Gordon Boys' Home No case of positive swab St. Jude's Home notified. Russell School Alum Precipitated Toxoid (A.P.T.) only used. (One injection). 73 Name of Institution. No. not completed, 1935. No. Primary Schick. No. Positive. % Positive. No. given A.P.T. No. retested. No. Negative. % Negative. Uncompleted. Defaulted. Fidelis Convent, Central Hill 5 — — — — 2 2 100 3 — Infirmary Convent, Central Hill 22 15 11 73.3 14 23 17 73.9 19 — Russell School 43 31 25 80.6 23 42 19 45.2 14 — Boys' Home, Beulah Hill 3 1 1 100 1 — — — 4 — St. Jude's Home, Dagnall Park 9 1 1 100 - 6 4 66.6 3 — P.A.C., Queen's Road 7 — — — 2 4 4 100 1 - P.A.C., 386, London Road 24 41 22 53.6 2 24 15 62.5 27 3 113 89 60 67.3 42 101 61 60.3 71 3 BOROUGH HOSPITAL. Table V. gives a summary of all cases treated at the Hospital during 1936. 1,247 patients were admitted, which, together with the patients in at the commencement of 1936 (90), gives a total of 1.337 cases dealt with. Thirty-eight died, giving a case mortality for the Hospital of 2.08%—an increase of 0.6% on 1935. The average number of days of each patient in Hospital for all classes of patients was 24.7 as against 24.2 in 1935. Penge Urban District Council has an agreement with the Corporation to send their cases to the Hospital. During 1936 a total of 36 cases was admitted: these are included in the Table. The Hospital is a recognised training school for fever nurses, During the year 12 probationers passed the Preliminary examination and one the Final. The accommodation of the Hospital remained as in 1935 and all the Wards including the emergency ones, were kept open except Ward E(Diphtheria), which was closed in the last quarter of the Year. The new Nurses Home, providing 22 additional bedrooms, was completed by the end of the year but not occupied. 74 A new High Pressure Steam Disinfector to replace, the old one, which had been in use nearly 40 years and had become obsolete and inefficient, was installed. This necessitated the rebuilding of the disinfecting room as the new apparatus was considerably larger than the old one. During the year, 15 cases were operated on for tonsils and adenoids and 3 for acute mastoiditis. One laparotomy was performed and 17 cases had glycerine uterine drainage, six of these also being curetted. Table V. Complaint for which admitted. Patients remaining in Hospital on 1st January, 1936. Patients admitted and discharged in 1936. Patients admitted during 1936 and remaining in Hospital on 1st January, 1937 Analysis of all Cases admitted in 1936, whether discharged or not during the year. Total. Recovered. Died. Total. Recovered. Died. Total. Recovered. Died. Total. Recovered. Died. Case Mortality. Average No. of days in Hospital. Scarlet Fever 82 82 ... 582 579 3 49 49 ... 631 628 3 0.5 38.9 Diphtheria 44 44 ... 251 245 6 31 31 ... 282 276 6 2.1 36.7 Enteric Fever 1 1 ... 11 7 4 ... ... ... 11 7 4 36.4. 35.6 Para Typhoid B. ... ... ... 4 4 ... ... ... ... 4 4 ... ... 31.5 Puerperal Fever 2 2 ... 14 12 2 ... ... ... 14 12 2 14.3 26.1 Puerperal Pyrexia ... ... ... 9 9 ... ... ... ... 9 9 ... ... 30 Erysipelas 1 1 ... 29 26 3 ... ... ... 29 26 3 10.3 20 Measles 7 7 101 90 11 ... ... ... 101 90 11 10.8 25.6 Rubella 1 1 ... 2 2 ... 1 1 ... 3 3 ... ... 10 C.S.M ... ... ... 7 5 2 1 1 ... 8 6 2 25.0 26 Whooping Cough 3 3 ... 56 50 6 4 4 ... 60 54 6 10.0 40 Chicken Pox 9 9 ... 32 32 ... 2 2 ... 34 34 ... ... 19.5 Ophthalmia ... ... ... 9 9 ... ... ... ... 9 9 ... ... 29.7 Mumps ... ... ... 13 13 ... 1 1 ... 14 14 ... ... 19 Tonsillitis ... ... ... 1 1 ... ... ... ... 1 1 ... ... ... Anterior-poliomyelitis ... ... ... 2 2 ... ... ... 2 2 ... ... 26.5 Acute Enteritis ... ... ... 1 ... 1 ... ... ... 1 ... ... 100 ... Bullous Impetigo ... ... ... ... ... ... 1 1 ... 1 1 ... ... ... Dermatitis ... ... ... 2 2 ... ... ... ... 2 2 ... ... 12 Coryza ... ... ... 1 1 ... ... ... ... ... Erythema ... ... ... 1 1 ... ... ... ... 1 ... ... ... 9 No Disease 2 2 ... 29 29 ... ... ... ... 29 29 ... 12 Totals . 1152 152 ... 1157 119 38 90 90 ... 1247 1209 38 ... ... 75 SCARLET FEVER. The total number of Scarlet Fever cases admitted during the year was 631: a decrease of 124 on 1935. 610 cases were admitted from the Borough and 21 from Penge. The type of the disease dining the year was generally mild, but there was once again a number of adult cases. 11 cases sent in as Scarlet Fever were not suffering from the disease. The following complications and sequela; occurred amongst the true Scarlet Fever cases. Table VI. Total cases Serum Cases. NonSerum Cases. 236 384 Adenitis 13 32 Otorrhoea 18 27 Rhinorrhoea 6 10 Albuminuria 1 4 Nephritis — 1 Rheumatism — 5 Relapses 1 5 Secondary Sore Throat 2 4 Abscesses and Boils 2 3 Diphtheria — 3 Mastoid 2 — Lobar Pneumonia — 1 The average stay in Hospital of serum cases was 39.6 days ; of •ion-serum cases 38.9 days. wo deaths occurred among Scarlet Fever cases: one being complicated by encephalitis, the other by septic arthritis of the hip. The number of complications amongst the 384 non-serum cases was 97 (25%) whereas the complications amongst the serum cases Was 45 (19%). 76 Ages and Sexes of Scarlet Fever Cases Admitted. Table VII. Age. Males. Females. Totals. Percentage. 0—1 2 1 3 0.47 1—2 9 8 17 2.69 2—3 21 19 40 6.34 3—4 22 29 51 8.08 4—5 25 29 54 8.56 5—10 120 140 260 41.20 10—15 47 51 98 15.53 15—20 15 11 26 4.12 20—30 23 20 43 6.81 30 or over 15 24 39 6.18 Total 1936 299 332 631 Total 1935 333 422 755 Monthly Admissions of Scarlet Fever Patients. Table VIII. Cases 1935. admitted. 1936. Cases notified. 1936. January 76 68 66 February 62 46 48 March 86 75 78 April 55 63 64 May 46 78 87 June 62 52 51 July 63 40 43 August 47 36 37 September 60 26 31 October 67 57 63 November 67 53 51 December 64 37 36 Total ... 755 631 655 77 DIPHTHERIA. 282 cases were admitted with a diagnosis of Diphtheria, a decrease of 183 cases on 1935. Of these 12 were found not to be cases of Diphtheria and 92 were cases of positive swab without clinical symptoms, leaving 178 cases of true clinical Diphtheria. Analysis of the 178 cases. Faucial Diphtheria 138 Nasal Diphtheria 15 Laryngeal Diphtheria 7 Faucial and Nasal Diphtheria 15 Faucial and Laryngeal Diphtheria 3 Total 178 Of the laryngeal cases, tracheotomy was necessary in 3 cases, and two recovered. The following complications and sequelae occurred amongst the Diphtheria cases:— Otorrhœa 5 Rhinorrhœa 4 Adenitis 6 Heart Failure 8 Secondary Throat 6 Paralysis:— Palatal Pharyngeal 10 Eyes 4 Facial 1 Hemiplegia 1 78 Ages and Sexes of Diphtheria Cases Admitted. Table IX. Age. Males. Females. Totals. Percentage. 0—1 2 2 4 1.42 1—2 8 7 15 5.32 2—3 5 5 10 3.55 3—4 10 12 22 7.80 4—5 17 15 32 11.35 5—10 54 75 129 45.74 10—15 15 17 32 11.35 15—20 2 7 9 3.19 20—30 6 13 19 6.74 30 or over 1 9 10 3.55 Total 1930 120 162 282 — Total 1935 230 235 465 — Monthly Admission of Diphtheria Patients. Table X. Cases notified. Clinical cases only. Cases admitted. Month. 1936. 1935. January 15 24 84 February 20 29 33 March 24 35 44 April 11 16 30 May 16 25 30 June 8 10 23 July 15 26 26 August 6 8 37 September 13 19 45 October 20 37 44 November 22 34 48 December 13 19 21 Totals 185 282 465 The type of Diphtheria which occurred in 1936 was, as a whole, less severe than in 1935. The average number of days in Hospital for Diphtheria cases was 36.7. 79 Particulars of Fatal Casts of Diphtheria. Table XI. Name. Age on Admission. Condition on admission. Subsequent progress. Date of Death (Days) after admission). 1. C.A. (F) 6 Membrane over both tonsils. Rhinorrhoea: Glands of neck †† Started showing signs of heart failure 9 days after admission and died from this 11 days later. 20 2. B.M. (F) 17/12 Cyanosed aphonic bilateral recession. Throat clean. Tracheotomy performed soon after admission with relief, but rapid heart failure followed and death. 7½ hrs. 3. N.S. (M) 5 9/12 Admitted with profuse rhinorrhoea & a clean throat. Adenitis. Showed signs of heart failure 6 days after admission: vomitting and cyanosis: died from this on 14th day. 15 4. J.P. (F) 10 Membrane over both tonsils: foetor ††: glands of neck †† v. toxic. Progressive heart failure until death on 3rd day. 3 5. P.T. (M) 10 9/12 Sloughing membrane both tonsils: "bull neck." Foetor and cyanosis. Showed signs of heart failure on admission, which became more marked: died on 4th day. 5 6. V.S. (m) 23/12 Membrane both tonsils: glands of neck + + Showed signs of heart failure on 4th day, which increased till death on 8th day. 8 The late administration of serum does not exert much influence on the course of the disease. Diphtheria toxin rapidly becomes fixed in the tissues and when once fixed anti-toxin has no effect in counteracting its poisonous effect. None of the fatal cases had received any anti-toxin before mission. Intra-venous and intra-muscular injections were given 80 in closes between 24,000 and 100,000 units. The combined use of intra-venous with intramuscular injection seems to be the best means of ensuring absorption in the system. No ill-effects followed its use. In markedly toxic cases the intra-venous injection of 20 c.c. 50% sterile glucose solution, combined with glucose in large quantities orally appeared to be most satisfactory in causing a general improvement. Coramine in doses of 0.5 c.c. to 1.7 c.c. intra-muscularly as a heart stimulant was also satisfactory; it was also given alternately with intra-muscular injections of 1 c.c. camphor in oil. For toxic cases with marked cardiac weakness adrenalin chloride 1-1,000 solution subcutaneously in doses of 0.5 c.c. to 1 c.c. were also beneficial. The low incidence of true clinical Diphtheria is probably a phase in the cyclic behaviour of the disease, but possibly the steady increase in the number of children immunised is also a factor. For a town of the size of Croydon, surrounded by thickly populated districts, the incidence of both Scarlet Fever and Diphtheria during 1936 has been satisfactorily low. This has necessitated a constant strict vigilance. Typhoid and Para-typhoid Cases. Eleven cases of Typhoid Fever were admitted; in nine the diagnosis was confirmed, the other two being cases of simple enteritis and streptococcal septicaemia respectively. Four deaths were recorded, all due to toxaemia with rapid heart failure. Four cases of para-typhoid fever were admitted. In all, the diagnosis was confirmed. Two of the cases were directly connected with the Bournemouth and Poole oubbrak. Both these cases were fatal. Puerperal Fever. Fourteen cases were admitted with a diagnosis of Puerperal Fever and nine with a diagnosis of Puerperal Pyrexia. Of the fourteen cases of Puerperal Fever in seven the diagnosis was confirmed. The other seven cases were as follows:— Sent in as Puerperal Fever but really Pyelitis 6 Mastitis 1 The cases of Puerperal Fever were of average severity and tow deaths occurred amongst them, one being complicated by Scarlet Fever. Towards the end of the year Prontosil Album was tried 81 and in the cases tried seemed to have a distinctly beneficial action. The number of cases is too small so far to make any definite statement. Erysipelas. There were 29 cases of Erysipelas admitted, the same number as for 1935. The disease was of average severity. There were 3 fatal cases, of which one was complicated by nephritis, one by sarcoma of the jaw, whilst the third was a senile subject. Measles. There were 101 cases of measles admitted, an increase of 74 cases on 1935. The disease was fairly severe and often complicated by broncho-pneumonia. There were 11 deaths from this complication. The cases were admitted either from hospitals or children's homes, or from private houses when the facilities for nursing were deficient or where there were a number of susceptibles. Whooping Cough. There were 60 cases admitted, an increase of 35 on 1935. There were 6 deaths. Cerebro-Spinal Meningitis. Eight cases were admitted but in only 3 was the diagnosis confirmed. The diagnosis of the other 5 cases was as follows:— 1 was really a case of constipation. 1 ,, ,, ,, marasmus. 1 „ ,, ,, pneumococcal meningitis. 1 „ ,, ,, tonsillitis. 1 „ „ „ thrombosis of the leg. Ophthalmia Neonatorum. Nine cases were admitted: in 6 the diagnosis was confirmed, the other three being cases of simple ophthalmia. Infantile Paralysis (Poliomyelitis). Two cases were admitted and in both the diagnosis was Both cases recovered. Encephalitis Lethargica (Sleepy Sickness). Only one case of this disease was disease. It was a case of Scarlet Fever which subsequently developed signs of Sleepy Sickness. 82 Age Group Disease 0—1 1—2 2—5 5—15 15—25 25—35 35—45 1 _ 45 & over Totals Deaths Table XII. Other Diseases. M F M F M F M F M F M F M F M F Enteric Fever ... ... ... ... 2 ... ... 1 2 2 1 ... ... ... 1 2 11 4 Para-typhoid B ... ... ... ... ... 3 ... ... 1 ... ... ... ... ... ... ... 4 1 Puerperal Fever ... ... ... ... ... ... ... ... 4 ... 9 ... 1 ... ... 14 2 Puerperal Pyrexia ... ... ... ... ... ... ... ... ... 3 ... 6 ... ... ... ... 9 ... Erysipelas ... ... ... ... ... ... ... ... 2 2 1 3 1 1 8 11 29 3 Measles 10 9 7 12 22 17 8 8 ... 5 ... 1 ... 2 ... ... 101 11 Rubella 1 ... ... ... ... ... ... 1 ... 1 ... ... ... ... ... ... 3 ... C.S.M. ... 2 ... 1 ... 3 1 ... ... ... ... 1 ... ... ... ... 8 2 Whooping Cough 5 12 10 5 8 13 ... 7 ... ... ... ... ... ... ... ... 60 6 Chicken Pox 2 2 4 ... 6 6 9 4 ... 1 ... ... ... ... ... ... 34 ... Ophthalmia 4 5 ... ... ... ... ... ... ... ... ... ... ... ... ... ... 9 ... Mumps ... 1 ... ... 5 3 ... ... ... 4 ... ... 1 ... ... ... 14 ... Tonsillitis ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ...... ... 1 ... Anterior Poliomyelitis ... ... 1 ... ... ... 1 ... ... ... ... ... ... ... ... ... 2 ... Acute Enteritis 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 Bullous Impetigo ... 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... Dermatitis ... ... ... ... ... ... 1 ... 1 ... ... ... ... ... ... ... 2 ... Coryza ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... 1 ... Erythema ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... ... 1 ... No Disease ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 29 ... Totals 23 32 22 19 43 46 20 22 6 22 2 20 2 4 9 13 334 29 83 Out of Borough Cases. Table XIII. Disease. Males. Females. Totals. Deaths. Scarlet Fever 10 11 21 Diphtheria 5 9 14 — C.S. Meningitis — 1 1 — Totals 15 21 36 — Croydon Borough Hospital Laboratory Report. Table XIV. DIPHTHERIA. Examination of Nose and Throat Swabs. Negative. Convalescent Cases. Positives. On Admission. Positives. Total. 5,558 374 179 6,111 ENTERIC (Agglutinating Tests). Negative. Typhoid Positives. Para Typhoid B. Positives. Total. 8 5 1 14 FAECES (Enteric or Dysentery Groups). Negative. B. Typhoid Positives. Para Typhoid B. Positives. Total. 22 6 1 29 SPECIMENS OF LOCHIA FOR HAEMOLYTIC STREPTOCOCCUS. Negative. Positives. Total. 8 9 17 84 OTHER EXAMINATIONS. Urines for Organisms (26): Cerebro-Spinal Fluids (9). Meningococcus. Pneumococcus. Sterile. - + T - + T 0—7—7. 0—1—1. 1. Sputums for T.B. (3): 1 positive, 2 negative. Blood Cultures (7): 5 sterile, 2 haemolytic streptococcus present. Pericardial Fluid (1): haemolytic streptococcus present. Fluids from Abdomen (4): 3 haemolytic streptococcus, 1 sterile. Swabs for Gonococci (9): 3 positive, 6 negative. Pus. Specimens (2): haemolytic streptococcus present in both specimens. Faeces for T.B. (6): 4 negative, 2 positive. CULTURE MEDIA. Loeffler's Blood Serum: 700 dozen tubes prepared. Agar Agar: 10,500 cc. Peptone Water: 2,000 cc. Endo's Media: 3,000 cc. Litmus Milk: 250 cc. Gelatine: 200 cc. Peptone Broth: 8,000 cc. 85 BACTERIOLOGICAL EXAMINATIONS. I am indebted to the Borough Pathologist, Dr H. W. Southgate, for the figures given in the appended tables: For private practitioners Mayday Hos. For Borough Hospital For Tub. Dispensary For School Medical Other Instns. of Corporation Other Institutions Total Table XV. At the Laboratory, Croydon General Hospital. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Swabs for Diphtheria 129 1057 14 441 3 3 ... 9 117 3934 2 158 26 391 291 5993 Virulence tests for Diphtheria ... ... 1 ... 9 ... ... ... 4 1 ... ... ... ... 14 1 Sputum for Tub. Bac. 75 574 268 320 ... ... 372 533 ... ... ... 1 16 84 731 1512 Pus for Tub. Bac. ... 3 3 683 ... 1 ... ... ... ... 3 83 ... ... 6 770 Pus for Gonococci ... 2 12 23 ... ... ... ... ... ... 5 23 ... ... 17 48 Pus for other organisms ... 7 ... 730 ... 1 ... ... ... ... ... 86 ... 1 ... 825 Blood for Typhoid Groups 3 17 5 15 ... ... ... ... ... ... ... ... 3 12 11 44 Blood for Wassermann ... 3 25 140 ... 3 ... ... ... ... ... 1 ... ... 25 147 Material for Spirochaetes ... ... 1 1 ... ... ... ... ... ... ... ... ... ... 1 1 Faeces for Typhoid Group ... 7 1 13 4 ... ... ... ... ... ... ... 1 12 6 32 Hair for Ringworm ... ... ... ... ... ... ... ... ... 1 ... ... 8 6 9 7 Examination of Urine ... 435 2 ... ... 77 2 516 Examination of Pleural Fluid ... 65 5 ... ... 8 ... 78 Examination o! C.S. Fluid ... 63 ... ... ... ... ... 63 Other Examinations 7 526 ... ... 1 83 6 623 86 The number of swabs examined for Diphtheria decreased by 3,241. The number of various examinations for Mayday Hospital increased. The decrease in the number of swabs examined was due to the low incidence of Diphtheria. Examinations Done Under National Health Insurance Act. Table XVI. Nature of Examination. Nature of Examination. Pus for Gonococci 8 (2 pos.) Urine for Chemical Exam. 5 Pus for other organisms 12 Urine for Microscopal Exam. 5 Pus for Tubercle B. 10 Urine for Tubercle B 5 Blood for Wasserman. 13 (3 pos.) Urine for Cultural Exam. 5 Complete Blood Counts 6 Other Examinations 13 Bacteriological Examination of Milk. Table XVII. Number of Samples submitted for Counts 457 Number under 10,000 per cc 225 No. over 10,000 but under 50,000 per cc 147 Over 50,000 but under 100,000 per cc 34 Over 100,000 but under 500,000 per cc 28 Over 500,000 but under 1,000,000 per cc 9 Over 1,000,000 per cc 14 Bacillus Coli Content— Not found in 0.1 cc 236 ,, ,, 0.01 cc 113 ,, ,, 0.001 cc 53 Present in 0.001 cc 55 Higher dilutions not made. Tubercle Bacilli— Number of samples of milk submitted 457 Number found positive by inoculation test 5 The number of milk examinations decreased by 49 87 VACCINATION ACTS. I am indebted to Mr. Huggins, the Vaccination Officer, for the particulars in the returns in subjoined Tables. Table XVIII. Registration Sub-Districts in V.O. District. Births Registered. Vaccinated. Insusceptible Statutory Declarations. Died Unvaccinated. P. P.O. Transferred to other V Os. Not traced Removals. In Default. Overage when Registered. South Sub-Disirict 1299 508 4 571 40 27 47 35 67 ... West „ 1385 405 2 743 52 22 13 80 67 1 North ,, 760 319 3 353 19 15 5 21 24 1 3444 1232 9 1667 111 64 65 136 158 2 During the year 2,303 Forms Q were sent to parents, and 237 Forms K and 131 Forms K "Final Notices." Form Q is the form drawing attention to the requirements of the Vaccination Acts and Form K refers to cases in default. 789 names were sent on the H lists to Public Vaccinators to be visited. During the past year proceedings were taken against parents who had failed to comply with the Vaccination Acts:— 6 summonses were taken out. 1 was dismissed on payment of 4s. costs, the child being vaccinated after the service of the summons. 1 was dismissed, the child being vaccinated after the service of the summons. 1 fined 10s. 1 fined 5s. 1 summons not served, left address and could not be traced. 1 adjourned until 15/1/37. Fined 5s. Return showing the Numbers of Persons vaccinated and re-vacceinated at the cost of the Kates by the Medical Officer of the Public Assistance Institutions and the Public Vaccinators during the year ended 30th September, 1936: 88 Table XIX. Name of Public Assistance 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 Near and upwards. Total. Croydon No. 1 Area 122 12 134 11 No. 2 Area 134 10 144 7 No. 3 Area 96 4 100 5 No. 4 Area 91 13 104 7 No. 5 Area 195 18 213 11 Addington 19 1 20 1 Queen's Road Homes 1 1 2 — Mayday Road Hospital 3 1 4 — Children's Homes — 1 1 — Shirley Schools - 3 3 — 661 64 725 42 89 SECTION V. PREVENTION AND CONTROL OF TUBERCULOSIS. The Tuberculosis Clinic is situated at 13, Katharine Street. The premises are unsuitable, being cramped, noisy and necessitate the climbing of a flight of stairs by patients. 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, advisory and distributing centre. To it come patients sent by private doctors, hospitals, etc., also cases and contacts 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 Medical Officer of Health for Tuberculosis, for the statistical part of this section of the report. Notification of Tuberculosis. One hundred and ninety-four cases of Pulmonary Tuberculosis and 31 of Non-Pulmonary Tuberculosis were notified on Form A (primary notifications), of these 93 males and 101 females were Pulmonary cases, 18 males and 13 females Non-Pulmonary. In addition, 61 Pulmonary cases and 25 Non-Pulmonary came to our notice as new cases otherwise than by notification. The total number of new cases of tuberculosis coming to the knowledge of the Medical Officer of Health during 1936 by notification or otherwise, was 311, as compared with 333 in 1935, 325 in 1934, 346 in 1933, 369 in 1932, 412 in 1931, and 387 in 1930. 255 of these were cases of Pulmonary Tuberculosis. 119 in males and 136 in females. There were 31 fewer cases of Pulmonary Ttuberculosis in males, and 17 more in females than in 1935. This increase in female Tuberculosis, especially among young adult members. has been a noticeable feature of the statistics in London and its environs, in recent years. There were 18 cases of Non-Pulmonary Tuberculosis among children under 15 years as compared with 26 in 1935. The number of cases in adults was 38, the same as in 1935. 90 Of the cases notified in 1936, 18 males and 14 females died from the Pulmonary form of the disease during the year, equal to 16.8% of those notified, and 4 males from the Non-Pulmonary form. The incidence rate of Tuberculosis of all forms was 1.28 per 1,000 of the population; for Pulmonary Tuberculosis 1.05 and for Non-Pulmonary 0.23 per 1,000 population. This rate is low as compared with other large centres of population. The Notification rate was 0.93 per 1,000. In 1935, the corresponding figures were 1.38, 1.11 and 0.27 per 1,000. Public Health (Tuberculosis) Regulations, 1930. Summary of Notifications during the period from the 1st January, 1936, to the 31st December, 1936:— Table I. Age periods FORMAL NOTIFICATIONS. No. of Primary Notifications of new cases of tuberculosis. Total Notifications on Form A. 0 to l 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 ... 1 3 3 8 16 17 19 11 13 2 93 106 ,, Females ... ... 3 5 17 24 24 12 6 6 4 101 117 Non-pulmonary Males 1 3 1 1 2 3 5 1 ... ... 1 18 19 ,, ,, Females ... 1 1 ... 2 3 4 ... 1 1 13 15 Table II. Supplemental Return. New cases of Tuberculosis coming to the knowledge of the Medical Officer of Health during the period from the 1st Jannaiy, 1936, to the 31st December, 1936, otherwise than by formal notification. Age periods 0 to 1 1 to 5 5 to 10 10 to 15 15 to 20 20 to 26 25 to 35 35 to 45 45 to 55 55 to 65 65 and upwards Total Cases Pulmonary Males ... ... ... 1 1 6 4 8 3 3 ... 26 ,, Females 1 ... 1 1 ... 11 11 4 3 2 1 35 Non-Pulmonary Males 1 1 ... 2 1 2 3 2 ... ... ... 12 ,, „ Females ... 3 1 2 1 1 3 1 ... ... 1 13 91 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 9 5 Transferable Deaths from Registrar General 2 1 "Transfers" from other areas (other than transferable deaths) 47 14 Posthumous notifications ... 1 Other Sources—Form I. 3 4 Notification Register. Number of cases of Tuberculosis remaining on the Notification register on the 31st December, 1936:— Table III. PULMONARY non-pulmonary Total Cases Males Females Total Males Females Total 568 510 1,078 113 138 251 1,329 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 4 5 9 5 1 6 15 2. Recovery from the Disease 12 20 32 12 8 20 52 3. Death 81 56 137 12 8 20 157 92 Interval Between Notification and Death From Pulmonary Tuberculosis in Cases Dying in 1936. 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 128 deaths during 1936, 22 (17.2%) were either not notified at all or only notified within a month prior to death. Id 1935, this figure was 31 or 20.9%. Of these, 9 were not notified during life; 3 of whom were cases of fulminating or complicated cases of Tuberculosis; and 3 cases were certified by the Coroner or after a post-mortem examination. These figures show a small, but welcome, improvement on 1935. In 32.0% notification preceded death by less than six months. Table IV. Not Notified Under 1 week 1-2 weeks 2-4 weeks 1-2 months 2 3 months 3-6 months 6-12 months 9 4 6 3 9 6 13 8 One Year Two Years Three Years Four Years Five Years Six Years Seven Years Eight years and over 17 8 9 8 7 2 8 11 For Non-Pulmonary Tuberculosis the proportion of non-notified fatal cases to the total deaths from this form of the disease was 56.2%. In other words, out of a total of 16 deaths, 9 were not notified during life; only 2 of these 9 cases died at home, the cause of death being ascertained after a post-mortem examination. Of the total deaths from Tuberculosis of all forms, 18 or 12.5%. were not notified prior to death, compared with 17.5% in 1935 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 and an improvement upon 1935, but it is still too high. In a certain number of predisposed persons' periodic medical examination might lead to apprehension. The early detection of disease is, nevertheless, of paramount importance. 93 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, although to carry it out would entail a heavy financial outlay. Ages at Death from Pulmonary Tuberculosis. Table V. Year. 0—5 5—15 15—25 25—45 45—65 Over 65 Total 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 1934 1 1 28 69 40 5 144 1935 1 ... 37 67 33 10 148 1936 2 3 23 52 38 10 128 The most fatal period is between '25 and 45 years; under 15, Pluhnonary Tuberculosis is not a prominent cause of death. The age incidence and fatality of Pulmonary Tuberculosis are the great causes of the immense economic importance of this disease. In 1936 the death-rate from all forms of Tuberculosis was 0.60 Per 1,000 population. The rate for Pulmonary Tuberculosis was 0.53 and the rate for Non-Pulmonary Tuberculosis 0.07. Similar figures for 1935 were 0.71, 0.61 and 0.09. This death-rate is one of the lowest among the larger centres Population in England and Wales. 94 Deaths from Non-Pulmonary Tuberculosis. During 1936, 16 deaths were certified to be due to Non-Pulmonary Tuberculosis, compared with 23 in 1935; 13 in 1934; 22 in 1933; 22 in 1932; 19 in 1931; 21 in 1930; 29 in 1929; 39 in 1928; 38 in 1927; 39 in 1926; and 33 in 1925. The deaths were due to:— Males Females Total Tuberculous Meningitis 6 17 Tb. Peritonitis and Mesenteric Glands — 1 1 Tb. Kidneys and Bladder — 1 1 Tb. Intestines and Peritonitis — 1 1 Tb. Spine 1 — 1 Miliary and General Tb 1 — 1 Tb. Kidney 1 2 3 Tb. Supra-renals 1 — 1 10 6 16 95 Table VI. TUBERCULOSIS (Summary of Notifications and Deaths at various age periods). Age periods. 1936 Population at ape period. (estimated) Pulmonary, Non-Pulmonary. New Cases. All Cases. New Cases. All Cases, Number. Incidence Rate. Deaths. Death Kate (based on 1936 figures). Number. Incidence Rate. Deaths. Death Rate (based on 1936 est. fig*.) M F M F M F M F M F M F M F M F M F Under one year 2126 1950 ... 1 ... 0.51 ... 1 ... 0.51 2 ... 0.94 ... 1 ... 0.47 ... 1— 5 years 6920 7292 1 ... 0.14 ... ... 1 ... 1.37 4 4 0.58 0.55 2 2 0.29 0.27 6—10 „ 11331 10424 3 4 0.27 0.38 ... 1 ... 0.10 1 2 0.08 0.19 ... ... ... ... 10—15 „ 11992 11412 4 6 0.34 0.53 1 1 0.08 0.09 3 2 0.25 0.18 1 ... 0.08 ... 15—20 „ 9862 10641 9 17 0.91 1.60 5 5 0.51 0.47 3 3 0.30 0.28 1 ... 0.10 20-25 ,, 7630 9904 22 35 2.88 3.53 7 6 0.91 0.61 5 4 0.65 0 40 2 1 0.26 0.10 25—35 „ 15659 20618 21 35 1.34 1.70 15 15 0.96 0.73 8 7 0.51 034 1 1 0.06 0.05 35—45 ,, 17445 21255 27 16 1.55 0.75 13 9 0.75 0 42 3 1 0.17 0 05 1 ... 0.06 ... 45-55 „ 13926 15986 14 9 1.00 0 56 12 5 0.86 0.31 ... 1 ... 0.06 1 ... 0.07 ... 55—65 ,, 8300 10134 16 8 1.93 0.78 16 5 1.93 0.49 ... 1 ... 0.10 ... ... ... ... 65 and upwards 6339 10567 2 5 0.31 0.47 4 6 0.63 0.57 1 1 0.16 0.09 ... 2 ... 0 19 Totals 111556 130183 119 136 1.07 1.04 73 55 0.65 0.42 30 26 0 27 0.20 10 6 0.90 0.05 In the above table the death rate is based upon the total deaths in 1930, and not on deaths in New Cases only. 96 Pulmonary Tuberculosis. In 1936 there were fewer deaths from Pulmonary Tuberculosis up to the 55th year of life than in 1935. The age group 25-30 years had the greatest number of deaths, greater in fact than in am other age group. From the 30th year onwards there was a gradual fall in the number of deaths, but there were two fairly definite but smaller peaks, one in the 40—45 age group and the other in the 55—60 age group. The latter peaks were due to deaths in males, whereas the 25 to 30 year peak was mostly due to deaths among females. In females the highest peak was reached in the 25—30 age group. In males the highest peak was in the 55 to 60 age group. After the 35lh 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 higher incidence in young adult females is probably accounted for by the increasing numbers employed at these ages, and the lack of a proper adjustment to the more strenuous way of life in modem times. The number of new cases of Pulmonary Tuberculosis in 1936 in the age groups 15 to 35 years was slightly less than in 1935, hut whereas in 1935 the greater proportion occurred in the 25—35 years group, in 1936 the greater proportion was in the 15—25 group. The greater proportion of new cases of notified Pulmonary Tuberculosis were in the age groups comprising 20 to 3o 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. This year the peak of new cases was in the 15—25 age group. The figures indicate that Pulmonary Tuberculosis is a rare disease in the first ten years of life. Non-Pulmonary Tuberculosis. This year the greater proportion of new cases of Non-Pul monary Tuberculosis occurred in adults, 67.8% in adults and 32.1% in children up to 15 years. Of the cases occurring in children 55.5% were in boys; in adults the greater proportion of the cases were in men—52.6%. 31.2% of the deaths occurred under the age of 10 years compared with 34.7% in 1935. 97 Table VII. The diagnoses of the new cases entered in Notification Register daring' 1936 were as follows:— Male. Female. Spine 1 5 Hip 3 1 Hip and Left Knee 1 — Knee — 2 Knees and Elbow 1 — Left Ilium — 1 Abdomen ... .. — 5 Testicle and Epididymis 7 — Meninges 5 2 Kidney 5 1 Miliary ... 1 — Glands ... 6 9 30 26 Table VIII. 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 the total population of 241,729. The death rate for the whole Borough was 0.60. 98 Table VIII. Ward. Density of Population persons per acre. Pulmonary Non-Pul monary Total Incidence Rate per 1000 Death Rate per 1000 Upper Norwood 20 33 4 37 1.7 0.59 Norbury 29 17 4 21 1.3 0.63 West Thornton 42 18 5 23 1.2 0.65 Ben ham Manor 50 24 1 25 1.6 0.38 Thornton Heath 51 10 4 14 0.9 0.65 South Norwood 29 26 6 31 1.8 0.81 Woodside 37 20 3 23 1.5 0,78 East 10 15 2 17 1.0 0.73 Addiscombe 49 14 4 18 1.3 0.49 Whitehorse Manor 63 16 1 17 1.0 0.91 Broad Green 69 10 6 16 1.1 0.46 Central 33 4 1 5 0.4 0.25 Waddon 22 26 7 33 1.5 0.65 South 13 9 7 16 1.1 0,34 Addington 1 10 2 12 1.4 0 "4 No fixed abode ... 3 ... 3 ... ... 255 56 311 1.29 0.60 The Wards showing the highest incidence of new patients in 1936 were: South Norwood (1.8) and Upper Norwood (1.7). The highest death-rates were in Whitehorse Manor (0.91). South Norwood (0.81), and Woodbide (0.78). With the relatively small figures available, these rates are subject to wide annual sons. CLASSIFICATION OF NEW PATIENTS. Pulmonary Tuberculosis. During 1936, 158 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) 53 or 33.5% T.B. plus 1 (earry cases, sputum positive) 7 or 4.4/° T.B. plus 2 (intermediate cases, sputum posi- tive) 60 or 37.9% T.B. plus 3 (advanced cases, sputum positive 38 or 24.0 158 or 100.0% This is 36 fewer than in 1935. 99 It is well known that Tuberculosis officers do not see many of the new cases in the early stages of the disease. 1936 was the same in this respect as 1935; only 37.9% of the cases were first seen at a stage when a definite arrest of the disease could reasonably be hoped for. 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 without careful physical and X-ray examination. 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 62.0% of the new cases were more or less advanced in the disease. Non-Pulmonary Tuberculosis. There were 18 cases examined at the Clinic and found to have Non-Pulmonary Tuberculosis in the following forms:— Bones and Joints 5 Abdominal 2 Other Organs 3 Peripheral Glands 8 18 Tables XIX. and XX. summarise the condition of all patients whose records are at the Clinic at the end of 1936. These tables show that of patients who came under treatment for Pulmonary Tuberculosis before 1926, 399 adults and 107 children have been discharged as recovered. Of these all but 16 were early cases. Of the 1926 cases, 24 adults of the 1927 cases, 27 adults and 2 children of the 1928 cases 28 adults and 2 children ,and of the 1929 rases 8 adults and 3 children, and of the 1930 cases 10 adults, have recovered. Of patients who first attended in 1936, 3 have been lost sight or otherwise removed from the Clinic Register. Of the 1935 cases 30 were lost sight of. Of patients who attended prior to 1296, 262 adults and 15 Children are known to have died ; since 1926, 999 adults and 24 Children are known to have died. Of patients attending for the first time in 1936, 23 have died. 100 It will be seen that in the years 1926 to 1936 (inclusive) there have been 24 deaths in children, and 17 of these were found to have a positive sputum. It will also be seen that during this period there is no record of recovery or of arrest of the disease in a single child with a positive sputum. It is fortunate that such cases are very rare. In sufferers from Non-Pulmonary Tuberculosis who first attended prior to 1926, 46 adults and 565 children have been discharged as recovered, and of those first attending in 1926 and following years, 44 adults and 154 children. 15 adults and 10 children died in the pre-1926 class; 37 adults and 18 children died in the 1926 and following years group. 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 182 cases of suspected Tuberculosis were referred by private medical practitioners; 56 were diagnosed as suffering from Tuberculosis and were subsequently notified. In addition, 46 children were referred by the School Medical Service, and 26 cases from the Maternity and Child Welfare section of the Public Health Department. 78.3% 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 83.9% in 1935, 84.2% in 1934, and 79.3% in 1933. The number of reports sent in by Insurance medical practitioners on their domiciliary cases (Form ft.P. 36) was 435. 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 usually recommended for admission to Mayday Hospital under his care. After their confinement these patients are advised to enter a sanatorium. If interference with the course of pregnancy is not considered necessary or advisable and tin patient requires sanatorium treatment this is arranged for a period prior to admission to Hospital for confinement. 101 The Clinic Register of Cases. The number of cases of Tuberculosis under the supervision of the Clinic at the end of the year was 849 This is equivalent to 3.51 persons per 1,000 of the population. The Clinic Register is revised annually, so as to make it a correct record of the cases in the Borough who are under the supervision of the clinic. By this yearly revision the Register is kept a "live" one. During the year 114 Clinic cases died; of this number, 23 or 20.1% were seen for the first time in 1936. Examination of Sputum. This is done by the Council's Bacteriologist in the Laboratory at the Croydon General Hospital. The results of examinations made in 1936 are as follows:— For Clinic. For General Practitioners. For Mayday Hospital. Totals. Positive (i.e., tubercle bacilli present) 369 98 289 756 Negative (i.e., tubercle bacilli absent) 530 676 392 1,598 Total 899 774 681 2,354 For each 100 new cases and contacts examined at the Clinic 127 specimens of sputum were examined. 1936 shows an 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. X-ray Work. A greater number of doubtful and difficult cases were sent for radiological examinations than in previous years. Each year this penalised examination is being increasingly used. By this means the number of beds necessary for the observation of such cases has been reduced and cases of Bronchiectasis, Pulmonary tumour, etc., discovered which otherwise would have been classed as suffering from Pulmonary Tuberculosis. 102 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. 376 X-ray examinations were made during the year, an increase of 9 over 1935. This is equivalent to 53.6 for every 100 new cases and contacts seen, and compares with a rate of 45.2 in 1935, 40.4 in 1934, and 30.4 in 1933. 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 in the above figures. The new X-ray plant installed at Mayday Hospital during the year will be available for X-ray examination of Dispensary cases in the future. Extra Nourishment. Provision of special nourishment in the form of milk was granted to a number of selected cases for varying periods. Sleeping Shelters. The loan of such shelters is made to suitable cases. That is, to patients in an infectious condition or on account of overcrowding, but frequently one finds there is no available space for a shelter in the garden or yard attached to the patient's bouse. When convenient to be used they form a useful continuation of Sanatorium practice for a conscientious patient. 103 INSTITUTIONAL TREATMENT. Table IX. Pulmonary Cases Treated in Institutions, 1936. In at beginning of 1936 Admitted during 1936 Discharged during 1936 Died during 1936 In at end of 1936 Adults Adults Adults Adults Adults M F C M F C M F C M F C M F C Croy. Boro' San., Cheam 49 26 ... 76 65 ... 64 58 ... 9 5 ... 52 38 ... Mayday Hospital 15 9 3 54 47 11 34 34 11 24 10 1 11 12 2 Grosvenor 1 ... ... 1 1 ... 1 ... ... ... ... ... 1 1 ... Burrow Hill Colony ... ... 1 ... ... ... ... ... ... ... ... ... ... ... 1 Brompton 1 2 ... 1 5 ... 2 4 ... ... ... ... ... 3 ... Papworth 1 ... ... 1 ... ... 1 ... ... ... ... ... 1 ... ... East Anglian San. ... ... ... ... ... 3 ... ... ... ... ... ... ... ... 3 R.N.H.C., Ventnor 1 ... ... ... 1 ... ... ... ... 1 ... ... ... 1 ... Royal Chest Hospital Royal National San. ... ... ... 5 5 ... 5 2 ... ... ... ... ... 3 ... Bournemouth ... 1 ... ... ... ... ... 1 ... ... ... ... ... ... ... Midhurst 1 ... ... 1 ... ... 1 ... ... ... ... ... 1 ... ... Eversfield Chest Hospital 1 ... ... 1 ... ... 2 ... ... ... 1 ... ... ... ... Preton Hall Colony National Children's San". 2 ... ... ... ... ... ... ... ... 1 ... ... 1 ... ... Harpenden ... ... 1 ... ... 7 ... ... 3 ... ... ... ... ... 5 72 48 5 40 ,25 21 110 99 14 35 16 1 67 58 11 This Table shows that, compared with last year, nine fewer patients were admitted during the year and eleven more cases remained, in institutions at the end of the year. 104 Table X Non-Pulmonary Cases Treated in Institutions, 1936. In on 1st Jan., 1935 Admitted during 1936 Discharged during 1936 Died during 1936 In on 31st Dec,1933 Adults Adults Adults Adults | Adults M F C M F C M F C M F C M F C M ayday Hospital 3 1 1 2 7 1 3 7 2 1 ... ... 1 1 ... Royal Sea Bathing Hosp. 4 7 1 8 2 ... 5 4 1 ... ... ... 7 5 ... All Saints' Hosp. 1 1 ... 1 ... ... 2 1 ... ... ... ... ... ... ... St. Nicholas Hosp. ... ... 2 ... ... 1 ... ... 2 ... ... ... ... ... 1 Tait Convalescent Home ... ... ... ... 2 ... ... 1 ... ... ... ... ... 1 ... Treloar Cripples' Hosp ... ... 1 ... ... ... ... ... ... ... ... ... ... ... 1 Croydon General Hosp ... 1 ... ... 2 1 ... 3 1 ... ... ... ... ... ... Pyrford ... ... 12 ... ... 2 ... ... 4 ... ... ... ... ... 10 Heritage Craft School ... ... 1 ... ... ... ... ... ... ... ... ... ... ... 1 Royal National Orthopaedic Hospital ... ... ... ... ... 1 ... ... 1 ... ... ... ... ... ... St. Thomas's Hospital ... ... ... ... 1 ... ... 1 ... ... ... ... ... ... ... ... 8 10 18 12 13 6 11 16 11 1 ... ... 8 7 13 The Immediate Results of Institutional Treatment. Table XVIII. 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 30.1% were classified as early cases, the percentage of early cases receiving treatment in institution was in women, 15.0% ; in men, 12.8% ; 38.0% of the total cases were intermediate cases, the males showing an excess in this group—21.7% males to 16.2% females—and 31.8% were definitely advanced. Of the total Pulmonary cases treated in Institutions 72.6% were potentially infectious. 99 males, 74 females and 6 children, suffering from Pulmonaary Tuberculosis, were discharged from or died in Institutions in connection with the Croydon Scheme during 1936. 105 Types of Cases Treated. In Class T.B. Minus, 12 males, 10 females, and 3 children were discharged with the disease in a quiescent condition, i.e., 51% of the total cases in this class; 5 males, 14 females and 1 child were not in a quiescent condition, 40.8% ; 4 males died, 8.1%. In Class T.B. Plus, Group I., the corresponding figures were 2 males and 3 females quiescent, 100% ; there were no deaths in this group. In Class T.B., Plus, Group II., 8 males and 9 females quiescent, 25%; 26 males and 15 females not quiescent, 60.3%; and 5 males and 5 females died, 14.7%. In Class T.B. Plus. Group III., or advanced group, 1 male was discharged quiescent; 21 males, 9 females nnd 1 child not quiescent, 54.3%; and 15 males and 9 females and 1 child died, 43.8%. Taking all groups together, 26.8% of cases were discharged as quiescent; 51.3% as not quiescent; and 21.7% died. An increase is recorded in the percentage of infectious cases dying in institutions. From 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. Non-Pulmonary Tuberculosis.—28 patients were discharged (luring the vear, and 57.1% of these were quiescent. 1 adult died, 3.5%. Deaths from Pulmonary Tuberculosis in Cheam Sanatorium and Mayday Hospital during 1936 according to sex and stage of disease:— Classification. THEAM. MAYDAY. Adults. Adults. Child. M ales. Females. Males. Females. T.B. minus 3 - 1 - - T.B. plus 1 - - - - - T.B. plus 2 2 4 2 2 - T.B, plus 3 4 1 20 8 1 Total 9 5 23 10 1 106 The Tuberculosis Clinic and Home Visiting. The subjoined table gives a summary of the work done in connection with the Clinic. 454 new cases were examined during the year; this is equal to 315 lor each 100 deaths from the disease. 168, or 117 for each 100 deaths, were found to be definitely Tuberculous. The total number of attendances at the Clinic was 4,763. The Tuberculosis Officer paid 145 home visits, and the District Health Visitors 2,4W4 visits for Clinic purposes. In addition, the Health Visitors made primary visits for the purpose of the Notification Register. The Tuberculosis Officer paid 62 visits to Mayday Hospital, in a consultative capacity, and there examined 21 2 patients. Patients requiring home nursing or surgical dressings are attended to by nurses from the Croydon Nursing Service, by arrangement with that organisation, and 666 such visits were made during the year. Their assistance is a valuable adjunct in the care of domiciliary cases. Contact Examination. Contacts are those persons who are living with, or have been in prolonged and intimate association with a. case of Tuberculosis The object of the examination is two-fold. Firstly, to ascertain if the contact has become infected and. secondly, to discover if the origin of the disease in the patient may be found in his associates. Not very infrequently a member of a family who has been thought for years to have been suffering from Bronchitis, is in reality suffering from Tuberculosis, and through the lack of proper precautions has infected one or more individuals around him. Tt is advisable to get a complete examination of all contacts and not only those who have developed symptoms: but owing to other duties imposed on the medical staff it has not been possible to have as many sessions at the Clinic for the examination of contacts as formerly. Tf the individual continues to live in contact with the patient repeated examinations with radiography seem to be necessary if the supervision is to have any value at all. 107 The contacts of definite cases are urged to attend the Clime for examination (and subsequent supervision). This is an impoitant preventive measure. During the year 250 contacts were examined, equal to 174 for each 100 deaths, compared with 343 in 1935, or 200 per 100 deaths. Of these, 5 were considered to be Tuberculous. This is equal to a Tuberculosis rate per 1,000 contacts of 20.0, compared with 1.28 per 1,000 of the general population. In 155 adult contacts examined the Tuberculosis rate per 1,000 contacts was 25.0. Included in the 5 contacts found to be Tuberculous are 2 who had been under observation from previous years. 527 appointments for examination were offered to new contacts during 1936, but only 250 new contacts attended and were examined. The importance of contact examination as a true preventive measure is not appreciated by the public. In this matter the family practitioner could be of much assistance. SUMMARY OF CLINIC STATISTICS FOR 1936. No. of persons on Clinic Register, January 1st, 1936 890 „ Notified Cases examined for the first time 75 „ Cases sent for an opinion 300 „ l'irst attendances, including 50 transfers in 754 „ Consultations of T.O. with private practitioners 35 „ \isits paid by T.O. to homes of patients 145 „ \ isits paid by T.O. Cheam Sanatorium 11 ,, Msits paid by T.O. to Mayday Hospital 62 „ Patients examined by T.O. at Mayday Hospital 212 „ Vsits paid to homes of patients by Health Visitors and Nurses 3,432 „ Attendances of patients at the Clinic— Men 1,591 Women 2,154 Children 1,018 Total 4,763 No. of patients under Domiciliary Treatment at end of year— Pulmonary 181 Non-Pulmonary 9 Total 190 No of Reports received from Panel Practitioners (G.P.36) 435 " Report forms sent to Panel Practitioners (G.P.36) 675 „Report received from Panel Practitioners on Forms G.P.17 and 35 4 " X-rays taken 378 " Reports made to Ministry of Pensions bv the T.O. on general progress of Tuberculosis Discharged Ex-Service men 3 „ Cases referred for "Light" Treatment 5 " Cases referred to Orthopaedic Clinic 11 " Cases receiving extra nourishment at end of year 41 108 Housing Statistics of Patients. Table XI. 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 19 6 3 28 15 years and over 479 97 325 901 498 103 328 929 Number of Non-Pulmonary Cases— Under 15 years 27 27 12 66 15 years and over 60 13 41 114 87 40 53 180 Totals 585 143 381 1,109 The above table gives a summary of the housing conditions found in notified cases. It is seen that 53.6% of the Pulmonary cases and 48.3% of the Non-Pulmonary cases were occupying a separate bedroom. In 35.3% of the Pulmonary and 29.4% of the Non-Pulmonary the sleeping arrangements were not satisfactory inasmuch as the patient did not have a separate bed. Council Houses for Tuberculous Families. A scheme was initiated in 1935 for the above purpose. It is very important part of any Care scheme as a means of maintaining health and preventing the occurrence of Tuberculosis. The tenancy of Council houses to Tuberculous families is subjeet to co-operation on the [tart of the latter, but the system of supervision applied does not involve any undesirable restiictions on those who are well intentioned. Up to the end of the year 11 families had been rehoused under the scheme, and all had complied with the special requirements laid down in the scheme. 109 PULMONARY TUBERCULOSIS Table XII. Shewing the Condition at the end of 1936 of cases discharged from Sanatoria during the years indicated. 1932 1933. 1934. 1935. 1936. 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 73= 60.8% 4 48=56.5% 4 49=49.4% 4 23= 25.8% ... 7=10.1% 14 200= 43.3% 51.0% 44.4% 42.4% 22.5% 6.3 % 34.5% Working or Fit for Work 22 31=25.8% 25 20= 23.5% 20 31 =31.3'/6 25 40= 44.9% 32 33 =47.8% 124 155 = 33.5% 36.0 % 38.4% 40.8 % 64.1% 59. 1% 45.1% Not able to Work 3 16= 13.3% 3 17=20.0% 2 19=19.2% 2 26= 29.2% 9 29=42.0% 19 107= 23.1% 12.9% 17.1 % 16.8% 23.3% 34.5% 20.3% Left District 13 27 16 22 8 20 7 21 8 44 98 40 147 48 107 34 119 38 110 41 77 201 560 110 It is instructive to compare the results obtained in cases discharged from Sanatoria during the five year 1932—1930, with those for 1927—1931, and this is done in the Table below. Result. Five years, 19271931. Five years, 19311936. T.B. T.B. T.B. T.B. 1927 1932 - + - + 1931 1936 Dead 21 292 = 48% 14 200 = 43.3% 313 214 42.0% 34.5% Working or fit for work 93 140 = 23% 124 155 = 33.5% 233 279 31.2% 45.1% Not able to work 23 176 = 28.9% 19 107 = 23.1% 199 120 26.7% 20.3% Left District 36 86 44 93 122 137 Totals 173 694 201 555 867 756 This Table shows clearly the improved results obtained during the last five years, 13.9% more patients are fit for work and the number who died during the five years decreased by 7.5%. The decreased incidence is shown in the smaller total number of cases, and the greater relative proportion of T.B.-—cases appears to indicate a tendency for cases to come earlier for treatment. TUBERCULOSIS CARE COMMITTEE REPORT. The following figures give an outline of the work of the Tuberculosis Care Committee during 1936. Grants were made in 35 cases to buy clothes for patients about to enter Sanatorium or to assist towards an outfit on discharge, bedding was purchased to enable patients to have separate sleeping accommodation. Financial help was given in 59 cases, for the most part pending a grant from the Public Assistance Authorities or the receipt of National Health Insurance benefit, and to provide extra nourishment. In all £175 was spent for the benefit of patients and their families. The problems of the tubercular patient are many. Where the bread winner is concerned there is often a drastic reduction of family income, or if it is the mother who has to undergo treatment and there are young children to be provided for, there will need to be entire re-adjustment of the household, even in some cases to the breaking up of the family. It is not therefore possible to express in terms of figures alone the extent and variety of the work under taken. 111 As far as possible patients are interviewed before their admission to Hospital or Sanatorium and in this way timely advice can be given on such questions as rental and insurance. The shock of the diagnosis may to a certain extent be alleviated by the knowledge that thought is being given to the welfare of those left at home and that the patient does not stand alone in his troubles. Much can be done in this way to reassure the patient himself and to save the family from serious financial difficulty. One of the main problems of the tubercular patient is that of employment on his discharge from Sanatorium. Owing to the length of the treatment it is not often that jobs can be kept open, and the nature of his illness makes it especially hard for him to find work even when fit for this. The discouragement of prolonged unemployment will in time affect his condition as much as the resulting straightened circumstances. Suitable occupation for the patient who is capable of light work only is extremely hard to find at a time when fit men cannot get work. Such cases present a very real problem to the After Care Committee and it is perhaps here that advice and assistance are most valuable. The Committee is indebted to the Officers' Association, the British Bed Cross Society, the Royal Naval Benevolent Trust, the Mayor's Peace Memorial Fund and the British Legion for help given to tubercular ex-service men and their families. Whenever possible patients are referred to suitable agencies when assistance is required outside the scope of the After Care Committee funds. CHEAM SANATORIUM. The Sanatorium is situated in North Cheam and has accommodation for 93 adult patients of both sexes. The beds are allocated as follows: Men, 53; Women, 40. Table XIII. Authority. In-patients on Jan. 1st, 1936. Admitted during year 1936. Discharged during year year 1936, including deaths. In on Jan. 1st, 1937. Died during year 1936. M F m f m f m f m f Croydon C.B. 49 36 82 67 79 65 52 38 9 5 112 No. of Artificial Pneumothorax cases begun 23 No. of Refills given 1,070 No. of X-Ray Screenings 1,350 No. of Films taken 505 No. of Sputum tests 918 No. of Gas Replacements 46 Immediate Results of Treatment. Table XIV. Group. Total number of cases discharged 1936. Quiescent. Improved. No Material Improve ment. Died in institution. Average dura_ 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 18 8 4 5 10 ... 1 ... ... 221 ... 3 Class T.B. Plus— Group I 1 2 ... 1 1 ... ... ... ... ... 164 ... 1 Group II 21 21 5 3 9 12 2 1 1 2 181 4 3 Group III 30 14 ... ... 6 4 10 5 8 3 180 6 2 Observation Non T.B. 4 2 ... ... ... ... ... ... ... ... ... ... 69 57 13 8 21 26 12 7 9 5 10 9 At the beginning of 1936 there were 85 patients in Cheam. During the year 149 were admitted and 130 discharged, whilst 14 died, thus leaving 90 patients in at the beginning of 1937. There were 12 observation cases sent in: 6 males and 6 females. Of the 6 males 4 were not tubercular, and of the 6 females 2 were not tubercular; therefore, there were 6 observation cases in nontuberculars which are shown above. The 6 that were tubercular are in with the tubercular cases and are not shown as observation. Artificial Pneumothorax cases discharged but still under treatment, 10 males, 8 females (see above), making total dischargesmales 79, females 65. These 18 Artificial Pneumothorax cases only refer to cases discharged in 1936 ; those discharged in 1935 and still having refills have not been included. 113 DENTAL REPORT. All the patients admitted to the Sanatorium were dentally inspected. Those in the acute wards were treated only when in pain, but patients in the ordinary wards were referred for all necessary treatment. Only those in the acute stages of tuberculosis were treated in the wards; the other patients attended the dental surgery in the Sanatorium. Patients were treated only if, in the opinion of the Resident Medical Superintendent, they were sufficiently fit. The question of treatment of tuberculous patients is one of great magnitude. Many patients exhibit gross sepsis in and around their teeth, and the treatment for such cases is the extraction of the offending teeth, and the insertion of dentures, if the prognosis of the case is good. It is useless, of course, to do extensive treatment for the advanced cases; all that can be done in such cases is to remove painful teeth. There are, however, cases in which sepsis is localised to several teeth only, and if they are removed the desirability or otherwise of fitting prosthetic appliances arises. Provided there is a reasonable number of occlusion points, and that most of the anterior teeth are present, there is no object in fitting dentures. Many people are able to masticate their food quite well with only a few occluding molar teeth present, and do not suffer any digestive trouble, whilst others may show evidence of digestive disturbance, and the problem of whether or not to fit dentures depends upon the medical report of the case. There is no need to emphasize that The wholesale extraction of teeth for the tuberculous patient is to be condemned, and that dentures should be inserted only when the aesthetic or masticatory effects are jeopardised. People may tolerate sepsis in their mouth for years, but if there is a profound disturbance in the general health, such as Tuberculosis, there is a danger of an overload of infection developing, which may cause pyrexia and general debility. The dental treatment for tuberculous patients differs from that Prescribed for ordinary patients. For instance, it is inadvisable to indulge in protracted treatments at one sitting, inasmuch as these People are definitely ill and their powers of endurance considerably reduced; moreover, the fatigue caused by long treatments may aggravate the patient's condition. The use of general anaesthetics in many cases is contraindeated, not because there is a greater risk that the patient might 114 die in the chair, but rather because the effect of the anaesthetic may cause exacerbation of the disease. As all extractions can be satisfactorily dealt with under regional and local anaesthesia without causing any marked condition of shock there should be no difficulty in this part of the treatment. The hyper-sensitive type may be controlled by the use of suitable drugs to reduce shock. It is important to limit the number of extractions to approximately three teeth at a single sitting. Furthermore, it must not be overlooked that the absorption of toxins following the extraction of a number of teeth may cause serious complications, and for that reason alone extractions should be reduced to a minimum. It should be the aim of any scheme of treatment for tuberculous patients to conserve the teeth as much as possible. Some patients have a disinclination for fillings, not because they have any real objection to conservative treatment but rather because they are afraid of any pain that this type of treatment might cause. This difficulty may be substantially overcome by the use of local anaesthesia in practically all types of conservative treatment. The use of X-rays is imperative to the Tuberculosis Officer, and it is likewise a very necessary aid to diagnosis for the dental officer, for many hidden roots may exist in the jaws of patients and be a source of insidious infection. X-ray interpretation of the teeth is invaluable in order that as many teeth as possible may be saved. Ordinary clinical examination can reveal the presence or absence of local dental disease, but it cannot, except in rare cases, disclose focal infection which is often associated with dead teeth. Without doubt the best time to treat the tuberculous patient is when he is an inmate of a sanatorium, as he is able to rest before and after treatment, and furthermore, he can have adequate postoperative nursing. The majority, when they leave the sanatoria, find it difficult to obtain employment, and even if they are in work it is often impossible for them to secure sufficient time off for treatment, with the consequence that in many cases only sporadic treatment is obtained. Moreover, for a time at least their wage-earning capacity is usually small, and the expense of the extra nourishment which is required to build up the resistance of the patient leaves very little margin for the cost of treatment. Most of the insur patients are even unable to pay their contribution for dental treat ment. The work accomplished at C'heam during the year has well maintained the average of previous years. It is very gratifying observe that conservative measures have formed a great part of the treatment. 116 Review of Work Done. Males. Females. Total. Number examined 41 52 93 Referred for treatment 41 45 86 Treated 41 29 70 Attendances 268 183 451 Extractions 124 53 177 Fillings 61 60 121 Dressings 17 10 27 Sealings and gum treatments 72 49 121 Denture dressings 65 30 85 Dentures fitted 17 12 29 Sessions treatment: 43. Cases X-rayed : 3. Special surgical treatments included the removal of two sequestra under local anaesthesia and the curettage of one infected socket. The majority of the extractions took place under regional anaesthetics. 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 45.1% are working or fit for work. The remainder are dead or too ill to work. In those cases with a positive sputum, i.e., those in whom tubercle bacilli have been found in the sputum, only 33.5%, or one third, are working or fit for work. 560, or 73.6% of the total cases discharged, were T.B. + cases; 142, or 18.7% of the total cases discharged, have removed from the Borough, and as we have no information about their condition at the end of 1936, they have been ignored in working out the above percentages. Dental Treatment of Tubercular Patients Referred from the Dispensary to Lodge Road. In the case of patients referred for treatment from the dispensary by the Tuberculosis Officer restriction of treatment at each visit is particularly necessary, as many have lost a certain amount of working time through illness, and further, enforced rest that might result from the effects of dental treatment may in some cases cause difficulties in relation to employment on account of shock. 116 The possibility of oral lesions in patients suffering from Tuberculosis producing secondary infections may be eliminated by proper care of the teeth. The most serious complications of Pulmonary Tuberculosis, such as pyrexia and cavity formation, may be ascribed to the invasion of the lesions by ordinary pyogenic bacteria, viz., pneumococci, streptococci and staphlococci, and that all these microorganisms thrive in a neglected mouth, and their aspiration would be certain. The value of an efficient masticatory apparatus is self evident in a class of patient whose recovery is so influenced by nutritional condition, and finally, oral infection, by imposing an added drain on the resources of a patient who needs all his strength to combat the tubercular infection may serve as the proverbial " last straw." It is desirable that all tuberculous patients should have some systematic dental treatment and that such treatment should be in conjunction with the local Tuberculosis Dispensary. Beyond dispute, it is eminently desirable that patients should be treated in a special clinic which can be thoroughly fumigated afterwards. It is impossible for the private practitioner to guard against infection of his surgery when the patient probably does not tell him that he is suffering from Tuberculosis, and even if the dental surgeon does know, it is difficult for him to arrange for adequate precautionary measures against possible infection of other patients. Patients referred from the Tuberculosis Dispensary are treated at Liodge Road treatment centre on Wednesday afternoons from 3.30 to 5 p.m., and after the treatments have been carried out the clinics are thoroughly disinfected. The majority of patients treated are referred by the Tuberculosis Officer, but some are patients discharged from Cheam before treatment is completed. Summary of Work Done. Males. Females. Total Referred from Dispensary 6 21 27 Treatment cases continued from Cheam 5 4 9 Attendances 54 131 185 Extractions 40 119 159 Fillings 1 14 15 Dressings 2 2 Scalings and gum treatments 7 7 14 Denture dressings 31 66 96 Dentures fitted 16 31 47 " Gas " cases (on the recommendation of the Tuberculosis Officer) 8 10 18 The amount received for attendance fees was £1 14s. 117 Annual Returns made to the Ministry of Health for the Year, 1936. Table XV. (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... 70 69 5 6 5 10 2 1 75 79 7 7 168 (b)Diagnosis not completed — — — — — — — — 8 5 3 5 21 (c)Non-tuberculous - - - - - - - - 79 96 46 44 265 B.-Contacts examined during year:— (a)Definitely tuberculous 1 3 — 1 — - — — 1 3 — 1 5 (b)Diagnosis not completed - - - - - - - - 1 4 — — 5 (c)Non-tuberculous - - - - - - - - 68 78 39 55 240 C.—Cases written off the Dispensary Register as:- (a)Recovered 11 17 1 2 5 3 5 6 16 20 6 8 50 (b)Non-tuberculous (including any such cases previously diagnosed and entered on the Dispensary Register as tuberculous) - - - - - - - - 153 184 92 102 531 D.-Number of Cases on Dispensary Register on December 31st:- (a)Definitely tuberculous 365 302 17 21 28 57 35 24 393 359 52 45 849 (b) Diagnosis not completed - — — — — — — — 9 9 3 5 26 1. Number of cases on Dispensary 2. Number of cases transferred from Register on January 1 st 890 other areas and cases returned after discharge under Head 3 in previous years 66 3.Number of cases transferred to 4.Cases written off during the year as other areas, cases not desiring Dead (all causes) 114 farther assistance under the scheme, and cases "lost sight of" 90 5.Number of attendances at the 6.Number of Insured Persons under Dispensary (including Contacts) 4,763 Domiciliary Treatment on the 31st December 190 7.Number of consultations with 8.Number of visits by Tuberculosis medical practitioners:— Officers to homes (including (a)Personal 35 personal consultations) 145 (b)Other 504 9.Number of visits by Nurses or 10. Number of:— Health Visitors to homes for (a) Specimens of sputum, etc., Dispensary purposes 3,150 examined 899 (b)X-ray examinations made in connection with Dispensary work 378 11.Number of "Recovered" cases 2.Number of "T.B.plus" cases on restored to Dispensary Register, Dispensary Register on 31st and included in A(a) and A(b) December 456 above 1 118 (B)Number of Dispensaries for the treatment of Tuberculosis (excluding centres used only for special forms of treatment) Provided by the Council One Provided by Voluntary Bodies Nil Table XVI. (C)Number of beds available for the treatment of Tuberculosis on the 31st December n Institutions belonging to the Council Name of Institution. For Pulmonary Cases For Non-Pulmonary Cases i Total. Adults Children under 15 Adults Children under 15 Croydon Borough Sanatorium, North Cheam, Surrey 94 ... ... ... 94 Mayday Hospital, Mayday Road, Thornton Heath (In C.B. of Croydon) Beds reserved for Tuberculosi s cases are used for Pulmonary or Non-Pulmonary patients, as required. 64 (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. Admitted during the year Discharged during the year. Died in the Institutions. In Institutions on Dec. 31st. (1) (2) (3) (4) (5) Number of doubtfully tuberculous cases admitted for observation : Adult males 1 12 12 1 - Adult females 1 10 10 - 1 Children 2 7 8 - 1 Total 4 29 30 1 2 Number of patients suffering from pulmonary tuberculosis: Adult males 71 131 101 34 67 Adult females 48 120 95 16 57 Children 3 18 10 1 10 Total 122 269 206 51 134 Number of patients suffering from non-pulmonary tuberculosis : Adult males 8 12 11 1 8 Adult females 9 13 15 — 7 Children 18 6 11 — 13 Total 35 31 37 1 28 Grand Total 161 329 273 53 164 119 Table XVII. (f) 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 2 5 2 1 — 1 - - - - - 1 3 5 4 Non-tuberculous 6 — 1 3 4 3 1 - — — 1 - 10 5 4 Doubtful - - - - - - - - - - - - - - - Totals 8 5 3 4 4 4 1 — — — 1 1 13 10 8 One man died in institution while under observation, the cause of death being certified as: Carcinoma of Lung. P.M. Table XVIII. (0) Return showing the immediate results of treatment of definitely Tuberculous patients discharged during the year from Institutions approved for the treatment of Tuberculosis. SECTION I.—Pulmonary Tuberculosis. Classification on admission to the Institution. Condition at time of discharge. Duration of Residential Treatment in the Institution. Grand Totals Under 3m'ths but exceeding 28 days 3-6 months. 6-12 months. More than 12 months. Totals. M. F. Ch. M. F. Ch. M. F. Ch. M. F. Ch. M. F. Ch Class T.B. minus. Quiescent — — — 4 4 1 5 3 — 3 3 2 12 10 3 25 Not quiescent Died in Institution 1 4 1 1 5 — 3 2 — — 3 — 5 14 1 20 1 - - - - - 2 - - - - - 4 - - 4 Class T.B. plus Group I. Quiescent — — — — 1 — 2 2 — — — - 2 3 — 5 Not quiescent Died in Institution — - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Class T.B. plus Group II. Quiescent - 2 — 2 2 — 4 4 — 2 1 — 8 9 - 17 Not quiescent Died in Institution 6 2 — 7 5 — 9 6 — 4 2 — 26 15 — 41 1 — — — 2 — — 1 — 4 2 — 5 5 — 10 Class T.B. plus Group in. Quiescent — — — — — — 1 — — — — — 1 - - 1 Not quiescent Died in Institution 9 2 1 7 2 — 4 3 — 1 2 — 21 9 1 31 8 2 1 3 4 — 1 2 — 3 1 — 15 9 1 25 Totals (pulmonary) 26 12 3 25 25 1 31 23 — 17 14 2 99 74 179 120 SECTION II.—Non-Pulmonary Tuberculosis. Classification on admission to the Institution. Condition at time of discharge. Duration of Residential Treatment in the Institution. Grand Total Under 3m'ths but exceeding 28 days 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 — - — — — 1 2 — — 1 1 4 3 1 5 9 Not quiescent Died in Institution 1 1 — — 1 1 — 1 — 1 1 — 2 4 1 7 - - - - - - - - - 1 - - 1 - - 1 Abdominal. Quiescent - - - - 1 - - - 1 - - - - 1 1 2 Not quiescent Died in Institution - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Other Organs. Quiescent — - — 1 1 — — — — — — - 1 1 - 2 Not quiescent Died in Institution 1 1 - - 1 - - - - 1 — - 2 2 - 4 - - - - - - - - - - - - - - - - Peripheral glands. Quiescent - - - - - - - - 1 - - 1 1 - 2 3 Not quiescent Died in Institution - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - — Totals (non-pulmonary) 3 2 - 1 4 2 2 1 2 4 2 5 10 9 9 23 TABLE XIX. PULMONAKY TUBERCULOSIS. Supplementary Annual Return showing in summary form (a) the condition at the end of 1936 of all patients remaining on the Dispensary Register; and (b) the reasons for the removal of all cases written off the Register. The Table is arranged according to the years in which patients were first entered on the Dispensary Register as definite cases of pulmonary tuberculosis, and their classification at that time. 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. 1934. 1935. 1936. 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.E. plus Class T.B. minus Class T.B. plus Class T.B. minus Class T.B. plus Class T.B. minus ( lass T.B. plus | Class 1 T.B. minus Class T.B. plus I Class 1 T.B. minus Class T.B. plus ClassT.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 (ClassT.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 (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 (Class T.B. plus) Group 1 Group 2 Group 3 Total (Class T.B.pIus) Group 1 Group 2 Group 3 Total (ClassT.B. plus) (a)Remninlng on Dispensary Register on December 31st. Disease Arrested Adults M 3 5 4 - 9 1 - 2 - 2 1 3 - - 3 1 1 1 - 2 5 2 2 - 4 8 4 4 - 8 5 - 4 1 5 8 1 5 - 6 5 2 4 - 6 4 - - - - - - - - - - - - - - F 3 2 5 — 7 — — 2 — 2 1 — - — — 2 — — — — 4 — — — — 6 — 4 — 4 6 — 3 - 3 10 — 5 - 5 7 1 2 — 3 2 — 1 - 1 — — — — — — — — — — Children 1 - - - - - - - - - - - - - - - - - - - - - - - - 5 - - - - 2 - - - - 1 - - - - 1 - - - - - - - - - - - - - - - - - - - Disease not Arrested Adults M - 8 5 1 14 -- 1 - - 1 - 2 1 - 3 - 1 5 - 6 1 1 6 1 8 - 2 5 - 7 - 2 12 1 15 - 2 16 1 19 2 6 13 1 20 8 4 21 2 27 15 5 32 7 44 20 3 25 10 38 F 2 5 7 - 12 — — 1 — 1 - 1 3 1 5 — — 1 — 1 — — 6 — 6 — — 7 1 8 — — 10 2 12 6 1 5 1 7 8 1 12 2 15 13 1 13 1 15 20 4 22 6 32 23 3 32 6 41 Children - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1 1 2 2 — — — — 3 1 — 1 3 — — — — 8 1 — 1 2 Condition not ascertained during the year — 1 1 - 2 1 — 1 — 1 — 1 1 — 2 — 1 — — 1 — 1 1 — 2 3 1 2 — 3 4 1 - 1 2 4 1 2 — 3 3 — 1 — 1 3 2 4 — 6 3 — 1 — 1 — — — Total on Dispensary Register at 31st December 9 21 22 1 44 2 1 6 — 7 2 7 5 1 13 3 3 7 — 10 12 4 15 1 20 22 7 22 1 30 17 3 29 5 37 29 5 34 3 42 28 10 32 3 45 33 8 39 3 50 41 9 55 13 77 51 7 57 17 81 (b) Not now on Dispensary- Registerand reasons for removal therefrom Discharg as Recovered Adults ed M 181 24 6 1 31 7 8 1 - 9 9 7 1 - 8 3 1 2 - 3 2 1 - - 1 5 - - - - - - - 1 - - - - - - - - - - - - - - - - - - - - - - - - - F 164 14 6 3 23 7 1 — — 1 7 2 1 — 3 19 2 1 — 3 5 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Children 106 1 - - - - - - - - 2 - - - - 2 - - - - 3 - - - - - - - - - 1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Lost sight of, or otherwise removed from Dispensary Register 217 44 50 9 103 31 17 29 7 53 19 20 18 1 39 34 15 16 - 31 36 8 30 — 38 31 15 33 7 55 36 5 43 6 54 28 5 31 3 39 25 5 32 1 38 23 3 21 4 28 13 — 16 1 17 1 — 1 1 2 Dead Adults M 20 32 52 52 136 4 26 28 12 66 2 11 34 8 53 1 7 34 8 49 4 5 42 16 63 7 - 41 11 52 6 3 29 31 63 3 4 36 21 61 5 - 20 17 37 3 15 19 34 4 1 7 21 29 1 - - 12 12 F 17 6 25 58 89 10 15 21 14 50 2 3 22 15 40 4 2 33 9 44 3 3 32 9 44 5 2 26 13 41 4 1 28 23 52 9 3 29 10 42 2 2 17 12 31 3 1 8 14 23 — — 10 13 23 — — 2 6 8 Children 3 1 5 6 12 — — 1 — 1 — — 2 2 4 1 — — — — 1 — 1 — 1 1 — — 2 2 — — 1 1 1 1 — — 1 1 — — - — — — 1 3 4 2 — — 1 1 — — — 2 2 Total written off Dispensary Register 708 122 144 129 395 59 67 80 33 180 41 43 78 26 147 64 27 86 17 130 54 17 105 25 147 54 17 100 33 150 54 9 102 60 171 41 13 96 34 143 33 7 69 30 106 29 4 45 40 89 19 1 33 36 70 2 — 3 21 24 Grand Totals 717 143 166 130 439 61 68 86 33 187 43 50 83 27 160 67 30 93 17 140 66 21 120 26 167 76 24 122 34 180 71 12 131 65 208 70 18 130 37 185 61 17 101 33 151 62 12 84 43 139 60 10 88 49 147 53 7 60 38 105 TABLE XX. NON-PULMONARY TUBERCULOSIS. Supplementary Annual Return showing in summary form (a) the condition at the end of 193G of all patients remaining on the Dispensary Register; and (b) the reasons for the removal of all cases written off the Register. 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. 1934. 1935. 1936. Bones and Joints Abdominal Other Organs Peripheral Glands Total Bones and loints 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 | 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 Total (a) Remaining on Dispensary Register on December 31st. Disease Arrested Adults M - - 1 - 1 1 - - - 1 - - - - - - - - - - - - 1 - 1 - - - - - 2 - - - 2 2 - - - 2 1 - - - 1 2 1 1 1 5 - - - - - - - - 1 1 F 1 — 1 1 3 - - - - - - - - - 1 - - - - - - - 3 1 4 — I — 2 3 2 — — — 2 3 1 1 — 5 — 1 — - 1 2 2 1 3 8 1 — 3 1 5 — 1 - 2 3 Children 3 — — — 3 — — — 1 1 1 — — — 1 3 — — — 3 1 2 — — 3 1 — — 2 3 3 2 - 2 7 2 1 — 3 6 1 — 1 1 3 1 1 — 1 3 — 2 — 1 3 — - — 1 1 Disease not Arrested Adults M - - - - - - - - - - - - - - - - - - - - 1 - - - 1 - 1 - - 1 - - - - - - - 2 - 2 - - - - - - - - - - 2 - 2 - 4 2 - 2 - 4 F 1 - 3 - 4 - - - - - - - - - - - - - - - - - - - - 1 - - - 1 1 - - - 1 — — — — — 2 — — — 2 2 - 1 — 3 2 1 1 — 4 3 1 1 2 7 Children 2 — — — 2 — — — — — 1 — — 1 2 — — — 2 2 — — — 2 2 — — — 2 1 — — - 1 2 — — — 2 2 — — — 2 1 — - - 1 3 — — 1 4 — - - 2 2 Condition not ascertained during the year - - - - - - - - - - - - - - - - - - 1 1 - - - - - - - - - - - - - - - - - - 1 1 - 1 - - 1 - - - - - - - - - - - - - - - Total on Dispensary Register at 31st December 7 — 5 1 13 1 — - 1 2 3 - — - 3 5 — — 1 6 4 2 4 1 11 4 2 — 4 10 9 2 2 13 9 2 3 4 18 6 2 1 1 10 8 4 3 5 20 8 3 6 3 20 5 2 3 8 18 Transferred to Pulmonary 1 - - - 1 - - - - - - - - - - - - - - - - 1 - - 1 - 1 - - 1 - 1 - - 1 - - - - - 1 - - - 1 1 - - - 1 - - - - - - - - - - (ft) Not now on Dispensary Register and reasons for removal therefrom. Discharged as Recovered Adult M 9 - 4 2 15 3 - - - 3 2 1 1 1 5 1 - - - 1 - 1 1 - 2 1 - 1 - 2 1 1 - - 2 1 1 - 1 3 - - - - - - - - - - - - - - - - - - - - F 14 5 4 8 31 2 — — 5 7 2 1 - 3 6 — — — 3 3 1 — 3 1 5 — 1 — 1 2 1 - - 1 2 - - 1 - 1 - - - - - - - - - - - - - - - - - - - - Children 41 4 5 515 565 7 3 2 54 66 4 1 - 33 38 3 — — 20 23 3 — 1 5 9 2 1 — 10 13 1 — 4 5 — — — — — — — — — — - - - — — — — — — — - - - - Lost sight of, or otherwise removed from Dispensary Register 19 11 10 133 173 4 6 4 26 40 6 3 3 20 32 6 1 - 6 13 4 — 3 3 10 9 — 2 5 16 2 2 2 2 8 4 1 3 8 3 1 1 5 10 4 - - 5 9 1 — 2 2 5 - - - - - Dead Adults M 3 1 3 1 8 2 - 1 1 4 2 - 1 - 3 3 1 1 - 5 1 - - - 1 - - - - - - - 1 - 1 4 - 1 - 5 2 - - - 2 - - - - - - - - — — — - - - - F 3 - 3 1 7 1 — — 1 2 - 1 — — 1 1 2 — 3 1 — — 1 1 — 1 — 2 — 2 - — 2 — — — — — — 3 — — 3 1 - — 1 2 — - — — — — - - - - Children 6 1 1 2 10 - 2 1 3 6 - — 1 — 1 2 2 1 2 7 - - - - - - 1 - - 1 - - - - - - - - - - - - 1 1 2 1 — — — 1 — — — — — — - - - - Total written off Dispensary Register 95 22 30 662 809 19 11 8 90 128 16 7 6 57 86 16 4 4 31 55 9 2 8 9 28 13 3 4 16 36 5 5 3 7 20 9 2 2 4 17 5 4 2 6 17 6 - - 6 12 1 — 2 2 5 — - - - - Grand Totals of (a) and(b) (excluding those transferred to Pulmonary). 102 22 35 663 822 20 11 8 91 130 19 7 6 57 89 21 4 4 32 61 13 4 12 10 39 17 5 4 20 46 14 7 3 9 33 18 4 5 8 35 11 6 3 7 27 14 4 3 11 32 9 3 8 5 25 5 2 3 8 18 121 SECTION VI. CANCER. The facilities available in the Croydon area for the diagnosis and treatment of cancer are provided at Mayday Hospital and the Croydon General Hospital, and comprise at the latter hospital radium treatment, deep X-Ray therapy, and other recognised methods. At the Mayday Hospital deep X-Ray therapy is now available, but cases recommended for radium treatment are referred to the Radium Institute, the Council being responsible for the cost of such treatment. There is co-operation between the Croydon General Hospital and the Mayday Hospital regarding cases of cancer for whom specialised treatment has been prescribed. Any widespread distribution of pamphlets among the general population has not been done, but the Health Visitors have given information and advice upon how to obtain treatment. Lectures are occasionally given on the subject. Deaths from Cancer numbered 421 as compared with 321 in 1935; 371 in 1934; 374 in 1933; 341 in 1932; 342 in 1931; 339 in 1930; 330 in 1929; 327 in 1928; 344 in 1927; 330 in 1926; and 319 in 1925. The death-rate is the highest recorded. Death-rates per 1,000 of the population for the previous 11 years are as follows :— 1925—1.60 (319) 1931—1.46 (342) 1926—1.60 (330) 1932—1.44 (341) 1927—1.62 (344) 1933—1.56 (374) 1928—1.54 (327) 1934—1.54 (371) 1929—1.48 (330) 1935—1.33 (321) 1930—1.52 (339) 1936—1.75 (421) 122 Deaths From Cancer in Municipal Wards. Table I. Ward. Male- Female. Total- Death-rate. Estimated Mid Male. Population 1936. Female. Upper Norwood 15 12 27 1.22 10000 12152 Norbury 11 17 28 1.78 7093 8620 West Thornton 15 13 28 1.41 9276 10546 Bensham Manor 13 15 28 1.77 7375 8438 Thornton Heath 8 21 29 1.89 7304 8026 South Norwood 17 21 38 2.18 7938 9512 Woodside 9 13 22 1.43 7287 8083 East 19 21 40 2.25 7788 9984 Addiscombe 13 18 31 2.19 6537 7626 Whitehorse Mnr 20 14 34 2.06 7855 8624 Broad Green 8 12 20 1.33 7158 7926 Central 9 11 20 1.68 5270 6624 Waddon 18 20 38 1.76 10270 11339 South 14 21 35 2.40 6178 8433 Addington U — 3 3 0.35 4227 4250 Total 189 232 421 1.74 111556 130183 Table II. Deaths from Cancer Occurred at the Following Ages:— Age period. Male. Female. Total. Calculated population at this age period. Incidence per 1,000 persons living. Under 25 years 1 1 101549 .010 25 and under 35 years 7 1 8 36257 .221 35 and under 45 years 10 16 26 38681 .672 45 and under 65 years 80 93 173 48339 3.579 65 years and over 92 121 213 16913 12.594 189 232 421 241739 1.742 123 Table III. Sites of Fatal Cancer. Site. Male. Female. Total. Percentage of Total. Skin 2 4 6 1.425 Tongue and Mouth 12 3 15 3.563 Lip 1 — 1 0.238 Oesophagus 8 3 11 2.613 Stomach 44 37 81 19.240 Liver 10 9 19 4.513 Bowel 27 31 58 13.777 Rectum 18 13 31 7.363 Bladder 4 2 6 1.425 Prostate 16 — 16 3.800 Larynx 4 2 6 1.425 Uterus — 18 18 4.276 Breast — 62 62 14.727 Ovary - 12 12 2.850 Pancreas 7 6 13 3.088 Gall Bladder and Duct 1 2 3 0.713 Bones 2 6 8 1.900 Lungs 22 8 30 7.126 Kidneys 3 4 7 1.663 Thyroid 1 3 4 0.950 Lymphatic Glands 3 — 3 0.713 Parotid Gland — 1 1 0.237 Other Urinary — 1 1 0.237 Other Reproductive 1 2 3 0.713 Not defined 3 3 6 1.425 189 232 421 Comments on Foregoing Table. The two main groups of organs attacked in both sexes are the alimentary system and the reproductive system. In males 31.4 per cent. of the total deaths fall within these groups and in females 46.3 per cent. In males Cancer of the digestive system is the commonest situation, amounting to 27.3 per cent. In females it was 24.0 per cent. Cancer of the reproductive system caused 22.3 per cent. of the total deaths in females and was the most prevalent type. Cancer of the larynx, tongue and mouth is commoner in males than females, 16 deaths occurring in males as compared with 5 in females. The organs most often attacked in descending order of incidence are, in males the Rectum and Bowels (23.8 per cent.); the Stomach (23.3 per cent.); the Lungs per cent.); the Prostate (8.5 per cent.); the Tongue and Mouth (6.3 per cent.); in females, the Breast (26.7 per cent.); 124 the Bowels and Rectum (19.8 per cent.); Stomach (15.9 percent.); and the Uterus (7.8 per cent.). This is slightly different from the incidence in 1935. There has been a noticeable increase in the number of deaths attributed to Carcinoma of the Prostate, and an equally noticeable decrease in the number of deaths attributed to Carcinoma of the Uterus. 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. The number of deaths from Cancer rose by 100 cases, a 30 per cent. increase over 1935; males showed 48 more deaths and females 52. The chief sites of increases were: In males, the Tongue and Mouth, the Stomach and Bowel, the Prostate and the Lungs; in females, the Stomach and Bowel, and Breast. Whether this increase in cancer deaths is due to the increasing average age of the population, or to better diagnosis is impossible to say upon the data available, but probably both have an influence. The high incidence of cancer in the digestive system is disturbing, pointing as it does to dietary errors, and modes of eating. 125 SECTION VII. VENEREAL DISEASES. The scheme in operation in the Borough consists of the Clinics held at the Croydon General Hospital. Males attend on Saturday afternoons and Thursday evenings, women and children on Wednesday afternoons. Irrigation facilities are available daily. The Clinic is conducted by Dr.P.W.Hamond, who is not otherwise connected with the Health Department. Croydon is also one of the participating authorities in the London County Council's scheme, under which clinics for the treatment of venereal diseases are provided at a large number of London Hospitals, and at resident hostels; the cost being apportioned among the ten participating authorities in the scheme on a basis of user. Table I. Attendances at the Croydon Clinic. 1927 1928 1929. 1930. 1931. 1932. 1933. 1934. 1935. 1936. New male patients 145 121 101 196 263 235 242 297 287 300a New female patients Attendances, 160 158 94 171 205 241 214 232 213 188a male patients attendances, 2643 3502 3581 505 4923 4691 4578 5858 5548 7525a female patients 1417 1632 2127 3029 3271 2724 2677 3962 5977 5226a a Includes 243 new c6ases and 6471 total attendances by patients from outside areas. Attendances of Croydon Patients at various London Hospitals under the General Scheme. 1927. 1928. 1929. 1930. 1931. 1932. 1933. 1934. 1935. 1936. New patients 132 139 131 125 139 119 134 103 132 107 Total attendances 3160 3080 3089 3150 2384 2835 2407 2222 2006 2587 126 Of the 595 new patients in 1936, 82 had syphilis, 2 soft chancre, 209 gonorrhœa, and 302 were not suffering from venereal disease. Pathological Examinations at London Hospitals for Croydon Patients. 1927. 1928. 1929. 1930. 1931. 1932. 1933. 1934. 1935. 1936. Tests for Clinics 540 716 924 715 829 900 855 968 1029 810 Tests for practitioners 667 570 932 2197 3198 1680 1775 1877 2221 2613 Table II. Attendances of Patients at Venereal Diseases Clinic at the Croydon General Hospital. Authority. 1931. 1932. 1933. 1934. 1935. 1936, Inpa tients (days.) Outpa tients. Inpa tients (days). Outpa tients. Inpa tients (days). Outpa tients. Inpa tients (days). Outpa tients. Inpa tients (days). Outpa tients. Inpa tients (days) Outpa tients. Croydon ... 6395 159 5405 ... 5615 56 6659 301 6675 23 6280 Surrey C.C. ... 1491 ... 1512 ... 1280 10 2227 63 3859 44 4631 Kent C.C. ... 232 ... 74 ... 87 ... 109 ... 232 ... 470 London C.C ... 72 ... 426 ... 255 6 794 ... 757 ... 1370 Sussex C.C. ... 4 ... 19 ... 18 ... 31 ... 2 ... ... ... 8194 159 7436 ... 7255 72 9820 364 11525 67 12751 127 Table III. 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 4 15 1 30 1386 ... No Information Guy's 4 12 1 11 781 ... King's College 2 ... ... 8 114 ... Great Ormond Street 2 ... ... 3 26 51 Royal Free ... ... ... 2 16 ... South London Hospital for Women ... ... ... 9 159 ... Whitechapel Clinic (L.C.C.) ... ... ... ... 78 ... St. Paul's ... 1 ... 1 20 ... Seamen's ... 1 ... ... 7 ... Total 12 29 2 64 2587 51 — Table IV. Bacteriological Examinations carried out at London Hospitals for Croydon Patients. Hospital. Detection of Spirochetes. Detection of Gonococci. Wassermann Re-action. Other Exams. Total. For Clinic. For Prac. For Clinic. For Prac. For Clinic. For Prac. For Clinic. For Prac. St. Thomas's 1 ... 122 ... 100 ... 105 ... 328 Great Ormond Street ... ... 3 ... 10 2 6 1 22 South London Hospital for Women ... ... 89 18 2 5 4 ... 118 Royal Free ... ... 6 ... ... ... 2 ... 8 King's College ... ... 1 25 ... ... 26 Whitechapel Clinic, L.C.C. ... ... 25 ... 6 ... 11 ... 42 Westminster Hospital ... ••• ... ... ... 1 ... 1 2 Guy's Hospital ... ... 159 902 49 660 76 1023 2869 St. Paul's ... ... 1 ... 3 ... 1 ... 5 Seamen's ... ... 1 ... 1 ... 1 ... 3 Total 1 ... 407 920 196 668 206 1025 3423 128 Table V. Return relating to all persons who were treated at the Treatment Centre at Croydon General Hospital during the vear ended the 31st December, 1936. 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 59 58 ... ... 52 35 2 2 113 95 208 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 1 ... ... ... ... 1 ... ... 1 1 2 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 6 ... ... ... ... ... ... 4 6 10 „ secondary 4 4 ... ... ... ... ... ... 4 4 8 „ latent in 1st year of infection ... 5 ... ... ... ... ... ... ... 5 5 „ all later stages 26 11 ... ... ... ... ... ... 26 11 37 „ congenital 2 8 ... ... ... ... ... ... 2 8 10 Soft Chancre ... ... ... ... ... ... ... ... ... ... ... Gonorrhoea,1st year of infection ... ... ... ... 131 42 ... ... 131 42 173 „ later ... ... ... ... 5 2 ... ... 5 2 7 Conditions other than venereal ... ... ... ... ... ... 128 110 128 110 238 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 12 9 ... ... 33 10 ... 5 45 24 69 Totals of Items 1,2,3 and 4 108 101 ... ... 221 90 130 117 459 308 767 5.Number of cases discharged after completion of treatment and final tests of cure or after diagnosis as non-venereal 21 16 ... ... 83 24 112 110 216 150 366 6.Number of cases which ceased to attend before completion of treatment and were, on first attendance suffering from :— Syphilis, primary 2 1 ... ... ... ... ... ... 2 1 3 „ secondary 2 2 ... ... ... ... ... ... 2 2 4 „ latent in 1st year of infection ... 1 ... ... ... ... ... ... ... 1 1 „ all later stages 14 1 ... ... ... ... ... ... 14 1 15 „ congenital ... ... ... ... ... ... ... ... ... ... ... Soft Chancre ... ... ... ... ... ... ... ... ... ... ... Gonorrhoea, 1st year of infection ... ... ... ... 34 7 ... ... 34 7 41 „ later ... ... ... ... 1 ... ... 7. Number of cases which ceased to attend after completion of treatment but before final tests of cure ... 11 ... ... 12 6 ... ... 12 17 29 8. Number of cases transferred to other centres or to institutions, or to care of private practitioners 3 9 ... ... 16 8 ... ... 19 17 36 9.Number of cases remaining under treatment or observation on 31st December 66 60 ... ... 76 45 18 7 160 112 272 Totals of Items 5,6,7,8 and 9 (These totals should agree with those of Items 1, 2, 3 and 4) 108 101 ... ... 221 90 130 117 459 308 767 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 2 1 ... ... ... ... ... ... 2 1 3 „ latent in 1st year of infection ... ... ... ... ... ... ... ... ... ... ... „ all later stages 1 1 ... ... ... ... ... ... 1 1 2 „ congenital ... ... ... ... ... ... ... ... ... ... ... 11. Number of attendances :— (a) for individual attention of the medical officers 1247 1152 ... ... 1550 481 381 239 3178 1872 5050 (b) for intermediate treatment, e.g., irrigation, dressing ... ... ... ... 4194 3211 153 143 4347 3354 7701 Total Attendances 1247 1152 ... ... 5744 3692 534 382 7525 5226 1275 129  Syphilis Soft Chancre Gonorrhoea Conditions other than venereal Totals M F M F M F M F M F Ttls |2, In-patients (a)Total number of persons admitted for treatment during the year ... 1 ... ... 1 ... ... ... 1 1 2 (b)Aggregate number of "in-patient days" of treatment given ... 23 ... ... 44 ... ... ... 44 23 67 Under 1 year 1 and under 5 years 5 and under 15 years 15 years and over Totals M F M F M F M F M F 13.Number of cases of congenital syphilis in Item 3 above classified according to age periods 1 2 ... ... ... 2 1 4 2 8 Approved Arsenobenzene Compounds Mercury Bismuth 14. Chief preparations used in treatment of Syphilis: (a)Names of preparations Stabilarsan Sulphostab ... Bismostab Quinostab (b) Total number of injections given (outpatients and in-patients) 1044 ... 1759 Microscopical Serum for syphilis for gonococci for Syphilis for Gonorrhoea 15. Pathological Work (a)Number of specimens examined at and by the medical officer of the treatment centre ... 834 602 325 (b)Number of specimens from patients attending at the treatment centre sent for tion to an approved laboratory ... ... ... ... Table VI. Statement showing the services rendered at the Treatment Centre during the year, classified according to the areas in which the patients resided. Name of Country or Country Borough (or Country in the case of residing elsewhere than in England and Wales) to be inserted in these headings. Croydon Surrey Kent London F. M. Total A.Number of cases in Item 3 and 4 from each area:— Syphilis 35 26 3 6 34 36 70 Soft Chancre ... ... ... ... ... ... ... Gonorrhoea 195 62 9 14 44 136 180 Conditions other than venereal ... 11 83 7 33 110 124 234 Total 241 171 19 53 188 296 484 B.Total number of attendances of all patients siding in each area 6280 4631 470 1370 5226 7525 12751 number of In-patient days" of all patients residing in each area 23 44 ... ... ... ... 67 130 The Croydon Branch of the British Social Hygiene Council, towards the expenses of which the Council give a grant of £51) annually, earned out a very full programme of work during the year 1936-37. Lectures entitled " How to Tell " were given as follows:— Attendance. Ashburton Library. 20th October 121 Chairman: Ald. Mrs. Robers. Lecturer: Dr. Naomi Dancy. South Norwood Library. 17th November 115 Chairman: Mr. Councillor Harry Regan. Lecturer: Dr. Naomi Dancy. Thornton Heath Library. 8th December CO Chairman: Mr. W H. Bentley, M.A. Lecturer: Dr. I. Feldman. Rolleston Hall. 21st January 75 Chairman: Mr. W.C. Berwick Sayers, F.L.A. Lecturer: Dr. Drummond Shiels, M.C. Norbury Library. 28th January 57 Chairman: Dr.William B.Watson, L.R.C.P. Lecturer: Dr. I. Feldman. Foresters' Hall. 17th February GO Chairman: Mr. W.H.Bentley, M.A. Lecturer: Dr. Drummond Shiels, M.C. These lectures led up to a Mass Meeting at the Large Public Hall, when the Mayor presided and an address entitled "The Race in Danger" was delivered by Sir Francis Fremantle, M.P., M.D., Chairman of the Parliamentary Medical Committee. This was followed by the projection of a sound film entitled " Trial for Marriage." The attendance was between four and five hundred persons. Much free literature was distributed at all the meetings, and a number of approved books and pamphlets were sold. There been co-operation with the public libraries and the schools, in whic the Education Officer, the Headmasters and Headmistresses an the Chief Librarian have assisted. 131 SECTION VIII. MATERNITY AND CHILD WELFARE. 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 Births. Still Births. Total. Midwives 2,587 95 2,682 Doctors, Parents and others 778 30 808 Total 3,365 125 3,490 As the total number of births and still births registered during 1936 was 3,693 (Live 3,557, Still 136), 192 births and 11 still births were not notified in accordance with the provisions of the Act. Maternal Mortality. There were 16 deaths directly due to pregnancy, as compared with 10 in 1935, The maternal mortality rate was consequently 4.7 per 1,000 births compared with 2.9 per 1,000 in 1935. In other words one mother died for every 211 babies born. The deaths directly due to pregnancy were caused by puerperal sepsis, 5 cases (1 of which followed abortion) ; eclampsia, 2 cases; ruptured ectopic gestation, 1 case; placenta praevia, 3 cases; postpartum haemorrhage, 1 case; pulmonary embolism, 3 cases; obstetric shock accelerated by intercurrent disease, 1 case. The Registrar General's figures for deaths directly due to pregnancy were as follows:— Total deaths allocated to Borough of Croydon, 12 ; maternal mortality, 3.56 per 1,000 births; in the previous paragraph the deaths are given as 16. This includes 4 deaths which the Registrar General did not include as deaths directly clue to pregnancy, but which in the light of local knowledge have been included in my report. One case tabulated under Placenta Praevia had Caesarean Section performed. 132 Table I. ]YEAR * BIRTHS. Puerperal Infection. Puerperal Toxaemias. Haemorrhages. Other Causes. Eclampsia. Hyperemesis. Ectopic Gestation. Placenta Praevia. Post.partum Haemorrhage. Pulmonary Embolism. Caesarean Section. Shock. Heart Disease. Syncope. Renal Trouble. Other Causes. TOTAL. *Maternal Mortality. Infant Mortality.. 1919 2965 5 1 ... ... ... ... ... ... ... ... ... ... 6 2.0 73 1920 4351 6 2 ... ... 2 ... 2 ... ... 3 1 2 18 4.1 63 1921 3631 4 2 ... ... 1 2 ... ... 2 ... 3 ... 14 3.9 74 1922 3505 8 1 ... ... 1 1 1 ... ... 2 ... 1 15 4.3 64 1923 3373 4 2 ... ... 1 ... ... 2 ... ... ... 1 10 3.0 52 1924 3456 2 1 ... ... ... 3 2 ... ... 1 ... ... 9 2.6 56 1925 3406 5 1 ... ... ... 3 2 1 ... ... 1 ... 13 3.8 55 1926 3477 13 ... ... ... 2 1 1 1 2 1 ... 3 24 6.9 61 1927 3174 5 ... ... ... 1 ... 1 ... ... ... 1 1 9 2.9 55 1928 3374 2 4 ... ... ... 1 3 ... ... ... ... 3 13 3.9 53 1929 3399 4 ... 1 1 1 2 1 ... ... ... ... 1 11 3.2 65 1930 3514 1 ... ... ... ... 2 1 ... ... ... ... 3 7 2.0 48 1931 3400 11 3 2 3 1 2 1 ... ... ... ... ... 23 6.8 57 1932 3311 2 3 ... ... ... ... ... ... 1 ... ... 1 7 2.1 49 1933 3147 5 2 1 1 ... ... 1 .... ... ... 1 1 12 3.8 47 1934 3185 5 3 ... 1 2 ... ... ... 1 ... ... 1 13 3.9 46 1935 3288 7 1 ... ... ... 1 ... 1 ... ... ... ... 10 3.0 45 1936 3248 5 2 ... ... 2 ... 3 ... 1 ... ... ... 13 3.9 41 94 28 4 6 14 18 19 5 7 7 7 19 227 *It has recently become the practice to give the maternal death ra per 1,000 live and still births. The above table gives the rate per 1,000 live births. Below are given the rates per 1,000 total births since 1931. 133 YEAR. BIRTHS. Live and Still. Puerperal Infection. Puerperal Toxaemias. Haemorrhages. Other Causes. Eclampsia. Hyperemesis. Ectopic Gestation. Placenta Praevia. Post.partum Haemorrhage. Pulmonary Embolism. Caesarean Section. Shock. Heart Disease. Syncope. Renal Trouble. Other Causes. TOTAL. Maternal Mortality. Infant Mortality. 1931 3501 11 3 2 3 1 2 1 ... ... ... ... ... 23 6.6 67 1932 3429 2 3 ... ... ... ... ... ... 1 ... ... 1 7 2.0 49 1933 3249 5 2 1 1 ... ... 1 ... ... ... 1 1 12 3.7 47 1934 3304 5 3 ... 1 2 ... ... ... 1 ... ... 1 13 3.9 46 1935 3391 7 1 ... ... ... 1 ... 1 ... ... ... ... 10 2.9 45 1936 3373 5 2 ... ... 2 ... 3 ... 1 ... ... ... 13 3.9 41 Totals (1919) (1936) 94 28 4 6 14 18 19 5 7 7 7 18 227 Puerperal Fever and Puerperal Pyrexia. Fourteen cases of Puerperal Fever and 48 cases of Puerperal Pyrexia were notified. This is a rate of 4.2 per 1,000 births (live and still births) for the former and 14.2 per 1,000 for the latter. The death-rates were:—Puerperal Fever, 1.5 per 1,000 births. Table II. The following Table gives fuller details concerning these cases. Puerperal Fever. Puerperal Pyrexia. A- No. of cases notified 14 48 ,, „ attended at home 4 7 (1)By doctor alone 3 1 (2)By doctor and maternity nurse 6 2 (3)By midwife alone 5 4 (4)Confinement unattended - - B- No. of cases attended in an Institution 10 41 C- ,, ,, attended in a Nursing Home - 3 D- ,, ,, treated at Home 3 5 E- ,, ,, treated at Hospital 11 39 G- ,, ,, treated at Nursing Homes - 2 G- ,, ,, treated at Home and Hospital 1 2 H,, ,, who died 3 2 134 Accommodation for Confinement, The following Table gives information concerning the accommodation utilized for confinements. Number. Percentage. In Private Houses 1490 40.4 In Public Institutions 1498 40.6 Registered Maternity Homes 703 19.0 There is a distinct trend towards confinement taking place in an Institution or Maternity Home. 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. Besides the Matron and Nursing Staff, an honorary lady medical officer attends the Home when necessary. The following figures give the main details regarding the work carried out in 1936, and I am indebted to Dr. Sutherland, the Hon. Medical Officer of the Home, for them:— No. of beds for patients 20 No. of cases admitted 27 Average duration of stay 5 months No. of cases delivered by (a) Mid wives 24 (b)Doctor 1 No. of cases in which medical assistance was sought by a midwife 14 No. of cases notified as (a) Puerperal Fever, (b) Puerperal Pyrexia — No. of cases notified as Pemphigus Neonatorum — No. of maternal deaths — No. of infant deaths (a) Still-born — (6) within 10 days of birth — Most of the infants were breast fed till 3 months old (2 had supplementary feeds much earlier), but many remained in the home long after they had been entirely weaned. As is seen, the duration of stay much exceeds that in ordinal) 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 135 go out to daily work, but reside in the Home. It is, however, becoming increasingly difficult to get the girls to stay as long as is advisable. Still Births. During 1936, 136 still births were registered in respect of Croydon, but of these 22 were outward transfers to other districts. There were 11 inward transfers, giving a total of 125 for the area. Of these 62 were male babies and 63 female; 2 male and 3 female were illegitimate. The proportion of still births to living children was as 1 to 26. The still birth rate was 3.8% of the total births. The rate in 1935 was 3.1%. The still birth rate, on the same basis as for Infant Mortality, was 38.5 per 1,000 births. STILL BIRTHS, 1936. Notified by Midwives, Home Cases 14 ,, Doctors, Home Cases 9 „ Institutions (Doctors or Midwives) 50* Attended by Midwives alone41 „ Doctors alone 18 „ Midwives and Doctors21 Occurred at 9 months 45 „ 8 months 15 „ 6-7 months 14 *Including registered Maternity Homes. An Analysis of 77 Still Births Occurring During the Year. Of the 77 still births investigated 35 were males and 42 females. Type of Delivery.—In 39 cases the confinement was difficult or prolonged. Normal confinement was noted in 35 cases; no information was obtainable in 3 cases. Age of Mother.—Under 20 years, 1; between 20 and 29 years, 31; between 30 and 39 years, 36; between 40 and 49 years, 4. The Health of the Mother during her pregnancy was stated to be good in 57 cases and indifferent or poor in 11 cases; no particulars were obtained in 9 cases. In 12 cases, however, the mother had had a shock or a fall before the still birth. In 35 instances the mother had attended the Ante-Natal Clinic. 35 cases had never attended the Clinic. 136 Attendance at Confinement.—Thirty of the still births investigated occurred in the Mayday Hospital; 12 in St. Mary's Hospital; 20 were attended in their own homes by a private medical practitioner either alone or in conjunction with a midwife; 9 were attended by a midwife alone, and 1 birth occurred before any skilled help was available; 5 occurred in private nursing homes. Forceps were reported to have been utilised in 15 of the cases. In 45 cases the baby was born at full term; in 15 during the 8th month of gestation; in 14 during the 7th month. The baby was apparently a normal child in 52 cases, abnormal in 10, whilst in 15 no record was available. The still birth was the first pregnancy in 25 instances; the 2nd in 17; the 3rd in 13; the 4th in 10; the 5th in 3; the 7th in 5; the 8th in 1; and beyond in 1. Previous still births had occurred in 9 cases. Ophthalmia Neonatorum. Twenty cases were notified during 1936. Under the Ophthalmia Neonatorum Regulations, 1926, notification by midwives ceased. Prior to 1926 the number of notifications remained fairly uniform, and it would appear as if only the most severe rases are now brought to the attention of the Authority. The following table gives the notifications in Croydon during the past eleven years:— Table III. 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 19.36 No. of cases 20 18 7 5 19 14 21 10 13 13 20 Rate per 1000 births 5.8 5.7 2.8 1.5 5.4 5.6 6 3 3.2 4.0 3.9 6.2 Results of Treatment. Table IV. Cases treated. Vision Unimpaired. Vision Impaired. Died. Removed Remaining under Treatment. Notified At home In hospital 18 - 1 — 1 20 3 13 137 Infant Mortality. The Infantile Mortality rate was 41 per 1,000 births. This is 4 per 1,000 births less than in 1935, and is the lowest rate yet recorded in the Borough. For the past 5 years the numbers of infant deaths have been: 1932, 161; 1933, 148; 1934, 145 ; 1935, 147 ; 1936, 134 ; 87 deaths of infants occurred in institutions, including Registered Nursing Homes. Among the 134 deaths, 74 occurred in boy babies and 60 in girls. Of the births, 1,675 were males and 1,573 females. The infantile mortality rate for the two sexes was, therefore:—Boys, 44: girls, 38. The rate of infant mortality amongst illegitimate children was 67 per 1,000. The rate in legitimate children was 40 per 1,000. Neo-Natal Mortality. Number of deaths within the first month of life:— Table V. Year. No. of Deaths. No. of Births. Rate. 1927 83 3174 26/1000 live births. 1928 66 3374 20 ,, ,, ,, 1929 88 3399 26 ,, ,, ,, 1930 82 3514 23 ,, ,, ,, 1931 88 3400 26 ,, ,, ,, 1932 82 3311 25 ,, ,, ,, 1933 83 3147 26 ,, ,, ,, 1934 68 3185 21 ,, ,, ,, 1935 83 3288 25 ,, ,, ,, 1936 64 3248 20 ,, ,, ,, 138 The following table gives the causes of death during the first month of life:— 1. Complications of Labour. Trauma at Birth 6 6 II. Foetal States. Congenital Heart Malformation 4 Other Congenital Deformities 2 Atelectasis 9 Congenital Debility 2 Ophthalmia Neonatorum 1 Haemorrhage 2 Melaena 1 21 III. Prematurity 29 29 IV. Post-Natal Causes 8 8 64 The rate of infantile mortality for England and Wales in 1936 was 59 and for the 122 large towns 63. The rate for Croydon is therefore considerably lower than the average rate. An analysis of Table VI. shows that, of the total infant deaths, 19.4% occurred on the first day of life and 47.8% 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) were concerned. If it was not for the persistently high rate of this mortality the total infant mortality figure would be better than it is. 139 Table VI. Deaths under one year, arranged in days, weeks and months. CAUSES OF DEATH. 1st day. 2nd day. 3rd day. 4th day. 5th day. 6th day. 7th day. lst-2nd wk. 2nd-3rd wk. 3rd-4th wk. Under 1 ninth. 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 25 8 7 3 3 3 8 3 3 63 16 10 7 4 5 9 3 5 5 3 3 133 Uncertified 1 ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... 1 Chicken-pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ..... 1 ... ... ... Measles ... ... ... ... ... ... ... ... ... ... ... ... ... ... .... ... ... ... ... ... 2 Scarlet Fever Whooping Cough ... ... ... ... ... ... ... ... ... ... ... 2 ... ... 1 ... ... 1 ... ... 1 1 6 Diphtheria and Croup ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Tuberculous Meningitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Abdominal Tuberculosis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Tuberculous Diseases ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... 2 Meningitis (not Tuberculous) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Convulsions ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Laryngitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Bronchitis ... ... ... ... ... ... ... ... ... ... ... ... 1 1 ... ... ... ... ... ... ... 3 Pneumonia (all forms) ... ... ... ... ... ... ... ... ... ... ...1 5 2 2 2 ... 3 1 2 1 1 ... 20 Diarrhoea and Enteritis ... ... ... ... ... ... ... ... ... ... 1 2 4 ... ... ... 3 1 1 2 1 ... 19 Gastritis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .... Syphilis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Rickets ... ... ... ... ... ... ... ... ... .... ... ... ... ... ... ... ... ... ... ... ... ... ... Congenital Malformations 1 ... 1 ... ... 1 ... i ... ... 6 2 ... ... ... ... ... ... ... ... ... ... 8 33 Premature Birth 17 5 1 ... 2 2 ... 2 ... ... 29 1 2 1 ... ... ... ... ... ... ... ... Atrophy, Atelectasis, Debility, and Marasmus 4 ... 2 1 1 ... ... 1 1 1 11 1 ... 1 ... ... 1 ... ... ... ... 14 Injury at birth 1 2 ... 1 ... ... ... 1 ... ... 6 ... ... ... ... ... ... ... ... ... ... ... 6 Other causes 3 1 2 1 ... ... ... 2 ... 1 10 3 1 1 1 ... 1 ... 1 2 ... 1 21 140 Deaths Under One Month. An analysis of Table VI. shows that 19.4% of the infant deaths occurred before the baby was 24 hours old ; 37.3% during the first week of life; and 47.8% before the end of the first month. In 1935 the corresponding figures were 23.1%, 44.9%, and 56.5%. These figures relate to infant deaths due to causes probably operating before birth. The chief individual cause was premature birth, which was the assigned cause in 45.3% of deaths under 1 month of life. In the same group can be placed debility which was the cause of 17.2%. Injury at birth is rather different, inasmuch as it is, by skilled ante-natal and natal attention, avoidable; injury caused 9.4% of the deaths. Deaths under one month due to congenital deformities constituted 9.4% 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. Deaths Under Three Months. Ninety babies died during the first three months of life, a percentage of the total infant deaths of 67%, and an infant mortality rate of 28 per 1,000 births. As the total infantile mortality rate was 41, it is seen that over 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: Pneumonia, 7 deaths, and Diarrhoea, 6 deaths. The effects of improper feeding, and exposure to infection, are commencing to make themselves felt. Deaths between the 4th month and the end of the first year of life numbered 37 and were caused chiefly by Diarrhoea (32.4%) and Pneumonia (27.0%). These two conditions, year by year, figure as the most prominent causes of death at this age period. The Pneumonia deaths occurred in the following months:— January 2, February 4, March 3, May 4, August 1, October 1, November 3, and December 2. 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 35.0% of the total deaths, and contributed 14.5 deaths per l,000 births towards the infantile mortality rate. 141 (2) Next to these come Pneumonia and Diarrhœa with 29.1% of the total deaths and a contribution of 12.0 per 1,000 to the infantile mortality rate. (3) Congenital Deformity, inconsistent with viability beyond the first year, was responsible for only 8 deaths, 6.0% of the total deaths, and contributed 2.5 per 1,000 towards the infantile mortality rate. There were ten deaths from the acute Zymotic diseases in infants under 1 year of age, of these 6 were due to Whooping Cough. In the tabulated deaths of children under 1 year of age, the child who died was a first child in 40.5%; a second child in 19.0%; a third child in 10.1%; a fourth child in 12.7%; a fifth child in 6.3%; a sixth child in 7.6%; a seventh child in 1.3%; a tenth in 1.3%, and an eleventh in 1.3%. The following table gives the chief causes of infant deaths, as compared with 1935:— Table VII. Percentage Deaths per Total Infantile Deaths. Deaths per 1,000 Births. 1936. 1935. 1936. 1935. Premature Births 24.6 29.3 10.1 13.1 Respiratory Diseases (Pneumonia and Bronchitis) 17.2 13.6 7.1 6.1 Infectious Diseases (inc. Tuberculosis) 9.0 1.4 3.7 0.6 Atelectasis, Debility and Marasmus 10.5 8.2 4.3 3.6 Diseases of Digestion 16.4 12.9 6.8 5.8 Accidental & Congenital 10.4 18.4 4.3 8.2 142 Maternity and Child Welfare—Deaths of Infants under one year of age. Table VIII. Births Deaths 1936 1935 1934 1933 Mortality per 1000 Births r General Birth Rate General Death Rate Mortality per 1000 Births General Birth Rate General Death Rale Mortality per 1000 Births General Birth Rate General Death Rate Mortality per 1000 Births General Birth Rate General Death Rate  January 284 16 56 15.4 13.7 49 13.3 10.7 42 14.3 14.6 78 14.5 17.9 February 303 15 50 12 5 13.7 63 14.7 12.9 45 14.6 12.0 72 14.2 19.5 March 249 11 44 13.4 13.6 53 15.3 12.0 49 14.3 14.2 48 15.0 11.8 April 271 8 30 15.7 11.3 32 15.0 10.4 36 16.5 11.3 61 16.3 10.9 May 366 19 52 14.5 9.2 29 16.6 10.2 45 13.2 9.2 19 15.1 8.6 June 283 8 28 15.2 9.8 35 15.3 8.4 28 15.6 7.4 24 16.6 7.9 July 284 9 32 14.5 8 .3 31 17.7 7.8 33 13.0 8.6 20 14.2 7.6 August 339 5 15 15.2 8.3 19 15.8 8.1 21 16.6 8.1 12 15.2 7.1 September 308 4 13 16.5 7.7 19 14.5 8.8 24 13.8 8.1 35 14.7 7.7 October 342 14 41 14.7 8.9 52 14.0 8.5 31 14.0 9.0 36 12.9 9.4 November 253 11 43 13.6 9.0 64 13.5 8.7 39 14.5 10.8 45 11.5 10.6 December 256 14 55 13.7 11.5 70 11.5 12.3 33 15.0 10.2 54 11.8 14.7 The Birth Rate was highest in September,April,January, June, and August, and the Infant Mortality was lowest during September, August, June, April and July. The Death Rate was highest in Februry , and March .Infant Mortality was highest during January, December. The Death Ratey was highest during January. December. 143 Infantile Mortality in Wards from 1929 to 1936:— Table IX. 1929 1930 1931 1932 1933 1934 1935 1936 Averages over 8 years.  Upper Norwood 70 108 80 76 57 33 26 53 63 Norbury 20 48 39 27 30 37 63 19 36 West Thornton 63 29 66 75 33 59 47 58 54 Bensham Manor 55 39 7 2 28 19 62 32 20 41 Thornton Health 99 66 66 69 44 42 31 62 61 South Norwood 54 51 48 32 42 52 40 47 46 Woodside 59 40 37 30 50 66 57 68 51 East 63 40 30 68 46 30 63 40 47 Addiscombe 71 33 47 31 85 43 62 44 46 Whitehorse Manor 74 62 74 48 62 60 47 62 61 Broad Green 76 38 46 60 57 41 51 40 51 Central 42 51 91 22 15 30 66 60 47 Wad on 63 56 53 55 63 50 54 26 52 South 61 25 63 34 91 71 56 55 57 Addington ... ... ... ... ... 15 36 11 ... The Wards with the highest infant mortality over an eight years period are: Upper Norwood, Thornton Heath, and Whitehorse Manor; the lowest averages are recorded Norbury, Bensham Manor and East, and Addiscombe. Midwise Acts, 1902 and 1918. 106 midwives notified the Local Supervising Authority of their intention to practise within the Borough during 1936; 26 ceased practising in the Borough ; so that 80 remained on the Register at the end of the year. of these 77 were trained and held the certificate the Central Midwives Board, and 2 were bona-fide midwives i.e.,they were in practice as midwives at the time of the passing of the midwives Act, 1902, while 1 held certificate of London Obstetrical. Under Section 2 (1) of Midwives and Materninty 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. One application was received and a payment of £2 2s. made therein. 144 The Committee also assist necessitous patients in the payment of the midwife's fee. 35 applications were made for assistance by midwives on behalf of the patients, and a total sum of £67 8s. was allowed. Midwives are also compensated if they lose a case through admission to a hospital or maternity home on the advice of a doctor. The sum of £119 1s. was paid out during the year. Confinements Attended by Midwives. Cases attended by midwives alone 1,886 i.e., 54% of total births Cases attended by midwives when a doctor was also engaged 528 Cases attended by midwives when a doctor was also summoned 495 Total 2,909 i.e., 83.1% 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. For Complications during Pregnancy: Albuminuria 24 Other 4 Abortion 7 35 For Complications during Labour: Breech 14 Foot 1 Face 2 Occipito-Posterior 2 Extended Breech 12 Prolapsed Cord 2 Transverse 2 Caesarean Section 4 Head 2 Undiagnosed 14 Hand 1 56 Obstructed Labour 5 5 Delayed Labour— Uterine Inertia 6 Prolonged 33 Delayed 27 66 Hemorrhage— Ante- Partum 21 Post-Partum 12 33 Other Causes— Adherent Placenta 5 Illness of Mother 28 Retained Placenta 3 Twins 1 Torn Perineum 132 Eclampsia 169 146 For Complications during Puerperium Pyrexia 18 Pain in Breasts 2 Pain in Legs 2 Other causes 2 24 For Complications in regard to the Baby : Inflammation of Eyes 38 Jaundice 1 Still-birth 2 Convulsions 1 Feebleness 15 Deformities 5 Premature Birth 4 Other causes 39 105 Other Reasons 2 In accordance with Rule 12a of the Central Midwives Board, the following reasons for the discontinuance of breast feeding were received:— Illness of Mother 2 Mother returning to business life 2 Insufficient 16 Other causes 5   Total 25 Inspection of Midwives. Dr. Jenkin-Lloyd, the Inspector of Midwives, interviewed 4 midwives at the Town Hall. 110 visits were paid by her to the homes of midwives. Of these visits 31 proved ineffective, the midedwife 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 was not always up-to-date, whilst ante-natal records are not kept as completely as is desirable. 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. 144 mothers were sent by midwives for this purpose. When the mdwife does not attend she is informed by letter of the findings at the Clinic. Disinfection of Midwives Bags, Etc. This is done by the Local Supervising Authority, free of charge for any midwife asking for it. In 13 instances midwives availed themselves of these facilities. 146 Table X. Nursing Homes (Registration) Act, 1927. Maternity Homes. Other Nursing Homes. Combined Maternity and other Nursing Homes.  Total. No. of Homes on Register, on 31/12/35 14 23 21 58 No. of Applications for Registration during 1936 3 2 5 No. of Homes registered during 1936 _ 3 2 5 No. of Orders made: (a) Refusing Registration — — — — (b) Cancelling 1 4 3 8 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 31/12/36 13 22 20 55 No. of Beds available 61 310 (a) Mat. beds 61 (a) 122 (b) Other Beds 77 (b) 387 Doctors' Accounts Under Section 14 (1) of the Midwives Act, 1918. 268 accounts were received from doctors for services rendered under the provisions of this section. This compares with 243 in 1935; 172 in 1934; 140 in 1933; 153 in 1932; and 136 in 1931 The total amount of the accounts was £406 1s. £105 11s. 9d. was ultimately recovered front the patients. In 1935 the amount paid to doctors was £329 14s. 6d., and in 1933, £225. 147 THE OBSTETRIC SERVICE. The obstetric service was fully described in the Annual Report for 1933. Some of the Mayday Hospital Booked cases are sent to the Ante-Natal Clinics by doctors and midwives because of abnormalities and complications. Many of the Emergency cases are seriously ill when they are received into hospital. The extent to which the Council provides for the serious cases may be judged by the fact that in 1933 all the 12 maternal deaths in Croydon occurred in the Council's beds, 9 of the 11 maternal deaths in 1934, 7 of the 10 deaths in 1935, and 10 of the 13 deaths in 1936. Taking the Registrar-General's figures for maternal mortality (deaths directly due to pregnancy) the rate for England and Wales for 1936 is 3.65 per 1,000 births. In Croydon there has been a rise from 2.36 in 1935 to 3.56 in 1936. In Booked cases treated by the Obstetric Service the rate for 1936 was 1.38 per 1,000 births. Of the cases treated to a conclusion at the Post-Natal Clinic during 1936, 82 per cent. were classified as "Health Unimpaired." This signifies that anatomically and functionally their condition was the same as before their pregnancies. The corresponding figure for 1935 was 92.0 per cent. The number of patients delivered in Mayday Hospital showed an increase of 15 per cent. on the total for 1935, and the strain on maternity accommodation is at times very great. The number of cases delivered of viable babies in Mayday Hospital, with a nominal 22 beds, was 768. The number delivered in St. Mary's Maternity Hospital, with 30 beds, was 575. GENERAL STATISTICS FOR 1936. Registrar General's Returns. Number of Live Births allocated to the Borough of Croydon 3,248 Number of Still Births allocated to the Borough of Croydon 125 Total 3,373 Number of Maternal Deaths (directly due to pregnancy) 13 Number of cases notified as Puerperal Fever 14 Number of cases notified as Puerperal Pyrexia 48 148 Statistics Prepared by the Obstetric Service. Number of Expectant Mothers who attended the Borough Antenatal Clinics 2,276 Number of cases delivered in Mayday Hospital as Booked cases 684 Number of cases delivered in Mayday Hospital as Emergency cases 190 Total cases delivered in Mayday Hospital 874 Number of cases delivered in St. Mary's Maternity Hospital as Booked cases 573 Number of cases delivered in St. Mary's Maternity Hospital as Emergency cases 2 Total cases delivered in St. Mary's Maternity Hospital ... 575 Number of cases admitted to the Puerperal Infection Unit, Borough Hospital and Mayday Hospital Isolation Wards, including 29 from Mayday Hospital and 5 from St. Mary's Maternity Hospital 51 Number of Maternal Deaths* in Borough of Croydon 13 Number of Maternal Deaths in Booked cases from Borough Ante-natal Clinics 2 Number of Maternal Deaths† in Emergency cases at Mayday Hospital 10 Number of Maternal Deaths in cases admitted as Puerperal Sepsis per se 3 Total Maternal Deaths† in beds of the Obstetric Service 10 The total number of patients treated by the Obstetric Service was:— (a) In Mayday Hospital 959 (b) In St. Mary's Maternity Hospital 582 (c) in the Borough Hospital Puerperal Infection Unit and Mayday Hospital Isolation Wards, excluding 30 from (a) and 4 from (b) 17 (d) At the Ante-natal Clinics and delivered outside the above Hospitals (about) 283 (e) At the Post-natal Clinics, excluding those included in (a), (b), (c), and (d), and including 100 delivered in 1936 140 (f) At the Ante-natal Clinics and undelivered on December 3lst, 1936 734 Total 2,313 149 ANTE-NATAL SUPERVISION. 1935. 1936.  Number of sessions at Ante-natal Clinics hold 255 255 Number of individuals who attended 1,992 2,276 Number of previous year's cases continuing attendance 410 504 Number of new cases 1,582 1,772 Number of cases undelivered on 31st December' 548 637 Total attendances made 11,839 14,107 Average attendances per session 46.4 55.3 Proportion of old to new cases per session New 6.2 6.9 Old 40.2 48.4 Number of cases delivered in Hospital as Booked cases 1,097 1,259 Number of cases delivered at other places under the care of private doctors or midwives (about) 270 283 Number of patients found not to be pregnant 27 18 Number of patients referred to Hospital for Antenatal treatment 274 373 The conditions for which these were admitted can be ascertained by reference to the "Booked" columns of the Numerical summary of Cases on page It is seen that the new cases have increased by 190 and the total attendances by 2,268. This increase has caused a severe strain on the accommodation available at Lodge Road, and gross and undesirable overcrowding has resulted. Extra sessions have not been possible to be arranged owing to limitations of available staff and accommodation. It is interesting to note that the number of births occurring in institutions and previously attending the Clinic has risen, and the number confined privately has also increased. Major Ante-Natal Conditions Treated at the Ante-Natal Clinic. Breech Presentation. Cases. Breech presentation diagnosed 205 Spontaneous version 0 External version successful 187 External version not successful 10 Allowed to go to term as Breech 17 Referred to Hospital for external version under anaesthesia 9 Of these : Version under anaesthesia successful 8 Version under anaesthesia not successful 1 Not recognised as Breech before labour 20 Dental Treatment. Number of cases referred to Borough Dental Surgeons 158 Number of cases referred to Private Dental Surgeons 143 Number of cases refusing dental treatment 73 Number of cases seen too late for necessary dental treatment 45 160 The inability of the Dental Service to deal with all the mothers anxious to obtain treatment is regrettable, inasmuch as it reacts upon the attitude of mothers. There are, however, insufficient dentists for sufficient supervision to be accomplished. Tuberculosis. Referred to Tuberculosis Officer because of pregnancy 2 Referred to Tuberculosis Officer for opinion on lung condition 8 Venereal Disease. GONORRHOEA-Total cases 5 Transferred to Borough V.D. Clinic 2 Transferred to Mayday Hospital 3 SYPHILIS-Total cases 2 Transferred to Borough V.D.Clinic 2 These cases are delivered in Mayday Hospital in Isolation Wards, and transferred to the Borough V.D. Clinic on discharge. Four of the cases were undelivered at the end of the year. Other Conditions Treated as Out-Patients. Chronic rheumatic carditis 4 Parenchymatous goitre 1 Retroverted gravid uterus 3 Scabies 4 Midwives' Cases. Many midwives' cases were sent when pregnancy was about 36 weeks advanced for a single consultation. A somewhat larger number was supervised entirely at the ante-natal Clinic after they had made their own arrangements for delivery at home in the care of doctors or midwives. Expectant mothers who cancelled hospital bookings are included in this group. These cases may be summarised as follows : — Total number of midwives' cases during 1936 268 Number of cases sent for one consultation only 144(54%) Number of cases supervised entirely 124 (46%) Number of first pregnancies 87 (32%) ,, second ,, 51 (19%) ,, third ,, 45 (17%) ,, fourth ,, 29 (11%) fifth 24 (9%) sixth ,, or more 32 (12%) Number of legitimate pregnancies 258 (96%) Number of illegitimate pregnancies 10 (4%) 161 SPECIAL INVESTIGATIONS. Special investigations were carried out on ante-natal patients attending the clinics, and on patients in St. Mary's Maternity Hospital and Mayday Hospital Maternity Wards. Pathological Investigations. Blood for Washerman 99 Blood for Kahn Reaction 45 Blood for Gonococcous Fixation Test 57 Blood for Culture 2 Blood for Urea Content 5 Blood for Sugar Content 1 Blood for Cell Count, etc. 11 Catheter urine for Routine Examination 212 Urine for Aschheim-Zondek Test 17 Urine for Urea Concentration Test 9 Lochia for Culture 26 Sputum for Examination 2 Pus for Identification of Organism 5 Urethral smears for Gonococci, etc 27 Cervical smears for Gonococci, etc 15 Conjunctival smears 2 Histological sections 25 Peritoneal Fluid 1 Thoracic Fluid 1 X-Ray Examinations (Mayday Hospital X-Ray Department). 106 cases were referred from Ante-natal Clinics and 141 films were used. Reasons for reference were:— Breech for attitude, etc 31 For presentation, attitude, etc 37 Twins 34 Foetal death 2 ,, bony deformity 1 ,, parts 1 22 cases were referred from the Maternity and Gynaecological Wards at Mayday Hospital and 40 films were used. Reasons for reference were: For presentation 6 For maturity 4 Twins 5 For foetal parts 1 Renal calculus 3 Foetal death 1 Hydramnios 1 Fracture of foetal skull 2 152 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 678 574 1,252 (2) Delivered in hospital before 28th week 6 1 7 (3) Admitted after delivery 18 4 22 (4) Discharged undelivered after ante-natal treatment and not subsequently delivered in hospital 1 3 4 (5) Died undelivered 0 0 0 (6) Ectopic pregnancy 0 0 0 Totals 703 582 1,285 B.—"Emergency" patients sent into Hospital with some compli- cations by outside doctors or midwives. No "Emergency'' cases were admitted to St. Mary's Maternity Hospital, excep two cases which had been seen by a medical officer at home and had been included in the Booked cases for convenience Mayday Hospital. (1) Before LabouR- (a) Discharged undelivered (d) Delivered in hospital after 28th week 90 (c) Delivered in hospital before 28th week 107 (d) Died 10 (2) After Delivery 33 (3) Ectopic Pregnancy 2 Total 252 A comparison of the patients delivered in the two hospitals as regards parity, legitimacy and the number of attendances made at the Ante-natal Clinics. Deliveries before 28 weeks gestation are excluded:— Mayday Hospital. Booked. Mayday Hospital. Emergency. St. Mary's Mat. Hospital. Booked. Totals.  First pregnancy 297 (43.8% 41 (45.6%) 358 (62.3%) 696 (51.8%) Second 180 (26.6%) 12 (13.3%) 114 (19.3%) 306 (22.8%) Third ,, 102 (15.0%) 6 (6.7%) 67 (11.7%) 175 (13.0%) Fourth ,, 46 (6.8%) 12 (13.3%) 21 (3.7%) 79 (5.9%) Fifth 18 (2.7%) 6 (6.7%) 10 (1.7%) 34 (2.5%) Sixth ,, 13 (1.9%) 4 (4.4%) 4 (0.7%) 21(1.5%) Seventh ,, . 16 (2.2%) 4 (4.4%) 0 (-) 19(1.4%) Eighth „ 4 (0.6%) 2 (2.2%) 1 (0.2%) 7(0.6%) Ninth ,, 1 (0.1%) 0 (-) 0 (-) 1(0.1%) Tenth pregnancy or more 2 (0.3%) 3 (3.3%) 0 (-) 5 (0.4%) Totals 678 90 575 1,343 legitimate 642 (94.7%) 79 (87.8%) 570 (99.1%) 1,291(96.1%) Illegitimate 36 (5.3%) 11 (12.2%) 5 (0.9%) 52(3.9%) 153 Table XI. 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 69 31 40 140 Eclampsia 0 2 0 2 Persistent vomiting of pregnancy 8 4 5 17 Chronic cervicitis 0 0 0 0 Acute pyelitis 5 8 5 18 Other urinary infection 4 3 2 9 Malnutrition, debility, simple anaemia, etc 11 1 2 14 Ante- partum thrombo- phlebitis 4 3 0 7 Breech presentation for version 6 0 3 9 Disproportion 16 4 8 28 Post-maturity 0 0 0 0 Retroverted gravid uterus 2 0 1 2 2. Intercurrent Diseases. Chronic nephritis 0 3 0 3 Pulmonary tuberculosis 0 2 0 2 Venereal disease 3 0 1 4 Chronic rheumatic carditis 8 4 3 15 Exophthalmic goitre 1 0 0 1 Non-rheumatic carditis 6 5 0 11 3. Conditions chiefly Natal. Presentations at Delivery- Anterior positions of the vertex Posterior positions of the vertex 623 33 67 5 503 55 1193 93 Breech 21 13 18 62 164 Mayday Hospital Booked. Mayday Hospital Emergency. St. Mary's Maternity Hospital Booked. 1 Total.  Presentations at Delivery (continued) Shoulder 2 3 1 6 Face and Brow 2 0 3 5 Complex 0 0 1 1 Caesarean section 14 2 5 21 Twins 7 2 10 19 Accidental haemorrhage 7 6 5 18 Placenta praevia 6 6 1 12 Hydramnios 7 2 2 11 Prolapse of cord 2 2 0 4 Retained placenta 3 3 7 13 Post-partum haemorrhage 8 4 12 24 B,B.A 18 10 4 32 Lacerated perineum 140 20 181 341 Obstructed labour 0 2 0 2 Precipitate labour 0 0 1 1 Premature labour 43 12 16 71 Abortion 3 107 1 111 Ectopic pregnancy 0 2 0 2 4. Conditions chiefly Post-Natal excluding re-admissions from Post-Natal Clinic. Retroversion 31 2 34 97 Delayed involution 62 10 69 141 Post-partum nephritis 0 1 1 2 Breast abscess 1 0 1 2 Notified pyrexia or fever 12 10 4 26 In addition 2 cases of Puerperal Fever per see were admitted Hospital Isolation Wards and 14 cases to the Puerperal Infection Borough Hospital. 155 Cardiac Disease. There were 24 cases. None died. Three infants were stillborn among the 22 births, a mortality of 14 per cent. Hydramnios. There were 11 cases: 7 "Booked" cases at Mayday Hospital, 2 "Booked" cases at St. Mary's Maternity Hospital, and 2 Mayday emergency cases. No mother died. Seven infants were still-born, a mortality of 63 per cent. 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 and calcium content (milk and egg yolk), copious fluids, alkalies and aperients. If the symptoms and signs did not disappear in about 10 days, or if they became progressively worse, labour was induced. Mayday Hospital Booked. Mayday Hospital Emergency. St. Mary's Maternity Hospital Booked. Total. Number of cases 69 31 40 140 Number of stillbirths and infant deaths 10 6 2 18 Foetal and infant mortality 15% 20% 5% 13% Number of maternal deaths 1 — 1 2 (Twins) Eclampsia (4 cases). Mayday Hospital Booked. Mayday Hospital Emergency. St. Mary's Mat. Hosp. Booked. Total. Number of cases 0 2 0 2 Maternal deaths 0 2* 0 2 *1 mother died undelivered. a 1 „ was delivered before admission. 156 Accidental Ante-Partum Haemorrhage ( 17 cases). Mayday Hospital Booked. Mayday Hospital Emergency. St. Mary's Mat. Hosp. Booked. Total. Number of cases 7 5 5 17 Number of stillbirths and infant deaths 1 0 0 1 Foetal and infant mortality 14% 0% 0% 6% There was no maternal death. Placenta Praevia (12 cases). Mayday Hospital Booked. Mayday Hospital Emergency St. Mary's Mat. Hosp. Booked. Total. Number of cases 6 5 1 12 Number of stillbirths and infant deaths 2 2 0 4 Foetal and infant tality 33% 40% 0% 33% There were 3 maternal deaths. Contracted Pelvis (including relative disproportion between the pelvis and foetal head). 30 cases of contracted pelvis or disproportion were treated during the year. There was 1 maternal death. In 26 "Booked" cases there were 7 infant deaths (28 per cent.), and in 4 "Emergency"cases there were 2 infant deaths (50 per cent.). Three cases were treated by induction of premature labour, 2 medical induction and 1 surgical. Mayday Hospital Booked. Mayday Hospital Emergency St. Mary's Maternity Hospital Booked. Total. Method of Treatment. No.of Cases. Infant Deaths No.of Cases. Infant Deaths No.of Cases. Infant Deaths No.of Cases. Infant Deaths Spontaneous delivery 10 0 2 1 1 0 13 1 Forceps delivery 2 2 1 1 5 3 9 6 Embryotomy 1 1 0 0 1 1 2 2 Caesarean section 4 0 1 0 3 0 8 0 Total 17 3 4 2 10 4 30 9 157 Vertex Presentations at Delivery. The number of deliveries in which the occiput was anterior at the beginning of labour was 1,193. The number of deliveries in which the occiput was posterior at the beginning of labour was 93. Breech Delivery (52 cases). (For Ante-natal treatment of breech cases, see page 149). Mayday Hospital Booked. Mayday Hospital Emergency. St. Mary's Maternity Hospital Booked. Total. Number of breech deliveries 21 13 18 52 Number of stillbirths and infant deaths 5 7 1 13 Foetal and infant mortality 25% 54% 5% 25% Maternal deaths 0 2 0 2 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, etc. Mayday Hospital Booked. Mayday Hospital Emergency. St. Mary's Maternity Hospital Booked. Total. Number of uncomplicated breech cases 15 6 14 35 Number of stillbirths and infant mortality 1 1 0 2 Foetal and infant mortality 7% 16% 0% 6% Number of complicated breech cases 6 8 3 17 Number of stillbirths and infant deaths 4 6 0 10 Foetal and infant mortality 66% 75% 0% 60% 158 Face and Brow Presentations (4 cases of Face and 1 of Brow). There were two cases of Face Presentation "Booked" at May day Hospital; no "Emergency" cases at Mayday Hospital; and two among the St. Mary's Maternity Hospital "Booked" cases. No mother died. Three infants were still born and one died: a mortality of 80 per cent. Shoulder Presentations (6 cases). There was a "Booked" case at Mayday Hospital and three "Emergencies" at Mayday Hospital. No mother died. Three infants were still born: a mortality of 50 per cent. Complex Presentation. One "Booked" case at St. Mary's Hospital had a live baby. The mother recovered. Prolapse of Cord (4 cases). At Mayday Hospital there were two "Booked" and two "Emergency cases. No mother died. The infants were stillborn. Post-Partum Haemorrhage (24 cases). There were eight cases in Mayday Hospital "Booked" cases; four in Mayday Hospital "Emergency" cases; and twelve in St. Mary's Maternity Hospital "Booked" cases. There were two maternal deaths, an "Emergency case at Mayday Maternity Hospital. Maternal mortality 3.6 per cent. There were two deaths of infants at Mayday and one at St. Mary's. Abortion. The service dealt with 107 cases of Abortion during the year. All were treated at Mayday Hospital (3 "Booked" cases and 104 "Emergency"). There was one maternal death due to Septic Endometritis. Conditions for which Abortion was induced:— Chronic nephritis 1 case Pulmonary tuberculosis 2 cases Recurrent pregnancy toxaemia 1 case Chronic rheumatic carditis 1 case 159 Ectopic Pregnancy. Two cases of Ectopic Pregnancy were admitted to Mayday Hospital. There was no maternal death. Laceration of Perineum. The perineum was lacerated in 341 cases. Table XII. Place of Delivery and Category. 1st and 2nd degree. 3rd degree Total. Mayday Hospital—Booked 136 4 140 Mayday Hospital—Emergency 18 2 20 St. Mary's Maternity Hospital—Booked 175 6 181 341 Induction of Labour. Labour was induced 22 times: 11 were medicinal and 11 instrumental. 8 were in Mayday Hospital "Booked" cases; 3 in Mayday Hospital "Emergency" cases; and 11 in St. Mary's Maternity Hospital "Booked" cases. Two mothers died. One infant was stillborn, an infant mortality of 5 per cent. Forceps Delivery. Forceps were applied 61 times (19 Mayday Hospital "Booked," 8 Mayday Hospital "Emergency," and 34 St. Mary's Maternity Hospital "Booked" cases). In two cases at St. Mary's Hospital forceps were applied after induction of labour. There was one maternal death. in Mayday Hospital "Booked" cases 2 babies were stillborn, an infant mortality of 10 per cent. In Mayday Hospital "Emergency" cases 2 were stillborn and one died, an infant mortality of 37 per cent. At St. Mary's Maternity Hospital, 4 babies were stillborn, an infant mortality of 12 per cent. 160 The main reasons for Forceps Deliveries were: Rigid soft parts, 23; Posterior position, delayed rotation, 15; Disproportion, 10; Foetal distress, 6 ; Various other causes, 7. Caesarean Section. Caesarean Section was performed 21 times: 13 "Booked" and 3 "Emergency" cases at Mayday Hospital, and 5 "Booked" case at St. Mary's Maternity Hospital In 9 cases the indication was contracted pelvis and disproportion , 4 pre-eclamptic toxaemia, placenta praevia, 5 heart disease, 1 albuminuria, and 1 twins. There was 1 maternal death due to placenta praevia and 1 still birth. Bipolar and Internal Version (10 cases). At both hospitals there were 3 "Booked" cases treated by internal version for shoulder presentation, 2 at Mayday and 1 at St. Mary's. Three "Emergency" cases at Mayday Hospital were treated for shoulder presentation. No mother died. Three babies were stillborn, a mortality of 100 per cent. Four cases were treated for placenta praevia. There were 2 maternal deaths, 4 stillborn babies. Embryotomy. Embryotomy was performed once in a Mayday Hospital "Booked" case admitted for obstructed labour and once in a St. Mary's "Booked" case. There was no maternal death. Manual Removal of Placenta. Manual removal was performed 13 times. There were 3 "Booked" cases at Mayday Hospital and 3 "Emergency at St. Mary's Maternity Hospital. Two mothers died, one "Booked" case at each hospital. 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 Sepsis after delivery elsewhere. These are given in the Report of the Puerperal Isolation Wards. 161 The Strasbourg Convention standard of pyrexia, as adopted by the Ministry of Health, has been used, namely, "A temperature of 100.4 deg. F. or more, sustained during a period of 24 hours or recurring during that period." Blood Transfusion (4 obstetrical and 6 gynaecological cases). The citrate method was employed, and 22 donors were supplied by the Blood Transfusion Service of the British Bed Cross Society and 19 by relatives or friends. Two Mayday "Emergency" cases died. In both of these haemorrhage was the indication for the transfusion, one patient died some time later of sepsis. Six blood transfusions were given to patients admitted for puerperal sepsis per se ; and all these patients recovered as also did the 6 gynaecological cases. Infants. Mayday Hospital. Booked. Mayday Hospital. Emergency. St. Mary's Mat. Hosp. Booked. Total. Per cent. Number of Infants in hospital on 1st January, 1936 37 3 20 57 - Total number of live births, stillbirths and infants admitted with mother (B.B.A.) ... 703 95 590 1,388 - Number of Infants in hospital on 31st December, 1936 36 - 30 66 - Living—alive on discharge from hospital 667 70 565 1,302 93.8 Stillborn (fresh) 16 12 13 41 3.0 Stillborn (macerated) 11 7 8 26 1.9 Died (born alive, but died in hospital) 9 6 7 22 1.6 Infant Feeding and Weight on Discharge from Hospital. In both hospitals normal infants were breast-fed every four hours, omitting the early morning feed. Of 737 infants discharged from Mayday Hospital, 485 were up to or over birth weight (65 per cent.). Of 665 infants discharged from St. Mary's Maternity Hospital, 375 were up to or over birth weight (56 per cent.). 162 Twins and Triplets. There were 20 cases of Twins and none of Triplets. There was no maternal death. Mayday Hospital Booked. Mayday Hospital Emergency. St. Mary's Mat. Hosp. Booked. Total. Number of cases 7 3 10 20 Number of infants discharged alive 12 3 20 35 Number of stillbirths and infant deaths 2 3 0 6 Foetal and infant mortality 14% 50% 0% 12.5% POST-NATAL AND GYNAECOLOGICAL CLINIC. In 1936, 68 per cent. of "Booked" cases delivered in the hospitals attended the Post-Natal Clinic six weeks after their confinements. This is practically the same as in 1935. Number of Sessions held 104 Number of individuals presented 1.021 Number of subsequent attendances 166 Total attendances 1,187 Average attendance per session 11.4 Number of Post-Natal cases 856 Number of Gynaecological cases 165 Table XIII. POST-NATAL CASES. After confinement at total Mayday Hospital. St. Mary's Hospital. Elsewhere. Total cases 383 400 73 856 Cases found to be normal 292 352 51 695 Cases found to be abnormal 91 48 22 161 Cases treted as Out-patients 32 35 17 84 Cases admitted to Mayday Hospital 4 5 1 10 163 Table XIV. 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 and Delayed Involution 34 34 8 59.4 8.9 Delayed Involution 9 1 6 12.5 1.9 Trauma 3 5 2 7.8 1.2 Infection 6 0 4 7.8 1.1 Chronic Nephritis 2 0 0 1.6 0.2 Other 4 8 2 10.9 1.6 Totals 58 48 22 100.0 15.0 END RESULTS. 809 cases were treated to their termination (other than death) during the year, and the results were classed as follows:— Result I.—Health unimpaired as a result of recent confinement (i.e., no symptoms and no anatomical or functional disability). (82%). 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). (15.8%). 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). (2.2%). Mayday Hospital. St. Mary's Hospital. Elsewhere. Totals. Result I. 316 379 54 749 Result II. 27 20 12 59 Result III. 0 1 0 1 Totals, treated to conclusion 343 400 66 809 164 Maternal Mortality (Obstetric Service). These cases fall into three categories. The first includes all "Booked" cases (i.e., those who had attended the Ante-Natal Clinic on two occasions, whether they were delivered in the Council's beds or not). The second consists of those admitted to Hospital as "Emergency" cases (i.e.,, they had not attended the Ante-Natal Clinics on more than one occasion, if at all). The third category is made up of cases admitted after delivery as Puerperal Sepsis per se and treated at Mayday Hospital or in the Borough Hospital Puerperal Infection Unit. This last group is dealt with in the Report of the Puerperal Isolation Wards (see below). Thirteen deaths occurred of mothers dealt with by the service, three of these, however, cases of sepsis, only came under the service after the onset of sepsis. 11 deaths occurred in "Emergency" cases, and 2 in "Booked" cases. The maternal mortality of "Booked'' cases, i.e., cases under the continued supervision of the service was 1.38 per 1,000. This is a sufficient commentary upon the value of such supervision in controlling maternal mortality. The Registrar-General's figures for deaths directly due to pregnancy were as follows:— Total Maternal Deaths allocated to Borough of Croydon 12 Maternal Mortality 3.56 per 1,000 REPORT OF THE PUERPERAL ISOLATION WARDS. 50 cases were treated in isolation for puerperal infection, 23 of them in the Borough Hospital Puerperal Infection Unit and 27 in Isolation Wards at Mayday Hospital. There were 4 deaths (8 per cent.). SOURCES OF THE CASES. From Mayday Hospital— Cases. Deaths. "Booked" cases 17 29 2 "Emergency" cases 12 From St. Mary's Maternity Hospital 6 0 From other hospitals 8 0 From private doctors, deliveries in nursing homes 7 2 From private doctors, deliveries at home DAY OF ADMISSION AFTER LABOUR. Before 0 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th After No.of cases 165 1 60322l03 47 cases followed Labour with 3 deaths (6 per cent.). 2 cases fallowed Abortion with 1 death (50 per cent.). 165 The 50 cases treated may be classified as follows:— Mortality Cases. Deaths. Rate. (1) Patients with infection of the genital tract 28 4 14% (a) Infection limited to uterus, vagina and perineum 17 0 0 (b) Infection involving pelvic cellular tissues, ovaries, Fallopian tubes, pelvic peritoneum or veins 2 0 0% (c) Infection of the birth canal spread beyond the pelvis (general peritonitis, septicaemia, etc.) 9 4 44% (2) Patients with infective conditions not originating in the genital tract 21 0 0 No. of cases No. of cases with with Factors Bearing on Aetiology. infection. infection. genital non-genital Uncomplicated labour 2 9 Long labour 2 0 Surgical induction of labour 2 0 Instrumental delivery 1 1 Spontaneous abortion 2 0 Evacuation of abortion 1 1 Manual removal of placenta 5 0 Excessive bleeding 6 3 Severe lacerations 2 0 Other interference 2 2 Parity of the Cases. Over Para 1 2 3 4 5 6 7 8 9 10 10 No. of cases 20 7 5 2 0 0 0 0 1 0 0 The large proportion of cases drawn from deliveries in Mayday Hospital is accounted for by 4 cases of Abortion and 14 cases in Group 2 (non-genital infection) who were isolated on the first day of a rise of temperature. This policy of isolating a case immediately, and often before a diagnosis is made, is necessary, because it is impossible at present completely to isolate a case within the maternity department. OBSTETRIC CONSULTATIONS. As Consulting Obstetrician to the Borough, the Assistant Medical Officer of Health for Obstetrics was called in by medical Practitioners to see 28 patients who could not afford to pay a private consultant. 166 The cases were as follows: Puerperal pyelitis, threatened abortion, transverse lie, persistent vomiting of pregnancy, disproportion, prolonged occipito-posterior labour, disproportion, contracted pelvis, puerperal septicaemia, acute vulvitis, prolonged labour, threatened abortion, puerperal sepsis, puerperal pyelitis, pregnancy and rheumatic carditis, obstructed labour due to fibroid, pre-eclampsia, postpartum haemorrhage, prolonged labour and inertia, puerperal phlebitis, vulval haematoma, prolonged labour, puerperal sepsis and mania, puerperal parametritis, ectopic gestation, progressive uterus neonatorum, elderly primigravida. In addition, he was asked by the Medical Superintendent of Mayday Hospital to give an opinion on the obstetric and gynaecological aspects of 34 cases in the medical and surgical wards of the hospital. The preceding pages deal with the maternity service in the clinical control of the Assistant M.O.H. for Obstetrics. In the following paragraphs some aspects of the general maternity work of the borough are reviewed. MATERNITY AND CHILD WELFARE CONSULTATIONS. 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 21 sessions per week are held and at all of these a doctor and a nurse on the staff of the Health Department attend. During 1936, 2,234 new cases under 1 year of age, and 772 over a year of age attended for the first time; this is an increase of 10 in the first class and a decrease of 85 in the second class. The total attendances of infants and young children from 0—5 years decreased from 79,299 in 1935 to 76,109 in 1936. Consultations with doctors decreased in numbers from 23,924 to 23,733. 231 expectant mothers were seen, an increase of 36 on 1935, and a total of 1,130 visits to the centres were paid by them. The total of all visits to the Centres was 77,239, a decrease of 2,912 compared with 1935. The highest average attendance of mothers and babies at each session was recorded at Municipal (104.6), St. Jude's (88.9), and Waddon (85.6). The fall in the number of total attendances has been caused by a deliberate restriction in the frequency of attendances. This is done to keep numbers within reasonable limits so that adequate attention can be given by the doctors and nurses to cases needing their expert advice. 167 Attendances at Infant Centres-1936 Municipal. Boston Road. St. Andrew's. South Croydon. Shirley. Woodside. Lr. 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 1936. Total 1935. Total 1934. Total 1933. Total 1932. Infants : New cases under 1 year 378 109 114 110 89 118 188 222 60 50 186 94 91 115 87 85 138 2234 2224 2190 2194 2278 No. of re-attendances 4943 1845 1860 1667 1665 1754 3217 3507 849 964 3464 1246 1762 1526 1897 1387 2313 35866 36235 33227 36620 35161 New cases over 1 year 107 35 32 31 27 39 98 64 43 13 67 29 19 51 43 46 28 772 857 1019 1027 1052 No. of re-attendances 4919 1957 1929 1781 1612 1464 2820 3160 1576 998 3543 1482 1450 2171 2105 2517 1753 37237 39983 36403 37622 34645 Attendances of children 0-5 10347 3946 3935 3589 3393 3375 6323 6953 2528 2025 7260 2851 3322 3863 4132 4035 4232 76109 79299 72839 77463 73136 Consultations with Doctor 2749 1025 1066 1208 854 1193 2446 2476 914 756 2466 1202 853 1438 796 1151 1140 23733 23924 24721 25251 24652 No. of Sessions 100 51 48 48 48 47 97 98 51 48 99 47 50 50 51 49 48 1030 991 978 979 972 Expectant Mothers : Nc. of new cases 52 1 ... 3 9 10 29 17 16 11 22 ... 9 4 5 28 15 231 195 312 305 33 No of re-attendances 61 43 11 17 32 20 70 119 104 40 102 26 31 46 27 130 20 899 657 826 906 103 Total attendances of Expectant Mothers 113 44 11 20 41 30 99 136 120 51 124 26 40 50 32 158 35 1130 852 1138 1211 1369 Total attendances 10460 3990 3946 3603 3434 3405 6422 7089 2648 2076 7384 2877 3362 3913 4164 4193 4267 77239 80151 73977 78674 74505 Average attendance per Session 1936 104.6 78.2 82.2 75.2 71.5 72.4 66.2 72.3 51.9 43.3 74.6 61.2 67.2 78.3 81.6 85.6 88.9 *75.0 1935 111.7 75.9 79.0 89.5 74.9 72.9 89.9 72.3 55.3 48.5 73.8 78.7 74.4 95.6 84.3 94.0 86.4 *80.9 1934 98.0 73.3 68.0 87.0 57.4 62.2 108.9 69.5 49.8 52.9 69.0 68.8 61.5 100.4 84.6 84.3 77.8 *75.6 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 ... * Total average attendance each week at all the Centres. 168 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 XVI. Deaths Attended M. & C. W centre Attended at Birth by Full Time Baby Births during the same period Deaths in Institutions Yes No Doctor Midwife Doctor & Midwife Not Known, etc. Yes No Not Known Mayday Hospital Kegel. Maternity Homes St. Mary's Hospital Other Institutions 79 15 64 15 47 13 4 44 32 3 3248 29 8 6 5 2,234 babies under one year of age attended the Clinics for the first time during 1936. Within the same period 3,248 babies were bom and 134 died; 55 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 79 babies tabulated who died, 15 had attended a clinic in Croydon and 64 had not attended, i.e., 19 per cent. of the deaths were in clinic babies and 81 per cent in non-clinic babies. Of the 3,248 babies born, approximately 68.8 per cent. attended or would attend on calculation based on past attendances. The infantile mortality, estimated on this basis is only 6.6 per 1,000 births for the clinic babies, and 62 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 84 per cent. 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, 72 per cent, 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 so because of some difficulty in management ; 69 per cent. of babies 169 under 1 year were being breast fed at their first visit, this figure being less than 1935 (70); 63.9 per cent. of the ailing babies were suffering from digestive troubles, 7.3 per cent. from respiratory trouble, and 2.7 per cent. from rickets. The individual centres showing the highest percentage of babies found healthy on their first visit were East Croydon (97) and Waddon (96). Woodside, Norbury, and Municipal with 93, 91, and 90 respectively, were next. The centres showing the highest percentage of babies found ailing on their first visit were Upper Norwood and St. Oswald's followed by St. Andrew's and Boston Road. Breast feeding seemed most usual in babies attending Waddon, West Croydon, All Saints', St. Alban's, and Municipal Centres, and least usual in cases attending Norbury, South Norwood, Woodside, and St. Jude's Centres. In children over one year of age, attending for the first time, the highest percentages healthy were shown by Waddon (93), South Croydon (88), and East Croydon and Woodside (83) ; the highest percentages found unhealthy were at Boston (70), All Saints' (50), and Upper Norwood (45). The largest number of first attendances was recorded at the Municipal Centre, followed by South Norwood, East Croydon, and St. Alban's. These Centres hold two sessions weekly. 170 Babies Under One Year. Children Over One Year. The Conditions of Babies on First Attendance at a Maternity and Child Welfare Centre. Table XVII. No. found healthy on 1st visit. Percentage. No. found ailing on 1st vi-it 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 Troubles. Rickets. Respiratory Troubles Other Causes. No. still on Breast at 1st visit. No. Weaned and on solid food. Percentage. No. not Weaned and on bottle entirely No. on solid food and the Breast No. on solid food and the bottle. Total first attendances tabulated. Mun.cipal (2) 314 90 35 16 1 1 17 254 73 64 31 57 74 20 3 1 2 14 0 75 97 0 1 1 426 St. Albans (2) 162 81 39 25 0 4 10 112 56 55 34 56 75 19 4 8 2 5 0 75 100 0 0 0 276 Boston Roaa 65 71 '27 24 0 1 2 68 74 19 5 8 29 19 3 4 3 9 0 27 100 0 0 0 119 West Croydon 94 87 15 6 1 3 5 71 66 27 10 23 68 11 0 3 0 8 0 32 94 0 0 2 143 Norbury 63 91 7 2 0 4 1 45 65 19 5 13 81 3 1 0 0 2 0 16 100 0 0 0 86 St. Paul's 80 86 13 6 1 3 3 53 57 31 9 13 65 7 0 3 2 2 0 20 100 0 0 0 113 All Saints 35 78 10 7 0 0 3 27 60 17 1 5 50 5 0 1 0 4 0 9 90 0 0 1 55 Shirley 65 83 13 7 0 0 6 58 74 14 6 18 67 9 0 0 0 9 0 27 100 0 0 0 105 South Croydon 74 80 18 9 0 1 8 70 76 17 5 21 88 3 1 1 1 0 0 23 96 1 0 0 116 South Norwood(2) 196 86 33 23 4 1 5 129 56 68 12 51 69 23 4 4 5 10 0 74 1011 0 0 0 303 St. Andrew's 72 69 33 22 0 2 9 82 78 18 5 16 80 4 2 0 0 2 0 19 95 0 1 0 125 Upper Norwood 35 64 20 13 0 1 6 45 82 8 2 11 31 25 3 3 6 13 0 86 100 0 0 0 91 Waddon 82 96 3 0 0 1 2 80 94 3 2 40 93 3 0 1 1 1 1 40 98 0 0 0 128 East Croydon (2). 175 97 6 5 0 1 0 133 73 29 19 91 83 19 1 1 6 11 0 110 100 0 0 0 291 Woodside 116 93 9 6 0 0 3 83 66 32 10 38 83 8 1 2 1 4 0 46 100 0 0 0 171 St. Oswald's 56 64 32 28 1 1 2 61 69 13 14 13 65 7 1 2 1 3 0 19 95 0 0 1 108 St. Jude's 102 86 17 12 i 0 4 89 75 20 10 16 76 5 1 0 1 3 0 20 95 0 0 1 140 Totals 1786 84 330 211 9 24 86 1460 69 454 180 490 72 190 25 34 31 100 1 670 98 1 2 6 2796 171 TABle XVIII. The Work of the Health Visitors.- Maternity and Child Welfare Only. I. II. III a IV. b V. VI. c VII. VIII. d IX. e X. XI. XII. XIII. XIV. XV. XVI. XVII. XVIII. XIX. f XX. XXI. XXII. XXIII. XXIV. Totals. C.W R.A. D.H. B.W. A.W. W. J.T. M.S. A.P. V.B. A.W. J.C. E.H. A.H. K.T. v.c M.C. R.S. M. Su. E.P. c. Wa. P.C. L.P. B.E. Others Sessions attended at Infant Welfare Centres 104 53 ... 26 77 39 43 18 25 53 51 46 62 49 99 55 49 ... 13 57 42 55 41 71 1128 Visits to Expectant Mothers. First visits 45 11 1 ... 32 1 22 ... 15 5 5 17 30 12 12 2 3 25 3 4 32 4 29 4 314 Re-visits 23 9 ... 2 2 ... 7 ... 8 1 6 65 ... 1 12 3 1 ... 10 92 2 15 1 260 Infants under 1 year. First visits 207 102 48 73 83 60 108 103 90 318 175 203 161 148 168 208 160 142 51 91 245 174 129 254 3501 Re-visits 374 225 98 57 229 159 123 48 186 377 386 803 486 313 489 839 475 158 57 593 783 711 263 550 8782 Children 1-2 years. 1 First visits 9 ... ... 9 ... 3 3 ... 1 6 16 I 1 8 6 4 3 ... 14 6 30 106 4 231 Re-visits 408 191 104 103 205 155 123 40 84 385 317 773 295 232 510 625 398 185 40 532 806 727 258 545 8041 Children 2-5 years. First visits 10 ... ... 14 ... 6 7 1 3 1 4 4 ... 1 8 5 12 1 ... 4 3 13 144 12 253 Re-visits 987 684 60 183 474 274 395 152 112 706 206 981 421 581 682 635 733 220 80 482 984 677 481 1064 12254 Ophthalmia Neonatorum. First visits 1 ... ... ... ... ... ... ... ... 1 1 1 1 ... ... 2 ... 2 ... ... 2 1 ... 12 Re-visits 2 ... ... ... ... ... ... ... ... 3 2 10 ... ... ... 1 ... ... ... ... 10 ... 2 1 31 Still Births 11 4 1 2 ... 2 1 ... 2 3 2 7 5 4 9 5 12 4 1 3 ... 5 10 12 105 Milk (Mothers' and Children's Order) 4 28 ... 15 ... 4 5 ... 4 1 5 1 3 1 2 ... 34 6 ... 43 2 2 8 10 178 Puerperal Fever and Pyrexia Visits 1 ... 2 3 Houses where deaths of Infants occurred 4 4 2 4 7 1 3 6 3 17 2 3 8 11 9 2 3 5 5 5 1 2 2 5 114 Miscellaneous Visits 24 10 ... 182 ... 18 77 16 12 14 5 4 31 114 6 3 21 57 4 8 32 1 20 3 662 Ineffective Visits 497 188 230 259 480 202 270 89 173 377 471 170 292 223 616 325 776 603 35 247 440 545 311 717 8536 Post Natal Visits ... ... ... ... ... ... ... ... 12 60 ... ... ... ... ... ... ... ... ... ... ... ... ... 1 73 Totals—1936 2606 1456 544 903 1512 885 1142 458 704 2271 1593 3058 1734 1642 2531 2661 2631 1412 276 2036 3438 2895 1779 3183 43350 1935 2211 1345 792 1582 1451 1888 1290 1203 1908 1637 1598 3096 920 1981 96 294 2107 2743 2597 1492 1116 842 1167 2516 38872 a Superannuated 1/12/36. b Left 31/7/36. c Off Duty since May 25, 1936. d 4 months sickness. e Partially incapacitated. f Left 28/3/36. 172 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 ordered at the Voluntary Centres or at the Municipal Centre. All wet milk ordered under cost price is also paid for by the Council. TABLE XIX. On Dec. 31st, 1935. New cases during the year. Cases discontinued. On Dec. 31st, 1936. Free 307 655 663 299 Half-price 72 148 136 84 Total 379 803 799 383 In cases where there has been a change from free milk to milk at half-price it has been counted as a new case. The year showed an increase of 4 in assisted milk cases. Assisted Fluid Milk Scheme. The amount of milk granted was 110,715 pints. In 1935 it was 129,591 pints. Supplied to Families. No. of Pints. Corporation Liability. Milk at l½d. pint 17,774 £ s. d. 137 4 8 Milk Free 92,941 1,300 4 3 110,715 £1,437 8 11 Dried Milks for Year. I am much indebted to Mrs. Horn, Hon. Secretary 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, up to May, 1936There is an increase from 1935 in the amount of dried milk free of 1,303 packets; of 4,819 packets obtained at cost price, an a decrease of 89 packets obtained at half-price. 173 On June 1st the system of supplying dried milks and other articles through the Infant Welfare Centres was changed. The Centres ceased to stock any of these substances and in place thereof coupons are given to mothers for the articles ordered. These coupons are taken to the nearest chemist whose name is on the roll of those undertaking to supply goods, etc., by agreement with the Council, and in exchange for the coupon the mother receives the goods, etc., ordered on the coupon. The coupons are of three different colours, according to whether the article is to be free of cost, half-price or cost price. The chemists send in the coupons they receive monthly to the Public Health Office, and are paid on them. The scheme, after one or two minor difficulties at the commencement, is now working smoothly. The chemists participating have co-operated excellently and have tried to make it successful. Table XX. Mothers and Infants Welfare Association. (19 sessions per week). Municipal Centre. (2 sessions per week). Free. Halfprice. Full price. Free. Halfprice Full price. January 549 93 1302 92 8 177 February 410 84 1240 89 5 156 March 402 129 1465 129 9 170 April 390 154 1085 70 4 203 May 409 175 1206 74 3 187 Totals 2166 635 6298 454 29 890 From June 1st, 1936, the Dried Milk was supplied through the Chemists, the Scheme being in operation at all Infant Centres. Free. Half. Price. Full. Price. June 348 120 1,174 July 387 128 1,822 August 505 76 1,393 September 506 93 1,509 October 661 111 1,757 November 692 141 1,723 December 728 130 1,866 Total Jan. to June 3,827 799 10,744 2,620 644 7,138 Total for year 6,447 1,463 17,932 174 Table XXI. comparative statement of wet and dried milks, 1935-1937. WET MILK. DRIED MILK. 1935—1936 1936—1937 1935—1936 1936—1937 Pints. Corporation Liability. Pints. Packets. Corporation Liability. Packets. Corporation Liability. Free. Half Price. Free. Half Price. Liability. Free. Half Price. Free. Half Price. April 9,767 1,806 £ s. 157 9 d. 8½ 7,348 1,302 £ s. 118 0 d. 2 276 103 £ 22 s. 2 d. 8 317 134 £ 21 S. 4 d. 6 May 11,820 1,834 159 4 3 6,851 1,212 93 4 3 265 135 22 3 3 323 144 21 14 5 June 8,980 1,554 121 19 3 6,539 1,428 91 13 3 236 131 19 3 4 *348 120 23 9 0½ July 8,696 1,694 119 5 9 7,014 1,708 98 7 0 358 201 27 4 61 387 128 27 18 3½ August 6,745 1,139 91 8 74 6,089 1,358 84 12 0 323 110 23 11 8 506 93 35 14 10 September 7,120 1,428 115 14 8 7,072 1,526 115 17 1 328 125 23 11 11 505 76 37 3 3 October 7,615 1,162 120 14 8½ 6,934 1,958 117 8 9 396 104 25 19 9 661 111 49 14 9 November 6,894 1,064 109 8 1 8,797 1,848 143 13 9½ 428 70 28 4 91 692 141 47 13 61 December 7,014 1,124 111 13 1 11,201 1,666 177 4 7½ 394 79 25 7 5 728 130 64 5 61 January 8,302 1,092 130 3 5 9,803 1,798 157 18 7½ 512 81 32 6 3 651 114 51 18 3 February 8,333 1,106 130 15 1½ 10,409 1,906 167 13 7½ 410 76 26 8 8 677 161 55 19 31 March 8,461 1,570 136 9 5½ 12,565 2,512 204 3 6½ 394 88 25 15 7 710 149 56 16 10 total 99,747 16,573 1,504 6 1½ 100,622 20,222 1,569 16 8½ 4,320 1,303 301 19 10 6,505 1,501 493 12 6½ From June, 1936, must be added cost of drugs, etc. now supplied by the Council 52 16 0 * From June , 1936 , Dried Milk and drugs were supplied through Chemist, all Hability being borne by the Council and not party by C.M. & I.W.A. , as heretofore 546 8 6½ 175 Observation Nursery.—Summary of Work Done. No. of mothers admitted 4 No. of cases in on 1st January, 1936 10 No. of cases admitted during 1936 94 Average duration of stay 30 days No. of cases discharged 96 (a) In good health 76 (b) Improved 8 (c) No improvement (taken out by parents against doctor's advice) 4 Referred to other institutions 7 No. of cases who died 1 No. in at end of 1936 8 1 case referred to Vincent Square—Pyloric Stenosis. 1 case referred to Mayday—Mastoid. 5 cases referred to Borough Hospital— Rubella 1, Mumps 1, Pertussis 2, Ophthalmia 1. Reasons for admission:— Failure to thrive 29 Enteritis 4 Rachitis 13 Urticaria 1 Marasmus 6 Anaemia 1 Mismanagement 8 Pyloric stenosis 1 Malnutrition 14 Convulsions 9 Bronchitis S Conjunctivitis 1 Vomiting 3 Dental case 1 Re-establishment of breast feeding 7 Massage Clinic. The Massage Clinic in connection with the Maternity and Child Welfare 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 Orthopedic Clinic and from London Hospitals. The following Table summarises the work done, and indicates the type of case referred. Total number of female patients 41 „ „ male patients 74 Total 115 176 Table XXII. Conditions for which referred. Males. Females. Total, Pigeon-chest 1 1 Talipes 1 1 Weak legs 19 10 29 Bow legs 19 9 28 General debility 9 6 15 Kinook-knees and flat feet 22 12 34 Hemiplegia 1 1 Torti-collis 2 2 Weak abdominal muscles 1 1 Secondary Amyotonia 1 1 Injury to thumb 1 1 Spastic diaplegia 1 1 74 41 115 Total number of sessions 255 „ „ attendances 1,790 Average attendance per session 7 Cases still under treatment at end of 1936 33 DENTAL TREATMENT FOR MATERNITY AND CHILD WELFARE PATIENTS. There has been a great improvement in the number of mothers who have attended the Clinics during the year. The improvement is due in a large measure to the increased numJber of women referred from the Clinics in the early stages of piegnancy. The ideal will not be reached, however, until every woman examined at the antenatal Clinic is dentally inspected, and when necessary X-Rayed,so that insidious dental infection, which may cause incalculable harm, can be eliminated at the earliest possible time. Unfortunately, many of the women examined have ven unhealthy mouths, and this dental sepsis is often the cause of vague ill-health during the expectant period. In view of the importance of dental treatment it is regrettable that the available staff of four dental officers (the fourth commenced duty only on the 30th November), devoting one-eleventh of their weekly time to this work, is not sufficient to cope with the large numbers requiring treatment. This deficiency is being made good in 1937, with the equivalent of a whole time dentist for this work and the supervision and treatment of the pre-school child. All the dentists will, however, take part. 177 Expectant Mothers. The days appear to be passing when pregnant women fear dental treatment, as each year sees an increase in the number treated, in 1936, 209 of these women were examined and 171 treated, as compared with 145 examined and 135 treated in the previous year. Although the number of extractions increased to 789 as against 486 in 1935, it is worthy of note that 102 fillings were inserted, which is 62 more than during the previous twelve months. The improvement in the amount of conservative treatment is probably due to the fact that many of the younger mothers have been treated in their school days by the dental officer and have been taught the principles of dental hygiene and the value of conservative measures in preserving their teeth. Other conservative treatments included 28 scalings and 70 dressings in teeth before inserting the permanent fillings. The number of attendances increased to 585 as against 375 in 1935. It is our aim to treat women as early in pregnancy as possible, and in 1936 30.7 per cent. were treated up to the third month, 46.5 per cent, between the fourth and sixth months and 22.8 per cent. from the seventh month onwards. These percentages show that the greater number of pregnant women were treated during the first six months of gestation. Nursing Mothers. As more expectant mothers were treated the number of nursing mothers treated decreased to 114, which is 68 less than in 1935. The attendances were reduced to 732 as compared with 939 in 1935. The scheme has for its aim the treatment of the expectant mother for the good of the unborn child, and the time spent on the nursing mother necessarily reduces that which should be devoted to the treatment of the pregnant woman. Dental treatment, of course, is essential for the nursing mother in certain cases, but the main purpose of the scheme is to concentrate upon the expectant mother. Here again, as in the case of the expectant women, there has been a welcome increase of conservative treatment. The number of fillings completed was 180 as compared with 135 in 1935, and other conservative measures included 40 dressings, 19 scalings and 19 gum treatments. Out of 112 referred for treatment 98 were completed. 178 The increased number of reparative treatments both for expectant and nursing mothers has resulted in a decrease in the number of dentures inserted, which totalled 101 as compared with 138 in the previous year. The percentage of nursing mothers when first seen and the age of the baby is as follows:— Age of child. 1—3. 4—6. 7-9. 9-12 months. % mothers seen in 1935 38 42 23 7 1936 35 35 20 10 It will be observed that the majority of mothers were treated during the early nursing period. Many of these women were referred during the time of pregnancy, but owing to the number of cases awaiting treatment they could not be called up earlier. It lias been the practice when mothers are referred late in the nursing period to give them emergency treatment only. Some mothers delay seeking dental advice until the nursing period is well advanced, and it is uneconomical to undertake extensive treatments tor them which could only be done at the expense of time which should be devoted to the more pressing claims of the expectant mother. The Pre-School Child. The number of young children examined was 274, which was 67 more than in 1935. Fillings inserted totalled 121 as against 90 in the previous year. While curative treatments have shown an improvement in number, it is regrettable that extractions of teeth should once again also show an increase. It is very unfortunate that often before all the teeth have fully erupted some have to be extracted in consequence of pain and sepsis, even at the early age of 18 months. Such a poor state of the child's teeth is much to be deplored, but perhaps it must be expected while so many mothers continue to feed their children on"pap" food. Many mothers appear still unaware that with the eruption of teeth food of a harder nature should be given, so that natural cleansing of the teeth may take place. It is an undoubted fact that children's teeth will continue to decay at the present rapid rate if the diet remains to a great extent non-detergent. It would be impossible, and perhaps in some respects undesirable, to attempt to revolutionise the dietetic habits of young children, but parents, with 179 advantage, might exert some influence and abstain from the practice of giving their children so many "tit-bits" between meals. It is to be feared that the majority of parents are apt to forget that although the child may get relief by the extraction of painful teeth the efficiency of the masticatory apparatus is thereby impaired, and various symptoms of ill-health may result from the child's inability to chew its food thoroughly. The truth of the maxim that what is good for the teeth is good for the body, and, conversely, that what is bad for the teeth (such as sticky foods) is also bad for the body, is becoming more evident from the increase in dental disease and child ailments. Approximately 70 per cent. of school children suffer from dental defects, and 20 per cent. are found to require treatment for such defects as mal-nutrition, rickets and rickety deformities, enlarged tonsils and adenoids. The greater part of these diseases is preventable, and correct diet and proper hygiene (including oral hygiene) would do much to improve the health of young school children. It is unnecessary to stress the fact that many more children than at present should attend dental clinics during the pre-school period, so that dental disease could be eliminated before they start their school life. For several years past, owing to the increase in curative treatments the dental officers' visits to the centres have been curtailed, and in 1936 only three visits were made, when the dental officers in addition to examining the children gave them instruction on the care of the teeth. These visits are especially valuable because they present an opportunity to interest mothers in dental matters. During the coming year many more visits to the centres will be possible. At present most of the dental officers' time is spent in reparative treatments, and it is important that more sessions should be devoted to the synteretic aspect of this work, even if it is to be at expense of time that should have been given to curative efforts. lnoat urgent problem in connection with dental schemes for Ae young child is to provide efficient prophylactic teaching for mothers with a view to reducing the prevailing amount of dental disease in the pre-school child. It is desirable that the pre-school child should be "followed up when the initial treatment is completed, and after a period of sixmonths an appointment should be made for re-examination and further treatment if necessary. Such a system will be put into practice during the coming year and that its effect will be that more teeth will be conserved and fewer extracted. 180 The following table gives a summary of the work accomplished daring the year for patients referred under the Maternity and Child Welfare treatment scheme:— Table XXIII. Expectant. Nursing. Young Children. Total. 1936. 1935 Number Examined 209 114 274 597 543 Referred for Treatment 171 112 222 505 513 Attendances 585 732 454 1771 1685 Fillings 102 180 121 403 235 Extractions 789 676 752 2217 2099 "Gas" Cases 125 83 157 365 283 Local Anaesthesia 163 123 36 322 298 Scalings 70 40 — 114 112 Dressings 86 72 20 178 159 Denture Dressings 71 239 — 310 432 Gum Treatment 28 19 — 47 36 AgNo3 1 1 5 7 7 Treatments completed 53 98 210 361 295 No. of Sessions (Treatment) 136 Dentures fitted 101 Inspections at Centres 3 Appointments kept 76.1% The number of forms issued from the Ante-Natal and PostNatal and various Infant Welfare Centres totalled 394, which is considerably fewer than in 1935. The reason for this is that the medical officers, realising the large number of patients awaiting treatment, have adopted the practice of referring only the more urgent cases. The cost of treatment (excepting the provision of prosthetic appliances) is 8d. per attendance, and 2s. Od. when a general anaesthetic is administered. The amount received for attendance fees was .£52 14s. 8d. as compared with £50 2s. 4d. in 1935. 181 The Babies' Help Committee of the Croydon Mothers' and Infants' Welfare Association. I am indebted to Mrs. Philpott for the following particulars:— In the beginning of the year the Committee was helping six cases. Eighteen have been helped during the year and we finish with nine on the books. Two mothers have mariied. One had arranged to marry baby's father but at the last moment he was suddenly sent to Palestine. Two have left the district. Beside the grants of money, dinners and milk the Committee often give prams, cots, fire guards and clothes. Anything useful would gratefully be collected if a card were sent to Hon. Secretary, Babies' Help, 33, St. -Tames' Road. 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. Convalescent Homes- Total number of children under 5 sent to Coombe Cliff during the year 34 Total number of children under 5 sent by the Committee during the year to other Convalescent Institutions (this includes one with mother to Bognor Convalescent Home) 8 Number of children under 5 sent with their mothers to cottages (this includes 11 who went to relations) 121 A grant of £6-50 was made by the Council to the Association for this work in 1936. The year is the financial year. Children under 5 Total Cost of sent to number other forms of Homes, of weeks. Cost. 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 1932-1933 47 361 322 18 11 379 7 7 1933-1934 56 378 287 6 11 387 0 2 1934-1935 48 337 279 10 10 470 3 4 1935-1936 25 240 212 11 6 427 9 0 1936 (April 1st to Dec.31st 198 11 1 332 19 8 182 Home Helps. Number of cases in which Home Helps have been provided during the period 1st January to 31st March, 1936 39 From April 1st the Home Helps were taken over by the Public Health Committee and the scheme was conducted from the Public Health offices. From April 1st to December 31st 149 mothers applied for Home Helps ; 132 Home Helps were sent and £97 8s. 6d. was collected in payment for their services. At the end of the year there were 16 names of Home Helps on the register. Croydon Rescue and Preventive Association. This Association has a Home at 34, Morland Road. As the Council now make a yearly financial grant of £100 towards its conduction, it is periodically inspected by the Council's officers. The Home has changed its function and is now more of the nature of a Remand Home. No babies are kept in residence as was formerly the case. Wilford Road, Lighthouse Mission Creche. The Council give an annual grant of £100 towards the cost of this Creche. A total of 5,641 attendances was recorded. The premises in which the Creche was conducted were cramped and unsuitable, but new and modern premises have been built in Whitehorse Road which were opened early in 1937. Towards the cost of this the Council made a grant of £875, and the annual grant is being increased to £300. COOMBE CLIFF CONVALESCENT HOME. 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 admited during year: 141. Total number of cases discharged: 168. No. of patient days: 65.1 per patient (1936 cases). 183 Table XXIV. Age groups of cases admitted. 0—4 5—8 9—12 Over 12 Total Male 9 39 21 3 72 Female 12 35 19 3 69 Total 21 74 40 6 141 Average length of stay in similar age groups. 0—1 5—8 9—12 Over 12 Total (days) Male Female 86.4 73.2 67.6 70.1 60.8 69.1 43.5 50.2 64.5 65.6 Total 79.8 68 8 64.9 46.8 65.0 Condition on discharge. 0—1 5—8 9—12 Over 12 Total M. F. M. R M. F. M. F. M. F. Improved 4 4 17 16 19 7 4 2 44 29 Much Improved 2 3 11 11 7 14 3 2 23 30 No change 3 3 6 7 8 | 4 1 1 18 15 Discharged at parent's request 4 3 1 — — 1 6 3 Total 13 13 35 34 34 25 9 5 91 77 CHILDREN ACTS, 1908—1933. Since April 1st, 1930, this Act has been administered by the Health Department. The work has been delegated to the Health \isitors, who are made responsible to the Medical Officer of Health 'wall foster-children and foster-mothers in their respective districts. lhe Tables helow fvivp fitmrpR for 193fi Table XXV. FOSTER CHILDREN No. as at Dec. 31st 1935 Notice of Reception of Children during the year Notice of removal to— Children Adopted Died Children reaching age of 9 No. as at Dec. 31st 1936 Parent Another area with Foster Parent Another Foster Mother Public Insti tution 285 215 106 9 45 27 20 2 15 276 The number of foster-children showed a decrease of 9 during the year. 184 Table XXVI. FOSTER MOTHERS. No. as at December 31st 1935 Applicati ons for Registration during the year. Removals during the year Registration cancelled for other reasons No. as at December 31st 1936 With Child Without child 154 41 6 ... 43 146 The number of foster-mothers decreased by 8 during the year. Complaints have been few but any which have arisen have been minutely investigated. Conditions are occasionally found which are not satisfactory, and there are two or three foster-mothers who do not appear to appreciate to the full their responsibilities. The chief difficulties encountered are (a) the action of some foster-mothers in adopting children, or taking a child's mother into her house and so evading the Act; (b) a tendency for foster-mothers to try and look after too many children with insufficient help; (c) where a foster-mother has children of her own to ignore these in her statements as to the number of foster-children she can look after. Unfortunately the law relating to foster-children allows of many loopholes and it cannot be said that it gives adequate powers to local authorities either in their supervision of the children, or in any proceedings which can be taken against foster-mothers. The Act does not require foster-mothers to be registered with the local authority, and from time to time persons are found by the health visitors having the care of children for gain who have never notified the fact to the local authority as is required by the Act. Ignorance is always pleaded as the excuse. Again it would seem that ah foster-children are taken under emergency action because it is the exception rather than the rule to receive the 7 days notice required under the Children Act, 1932; 48 hours or less, or even after the reception of the child, is the most usual intimation. The Health Visitors paid 2,400 visits to foster-mothers for the purposes of supervision. 185 SECTION IX. MENTAL DEFICIENCY. The staff of the department dealing with the mentally defective consists of the Medical Officer of Health and the Deputy Medical Officer, who are certifying officers; two whole-time Visitors; the Supervisor of the Occupation Centre, with three helpers. 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 ages of 7 and 16 years 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 main sources of notifications of school children suspected to be suffering from mental defects are received from School leachers and the School Enquiry Officers. Sources of information regarding cases not coming within the category of school children are mainly the Infant Welfare Centres, Health Visitors, I'robation Officers, Private Practitioners and Social Workers. Number of known Mentally Defective Persons in the Borough I. Statutory Cases— Aged 0—5 years 6 Aged 5—16 years 98 Over 16 years 468 Total 572 II. Education Cases— Aged 7—16 years 158 Combined Total 730 186 Compared with 1935, the Statutory cases show au increase of 76 and the Education cases an increase of 4. The increase is due to a number of cases previously dealt with by the Public Assistance Committee, being transferred to the Mental Deficiency Committee. Eive of the cases under Statutory supervision have died. Two died at home and 3 in Institutions. The Statutory cases are distributed as follows:— In Certified Institutions 143 In Places of Safety and Approved Homes 7 On Leave from Institutions 10 Under Statutory Supervision at Home 292 Under Guardianship 54 In Mental Hospitals 14 Cases under Public Assistance 20 Observation Cases 32 There is a steady increase in the number of cases under Statutory Supervision at home, due to the difficulty of finding suitable residential accommodation within reasonable distance of Croydon. No new cases are dealt with by the Public Assistance Committee, the Mental Deficiency Committee now being responsible for the care and supervision of all new cases of mentally defectives. The Education cases were distributed as follows:— In Certified Residential Schools 11 In Certified Day Schools 126 At Private Schools 6 At Council Schools (awaiting vacancies at St. Christopher's) 6 At no school: resident at home 1 Released for work 8 During the year, the Certifying Medical Officers made examinations and paid visits to the number of 123 to Statutory cases and 308 to Education cases—a total of 431, an increase of 30 over 1935. The Mental Deficiency Visitors paid 2,307 visits to Statutory cases and 1,839 to Education cases, 4,146 visits in all, a decrease of 54 on 1935 figures. During the year, 78 names have been added to the Statu ton List:—29 of these being notified from the Local Education Authority, and the remaining 49 from other sources. 5 names have been removed from the list. 5 cases chargeable to other Local Authorities are under supervision in the Borough. 187 Notified Cases. Of the "29 cases notified by the Local Education Authority— 3 are now in a Certified Institution ; 8 are attending the Occupational Centre ; 8 are at work; 10 are at home. During 1936, twenty-five Statutory cases were dealt with as follows, viz:— Sent to Certified Institutions 11 Sent to an Approved Home 1 Placed under Guardianship 1 Leave granted to care of brother 4 Sent to Croydon Mental Hospital 2 Varying Orders— (a) Change of Guardian 3 (6) From one Institution to another 1 (c) From Guardianship to Institution 1 (d) From Institution to Guardianship Orders Closed (for the Warwickshire County Council) 1 25 15 Orders were renewed during the year—13 of which were guardianships. The number of cases sent to Certified Institutions shows an increase of 2. It is hoped when the Botley's Park Colony of the Surrey County Council is available, two desirable steps can be taken, firstly, that more cases can be sent to an institution, and secondly, that cases now placed in institutions a long distance from Croydon ran be withdrawn from those institutions and placed in the Colony. Guardianship Cases. I here are 54 cases under Statutory guardianship—30 of these under the care of relatives, and 24 with guardians who are not le t'ions. 8 males and 6 females are at work. 20 cases are out 188 of the Borough; 12 under the Brighton Guardianship Society; 1 in Maidstone; 1 in Godalming; 1 in Streathain; 1 in Anerley; 1 in Essex; 1 in Suffolk; 1 in Harrow; 1 in Selsdon. 4 boys and 2 girls attend the Occupation Centre at Grange wood. 38 of the guardianship cases are doing useful work under supervision and 16 are quite unemployable. 2 of the patients are under supervision for other Authorities. 1 new case has been placed under guardianship. 279 visits have been paid to guardianship cases during the year. Cases on Leave from Institutions. There are 10 cases on licence from institutions; 4 are boys, and of these 1 is at home and 3 are in Mayday Hospital. These 3 cases are on licence because their parents complained of the distance they had to travel when they were away in the various institutions. Six are girls, 5 in regular work and one is acting as housekeeper for her father. There are 7 cases in Queen's Road Homes under a temporary licence from the Board of Control. St. Christopher's Special School. The year 1936 opened with 106 scholars on the roll. During the year 40 children were admitted, and 20 left, leaving 126 names on the Register on December 31st. Further particulars regarding the special school are included in the School Medical Section of this report (See page 304). Town Hall Clinic for Mentally Defective, Backward and Abnormal Children. 88 children were examined during 1936. The classifications arrived at, together with the recommendations made, are summarised as under:— I. (a) Certified as Mentally Defective 41 (b) Confirmed as Mentally Defective 8 49 Recommendations— 28 (a) Recommended for Special Day School (b) Recommended for Residential Schools 2 11 (c) Referred to Occupation Centre or Institution (d) Observation at home 8 49 189 II. Found to be dull and backward 28 (a) Referred to a Special Class 17 (b) Further trial in Ordinary Class 3 (c) To have physical treatment 1 (id) Change of school recommended 3 (e) Deferred pro tern 3 /) Recommended to Approved School 1 — 28 III. Found to be Physically Defective 1 (a) To attend St. Giles' 1 IV. (a) Considered to be of normal intelligence and referred to ordinary school 1 (b) Referred to Child Guidance Clinic 2 (c) Recommended to Institute of Child Psychology 1 (d) Recommended to Education Committee for Foster Mother away from home 1 (e) Change of School recommended 2 (/) Mother advised and observation at home 1 8 V. Decision Deferred and for re-examination later 2 VI. Mental and physical examinations at St. Christopher's School 157 Grangewood 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 opeu for five days a week from 9.30 a.m. to 3.30 p.m. and occupies rooms on the first floor of Grangewood Museum. Younger children attend daily, mornings and afternoons, the senior girls on Monday, Wednesday and Friday afternoons from '2 to4p.m. (3 sessions), and the senior boys on Tuesday and Thursday from 2 to 3.30 p.m. (2 sessions). The Mental Deficiency Committee are considering the matter of alternative and more suitable accommodation as Grangewood is situated in a public park and the facilities for outdoor activity are thereby restricted. The Centre is divided into three classes, each in charge of a teacher who is responsible for her class to the Supervisor. The staff consists of a Supervisor and three assistants. T he subjects taught to the Junior Class are; rhythmic movement drill band, rhythmic singing games, singing, sense and memory training, colour, sound, numbers, elements of stitching and rug making. As handicrafts are taught cork bead mat making, paper winding, mats, raffia weaving, knitting, ravelling, wool sorting. In addition 'dancing exercises, team games, and country dancing are indulged fibber shoes are provided for the children. 190 The senior girls have instruction in hemstitching, English embroidery, wooi 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, and baskets are made. Country dancing, drill and singing are also taught. The senior boys learn basket making, making wool rugs, sea grass stools, raffia and cane work, papier-niaclie bowls. All grades have domestic duty in preparing meals, washing up, polishing, etc. The children are conveyed to and from the Centre in a motor bus, and consequently do not mix with the travelling public, as was formerly the case when they went by bus or tram. The Christmas Party was held as usual and was attended by about 70 parents, tea being provided together with presents off the Christmas tree for the children. Two open days for parents were also held. Details. Full Time. No. on register January 1st, 1936 54 No. of pupils who left during the year 10 No. of pupils admitted during the year 9 No. of pupils on register January 1st, 1937 53 Total attendances 7,909 Average attendances 36 Average afternoon attendance— Senior girls' class 1 Senior boys' class 1 Sessions held 817 Girls' Afternoon Class- Total attendances 251 Sessions held 129 Boys' Afternoon Class— Total attendances 102 Sessions held 86 191 SECTION X. ORTHOPAEDIC DEPARTMENT. Cases referred for Orthopaedic treatment from the various 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 Orthopedic institutions for in-patient treatment. The after-care organiser of the Department attends at each session. Mrs. Connor, the after-care organiser, died during the year, and her post was filled by Miss Ilailey, who took up her duties on 21st September. In addition to the Clinic at the General Hospital, concerning which only the tables below apply, 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 Mcdical Officers at the Welfare Centres. Table I. Summary of ( ases Attending the Orthopedic Clinic. Jan- 1st, 1936. New Cases, 1936. Cases Discharged, 1936. Cases on books, Dec. 31st, 1936. M.C.W. S.M.S. Tuberc. M.C.W. S.M.S. T uberc. M.C.W. S.M.S. T uberc M.C.W. S.M.S. T uberc 156 242 48 129 167 11 113 200 16 172 209 43 446 307 323 424 192 Table II. Cases Seen by the Orthopedic Surgeon. Defect. School. M.C.W. T uberculosis. Total. Cases. Visits paid. Cases. Visits paid. Cases. Visits paid. Cases Visits paid Infantile Paralysis 17 57 5 22 ... ... 22 79 Curvature or postural defects 33 97 3 0 ... ... 36 106 Pes Cavus 8 24 5 19 ... ... 13 43 Pes Planus 90 185 21 39 ... ... 111 224 Genu Valgum 38 85 80 iso ... ... 118 265 Talipes 3 7 3 15 ... ... 6 22 Obstetrical Paralysis 4 13 6 19 .... ... 10 32 Joint Disease 11 32 4 11 25A 19S 3M 63A 48S 4 M 62 158 Injuries 16 47 1 3 1s 1s 18 51 Rickets 2 7 10 27 ... ... 12 34 Wry Neck 8 29 6 10 ... ... 14 39 Spastic Paraplegia 15 38 4 8 ... ... 19 46 Other Deformities 57 120 32 61 ... ... 89 181 302 741 180 423 48 ll6 530 1280 *Includes cases of ankle valgus, spasmodic valgus, and other predisposing causes of flat feet. Summarised, the Table shows 302 school children attended and made 741 attendances; 180 babies made 423 attendances;and 48 tuberculosis cases made 110 attendances; a total of 530 cases, making 1,280 attendances. These figures show a considerable decline upon 1935, this decline being greatest in the Maternity and Child Welfare cases. This is a favourable sign pointing, as it would seem to do, to the good effects of the teaching and the instruction of mothers at the Infant Welfare Centres. Although the number of actual school cases declined, the attendances rose. 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. 193 Table III. Cases referred from Orthopedic Clinic for Remedial Treatment and X-Ray at Croydon General Hospital. Defects School Cases M.C.W. Cases Tuberculosis Cases Total] Casts No. of Treatments X-Rays Cases N o. of Trealmen s X-R&ys Cases No. of Treatments X-Rays Cases No. of Treatments x-Rays Infantile Paralysis 6 66 ... 2 63 ... ... ... ... 8 129 ... Corvature or postur.al defects 17 325 3 ... ... ... ... ... ... 17 325 3 pes planus 18 249 ... 5 96 ... ... ... ... 23 345 ... Pes Cavus 2 85 1 ... ... ... ... ... ... 2 85 1 Talipes 1 11 ... 4 19 ... ... ... ... 5 30 ... Genu Valgum 3 38 ... 9 35 5 ... ... ... 12 73 5 Obstetrical Paralysis 3 48 ... 2 70 ... ... ... ... 5 118 ... Joint Disease ... ... ... ... ... ... 19 19 19 19 19 19 Injuries 7 80 6 2 ... 2 ... ... ... 9 80 8 Rickets ... ... ... 3 15 3 ... ... ... 3 15 3 why Neck 3 34 ... 1 ... 1 ... ... ... 4 34 1 Spastic Paraplegia 4 38 1 ... ... ... ... ... ... 4 38 1 Other Deformities 16 291 7 12 21 10 ... ... ... 28 312 17 80 1265 18 40 319 21 19 19 19 139 1603 58 Table IV. Cases Sent to Residential Institutions. Name of Institution School Cases M.C.W. Cases Tuberculosis Case! Total No. in on Jan. lit. 1937. No. in on Jan. 1st, 1936 Admitted Discharged j No. in on Jan 1st, 193R, Admitted Discharged No. in on Jan. 1st, 1086. Admitted Discharged No. in on Jan. 1st, 1938- Admitted Discharged Pyrford 4 1 2 4 1 2 8M lM 3 M } 22 5 10 17 6 s 2s 3s Croydon General 2 l1 14 2 8 7 ... Is Is 4 22 24 2 2A 2A Heritage Craft School 1 ... 1 ... ... ... ... ... ... 1 ... 1 ... 7 12 17 6 9 9 14 6 9 27 27 35 19 194 The following Table shows the conditions for which patients were admitted to Hospitals and the results of treatment. Table V. Condition. In on Jan. 1st, 1936. Admilted. Discharged In on Jan. 1st, 1937. Cured. Much Improved. Improved. Infantile Paralysis 1 3 ... 2 2 ... Tubercular Joint Disease 14 5 1 4 3 11 Other Joint Disease 6 2 1 6 ... 1 Hemiplegia 1 1 ... ... 1 1 Knock Knees 1 5 4 1 ... 1 Flat Feet ... 1 ... 1 ... ... Talipes ... 2 ... 1 ... 1 Rickets 4 2 2 1 ... 3 Wry Neck ... 3 2 1 ... ... Other Deformities ... 3 2 ... ... 1 27 27 12 17 6 19 The percentage of cures in cases discharged was 34 per cent, whilst 49 per cent, 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, January 1st, 1937 424 Total number actually in receipt of massage, electrical, Swedish remedial treatment, on January 1st, 1937 19 New splints and appliances supplied 75 Repair of existing appliances 17 Part cost met by parents 22% Full cost met by parents 39% Full cost met by Local Authority 39% Miss Hailey, since her appointment (on 2lst September. 1936) has paid 267 home visits to enquire into financial circumstances. 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. 195 SECTION XI. CROYDON AERODROME. 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 medical officer was on duty for 6 hours per day throughout the year. This was necessitated by the increased traffic and the growing independence of aircraft on weather conditions. In addition, this medical officer carries out urgent inspections which would otherwise necessitate a medical officer or sanitary inspector being sent up specially from the Public Health Office. The arrangements made at the Aerodrome for the convenience of passengers and for the examination of aliens are satisfactory, and work smoothly and efficiently. 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 I. LONDON TERMINAL AERODROME. Aliens Act, 1930. Medical Officer's Return for the year ending 31st December, 1936. Number of Planes. Arrived from Amsterdam. Brussels. Elsewhere. Arr. Seen. Paris. Total: 7,226 3,114 2,764 1,769 1,286 1,407 Passengers. British. Others. Inspected. Exd. 68,195 65,356 29,849 145 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 method of travel is becoming steadily more popular, as the following figures show: 1,199 more planes arrived, and the number of passengers arriving increased by 75,002, a figure greater than the total number of passengers carried in 1935. 196 SECTION XII.—MISCELLANEOUS. ULTRA-VIOLET LIGHT CLINIC. The Clinic is held at the Croydon General hospital on four days a week under the superintendence of Dr. F. Hernaman- Johnson. Cases were referred from the Maternity and child Welfare Department (38), the School Medical Service (20), and the Tuberculosis Dispensary (6). The number of cases referred has decreased by 17. The following Table gives a summary of the attendances made: — Table I. Department. No. of Cases. Aggregate duration of treatment in weeks. Aggregate No. of Sessions Attended. No. of Patients discharged. No. continuing treatment end of 193 6 School Medical 20 181 482 13 7 M. & C. W. 38 426 1074 24 11 Tuberculosis 6 83 215 6 – 64 690 1771 43 21 The Table under gives the complaints treated and the results achieved in completed cases. Twenty-two cases ceased attending before completion of treatment, and one case left the Borough. Table II. Condition. School Cases. M. & C. W. Cases. T.B. Cases. Total completed Case. Much Improved. Improved. Slight Imp. I.S.Q. Much Improved. Improved. Slight Impt. I.S.Q. Much Improved. Improved. Slight lmpt. I.S.Q. Debility 1 4 – 1 1 1 – 1 – – –  – 9 Bronchitis 1 – – – – – – – – – – – 1 Glands – – – – – – – – – – – 1 5 Rickets – – – – 4 1 – – — – – – 4 Miscellaneous 1 — — — 2 – – – – 1 – – – 3 4 — 1 7 2 — 1 – 1 – 1 20 197  Much Improved. Improved. Slight Impr. I.S.Q. Ceased Attending. Total. Debility 2 5 – 2 9 18 Asthma – – – – 1 1 Bronchitis 1 – – – – 1 Glands – – – 1 4 5 Rickets 4 1 – – 7 12 Miscellaneous 3 1 — — 2 6 10 7 - 3 23 43 School Cases. Seven school cases were still attending the Clinic at the end of the year. These were suffering from the following conditions, viz.:— General Debility, 2; Bronchitis, 2; Glands, 1; Rickets, 1; Rheumatism, 1. Maternity and Child Welfare Cases. Fourteen 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, 5; chitis, Glands, 1. Of the School cases, 12 were boys and 8 girls; the Maternity and Child Welfare cases, 23 boys and 15 girls; and the culosis Patients, 2 male and 4 female. All the cases referred to the Clinic had been carefully selected as likely to benefit; of those discharged, after completion of treatment, 50 per cent. were much improved, 35 per cent. were improved, and 15 per cent. were not benefited. These figures show that this treatment, under expert supervision of dosage, exposure, etc.,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 44 of the cases; the latter alone in 15 cases, and both lamps in 5 cases. The use of artificial sunlight lamps in bathrooms is fraught with considerable risk and their installation should only bo made under strict expert supervision. 198 BLIND PERSONS ACT, 1920. The scheme under Section 102 (1) of the Local Government Act, 1929, came into force on April 1st, 1930. It has continued unchanged. 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. 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 Medical Officer of Health. I am indebted to the Secretary of the Voluntary Association for the figures below:— Number of blind on Register 395 Number of blind who benefit from instruction in Braille or Moon Type (including those who already read) 76 Number of blind who benefit from part-time instruction 12 Number in remunerative handicrafts— (a) Home workers 34 (b) In workshops 7 (c) St. Dunstan's 11 (d) Workers not included in scheme 10 Home Teacher 1 The Health Visitors paid 692 visits to blind persons during the year. The following Table shows: (a) the number of blind persons registered; (b) the ages at which blindness occurred; (c) the method of training ; (d) the occupations of employed blind persons, (e) the defective blind ; and (f) the unemployable blind persons in homes, mental hospitals or institutions. 199 200 TABLE I. WELFARE OF THE BLIND—REGISTRATION. As at 31/3/37. M.=Male. F.=Female. T.=Total. Name of Authority: CROYDON. Age period 0-1 Age period 1—5 Age period 5—16 Age period 16—21 Age period 21—40 Age period 40—50 Age period 50—65 Age period 65—70 Age period 70 and over (i) Total of all age groups (ii) Age unknown M. F. T. M. F. T. M. F. T. M. F. T. M. F. T. M. F. T. M. F. T. M. F. T. M. F. T. M. F. T. – - - 3 — 3 6 3 9 4 3 7 30 28 58 26 15 41 51 51 102 23 26 49 48 78 126 (i) 191 (i) 204 (i) 395 (ii)– (ii) 2 (ii) 2 TABLE II.—AGES AT WHICH BLINDNESS OCCURRED. (The total of this Table should agree with the total of Table I.) Age period 0-1 Age period 1—5 Age period 5—10 Age period 10—20 Age period 20—30 Age period 30—40 Age period 40—50 Age period 50—60 Age period 60—70 Age period 70 and over Age period Unknown M. F. T. M. F. T. M. F. T. M. F. T. M. F. T. M. F. T. M. F. T. M. F. T. M. F. T. M. F. T. M. F. T. 22 12 34 6 11 17 11 9 20 13 7 20 15 15 30 25 19 44 18 28 46 26 26 52 19 30 49 17 29 46 19 20 39 TABLE III.—Children of School Age, 5—16. Normal Mentally Defective Physically Defective M. F. M. F. M. F. In Schools for the Blind 6 2 — — — — Other Schools — — – — — — Not at School — — – 1 – — TABLE IV.—Training and Employment. Age Period 16 and upwards. Employed Undergoing Training. (h) Trained but unemployed (i) No training but trainable (j) Unemployable (k) Total By Blind Organisations (c) All others not included in (a) and (b) (d) Total Employed (e) Industrial (f) Secondary (g) Professional and University (a) Workshops (b) Home M. F. T. M. F. T. M. F. T. M. F. T. M. F. T. M. F. T. M. F. T. M. F. T. M. F. T. M. F. T. M. F. T. 5 3 8 21 13 34 25 1 26 51 17 68 3 3 6 1 1 2 – – – – – – – – – 127 182 309 182 203 385 TABLE V.—Occupations of Employed Blind Persons included in (d) of Table IV. Agents, Collectors, &c. Basket Workers Bedding (including Divans & Ottomans) and Upholstering Boot Repairers Braille Copyists and Proof Readers Brush Makers Carpenters and Woodworkers Chairseaters Clerks and Typists Coal Bag Makers Dealers, Tea Agents, Newsagents, ShopKeepers Firewood Workers Gardeners Hawkers, Newsvendors, &c. Home Teachers Knitters Labourers Massage Mat Makers Ministers of Religion Musicians and Music Teachers Netting Makers Porters, Packers, Cleaners Poultry Fanners School Teachers Ships Fender (Fendoff) Makers Telephone Operators Tuners Weavers Miscellaneous Total Makers Mattress Machinists Upholsterers Hand Machine within Institution for the Blind — 5 – – – – – – – – – – – – – – 1 – 2 – – – – – 1 – – 3 – – – – – 12 In approved Home Workers Schemes - 2 – – – – – – – 5 – – – 1 – – – – 12 – – 1 – – – – – – – – 13 – – 34 . Other (not pastime workers) — – – – – 2 – – – – 1 – 7 – – – – – – – 1 2 2 1 2 — — — — 4 — — — 22 Total - 7 — – — 2 — — – 5 1 – 7 1 — — 1 — 14 – 1 3 2 1 3 — — 3 — 4 13 — — 68 TABLE VI.—Physically and Mentally Defective (including those given in Table III.) (a) Mentally Defective. (b) Physically Defective. (c) (i) Deaf (ii) Deaf-mute Combinations of (a) and (b) Combinations of (a) and (c) Combinations of (b) and (c) Combinations of (a), (b), (c) Total M. F. T. M. F. T. M. F. T. M. F. T. M. F. T. M. F. T. M. F. T. M. F. T. 4 3 7 a 3 12 (i) 7 (i) 6 (i) 13 1 – 1 – — — – – — — — — 21 12 33 (ii) - (ii) 2 (ii) 2 TABLE VII.—Unemployable persons resident in Homes for the Blind, Mental Hospitals or Poor Law Institutions. Homes for the Blind Mental Hospitals Poor Law Institutions M. F. T. M. F. T. M. F. T. 1 4 5 2 1 3 4 14 18 201 SECTION XIII. 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, 1930, of the work carried out by the Sanitary Inspectors and other officers under my supervision. ROBERT J. JACKSON, Chief Sanitary Inspector. List of Adoptive Acts and Local Acts and Regulations Relating to Public Health. Local Acts. 1884. Croydon Corporation Act. 1895. 1900. 1905. 1920. 1921. Croydon Corporation Water Act. 1924. Croydon Corporation Act. 1927. 1930. General Adoptive Acts. Baths and Washhouses Act, 1846-1899. Public Health Acts Amendment Act, 1890, Part 3 (sections 16-50). Section 19 repealed by Croydon Corporation Ac!, 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). 202 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. „ for Public Slaughterhouses, 1923. Byelaws. With respect to Common Lodging Houses, 1931. „ Tents, Vans, Sheds and similar structures used for human habitation, 1931. „ New Streets and Buildings, 1929. „ Offensive Trades, 1925. „ Conduct of Persons using Public ences, 1926. „ Street Trading, 1927. „ Slaughterhouses, 1934. „ 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, 1931 and 1936. „ Nuisances from Dogs, 1932. „ Improvement Areas, 1935. 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) 4877 No. of houses inspected under the Housing (Consolidated lations) 1925 3095 No. of Houses inspected under the Rent Restriction Acts 91 No. of Houses inspected where zymotic diseases have occurred 588 House drains tested with smoke (primary) 1479 203 House drains tested with smoke (on application) 33 No. of smoke tests (luring repair 530 inspection of drainage work during construction 4235 No. of water tests during repair 488 Final tests of drains after repair 109 Final tests of drains when completely relaid 85 Length of new drains tested with water yards 2316 Inspection of yards, stables and manure pits 691 „ Passages 144 „ Public Conveniences 4127 „ Pigstyes 65 „ Tents, Vans, and similar structures 26 „ Theatres, Cinemas, Halls, etc. 171 „ Ponds and Ditches 38 „ Schools and School Lavatories 90 „ Common Lodging Houses (including night visits) 77 „ Houses let in lodgings. 114 „ Premises where offensive trades are conducted 223 „ Aviaries 2 Smoke Observations 72 No. of Visits re Infectious Diseases 1400 Inspections of Shops (under Shops Acts) 5462 Special Early Closing Patrols 146 Special Evening Inspections under Shop Hours Act 192 Inspections under Fertilisers and Feeding Stuffs Act 45 „ under Pharmacy and Poisons Act 1379 „ Dairies 380 „ Farms and Cowsheds 67 „ Milkshops 401 „ Premises where food is prepared or sold 7402 „ Slaughterhouses 919 „ Factories 686 „ Factory Laundries 29 „ Workshops 673 „ Workshop Laundries 17 „ Workplaces 221 „ Factory Bakehouses 226 „ Workshop Bakehouses 74 „ Outworkers Premises 99 Baths Inspections 20 Water Samples examined 20 Visits to Employers of Outworkers 17 Reinspections of Work in Progress. 28797 Sundry Inspections and Visits 6060 Appointments kept with Owners, Builders, etc. 3560 Complaints from public investigated (for purposes other than inspection of House) 4709 Examination of Building Plans 107 Informal Notices outstanding 31/12/35 4106 „ served 10779 „ complied 11247 No. of Informal Notices referred for Statutory Orders 729 Informal Notices outstanding 2909 Statutory Notices outstanding 31/12/35 286 „ served 552 „ complied 628 Total number of complaints received 3824 Interviews with callers 4383 Letters received 6742 Letters and other intimations, etc., sent (not including notices) 8761 204 Nuisances, Infringements of Acts, Byelaws, Regulations or Orders, ascertained by the Sanitary Inspectors during the year 1936 and for which action was taken to enforce compliance:— (1) NUISANCES AND HOUSING DEFECTS AT HOUSES, &c. Insufficient means of ventilation— Defective sashcords 129 „ windows 1214 Want of windows or ventilators 48 Conditions causing dampness— Defective roofs 1617 „ gutters 756 „ downspouts 318 „ walls, etc. 1073 Deposits of refuse causing dampness 9 Want of proper damp proof course 396 Other internal defects and nuisances— Defective plaster 1669 Cleansing and limewashing required 2261 Defective floors 751 Insufficient ventilation under floor 102 Defective stoves and fireplaces 746 Defective sanitary fittings— Defective sinks 317 „ waste pipes 327 Abolition of drinking water cisterns 35 Defective w.c.'s 1120 „ drainage 699 Stoppage in drains 293 Domestic nuisances— Want of cleanliness 19 Dirty w.c. pans 11 Other nuisances and infringements— Bad smells 3 Offensive accumulations 144 Insufficient accommodation for sub-tenants 12 Defective manure receptacles 14 Want of manure receptacles 7 Defective sanitary conveniences 40 Dirty sanitary conveniences 14 Smoke nuisances 4 Sundry nuisances or defects 1168 Limewashing of stables 9 Building unsuitable for use as stable 1 Accumulation of manure 3 Particulars not inserted in Rent Book (Housing Act) 258 „ „ ,, „ (Rent Restriction Act) 193 205 (2) FACTORIES, WORKSHOPS & WORKPLACES— Cleansing and whitewashing required 49 Additional ventilation 6 Dustbins required 14 Repairs to floors Drainage of floors 4 Repairs to paving 2 Overcrowding 1 Ventilation of stoves 1 Infringements of drinking water supply regulations 23 Sundry other nuisances or defects 30 Abstract not exhibited 5 W.c.'s— Insufficiently screened 1 Insufficient 5 Defective 105 Not kept clean 87 Not separate for sexes 2 Want of intervening ventilated space 10 (3) INFRINGEMENTS OF CROYDON CORPORATION ACT, 1924— Food cupboards defective or required 215 Dustbins required 1020 Verminous conditions 108 (4) INFRINGEMENTS OF PUBLIC HEALTH ACT. 1925 (S.72-75) AND INFRINGEMENTS OF FOOD LAWS- Cleansing or repair of walls and ceilings 233 ,, ,, repairs of floors, utensils, fixtures, etc 74 Dirty or defective w.c. accommodation 110 Food storage accommodation required 4 Animals kept in food store 1 Refuse bins uncovered 3 Accumulation in food store and yards adjacent 92 Food in uncovered vehicles or baskets 11 Food improperly kept or manufactured 18 Premises not suitable for storage or manufacture of food 11 Want of provision of towels 9 Provision of cloak room accommodation 33 Overalls required 3 Illegal wrapping of food 6 Household washing in food store 6 Want of ventilation in food store 8 „ intervening ventilated space between w.c. and food store 4 Defective swill bin 1 Drain inlet in food store 1 Insufficient sink accommodation and water supply 24 Provision of drainage for fish show slabs 1 Defective sanitary fittings 7 (5) INFRINGEMENTS OF PUBLIC HEALTH ACTS (AMENDMENT) ACT, 1907— Defective yard paving 597 206 (6) INFRINGEMENTS OF SHOPS ACTS— Insufficient w.c. accommodation l00 Dirty or defective w.c. accommodation and insufficient lighting, etc. 264 Reasonable temperature required 23 Provision of means of heating 62 Unsuitable or insufficient washing facilities 37 Insufficient accommodation for assistants' meals 20 Notices not exhibited in accordance with 1913 Act 2 Notices not exhibited in accordance with 1934 Act 916 Assistants Weekly Half-Holiday Notices required, etc. 311 Mixed Shop Notices required 247 Infringements after general closing hour 53 Infringements of 1934 Act in regard to young persons 3 Infringements of 1912 Act in regard to females 18 (71 INFRINGEMENTS OF COMMON LODGING HOUSE BYELAWS Room not numbered 1 Dustbins required 4 Dirty or defective plaster 7 Defective windows and sashcords 2 Defective sanitary accommodation 7 Defective floors 2 Verminous conditions 1 (8) INFRINGEMENTS OF HOUSES LET IN LODGINGS BYELAWS— Additional cooking and sink accommodation 1 Want of food storage accommodation 3 Provision of washing accommodation 2 Want of w.c. accommodation 2 „ artificial lighting to common staircase 1 Handrail required to stairs 1 Cleansing required 5 Defective windows and sashcords 2 Provision of dustbins 2 Means of escape from fire 1 (0) INFRINGEMENTS OF OFFENSIVE TRADE BYELAWS. Fishfryuing premises— Limewashing required 1 Offensive accumulations 1 Other premises— Dirty or defective w.c. accommodation 2 Cleansing and whitewashing required 6 Dirty floors 2 Dirty or defective yard paving 2 Dustbins required 3 (10) INSPECTION OF AMUSEMENT HOUSES- Defective sanitary fittings 11 W.C. not sufficiently screened 1 Defective plaster 1 W.c. required cleansing 3 W.c. insufficiently lighted 7 Insufficient ventilation 7 Notices to be fixed to door of lavatories 1 Defective floors in dressing room 1 Dirty walls and ceiling in dressing room 1 207 (11) KEEPING OF ANIMALS— Pigstves within 100 feet of dwelling 8 Other nuisances in connection with the keeping of pigs 2 Nuisances arising from the keeping of other animals 21 (12) INSPECTION OF WATERCOURSES, etc.— Cleansing of watercourses and ponds 1 (13) INFRINGEMENTS OF PHARMACY & POISONS, &c., ACT— Article not labelled in accordance with the Act 12 (14) INFRINGEMENTS OF FERTILISERS & FEEDING STUFFS ACT, Sec. 1 (1) (11) 1 (15) INFRINGEMENTS OF RATS & MICE DESTRUCTION ACT- Infestation of rats on premises where food is prepared or sold 6 Accumulations of refuse, etc., harbouring rats 12 Defective drainage 5 Structural defects allowing ingress of rats into dwelling houses 13 Rats on waste land 3 Dilapidated sheds, etc., harbouring rats 5 (16) INFRINGEMENTS OF MERCHANDISE MARKS ACT 5; AGRICULTURAL PRODUCE & MARKING ACT— Apples not marked 89 Tomatoes „ 63 Eggs „ 2 Butter not marked 5 Currants „ 13 Sultanas „ 11 Raisins „ 11 Bacon „ 8 Meat„ 63 (17) INSPECTION OF SCHOOL LAVATORIES— Defective Sanitaiy fittings 6 (18) INFRINGEMENTS OF OTHER BYELAWS— Washing down shop fronts 6 Noisy animals 11 Noisv instruments 2 Offensive washing up water thrown over footpath 7 Infringements in slaughterhouses 2 Milk bottles on public highway 6 (19) INFRINGEMENTS OF PUBLIC HEALTH (MEAT) REGULATIONS- Cleansing of utensils, tables, etc. 3 Meat displayed in front of shop 4 Basket containing meat not covered 1 Bins required for offal 2 208 (20) INFRINGEMENTS OF FOOD AND DRUGS (ADULTERATION) ACT, 1928— Margarine not marked 15 (21) INFRINGEMENTS OF MILK & DAIRIES REGULATIONS, &c.— Defective dairy floors and paving 5 „ sanitary fittings 2 Dirty dairies 9 „ conveniences 4 Illegal bottling of milk 1 Cowshed requiring limewashing 1 Sanitary Certificates. On application, an intending or actual occupier or owner, may have a sanitary survey made of the house, to ascertain whether there are conditions existing which may be injurious to health or requiring attention. In each case an examination is made of the premises and the drains are tested. During 1936 requests were made in connection with 33 houses. The following defects were ascertained in consequence of these inspections:— Defective gutters 1 „ downspouts 1 „ drains 12 „ sanitary fittings 9 „ w.c.'s 6 „ yard paving 2 Dampness 2 Defective floor 1 Unventilated food cupboard 1 Rent Restriction Acts. A number of applications were received for certificates as to the condition of repair of the houses concerned. In 33 instances where the Acts applied certificates were granted. In 12 instances certificates were given to owners stating that the work had been carried out. HOUSING. Individual Unfit Houses- In the Five Year Plan it was estimated that some 150 individual unfit houses were subject to be dealt with in the Borough. Up to the end of 1936, 119) houses had been approved for demolition , and demolition orders had been made; 101 houses had been actually demolished, the tenants being re-housed, when they desired, by the Council; 312 persons were displaced. In addition, 12 closing orders have been made and 3 parts of houses closed for human habitation. 209 The following tables gives particulars as to Housing during 1936 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) 4,877 (b) Number of inspections made for the purpose 4,877 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 3,095 (b) Number of inspections made for the purpose 3,095 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 26 (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 2,867 1-Remcdy 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... 2,393 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 332 (2) Number of dwelling houses which were rendered fit after service of formal notices :— (a) By owners +118 (b) By local authority in default of owners 5 L>. Proceedings under Public Health Acts : — (1) Number of dwelling houses in respect of which notices were served requiring defects to be remedied 45 (2) Number of dwelling houses in which defects were remedied after service of formal notices :— (a) By owners *39 (b) By local authority in default of owners — ' Proceedings under sections 19 and 21 of the Housing Act, 1930:— (1) Number of dwelling houses in respect of which Demolition Orders were made i'Xi (V) Number of dwelling houses demolished in pursuance of Demolition Orders 44 210 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 – (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit – *This number does not include 49 houses in regard to which notices were served prior to 1936. † Not including 147 houses concerning which notices were served prior to 1936. OVERCROWDING. The Housing Act, 1935, required a survey to be made to discover the amount of overcrowding. This survey was carrier out in the latter part of the year 1935 and early in 1936. This Act made considerable changes in the method of dealing with overcrowding. Investigations were made in regard to 17,549 families during 1936, bringing the total number of families found overcrowded to 650. The number of persons in these families was 3,686. During 193G overcrowding was relieved in 108 cases. Housing Act, 1935—Overcrowding. (a) (i) Number of dwellings overcrowded at the end of the year 650 (ii) Number of families dwelling therein 650 (iii) Number of persons dwelling therein 3,686 (b) Number of new cases of overcrowding reported during the year 40 (c) (i) Number of cases of overcrowding relieved during the year 108 (ii) Number of persons concerned in such cases 546 (d) Particulars of any cases in which dwelling houses have again become overcrowded after the Local Authority have taken steps for the abatement of overcrowding No record 211 Table I. FACTORIES, WORKSHOPS, AND WORKPLACES. 1. Inspection. Premises. Number of Inspections. Written Notices. Prosecutions FACTORIES (including Factory Laundries) 715 58 ... WORKSHOPS (including Workshop Laundries) 690 152 ... WORK PLACES (other than Outworkers premises) 221 32 .... Total 1626 242 ... Table II. 2. Defects Found in Factories, Workshops, and Workplaces. Particular. No of Defects. Referred to H.M. Inspector. Prosecutions. Found. Remedied. Nuisances under the Public Health Acts- Want of Cleanliness 49 43 ... ... Want of Ventilation 6 6 ... ... Overcrowding 2 1 ... ... Want of Drainage of Floors 4 4 ... ... Other Nuisances 76 67 ... ... Sanitary Accommodation— Insufficient 5 4 ... ... Unsuitable or Defective 203 189 ... ... Not separate for sexes 2 2 ... ... Offices 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 (lactones and Work- shop Tranfer of Powers Older, 1921) ... ... ... ... Reports to H. M. Inspector ... ... 4 ... Total 347 316 4 ... 212 3. List of Registered Workshops. Trades. Totals. Bakers and Confectioners 122 Basket and Rug Maker 1 Blacksmiths 17 Blind Makers 3 Bookbinders 5 Bootmakers 198 Bottle Washer 1 Brewers 6 Brush Makers 4 Building Trades 125 China Rivetters 2 Coach Builders 20 Cycle Works 32 Dressmakers 104 Dyers and Cleaners 34 Electricians 60 Engineers 104 Fancy Goods Manufacturers 52 Florist 8 French Polishers 4 Furriers 3 Ladder and Barrow Makers, etc. 1 Laundries 42 Marine Stores 12 Metal Works 46 Milliners 26 Monumental Masons 15 Motor Engineers 234 Opticians 20 Patent Medicine Manufacturers 6 Photographers 19 Printers 93 Rubber Stopper Maker; 1 Saddlers 7 Sausage Makers 2 Scale Makers 2 Sheet Metal Workers 14 Sign Writers 19 Sports Goods Makers 13 Stables 4 Tailors 111 Tea Packer 2 Toy Makers 4 Umbrella Makers 3 Upholsterers 62 Vulcanizers 2 Watchmakers 32 Wig Makers 3 Wire Mattress Makers 1 Woodworkers 161 4. Bakehouses. The control of Bakehouses is dealt with under the Factory and Workshops Act, the Public Health Acts, Croydon 213 tion Act, 1924, and Cleanliness of Food Byelaws. Foi details of Croydon Corporation Act, see under Food Inspection. Number of bakehouses on Register, 31st December, 1936 98 Number of underground bakehouses (included in above) 6 Visits made to bakehouses during the year 300 Defects found 89 Notices issued 64 Notices complied 69 5. Home Work. Lists of home-workers are sent in twice yearly, and last year contained the names of 103 outworkers residing within the Borough. 99 visits were paid to outworkers and 17 visits were paid to premises of employers of outworkers to examine lists and for other purposes. Table III. NATURE OF EMPLOYMENT OF WORKERS ON THE REGISTER, 31st DECEMBER, 1936. Nature of Work. Number employed. Outwork in infected premises. Outwork in unsatisfactory prem ses. Remark^. Making, cleaning altering and repairing wearing apparel.. 72 .. 1 ... Upholstery work 5 ... ... Lace goods ... Other classes of work 32 .. 1 . 109 ... 2 ... 214 REGISTERED AND LICENSED PREMISES IN THE BOROUGH, 31st DECEMBER, 1936. Slaughterhouses (not including Public) 3 Bakehouses 98 Common Lodging Houses 9 Houses Let in Lodgings 92 Dairies and Milkshops 393 Cowsheds 20 Offensive Trades 107 Wholesale Dealers in Margarine, etc. 34 Registered Workshops 1,862 Premises registered under Artificial Cream Act, 1929 0 Premises registered for preparation or manufacture of potted, pressed, pickled or preserved meat, fish, or other food intended for the purpose of sale for human food 145 SHOPS ACTS. The Shops Act, 1934, contains provisions for dealing with the health and comfort of persons employed and also regarding ventilation, temperature, sanitary conveniences, washing facilities and the facilities for taking meals in shops. This is an advance on the previous legislation, and has naturally entailed a considerable amount of extra work on the staff. 5,800 inspections were made, and a number of infringements were found, as set out on page 206. COMMON LODGING HOUSES. 1. Municipal Lodging House. The Municipal Lodging House (built by the Corporation owing to displacement of private common lodging houses due to improvement scheme) is situate at Pitlake, and contains 101 cubicle beds for nightly letting to lodgers. In addition there are three cubicles allotted to members of the Municipal Lodging House Staff, making a total of 104 cubicles on the premises. The charge per night to lodgers is 1s., the cost of a weekly ticket is 6s. for seven nights. 216 The number of men accommodated during the year was 24,558. The number of men lodgers exceeded 67 per night throughout the year. The receipts and expenditure for the last ten years are as follows:— Receipts. Expenditure. £ s. d. £ s. d. 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 1934 1469 16 1 1695 8 9 1935 1488 11 5 1420 14 9 1936 1446 0 2 1381 19 2 2. Private Common Lodging Houses. There are 9 common lodging houses on the register. During 1936, 63 day and 14 night inspections were made. Notices were served for the conditions and defects as set out in the summary of defects found (paragraph 7). Table IV. The following Table gives the situation of and the accommodation in the common lodging houses :— Premises. No. of Rooms. Accommodation. 9, Prospect Place 3 15 men 19, 20, 21, 22, 23 & 24, Lahore Road 30 63 men 11 and 12, Princess Road 10 36 men and women 9 43 114 men and women HOUSES LET IN LODGINGS. There are 92 houses registered under the Byelaws. 114 visits were made for inspection purposes. 15 notices were served for various amendments. 15 notices were complied with. 216 Table V. The following Table gives the situation of these premises:- Road. No. of Houses Let in Lodgings. Beulah Grove 2 Princess Road 1 Queen's Road, Croydon 2 Ely Road 4 Forster Road 8 Holmesdale Road 3 Wilford Road 16 Donald Road 1 Canterbury Road 1 London Road 2 Whitehorse Lane 1 Nursery Road 1 St. James' Road 1 Queen's Road, South Norwood 1 Lodge Road 1 Tamworth Road 2 Bert Road 1 Bensham Manor Road 1 Albert Road 1 Clyde Road 4 Brighton Road 1 Canning Road 2 Grosvenor Road 1 Clifton Road 1 Derby Road 2 Belgrave Road 6 Pawsons Road 1 Windmill Road 4 Heathfield Road 1 Harrington Road 1 St. Peter's Road 2 Alexandra Road 1 Whitehorse Road 3 Grange Road 1 Penge Road 4 Newark Road 1 Addison Road 1 Selhurst Road 1 Wellesley Road 1 Auckland Road 1 South Norwood Hill 1 Furze Road 1 Notices were served for the conditions and defects as set out in the summary of defects found (paragraph 8). OFFENSIVE TRADES. Byelaws relating to Offensive Trades were adopted during the latter part of the year 1925. 217 223 inspections were made of premises where such trades were carried on and notices issued requiring amendments in accordance with the Byelaws. The following are on the register:- Rag and Bone Dealers 33 Gut Scrapers 2 Fish Friers 70 Rabbit Skin Drier 1 Fellmonger 1 107 RAG FLOCK ACTS, 1911 AND 1928. Seven samples were obtained and subjected to analysis, the results being as follows:— No. 1 contained 17 parts of Chlorine per 100,000 „ 2 „ 19 „ „ „ „ 3 „ 7 „ „ „ „ 4 „ 21 „ „ „ „ 5 „ 10 „ „ „ „ 6 „ 17 „ „ „ „ 7 „ 30 „ „ „ 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 72 observations were made of factory chimneys for the purpose of detecting offences under the Act. Two notices were sent and amendments carried out to stop the nuisance. AMUSEMENT HOUSES. 171 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). 218 KEEPING OF ANIMALS. 70 inspections were made in connection with the keeping of animals. There were 19 premises, including institutions, where pigs were known to be kept in the Borough. 10 notices were served to abate nuisances arising from various causes in connection with the keeping of pigs, and 21 notices were served to abate nuisances arising from the keeping of other animals. SCHOOLS. 90 inspections of schools and school lavatories were made during 1936. The water supply in all cases is from the mains. INSPECTION OF WATERCOURSES, ETC. During the year 38 visits were made to ditches, watercourses, etc., in order to see whether there were any infringements of the several Acts, etc. In one instance a notice was served to remove accumulations from a ditch. PHARMACY AND POISONS ACT, 1933. The 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. During the year the number of applications granted for the entry of names on the List of Persons entitled to sell Poisons under Part II. of this Act was 267. In addition, application was made and granted for entry in the List of the names of 226 deputies. It should be noted that the number of applications under the new Act has increased from 6 on the previous occasion to 267. Twelve infringements of the Act were found. FERTILISERS AND FEEDING STUFFS ACT, 1926. Forty-five inspections of premises where fertilisers and feeding stuffs were sold were carried out during the year. One infringement of the Act was found. A reinspection was made at a later date and the infringement found to have been rectified. Two samples of feeding stuffs were taken during the year. 219 DISINFECTION. The Borough Disinfecting Station is situate at Factory Lane. Two steam disinfectors are in use and are supplied with steam from the refuse destructor. A Cleansing Station, consisting of reception rooms, four baths and discharge room, is attached to the Disinfecting Station, and is used for dealing with verminous conditions in children and adults. A part-time woman attendant deals with school children. The following articles were disinfected at the Disinfecting Station during the year:— By Steam 44,595 articles By Formalin gas 3,597 „ By Formalin spray 1,034 „ 49,226 „ In addition 974 articles were destroyed on request. Disinfection after infectious or contagious disease was carried out in 2,277 rooms at 1,546 houses. 83 class rooms. 12 hospital wards. 57 hospital and other rooms. 27 vehicles. 13 bags. 1 school department. Disinfecting of bedding and other upholstered goods is carried out for traders who deliver to and collect the articles from the Station. For this service a charge is made. During 1936, 746 such articles were disinfected, the receipts for this work amounting to £30 7s. 6d. DISINFESTATION. Disinfestation by Hydrogen Cyanide is carried out in certain cases before tenants occupy Corporation houses. 220 Two specially built furniture vans are used. The furniture and effects are collected and taken to the Disinfecting Station, here the contents, still in the vans, are treated with Cyanide for the required time. The van doors are then opened and the air extracted by means of fans in the van roof. The whole of the furniture, etc., is now removed to the open air, any packed goods are opened out, clothes shaken and upholstered furniture beaten to remove any traces of gas. Frequent chemical tests are made to ascertain that no gas is left in the articles. The furniture and effects are repacked into the vans and delivered to the new address. The air in the van and also the articles are chemically tested at the place of delivery. No bedding is treated by Hydrogen Cyanide, this is passed through a steam disinfector and delivered in a second van to the house. One day is taken to carry out the removal, disinfestation and delivery of each household's effects. Eighty-six cases were dealt with during the course of 1936 without any ill effects to any person, either householder or operator. Non-chemical gas masks are used by the operators. In place of the usual chemical element a long armoured tube is supplied to the mask. This tube is provided with a spike to secure the end in a safe position away from the gas. DISINFESTATION OF HOUSES (OTHER THAN OF CONTENTS) FOR BED BUGS, ETC. Houses are disinfested by means of sulphur and spraying with various types of vermicides. Cyanide is not used in houses, but is used for furnishings. This latter process is carried out in the special vans. Number of Council houses— (1) Infested 19 (2) Disinfested 19 Number of houses other than Council houses— (1) Infested 8 (2) Disinfested 8 Number of houses, other than Council houses, disinfested by owners or tenants—168. 221 CLEANSING OF VERMINOUS PERSONS, ETC. During the year 21 adults and 167 children were cleansed for verminous conditions, and 12 adults and 35 children for scabies. 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. The following is a summary of the visits paid under the Rats and Mice (Destruction) Act, 1919 :— Table VI. during 1936 Premises. No. of Visits made. No. of Poison and other baits laid. No. of Rats Killed. Private Houses 1502 2215 Butchers 32 Other premises where food is prepared or sold 230 77 Other premises 253 1 Total 2017 2215 777 In addition to the above, 1,048 rats were killed at Corporation refuse tips by employees of another department. PARROTS (PROHIBITION OF IMPORT) REGULATIONS, 1930. At the request of the Authorities at the Croydon Airport three budgerigars were destroyed during the year. 222 FOOD SUPPLY. The supervision and inspection of the food supplies is carried out by fifteen 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 action is taken to procure for the public a wholesome supply of pure, unadulterated food, and it entails a great amount of detail work at all times of the year, especially intensified during the hot months, for it is only by constant vigilance that a satisfactory standard can be maintained. 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 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 this work there are no set hours of duty. The Public Slaughterhouses are under the control of the Superintendent, who also acts under the supervision of the Chief Sanitary Inspector. During the year there were 40,993 animals slaughtered for human consumption, these figures being an increase of 2,376 on those for the year 1935. 223 The following table shows the premises in the Borough at which foodstuffs are known to be sold, manufactured or stored:— General Shops 213 Grocers and Provision Shops 693 Greengrocers and Fruiterers 469 Confectioners, Bakers and Pie Makers 668 Ice-Cream Shops 368 Hotel and Restaurant Kitchens and Dining Rooms. 296 Butchers 194 Fishmongers (including Fried Fish Shops) 141 Ham and Beef Shops 86 Sweet Manufacturers 10 Other Food Premises 23 3,161 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. A watch has been kept especially for street traders who frequent the public Elementary Schools when the children are going in or coming out, and who trade toys, sweets, etc., for old clothing. 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 lairage attached, are let on agreement to tenant butchers, and the remainder are used for public slaughtering, for which head rate tolls are charged. 224 Table VII. The following animals were slaughtered at the Public Slaughterhouses during 1936:— Pitlake. Public Slaughterhouses- Cattle. Sheep. pigs.. Calves. Total. Public section 214 760 1284 476 2734 Private section 807 9729 15907 3661 30104 Totals 1021 10489 17191 4137 32838 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 1936:— Description. Cause. 9 beef carcases and offal General tuberculosis. 3 „ forequarters Localised tuberculosis. 9 „ parts „ „ 14 „ Offals, complete Tuberculosis. 60 sets beef lungs Localised tuberculosis. 28 beef heads „ „ 19 „ various offals „ „ 3 „ carcases and offals Inflammatory, emaciated, etc. 4 „ heads Actinomycosis. 6 „ various parts Inflammatory, etc. 34 „ various offals Inflammatory conditions, etc. 3 veal carcases General tuberculosis. 2 „ heads Tubercular. 4 „ offals, complete „ „ 8 ,, plucks „ „ 5 ,, various offals „ „ 10 ,, carcases Immaturity, etc. 7 ,, various offals Inflammatory, etc. 3 ,, plucks Inflammatory conditions. 13 pig carcases and offals General tuberculosis. 2 ,, various parts „ „ 168 ,, heads „ „ 25 ,, plucks „ „ 5 ,, various offals „ „ 127 ,, offals, complete Tubercular. 22 ,, carcases and offals Swine fever. 23 ,, carcases and offals Inflammatory conditions, etc. 161 ,, plucks „ „ 8 ,, heads „ „ 117 ,, various offals and 22 parts „ „ 22 ,, carcases and offals Oedema and emaciation. 7 sheep carcases and offals Inflammatory, etc. 3 ,, parts Inflammatory, traumatic, etc. 3 plucks Parasitical, etc. 17 ,, various offals „ „ Total weight destroyed : 24,459 lbs. 225 PRIVATE SLAUGHTERHOUSES AND MEAT INSPECTION At the end of 1936 there were 3 registered 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 1936 was 919. Table VIII. The number of animals slaughtered in the Private Slaughterhouses during the year was:— Cattle. Sheep. Pigs. Calves. Total. 96 2071 3923 2065 8,155 The following meat and offal from Private Slaughterhouses was surrendered and destroyed during 1936:— Description. Cause. 1 beef liver Parasitical. 2 veal plucks Localised tuberculosis. 1 „ sundry offal Inflammatory. 26 pig heads Localised tuberculosis. 11 „ plucks „ „ 23 „ sundry offals „ „ 23 „ plucks Inflammatory, etc. 72 „ offals (various) „ „ 4 pig carcases and offal „ „ 7 sheep carcases ... Emaciation and oedema. 7 „ plucks ... Parasitical, etc. 10 sheep offals (various) „ „ Total weight destroyed : 1,400 lbs. Table IX. Total number of animals slaughtered for human consumption in the Borough during 1936:- Cattle. Sheep. Pigs. Calves. Total. 1,117 12,560 21,114 6,202 40,993 226 Table X. Summary of whole carcases destroyed with the reasons for such destruction. Class of Animal. Tuberculosis. Emaciated and Dropsical. Inflammatory Conditions. Immaturity, etc. Moribund, etc. Swine Fever. Total carcases. Cattle 9 - 3 - - 12 Calves 3 10 - 13 Sheep - 7 7 - 1 15 Pigs 13 22 27 - 22 84 Totals 25 29 37 10 1 22 124 Table XI. 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) 12 42 112 166 Pigs 13 196 191 400 Total 25 238 303 566 227 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 2137 Fishmongers 218 Fried Fish Shops 182 Grocers 890 Greengrocers 609 Poultry and Game Dealers 28 Cooked and Prepared Meat Shops 250 Bakers' Premises 114 Confectioners' Premises 754 Markets 562 Hawkers' Carts and Barrows 232 Hotel and other Kitchens, etc 664 Ice Cream Manufacturers and Vendors 349 General Shops 344 Other premises 69 7,402 The following articles of food were surrendered and destroyed during 1936:— 63 beef parts and trimmings (Imported) Unsound 33 lbs. beef kidneys „ „ 62 lbs. beef livers, etc. ,, „ 1 mutton carcase ,, „ 4 „ parts „ „ 299 lbs. lambs' liver, etc. ,, „ 51 lbs. pork ,, „ 10 lbs. pig livers ,, „ 12 lbs. pig kidneys ,, „ 60 lbs. rabbits „ 264 lbs. ham and bacon „ 881 lbs. smoked fish fillets, etc „ 19 turkeys „ 90 tins salmon, etc. „ 1405 tins, etc., plums, cherries, pineapple, etc „ 43 lbs. pears „ 28 lbs. carrots „ 462 lbs. apples „ 186 tins milk and cream „ 11 cwts. potatoes „ 9 lbs. tomatoes „ 52 jars jam, etc „ 54 jars pickles, etc „ 21 tins soup „ 72 lbs. ice cream „ 65 tins beef, etc. „ Total weight destroyed : 9,412 lbs. 228 Table XII. General Summary of Meat and other articles destroyed during the year 1936. ARTICLES. Weight in lbs. Remarks. Diseased. Unsound. Total. Beef 7,689 2,855 10,544 Including 12 carcases. Veal 420 144 570 „ 13 „ Mutton 366 224 590 „ 15 „ Pork 8,712 945 9,657 „ 84 „ Offal 7,481¾ 572 8,053¾ „ imported offal. Fish - 864 864 Fish fillets, etc. Fruit & Vegetables - 1,773½ 1,773 Apples, potatoes, etc. Tinned Goods - 2,902¾ 2,902½ 1,742 tins, 116 jars, etc. Sundries 322¼ 322¼ Turkeys, rabbits, etc. 24,674¾ 10,602½ 35,277¼ 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 very small proportion is produced in the Borough, due to the absorption of land for building purposes and the-consequent decreasing amount of pasture land. 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. Mechanical refrigeration and cooling is used by increasing numbers of dairymen in the Borough as part of their equipment. 229 $Enquiries show that approximately 20,237 gallons of milk are sold daily in the Borough. Of this amount 93 per cent. is bottled, just under 7 per cent. is loose, which is sold wholesale, and the remaining small portion, namely, 26 gallons, is retailed as loose milk. These figures are interesting in view of the fact that thirteen 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. Sterilised milk continues to be sold in the Borough. Carton milk is sold in the Borough from three producers. In addition, a local producer uses this method for part of his milk. This method, which appears to be gaining favour, entirely eliminates the bottle, the carton being destroyed after the milk is removed. 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. The majority of milk retailed in the Borough is uniformly of excellent quality. The milk, however, sent in by the farmer to the wholesalers continues to give trouble owing to the unnecessarily high bacterial count, 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. MILK AND DAIRIES (CONSOLIDATION) ACT, 1915, THE MILK AND DAIRIES AMENDMENT ACT, 1922, AND THE MILK AND DAIRIES ORDERS, 1926. Cowkeepers, Dairymen and Purveyors of Milk. The following statement shows the number of Cowkeepers, Cowsheds, Dairies and Purveyor of Milk premises on the register:- Cowkeepers on register (1935) 10 „ added to the register (1936) — „ discontinued (1936) — Net 10 230 Cowsheds on register (1935) 20 „ added to the register (1936) — „ discontinued (1936) — Net 20 Number of cows provided for 275 Average number of cows in sheds (1936) 233 No. of dairies and purveyors of milk on register (1935) 408 No. of dairies and purveyors of milk added to register (1936) 58 No. of dairies and purveyors of milk discontinued during 1936 73 Net 393 Grand total of cowsheds, dairies and purveyors of milk on register, 31st December, 1936 , 413 During the year 848 inspections were made of dairies, cowsheds and milkshops. Mr. P. Thrale, the part-time veterinary surgeon, make quarterly reports on his visits to the farms and his examination of the cattle thereon. Milk (Special Designations) Order, 1923. The following licences were granted during the year uncle this Order:— Description of Licences. No. (1) Producers' Licences to use the designation "Grade A" 2 (2) Dealers' Licences to use the designation "Certified" 19 (3) Dealers' Licences to use the designation "Grade A" (Tuberculin tested)— (a) Bottling establishments 1 (b) Shops 23 (4) Dealers' Licences to use the designation "Grade A"— (a) Bottling establishments - (b) Shops 4 231 (5) Dealers' Licences to use the designation "Grade A Pasteurised"— (a) Shops 5 (6) Dealers' Licences to use the designation "Pasteurised"— (a) Pasteurising establishments 2 (b) Shops 60 (7) Dealers' Supplementary Licences to use the designation— (a) Certified 2 (b) Grade A T.T 4 (c) Grade A 1 (d) Pasteurised 5 Inspection of these licensed premises has been carried out regularly during the year to see that the conditions of the licences were observed. On the 1st June, 1936, the Milk (Special Designations) Order, 1936, came into force. The subjoined tables referring to the graded milk samples are therefore divided. The first set of tables being from 1st January to 31st May, 1936, and the second set of tables referring to 1st June to 31st December, 1936. During the first five months 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 2 Crade A (Tuberculin Tested) and Grade A Milks. Licensed country producers of Grade A (Tuberculin Tested) milk supplying milk to licensed local dairymen 2 Licensed local producer of Grade A milk supplying milk to a licensed local dairyman 32 Pasteurised Milk. Samples from Licensed Dealers 62 232 The following tables summarise the result of the bacteriological examinations of Certified, Grade A (Tuberculin Tested), Grade A and Pasteurised samples, from 1st January to 31st May, 1936:— Table XIII. CERTIFIED MILK Present. Absent. IOver 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 1 a. trace. Tubercle bacillus ... 2 Total number of bacteria ... 2 Bacillus Coli ... 2 Blood ... 2 Pus ... 2 Detritus ... 2 ... 2 ... 2 ... 2 ... 2 ... 2 ... 2 The above 2 Certified Milk samples contained total bacteria per c.c. as follows:— 5,000—10,000 1 20,000—30,000 1 2 Under the Regulations Certified Milk must not contain more than 30,000 bacteria per c.c. Table XIV. GRADE A (TUBERCULIN TESTED) AND GRADE A MILKS. Present. Absent. Over 200,000 per c.c. Under 200,000 per c.c. Present in 1/100 c.c. Not Present in 1/100 c.c. Present. Absent. Present. Absent. Exceeding a trace. Not exceeding a trace. Tubercle bacillus 2 32 Total number of bacteria 1 33 Bacillus Coli 1 33 Blood Pus ... 34 ... 34 Detritus ... 34 2 3 1 33 1 33 ... 34 ... 34 ... 34 233 The 34 Grade A (Tuberculin Tested) and Grade A milks contained bacteria per c.c. as follows:— 0—1,000 7 1,000—5,000 15 5,000-10,000 5 10,000—20,000 1 30,000—40,000 1 50,000—60,000 2 80,000—90,000 1 100,000—200,000 1 Over 200,000 1 34 "Two samples from a local Grade A producer's farm proved to be tuberculous. On following this up, one cow was found to be tuberculous and was slaughtered in accordance with the Order. 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 May, 1936. 234 Table XV URISED MILK (Licences granted under the Milk (Special Designations) Order, 1923). Present. Absent. over iuu,uuu per c.c. Under 100,000 per c.c. Present. Absent. Present. Absent. Present. Absent. Exceeding a 1 trace. 1 Not exceeding 1 a. trace. Tubercle bacillus ... 62 Total number of bacteria ... 62 Bacillus Coli 15 47 Blood ... 62 Pus ... 62 Detritus ... 62 ... 62 ... 62 15 47 ... 62 ... 62 ... 62 The above 62 Pasteurised Milk Samples contained bacteria per c.c. as follows:— Under 1,000 1 1,000—5,000 24 5,000—10,000 15 10,000—20,000 8 20,000—30,000 5 30,000—50,000 8 50,000-100,000 1 62 Under the Regulations Pasteurised Milk must not contain more than 100,000 bacteria per c.c. The Milk (Special Designations) Order, 1936, changed the designations in force previously, and during the period 1st June to 31st December, 1936, the following samples of milk were examined under this new Order:— Tuberculin Tested Milk— Licensed country producers supplying milk to licensed local dairymen 9 235 Accredited Milk— Licensed local producer supplying milk to a licensed dairyman 7 Pasteurised Milk— Samples from licensed dealers 105 The following tables summarise the result of the bacteriological examinations of Tuberculin Tested, Accredited and Pasteurised samples, from 1st June to 31st December, 1936 : — Table XVI. Tuberculin TESTED (Licences granted under the Milk (Special Designations) Order, 1936). Present. Absent. Over 200,000 per m.l. Under 200,000 per m.l. Present in 1/100 m.l. Absent. Present. Absent. Present. Absent. Exceeding a trace. Not exceeding a trace. Tubercle bacillus ... 9 Total number of bacteria 1 8 Bacillus Coli 3 6 Blood ... 9 Pus ... 9 Detritus ... 9 ... 9 1 8 3 6 ... 9 ... 9 ... 9 The above 9 Tuberculin Tested milk samples contained total bacteria per m.l. as follows: — 0—1,000 1 1,000—5,000 3 5,000—10,000 1 10,000—20,000 2 150,000—200,000 1 Over 200,000 1 9 Under the Regulations Accredited Milk must not contain more than 200,000 bacteria per m.l. 236 Table XVII. ACCREDITED MILK (Licences granted under the Milk (Special Designations) Order, 1936). Present. Absent. Over 200,000 per m.l. Under 200,000 per m.l. Present in 1/100 ml Absent. 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 T Accredited Milk samples contained total bacteria per m.l. as follows:— 1,000—5,000 2 5,000—10,000 2 10,000—20,000 1 50,000—100,000 1 100,000—150,000 1 7 Under the Regulations Accredited Milk was not contain more than 200,000 bacteria per m.l. 237 The following tables summarise the results of the bacteriological examinations of Pasteurised Milk Samples from 1st June to 31st December, 1936:— Table XVIII. PASTEURISED milk (Licences granted under the Milk (Special Designations) Order, 1936). Present. Absent. Over 100,000 per m.l. Under 100,000 per m.l. Present. Absent. Present. Absent. Present. Absent. Present. Absent. Tubercle bacillus ... 105 Total number of bacteria 5 100 Bacillus Coli 36 69 Blood ... 105 Pus ... 105 Detritus ... 105 ... 105 5 100 36 69 ... 105 ... 105 ... 105 The above 105 Pasteurised Milk Samples contained bacteria per m.l. as follows:— Under 1,000 3 1,000—5,000 35 5,000—10,000 19 10,000—20,000 13 20,000—30,000 15 30,000—50,000 9 50,000—100,000 6 Over 100,000 5 105 Under the Regulations Pasteurised Milk must not contain more than 100,000 bacteria per millilitre. PROVISION AS TO MILK SUPPLY. During the year 240 samples of ordinary milk were procured and submitted to examination for tuberculosis in accordance with the Milk and Dairies (Consolidation) Act, 1915. 238 These samples were taken as follows:— Samples taken at cowsheds in the Borough 14 Samples in course of delivery from country cowsheds to local dairymen and purveyors of milk in the Borough 23 Samples taken at dairymen's premises in the Borough 68 Samples taken in course of delivery bv local dairymen or milk sellers on their rounds in different parts of the Borough 132 Other samples taken 3 240 Three samples proved to be tuberculous. Two samples were from supplies coming from Sussex, and one from Surrey. A considerable number of cows were examined by the Authorities' Veterinary Officers, suspected animals isolated, and samples taken. As the result of their investigations two animals were dealt with under the Tuberculosis Order, 1025, and one animal had died which, on post-mortem examination, was found tuberculous. 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, 1936:— Table XIX. Ordinary milk Present. Absent. Over 200,000 per c.c. Under 200,000 per c.c. Present in 1/100 c.c. Absent from 1 100 c.c. Present. Absent. Present. Absent. Exceeding a trace. Not exceeding | a trace. Tubercle bacillus 3 237 Total number of bacteria 31 209 Bacillus Coli 82 158 Blood ... 240 Pus ... 240 Detritus ... 240 3 237 31 209 82 158 ... 240 ... 240 ... 240 239 The 240 samples of Ordinary Milk contained total bacteria per c.c. as follows : — 0—1,000 13 1,000—5,000 43 5,000—10,000 29 10,000—20,000 37 20,000—30,000 31 30,000—40,000 10 40,000—50,000 11 50,000—100,000 23 100,000—150,000 7 150,000—200,000 5 200,000—250,000 5 250,000—500,000 8 500,000—750,000 2 750,000—1,000,000 4 1.000,000—2,000,000 2 Over 2,000,000 10 240 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 209 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. 240 The 240 samples taken under the Milk and Dairies (Consolidation) Act, 1915, were samples of milk which had been produced in the following areas: — Table XX. Areas. No. obtained. No. Tuberculous. Croydon 14 — Kent 5 — Surrey 3 1 Sussex 29 2 *Unclassified 189 — Totals 240 3 *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 368 samples of milk (307 new, 1 condensed) and 489 other samples were taken. In one instance a prosecution was instituted. In this case a fine was inflicted which, with the costs incurred, amounted to £1 2s. Od. In 9 instances the vendors were warned. 21 samples of Ice Cream were taken during (lie year. Hie Public Analyst reports that 2 of these samples contained fat in amounts varying from 4.9 per cent, to 5.0 per cent. The remaining 19 contained fat in amounts varying from 10.1 per cent, to 17.0 per cent. There is no legal standard for fat in Ice Cream. 10 percent, 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 above this suggested standard. 241 Summary of Samples. During 1936 samples were obtained and submitted to the Public Analyst as follows:— Table XXI. Samples of Total Samples Genuine. Not Genuine. Prosecutions. Convictions. Cautions. Milk 367 350 17* - - 3 Condensed Milk, Full Cream Unsweetened (Inf.) 1 1 - - - - Arrowroot 9 8 1 1 1 — Asparagus Tips 1 1 - - — — Aspirin Tablets 6 4 2 — — 1 Bacon 7 7 — — — — Baking Powder 9 9 — — — — Black Treacle 4 4 — — — — Boric Ointment 2 2 — — — — Brawn 10 10 — — — — Bread 8 8 — — — — Bun Flour 2 2 — — — — Butter 16 16 — — — — Camphorated Oil 2 2 — — — — Candied Peel 1 1 — — — — Castor Oil 7 7 - — — - Cocoa 8 8 - — - - Coffee 9 9 — — — - Coffee and Chicory 2 2 — — — — Coffee Essence 7 7 — — — — Cod Liver Oil 10 10 - - - - Comp. Powder of Liquorice 4 4 — — — — Comp. Syrup of Figs 3 3 — — — — Comp. Syrup of Figs (Inf.) 1 1 — — — — Comp. Tincture of Rhubarb 3 3 - - - - Confection of Senna 2 2 - - - - Cooking Fat 1 1 - - - - Comed Beef 1 1 - - - - Cora Flour 3 3 - - - - Cream Cheese 1 1 - - - - Cream of Tartar 8 8 - - - - Curried Brawn 1 1 - - - - Custard Powder 3 3 - - - - Custard Fo.vder (Inf.) 1 1 - - - - Dripping 4 3 1 - - 1 Faggots 5 5 - - - - Fish Paste 13 13 - - - - Fish Paste (Inf.) 1 1 - - - - Flour (incl. Self Raising) 9 9 — — — — Ginger Ale 2 2 — — — — Ginger Beer 4 4 - - - - Ginger Wine 1 1 - - - - Glycerine 8 8 - - - - Golden Syrup 4 4 - - - - Gooseberries 1 1 - - - - Ground Almonds 9 9 — — — — Ground Ginger 8 8 — — — — Ground Rice 6 6 - - - - Ham 1 1 - - - - Ham and Tongue Galantine 1 1 - - - - Honcy 10 10 - - - - Ice Cream 21 21 — — — — Jam 15 14 1 — — 1 Kaola 1 1 — — — — Carried forward 644 622 22 1 1 6 * Includes two " appeal to cow " samples found to be below legal " standard, but included under this heading for purposes of comparison. 242 Table XXII. Samples of Total Samples. Genuine. Not Genuine. Prosecutions. Convictions. Cautions. Brought forward 644 622 22 1 1 6 Lard 11 11 - - - - Lard Substitute 1 1 — - - - Lemonade Powder 1 1 — - — - Lemon Curd 1 1 — - — - Lemon Squash 2 2 — - — — Malt Vinegar 13 13 — - — — Margarine 14 14 — - — — Meat Paste 6 6 — - — — Mincemeat 6 6 — - — - Mixed Spice 1 1 — - — — Mustard Mixture 3 3 — - — — Olive Oil 7 7 — - — - Pearl Barley 5 5 — - — — Pepper 7 7 — - — — Pickles 2 2 — - — — Pickles, Mixed i 1 — - — — Pickled Onions 4 4 — - — — Pineapple Squash 1 1 — - - — Powdered Ginger 1 1 — - — — Raisin Wine 1 1 — — — — Rissoles 1 1 — - — — Sausage, Beef 17 17 — - — — „ Beef (Pres.) 1 1 — - — — „ Liver 2 2 — - — — „ Luncheon 11 11 — - — — „ Pork 15 15 — - - — „ Pork (Pres.) 2 2 — - - — „ Veal and Ham 1 1 — - - — Saveloys 2 2 — - — - Sherbet 1 1 - - — — Steak and Kidney Pies 1 1 — - — — Stout 1 - 1 - — — Suet, Chopped 2 2 — - - — Suet, Chopped with Rice Flour 3 2 1 - - 1 Sugar, Brown 1 1 — - — — Sweets 13 13 — - — — Sweets (Inf.) 1 1 — - — — Tea 17 17 - - — — Tinned Asparagus 5 4 1 - — 1 Tincture of Iodine 4 2 2 - — — (inc. 1 inf.) Tinned Beans 6 6 — - — - Tinned Cream 2 2 - - — - Tinned Peas 12 12 - - — - Vinegar Essence with Water 1 1 — - — - Whisky 3 2 1 - - 1 Totals 857 829 28 1 1 9 243 2. Result of Analysis of New Milk Samples. SOLIDS NOT FAT.* (Legal standard is 8.5%). 8.4 8.5* 8.6 8.7 8.8 8.9 9.0 9.1 9.2 9.3 Total 367 4 10 27 71 118 95 31 7 2 2 MILK FAT.* (Legal standard is 3%). 2.4 2.5 2.7 2.8 2.9 3.0* 3.1 3.2 3.3 3.4 3.5 3.6 3.7 1 1 2 3 4 2 7 17 35 76 77 52 40 3.8 3.9 4.0 4.1 4.2 4.3 4.4 4.5 4.7 5.5 Total 367 25 644321221 Total Samples of New Milk : 367. In addition, 4 samples of milk were taken and subjected to the phosphatase test for correctness of pasteurisation. All these samples satisfied the test. The Samples of Milk for analysis were obtained as follows : — Country Milk in course of delivery by train to Local Dairymen — Country Milk in course of delivery by motor lorry to Local Dairymen 9 On Milk Rounds (Sundays) 13 „ „ (Week-days) 229 Cowsheds — At Shops 81 Taken at Institutions 33 "Appeal to Cow" Samples taken at farms outside Borough 2 367 AVERAGE COMPOSITION OF NEW MILK SAMPLES. Solids not Fat 8.8% Milk Fat 3.5% Percentage of New Milk Samples below legal standard : 4.6% Adulterated Samples. lhe following is a detailed statement of the adulterated samples and action taken: — No. Sample. Adulteration or Deficiency. Remarks. 154. Milk A small proportion of added water, one half of one per cent. Further sample taken proved genuine, 139. Milk One per cent, added water Vendor warned. Further samples taken provedgenuine. 183. Milk Abstraction of 11 percent, of milk fat. Vendor warned. Further samples taken proved genuine. 244 341. Milk Abstraction of 4 per cent, of milk fat. Vendor warned. Further samples taken proved genuine. 343. Milk Attraction of 3% Milk Fat 344. Milk „ 15% „ „ 345. Milk „ 18% „ „ 346. Milk „ 5% „ „ 388. Milk 11% „ „ 389. Milk „ 2% „ „ B103. Milk „ 7% „ „ B104. Milk 7% „ „ Appeal samples B103 and B104 taken showed a deficiency. Subsequent samples from this producer proved genuine. 352. Tincture of Iodine. 0.2 per cent, deficient in iodine. A further sample taken proved genuine. 454. Milk A small proportion of added water. Further sample taken proved genuine. 562. Milk A small proportion of added water. Further sample taken proved genuine. 478. Milk A small proportion of added water. Further samples taken proved genuine. 488. Milk Slightly deficient milk solids other than milk fat. in Further samples taken proved genuine. 808. Apricot Jam (Full Fruit Standard). Deficiency of 2.5 per cent, soluble solids. Manufacturers of this jam were warned. 497. Milk Deficiency of 6 per cent, of the milk fat. Further samples taken proved genuine. 505. Dripping Contained 3.4 per cent, of free fatty acid calculated as oleic acid. Further sample taken roved genuine.Vendor Warned. 510. Aspirin Tablets (5 gr.). Variation in weight of aspirin of 5.2 to proved genuine. 5.7 grains. Further sample taken Manufacturers warned. 607. Tinned Asparagus. Contained 0.04 per cent. tin. Vendor Warned. 660. Chopped Beef Suet with Rice Flour. Contained 17.1 per cent, rice flour, an excessive amount. Manufacturers warned. 710. Arrowroot Contained sugar, 48 per cent., ground rice 20 per cent., and arrowroot 32 per cent. Proceedings taken and fine and costs of £7 2s. 783. Aspirin Tablets (5 gr.). Variation in weight of aspirin of 5.3 to 5.7 grains. Manufacturers warned 852. Whisky Excess water, 3.6 per cent. Vendor warned. 756. Tincture of Iodine (inf.) 0.2 per cent, deficient in Iodine. Further sample take proved genuine. 868. Stout (inf.) Contained a small proportion of a light hydrocarbon oil. Further sample proved genuine. 245 Public Health (Preservatives, etc., In Food) Regulations, 1925 to 1927. During the course of inspections of food shops particular attention is paid to the above Regulations regarding the marking of foodstuffs to which the Regulations apply. Open-Air Swimming Pool—Purley Way. During the year a number of samples for bacteriological and chemical investigation have been taken to ensure that the condition of the water was satisfactory 246 MEMBERS OF THE EDUCATION COMMITTEE. NOVEMBER, 1935-36. The Mayor (Alderman A. Peters, C.B.E., J.P.). Alderman H. J. Morland, M.A., J.P. (Chairman). P. Squire, Esq. (Vice-Chairman). Alderman T. Betteridge, J.P. Councillor Major J. Petrie, O.B.E. Alderman Major F. W. Rees. Councillor H. Regan. Alderman T. W. Wood Roberts, J.P. Councillor Dr. A. Sandison, O.B.E. Alderman W. West. W. A. Clarke, Esq. Councillor E. E. L. Arkell, J.P. Mrs. R. L. Gurner. Councillor A. J. Carpenter, J.P. Mrs. M. A. Hinks. Councillor W. F. Chandler. B. Holden, Esq. Councillor A. H. Harding. Miss A. M. Jackson, M.A. Councillor Eng.-Rear-Adml. J. H. Harrison. Capt. H. Lethbridge-Abell, F.Z.S. Councillor W. G. Higgins. Mrs. M. M. Wood Roberts. Councillor H. L. Kendell. G. Robinson, Esq. Councillor G. Lewin. Rev. Canon G. M. Scott, M.A. Councillor, J. Marshall. Rev. H. E. Spelman. Councillor S. A. Maycock. The Lord Bishop of Croydon. J. M. Newnham, O.B.E., D.L., LL.D., Clerk to the Local Education Authority. Herbert Roberts, M.A. (Oxon.), 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: John W. Pickup, M.D., Ch.B., D.P.H. (left 31sf August, 1936). Wm. Robert Martine, M.B.E., M.B., Ch.B., D.P.H. iris Jenkin-Lloyd, M.R.C.S., L.R.C.P., D.P.H. Aileen I. McMahon, M.R.C.S., L.R.C.P., D.P.H. Rosa Morrison, M.B., Ch.B., D.P.H. Specialist Part-Time Medical Officers : J. S. Bookless, F.R.C.S. (Ophthalmic Surgeon). Rota of 4 local medical practitioners for surgical treatment of tonsils and adenoids. In addition there is a Consulting Physician, a Consulting Surgeon, a Consulting Laryngologist and Otologist and a Consulting Orthopaedic Surgeon, who are classified as Consultants to the Public Health Department and whose services are available for school medical cases if the need arises. Senior Dental Surgeon : J. F. Pilbeam, L.D.S. Assistant Dental Surgeons : j. k. r. Bryce, L.D.S., g. M. Davie, L.D.S., w. A. Sowden Hills, L.D.S Remedial Gymnasts : Miss F. Davey and Miss M. K. Thomas (part-time). Mental Deficiency Visitor : Miss E. McQuade (part-time). Assistant Mental Deficiency Visitor : Miss S. A. Abley (part-time). Orthopaedic Work Almoner : Miss A. Hailey (part-time). School Nurses: 22 district nurses (part-time). Clerks : Five full-time and eight part-time. 247 SCHOOL CLINICS. Name. Purpose. Where held. T imes. inspection Special examination of cases referred by teachers, school enquiry officers and school nurses and on application of parents. Municipal Clinic, Lodge Road. 47, St. James' Rd. when necessary. 206, Selhurst Rd. when necessary. Wed. and Sat., 9 a.m., and more frequently as necessary. minor ailments Treatment of Minor Diseases of Skin, etc. Lodge Road. Selhurst Road. Duppas School. Daily, 9 a.m. Mon., Tues., Wed., Thurs., and Fri., 9 a.m. ophthalmic. Treatment of Visual Defects. Lodge Road. Tues., Thurs., and Fri., 9 a.m. dental Dental Treatment. Lodge Road, Selhurst Road, and Waldrons Hall. Daily, 9 a.m. and 2 p.m. ear Treatment of Chronic Ear Discharge. Lodge Road. Fridays, 2 p.m. defective children Examination. Town Hall. As required. x-ray Treatment of Ringworm. Dr. Greig's Surgery. By appointment. orthopaedic Treatment of Crippling Defects. General Hospital. Thurs., 10 a.m. throat Operative Treatment of Enlarged Tonsils and Adenoids. Do. Mon. and Wed., 1.45 p.m. synthetic sunlight Treatment of Rickets, etc. Do. Tues., 2 p.m., and Fri., 3.30 p.m. remedial exercises Treatment of Deformities. Welcome Hall, Scarbrook Road. 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. Tues., Wed., Thurs. Fri. and Sat., a.m.; Mon. and Fri., p.m. rheumatism Examination. Lodge Road. Mon. and Thurs., 9 a.m. immunization Protection against Diphtheria. Winterbourne Sch. Lodge Road. Selhurst Road. Mon., 2 p.m. Tues., 2 p.m. Thurs., 2 p.m. 248 County Borough of Croydon. ANNUAL REPORT OF THE SCHOOL MEDICAL OFFICER For the Year ending December 31st, 1936. Ladies and Gentlemen, I have the honour to present to you my Ninth Annua! Report on the work carried out by the School Medical Service. The form of the report follows that adopted previously, and includes the requirements as set out in Form 6M (Schedule) of the Board of Education. Routine school medical inspection has now been in force for a quarter of a century, and there has been little change in the methods of its conduction. There is a growing opinion that the time is overdue for some national modification of the present system. The present method was undoubtedly the best when introduced, but the mass of facts so obtained should now be 249 analysed for the country as a whole and a new, more elastic system of medical supervision devised. As the School Medical Service is a national service, the reforms must come from the central authority. In the Board of Education's Tables for 1933 a new group of cases was incorporated in Table IV. in respect of the treatment of Orthopaedic and postural defects, and this has been included again this year. Dr. J. W. Pickup resigned in August, but his successor had not taken up his duties when the year closed. Dr. G. B. Matthews has acted as locum tenens in the meanwhile. The complete Sanitary Survey of the Schools, which was originally included in my report for 1934, has again been revised. This table shows interesting differences as between the schools. The survey, however, embraced all aspects of school hygiene, including lighting, ventilation, size of class-rooms, etc. For the sake of brevity much of this has had to be omitted from this report. 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 litter service are also engaged for a part of their time in Public Health work. 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, it would be a valuable preventive measure. Very few children attend Infant Welfare ' tntres after the age of 3 years, and, unfortunately, there is no method comparable with that of the School Medical Service for parents to obtain treatment for defects that may arise. The continued co-operation of the Head Teachers and of the School Enquiry Officers has been a valuable help without which much of the medical work and following up would have been difficult of proper fulfilment. The Voluntary School Care 260 mittees, 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 their inspectors, Mr. Brown and Mr. Evans (Upper Norwood), rendered assistance with intractable cases. 13 cases have been dealt with, and of these 10 have been brought to a satisfactory conclusion, whilst 3 still remain under supervision. The inspectors paid 49 visits during the year. 251 Structural Work and Decorations Carried Out in Schools. 1 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— Ashburton Senior. Beulah Infants. Kingsley Junior and Infants. Lanfranc. Oval. Portland. Rockmount Infants. Sydenham. Tavistock Senior Winterbourne. Woodside. Internal Painting and Distempering at the following Schools— Ashburton Senior. Beulah Infants. Kingsley Junior and Infants. Lanfranc. Oval. Portland. Tavistock Senior. Winterbourne. Selhurst Grammar School for Boys Selhurst Grammar School for Girls. Christ Church. Parish Church Girls and Infants. St. Joseph's. St. Mary's R.C. St. Peter's. Archbishop Tenison's. 259 Sanitary Accommodation. School. Approx. No. of scholars No. of W.C.S Type of closet. Urinal space. No. of wash basin No.o towels in use at time of insp No. of towels used ea. wk. Ashburton Boys 181 4 Pedestal sep. cistn. 20 ft. A.F. *9 4 12 Sen. Mixed Girls 215 10 Do. do. — *9 4 12 Jun. Mixed Boys 200 4 Do. do. 20 ft. A.F. *6 5 15 Girls 194 10 Do. do. — *6 4 12 Benson Infants Junior B. 126 2 Do. do. 20 ft. A.F. 5 3 6 G. 134 7 Do. do. — Sen. Mixed Boys 31 3 Do. do. 20 ft. A.F. 5 3 6 Girls 32 5 Do. do. — 5 3 6 Beulah Junior Boys 406 6 Do. do. 45 ft. A.F. 13 3 9 Junior Girls 397 20 Do. do. — 13 4 8 Infants B. 208 4 Do. do. 24 ft. A.F. 18 4 8 G. 189 11 Do. do. — John Ruskin Boys 386 21 Do. do. 42 ft. A.F. 3 Wg. Tr'ghs 7 21 Davidson Senior Boys 159 5 Do. do. 36 ft. A.F. 2 tr'ghs 4 12 Senior Girls 135 14 Do. do. — Do. 5 15 J.G.S B. 135 3 Do. do. 20 ft. A.F. Wshg. tr'ghs 2 3 21 G. 209 6 Do. do. - 4 Duppas Junior Boys 137 4 Do. do. 15ft. 6in.A.F. 6 3 †8 Junior Girls 166 8 Do. do. — 6 4 †12 Infants B. 152 3 Do. do. 15½ ft. A.F. 8 3 †8 G. 156 6 Do. do. — Ecclesbourne Junior Boys 320 6 Trough. 42½ ft. stop cock 10 4 19 2 Pedestal. Senior Girls 290 9 Tr'gh A.F. — 6 2tr'gh 4 24 7 Ped'l A.F. Infants B. 122 2 Tr'gh A.F. 24 ft. stop cock 2 tr'ghs 2 16 G. 141 6 Tr'gh A.F. — Elmwood Senior & J. B. S. 250 4 Pedestal sep. c'stn. 25 ft. A.F. 9 2 8 J. 160 3 16 ft. A.F. 6 2 S. & J. G. S. 321 8 Do. do. — 7 3\ 18 J. 8 Do. do. — b J) Infants B. 370 4 Do. do. 26 ft. A.F. 16 4 14 & 12 hnd. G. 10 Do. do. (inft. sze.) - Gonville Junior Boys 122 3 Do. do. 19ft. Cin.A.F. 5 4 ‡ Junior Girls 114 11 Do. do. — 7 3 ‡ Infants G. 187 2 Do. do. — 6 3 ‡ B. 12 ft. A.F. * Plus 1 sink. † More if necessary. ‡ Towels changed as required. 253 Sanitary Accommodation. School. Approx. No. of scholars. No. of W.C.s Type of closet. Urinal space. No. of wash basins No. of towels in use at time of insp. No of towels used ea. wk. Howard Junior Boys 133 5 Pedestal sep. c'stn. 20 ft. A.F. 4 3 9 Junior Girls 119 6 Do. do. 4 2 6 Infant B. 18 3 Do. do. 10 ft. A.F. 3 1 3 Infant G. 32 4 Do. do. — Ingram Senior Boys 269 5 Do. do. 28 ft. A.F. *4 4 16 Senior Girls 170 12 Do. do. - 4 5 15 Infants B. 142 3 Do. do. 24 ft. A.F. 1 tr'gh 1 do. 3 9 G. 124 6 Do. do. — 2 6 Kensington Avenue Junior Boys 105 3 Do. do. 12 ft. A.F. 5 4 8 Junior Girls 137 7 Do. do. - 6 3 6 Infants B. 66 2 Do. do. 6 ft. A.F. 5 3 6 G. 73 4 — Kingsley Senior Boys 360 6 Do. do. 30 ft. A.F. 14 6 ... Towels changed twice a week or as necessary. Senior Girls 378 18 Do. do. - 14 7 ... Junior Mixed B. 183 4 Do. do. 17 ft. A.F. 16 8 ... G. 203 10 Do. do. — Infants B. 381 4 Do. do. 17 ft. A.F. 16 8 ... G. 10 Do. do. — Lanfranc Senior Boys 226 6 Do. do. 41 ft. A.F. 16 5 ‡ Senior Girls 205 16 Do. do. — 16 5 ‡ Norbury Manor Senior Boys 280 5 Do. do. 40 ft. A.F. Tr'ghs 6 ft. 6 12 Senior Girls 250 14 Do. do. — 2 ditto 5 10 Junior Girls 6 Do. do. - J. B. & I. 293 6 Do. do. 18 ft. A.F. 21 9 18 J. G. & I. 303 14 Do. do. — Oval Senior Boys 166 4 Do. do. 15 ft. A.F. 10 3 6 to 9 Towels changed when necessary Senior Girls 135 8 Do. do. — 10 3 6 to 9 J. B. & G. B. 240 4 inc. inf. b 10 inc. inf. g Do. do. 21 ft. A.F. 8 4 8 to 12 G. Do. do. - Inf. B. & G. 181 Do. do. — 10 4 8to 12 I Portland Senior Boys 254 7 Do. A.F. 29 ft. stop cock 2 tr'ghs 5 ft. 6 6 Senior Girls 224 10 Do. do. — Do. 5 5 Infants B. 333 2 Do. do. 24 ft. stop cock 2 tr'ghs 6 ft. 6 6 G. 7 Do. do. - 2 Troughs. † More if necessary. ‡ Towels changed when necessary. Sanitary Accommodation. School. Approx. No. of scholars No. of W.C.s Type of closet. Urinal space. No. of wash basin No.o towels in us at time of insp. No. Of towels used ea. wk. Purley Oaks S.B. 113 6 Ped.Sep.Cis 33 ft. A.F. 3 2 *4 S.G. 82 9 Do. do — 2 2 *4 J. B. & G. B. 83 Shared with Senior Boys 4 3 *6 G. 67 Shared with Senior Girls Infants B. 74 4 Ped. sep. cistern 14ft.6in. A.F. 4 3 4 G. 96 4 — Rockmount S. & J. B. 155 4 Do. do. 22 ft. A.F. 7 4 12 S. & J. G. 116 10 Do. do. - 7 3 12 Inft. B. 88 6 Do. A.F. 21 ft. A.F. 8 2 6 Inft. G. 89 6 Do. A.F. — 2 6 South Norwood Jnr. B. 333 7 Do. sep. cistern 36 ft. A.F 6a 5 15 Jnr. G. 186 10‡ Do. do. — 6 4 12 Infants B. 153 3 Do. do. 27 ft. A.F. 4 5 15 G. 104 5‡ Do. do. — 4 Sydenham Jnr. Boys 294 6 Do. do. 33 ft. A.F. 5 6 12 J.G. Infants 388 16 Do. do. 34 ft. A.F. 8 8 16 4 Tavistock Snr. Boys 256 7 Do. do. 54 ft. A.F. 2 tr'ghs 5 .... Changed once or twice per week Snr. Girls 252 17 Do. do. — Do. 6 .... Infants B. 101 2 Do. do. 7 ft. A.F. 7 4 .... G. 88 5 Do. do. — Waddon Snr. Boys 312 4 Do. do. 20 ft. A.F. 8 6 .... changed twice weekly. Snr. Girls 318 10 Do. do. — 10 6 .... J.B. & G. B. 150 7 Do. do. 22ft. 6in.AF. 6 4 .... G. 158 10 Do. do. — 6 Infants B. 125 3 Do. do. 13 ft. A.F. 3 4 .... G. 107 7 Do. do. — 6 changed three times per week or as necessary West Thornton J. B. 266 9 Do. do. 30 ft. A.F. 9 6 .... J.G. 234 13 Do. do. — 7 6 .... Infants B 344 3 Do. do. 23 ft. A.F. 41 3 .... G. 6 Do. do. — 4 3 Whitehorse Manor S.B. 190 10 Do. do. 32 ft. A.F. 11 5 5 J.G. 284 16 Do. do. — 7 3 15 Infants B 200 4 Do. do. 26 ft. A.F. 5 2 6 Towels changed as necessary. G. 112 8 Do. do. — Winterbourne J. B. 359 7 Do. do. 39 ft. A.F. 16 2 .... J. G. 380 17 Do. do. — 18 2 .... Infants B 201 3 Do. do. 24 ft. A.F. 15 2 ... G. 188 12 Do. do. | - * Towels changed approx. every other day. † More towels if required. ‡ J.G. & I.G. now sharing 6 W.C.'s (rebuilding in progress). a 4 removed (rebuilding) Sanitary Accomm0dation. School. Approx. No. of scholars. No. of W.C.s Type of closet. Urinal space. No. of wash basins No.of towels in use at time of insp. No. of towels used ea. wk. Wo0dside Jnr. Boys 404 9 Pedestal sep. cist. 37 ft. A.F. *7 8 ... Towels changed daily. Jnr. Girls 297 13 Do. do. — 10 5 ... Infants B. 140 5 Do. do. 9 ft. A.F. 5 4 ... G.. 135 7 Do. do. — Heath Clark Cent. B. 190 5 Do. do. 22 ft. stop cock 8 4 ... 3 times per week or as necessary. Cent. G. 213 10 Do. do. — 8 4 ... CroyJon British Senior Girls 183 12 Do. do. — 10 7 21 Lady Edridge Cent. G. 324 8 Do. do. — 4 8 16 St Christophers B. 82 10 Do. do. 30 ft. A.F. 7 13 ... Towels changed as necessary. G. 43 6 Do. do. 3 1 I. — — Do. do. — 3 St Giles B. 45 3 Do. do. 9 ft. A.F. 3] 1 small towel to ea. child renewed f'tnightly G. 48 5 Do. do. 3 St. Luke's Myope B. ... ... ... ... ... ... ... Rebuilding School. G. ... ... ... ... ... — St George's Hall B. 38 1 Do. do. 6ft. & 1 stall with w.w.p. 2 2 ... Towels changed weekly. G. 43 2 Do. do. — Suffolk Road Temporary Infants B. 96 2 Standard pattern and height space for 3 persons 2 4 ... Towels changed as required. G. 74 4 — 4 All Saints S.B. 40 1 Pedestal sep. cist. 6 ft. hand flushed cist. 2 1 3 S.G. 39 2 Do. do. — 2 1 3 J.B. 122 3 Do. do. 6½ ft. A.F. 2 2 6 J.G. 95 5 (J.G. & I.G.) Do. do. — 2 2 6 Infants 87 3 (Inf. boys) Do. do. 8 ft. A.F. 2 2 6 Christ Church J.M. & I. J.B. 144 4 Do. do. 16 ft. A.F. 4 8 ... Twice per week or as necessary. J.G. 159 14 Do. do. — Inf. B. 72 7 Do. do. ... Inf. G. 64 * Plus 1 sink. 256 Sanitary Accomm0dation. School. Approx. No. of scholars No. of W.C.s. Type of closet. Urinal space. No. of wash basin No.of towels in us at time of insp. No. of towels used ea. wk. Holy Trinity J. G. & I. G. 258 11 Pedestal sep. cist. - 6 3 15 Parish Church S. & J.B. 238 4 Do. do. 21 ft. A.F. 16 5 15 j. G. & i. 312 16 Do. do. 11 ft. A.F. 5 6 12 St. Andrew's s. & j. b. 184 3 Do. do. 25 ft. A.F. 5 3 6 S. & J. G. 140 9 Do. do. — 7 2 4 Infants B. 41 2 Do. do. 8 ft. A.F. 6 3 6 G. 49 4 Do. do. St. Joseph's Boys 88 3 Do. do. 8 ft. stop tap 2 2 6 Girls 92 6 Do. do. — 3 2 6 Infants B. 25 — 2 2 6 G. 17 — St. Mark's J. G. & I. B. 36 2 — 5 ft. A.F. 3 3 7 G. 138 5 Do. do. — St. Mary's (Addington) J. M. & I. Junior B. 26 3 Do. do. 12 ft. A.F. 3 1 2 Junior G. 18 4 Do. do. — Infants B. 17 Shared with Junior Boys 3 1 2 G. 15 Shared with Junior Girls St. Mary's R.C Mixed B. 155 4 Do. do. 16 ft. A.F. 6 2 4 Infants B. 44 2 Do. do. 8 ft. A.F. Mixed G. 191 9 Do. do. — 6 (2 inft.) 2 6 (inc. 2 inft.) St. Peter's Inf. B. 54 3 sts. trough A. F. 4 ft. A.F. 3 1 2 Inf. G. 69 Do. Do. do. — 1 1 2 St. Saviour's J.M. B. 80 4 Do. do. 23 ft. A.F. 4 4 8 G. 98 7 Do. do. — Infants 110 2 Do. do. 7 ft. 3 4 8 Shirley J. Mxd. B. 71 3 Pedestal sep. cist. 10½ ft. stop cock 2 2 4 G. 65 4 Do. do. — Infants B. 45 2 Do. do. 4 ft. A.F. 2 2 4 G. 29 3 Do. do. — Archbishop Tenison's Central B. 180 4 Do. do. 18 ft. A.F. 9 4 20 Senior G. 142 8 Do. do. — 5 3 6 St. Michael's Central G. 233 9 Do. do. — 3 3 6 Monks Orchard Junior B. 45 3 P.W.D. 13 ft. 4 1 2 Junior G. 42 6 P.W.D. 5 2 4 Infant B. 47 2† P.W.D. 14 ft. 5 2 4 Infant G. 40 4† P.W.D. *Towels changed more frequently if required. †1 Babies(Boys and Girls) 257 One provided and two non-provided schools have trough closets : the sooner these are replaced by m0dern pedestal closets, hand Hushed, the better hygienically. Glo6ets with automatic flushes engender careless habits, which are reflected in the stoppage of closets so often happening in private houses, and so often found to be due to improper use. There has been a notable improvement in the number of towels provided for the children's use in the schools. The Committee have now considered the subject and have decided to allow 3 roller towels per week per 50 children. This is an excellent forward step in the inculcation of cleanliness in the children. Cost of the School Medical Service. The gross cost of the medical, dental, and nursing services was £11,327; from this an income of £741 should be deducted, making a nett cost of £10,586. The rateable value of the Borough in 1936 was £2,245,109. The Government grant is 50 per cent. of the expenditure, hence the actual cost to the rates was £5,293, i.e., a rate of 0.57 pence. The nett cost of these services to the rates for 1036 per child on the school registers was 4s. 0.3d. The figures do not include £300 for Medical Inspection (Highei Education) and for Blind persons £711. Cost of Special Schools. Schools maintained by the Council, £6,880 ; Contributions to schools under other authorities, £3,615 ; Loans charges, £538 ; Other expenses (travelling), etc.), £6 ; Income from parents' contributions and other receipts, £719, giving an actual cost of £10,320, of which £5,207 was payable out of local rates, giving a rate of 0.56 pence. Cost of Milk and Meals. Milk and meals cost £1,613 17s. 6d.; Income from parents contributions, £56 1s. 0d. ; giving an actual cost of £1,557 16s. 6d. There has been a slight increase in the cost of the actual Medical services rendered in the Public Elementary Schools from 0.54 in 1935 to 0.57 of a penny rate in 1936. The cost of maintenance in Special Schools has also increased from a rate of 0.52 to 0.56 pence. The cost of milk and meals has increased by £177. 258 The Elementary Schools are now classified under the Hadow Scheme 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 by the average number on the registers has decreased by 334. The average attendance was 90 per cent. This decrease in the number of children on the school registers is interesting, as the population of Croydon continues to increase, due doubtless to immigration. The fall in the birth-rate which has been noticeable for a number of years past, is making itself felt in the school population, and the school population will continue to decrease unless the birth-rate rises again. Table I. No. of Schools. Average number on the Registers. Average attendance. Average attendance per cent. Senior Boys 10 C. 2968 2755 93 2 N.P. 433 412 95 Senior Girls 11 C. 2989 2733 91 2 N.P. 404 381 94 Senior Mixed 7 C. 2480 2295 93 4 N.P 1341 1184 88 Junior Boys 7 C. 2384 2162 91 Junior Girls 8 C. 2713 2440 90 3 N.P. 730 668 92 Junior Mixed 12 C. 4469 3959 86 4 N.P. 990 840 85 Infants (369 under 5) 14 C. 3829 3298 86 2 N.P. 192 165 86 Schools— Church of England 13 4090 3650 89 Roman Catholic 2 Council 29 21832 19642 90 Total 44 25922 23292 90 " C."—Council. " N.P."—Non-Provided. Medical Inspection in Schools. The work of medical inspection is spread over all the staff of Assistant Medical Officers, excepting those acting as Resident Medical Officers in Institutions, or as specialist officers. 259 The Deputy Medical Officer, Dr. Watson, devoted 6/llths of his time to school medical duties; Dr. Pickup 7/llths; Dr. Martine 6/llths; Dr. Jenkin-Lloyd 2/llths; Dr. McMahon 3/llths; Dr. Morrison 5/llths. The groups examined have been entrants, usually aged 5-7 years; intermediates 6 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, enquiry officers, school nurses, etc., are classified ar " specials." The same arrangements as appertained in 1935, continues The Leaver group (13th birthday) are examined the first term ; tht Intermediates (8-9 years) the second term; and the entrants (5 years) the last term. An effort, somewhat hampered by illness among the medical staff, has been made to carry out reinspections more frequently. It is still far from complete. 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 7,312 children were examined as compared with 8,342 in 1935, and 5,309 parents attended the examinations. The percentage attendance of parents in the Entrants group was for boys 81.7 per cent., and girls 87.2 per cent.; in the Intermediate group, boys 69.7 per cent., girls 7.9 per cent.; and in the Leavers' group, boys 43.8 per cent., girls 56.0 per cent. 12,122 re-inspections were made as against 8,719 in 1935, and 8,286 in 1934. There has been an increase in the number of parents who attend the medical inspections with their children. It is pleasing to note this increase is over all the groups and not confined to the younger children. The present set routine medical inspection at fixed age groups is in need of revision and a more fluid system adopted. The service has now had many years experience of the present methods and there is nothing more to be learnt on the old lines. The times of examination are too far apart and too infrequent to be of great value, whilst the thorough examination of perfectly normal children consumes time which might be more profitably spent in concentrating upon the weakly and those exhibiting minor degrees of defects. 260 A better method would be for the school medical officers to be, in actuality, the medical officers of the schools allotted to them, and each term they would overhaul scholars whose physical or mental progress was slow, or who had shown a higher rate of absenteeism than the average for the school. In this way a closer contact would be maintained than at present, though it might happen that a number of children would have fewer medical examinations than at present. For all children, careful height, weight and nutritional index records would be compiled term by term, together with the medical history. Children who had returned to school after a severe illness, would be thoroughly re-examined. Every child on first entry into a school would have a more complete examination than is now done and from thenceforth the medical history would proceed on the above lines. For such a scheme to be successful it would require the close co-operation of head teachers, but as such co-operation is practically always forthcoming, there is little to apprehend on this score. The total percentage of parents attending was 72.6, as against 71.3 last year. This shows an increasing interest by parents in medical examinations: a trend which is to be welcomed. 261 Table II. Entrants. Intermediate. Leavers. Other Ages. Number Exmnd. Parents Present. Number Exmnd. Parents Present. Number Exmnd. Parents Present. Number Exmnd. Parents Present. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. Ashburton 33 33 29 31 24 42 20 37 17 22 7 19 ... ... ... ... Benson 23 22 21 22 ... ... ... ... ... ... ... ... ... ... ... ... Beulah 124 102 110 92 130 159 99 123 ... ... ... ... ... ... ... ... British ... ... ... ... ... ... ... ... ... 52 ... 33 ... ... ... ... Davidson 53 33 45 30 ... ... ... ... 46 37 15 15 ... ... ... ... Duppas 25 21 10 8 49 49 34 45 ... ... ... ... ... ... ... ... Ecclesbourne 53 41 47 39 49 ... 30 ... ... 48 ... 26 ... ... ... ... Elmwood 83 87 54 68 65 52 29 43 58 26 26 7 6 31 ... 9 Gonville 42 35 38 34 33 34 32 31 ... ... ... ... ... ... ... ... Howard 13 15 10 10 14 10 7 6 ... ... ... ... ... ... ... ... Ingram 61 62 56 56 ... ... ... ... 76 67 46 46 ... ... ... ... Kensington 39 49 36 45 11 16 9 16 ... ... ... ... ... ... ... ... Kingsley 134 94 121 89 86 109 55 85 95 22 51 13 ... ... ... ... Lanfranc ... ... ... ... ... ... ... ... 109 46 44 25 ... ... ... ... Monks Orchard 18 24 16 23 1 ... ... ... ... ... ... ... ... ... ... ... Norbury Manor 55 66 28 62 82 75 69 61 92 56 37 39 5 7 3 5 Oval 61 50 58 47 26 48 23 42 36 12 20 9 2 7 2 3 Portland 57 45 42 33 12 ... 12 ... 99 44 34 25 ... ... ... ... Purley Oaks 19 25 15 17 3 ... 2 ... 22 9 3 5 ... ... ... ... Rockmount 26 29 20 28 4 3 3 ... 14 3 ... 2 ... ... ... ... South Norwood 57 49 43 38 118 91 73 61 ... ... ... ... ... ... ... ... S. Norwood Tern. 20 18 15 17 1 ... 1 ... ... ... ... ... ... ... ... ... St. George's 24 24 23 24 2 4 1 2 ... ... ... ... ... ... ... ... Sydenham 58 44 53 36 136 16 76 10 ... ... ... ... ... ... ... ... Tavistock 45 38 40 31 ... ... ... ... 130 63 54 28 ... ... ... ... Waddon 36 31 33 31 74 52 55 42 70 48 35 19 ... ... ... ... West Thornton 73 47 46 39 33 100 16 54 15 ... 12 ... ... ... ... ... Whitehorse 84 55 78 52 ... 25 ... 17 47 ... 16 ... ... ... ... ... Winterbourne 100 74 82 65 53 62 50 56 ... ... ... ... ... ... ... ... Woodside 65 62 53 58 69 14 55 14 ... ... ... ... ... ... ... ... Addington 8 5 6 4 6 3 4 2 ... ... ... ... ... ... ... ... All Saints 35 19 19 10 36 27 29 16 10 12 4 7 ... 2 ... 2 A. Tenison's Gls. ... ... ... ... ... ... ... ... ... 36 ... 18 ... ... ... ... Christ Church 27 16 25 15 18 14 18 14 ... ... ... ... ... 13 ... 12 Holy Trinity ... 43 ... 33 ... 34 ... 32 ... ... ... ... ... ... ... ... Parish Church 31 39 25 34 26 24 20 20 13 ... 12 ... ... ... ... ... St.Andrew's 15 23 15 19 25 13 17 10 24 10 11 6 ... ... ... ... St. Joseph's 4 7 1 2 11 10 8 7 6 2 3 1 ... ... ... ... St. Mark's 12 20 11 20 2 38 2 29 ... ... ... ... ... ... ... ... St. Mary's 12 12 10 8 16 ... 6 ... 4 7 ... 5 1 ... 1 ... St. Peter's 31 30 19 27 ... ... ... ... ... ... ... ... ... ... ... ... St. Saviour's 26 22 19 19 13 26 3 19 ... ... ... ... ... ... ... ... Shirley 20 17 18 17 10 10 5 10 ... ... ... ... ... ... ... ... 1702 1528 1390 1333 1238 1160 863 904 983 622 430 348 16 63 7 34 3230 2723 2398 1767 1605 778 79 41 PERCENTAGE OF PARENTS PRESENT AT MEDICAL INSPECTIONS. Entrants Boys 81.7 84.3 72.6 „ Girls 87.2 Intermediate Boys 69.7 73.7 „ Girls 77.9 Leavers Boys 43.8 48.5 „ Girls 56.0 Other Ages Boys 43.9 51.9 „ Girls 54.0 262 FINDINGS AT ROUTINE MEDICAL INSPECTIONS. Uncleanliness. For uncleanliness surveys the health visitors made 446 visits to schools, a decrease of 143. At the primary inspections they found vermin in 188 and nits alone in 1,562 children. On these inspections, 3.1 per cent. of the children showed evidence of infestation as against 3.4 in 1935 and 3.9 in 1934. 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. During 1935 a new scheme was evolved and put into practice, tightening up the whole of this work, and establishing a cleansing station with an employee in charge. Previously, children found verminous attended the Minor Ailments Clinic. The health visitors now have the power to take children found to be persistently verminous direct from the school to the Cleansing Station. Authority for this step is provided by Section 87 (2) of the Education Act, 1921. This has resulted in a welcome improvement in the general level of cleanliness and has strengthened the hands of the head teachers. Clothing and Footgear. At routine medical inspections 99.2 per cent. of the boys and 99.6 per cent. girls were clothed and shod properly. Close scrutiny has been exerted by the medical inspectors and the findings are satisfactory. Nutrition. In the Entrants 8.6 per cent. of the boys and 7.9 per cent. of the girls were below normal nutrition for the area. In the Intermediate group 8.6 per cent. of the boys and 8.3 per cent. of the girls were under average; in the Leavers' group 3.2 per cent. of the boys and 5.3 per cent. girls, giving in the whole school groups examined 8.2 per cent. boys and 7.5 per cent. girls. The words Nutrition and Malnutrition vary greatly in their significance and meaning with the persons making the investigations, and the lack of any universally recognised standard, or group of criteria, is a heavy handicap, and renders accurate comparisons between groups of children in different areas, impossible. Heights and weights alone are insufficient. Malnourished children may actually weigh as much as properly nourished children. The whole " make up," physical and mental, must be assessed on identical lines—a matter of no small difficulty. Meanwhile, until some more 263 satisfactory method has been promulgated, the comparisons now made must be regarded as approximate only. Insufficiency of trained staff to make the necessary enquiries and investigations is the greatest handicap to the compilation of more valuable data. B0dy nutrition is a complex of many factors and its scientific study unfortunately requires complicated methods which are outside the present scope of the school medical service. The fundamental fact which appears to emerge from the welter of theories and opinions so continuously put forward, is that a plain, straightforward diet on old established lines, containing meat once a day, green vegetables, bread and butter and milk, contains all the necessary fo0d factors and main chemical groups necessary for proper nutrition. Whether a child gets a sufficient quantity is consequent on a combination of financial circumstances and skilful buying. One mother will cater for a growing family successfully on a low income, whilst another mother will fail hopelessly. The art of wise buying and economical cooking is one which might be developed in school education. It is truly an educational subject upon which too little time and thought has, as yet, been spent by those responsible for the educational system of this country. It is not denied that something is being done on these lines, but its effect so far on the dietary habits of the mass of the population has not been conspicuous in any of the special investigations which have been made in various parts of the country. Milk Marketing Board Scheme. During 1936, by arrangement with the Milk Marketing Board, milk was supplied to schools in bottles containing one-third of a pint at a cost of ½d. per bottle. Some 13,000 bottles of milk were consumed per day, an increase of 1,000 bottles a day. All the milk supplied is Pasteurised milk, and the sources of supply are subject to the approval of, and constant supervision by, the Medical Officer of Health, through the Sanitary Inspectors. Any falling off in quality or cleanliness is enquired into as soon as detected, and should any source prove consistently below standard, the supply from this source would be suspended. Heights and Weights. Table ITT. gives the results of an enquiry made to ascertain the average heights and weights of all children examined at routine inspections during 1936: The full value of this Table will not he 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. 264 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. 1932 161 41.5 39.6 43.7 45.0 38.1 34.7 126 40.7 37.4 42.5 42.2 37.6 33.0 1931 976 42.8 42.2 47.0 51.2 38.8 34.9 829 42.4 40.9 45.9 51.5 38.7 32.8 1930 473 44.1 44.2 47.6 52.2 40.5 37.1 427 43.9 43.4 47.4 52.2 41.1 36.4 1929 98 46.0 47.9 48.8 52.7 43.1 40.4 105 46.2 48.1 48.5 54.0 44.2 43.6 1928 579 49.3 55.3 53.6 69.8 45.9 46.2 436 49.1 53.8 52.5 68.5 45.5 43.9 1927 525 50.5 58.5 55.9 76.8 46.0 46.8 470 49.6 56.1 55.0 71.7 46.0 46.5 1926 146 52.3 63.7 56.0 77.6 48.6 50.9 160 52.0 61.8 56.3 81.9 48.1 49.8 1925 44 54.6 71.4 56.7 87.5 50.8 50.7 36 53.8 68.2 56.7 63.3 51.2 45.9 1924 128 55.3 76.7 59.7 113.1 50.9 62.2 44 56.6 78.5 59.9 97.2 53.2 68.9 1923 696 57.1 82.4 62.8 112.8 50.9 62.6 441 57.9 82.1 63.9 119.1 52.0 62.4 1922 122 59.0 91.2 65.2 115.8 54.9 69.7 109 58.8 92.0 64.3 122.4 55.7 69.1 1921 5 59.1 89.5 ... ... ... ... 4 64.1 92.2 ... ... ... ... 265 Children Born in 1931.—The boys are 0.4 inches taller and 1.3 lbs. heavier on the average than the girls. The average minimum weights of the boys is 2.1 lbs. more and their average minimum height 0.1 inches taller than the corresponding figures for the girls. The average maximum weight of the boys is 0.3 lbs. less and their average maximum height 1.1 inches taller than the girls. Children Born in 1930.—The boys are 0.2 inches taller and 0.8 lbs. heavier on the average than the girls. The average minimum weights of the boys is 0.7 lbs. more and their average minimum height 0.6 inches shorter than the corresponding figures for the girls. The average maximum weight of the boys is the same as the girls, and their average maximum height 0.2 inches taller than for the girls. Children Born in 1928.—The boys are 0.2 inches taller and 1.5 lbs. heavier on the average than the girls. The average minimum weight of the boys is 2.3 lbs. more and their average minimum height 0.4 inches taller than the corresponding figures for the girls. The average maximum weight of the boys is 1.3 lbs. more than the girls and their average maximum height is 1.1 inches taller than the girls. Children Born in 1923 and 1924.—The boys in this group were 1.0 inches shorter and 0.7 lbs. lighter on the average than the girls. The average minimum weight of the boys is 3.2 lbs. less and their average minimum height 1.7 inches shorter than the girls. The average maximum weight of the boys is 4.8 lbs. more and their average maximum height 0.7 inches 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. RANGE OF VARIATION. Height. inches. Weight. pounds. Born in 1931 : Boys 8.2 16.3 Girls 7.2 18.7 Born in 1930 : Boys 7.1 15.1 Girls 6.3 15.8 Born in 1928 : Boys 7.7 23.6 Girls 7.0 24.6 Born in 1923 and 1924 : Boys 10.3 50.5 Girls 9.3 42.5 266 The average maxima 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. During the peri0d of growth from 5 years to 8 years the boys gained on the average 13.1 lbs. in weight and 6.5 inches in height. The girls gained 12.9 lbs. in weight and 6.7 inches in height. From 8 years to 12 years the corresponding gains are 21.4 lbs. for boys and 24.7 lbs. for girls; 6.0 inches for boys and 7.5 inches for girls. During the peri0d of growth from 5 years until the end of the 12th year the boys increased by 12.5 inches in height and 34.5 lbs. in weight; the girls increased 14.2 inches in height and 37.6 lbs. in weight. These figures show, taking into consideration the successive groups of children examined year by year, a significant constancy. Graphic comparison with the average increase in weight of London County Council school children over the school period, shows that the Croydon children follow an almost identical curve. Heart and Circulatory System. At routine medical inspections among the Entrant group 84 boys and 64 girls were found to have organic disease. In the Intermediate group, the figures were 78 boys and 56 girls, and in the Leaver group 59 boys and 44 girls. Functional disease was found in 51 boys and 43 girls in the Entrants; 84 boys and 82 girls in the Intermediate; 100 boys and 43 girls in the Leaver group. Anæmia was present in 43 boys and 43 girls in the Entrant group; 43 boys and 23 girls in the Intermediate; and 33 boys and 18 girls in the Leavers. The percentage of all Heart and Circulatory defects among children examined at routine medical inspection was 13.6, a small increase on 1935. Chest Complaints (Other than Tuberculosis). In all the groups combined 5.4 per cent. of the boys and 4.3 per cent. of the pills had some minor affection of the lungs. This was usually a mild Bronchitis. Tuberculosis. Forty-six children were referred to the Tuberculosis Officer for further examination. One case was diagnosed as definitely tuberculous on further examination. 267 All contacts of known cases of Tuberculosis are kept under supervision and re-examined at each school medical inspection. 288 children were under such surveillance at the beginning of the year, 44 were added during the year, 42 were discharged, leaving 290 under observations at the end of the year. Seventeen cases of pulmonary Tuberculosis and 8 cases of nonpulmonary Tuberculosis in children of school age were notified to the Medical Officer of Health during the year. Five children died of pulmonary Tuberculosis and one of non-pulmonary Tuberculosis. The ages at death of these cases were:—Pulmonary, 6 years, 12 years, 14 years and 15 years (two); Non-Pulmonary, 14 years. The non-pulmonary death was certified to be due to Tuberculous Meningitis. Taking the total school population as 25,922, the mortality rate from Pulmonary Tuberculosis in school children was 19.3 per 100,000, and the incidence rate 65.6 per 100,000. For Non-pulmonary Tuberculosis the respective figures were 3.1 and 30.9. Nose and Throat. In all the groups 1,085 boys and 911 girls had enlarged tonsils; 53 boys and 39 girls had adenoids only; 431 boys and 338 girls had adenoids and enlarged tonsils; 224 boys and 136 girls were mouth breathers; 932 boys and 737 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 5.3 per cent. of all school children examined in the three groups were in need of surgical attention to the throat and nose. The number of children referred for adenoids and enlarged tonsils varies from year to year within small limits. In 1934, dealing with another group of children, the figure was 4.8 per cent. The importance of training in correct meth0ds 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 227 cases attended. This is 47 per cent. of the children who were operated upon, and although rather better then last year is a disappointing proportion. The distance of the Remedial Exercises Clinic from the homes of the children, together the dangers of traffic, played a part in deterring parents from sending the children. 206 Of all children examined at Routine Medical Inspection, in the Entrant group 29.8 per cent. had enlarged tonsils; 2.1 per cent. had adenoids alone; 14.5 per cent. enlarged tonsils and adenoids; and 30.1 per cent. had enlargement of the submaxillary or cervical glands. In the Intermediate group the respective percentages were 28.5 per cent., 0.8 per cent., 8.8 per cent., and 20.8 per cent.; and in the Leaver group, 20.3 per cent., 0.3 per cent., 5.3 per cent., and 11.4 per cent. The percentages for the three groups in relation to the total number of children examined, were 27.3 per cent., 1.3 per cent., 10.6 per cent., and 22.9 per cent. 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 50.1 48.6 29.9 30.4 Intermediates 41.9 39.2 23.5 17.8 Leavers 29.8 24.0 12.9 9.00 Other Ages 56.3 33.3 37.5 14.3 * Does not include mouth breathers, but includes other defects of nose and throat. Defective Hearing. The commonest causes of deafness in children are middle ear disease and adenoids. Routine medical inspection showed that 0.1 per cent. Entrants, 0.3 per cent. Intermediates, and 0.5 per cent. Leavers in the children examined had defective hearing. The report on the work done in the Ear Clinic is given on page 49. Routine medical inspection findings showed in the Entrant group 0.4 per cent. children defective, in the Intermediate group 0.7 per cent., and 0.4 in the Leaver group: figures very similar to 1935. Speech Defects. The special class is held twice weekly, and is conducted by two qualified lady teachers. During 1936, 33 children attended. A special report on the results of the class is given on page 57. 269 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 2.7 per cent. incidence in boys and 3.0 per cent. in girls; intermediate boys 1.9 per cent. and girls 1.6 per cent. ; Leavers 1.7 per cent. boys and 1.1 per cent. girls; a total in all groups of 2.2 per cent. boys and 2.1 per cent. girls. Deformities. Among children examined at Routine Medical Inspection 1.4 percent. of the boys and 0.7 per cent. of the girls showed evidences of rickets; 2.2 per cent. boys and 2.9 per cent. girls had some abnormal degree of spinal curvature, and 4.5 per cent. boys and 5.5 per cent. girls showed some other physical deformity. External Eye Diseases. Squint was present in 1.9 per cent. of all children examined in the various groups and was most frequently found in the Entrant group (2.6 per cent. boys and 2.8 per cent. girls). Its incidence declined as age advanced. Blepharitis occurred in 0.8 per cent. of all the children and other external eye defects in 0.3 per cent. The total percentages of eye defects in the various groups was 3.9 for Entrants ; 2.6 for Intermediates; and 1.7 for Leavers. For 1935 the corresponding figures were 2.9, 2.3 and 1.9. 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 6.5 per cent. of the boys and 6.2 per cent. of the girls were referred for treatment or observation for defective vision, and in the Leaver group 9.0 per cent. of the boys and 12.5 per cent. of the girls. The Leaver group of girls invariably gives the worst figures for vision. Taking several consecutive years there is manifest a small upward trend in the number of school children with defective vision, but the curve of this trend is undoubtedly flattening out as the objection to the wearing of spectacles becomes progressively less. 270 Table V. Extent of Defect. Intermediate. Leavers. Total. Boys. Girls. Boys. Girls. Boys. Girls. No. % No. % No. % No. % No. % Normal : 6/6ths or 6/9ths R 1187 95.9 1114 96.0 908 92.4 577 92.7 94.3 94.9 L 1187 95.9 1108 95.5 914 93.0 563 90.5 94.6 93.8 6/12ths or 6/24ths R 44 3.5 44 3.8 64 6.5 41 6.6 4.9 4.8 L 45 3.6 48 4.1 60 6.1 48 7.7 4.7 5.4 6/36ths or worse R 7 0.6 2 0.2 11 1.1 4 0.7 0.8 0.3 L 6 0.5 4 0.4 9 0.9 11 1.8 0.7 0.8 Table VI. TEETH. Entrants. Intermediate. Leavers. Boys. Girls. Boys. Girls. Boys. Girls. No. % No. % No. % No. % No. % No. % Perfect set of Teeth 818 48.0 743 48.6 887 71.6 840 72.4 783 79.7 486 78.1 One to four Decayed 476 28.0 416 27.2 205 16.6 180 15.5 137 13.9 106 17.1 Four or more Decayed 408 24.0 369 24.2 146 11.8 140 12.1 63 6.4 30 4.8 Totals 1702 1528 1238 1160 983 622 It is interesting to note that 5,066 children of all groups, or 63.0 per cent., were said to have sound teeth at medical inspection. The percentage of sound teeth found by the Dental Inspectors was 28 per cent. The examination made by the dentists is more searching than that made by the medical inspectors, who are instructed to concentrate rather on purely medical signs. The need for systematic instruction on the care of the teeth is certainly indicated. This is one of the investigations now carried out at routine medical inspections which could, without any loss, be discontinued. As the school dental service has become more developed, the examination of the teeth could be left to them. That the proper care of the teeth before the school age is reached would lead to much less attention being necessary during school age is repeatedly emphasised in the dental section of the report. 271 Table VII. SUMMARY OF THE FINDINGS AT ROUTINE EXAMINATIONS. (Percentages.) Condition. Entrants. Intermediate. Leavers. Other Ages. All Groups. Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Cleanliness: (Percentage Clean) Head 99.5 98.7 99.1 97.9 99.9 99.1 100.0 100.0 99.5 98.5 Body 99.9 100.0 99.7 99.5 99.9 100.0 100.0 100.0 99.8 99.8 Clothing (satisfactory) 99.8 99.7 99.8 99.7 97.7 99.5 100.0 98.4 99.2 99.6 Footgear (satisfactory) 99.8 99.7 99.3 99.8 97.8 99.5 100.0 100.0 99.2 99.7 Nutrition (normal) 91.4 92.1 91.4 91.7 96.8 94.7 81.3 95.2 91.8 92.5 Defects: Circulatory System 10.5 10.5 16.0 13.9 19.5 16.7 ... 0.8 14.3 12.8 Pulmonary System 0.2 0.3 0.2 0.3 0.4 0.6 ... ... 0.2 0.4 Skin Disease 2.7 3.0 1.9 1.6 1.7 1.1 6.2 ... 2.2 2.1 Defects of Nose and Throat 57.7 54.7 47.8 42.7 32.3 24.8 56.2 33.3 48.3 44.6 Enlarged Cervical Glands 29.9 30.4 23.5 17.9 12.9 9.0 37.5 14.3 23.7 21.9 External Eye Disease 3.8 3.9 2.0 3.2 1.9 1.5 ... 6.4 2.8 3.3 Defective Vision 0.1 0.4 6.5 6.2 9.0 12.5 6.2 9.5 4.3 4.8 Defective Hearing 0.1 0.1 0.3 0.2 0.6 0.3 ... ... 0.3 0.2 Speech Defects 0.6 0.1 0.6 0.7 0.4 0.3 ... ... 0.6 0.4 Dental Disease (more than four decayed) 24.0 24.1 11.8 12.1 6.4 5.0 12.5 6.4 15.7 16.1 Dull and Backward 0.3 0.1 2.9 1.0 0.4 0.6 6.2 ... 1.1 0.5 The above Table gives in a concise form the findings at Routine Medical Inspections. Defects of the nose and throat are once again the commonest defects found and show an increase on last year's findings; the Entrant group is still the worst, and the Leaver group the best. For nutrition, the Intermediate group (aged 8) gave the worst figures, whilst as a group the Leavers (12—13 years) showed the best findings. Taking all the groups examined subnormal nutrition was recorded in 7.9 per cent. of the children as contrasted with 6.9 per cent. in 1935. Enlarged cervical glands were recorded most often in the Entrants group in both sexes; a finding of interest as a pointer to the need for the pre-school age medical supervision which is lacking at the present time. There is a close relationship between enlarged cervical glands and unhealthy conditions of the nose and throat, Which is brought, out each year in the figures from medical inspections. In themselves simple enlarged neck glands are of no great 272 moment, but they serve as pointers to unhealthy conditions elsewhere, and may become the nidus of Tubercular infection. The influence of school work on eyesight is shown by the higher figures for the Leaver group, and if these figures are contrasted with those for secondary school children, it is seen that the latter are even less favourable. This is not the actual amount of defective vision, as children whose vision is normal by the aid of spectacles are classified as having normal vision. There is no doubt that school work does lead to a breakdown of normal vision in a fairly high proportion of school children. This may be due to breakdown of inherently weak accomm0dation, or to the overtaxing of accomm0dation by incorrect postures when reading and writing. The tendency of children, unless corrected, is to sit with their eyes too close to the paper when writing or reading. The number of children suffering from circulatory defects is high, and is mainly caused by the ravages of rheumatism upon the heart and its valves. This is one of the disabilities of childho0d against which no effective preventive measure has yet been found, although much more is now done to compensate the disability when once it has arisen. The incidence of various defects on the different age groups is an instructive finding. There is a steady rise in those defects which might arise from educational stress, and a steady fall in defects readily amenable to measures operated under the School Medical Services. 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 thought to be in need of spectacles. 273 Table VIII. School. Intermediates. Leavers. School. Intermediates. Leavers. Boys Girls Boys Girls Boys Girls Boys Girls Ashburton 16.6 2.4 — 9.1 St. George's — ... ... Benson ... ... ... ... Sydenham 4.4 6.3 ... ... Beulah 4.6 5.6 ... ... Tavistock ... ... 13.1 12.7 British ... ... ... 13.5 Waddon 4.1 1.9 7.1 6.3 Davidson ... ... 2.2 8.1 West Thornton 3.0 5.0 — ... Duppas 10.2 4.1 ... ... Whitehorse ... 12.0 6.4 ... Ecclesbourne 8.2 ... ... 2.1 Winterbourne — 9.7 ... ... Elm wood 6.2 — 6.9 3.8 Woodside 7.3 — ... ... Gonville 6.1 6.0 ... ... Addington 16.6 — ... ... Howard 7.1 — ... ... All Saints 2.8 3.7 20.0 8.3 Ingram ... ... 13.2 8.9 Arch. Tenison's Gls. ... ... ... 16.6 Kensington — — ... ... Christ Church 5.5 7.1 ... ...... Kingsley 3.5 6.4 10.5 18.2 Holy Trinity ... 8.8 ... ... Lanfranc ... ... 8.3 23.9 Parish Church — 4.2 — ... Monks Orchard — ... ... ... St. Andrews 16.0 30.8 16.6 ... Norbury Manor 9.8 2.7 5.4 17.9 St. Joseph's — — — - Oval 7.7 8.4 16.7 25.0 St. Mark's — 2.6 ... ... Portland 8.3 ... 12.1 15.9 St. Mary's — ... ... 42.9 Purley Oaks — ... — 22.2 St. Peter's ... ... ... ... Rockmount — — — — St. Saviour's 7.7 2.7 ... ... South Norwood 13.6 13.2 ... ... Shirley 10.0 20.0 ... ... South Norwood Temporary — ... ... ... Note.—Where a dash is placed, children were examined, but no visual defects were found The true meaning of this Table will not be apparent until the findings for 9 years are summarised. In this time an Entrant group will have passed through the whole school period. 274 Table IX. Return of Defects Found in the Course of Medical Inspection 1936. 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 110 68 4.52 73 66 4.12 Uncleanliness— Head 1 ... 0.03 1 1 0.06 Body Skin Disease 10 4 0.36 13 1 0.42 Eye Disease— Defective Vision 155 16 4.34 147 15 4.80 Squint 51 8 1.50 35 22 1.63 External Eye Trouble 8 4 0.30 7 1 0.24 Ear Disease— Deafness 6 1 0.18 1 2 0.09 Otitis Media 5 4 0.23 3 ... 0.09 Other Disease 3 3 0.15 3 ... 0.09 Nose and Throat— Enlarged Tonsils only 110 277 9.82 112 256 10.91 Adenoids only 11 28 0.99 7 23 0.89 Enlarged Tonsils and Adenoids 219 113 8.43 153 93 7.29 Other Conditions 79 37 2.95 24 27 1.51 Enlarged Cervical Glands (not T.B.) 2 44 1.17 ... 21 0.62 Dental Defects 33 5 0.97 32 5 1.10 Speech Defects 2 7 0.23 2 3 0.15 Heart and Circulation— Organic 45 117 4.11 28 116 4.30 Functional 5 41 1.17 5 42 1.39 Anaemia 17 15 0.80 2 19 0.62 Bronchitis 9 57 1.68 6 46 1.30 Other Non-T.B. 4 12 0.43 2 3 0.15 Pulmonary Tuberculosis 1 7 0.20 1 11 0.35 Other Tuberculosis 1 8 0.23 ... 6 0.18 Nervous System Disorders (including Epilepsy, chorea, etc.) 15 73 2.23 13 57 2.08 Deformities— Rickets 2 3 0.13 1 2 0.09 Spinal Curvature 25 14 0.99 33 22 1.63 Others 43 21 1.63 57 43 2.97 Other Defects and Diseases 35 38 1.85 27 33 1.78 Totals 1007 1025 51.59 788 936 51.11 Total Children Examined 3939 3373 276 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 referred for treatment. Corresponding percentage for 1935. Entrants 3230 650 20.1 15.3 Intermediates 2398 466 19.4 19.8 Leavers 1605 348 21.7 21.1 Other Ages 79 20 25.3 15.4 7312 1484 20.3 18.0 The fact that 20.1 per cent. of 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 systematic 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. A 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 arisen. In other cases the departure from normal is so insidious that irreparable consequences may have supervened before the parent notices anything amiss. Initial flight defects, if unremedied, become, in not a few cases, serious and permanent as school life advances. 276 Table XI. CHIEF CAUSES OF EXCLUSIONS FROM SCHOOL. Condition. Exclusions during 1936. Percentage of total exclusions. Exclusions during 1935. Percentage of total exclusions. Ringworm—Head 3 0.04 2 0.02 „ B0dy 26 0.33 36 0.35 Verminous Conditions 1750 22.69 2223 21.76 Impetigo 336 4.35 267 2.61 Scabies 58 0.75 37 0.36 Scarlet Fever 326 4.23 417 4.08 Measles 2093 27.14 619 6.06 Diphtheria 145 1.88 256 2.80 Whooping Cough 770 9.98 311 3.04 Chicken Pox 1011 13.11 841 8.23 Mumps 199 2.58 3561 34.85 Tuberculosis (all forms) 24 0.31 28 0.27 External Eye Disease 35 0.45 24 0.23 Sore Throat 196 2.54 236 2.31 Other Causes 740 9.59 1330 13.02 7712 ... 10180 ... It must be remembered that the figures for exclusions are not related in any way to the figures obtained in routine medical inspections. There were 2,506 fewer children excluded from school on account of various illnesses than in 1935. The chief causes of exclusion were Infectious Diseases, 58.9 per cent., practically the same figures as for 1935. The Infectious Diseases constituting the major causes of these exclusions changed, however. Measles followed its biennial incidence and became prevalent during the early part of the year. Mumps, however, which was very prevalent in 1935, subsided. Both Diphtheria and Scarlet Fever were less prevalent but Chicken Pox and Whooping Cough showed an increased incidence. The total cases of this group of infectious diseases declined, however, from 6,035 in 1935 to 4,544. Exclusions on account of verminous conditions were higher than in 1935 or 1934 and constituted 22.69 per cent. of the total exclusions. The health visitors examined 58,723 children in the schools in connection with their primary inspections for the personal cleanliness of the scholars. Impetigo was more prevalent than in 1935. 277 CONDITIONS NOTIFIED BY TEACHERS AND SCHOOL ATTENDANCE OFFICERS. Name of School. School Population. Scarlet Fever. Diphtheria. Ac. Primary Pneumonia. Measles. Whooping Cough. Chicken Pox. Mumps. Scabies. Impetigo. Sore Throats. Ringworm (B0dy). Ringworm (Scalp). Indefinite Sickness. III. Not Infectious Conjunctivitis. Percentage incidence of Infectious Diseases in Schools. Ashburton 845 6 1 ... 84 33 52 3 ... 5 ... 1 ... 21 22 ... 21.0 Benson 156 10 ... ... 7 ... 1 4 ... ... ... ... ... 2 ... ... 14.1 Beulah 1241 8 7 ... 107 23 30 3 3 24 4 2 ... 10 37 2 14.3 Crydon British 177 ... ... ... ... ... ... ... ... 4 2 1 ... 2 1 ... ... Davidson 696 5 ... ... 83 31 12 5 ... 11 9 1 ... 11 9 ... 19.5 Duppas 572 10 9 ... 27 19 67 1 5 5 3 ... ... 2 14 ... 23.0 Ecclesbourne 905 12 6 ... 136 30 40 2 3 1 2 2 ... 4 24 1 25.0 Ernwood 1039 18 4 ... 134 25 43 1 4 26 6 2 ... 11 24 1 21.6 Gonville 408 2 ... ... 41 52 14 8 1 3 6 ... ... 14 13 3 28.7 Howard 323 2 ... ... 130 10 4 ... ... 2 ... ... ... ... 2 ... 45.2 Ingram 715 11 4 ... 60 40 10 1 ... 6 7 ... ... 6 11 ... 17.6 kensington Avenue 401 42 3 ... 35 18 1 2 ... 2 4 ... ... 1 9 ... 25.1 Kingsley 1585 15 20 ... 113 17 78 1 2 37 17 1 ... 10 39 1 15.4 Manfranc 583 1 1 ... 1 2 1 ... ... 4 13 1 ... 2 5 ... 10.3 Norbury Manor 1109 11 ... ... 5 14 6 ... ... 4 3 1 ... 3 4 3 3.2 Oval 760 9 1 ... 10 16 4 1 ... 18 14 3 1 11 22 3 5.4 Portland 808 10 ... 1 122 49 33 ... 2 6 6 3 1 7 14 1 26.6 Purley Oaks 504 4 8 ... 7 43 4 ... ... 9 9 ... ... 6 8 ... 13.1 Rockmount 470 3 3 ... 38 26 11 80 ... 4 3 1 ... 1 9 ... 34.2 South Norwood 826 7 14 ... 66 10 83 2 5 10 5 ... ... 7 11 ... 22.0 Sydenham 715 10 3 ... 42 9 8 1 1 18 8 ... ... 1 8 ... 10.2 Tavistock 650 8 3 ... 38 11 5 ... 1 11 6 ... ... 6 9 ... 10.0 Waddon 1153 5 5 ... 65 28 91 ... 6 1 12 1 ... 3 14 ... 16.8 West Thornton 911 30 5 1 152 31 34 ... 5 21 16 ... ... 14 19 3 27.8 Whitehorse Manor 836 5 5 ... 16 11 100 ... 6 11 6 ... ... 4 22 ... 16.4 Winterbourne 1159 5 6 1 176 29 58 ... ... 2 ... ... ... 4 25 ... 23.7 Woodside 1008 6 2 ... 126 83 23 4 2 12 ... 1 ... 18 21 1 24.2 Health Clark 348 2 ... ... 1 ... 2 ... ... ... ... ... ... ... ... ... 1.4 Ruskin 383 2 ... ... ... ... 8 ... ... ... ... ... ... ... 1 1 2.6 Edridge 290 5 ... ... ... ... ... ... ... ... ... ... ... 1 1 ... 1.7 Christopher's 124 3 ... ... ... ... 1 ... 2 6 1 ... ... ... ... ... 3.2 Giles' 90 ... 11 ... 1 1 1 ... ... ... ... ... ... ... 2 3 15.5 Topic Class 34 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Wdington St.Mary's 61 1 ... ... 3 5 ... ... ... ... 11 ... ... 5 8 ... 14.7 Saints' 389 1 1 ... 4 21 75 76 ... ... ... ... ... 1 10 ... 45.7 Tenison's 315 5 ... ... 5 ... 1 ... ... ... ... ... ... ... 1 ... 3.5 Christ Church 453 4 8 ... 6 18 6 3 6 28 5 ... ... 6 16 4 10.0 Trinity 250 4 ... ... 32 8 9 1 ... 2 ... ... ... 3 6 2 21.6 Parish Church 570 1 5 ... 15 13 3 ... 2 7 11 ... ... 5 12 ... 6.5 Andrew's 421 11 ... ... 36 7 2 ... ... 11 ... 3 ... 2 10 ... 13.3 Joseph's 231 ... ... ... 1 ... 5 ... ... ... ... ... ... ... ... 2.6 Mark's 171 ... ... ... 39 3 6 ... ... 5 1 ... ... 5 5 1 28.0 Mary's 379 4 1 ... 24 4 31 ... 2 13 3 ... ... 5 13 ... 16.9 Peter's 131 2 ... ... 6 11 1 ... ... 2 2 ... ... 2 18 ... 15.3 Saviou's 294 8 5 l 9 ... 4 ... ... 3 1 2 ... 1 3 3 9.2 Sairley 229 12 2 ... 18 1 16 ... ... ... ... ... ... ... ... ... 21.4 Michael's 208 ... 1 2 ... ... 1 ... ... ... ... ... ... ... ... ... 2.0 selhurst Grammar 959 5 ... ... ... ... 2 ... ... ... ... ... ... ... ... ... 0.7 Norwood (Temp.) 151 ... 1 1 59 13 18 ... ... 1 ... ... ... 7 14 ... 60.9 George's 106 1 ... ... 12 5 6 ... ... ... ... ... ... ... ... ... 22.6 Orchard 138 ... ... ... 1 ... ... ... ... 1 ... ... ... ... ... 0.7 Totals 326 145 7 2093 770 1011 199 58 336 196 26 3 224 516 35 * Opened September, 1936. 278 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 South Norwo0d Temp. (60.9) and All Saints' (45.7), due chiefly to Measles and Chicken Pox ; next were Howard (45.2) and Rockmount (34.2), due chiefly to Mumps and Measles. The lowest incidence was in Selhurst Grammar (0.7). Scarlet Fever. Three hundred and twenty-six cases were notified from the schools, 91 less than in 1935. Kensington (42) and West Thornton (30) had the most cases. Diphtheria. One hundred and forty-five cases were notified from schools. This was 141 less than in 1935. The Kingsley with 20 cases, and South Norwo0d with 14 cases, had the highest individual numbers. Mumps. One hundred and ninety-nine cases were notified from schools. Rockmount (80) and All Saints' (76) had the highest individual numbers. Chicken Pox. One thousand and eleven cases occurred in schools and were notified therefrom, 170 more than last year. Whitehorse (100), Waddon (91), South Norwo0d (83), and Kingsley (78) showed the highest incidence. Whooping Cough. Seven hundred and seventy notifications were received from schools, 4.59 more than in 1935. The highest numbers for individual schools were: Wo0dside (83), Gonville (52), and Portland (49). Measles. Two thousand and ninety-three cases occurred in schools. Those showing the highest incidence were Winterbourne(176), West Thornton (152), Ecclesbourne (136), Elmwo0d (134). The reorganisation of schools in conformity with the Hadow Report, and the consequent grouping of children of the most susceptible ages into Junior Mixed and Infants Schools, has to a higher incidence of all the common infectious diseases in these 279 schools then occurred under the former arrangements. However desirable the re-grouping recommended may be educationally, it is not advantageous from the medical aspect. FOLLOWING UP There are 22 Health Visitors, who devote 5/llths of their time to school work. 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 four whole-time dental assistants. The nurses also assist at routine and special medical inspections in the schools and pay peri0dical visits to schools for cleanliness surveys. With the helpful co-operation of the Chief Enquiry Officer and his staff, persistent offenders against cleanliness have been proceeded against in Court, others have been brought before the Committee and warned. School Visits. The following Table summarises the visits paid, etc., in connection with these duties:— Visits to Schools re Cleanliness 47 Visits to School Departments re Cleanliness 446 Number of children inspected for cleanliness (first inspection) 55,908 Number of children inspected (subsequent inspections) 2,815 Number of occasions in which children found unclean (first inspection) 1,750 Number of occasions in which children found unclean (subsequent inspections) 1,302 In addition, 1,282 " other visits " to schools were made. Home Visits. Concerning defects found at routine medical inspections 1,745 Subsequent visits re defects found at routine medical inspections 793 Visits re special cases 1,172 Visits to dental cases 74 Visits in connection with infectious cases and other visits (including 102 visits concerning uncleanliness) 15,385 280 These figures show a decrease of 9,790 in the number of children inspected for cleanliness; a decrease of 1,394 in visits paid in connection with infectious cases and other visits for miscellaneous reasons, and of 13 in the following-up visits to dental cases; increases of 153 in visits to special cases; and of 290 in the visits made regarding defects found at routine medical inspections, and a decrease of 16 in the home visits regarding uncleanliness. TREATMENT. The Work of the School Clinics. Table XIII. Summary of Attendances. 1936. 1935. Increase or Decrease. Minor Ailments Clinics 13765 9275 †4490 Inspection Clinic 1732 1685 † 47 Dental Clinics 14749 13611 † 1138 Ophthalmic Clinic 3493 3144 † 349 Orthopaedic Clinic 2055 1620 † 435 Remedial Exercises Clinic 8813 8051 † 762 Nose and Throat Clinic 1388 965 † 423 Ionization Clinic 316 311 † 5 Rheumatism Clinic 618 456 † 162 46929 39118 + 7811 The Minor Ailments Clinics. Clinics are held each morning at L0dge Road and on five mornings at Selhurst Road, and at Duppas School. 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 these Clinics is to render first aid and to treat the minor disabilities peculiar to school children, and to advise what further measures may be necessary. At the subsidiary Clinics held at 206, Selhurst Road on five days weekly, 799 children made 3,857 attendances, and at the Duppas School 793 children made 3,374 attendances. 281 Table XIV. Complaint. 1936. 1935. Cases. Attendances. Average No. of Attendances. per case. Cases. Attendances. Average No. of Attendances. per case. Ringworm of Scalp 9 15 1.7 6 40 6.7 „ „ B0dy 32 166 5.2 32 249 7.8 Scabies 62 267 4.3 42 171 4.1 Impetigo 305 1811 5.9 262 1605 6.1 Other Skin Diseases 214 675 3.2 167 542 3.2 Otorrhœa and other Ear defects 305 1394 4.6 236 1533 6.5 External Eye Disease 328 2981 9.1 256 1245 4.9 Miscellaneous 1574 6456 4.1 1090 3988 3.7 2829 13765 4.9 2091 9373 4.5 From this Table it is seen that the average number of attendances per child increased from 4.5 to 4.9; the total attendances increased by 4,392, and the number of individual cases increased by 738. Otorrhœa, which used to be one of the most intractable conditions, has become, with revised meth0ds of treatment, no longer the long drawn-out affair it used to be. Impetigo still remains troublesome, while in the cases of scabies attending, the improvement noted in last year's report was not maintained. Adenoids and Enlarged Tonsils. During 1936, 248 cases of tonsils only, 19 cases of adenoids only, and 372 cases of adenoids and enlarged tonsils, a total of 639 rases, were recommended for treatment. In 480 cases the Local Education Authority was requested to arrange for the operation. There were 85 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 peri0ds of three months, and remunerated by the Education Committee. All other expenses of the Clinic are also borne by the Committee. The children were examined at the Throat Clinic the week prior to the operation. 282 480 children were operated upon, an increase of 144 on 1935. 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. During the year no parent accepted this responsibility. If needful, children are kept longer. All children are conveyed home by ambulance. In all there were 277 non-attendances. Of the 480 children operated on 227 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 47 per cent. compared with 41 per cent. in 1935. 53 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. A few cases were operated upon in Mayday Hospital. 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. 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 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. 1,732 attendances were made by children during the year, an increase of 47. 283 Treatment of Visual Defects. Table XV. Number of defects dealt with. Spectacles prescribed. Spectacle obtained. Under the Authority's Scheme. Submitted to refraction 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 938 16 954 584 16 622 16 Secondary Schools 125 7 132 92 7 100 7 1063 23 1086 676 23 722 23 This Clinic showed an increase upon 1935 of 61. 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 Out-patient Clinic held by Mr. Alan T0dd 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. 1936. 1935. ances. Sessions. Av. att. Attendances. Sessions. Av. att. Spinal 2,734 553 4.9 . 2,482 527 4.7 Massage 176 176 1.0 114 114 1.0 Flat Feet 1,520 190 8.0 1,685 240 7.0 Breathing 2,996 287 10.4 2,100 189 11.1 7,426 1,206 6,381 1,070 284 St. Giles' School, Addington. Total number of sessions 205 Total number of attendances 1,387 Average attendance per session 7 Total number of females 21 Total number of males 17 Total number of patients 38 Still under treatment 24 Complaints. Male. Female. Total. Flat Foot and K.K. — 6 6 Scoliosis 3 5 8 Kyphosis 4 2 6 Spastic Diplegia 3 1 4 Hemiplegia 1 — 1 Infantile Paralysis 3 4 7 Lordosis 1 1 2 Muscular dystrophy — 1 1 Paresis 1 — 1 For breathing exercises 1 1 2 17 21 38 SCHOOL DENTAL SERVICE. The year 1935 saw the establishment of a new clinic at Waddon, to serve a large area with a school population of approximately 4,600. The clinic is at the Waldrons, Duppas Mill Lane, and several rooms of the house have been adapted to make an excellent clinic. The dental surgery is a large, welllighted room and has been adequately fitted with m0dern equipment. The waiting room is well apart from the surgery, but the recovery room adjoins the latter. The clinic serves as a fulltime treatment centre for school children and maternity and child welfare cases from the South Croydon and Waddon districts. Since the clinic has been open the attendances have been extremely go0d. There are now two branch clinics, the other being at Selhurst, which was opened in 1930. The school dental service is staffed by four dental officers, and their duties include the inspection and treatment of all children attending the public elementary and central schools and scholarship children attending the secondary schools. Patients 283 are also referred and treated under the Maternity and Child Welfare, Tuberculosis and Mental Deficiency schemes, and children attending the special schools for the partially sighted and physically defective are included. The dental officers have made several visits to Mayday Hospital to treat patients referred under the various schemes. The total number of children eligible for treatment is 26,960, consisting of 26,100 children attending the public elementary schools and approximately 860 scholarship children attending the secondary schools. Each dental officer on this basis has therefor allocated to his care the dental needs of no fewer than 6,525 elementary school children, which is considerably in excess of the 5,000 per dental officer as advocated in the Circular 1444 of the Board of Education issued to local authorities in January, 1936. Inspection. Out of the above-mentioned 26,100 children, 18,316 were inspected and 1-3,250 referred for treatment, compared with 15,046 inspected and 10,450 referred for treatment in the previous year. The percentage of children suffering from dental disease was 72 as against 69 in 1935. The number inspected represents "0 per cent. of the total school roll as compared with 60 per cent. in 1935. The sessions devoted to inspections totalled 100 as against 83 last year, and 183 children were inspected per session, as against 181 in the previous year. The incidence of caries in some of the age groups varies considerably. For instance, in the six-year-old boys' group 62 per cent. were referred for treatment as compared with 68 per cent. girls of similar age, while the 12-year-old boys have 79 per cent. caries, and girls in the same group 77 per cent. There are three factors which probably account for this variation : firstly, at 12 years of age there are more teeth in the jaws and therefore more tooth surfaces likely to decay; secondly, many children as they grow older tend to become more slack with oral hygiene; and lastly, children at 12 years of age usually have more pocket money to spend on sweets. It is very regrettable that the school entrants have a high percentage of dental defects when one considers that the majority of these children should have been treated under the scheme for 286 treatment for the pre-school child. In the case of boys 70 per cent. were referred, and in the case of girls, 71 per cent. Summary of work done at Selhurst Clinic. During the dental inspection a survey of the incidence of malocclusion was made for the second time, and out of 18,316 children examined 913 were found to be suffering from irregularity of the teeth and malformation of the jaws, i.e, 5.0 per cent., which compared with 3.7 per cent. at the previous survey, represents an increase of 1.3 per cent. Treatment. The total number of children treated during the past year was 0,899, compared with 7,110 in the previous year; the aggregate of treatment sessions was 1,179, as against 1,148 in 1935, an increase of 31. The total number of fillings in permanent teeth was 6,254, which is an increase of 542 on last year's total, and fillings in temporary teeth numbered 399, as against 330 in 1935. The number of fillings per 100 children treated was 90 in 1930, compared with 78 in 1935. These figures should be contrasted with those of 1930, when the number of fillings was 32 per 100 children treated. This shows a welcome advance by parents towards appreciation of conservative measures for their children's teeth. In connection with conservative treatment there is a large amount of work done by means of dressings in teeth, which totalled 3,542. In this total is included zinc oxide dressings, capping of exposed nerves, temporary cement fillings, root dressings, scalings and gum treatments; and in addition 34 dressings were inserted in temporary teeth and 42 applications of silver nitrate were made. Special Treatments. These included 47 root fillings in anterior teeth, extirpation of 12 nerves under local anæsthesia, and three under nitrous oxide; also three cases of fraenectomv. Four stainless steel partial dentures for children were fitted. These dentures were inserted in the mouths of children of over 13 years of age who had lost their front teeth through injuries or caries. In addition, two vulcanite dentures were fitted. 287 Three cases of intermediary hæmorrhage were successfully treated with Russell Viper Venom (Stypven). In the few cases treated it would appear that the snake venom is a most reliable and economical meth0d of dealing with troublesome haemorrhage. Two visits were made to Mayday Hospital for children referred for dental extractions. Extractions of Teeth. Dental extractions were reduced in the permanent dentition from 3,307 in 1935 to 2,182 in 1936, and fewer temporary teeth were removed than in 1935, when 10,130 teeth were extracted, compared with 9,785 in 1936. The number of permanent teeth extracted per 100 children treated was 32. The ratio of permanent fillings to extractions of permanent teeth was 1:0.35 and the ratio of temporary fillings to extractions of temporary teeth, 1:24.52. It is hoped that next year, with more frequent inspections and treatment, there will be a considerable reduction in the number of teeth extracted. Local anæsthesia was given on 3,074 occasions as against 3,447 in 1935 for the extraction of teeth, and also for the preparation of painful cavities. Nitrous oxide was administered on 2,075 occasions, as compared with 1,904 in 1935. At the L0dge Road clinic "gas" is administered by the dental officers, and at the branch clinics at Selhurst and Waddon by medical officers. Special Cases. The number of special forms issued by head teachers was 2,057 as against 1,864 in 1935. The increase in the number of "specials" can be attributed to the fact that it was again found impossible to inspect every child attending the public elementary schools. Children who would have been called up as routine rases, had they been inspected, have been unable to wait for the inspection, and consequently have been compelled through pain to seek emergency treatment. Attendances. The attendance fee is 8d., and when gas is required, 2s. The total number of attendances for the year was 14,749 as against 13,611 in 1935. Parents who are in straitened circumstances are offered free treatment for their children. The sum of £449 12s. 8d. was received in payment for attendances made by children, and £5 5s. 2d. was received from the voluntary box contributions. 288 Cases X-Rayed. Cases referred to Mayday Hospital numbered 50 as compared with 72 in 1935. Children can be referred to the hospital on certain days only, and consequently many cases in which immediate X-Ray was required have not been referred. The children X-Rayed included those suffering from traumatic injuries of incisor teeth, those who had undergone root canal treatments and others who had undergone orth0dontic treatments. The Treatment of Scholarship Children. Attendances 266 Other operations 31 New cases 83 Scalings 11 Permanent fillings 201 Gas cases 4 Extraction of permanent Local anaesthesia 30 teeth 70 Cases completed 49 Extraction of temporary teeth 10 Root fillings, anterior teeth 3 Scholarship children are treated at all the Clinics. Summary of work done at The Waldrons Clinic (Opened November 10th, 1936). Attendances 470 Other operations 138 Extractions 143 Gas cases 10 Fillings 350 Local anæsthesia 75 Patients treated 116 Sessions held : Inspection 4; Treatment 41; "Gas" 1. The average attendance at this clinic during the year was 11.4. 1936. 1935. Attendances 4,798 4,609 Extractions 3,864 4,061 Fillings 2,160 2,033 Patients treated 2,310 2,185 Other operations 1,045 577 "Gas" cases 613 678 Local anæsthesia 1,219 881 New cases 2,775 2,655 Sessions held: Inspection 47; Treatment 418; "Gas' 49. The average attendance at this clinic during the year was 11.4 (the same as at the Waddon Centre). 289 The returns for the year show that the attendances, iillings, patients treated, and other operations have all increased in number, while extractions show a welcome reduction. Preventive and Educative Measures. The dental officers have continued to give talks at the routine dental inspections, and during the year a large number of mothers attended these informal lectures. At the clinics leaflets are given to the children, and those sent by the Dental Board are particularly helpful and instructive, especially the latest leaflet " A Story of a Tooth." The Dental Board of the United Kingdom very kindly sent films free of charge for exhibition to the children in the schools. There are many aspects of these films that are extremely instructive and educational, but in some respects the stories might be strengthened. Non-Acceptance of Treatment. The greatest problem of school dentistry is non-acceptance of treatment. Everything has been done to popularise dentistry; improved technique has been adopted, but still the number refusing treatment is considerable. Efforts are being made to educate parents, but results are inclined to be disappointing. The increase of staff, which will enable more frequent inspections and more rapid calling up for treatment, will undoubtedly in time bring about a great reduction in the number of refusals. Thanks are due to the teachers for their co-operation and support. It is hoped that they will continue to use their influence to obtain more consents to treatment. Healthy Dentitions. The number of children with caries-free dentitions totalled 10,177, which comprised 5,111 children whose teeth were rendered artificially sound (i.e., those whose treatments were completed) and 5,066 found to be healthy at the dental inspections. These figures show that approximately 40 per cent. of the total school Population of 26,100 was free from dental disease. Acceptances For Treatment. Out of 13,250 forms issued at dental inspections 7,155 Parents consented to have treatment at the Council's clinics, i.e., 54 percent.; private dental treatments totalled 3,843, i.e., 29 per cent., but the greater part of this total can be considered as 290 refusals, as only a small percentage of parents are able to pay fees for complete private treatment. Forms not returned totalled 2,120, i.e., 16 per cent., and 132, or 1 per cent. definitely refused to have any treatment. The acceptances rate was the same as in 1935. As many children have to attend several times when there is a lot of conservative treatment to he done it is possible that a revision of the attendance fee might bring about an increase in the number of acceptances, as the present arrangement tends to make conservative treatment more expensive to parents than the extraction of teeth, because extractions are often completed in one session, and therefore there is only one attendance fee to pav. Summary of School Children Inspected and Treated DURING THE YEAR. Patients examined 20,373 Patients treated 6,899 Attendances 14,749 Fillings 6,653 Extractions 11,967 "Gas" cases 2,075 Other operations 3,576 Local anæsthesia 3,074 Sessions held. Inspections 100 Treatment 1,179 Administration 18 orthodontia 43 "Gas" administration 91 Total sessions 1,431 In addition, 182 sessions were occupied in other than school work. The dental officers devoted 91 sessions and the medical officers 52 sessions to gas administrations. The average amount of work by each dental officer per treatment session was as follows : — Average attendance 12.5 „ number of fillings 5.6 „ „ extractions 10.2 „ „ other operations 3.0 „ „ local anæsthesia 2.6 ORTH0dONTIC SERVICE. As previously pointed out, 4.99 per cent. of children examined at dental inspections were found to be suffering; from malocclusion, but as this represents 913 children it would be impossible to treat such a number, and only those with market deformity have been referred for treatment. 291 Some of the parents are unable to pay 15s. 0d., which is the cost of treatment, and these are treated as far as possible by extraction of teeth only. It would appear desirable that as orthodontia in the school dental service has passed the empirical stage it should be placed on the same basis as other branches of orthopaedics, and cases should be treated not necessarily on the ability to pay, but treatment should be available for all, so that children of indigent parents may be treated free of charge or at a specially reduced fee. Many cases of malocclusion have a direct bearing on health, and it is expedient that all children whose dental deformity is associated with mouth breathing, enlarged tonsils, malnutrition and speech defects due to contracted arches should have the necessary orth0dontic treatment. The total number of children treated since the inception of the scheme five years ago is 702. Of this total, 499 have been treated by special appliances and 203 by extraction of permanent teeth. The number of such teeth extracted for the purpose of relieving overcrowding was 49. The sessions devoted to orthodontia totalled 43, as compared with 39 in 1935. Extra verbal appointments reached a total of 1,501. During the year 256 removable and five fixed appliances were fitted. The fixed appliances inserted were in the nature of splints for cases of linguoversion of upper incisor teeth. The treatment of some cases may take as long as two years, and despite the fact that a large number of new cases were taken on during the year 72 treatments were completed. Summary of Treatment Carried Out During the Year. Number of children under treatment during the year 261 Number of children whose treatment was completed 72 Number of removable appliances fitted 256 Number of fixed appliances fitted 5 Number of mouth screens fitted 3 Number of Friel's lip discs given for lip exercises 26 Number of cases X-rayed 26 Number of sessions devoted to orthodontia 43 Number of attendances 937 The orth0dontic session is held on Monday mornings from 10 a.m. to 12.30 p.m., and two dental officers devote one session per week to this important work. 292 Year 1935. (1) Number of children who were— (a) Inspected by the Dental Officers: — Aged 5—6 1,2101 903 „ 6-7 1,726 1,534 „ 7—8 1,796 1,543 „ 8-9 2,058 1,261 „ 9-10 1,911 1,551 „ 10—11 2,070 Total : 18,316 1,743 „ 11—12 2,112 1,779 „ 12—13 1,815 1,517 „ 13—14 1,939 1,540 „ 14-15 1,248 1,165 „ 15 up 421 510 Specials 2,057 1,864 20,373 16,910 (b) Found to require treatment 15,307 12,314 (c) Actually treated 6,899 7,116 (2) Half-days devoted to inspection. 100 83 Do., treatment 1,179 1,148 Do., administration 18 16 Do., gas administration— (by dental officers) 91 80 (by medical officers) 52 55 Do., orthodontia 43 39 1,483 1,421 (3) Attendances made by children for treatment 14,749 13,611 (4) Fillings—Permanent teeth 6,254 5,712 —Temporary teeth 399 336 6,653 6,048 (5) Extractions—Permanent teeth 2,182 2,307 —Temporary teeth 9,785 10,130 11,967 12,437 (6) Administrations of general anæsthetics for extractions 2,075 1,904 (7) Administrations of local anaesthetics for extractions 3,074 3,447 (8) Other operations— Permanent teeth 3,542 2,705 Temporary teeth 34 46 3,576 2,751 293 EAR CLINIC. 1936. 1935. Number of Sessions held 41 41 Number of first attendances 62 73 Number of re-attendances 254 239 There were no names on the waiting list at the end of the year. The classification of cases shows a 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 8 2.—Deafness only.—Some of these were due to old otitis media 9 3.—Otorrhoea, active, quiescent or cured 45 Group 2.—9 cases.—Five were catarrhal in type and fit to attend the ordinary school. Of these, one was referred for removal of tonsils and adenoids, one for breathing exercises, one for Eustachian catheterisation, and two called for no special treatment. Two were due to old otitis media, of which one was referred for a special school, and the other for ordinary school. One was due to wax and one is undiagnosed and under observation. Group 3.—(a) Found dry and requiring no treatment 13 (b) Found dry but recommended for accessory treatment such as tonsillectomy 2 (c) Active case 30 These thirty cases were treated as follows:— Five were ionised, of which four cleared up, two after one application, one after three, and the other after four. The fifth case contracted measles during treatment and had to be operated for acute mastoiditis. Six cleared up without any special treatment. Thirteen were treated with i0dine and boric powder, and a dry ear resulted in every case except one which is still attending. Two were referred to the Croydon General Hospital with mastoid infection. Three left the Borough during treatment. One is under observation. 294 The number of relapses one meets with is not great— probably no more than six in a year—and they usually clear up quickly. There are a few chronics who attend year after year. One or two are suitable for a mastoid operation but refuse, others are kept going by a chronic nasal infection. Much the same procedure has been followed as in the previous year. Obviously suitable cases were ionised, most of the others having i0dine and boric powder. In many cases the powder is applied at the Minor Ailments Clinic several times a week, and the regular cleansing, with application of fresh powder, is very effective. This powder is a great boon, for, not only is it often effective in bringing about a dry ear, but it cleans up foul ears in a wonderful way, and while it is being used one never hears complaints of offensive smell from an ear. RHEUMATISM CLINIC. This Rheumatism Clinic is concerned with the diagnosis, supervision. advice and re-examination of cases of juvenile rheumatism. Whilst the Clinic does not itself undertake the treatment of cases, it provides and arranges for the appropriate treatment to be administered. In the active and acute stage of the disease, children are referred to the Croydon General Hospital or Mayday Hospital for a peri0d of in-patient treatment, when the constant medical supervision, skilled nursing and complete rest under satisfactory hygienic conditions required cannot be obtained otherwise. When the home conditions are favourable such children are referred for domiciliary treatment by the patients' own doctor. The mild and potential cases are greatly benefited by a peri0d of convalescence. These children often show some degree of general or nervous debility, and by improving health and nutrition, the rheumatic symptoms frequently clear up. For this type of case, more especially when the home conditions are poor, Coombe Cliff Convalescent Home is an invaluable asset. For other suitable cases extra nourishment in school such as milk or c0d liver oil and malt are provided. Cases of fully developed valvular heart disease who are unfit for the rough and tumble of a public Elementary school are recommended to St. Giles' School for Physical Defectives. They then attend this school until the age of 16. 295 Children who have recently been discharged from hospital or convalescent home following a rheumatic attack, and others in whom a slight degree of rheumatic carditis is found or suspected, are not allowed to play games, or to drill or swim, for a period of at least three months after their return to school. In all cases the general health is carefully watched and particular attention is paid to the tonsils and teeth, treatment being provided when required. The houses of all cases attending the Clinic are inspected by a sanitary inspector, and in cases of dampness, unhealthy conditions, or overcrowding, notices are served on the owners, or the family recommended for consideration for a Council house. Rheumatism is a most insidious disease. Acute rheumatic fever is far less common than the vague growing pains or mild chorea so frequently met with. Unfortunately this mild form may cause irreparable cardiac damage if neglected or overlooked; it is for this reason and also for the fact that relapses are common, that the constant supervision afforded by the Clinic is so necessary, and of which the parents of affected children are becoming increasingly appreciative. Difficult and severe cases have been referred to the OutPatients' Department at the Croydon General Hospital, where Dr. Preston, as in previous years, has very kindly given his assistance and advice. The statistics of the work accomplished have been drawn up on the same lines as those in previous reports, so that a comparison ran be readily obtained. The total number of children whose names were on the "live" register at the end of 1936 was 659. Table XVII. Cases Examined at Rheumatism Clinic. 1934. 1935. 1936. Primary 119 160 154 Re-examinations 169 246 407 288 406 561 Rheumatic 108(90.8%) 143(89.4%) 145(94.2%) Non-Rheumatic 11(9.2%) 17(10.6%) 9(5.8%) 119 160 154 296 Classification of Rheumatic Cases— Primary. Re-examination. Sex Males 77 (53.1%) 175 (43.0%) Females 68 (46.9%) 232 (57%) Total 145 407 Age when Examined— Ages 5 6 7 8 9 10 11 12 13 14 15 16 Primary 10 10 9 22 17 23 16 19 16 2 1 — Re-examinations 5 11 19 22 44 57 61 78 60 35 14 1 The fact that the attendance at the Clinic has doubled during the past two years, is evidence that the parents appreciate the supervision and advice given, and that they realise the value of close medical observation of cases of juvenile rheumatism. Grouping and Classification. This continues to follow the scheme laid down in my Report for 1931. Group 1.— Symptoms referring to the digestive system and intestinal tract, e.g., abdominal pains, constipation and lack of appetite 37 cases Group 11.—Symptoms suggesting the presence of a toxaemia, e.g., aching limbs, lassitude, headache 121 cases Group III.—Symptoms suggesting a disturbance of the nervous system, e.g., irritability, disturbed sleep, nocturnal eneuresis, fidgetiness 127 cases Groups II. and III. include the majority of cases. In many cases there is a combination of the symptoms specified in Groups II. and III., varying in severity according to the type of case observed. Grouping of Cases (Classification of Dr. R. Miller). 1935. 1936. Mild and Potential 102 (71.4%) 119 (82.1%) Definite Active 26 (18.1%) 16 (11.0*) Definite Quiescent 15 (10.5%) 10 (6.9%) 297 The relative increase in the group "Mild and Potential" is the result of the increased care and understanding of parents, and, in association with the decreased percentage in the group ''Definite Active," is a very encouraging sign. The "Mild and Potential "included those cases showing the first initial symptoms of "growing pains" in highly-strung children, with or without slight cardiac involvement. The "Definite and Active Group" included, besides cases of frank rheumatic carditis, those with marked physical signs of Rheumatic Fever or Chorea. Group IV.—Rheumatic manifestations. Total: 145 cases. Rheumatic Pains 116 (80.0%) Rheumatic Fever 14 (9.6%) Chorea 19 (13.1%) Carditis, Definite 55 (37.9%)* Slight* 43 (29.6%) Marked* 12 (8.3%) Carditis, Suspected 31 (21.4%) Tonsillitis 13 (9.0%) Rheumatic Fever Cases. There were 14 children who gave a definite history of Rheumatic Fever. Of these, 3 had sound hearts, and 11 had definite carditis. Chorea Cases. There were 10 cases of Chorea and 9 of a Prechoreiform type. Of these, 1 had definite carditis, 13 slight or suspected, and 5 sound hearts. Family Histories. In the case of 27 families (18.6 per cent.), either the father or the mother had had rheumatic fever, chorea or juvenile rheumatism. In 15 other cases (10.3%) a history of rheumatism was obtained in near relatives of the parents. In the case of 20 children (13.8%) their brothers or sisters gave a similar history of rheumatic manifestations. Skin Conditions. Recorded in 145 cases. Fair 91 (62.8%) Dark 54 (37.2%) 298 Moist skin and a history of liability to sweating was recorded in 20 cases. A history of flushing and rashes in 35 cases. Nervous Conditions. Recorded in 145 cases. Children recorded as highly strung 121 (63.4%) Headaches 86 (59.3%)* *Occasional 83 (57.2%) *Frequent 3 (2.1%) Night terrors, etc. 66 (45.5%)† †Slight 60 (41.4%) †Severe 6 (4.1%) Enuresis 21 (14.5%) Twitchings 50 (34.5%) Often a combination of more than one of the above symptoms was manifested. Catarrhs. A history of various catarrhs, not tonsillitis, was reported in 9 cases (6.2 per cent.). Tonsillectomy. Operation reported in 48 cases (33.1 per cent.). Re-Examinations. Four hundred and seven re-inspections were carried out. In 31 (7.6 per cent.) of these the conditions had become worse; 1 (0.2 per cent.) was considered to be non-rheumatic; 65 (13.5 per cent.) stationary; 234 (57.5 per cent.) were definitely improved; and 76 (18.7 per cent.) quiescent. Environment and Other Conditions in Rheumatism Clinic Cases. Reported in 132 cases. Wards.—Cases were drawn from all Wards in the Borough with the exception of Addington. Woodside 8 Thornton Heath 14 Addiscombe 4 Bensham Manor 10 South Norwood 6 South 4 Upper Norwood 6 West Thornton 11 Norbury 4 Waddon 28 Whitehorse Manor 13 East 3 Broad Green 14 Central 7 299 Housing Conditions Drainage of Subsoil and Condition of Houses. One hundred and one of the houses were sufficiently drained and 28 were well drained ; in 3 drainage was problematical. Houses which were perfectly dry and did not show any signs of dampness numbered 72, whilst 48 showed traces of damp; 11 were damp; one house was specified as very damp, this house being included in a demolition order. Aspect. 132 cases reported. The aspects of the houses were as follows:— S.E. 27 S.W. 21 E. 12 N.E. 12 N.W. 18 S. 15 N. 12 W. 15 The bulk of houses in which cases occurred were ordinary terrace houses (71), 55 were semi-detached, and 6 were detached houses; definite overcrowding was found in two families. The percentage of families living in terrace houses shows a further decline in 1936, during the past three years it has decreased from 80.5 per cent. to 62.9 per cent. to 53.8 per cent. This is almost entirely due to the increasing accommodation provided by the Corporation in their new housing estates. Economic Status. The economic status of the families from whom patients were examined was as follows:— Poor in 9; average working class, 88; better working class, 19; clerical work, 12 ; and superior, 4. The interior home conditions were classified as follows:— Clean, 82; moderately clean, 39; superior, 9; unsatisfactory, 2; one of the families living in the last mentioned unsatisfactory conditions has recently removed to better housing accommodation. BLIND. DEAF, DEFECTIVE AND EPILEPTIC CHILDREN. Full statistical details are given in Table III. of the Tables required by the Board of Education. Blind Children. Six boys and 3 girls are resident at special schools for the blind. The institutions which these children attend are as follows:—Royal Normal College for the Blind, 5 boys; Chorley Wood Blind College, 300 1 girl; Barclay Blind School, Brighton, 2 girls; Abbotskerswell, Devon, 1 boy. St. Luke's Special School For Partially Sighted Children. At the end of the year there were 33 children in attendance. Of these, 25 were cases of myopia, 7 were non-myopes, and 1 had myopia combined with other ocular defect. The curriculum is that usually laid down for the myope and the partially sighted, respectively, but is under constant review, and changes are introduced according to experience. Both boys and girls have attended domestic science classes, and the system of mixing the children with those in the ordinary elementary school for certain lessons, has been continued. Again physical exercises, suitably restricted for certain children, are in regular use, with a noticeable improvement in carriage and posture. Nominally the myopes leave school at 14 years of age, and the others at 16, but no strict rule can be enforced, and much depends on the type of cases and the earning capacity. The Head Teacher is alive to the need for supervision in the selection of jobs and for after-care, but this is often difficult, especially with the dull child from a poor home. The subsequent ophthalmic supervision of the children is assisted by the circumstance that the Ophthalmic Surgeon to the School is also the Ophthalmic Surgeon attached to the Mayday and Croydon General Hospitals. The erection of new permanent premises on the existing site, consisting of a Hall, two classrooms, staffroom and medical inspection room, was commenced in December last, and it is anticipated that they will be ready for occupation by the Whitsun Vacation, 1937. Temporary accommodation is being afforded in the Technical School, Thornton Heath. Deaf Children. Nine boys and 7 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 7 girls; Balham L.C.C. Day (Deaf) School, 1 boy, at Hearnville Road ; Anerley Deaf School, 1 boy. Epileptic Children. Three boys and 2 girls are resident at the Lingfield Epileptic Colony. 301 Mentally Defective Children. In addition to the day accommodation provided at St. Christopher's School, 4 girls are resident in the Monyhull M.D. School, Birmingham; 1 girl is at Knotty Ash M.D. School, Liverpool; 1 boy at Sandlebridge, Cheshire; 1 boy at Besford Court, Worcestershire; 1 girl at Allerton Priory, Liverpool; 1 boy at Trenmar Lodge, London; and 1 girl at All Souls' (R.C.) School, Hillingdon, Middlesex. 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, 3 boys and 2 girls: 1 boy at Coney Hill School, Hayes; St. Catherine's, Ventnor, 1 boy and 1 girl. The Committee maintained 1 girl at West Wickham Heart Home, a special school for cardiac cripples; and 1 boy at Lancing Convalescent Home for Cardiac cases. During 1937, the St. Giles' School will be extended to accommodate 90 delicate children. Speech Defects Class. The bi-weekly class conducted by two trained speech therapists has continued throughout the year and has thoroughly proved its usefulness. The number of children that can attend each class at any given time is limited as each child has to be dealt with individually. Total number of children treated 34 Number of children discharged 23 Number of children still attending 12 Number of children kept under observation after discharge 17 Number of children referred for physical treatment 10 Number of children referred for psychological investigation 4 Types of Speech Defects Treated. Stammering 11 Lalling 11 Lisping 2 Cleft Palate 5 Aphasia 2 Tongue Tie 1 Backward Speech 1 Hemiparesis 1 302 Results of Treatment. Cases definitely cured. Improved. Ceased Attending. Still Attending. Lalling 5 Stammering 2 Stammering 2 Stammering 3 Stammering 4 Cleft Palate 2 Cleft Palate 1 Lalling 3 Cleft Palate 1 Lalling 1 Lalling 1 Lisping 1 Lisping 1 Other various Undeveloped Speech 1 defects 8 Of the cases discharged as "Improved," one case of Stammering was referred for medical treatment for Chorea, and the other case of Stammering was referred to the West End Hospital for Psychological investigation. One case of Cleft Palate was sent back to Great Ormond Street Hospital for further operative treatment. Of the cases who "Ceased Attending," the Cleft Palate case ceased temporarily on account of the mother's illness. The case of Lalling left the district. One case of Stammering was discharged to Coombe Cliff Convalescent Home and the other case of Stammering ceased on account of the non-co-operative attitude of the parent. One case of Stammering in whom the speech defect was overcome was referred thereafter to the West End Hospital for further investigation of a Psychological character. SCHOOL CAMPS. A school camp was held, as usual, 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, etc., for sleeping purposes are provided, and the cookhouse is to be rebuilt. The sanitary arrangements have been replaced by a modern water flushed system. Three hundred and thirty-four boys and girls from the elementary schools went to the Camp during 1936 in parties, each party going for one week. Fourteen weekly camps were held. All the children are medically inspected before proceeding to camp. The following are the schools which sent parties:—Ashburton, 42 boys? 303 Oval, 38 boys; Portland, 21 hoys, 29 girls; Ecclesbourne, 23 boys; Kingsley, 40 boys, 46 girls; Waddon, 18 girls; Sydenham, 23 boys; Tavistock, 20 boys, 34 girls. JUVENILE EMPLOYMENT RETURN. The following numbers of children were examined by the medical officers during 1936 as to their fitness to follow the parttime employment indicated. There has been a decrease of 57 in the delivery of goods for shopkeepers; of 40 in the delivery of newspapers, and an increase of 1 in the delivery of milk:— 1936 1935. 1934. 1933 1932. Delivery of Goods for Shopkeepers Delivery of Newspapers Delivery of Milk 151 245 43 208 285 42 96 190 34 105 163 24 119 178 37 439 536 320 292 334 Thirty-three girls and 3 boys were medically examined, and subsequently licensed by the Education Authority to take part in public entertainments. THE PROVISION OF MEALS AND MILK AND COD LIVER OIL AND MALT. The arrangements for the provision of meals have been continued during the past year. Children are now provided with free dinners at the Domestic Subjects Centres, as follows.—Davidson, Ecclesbourne, Elm wood, Ingram, Kingsley, Sydenham, Tavistock and Waddon. Milk and cod-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 Officers, Teachers, School Enquiry Officers and Care Committees and are considered by the Attendance 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 has undoubtedly had beneficial results. By arrangement with the Milk Marketing 304 Board, some 13,000 bottles of milk, containing one-third of a pint, are delivered daily at the schools at a cost of ½d. per bottle. This supply is available for all elementary school children irrespective of any medical recommendation. 1936. 1936. No. of Children who received Free Dinners 431 464 ,, Free Dinners provided 53,407 53,633 No. of Children who received pints pints Free Milk 129—12,439 161-16,876 ,, ,, Milk (part payment) 20—1,094 39—2,941 ,, ,, Milk (whole payment) 29—883 15—1,987 issues issues Free Malt 18—2,014 37—4,069 ,, ,, Malt (whole payment) 23—2,653 45—5,178 As an experiment the Committee, during the Midsummer and Christmas vacations, provided facilities at the Free Dinner Centres for children to receive milk under the Milk Marketing Board's scheme at a cost of ½d. per one-third of a pint. In the Midsummer vacation, the experiment was to some extent justified, 9,280 bottles being sold during twenty-five days, but only 579 bottles were sold during seven days of the Christmas holidays. ST. CHRISTOPHER'S SPECIAL SCHOOL. I am indebted to Mr. H. J. Edmonds, the Head Master, for the following report. 1936 has been a memorable at St. Christopher's. Permission to extend the accommodation was received from the Board of Education, and at once all children on the waiting list were admitted. The accommodation of the School is now 120, and actually 126 children were on the School Boll on December 31st, 1936. During the year, 40 childen were admitted and 20 children left the School. The Staff now consists of the Head Teacher and five assistant teachers. With the admission of so many new scholars, many details of organisation have had to be revised, but all children have now settled down, and all are working to the full mental limits. Special efforts have been taken in the teaching of Beading: the whole school has been graded in Beading Classes, and very satisfactory progress has been made. Some very fine models in Woodwork have been made by the Senior boys and it is hoped to hold an exhibition of these models early in 1937. 305 The adoption of a new scheme in Physical Training, has had, after a year's working, remarkable results; the carriage and activity of the children has greatly improved, and favourable comment has been made by the Inspecting Medical Officer. The annual excursion to Littlehampton was held on July 2nd, when 47 children participated. A very jolly day was spent by all, and the weather this year was splendid. It is hoped to extend these visits in the New Year to places of popular interest. In closing this Report, 1 must thank the Head Master and Stall of the John Ruskin School for the continued interest in this School. Number of children notified during the year to the Local Mental Deficiency Authority 23. PHYSICAL TRAINING IN SCHOOLS. Detailed reports have been presented by the Assistant Inspector of Schools and the Organiser of Physical Training to the Education Committee, and the following is only a precis of these reports. Boys. There have been no fresh developments with regard to syllabuses during the year. it has been one of steady work on the 1933 syllabus. The increased interest and alertness which were noted last year have been continued. All Senior Departments are fitted with portable apparatus and all Junior Schools have now been equipped with jumping stands and mats for agility work. The usual portable equipment (such as balls, ropes, quoits, etc.) was provided to each department as before. The past was one of the most successful swimming seasons we have experienced. There was an increase in the number of certificates for distance swimming and life-saving, and Croydon Schools gained notable successes at the London School Swimming Galas—Obtaining a good proportion of the trophies open for competition. Bath accommodation is fully utilised at present. Many schools take periods out of school hours. New schools, such as the Benson and Monks Orchard, have not yet obtained periods for swimming. To fit these in will cause further congestion at the Central Baths. The number of schools having their own galas shows an increase upon last year. There has been an extension in the use of the school playing The Committee's omnibuses are invaluable for conveying children from the crowded parts of the town to the more distant fields. Additional playing field accommodation has been obtained. 306 Practically every Senior and Junior School now holds its annual sports meeting to which the general public is invited. The Committee have resumed the grants to teachers who attend holiday courses. Four teachers availed themselves of the opportunity to attend such courses. There has been in each case an improvement in efficiency and interest. The courses in Morris Dancing and Sword Dancing were continued with encouraging results. A special party was organised for these dances, when many Senior Schools were represented. A series of demonstrations on the methods of class teaching applied to swimming were held at the Thornton Heath Baths. They were very well attended. Practically every school in the Borough sent teachers to observe the methods used. The year's results show their influence. The Croydon Schools Athletic Association has continued its work. Inter-School competitions in cricket, football, boxing, swimming, country dancing and general athletics have been carried on throughout the year. The work of organising and supervising these inter-schools activities is undertaken voluntarily by the teachers in their own time and is worthy of the highest praise. Girls. (Central Senior and Junior Mixed, Senior and Junior Girls', Infants' and Special Schools). In spite of much unsettled weather during the year, which hampered out of doors work, Physical Training was carried on steadily in every department enumerated above. All schools follow the methods outlined in the Syllabus of Physical Training for Schools, 1933—embodying Physical Exercises, Organised Games, Athletics, Swimming, and Folk Dancing. It is now generally recognised that Physical Training is an essential part of every child's education and a daily period is allotted to this subject in every Junior and Infants' department as far as possible. In the case of Central and Senior Schools, where longer lessons are desirable owing to the use of gymnastic apparatus, at least one hundred minutes per week (in many cases more) are given to this subject. Corrective Classes, for girls with faulty posture, were continued in certain schools, as before. 307 With few exceptions, the girls in Senior and Junior departments now remove their tunics or skirts for the physical training lessons, thus ensuring greater freedom of movement. Suitable footwear is still a problem in many schools and to obtain gymnastic shoes entails much effort. It is hoped that this difficulty will be overcome, however, in 1937, if the principles embodied in Circular 1450, issued by the Board of Education, are adopted. The provision of shoe lockers in the new schools opened in 1936 will do much to facilitate the changing necessary for physical training lessons and the provision of hot water in the lavatories will overcome the difficulty experienced, in the past, of classes returning to the classroom with hands too dirty to handle material for the next lesson. Arrangements for the provision of the necessary gymnastic apparatus and equipment were made on the same lines as in former years and the children were taught to handle this equipment carefully and speedily. Swimming. All schools (Central, Senior and Junior) with the exception of two, sent classes to the Baths during the season. The Bath accommodation available is now taxed to the limit and it was found impossible to increase the quota of each school, in spite of the desire expressed by many departments for this to be done. The problem of giving the new schools, opened since the swimming season of 1936, a place on the swimming time table in 1937 has yet to be solved. The results of the 1936 swimming season are most gratifying and show an increase in numbers of every class of certificate obtained but most noticeably in Life Saving awards. The number of Bronze Medallions of the Royal Life Saving Society (not granted to anyone under 14 years of age) increased from 42 to 78, whilst 4 Bars to this Medallion and seven Instructor's certificates were gamed. Owing to the advanced standard required for these tests, and the age qualification, the majority of these Medallions were rained by girls in the Central Schools, but it is worthy of record that one Senior Girls' School obtained 20 such honours. The number of girls who learned to swim a width for the first time was again over one thousand and the total certificates gained by the girls rose to over three thousand. Girls from thirty-one departments entered for the Inter-Schools 308 Gala, in July, and School Swimming Galas were arranged by twenty departments. Playing Field or Recreation Ground accommodation is now available for all Central and Senior departments with the exception of three and it is anticipated that the necessary grounds will be found for these early in 1937—also for five of the twelve Junior Schools not yet sending classes to a field for Organised Games. The opportunities for practice in Athletics afforded by this accommodation has facilitated the holding of School Sports Afternoons and thirty-three schools arranged for such an afternoon as well as taking part in the Inter-School Sports Afternoons on the 29th and 30th June. Only in six schools is the teaching of National and Folk Dancing omitted from the curriculum and this, as stated last year, is largely due to the lack of suitable facilities. School Journeys to Llanfairfechan, Broadstairs, Shanklin, Seaford (2), Ewhurst, Ryde, Folkestone, Worthing, Rhyl, Germany and Paris were taken by girls from various schools and Pilgrim Fort was used for camping holidays by four Girls' Schools. The following Courses and Demonstrations for Teachers were arranged:— Scottish Country Dancing. 2 Courses. Three Demonstrations of Class Teaching of Swimming. Physical Training suitable for girls 10-12 years of age. Organised Games for Junior Schools. INSTRUCTION IN SPECIAL SUBJECTS. In the time-table for the year commencing 1st August, 1936, the following provision is made for the instruction of Senior girls in special subjects, e.g., Cookery, Homecraft, Housewifery, Domestic Science.— Intensive Housewifery Centres— Purley Oaks. Tavistock. Cookery and Homecraft Centres— Howard (Domestic Science). Ingram (Domestic Science and Homecraft). Sydenham (Cookery, Homecraft and Domestic Science). 309 Special Rooms or Centres reserved for School named— Ashburton (Domestic Science). Benson (Domestic Science). British Girls, Polytechnic (Domestic Science). Davidson (Domestic Science). Ecclesbourne (Domestic Science). Elmwood (Domestic Science). Kingsley (Domestic Science). Lanfranc (West Thornton Centre—Domestic Science). Oval (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 1936; 1,508 children were examined, 745 of whom were boys and 763 girls. Table II. of Appendix gives the detailed findings. 99 boys (13.3 per cent.) and 126 girls (16.5 per cent.) were found to require treatment, the most usual defect being defective vision. Although the figures are small, a table similar to that given for elementary school children and relating to heights and weights has been included below. 310 Table XVIII. SECONDARY SCHOOLS. HEIGHTS AND WEIGHTS. Year of Birth. BOYS. GIRLS. 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. 1930 ... ... ... ... ... ... ... 2 45.2 41.0 ... ... ... ... 1929 ... ... ... ... ... ... ... 2 49.2 54.5 ... ... ... ... 1928 ... ... ... ... ... ... ... 3 50.8 64.8 ... ... ... ... 1927 ... ... ... ... ... ... ... 7 53.1 69.1 58.5 113.5 53.5 66.0 1926 8 54.8 76.2 57.5 89.0 51.0 60.5 20 55.0 73.5 59.7 86.0 51.6 60.2 1925 138 57.0 80.4 63.8 119.4 52.5 60.6 189 57.2 82.0 63.6 132.6 51.9 56.8 1924 155 57.5 83.1 63.0 113.5 53.0 59.7 167 58.6 84.6 64.2 127.9 52.5 53.4 1923 69 59.7 90.4 63.8 107.9 54.3 72.0 40 60.0 90.0 62.9 110.0 56.8 72.7 1922 104 62.0 102.5 68.1 144.1 54.8 70.3 89 62.3 104.8 67.2 150.8 56.4 81.9 1921 129 64.9 115.3 70.3 151.4 58.7 84.4 142 63.3 110.8 67.7 160.4 58.2 84.5 1920 98 65.8 127.2 71.3 171.1 61.6 98.3 80 63.7 116.4 66.4 147.2 60.0 92.7 1919 28 68.0 136.4 70.6 150.4 63.7 104.5 14 64.2 118.2 66.5 123.5 62.5 95.5 1918 5 67.9 140.2 73.0 171.5 63.5 112.5 8 63.6 118.1 66.5 133.5 63.0 114.5 1917 3 68.0 145.3 68.0 152.5 68.0 133.5 ... ... ... ... ... ... ... 311 In conclusion, the report shows that there is considerable disability in school children, due almost entirely to ignorance or neglect of simple physiological functions, and it is certain that if children are 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 will 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 also to acknowledge my indebtedness to the Education Officer and the members of his staff for their helpful co-operation. The burden of the work has fallen upon the Assistant Medical Officers, Health Visitors, and the Clerical Staff, to all of whom 1 desire to record my thanks for their loyalty and co-operalion. I am, Yours faithfully, OSCAR M. HOLDEN, School Medical Officer. 312 Table I. MEDICAL INSPECTIONS OF CHILDREN ATTENDING PUBLIC ELEMENTARY SCHOOLS. A.—Routine Medical Inspections. Number of Inspections in the prescribed Groups: Year Year 1936. 1935. Entrants 3230 3859 Second Age Group 2398 2762 Third Age Group 1605 1708 Total 7233 8329 Number of other Routine Inspections 79 13 Grand Total 7312 8342 B.—Other Inspections. Number of Special Inspections 5604 5499 Number of Re-Inspections 12122 8719 Total 17726 14218 C.—Children Found to Require Treatment. Number of individual children found at Routine Medical Inspection to require treatment (excluding Nutrition, Uncleanliness and Dental Diseases). Group. For Defective Vision (excluding squint). For all other conditions recorded in Table 11 A. Total. Total, 1935. Entrants 7 654 596 564 Second Age Group 137 363 391 521 Third Age Group 154 211 295 347 Total (Prescribed Groups) 298 1228 1282 1432 Other Routine Inspections 4 15 19 — Grand Total 302 1243 1301 1432 Total visits to Elementary Schools: 490. 313 TABLE II. A.—Return of Defects found by Medical Inspection in the Year ended 31st December, 1936. defect or disease. Routine Inspections. Special Inspections. No. of Defects. 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. (1) (2) (3) (4) (5) Skin— (1) Ringworm: Scalp ... ... ... ... (2) Body 1 ... ... ... (3) Scabies 5 ... 1 ... (4) Impetigo 6 ... 5 ... (5) Other Diseases (Non-Tuberculous 11 5 8 1 Total (Heads 1 to 5) 23 5 14 1 Eve— (6) Blepharitis 10 3 1 • •• (7) Conjunctivitis ... • •• 1 1 (8) Keratitis ... ... ... ... (9) Corneal Opacities ... ... ... ... 10) Other Conditions (excluding Defective Vision and Squint) 5 2 ... ... Total (Heads 6 to 10) 15 5 2 1 (11) Defective Vision (excluding Squint) 302 31 95 1 (12) Squint 86 30 9 ... Ear— (13) Defective Hearing 7 3 4 1 04) Otitis Media 8 4 2 ... (15) Other Ear Diseases 6 3 3 ... Nose and Throat— (16) Chronic Tonsillitis only 222 533 15 11 (17) Adenoids only 18 51 3 2 (18) Chronic Tonsillitis and Adenoids 372 206 30 5 (19) Other Conditions 103 64 12 3 (20) Enlarged Cervical Glands (Non-Tuberculous) 2 65 2 6 (21) Defect,ve Speech 4 10 7 4 Heart and Circulation— Heart Disease: (20) Organic 73 233 8 11 Functional 10 83 1 5 Anaemia 19 34 7 3 314 TABLE II—continued. DEFECT OR DISEASE. Routine Inspections. Special Inspections. No. of Defects. 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. (1) (2) (3) (4) (5) Lungs— (25) Bronchitis 15 103 5 10 (26) Other Non-Tuberculous Diseases 6 15 ... 1 Tuberculosis— Pulmonary: (27) Definite ... ... ... ... (28) Suspected 2 18 1 Non-Pulmonary: (29) Glands ... 5 1 ... (30) Bones and Joints ... 1 ... ... (31) Skin ... ... ... ... (32) Other Forms 1 8 ... 1 Total (Heads 29 to 32) 1 14 1 l Nervous System— (33) Epilepsy ... 8 ... ... (34) Chorea 6 33 4 1 (35) Other Conditions 22 89 1 10 Deformities— (36) Rickets 3 5 1 ... (37) Spinal Curvature 58 36 2 5 (38) Other Forms 100 64 18 2 (39) Other Defects and Diseases (excluding Uncleanliness and Dental Diseases 62 71 18 12 Total 1,545 1,816 264 99 B.—Classification of the Nutrition of Children Inspected during the year in the routine age groups. Age-groups. Number of Children Inspected. A (Excellent). B (Normal). C (Slightly subnormal). D (Bad). No. % No. % No. % No. % Entrants 3230 277 8.6 2685 83.1 265 8.2 3 0.1 Second Age-group 2398 177 7.4 2019 84.2 194 8.1 8 0.3 Third Age-group 1605 173 10.8 1332 83.0 98 6.1 2 0.1 Other Routine Inspections 79 16 20.3 57 72.2 6 7.6 ... Total 7312 643 8.8 6093 83.3 563 7.7 13 0.2 315 TABLE II!. Return of all Exceptional Children in the Area. Children Suffering from Multiple Defects. Number of children suffering from combination of defects 2 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. T otal. 8 ... ... ... 8 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. ... 33 24 ... 2 59 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. 13 ... ... ... 13 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. ... ... 9 ... ... 9 316 MENTALLY DEFECTIVE CHILDREN. Feeble-Minded Children. Mentally Defective children are children who, not being imbecile and not being merely full 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. 135 6 6 1 148 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. 3 ... ... 1 4 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 inctruction 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. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 8 ... 2 ... 10 317 II.—Children Suffering from Non-Pulmonary Tuberculosis. (This category includes tuberculosis of all sites other than those shown in (I) above. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 19 1 1 1 22 B. Delicate Children. This Section is confined to children (except those included in other groups) whose general health renders it desirable that they should be specially selected for admission to an Open Air School. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 23 8 1 4 36 C. Crippled Children. This Section is confined to children (other than those diagnosed as tuberculous and in need of treatment for that disease) who are suffering from a degree of crippling sufficiently severe to interfere materially with a child's normal mode of life, i.e., children who generally speaking are unable to take part, in any complete sense, in physical exercises or games or such activities of the School curriculum as ga dening or forms of handwork usually engaged in by other children. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 39 9 1 4 53 D. Children with Heart Disease. This Section is confined to children whose defect is so severe as to necessitate the provision of educational facilities other than those of the Public Elementary School. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 35 12 3 9 59 Children Suffering from Multiple Defects. Combination of Defect. At Certified Special Schools. At Public Elementary Schools. At Other Institutions. At No School or Institution. Total. Blind and Deaf ... ... ... 1 1 Epilepsy and M.D. 1 ... ... ... 1 Cripple and M.D. 1 ... ... ... 1 318 TABLE IV. Treatment Tables. Group I.—Minor Ailments (excluding Uncleanliness, for which see Table VI). 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: (i) X-Ray Treatment 4 ... 4 (ii) Other Treatment 5 ... 5 Ringworm-Body 32 ... 32 Scabies 62 ... 62 Impetigo 304 ... 304 Other Skin Disease 209 ... 209 Minor Eye Defects— External and other, but excluding cases falling in Group II 295 ... 295 Minor Ear Defects 321 ... 321 Miscellaneous— Minor Injuries, Bruises, Sores, Chilblains, etc. ... 1541 ... 1541 Total 2773 ... 2773 Group II.—Defective Vision and Squint (excluding Minor Eye Defects treated as Minor Ailments—Group I). Number of Defects dealt with. Under the Authority's Scheme. Otherwise. Total. Errors of Refraction (including squint) 938 16 954 Other defect or disease of the eyes (excluding those recorded in Group I) ... ... ... Total 938 16 954 No. of Children for whom spectacles were (a) Prescribed 584 16 600 (b) Obtained 622 16 638 319 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, part from the Authority's Scheme. Total. (1) (2) (3) (4) (5) (i) (ii) (iii) (iv) (i) (ii) (iii) (iv) (i) (ii) (iii) (iv) 11 13 453 ... 14 1 34 1 25 14 487 1 ... 527 (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. Total number treated. Residential treatment with education. Residential treatment without education. Non-residential treatment at an orthopaedic clinic. (0 (ii) (iii) Number of children treated 17 21 322 344 TABLE V.—Dental Inspection and Treatment. (1) Number of children inspected by the Dentist— (a) Routine age-groups: Age 5 6 7 8 9 10 11 12 13 14 up. Total. Number 1210 1726 1798 2058 1919 2070 2112 1815 1939 1669 18316 (b)Specials 2057 (c) Total (Routine and Specials) 20373 (2) Number found to require treatment 15307 (3) Number actually treated 6899 (4) Attendances made by children for treatment 14749 (5) Half-days devoted to: (7) Extractions: Inspection 100 Permanent Teeth 2182 Treatment 1179 Temporary Teeth 9785 Total 1279 Total 11967 (8) Administrations of general anaesthetics for extractions 2075 (6) Fillings: Permanent Teeth 6254 (9) Other Operations: Permanent Teeth 3542 Temporary Teeth 399 Temporary Teeth 34 Total 6653 Total 3576 TABLE VI.—Uncleanliness and Verminous Conditions. (i) Average number of visits per school made during the year by the School Nurses 9.5 (ii) Total number of examinations of children in the Schools by School Nurses 58723 (iii) Number of children found unclean 1750 (iv) Number of children cleansed under arrangements made by the Local Education Authority 167 (v) Number of cases in which legal proceedings were taken: (a) Under the Education Act, 1921 3 (b) Under School Attendance Byelaws ... 320 SECONDARY SCHOOLS. Year ended. 31st December, 1936. Table I. RETURN OF MEDICAL INSPECTIONS. A.—Routine Medical Inspections. Number of Code Group Inspections— Year 1936. Year 1935. Age 11 or under 361 283 12 341 326 13 108 237 14 185 127 15 268 212 16 187 105 17 41 23 18 or over 17 5 Total 1,508 1,318 B.—Other Inspections. Year 1936. Year 1935. Number of Special Inspections 59 25 Number of Re-inspections 364 193 Total 423 218 Visits to Secondary Schools 84 70 321 SECONDARY TABLE II.—A.—Return of Defects Found by Medical Inspection in the Year Ended 31st December, 1936. 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 treatment (1) (2) (3) (4) (5) Malnutrition 2 15 1 ... Uncleanliness. (See Table IV.—Group V.) Skin— Ringworm: Scalp ... ... ... ... Body ... ... ... ... Scabies ... ... ... ... Impetigo ... ... ... ... Other diseases (non tuberculous) 1 ... ... ... Eye— Blepharitis 2 ... ... ... Conjunctivitis ... 1 ... Keratitis ... ... ... ... Corneal opacities ... ... ... ... Defective vision (excluding squint) 62 20 17 ... Squint ... ... ... ... Other conditions ... ... ... ... Ear— Defective hearing ... 1 ... ... Otitis media ... ... ... ... Other ear diseases ... ... 1 ... Nose and Throat— Enlarged tonsils only 26 27 4 ... Adenoids only 1 ... ... ... Enlarged tonsils and adenoids ... 1 ... ... Other conditions ... ... ... ... Enlarged Cervical Glands (Non Tuberculous) ... ... ... 1 Defective Speech ... 1 ... ... Teeth—Dental Disease ... ... 1 ... Heart and Circulation— Heart Disease— Organic 2 26 ... 2 Functional ... 22 ... ... Anaemia ... 3 ... 4 Lungs— Bronchitis ... 4 ... 2 _ Other non-tuberculous diseases ... 1 ... ... Tuberculosis— Pulmonary— Definite ... 1 ... ... Suspected ... 6 ... 1 Non-pulmonary— Glands ... ... ... ... Spine ... ... ... ... Hip ... ... ... ... Other bones and joints Skin ... ... ... ... Other forms ... ... ... ... Nervous System— Epilepsy ... 2 ... 1 Chorea 1 2 ... 1 Other conditions ... ... ... ... Deformities— Rickets ... ... ... ... Spinal curvature 1 7 2 ... Other forms ... 5 4 ... Other Defects and Diseases 1 17 1 1 322 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. Found to require treatment. (1) (2) (3) (4) 11 or under 361 57 15.8 12 341 69 20.2 13 108 12 11.1 14 185 17 9.2 15 268 43 16.0 16 187 18 9.6 17 41 8 19.5 18 and over 17 1 5.9 1508 225 14.9 TABLE III.—Return of Defects Treated During the Year Ended 31st December, 1936. Group I.—Minor Ailments. Disease or Defect. number of defects treated, or under treatment during the year. Under the Authority's scheme. Otherwise. Total. (0) (2) (3) (4) Skin— Ringworm (scalp) ... ... ... ,, (body) ... ... ... Scabies ... ... ... Impetigo 1 ... 1 Other skin disease 5 ... 5 Minor Eye Defects— (External and other, but excluding cases falling in Group II) 10 ... 10 Minor Ear Defects 7 ... 7 Miscellaneous— (e.g. minor injuries, bruises, sores, chilblains, etc.) 33 ... 33 Total 56 ... 56 323 SECONDARY Group—11. Defective Vision and Squint (excluding minor eye defects treated as minor ailments.—Group I). Defect or Diseases. number of defects dealt with. Under Authority's Scheme. Submitted to refraction by private practitioners or at Hospital apart from the Authority's scheme. Otherwise. Total. Year 1935. (1) (2) (3) (4) (5) (6) Errors of refraction (including squint) 125 7 132 148 Other defects or disease of the eyes (excluding those recorded in Group I) ... ... ... Total 125 7 132 148 Total number of children for whom spectaoles ere prescribed:— (a) Under the Authority's scheme 92 (b) Otherwise 7 Total number of children who obtained or received spectacles:— (a) Under the Authority's scheme 100 (b) Otherwise 7 Group III.—Treatment of Defects of Nose and Throat. number of defects. Received operative treatment. Received other forms of treatment. Total number treated. Year 1935. Under the Authority's scheme in clinic or hospital. By private practitioner or hospital apart from the Authority's scheme. TOTAL. (1) (2) (3) (4) (5) (6) (1) (2) (3) (4) (1) (2) (3) (4) (1) (2) (3) (4) ... ... 3 ... 3 ... ... ... 3 ... 3 ... ... 6 4 (1) Tonsils only ; (2) Adenoids only ; (3) Tonsils and Adenoids; (4) Other Defects of Nose and Throat.