Cro 39 County Borough of Crondon. ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER For the Year 1937 OSCAR M. HOLDEN, M.D., D.P.H. CROYDON: Printed by the "Croydon Times," Ltd., 104, High Street. 2 PUBLIC HEALTH COMMITTEE. NOVEMBER, 1936— 1937. 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). (Died 15th April, 1937). Alderman H. J. Morland, M.A., J.P. Alderman C. H. Gibson. Councillor H. W. Anderton. Councillor E. E. L. Arkell. Councillor E. E. Constable. Councillor H. Craske. Councillor Mrs. P. J. Dale. Councillor F. Gardner. Councillor Miss M. H. Glazier. Councillor H. S. Izzett. Councillor G. Lewin (Vice-Chairman as from 13th April, 1937). Councillor H. T. Muggeridge, J.P. Councillor Major J. Petrie, O.B.E. Councillor H. Regan. Councillor Mrs. M. 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 For the Year 1937. To the Chairman and Members of the Public Health Committee. Ladies and Gentlemen, I have the honour to present herewith my tenth Annual Report, being the thirty-eighth of the series, dealing with the health of Croydon, and the various branches of the work carried out under the Public Health, Housing, Foods and Drugs, Mental Deficiency and other Acts and Orders. There is also incorporated my report to the Education Committee as School Medical Officer. The form of report is unaltered. It is divided into sections, each section dealing with a particular branch of the work. It is hoped that those who are more especially interested in one branch will find this convenient. Epidemiology and Vital Statistics. The health record of the year was unfortunately marred by an outbreak of Typhoid Fever in parts of Croydon supplied by The High Level Water Supply. A full report on the outbreak will be made at a later date. This outbreak, though not so extensive as an outbreak in another Southern town in 1936, obtained very great publicity. Upon representations made by a group of citizens, who formed The South Croydon Typhoid Outbreak Committee, the Minister 0f Health decided to hold a Public Inquiry into the causes giving Rise to, and the steps taken to combat, the outbreak. This Inquiry is the first of its kind to be held. It opened on 6th December, when an adjournment was made until 21st December. from which date it continued until l2th January, 1938. 4 The holding of so comprehensive an Inquiry, tor which much detailed information had to be compiled, and at which many criticisms had to be met and combated, during the actual course of a serious outbreak of epidemic disease, placed additional heavy burdens upon the department, already working at high pressure to deal with the outbreak. It says much for the energy and loyalty of the staff of the department that both burdens were shouldered successfully. The findings of the Commissioner are now too well known to need any reiteration, but it is justifiable to enquire, firstly, if the Inquiry could not have been held just as usefully after the outbreak had been dealt with; and secondly, if the findings could not have been arrived at as efficiently and more expeditiously by methods of a less elaborate and costly nature. If this procedure is to form a precedent, then medical officers of health will, in future, when called upon to tackle an outbreak of epidemic disease, also have to take steps to protect themselves at the Public Inquiry held thereinto. Scarlet Fever and Diphtheria were both more prevalent than in 1936, the latter giving rise to a limited outbreak in one portion of the town during November. The weekly average of cases over the year for Scarlet Fever was 11.7, and for Diphtheria, 5. Three deaths were caused by Scarlet Fever, and 15 by Diphtheria. When it is remembered that Diphtheria can be prevented by immunisation, and that the means are available in Croydon, either through the Public Health Department, or if so desired, through the private doctor, it is a somewhat sad reflection upon the attitude of parents, that 289 cases were notified and 15 deaths resulted, and of these deaths 14 were in children under 15 years of age. Among the non-notifiable diseases, the expected biennial increase of Measles commenced in December, and the number of cases rose steadily until the end of the year. A limited supply of human anti-serum was available, whilst Measles Globulin was obtainable from the department, free of cost in necessitous caws, to any practitioner who applied for it. The number of requests was very small. Mumps and Chicken-Pox were both more prevalent than in 1936. The Birth Rate (13.5) was very slightly higher than in 1936. but was still 1.4 per 1,000 less than that for England and Wales 5 The Death Bate was 11.6 a figure 0.9 per 1,000 higher than in 1936, but 0.8 per 1,000 lower than the rate for England and Wales, and 0.7 lower than London's rate. The rising death rate is to be expected in consequence of the low birth rate for many years past and the consequent rise in the mean age of the population. The Infantile Mortality showed a most unwelcome rise, after the new low record obtained in 1936 (41 per 1,000 births). For the year under review it rose sharply to 60 per 1,000. This was caused by an increase in the number of deaths from diarrhoea, and the high mortality among illegitimate children. The chief causes of death were substantially the same as in 1936, and once again Cancer ranked next to Organic Heart Disease as the chief cause. The number of deaths due to violence, other than suicide, rose from 85 to 102, and deaths from Influenza, from 39 to 71. The Tuberculosis death rate remained stationary. There were 35 deaths from the Enteric Group of diseases during the year. Hospitals. Section 3 of the Report gives in detail the work done at Mayday Hospital. With the new wards functioning the number of beds available is now 585, though this figure is based on the computation of 32 beds in each of the 12 old wards, whereas the number witn proper spacing should be only 28 per ward. The new Maternity Block and the Gynaecological Block came into operation during the year and have proved excellent in every way, being light, airy and easy to work, circumstances which are fortunate as the demand on the beds has been very heavy. One of the major problems which has arisen in hospital administration of recent years is the shortage of nurses, both of probationers entering for training and of trained nurses. The causes for this are probably several and of long duration. A nurse's life is a hard one, it is subject, as it inevitably must be in the interests of the patients, to discipline, and it is not possible for a girl leaving school to enter upon the work immediately. Many girls undoubtedly, on economic grounds obtain other employment on leaving school, when, if there was in existence some scheme of preliminary hospital training with salary attached, they would have entered the nursing profession. Also the ultimate financial awards do not compare very favourably with similar rewards in other branches of life; though in comparing nursing with other occupations, it is sometimes forgotten that although a nurse may seem to receive a mediocre income in cash, she has no expenses comparable to those entailed in occupations where the occupant has to house and maintain herself. 6 Superannuation applicable throughout all hospitals both Municipal and Voluntary would undoubtedly help in securing a larger flow of recruits. Another problem of recent years with regard to the nursing staffs of hospitals, has been brought about by the increase in the number of Nursing Co-operations. These co-operations are hiring agencies, and they offer two inducements, namely: the nurse lives out in between her engagements, and secondly, she receives a higher rate of salary. The result in practice is that a nurse, on obtaining her final certificate prefers to leave her training hospital and join a co-operation, from which she may be hired out to the same hospital she has recently left, at a rate of pay considerably higher than if she had continued at the hospital. Mayday Hospital took a prominent part in the nursing and treatment of the Typhoid cases, and as shown in the section dealing with the outbreak, at one time had 157 cases in the wards. There was, however, always a large margin of empty beds. For the nursing of these cases 56 additional nurses were engaged, and the average number of patients per nurse never exceeded three. The Borough Hospital also had a busy year owing to the increase in the admissions of Diphtheria, Scarlet Fever and Typhoid Fever. In connection with the accommodation of the Typhoid cases a Scarlet Fever ward was taken over by the transfer of convalescent Scarlet Fever cases to Coombe Cliff. The highest number of Typhoid cases in the Hospital at any one time was 40. Twenty additional nursing staff were engaged to deal with the cases. This hospital is small taking into consideration the size of the Borough, and it is becoming increasingly difficult to accommodate cases requiring admission. There is a greater demand for the admission of severe cases of Measles and Whooping Cough than formerly. This is to be welcomed, as adequate nursing plays a very important function in the managment of these cases. With the multiplication of flats and the limited home facilities, hospital is decidedly to be recommended, but it has been necessary to refuse admission to all but outstandingly urgent cases. The situation of the hospital is not a happy one, as it is next door to the Beddington Sewage Farm, and much trouble is experienced from flies and smell. Also in the last few years with the growth of factories along Purley Way, and the development of a large private housing estate, the open land around the hospital has been encroached on. The hospital, also, wants modernising in several respects, whilst the action of the clay soil upon which it stands, is a source of continual expense, in the repair of the buildings. 7 During the year an addition was made to the hospital to provide 20 extra bedrooms and recreation rooms for the nursing staff, and doctors' rooms. Each nurse has now a bedroom to herself. Tuberculosis. There have been no new developments during the year in this branch of the department. In each of my Annual Reports I have drawn attention to the inadequate and unsuitable Dispensary premises, which are much inferior to those provided by many neighbouring boroughs. It is unfortunate that, when dealing with a widespread illness causing heavy loss of life and heavier financial loss to the community, the cardinal principles of healthy environment, fresh air and bright homes, in combating this scourge, should not be illustrated in the building to which patients go for examination and advice. The work at Cheam has gone steadily on and in view of the high proportion of advanced cases admitted, the results are good. Cheam is, in reality, a Tuberculosis hospital and not a Sanatorium. It was designed, originally, as a Small Pox Hospital. It plays, however, an important part in the scheme. Owing to the extensive building development which has taken place all round the hospital the Committee have had under consideration moving the hospital to another site upon which could be erected a Sanatorium as well as a Tuberculosis Hospital, whereby the present necessity of sending cases to outside institutions would be overcome No definite decision had been arrived at by the end of the year. Venereal Diseases. There are no new developments to report upon in 1937. The number of patients dealt with at the Clinic at the Croydon General Hospital has, however, risen, and is the highest since 1931. The Local Branch of the British Social Hygiene Council has carried out propaganda work during the year and was assisted by a grant from the Council. Maternity and Child Welfare. The chief developments during the year were the transfer of the administration of St. Mary's Maternity Hospital to the Council from the Mothers' and Infants' Welfare Association; and the commencement of the Municipal Midwives Service. This service arose to comply with the requirements of the Midwives Act, 1936. It was decided to commence with 6 district midwives and a super- intendent, and to increase the number up to a total of 15 as the demand arose. From its inception the service seems to have been welcomed, and as it has become better known the calls for the midwives services have multiplied. At the end of the year the number had reached a point at which the appointment of two additional midwives was justified and their appointment took place early in 1938. 8 Both Mayday Hospital and St. Mary's Hospital are approved training school for midwives. Pupils are now able, also, to obtain their district training in Croydon. The new rules for training issued by the Central Midwives' Board have altered the original scheme very materially. The examination for the full certificate is now in two parts. Part I. is intended to be for candidates who do not intend to practise midwifery, Part II. is an extension to be taken by those who desire to become practising midwives. Mayday Hospital is approved for Part I. and St. Mary's Hospital for Part II. In addition every local supervising authority shall provide or arrange for the provision of post-graduate courses of instiuction for midwives practising in its area. The new schedule laid down will have the advantage of enabling the Midwives Roll to differentiate between midwives who are academic midwives only, and midwives who are practising. The object of the extended period of training is undoubtedly to raise the standard of midwifery practise as an aid towards a reduction of maternal mortality. Whether this purpose will be attained remains to be seen; the immediate effects will probably be to reduce the number of candidates on account of the extension of time and added expense. A strict supervision has been kept upon Nursing Homes in the town and on the whole the majority are correctly conducted and efficiently managed. The matter of foster-children and fostermothers is one, however, which calls for legislation. There are far too many loopholes in the relevant part of the Children Act for a really satisfactory supervision to be maintained by the officers of the Local Authority. A full account of the complete Obstetric Service is given in the body of the report. This service is much appreciated as is evidenced by the increasing, and at times embarrassingly great, demands made upon it. It is now a complete service and is functioning as a fully co-ordinated unit. The work of the Chief Sanitary Inspector's department is detailed in Section 13. A heavy increase of work fell upon it on account of the Typhoid outbreak, and temporary extra assistance was sanctioned and obtained. In the five year plan it was estimated that 150 individual unfit houses were subject to be dealt with, but a revised estimate brings the figure up to 274. Up to the end of 1937, 152 houses had been approved for demolition and demolition orders made. Re-development Areas have been put forward for the Leighton Street Area, and this has been in due course approved by the 9 Ministry of Health; and for the Wilford and Forster Road Area. This had not been approved by the end of the year. One of the most difficult of the Housing problems in Croydon, is the conversion of old three or four storeyed houses, formerly occupied by one family, into flats occupied by 4 or more families, of whom at least one family live in the basement quarters. A commencement has been made to deal with basements and unfit attic rooms under the powers given by the Housing Act, 1936. The usual close chemical and bacteriological watch has been maintained on the milk supplies. 504 bacteriological and 370 chemical samples were submitted for analysis. 15 of the graded milks were below the necessary standard; whilst for the ungraded milks, those which failed to reach any graded milk standard numbered 99. Eleven of the 370 samples submitted for chemical analysis, proved not to be genuine. Two samples of accredited milk and 8 samples of ungraded milk contained Tubercle bacilli. The year has been a full one, but its record has been marred by the Typhoid outbreak, a catastrophe which could hardly have been anticipated. It, however, served to emphasise the devotion to duty and the loyalty of my staff, and I wish to express my indebtedness to them for the way in which they met the emergency and the cheerful manner in which heavy extra burdens were undertaken. Criticism is made, from time to time, of the rising cost of the social services, including those coming under the title of Public Health. The blame for this increase should not be placed at the door of the members of local government bodies, but rather before the doors of Parliament. Enactments are, from time to time passed for various reasons, in which the sponsors do not appear always to have ascertained clearly beforehand the balance between tle cost entailed and the benefits likely to accrue. Local authorities must carry out the Acts passed, which, though national, may apply more particularly to certain areas. I wish to tender my thanks to the Chairman and Members of the Public Health Committee, the Housing Committee, the maternity and Child Welfare Committee, the Education Committee and the Mental Deficiency Committee for the sympathetic conderation they have given to any proposals submitted to them and for the interest they have taken. I am, Yours faithfully, OSCAR M. HOLDEN, Medical Officer of Health. 10 CONTENTS. A.— PUBLIC HEALTH REPORT. PAGE Acts, Adoptive 205 Ambulance Service 20 Amusement Houses 220 Animals, Keeping of 221 Ante-natal Clinic 156 Aerodrome 199 Babies Help Committee 185 Bacteriological Examination 94 Bakehouses 216 Births 14, 25 Blind Persons 202 Borough Hospital 18, 77 Bye-laws and Regulations 206 British Social Hygiene Council 135 Cancer 127 Cerebro-Spinal Meningitis 89 Children Acts 186 Chicken Pox 59 Closet Accommodation 17 Contacts, Tuberculosis 113 Committee 2 Cowkeepers 232 Croydon Nursing Service 113 Croydon General Hospital 19 Convalescence 184 Coombe Cliff Convalescent Hosp. 17,185 Creche 185 Dairies, Cowsheds and Milkshops 232 Deaths 14,25,29,31 Dental Treatment—M.&C.W. 156,174,180 Diphtheria 57, 65, 66, 81 Disinfection 149,222 j Disinfestation 223 Dispensary, Tuberculosis 97 Dried Milk 178 Drainage and Sewage 16 Encephalitis Lethargica 90 Enteric Fever 86 Erysipelas 89 Expectant Mothers 156 Extra Nourishment 109 Factories & Workshops Acts 208, 214 Fertilisers & Feeding Stuffs Act 221 Foods, Inspection of 225, 230 Food & Drugs Acts 239 Foster-Mothers 187 Foster-Children 186 Gynaecological Clinic 169 Health Visitors, Work of 177 Home Helps 185 Home Nursing 113 Homework 216 Hospitals 17 Hospital, St. Mary's (Maternity) 17, 154 Houses Let in Lodgings 219 Housing 212 ! Housing Act, 1936 213 Immunisation Clinic 66 Infant Welfare Clinics, Municipal 172 ; PAGE Infant Welfare Clinics, Voluntary 172 Infant Mortality 15, 141 Infantile Paralysis 90 Infectious Diseases 55 Laboratory Work 39,92,94,157 Local Acts 205 Local Government Act 24 Lodging Houses, Common 218 Marriages 25 Massage Clinics 38,179,198 Maternity Homes 150 Maternity Homes, Registration 150 Mayday Hospital 18,34,153 Measles 58,89 Meat Inspection 216 Medical Help Records 148 Meteorology 33 Mental Deficiency, etc. 38,188 Midwives 147,151 Midwives Acts 147,150 Milk, Provision of 109,178 Milk, Examination of 95,231 Milk, Tuberculous 234 Milkshops 232 Mortality in Child-birth 14,136,170 Mothers' and Infants' Welfare Association 172 Mumps 80 Municipal Lodging House 218 National Free Church Women's Council 139 Neo-natal Deaths 142 Norwood Cottage Hospital 19 Notification of Births Acts 136 Nuisances 207,221 Nursing Arrangements 113 Nursing Homes 150 N.S.P.C.C 20 Obstetrical Unit 153 Occupation Centre (Grange Wood) 192 Offensive Trades 220 Ophthalmia Neonatorum 90,141 Orthopaedic Department 195 Out of Borough Cases 92 Overcrowding 213 Parrots (Prohibition of Imports) Reg. 224 Pemphigus 90 Poisons & Pharmacy Act 221 Poliomyelitis 90 Poor Law Relief 22 Population 14 Post-natal Clinic 169 Public Laboratory 94 Puerperal Sepsis and Pyrexia 89,138, 171 Purley War Memorial Hospital 19 Queen's Road Homes 21 Rag Flock Acts 220 Rats & Mice (Destruction) Act 224 Rescue Home 185 Rent Restriction Acts 212 11 PAGE Rivers and Streams 16,221 Sanatorium, Cheam 120 Sanatoria, Treatment in 120 Sanitary Administration 205 Sanitary Certificates 211 Sanitary Inspectors, Work of 206 Scavenging 17 Scarlet Fever 56, 64, 79 Schick Test 66 Schools 221 St. Christopher's Special School 191 Shop Hours Acts 209, 217 Slaughterhouses 226 Social Conditions 16 Small Fox 18 Smoke Observations 220 Sputum, Examination 94, 108 Staff 12 Still-births 14,140 St. Mary's Maternity Hospital 17, 154 Swimming Pool 243 Tomography 109 Tuberculosis— Care Committee 119 „ Cheam Sanatorium 120 „ Contacts 113 „ Deaths 101 PAGE Tuberculosis—Dental Treatment 118 „ Notifications 97 „ Home Nursing 113 „ Home Visits 113 „ Housing 115 „ Tables 122 „ Pregnancy 108 „ Pneumothorax 121 „ Institutional Treatment 110 Typhoid Fever 8(5 Unmarried Mothers 20, 185 Ultra-Violet Light 200 Vaccination 90 Venereal Diseases 130, 157 Verminous Persons 224 Vital Statistics 14,25 Watercourses 221 Water Supply 16 Whooping Cough 58,89 Workplaces 214 Workshops 214 X-ray Examination 37, 109, 158, 197 B.— SCHOOL MEDICAL REPORT. PAGE Accommodation 259 Adenoids 266, 278,311 Blind Children 299 Cleansing of Children 262 Clinics 247, 277 Clothing and Footgear 262 Committee 246 cost 258 Crippling Defects 280 Deaf Children 299 Deaths 309 Defective Children 299 Defective Hearing 266 Deformities 267 Dental Disease 268 Dental Treatment 281 Domestic Subjects 308 Ear Clinic 291 Ear Disease 279 Epileptic Children 299 Exclusions 273 Eye Clinic 279 Eye Disease 267 Following up 276 Health Visitors, Work of 276 Heart Defects 265 eights and Weights 262,310 Infectious Diseases 275 nspection Clinic 279 nspections, Routine 259 nspections, Special 259 PAGE Juvenile Employment 302 Lungs, Diseases of 265 Malnutrition 262 Massage Clinic 280 Meals, Provision of 258 Mentally Defective Children 300, 303 Milk, etc., Provision of 258, 302 Minor Ailments 277 Nutrition 262 Orthopaedic Work 280 Orthodontic Service 288 Physical Training 304 Physically Defective Children 300 Remedial Exercises 280 Rheumatism Clinic 293 Sanitary Accommodation 252 School Camps 301 Schools, Special 258 Secondary Schools 309 Skin Affections 267 Speech 267 Staff 246 Statistical Tables 311 Surveys, Uncleanliness 262 St. Christopher's 303 St. Giles 280 St. Luke's 299 Throat and Nose 266, 278, 311 Treatment 277 Tuberculosis 285 Uncleanliness 262 Vision, Defective 267 12 STAFF OF THE HEALTH DEPARTMENT. The staff of the Public Health Department on the 31st December, 1937, 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. D. D. Payne, M.D., B.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. Rufus 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. John T. R. Lewis, M.D., D.P.H., Assistant Medical Officer of Health and Assistant School Medical Officer. C. G. Payton, M.D., D.P.,H., Assistant Medical Officer of Health and Assistant School Medical Officer. Iris A. Jenkin-Lloyd, M.R.C.S., L.R.C.P., D.P.H., Assistant Medical Officer of Health and Assistant School Medical Officer. Aileen I. McMahon, M.R.C.S., L.R.C.P., D.P.H., Assistant Medical Officer of Health and Assistant School Medical Officer. Rosa Morrison, M.B., Ch.B., D.P.H., Assistant Medical Officer of Health 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. (b) Part-time:— H. W. Southgate, M.B., B.S.. B.Sc., Pathologist. 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 surgical treatment of tonsils and adenoids Mayday Hospital.— Arnold Gilray, M.B., Ch.B. (N.Z.), Medical Superintendent. John Joseph Walsh, M.D., F.R.C.S. (Eng.), Assistant Medical Superinten dent. John Ewart Edson, M.B., Ch.B., M.R.C.P., M.Sc., Assistant Medical Officer. Julius L. Rosenfield, M.B., Ch.B., B.A.O., Junior Resident Assistant Medi- cal Officer. James T. Laurenson, Resident Surgical Officer. Catherine F. O'Connor, M.R.C.S., L.R.C.l'., Assistant Bacteriologist and Pathologist. (Part-time.) Consultants to the Public Health Department.— Thomas Warwick Preston, M.D., 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 H. W. Southgate, M.B., B.S., B.Sc., Pathologist. Visiting Radiologist, Mayday Hospital.— David Low Grieg, M.R.C.S., L.R.C.P., D.M.R.E. 13 District Public Assistance Medical Officers.— William Vaudrey Braddon, M.B., Ch.B., L.8.A. Henry Fleming Hamilton, M.B., Ch.B., F.R.C.S. Charles Aloysiua McGuire, M.B., Ch.B. Alan Pride, M.D. Austin Stafford, L.R.C.P.I. & L.M., L.R.C.S.I. & L.M Panel of medical practitioners appointed for Addiscombe, Central, East, South Norwood, Woodside, 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.S. Walter Hugh Montgomery Smith, M.R.C.S., L.R.C.P. Harold Trafford, M.R.C.S., L.R.C.P. Sydney Duke Turner, M.D., D.P.H. Gilbert Charrington Wellish, M.B., Ch.M., F.R.C.S. 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.D.S W. A. Sowden Hille, L.D.S. Deutal Surgeon: Mayday Hospital: E. H. Laurence, L.D.S. (part-time). Inspectors.— R. J. Jackson, M.R.S.I., A.M.I.S.E., M.S.I.A., Chief Sanitary Inspector, F. F. Fulker, A.R.S.I., A.I.S.E., M.S.I.A., Deputy Chief Inspector. 17 District Sanitary Inspectors. In addition, there are 7 disinfectors, 1 rat-catcher, and 5 assistants to the Sanitary Inspectors. Health Visiting Staff.— Alice M. Allford (Superintendent). 22 District Health Visitors; 2 Special Visitors: 1 Tuberculosis Nurse; 3 Almoners and 4 Dental Attendants. Also 2 whole-time Masseuses and Remedial Gymnasts Municipal Midwives.— N'orah A. Rigby (Superintendent). 6 District Municipal Midwives. Clerical Staff.— B. W. Cummins (Chief Clerk). Twenty-nine 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. Vaccination Officer.— Gerald H. Huggins, Csrt. R.S.I. Mayday Hospital, Croydon Borough Hospital, Croydon Borough Sana- torium, Coombe Cliff Convalescent Home, and St. Mary's Hospital. Nursing and Domestic Staffs. Occupation Centre for Low Grade Mental Defectives.— Miss K. M. Stupart (Supervisor). 3 Assistants and One Guide. Pathological Laboratory.— 4 Laboratory Assistants. 14 SUMMARY OF VITAL STATISTICS FOR 1937. Area, 12,617 acres. Population (Census 1931), 233,115. Population (estimated middle of 1937), 242,300. Number of Inhabited Houses (1931 Census), 56,429. Overcrowding Census (1936), 65,550. Rateable Value (1st April, 1937), £2,329,423. Product of a Penny Rate (1937), £9,022. Rate in the £ (1936-37), 10/6. Gross expenditure on Health Services (administered by Medical Officer of Health) £162,685 4 11 Income on Health Services (excluding transfers) 14,268 5 1 Net expenditure on Health Services £148,416 19 10 Expressed as a Penny Rate, 16.45d. pence in the pound. Live Births— M. F. Total. Legitimate 1,584 1,529 3,113 Illegitimate 70 80 150 Birth-rate per 1,000 of the estimated resident population, 13.5 Still Births— 94. Rate per 1,000 total (live and still) births, 28.0. Deaths— 2,800. Death-rate per 1,000 of the estimated resident population, 11.6. Deaths from diseases and accidents of pregnancy and childbirth: From sepsis, 2; other causes, 11. Maternal mortality: 3.87 per 1,000 total live and still births. 15 Death-rate of Infants under one year of age— All infants per 1,000 live births 60 Legitimate infants (167 deaths) per 1,000 legitimate live births 54 Illegitimate infants (29 deaths) per 1,000 illegitimate live births 193 Deaths from Influenza 71 ,, ,, Measles (all ages) 5 ,, ,, Whooping Cough (all ages) 5 ,, ,, Diarrhoea (under 2 years of age) 38 „ ,, Diphtheria (all ages) 15 ,, ,, Typhoid or Paratyphoid Fever 35 „ ,, Pneumonia 179 Per 1,000 of the population. Deaths from diseases of Cardiac and Circulatory System (including Cerebral Haemorrhage) 4.21 ,, ,, diseases of the Respiratory System (including Tuberculosis) 1.56 ,, ,, diseases of Renal System 0.35 ,, ,, diseases of Digestive System 0.74 ,, ,, Suicide and Accidents 0.54 „ Old Age 0.12 16 SECTION I. SOCIAL CONDITIONS, HOSPITAL ACCOMMODATION AND VITAL STATISTICS. The population of Croydon has for years shown a rapid and continuous increase. The rate of increase now seems definitely to be slackening. 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 1936 was 241,739. For the middle of 1937 the population is given as 242,300 (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. I am indebted to the Borough Engineer for the following information upon water supply, drainage and scavenging. A constant supply of water was maintained throughout the year from the Corporation's .own wells and the supply from the Metropolitan Water Board. Corporation's Wells 2,098.786,629 Metropolitan Water Board in Bulk 699,188,000 2,797,974,629 gallons. Rivers and Streams. There are only small streams or ditches. 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 £39,000 has been expended in maintenance and 17 laying of new main sewers and surface water drains and a loan for £21,150 has been sanctioned by the Ministry of Health for further extensions, of which about £16,000 has been expended. At the Sewage Disposal Works at Beddington three Activated Sludge Plants are in operation dealing with 3½ to 5 million gallons per day, six Sludge Digestion Tanks have been constructed, four of which have been brought into use. A similar tank has been put into operation at South Norwood. Closet Accommodation. There are still certain houses not connected to the main sewers, either because a sewer is not available, or because levels are such that connection cannot be made with existing sewers. In those districts where sewers have not hitherto been available, the deficiency is rapidly being made up; whilst in those areas where the configuration of the ground is such that certain houses cannot be connected, the development of new estates and the consequent laving of new lines of sewers is reducing rapidly the number of self-contained sewage plants installed in connection with house sewage. 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. (2) Maternity. St. Mary's Maternity Hospital, St. James' Road, Croydon. This Hospital was until the 31st March, 1937, conducted under The auspices of the Croydon Mothers' and Infants' Welfare Association. Thirty-two beds (with cots attached) are provided. The Hospital, so far as administration and general conditions are conearnd was transferred to the Council on April 1st, 1937. (3) Children. Coombe Cliff Convalescent Hospital. This Home is for the reception of infants and children convalescing after acute illnesses. The majority of the cases are 18 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 tuberculosis. (5) Small Pox. The Croydon and District Joint Small Pox Hospital Board's Hospital is now used as the Borough Sanatorium. Arrangements have been made with the Surrey County Council to receive into their Clandon Hospital cases of small pox arising in Croydon. General Hospitals. Mayday Hospital— Local Authority's General Hospital. No. of beds provided for sick, maternity and mental cases at 31.12.37. (a) For Men 234 (b) For Women 281 (c) For Children (under 10 years of age) 70 585 No. of Wards. Men. Women. Children. Total. Provided. Occupied. Provided. Occupied. Provided. Occupied. Provided. Occupied. Medical 1 - - 32 33 - - 32 33 Surgical 2 32 26 32 34 - - 64 60 Ch. Sick 1 32 31 - - - - 32 31 Children 3 - - - - 70 80 70 80 Tuberculosis 1 32 33 - - - - 32 33 Gynaecl 1 - - 24 17 - - 24 17 Maternity 2 - - 44 46 - - 44 46 Mental 2 32 25 32 34 - - 64 59 Isolation 1 - - 4 4 - - 4 4 General Wards appropriated to accommodate Typhoid Patients 8 106 70 113 66 - - 219 136 Totals 22 234 185 281 234 70 80 585 499 19 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. 1 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 1937 was 3,269; the average stay of each in hospital being 18.6 days. The number of out-patient attendances, including casualties, was 171,464. 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. He Aorwood 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. 20 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 South 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 National Society for the Prevention of Cruelty to Children. This Society, through their Inspectors, helped the department in various ways. During the year 11 cases were dealt with. The reasons for reference were: general neglect, 5; other causes, 6. These cases affected the welfare of 13 children, and entailed 34 visits by the Inspectors. AMBULANCE FACILITIES. (1) Two Motor Ambulances are provided by the Council for the removal of infectious cases from the Borough and Penge. (2) For non-infectious, surgical or medical cases— (a) Two motor ambulances 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's Ambulance Brigade. (d) One motor ambulance provided by the Public Assistance Committee and operating from Queen s Road Homes. 21 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 57 (b) For Women 130 (c) For Children (under 16 years of age) 6 193 Table I. Table showing the classification of the accommodation and the number of beds occupied on the 31st December, 1937. Classification. Number of Wards. Men. Women. Children under 16 yrs. of age. Total. Provided. Occupied. Provided. Occupied. Provided. Occupied. Provided. Occupied. Chronic Sick 7 50 49 122 115* - - 172 164 Mental (Lunacy Act, 1890) 2 6 6 8 8 — — 14 14 Mental Defectives 1 1 1 — — 6 6 7 7 Totals 10 57 56 130 123 6 6 193 185 *Including 67 chargeable to Mayday Hospital. IN-PATIENTS. Total number of admissions (including 88 to Nursery Sick Block): 160. Total number of deaths: 64. Total number of discharges: 19. Duration of stay of patients— (a) Four weeks or less: 32. (b) Exceeding four weeks but under thirteen weeks: 4. (c) Thirteen weeks or more: 68. Number of beds occupied— (a) Average during the year: 98. (b) Highest: 100 (on 12.2.37). (c) Lowest: 95 (on 4.12.37). 22 Classification of In-Patients who were discharged from or who died in the Institution during the year ended 31st December, 1937— Disease Groups. Men and Women. Discharged.  Acute Infectious Disease — 2 Malignant disease — 1 Mental Diseases— Senile Dementia 3 — Senile Decay 6 7 Disease of the Nervous System and Sense Organs 2 4 ,, „ Respiratory System — 8 ” ,, Circulatory System — 39 ,, „ Digestive System — 1 ,, ,, Genito Urinary System — 1 Other Diseases 1 1 Other Persons 7 — Totals 19 64 POOR LAW RELIEF. No. of residents in Croydon County Borough Area in receipt of outdoor poor relief on the 1st January, 1937 5,253 persons; 2,289 cases (including ablebodied). lst July, 1937 ... 3,809 „ 1,879 ,, „ 1st January, 1938 4,092 ,, 2,104 ,, ,, Number of Croydon poor persons relieved in the Mayday Hospital on 1st January, 1938, and in the Queen's Road Homes on the same date— Mayday Hospital 89 Queen's Road Homes 426 Expenditure on Out-relief to Croydon cases during the 12 months ended 30th September, 1937. Half-year ended 31st March, 1937 £49,449 15 11 Half-year ended 30th Sept., 1937. £38,466 10 3 During the year the District Medical Officer for the Number 6 Medical District resigned, and a Panel Medical Service Scheme, similar to those already operating in the Numbers 2 and 3 Medical Districts was evolved to take his place. This scheme commenced on July 1st, 1937. No. 3 District. Year to 31/3/38. Average number of separate patients attended during each quarter 229 Particulars of services rendered: Attendances at patients' homes 1235 Attendances on a second person in the same house at the same visit 189 3498 Attendances on patients at the surgery 1797 Medical Certificates issued 277 Total number of prescriptions written 3748 Total number issued during corresponding period of previous year 3045 Estimated cost of drugs and dressings, and dispensing £126 Estimated cost for corresponding period of previous year £101 Estimated amount of per capita payment to doctors in respect of patients s. d. actually attended 2/2.2 Estimated average payment per service point 1.05d. No. 2 District. Year to 31/3/38. 205 1119 11 3306 1830 346 2851 2411 £96 £82 s. d. 1/9.9 .85d. No. 6 District. 9 months to 31/3/38. 306 1005 137 3408 1838 428 2504 1117 (9 months to 31/3/1937) £84 £37 (9 months to s. d. 31/3/1937) 1/7.6 .87d. NUMBER 3 DISTRICT. Prev. Arrangement. Panel Medical Scheme. £ £ D.M.O.'s salary 150 Pool for Payment Drugs, Dressings of Practitioners 200 and Dispensing 62 Drugs, Dressings and Dispensings 126 £212 £326 NUMBER 2 DISTRICT. Prev. Arrangement. Panel Medical Scheme. £ £ D.M.O.'s salary 120 Pool for Payment Drugs, Dressings of Practitioners 150 and Dispensing 51 Drugs, Dressings and Dispensings 96 £171 £246 NUMBER 6 DISTRICT. Prev. Arrangement. Panel Medical Scheme. For 9 months £ For 9 months £ D.M.O.'s salary 150 Pool for Payment Drugs, Dressings of Practitioners 150 and Dispensing 37 Drugs, Dressings and Dispensings 84 £187 £234 23 554 LOCAL GOVERNMENT ACT, 1929. In Croydon the delegated duties under the Local Government Act, 1929, comprise the carrying out of the duties under the Children's Act and the Vaccination Acts, for which the Public Health Commitee has been responsible since 1931. 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 1937-8 were as follows:— Croydon Mothers' and Infants' Welfare Association— 1937/8 £ (a) Infant Welfare Centres 850 (b) Convalescence 500 (c) Care-work (Unmarried Mothers) 200 £1,550 Other Grants— 1937/8 £ The Retreat, Ross Road 650 Croydon Creche 300 Croydon Association of Moral Welfare 100 Children's Aid Society 230 £1,280 £2,830 26 SECTION II. VITAL STATISTICS. Marriages.—The number of marriages solemnised was 2,210 compared with 2,198 in 1936; 2,132 in 1935 ; 2,125 in 1934; 2,244 in 1933; 2,134 in 1932; and 2,212 in 1931. The marriage rate was 9.1 per 1,000 of the population; 1,141 were solemnised in Established Churches, 268 in other places of worship, 801 in the Register Office; no ceremony was performed under Jewish ritual. Births.—The births registered were 3,113 legitimate and 150 illegitimate. The birth-rate consequently was 13.5. For England and Wales and in the Great Towns the rate was 14.9. The illegitimate births in Croydon were 4.6% of the total, compared with 5.5% in 1936, 4.4% in 1935, 4.7% in 1934, 4.2% in 1933 and 4.9% in 1932. The live male births numbered 1,654, the female 1,609, being a proportion of 1,028 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 South Norwood (17.1), Broad Green (16.7), and Whitehorse Manor (16.6). Those with the lowest were: Norbury (6.7), Upper Norwood (11.0), South (11.4), and East (11.5). Deaths.—The deaths numbered 2,800, compared with 2,590 in 1936. For 1937 the death-rate was 11.6. For 1936 it was 10.7. The death-rate for England and Wales was 12.4, and for the Great Towns 12.5. For London the death-rate was 12.3. The male death-rate was 11.8, the female 11.3 for the Borough. There were 171 inquests held by Coroners in respect of Croydon residents during 1937, and 159 findings by Coroners after postmortem examination without inquest. Wards with the highest death-rates were: South (14.6), Whitehorse Manor (13.8), and Central (13.6); lowest in Addington (6.9), Norbury (8.6), and Waddon (9.5). Natural Increase.—The excess of births over deaths was 463, ' Per 1,000 of the population. Table 1. WARDS. Estimated Population. Births. Deaths. Birth Rate. Death Rate. Deaths under 1 year per 1.000 Births. Death Rate from Six Zymotic Diseases (excluding Diarrhoea) Death Rate from Diarrhoea. Death Rate from Bronchitis and Pneumonia. Death Rate from Pulmonary Tuberculosis. 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. al Increase or Decrease of Population. Upper Norwood 16858 186 205 11.0 12..2 70 0.24 0.41 1.36 0.53 0.06 3.92 0.06 1.84 20 —19 Norbury 16099 108 139 6.7 8.6 46 — 0.12 0.68 0.50 0.12 2.86 0.37 1.80 29 —31 West Thornton 19537 231 209 12.3 10.7 87 0.15 0.15 1.79 0.67 — 2.82 0.20 1.53 42 22 Bensham Manor 16723 226 172 13.5 10.3 35 0.06 0.12 0.66 0.84 0.06 3.59 0.18 1.67 50 54 Thornton Heath 17983 279 196 15.5 10.9 86 0.17 0.44 1.17 0.50 0.17 4.28 0.17 1.00 51 83 South Norwood 17490 299 222 17.1 12.7 50 — 0.17 1.37 0.40 0.06 4.40 0.57 1.94 29 77 Woodside 16116 207 179 12.8 11.1 39 0.06 0.06 1.12 0.74 — 3.99 0.25 2.17 37 -28 East 16140 185 175 11.5 10.8 27 0.31 0.06 0.50 019 0.12 4.03 0.49 2.11 10 —10 Addiscombe 16282 226 204 13.9 12.5 66 0.37 0.06 1.29 0 49 — 4.85 0.25 1.84 49 22 Whitehorse Manor 16931 281 233 16. 6 13.8 89 0.18 0.35 1.24 0.89 0.12 4.78 0.47 1.65 63 48 Broad Green 17408 291 224 16.7 12.9 69 0.40 0.29 2.07 0.69 — 3.56 0.23 1.78 69 67 Central 12393 159 168 12.8 13.6 38 0.08 0.32 0.97 0.80 0.08 5.24 0.24 1.94 33 —9 Waddon 18173 276 172 15.2 9.5 25 0.17 0.17 1.05 0.55 0.11 2.64 0.11 1.32 22 104 South 15187 173 221 11.4 14.6 58 1.44 0.07 1.78 0.46 — 4.28 0.26 2 44 13 —48 Addington 8980 136 62 15.1 6.9 59 0.44 — 0.33 0.33 — 1.78 0.33 0.78 1 74 The Borough 242300 3263* 2800* 13.5 11.6 60 0.26 0.19 1.20 0.58 0.06 3.82 0.28 1.73 19 483 *There are the corrected figures. 26 27 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 Whitehorse Manor (89), West Thornton (87), and Thornton Heath (86); lowest in Waddon (25), East (27), Bensham Manor (35), Central (38), and Woodside (39). The Infantile Mortality rate was above the average for the whole Borough in the following Wards: Upper Norwood, West Thornton, Thornton Heath, Addiscombe, Whitehorse Manor, and Broad Green. Birth-rates were highest in South Norwood, Broad Green, and Whitehorse Manor; lowest in Norbury, Upper Norwood, South, and East. The general death-rate was highest in South, Wliitehorse Manor, and Central; lowest in Addington, Norbury, and Waddon. The death-rate was above the average for the whole Borough in the following Wards: Upper Norwood, South Norwood, Addiscombe, Whitehorse Manor, Broad Green, Central, and South. The death-rate from Diarrhoea was highest in Thornton Heath Upper Norwood; from Bronchitis and Pneumonia in Broad Green, West Thornton, and South; from Pulmonary Tuberculosis in Whitehorse Manor, Bensham Manor, and Central; from NonPullmonary Tuberculosis in Thornton Heath, Norbury, East, and Whitehorse Manor; from Diseases of the Heart and Circulation in Central, Addiscomhe, and Whitehorse Manor; from Nervous seases in South Norwood and East; from Cancer in South, Woodside, and East. 28 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. Uncorrected Number. of Non-residents registered in the District. of Residents not registered in the District. Under 1 Year of Age. At all Ages. Number. Rate. Number. Rate. Number. Rate per 1,000 Nett Births. Number. Rate. 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 1937 242,300 3574 3263 13.5 2676 11.0 253 377 195 60 2800 11.6 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— 65— 75- All Causes M 1324 120 10 19 25 43 55 80 137 228 292 315 F 1476 76 11 11 25 51 43 82 127 178 342 530 1. Typhoid and paratyphoid fevers ... M 16 ... ... ... 2 6 4 1 2 1 ... ... F 19 ... ... ... ... 2 4 5 2 5 ... 1 2 Measles M 2 ... 1 ... 1 ... ... ... ... ... ... ... F 3 ... 1 2 ... ... ... ... ... ... 3. Scarlet fever M 2 ... 1 ... ... ... ... ... ... ... 1 ... F 1 ... ... ... 1 ... ... ... ... ... ... ... 4. Whooping cough M 1 1 ... ... ... ... ... ... ... ... ... ... F 4 ... 3 ... 1 ... ... ... ... ... ... ... 5. Diphtheria M 8 ... ... 5 3 ... ... ...... ... ... ... ... F 7 1 ... 1 4 ... ... ... ... ... 1 ... 6. Influenza M 29 ... 1 ... 2 ... ... 3 3 5 7 8 F 42 ... ... 1 1 ... ... 2 2 8 10 16 7. Encephalitis lethargica M 2 ... ... ... ... ... ... 1 ... ... 1 ... F ... ... ... ... ... ... ... ... ... ... ... ... 8 Cerebro-spinal fever m 2 1 ... ... ... ... ... 1 ... ... ... ... F 1 ... ... 1 ... ... ... ... ... ... ... ... 9. Tuberculosis of respiratory system M 74 ... ... ... 2 6 13 21 12 16 3 1 F 62 ... ... ... 1 26 9 10 8 4 2 2 10. Other tuberculous diseases M 8 3 ... ... 1 1 2 1 ... ... ... F 11 ... 1 1 1 6 ... 2 ... ... ... ... 11. Syphilis M 3 ... ... ... ... ... ... 1 1 1 ... ... F 1 ... ... ... ... ... ... ... ... ... 1 ... 12. General paralysis of the insane, tabes dorsalis M 9 ... ... ... ... ... ... 2 4 2 ... 1 F 3 ... ... ... ... ... ... 1 1 1 ... ... 13. Cancer, malignant disease M 192 ... ... 2 ... 1 6 7 27 44 58 47 F 240 ... ... ... 1 ... 2 19 41 48 75 54 14. Diabetes M 19 1 ... ... 1 ... ... ... 2 5 9 1 F 25 ... ... ... ... ... ... 2 2 8 9 4 15. Cerebral haemorrhage, etc M 42 ... ... ... ... . . . ... 2 2 12 14 12 F 68 ... ... ... ... ... ... ... 4 8 20 36 16. Heart Disease M 327 ... ... 1 1 1 2 9 30 52 94 137 F 443 ... ... ... ... 1 5 8 16 47 117 249 17. Aneurysm M 6 ... ... ... ... 1 2 ... 1 ... 2 ... F 3 ... ... ... ... ... ... ... ... 1 2 ... 18 Other circulatory diseases M 66 ... ... ... ... ... ... 1 3 18 25 19 F 64 ... ... ... ... ... 1 1 2 3 26 31 19. Bronchitis M 24 2 1 ... ... 1 1 ... 3 2 5 9 F 26 1 ... ... 1 ... ... ... 1 ... 4 19 20. Pneumonia (all forms) M 93 23 2 5 2 1 2 8 10 14 13 13 F 86 11 2 3 3 3 4 8 8 6 16 22 21. Other respiratory diseases M 7 ... ... ... 1 1 ... ... ... 1 1 3 F 5 1 ... ... ... ... ... ... 1 2 1 ... 22. Peptic ulcer M 22 ... ... ... ... 1 1 2 4 6 5 3 F 4 ... ... ... ... ... ... ... 1 1 1 1 23. Diarrhoea, etc. M 21 16 2 ... ... 1 ... ... ... 1 1 ... F 24 20 ... ... ... ... ... ... 1 ... 3 24. Appendicitis M 12 ... ... 2 ... ... 3 4 1 ... 1 ... F 11 ... ... 1 ... ... 2 1 2 2 3 ... 25. Cirrhosis of liver M 4 ... ... ... ... ... ... ... 2 1 1 ... F 5 ... ... ... ... ... ... 1 2 2 ... ... 26 Other diseases of liver, etc. M 3 ... ... ... ... ... ... ... 1 1 1 F 11 ... ... ... ... ... 1 ... 1 1 2 6 27.Other digestive diseases M 34 2 ... 1 ... 1 3 3 3 6 8 7 F 29 ... ... ... 1 2 ... 3 3 5 4 11 28. Acute and chronic rephritis M 30 ... ... ... ... ... 2 5 5 7 3 8 F 54 ... ... ... 1 ... 2 2 9 7 16 17 29. Puerperal sepsis F 1 ... ... ... ... ... 1 ... ... ... ... ... 30. Other puerperal causes F 11 ... ... ... ... 1 6 4 ... ... ... ... 31. Congenital debillity, premature birth,malformation,etc. m 67 65 ... ... 1 ... 1 ... ... ... ... ... F 38 36 1 ... ... 1 ... ... ... ... ... ... 32. Semillity M 10 ... ... ... ... ... ... ... ... ... 3 7 F 18 ... ... ... ... ... ... ... ... ... 1 17 33. Suicide M 15 ... ... ... ... 1 2 2 4 3 1 2 F 15 ... ... ... ... ... 2 4 5 2 2 ... 34. Other violence M 61 ... 2 ... 3 11 7 6 9 9 7 7 F 41 3 ... ... 1 4 ... 1 1 6 4 21 35. Other defined diseases M 113 6 ... 3 4 9 4 1 8 21 28 29 F 98 3 2 1 8 3. 4 8 14 11 25 19 36. Causes ill-defined, or unknown m ... ... ... ... ... ... ... ... ... ... ... ... F 2 ... 1 ... ... ... ... ... ... ... ... 1 30 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., and Diarrhoea, it was the greatest cause of death at this age. Other illuminating and important causes of death are Other Circulatory Diseases and 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, and was 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. Influenza caused 71 deaths, an increase of 32 on 1936. The outbreak of Typhoid Fever caused, in 1937, 16 deaths in males, and 19 in females. In 1936 there were 4 deaths. Comparisons with 1936. There was a fall in the deaths from the Zymotic diseases excluding Typhoid Fever and Diphtheria. In 1937 there were 5 deaths from Measles and 3 from Scarlet Fever. Whooping Cough caused 5 deaths (15 in 1936), and Diphtheria 15 deaths (8 in 1936). The deaths from Pulmonary Tuberculosis increased by 4 in 1937. The number of deaths attributed to Cancer totalled 432 compared with 428 in 1936. Deaths from Heart Disease increased by 21. Pneumonia deaths showed a decrease of 6, and those due to Bronchitis an increase of 6. Deaths from Digestive Diseases, including Appendicitis, increased by 33. Deaths from Suicide and Violence increased from 114 to 132. The percentage of deaths under 1 years of age to total deaths was 7.0%. Deaths under 15 years, 10.6%; deaths under 65 years, 47.2%; deaths over 65 years, 52.8%. The corresponding figures for 1936 were 5.2%, 9.4%, 45.5%, and 54.5%. 31 Table IV. classification of deaths according to disease over a period of 10 years. Cause of Death. 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 D^ath Rate. Total Deaths. Total Deaths. Total Deaths Total Deaths. Total Deaths. Total Deaths. Total Deaths Total Deaths. Total Deaths Total Deaths. Enteric Fever ... 1 ... ... 2 ... 1 ... 4 35 0.144 Malaria ... ... ... ... ... ... ... ... ... ... ... Small Pox ... ... ... ... ... ... ... ... ... ... Measles 30 1 22 ... 2 13 14 ... 21 5 0.021 Scarlet Fever 5 4 2 3 ... ... 3 ... 2 3 0.012 Whooping Cough 14 24 3 9 12 3 18 2 15 5 0.021 Diphtheria and Croup 32 23 14 5 11 17 24 12 8 15 0.069 Influenza (including Influenzal pneumonia) 38 199 32 84 100 103 28 25 39 71 0.293 Dysentery ... ... 1 1 ... ... ... ... ... ... ... Erysipelas 3 8 7 4 3 8 5 2 6 3 0.012 Crebro-Spinal Fever 2 ... 2 3 2 2 3 3 ... 3 0.012 Pulmonary Tuberculosis 167 170 154 155 144 162 144 148 132 140 0.578 Tuberculous Meningitis 13 10 7 11 9 10 6 9 19 15 0.062 Other Tuberculous Disease 26 19 14 11 13 12 7 14 Cancer, Malignant Disease 327 330 339 342 341 374 371 321 428 432 1.783 Rheumatic Fever 6 5 4 7 4 4 6 9 6 11 0.045 Meningitis 11 17 14 15 9 7 9 14 4 4 0.017 Organic Heart Disease 405 308 375 490 469 627 591 780 749 770 3.178 Bronchitis, Acute and Chronic 92 226 125 200 145 130 93 45 44 50 0.206 Pneumonia 158 272 199 258 238 210 199 120 135 179 0.739 Other Diseases of the Respiratory Organs 33 21 16 20 15 22 24 29 23 12 0.050 Diarrhoea and Enteritis 28 45 32 15 25 26 18 29 31 45 0.186 Appendicitis and Typhlitis 16 27 23 23 28 44 23 48 18 23 0.095 Cirrhosis of Liver 11 10 5 5 8 6 5 2 8 9 0.037 Alcoholism 3 4 3 1 1 ... 5 2 ... 1 0.004 Nephritis and Bright s Disease 79 117 45 60 81 78 75 66 89 84 0.347 Puerperal Fever 2 6 1 8 2 7 5 7 5 1 0.004 Other Diseases and Accidents of Pregnancy & Parturition 11 5 6 14 5 5 8 1 7 11 0.045 Congenital Debility and Malformation 26 42 42 49 27 19 33 87 63 105 0.433 Premature Birth 32 47 40 49 48 47 70 34 Violent deaths (excluding Suicide) 75 64 74 92 75 91 85 85 102 0.421 Suicide 35 29 19 33 43 30 37 26 29 30 0.124 Other Defined Diseases 664 748 713 706 684 677 688 567 570 634 2.617 Diseases Ill-defined or unknown 10 10 4 1 10 8 3 ... ... 2 0.009 Total 2354 2792 2337 2674 2556 2721 2571 2453 2590 2800 11.6 1937 showed an increase in the general death-rate, a slight increase in the birth-rate and a sharp rise in the infant mortality rate which rose to the highest figure since 1929. 32 Taking diseases of bodily systems and group diseases to which deaths were definitely assigned by the Registrar General, we find:— ,000 population. Circulatory System (including Atheroma and Cerebral Haemorrhage) 1019 or 4.21 Cancer 432 1.78 Respiratory System (not Tubercular) 241 0.99 Tuberculosis (all forms) 155 0.64 Diseases of the Digestive System (excluding Cancer and Tuberculosis) 180 0.74 Diseases of the Nervous System (not Tubercular) 67 0.28 Diseases of Renal System 84 0.35 Infectious Diseases (excluding Tuberculosis but including Influenza) 139 0.57 Suicides and Violent Deaths 132 0.54 Old Age 28 0.12 Congenital Debility, Prematurity and Malformation 105 0.43 ' The greatest single group of causes of death as in 1936 was diseases of the Circulatory system, and of this group Organic Heart Disease was the most prominent member (770 deaths). Arterio-sclerosis (251 deaths) is the second great cause of death in this group. Cerebral Haemorrhage, which caused, incidentally, 127 deaths, is one of the sequelae of Arterio-sclerosis, combined with excessive blood pressure. Arterio-sclerosis and Cerebral Haemorrhage between them caused 378 deaths, an increase of 59 upon 1936. 33 Table V. METEOROLOGICAL RECORD. Months. Air Temperature in Degrees Fahrenheit. Rainfall Total. Bright Sunshine. Hrs. per day. ntage. Means of Mean of A. & B. A. Max. B. Min. Daily Mean °F. °F. °F. in. mm. hrs. January 46.7 39.4 43.1 5.37 137 1.60 19 February 48.3 39.9 44.1 4.66 118 2.07 21 March 45.6 34.3 39.9 3.25 83 3.37 29 April 56.6 43.7 50.1 2.51 64 3.40 25 May 63.4 48.4 55.9 2.50 63 5.54 36 June 67.9 51.2 59.5 1.72 44 6.83 41 July 69.9 56.1 63.0 0.69 18 4.35 27 August 74.9 56.2 65.5 2.50 63 6.02 42 September 65.9 49.7 57.8 2.40 61 4.89 39 October 59.0 46.7 52.9 3.30 84 2.64 25 November 47.6 37.0 42.3 1.89 48 1.73 19 December 42.2 35.7 38.9 4.41 112 0.68 9 Means and Totals for Year 57.3 44.9 51.1 35.20 895 3.59 28 34 SECTION III. MAYDAY HOSPITAL. I am indebted to the Medical Superintendent, Dr. Arnold Gilray, for this section of the Report. Staffing.—Medical Superintendent. 4 Other Resident Medical Staff. 3 Non-resident Staff. 8 Consulting Staff. Specialised Services.—Orthopaedic, Gynaecological, Dental, X-ray, Massage, Ultra Violet Light, Ophthalmic, Ear, Nose and Throat. No. of Trained Nurses 65 plus 2 Masseuses and 1 X-ray. Probationer Nurses 82 Assistant Nurses 7 Male Attendants 13 No. of beds provided in the Institution for sick, maternity and mental cases at 31.12.37. (a) For Men 234 (b) For Women 281 (c) For Children Under 16 Years of Age 70 585 Men. Women. Children. Total. No. of Wards. vided. pied. vided. pied. vided. pied. vided. pied. Medical 1 ... ... 32 33 ... ... 32 33 Surgical 2 32 26 32 34 ... ... 64 60 Chr. Sick 1 32 31 ... ... ... ... 32 31 Children 3 ... ... ... ... 70 80 70 80* Gynae. 1 ... ... 24 17 ... ... 24 17 Tuberculosis 1 32 33 ... ... ... ... 32 33 Isolation 1 ... ... 4 4 ... ... 4 4 Maternity 2 ... ... 44 46 ... ... 44 46 Mental 2 32 25 32 34 ... ... 64 59 Other †8 106 70 113 66 ... ... 219 136 22 234 185 281 234 70 80 585 499 *Extra beds put up to meet demand. †General Wards appropriated for the accommodation of Typhoid patients. 35 Table I. l. Total number of admissions (including infants born in hospital) 6,424 2. Number of women confined in hospital 952 3. Number of live births 924 4. Number of still births 41 5. Number of deaths among the newly-born (i.e., under 4 weeks of age) 24 6. Total number of deaths among children under one year (including those given under 5) 95 7. Number of Maternal deaths among women admitted to hospital for confinement 7 8. Total number of deaths 876 9. Total number of discharged (including infants born in hospital) 5,538 10. Duration of stay of patients included in 8 and 9 above— (a) Under four weeks 4,532 (b) Four weeks and under thirteen weeks 1,477 (c) Thirteen weeks or more 405 11. Number of beds occupied (excluding cots in maternity wards)— (a) Average during the year 499 (b) Highest 568 on 26.11.37. (c) Lowest 453 on 13.10.37. 12 Number of surgical operations under general anaesthetic (excluding dental operations) 1,051 13. Number of abdominal sections 432 30 Table II. Classification of In-Patients who were Discharged from or who Died in the Institution during the year ended 31st December, 1937. Disease Groups. Children (under 16) Men and Women. Discharged. Died. Discharged. Diei. a. Acute infectious disease 19 2 30 16 b. Influenza 5 - 30 4 C. Tuberculosis : Pulmonary 10 2 59 38 Non-Pulmonary 1 3 7 11 d. Malignant Disease - 1 96 118 E. Rheumatism, Acute rheumatism (rheumatic fever) together with sub-acute rheumatism and chorea 13 2 36 22 Non-articular manifestations of so called "rheumatism" (muscular rheumatism, fibrositis, lumbago, and sciatica) 2 - 24 - Chronic Arthritis 1 1 31 2 F. Venereal Disease 2 — 12 3 G. Puerperal pyrexia — — 20 — H. Puerperal fever (a) Women confined in hospital - - - - (b) Other cases — — — — I. Other diseases and accidents connected with Pregnancy and childbirth — — 361 9 J. Mental disease (Senile Dementia) - - 284 — (Other) 4 — — — K. Senile Decay — — 64 40 L. Accidental injury and violence 84 1 265 31 In respect of cases not included above— M. Diseases of the Nervous System and 76 Sense organs 17 7 108 N. „ „ Respiratory System 108 27 206 85 0. „ „ Circulatory System 5 6 178 175 P. „ „ Digestive System 254 30 534 73 Q. „ „ Genito-Urinary System 26 3 286 36 R. ” ”Skin 84 2 105 6 S. Other Diseases 84 8 126 12 T. Mothers and infants discharged from Maternity Wards and not included in above figures Mothers - - 938 — Infants 913 — — ~~ U. Any persons not falling under any of the above headings 50 24 56 - Totals 1682 119 3856 757 37 Actual number of cases treated 2,126 NUMBER OF X-RAY FILMS TAKEN. Diagnostic Department. 1935. 1936. 1937 Spine 113 161 134 Long bones 790 936 1,107 Pelvis 20 32 29 Skull 155 163 198 Chest (including lungs) 385 405 970 Barium meals 199 129 246 Barium enemata 26 18 22 Urinary tract 196 176 175 Gall-bladder 105 55 65 Teeth 140 118 192 Abdominal 16 10 42 Maternity cases 226 164 391 Total 2,371 2,367 3,561 Actual no. of cases examined 968 1,382 2,124 38 THERAPY DEPARTMENT. Condition for which Treatment was given. No. of Patients. No. of Applications. Cured. Relieved. Died. Transferred to other Hosps. Still under Treatment. Carcinoma of Oesophagus 1 42 ... ... 1 ... ... „ „ Stomach 1 3 ... ... 1 ... ... „ Colon 1 24 ... ... ... ... 1 „ „ Rectum 1 72 ... ... ... ... 1 „ „ Breast 5 81 ... 1 ... ... 4 „ Ovary 2 28 ... 1 ... ... 1 „ „ Uterus 1 30 ... ... ... ... 1 Rodent Ulcer 1 23 ... ... ... 1 ... Lympho-sarcoma 2 11 ... ... 1 1 ... Sarcoma of rib 1 21 ... ... 1 ... ... Hodgkin's Disease 2 45 ... ... 2 ... ... Malignant glands in Neck 2 17 ... ... 2 ... ... Eczema of Breast 1 6 1 ... ... ... ... Menorrhagia 2 8 ... ... ... ... 2 Goitre 1 12 ... 1 ... ... ... Osteo-arthritis 1 20 ... 1 ... ... ... Ringworm of Scalp 5 35 5 ... ... ... ... Total 30 478 6 4 8 2 10 MASSAGE 7,218 Exercises 3,439 Radiant Heat 1,792 Electrical 556 Diathermy 826 Ultra Violet Light 1,440 Wax 24 15,295 Actual number of patients treated 383 MENTAL PATIENTS DEALT WITH DURING THE YEAR. Male. Female. Admitted 211 257 Certified and sent to Warlingham Park Hospital 44 74 As Voluntary Patients to Warlingham Park Hospital 13 11 Discharged not certified 97 138 39 NUMBER OF SPECIMENS SENT TO THE COUNCIL'S LABORATORIES DURING THE YEAR. Sent to Croydon General Hospital 1,501 Examined at Mayday Hospital. 2,378 NUMBER OF POST MORTEMS ORDERED BY THE CORONER AND PERFORMED AT MAYDAY HOSPITAL DURING THE YEAR. Outside Cases 213 Hospital Cases 66 NUMBER OF POST MORTEMS NOT ORDERED BY THE CORONER 119 OPERATIONS PERFORMED AT MAYDAY HOSPITAL, 1937. Number. ABDOMINAL. Appendicectomy 175 Suture of Perforated Duodenal Ulcer 6 Suture of Perforated Gastric Ulcer 8 Drainage of appendix abscess 9 Drainage of subphrenic abscess 1 Caecostomy 4 Gastrectomy 4 Resection of Colon 1 Cholecystectomy 10 Excision of Fistula 1 Closure of fistula 1 Colostomy 11 Gastro-jejunostomy 2 Sigmoidoscopy 16 Excision of Haemorrhoids 12 Herniotomy 47 For Acute obstruction 15 Laparotomy (Carcinatomosis, etc.) 22 Removal of Umbilical Calculus 1 Removal of Foreign Body from Oesophagus 1 For Pyloric Stenosis 11 Removal of Rectal Papilloma 1 Closure perforation of Ileum (Typhoid Fever) 3 362 BONES AND JOINTS. Reduction of Joints 10 Application of Plasters 76 For Osteo-myelitis 8 Wiring of Bones 29 Plating of Fractures 4 Manipulation of Limbs 19 Fixing Caliper 2 Resection of Rib 9 Removal of Sequestra 1 Amputation of Limbs 10 For recurrent dislocation 1 For Hallux Valgus 1 For Acute Suppurative Arthritis 4 Trephining of Bones 2 Bone Graft for T.B. Spine 1 Decompression (Fractured Skull) 1 Craniotomy 1 179 40 Number. EAR, NOSE AND THROAT. Tonsillectomy 126 Mastoidectomy 18 Puncture and Irrigation of Antrum 3 Incision of Mastoid 1 Removal of Nasal Polypi 3 Incision of Ethmoid Abscess 1 Thyroidectomy 1 Laryngotomy 1 Adenoidectomy 3 Excision of portion of Septum 1 158 GENITO-URINARY. Circumcision M Pyelography 8 Prostatectomy 5 Cystostomy 13 Cystoscopy 38 Nephrolithotomy 1 Suture of Ruptured Urinary Bladder 1 For Hydrocele 2 Passage of Urethral Bougies 2 Nephrectomy 1 Reduction of ParaPhimosis 1 Dilatation of Urethral stricture 4 90 GYNAECOLOGICAL. Examination under Anaesthesia 16 Total Hysterectomy12 Subtotal Hysterectomy 22 For Complete Collapse of Uterus 6 Ovariotomy 6 6 Removal of Cervical Polypi 4 Ant. Colporrhaphy 2 Removal of Ovarian Cyst 7 Colpo-perineorrhaphy 1 Salpingectomy 9 Salpingo-oophorectomy 6 Salpinography 1 Dilatation and Curetage 46 Incision of Mammary Abscess 19 Resection of Fibroids 2 Evacuation of Vesicular Mole 2 Excision of Bartholin's Cyst. 1 Incision of Bartholin's Abscess 1 Cauterization of Cervix 4 Uterine Tampionage 1 Repair of Pelvic Floor 2 Ant. Post. Colporrhaphy 5 175 41 Number. OBSTETRICAL. Caesarean Section 38 Forceps Delivery 18 For Ectopic Gestation 5 Drainage for Pelvic Peritonitis 3 Evacuation of Uterus and Glycerine Pack 101 Induction of Labour 37 Manual removal of placenta 8 Episiotomy 9 219 MISCELLANEOUS. Exploration of Chest 34 Incisions (Abscesses, Whitlows, Cellulitis, etc.) 109 Lumbar Punctures 43 Excision of sinuses 5 Excision of glands 3 Avulsion of nails 3 Excision of varicose veins 1 Application of Tannic Acid 3 Thiersch Skin Graft 2 Suture of Wounds 25 Suture of Tendons 3 Removal of Breast 2 Excision of Olecranon Bursa 5 Excision of Cartilage 1 Blood Transfusion 19 Venesection 3 Intravenous saline 3 Paracentesis Abdominis 4 268 Total 1,451 Number of patients who had teeth extracted 305 Total Number of Patients Discharged from Mayday Hospital, Year Ended 31.12.37. Cured 3,915 Relieved 1,223 Unrelieved 400 Died 876 6,414 42 On June 7th, 1937, a laboratory was opened at Mayday Hospital, and Dr. C. F. O'Connor was appointed whole-time bacteriologist and pathologist. In addition, Dr. H. W. Southgate was appointed as consultant bacteriologist and pathologist, to devote one session a week to the work. This laboratory takes all the specimens from Mayday Hospital and has consequently relieved the Central Laboratory of work which was steadily increasing. Since its establishment, the number of speciments of all kinds sent for examination has increased, a feature which shows that the medical officers at the hospital find it a useful aid. The appended table shows the work done up to the 31st December, 1937. Positive. Negative. Swabs for Diphtheria 3 134 Sputum for T.B 104 168 Pus for T.B. — — Pus for Gonococci 26 69 Pus for other organisms 36 — Blood for typhoid group 104 38 Faeces for typhoid group 5 273 Urine for typhoid group 13 100 Examination of pleural fluid 21 — Examination of cerebro-spinal fluid 15 — Test Meals 5 — Blood for Urea 43 — Blood for Sugar 26 — Hair tor Ringworm 1 4 Other examinations— 1. Blood examinations 276 — 2. Urine analysis and Diastase, etc. 689 — 3. Other examinations 80 - 1,447 786 43 Table III. Diagnoses In Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Alimentary. Appendicitis — — — — 178 15 2 8 203 Gastric ulcer 16 24 2 6 9 4 — 4 65 Duodenal ulcer 8 8 — 4 3 2 — — 25 Ulcer of Caecum — — — — — — — 1 1 Dyspepsia 2 3 — — — — — — 5 Abdominal fistula — — — — — — 1 — 1 Abdominal tumour - - - - - - — 1 1 Acidosis 2 - - - - - - - 2 Corcatto's disease — — — — — — 2 — 2 Cholilithiasis — — — — 10 2 — — 12 Intestinal obstruction — — — — 5 4 — 14 23 Colitis 5 4 - - - - - - 9 Hernia — — — — 49 10 1 2 62 ischio rectal abscess — — — — 12 1 — — 13 Constipation 10 13 - - - - - - 23 Haemorrhoids — — — — 14 2 1 — 17 Intestinal colic 3 - - - - - - - 3 Papilloma of Rectum — — — — 2 — — — 2 Cholecystitis — — - - 15 13 - - 28 Adhesions following operation - - - - 1 - - - 1 pyloric spasm 1 — — — - — — — 1 Intussusception — — — — 1 1 — — 2 Rupture of oesophagus - - - - - - - 1 1 Gastritis 12 6 - - - - - - 18 Fissure in Ano - - - - - 2 - - 2 Pyorrhoea - - - - 9 1 - - 10 Cirrhosis of Liver - 4 1 1 — — 6 44 [$$$}Diagnoses In Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Gastrostaxis 1 - - - - - - - 1 Gastro enteritis 28 2 — 37 — — — - 67 Pyloric stenosis — — — — 4 — — 1 5 Stomatitis 2 1 — 1 — — — — 4 Cholangitis 1 — — — — — — — 1 Swallowed F.B. — — — — 3 — — 1 4 Diverticulitis — — — — — 3 — — 3 Chill 2 — — — — — — — 2 Rectal Prolapse — — — — — 1 — - 1 Umbilical calculus — — — — 1 — — - 1 Volvulus of Sigmoid colon - - - - - - - 1 1 Catarrhal jaundice — 8 — — — — — - 8 Threadworms — 2 — — — — — - 2 638 Bones, Joints and Muscles. Arthritis 4 29 4 2 — — - - 39 Spinal tumour — — — — — 2 - - 2 Fibrositis 3 5 — — — — - - 8 Osteo-myelitis — — — — 5 5 1 - 11 Ac. and subacute rheumatism 8 16 — — — - 24 Pleurodynia 1 1 — — ' — " — — - 2 Periostitis 5 — — — — — — - 5 Lumbago — 4 — — — — — - 4 Bursitis 2 — — — 2 — — — 4 Muscular Atrophy — 1 1 — — — — — 2 Flat Foot — — — — — 2 — — 2 Semi membranosus — — — — 1 — — — 1 45 Diagnoses In Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Erb's myopathy — — 1 — — — 1 Sacro iliac strain 1 - - - - - - - 1 Exostosis 2 — — — — — — — 2 Cyst of Semilunar Cartilage — — — — 2 — — — 2 110 Carcinoma. Stomach — — — — 4 1 — 18 23 Cervix Uteri — — — — 2 14 11 17 44 Ovary — — — — — 2 1 — 3 Rectum — — — — 1 6 3 18 28 Colon — — — — 2 3 4 11 20 Breast — — - — 2 9 1 10 22 Lung — — - — — 3 4 6 13 larynx — — — — — 1 1 2 4 Rodent ulcer face — — — — — 2 2 3 7 Tongue and Mouth - - - - - - 3 3 6 Pancreas — - — — — — 2 6 8 Liver — - — — — — — 3 3 Oesophagus - - - - - 2 1 7 10 Bladder - - - - - - - - - Prostate — — - - - 2 - 6 8 Spine — — — - - 1 - - 1 Ventriculi — - - - - - - 1 1 Vulva - - - - - - 2 - 2 Urethra - - - - - 1 - - 1 Mandible - - - - - - - 2 2 Sarcoma of Leg - - - - - 1 1 3 5 Sarcoma of Pubic bone — — — - - - 1 — 1 46 Diagnoses In Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Malignant Disease Conjunctiva - - - - - 1 - - 1 Lympho Sarcoma - - - - - - - 2 2 215 Circulatory (Blood). Anaemia 2 9 1 6 — — — - 18 Septicaemia — — — 3 — — — - 3 Pyaemia — — — 1 - — — - 1 Leukemia — — 1 1 — — — — 2 24 Circulatory (Heart and Vessels). Varicose Veins 5 2 - - - - - - 7 Hyperpiesia 12 4 - - - - - — 16 Epistaxis 4 1 - - - - - - 5 Phlebitis 6 2 - - - - - — 8 Haemorrhage following dental extraction — 2 — — — — — - 2 Lymphangitis 2 2 — — — - — — 4 Myocardial degeneration. — 10 — 119 — - — — 129 Arterio sclerosis — 17 3 9 — — — — 29 Endocarditis — 22 5 15 — — — — 42 Tachycardia 2 6 — — — — — — 8 Aortic stenosis — 4 — 1 — — — 5 Myocarditis — 17 4 27 — — — - 48 Auricular fibrillation — 13 1 4 — — — — 18 Coronary thrombosis — 1 — 12 — — — — 13 Mitral stenosis — 3 — — — — — — 3 Pericarditis — 2 — — — — — - 2 47 Diagnoses In Cases Treated Medical. Surgical. Total Cured Re- Unrelieved lieved Died Cured Relieved Unrelieved Died Aortic regurgitation — 2 — — — — — — 2 Coronary atheroma — — — 2 — — — — 2 Syncope 4 - - - - - - - 4 347 Constitutional. Diabetes mellitus 3 15 5 12 — — — — 35 Collapse 4 7 — 2 — — — — 13 Nutritional disorders 19 9 3 3 — — — — 34 Marasmus 19 1 1 17 — — — - 38 Rickets 7 6 - - - - - - 13 Debility — 4 3 - - - - - 7 Fat intolerance — 2 - - - - 4 - 2 Gout — 2 - - - - - - 2 Asthma — 1 - - - - - - 1 Malaria — 1 — — — — — — 1 146 Ear, Nose and Throat. Otitis Media — — — — 34 8 1 — 43 Mastoiditis — — — — 21 3 — 1 25 Sinusitis — — — — 3 2 — - 5 Quinsy — — — — 8 — — - 8 Tonsillitis — — — — 172 10 4 - 186 Deflected Nasal Septum - - - - - 5 3 - 8 Laryngeal spasm 1 — — — — — — - 1 Naso-Pharangeal Catarrh - - - - - 2 1 - 3 Tracheitis - - - - 1 2 - - 3 Perforation of Ear Drum - - - - - 1 - - 1 Rhinitis — — — — 2 — — — 2 285 48 Diagnoses in Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Eye. Glaucoma - - - - - 2 1 - 3 Cataract - - - - - 1 - - 1 Keratitis - - - - - - 3 - 3 Conjunctivitis — — — — 1 1 — - 2 9 Genito Urinary. Nephritis 5 8 5 9 — — — - 27 Pyelitis 19 10 - - - - - - 29 Prostate Enlargement — — — — 8 7 - 7 22 Urethral Stricture — — — — 4 — - - 4 Trigornitis 2 — — — — — - - 2 Contusion of Kidney - - - - - 1 — - 1 Oxaluria - - - - - 4 1 - 5 Phimosis — — — - 13 — - - 13 Paraphimosis — — — — 1 - — — 1 Pyo-nephrosis — 2 — 15 — — — — 17 Cystitis 1 8 1 1 — — — — 11 Urethritis — 2 — 1 — — — — 3 Uraemia — — — 12 — — - — 12 Suprapubic Fistula — — — — 1 — — — 1 Enuresis 2 — — — — — — — 2 Varicocele — 1 - — — 1 — — 2 Undescended Testis - - - - - 2 1 — 3 Epididymo-orchitis 3 2 — — — — — - 5 Renal Colic 1 2 — — — — — — 3 Epidymal Cyst 1 — — — 1 — — — 2 Abscess of Kidney — — — — 2 — — — 2 Urinary calculus - - - - 2 - - - 2 169 49 Diagnoses in Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Glands. Adenitis — — — — 14 7 — — 21 Thyro-toxicosis — 1 — — — — — — 1 Parotitis — — — 1 — — — — 1 Hodgkins Disease - - - - - 2 — 1 3 26 Gynaecological. Abortion — — — — 143 4 — 1 148 Ovarian Cyst — — — — 13 — — 1 14 Fibrosis Uteri — — — — 18 3 — — 21 Uterine Haemorrhage — — — — 3 2 1 — 6 Mastitis — — — — 13 — — — 13 Sterility — — — — 2 — 4 — 6 Menorrhagia — — — — — 2 1 3 — 5 Vaginitis — — — — 3 — — 4 Metrorrhagia — — — — 2 1 — — 3 Bartholins abscess — — — — 3 — — — 3 Bartholins cyst — — — — — 3 — — 3 Dysmenorrhea — — — — 4 1 — — 5 Uterine Polypus — — — — 5 — — — 5 Erosion of Cervix — — — — 4 2 — — 6 Endometritis - - - - 5 4 - - 9 Endocervicitis - - - - 2 2 - - 4 Deficient Pelvic Floor - - - - 11 - 2 - 13 Subinvolution — — — — 2 — — - 2 Pyosapynx - - - - 5 - - 1 6 Pelvic Peritonitis(abscess,etc.) - - - - 5 2 - - 7 Salpingitis — — — — 12 7 — — 19 50 Diagnoses in Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Salpingo-oophritis — — — — 2 1 — — 3 Retroversion — — — — 3 — — - 3 Trichinomosis — — — — 1 — — - 1 Uteric prolapse — — — — 6 — — - 6 Leucorrhoea — — — — 2 2 — - 4 For Sterilization — — — — 5 3 — - 8 Retained Products — — — — 10 — — - 10 337 Infections. Influenza 27 4 — 4 — — — - 35 Erysipelas — — 1 1 — — — - 2 Whooping Cough — — 6 - - - - - 6 Measles — 2 4 - - - - - 6 Mumps — 1 1 - - - - - 2 Cerebro Spinal Meningitis — — 2 1 — — — - 3 Typhoid 14 6 5 18 — — — - 43 Scarlet Fever — I 3 — — — — - 4 Ophthalmia Neonatorum. 4 - - - - - — - 4 Paratyphoid 1 — 1 — — — — — 2 Chickenpox — — 2 — — — — — 2 Diphtheria — — 1 — — — — — 1 110 Maternity. Deliveries — — — — 945 — — 7 952 Live Births — — — — 900 — — 24 924 Delivered before Admission — — — — 13 — — — 13 51 Diagnoses In Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died For Version — — — — 14 3 8 — 25 Pyelitis of Pregnancy — — — — 8 5 — — 13 Albuminuria of Pregnancy — — — — 15 10 — — 25 False Labour Pains — — — — 26 30 — — 56 Pseudocyesis — — — — 3 — — — 3 Ante Partum haemorrhage — — — — 12 — — — 12 Vesicular Mole — — — — 1 — — — 1 Ectopic gestation — — — — 5 — — — 5 H.B.P. of Pregnancy — — — — 5 12 — — 17 Vomiting of Pregnancy — — — — 20 6 — — 26 Toxaemia of Pregnancy - - - - - 4 — — 4 Ante Natal observation — — — — 18 10 6 — 34 Buried Perineal Suture — — — — 1 — — — 1 2111 Mental Certified — — 118 - - - - - 118 Uncertified 38 101 - - - - - - 139 Epilepsy — 19 2 1 — — — — 22 M.D. — 3 4 — — — — — 7 286 Nervous and Sensory. Chorea — 7 7 - - - - - 14 Cerebral Haemorrhage 2 16 5 47 — — — — 70 Nervous Debility — 2 2 - - - - - 4 Hysteria — 2 7 - - - - - 9 Sciatica 4 4 - - — — — 8 Spina Bifida — — 2 3 — — — — 5 52 Diagnoses In Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Cerebral Tumour or Abscess — 1 3 1 — — — — 5 Degeneration of Cord — 1 1 - - - - - 2 Syringo myelia — — — 1 — — — - 1 Tabo-paresis — — 2 2 — — — - 4 Subarachnoid Haemorrhage 1 1 — 2 — — — - 4 Neurasthenia 4 15 2 - - - - - 21 Paralysis Agitans — — 2 1 — — — - 3 Hemiplegia — 14 3 11 — — — — 28 Post Encephalitis — — 3 1 — — — — 4 Disseminated Sclerosis — 2 1 3 — — — — 6 Meningitis — — — 3 — — — - 3 Meningioma — — — 1 — — — — 1 Paraplegia — 2 1 2 — — — — 5 Anxiety Neurosis 2 2 - - - - - - 4 Neuralgia 2 2 - - - - - - 4 Neuritis (Peripheral, etc.) 3 2 — — — — — — 5 Loss of Memory 1 1 - - - - - — 2 Cerebral Arterio Sclerosis — 3 2 1 — — — — 6 Cerebral thrombosis — 13 5 6 — — — — 24 Intra-Cranial haemorrhage — — — 4 — — — — 4 Ketosis 1 - - - - - — — 1 Shock — 3 — — — — — — 3 Paralysis — 2 2 — — — — — 4 Cerebellar abscess - - - - - - - 2 2 256 Respiratory. Bronchitis 71 37 6 21 — — — — 135 Pneumonia 105 6 3 93 — — — — 207 Pleurisy 16 1 — — — — - 17 53 Diagnoses in Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Asthma — 21 3 3 — — — — 27 Influenzal Pneumonia — 3 — 2 — — — — 5 Empyema — — — — 3 1 1 — 5 Bronchial Cyst — — — — — 1 — — 1 Tracheitis — — — — — 1 — — 1 Emphysema — — — 1 — — — — 1 Atelectasis — — — 1 — — — — 1 Lung abscess — — — — — 1 — — 1 Congestion and Fibrosis 1 2 1 - - - - - 4 405 Senility — 42 21 33 — — — — 96 Skin. Cellulitis — — — — 6 2 1 — 9 Boils, Abscesses, Carbuncles, etc — — — — 40 12 2 1 55 Impetigo 37 2 - - - - - - 39 Eczema 12 8 - - - - - - 20 Scabies 6 - - - - - - - 6 Paronychia — — — — 3 — — — 3 Burns and Scalds — — — — 11 6 1 2 20 Septic Spots 10 1 - - - - - - 11 Dermatitis 6 7 - - - - - — 13 Seborrhoea 1 1 - - - - - - 2 Herpes 5 - - - - - - - 5 Psoriasis — 1 — — — — — — 1 Urticaria — 3 1 - - - - - 4 Sebaceous Cyst — — - — — 2 — — 2 Lipomata — — - — 1 — — 1 2 Varicose Ulceration — — - — 1 19 1 — 34 226 54 Diagnoses In Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Tuberculosis (Non Pulmonary). Glands - - - - - 2 1 1 4 Kidney - - - - - - - 1 1 Axilla - - - - - 1 - 1 Meninges - - - - - - - 6 6 Spine - - - - - - - 1 1 Hip - - - - - 1 2 — 3 16 Pulmonary — 58 7 40 — — — - 105 Pleural Effusion 1 2 1 — — — — - 4 109 Venereal. Gonorrhoea — 8 1 — — — — - 9 Syphilis — 4 1 3 — — — — 8 17 Violence. Concussion — — — — 41 11 3 — 55 Fractured Limbs — — — — 78 51 9 18 156 Minor Injuries — — — — 20 9 — 2 31 Bruising and Abrasions — — — — 12 7 2 — 21 Lacerations and Wounds — — — — 33 6 — — 39 Dislocations — — — — 8 3 — — 11 Sprains — — — — 5 2 — — 7 Crushed Shoulder - - - - - - - 1 1 55 Diagnoses in Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Fractured Malleolus — — — — 3 — — — 3 Fractured Spine — — — — 2 — — 1 3 Fractured Clavicle — — — — 3 2 — 1 6 Fractured Mandible — — — — 2 — — — 2 Fractured Maxilla — — — — — 1 — 1 Fractured Pelvis — — — — 2 1 - 1 4 Fractured Skull — — — — 5 2 - 5 12 Crushed Leg — — — — — 3 — — 3 Fractured Ribs - - - - - 2 — 1 3 Rupture of Diaphragm - - - - - - - 1 1 359 N.A.D. (with Mother, etc.) - - - - 98 - - - 98 Poisoning — — — — 6 2 — 2 10 Alcoholism — — — — 9 — — — 9 117 56 SECTION IV. PREVALENCE AND CONTROL OF INFECTIOUS DISEASE. Table I. gives the figures for ages and Wards. Scarlet Fever was more prevalent than in 1936; the largest incidence has been in Whitehorse Manor, South Norwood, West Thornton and Waddon Wards. Based on the estimated ward populations, the case rate for these wards was respectively 561, 411, 312, and 385 per 100,000 of the population. The age group 6-15 years, as usual, suffered most; cases in this group comprising 57.3 per cent. of the total. Diphtheria was also more prevalent than in 1936; most cases occurred in Broad Green (78), Waddon (53), and Whitehorse Manor (34). Once again the age group 6-15 years gives the highest figures, constituting 58.5 per cent. of the total. No cases of Small Pox occurred during the year. There were 12 cases of Puerperal Fever and 67 of Puerperal Pyrexia; 27 occurred in the age group 16-25 years and 52 in the age group 26-45 years. A majority of the cases occurred in women having their first confinement. Under the Public Health Act, 1936, Puerperal Fever is no longer notifiable as a clinical entity. All cases of rise of temperature over 100° F. occurring during the puerperium are now notifiable under the term Puerperal Pyrexia. 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 1931, the incidence was relatively constant, with a slight decline in thf number of cases in August and September. During 1932 there was a steady increase in cases until the begininng of May, when 57. the incidence fell rapidly and remained low until the beginning of a new wave in November. In 1933 the incidence remained fairly steady throughout the year. In 1934 there were two peaks of incidence, the first and smaller came in the second week in 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 continued during 1936. September and October had the lowest incidence of cases, and May the highest. Scarlet Fever showed a gradual rise throughout the year 1937, with a remission during August until November, when the incidence commenced to decline. The highest number of cases notified in a week was the week ending October 23rd, when 43 cases were notified. The average weekly number of cases was 11.7. Diphtheria.—During 1924 there was a small but steady incidence throughout the year; in 1925 a trough occurred in the curve and very few cases were notified, but towards the end of the year the notifications began to increase steadily, the curve reaching its apex in November and December, 1926; the curve then declined through 1927 until the last quarter, when the 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 incidence was low throughout the year and there were no pronounced waves of incidence. During 1936 the incidence 58 remained exceptionally low. In 1937 the incidence remained low until October, when it rose sharply, reaching a maximum the week ending November 6th with 21 cases notified. The weekly average of cases was 5. Whooping Cough.—From being inconspicuous in 1924, the curve rose gradually to a maximum in May, June and July, 1926, then fell rapidly to a minimum in November and December, then rose very gradually to a lower maximum in September, 1926; once again the curve fell abruptly to a minimum in January, 1927, rose in June and July, and fell again gradually to a minimum in November and December, then rose steadily to the highest level of the period under review in January, 1929, from when it fell steadily to the end of the year. Throughout 1930 it remained quite inconspicuous, until December, when there were indications of the commencement of a wave of increased incidence which persisted in 1931 until the end of July, after which the number of cases dropped considerably. December showed a small rise in cases. A wave of increased incidence occurred in 1932, commencing the second week in April and persisting until the end of July. Two small waves showed themselves during 1933, the first commencing early in February and persisting until the beginning of August; the second beginning in late October and continuing until the end of the year. 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. During 1937, the incidence was moderate during the first half-year, but it fell to very small dimensions during the second half. The highest number of cases in a week was 33 during the week ending February 27th. Measles was very prevalent in April and May, 1924, then dropped suddenly, but showed a small rebound during September, October and November, after when it died away until a sudden rise in May, June and July, 1925, and was followed, after a fall, by a further and more prolonged rise from October, 1925, to May, 1926. During 1927 there was verv little Measles in Croydon; a small rise in October, November and December, 59 however, heralded a very big incidence of cases—the highest during the period under review—during the first six months of 1928, Practically no cases occurred after this exacerbation, until March, 1929, but during this month, and April, May and June, 1929, a number of cases occurred from when the incidence dropped away until the end of the year. Another wave of considerable intensity commenced abruptly during the last week of February, 1930, reaching its maximum in the second week of March and dying away gradually until terminating at the end of June. During 1931, Measles was quite inconspicuous; but in 1932 there was a sharp rise in cases in the second week in April which reached a maximum in the last week in June, falling then rapidly. The beginning of another wave showed itself at the end of November and the cases were steadily increasing in number for the rest of the year. The measles waves, therefore, were as follows: the first half of 1924, the second half of 1925, and the first quarter of 1926; 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. Early in March, 1937, it became prevalent again, reaching a maximum in the middle of April; it then fell rapidly, but a second wave occurred during July. The incidence then fell and remained low until December, when a fresh wave commenced, increasing in height until the end of the year. The greatest number of cases brought to our notice was 73 in the week ending April 10th. 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 experienced during the first half of 1926, followed by a secondary in the last quarter. During 1927 and 1928 there was a fairly high and steady incidence with a peak in October and November, 1927. Another wave came during the latter half of 60 1929 with its maximum in December; this wave continued into 1930, gradually declining to a minimum at the end of July. Another wave commenced in November and continued until the end of the year. In 1931 Chicken fox 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 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. During 1937 the incidence has shown a steady rise during the year, with remissions in September and October. In November and December the number of cases rose sharply. The highest number of cases brought to our notice was 55 during the week ending November 6th. 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 verv 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 61 November, when the cases rose slightly and continued raised for the remainder of the year. Although showing no epidemic tendency, the incidence was moderately high during the first seven months of 1937, but after that until early November it fell. During November a minor peak occurred, but thereafter the incidence declined. The greatest number of cases brought to our notice was 43 during the week ending April 10th. 62 Table I. CASES OF NOTIFIED INFECTIOUS DISEASE, 1937. 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. 1937. At all Ages. At ages—years. Upper Norwood. Norbury. West Thornton. Bensham Manor. Thornton Heath. South Norwood. Woodside. East. Addiscombe. Whitehorse Manor. Broad Green. Central. Waddon. South. Addington. Under 1 year. 1—5. 6—15. 16—25. 26—45. 46—65. 66 and up. M F Small Pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cholera ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diphtheria (inc. Membranous Croup) 289 5 63 169 31 20 ... 1 9 5 23 14 23 15 3 16 6 34 78 4 53 5 1 233 15 144 145 Erysipelas 59 ... 1 ... 3 11 34 10 2 2 10 8 2 7 2 3 5 8 1 ... 6 3 ... 26 4 22 37 Scarlet Fever 776 5 229 445 37 50 9 1 30 47 71 51 61 72 36 38 30 95 59 28 70 61 27 734 3 369 407 Typhus Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Enteric Fever (including Paratyphoid) 305 ... 5 76 87 79 52 6 2 2 5 ... ... 1 ... 40 14 2 2 11 7 164 55 82‡ 35 138 167 Puerperal Fever 12 ... ... ... 4 8 ... ... 1 ... ... ... 2 ... ... ... ... 1 2 ] 3 2 ... 22 1 ... 12 Puerperal Pyrexia 67 ... ... ... 23 44 ... ... 2 ... 37 ... ... 3 1 2 ... 2 15 ... ... 5 ... 6 ... ... 67 Cerebro-Spinal Meningitis 4 2 2 ... ... ... ... ... ... ... 2 ... ... ... 1 ... ... ... 1 ... ... ... ... 7 3 1 3 Ophthalmia Neonatorum 21 21 ... ... ... ... ... ... ... ... 3 1 4 1 ... 1 ... ... 8 ... 2 1 ... 7 1 1 10 Poliomyelitis 6 1 1 2 2 ... ... ... ... 1 ... ... ... 1 ... ... ... ... 3 ... 1 ... ... 3 ... 5 1 Encephalitis Lethargica ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2 2 ... ... Dysentery 2 ... ... ... ... 1 ... 1 ... ... ... ... ... 2 ... ... ... ... ... ... ... ... ... ... ... 1 1 Malaria ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Ac. Primary and Ac. Inf. Pneumonia 73 2 14 9 9 19 14 6 8 2 11 9 1 10 2 6 ... 5 8 3 2 6 ... ... 7*† 40 33 Polio-Encephalitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... * Influenzal Pneumonia only. † Not accommodated at Borough Hospital. ‡ cases of Typhoid Fever were admitted to Mayday Hospital under the emergency arrangements in 1937. 63 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. 1937 1936 Small Pox — — — — — — — Diphtheria 1.19 0.75 3 244 20 22 289 Erysipelas 0.24 0.24 2 44 9 4 59 Scarlet Fever 3.203 2.709 24 587 116 49 776 Enteric Fever (inc. Paratyphoid) 1.26 0.066 — 104 161 40 305 Puerperal Fever 0.050 0.058 — 2 — 10 12 Puerperal Pyrexia 0.276 0.198 — 3 — 64 67 Cerebro-Spinal Meningitis 0.016 0.014 — 1 — 3 4 Ophthalmia Neonatorum 0.086 0.070 — 9 — 12 21 Poliomyelitis 0.025 0.007 — 4 — 2 6 Encephalitis Lethargica — — — — — — Acute Primary or Acute Influenzal Pneumonia 0.30 0.22 — 50 18 5 73 Dysentery 0.008 — — 2 — — 2 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.% 64 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 1927 717 338 3 .4 686 3 .4 1928 552 259 4 .7 574 8 1.3 1929 759 335 4 .54 714 3 0.42 1930 681 306 2 .29 679 2 0.29 1931 527 225 3 .57 528 2 0.38 1932 441 186 1† .23 38 1 0.26 1933 633 264 ... ... 599 1 0.17 1934 1003 416 3 .29 968 5 0.51 1935 775 320 ... ... 755 1 0.13 1936 655 271 2 0.31 631 2 0.32 1937 776 320 2 0.26 799 2 0.25 * Cases admitted to the Borough Hospital from Penge are included in arriving at the figures in Cols. 6 to 8. † Death not due to Scarlet Fever. There was an increase in the number of cases notified and admitted to Hospital in 1937 as compared with 1936. The type was mild and the case mortality was 0.26. The attack rate (Col. 3) for England and Wales was 233. Croydon shows a higher figure. 65 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 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 1938 183 76 8 4.4 282 6 2.1 1937 289 119 15 5.2 375 13 3.47 * Cases from Penge are included in Cols. 6 to 8. The incidence of Diphtheria showed an increase in 1937, and the mortality was 5.2 per cent. The type of the disease was moderately severe. Ninety-nine 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 149. Croydon's rate was therefore lower than for the whole country. 66 DIPHTHERIA IMMUNIZATION CLINIC The Clinic for Immunization against Diphtheria was commenced in Croydon in 1934, and a detailed account of the working of the Clinic is contained in the 1935 and 1936 Reports. Although there has been no departure in 1937 from the method and routine that have proved themselves successful in previous years, a brief recapitulation of the procedure adopted may not be out of place. Sessions were held at the Lodge Road and Selhurst Road Clinics once weekly. At the former centre, owing to an increase in the numbers on the waiting list, it was necessary, in the early part of the year, and again in the later part, to hold an additional session, and additional sessions were also held in two schools, namely, Winterbourne Junior and Kingsley, where the numbers desiring Immunization justified the holding of a special session in the schools themselves. Parents accompanying their children are told of the purpose of the injections, and any information they may desire is given. When a child has completed the course and has been found to be immune by means of a posterior Schick Test, the mother is told that, although the child is unlikely to contract diphtheria, and in the event of this happening, still more unlikely to experience a severe form of the disease, the possibilities cannot be absolutely precluded. She is further advised that, as the immunity may be gradually reduced or lost, it is a wise precaution to have the child re-tested at intervals of two or three years. As a general rule children of 5 years or over have been submitted to a Schick Test to determine their state of immunity. Children under 5 years are given their first injection of T.A.M. without a preliminary test, as a higher proportion of children under 5 years are found to be susceptible to diphtheria. This is not a hard and fast rule, and if the mother specially requests, or if there are exceptional circumstances, as in the case of a large family, a preliminary or Anterior Schick Test is carried out. The Immunizing agent employed has again been Toxoidantitoxin mixture (T.A.M.) or Toxin-antitoxin floccules (T.A.F.) 1 c.c. given on three occasions with a fortnightly interval. Not less than three months after the date of the last injection, a reSchick or posterior Schick Test is performed. 67 Statistics of the Year's Work. On the 1st January, 1937, 608 cases were under treatment at the Clinic. Of these, 562 completed a course of T.A.M. and 41 of T.A.F., while 5 defaulted, so that 603 of the cases carried over from 1936 completed their treatment and had a posterior Schick Test performed. In 1937, 1,286 new cases attended, 1,017 being given a Primary or Anterior Schick Test, while 269 younger children under 5 years commenced their course with no primary test. The new cases in 1937 were derived from the following sources— Definite School cases 928 Definite Infant Welfare Centre cases 155 Others under 5 years 198 Nursery School 5 1,286 Of the 1,017 which were submitted to a Primary Schick Test 877 were found to be positive, giving a percentage of 86%; while 140 were negative, a percentage of 14%. A more detailed table giving the result of Schick Tests at ages is appended. 574 of the new 1937 cases completed a course of T.A.M. and 45 a course of T.A.F., making a total of 619 completed cases. Cases are not considered completed, even though they had received three injections, if they had not been proved negative by a re-test. 511 cases were unfinished on December 31st, 1937, including 41 cases that had received A.P.T. and were awaiting a re-test. 16 cases defaulted or left the district. 31 teachers who commenced an immunizing course have not been included in the above figures. The 603 cases carried over from 1936, together with the 619 1937 cases, give 1,222, which is the total number of cases that completed an immunizing course with a posterior Schick Test, in 1937. The total number of cases that attended for testing or treatment, whether completed or not, and not counting; defaulters, was 1,894. 68 As stated above, 1,222 cases completed their treatment and were re-Schicked three months later. One of the cases on which T.A.F. was used was still positive after three injections, which gives a percentage Schick negative rate for T.A.F. of 99.9%. Six of the cases given T.A.M. were positive, which gives a Schick negative conversion rate for T.A.M. of 99.5%. The case that had had T.A.F. was given a further injection, and on re-test three months later was negative. Five of the cases that had received T.A.M. were given a further injection, and on re-test in three months were all negative. One of these was a 1936 case. The sixth case was one which was positive after the ordinary course of T.A.M. Another injection of T.A.M. was given, and the reaction was still positive. A further injection of T.A.M. was given, and the Schick Test still revealed a faint positive reaction. The child is now having a further course of three injections of T.A.M. It may be that this child belongs to the class that has been called "non-antitoxin producers." This name has been given to the small number of cases in which it is found very difficult to produce an acquired immunity to diphtheria as tested by the Schick Reaction. The following figures give some further details of attendances at the Clinics:— Total attendances throughout the year 7,104 Total number of sessions held 122 Highest attendances at any one session 124 Lowest attendances at any one session 11 Average attendances per session 58.2 Reactions During Treatment. No serious reactions were recorded during the year. The following, however, is a resumé of those that did occur:— Local Reactions to T.A.M. 3 slight reactions following the 1st injection. No ability except slight discomfort. 4 slight reactions following 2nd injection. 4 „ „ ,, 3rd ,, None of these suffered any disability. 69 2 marked reactions followed the 1st injection. Redness and some swelling appeared at the site of the injection, with some pain in the arm lasting for a few days, when it subsided satisfactorily. Focal Reaction.— None reported. General Reactions.— One case complained of sore throat and spots on the body following the 3rd injection of T.A.M. They caused no discomfort and disappeared in a day. Local and General Reaction.— One case experienced a sharp local reaction with slight temperature, malaise and headache coming on on the second day. No subsequent trouble. This occurred after the 1st injection of T.A.M. One case had a slight general reaction as shown by malaise after the 2nd injection. A second case after the 2nd injection experienced a sharp local reaction with a slight malaise and headache. Total number of Reactions to T.A.M. 17 „ „ „ T.A.F. 0 The Schick Test. One child suffered from a very severe local reaction and complained of sore throat four days after a Primary Schick Test. No other abnormal reactions were recorded. Pseudo-Reactions.— As cases are seen one week after the injections, many of the pseudo-reactions are not seen, as in 7 days' time the pseudo-reaction has disappeared. Accordingly, only 3 pseudo-reactions were recorded, all in cases who had been reSchicked after completing their course of injections. They were of a transitory nature and caused no discomfort. Diphtheria.— Previous, Intercurrent and Subsequent. Previous.—18 cases gave a history of having had diphtheria. Of these 14 were Schick positive and 4 Schick negative. The 4 Schick positive were immunized, 2 with T.A.M. and 2 with T.A.F., and all were negatived on re-Schick. Two cases gave histories of having been carriers, and both were Schick negative. 70 Intercurrent.— One case developed a moderately severe attack of diphtheria one week after the 2nd injection of T.A.M. It gave negative reaction on re-test. Two other cases developed mild diphtheria, both starting one week after the 3rd injection of T.A.M. Both were Schick negative on re-test later. Acquired immunity to diphtheria does not attain a level sufficiently high to give protection against the disease, until three or four months have elapsed after the last injection. A child cannot, therefore, be regarded as immune during this period. Subsequent.— Only 3 cases have come to notice of diphtheria in children who have undergone an immunizing course at the Clinic. All were treated in the Borough Hospital. One was a mild case of Faucial Diphtheria and another a mild case of Nasal Diphtheria. Neither had any marked clinical symptoms, but swabs taken were positive. The third case was a moderately severe case with membrane on both tonsils, some general toxæmia and fœtor. She was given 40,000 units A.D.S. on admission, and this was repeated the following day. The parents of children who have had their children immunized against diphtheria, at perhaps some inconvenience to themselves, are not unnaturally somewhat annoyed if their children subsequently develop diphtheria. The susceptibility of a person to diphtheria depends in the main on two factors, (1) the individual degree or level of immunity to the disease, (2) the type of diphtheria organism whether of low or high virulence. If a person's level of immunity is very low an organism of low virulence may cause clinical symptoms. A person with an intermediate level of immunity might be protected against a bacillus of low virulence, but might succumb to one of high virulence, the return of the disease probably being mild or moderately severe. A high level of immunity should give protection against germs of high virulence. Immunization with the prophylactics at present in use does give a high level of immunity. It is known, however, that this level may not be maintained indefinitely, hence the importance of having a repeat Schick Test carried out two or three years after concluding the course. If, then, a child who has been immunized, but whose level of immunity has been reduced to the 71 intermediate level, becomes infected with an organism of high virulence, he might succumb to a mild or moderately severe attack of diphtheria. Such an event disturbs the parents not a little. They may, however, take comfort from the fact that, had their child not been treated at the Clinic, the attack of diphtheria would have been much more severe and possibly fatal. Summary of Results of 1,017 Primary (Anterior) Schick Tests. Age Group. Positive. % Positive. Negative. % Negative. Total. Under 5 years 119 83 25 17 144 Over 5 under 6 169 91 17 9 186 „ 6 „ 7 107 92 9 8 116 „ 7 „ 8 109 84 20 16 129 „ 8 „ 9 95 87 14 13 109 „ 9 all ages 278 83 55 17 333 Total 877 86 140 14 1,017 Summary of Attendances and Treatment, 1937. Under treatment 1/1/37. Received T.A.M. Received T.A.F. Defaulted. Given Primary Schick Test 1937. No. Pos. % Pos. No. not given Primary Schick. Total new cases 1937. 608 562 41 5 1017 877 86 269 1286 No. 1937 cases completed treatment. Received T.A.M. Received T.A.F. No. given Posterior Schick. No. negative on Post. Schick. % negative on Post. Schick. Total cases attended 1937. Under treatment 31/12/37 Defaulted or left district. 619 574 45 1222 1215 99.4 1894 511 16 72 The following Tables give, in summary form, the work done from the commencement of the Clinic. Year. Total attended for treatment. New cases attended. No. of sessions held. Av. attend per session. No. given Primary Schick. % Pos. on Primary Schick. No. given Posterior Schick. No. Neg. on Posterior Schick. % Neg. on Posterior Schick. No.completed treatm't Schick neg.. 1934 509 509 ... 36 389 ... 185 ... ... 185 1935 1431 1151 97 58 634 76 781 766 98.8 781 1936 2285 1661 145 61 1215 78 1264 1254 99.2 1264 1937 1894 1286 122 58.2 1017 86 1222 1215 99.5 1222 The number of children immunized so far is much too small to have any effect upon the incidence of Diphtheria in Croydon as a whole. It has been calculated that at least 60 per cent. of the population at risk should be immunised to exert an observable influence upon diphtheria incidence. No active propaganda has been undertaken. The facilities have been brought to parents' notice at the Schools and Infant Welfare Centres by means of leaflets and talks. No attempt has been made to try and persuade parents. The facts have been put before them and they have been left to make their own decisions. The attitude has been that the service is available and any child can be immunised if the parents desire it. The following Table gives the numbers of children who have been referred for immunisation and the source of the reference:- Year. School. Inft. Welfare C. Nursery School. Others under 5 yrs. Total. Percent. Total. Percent. Total. Percent. Total. Percent. 1934 339 67 ... ... ... ... 170 33 1935 944 66.6 265 18.7 10 0.7 198 14.0 1936 1620 74.8 310 14.3 5 0.2 232 10.7 1937 (new cases only) 928 72.2 155 12.0 5 0.4 198 15.4 73 The great majority of children were referred from the Public Elementary Schools and consequently were over 5 years of age. The pre-school group of children are, however, an important group, but, for various reasons, parents are more reluctant to avail themselves of immunisation for their children coming within this group, a fact which is well brought out by the subjoined Table:— Age Group. 1935. 1936. 1937. Total cases tested. Percent. Positive. Total cases tested. Percent. Positive. Total cases tested. Percent. Positive. Under 5 years 48 96 49 94 144 83 Over 5 years, under 6 years 100 87 160 88 186 91 „ 6 „ „ 7 „ 80 85 144 90 116 92 „ 7 „ „ 8 „ 90 86 167 85 129 84 „ 8 „ „ 9 „ 88 83 171 83 109 87 Over 9 228 65 524 66 333 83 Totals 634 76 1215 78 1017 86 The influence of Head Teachers, and of the occurrence of cases of diphtheria in a school are factors in immunisation figures. The following Table shows these figures up to the end of the year, for the schools in the Borough:— 74 Distribution of School Children who have attended the Immunisation Clinic since its Inauguration. School. Completed treatment or Schick negative in: New cases attended clinic in 1937. Total Schick negative to end of 1937. Population of School. 1934. 1935. 1936. 1937. Ashburton 4 8 28 105 99 145 725 Benson 1 5 1 ... 4 7 413 Beulah 10 28 21 26 29 85 1137 British 2 1 1 ... ... 4 181 Davidson 1 7 8 4 8 20 675 Duppas ... 14 7 9 21 30 596 St. George's ... 2 ... 6 5 8 85 Ecclesbourne ... 9 15 17 15 41 870 Elmwood 2 5 8 24 14 39 1080 Gonville 8 41 25 27 34 101 424 Howard ... 1 6 8 7 15 291 Ingram 8 14 18 16 14 56 701 Kensington 1 13 42 109 51 165 364 Kingsley 14 52 32 30 96 128 1537 Lanfranc 2 9 3 2 2 16 468 Norbury Manor 2 14 31 66 59 113 1174 Oval 2 23 21 15 18 61 698 Portland ... 10 53 23 9 86 779 Purley Oaks 2 3 ... 29 20 34 491 Rockmount 1 5 49 11 1 66 468 South Norwood 3 10 39 15 13 67 732 Suffolk Rd. (Cypress) 1 3 3 2 8 9 281 Sydenham 1 2 10 4 1 17 655 Tavistock ... 3 12 9 5 24 730 Waddon 12 26 16 11 19 65 1123 West Thornton 3 33 20 16 11 72 806 Whitehorse Manor 1 5 6 6 13 18 716 Winterbourne 1 45 285 116 155 447 1054 Woodside 10 15 72 26 21 123 958 St. Christopher's 1 2 2 ... ... 5 112 76 School. Completed treatment or Schick negative in: New cases attended clinic in 1937. Total Schick negative to end of 1937. Population of School. 1934. 1935. 1936. 1937. St. Luke's ... ... ... ... ... ... 118 St. Giles' 1 ... 1 2 4 4 73 All Saints 53 33 38 28 14 152 344 Tenisons 1 2 2 2 2 7 366 Christ Church 2 15 6 6 5 29 421 Holy Trinity ... 4 6 9 5 19 251 Parish Church 3 18 7 8 10 36 533 St. Andrew's 1 5 4 3 3 13 416 St. Joseph's ... ... 1 2 ... 3 232 St. Mark's 1 4 7 6 3 18 163 Addington ... ... ... ... ... ... 95 St. Mary's 3 8 2 1 ... 14 375 St. Peter's ... 3 1 4 ... 8 124 St. Saviour's ... 4 4 9 8 17 275 Shirley ... 2 2 ... ... 4 194 Monk's Orchard ... ... ... 9 7 9 229 John Ruskin ... ... 4 5 3 9 398 Lady Edridge 1 3 4 1 1 9 342 Heath Clark ... 6 7 35 32 48 427 St. Michael's ... ... 3 6 5 9 216 Selhurst Grammar 4 3 7 10 12 24 929 Croydon High ... 8 1 3 4 12 714 Coloma ... 5 6 2 1 13 446 Old Palace 9 3 2 4 3 18 383 Whitgift ... 2 5 ... ... 7 ... Polytechnic 1 ... 2 1 ... 4 ... Private 6 17 20 21 20 64 ... Unknown 4 33 3 7 25 47 ... 76 IMMUNISATION AT RESIDENTIAL SCHOOLS AND HOMES. The Routine treatment started in October, 1936, of giving two doses A.P.T. 0.1 c.c. followed by 0.5 c.c. has been continued with the slight modification, as the result of further experience, of allowing an interval of two weeks instead of one week between the two doses of A.P.T. This method seems very satisfactory and has the advantage of necessitating one dose less than T.A.M., with consequent saving of time and expense. No reactions were reported. The table on page 72 gives a detailed analysis of immunization done at the various schools and homes. It is almost inevitable, when dealing with large numbers of children in Residential Schools and Homes, to find that some are removed out of the Borough before treatment is completed. These changes of address have been noted and the Medical Officer of Health of the district concerned has been informed. During the autumn most of the children undergoing treatment at the Public Assistance Committee's Queen's Road Homes were transferred to the Public Assistance Committee's London Road Homes, where treatment was continued and recorded in the table below, under the latter Home:— Name of Institution. No. not completed, 1936. No. Primary Schick. No. Positive. % Positive. No. given A.P.T. No. retested. No. Negative. % Negative. Uncompleted. Removed from District. Fidelis Convent, Central Hill 2 25 22 88.0 22 17 16 94.1 7 1 Infirmary Convent, Central Hill 9 55 28 50.9 28 23 23 100.0 9 5 Russell School 26 21 18 85.7 18 38 38 100.0 6 - Boys' Home, Beulah Hill 2 15 8 53.3 7 7 7 100.0 3 - St. Jude's Home, Dagnall Park 2 15 7 46.7 7 5 5 100.0 2 2 P.A.C., Queen's Road 2 7 7 100.0 7 4 4 100.0 4 1 P.A.C., 386, London Road 27 49 37 75.5 35 35 35 100.0 17 12 70 187 127 67.9 124 129 128 99.2 48 21 77 BOROUGH HOSPITAL. Table V. gives a summary of all cases treated at the Hospital during 1937. 1,493 patients were admitted, and discharged, which, together with patients in at the commencement of 1937 (90), gives a total of 1,583 cases dealt with. Forty-one died, giving a case mortality for the Hospital of 2.02 per cent., an increase of .06 per cent. on 1936. The average number of days of each patient in Hospital for all classes of patient was 22.1 as against 24.7 in 1936. Penge Urban District Council has an arrangement with the Corporation to send their cases to the Hospital. During 1937 a total of 88 cases was admitted; these are included in the Table. The Hospital is a recognised training school for fever nurses. During the year 5 probationers passed the preliminary examination and 7 the final examination. The accommodation of the Hospital remained as in 1936, and all the Wards, including the emergency ones, were kept open. The new Nurses' Home—providing 22 additional bedrooms, a large recreation room, a doctor's sitting room and a doctor's dining room—is now in use. During the year 3 cases were operated on for tonsils and adenoids and 4 for acute mastoiditis. 3 laparotomies were performed, and 22 cases had glycerine uterine drainage. 78 Table V. Complaint for which admitted. Patients remaining in Hospital on 1st January, 1937. Patients admitted and discharged in 1937. Patients admitted during 1937 and remaining in Hospital on 1st January, 1938 Analysis of all Cases admitted in 1937, 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 49 49 ... 728 726 2 71 70 1 799 797 2 0.2 36 Diphtheria 31 31 ... 297 284 13 78 77 1 375 362 13 3.5 36 Enteric Fever ... ... ... 25 15 10 39 36 3 64 54 10 15.6 36.9 Para Typhoid b. ... ... ... 7 6 1 3 3 ... 10 9 1 10.0 33.2 Puerperal Pyrexia ... ... ... 6 6 ... ... ... ... 6 6 ... ... 14 Puerperal Fever ... ... ... 22 20 2 ... ... ... 22 20 2 9.1 21.6 Erysipelas ... ... ... 27 26 1 ... ... ... 27 26 1 3.7 14.7 Measles ... ... ... 53 49 4 1 1 ... 54 50 4 7.4 22 Rubella 1 1 ... 3 3 ... ... ... ... 3 3 ... ... 12 C.S.M. 1 1 ... 7 2 5 ... ... ... 7 2 5 71.4 17.4 Whooping Cough 4 4 ... 21 18 3 1 1 ... 22 19 3 13.6 35 Chicken Pox 2 2 ... 34 34 ... ... ... ... 34 34 ... ... 20.3 Ophthalmia ... ... ... 6 6 ... 1 1 ... 7 7 ... ... 26.4 Mumps 1 1 ... 10 10 ... ... 2 ... 12 12 ... ... 18.2 Tonsillitis ... ... ... 1 1 ... ... ... ... 1 1 ... ... 9 Anterior-poliomyelitis ... ... ... 3 3 ... ... ... ... 3 3 ... ... 30.6 Encephalitis Lethargica ... ... ... 2 1 1 ... ... ... 2 1 ... 50.0 11 Pemphigus ... ... ... 4 4 ... ... ... ... 4 4 ... ... 13 Dermatitis ... ... ... 3 3 ... ... ... ... 3 3 ... ... 26.5 Acute Laryngitis ... ... ... ... ... ... 1 1 ... 1 1 ... ... 23 Influenza ... ... ... 2 2 ... ... ... ... 2 2 ... ... 8.5 Bullous Impetigo 1 1 ... ... ... ... ... ... ... ... ... ... ... ... No Disease ... ... ... 35 35 ... ... ... ... 35 35 ... ... ... Totals 90 90 ... 1296 1254 42 197 192 5 1493 1451 42 ... ... 79 SCARLET FEVER. The total number of scarlet fever cases admitted during the year was 799, an increase of 168 on 1936. 734 cases were admitted from the Borough and 65 from Penge. The type of disease during the year was generally mild, but otorrhoea was a frequent complication. 17 cases sent in as scarlet fever were not suffering from that disease. The following complications and sequela; occurred amongst the true Scarlet Fever cases :— Table VI. Total cases Serum Cases. NonSerum Cases. Total. 195 587 782 Adenitis 20 44 64 Otorrhoea 12 32 44 Rhinorrhoea 15 35 50 Albuminuria 3 4 7 Nephritis 2 2 4 Rheumatism 5 2 7 Relapses 2 3 5 Secondary Sore Throat 2 3 5 Abscesses and Boils 4 4 8 Mastoid 2 3 5 The average stay in hospital of serum cases was 37 and of non-serum cases 35.7 days. Two deaths occurred amongst the Scarlet Fever cases, one being a toxic case, the other complicated by broncho-pneumonia. the number of complications amongst the 587 non-serum cases was 132(22%), whereas the complications amongst the serum cases was 67(33%). Prontosil Album was also tried in 41 cases and the results Were favourable. One case showed meth hæmoglobinaemia, but recovered quickly with appropriate treatment. 80 Ages and Sexes of Scarlet Fever Cases Admitted. Table VII. Age. Males. Females. Totals. Percentage. 0—1 4 3 7 0.88 1—2 14 20 34 4.26 2—3 28 26 54 6.76 3—4 26 35 61 7.63 4—5 48 54 102 12.77 5—10 175 170 345 43.18 10—15 35 60 95 11.88 15-20 14 14 28 3.50 20—30 14 24 38 4.76 30 or over 8 27 35 4.38 Total 1937 366 433 799 Total 1936 299 332 631 Monthly Admissions of Scarlet Fever Patients. Table VIII. Cases admitted. Cases notified. 1936. 1937. 1937. January 68 28 31 February 46 40 33 March 75 49 56 April 63 79 72 May 78 60 65 June 52 91 77 July 40 107 89 August 36 29 25 September 26 60 76 October 57 131 118 November 53 75 84 December 37 50 50 Total 631 799 776 81 DIPHTHERIA. 375 cases were admitted with a diagnosis of Diphtheria, an increase of 91 cases on 1936. Of these, 22 were found not to be cases of Diphtheria and 99 were cases of positive swab without clinical symptoms, leaving 254 cases of true clinical Diphtheria. Analysis of the 254 cases :— Faucial Diphtheria 213 Nasal Diphtheria 19 Laryngeal Diphtheria 6 Faucial and Nasal Diphtheria 10 Faucial and Laryngeal Diphtheria 6 Total 254 Of the laryngeal cases, tracheotomy was necessary in 4 cases and two recovered. The following complications and sequelae occurred amongst the Diphtheria cases :— Otorrhoea 6 Rhinorrhoea 5 Adenitis 10 Heart Failure 20 Secondary Throat 4 Paralysis— Palatal Paralysis 16 Eyes 6 Facial 1 Diaphragm 2 One of the two cases who developed diaphragmatic paralysis, and was a severe case of diphtheria with palatal and eye paralysis, developed in addition intercostal paralysis in the 'th week. The intercostal and diaphragmatic paralysis was treated by a Bragg-Paul pulsator. The apparatus was continued intermittently for three consecutive days and nights, after which period there was a gradual recovery of the paralysed muscles. This apparatus undoubtedly saved the child's life by keeping up the respiratory movements, which had practically ceased. The other case of paralysis of the diaphragm, which developed rapidly in the 5th week, and was treated with constan nasal oxygen inhalations, proved fatal. 82 Ages and Sexes of Diphtheria Cases Admitted. Table IX. Age. Males. Females. Totals. Percentage. 0—1 5 3 8 2.13 1—2 8 8 16 4.26 2—3 12 9 21 5.60 3—4 15 4 19 5.06 4—5 13 16 29 7.73 5—10 74 85 159 42.40 10—15 29 31 60 16.00 15—20 6 22 28 7.46 20—30 2 19 21 5.60 30 or over 7 7 14 3.73 Total 1937 171 204 375 — Total 1936 120 162 282 — Monthly Admission of Diphtheria Patients. Table X. Cases notified. Clinical cases only. Cases admitted. Month. 1937. 1936. January 29 38 24 February 17 30 29 March 21 30 35 April 5 13 16 May 12 16 25 June 8 10 10 July 19 28 26 August 6 15 8 September 19 27 19 October 74 81 37 November 49 51 34 December 30 38 19 Totals 289 375 282 The average number of days in Hospital for Diphtheria cases was 36. The late administration of serum does not exert much influence on the course of the disease. Diphtheria toxin becomes fixed in the tissues, and when once fixed, anti-toxin has no effect in counteracting its poisonous effect. 83 Intra-venous and intra-muscular injections were given in doses between 24,000 and 100,000 units. The combined use of intra-muscular with intra-venous injections 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 per cent. sterile glucose solution, combined with glucose in large quantities orally, appeared 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. of camphor in oil. For toxic cases with marked cardiac weakness, adrenalin chloride 1/1000 solution subcutaneously in doses of 5 c.c. to 1 c.c. was also beneficial. Particulars of Fatal Cases of Diphtheria. Table XI. Table XI. Same. Age on Admission. Condition on Admission. Subsequent Progress. Time °f Death after admission. F.S. (M) 4 3/12 Moribund, extreme cyanosis, sloughing membpaine over whole pharynx, glands of neck ††† , foetor, toxaemia. Did not respond to treatment, dying in coma soon after admission, from rapid heart failure. 1 ¾hre. D.W. (M) 2 4/12 Collapsed, v. toxic. Extensive membrane over whole pharynx, bull - neck, rhinorrhoea, foetor. Did not respond to treatment, increasing heart failure, became unconscious', dying the same day. 10 hrs. DJ. (F) 10/12 Exudate on both tonsils, profure rhinorrhoea. Showed signs of heart failure 1 week after admission, with persistent vomiting anc! "gallop" rhythm, grew steadily worse, child collapsed on 11th day. 11 days. G.C. (M) 7 Membrane over both tonsils with enlargement of neck glands. Heart became irregular on 5th day after admission and signs of heart failure increased. The child collapsed on the 11th day. 11 days. 84 Name. Age on Admission. Condition on Admission. Subsequent Progress. Time °f Death after admission. A.G. (M) 7 11/12 Extensive sloughing membrane over whole pharynx, rhinorrhoea, bull-neck. Started showing signs of heart failure with persistent vomiting 5 days after admission, and this persisted. The child collapsed on the 12th day. 12 days. J.D. (F) 6 Extensive membrane over whole pharynx, foetor, bull - neck, cyanosis, heart sounds rapid and weak, toxaemia. The signs' of heart failure present on admission persisted, and child died from this, collapsing 4 days later. 4 days. D.C. (M) 4 Extensive membrane over whole pharynx, glands of neck †† v. toxic. Showed signs of laryn. geal obstruction on morning after admission with marked recession and restlessness ; tracheotomy performed with relief, but progressive heart failure with vomiting ensued, the child collapsing 5 hours later. 2 days. L.H. (M) 3 11/12 Membrane over both tonsils, glands of neck ++, rhinorrhoea +† The throat condition cleared up 6 days after admission. Developed palatal pariesis 29 days after admission, which was soon followed by intercostal paralysis and paralysis of diaphragm, which caused death. 38 days. J.D. (F) 10 Extensive membrane over both tonsils, bull-neck, rhinorrhoea, marked cyanosis, toxaemia + + Condition grew steadily worse, with much bleeding from mouth and nose, and rash on trunk. Child died from toxaemia & hæmorrhage on 3rd day. 3 days. 85 Name. Age on Admission. Condition on Admission. Subsequent Progress. Time of Death after admission. V.M. (F) 11 Membrane over both tonsils, also in nostrils, profuse rhinorrhcea, bull-neck. Had attacks of persistent epistaxis for several days after admission, started shewing signs of heart failure 12 days later with vomiting, and this caused death on 16th day. 16 days. W.A. (M) 8 Extensive membrane over whole pharynx, glands of neck ++, marked cyanosis. Shewed sign? of laryngeal obstruction on following day with marked recession. Tracheotomy performed with relief, but pulse rate persisted very rapid and weak. Collapsed suddenly on 9th day (heart failure). 9 days. C.A. (F) 68 Semi-conscious on admission, marked emphysema with very weak heart sounds. Deposit on both ton sils. Double incontinence. Condition grew steadily worse and patient died next day. 2 days. C.I. (M) 4 Sloughing membrane over both tonsils, bull-neck, rhinorrhoea. Developed palatal paresis 23 days after admission, which was severe, and this was followed by increasing heart failure, the child collapsing on the 45th day. 45 days. None of these cases had had serum administered before admission. 86 Administration of Anti-typhoid Serum (Felix). A supply of serum was obtained from the Lister Institute, through the kindness of Dr. Felix, who also gave full directions as to its use. The serum was given in doses of 33 c.c. on three consecutive days, and 17 patients received the full course. Of these 12 recovered and 5 died. Case. Day when adminstn. commenced. Immediate Reaction. t. 1. D.G. 8th day Rigors and vomiting about 2 hours after each injection with rise of temperature. Temperature came down for 3 days after injections. Died from heart failure on 2411-37. 2. J.T. 28 yrs. (M.) 24th day Nil except profuse perspiration after injection ; no rise of temperature. No effect. Died 10 days after last injection. 3. J.B. 14 yrs. (M.) 24th day Vomited after first injection and T. 103° rigor and T.1030 after second. Good effect, nervous symptoms, delirium and restlessness improved steadily. 4. A.W. 31 yrs. (M.) 3rd day Shivering and temperature 103.2° after 2nd injection. No effect. 5. K.H. 10 yrs. (M.) 7th day Temperature 104° after 2nd injection and 103.8° after 3rd ininjection. No effect. 6. M.I. 24 yrs. (M.) 11th day Rise of temperature 103° after first injection, rigor and T. 104° after 2nd. Good effect, temperature came down to normal 6 days after last injection. 7. H.R. 10 yrs. (M.) 4th day Nil; temperature keeping high constantly. No effect. Died from toxemia and meteorism 6 days after last injection. 8. P.H. 12 yrs. (M.) 5th day Nil. Improved, toxemia steadily diminished. 9. L.P. 31 yrs. (F.) 9th day Temperature 103.° after 3rd injection. No effect. 10. A.G 33 vrs. (M.) 6th day Shivering with rise of temperature after each injection. No effect. 87 Case. Day when adminstn. commenced. Immediate Reaction. Result. 1. I.S. 33 yrs. (F.) 10th day Temperature 104° only after 1st injection. No effect. Died from perforation and hæmorrhage (operated on). 2. M.B. 10th day Temperature 103.6° after 1st injection, and 102° after 3rd. No effect. 3. M.B. 20 yrs. (F.) 19th day Temperature 103.8° & slight rigor after 1st injection ; 103.2° after 3rd. No effect. 14. E.B. 46 yrs. (F.) 11th day Nil. No effect. 5. J.J. 23 yrs. (F.) 7th day Nil. No effect. 16. I.F. 16 yrs. (F) 20th day Perspired profusely after 1st and 3rd injection. No effect. Died from perforation and hypostatic pneumonia following operation. 17. K.P. 24 yrs. (F.) 8th day Vomited and had rises of temperature after each injection to 102.8°—102.6°. Improved toxemia and temperature came down. No effect 12 cases. Good effect 4 „ Temporary improvement 1 case. (D.G.) - Total 17 cases. Typhoid and Para-typhoid Cases. During the year 67 cases of Typhoid Fever or Paratyphoid Fever were admitted, and in 63 the diagnosis was confirmed; the other four cases were as follows :— 2 were really cases of simple enteritis; 1 was a case of gastritis; 1 was a case of tubercular meningitis. 88 An outbreak of Typhoid Fever occurred in Croydon during November and December. The disease was a severe type, marked by profound toxaemia, high fever, and dangerous complications. The following complications occurred amongst the Typhoid cases:— Hæmorrhage 6 Perforation 3 Thrombosis of Femoral Vein 1 Bronchitis 1 Pneumonia 1 Heart Failure and Toxæmia 5 Delusions and Mania 1 Parotitis 1 Hyperpyrexia 3 Relapse 2 24 There were 10 fatal cases of Typhoid Fever. Three of the Typhoid cases were operated on for perforation of the intestine; all had previously had intestinal hæmorrhage. One case made an uninterrupted recovery, whilst the other two proved fatal, one having developed hypostatic pneumonia after operation. The other case succumbed to the profound toxaemia. Two cases had severe rectal haemorrhage and died from this complication. Three cases died from severe toxaemia and heart failure. One case was complicated by old valvular disease of the heart and one had severe toxaemia with persistent hyperpyrexia. There were 10 cases of Para-typhoid Fever B admitted, and one died, being complicated by pneumonia. 89 Puerperal Fever. Twenty-two cases were admitted with a diagnosis of Puerperal Fever and six with a diagnosis of Puerperal Pyrexia. Of the 22 cases of Puerperal Fever, in 10 the diagnosis was confirmed, the other 12 cases being as follows :— Sent in as Puerperal Fever but really Influenza 4 Sent in as Puerperal Fever but retained chorion 8 The cases of Puerperal Fever were of average severity and two deaths occurred amongst them, one being complicated by peritonitis, the other by myocardial failure. Protosil album was tried in 25 cases of Puerperal Fever, and in some it appeared to have a beneficial effect. Erysipelas. There were 27 cases of Erysipelas admitted, two less than in 1936. The disease was of average severity, one death occurring, which was complicated by senility. The cases were admitted either from private houses or hospitals. Measles. There were 54 cases of measles admitted, a decrease of 47 on 1936. The disease was fairly severe, and often complicated by broncho-pneumonia. There were 4 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 22 cases of Whooping Cough admitted, a decrease of 38 cases on 1936. There were 3 deaths. Cerebro-Spinal Meningitis. Seven cases were admitted. In 3 the diagnosis was confirmed. The diagnosis in the other 4 cases was as follows :— 1 was really a case of influenzal meningitis. 1 was really a case of encephalitis lethargica. 2 were really cases of tubercular meningitis. 90 Ophthalmia Neonatorum. Seven cases were admitted; in 2 the diagnosis was confirmed. The other 5 were cases of simple ophthalmia. All recovered without damage to eyesight. Infantile Paralysis (Poliomyelitis). Three cases were admitted. In 2 the diagnosis was confirmed. The other was a case of abscess in the thigh in an infant. Encephalitis Lethargica (Sleepy Sickness). Two cases were admitted. In one the diagnosis was confirmed; the other was a case of streptococcal meningitis. Pemphigus Neonatorum. Four cases were admitted, and in one the diagnosis was confirmed; the other three were cases of simple dermatitis. 16 Table XII. Other Diseases. Age Group Disease 0-1 1—2 2—5 5—15 15—25 25—35 35—45 45 & over Totals Deaths m F m F m F M F M 1 F M F M F M F Enteric Fever ... ... ... ... ... ... 6 2 8 13 5 13 3 ... 3 11 64 10 Para-typhoid B ... ... ... ... ... ... 1 1 1 5 ... ... 1 ... ... 1 10 1 Puerperal Fever ... ... ... ... ... ... ... ... ... 7 ... 14 ... 1 ... ... 22 2 Puerperal Pyrexia ... ... ... ... ... ... ... ... ... 2 ... 3 ... 1 ... ... 6 Erysipelas ... ... ... ... ... ... ... ... ... 2 ... 2 ... 3 8 12 27 1 Measles 5 2 7 ... 18 10 5 5 ... 2 ... ... ... ... ... ... 54 4 Rubella ... ... ... ... ... ... ... 3 ... ... ... ... ... ... ... ... 3 ... C.S.M ... ... 2 1 ... 1 1 1 ... ... ... ... ... ... ... ... 7 5 Whooping Cough ... ... 6 6 4 3 ... 3 ... ... ... ... ... ... ... ... 22 3 Chicken Pox ... ... 1 ... 13 6 3 8 2 1 ... ... ... ... ... ... 34 ... Ophthalmia 4 3 ... ... ... ... ... ... ... ... ... ... ... ... ... ... 7 ... Mumps ... ... ... ... 3 ... ... 4 1 4 ... ... ... ... ... ... 12 ... Tonsillitis ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... 1 ... Anterior Poliomyelitis I ... ... ... ... ... ... ... ... ... ... ... 2 ... ... ... 3 ... Encephalitis Lcthargica 1 ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... 2 1 Pemphigus 4 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 4 ... Dermatitis 1 ... 1 ... ... ... ... ... ... 1 ... ... ... ... ... ... 3 ... Acute Laryngjtis ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... 1 ... Influenza ... ... ... ... ... ... ... ... ... 2 ... ... ... ... ... ... 2 ... No Disease ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 35 ... Totals 16 5 17 7 38 21 16 28 12 39 5 32 7 5 12 24 319 27 92 Out of Borough Cases. Table XIII. Disease. Males. Females. Totals. Deaths. Scarlet Fever 25 40 65 — Diphtheria 6 15 21 - Erysipelas — 1 1 — Typhoid Fever 1 — 1 1 Totals 32 56 88 1 Croydon Borough Hospital Laboratory Report. Table XIV. DIPHTHERIA. Examination of Nose and Throat Swabs. Positives on Admission. Convalescent Cases Positive. Negatives. Total. 304 287 5.238 5,829 FAECES. Examination for Enteric Group. Positives B. Typhosum. Positives B. Tvphosum Para. B. Negatives. Total. 19 3 85 107 WIDALS. Agglutination Tests. Positives B. Typhorum. Positives B. ParaTyphoid B. Negatives. Total. 10 1 4 15 93 OTHER EXAMINATIONS. Blood Cultures (9): 1 Hemolytic Streptococcus Longus, 8 remained sterile. Cerebro-Spinal Fluids (9): 4 Meningococcus present, 1 T.B. present, 1 Hæmolytic Strept. Longus present, 1 Pfeiffers Bacillus present, 2 sterile. Sputums (1): T.B. negative. Urines for Organisms (15). Lochia Examinations (13): 5 Haemolytic Streptococcus Longus present, 3 Staphylococci present, 5 specimens sterile. Swabs for Gonococci (12): 3 swabs positive, 9 negative. Pus examined for Organisms (3). CULTURE MEDIA. GOO doz. tubes Loeffler's Blood Serum. 8,200 cc Peptone Broth. 4,250 cc Peptone Water. 5,350cc Agar Agar. 2,250 cc McConkey's Media. 4,550 cc Endo's Media. 94 BACTERIOLOGICAL EXAMINATIONS. I am indebted to the Borough Pathologist, Dr H. W. Southgate, for the figures given in the appended tables: Table XV. At the Laboratory. Crovdon General Hospital. For private practitioners Mayday Hos. For Borough Hospital For Tub. Dispensary For School Medical Other Instns. ofCorporation Other Institutions Total Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Swabs for Diphtheria 191 1569 3 167 ... 2 ... 2 161 3689 ... 10 32 473 387 5932 Virulence tests for Diphtheria 1 1 ... ... 8 4 ... ... 4 1 ... ... ... 1 13 7 Sputum for Tub. Bac 114 672 122 163 ... ... 459 715 ... ... ... ... 18 93 713 1643 Pus for Tub. Bac ... 13 3 461 ... 3 ... ... ... ... ... 124 ... ... 3 601 Pus for Gonococci 5 4 9 52 2 2 ... ... ... ... ... 35 ... ... 16 93 Pus for other organisms ... 21 ... 489 ... 7 ... ... ... ... ... 129 ... ... ... 646 Blood for Typhoid Groups 261 179 28 26 1 ... ... ... ... ... 10 63 20 11 320 279 Blood for Wassermann ... 1 31 207 ... 1 ... ... ... ... ... 4 ... 1 31 214 Material for Spirochaetes ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Faeces for Typhoid Group 17 119 ... 18 ... 1 ... ... ... ... ... 22 ... 2 17 162 Hair for Ringworm ... ... 8 2 ... ... ... ... ... ... ... ... 2 ... 10 2 Examination of Urine 80 300 ... ... ... 145 1 526 Examination of Pleural Fluid ... 18 ... ... ... ... ... 18 Examination ol C.S. Fluid 5 58 3 ... ... ... ... 66 Other Examinations 38 377 14 ... ... 417 18 864 95 Examinations Done Under National Health Insurance Act. Table XVI. Nature of Examination. Nature of Examination. Pus for Gonococci 10 (2 pos.) Urine for Chemical Exam. 10 Pus for other organisms 18 Urine for Microscopal Exam 10 Pus for Tubercle B. 15 Urine for Tubercle B. 10 Blood for Wassermann 23 (2 pos.) Urine for Cultural Exam. 10 Complete Blood Counts 9 Other Examinations 20 Bacteriological Examination of Milk. Table XVII. Number of Samples submitted for Counts 491 Number under 10,000 per cc 147 Number over 10,000 but under 50,000 per cc 178 Over 50,000 but under 100,000 per cc 53 Over 100,000 but under 500,000 per cc 71 Over 500,000 but under 1,000,000 per cc 22 Over 1,000,000 per cc 20 Bacillus Coli Content (47 examined by this method)— Not found in 0.1 cc 26 „ „ 0.01 cc 12 „ „ 0.001 cc 6 Present in 0.001 cc 3 Higher dilutions not made. Tubercle Bacilli— Number of samples of milk submitted 503 Number found positive by inoculation test 10 The number of milk examinations increased by 46 There are 31 samples still under investigation for Tubercle Bacilli. Milk Samples 47 samples examined for Bacillus Coli Content. 444 milk samples submitted to the Methylene Blue Test, of which 35 failed to satisfy. Of these, 4 were further investigated ,and found satisfactory to the Bacillus Coli test. 96 VACCINATION ACTS. I am indebted to Mr. Huggins, the Vaccination Officer, for the particulars in the returns in subjoined Tables. Table XVIII. Registration Sub-Dialricts in V.O. District. Births Registered. Vaccinated. Insusceptible Statutory Declarations Died Un vaccinated. p.p.o Transferred tootherVOs. Not traced Removals. In Default. Overage when Registered. South Sub-District 1339 479 6 594 64 25 70 49 52 ... West „ 1611 459 1 840 68 26 24 103 90 ... North „ 652 224 4 323 23 8 4 32 33 l 3602 1162 11 1757 155 59 98 184 175 l During the year 2,308 Forms Q were sent to parents, and 375 Forms K. and 125 Forms K "Final Notices." Form Q is the Form drawing attention to the requirements of the Vaccination Acts and Form Krefers to cases in default. 951 names were sent on the H lists to Public Vaccinators to be visited. During the past year one summons was taken against parents who had failed to comply with the Vaccination Acts. Fined 10s. and 10s. 6d. costs. Return showing the Numbers of Persons vaccinated and revaccinated at the cost of the Rates by the Medical Officer of the Public Assistance Institutions and the Public Vaccinators during the year ended 30th September, 1937:— 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 year and upwards. Total. Crovdon No. 1 Area 115 9 124 7 No. 2 Area 154 10 164 9 No. 3 Area 78 3 81 7 No. 4 Area 112 18 130 7 No. 5 Area 222 16 238 7 Addington 24 - 24 2 Queen's Road Homes 4 - 4 - Mayday Road Hospital 10 — 10 1 Children's Homes — — - - Shirley Schools — 3 3 - 719 59 778 40 97 SECTION Y. PREVENTION AND CONTROL OF TUBERCULOSIS. The Tuberculosis Clinic is situated at 13, Katharine Street. The premises are not suitable, being too small in extent and inconvenient in arrangement. In addition, as they abut on a very busy thoroughfare, the noise makes examination of patients difficult. The Committee have had under consideration -the finding of better accommodation, but up to the end of the year no final decision had been arrived at. 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 & 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. Two hundred and twenty-nine cases of Pulmonary Tuberculosis ffld 31 of Non-Pulmonary Tuberculosis were notified on Form A (primary notifications) ; of these 134 males and 9-5 females were Pulmonary cases, 16 males and 15 females Non-Pulmonary. In addition, 59 Pulmonary cases and 19 Non-Pulmonary came to our notice m 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 1937 by notification or otherwise, was 338, as compared with 311 in 1936, 333 in 1935, 3-25 in 1934, 346 in 1933, 369 in 1932, and 412 in 1931. 288 of these were cases of Pulmonary Tuberculosis; 163 in males and 125 in females. There were 44 more cases of Pulmonary Tuberculosis in males, and 11 fewer in females than in 1936. There were 22 cases of Non-Pulmonary Tuberculosis among children under 15 years as compared with 18 in 1936. The number f,ases in adults was 28 compared with 38 in 1936. 98 Of the cases notified in 1937, 19 males and 16 females died from the Pulmonary form of the disease during the year, equal to 14.6% of those notified, and 2 males and 4 females from the NonPulmonary form. The incidence rate of Tuberculosis of all forms was 1.39 per 1,000 of the population; for Pulmonary Tuberculosis 1.19 and for Non-Pulmonary 0.20 per 1,000 population. This rate is low as compared with other large centres of population. The Notification rate was 1.07 per 1,000. In 1936, the corresponding figures were 1.28, 1.05 and 0.23 and 0.93 per 1,000. Public Health (Tuberculosis) Regulations, 1930. Summary of Notifications during the period from the 1st January, 1937, to the 31st December, 1937:— Table I. FORMAL NOTIFICATIONS. No. of Primary Notifications of new cases of tuberculosis. Total Notifications on Form A. 0 to 1 1 to 5 5 to 10 10 to 15 15 to 20 20 to 25 25 to 35 35 to 45 45 to 55 55 to 65 65 and upwards Total (all ages) Age periods Pulmonary Males ... ... 1 3 15 17 31 26 22 11 8 134 160 „ Females ... 1 1 5 15 24 21 14 7 3 4 95 111 Non-pulmonary Males ... ... 4 1 5 1 2 1 1 ... 1 16 21 „ Females ... ... 4 1 4 4 1 ... 1 ... ... 15 17 Table II. Supplemental Return. New cases of Tuberculosis coming to the knowledge of the Medical Officer of Health during the period from the 1st January, 1937, to the 31st December, 1937, otherwise than by formal notification. Age periods 0 to 1 1 to 5 5 to 10 10 to 15 15 to 20 20 to 25 25 to 35 35 to 45 45 to 55 55 to 65 65 and upwards Total Cases Pulmonary Males 1 ... 1 ... 2 4 6 7 2 6 ... 29 „ Females ... ... ... 2 2 7 11 4 4 ... ... 30 Non-Pulmonary Males 2 ... 1 4 ... 2 1 1 1 ... ... 12 „ „ Females ... 1 3 1 ... ... ... 1 ... ... 1 7 99 The sources from which information as to the above-mentioned cases was obtained are shown below:— Sources of Information. No. of Cases. Pulmonary. NonPulmonary. Death Returns from local Registrars 9 5 Transferable Deaths from Registrar General 5 2 "Transfers" from other areas (other than transferable deaths) 35 11 Posthumous notifications 1 ... Other Sources — Form I. and II. 9 1 Notification Register. Number of cases of Tuberculosis remaining on the Notification register on the 31st December, 1937:— Table III. pulmonary non-pulmonary Total Cases Males Females Total Males Females Total 582 503 1,085 108 117 225 1,310 Number of cases removed from the Registers during the year and the reasons for such removal. Pulmonary. Non-Pulmonary. Total Cases. Males. Females. Total. Males. Females. Total. 1. Withdrawal of Notification 6 13 19 5 1 6 25 2. Recovery from the Disease 25 16 41 8 22 30 7 3. Death 80 66 146 6 10 16 162 4.Otherwise 38 37 75 14 10 24 99 100 Interval Between Notification and Death From Pulmonary Tuberculosis in Cases Dying in 1937. 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 140 deaths during 1937, 26 (18.5%) were either not notified at all or only notified within a month prior to death. In 1936, this figure was 22 or 17.2%. Of these, 12 were not notified during life; 2 of whom were cases of fulminating or complicated cases of Tuberculosis; and 4 cases were certified by the Coroner or after a post-mortem examination; 4 cases died in other areas; and 2 cases were not notified through a misunderstanding. In 34.2% 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 12 9 3 2 6 8 8 11 One Year Two Years Three Years Four Years Five Years Six Years Seven Years Eight years and over 18 12 14 8 10 5 2 12 For Non-Pulmonary Tuberculosis the proportion of non-notified fatal cases to the total deaths from this form of the disease was 60%. In other words, out of a total of 15 deaths, 9 were not notified during life; only 1 of these 9 cases died at home, the cause of death being ascertained after a post-mortem examination. Pour of the other cases were certified after a post-mortem examination. Of the total deaths from Tuberculosis of all forms, 21 or 13.5%, were not notified prior to death, compared with 12.5% in 1936. 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. 101 Ages at Death from Pulmonary Tuberculosis. Table V. Year. 0—5 5—15 15—25 25—45 45—65 Over 65 Total 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 2s 69 40 5 144 1935 1 ... 37 67 33 10 148 1936 2 3 23 52 38 10 128 1937 ... 2 35 55 40 8 140 In 1937 the death-rate from all forms of Tuberculosis was 0.64 per 1,000 population. The rate for Pulmonary Tuberculosis was 0.58 and the rate for Non-Pulmonary Tuberculosis 0.06. Similar figures for 1936 were 0.60, 0.53 and 0.07. This death-rate is one of the lowest among the larger centres of population in England and Wales. Pulmonary Tuberculosis. In 1937 there were more deaths from Pulmonary Tuberculosis than in 1936, the greatest number occurring in the age group 35-45 years, whereas in 1936 the greatest number occurred in the 25-35 years age group. Apart from the 25-35 age group there were more deaths in all the age groups from 20 to 55 years than in 1936. In females the highest peak was reached in the 20-25 age group. In males the highest peak was in the 35-45 age group. After the 25th year the male deaths exceed those in females. This is probably 102 connected with the fact that women lead a more sheltered existenoe than men in the later years of life. The higher proportion of deaths in young adult females is probably accounted for by the increasing numbers employed at these ages and by the lack of a proper adjustment to the more strenuous way of life in modern times. The number of new cases of Pulmonary Tuberculosis in 1937 in the age groups 15 to 35 years was greater than in 1936, but whereas in 1936 the greatest number occurred in the 20-25 years group, in 1937 the greatest number was in the 25-35 group. The greater proportion of new cases of Pulmonary Tuberculosis were in the age groups comprising 20 to 45 years. In the age groups 15 to 25 years there was a greater number of new cases among women but after 25 years there was a greater number in men. There is a close similarity between the age distribution of new cases and of deaths from Pulmonary Tuberculosis. This year the peak of new cases was in the 25-35 age group. The figures indicate that Pulmonary Tuberculosis is a rare disease in the first ten years of life. It is rather disappointing to find that although there has been a great fall in the number of new cases and deaths compared with 20 years ago, there has been no appreciable change in the ratio of new cases to deaths. In other words, for every 100 cases developing Tuberculosis to-day about the same number die from the disease as was the case 20 years ago. It has been shown, however, that modern methods of treatment prolong the lives of those who are found to be suitable for such treatment. Deaths from Non-Pulmonary Tuberculosis. During 1937, 15 deaths were certified to be due to Non-Pulmonary Tuberculosis, compared with 16 in 1936; 23 in 193-5; 13 in 1934 ; 22 in 1933; 22 in 1932; 19 in 1931; 21 in 1930; 29 in 1929, and 39 in 1928. The deaths were due to;— Males Females Total Tuberculous Meningitis 5 6 11 Tb. Kidneys and Bladder - 1 1 Tb. Intestines - 1 1 Miliary and General Tb 1 — 1 Tb. Kidney 1 — 1 7 8 15 103 Non-Pulmonary Tuberculosis. This year the greater proportion of new cases of Non-Pulmonary Tuberculosis occurred in adults, 56% in adults and 44% in children up to 15 years. Of the cases occurring in child] en, 54.5% were in boys; in adults the greater proportion of the cases were in men— 57.1%. 53.3% of the deaths occurred under the age of 10 years compared with 31.2% in 1936. Table VI. The diagnoses of the new cases entered in the Notification Register during 1937 were as follows:— Male. Female. Spine - 2 Hip 1 1 Hip and Knee 1 — Knee 4 2 Ankle 3 1 Shoulder and Glands 1 - Abdomen 4 2 Glands 3 7 Epididymis 1 — Skin 1 - Meninges 5 4 Kidney 4 2 Kidney and Bladder — 1 28 22 104 TABLE VII. TUBERCULOSIS. (Summary of Notifications and Deaths at various age periods). Age periods. 1937 Population at age period, (estimated) Pulmonary, Non-Pulmonary. New Cases, All Cases, New Cases. All Cases. Number. Incidence Rate. Deaths. Death Kate (based on 1937 figures). Number. Incidence Rate, Deaths. Death Rate (based on 1937 est. figs.) M F M F M F M F M F M F M F M F M F Under one year 2131 1955 1 ... 0.47 ... ... ... ... ... 2 ... 0.94 ... 3 ... 1.41 ... 1— 5 years 6942 7310 ... 1 ... 0.14 ... ... ... ... ... 1 ... 0.14 ... 2 ... 0.27 5—10 „ 11356 10449 2 1 0.18 0.10 ... ... ... ... 5 7 0.44 0.67 2 1 1.76 0.96 10—15 „ 12028 11439 3 7 0.25 0.61 1 1 0.08 0.09 5 2 0.42 0.17 ... 1 ... 0.87 15-20 „ 9834 10667 17 17 1.72 1.59 1 9 0.10 0.84 5 4 0.51 0.37 1 2 0.10 0.19 20—25 „ 7667 9928 21 31 2.74 3.12 5 20 0.65 2.01 3 4 0.39 0.40 ... 1 ... 0.10 25-35 „ 15694 20667 37 32 2.36 1.55 15 9 0.96 0.43 3 1 0.19 0.05 ... ... ... ... 35—45 „ 17484 21305 33 18 1.89 0.85 21 10 1.20 0.47 2 1 0.11 0.05 ... 1 ... 0.05 45-55 13957 16024 24 11 1.72 0.69 12 8 0.86 0.50 2 1 0.14 0.06 1 ... 0.07 ... 55—65 8318 10158 17 3 2.04 0.30 16 4 1.92 0.39 ... ... ... ... ... ... ... ... 65 and upwards 6354 10583 8 4 1.26 0.38 4 4 0.63 0.38 1 1 0.16 0.09 ... ... ... ... totals 111815 130485 163 125 1.46 0.96 75 65 0.67 0.50 28 22 0.25 0.16 7 8 0.06 0.06 In the above table the death rate is based upon the total deaths in 1937 and not on deaths in New Cases only. 105 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 242,300. The death rate for the whole Borough was 0.64. Table VIII. Ward. Density of Population persons per acre. New Cases Total Incidence Rate per 1000 Death Rate per 1000 Pulmonary Non-Pul monary Upper Norwood 20 16 3 19 1.1 0.59 Norbary 29 25 7 32 .0 0.62 West Thornton 42 26 1 27 1.4 0.66 Bensham Manor 50 21 5 26 1.6 0.90 Thornton Heath 51 23 6 29 1.6 0.67 South Norwood 29 20 3 23 1.3 0.46 Wood side 37 20 ... 20 1.2 0.74 East 10 16 3 19 1.2 0.31 Addiscombe 49 14 1 15 0.9 0.49 White horse Manor 63 24 5 29 1.7 1.04 Broad Green 69 25 2 27 1.6 0.69 Central 33 20 2 22 1.8 0.89 Waddon 22 18 10 28 1.5 0.66 South 13 16 1 17 1.8 0.46 Addington 1 4 1 5 0.6 0.35 No fixed abode ... ... ... ... ... ... 288 50 338 1.39 0.64 The Wards showing the highest incidence of new patients in 1937 were: Norbury (2.0) and Central and South (1.8). The highest death-rates were in Whitehorse Manor (1.04), Bensham Manor (0.90), and Central (0.89). With the relatively mil figures available, these rates are subject to wide annual variations. 106 CLASSIFICATION OF NEW PATIENTS. Pulmonary Tuberculosis. During 1937, 205 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) 55 or 26.8% T.B. plus 1 (early cases, sputum positive) 10 or 4.8% T.B. plus 2 (intermediate cases, sputum positive) 101 or 49.2% T.B. plus 3 (advanced cases, sputum positive 39 or 19.0% 205 or 100.0% This is 47 more than in 1936. It is well known that Tuberculosis Officers do not see many of the new cases in the early stages of the disease. 1937 was the same in this respect as 1936; only 31.6% of the cases were first seen in this stage. The insidious onset of Pulmonary Tuberculosis 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. Tuberculosis in its early stage is readily capable of arrest by proper treatment. It is unfortunate that 68.2% of the new cases were more or less advanced in the disease. Non-Pulmonary Tuberculosis. There were 21 cases examined at the Clinic and found to have Non-Pulmonary Tuberculosis in the following forms:— Bones and Joints 9 Abdominal — Other Organs 6 Peripheral Glands 6 21 Tables XX. and XXI. summarise the condition of all patients whose records are at the Clinic at the end of 1937. These tables 107 show that of patients who came under treatment for Pulmonary Tuberculosis before 1927, 430 adults and 107 children have been discharged as recovered. Of these all but 20 were early cases. Of the 1927 cases, 27 adults and 2 children of the 1928 cases, 29 adults and 2 children; of the 1929 cases 10 adults and 3 children ; of the 1930 cases 20 adults and 3 children; and of the 1931 cases 14 adults and 3 children, have recovered. Of patients who first attended in 1937, 11 have been lost sight of or otherwise removed from the Clinic Register. Of t he 1936 cases 21 were lost sight of. Of patients who attended prior to 1927, 397 adults and 16 children are known to have died ; since 1927, 981 adults and 29 children are known to have died. Of patients attending for the first time in 1937, 23 adults and 2 children have died. It will be seen that in the years 1927 to 1937 (inclusive) there have been 29 deaths in children, and 21 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 1927, 57 adults and 632 children have been discharged as recovered, and of those first attending in 1927 and following years, 46 adults and 101 children. 21 adults and 16 children died in the pre-1927 class; 33 adults and 13 children died in the 1927 and following years group. Co-ordination with Medical Practitioners, and Other Branches of the Health Department. During the year 224 cases of suspected Tuberculosis were referred by private medical practitioners ; 64 were diagnosed as suffering from Tuberculosis and were subsequently notified. In addition, 18 children were referred by the School Medical Service, and 26 cases from the Maternity and Child Welfare section of the Public Health Department. 87% of all notified cases were examined at the Clinic or were seen at the request of the medical attendant at the patient's home, as compared with 78.3% in 1936, 83.9% in 1935, 84.2% in 1934, and 79.3% in 1933. 108 The number of reports sent in by Insurance medical practitioners on their domiciliary cases (Form G.P. 36) was 449.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 the patient requires sanatorium treatment this is arrange for a period prior to admission to Hospital for confinement. The Clinic Register of Cases. The number of cases of Tuberculosis under the supervision of the Clinic at the end of the year was 852. 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. During the year 124 Clinic cases died; of this number,27 or 21.7% were seen for the first time in 1937. Examination of Sputum. This is done by the Council's part-time Bacteriologist in the Laboratory at the Croydon General Hospital. The results of examinations made in 1937 are as follows:- For Clinic. For genral Practitioners. Totals 602 Positive (i.e., tubercle bacilli present) 469 133 Negative (i.e., tubercle bacilli absent 704 769 1,473 Total 1,173 902 2,075 For each 100 new cases and contacts examined at the Clinic 146 specimens of sputum were examined. . 1937 shows an increase of 16½% in the number of examinations of sputa made for General Practitioners. 109 X-Ray work. A number of doubtful and difficult cases were sent for radiological examinations than in previous years. Each year this specialised examination is being increasingly used. 547 X-ray examinations were made during the year, an increase of 169 over 1936. This is equivalent to 68.4 for every 100 new cases and contacts seen, and compares with a rate of 53.6 in 1936,45.2 in 1935, 40.4 in 1934, and 30.4 in 1933. In addition a certain number of Who have already been examined at various Hospitals are referred to the Clinic. The new X -ray plant installed at Mayday Hospital in 1936 has been available for X -ray examinations of Dispensary cases, and during the year most of the X-ray examinations were carried out. at this Hospital. Tomography. During the Past year or two a new method of radiology has been developed called tomography. By this method it is possible to take X -ray films of the lungs,etc., in sections or slices at any predeter- This method is especially useful in Pulmonary Tuberculosis in the selection of eases for major operative measures and as a help in deciding Which from of operation is likely to be most beneficial. It is also useful afterwards to find if such treatment has been successful, thus giving definite information which could not be obtained by the oradinary X -ray examination. In Croydon we have fortunate in having one of the first tomographs in this contury, Which was devised by Dr. H. C. Colyer, through whose kindness a number of Croydon patients have been 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 condition or on account of overcrowding, but frequently in an infectious there is no available space for a shelter in the garden or yard attached to the patient's house. When convenient to be used they form a useful continuation of Sanatorium practice for conscientious patient. 110 INSTITUTIONAL TREATMENT. Table IX. Pulmonary Cases Treated in Institutions, 1937. In at beginning of 1937 Admitted during 1937 Discharged during 1937 Died during 1937 In at end of 1937 Adults Adults Adults Adults Adults M F C M f C M f C M f C M F C Croy. Boro' San., Cheam 52 38 ... 94 67 1 80 59 ... 12 6 ... 54 40 ... Mayday Hospital 11 12 2 58 43 8 32 33 9 22 14 1 15 8 1 Grosvenor 1 1 ... ... ... ... 1 1 ... ... ... ... ... ... ... Burrow Hill Colony ... ... 1 ... ... ... ... ... 1 ... ... ... ... ... ... Brompton ... 3 ... 6 5 ... 5 6 ... ... 1 ... 1 1 ... Papworth 1 ... ... ... ... ... ... ... ... ... ... ... 1 ... ... East Anglian San. ... ... 3 ... ... 4 ... ... 5 ... ... ... ... ... 2 R.N.H.C., Ventnor ... 1 ... 1 2 ... 1 2 ... ... ... ... ... 1 ... Royal Chest Hospital ... 3 ... 10 6 ... 8 8 ... ... ... ... ... 1 ... King George's San. ... ... ... 1 ... ... ... ... ... ... ... ... 1 ... ... Midhurst 1 ... ... 1 2 ... 2 ... ... ... ... ... ... 2 ... Eversfield Chest Hospital ... ... ... 3 2 ... 2 1 ... ... ... ... 1 1 ... Preston Hall Colony 1 ... ... ... ... ... ... ... ... ... ... ... 1 ... ... National Children's San. Harpenden ... ... 5 ... ... 5 ... ... 4 ... ... ... ... ... 6 Cornish Riviera San. ... ... ... 1 ... ... ... ... ... ... ... ... 1 ... ... Cotswold San. ... ... ... 1 ... ... ... ... ... ... ... ... 1 ... ... L.C.C. Hospitals ... ... ... 1 1 ... 1 1 ... ... ... ... ... ... ... London Chest Hospital ... ... ... ... 1 ... ... ... ... ... ... ... ... 1 ... 67 58 11 177 129 18 132 111 19 34 21 1 78 55 9 This Table shows that, compared with last year, 38 more patients were admitted during the year and six more cases remain in institutions at the end of the year. 111 Table X. Non-Pulmonary Cases Treated in Institutions, 1937. In on 1st Jan., 1937 Admitted during 1937 Discharged during 1937 Died during 1937 In on 31st Dec., 1937 Adults Adults Adults Adults Adults M F C M F C M F C M F C M F C Mayday Hospital 1 1 ... 1 5 3 1 4 1 ... 1 2 1 1 ... Royal Sea Bathing Hosp. 7 5 ... 3 3 2 5 4 ... ... ... ... 5 4 2 St Piter's Hosp. ... ... ... 1 ... ... 1 ... ... ... ... ... ... ... ... St.Nicholas Hosp. ... ... 1 ... ... 1 ... ... 1 ... ... ... ... ... 1 Tait Convalescent Home ... 1 ... ... 2 ... ... 2 ... ... ... ... ... 1 ... Treloar Cripples' Hosp ... ... 1 ... ... ... ... ... ... ... ... ... ... ... 1 Croydon General Hosp ... ... ... 1 2 1 ... 1 1 ... ... ... 1 1 ... Pyrford • •• ... 10 ... ... 1 ... ... 5 ... ... ... ... ... 6 Heritage Craft School ... ... 1 ... ... 1 ... ... ... ... ... ... ... ... 2 Leatherhead Cripples College ... ... ... 1 ... ... 1 ... ... ... ... ... ... ... ... King George's San. ... ... ... 2 ... ... 1 ... ... ... ... ... 1 ... ... 8 7 13 9 12 9 9 11 8 ... 1 2 8 7 12 The Immediate Results of Institutional Treatment. Table XIX. 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 27.4% were classified as early cases; the percentage of early cases receiving treatment in institutions was in women, 10.1%; in men, 12.5%; 46.1% of the total cases were intermediate cases, the males showing an excess in this group— males to 21.6% females—and 26.4% were definitely advanced. of the total Pulmonary cases treated in Institutions 76.0% were Potentially infectious. 112 males, 84 females and 12 children, suffering from Pulmonary Tuberculosis, were discharged from or died in Institutions in connection with the Croydon Scheme during 1937. 112 Types of Cases Treated. In Class T.B. Minus, 11 males, 8 females, and 7 children were discharged with the disease in a quiescent condition, i.e., 52% of the total cases in this class; 8 males, 9 females and 2 children were not in a quiescent condition, 38%; 2 males and 3 females died, 10%. In Class T.B. Plus, Croup I., the corresponding figures were 2 males and 1 child quiescent, 42.8%; 3 males and 1 female not quiescent, 57.1% ; there were no deaths in this group. In Class T.B., Plus, Croup II., 6 males and 11 females quiescent, 17.7%; 39 males and 27 females not quiescent, 68.7%; and 6 males and 7 females died, 13.5%. In Class T.B., Plus, Group III., or advanced group, 1 male was discharged quiescent; 19 males, 11 females and 1 child not quiescent, 56.3%; and 15 males and 7 females and 1 child died, 41.8%. Taking all groups together, 22.6% of cases were discharged as quiescent; 57.7% as not quiescent; and 19.7% died. An increase is recorded in the number but not in the percentage of infectious cases dying in institutions. 45.4% of the deaths occurred in institutions. Non-Pulmonary Tuberculosis.—19 patients were discharged during the year, and 73.7% of these were quiescent. Deaths from Pulmonary Tuberculosis in Cheani Sanatorium and Mayday Hospital during 1937 according to sex and stage of disease:— Classification. CHEAM. MAYDAY. Child. Adults. Adults. Males. Females. Males. Females. T.B. minus 2 1 — 2 - T.B. plus 1 — — — — — T.B. plus 2 5 2 2 5 — T.B. plus 3 5 3 20 7 1 Total 12 6 22 14 1 113 The Tuberculosis Clinic and Home Visiting. The subjoined table gives a summary of the work done in connection with the Clinic. 503 new cases were examined during the year; this is equal to 324 for each 100 deaths from the disease. 219, or 141 for each 100 deaths, were found to be definitely Tuberculous. The total number of attendances at the Clinic was 4,780. The Tuberculosis Officer paid 202 home visits, and the District Health Visitors 2,966 visits for Clinic purposes. In addition, the Health Visitors made 338 primary visits for the purpose of the Notification Register. The Tuberculosis Officer paid 58 visits to Mayday Hospital, in a consultative capacity, and there examined 205 patients. Patients requiring home nursing or surgical dressing's are attended to by nurses from the Croydon Nursing Service, by arrangement with that organisation, and 922 such visits were made luring the year. Their assistance is a valuable adjunct in the care of domiciliary cases. Contact Examination. The contacts of definite cases are urged to attend the Clinic for examination (and subsequent supervision). This is an important preventive measure. During the year 296 contacts were examined, equal to 191 for each 100 deaths, compared with 250 in 1936, or 174 per 100 deaths. Of these, 5 were considered to be Tuberculous This is equal to a Tuberculosis rate per 1,000 contacts of 16.8, compared with 1.39 per 1,000 of the general population. Included in the 5 contacts found to be Tuberculous are 3 who had been under observation from previous years. 587 appointments for examination were offered to new contacts during 1937 but only 296 new contacts attended and were examined. The importance of contact examination as a true preventive measure is not appreciated by the public. The number of contacts examined is low, due to the impossibility of finding time with the medical staff available. In this matter the family practitioner could be of much assistance. The National Health Insurance medical service Provides a means through which contact examinations could be done by private medical practitioners. 114 SUMMARY OF CLINIC STATISTICS FOR 1937. No. of persons on Clinic Register, January 1st, 1936 875 „ Notified Cases examined for the first time 102 „ Cases sent for an opinion 321 „ First attendances, including 39 transfers in 838 „ Consultations of T.O. with private practitioners 39 „ Visits paid by T.O. to homes of patients 202 „ Visits paid by T.O. to Cheam Sanatorium 11 „ Visits paid by T.O. to Mayday Hospiltal 58 „ Patients examined by T.O. at Mayday Officer 205 „ Visits paid to homes of patients by Health Visitors 2,966 „ Visits paid to homes of patients by Nurses 922 „ Attendances of patients at the Clinic— Men 1,713 Women 2,207 Children 860 Total 4,780 No. of patients under. Domiciliary Treatment at end of year— Pulmonary 189 Non-Pulmonary 15 Total 204 115 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 18 11 1 30 15 years and over 522 94 321 937 540 105 322 967 Number of Non-Pulmonary Cases— Under 15 years 17 30 10 57 15 years and over 45 14 42 101 62 44 52 158 Totals 602 149 374 1,125 The above table gives a summary of the housing conditions found in notified cases. It is seen that 55.9% of the Pulmonary cases and 39.3% of the Non-Pulmonary cases were occupying a separate bedroom. In 33.2% of the Pulmonary and 32.9% 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 giving preference in the allocation of Council houses to families in whom a member is a Tuberculous person. It is a very important part of any Care scheme as a means of maintaining health and preventing the occurrence of Tuberculosis in family contacts. The tenancy of Council houses to Tuberculous families is subject to co-operation on the part of the latter, but the system of supervision applied does not involve any undesirable restrictions on those who are well intentioned. Up to the end of the year 17 families had been rehoused under the scheme, and all had complied with the special requirements laid down in the scheme. 116 PULMONARY TUBERCULOSIS. Table XII. Shewing the Condition at the end of 1937 of oases discharged from Sanatoria during the years indicated. 1933 1934. 1935. 1936. 1937. 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 5 52=62.6% 5 55 = 56.1% 4 34= 39.1% 2 18=29.0% ... 10=8.9% 16 169 = 38.2% 49.5% 49.2% 33.1% 21.7% 6.4% 30.8% Working or Fit for Work 26 23=27.7% 17 28= 28.6% 23 32 =36.8 24 26=41.9% 36 48 =42.8% 126 157= 35.5% 42.6% 36.9 % 47.8 % 54.3% 53.8% 47.1% Not able to Work 1 8=9.6% 2 15=15.3% 1 21=24.1% 4 18=29.0% 8 54=4 % 16 116=26.2% 7.8% 13.9% 19.1% 23.9% 39.7% 22.0% Left District 16 24 8 23 9 24 11 16 ... 6 44 92 48 107 32 121 37 111 41 77 44 118 202 524 117 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 47.1% 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 35.5%, or just over one third, are working or fit for work. 534, or 72.6% of the total cases discharged, were T.B. + cases; 136, or 18.5% of the total cases discharged, have removed from the Borough, and as we have no information about their condition at the end of 1937, they have been ignored in working out the above percentages. It is instructive to compare the results obtained in cases discharged from Sanatoria during the five years 1933—1937, with those for 1928—1932, and this is done in the Table below. Result. Five years, 19281932. Five years, 19331937. 19281932. 19331937. T.B.- T.B. + T.B.- T.B. + Dead 16 279 = 45.8% 16 169=38.2% 295 185 39.0% 30.8% Working or fit for work 106 121=19.9% 126 157 =35.5% 227 283 30.0% 47.1% Not able to work 26 208 = 34.2% 16 116=26.2% 234 132 30.9% 22.0% Left District 30 95 44 92 125 136 Totals 178 703 202 534 881 736 This Table shows clearly the improved results obtained during the last five years, 17.1% more patients are fit for work and the number who died during the five years decreased by 8.2%. 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. 118 Dental Treatment of Patients Referred from the Tuberculosis Dispensary to Lodge Road. Patients referred from the Tuberculosis Dispensary are treated at Lodge Road Treatment Centre on Wednesday afternoons from 3.30 to 5 p.m. and after the treatments are 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 7 10 17 Treatment cases continued from Cheam 8 6 14 Attendances 113 91 204 Extractions 61 50 111 Fillings 16 14 30 Dressings 6 4 10 Scalings and Gum Treatments 12 7 19 Denture Dressings 52 41 93 Dentures fitted 23 10 33 "Gas " cases (on the recommendation of Tuberculosis Officer) 4 - 4 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. Dental Report—Cheam Sanatorium. The dental treatment for Tuberculosis 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 fatigue caused by long treatments may aggravate the patients' condition. Nearly 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 119 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. Review of Work Done. Males. Females. Total. Number examined 76 61 137 Referred Treatment 76 60 136 Treated 49 56 105 Attendances 184 283 467 Extractions 167 176 343 Fillings 31 120 151 Dressings 20 55 75 Scalings and Gum Treatments 56 59 115 Denture Dressings 43 14 57 Dentures fitted 9 5 14 Sessions treatment, 43 ; Cases X-rayed, 2. The work accomplished at Cheam during the year has well maintained the average of previous yars. An encouraging feature is that conservative measures have formed a great part of the treatment. The amount of 18s. 8d. was taken in attendance fees during the year, at Lodge Road. TUBERCULOSIS AFTER-CARE COMMITTEE. During 1937 the Care Committee assisted 96 tubercular patients and their families. Grants for extra nourishment were made in 19 cases, bedding was provided in 8 cases, fares were paid to enable relatives to visit the patient in two cases; grants for clothing, surgical instruments and help with the cost of dentures comprising the remainder. In two instances the Committee assisted with the payment of arrears of insurance. The increased strain of modern conditions tells especially on the tubercular patient. The system prevalent of buying a house on mortgage, furniture on hire purchase and clothes by weekly payments means that the weekly budget for food is cut down to a very fine margin, and any reduction of the weekly earnings has serious consequences. Thus the breadwinner, in many cases, feels inpelled to remain at work when he is no longer fit to do so or to return to work against medical advice. 120 The question of finding employment after a period of sanatorium treatment is a serious one for the tubercular patient. His former occupation is often unsuitable and if he is to find alternative work some form of training is necessary. Such cases present some of the most difficult problems of the Care Committee, and the help given by the Unemployment Assistance Board in providing training for suitable patients is very greatly appreciated. In addition, there are a large number of patients who are not fit to return to work: many of these, both men and women, have learnt to do excellent handwork whilst at Cheam and orders for their work are very welcome. Once again thanks are due to the ex-service men's associations for the sympathetic consideration shown to Tubercular ex-servicemen and their families. The British Legion, the Royal Naval Benevolent Fund and the Mayor's Peace Memorial Fund, together with several of the Regimental Funds have each rendered valuable assistance. Help has been given in the form of extra nourishment, convalescence and boarding out of children of Tubercular patients, and maintenance grants in special circumstances. Whenever possible patients are referred to other agencies for help outside the scope of the 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. In-patients on Jan. 1st, 1937. Admitted during year 1937. Discharged during year 1937, including deaths. In on Jan. 1st, 1938. Died during year 1937. M F M F M F M F M F 52 38 94 69 92 66 54 41 12 6 No. of Artificial Pneumothorax cases begun 46 No. of Refills given 1,236 No. of X-ray Screenings 1,424 No. of Films taken 590 No. of Sputum tests 1,044 No. of Gas Replacements 33 121 Immediate Results of Treatment. Table XIV. Group. Total number of cases discharged 1937. Quiescent. Improved. No Material Improve ment. Died in institution. Average duraof stay in days. Discharged before completion of treatment. M F M F M F M F M F M F Class T.B. Minus 14 13 7 8 3 5 1 ... ... ... 175 3 ... Class T.B. Plus— Group I 1 2 ... 1 1 1 ... ... ... ... 152 ... ... Group II 35 21 3 5 26 8 1 2 2 1 224 3 5 Group III 30 19 ... ... 8 7 11 5 10 5 295 1 2 Observation Non T.B. 5 2 ... ... ... ... ... ... ... ... ... ... ... 85 57 10 14 38 21 13 7 12 6 846 7 7 At the beginning of 1937 there were 90 patients in Cheam. During the year 163 were admitted and 140 discharged, whilst 18 died, thus leaving 95 patients in at the beginning of 1938. There were 10 observation cases sent in: 8 males and 2 females. Of the 8 males 5 were not tubercular, and of the 2 females neither was tubercular; therefore, there were 7 observation cases in nontuberculars which are shown above. The 3 that were tubercular are in with the tubercular cases and are not shown as observation. Artificial Pneumothorax cases discharged but still under treatment, 7 males, 9 females (see above), making total discharges: males 92, females 66. These 16 Artificial Pneumothorax cases only refer to cases discharged in 1937; those discharged in 1936 and still having refills have not been included. 122 Annual Returns made to the Ministry of TIcalth for the Year, 1937. 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 121 71 3 4 7 10 2 1 128 81 5 5 219 (b) Diagnosis not completed — — - — — — — - 5 10 — 3 18 (c) Non-tuberculous - - - - - - - - 85 99 38 44 266 B. —Contacts examined during year:— (a) Definitely tuberculous — 1 1 2 - — — 1 — 1 1 3 5 (b) Diagnosis not completed - - - - - - - - 1 2 1 — 4 (c) Non-tuberculous — — — — — - — — 63 118 60 46 287 C. —Cases written off the Dispensary Register as:— (a) Recovered 16 11 3 3 2 11 7 7 18 22 10 10 60 (b) Non-tuberculous (including any such cases previously diagnosed and entered on the Dispensary Register as tuberculous) - - - - - - - - 157 231 99 92 579 D. —Number of Cases on Dispensary Register on December 31st:— (a) Definitely tuberculous 379 301 18 20 31 50 31 22 410 351 49 42 852 (b) Diagnosis not completed - — — — — — — - 6 12 1 3 22 1. Number of cases on Dispensary 2. Number of cases transferred from Register on January 1st 875 other areas and cases returned after discharge under Head 3 in previous years 64 3. Number of cases transferred to 4.Cases written off during the year as other areas, cases not desiring Dead (all causes) 124 further assistance under the scheme, and cases "lost sight of" 101 5. Number of attendances at the 6. Number of Insured Persons under Dispensary (including Contacts) 4,780 Domiciliary Treatment on the 31st December 204 7. Number of consultations with 8. Number of visits by Tuberculosis medical practitioners:— Officers to homes (including (a) Personal 39 personal consultations) 202 (b) Other 607 9. Number of visits by Nurses or 10. Number of:— Health Visitors to homes for (a) Specimens of sputum, etc., Dispensary purposes 3,888 examined 1173 (b) X-ray examinations made in connection with Dispensary work 547 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 476 above 2 (B) Number of Dispensaries for the treatment of Provided by the Council One Tuberculosis (excluding centres used only for special forms of treatment) 123 Table XVI. (c) Number of beds available for the treatment of Tuberculosis on the 31st December Institutions belonging to the Council Name of Institution. For Pulmonary Cases For Non-Pulmonary Cases Total. Adults Children under 15 Adults Children under 15 Croydon Borough Sanatorium, North Cheam, Surrey 94 ... ... ... 94 Mayday Hospital, Mayday Road, Thornton Heath (In C.B. of Croydon) Beds reserved for Tuberculosis cases are used for Pulmonary or Non-Pulmonary patients, as required. 64 Table XVII. (D) Return showing the extent of Residential Treatment and Observation during the year In Institutions (other than Poor Law Institutions) approved for the treatment of Tuberculosis In Institutions on Jan. 1st. (1) Admitted during the year (2) Discharged during the year. (3) Died in the Institutions. (4) In Institutions on Dec. 31st. (5) Number of doubtfully tubercuous cases admitted for observato on: Adult males — 6 6 — — Adult females 1 7 7 1 — Children 1 5 6 — — Total 2 18 19 1 - Number of patients suffering from pulmonary tuberculosis: Adult males 67 173 128 34 78 Adult females 57 124 105 21 55 Children 10 19 19 1 9 Total 134 316 252 56 142 Number of patients suffering from non-pulmonary tuberculosis : Adult males 8 9 9 - 8 Adult females 7 10 10 — 7 Children 13 9 8 2 12 Total 28 28 27 2 27 Grand Total 164 362 298 59 169 124 Table XVIII. (F) Refurn showing the results ot 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 — 1 — — 4 — — 1 — - - 2 - 6 Non-tuberculous — 2 — 4 4 — — — — — 2 — 4 8 - Doubtful — - — — — - — — — — - - - - - Totals 2 2 1 4 4 4 - — 1 — 2 - 6 8 6 One woman died in Hospital while under observation, the cause of death being certified as : Chronic toxæmia—Multiple chronic abscesses—non-tuberculous. Table XIX. (G) Return showing the immediate results of treatment of definitely tuberculous patients discharged durig 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 Under3m'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 2 1 - 3 1 — 5 4 5 1 2 2 11 8 7 26 Not quiescent 4 3 - 2 5 — 1 — 2 1 1 - 8 9 2 19 Died in Institution — 1 — 1 1 - 1 1 — — — - 2 3 - 5 Class T.B. plus Group I. Quiescent 1 - - - - - 1 - - — — 1 2 - 1 3 Not quiescent - - - 1 1 - 1 — — 1 — - 3 1 - 4 Died in Institution - - - - - - - - — — — - - — — - Class T.B. plus Group II. Quiescent 1 - 2 1 - 2 8 — 1 2 — 6 11 - 17 Not quiescent 5 9 - 16 8 — 9 7 — 9 3 - 39 27 — 66 Died in Institution 1 4 — 1 1 - 2 — - 2 2 — 6 7 - 13 Class T.B. plus Group III. Quiescent - - - - - - - — — 1 — — 1 - - 1 Not quiescent 9 5 1 3 3 - 1 1 - 6 2 - 19 11 1 31 Died in Institution 8 2 1 3 1 - 2 1 - 2 3 — 15 7 1 23 Totals (pulmonary) 31 25 2 32 22 - 25 22 7 24 15 3 112 84 12 208 TABLE XX. PULMONARY TUBERCULOSIS. Supplementary Annual Return showing in summary form (a) the condition at the end of 1937 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 1927 1927 1928 1929 1930 1931 1932 1933. 1934. 1935. 1936. 1937 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.L., 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 T.B. minus Class T.B. plus I Class I T.B. minus Class T.B. plus Class T.B. Minus. Class T.B. plus Class T.B. minus Class T.B. plus Class T.B. minus Class T.B. plus Group 1 Group 2 Group 3 Total (Class T.B. plus) Group 1 Group 2 Group 3 Total (Class T.B. plus) Group 1 Group 2 Group 3 Total (Class T.B. plus) Group 1 Group 2 Group 3 Total (Class T.B. plus) Group 1 (iroup 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.plus) Group 1 Group 2 Group 3 Total (Class T.B. plus) Group 1 Group 2 Group 3 Total (Class T.B. plus) (a)Reaminig on dispensary Register on December 31st. Disease Arrested Adults M 4 5 4 - 9 1 2 - - 2 1 1 1 - 2 4 2 2 - 4 4 2 2 - 4 4 - 3 2 5 6 1 5 - 6 5 3 2 — 5 6 1 2 — 3 1 1 - - 1 - - - - - - - - - - F 1 2 6 - 8 1 - - - - 1 - 1 - 1 3 - - - - 4 - 4 - 4 4 - 4 - 4 11 - 3 - 3 8 1 5 1 7 5 - 3 - 3 1 - - - - - - - - - - - - - Children 1 - - - - - - - - - - - - - - 1 - - - - 4 - - - - 3 - - - - 1 - - - - 3 - - - - 3 - - - - - - - - - - - - - - - - - - - Disease not Arrested Adults M - 5 5 1 11 - 2 - - 2 - 1 4 - 5 1 1 4 - 5 - 3 7 - 10 - 2 6 - 8 2 2 11 - 13 2 6 11 1 18 5 3 14 1 18 9 4 28 2 34 13 2 18 6 26 29 5 55 13 73 F 2 3 8 - 11 1 1 3 1 5 - - - - - - 1 5 - 6 - - 3 - 3 - - 8 - 8 3 2 4 1 7 2 1 8 1 10 7 1 11 - 12 17 4 16 - 20 17 1 26 4 31 14 4 35 7 46 Children - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1 - - 1 3 - - - - 8 1 - - 1 5 - 2 - 2 Condition not ascertained during the year - 2 - - 2 - - - - - - - - - - - 1 - - 1 1 - - - - 1 - 2 - 2 2 - 3 - 3 2 - 1 - 1 1 2 3 - 5 4 - 1 1 2 - 1 2 - 3 - - - - - Total on Dispensary Register at 31st December 8 17 23 1 41 3 5 3 1 9 2 2 6 - 8 9 5 11 - 16 13 5 16 - 21 12 2 23 2 27 25 5 26 1 32 22 11 27 3 41 27 8 33 1 42 35 9 45 3 57 38 5 46 10 61 48 9 92 20 121 (b) Not now or. Dispensary Register and reason for remuval there from Discharged as Recovered Adults M 188 34 9 1 44 9 7 1 - 8 3 1 2 - 3 3 1 - - 1 9 1 1 - 2 5 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - F 173 15 7 3 25 7 2 1 - 3 19 3 1 - 4 6 - - - - 8 - 1 - 1 8 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Children 106 1 - - 1 2 - - - - 2 - - - - 3 - - - - 3 - - - - 3 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Lost sight of, or otherwise removed from Dispensary Register 248 62 82 16 160 19 21 19 1 41 35 15 16 - 31 37 8 32 - 40 30 15 34 7 56 34 5 44 7 56 30 6 34 3 43 27 5 35 1 41 27 5 18 4 27 21 2 20 2 24 11 1 7 2 10 4 1 5 1 7 Dead Adults M 24 60 81 64 205 2 12 35 8 55 1 7 35 8 50 4 5 44 17 66 7 1 42 11 54 6 4 34 31 69 4 4 39 22 65 5 - 24 17 41 3 - 21 20 41 5 1 13 25 39 1 - 8 15 23 1 - 1 10 11 F 27 21 48 72 141 3 3 22 15 40 4 2 33 9 44 3 3 32 9 44 5 2 29 14 45 4 1 28 25 54 9 3 30 10 43 5 2 18 12 32 5 1 12 16 29 - - 13 18 31 1 1 6 9 16 2 - 2 7 9 Children 3 1 6 6 13 - - 2 2 4 1 - - - - 1 - 1 - 1 1 - - 2 2 - - 1 - 1 2 1 1 1 3 1 - - - - - - 1 3 4 2 - - 1 1 - - - 3 3 - - 1 1 2 Total written off Dispensary Register 769 194 233 162 589 42 45 80 26 151 65 28 87 17 132 57 17 109 26 152 63 19 107 34 160 60 10 108 63 181 45 14 104 36 154 38 7 77 30 114 35 6 52 43 101 28 3 46 46 95 13 2 21 29 52 7 1 9 19 29 Grand Total 777 211 256 163 630 45 50 83 27 160 67 30 93 17 140 66 22 120 26 168 76 24 123 34 181 72 12 131 65 208 70 19 130 37 186 60 18 104 33 155 62 14 85 44 143 63 12 91 49 152 51 7 67 39 113 55 10 101 39 150 TABLE XXL NON-PULMONARY TUBERCULOSIS. Supplementary Annual Return showing in summary form (a) the condition at the end of 1937 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 1927 1927 1928 1929 1930 1931 1932 1933. 1934. 1935. 1936. 1937. 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 Glands Total Bones and Joints Abdominal j Other Organs Peripheral Glands Total Bones and Joints Abdominal Other Organs Peripheral Glands Totals (a) Remaining on Dispensary Register on December 31st. Disease Arrested Adults M 1 — 1 — 2 - — — — — — — — — — — — 1 — 1 — 1 — — 1 2 — — — 2 2 — — — 2 — — — — — 2 1 1 1 5 1 — — — 1 1 — 1 1 3 - - - - - F - - 3 - 3 1 - - - 1 — - - - - - - 1 1 2 — — — — — 1 — — - 1 2 1 - - 3 - - - - _ - 2 - 3 5 2 1 3 1 7 1 1 1 2 5 1 - - - - Children 4 - - - 4 2 - - - 2 1 1 - - 2 1 - - - 1 1 - - 1 2 2 - - 1 3 1 - - 3 4 2 - - - 2 1 — - 2 3 - 2 - 1 3 - - - 4 4 - - - - - Disease not Arrested Adults M - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 2 - 2 1 - - - 1 — - - - - - - 1 — 1 1 - 1 - 2 2 1 4 - 6 F 2 - 1 - 3 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 2 3 - 1 - 4 1 — 1 - 2 2 - - - 2 4 - - 3 7 Children — — - - - - - - - - 1 — — - 1 1 — - - 1 1 - - — 1 1 — - - 1 1 - - - 1 4 - - — 4 1 - - — 1 4 — — — 4 — - — - - 2 - - 1 3 Condition not ascertained during the year - - - - - - - — — - - - - - - - - 2 — 2 - - - - - 2 - — - 2 - - - — — — — - - — - 2 - — 2 - - 2 — 2 — — — - - - - - - - Total on Dispensary Register at 31st December 7 - 5 — 12 3 — - - 3 2 1 - - 3 3 — 4 1 8 2 1 - 1 4 8 - - 1 9 6 1 2 3 12 9 - — - 9 7 5 2 6 20 8 3 7 2 20 5 1 3 7 16 9 - 4 5 18 Transferred to Pulmonary 1 - - - 1 - - - - - - - - - - - 1 - - 1 - 1 - - 1 - 1 - - 1 - - - - - 1 - - - 1 1 - - — 1 — — - — — — - - - - - - - - - (b) Not now on Dispensary Register and reasons for removal therefrom. Discharged as Recovered Adults M 12 - 4 2 18 2 1 1 1 5 1 - - - 1 — 1 1 — 2 2 — 1 — 3 1 1 — — 2 1 1 - 2 4 - - - - - - - - - - - - - - - - - - - - - - - - - F 16 5 4 14 39 2 1 - 3 6 — — — 3 3 1 - 3 1 5 1 2 - 3 6 3 — — 1 4 1 - 2 - 3 1 1 - - - - - - - - - - - - - - - - - - - - - - - Children 48 7 7 570 632 4 1 — 33 38 5 - - 21 26 4 1 1 5 11 3 1 — 11 15 1 1 — 5 7 — 1 — - 1 — - 1 2 3 - - - - - - - - - - - - - - - - - - - - Lost sight of, or otherwise removed from Dispensary Register 24 17 14 159 214 6 3 3 20 32 7 1 - 6 14 4 1 3 3 11 9 - 2 5 16 1 3 2 2 8 6 1 - 3 10 2 2 1 4 9 6 - 1 5 12 3 - 1 3 7 — 1 - 1 2 - - - 1 - Dead Adults M 5 1 4 2 12 2 — 1 — 3 3 1 1 — 5 1 — — — 1 — - - — — — — 1 - 1 4 - 1 - 5 2 - - - 2 - - - - - - - - - - - - - - - - - - - - F 4 - 3 2 9 - 1 - — 1 1 - 2 - 3 - 1 - - 1 1 - 1 - 2 — 2 - - 2 — - - — - — 3 - - 3 7 - — 1 2 - — — — — — — — 1 1 - - 1 - 1 Children 6 3 2 5 16 — — 1 — 1 2 2 1 2 7 — — - - - - 1 — — 1 — — - - — — — — — - - — 1 1 2 1 — - — 1 - - — — — — — - - - - -- 1 - 1 Total written off Dispensary Register 115 33 38 754 940 16 7 6 57 86 19 4 4 32 59 10 4 8 9 31 16 4 4 19 43 6 7 3 8 24 12 3 3 5 23 5 6 3 7 21 8 - 1 6 15 3 - 1 3 7 - 1 - 2 3 - -- 2 1 3 Grand Totals of (a) antl(b) (excluding those transferred to Pulmonary). 122 33 43 754 952 19 7 6 57 89 21 5 4 32 62 13 4 12 10 39 18 5 4 20 47 14 7 3 9 33 18 4 5 8 35 14 6 3 7 30 15 5 3 12 35 11 3 8 5 27 5 2 3 9 19 9 - 6 6 2 125 SECTION II.—Non-Pulmonary Tuberculosis. tion on Admission to the tion. Duration of Residential Treatment in the Institution. Condition at time of discharge. Under 3m'ths but exceeding 28 days 3-6 months. 6-12 months. More than 12 months. Totals. Grand Totals M. F. Ch. M. F. Ch. M. F. Ch. M. F. Ch. M. F. Ch. Bones and Joints. Quiescent - - - - 1 - - - - 2 1 5 2 2 5 9 Not quiescent - - - - - - - - - - 2 - - 2 - 2 Died in Institution - - - - - - - - - - - - - - - - inal. Quiescent - - - - - - - 1 - - - - - 1 - 1 Not quiescent - - - - - - - - - - - - - - - - Died in institution - - - - - - - - - - - - - - - - Other Organs. Quiescent — — 2 — — 1 — — — — — 3 — 3 Not quiescent - — — — - — 1 — — — — — 1 — — 1 Institution - - - - - - - - - - - - - - - - Peripheral glands. Quiescent - - - - - - - - 1 - - - - - 1 1 Not quiescent - 1 - - - - - - - 1 - - 1 1 - 2 Institution - - - - - - - - - - - - - - - - Totals (non-pulmonary) — 1 — 2 1 — 2 1 1 3 3 5 7 6 6 19 126 127 SECTION VI. CANCER. The facilities available in the Croydon area for the diagnosis and treatment of cancer are the same as were given in my Report for 1936. No special propaganda has been undertaken. Deaths from Cancer numbered 421 as compared with 421 in 1936; 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; and 330 in 1926. Death-rate per 1,000 of the population for the previous 11 years are as follows:— 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) 1931—1.46 (342) 1937—1.74 (421) Deaths From Cancer in Municipal Wards. Table I. ward. Male. Female. Total. Death-rate. Estimated Mid Male. Population. 1937. Female. Upper Norwood 14 17 31 1.84 7731 9127 Norbury 10 19 29 1.80 7339 8760 West Thornton 14 16 30 1.53 8764 10773 Bensham Manor 8 20 28 1.67 7872 8851 Thornton Heath 5 13 18 1.00 8460 9523 South Norwood 15 19 34 1.94 8018 9472 Woodside 16 19 35 2.17 7589 8527 East 19 15 34 2.11 6985 9155 Addiscombe 8 22 30 1.84 7469 8813 Whitehorse Mnr 16 12 28 1.65 8035 8896 Broad Green 16 15 31 1.78 8314 9094 Central 11 13 24 1.94 5644 6749 Waddon 12 12 24 1.32 8722 9451 South 14 23 37 2.44 6395 8792 Addington 5 2 7 6.78 4478 4502 No Fixed Abode 1 - 1 - - - Total 184 237 421 1.74 111815 130485 128 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 2 2 2 101785 .020 25 and under 35 years 5 20 7 36341 .193 35 and under 45 years 6 87 26 38771 .671 45 and under 65 years 65 128 152 48451 3.137 65 years and over 106 — 234 16952 13.804 184 237 421 242300 1.737 Table III. Sites of Fatal Cancer. Site. Male. Female. Total. Percentage of Total. Skin 3 1 4 0.950 Tongue and Mouth 8 2 10 2.375 Eye — 1 1 0.237 Oesophagus 10 6 16 3.800 Stomach 31 33 64 15.202 Liver 3 11 14 3.325 Bowel 33 34 67 15.914 Rectum 28 16 44 10.451 Bladder 1 1 2 0.475 Prostate 12 — 12 2.850 Larynx 4 1 5 1.188 Uterus — 43 43 10.214 Breast 1 46 47 11.164 Ovary — 12 12 2.850 Pancreas 12 6 18 4.278 Gall Bladder and Duct 1 4 5 1.188 Bones 1 4 5 1.188 Lungs 22 9 31 7.363 Kidneys 2 1 3 0.713 Thyroid 2 1 3 0.713 Lymphatic Glands 5 1 6 1.425 Pharynx 1 — 1 0.237 Testicle 1 - 1 0.237 Not defined 3 4 7 1.663 184 237 421 129 Comments on Foregoing Table. The two main groups of organs attacked in both sexes are the alimentary system and the reproductive system. In males 33 per cent of the total deaths fall within these groups and in females 50.6 per cent. In males Cancer of the digestive system is the commonest situation, amounting to 30 per cent. In females it was 26.6 per cent. Cancer of the reproductive system caused 24 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, 12 deaths occurring in males as compared with 3 in females. The organs most often attacked in descending order of incidence are, in males the Rectum and Bowels (33.15 per cent.); the Stomach (16.8 per cent.); the Lungs (12.0 per cent.); the Prostate (6.5 per cent.); the Pancreas (6.5 per cent.); in females, the Bowels and Rectum (21.1 per cent.); the Breast (19.4 per cent.); the Uterus (18.1 per cent), and the Stomach (13.9 per cent.). This is slightly different from the incidence in 1936. There has been a noticeable increase in the number of deaths attributed to Carcinoma of the Bowel and Rectum and Carcinoma of the Uterus, and an equally noticeable decrease in the number of deaths attributed to Carcinoma of the Stomach and Carcinoma of the Breast. 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. 130 SECTION VII. VENEREAL DISEASES. No changes have been made in the Scheme as given in my Report for 1930. Table I. Attendances at the Croydon Clinic during past 10 years. 1928 1929. 1930. 1931. 1932. 1933. 1934. 1935. 1936. 1937 New male patients 121 101 196 263 235 242 297 287 300 395a New female patients 158 94 171 205 241 214 232 213 188 184a Attendances, male patients 3502 3581 5050 4923 4691 4578 5858 5548 7525 8610a Attendances, female patients 1632 2127 3029 3271 2724 2677 3962 5977 5226 5405a a Includes 228 new cases and 5193 total attendances by patients from outside areas. Attendances of Croydon Patients at various London Hospitals under the General Scheme during past 10 years. 1928. 1929. 1930. 1931. 1932. 1933. 1934. 1935. 1936. 1937. New patients 139 131 125 139 119 134 103 132 107 128 Total attendances 3080 3089 3150 2384 2835 2407 2222 2006 2587 3407 131 Table II. Attendances of Patients at Venereal Diseases Clinic at the Croydon General Hospital during the past 5 years. Authority. 1933. 1934. 1935. 1936. 1937. 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 ... 5615 56 6659 301 6675 23 6280 ... 8822 Surrey C.C. ... 1280 10 2227 63 3859 44 4631 183 4234 Kent C.C. ... 87 ... 109 ... 232 ... 470 ... 367 London C.C ... 255 6 794 ... 757 ... 1370 ... 592 Sussex C.C. ... 18 ... 31 ... 2 ... ... ... ... ... 7255 72 9820 364 11525 67 12751 183 14015 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 2 13 1 55 1529 35 No Information Guy's ... 7 ... 22 1097 5 King's College 1 1 ... ... 159 ... Great Ormond Street ... ... ... 2 77 ... Royal Free 1 1 ... 1 64 ... South London Hospital for Women 1 5 ... 9 323 ... Whitechapel Clinic (L.C.C.) ... ... ... 3 80 ... St. Paul's ... ... ... 1 6 ... Stamen's ... ... ... ... 15 ... Westminster 2 ... ... ... 57 ... Total 7 27 1 93 3407 40 — 132 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 ... ... 257 ... 137 ... 179 ... 573 Great Ormond Street ... ... ... ... 15 2 8 1 26 South London Hospital for Women ... ... 79 11 10 2 17 4 123 Royal Free ... ... 8 ... 11 ... 13 ... 32 King's College ... ... 1 ... 26 ... ... ... 27 Whitechapel Clinic, L.C.C. ... ... 22 ... 4 ... 6 ... 32 Westminster Hospital 1 ... 4 ... 4 ... 12 ... 21 Guy's Hospital 1 ... 287 1081 60 681 138 1066 3314 St. Paul's ... ... ... ... 1 ... ... ... 1 Seamen's ... ... 8 ... — ... 4 ... 12 Miller ... ... ... ... ... 1 ... ... 1 Total 2 ... 666 1092 268 686 377 1071 4162 133 Table V. Return relating to all persons who were treated at the Treatment Centre at Croydon General Hospital during the year ended the 31st December, 1937. Syphilis Soft Chancre Gonorrhoea Conditions other than venereal Totals M F M F M F M F M F Ttls Number of cases on 1st January under treatment or observation 66 60 ... ... 76 45 18 7 160 112 272 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 9 2 ... ... ... ... ... ... 9 2 11 „ secondary 5 2 ... ... ... ... ... ... 5 2 7 „ latent in 1st year of infection 3 6 ... ... ... ... ... ... 3 6 9 „ all later stages 19 15 ... ... ... ... ... ... 19 15 34 „ congenital 9 10 ... ... ... ... ... ... 9 10 19 Soft Chancre ... ... ... ... ... ... ... ... ... ... ... Gonorrhoea, 1st year of infection ... ... ... ... 168 36 ... ... 168 36 204 „ later ... ... ... ... 12 11 ... ... 12 11 23 Conditions other than venereal ... ... ... ... ... ... 170 102 170 102 272 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 5 13 ... ... 30 9 ... ... 35 22 57 Totals of Items 1,2,3 and 4 117 109 ... ... 286 102 188 109 591 320 911 5.Number of cases discharged after completion of treatment and final tests of cure or after diagnosis as non-venereal 20 1 ... ... 106 7 183 91 309 99 408 Number of cases which ceased to attend before completion of treatment and were, on first attendance suffering from:— Syphilis, primary 2 ... ... ... ... ... ... ... 2 ... 2 „ secondary 1 ... ... ... ... ... ... ... 1 ... 1 „ latent in 1st year of infection 3 ... ... ... ... ... ... ... 3 ... 3 „ all later stages 7 2 ... ... ... ... ... ... 7 2 9 „ congenital 1 ... ... ... ... ... ... ... 1 ... 1 Soft Chancre ... ... ... ... ... ... ... ... ... ... ... Gonorrhoea, 1st year of infection ... ... ... ... 41 4 ... ... 41 4 45 „ later ... ... ... 2 1 ... ... 2 1 3 7.Number of cases which ceased to attend after comPletion of treatment but before final tests of cure 1 1 ... ... 11 5 ... ... 12 6 18 8.Number of cases transferred to other centres or to institutions, or to care of private practitioners 8 5 ... ... 12 5 ... ... 20 10 30 9.Number of cases remaining under treatment or ooservation on 31st December 74 100 ... ... 114 80 5 18 193 198 391 Totals of Items 5, 6, 7, 8 and 9 117 109 ... ... 286 102 188 109 591 320 911 These totals should agree with those of Items 1, 2, 3 and 4 ) 10.Number of cases in the following stages of syphilis inculded in Item 6 which failed to complete one course of treatment:- Syphilis, primary 1 ... ... ... ... ... ... ... 1 ... 1 „ secondary ... ... ... ... ... ... ... ... ... ... ... „ latent in 1st year of infection ... ... ... ... ... ... ... ... ... ... ... „ all later stages 2 2 ... ... ... ... ... ... 2 2 4 congenital 1 ... ... ... ... ... ... ... 1 ... 1 11.Number of attendance:— (a) for individual attention of the medical officers 1085 1234 ... ... 1724 490 655 278 3464 2002 5460 (b)for intermidiate treatment, e.g., irrigation, dressing ... ... ... ... 4941 3003 205 400 5146 3403 8549 Total Attendances 1085 1234 ... ... 6665 3493 860 678 8610 5405 14015 134  Syphilis Soft Chancre Gonorrhoea Conditions other than venereal Totals M P M F M F M F M F Ttls 12. In-patients:— (a) Total number of persons admitted for treatment during the year ... 2 ... ... ... ... ... ... ... 2 2 (b) Aggregate number of "in-patient days" of treatment given ... 183 ... ... ... ... ... ... ... 183 183 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 ... ... 2 1 3 ... 4 9 9 10 Approved Arsenobenzene Compounds Mercury Bismuth 14. Chief preparations used in treatment of Syphilis: (a) Names of preparations Stabilarsan Sulphostab ... Bismostab (b) Total number of injections given (outpatients and in-patients) 1079 ... 1454 Microscopical Serum Others for diagnosis of Venereal Disease. for syphilis for gonorrhoea for Syphilis for Gonorrhoea 15. Pathological Work:— (a) Number of specimens examined at and by the medical officer of the treatment centre ... 8 ... ... 13 (b) Number of specimens from patients attending at the treatment centre sent for examination to an approved laboratory ... 830 Kahn593 W.R. 601 380 ... 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 County or County Borough (or Country in the case of persons residing elsewhere than in England and Wales) to be inserted in these headings. Croydon Surrey Kent London Total a Number of cases in Item 3 and 4 from each area:— Syphilis 49 28 1 2 80 Soft Chancre ... ... ... ... ... Gonorrhoea 142 09 3 13 227 Conditions other than venereal 160 75 10 27 272 Total 351 172 14 42 579 B. Total number of attendances of all patients residing in each area 8822 4234 367 592 14015 C. Aggregate number of "In-patient days" of all patients residing in each area ... 183 ... ... 183 135 The Croydon Branch of the British Social Hygiene Council, towards the expenses of which the Council give a grant of £50 annually, carried out the following programme during the year. For these details I am indebted to the Hon. Secretary, Mrs. D. G. Frankish:— Meetings for the Winter Session began on October 4th with one for the general public, held at the Central Library, and addressed by Dr. Blackbill-Jefferies. Then followed a series of 3 lectures for young men on "Preparation for Marriage," given by Dr. Drummond Shiels. A series of 3 lectures for young women on the same subject was given by Dr. Dancy and Dr. Grace Culver. Both these series of talks were held in the Horniman Hall and were well attended. The session terminated with a lecture by Dr. Edward Griffith, for the general public, on "Sex and Human Relationships." This was held in the Large Public Hall, and the attendance was calculated as over 500 people. At all the lectures free literature was distributed and selected publications sold. 136 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. Notifications were received from— Live Births. Still Births. Total. Midwives 2,856 82 2,938 Doctors, Parents and others 688 23 711 Total 3,544 105 3,649 As the total number of births and still births registered during 1937 was 3,682 (Live 3,574, Still 108), 30 births and 3 still births were not notified in accordance with the provisions of the Act. Maternal Mortality. There were 13 deaths directly due to pregnancy, as in 1936. The maternal mortality rate was consequently 3.9 per 1,000 births, the same as 1936. In other words one mother died for every 258 babies born. The deaths directly due to pregnancy were caused by Puerperal Sepsis, 2 cases; Pulmonary Embolism, 1 cases; Obstetric Shock, 2 cases; Renal trouble, 4 cases; Other Causes, 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. 137 Table I. Puerperal Toxaemias. Haemorrhages. Other Causes. YEAR. *BIRTHS. Puerperal Infection. Eclampsia. Hyperemesis. Ectopic Gestation. Placenta PTaevia. 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 1911 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 3 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 1937 3263 2 ... ... ... ... ... 5 ... 1 ... 3 2 13 4.0 60 96 28 4 6 14 18 24 5 8 17 10 20 240 * It has recently become the practice to give the maternal death rate 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. 138 YEAR. BIRTHS. Live and Still. TOTAL. Deaths. Maternal Mortality. Infant Mortality. 1931 3501 23 6.6 57 1932 3429 7 2.0 49 1933 3249 12 3.7 47 1934 3304 13 3.9 46 1935 3391 10 2.9 45 1936 3373 13 3.9 41 1937 3357 13 3.9 60 Totals (1919-1937) 240 Puerperal Fever and Puerperal Pyrexia. Twelve cases of Puerperal Fever and 67 cases of Puerperal Pyrexia were notified. This is a rate of 3.6 per 1,000 births (live and still births) for the former and 20.0 per 1,000 for the latter. The death-rates were:— Puerperal Fever, 1.5 per 1,000 births. The designation Puerperal Fever has been dropped under the Public Health Act, 1936, and all cases of temeprature of 100.4° F. or over occurring for more than 48 hours during the puerperium are now designated Puerperal Pyrexia. Table II. The following Table gives fuller details concerning these cases. Puerperal Fever. Puerperal Pyrexia. A—No. of cases notified 12 67 „ attended at home 4 6 (1) By doctor alone 3 2 (2) By doctor and maternity nurse — 4 (3) By midwife alone 1 - (4) Confinement unattended — - B—No. of cases treated at Home — 4 C— „ treated at Hospital 1 43 D— „ treated at Nursing Homes and Hospital 5 6 E— ,, treated at Home and Hospital 6 14 F— ,, who died. 2 — 189 Accommodation for Confinement. The following Tables gives information concerning the accommodation utilized for confinements. Number. Percentage. In Private Houses 1364 37.25 In Public Institutions 1598 43.64 Registered Maternity Homes 700 19.11 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 1937, and I am indebted to Dr. Sutherland, the Hon. Medical Officer of the Home, for them:— No. of beds for patients 18 No. of cases admitted 32 Average duration of stay 4 1/2 months No. of cases delivered by (a) Midwives 17 (b) Doctor 2 No. of cases in which medical assistance was sought by a midwife 14 No. of cases notified as (a) Puerperal Fever, (b) Puerperal Pyrexia 1 (b) No. of cases notified as Pemphigus Neonatorum — No. of maternal deaths — No. of infant deaths (a) Still-born 1 (b) Within 10 days of birth — As is seen, the duration of stay much exceeds that in ordinary maternity homes. The girls are kept, with their babies, until suitable situations can be secured for them, and when necessary foster-mothers are found for the babies. Whilst the girls are in the Home they are employed in domestic work. Some of them go out to daily work, but reside in the Home. It is becoming increasingly difficult to get the girls to stay as long as is advisable. 140 Still Births. During 1937, 108 still births were registered in respect of Croydon, but of these 16 were outward transfers to other districts. There were 2 inward transfers, giving a total of 94 for the area. Of these 54 were male babies and 40 female; 1 female was illegitimate. The proportion of still births to living children was as 1 to 35. The still birth rate was 2.8 per cent. of the total births. The rate in 1936 was 3.8 per cent. The still birth rate, on the same basis as for Infant Mortality, was 28.0 per 1,000 births. STILL BIRTHS, 1937. Attended by Midwives alone 28 „ Doctors alone 6 ,, Midwives and Doctors 39 Occurred at 9 months 45 ,, 8 months 19 ,, 6-7 months 11 An Analysis of 76 Still Births Occurring During the Year. Of the 76 still births investigated 42 were males and 33 females, while in one case sex was not stated. Type of Delivery.—In 26 cases the confinement was difficult or prolonged. Normal confinement was noted in 46 cases; no information was obtainable in 4 cases. Age of Mother.—Under 20 years, 1; between 20 and 29 years, . 38; between 30 and 39 years, 32; between 40 and 49 years, 4. The Health of the Mother during her pregnancy was stated to be good in 59 cases and indifferent or poor in 11 cases; no particulars were obtained in 6 cases. In 6 cases, however, the mother had had a shock or fall before the still birth. In 36 instances the mother had attended the Ante-Natal Clinic. 39 cases had never attended the Clinic. Attendance at Confinement.—Twenty-six of the still births investigated occurred in the Mayday Hospital; 13 in St. Mary s Hospital; 17 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; 7 occurred in private nursing homes. Forceps were reported to have been utilised in 18 of the cases. 141 In 45 cases the baby was born at full term; in 19 during the 8th month of gestation; in 11 during the 7th month. The baby was apparently a normal child in 56 cases, abnormal in 9, whilst in 11 no record was available. The still birth was the first pregnancy in 37 instances; the 2nd in 13; the 3rd in 9; the 4th in 6; the 5th in 5; the 6th in 3; and the 7th in 3. Previous still births had occurred in 16 cases. Ophthalmia Neonatorum. Twenty-one cases were notified during 1937. The following table gives the notifications in Croydon during the past eleven years:— Table III. 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 No. of cases 18 7 5 19 14 21 10 13 13 20 21 Rate per 1000 births 5.7 2.8 1.5 5 4 5 6 6 3 3.2 4.0 3.9 6.2 6.4 Results of Treatment. Table IV. Cases treated. Vision Unimpaired. Vision Impaired. Died, Removed Remaining under Treatment. Notified At home In hospital 21 9 10 18 — 1 1 1 Infant Mortality. The Infantile Mortality rate was 60 per 1,000 births. This is 19 per 1,000 births more than in 1936. For the past 5 years the numbers of infant deaths have been: 1933, 148; 1934, 145; 1935, 147; 1936, 134; 1937, 195. 142 deaths of infants occurred in institutions, including Registered Nursing Homes. Among the 195 deaths, 116 occurred in boy babies and 79 in girls. Of the births, 1,654 were males and 1,609 females. The infantile mortality rate for the two sexes was, therefore:—Boys, 70; girls, 49. The rate of infant mortality amongst illegitimate children was 193 per 1,000. The rate in legitimate children was 54 per 1,000. 142 Neo-Natal Mortality. Number of deaths within the first month of life:— Table V. Year. No. of Deaths. No. of Births. Rate. 1928 66 3374 20/1000 live births. 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 „ „ „ 1937 91 3263 28 „ „ „ The following table gives the causes of death during the first month of life:— 1. Complications of Labour. Trauma at 7 II. Foetal States. — 7 Congenital Heart Malformation 3 Other Congenital Deformities 10 Atelectasis 9 Oedema 1 Convulsions 1 — 24 III. Prematurity 41 — 41 IV. Post-Natal Causes 19 19 91 The rate of infantile mortality for England and Wales in 1937 was 58, and for the 125 large towns 62. The rate for Croydon is therefore higher than the average rate. This is very unusual, as the Croydon rate has been for many years lower than the general rate. An exceptionally large number of deaths from Enteritis contributed to this unfavourable result. An analysis of TABLE VI. DEATHS UNDER ONE YEAR, ARRANGED IN DAYS, WEEK 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 mnth. 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 45 6 7 6 1 1 1 9 8 6 90 22 12 10 12 6 7 14 6 8 3 4 194 Uncertified 1 ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... 1 Chicken-pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Measles ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Scarlet Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Whooping Cough ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... 1 Diphtheria and Croup ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... 1 Tuberculous Meningitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 ... ... 2 Abdominal Tuberculosis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Tuberculous Diseases ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... 1 Meningitis (not Tuberculous) ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... 1 Convulsions ... 1 ... ... ... ... ... ... ... ... 1 l ... ... ... ... ... ... ... ... 1 ... 3 Laryngitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Bronchitis ... ... ... ... ... ... ... ... ... ... ... 1 ... 1 ... ... ... 1 ... ... ... ... 3 Pneumonia (all forms) ... ... ... 1 ... ... 1 2 3 4 11 2 3 1 4 2 1 2 2 4 ... 3 35 Diarrhoea and Enteritis ... ... ... ... ... ... ... 1 2 ... 3 7 7 4 2 2 3 7 2 1 1 ... 39 Gastritis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... 1 Syphilis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Rickets ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Congenital Malformations 5 ... 2 2 ... ... ... 3 ... 1 13 4 1 ... ... 1 ... 1 ... ... ... 1 21 Premature Birth 30 4 2 1 ... 1 ... 1 1 2 ... 41 3 ... 1 1 ... ... ... ... ... ... ... 46 Atrophy, Atelectasis, Debility, and Marasmus 5 1 1 1 ... ... ... 1 ... ... 9 3 1 3 2 1 2 ... ... ... ... ... 21 Injury at birth 3 ... 2 1 ... ... ... 1 ... ... 7 1 ... ... 1 ... ... ... ... ... ... ... 9 Other causes 3 ... ... ... 1 ... ... ... 1 1 6 ... ... ... ... ... ... 2 1 2 ... ... 11 Table VI. shows that, of the total infant deaths, 23.5 per cent. occurred on the first day of life and 46.4 per cent. 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 (7) were concerned. 143 144 Deaths Under One Month. An analysis of Table VI. shows that 23.5 per cent. of the infant deaths occurred before the baby was 24 hours old; 34.2 per cent. during the first week of life; and 46.4 per cent before the end of the first month. In 1936 the corresponding figures were 19.4%, 37.3%, and 47.8%. 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 45.1 per cent. of deaths under 1 month of life. In the same group can be placed debility which was the cause of 9.9 per cent. Injury at birth is rather different, inasmuch as it is, by skilled ante-natal and natal attention, avoidable; injury caused 7.7 per cent. of the deaths. Deaths under one month due to congenital deformities constituted 14.3 per cent. of the whole during this age period. Deaths Under Three Months. One hundred and twenty-five babies died during the first three months of life, a percentage of the total infant deaths of 64%, and an infant mortality rate of 38 per 1,000 births. As the total infantile mortality rate was 60, it is seen that nearly twothirds of that rate was due to deaths in infants under 3 months of age. A perusal of the causes of death between the end of the period dealt with in the preceding section, and the end of the third month shows the chief of these to be : Diarrhoea, 14 deaths, and Pneumonia, 5 deaths. Deaths between the 4th month and the end of the first year of life numbered 69 and were caused chiefly by Diarrhoea (31.0%) and Pneumonia (26.8%). These two conditions, year by year, figure as the most prominent causes of death at this age period The Pneumonia deaths in all babies under 1 year occurred in the following months:—January 5, February 3, March 2, April 4, May 4, June 3, August 1, September 1, October 1, November 3, and December 8. Taking the figures in the table as a whole, the outstanding features are:— (1) The predominance of Pneumonia and Diarrhoea. Between them they accounted for 37.8 per cent. of the total deaths, and contributed 22.7 deaths per 1,000 births towards the infantile mortality rate. 145 (2) Next to these come Prematurity and conditions classified as Debility and Marasmus with 34.2 per cent. of the total deaths and a contribution of 20.5 per 1,000 to the infantile mortality rate. (3) Congenital Deformity, inconsistent with viability beyond the first year, was responsible for 21 deaths, 10.7 per cent. of the total deaths, and contributed 6.4 per 1,000 towards the infantile mortality rate. There were four deaths from the acute Zymotic diseases in infants under 1 year of age. In the tabulated deaths of children under 1 year of age, the child who died was a first child in 38.7%; a second child in 22.5%; a third child in 14.0%; a fourth child in 6.2%; a fifth child in 6.2%; a sixth child in 2.3%; a seventh child in 3.1%; an eighth in 2.3%; a ninth in 0.8%; a tenth in 0.8%; an eleventh in 0.8% a twelfth in 1.5%; and a fourteenth in 0.8%. The following table gives the chief causes of infant deaths, as compared with 1936:— Table VII. Percentage Deaths per Total Infantile Deaths. Deaths per 1,000 Births. 1937. 1936. 1937. 1936. Premature Births 23.5 24.6 14.1 10.1 Respiratory Diseases 19.9 17.2 12.0 7.1 (Pneumonia and Bronchitis) Infectious Diseases (inc. Tuberculosis) 3.6 9.0 2.5 3.7 Atelectasis, Debility and Marasmus 10.7 10.5 6.4 4.3 Diseases of Digestion 20.9 16.4 12.6 6.8 Accidental & Congenital 18.0 10.4 9.2 4.3 Table VIII. Births Deaths 1937 1936 1935 1934 Mortality per 1000 Births General Birth Rate General Death Rate Mortality per 1000 Births General Birth Rate General Death Rate Mortality per 1000 Births General Birth Rate General Death Rate Mortality per 1000 Births General Birth Rate General Death Rate January 256 12 47 13.7 16.4 56 15.4 13.7 49 13.3 10.7 42 14.3 14.6 February 279 18 65 15.0 12.4 50 12.5 13.7 63 14.7 12.9 45 14.6 12.0 March 253 20 79 13.6 12.3 44 13.4 13.6 53 15.3 12.0 49 14.3 14.2 April 372 17 46 16.0 11.6 30 15.7 11.3 32 15.0 10.4 36 16.5 11.3 May 306 14 46 16.5 10.1 52 14.5 9.2 29 16.6 10.2 45 13.2 9.2 June 398 18 48 17.1 10.7 28 15.2 9.8 35 15.3 8.4 28 15.6 7.4 July 261 11 42 14.0 6.5 32 14.5 8.3 31 17.7 7.8 33 13.0 8.6 August 325 13 40 17.5 8.1 15 15.2 8.3 19 15.8 8.1 21 16.6 8.1 September 298 20 68 12.7 9.1 13 16.5 7.7 19 14.5 8.8 24 13.8 8.1 October 277 15 54 14.9 8.8 41 14.7 8.9 52 14.0 8.5 31 14.0 9.0 November 247 13 53 13.3 10.3 43 13.6 9.0 64 13.5 8.7 39 14.5 10.8 December 300 24 80 12.9 15.1 55 13.7 11.5 70 11.5 12.3 33 15.0 10.2 The Birth Rate was highest in August, June, May and April, and the Infant Mortality was lowest during August. July and June. The Death Rate was highest in January and December Infant Mortality was highest during December, March and September . 146 Maternity and Child Welfare—Deaths of Infants under one year of age. 147 Infantile Mortality in Wards from 1930 to 1937:— Table IX. 1930 1931 1932 1933 1934 1935 1936 1937 Average over 8 years. Upper Norwood 108 80 76 57 33 26 53 70 63 Norbury 48 39 27 30 37 63 19 46 39 West Thornton 29 66 75 33 59 47 58 87 57 Bensham Manor 39 72 28 19 62 32 20 35 38 Thornton Heath 66 66 69 44 42 31 02 86 58 South Norwood 51 48 32 42 52 40 47 50 45 Woodside 40 37 30 50 66 57 68 39 48 East 40 30 68 46 30 63 40 27 43 Addiscombe 33 47 31 35 43 62 44 66 45 Whitehorse Manor 62 74 48 62 60 47 62 89 63 Broad Green 38 46 60 57 41 51 40 69 50 Central 51 91 22 15 30 66 60 38 47 Waddon 56 53 55 63 50 54 26 25 48 South 25 63 34 91 71 56 55 58 57 Addinton ... ... ... ... 15 36 11 59 ... The Wards with the highest average infant mortality over an eight years period are:—Upper Norwood, Whitehorse Manor, and Thornton Heath; the lowest averages are recorded in Bensham Manor, Norbury, East, South Norwood, and Addiscombe. Midwives Acts, 1902 and 1918. 121 midwives notified the Local Supervising Authority of their intention to practise within the Borough during 1937; 43 ceased practising in the Borough; so that 78 remained on the Register at the end of the year. Of these 78 were trained and held the certificate of the Central Midwives Board. Under Section 2 (1) of the Midwives and Maternity Homes Act, 1926, a midwife is enabled to claim compensation for loss of Practice on account of suspension from work to prevent the possible spread of infection. Three applications were received and payments of £38 0s. 6d. made therein. Under the Midwives Act, 1936, a commencement was made towards a comprehensive Service of Municipal Midwives. On 148 the basis of 70 midwifery cases and 30 maternity cases per midwife, a full complement of 15 midwives would be required for the Borough. On July 1st the service opened with 6 midwives and a Superintendent Midwife. From the beginning the service has proved popular with mothers, and at the end of the year the bookings had become sufficient to justify the appointment of additional midwives. The Committee also assist necessitous patients in the payment of the midwife's fee. 28 applications were made for assistance by midwives on behalf of the patients, and a total sum of £51 12s. was allowed. This concession has ceased since the inception of the Municipal Midwives Scheme. 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 £45 17s. was paid out during the year. Confinements Attended by Midwives. Cases attended by midwives alone 2,030—i.e., 55.6% of Cases attended by midwives when a total births doctor was also engaged 577 Cases attended by midwives when a doctor was also summoned 622 Total 3,229—i.e., 88.5% 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 29 Other causes 27 Abortion 3 - 59 For Complications during Labour: Breech 8 Hand 1 Face 4 Occipito-Posterior 1 Extended Breech 6 Prolapsed Cord 2 Head 3 Undiagnosed 12 - 37 Obstructed Labour 11 11 Delayed Labour— Uterine Inertia 12 Prolonged 25 Delayed 16 53 149 Hœmorrhage— Ante- Partum 26 Post- Partum 19 - 45 Other Causes— Adherent Placenta 3 Illness of Mother 39 Retained Placenta 3 Twins 5 Torn Perineum 220 Eclampsia 2 - 272 For Complications during Puerperium: Pyrexia 20 Pain in Breasts 3 Pain in Legs 8 Other causes 15 Toxaemia 1 - 47 For Complications in regard to the Baby: Inflammation of Eyes 48 Convulsions 1 Still-birth 3 Deformities 5 Feebleness 2 Other causes 35 Premature Birth 2 — 96 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 6 Mother returning to business Insufficient Milk 21 life 8 Inverted Nipples 4 Other causes 5 Total 44 Inspection of Midwives. Dr. Jenkin-L1ovd, the Inspector of Midwives, interviewed 3 midwives at the Town Hall. 89 visits were paid by her to the homes of midwives. Of these visits 11 proved ineffective, the midwife being out. The cleanliness of the midwives' homes and the condition of their bags were on the whole satisfactory. The keeping of case records shows some improvement. 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. 155 mothers were sent by midwives for this purpose. When the midwife 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 22 instances midwives availed themselves of these facilities. 150 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 31/12/36 13 22 20 55 No. of Applications for Registration during 1937 - 9 1 10 No. of Homes registered during 1937 - 9 1 10 No. of Orders made: (a) Refusing Registration — - — - (b) Cancelling Registration 2 4 1 7 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 31/12/37 11 27 20 58 No. of Beds available 56 354 (a) Mat. beds 62 (a) 118 (b) Other Beds 77 (b) 431 Doctors' Accounts Under Section 14 (1) of the Midwives Act, 1918. 284 accounts were received from doctors for services rendered under the provisions of this section. This compares with 268 in 1936; 243 in 1935; 172 in 1934; 140 in 1933; and 153 in 1932. The total amount of the accounts was £372 13s. 0d. £93 16s. was ultimately recovered from the patients. In 1936 the amount paid to doctors was £406 1s. 0d., and in 1935, £329 14s. 6d. 151 THE MUNICIPAL MIDWIFERY SCHEME. 1st July to 31st December, 1937. The Croydon Domiciliary Scheme was started on the 1st July, 1937, with six midwives, three of whom were not general trained nurses, but midwives who had practised in Croydon for some years. The other three were general trained nurses and certificated midwives. They were assigned to different districts and were given half the cases of the midwives who were already practising. Two of the midwives made good uses of the advantages afforded thereby, but the other left the service after six months. The patients have booked well and the midwifery has been on the whole normal, except for booked doctor's cases and emergencies. The Ante-natal Clinic attendance of district patients is not all that could be wished, but the nurses have given every home attention to this important phase of the pregnant woman's life. Two cases were sent into Mayday Hospital in labour or Caesarean section, one breech, the other disproportion. The Superintendent Muncipal Midwife took up her duties on 19th July and the service under her guidance has worked smoothly and efficiently. The district is probably unique in that sterilized sheets, towels and gowns are taken to every case. So in the poorest and most unclean homes the mother has the advantage of a Hospital Labour Ward for her confinement. The special gowns worn by the nurses have a mask attached, thus preventing any infection of the throat of the attendant being spread to the mother. There have been no maternal deaths and no neo-natal deaths Twenty-one cases were sent to Mayday Hospital for delivery. 180 deliveries. 150 normal. 19 abnormal emergencies (i.e., forceps). 20 maternity cases. 6 miscarriages. 3 still births. 152 284 new cases were booked. 1,232 ante-natal visits were made by midwives. Medical aid was sought on 57 occasions. Ante-Natal. Toxemia. Albuminuria 9 Albuminuria and B.P. 2 11 Toxic A.P.H 3 Threat: Abortion 2 Rash on body 1 Pain in lumbar region 1 Varicose veins 1 Cardiac 1 20 Baby. Sticky Eyes Rash? Pemphigus 1 9 In Labour. ? Presentation 1 Face Presentation 8 Extended Breech 1 Prolapsed Cord 1 Delayed labour 7 13 Ruptured Perineums 10 Flushed Breast 1 Legs? Phlebitis 3 Influenza? 1 15 153 THE OBSTETRIC SERVICE. The Municipal Obstetric Service in Croydon may now be described as complete, in that it provides:— (a) In-patient accommodation for all booked cases whose pregnances become abnormal, whose confinements are likely to be abnormal, or whose home conditions are such as to make delivery in Hospital advisable. First pregnancies are, as far as possible, included in this group. (b) In-patient treatment for practically all the emergency midwifery of the Borough. (c) The services of a midwife for those cases whose confinements can be safely undertaken in their own homes. These are the booked cases of the Municipal Midwifery Service, and their numbers will increase as more and more normal cases are referred to the municipal midwives for delivery at home. The pressure on the accommodation at Mayday Hospital will thereby be considerably relieved. (d) In-patient accommodation, in the Isolation Wards at the Borough Hospital, for cases of sepsis, whether drawn from the Borough Maternity Hospitals or from outside practitioners and Nursing Homes. (e) In-patient accommodation, in the Gynaecological Wards of Mayday Hospital, for those cases who are in need of post-natal treatment for any abnormality resulting from their confinements. In February, the new Maternity Block at Mayday Hospital was put into commission. It consists of 44 beds for ante-natal and lying-in cases, two labour theatres with two waiting wards, and four nurseries, all contained in the main building. In addition, there is a separate isolation block of 4 single wards. The new Department has proved very easy to administer, and all the equipment has been found satisfactory. The single-bedded wards, of which there are 8, have been of great value, as they permit operation cases, such as Caesarean section, to be separately Nursed, and it has been possible to isolate immediately cases of Pyrexia of doubtful origin, thus eliminating the danger of crossinfection. The nurseries are spacious, airy, well lighted and adequately heated, and afford ample accommodation. 164 in April, the administration of St. Mary's Maternity Hospital was taken over by the Council. A Resident Medical Officer was not appointed, however, until November, and from April to November the Rota of four general practitioners continued to visit St. Mary's Hospital as before. Since November, St. Mary's Hospital has been entirely under the clinical guidance of the Assistant Medical Officer of Health for Obstetrics and there has been a whole time resident in the hospital. 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, 10 of the 13 deaths in 1936, and 11 of the 13 deaths in 1937. Taking the Registrar-General's figures for maternal mortality (deaths directly due to pregnancy) the rate for England and Wales for 1937 is 3.65 per 1,000 births. In Croydon the rate was 3.56 in 1937. In Booked cases treated by the Obstetric Service the rate for 1937 was 3.8 per 1,000 births. Of the cases treated to a conclusion at the Post-Natal Clinic during 1937, 87 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 1936 was 82.0 per cent. The number of patients delivered in Mayday Hospital showed an increase of 24 per cent. on the total for 1936, 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 48 beds, was 952. The number delivered in St. Mary's Maternity Hospital, with 30 beds, was 536. GENERAL STATISTICS FOR 1937. Registrar General's Returns. Number of Live Births allocated to the Borough of Croydon 3,263 Number of Still Births allocated to the Borough of Croydon 94 Total 3,357 Number of Maternal Deaths (directly due to pregnancy) 12 Number of cases notified as Puerperal Fever 12 Number of cases notified as Puerperal Pyrexia 67 156 Statistics Prepared by the Obstetric Service. Number of Expectant Mothers who attended the Borough Antenatal Clinics 2,427 Number of cases delivered in Mayday Hospital as Booked cases 855 Number of cases delivered in Mayday Hospital as Emergency cases 279 Total cases delivered in Mayday Hospital 1,134 Number of cases delivered in St. Mary's Maternity Hospital as Booked cases 534 Number of cases delivered in St. Mary's Maternity Hospital as Emergency cases 2 Total cases delivered in St. Mary's Maternity Hospital 536 Number of cases delivered by Municipal Midwives 180 Number of cases admitted to the Puerperal Infection Unit, Borough Hospital and Mayday Hospital Isolation Wards, including 30 from Mayday Hospital and 22 from St. Mary's Maternity Hospital 62 Number of Maternal Deaths in Borough of Croydon 13 Number of Maternal Deaths in Booked cases from Borough Ante-natal Clinks 6 Number of Maternal Deaths in Emergencies cases at Mayday Hospital 4 Number of Maternal Deaths in cases admitted as Puerperal Sepsis per se 1 Total Marternal Deaths in beds of the Obstetric Service 11 The total number of patients treated by the Obstetric Service was:— (a) In Mayday Hospital 1,134 (b) In St. Mary's Maternity Hospital 574 (c) In the Borough Hospital Puerperal Infection Unit and Mayday Hospital Isolation Wards, excluding 30 from (a) and 22 from (b) 10 (d) At the Ante-natal Clinics and delivered outside the above Hospitals (about) (including Municipal Midwives' cases) 350 (e) At the Post-natal Clinics, excluding those included in (a), (b), (c), and (d) 254 (f) At the Ante-natal Clinics and undelivered on December 31st, 1937 686 Total 3,008 156 ANTE-NATAL SUPERVISION 1936. 1937. Number of sessions at Ante-natal Clinics held 255 254 Number of individuals who attended 2,276 2,427 Number of previous year's cases continuing attendance 504 549 Number of new cases 1,772 1,878 Number of cases undelivered on 31st December 637 686 Total attendances made 14,107 14,233 Average attendances per session 55.3 56 Proportion of old to new cases per session— New 6.9 7.3 Old 48.4 48.7 Number of cases delivered in Hospital as Booked cases 1,259 1,391 Number of cases delivered at other places under the care of private doctors or midwives (about) 283 350 Number of patients found not to be pregnant 18 22 Number of patients referred to Hospital for Antenatal treatment 373 393 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 106. 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. Alterations are, however, in hand to provide more accommodation and extra sessions. Major Ante-Natal Conditions Treated at the Ante-Natal Clinic. Breech Presentation. Cases. Breech presentation diagnosed 217 Spontaneous version 21 External version successful 177 External version not successful 20 Allowed to go to term as Breech 16 Not recognised as Breech before labour 12 Dental Treatment. Number of cases referred to Borough Dental Surgeons 348 Number of cases referred to Private Dental Surgeons 115 Number of cases refusing dental treatment 62 40 Number of cases seen too late for necessary dental treatment 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. The appointment of another dentist will help to remedy this in 1938. 157 Tuberculosis. Referred from Tuberculosis Officer because of pregnancy 6 Referred to Tuberculosis Officer for opinion on lung condition 6 Yenereal Disease. GONORRHOEA—Total cases 9 Transferred to Borough V.D. Clinic 9 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. 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 1937 350 Number of cases sent for one consultation only 168 (47%) Number of cases supervised entirely 182 (53%) 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 Wassermann 90 Blood for Kahn Reaction 52 Blood for Gonococcus Fixation Test 50 Blood for Grouping 10 Blood for Culture 12 Blood for Urea Conitent 19 Blood for Widals 18 Blood for Cell Count, etc. 43 Catheter urine for Routine Examination 554 Urine for Aschheim-Zondiek Test 20 Urine for Urea Concentration Test 9 Lochia for Culture 20 Sputum for Examination 6 Pus for Identification of Organism 4 Urethral smears for Gonococci, etc. 78 Cervical smears for Gonococci, etc. 28 Conjunctival smears 26 Histological sections 30 Van den Burgh 3 Throat Swabs for Organisms 38 Faeces for Occult Blood 3 158 X-Ray Examinations (Mayday Hospital X-Ray Department). 156 cases were referred from Ante-natal Clinics and 228 films were used. Reasons for reference were:— Breech for attitude, etc 45 For presentation, attitude, etc. 42 Twins 39 Foetal death 2 ,, bony deformity 1 ,, parts 6 Disproportion 16 Others 5 106 cases were referred from the Maternity and Gynaecological Wards at Mayday and St. Mary's Hospitals and 159 films were used. Reasons for reference were: For presentation 46 Twins 11 For foetal parts 13 Foetal death 2 Hydramnios 1 Fracture of foetal skull 1 Breech? Extended legs 8 Disproportion 12 Diseases of bones 3 Hydrocephalus 2 Anencephaly 1 Others 6 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 855 534 1,389 (2) Delivered in hospital before 28th week 6 1 7 (3) Admitted after delivery 4 1 5 (4) Discharged undelivered after ante-natal treatment and not subsequently delivered in hospital 0 0 0 (5) Died undelivered 0 0 0 (6) Ectopic pregnancy 0 0 0 Totals 865 536 1,401 159 B—"Emergency" patients sent into Hospital with some complications by outside doctors or midwives. No "Emergency" cases were admitted to St. Mary's Maternity Hospital, except 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 0 (b) Delivered in hospital after 28th week 97 (c) Delivered in hospital before 28th week 182 (d) Died undelivered 0 (2) After Delivery 9 (3) Ectopic Pregnancy 2 Total 200 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 415 (45.5%) 41 (42.2%) 307 (57.2%) 763 (51.2%) Second,, 243 (28.0%) 25 (24.3%) 142 (26.5%) 410 (27.6%) Third „ 77 (8.9%) 13 (7.9%) 49 (9.0%) 139 (9.4%) Fourth „ 60 (6.8%) 6 (6.2%) 26 (4.6%) 91 (6.1%) Fifth ,, „ .. 24 (2.9%) 4 (3.8%) 9 (1.6%) 37 (2.5%) Six ,, 12 (1.3%) 1 (4.4%) 2 (0.3%) 15 (1.0%) Seventh „ 13 (1.4%) 1 (0.1%) 2 (0.3%) 16 (1.1%) Eighth „ 4 (0.5%) 3 (2.7%) 0 (-) 7 (0.6%) Ninth,, 1 (0.1%) 1 (0.9%) 0 (-) 2 (0.1%) Tenth pregnancy or more 6 (0.6%) 2 (2.1%) 0 (-) 8 (0.4%) Totals 855 97 536 1,488 Legitimate 819 (90.5%) 79 (81.4%) 532 (99.2%) 1,430 (96.6%) Illegitimate 36 (4.2%) 18 (18.5%) 4 (0.7%) 58 (3.2%) 160 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 101 21 60 182 Eclampsia 2 0 1 3 Persistent vomiting of pregnancy 9 0 0 9 Chronic cervicitis 3 0 0 3 Acute pyelitis 12 2 7 21 Malnutrition, debility, simple anaemia, etc 10 0 2 12 Breech presentation for version 6 0 3 9 Disproportion 35 7 8 50 Post-maturity 0 0 0 0 Retroverted gravid uterus 2 0 0 2 2. Intercurrent Diseases. Chronic nephritis 3 0 0 3 Pulmonary tuberculosis 2 0 0 2 Venereal disease 9 0 0 9 Chronic rheumatic carditis 6 2 2 10 Exophthalmic goitre 1 0 0 1 Non-rheumatic carditis 8 2 2 12 3. Conditions chiefly Natal. Presentations at Delivery— Anterior positions of the vertex 804 58 495 1357 Posterior positions of the vertex 29 3 26 58 Breech 33 17 14 64 161  Mayday Hospital Booked. Mayday Hospital Emergency. St. Mary's Maternity Hospital Booked. Total. Presentations at Delivery (continued) Shoulder 1 3 1 5 Face and Brow 3 1 2 6 Complex 0 1 0 1 Caesarean section 30 9 6 45 Twins 16 2 6 24 Accidental haemorrhage 6 5 3 14 Placenta praevia 15 10 5 30 Hydramnios 6 0 0 6 Prolapse of cord 3 1 1 5 Retained placenta 10 3 10 23 Post-partum haemorrhage 22 3 26 51 B.B.A 6 7 1 14 Lacerated perineum 236 17 205 458 Obstructed labour 1 4 1 6 Precipitate labour 0 0 0 0 Premature labour 78 17 28 123 Abortion 8 165 0 173 Ectopic pregnancy 0 2 0 2 Abdominal Hysterotomy 0 9 0 9 4. Conditions chiefly Post-Natal excluding re-admissions from Post-Natal Clinic. Retroversion 20 2 25 47 Delayed involution 57 9 48 114 Post-partum nephritis 4 1 1 6 Breast abscess 1 0 3 4 Notified pyrexia or fever 10 20* 2l 51 In addition 1 case of Puerperal Fever per se was admitted to Mayday Hospital Isolation Wards and 9 cases to the Puerperal Infection Unit at the Borough Hospital. * Including 13 cases of septic abortion. 162 Cardiac Disease. There were 21 cases. None died. One infant was stillborn among the 14 births, a mortality of 9 per cent. In 7 cases, Hysterotomy and Sterilization was performed at about the third month. Hydramnios. There were 6 cases: "all " Booked " cases at Mayday Hospital. No mother died. Five infants were still-born and one died, a mortality of 70 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. St. Mary's Mayday Mayday Maternity Hospital Hospital Hospital Total. Booked. Emergency. Booked. Number of cases 101 21 60 182 Number of stillbirths and infant deaths 5 6 2 13 Foetal and infant mortality 5% 29% 3% 7% Number of maternal deaths - 3 1 4 Eclampsia. Mayday Mayday St. Mary's Hospital Hospital Mat. Hosp. Booked- Emergency. Booked. Total. Number of cases 2 ... 0 ... 0 ... 2 All the infants were born alive. There were no maternal deaths. 163 Accidental Ante-Partum Haemorrhage (14 cases). Mayday Mayday St. Mary's Hospital Hospital Mat. Hosp. Booked. Emergency. Booked. Total. Number of cases 6 5 3 14 Number of stillbirths and infant deaths 3. 2 1 6 Foetal and infant mortality 50% 40% 33% 42% There were 3 maternal deaths, all emergencies, suffering from acute nephritic toxaemia. Placenta Praevia (30 cases). Mayday Mayday St. Mary's Hospital Hospital Mat. Hosp. Booked. Emergency. Booked. Total. Number of cases 15 10 5 30 Number of stillbirths and infant deaths 3 1 3 7 Foetal and infant mortality 21% 10% 60% 22% No mother died. Contracted Pelvis (including relative disproportion ' between the pelvis and foetal head). 50 cases of contracted pelvis or disproportion were treated during the year. There were 2 maternal deaths. In 43 "Booked" cases there were 4 infant deaths (9 per cent.). In 7 "Emergency'' cases there were no infant deaths. 20 cases were treated by surgical induction of premature labour and 26 by Caesarean Section. St. Mary's Mayday Mayday Maternity Method of Treatment. Hospital Hospital Hospital Total. Booked. Emergency. Booked. No.of Infant No.of Infant No.of Infant No.of Infant Cases. Deaths Cases. Deaths Cases. Deaths Cases. Deaths Spontaneous delivery 17 0 3 0 0 0 20 1 Forceps delivery 1 0 0 0 0 0 1 0 Embryotomy 2 2 0 0 1 1 3 3 Cesarean section 16 0 4 0 6 0 26 0 Total 36 2 7 0 7 1 50 3 164 Vertex Presentations at Delivery. The number of deliveries in which the occiput was anterior at the beginning of labour was 1,357. The number of deliveries in which the occiput was posterior at the beginning of labour was 58. Breech Delivery (64 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 34 17 13 64 Number of stillbirths and infant deaths 9 8 6 23 Foetal and infant mortality 26% 48% 46% 36% Maternal deaths 1 1 1 3 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 28 0 6 34 Number of stillbirths and infant mortality 3 0 0 3 Foetal and infant mortality 10% 0 0 8.8% Number of complicated breech cases 13 9 7 29 Number of stillbirths and infant deaths 6 8 6 20 Foetal and infant mortality 46% 88% 85% 68% 165 Face and Brow Presentations (4 cases of Face and 2 of Brow). There were two cases of Face Presentation "Booked" at Mayday Hospital; one ''Emergency'' case of Brow Presentation at Mayday Hospital: and two of Face Presentation among the St. Mary's Maternity Hospital "Booked" cases. No mother died. One infant was stillborn and one died: a mortality of 33 per cent. Shoulder Presentations (5 cases). There was a "Booked" case at Mayday Hospital, three "Emergencies" at Mayday Hospital, and one "Booked" case at St. Mary's Maternity Hospital. One mother died. Three infants were still born: a mortality of 60 per cent. Complex Presentation. One "Booked" case at Mayday Hospital had a live baby. The mother recovered. Prolapse of Cord (5 cases). At Mayday Hospital there were three "Booked" and one "Emergency" cases and one "Booked" case at St. Mary's Maternity Hospital. No mother died. One infant was stillborn, a mortality of 20 per cent. Post-Partum Haemorrhage (50 cases). There were twenty cases in Mayday Hospital "Booked" cases; four in Mayday Hospital ''Emergency'' cases; and twenty-six in St. Mary's Maternity Hospital " Booked " cases. There were no maternal deaths. Abortion. The service dealt with 173 cases of Abortion during the year. All were treated at Mayday Hospital (6 " Booked " cases and 167 Emergency "). There were no maternal deaths. Conditions for which Abortion was induced:— Chronic nephritis 1 case Vesicular mole 2 cases Recurrent pregnancy toxaemia 1 case Abdominal hysterotomy 9 cases 166 All ware "Emergency" cases at Mayday Hospital, and Sterilization was performed in every case. The following were the conditions for which the operation was performed. Cardiac disease 7 cases Chronic nephritis 1 case Pulmonary tuberculosis 1 case There were no deaths Laceration of Perineum. The perineum was lacerated in 458 cases. Table XII. Place of Delivery and Category. lst and 2nd degree. 3rd degree. Total. Mayday Hospital—Booked 236 0 236 Mayday Hospital—Emergency 17 0 17 St. Mary's Maternity Hospital—Booked 202 3 205 458 Surgical Induction of Labour. Labour was surgically induced 61 times. 40 were in Mayday Hospital '' Booked '' cases; 8 in Mayday Hospital '' Emergency" cases; and 14 in St. Mary's Maternity Hospital " Booked cases. One mother died. Five infants were stillborn and five died, an infant mortality of 16 per cent. Forceps Delivery. Forceps were applied 78 times (38 Mayday Hospital "Booked," 4 Mayday Hospital "Emergency" and 36 St. Mary's Maternity Hospital "Booked " cases). There was one maternal death. In Mayday Hospital "Booked" cases 8 babies were stillborn, an infant mortality of 21 per cent. In Mayday Hospital Emergency " cases 1 was stillborn, an infant mortality of 25 per cent. At St. Mary's Maternity Hospital, 2 babies were stillborn and 5 died, an infant mortality of 19 per cent. 167 The main reasons for Forceps Deliveries were: Rigid soft parts, 25; Posterior position, delayed rotation, 16; Disproportion, 15; Foetal distress, 19 ; Various other causes, 3. Caesarean Section. Caesarean Section was performed 45 times: 30 "Hooked" and 9 "Emergency " cases at Mayday Hospital, and 6 "Booked" cases at St. Mary's Maternity Hospital. In 26 cases the indication was contracted pelvis and disproportion, 4 pre-eclamptic toxaemia, 4 placenta praevia, 4 heart disease, 1 obstructed labour, 1 eclampsia, 1 ruptured rectus muscle, 1 prolapsed cord, and 3 accidental haemorrhage. There were 3 maternal deaths due to accidental haemorrhage and 1 of contracted pelvis. There were 2 still births. Bipolar and Internal Version (9 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, and 1 "Booked" case for transverse presentation at Mayday Hospital. No mother died. 2 infants were stillborn. Three "Emergency" cases at Mayday Hospital were treated for shoulder presentation. One mother died. One baby was stillborn and 1 died, a mortality of 66 per cent. Two cases were treated for placenta praevia. There were no maternal deaths, 2 stillborn babies. Embryotomy. Embryotomy was performed 3 times in Mayday Hospital "Booked " cases admitted for obstructed labour, and twice in St. Mary's " Booked " cases. Also in 1 Mayday Hospital " Booked " case, in uterine inertia, and 1 St. Mary's " Booked " case after internal version. There were 3 maternal deaths. Manual Removal of Placenta. Manual removal was performed 23 times. There were 10 "Booked " cases and 3 " Emergency " cases at Mayday Hospital, and 10 " Booked " cases at St. Mary's Hospital. One "Booked " case died, at St. Mary's Hospital, 168 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. 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 (14 obstetrical and 3 gynaecological cases). The citrate method was employed, and all donors were supplied by the Blood Transfusion Service of the British Bed Cross Society. One Mayday " Emergency " case died. Infants. Mayday Mayday St. Mary's Hospital. Hospital. Mat. Hosp. Booked. Emergency. Booked. Total. Percent. Number of Infants in hospital on 1st January, 1937 36 — 30 66 - Total number of live births, stillbirths and infants a d m i tt e d with mother (B.B.A.) 885 97 542 1,524 - Number of Infants in hospital on 31st December, 1937 41 — 26 67 — Living—alive on discharge from hospital 839 77 512 1,428 93.7 Stillborn 32 8 15 55 3.7 Died (born alive, but died in hospital) 18 6 14 38 2.6 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 916 infants discharged from Mayday Hospital, 698 were up to or over birth weight (76 per cent.). Of 512 infants discharged from St. Mary's Maternity Hospital, 329 were up to or over birth weight (64 per cent.). 169 Twins and Triplets. There were 23 cases of Twins and none of Triplets. There was no maternal death. Mayday Mayday St. Mary's Hospital Hospital Mat. Hosp. Booked. Emergency. Booked. Total. Number of cases 14 3 6 23 Number of infants discharged alive 21 2 10 33 Number of stillbirths and infant deaths 7 4 2 13* Foetal and infant mortality 25% 66% 16% 28.2% *Of this number, 5 weighed less than 21bs. at birth. POST-NATAL AND GYNAECOLOGICAL CLINIC. In 1937, 63 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 1936. Number of Sessions held 104 Number of individuals presented 1,303 Number of subsequent attendances 764 Total attendances 2,067 Average attendance per session 19.8 Number of Post-Natal cases 899 Number of Gynaecological cases 404 Table XIII. POST-NATAL CASES. After confinement at Mayday Hospital. St. Mary's Hospital. Elsewhere. Totals. Total cases 468 397 34 899 Crises found to be normal 403 342 30 775 Cases found to be abnormal 65 55 4 124 END RESULTS. 871 cases were treated to their termination (other than death) luring 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). (87%). 170 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). (11%). 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%). Mayday St. Mary's Hospital. Hospital. Elsewhere. Totals. Result I 433 362 30 825 Result II 20 15 5 40 Result III 4 2 0 6 Totals, treated to conclusion 457 379 35 871 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). Eleven deaths occurred of mothers dealt with by the service, one of these, however, a case of sepsis, only came under the service after the onset of sepsis. 4 deaths occurred in " Emergency " cases, and 6 in Booked " cases. The maternal mortality of " Booked cases, i.e., cases under the continued supervision of the service was 4.3 per 1,000. 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 births. 171 REPORT OF THE PUERPERAL ISOLATION WARDS, 62 cases were treated in isolation for puerperal infection, 28 of them in the Borough Hospital Puerperal Infection Unit and 34 in Isolation Wards at Mayday Hospital. There were 2 deaths (32 per cent.). Table XIV. SOURCES OF THE CASES. From Mayday Hospital— Cases. Deaths. " Booked " cases 10 30 1 " Emergency " cases 20 From St. Mary's Maternity Hospital 22 ... 0 From other hospitals 0 ... 0 From private doctors, deliveries in nursing homes 10 ... 1 From private doctors, deliveries at home 49 cases followed Labour with 2 deaths (4 per cent.). 13 cases followed Abortion with no deaths. The 61 cases treated may be classified as follows:— Cases. Deaths. Mortality Rate. 1) Patients with infection of the genital tract 35 2 3% (a) Infection limited to uterus, vagina and perineum 30 0 0% (b) Infection involving pelvic cellular tissues, ovaries, Fallopian tubes, pelvic peritoneum or veins 11 0 0% (c) Infection of the birth canal spread beyond the pelvis (general peritonitis, septicaemia, etc.) 5 2 40% 2) Patients with infective conditions not originating in the genital tract 6 0 0% Factors Bearing on Aetiology. No. of cases with infection. (genital) No. of cases with infection. (non-genital) Uncomplicated labour 12 4 Long labour 2 0 Surgical induction of labour 0 1 Instrumental delivery 10 0 Spontaneous abortion 0 0 Evacuation of abortion 13 0 Manual removal of placenta 3 0 Excessive bleeding 4 0 Severe lacerations 1 0 Other interference 2 1 Caesarean Section 8 0 The large proportion of cases drawn from deliveries in May­ day Hospital is accounted for by 13 cases of septic abortion. 172 OBSTETRIC CONSULTATIONS. As Consulting Obstetrician to the Borough, the Assistant Medical Officer of Health for Obstetrics was called in by medical practitioners to see 12 patients who could not afford to pay a private consultant. The cases were as follows: Pueperal pyelitis, persistent vomiting of pregnancy, disproportion (2), puerperal septicaemia, prolonged labour, puerperal sepsis, puerperal pyelitis, obstructed labour due to ovarian cyst, pre-eclampsia, puerperal sepsis and fibroid, puerperal parametritis, and cerebral haemorrhage (baby) after forceps delivery. In addition, he was asked by the Medical Superintendent of Mayday Hospital to give an opinion on the obstetric and gynaecological aspects of 19 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. A new Clinic was opened at Selhurst during the year, whilst the Moffat Road Centre was closed down owing to the small number attending. During 1937, 2,446 new cases under 1 year of age, and 912 over a year of age attended for the first time; this is an increase of 212 in the first class and of 140 in the second class. The total attendances of infants and young children from 0—5 years increased from 76,109 in 1936 to 79,851 in 1937. Consultations with doctors decreased in numbers from 23,733 to 23,024. 101 expectant mothers were seen, a decrease of 130 on 1936, and a total of 688 visits to the Centres were paid by them. The total of all visits to the Centres was 80,629, an increase of 3,390 compared with 1936. The highest average attendance of mothers and babies at each session was recorded at Municipal (101.6), St. Andrew's (96.5), South Croydon (92.6), and Waddon (90.5). 173 Attendances at Infant Centres- 1937 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. Selhurst. ‡ Total 1937. Total 1936. Total 1935. Total 1934. Total 1933. Infants: New cases under 1 year 388 109 141 138 119 1ll 253 207 94 11 205 138 95 80 90 79 122 66 2446 2234 2224 2190 2194 No. of re-attendances 5979 1710 2255 1981 1555 1926 3721 3368 1285 264 3420 2056 1753 1561 1569 1506 2171 505 38585 35866 36235 33227 36620 New cases over 1 year 96 42 38 51 34 41 101 63 59 4 73 43 43 35 51 36 32 70 915 772 857 1019 1027 No. of re-attendances 3611 2095 2182 2367 1846 1849 3246 3533 1674 294 3561 1670 1550 1894 1769 2499 1711 557 37908 37237 39983 36403 37622 Attendances of children 0-5 10074 3956 4616 4537 3554 3927 7321 7171 3112 573 7259 3907 3441 3570 3479 4120 4036 1198 79851 76109 79299 72839 77463 Consultations with Doctor 2624 1055 1149 1125 797 994 2152 2579 970 181 2353 1156 889 1321 871 1159 1098 551 23024 23733 23924 24721 25251 No. of Sessions 100 50 48 49 48 49 97 99 49 12 97 48 49 50 47 47 48 30 1017 1030 991 978 979 Expectant Mothers: No. of new cases 18 ... 1 ... 13 6 ... 13 3 ... 3 4 4 3 5 25 2 1 101 231 195 312 305 No, of re-attendances 73 51 18 ... 19 12 ... 128 54 2 6 22 3 44 24 108 12 11 587 899 657 826 906 Total attendances of pectant Mothers 91 51 19 ... 32 18 ... 141 57 2 94 26 7 47 29 133 14 12 773 1130 852 1138 1211 Total attendances 10165 4007 4635 4537 3586 3945 7321 7312 3169 575 7358 3933 3448 3617 3508 4253 4050 1210 80629 77239 80151 73977 78674 Average attendance per Session 1937 101.6 80.1 96.5 92.6 74.7 80.5 75.5 73.9 64.7 47.9 75.9 81.9 70.4 72.3 74.6 90.5 84.4 40.3 *79.3 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 * Total average attendance each week at all the Centres. ‡ Commenced in May. † Operating for 3 months only, 174 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 Deat s in Institutions Yes No Doctor Midwife Doctor & Midwife Not Known, etc. Yes No Not Known Mayday Hospital Regd. Maternity Homes St. Mary's Hospital Other Institutions 130 35 95 7 68 43 12 81 47 2 3263 67 12 11 7 2,446 babies under one year of age attended the Clinics for the first time during 1937. Within the same period 3,263 babies were bom and 195 died ; 65 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 precisely the same periods, the attendances of new cases at the clinics do not fluctuate so greatly as to cause serious error. Of the 130 babies tabulated who died, 35 had attended a clinic in Croydon and 95 had not attended, i.e., 27 per cent, of the deaths were in clinic babies and 73 per cent. in non-clinic babies. Of the 3,263 babies born, approximately 2,444 attended on calculation based on past attendances. The infantile mortality, estimated on this basis is only 14.3 per 1,000 births for the clinic babies, and 116 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, 73 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; 66 per cent, of babies under 1 year were being breast fed at their first visit, this figure being less than 1936 (69); 58.4 per cent. of the ailing babies were suffering from digestive troubles, 17.9 per cent. from respiratory trouble, and 5.6 per cent. from rickets. 176 The individual centres showing the highest percentage of babies found healthy on their first visit were Waddon (96) and East Croydon and St. Jude's (95), Municipal and South Croydon with 94, and Woodside with 91 were next. The centres showing the highest percentage of babies found ailing on their first visit were Holy Trinity and St. Oswald's, followed by St. Andrew's and St. Paul's. Breast feeding seemed most usual in babies attending St. Alban's, Waddon, and St. Jude's Centres, and least usual in cases attending Norbury, St. Paul's and Holy Trinity Centres. In children over one year of age, attending for the first time, the highest percentages healthy were shown by East Croydon (90), St. Jude's (88), and South Croydon and Waddon (84); the highest percentages found unhealthy were at St. Oswald's (61), St. Andrew's (46), and Holy Trinity and St. Alban's (43). The largest number of first attendances was recorded at the Municipal Centre, followed by East Croydon, St. Alban's, and South Norwood. These Centres hold two sessions weekly. 176 The Conditions of Babies on First Attendance at a Maternity and Child Welfare Centre. Table XYII. Babies Under One Year. Children Over One Year. No. found healthy on 1st visit. Percentage. No. found ailing on 1st visit Digestive Troubles. Rickets. Respiratory Troubles Other Causes. Babies on Breast Feeding only. Percentage. Babies Bottle fed only. Babies partly breast and partly bottle fed. No. found healthy on 1st visit. Percentage. No. found ailing on 1st visit. Digestive 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. Municipal (2) 417 94 26 15 1 3 7 275 62 86 56 65 82 14 3 3 0 8 1 78 99 0 0 0 522 St. Albans (2) 141 78 40 20 3 11 6 166 86 42 14 37 57 28 7 7 6 8 0 53 82 0 2 10 246 Boston Road 75 79 20 14 2 3 1 60 63 27 8 24 65 13 4 2 6 1 0 36 97 0 0 1 132 West Croydon 57 78 16 8 1 1 6 43 59 19 11 20 80 5 1 1 1 2 0 25 100 0 0 0 98 Norbury 63 80 16 4 0 2 10 33 42 18 12 30 68 14 5 2 5 2 1 26 59 0 7 10 123 St. Paul's 100 74 36 18 5 7 10 71 52 55 10 28 68 13 4 1 3 5 0 30 73 0 0 11 177 Holy Trinity 41 60 27 15 0 9 3 38 56 21 9 35 56 27 5 5 6 11 0 59 95 0 1 2 130 Shirley 95 83 20 12 0 6 2 82 71 21 12 19 83 4 2 0 2 0 0 23 100 0 0 0 138 South Croydon 125 94 8 2 0 2 4 92 69 32 9 47 84 9 0 1 2 6 0 55 98 0 0 1 189 South Norwood(2) 150 79 39 18 4 6 22 129 68 51 9 35 65 19 4 3 5 7 0 54 100 0 0 0 243 St. Andrew's 90 73 34 31 0 3 0 85 69 29 10 14 54 12 1 4 1 6 0 24 92 0 1 1 150 Upper Norwood . 61 74 21 13 2 4 2 48 59 31 3 31 79 8 1 2 1 4 0 39 100 0 0 0 121 Waddon 87 96 3 1 0 1 1 68 76 9 13 21 84 4 0 2 0 2 1 24 96 0 0 0 115 East Croydon (2). 174 95 9 7 0 1 1 130 71 39 14 111 90 12 0 0 2 10 0 123 100 0 0 0 306 Woodside 90 91 9 4 1 3 1 67 68 26 6 33 75 11 5 1 4 1 0 44 100 0 0 0 143 St. Oswald's 61 68 29 22 1 2 4 55 61 23 12 12 39 19 3 6 2 8 0 30 97 0 0 1 121 St. Jude's 96 95 5 5 0 0 0 76 75 19 6 21 88 3 1 1 1 0 0 24 100 0 0 0 125 Totals 1923 84 868 209 20 64 80 1508 66 548 214 583 73 215 46 41 47 81 3 747 94 0 11 37 3079 Table XVIII. The Work of the Health Visitors.- Maternity and Child Welfare Only. I. II. III. IV. V. VI. VII. VIII. IX. X. a XI. XII. b XIII. c XIV. XV. XVI. XVII. d XVIII. e XIX. XX. XXI. XXII. XXIII. XXIV. XXV. Totals. C.W. R.A. A.W. W. M.S. A.P. A.W. J.C. E.H. A.H. K.T. v.c. M.C. R.S. M.B. c. Wa. P.C. I..P. B.E. M. W. I.E. A.O. l.W. D.S. j.A. Others Sessions attended at Infant Welfare Centres 92 54 95 43 ... 73 45 43 52 16 94 12 38 4 52 45 47 11 26 22 56 43 49 90 14 1116 Visits to Expectant Mothers. First visits 30 2 35 18 1 4 7 32 5 10 14 1 4 ... 4 16 10 8 ... 1 ... ... ... 4 4 210 Re-visits 19 1 8 5 1 4 8 37 ... 4 4 2 1 ... ... 35 6 10 ... ... ... 1 ... 1 ... 147 Infants under 1 year. First visits 142 81 118 99 254 251 195 251 177 87 154 15 126 12 79 221 140 56 79 217 279 110 228 148 82 3601 Re-visits 323 195 342 130 173 343 413 907 764 228 459 127 287 12 392 914 250 87 226 375 394 306 354 473 99 8573 Children 1-2 years. First visits 6 ... 1 2 4 1 21 6 3 2 10 ... 4 2 7 4 15 1 2 32 7 5 3 1 139 Re-visits 376 173 291 135 121 430 364 603 561 209 466 63 256 19 304 832 399 158 190 570 380 210 248 316 130 7804 Children 2-5 years. First visits 13 ... ... 6 1 3 14 6 2 9 5 ... 5 1 7 4 9 ... ... 2 14 4 5 3 4 117 Re-visits 901 503 587 458 498 727 293 1056 706 458 665 66 459 30 394 1076 413 180 426 485 512 512 419 817 186 12827 Ophthalmia Neonatorum. First visits 5 ... ... ... 2 ... ... ... 2 ... ... 1 ... ... ... 1 1 ... 1 1 1 ... ... ... ... 15 Re-visits 1 1 ... ... ... 1 ... ... ... ... ... ... ... ... ... 2 2 ... ... ... 1 ... ... ... 8 Still Births 8 1 2 3 ... 6 3 3 8 2 4 ... 3 1 3 1 1 2 l 12 4 1 10 4 3 86 Milk (Mothers' and Children's Order) 4 18 ... 7 ... 1 7 2 2 ... 5 ... 43 3 29 1 13 2 28 11 8 ... 41 12 1 238 Puerperal Fever and Pyrexia Visits ... ... ... ... ... ... ... ... ... ... ... ... ... ... 4 ... ... 1 ... ... ... ... ... ... 1 6 Houses where deaths of Infants occurred 10 3 11 5 13 9 3 3 9 3 5 1 1 ... ... 2 10 6 14 9 5 3 4 6 5 140 Miscellaneous Visits 20 3 4 87 16 10 3 12 31 53 22 4 14 1 14 5 9 17 5 11 13 21 ... 7 27 409 Ineffective Visits 481 168 340 371 394 434 420 171 382 230 607 69 599 11 228 457 299 60 480 972 283 515 233 307 170 8681 Post Natal Visits ... ... ... ... ... 8 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 8 Totals—1937 1936 2431 1203 1834 1369 1478 2305 1796 3132 2704 1311 2514 361 1840 96 1517 3616 1624 598 1477 2690 1981 1734 1596 2191 727 44125 2606 1456 1512 1142 458 2371 1593 3058 1734 1642 2531 2661 2631 ... 2036 3438 2895 1779 ... ... ... ... ... ... 3183 43350 a 3 months sickness. b Partially incapacitated c Left 6/11/37. d Left 30/11/37. e Left 7/4/37. 177 178 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, 1936. New cases during the year. Cases discontinued. On Dec. 31st, 1937. Free 299 954 807 446 Half-price 84 208 223 69 Total 383 1,162 1,030 515 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 132 in assisted milk cases. Assisted Fluid Milk Scheme. The amount of milk granted was 173,000 pints. In 1936 it was 111,000 pints. Table XX. Supplied to Families. No. of Pints. Corporation Liability. £ s. d. Milk at 1½d. pint 29,000 143 8 10 Milk Free 144,000 1,949 0 9 173,000 £2,092 9 7 Dried Milk (Coupon) Scheme. The amount of dried milk granted free or at half-price was 11,480 packets. In 1936 it was 7,910 packets. Table XXI. No. of Packets. Corporation Liability. £ s. d. Dried Milk at Half-price 2,290 79 2 6 Dried Milk Free 9,190 692 5 0 11,480 £771 7 6 179 In addition, during the year 17,000 packets of dried milk were obtained from the chemists at cost price, through the Coupon Scheme. During 1936, 18,000 packets were obtained. The increase in the amounts of milk supplied during the year is due to the putting into operation of Circular 1519 issued by the Ministry of Health dated 1st April, 1937. Massage Clinic. The Massage Clinic in connection with the Maternity and Child Welfare Scheme is held at 47, St. James' Road on five afternoons a week. Cases are referred thereto by the doctors at the Infant Welfare Centres. A few cases are also referred from the Orthopaedic Clinic and from London Hospitals. The following Table summarises the work done, and indicates the type of case referred. Total number of female patients 33 „ male patients 67 Total 100 Table XXII. Conditions for which referred. Males. Females. Total. Pigeon-chest 1 - 1 Talipes 3 1 4 Weak legs 5 7 12 Bow legs 34 10 44 General debility 3 2 5 Knock-knees and flat feet 16 8 24 Hemiplegia 1 - 1 Torti-collis 1 3 4 Ventral hernia 1 - 1 Ankylosis - 1 1 Infantile paralysis 1 - 1 Spastic diaplegia 1 - 1 Scoliosis — 1 1 67 33 100 Total number of sessions 249 „ „ attendances 1,437 Average attendance per session 6 Cases still under treatment at end of 1937 35 180 DENTAL TREATMENT FOR MATERNITY AND CHILD WELFARE PATIENTS. Expectant and nursing mothers and young children requiring treatment are referred by the medical officers attending the Ante-Natal and Post-Natal Clinics. Now that there has been inaugurated a Municipal Midwives Service women may be referred from this source for treatment as if they had been referred from the Ante-Natal Clinic. Four dental officers devote one-eleventh of their time to the treatment of expectant and nursing mothers and young children. This small amount of time is inadequate to deal with the large number of cases awaiting treatment, and in the circumstances it has been impossible to treat all the cases referred by the medical officers. There were 206 cases awaiting treatment on December 31st, 1937. It is hoped that a new appointment will be made in 1938, and it will be possible then to offer a more complete service for the treatment of these patients. The following table gives a summary of the work accomplished during the year for patients referred under the Maternity and Child Welfare treatment scheme: — Expectant. Nursing. Young Children. Total. 1937. 1936. Number Examined 239 161 335 725 697 Referred for Treatment 225 149 295 669 505 Attendances 695 1077 698 2470 1171 Fillings 172 216 293 681 403 Extractions 871 917 917 2705 2217 "Gas" Cases 106 139 205 450 365 Local Anaesthesia 199 198 16 313 322 Scalings 72 57 — 129 114 Dressings 119 91 49 259 178 Denture Dressings 76 397 — 473 310 Gum Treatment 18 16 — 34 47 Silver Nitrate 2 — 20 22 7 181 Number of Sessions (Treatment) 178 Dentures fitted 181 Inspections at Centres 5 Appointments kept 79.8% Expectant Mothers. The volume of work carried out for the expectant mother has increased during the year. The number examined was 239 as against 209 in 1936. The most encouraging feature is that conservative measures totalled 291 as compared with 188 in the previous year. This is due in a very large measure to the excellent work of the medical officers, who have referred patients for dental examination during the early months of pregnancy. The younger women appear very glad to avail themselves of the opportunities for treatment, and consequently there has been a considerable reduction in the incidence of broken appointments. It is expected that in 1938, when more sessions will be available for the work, that immediately pregnancy has been confirmed the patients will be sent to the dental department for examination and treatment, if required, as it is extremely important that dental sepsis, if present, should be removed without delay. It is regretted that more teeth had to be extracted and more dentures fitted, but as pointed out in other reports, many of the women's teeth are in such a poor state that conservative treatment is often impossible. It has been noticed that there is a tendency for more women to seek treatment during the early months of pregnancy. The percentage treated up to the third month was 31.2 as compared with 30.7 in 1936. Between the fourth and sixth months the percentage was 44.4; that is slightly lower than in the previous year. From the seventh month onwards 24.4 per cent. were treated during this period as compared with 22.8 in 1936. These percentages show that the greater number of pregnant women received treatment during the first six months of gestation. Nursing Mothers. The number of nursing mothers examined was 161. This if. an improvement on 149 examined in 1936. Attendances showed a welcome increase from 732 in 1936, to 1,077. Fillings and other operations to the teeth totalled 307, as compared with 252 in the previous year. 182 Age of Baby when Mother was First Seen. 1-3 mths. 4-6 mths. 7-9 mths. 9-12 mths. 21.6 22.9 44.5 10.8 Those mothers seen when the baby was 1 to 3 months were referred late in pregnancy, and it was impossible to call them up for treatment before the baby was born. The percentage of 44.5 seen for the first time when the age of the baby ranged from 7 to 9 months emphasises the fact that although there has been a great improvement in the number of women treated during the early months of pregnancy, the proportion of those who wait till the nursing period is still too high. The treatment for those referred late in the nursing period is confined to the elimination of pain and sepsis. The Pre-School Child. The number of young children examined was 335, i.e., an increase of 61 on the figure of 1936. Attendances improved by approximately 45 per cent., and conservative measures totalled 353, as against 146 in 1936. This is very gratifying, as it shows that more parents are beginning to realise the importance of remedial treatment. It is regrettable that a certain number of toddlers of eighteen months and under were referred for the extraction of upper incisor teeth. The dental suffering which these children endured was caused through sucking "dummies" dipped in sugar, which produced rapid decalcification of the teeth. The increase in the number of extracted teeth suggests that there is a need to educate parents to bring their children much earlier to the clinics for periodical examination, so that small defects may be treated before thev become too extensive. Neglect of such precautionary measures may lead to unnecessary pain and loss of important teeth. When treatment is completed parents are invited to write to the Clinic at the end of six months for another appointment so that further examination may he carried out. The excuse that some mothers offer for not bringing their children to the Clinic before the "toothache" stage, is that the teeth "came through bad" and they thought it was not worth while having anv conservative treatment. Tt is sometimes hard 183 to convince such mothers that it is a fallacy to imagine that teeth erupt in an unhealthy condition. Some of the teeth may be of a softer structure than the others, but they are nevertheless free from disease when they grow through the gums, and may be kept healthy by proper diet, and prophylactic measures and by frequent examination by the dentist. In the report of the School Dental Service reference is made to an investigation carried out into the incidence of malocclusion and types of deformity which frequently appear in the jaws of children who have prematurely lost their deciduous teeth. These defects when treated often take a long time to correct, and cause a certain amount of inconvenience to the child. If parents would take more care of their children's temporary teeth a large proportion of this treatment would not be necessary, and consequently there would be a great saving of time and energy to both parent and dentist. It is desirable that there should be a complete scheme of inspection and treatment, if required, for all children of preschool age irrespective of their having attended a Welfare Centre. It is only by the inauguration of a complete system of dental supervision that it is possible to control the incidence of dental disease in the young child. The Centres at which patients were examined, 01 from which they were referred, are given in the following list:— Ante-Natal 341 Post Natal 7 Municipal 78 East Croydon 53 Upper Norwood 16 West Croydon 29 South Norwood 46 South Croydon 50 St. Alban's 45 Woodside 17 Norburv 24 St. Paul's 21 St. Oswald's 22 St. Andrew's 42 Waddon 55 Shirley 12 Boston Road 27 St. Jude's 34 Holy Trinity 6 Nursery School 5 The Creche 1 Total 931 184 The amount received for attendance fees was £69 13s. 4d. as compared with £52 14s. 8d. in 1936. Convalescence Committee of the Croydon Mothers' and Infants Welfare Association. This Committee undertakes the arrangements for conva lescence 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, January—March, 1937 5* Total number of children under 5 sent by the Association during the year to other Convalescent Institutions (two alone, and four with mothers) 6 Number of mothers sent for convalescence 117 Number of children under 5 sent with their mothers to cottages (this includes 5 who went to relations) 156 A grant of £500 was made by the Council to the Association for this work in 1937. The year is the financial year. Children under 5 sent to Homes. Total number of weeks. Cost. Cost of other forms of Convalescence. £ s. d. £ s. d. 1934—1935 48 337 279 10 10 470 3 4 1935—1936 25 240 212 11 6 427 9 0 1936—1937 35 255 198 11 1 353 0 8 1937—(April 1st to Dec. 31st) 6 25 30 2 4 389 7 1 *As from 1st April, children under 5 ceased to be sent to Coombe Clin through the auspices of the Croydon Mothers' and Infants' Welfare Association, but were sent directly by reference of the medical officers of the Welfare Centres. Home Helps. From January 1st to December 31st, 392 mothers applied for Home Helps, and all applications were supplied. £113 16s. 0d. was collected in payment for their services. At the end of the year there were 21 names of Home Helps on the register. This service has shown a very considerable growth during the year. 185 Babies Help Report. I am indebted to Mrs. Philpott for the following particulars:— "In January, 193.7, the Committee was helping eight cases, during the year twenty mothers and babies were helped and in December nine names were on our books. One baby was admitted to hospital with eczema but our other babies are very well. Clothes, prams, cots and fire-guards have been given and we always welcome gifts of any of those things. The grants are paid at the centres and we thanks the health visitors for their very willing co-operation in the work." Croydon Rescue and Preventive Association. This Association has a Home for Girls 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. The Creche, Whitehorse Road. The Council give an annual grant of £300 towards the cost of this Creche. A total of 6,460 attendances was recorded. New and modern premises have been built in Whitehorse Road and were opened early in 1937. Towards the cost of this the Council made a grant of £875, and the annual grant was increased to £300. COOMBE CLIFF CONVALESCENT HOME. The following is a summary of the cases dealt with:— Number of cases admitted during the year—121. Total number of cases discharged—152. Number of patient days—56.4 per patient (1937 cases). The Home was closed for the admission of convalescent children from the middle of November until the year ended. During this time it was utilized for Scarlet Fever cases transferred from the Borough Hospital, in order to meet the emergency caused by the outbreak of Typhoid. 186 Table XXIII. Age groups of cases admitted. 0—4 5—8 9—12 Over 12 Total Male 7 32 16 4 59 Female 11 28 20 3 62 Total 18 60 36 7 121 Average length of stay in similar age groups. 0—1 5—8 9—12 Over 12 Total (days) Male 81.6 62.1 62.3 14.2 55.1 Female 73.4 73.2 63.8 23.9 58.6 Total 77.5 67.6 63.1 19.0 56.8 Condition on discharge. 0—1 5—8 9—12 Over 12 Total M. F. M. F. M. F. M. F. M. F. Improved 3 2 11 17 22 6 3 2 39 27 Much Improved 2 4 12 10 12 5 2 1 28 20 No change 2 3 5 4 5 5 3 — 15 12 Discharged at parent's request 1 5 3 — 1 — 1 — 6 5 Total 8 14 31 31 40 16 9 3 88 64 CHILDREN ACTS, 1908—1933. Since April, 1930, this Act has been administered by the Health Department. The work has been delegated to the Health Visitors, who are made responsible to the Medical Officer of Health for all foster-children and foster-mothers in their respective districts. The Tables below give figures for 1937: — Table XXIV. FOSTER CHILDREN No. as at Dec. 31st 1936 Notice of Reception of Children during the year Notice of removal to— Children Adopted Died Children reaching age of 9 No. as a Dec. 31s 1937 Parent Another area with Foster Parent Another Foster Mother Public Institution 276 336 158 3 51 34 27 5 10 324 The number of foster-children showed an increase or during the year. 187 Table XXV. FOSTER MOTHERS. No. as at December 31st 1936 Applications for Registration during the year. Removals during the year Registration cancelled for other reasons No. as at December 31st 1937 With Child Without child 146 45 3 1 8 179 The number of foster-mothers increased by 33 during the year. 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 fostermother has children of her own to ignore these in her statements as to the number of foster-children she can look after. 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, but only to notify their intention to take a foster-child. 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 all 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. Unsuitable persons are taking foster-children, but effective action cannot be taken under the powers conferred on local authorities. There is urgent need for the legal position to be clarified and strengthened. The Health Visitors paid 2,808 visits to foster-mothers for the purpose of supervision 188 SECTION IX. MENTAL DEFICIENCY. The staff of the department dealing with mental defectives 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 Teachers 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, Probation 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 100 Over 16 years 564 Total 670 II. Education Cases— Aged 7—16 years 157 Combined Total 827 189 Compared with 1936, the Statutory cases show an increase of 98 and the Education cases a decrease of 1. There was a steady increase due wholly to routine ascertainment. Seven of the cases under Statutory supervision have died. Six died at home and 1 in an Institution. The Statutory cases are distributed as follows:— In Certified Institutions 141 In Places of Safety and Approved Homes 7 On Leave from Institutions 10 Under Statutory Supervision at Home 348 Under Guardianship 57 In Mental Hospitals 20 Cases under Public Assistance 20 Observation Cases 67 There is a continued 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. The Education cases were distributed as follows:— In Certified Residential Schools 13 In Certified Day Schools 130 At Private Schools 8 At Council Schools (awaiting vacancies at St. Christopher's) 1 Released for work 5 During the year the Certifying Medical Officers made examinations and paid visits to the number of 150 to Statutory cases and 213 to Education cases—a total of 363, a decrease of 68 compared with 1936. The Mental Deficiency Visitors paid 2,395 visits to Statutory cases and 2,076 Education cases, 4,471 visits in all, an increase of 325 on 1936 figures. During the year 98 names have been added to the Statutory list—29 of these being notified from the Local Education Authority, and the remaining 69 from other sources. 2 names have been removed from the list. 5 cases chargeable to other Local Authorities are under supervision in the Borough. 190 Notified Cases. Of the 29 cases notified by the Local Education Authority— 3 are now in a Certified Institution; 6 are attending the Occupational Centre; 15 are at work; 5 are at home, of whom 3 are awaiting admission to Institutions. During 1937, twenty-two Statutory cases were dealt with as follows, viz.:— Sent to Certified Institutions 6 Placed under Guardianship 4 Sent to Croydon Mental Hospital 4 Transferred from the Public Assistance Committee to the Mental Deficiency Committee 2 Varying Orders— (a) Change of Guardian 2 (b) From one Institution to another 2 4 Orders Closed by operation of Law 2 22 20 Orders were renewed during the year—16 of which were guardianships. The number of cases sent to Certified Institutions shows a decrease of 5. Guardianship Cases. There are 57 cases under Statutory guardianship—33 of these under the care of relatives, and 24 with guardians who are not relations. 8 males and 6 females are at work. 22 cases are out of the Borough; 14 under the Brighton Guardianship Society; 1 in Maidstone; ;1 in Godalming; 1 in Streatham; 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 Grangewood. 38 of the guardianship cases are doing useful work under supervision and 19 are quite unemployable. 5 of the patients are under supervision for other Authorities. 4 new cases have been placed under guardianship. 191 351 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 on licence to an employer 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. Five are girls, 4 in regular work and 1 is at home. One has died. 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 1937 opened with 126 scholars on the roll. During the year 33 children were admitted, and 29 left, leaving 130 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 321). Town Hall Clinic for Mentally Defective, Backward and Abnormal Children. 94 children were examined during 1937. The classifications arrived at, together with the recommendations made, are summarised as under:— I. (a) Certified as Mentally Defective 34 (b) Confirmed as Mentally Defective 12 46 Recommendations— (a) Recommended for Special Day School 31 (b) Recommended for Residential Schools 3 (c) Referred to Occupation Centre or Institution 8 (d) Observation at home 3 (e) For further trial at Ordinary Elementary School with glasses 1 46 II. Found to be dull and backward 38 (a) Referred to a Special Class 19 (b) Further trial in Ordinary Class 10 (c) Deferred pro tem 7 (d) Recommended to Royal Normal College for the Blind 1 (e) Continue at St. Luke's 1 38 192 III. Found to be Physically Defective 4 (a) To attend St. Giles' 1 (b) Observation at home 2 (c) To continue at Ordinary Elementary School 1 4 IV. (a) Considered to be of normal intelligence and referred to technical school 1 (b) Referred to Child Guidance Clinic 1 (c) Mother advised and observation at home 4 6 V. Mental and physical examinations at St. Christopher's School 96 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 open 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 to 4 p.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. The training consists of personal daily hygiene, domestic training appertaining to help with mid-day meal in kitchen, laying of meal tables, serving meals, cleaning plates, washing up, polishing, sweeping. Boys— Handwork: Sea-grass stools, cane waste-paper baskets, teapot stands, work baskets, cane bordered trays, wool and canvas rugs and bags. Woodwork—learning to use tools, making apparatus for sense training, and small weaving frames. Girls—Handwork: Knitting baby shoes, dish cloths, baby coats. Needlework: Useful aprons, peg bags, simple rugs, chair seats, bedsocks, hot-water bottle covers. Paper cutting, free drawing; Plasticene. Action songs, poems. Games are also given. 193 Babies' Class.—Knitting on wooden needles, simple bedroom slippers, wood balls, paper cutting, pictures, paper flowers, etc.; weaving on string frames, knitting dish cloths. Girls' Afternoon Class.—Knitting dish cloths, tapestry wool work, tea cosies, etc.; embroidery on crash, painting on vellum, Christmas articles, plate mats, d'oyley cases, paper cases. Classes of physical training for both girls and boys are given, two lessons each week; also a mixed class for country dancing, which is making good progress. The physical training classes have shown very good results. All classes have period for sense training, speech training, education individual games, also to learn to tell the time. Special period of physical training, team collective games, singing of seasonable nature songs, poems, dealing with same, observation of nature when possible. 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. During the year the Centre has had Coronation mugs and books. Has also exhibited handwork at the Surrey Handicrafts Exhibition, and held sales of work at the Centre. At Christmas the children had a Christmas tree tea, with a period of Christmas carol singing. Gifts were provided for every case attending the Centre, and about 50 parents and friends attended and were given tea. I he sale of handwork during the year amounted to £3 10s. Most sales were made by basketry, sea-grass stools, small rugs, girls' useful needlework articles, and knitting. The Centre during the year has also had a medical examination of children in attendance. A mid-day meal is given at 1s. 6d. per week, and 22 cases during the year were given free dinners. Cocoa made with milk is partaken of at 10.30 every morning by the children. Special milk is also provided where needed. 194 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, 19J7 54 No. of pupils who left during the year 5 No. of pupils admitted during the year 8 No. of pupils on register January 1st, 1938 57 Total attendances 8,306 Average attendances 37 Average afternoon attendance— Senior girls' class 2 Senior boys' class 1 Sessions held 217 Girls' Afternoon Class— Total attendances 248 Sessions held 131 Boys' Afternoon Class— Total attendances 115 Sessions held 91 195 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 Orthopaedic institutions for in-patient treatment. The after-care organiser of the Department attends at each session. In addition to the Clinic at the General Hospital, concerning which only the tables below 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 Medical Officers at the Welfare Centres. Table I. Summary of Cases Attending the Orthopedic Clinic. Jan.'1st, 1937. New Cases, 1937. Cases Discharged, 1937. Cases on books, Dec. 31st, 1937. M.C.W. S.M.S. T uberc. M.C.W. S.M.S. T uberc. M.C.W. S.M.S. T uberc. M.C.W. S.M.S. T uberc 172 209 43 1ll 154 19 119 132 14 63 229 48 424 284 265 40 196 Table II. Cases Seen by the Orthopedic Surgeon. Defect. School. M.C.W. Tuberculosis. Total. Cases. Visits paid. Cases. Visits paid. Cases. Visits paid. Cases. Visits paid Infantile Paralysis 18 57 5 19 ... ... 23 76 Curvature or postural defects 35 79 2 3 ... ... 37 82 Pes Cavus 7 21 2 2 ... ... 9 23 Pes Planus 112 224 30 58 ... ... 142 382 Genu Valgum 28 45 88 164 ... ... 116 209 Talipes 4 23 18 67 ... ... 22 90 Obstetrical Paralysis 1 1 3 5 ... ... 4 6 8 41 ... ... 28a 72a 51 161 Toint Disease 13s 45s 2m 3m Injuries 13 26 1 3 ... ... 14 29 Rickets 7 10 15 30 ... ... 22 40 Wry Neck 6 15 1 3 ... ... 7 18 Spastic Paraplegia 15 44 3 8 ... ... 18 52 Other Deformities 47 87 28 61 ... ... 75 148 301 673 196 423 43 120 540 1216 Summarised, the Table shows 301 school children attended and made 673 attendances; 196 babies made 423 attendances; and 43 tuberculosis cases made 120 attendances; a total of 540 cases, making 1,216 attendances. These figures show a small decline upon 1936. 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. 197 Table III. Cases referred, from Orthopæedic Clinic for Remedial Treatment and X-Ray at Croydon General Hospital. Defects School Cases M.C.W. Cases Tuberculosis Cases Total Cases No. of Treatments X-Rays Cases no. of Treatments X-Rays Cases No. of Treatments X-Rays Cases No. of Treatments X-Rays Infantile Paralysis 5 59 2 4 171 9 230 2 Curvature or postural defects 14 322 6 14 322 6 Pes Planus 10 130 2 13 12 143 Pes Cavus 6 87 2 6 87 2 Talipes 3 19 1 4 134 2 7 153 3 Genu Valgum 4 37 4 37 Obstetrical Paralysis 1 7 1 7 Disease 10 10 12 1 2 28 29 32 39 39 46 Iayuries 3 22 2 3 22 2 Rickets 2 3 1 2 3 1 Tarticollis 4 57 1 7 6 64 Spastic Paraplegia 2 33 2 23 Other Deformities 15 22 12 8 3 11 23 25 23 74 754 38 25 372 15 28 29 32 127 1155 85 Table IV. Cases Sent to Residential Institutions. Nime of Institution School Cases M.C.W. Cases Tuberculosis Cases Total No. in on Jan. 1st. 1938. No. in on Jan. 1st, 1937. Admitted Discharged No. in on Jan 1st, 1937. Admitted Discharged No. in on Jan. 1st, 1937. Admitted Discharged No. in on Jan. 1st, 1937. Admitted Discharged Pyrford 4 2 3 3 2 4 6s 1s 3s 17 5 12 10 4m 2m Croydon General Heritage Craft 1 15 15 1 5 6 3a 1a 2 23 22 3 Schools 2 1 1 1s 1s 3 2 1 4 Pinner 3 3 3 Treloar 1 1 1ts 1 1 1 1 Mayday 3 2 2 2 1a 5a 4a 1 10 8 3 6a 6a 4a 8 7 6 9 Royal Sea Bathing Hospital 2s 1s 2s 7 25 22 4 9 12 21 17 16 32 51 50 33 198 Table V. Conditions for which Patients were admitted to Hospital, and the results of treatments. Condition. In on Jan. 1st, 1937 Admitted. Discharged In on Jan. 1st, 1938. Cured. Much Improved. Improved. Infantile Paralysis 1 1 Tubercular Joint Disease 11 4 5 2 8 Other Joint Disease 4 6 3 1 6 Hemiplegia 1 1 Genu Valgum 1 4 4 1 Fes Cavus 1 1 Talipes 1 4 1 3 1 Rickets 3 1 3 1 Wry Neck 1 1 Other Deformities 4 2 2 Spastic Paraplegia 2 2 Scoliosis 3 3 21 31 11 19 5 17 Children sent through the Education Committee were not included in 1936, hence the discrepancy in the present figures with last year's. Nor were the adult tubercle cases previously included. The percentage of cures in cases discharged was 31 per cent., whilst 54 per cent. were much improved. Table to show number of cases from whom appliances were ordered and how the expenses thereof were met:— Total cases on books of this Clinic, January 1st, 1938 440 Total number actually in receipt of massage, electrical, Swedish remedial treatment on January 1st, 1938 12 New splints and appliances supplied 152 Repairs to existing appliances 29 Part cost met by parents 31% Full cost met by parents 40% Full cost met by local authority 29% Number of home visits Maternity and Child Welfare Massage Clinic 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. 199 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. 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, 1937. Arrived from Number of Planes. Paris. Amsterdam. Brussels. Elsewhere. Arr. Seen. Total: 9,188 3,836 4,210 2,212 1,233 1,533 Passengers. British. Others. Inspected. Exd. 42,910 40,827 33,113 147 These figures show a considerable increase on last year's figures both in the number of machines arriving and departing and in the number of passengers carried. This expeditious and safe method of travel is becoming steadily more popular. 200 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. HernamanJohnson. Cases were referred from the Maternity and Child Welfare Department (56), the School Medical Service (34), and the Tuberculosis Dispensary (2). The number of cases referred has increased by 28. 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 1937 School Medical 34 276 682 28 6 M. & C. W. 56 484 1374 41 15 Tuberculosis 2 18 42 2 - 92 778 2098 71 21 The Table under gives the complaints treated and the results achieved in completed cases. Nineteen ceased attending before completion of treatment, and three cases left the Borough. Table II. Condition. School Cases. M. & C. W. Cases. T.B. Cases. Total Completed Cases. Much Improved. Improved. Slight Imp. I.S.Q. Much Improved. Improved. Slight Impt. I.S.Q. Much Improved. Improved. Slight Impt. I.S.Q. Debility 5 7 4 3 12 3 - 1 — — — - 35 Bronchitis 2 - - - - - - - - - — — 2 Glands - - - - - - - - - - - - - Rickets - - - - 3 2 - - - - - - 5 Miscellaneous 3 - - - 1 - 1 - - 1 1 - 7 10 7 4 3 16 5 1 1 - 1 1 - 49 •201 Much Improved. Improved. Slight Impr. I.S.Q. Attending. Ceased Attending Total. Debility 17 10 4 4 8 43 Asthma— — — — 1 1 Bronchitis 2 — — — — 2 Glands — — — — 4 4 Rickets 3 2 — — 7 12 Miscellaneous 4 1 2 — 2 9 26 13 6 4 22 71 School Cases. Six school cases were still attending the Clinic at the end of the year. These were suffering from the following conditions, viz.:—General Debility, 3; Bronchitis, 1; Rickets, 1; Acne, 1. Maternity and Child Welfare Cases. Fifteen 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, 4; Rickets, 4; Bronchitis, 7; Glands, 1. Of the School cases, 18 were boys and 16 girls; the Maternity and Child Welfare cases, 34 boys and 22 girls; and the Tuberculosis patients, 2 males. All the cases referred to the Clinic had been carefully selected as likely to benefit; of those discharged, after completion of treatment, 42 per cent. were much improved, 46 per cent. were improved, and 12 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. Two types of lamps were used—the Mercury Vapour and the Carbon Arc; the former alone was used 52 of the cases; the latter alone in 16 cases, and both lamps in 3 cases. The use of artificial sunlight lamps in bathrooms is fraught with considerable risk and their installation should only be made under strict expert supervision. 202 BLIND PERSONS ACT, 1920. A revised scheme under Section 102 (1) of the Local Government Act, 1929, came into force on April 1st, 1937. 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 404 Number of blind who benefit from instruction in Braille or Moon Type (including those who already read) 100 Number of blind who benefit from pastime instruction 56 Number in remunerative handicrafts— (a) Home workers 34 (b) In workshops 7 (c) St. Dunstan's 11 (d) Workers not included in scheme 13 Home Teacher 1 The Health Visitors paid 850 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 peisons. (e) the defective blind; and (f) the unemployable blind persons in homes, mental hospitals or institutions. 203 204 M. = Males. F.=Females. T.= Total WELFARE OF THE BLIND—REGISTRATION. As at 31/3/38. TABLE I. 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. - - 1 1 2 8 3 11 6 2 8 30 27 57 22 20 42 54 53 107 21 28 49 50 76 126 (i) 192 (ii) - (i) 210 (ii) 2 (i) 402 (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. 25 15 40 4 10 14 10 8 18 15 9 24 14 15 29 26 21 47 21 31 52 22 26 48 20 31 51 15 29 44 20 17 37 TABLE III.—Children of School Age, 5—16. Normal Mentally Defective Physically Defective M. F. M. F. M. F. In Schools for the Blind 8 2 — - — — Other Schools — — — — — — Not at School — — — 1 — — TABLE IV.—Training and Employment. Age Period 16 and upwards. Employed Undergoing Training. (h) (i) (j) (k) By Blind Organisations (c) (d) (e) (f) (g) (a) Workshops (b) Home workers All others not included in (a) and (b) Total Employed Industrial Secondary Professional and University Trained but unemployed No training but trainable Unemployable 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. M. F. T. M. F. T. M. F. T. 5 3 8 21 13 34 21 4 25 47 20 67 3 3 6 1 1 — — — — — 2 — 2 130 185 315 183 208 391 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, Newevendors, &c. Home Teachers Knitters Labourers Massage Mat Makers Ministers of Religion Musicians and Music Teachers Netting Makers Porters, Packers, Cleaners Poultry Farmers School Teachers Ships Fender (Fendoff) Makers Telephone Operators Tuners Weavers Miscellaneous Total Mattress Makers Machinists Upholsterers Hand Machine Within Institution lor the Blind — 5 - - - - - - - - - - - - - - 1 - 1 - - - - 1 1 — — 3 - — - - - 13 In approved Home Workers Schemes - 2 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 34 Others (not pastime workers) - - - - — 1 — — - — 1 — 5 — — 1 — - — 1 2 2 1 2 — — — 4 — — — 20 Total — 7 - - — 1 — — - 5 1 — 5 1 - 1 1 — 13 1 3 2 2 3 - — 3 — 4 13 — 1 67 TABLE VI.—Physically and Mentally Defective (including those given in Table III.) (a) (b) (c) Combinations of (a) and (b) Combinations of (a) and (c) Combinations of (b) and (c) Combinations of (a). (b). (c) Total Mentally Defective. Physically Defective. (i) Deaf (ii) Deaf-mute 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 9 3 12 (i) 7 (ii) - (i) 6 (ii) 2 (i) 13 (ii) 2 1 — 1 — — — — - — — — 21 12 33 TABLE YII.—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. — 4 4 2 2 4 6 9 15 205 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, 1937, 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. Public Health Acts Amendment Act, 1890, Part 3 (sections 28, 29, 30, 31, 34, 35 , 37 to 46, 48, 49, 50 (part). Infectious Diseases (Prevention) Act, 1890 (part repealed). Public Health Acts Amendment Act, 1907, Sections 19, 20, 21, 28, 33. Public Health Act, 1925. Sections 14, 17, 18, 19, 23 to 26 (inclusive), 28, 30, 31, 33, 35. 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. 206 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) 3901 No. of houses inspected under the Housing (Consolidated Regulations) 1925 2141 No. of Houses inspected under the Rent Restriction Acts 47 No. of Houses inspected where zymotic diseases have occurred 716 House drains tested with smoke (primary) 1532 House drains tested with smoke (on application) — No. of smoke tests during repair 497 Inspection of drainage work during construction 3896 No. of water tests during repair 485 Final tests of drains after repair 106 Final tests of drains when completely relaid 83 Length of new drains tested with water yards 1565 Length of drains tested other than with water yards 34535 Inspection of yards, stables and manure pits 496 ,, Passages 177 ,, Public Conveniences 5142 Pigstyes Vans, and similar structures 65 207 Inspection of Theatres, Cinemas, Halls, etc. 133 „ Ponds and Ditches 61 „ Schools and School Lavatories 129 „ Common Lodging Houses (including night visits) 28 ,, Houses let in lodgings 100 „ Premises where offensive trades are conducted 106 ,, Camps, gathering grounds, cesspools 97 Smoke Observations 89 No. of Visits re Infectious Diseases 2690 Inspections of Shops (under Shops Acts) 5164 Special Early Closing Patrols 90 Sunday Patrols 93 Special Evening Patrols under Shop Hours Act 258 Inspections under Fertilisers and Feeding Stuffs Act 38 „ under Pharmacy and Poisons Act 516 „ Dairies 278 „ Farms and Cowsheds 121 „ Milkshops 352 „ Premises where food is prepared or sold 6005 „ Slaughterhouses 774 „ Factories 628 „ Factory Laundries 14 „ Workshops 662 „ Workshop Laundries 8 „ Workplaces 188 „ Factory Bakehouses 90 „ Workshop Bakehouses 43 „ Outworkers Premises 129 Baths Inspections 15 Water Samples examined 19 Visits to Employers of Outworkers 4 Reinspections of Work in Progress 29802 Sundry Inspections and Visits 7789 Appointments kept with Owners; Builders, etc. 3756 Complaints from public investigated (for purposes other than inspection of House) 4847 Examination of Building Plans 120 Informal Notices outstanding 31/12/36 2909 „ „ served 10775 „ „ complied 9564 No. of Informal Notices referred for Statutory Orders 979 Informal Notices outstanding 3141 Statutory Notices outstanding 31/12/36 210 „ ,, served 812 „ ,, complied 862 Total number of complaints received 4184 Interviews with callers 4473 Letters received 6343 Letters and other intimations, etc., sent (not including notices) 5715 Nuisances, Infringements of Acts, Byelaws, Regulations or Orders, ascertained by the Sanitary Inspectors during the year 1937 and for which action was taken to enforce compliance:— (1) NUISANCES AND HOUSING DEFECTS AT HOUSES, Etc. Insufficient means of ventilation— Defective windows and sashcords 1997 Want of windows or ventilators 77 208 Conditions causing dampness— Defective roofs 1518 ,, gutters and downspouts 1052 „ walls, etc. 823 Deposits of refuse causing dampness 9 Want of proper damp proof course 564 Other internal defects and nuisances— Defective plaster 1451 Cleansing and limewashing required 1721 Defective floors 650 Insufficient ventilation under floor 54 Defective stoves and fireplaces 563 Defective sanitary fittings— Defective sinks and waste pipes 476 Abolition of drinking water cisterns 19 Defective w.c.'s 746 „ drainage 848 Stoppage in drains 224 Defective brickwork, cills, lintels, etc. 303 No concrete site under floors 10 Domestic nuisances— Want of cleanliness 20 Dirty w.c. pans 30 Other nuisances and infringements— Bad smells 6 Offensive accumulations 216 Insufficient accommodation for sub-tenants 10 Defective manure receptacles 9 Want of manure receptacles 6 Defective sanitary conveniences 44 Dirty sanitary conveniences 19 Smoke nuisances 9 Sundry nuisances or defects 735 Limewashing of stables 14 Defective stables 6 Particulars not inserted in Rent Book (Housing Act) 504 „ „ „ „ (Rent Restriction Act) 242 (2) FACTORIES, WORKSHOPS & WORKPLACES— Cleansing and whitewashing required 79 Additional ventilation 5 Repairs to floors 2 Drainage of floors 2 Overcrowding 2 Ventilation of stoves 1 Infringements of drinking water supply regulations 36 Sundry other nuisances or defects 28 Abstract not exhibited 10 Outworkers' List not in accordance with Act 5 W.c.'s— Insufficiently screened 5 Insufficient 13 Defective and not kept clean 202 Not separate for sexes 1 Want of intervening ventilated space 12 209 (3) INFRINGEMENTS OF CROYDON CORPORATION ACT, 1924— Food cupboards defective or required 248 Dustbins required 951 Verminous conditions 140 (4) INFRINGEMENTS OF PUBLIC HEALTH ACT, 1925 (S.72—75) AND INFRINGEMENTS OF FOOD BYE- LAWS— Cleansing or repair of walls and ceilings 109 ,, ,, repairs of floors, utensils, fixtures, etc. 60 Dirty or defective w.c. accommodation 54 Food storage accommodation required 2 Animals kept in food store 4 Refuse bins uncovered 1 Accumulation in food store and yards adjacent 38 Food in uncovered vehicles or baskets 1 Food improperly kept or manufactured 10 Premises not suitable for storage or manufacture of food 10 Want of provision of towels 1 Provision of cloak room accommodation 13 Illegal wrapping of food 1 Household washing in food store 1 Want of ventilation in food store 5 „ intervening ventilated space between w.c. and food store 6 Drain inlet in food store 6 Offal bins required 1 Insufficient or defective sink accommodation and water supply 30 Defective sanitary fittings 3 Ceiling required to bakehouse 1 (5) INFRINGEMENTS OF PUBLIC HEALTH ACTS (AMENDMENT) ACT, 1907— Defective yard paving 658 Rainwater pipe used as ventilation pipe 2 (6) INFRINGEMENTS OF SHOPS ACTS— Insufficient or defective w.c. accommodation 92 Reasonable temperature required 48 Provision of means of heating 19 Unsuitable or insufficient washing facilities 12 Insufficient ventilation in shop 6 Insufficient accommodation for assistants' meals 6 Notices not exhibited in accordance with 1913 Act 6 Notices not exhibited in accordance with 1934 Act 258 Meal times incorrect 5 Assistants Weekly Half-Holiday Notices required, etc. 151 Mixed Shop Notices required 86 Infringements after general closing hour 24 Sunday closing forms not exhibited 818 Infringements of 1934 Act in regard to young persons 17 Infringements of 1912 Act in regard to females 7 (7) INFRINGEMENTS OF COMMON LODGING HOUSE BYELAWS— Defective windows and sashcords 1 Defective sanitary accommodation 1 210 (8) INFRINGEMENTS OF HOUSES LET IN LODGINGS BYELAWS— Defective w.c. accommodation 1 Additional cooking and sink accommodation 1 Want of food storage accommodation 5 Provision of washing accommodation 3 Want of w.c. accommodation 3 ,, artificial lighting to common staircase 3 Handrail required to stairs 2 Cleansing required 8 Defective windows and sashcords 5 Provision of dustbins 3 Verminous conditions 1 (9) INFRINGEMENTS OF OFFENSIVE TRADE BYELAWS— Fishfrying premises— Limewashing required 1 Offensive accumulations 1 Other premises— Unsuitable premises 1 Dirty or defective w.c. accommodation 1 Cleansing and whitewashing required 3 Dirty floors Dirty or defective yard paving Bins required for storage of skins 1 (10) INSPECTION OF AMUSEMENT HOUSES— Defective sanitary fittings 3 W.c. defective 9 W.c. required cleansing 3 W.c. insufficiently lighted 1 Notices to be fixed to door of lavatories 2 Dirty walls and ceiling in dressing room 2 (11) KEEPING OF ANIMALS— Pigstyes within 100 feet of dwelling 1 Other nuisances in connection with the keeping of pigs 1 Nuisances arising from the keeping of other animals 4 (12) INSPECTION OF WATERCOURSES, etc.— Cleansing of watercourses and ponds 2 (13) INFRINGEMENTS OF PHARMACY & POISONS, &c., ACT- Article not labelled in accordance with the Act 9 (14) INFRINGEMENTS OF FERTILISERS & FEEDING STUFFS ACT, Sec. 1 (1) (11) (15) INFRINGEMENTS OF RATS & MICE DESTRUCTION ACT— Infestation of rats on premises where food is prepared or sold 2 Accumulations of refuse, etc., harbouring rats 33 Defective drainage 14 Structural defects allowing ingress of rats into dwelling houses 47 Dilapidated sheds, etc., harbouring rats 10 Rats in business premises 18 211 (16) INFRINGEMENTS OF MERCHANDISE MARKS ACT & AGRICULTURAL PRODUCE & MARKING ACT— Apples not marked 28 Tomatoes ,, 26 Eggs „ 2 Butter not marked 2 Currants ,, 3 Sultanas „ 6 Raisins „ 3 Bacon ,, 4 Meat „ 22 Salmon 1 (17) INSPECTION OF SCHOOL LAVATORIES— Defective sanitary fittings 4 Defective drain 1 (18) INFRINGEMENTS OF OTHER BYELAWS— Washing down shop fronts 1 Noisy animals 18 Noisy instruments 6 Milk bottles on public highway 6 (19) INFRINGEMENTS OF PUBLIC HEALTH (MEAT) REGULATIONS— Meat displayed in front of shop 4 (20) INFRINGEMENTS OF FOOD AND DRUGS (ADULTERATION) ACT, 1928— Margarine not marked 3 (21) INFRINGEMENTS OF MILK AND DAIRIES REGULATIONS, etc.— Defective sanitary fittings 3 Dirty dairies 1 Pasteurised milk sold unlabelled 2 Offensive accumulation 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 1937 requests were made in connection with 27 houses. The following defects were ascertained in consequence of These inspections:— Defective gutters 1 „ downspouts 3 „ drains 11 ,, sanitary fittings 10 ,, w.c.'s 3 Dampness 1 Defective roof 1 212 Rent Restriction Acts. A number of applications were received for certificates as to the condition of repair of the houses concerned. In 12 instances where the Acts applied certificates were granted. In 4 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. A revised estimate now brings this total to 274. Up to the end of 1937, 152 houses had been approved for demolition, and demolition orders had been made; 113 houses had been actually demolished, the tenants being re-housed, when they desired, by the Council; 411 persons were displaced. In addition, 34 closing orders have been made and 21 parts of houses closed for human habitation, 69 persons being displaced. The following tables give particulars as to Housing during 1937 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) 3,901 (b) Number of inspections made for the purpose 3,901 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 2,141 (b) Number of inspections made for the purpose 2,141 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 33 (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 2,417 2.—Remedy of Defects during the year without service of Formal Notices:— Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers 1,873 3.—Action under Statutory Powers during the Year: — A. Proceedings under sections 9, 10 and 16 of the Housing Act, 1936:— (1) Number of dwelling houses in respect of which notices were served requiring repairs 564 (2) Number of dwelling houses which were rendered fit after service of formal notices:— (a) By owners †427 (b) By local authority in default of owners 19 213 B. Proceedings under Public Health Acts:— (1) Number of dwelling houses in respect of which notices were served requiring defects to be remedied 9 (2) Number of dwelling houses in which defects were remedied after service of formal notices :— (a) By owners *9 (b) By local authority in default of owners — C. Proceedings under sections 11 and 13 of the Housing Act, 1936:— (1) Number of dwelling houses in respect of which Demolition Orders were made 33 (2) Number of dwelling houses demolished in pursuance of Demolition Orders 12 D. Proceedings under Section 12 of the Housing Act, 1936:— (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made 34 (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 6 houses in regard to which notices were served prior to 1937. +Not including 136 houses concerning which notices were served prior to 1937. OYEROROWDING. Housing Act, 1936—Overcrowding. (a) (i) Number of dwellings overcrowded at the end of the year 382 (ii) Number of families dwelling therein 382 (iii) Number of persons dwelling therein2,292 (b) Number of new cases of overcrowding reported during the year 55 (c) (i) Number of cases of overcrowding relieved during the year 215 (ii) Number of persons concerned in such cases 1,694 (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 Nil 214 Table I. FACTORIES, WORKSHOPS, AND WORKPLACES. 1. Inspection. Premises. Number ot Inspections. Written Notices. Prosecution FACTORIES (including Factory Laundries) 642 172 WORKSHOPS (including Workshop Laundries) 670 115 WORK PLACES (other than Outworkers premises) 188 46 Total 1,500 333 Table II. 2. Defects Found in Factories, Workshops, and Workplaces. Particulars. No of Defects. Referred to H.M. Inspector. Prosecutions. Found. Remedied. Nuisances under the Public Health Acts— Want of Cleanliness 79 76 Want of Ventilation 5 5 Overcrowding 2 2 Want of Drainage of floors 2 2 Other Nuisances 85 74 Sanitary Accommodation— Insufficient 13 8 Unsuitable or Defective 219 198 Not separate for sexes 1 1 Offences under the Factory and Workshops Acts- Illegal occupation of underground bakehouses Other offences— (excluding offences relating to outwork and offences under the Sections mentioned in the Schedule to the Ministry of Health (Factories and Workshops Transfer of Powers Order, 1921) Reports to H. M. Inspector 12 Total 406 366 12 215 3. List of Registered Workshops. Trades. Totals. Art Paving Manufacturers 6 Bakers and Confectioners 100 Basket and Rug Maker 1 Blacksmiths 24 Blind Makers 2 Bookbinders 6 Bootmakers 213 Bottle Washer 1 Brewers 6 Brush Makers 4 Building Trades 127 Chemical Works 2 Chimney Sweep 1 China Rivetters 2 Coach Builders 22 Cycle Works 37 Dentists 5 Distributing Depot 1 Dressmakers 106 Dyers and Cleaners 34 Electricians 63 Engineers 145 Fancy Goods Manufacturers 32 Fish Storage 1 Florist 13 Foundries 4 French Polishers 2 Furriers 5 Ladder and Barrow Makers, etc. 9 Laundries 53 Leather Dressing 6 Marine Stores 11 Metal Works 20 Milliners 34 Mineral Waters 2 Monumental Masons 21 Motor Engineers 264 Opticians 16 Patent Medicine Manufacturers 14 Photographers 20 Printers 99 Rubber Stopper Maker: Saddlers 10 Sausage Makers 3 Scale Makers Sheet Metal Workers 8 Sign Writers 20 Sports Goods Makers 14 Stables 12 Tailors 120 Tea Packer 3 Toy Makers 9 Umbrella Makers 3 Upholsterers 66 Vulcanizers 6 Watchmakers 41 Wig Makers 3 Wire Mattress Makers 1 Woodworkers 180 216 Bakehouses. The control of Bakehouses is dealt with under the Factory and Workshops Act, the Public Health Acts, Croydon Corporation Act, 1924, and Cleanliness of Food Byelaws. For details of Croydon Corporation Act, see under Food Inspection. Number of bakehouses on Register, 31st December, 1937 98 Number of underground bakehouses (included in above) 6 Visits made to bakehouses during the year 133 Defects found 49 Notices issued 30 Notices complied 16 5. Home Work. Lists of home-workers are sent in twice yearly, and last year contained the names of 102 outworkers residing within the Borough. 129 visits were paid to outworkers and 4 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, 1937. Nature of Work. Number employed. Out work in infected premises. Outwork in unsatisfactory pr emises. Remarks. Making, cleaning altering and repairing wearing apparel 65 ... 2 ... Upholstery work 5 ... ... ... Lace goods ... ... ... ... Other classes of work 32 ... 1 ... 102 ... 3 ... 217 REGISTERED AND LICENSED PREMISES IN THE BOROUGH, 31st DECEMBER, 1937. Slaughterhouses (not including Public) 3 Bakehouses 98 Common Lodging Houses 9 Houses Let in Lodgings 85 Dairies and Milkshops 404 Cowsheds 20 Offensive Trades 106 Wholesale Dealers in Margarine, etc. 34 Registered (Workshops 2,037 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 150 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. The Shops (Sunday Trading Restriction) Act, 1936, which came into force during the year, restricted the sale of certain goods on Sunday, dealt with the hours which the assistants had to work, and introduced new requirements. The Retail Meat Dealers' Shops (Sunday Closing) Act, 1936, also came into force during the year and prohibited the sale of meat on Sundays, with certain exceptions. All the matters mentioned above are an advance on previous legislation and have entailed a considerable amount of extra work on the staff in order to see that the requirements were carried out. 5,605 inspections were made and a number of infringements were found, as set out on page 227. In 58 cases proceedings were taken for offences under the Acts and fines and costs amounting to £30 were imposed. 218 COMMON LODGING HOUSES. 1. Municipal Lodging House. The Municipal Lodging House (built by the Corporation owing to displacement of private common lodging houses due to improvement scheme) is situate at Pitlake, and contains 101 cubicle beds for nightly letting to lodgers. In addition there are three cubicles allotted to members of the Municipal Lodging House Staff, making a total of 104 cubicles on the premises. The charge per night to lodgers is 1s., the cost of a weekly ticket is 6s. for seven nights. The number of men accommodated during the year was 28,788. The number of men lodgers exceeded 78 per night throughout the year. The receipts and expenditure for the last ten years are as follows:— Receipts. Expenditure. £ s. d. £ s. d. 1928 1346 2 8 1516 7 11 1929 1329 5 1 1483 1 5 1930 1324 10 8 1477 18 6 1931 1385 6 4 1711 19 6 1932 1517 8 4 1547 6 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 1937 1378 14 8 1348 7 2 2. Private Common Lodging Houses. There are 9 common lodging houses on the register. During 1937, 19 day and 9 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 60 men 11 and 12, Princess Road 10 38 men and women. 9 43 113 men and women. 219 HOUSES LET IN LODGINGS. There are 85 houses registered under the Byelaws. 100 visits were made for inspection purposes. 21 notices were served for various amendments. 17 notices were complied with. 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 5 Forster Road 8 Wilford Road 16 Canterbury Road 1 London Road 1 Whitehorse Lane 1 Nursery Road 1 St. James' Road 1 Queen's Road, South Norwood 1 Lodge Road 1 Tamiworth Road 2 Bert Road 1 Bensham Manor Road 1 Albert Road 1 Clyde Road 4 Brighton Road 1 Canning Road 2 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 3 Newark 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). 220 OFFENSIVE TRADES. Byelaws relating to Offensive Trades were adopted during the latter part of the year 1925. 106 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 69 Rabbit Skin Drier 1 Fellmonger 1 106 RAG FLOCK ACTS, 1911 AND 1928. Six samples were obtained and subjected to analysis, the results being as follows:— No. 1 contained 13 parts of Chlorine per 100,000 „ „ 2 ,, 9 „ ,, „ „ 3 „ 8 „ „ „ 4 „ 20 „ „ ,, 5 ,, 18 ,, „  „ „ 6 „ 8 „ „ „ The six 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 89 observations were made of factory chimneys for the purpose of detecting offences under the Act. Nine notices were sent and amendments carried out to stop the nuisance. AMUSEMENT HOUSES. 133 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). 221 KEEPING OF ANIMALS 38 inspections were made in connection with the keeping of animals. There were 18 premises, including institutions, where pigs were known to be kept in the Borough. 2 notices were served to abate nuisances arising from various causes in connection with the keeping of pigs, and 4 notices were served to abate nuisances arising from the keeping of other animals. BYELAW—NUISANCES FROM DOGS. In connection with the fouling of footpaths by dogs a number of warning have been given. In one instance proceedings were taken and a fine of ten shillings was incurred. SCHOOLS. 129 inspections of schools and school lavatories were made during 1937. The water supply in all cases is from the mains. INSPECTION OF WATERCOURSES, ETC. During the year 61 visits were made to ditches, watercourses, etc., in order to see whether there were any infringements of the several Acts, etc. In two instances notices were served to remove accumulations from a pond and stream. 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 37, and application was made and granted for entry in the List of the names of 43 deputies. In addition, 256 applications were made for retention of names on the List for a further period of twelve months. Nine infringements of the Act were found. FERTILISERS AND FEEDING STUFFS ACT, 1926. Thirty-eight inspections of premises where fertilisers and feeding stuffs were sold were carried out during the year, and no infringement of the Act was found. 222 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 woman attendant deals with school children and women. The following articles were disinfected at the Disinfecting Station during the year:— By Steam 67,649 articles By Formalin gas 2,872 ,, By Formalin spray 1,490 ,, 72,011 „ In addition 1,430 articles were destroyed on request. Disinfection after infectious or contagious disease was carried out in 2,915 rooms at 1,801 houses. 4 schools. 14 class rooms. 2 corridors. 2 landings. 2 cupboards. 17 w.c.'s. 45 hospital wards. 34 hospital and other rooms. 31 vehicles. 22 bags. 6 school departments. 2 shelters. 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 1937, 1,045 such articles were disinfected, the receipts for this work amounting to £43 16s. 6d. 228 DISINFESTATION. Disinfestation by Hydrogen Cyanide is carried out in certain cases before tenants occupy Corporation houses. 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. Bedding is treated by steam disinfection 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. One hundred and thirteen cases were dealt with during the course of 1937 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 33 (2) Disinfested 33 Number of houses other than Council houses— Disinfested Nil Number of houses, other than Council houses, disinfested by owners or tenants—140. 224 CLEANSING OF VERMINOUS PERSONS, ETC. During the year 11 adults and 161 children were cleansed for verminous conditions, and 9 adults and 41 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 during 1937 under the Rats and Mice (Destruction) Act, 1919:— Table VI. Premises. No. of Visits made. No. of Poison and other baits laid. No. of Rats Killed. Private Houses 1512 1773 776 Butchers 34 Other premises where food is pre pared or sold 163 Other premises 273 Total 1982 1773 776 In addition to the above, 2,044 rat? 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 two budgerigars were destroyed during the year. 225 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. Examination of foodstuffs at the Croydon Airport has also been carried out as required. 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 Rorough 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 34,834 animals slaughtered for human consumption. 226 The following table shows the premises in the Borough at which foodstuffs are known to be sold, manufactured or stored: — General Shops 207 Grocers and Provision Shops 681 Greengrocers and Fruiterers 459 Confectioners, Bakers and Pie Makers 680 Ice-Cream Shops 354 Hotel and Restaurant Kitchens and Dining Rooms. 312 Butchers 202 Fishmongers (including Fried Fish Shops) 154 Ham and Beef Shops 93 Sweet Manufacturers 9 Other Food Premises 25 3,176 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 whc 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 with lairage attached, are let on agreement to tenant butchers, and the remainder are used for public slaughtering, for which head rate tolls are charged. 327 Table VII. The following animals were slaughtered at the Public Slaughterhouses during 1937: — Pitlake. Public Slaughterhouses. Cattle. Sheep. Figs. Calves. Total. Public section 166 1280 1094 211 2751 Private section 676 7524 14842 2445 25487 Totals 842 8804 15936 2656 28238 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 1937:— Description. Cause. 8 beef carcases and offals General tuberculosis. 5 ,, forequarters Localised tuberculosis. 3 „ Parts „ „ 21 „ offals, complete Tuberculosis. 52 sets beef lungs Localised tuberculosis. 43 beef heads „ „ 11 „ various offals „ „ 5 „ carcases and offals Inflammatory, emaciated, etc. 1 „ head Actinomycosis. 4 „ various parts Inflammatory, etc. 36 ,, various offals Inflammatory conditions, etc. 2 veal carcases General tuberculosis. 5 „ heads Tubercular. 5 „ offals, complete „ 9 „ plucks „ 9 „ carcases Immaturity, etc. 6 „ various offals, etc. Inflammatory, etc. 24 pig carcases and offals General tuberculosis. 2 „ various parts Localised tuberculosis. 146 „ heads „ 3 „ plucks „ „ 133 ,, various offals ,, ,, 133 „ offals, complete Tubercular. 3 „ carcases and offals Swine fever. 20 ,, carcases and offals Inflammatory conditions, etc. 201 „ plucks „ „ 8 „ heads „ ,, 257 ,, various offals and 14 parts ,, ,, 35 carcases and offals Oedema and emaciation. 5 sheep carcases and offals Inflammatory, etc. 12 „ parts Inflammatory, traumatic, etc. 4 „ plucks Parasitical, etc. 12 ,, various offals „ ,, Total weight destroyed : 28,518 lbs. 228 PRIVATE SLAUGHTERHOUSES AND MEAT INSPECTION At the end of 1937 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 1937 was 774. Table VIII. The number of animals slaughtered in the Private Slaughterhouses during the year was:— Cattle Sheep. Pigs. Calves. Total. 86 1370 3450 1690 6,596 The following meat and offal from Private Slaughterhouses was surrendered and destroyed during 1937:— Description. Cause. 1 beef carcase and offal General tuberculosis. 2 ,, sundry offals Localised tuberculosis. 3 „ livers Parasitical, etc. 4 veal plucks Localised tuberculosis. 2 sundry offals Inflammatory. 3 pig carcases and offals General tuberculosis. 43 ,, heads Localised tuberculosis. 21 „ plucks „ „ 14 „ sundry offals ,, ,, 17 ,, plucks Inflammatory, etc. 47 ,, offals (various) ,, ,, 2 ,, carcases and offal Asphyxia. 9 ,, ,, „ Swine fever. 4 sheep lungs', etc. Parasitical. Total weight destroyed : 2,651 lbs. Table IX. Total number of animals slaughtered for human consumption in the Borough during 1937:— Cattle. Sheep. Pigs. Calves. Total. 928 10,174 19,386 4,346 34,834 229 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. Acute swine erysipelas Jaundice Total carcases. Cattle 9 2 2 ... 1 ... ... ... 14 Calves 2 2 2 4 1 ... ... ... 11 Sheep ... 5 ... ... ... ... ... ... 5 Pigs 27 35 10 ... 5 12 5 2 96 Totals 38 44 14 4 7 12 5 2 126 Table XI. Carcases Inspected and Condemned. Cattle. Calves. Sheep and Lambs. Pigs. Number killed 928 4,346 10,174 19,386 Number inspected 928 4,346 10,174 19,386 All diseases except tuberculosis: Whole carcases condemned 5 9 5 69 Carcases of which some part or organ was condemned 41 8 31 531 Percentage of the number inspected affected with disease other than tuberculosis 4.9 .39 .35 3.09 Tuberculosis only: Whole carcases condemned 9 2 - 27 Carcases of which some part or organ was condemned 99 18 - 242 Percentage of the number inspected affected with tuberculosis 11.6 .46 - 1.38 230 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 2042 Fishmongers 198 Fried Fish Shop 144 Grocers 769 Greengrocers 469 Poultry and Game Dealers 23 Cooked and Prepared Meat Shops 161 Bakers' Premises 102 Confectioners' Premises 641 Markets 491 Hawkers' Carts and Barrows 65 Hotel and other Kitchens, etc. 409 Ice Cream Manufacturers and Vendors 210 General Shops 247 Other premises 34 6,005 The following articles of food were surrendered and destroyed during 1937: — 105 beef parts and trimmings (Imported) Unsound 172 lbs. beet kidneys „ ,, 66 lbs. beef livers, etc. „ „ 36 lbs. veal „ 5 mutton parts ,, „ 713 lbs. lambs' liver, etc. ,, „ 348 lbs. pork „ ,, 76 lbs. pig kidneys, etc. „ ,, 23 rabbits „ 30 lbs. ham, brawn, etc. „ 698 lbs. cod, herrings, etc. „ 12 turkeys „ 105 tins salmon, etc. „ 594 tins, etc., cherries, pineapple, tomatoes, etc. „ 63 lbs. prunes, sultanas, etc „ 131 tins milk and cream ,, 75 tins soup, sauce, etc. ,, 25 tins beef, etc. ,, Total weight destroyed : 6,582 lbs. 231 Table XII. General Summary of Meat and other articles destroyed during the year 1937. articles. Weight in lbs. Remarks. Diseased. Unsound. Total. Beef 8,788 3,614 12,402 Including 14 carcases. Veal 533 135 668 „ 11 „ Mutton 371 65 436 „ 5 „ Pork 11,156 748 11,904 „ 96 „ Offal 9,078 1206 10,284¾ „ imported offal. Fish ... 698 698 Fish fillets, etc. Fruit &Vegetables ... 63 63 Sultanas, etc. Tinned Goods ... 1,140 1,140 923 tins, 7 jars, etc. Sundries ... 155¼ 155¼ Turkeys, rabbits, etc. 29,926¾ 7,824¼ 37,751 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 wa'shing 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. 232 Enquiries show that approximately 22,907 gallons of milk are sold daily in the Borough. Of this amount 96 per cent. is bottled, just under 4 per cent. is loose, which is sold wholesale, and the remaining small portion, namely, 46 gallons, is retailed as loose milk. These figures are interesting in view of the fact that fourteen 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, local producers use this method for part of their milk distribution. 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 Inspeotor. 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 Purveyors of Milk premises on the register:— Cowkeepers on register (1936) 10 ,, added to the register (1937) — ,, discontinued (1937) — Net 10 233 Cowsheds on register (1936) 20 ,, added to the register (1937) — ,, discontinued (1937) — Net 20 Number of cows provided for 275 Average number of cows in sheds (1937) 221 No. of dairies and purveyors of milk on register (1936) 393 No. of dairies and purveyors of milk added to register (1937) 53 No. of dairies and purveyors of milk discontinued during 1937 42 Net 404 Grand total of cowsheds, dairies and purveyors of milk on register, 31st December, 1937 424 During the year 751 inspections were made of dairies, cowsheds and milkshops. Mr. P. Thrale, the part-time veterinary surgeon, makes quarterly reports on his visits to the farms and his examination of the cattle thereon. Milk (Special Designations) Order, 1936. The following licences were granted during the year under this Order :— Description of Licences. No. (1) Producers' Licences to use the designation "Accredited" 2 (2) Dealers' Licences to use the designation ''Tuberculin -Tested"— (a) Bottling establishments 1 (b) Shops 26 (3) Dealers' Licences to use the designation "Accredited"— (a) Bottling establishments — (b) Shops 1 (4) Dealers' Licences to use the designation "Pasteurised"— (a) Pasteurising establishments 2 (b) Shops 60 234 (5) Dealers' Supplementary Licences to use the designation— (a) Tuberculin-Tested 3 (b) Accredited 1 (c) Pasteurised 3 Inspection of these licensed premises has been carried out regularly during the year to see that the conditions of the licences were observed. During the year the following samples were examined under the Milk (Special Designations) Order, 1936:— Tuberculin Tested Milk— Licensed country producers supplying milk to licensed local dairymen 7 Accredited Milk— Licensed local producers supplying milk to a licensed dairyman 19 Pasteurised Milk— Samples from licensed dealers 162 The following tables summarise the result of the bacteriological examinations of Tuberculin Tested, Accredited and Pasteurised samples during the year:— Table XIII. TUBERCULIN TESTED (Licences granted under the Milk (Special Designations) Order, 1936). Present. Absent. Present in 1/100 m.l. Absent. Present. Absent. Present. Absent. Exceeding a trace. Not exceeding a trace. Satisfied test. Tubercle bacillus ... 7 Bacillus Coli ... 1 Blood ... 7 Pus ... 7 Detritus ... 7 Methylene Blue Test 6 ... 7 ... 1 ... 7 ... 7 ... 7 6 235 The above 7 Tuberculin Tested milk samples contained total bacteria per m.l. as follows:— 1,000—5,000 5 5,000—10,000 2 7 Under the Regulations Tuberculin Tested Milk shall satisfy a methylene blue reduction test and contain no coliform bacillus in one hundredth of a millilitre. Table XIV. accredited milk (Licences granted under the Milk (Special Designations) Order, 1936). Present. Absent. Present in 1/100 m.l. Absent. Present. Absent. Present. Absent. Exceeding a trace. Not exceeding a trace. Satisfied. Not satisfied. Tubercle bacillus †2 17 Bacillus Coli 2 11 Blood ... 13 Pus ... 13 Detritus ... 13 Methylene Blue Test 12 1 2 *17 2 11 ... 13 ... 13 ... 13 12 1 *This figure includes 6 samples examined for presence of tubercle bacilli only. †Two samples from a local Accredited Producer's farm proved to be tuberculous. Systematic sampling of the herd followed with negative results. A cow, however, died in the interim period from an unknown cause. 236 The following tables summarise the results of the bacteriological examinations of Pasteurised Milk Samples during the year:— Table XV. 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. Tubercle bacillus ... 162 Total number of bacteria 13 149 Blood ... 162 Pus ... 162 Detritus ... 162 ... 162 13 149 ... 162 ... 162 ... 162 The above 162 Pasteurised Milk Samples contained bacteria per m.l. as follows:— Under 1,000 3 1,000—5,000 29 5,000—10,000 23 10,000—20,000 32 20,000—30,000 2T 30,000—50,000 24 50,000—100,000 11 Over 100,000 13 162 Under the Regulations Pasteurised Milk must not contain more than 100,000 bacteria per millilitre. PROVISION AS TO MILK SUPPLY. During the year 316 samples of ordinary milk were procured and submitted to examination for tuberculosis in accordance with the Milk and Dairies (Consolidation) Act, 1915. 237 These samples were taken as follows:— Samples taken at cowsheds in the Borough 25 Samples in course of delivery from country cowsheds to local dairymen and purveyors of milk in the Borough 48 Samples taken at dairymen's premises in the Borough 85 Samples taken in course of delivery by local dairymen or milk sellers on their rounds in different parts of the Borough 157 Other samples taken 1 316 Eight samples proved to be tuberculous. Five samples were from supplies coming from Sussex, one from Surrey, one from Kent, and one from a local farm. 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, 1925, and in one case, while investigations were being carried out, an outbreak of Foot and Mouth Disease occurred, necessitating slaughter of the entire herd. 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, 1937:— Table XVI. ORDINARY MILK Present. Absent. Over 100,000 per m.l. Under 100,000 per m.l. Present. Absent. Present. Absent. Exceeding a trace. Not exceeding a trace. Satisfied. Not Satisfied Tubercle bacillus 8 300 Total number of bacteria 99 209 Blood 2 306 Pus 2 306 Detritus ... 308 Methylene Blue Test 257 24 8 300 99 209 2 306 2 306 ... 308 *257 24 *Methylene Blue Test Results for period of 11 months. Eight samples were taken for inoculation test only. There is no standard fixed for total bacteria per millilitre in ordinary commercial milk, but for the purposes of comparison a maximum count of 100,000 per m.l. is taken. It will be seen that 209 of the samples contained total bacteria in accordance with that comparison. It has to be remembered that a proportion of this milk has been subjected to commercial pasteurisation. One sample of sterilised milk was taken during the year and contained 1,200 bacteria per millilitre. 238 The 308 samples of Ordinary Milk contained total bacteria per m.l. as follows:— 0—1,000 7 1,000—5,000 37 5,000—10,000 39 10,000—20,000 36 20,000—30,000 23 30,000—40,000 18 40,000—50,000 13 50,000—100,000 36 100,000—150,000 22 150,000—200,000 8 200,000—250,000 12 250,000—500,000 22 500,000—750,000 8 750,000—1,000,000 8 1,000,000—2,000,000 6 Over 2,000,000 13 308 239 The 308 samples taken under the Milk and Dairies (Consolidation) Act, 1915, were samples of milk which had been produced in the following areas:— Table XVII. Areas. No. obtained. No. Tuberculous. Croydon 14 1 Kent 14 1 Surrey 6 1 Sussex 44 5 Somerset 2 — *Unclassified 228 - Totals 308 8 *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 371 samples of milk (370 new, 1 condensed) and 478 other samples were taken. In 5 instances the vendors were warned. 19 samples of Ice Cream were taken during the year. The public Analyst reports that 5 of these samples contained fat in amounts varying from 1.8 per cent, to 9.1 per cent., 10 contained fat in amounts varying from 10.0 per cent, to 16.7 per cent., and 4 had little or no fat content derived from milk. There is no legal standard for fat in Ice Cream. 10 per cent, is suggested as a reasonable minimum amount. Bearing in mind this figure, it will be seen that the majority of the samples of Ice Cream were above this suggested standard. Table XVIII. Samples of Total Samples. Genuine. Not Genuine. Prosecutions. Convictions Cautions. Milk 370 359 11 — — 2 Condensed Milk, (Inf.) 1 1 — — — — Arrowroot 11 11 — — — — Aspirin Tablets 9 9 — — — — Bacon 8 8 — — — — Baking Powder 8 8 — — — — Boric Ointment 1 1 — — — — Brawn 11 11 — — — — Bread 10 10 — — — — Bun Flour 4 4 — — — — Butter 13* 13 — — — — Camphorated Oil 4 4 — — — — Candied Peel 1 1 — — — — Castor Oil 6 6 — — — — Chopped Suet 2 2 — — — — Chopped Suet with rice flour 4 4 — — — - Cocoa 11 11 — — — - Cod Liver Oil 5 3 2 — — 1 Coffee 9 9 — — — - Coffee and Chicory 3 3 — — — - Coffee Essence 5 5 — — — - Comp. Liquorice Powder 2 2 — — — - Comp. Syrup of Figs 2 2 — — — - Comp. Tincture of Rhubarb 1 1 — — — - Confection of Senna 2 2 — — — - Corn Flour 6 6 — — — - Cream Doughnuts 1 1 — — — - Cream of Tartar 7 7 — — — - Custard Powder 5 5 — — — - Demerara Sugar 10 10 — — — - Dripping 10 10 — — - - Faggots 3 3 — — - - Fish Paste 10 10 — — - - Flour 9* 8 1 — — - Ginger Ale 3 3 — — - - Ginger Beer 5 5 — — - - Ginger Wine 1 1 — — - - Glycerine 4 4 — — - - Golden Syrup 2 2 — — - - Ground Almonds 8 8 — — - - Ground Ginger 10 10 — — — - Ground Rice 8 8 — — - - Honey 9 9 — — - - Ice Cream 19 15 4 — - 1 Jam 12 8 4 — — - Jellied Veal 1 1 - - - - Carried forward 646 624 22 — — 4 *Including 1 inf. 240 Summary of Samples. During 1937 samples were obtained and submitted to the Public Analyst as follows:— 241 • Table XVIII. (Continued). Samples of Total Samples. Genuine. Not Genuine. Prosecutions. Convictions. Cautions. Brought forward 646 624 22 — — 4 Lard 10 9 1 — — 1 Lard Substitute 1 1 - — — — Lemonade 2 2 - — — — Lemonade Powder 4 4 - — — — Lemon Cheese 1 1 - — — — Lemon Squash 3* 3 - — — — Malt Vinegar 10 10 - — — — Margarine 11 11 - — — — Meat Paste 8 8 - — — — Mincemeat 5 5 - — — — Mixed Pickles 3 3 - — — — Mixed Spice 2 2 - — — — Mustard Mixture 3 3 - — — — Oats 1 (inf.) 1 - — — — Olive Oil 5 5 - — — — Pearl Barley 10 10 - — — — Peas, Tinned 11 11 - — — — Pepper 7 7 - - — — Pickled Onions 8 8 - - — — Rissoles 2 2 - - - — Sausage, 1 1 - — — — „ Beef 10 10 - — — — „ Pres. Beef 3 3 - — — — „ Liver 2 2 - — — — „ Luncheon 9 9 - — — — „ Pork 9 9 - — — — „ Pres. Pork 3 3 - — — — „ Smoked 1 1 - — — — Saveloys 9 9 - — — — Sild 1 1 - — — — Sponge Mixture 1 1 - — — — Stout 1 1 - — — — Sweets 9 9 - — — — Tapioca 3 3 - — — — Tea 11 11 - — — — Tincture of Iodine 3 3 - — — — Tinned Asparagus 5 5 - — — — Tinned Beans 8 8 - — — — Tinned Cream 1 1 - — — — Treacle 4 4 - — - — Vinegar 2 2 - — - - Totals 849 826 23 — - 5 *Including 1 inf. 242 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 9.5 Totpl 370 6 21 44 94 117 65 17 3 1 1 1 MILK FAT.* (Legal standard is 3%). 2.8 2.9 3.0* 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 4.0 2 2 3 22 51 76 76 66 30 18 9 4 4.1 4.2 4.3 4.4 5.1 5.5 Total 370 2 3 12 12 Total Samples of New Milk: 370. 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 7 On Milk Rounds (Sundays) 14 ,, „ (Week-days) 243 Cowsheds — At Shops 78 Taken at Institutions 28 370 AVERAGE COMPOSITION OF NEW MILK SAMPLES. Solids not Fat 8.8% Milk Fat 3.5% Percentage of New Milk Samples below legal standard: 2.97% Adulterated Samples. The following is a detailed statement of the adulterated samples and action taken:— No. Sample. Adulteration or Deficiency. Remarks. 1103. Cod Liver Oil Not in accordance with B.P. standard in respect of Vitamin A activity. See Sample 1137. 1137. Cod Liver Oil Not in accordance with B.P. standard in respect of Vitamin A activity. Stock withdrawn from sale. Vendor warned. 878. Greengage Jam, full Fruit Standard. Not of Full Fruit Standard. Further sample taken proved genuine. Manufacturers warned. 895 (inf.) Greengage .. Jam, Full Fruit Standard. Not of Full Fruit Standard. ' 1024. Greengage Jam, Full Fruit Standard. Not of Full Fruit Standard. 243 966. Lard The sample was a lard substitute. The vendor was warned. 730. Milk A very small percentage of added water. The matter was referred to the County Authority in which the farm is situated. 731. Milk 732. Milk 733. Milk 892. Milk 1033. Milk 2 per cent, deficient in milk fat. Further sample taken proved genuine. Vendor warned. 106. Milk 6 per cent, deficiency in milk fat. Further sample taken proved genuine. Vendor warned. 85. Ice Cream The samples con- tained fat which was mainly not derived from milk. The manufacturer was interviewed. 164. Ice Cream 179. Ice Cream 222. Ice Cream J 282. Blackcurrant Jam, Full Fruit Standard. Not of Full Fruit Standard. Manufacturer's explanation accepted. 127. Milk 3 per cent, deficient. in milk fat. See Sample 183. 183. Milk 6 per cent, deficient. in milk fat. Further samples taken proved genuine. 128. Milk 1 per cent, deficiency in milk fat. Vendor's explanation accepted. 202. Milk 1 per cent, added water. Further samples taken proved genuine. 516 (inf.) Flour Contained numbers of acari or "mites." The vendor had no stock left from which this sample was taken. New stock free from "mites." 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 investigation have been taken to ensure that the condition of the water was satisfactory. The following are the details of the samples taken from the Open Air Swimming Pool, Purley Way, Croydon, and submitted for bacteriological examination to the Borough Pathologist:— Date taken. Time taken. P.M. Temp. of water. Degrees FAHR. No. of bathers during the day up to time of sampling. Weather Conditions. Remarks. Result. 16/6/37 7.15 65.5 289 Overcast, slight rain. Filters on from 7 a.m. Chloramine process in use. No B. Coli in 50 cc. or under. No strept. or staph, present. Organisms: 700 per 1 cc. 23/6/37 7.00 69 1,096 Clouds and sun. Do. No B. Coli in 50 cc. or under. No strept. or staph, present. Organisms: 300 per 1 cc. 30/6/37 7.25 64 97 Overcast, cloudy. Do. No B. Coli in 50 cc. or under. No strept. or staph, aureus present. Organisms: 100 per 1 cc. 7/7/37 7.15 66 325 Clouds and sun. Do. No B. Coli in 50 cc. or under. No strept. or staph, aureus in 1 cc. Organisms: 0 in 1 cc. 14/7/37 7.15 70 2,307 Sunny and warm blue sky. Do. No B. Coli in 50 cc. or under. No strept. or staph, aureus present. Organisms : 900 per 1 cc. 21/7/37 7.15 68.5 383 Overcast, cloudy. Do. No B. Coli in 50 cc. or under. No strept. or staph, aureus present. Organisms: 0 per 1 cc. 28/7/37 7.15 68 757 Overcast. Do. No B. Coli in 50 cc. or under. No strept. or staph, present. Organisms : 0 per 1 cc. 4/8/37 7.15 71 4,000 Overcast, very warm and sultry. Do. No B. Coli in 50 cc. or under. No strept. or staph, aureus present. Organisms : 10 per 1 cc. 11/8/37 7.15 71 3,439 Overcast, cloudy and warm. Do. No B. Coli in 50 cc. or under. No strept. or staph, aureus present. Organisms: 10 per 1 cc. 244 The following are the details of the samples taken from the open Air swimming pool, purley way bacteiioJofficul examination to the Borougli Pathologist: — ('Continued) Date taken. Time taken. P.M. Temp, of water. Degrees FAHR. No. of bathers during the day up to time of sampling. Weather Conditions. Remarks. Result. 18/8/37 7.15 68 1,220 Blue sky and clouds, sunny. New ozone plant in operation. B. Coli present in 0.1 cc., but not in 0.01 cc. No staph, aureus or strept. present. Organisms: per 1 / 100th of a cc. were too numerous to count. 25/8/37 7.20 69 3,035 Overcast, warm. New ozone plant working all day. B. Coli present in 1 cc. and over. Absent in 0.1, 0.01, and 0.001 cc. No staph, aureus, but a few haemolytic streptococcal colonies present on plates. Organisms: 56,000 per 1 cc. 1/9/37 7.10 66.5 721 Overcast. Filtering from 7 a.m. Ozone on all day. B. Coli present in 10 cc., but not in 1 cc. or under. No staph, aureus or streptococci present. Organisms : 16,400 per 1 cc. 8/9/37 7.10 67 1,107 Clouds and sun. Continuous filtration, and ozone on. B. Coli present in 10 cc. and over but absent in 1 cc. and under. No staph, aureus or strept. present. Organisms: 1,500 per 1 cc. 15/9/37 7.15 65 77 Overcast and cloudy. Ozone on all day. No B. Coli in 50 cc. or under. No staph, aureus or strept. present. Organisms: 400 per 1 cc. 22/9/37 7.15 67 74 Overcast. Ozone on all day. Filtering continuous. B. Coli absent in 50 cc. and under. No staph, aureus or strept. present. Organisms: 240 per 1 cc. 245 246 MEMBERS OF THE EDUCATION COMMITTEE. NOVEMBER, 1936-37. 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 A. Jackson. Councillor H. Regan. Alderman J. Marshall, J.P. Councillor Dr. A. Sandison, O.B.E. Alderman T. W. Wood Roberts,J.P .Mrs. R. L. Gurner. Alderman W. West. Mrs. M. A. Hinks. Councillor E. E. L. Arkell, J.P. B. Holden, Esq. Councillor A. J. Carpenter, J.P. Miss A. M. Jackson, M.A. Councillor W. F. Chandler. Capt. H. Lethbridge-Abell, F.Z.S. Councillor A. H. Harding. Mrs. M. M. Wood Roberts. Councillor Eng.-Rear-Adml. J. H. Harrison. G. Robinson, Esq. Councillor W. G. Higgins. Rev. Canon G. M. Scott, M.A. Councillor H. L. Kendell. Rev. H. E. Spelman. Councillor G. Lewin. H. Watson, Esq. Councillor S. A. Maycock. Sir Frederic Williamson, C.B., C.B.E. 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: D. D. Payne, M.D., B.S., D.P.H. Assistant Medical Officers of Health and Assistant School Medical Officers: J. T. R. Lewis, M.D., B.S., D.P.H. C. G. Payton, M.D., 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, a Consulting Orthopaedic Surgeon, and a Consulting Pathologist, 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 C. W. Brown (part-time). Orthopaedic Work Almoner: Miss A. Hailey (part-time). Supt. Health Visitor: Miss A. M. Allford (commenced 1st Dec. 1937) School Nurses: 22 district nurses (part-time). Clerks: Six full-time and eight part-time. 247 SCHOOL, CLINICS. Name. Purpose. Where held. Times. 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, (by appointment). 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. 47, St. James' Rd. Mon., 1.30 p.m., Tues., Thurs., and Fri., 9 a.m. DENTAL Dental Treatment. Lodge Road, Selhurst Road, and Waldrons Hall. (by appointment). Daily, 9 a.m. and 2 p.m. EAR Treatment of Chronic Ear Discharge. Lodge Road. Fridays, 2 p.m. (by appointment). DEFECTIVE CHILDREN Examination. Town Hall. As required. X-RAY Treatment of Ringworm. Mayday Hospital. 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. (by appointment). SYNTHETIC SUNLIGHT Treatment of Rickets, etc. Do. Tues., 2 p.m., and Fri., 3.30 p.m. (by appointment). REMEDIAL EXERCISES Treatment of Deformities. Welcome Hall, Scarbrook Road. Daily. (by appointment). 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. (by appointment). IMMUNIZATION Protection against Diphtheria. 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, 1937. Ladies and Gentlemen, I have the honour to present to you my Tenth Annual 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. 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. The complete Sanitary Survey of the Schools, which was originally included in my report for 1936 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. 249 Three changes took place in the staff during the year, Dr. W. B. Watson, the deputy school medical officer, left in May to take up an appointment elsewhere. His post was filled by the promotion of one of the Assistant Medical Officers, Dr. D. D. Payne. Dr. J. T. R. Lewis took up his duties as an assistant medical officer in July vice Dr. W. R. Martine, and Dr. C. G. Payton was appointed in September to occupy the post vacated by Dr. Payne. CO-ORDINATION WITH OTHER HEALTH SERVICES. As all the assistant school medical officers are also assistant medical officers of health, and the Medical Officer of Health is also the School Medical Officer, there is consequently a very desirable degree of co-ordination which leads to efficiency in time and methods and also extends the sphere of influence of the medical officers. At the end of the year, following the issue of Circular 1550 by the Ministry of Health, the Public Health Committee decided that facilities for the treatment of children under 5 years should be given through the school clinics. Although up to the present very little use has been made of this provision, doubtless as it becomes better known, more advantage will be taken. In this way it is hoped to bring about some improvement in the standard of health of the Entrant Group. By far too great a number of children are found medically unsatisfactory at this examination, and the defects from which the majority suffer could either have been prevented or mitigated if appropriate treatment had been put in hand during the pre-school years. More especially does this apply to dental defects, so that the appointment of an additional dental surgeon by the Maternity and Child Welfare Committee, will, it can confidently be predicted, exert a beneficial effect. There was no severe or widespread epidemic disease among the public elementary school population during the year. The outbreak of Typhoid Fever in an area of the Town affected largely adults, and children attending private schools in the area. Among public elementary school children only 16 were attacked. A rather severe, but localised outbreak of Diphtheria occurred in the Kingsley School during October, November and December (64 cases in all). The type of the illness was severe and it is unfortunate that so few children had been immunised at this School although in 1936, it showed the highest number of Diphtheria cases. The outbreak, however, stimulated the demand very markedly, and by the end of the year some 126 children had been immunised or were in process of becoming immunised. 250 As regards notifiable diseases there was an increase of 141 in the cases of Scarlet Fever, and of 68 in the cases of Diphtheria. As regards the non-notifiable infectious diseases there was a decrease of 1,330 in the number of Measles cases reported by Teachers and others; of 217 in the cases of Whooping Cough and of 80 in the cases of Chicken Pox, and an increase of 394 in the cases of Mumps. Table XII. shows the incidence of these conditions in the various schools. The work of the school clinics has proceeded on the same lines as in former years. The utilisation of 47, St. James Eoad for the Ophthalmic Clinic and for certain Inspection Clinics has tended to relieve some of the overcrowding which took place at Lodge Eoad. The subsidiary clinics at Selhurst and at Duppas School and Waldrons Hall have been fully utilised. In the near future the Committee will have to consider the establishment of another subsidiary clinic to serve the very rapidly growing Addington Estate and I would suggest that, when the Elementary School for this area is planned, that provision be made in the plans for a branch clinic. The work done in connection with Immunisation against Diphtheria is not included in this report, as it is concerned with other groups of children besides those of school age. The total number of public elementary school children who attended for Immunisation was 1,596. The continued help and co-operation of the Head Teachers and of the School Enquiry Officers has been of the greatest assistance. Without their interest much of the medical work and following up would have been difficult of proper fulfilment. The Voluntary School Care Committee, and also the Society for the Prevention of Cruelty to Children have been of much value. I am especially indebted to Mr. Brown and Mr. Evans, the Society's Inspectors, for their help in certain difficult cases. The burden of the work has fallen upon the Assistant Medical Officers, Health Visitors, and the Clerical Staff, to all of whom I desire to record my thanks for their loyalty and co-operation. I am, Yours faithfully, OSCAR M. HOLDEN, School Medical Officer. 251 Structural Work and Decorations Carried Out in Schools. I am indebted to the Education Officer for the following particulars of work carried out at the various schools during the past year:— External Painting at the following— Beulah Junior. Kensington Avenue. Kingstey Senior. Norbury Manor Junior. Rockmount Senior. Whitehorse Manor. John Ruskin. Internal Painting and Distempering at the following Schools— Beulah Junior. Ingram. Kensington Avenue. Kingsley Senior. Norbury Manor Junior. Norbury Manor Senior. Rockmount Senior All Saints. Holy Trinity. Shirley. 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. Ashburton Sen. Mixed Boys 169 4 Pedestal sep. cistn. 20 ft. A.F. *9 4 12 Girls 199 10 Do. do. — *9 4 12 Jun. Mixed Boys 172 4 Do. do. 20 ft. A.F. *6 5 15 Girls 174 10 Do. do. — *6 4 12 Benson Junior Mixed & Infants B. 144 2 Do. do. 17 ft. A.F. 5 3 6 G. 161 7 Do. do. — Sen. Mixed Boys 61 3 Do. do. 20 ft. A.F. 5 3 6 Girls 60 5 Do. do. — 5 3 6 Beulah Junior Boys 398 6 Do. do. 44 ft. A.F. 13 9 15 Towels changed when necessary. Junior Girls 396 20 Do. do. — 13 8 8 Infants B. 197 4 Do. do. 22 ft. A.F. 18 6 8 G. 171 11 Do. do. — John Ruskin Boys 390 21 Do. do. 42 ft. A.F. 3 Wg. Trghs 7 21 Davidson Senior Boys 158 5 Do. do. 36 ft. A.F. 2 tr'ghs 4 12 Senior Girls 131 14§ Do. do. — Do. 5 15 J. G.& I. b. 152 3 Do. do. 20 ft. A.F. Wshg. tr'ghs 2 3 21 G. 216 6 Do. do. - 4 Duppas Junior Boys 169 4 Do. do. 15ft. 6in.A.F. 6 4 - Towels changed when necessary. Junior Girls 188 8 Do. do. — 6 4 †- Infants' B. 123 3 Do. do. 15½ ft. A.F. 8 4 - G. 133 6 Do. do. — - Ecclesbourne Junior Boys 320 6 Trough. 42½ ft. stop cock 10 6 19 12 Pedestal. Senior Girls 289 9 Tr'gh A.F. - 6 2tr'gh 7 21 7 Ped'l A.F. Infants B. 123 2 Tr'gh A.F. 24 ft. stop cock 2 tr'ghs 2 6 G. 124 6 Tr'gh A.F. — 2 2 Elmwood Senior & J. B. S. 247 4 Pedestal 25 ft. A.F. 9 3 12 J. 139 3 sep. c'stn. 16 ft. A.F. 6 2 S. & J. G. s. 153 8 Do. do. - 7 3 18 j. 155 8 Do. do. — 6 3 Infants B. 185 4 Do. do. 26 ft. A.F. 16 7 14 & 12 hnd. G. 179 10 Do. do. (inft. sze.) - Gonville Junior Boys 119 3 Do. do. 19ft. 6in.A.F. 5 4 ‡ Junior Girls 204 11 Do. do. — 7 3 ‡ Infants G. 103 2 Do. do. - 6 3 ‡ B. 12 ft. A.F. *Plus 1 sink. †More if necessary. ‡Towels changed as required. § 4 W.C.'s reserved for use of Infant Girls. 252 253 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. 7 4 12 Junior Girls 119 6 Do. do. — 6 3 9 Infant B. 18 3 Do. do. 10 ft. A.F. 4 2 6 Infant G. 32 4 Do. do. — Ingram Senior Boys 230 5 Do. do. 28 ft. A.F. *4 6 16 Senior Girls 191 13 Do. do. — 4 6 15 Infants B. 116 3 Do. do. 24 ft. A.F. 1 6 9 G. 128 6 Do. do. — tr'gh 1 do. 6 6 Towels changed when necessary. Kensington Avenue Junior Boys 112 3 Do. do. 12 ft. A.F. 6 3 6 Towels changed more often if required. Junior Girls 120 7 Do. do. — 6 2 6 Infants B. 64 2 Do. do. 5ft.3in. A.F. 6 3 6 G. 74 4 — Kingsley Senior Boys 342 6 Do. do. 30 ft. A.F. 14 6 ... Towels changed twice a week or as necessary. Senior Girls 362 18 Do. do. — 14 7 ... Junior B. 204 4 Do. do. 17 ft. A.F. 16 8 ... Mixed G. 205 10 Do. do. Infants B. 420 4 Do. do. 17 ft. A.F. 16 8 ... G. 10 Do. do. — Toweis clxauged when necessary. Lanfranc Senior Boys 198 6 Do. do. 41 ft. A.F. 16 5 ‡ Senior Girls 228 16 Do. do. — 16 5 t Norbury Manor Senior Boys 267 5 Do. do. 40 ft. A.F. 2 Tr'ghs 6 ft. 6 12 Towels changed more often if required. Senior Girls 249 14 Do. do. - 2 ditto 5 10 Junior Girls 6 Do. do. - J. B. & I. 317 6 Do. do. 18 ft. A.F. 21 9 18 J. G. & I. 310 14 Do. do. — Oval Senior Boys 156 4 Do. do. 15 ft. A.F. 10 3 6 to 9 Towels changed when necessary Senior Girls 130 8 Do. do. — 10 3 6 to 9 J. B. & G. B. 208 4 inc. inf. b Do. do. 21 ft. A.F. 8 4 8 to G. 10 inc. inf. g Do. do. - 12 Inf. B. & G. 168 Do. do. — 10 4 8tol2 Portland Senior Boys 227 7 Do. A.F. 29 ft. stop cock 2 tr'ghs 5 ft. 6 6 Senior Girls 182 10 Do. do. — Do. 5 5 Infants B. 305 2 Do. do. 24 ft. stop cock 2 tr'ghs 6 6 G. 7 Do. do. — 5 ft. *2 Troughs. ‡More if necessary. ‡ Towels charmed when necessary. 254 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. Purley Oaks S.B. 100 6 Ped.Sep.Cis 33 ft. A.F. 3 2 *4 S.G. 76 9 Do. do — 2 2 *4 J. B. B 80 Shared with Se nior Boys 4 3 *6 & G. G. 81 Shared with Se nior Girls Infants B. 72 4 Ped.sep. cistern 14ft. 6in. A.F. 4 3 4 G. 69 4 — Rockmount S.& J. B. 169 4 Do. do. 22 ft. A.F. 7 4 ... Towels changed three times uer week or as necessary. S. & J. G. 119 10 Do. do. — 7 3 ... Inft. B. 88 3 Do. A.F. 20 ft. A.F. 8 2 ... Inft. B. 96 7 Do. A.F. — 2 ... South Norwood Jnr.B 282 7 Do. sep. cistern 36 ft. A.F 4 4 12 School in course of Re-building. Jnr. G. 159 Do. do. — ... ... ... Infants B. 185 21‡ Do. do. 16 ft. A.F. 19 7 21 G. 110 Do. do. — Sydenham Jnr. Boys 283 7 Do. do. 33 ft. A.F. 12 6 12 J.G. Infants 380 16 Do. do. 34 ft. A.F. 17 9 18 3 Tavistock Snr. Boys 229 7 Do. do. 54 ft. A.F. 2 tr'ghs 5 ... Changed once or twice per wheek. Snr. Girls 254 17 Do. do. — Do. 6 ... Infants B. 103 2 Do. do. 7 ft. A.F. 7 4 ... G. 95 5 Do. do. — Waddon Snr. Boys 266 4 Do. do. 20 ft. A.F. 8 6 ... Changed twice weekly or as necessary. Snr. Girls 294 10 Do. do. — 10 6 ... J.B. B. 142 7 Do. do. 22ft. 6in.AF. 6 6 ... & G. G. 158 10 Do. do. — 6 Infants B. 128 3 Do. do. 13 ft. A.F. 3 5 ... G. 109 7 Do. do. — 6 West Thornton J. B. 280 9 Do. do. 30 ft. A.F. 9 6 ... Changed three times per wheek or as necessary. J.B. 240 13 Do. do. — 7 6 ... Infants B. 299 3 Do. do. 23 ft. A.F. 4 3 \G. 6 Do. do. ~ 4 3 *Towels changed approx. every other day. †More towels if required. ‡J.G. & I.G. now sharing 6 W.C.'s (rebuilding in progress). 255 Sanitary Accommodation. School. Approx. No. of scholars. No. of W.C.s Type of closet. Urinal space. No. of wash basins No.or towels in use at time of insp. No. of towels used ea. wk. Whitehorse Manor S.B. 170 10 Do. do. 32 ft. A.F. 12 4 8 J.G. 252 16 Do. do. - 7 3 15 Infants B. 188 4 Do. do. 26 ft. A.F. 5 6 ... Towels Change as neces- sary. G. 88 8 Do. do. — Winterbourne J. B. 332 7 Do. do. 39 ft. A.F. 16 8 ... Towels changed as necessary. J. G. 405 17 Do. do. — xl8 7 ... Infants B. 188 3 Do. do. 24 ft. A.F. xl5 4 ... G. 147 11 Do. do. — Woodside Jnr. Boys 381 9 Pedestal sep. cist. 37 ft. A.F. *7 8 ... Towels changed dallv. Jnr. Girls 297 13 Do. do. — 10 5 ... Infants B. 143 5 Do. do. 9 ft. A.F. 5 4 ... G. 145 7 Do. do. — Heath Clark Cent. B. 210 5 Do. do. 22 ft. stop cock 8 4 ... 3 times per week or as necessary Cent. G. 210 10 Do. do. — 8 4 ... Croydon British Senior Girls 183 12 Do. do. — 10 7 21 Lady Edridge Cent. G. 328 8 Do. do. — 4 8 16 St Christophers B 90 10 Do. do. 30 ft. A.F. 7 3 ... Towels changed as necessary. G 38 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 New Block B. 48 3 Do. do. 9 ft. A.F. 3 G. 20 5 Do. do. — 3 St. Luke's Myope B. 23 2 Do. do. 4 ft. A.F. 2† 1 ... Towels changed twice weekly. G. 14 3 Do. do. — 2† 2 St. George's Hall B. 53 1 Do. do. 6ft. & 1 stall with w.w.p. 2 2 ... Towels changed weekly. G. 41 2 Do. do. — † 1 Shower Bath for Boys. † 1 Shower Bath for Girls. x Plus one sink. 256 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. Suffolk Road Temporary Infants B. 96 2 Standard pattern and height space for 3 persons 2 4 ... Towels changed a.s required. Not Now in Use as a Sc[hool. - G. 74 4 - 4 All Saints S.B. 37 1 Pedestal sep. cist. 6 ft. hand flushed cist. 2 1 3 S.G. 38 2 Do. do. - 2 1 3 J.B. 102 Do. do. 6½ ft. A.F. 2 2 6 J.G. 82 5 (J.G. & I.G.) Do. do. - 2 2 6 Infants 78 3 (Inf. boys) Do. do. 8 ft. A.F. 2 2 6 Chrit Church J.M. & I J.B. 125 4 Do. do. 16 ft. A.F. 4 ... ... Toweis changed as necessary. J.G. 137 14 Do. do. — Inf. B. 63 1 7 Do. do. Inf. G. 64 J Cypress School Jnr. Boys 79 3 Do. do. 17 ft. A.F. 4 2 ... Towels changed Iw lue Jnr. Girls 63 11 Do. do. — 10 4 ... Inft. Boys 88 2 Do. do. 11 ft. A.F. Shared with J.B. Inft. Girls 69 Use Girls above — - Shared with J.G. Kindgtn. — 1 — — 1 1 ... Towels changed Iwlce weekly. Holy Trinity I. G. & 250 11 Pedestal sep. cist. — 6 4 ... I. G. Parish Church S. & J. B. 238 4 Do. do. 21 ft. A.F. 6 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. — 257 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. St. Joseph's Boys 81 3 Do. do. 8 ft. stop tap 2 2 6 1 Towels Changed when necessary. Infant Boys 25 ... Girls and 98 6 Do. do. 3 2 6 Infant Girls 28 — 2 2 6 St. Mark's J. G. & 1. B 31 2 — 5 ft. A.F. 3 3 Towels changed daily. G. 140 5 Do. do. — St. Mary's (Addington) J. M. & I. Junior B. 34 3 Do. do. 12 ft. A.F. 3 1 2 Junior G. 36 4 Do. do. — Infants B. 25 Share d with Ju nior Boys 3 1 2 G. 20 Share d with Ju nior Girls St. Mary's R.C Mixed B. 151 4 Do. do. 16 ft. A.F. 6 2 4 Infants B. 77 2 Do. do. 8 ft. A.F. Mixed G. 137 9 Do. do. 6 (2 inft.) 2 6 (inc. 2 inft.) St.Peter's Inf. B. j-122 3 sts. troughA.F. 4ft.6in. A.F 3 1 2 Towels changed when necessary Inf. G. Do. Do. do. — 1 1 2 St. Saviour's J. M. B. l64 4 Do. do. 23 ft. A.F. 4 4 8 10. 7 Do. do. — Infants 98 2 Do. do. 7 ft. 3 4 8 Shirley J. Mxd. B. 118 3 Pedestal rep. cist. Do. do. 10i ft. stop cock 2 2 4 G, 86 4 Infants B. 45 2 Do. do. 4 ft. A.F. 2 2 4 G. 21 3 Do. do. — Archbishop Tenison's Central B. 203 4 Do. do. 18 ft. A.F. 9 4 12 Senior G. 146 8 Do. do. — 5 3 6 St. Michael's Central G. 218 9 Do. do. — 3 4 8 Monks Orchard Junior B. 38 3 P.W.D. 13 ft. ‡4 1 Towel changed three times per week. Junior G. 39 6 P.W.D. ‡4 2 Infant B. 66 2t P.W.D. 14 ft. ‡6 Infant G. 65 5 P.W.D. i I t 1 Babies (Boys and Girls). $ Plus one sink. 258 One provided and two non-provided schools have trough closets; the sooner these are replaced by modern pedestal closets, hand flushed, the better hygienically. Closets 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. Cost of the School Medical Service. The gross cost of the medical, dental, and nursing services was £11,852; from this an income of £800 should be deducted, making a nett cost of £11,052. The rateable value of the Borough in 1937 was £2,284,119. The Government grant is 50 per cent. of the expenditure, hence the actual cost to the rates was £5,526, i.e., a rate of 0.58 pence. The nett cost of these services to the rates for 1937 per child on the school registers was 4s. 2.6d. The figures do not include £300 for Medical Inspection (Higher Education) and for Blind persons £573. Cost of Special Schools. Schools maintained by the Council, £7,709; Contributions to schools under other authorities, £3,737 ; Loans charges, £459 ; Other expenses (travelling, etc.), £11; Income from parents' contributions and other receipts, £694, giving an actual cost of £11,222, of which £5,685 was payable out of local rates, giving a rate of 0.60 pence. Cost of Milk and Meais. Milk and meais cost £1,330 14s. 2d. ; wages, fuel, printing, etc., £669 13s. 4d. ; income from parents' contributions, £85 8s. 7d.; giving an actual cost of £1,914 18s. 11d. There has been a slight increase in the cost of the actual medical services rendered in the Public Elementary Schools from 0.57 in 1936 to 0.58 of a penny rate in 1937. The cost of maintenance in Special Schools has also increased from a rate of 0.56 to 0.60 pence. The cost of milk and meals has increased by £357 2s. 5d. 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 218. The average attendance was 89 per cent. 259 It is interesting to note that the fall in the birth-rate, which has been noticeable for some years, has caused a decrease in the school population, although the total population of Croydon continues to increase owing to immigration. Table I. No. of Schools. Average number on the Registers. Average attendance. Average attendance per cent. Senior Boys 10 C. 2698 2503 93 2 N.P. 414 391 94 Senior Girls 11 C. 2746 2487 91 2 N.P. 369 342 93 Senior Mixed 7 C. 2370 2172 92 4 N.P 1300 1158 89 Junior Boys 7 C. 2336 2187 94 Junior Girls 8 C. 2792 2485 89 3 N.P. 745 655 88 Junior Mixed 13 C. 4796 4213 88 4 N.P. 1005 857 85 Infants (323 under 5) 13 C. 3927 3257 83 2 N.P. 206 174 84 Schools— Church of England 13 4039 3577 89 Roman Catholic 2 Council 32 21665 19304 89 Total 47 25704 22881 89 " 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. The Deputy Medical Officer, Dr. Payne, devoted 3/11ths of his time to school medical duties ; Dr. Lewis 9/11ths; Dr. Payton 7/11ths; Dr. Jenkin-Lloyd 2/11ths; Dr. McMahon 3/llths; Dr. Morrison 6/11ths. The groups examined have been entrants, usually aged 5-7 years; intermediates 8 years; and leavers 12-14 years. These are the three statutory groups. Examinations of children outside these groups are classified as " others." Children brought forward by head teachers, enquiry officers, school nurses, etc., are classified as " specials." 260 The same arrangements as appertained in 1936, continued. The Leaver group (13th birthday) are examined the first term ; the 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 7,855 children were examined as compared with 7,312 in 1936, and 5,711 parents attended the examinations. The percentage attendance of parents in the Entrants group was for boys 86.0 per cent., and girls 87.0 per cent. ; in the Intermediate group, boys 70.0 per cent., girls 77.0 per cent. ; and in the Leavers' group, boys 42.7 per cent., girls 58.7 per cent. 12,399 re-inspections were made as against 12,122 in 1936, and 8,719 in 1935. There has been an increase in the number of parents who attend the medical inspections with their children. The present set routine medical inspection at fixed age groups is in need of revision and a more fluid system adopted. 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 examine 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, 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 present requirements of the Board of Education would not be met by such a scheme, as no routine groups would be selected. Until some change is made in the requirements, a scheme as suggested above cannot very well bo put into operation. The total percentage of parents attending was 72.9, as against 72.6 last year. 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 31 22 30 10 16 62 14 53 42 49 23 44 ... 5 ... 5 Benson 37 40 34 37 25 25 20 23 13 11 3 2 ... ... ... ... Beulah 82 79 75 69 25 100 21 81 ... ... ... ... 1 ... ... ... Croy. British ... ... ... ... ... ... ... ... ... 57 ... 22 ... ... ... ... Cypress 35 32 32 28 26 15 18 15 ... ... ... ... ... ... ... ... Davidson 52 62 49 59 13 55 8 36 54 51 23 33 13 5 11 4 Duppas 37 36 28 30 41 54 46 30 ... ... ... ... ... ... ... ... Ecclesbourne 17 69 17 55 116 ... 72 ... ... 67 ... 41 19 ... 12 ... Elmwood 47 52 39 39 38 42 15 31 104 50 31 32 ... 14 ... 8 Gonville 62 39 60 37 25 31 23 25 ... ... ... ... ... ... ... ... Howard 19 10 16 8 23 ... 12 ... ... ... ... ... ... ... ... ... Ingram 35 47 22 46 ... ... ... ... 68 100 38 68 ... ... ... ... Kensington 30 30 27 28 45 51 39 51 ... ... ... ... 4 3 3 3 Kingsley 91 91 82 86 85 52 51 31 35 103 14 58 4 ... 1 ... Lanfranc ... ... ... ... ... ... ... ... 104 98 39 65 ... ... ... ... Monks Orchard 27 23 28 20 7 21 3 16 ... ... ... ... 18 5 15 4 Norbury Manor 52 48 44 42 39 54 33 49 87 81 52 51 ... 3 ... 3 Oval 37 34 36 32 40 32 31 29 25 32 14 18 7 5 6 3 Portland 48 44 41 44 ... ... ... ... 75 63 22 19 5 5 4 3 Purley Oaks 30 27 25 20 29 35 13 16 40 23 7 14 ... ... ... ... Rockmount 28 33 23 28 34 29 23 13 34 23 16 16 ... ... ... ... St. George's 36 34 35 30 ... ... ... ... ... ... ... ... ... ... ... ... South Norwood 66 53 49 47 63 16 43 14 ... ... ... ... 3 21 3 14 Sydenham 40 22 28 13 8 42 6 22 ... ... ... ... ... 3 ... 2 Tavistock 31 31 27 27 ... ... ... ... 80 90 41 42 ... ... ... ... Waddon 42 43 37 38 31 40 22 33 80 70 38 52 ... ... ... ... West Thornton 77 99 66 75 64 42 39 39 ... ... ... ... 6 4 4 3 Whitehorse Mnr. 64 36 52 32 ... 112 ... 85 68 ... 28 ... ... 1 ... 1 Winterbourne 57 62 54 57 105 128 80 108 ... ... ... ... ... ... ... ... Woodside 64 73 54 72 59 53 47 50 ... ... ... ... 40 28 27 24 Addington 10 11 8 8 5 13 4 10 ... ... ... ... 2 ... 2 ... All Saints 23 21 18 18 14 8 12 7 15 9 8 6 ... ... ... ... A. Tenison's Gls. ... ... ... ... ... ... ... ... ... 47 ... 25 ... ... ... ... Christ Church 52 54 48 47 15 13 10 10 ... ... ... ... ... ... ... ... Holy Trinity ... 41 ... 39 ... 39 ... 27 ... ... ... ... ... 7 ... 6 Parish Church 41 44 35 40 33 52 28 46 48 ... 24 ... ... ... ... ... St. Andrew's 22 21 16 20 11 9 7 7 26 14 13 4 ... ... ... ... St. Joseph's 8 9 5 6 10 15 4 4 13 9 5 5 ... ... ... ... St. Mark's 17 23 10 20 ... 10 ... 10 ... ... ... ... ... ... ... ... St. Mary's 17 27 13 21 24 20 9 9 19 13 2 5 1 ... ... ... St. Peter's 26 22 24 18 ... ... ... ... ... ... ... ... ... ... ... ... St. Saviour's 23 22 11 18 16 18 2 9 ... ... ... ... 2 ... ... ... Shirley 21 15 21 12 27 5 23 6 ... ... ... ... ... 11 ... 9 1534 1581 1319 1376 1112 1293 778 995 1030 1060 441 622 125 120 88 92 3115 2695 2405 1773 2090 1063 245 180 262 FINDINGS AT ROUTINE MEDICAL INSPECTIONS. Uncleaniiness. For uncleaniiness surveys the health visitors made 465 visits to schools, an increase of 19. At the primary inspections they found vermin in 201 and nits alone in 1,612 children. On these inspections, 3.0 per cent, of the children showed evidence of infestation as against 3.1 in 1936 and 3.4 in 1935. The scheme inaugurated in 1935 has continued to function very satisfactorily. Clothing and Footgear. At routine medical inspections 99.7 per cent, of the boys and 99.5 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 14.6 per cent, of the boys and 16.1 per cent of the girls were below normal nutrition for the area. In the Intermediate group 8.5 per cent, of the boys and 11.2 per cent, of the girls were under average ; in the Leavers' group 8.6 per cent, of the boys and 8.5 per cent, girls, giving in the whole school groups examined 11.Q per cent, boys and 12.2 per cent, girls. There is no standard of nutrition, and no universally reliable method of assessment has been arrived at. The Board of Education has laid down the following grades, but in the absence of standardised tests, and criteria, actual assessment naturally varies with the varying ideas of the examining medical officers. A. Excellent. B. Normal. C. Slightly sub-normal. D. Bad. Height and Weights. Table III. gives the results of an enquiry made to ascertain the average heights and weights of all children examined at routine inspections during 1937. The full value of this Table will not be obtained until similar records for ten consecutive years have been analysed ; when this is completed the rate of growth can be followed, so far as Croydon children are concerned, throughout school life. 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. 1933 120 41.1 39.2 42.9 43.7 39.3 35.3 117 40.8 38.2 42.3 42.2 39.3 34.7 1932 899 43.0 42.2 45.5 48.2 40.1 36.5 940 42.5 40.8 44.9 47.3 40.1 35.1 1931 422 44.3 44.6 46.5 50.1 42.3 40.3 418 44.5 43.6 47.0 50.9 42.8 39.2 1930 94 47.5 51.2 49.7 58.2 45.9 47.4 97 46.4 49.6 47.7 53.8 44.9 43.6 1929 422 49.6 55.7 52.8 64.6 46.7 48.2 470 49.2 54.3 52.2 63.2 46.7 47.5 1928 574 50.7 58.7 54.0 70.4 47.6 49.3 674 50.3 57.5 54.0 71.6 47.9 47.6 1927 175 52.6 63.3 55.6 71.5 50.2 56.3 189 52.1 62.5 54.5 72.5 49.9 54.6 1926 63 54.9 71.2 57.2 80.2 50.6 58.0 38 53.5 66.1 55.8 78.4 50.5 55.5 1925 86 55.7 77.4 58.7 92.5 52.6 65.0 77 56.9 77.2 60.1 91.9 52.5 61.9 1924 848 57.6 83.8 62.5 112.6 53.0 64.9 909 58.2 85.1 63.1 114.8 53.5 64.6 1923 96 59.2 90.0 63.6 116.2 58.0 86.0 86 58.6 89.8 62.2 109.2 56.7 80.1 1922 1 60.0 106.0 ... ... ... ... 7 64.5 126.0 68.0 138.0 60.0 105.5 263 264 Children Born in 1932.—The Boys are 0.5 inches taller and 1.4 lbs. heavier on the average than the girls. The average minimum weights of the boys is 1.4 lbs. more and their average minimum height the same as the corresponding figures for the girls. The average maximum weight of the boys is 0.9 lbs. less and their average maximum height 0.6 inches taller than the girls. Children Born in 1931.—The boys are 0.2 inches shorter and 1.0 lbs. heavier on the average than the girls. The average minimum weights of the boys is 1.1 lbs. more and their average minimum height 0.5 incnes shorter than the corresponding figures for the girls. The average maximum weight of the boys is 0.8 less than the girls, and their average maximum height 0.5 inches shorter than for the girls Children Born in 1929.—The boys are 0.4 inches taller and 1.4 lbs. heavier on the average than the girls. The average minimum weight of the boys is 0.7 Lbs. more and their average minimum height the same as the corresponding figure for the girls. The average maximum weight of the boys is 1.4 more than the girls, and their average maximum height is 0.6 inches taller than the girls. Children Born in 1924 and 1925.—The boys in this group were 0.6 inches shorter and 1.3 lbs. lighter on the average than the girls. The average minimum weight of the boys is 0.3 lbs. more, and their average minimum height 0.5inches shorter than the girls. The average maximum weight of the boys is 2.2 lbs. less and their average maximum height 0.6 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 1932 : Boys 5.4 11.9 Girls 4.8 12.2 Born in 1931 : Boys 4.2 9.8 Girls 4.2 11.7 Born in 1929 : Boys 6.1 16.4 Girls 5.7 15.7 Born in 1924 and 1925 : Boys 9.5 47.7 Girls 9.6 50.2 265 Heart and Circulatory System. At routine medical inspections among the Entrant group 20 boys and 19 girls were found to have organic disease. In the Intermediate group, the figures were 54 boys and 56 girls, and in the Leaver group 49 boys and 65 girls. Functional disease was found in 45 boys and 36 girls in the Entrants; 68 boys and 79 girls in the Intermediate; 36 boys and 57 girls in the Leaver group. Anaemia was present in 61 boys and 77 girls in the Entrant group; 42 boys and 73 girls in the Intermediate; and 43 boys and 52 girls in the Leavers. The percentage of all Heart and Circulatory defects among children examined at routine medical inspection was 12.5, a small decrease on 1936. Chest Complaints (Other than Tuberculosis). In all the groups combined 3.2 per cent. of the boys and 2.1 per cent. of the girls had some minor affection of the lungs. This was usually a mild Bronchitis. Tuberculosis. Eighteen children were referred to the Tuberculosis Officer for further examination. All contacts of known cases of Tuberculosis are kept under supervision and re-examined at each school medical inspection. 290 children were under such surveillance at the beginning of the year, 43 were added during the year, 30 were discharged, leaving 303 under observation at the end of the year. Twenty cases of pulmonary Tuberculosis and 12 cases of nonpulmonary Tuberculosis in children of school age were notified to the Medical Officer of Health during the year. Two children died of pulmonary Tuberculosis and four of non-pulmonary Tuberculosis. The ages at death of these cases were:—Pulmonary: 11 years, 12 years. Non-pulmonary: 6 years, 8 years, 9 years, 13 years. Three of the non-pulmonary deaths were certified to be from tuberculous meningitis: and one from tuberculous meningitis and miliary tuberculosis Taking the total school population as 25,704, the mortality rate from pulmonary Tuberculosis in school children was 7.8 per 100,000, and the incidence rate 77.8 per 100,000. For non-pulmonary Tuberculosis the respective figures were 15.6 and 46.7. 266 Nose and Throat. In all the groups 695 boys and 836 girls had enlarged tonsils; 31 boys and 25 girls had adenoids only; 350 boys and 376 girls had adenoids and enlarged tonsils; 120 boys and 111 girls were mouth breathers; 766 boys and 594 girls exhibited enlarged glands in the neck. Of all children examined at Routine Medical Inspection, in the Entrant group 15.0 per cent. had enlarged tonsils; 0.8 per cent. had adenoids alone; 15.3 per cent. enlarged tonsils and adenoids; and 14.0 per cent. had enlargement of the submaxillary or cervical glands. In the Intermediate group the respective percentages were 25.5 per cent., 10.4 per cent., 7.7 per cent., and 23.9 per cent.; and in the Leaver group, 18.8 per cent., 0.1 per cent., 2.3 per cent., and 14.4 per cent. The percentages for the three groups in relation to the total number of children examined, were 18.8 per cent., 0.7 per cent., 9.1 per cent., and 16.7 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 33.3 33.8 17.1 11.0 Intermediates 33.2 39.0 26.3 21.8 Leavers 22.5 23.2 17.8 10.9 Other Ages 37.6 30.8 24.8 18.3 * 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 0.2 per cent. Entrants, 0.7 per cent. Intermediates, and 0.7 per cent Leavers in the children examined had defective hearing. The report on the work done in the Ear Clinic is given on page 47. 267 Speech Defects. The special class is held twice weekly, and is conducted by two qualified lady teachers. During 1937, 37 children attended. A special report on the results of the class is given on page 56. Routine medical inspection findings showed in the Entrant group 0.4 per cent. children defective, in the Intermediate group 0.3 per cent., and 0.5 in the Leaver group: figures very similar to 1936. 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 1.5 per cent incidence in boys and 1.1 per cent. in girls ; Intermediate boys 2.2 per cent. and girls 3.0 per cent. ; Leavers 1.7 percent. boys and 2.6 per cent. girls; a total in all groups of 1.8 per cent. boys and 2.1 per cent. girls. Deformities. Among children examined at Routine Medical Inspection 0.5 per cent. of the boys and 0.1 per cent. of the girls showed evidences of rickets; 2.3 per cent. boys and 2.8 per cent. girls had some abnormal degree of spinal curvature, and 3.9 per cent. boys and 6.2 per cent. girls showed some other physical deformity. External Eye Diseases. Squint was present in 2.0 per cent. of all children examined in the various groups and was most frequently found in the Entrant group (2.1 per cent. boys and 2.1 per cent. girls). Its incidence declined as age advanced. Blepharitis occurred in 1.2 per cent. of all the children and other external eye defects in 0.2 per cent. The total percentages of eye defects in the various groups was 3.2 for Entrants; 4.0 for Intermediates ; and 3.1 for Leavers. For 1936 the corresponding figures were 3.9, 2.6 and 1.7. 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. 268 In the Intermediate group 7.7 per cent. of the boys and 8.8 per cent. of the girls were referred for treatment or observation for defective vision, and in the Leaver group 12.1 per cent. of the boys and 14.3 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 but steady upward trend in the number of school children with defective vision. Table V. Extent of Defect. Intermediate. Leavers. Total. Boys. Girls. Boys. Girls. Boys. Girls. No. % No. % No. % No. % % % Normal: R 1058 95.1 1205 93.2 939 91.2 966 91.1 93.2 92.3 6/6ths or 6/9ths L 1059 95.2 1225 94.7 951 92.3 971 91.6 93.8 93.3 6/12ths or 6/24ths R 47 4.2 81 6.3 81 7.9 80 7.5 6.0 6.8 L 47 4.2 65 5.0 72 7.0 81 7.6 5.6 6.2 6/36ths or worse R 7 0.7 7 0.5 10 0.9 14 1.4 0.8 0.9 L 6 0.6 3 0.3 7 0.7 8 0.8 0.6 0.5 Table VI. TEETH. Entrants. Intermediate. Leavers. Boys. Girls. Boys. Girls. Boys. Girls. No. % No. % No. % No. % No. % No. % Perfect set of Teeth 746 48.6 787 49.8 744 66.9 884 68.4 715 69.4 805 75.9 One to four Decayed 420 27.4 417 26.4 247 22.2 249 19.2 258 25.1 185 17.5 Four or more Decayed 368 24.0 377 23.8 121 10.9 160 12.4 57 5.5 70 6.6 Totals 1534 1581 1112 1293 1030 1060 It is interesting to note that 4,844 children of all groups, or 61.7 per cent., were said to have sound teeth at medical inspection. The percentage of sound teeth found by the Dental Inspectors was 24 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. 269 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 emphasised in the dental section of the report. 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 99.9 98.7 99.6 98.3 99.3 98.3 97.6 100.0 99.6 98.5 Body 99.9 99.7 99.7 99.5 99.2 99.5 100.0 99.2 99.7 99.6 Clothing (satisfactory) 99.9 99.9 99.5 99.5 99.5 98.9 100.0 100.0 99.7 99.5 Footgear (satisfactory) 99.9 100.0 99.5 99.2 99.4 98.8 100.0 100.0 99.7 99.4 Nutrition (normal) 85.4 83.9 91.5 88.8 91.4 91.5 91.2 95.8 89.0 87.8 Defects: Circulatory System 8.3 8.4 14.7 16.1 12.4 16.4 16.8 24.2 11.5 13.4 Pulmonary System 4.9 3.0 1.3 1.7 2.7 1.5 4.0 0.8 3.2 2.1 Skin Disease 1.5 1.1 2.2 3.0 1.7 2.6 4.0 ... 1.8 2.1 Defects of Nose and Throat 36.8 37.8 37.0 41.5 24.3 24.4 42.4 32.5 33.6 35.3 Enlarged Cervical Glands 17.1 11.0 26.3 21.8 18.0 10.9 14.8 18.3 20.3 14.6 External Eye Disease 0.9 1.4 2.0 1.4 1.7 1.3 2.4 1.7 1.5 1.4 Defective Vision 0.2 0.3 7.7 8.8 12.1 14.3 11.2 10.0 6.0 7.0 Defective Hearing 0.1 0.3 0.8 0.5 0.8 0.6 ... 0.8 0.5 0.4 Speech Defects 0.4 0.3 0.4 0.3 0.8 0.3 ... ... 0.5 0.3 Dental Disease (more than four decayed) 24.0 23.8 10.9 12.4 5.5 6.6 15.2 10.8 14.9 15.3 Dull and Backward 0.4 0.1 1.3 1.2 1.6 1.1 2.4 0.8 1.1 0.7 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. For nutrition, the Entrant group (aged 5) 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 11.6 per cent. of the children as contrasted with 7.9 per cent. in 1936. Enlarged cervical glands were recorded most often in the Intermediate group in both sexes. There is a close relationship between enlarged cervical glands and unhealthy conditions of the nose and throat. In themselves simple enlarged neck glands are of no great moment, but they serve as pointers to unhealthy conditions elsewhere, and may become the nidus of Tubercular infection. 270 The influence of school work on eyesight is once again 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. 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 accommodation, or to the overtaxing of accommodation 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. 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. Table VIII. School. Intermediates. Leavers. School. Intermediates. Leavers. Boys Girls Boys Girls Boys Girls Boys Girls Ashburton 25.0 6.5 14.3 10.4 Tavistock ... ... 15.0 12.2 Benson 4.0 — — 9.1 Waddon 6.5 5.0 11.2 2.9 Beulah 4.0 6.0 ... ... West Thornton 4.7 9.5 ... ... Croydon British ... ... ... 15.8 Whitehorse ... 12.5 10.3 ... Cypress 3.8 6.6 ... ... Winterbourne 1.9 6.3 ... ... Davidson 23.1 16.4 5.5 15.5 Woodside 3.4 5.7 ... ... Duppas — 5.5 ... ... Addington St.Mary's — 7.7 ... ... Ecclesbourne 6.9 ... ... 2.7 All Saints' 14.3 — 13.3 11.1 Elmwood 4.0 — 4.8 6.0 ArchbishopT enison's ... ... ... 4.3 Gonville 4.0 6.5 ... ... Christ Church — — ... ... Howard 13.0 ... ... ... Holy Trinity ... 7.7 ... ... Ingram ... ... 11.8 14.0 Parish Church 9.1 1.9 1.5 Kensington 13.3 17.6 ... ... St. Andrew's — — 11.5 21.4 Kingsley 1.2 5.8 11.4 18.4 St. Joseph's — 6.6 — — Lanfranc ... ... 8.7 11.0 St. Mark's ... — ... ... Monks Orchard 14.3 14.3 ... ... St. Mary's 12.5 5.0 21.1 15.4 Norbury Manor 5.1 7.4 4.6 2.5 St. Peter's ... — ... ... Oval 5.0 15.6 20.0 28.1 St. Saviour's 18.8 11.1 ... ... Portland ... 10.7 12.7 Shirley 3.7 — ... ... Purley Oaks — 8.6 5.0 — St. Michael's ... ... ... ... Rockmount — — 5.9 8.7 Selhurst Grammar ... ... ... ... South Norwood 17.5 18.8 ... ... St. George's ... ... ... ... Sydenham 12.5 4.8 ... ... 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 10 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, 1937. 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 155 40 5.13 163 52 5.30 Uncleanliness— Head ... ... 1 0.02 Body Skin Disease 16 2 0.47 7 4 0.27 Eye Disease— Defective Vision 179 49 5.00 234 49 6.98 Squint 42 21 1.66 38 25 1.55 External Eye Trouble 11 4 0.39 11 3 0.35 Ear Disease— Deafness 4 1 0.13 5 7 0.29 Otitis Media 7 4 0.29 6 5 0.27 Other Disease 8 1 0.24 4 4 0.20 Nose and Throat— Enlarged Tonsils only 53 208 6.87 60 237 7.33 Adenoids only 9 15 0.63 7 13 0.49 Enlarged Tonsils and Adenoids 142 140 7.42 171 131 7.45 Other Conditions 53 41 2.47 58 50 2.66 Enlarged Cervical Glands (not T.B.) 3 26 0.76 5 18 0.57 Dental Defects 42 6 1.26 56 3 1.47 Speech Defects 6 3 0.24 6 3 0.22 Heart and Circulation— Organic 17 66 2.18 25 85 2.74 Functional ... 38 1.00 2 31 0.81 Anaemia 28 20 1.26 38 40 1.92 Bronchitis 5 28 0.87 7 15 0.54 Other Non-T.B 4 10 0.37 4 9 0.32 Pulmonary Tuberculosis 5 8 0.34 3 11 0.15 Other Tuberculosis 1 2 0.08 3 4 0.17 Nervous System Disorders (including Epilepsy, chorea, etc.) 10 66 2.00 12 87 2.44 Deformities— Rickets 1 1 0.05 ... ... ... Spinal Curvature 33 11 1.16 33 24 1.41 Others 44 24 1.79 12 39 1.26 Other Defects and Diseases 31 37 1.79 21 26 1.16 Totals 909 872 46.86 991 976 48.52 Total Children Examined 3801 4054 272 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 1936. Entrants 3115 640 20.5 20.1 Intermediates 2405 467 19.4 19.4 Leavers 2090 446 21.3 21.7 Other Ages 245 54 22.0 25.3 7855 1607 21.7 20.3 The fact that 20.5 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. If the number of children already showing defects on school entry is to be reduced, the experience of many years shows that systematic yearly examination from the age of 2 years upwards to the school entrance age of 5 years, is necessary. 273 Table XI. CHIEF CAUSES OF EXCLUSIONS FROM SCHOOL. Condition. Exclusions during 1937. Percentage of total exclusions. Exclusions during 1936. Percentage of total exclusions. Ringworm—Head 6 0.09 3 0.04 „ Body 18 0.27 26 0.33 Verminous Conditions 1511 23.1 1750 22.69 Impetigo 291 4.45 336 4.35 Scabies 95 1.45 58 0.75 Scarlet Fever 467 7.14 326 4.23 Measles 763 11.67 2093 27.14 Diphtheria 212 3.24 145 1.88 Whooping Cough 553 8.46 770 9.98 Chicken Pox 931 14.24 1011 13.11 Mumps 593 9.7 199 2.58 Tuberculosis (all forms) 43 0.66 24 0.31 External Eye Disease 20 0.3 35 0.45 Sore Throat 352 5.38 196 2.54 Other Causes 683 14.47 740 9.59 6538 ... 7712 ... 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 1,174 fewer children excluded from school on account of various illnesses than in 1936. The chief causes of exclusion were Infectious Diseases, 53.9 per cent. The Infectious Diseases constituting the major causes of these exclusions changed, however. Measles followed its bienniail behaviour and became much less prevalent during the early part of the year. Mumps, however, which was insignificant in 1936, increased. Both Diphtheria and Scarlet Fever were slightly more prevalent, but Chicken Pox and Whooping Cough showed a decreased incidence. The total cases of this group of infectious diseases declined, however, from 4,544 in 1936 to 3,519. Exclusions on account of verminous conditions were lower than in 1936 and constituted 23.11 per cent. of the total exclusions. The health visitors examined 59,696 children in the schools in connection with their primary inspections for the personal cleanliness of the scholars. Impetigo was less prevalent than in 1936. 274 Table XII. 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 (Body). Ringworm (Scalp). Indefinite Sickness. III. Not Infectious Conjunctivitis. Percentage incidence of Infectious Diseases in Schools. Ashburton 725 16 5 ... 4 5 2 1 ... 3 1 ... ... 2 10 ... 4.5 Benson 413 8 ... ... 1 22 24 12 ... ... ... ... ... 2 6 ... 16.2 Beulah 1137 24 6 ... 5 11 42 75 5 18 11 ... ... 5 51 2 14.3 Croydon British 181 1 ... ... ... 1 ... ... ... 1 1 ... ... 1 1 ... 1.1 Davidson 678 19 3 ... 6 13 10 3 3 8 29 1 ... 9 16 1 8.0 Duppas 596 16 25 ... 3 ... 14 1 3 4 23 ... ... 2 16 1 10.0 Ecclesbourne 870 16 10 ... 2 28 5 76 4 14 14 ... ... 2 17 1 15.7 Elmwood 1080 25 7 ... 34 11 59 10 3 9 12 1 ... 5 27 4 13.5 Gonville 424 22 6 ... 3 20 25 64 1 4 4 ... ... 8 15 ... 33.0 Howard 291 7 1 ... ... ... 7 ... ... 6 ... ... ... ... 1 ... 5.2 Ingram 701 4 2 ... 1 4 19 19 5 6 5 ... ... 2 8 ... 7.0 Kensington 364 17 ... ... 86 3 ... 1 2 3 ... ... ... 6 7 ... 29.4 Kingsley 1537 17 64 ... 78 23 31 57 9 21 87 1 ... 2 73 ... 11.1 Lanfranc 468 3 2 ... ... ... 4 ... 2 2 11 4 ... 3 3 ... 1.9 Monks Orchard 205 ... ... ... 8 9 6 2 ... 3 ... ... ... 1 5 ... 22.2 Norbury Manor 1174 13 2 ... 67 24 11 5 4 7 3 1 ... 1 6 1 10.4 Oval 698 5 ... ... 2 5 12 ... 5 13 10 1 ... 5 16 ... 3.4 Portland 779 10 2 1 65 32 32 10 6 4 6 1 ... 4 13 ... 19.4 Purley Oaks 491 35 1 1 9 8 2 4 ... 17 19 ... ... 16 28 12.0 Rockmount 468 ... ... ... 1 13 39 12 1 10 6 1 1 6 ... 14.0 South Norwood 732 25 2 1 51 15 36 4 9 15 2 ... ... 7 9 ... 18.3 Sydenham 655 17 4 ... 46 24 68 36 4 8 5 ... ... 5 8 ... 29.8 Tavistock 730 22 1 ... 24 20 16 9 3 2 23 ... ... 8 15 12.6 Waddon 1123 10 8 ... 1 13 15 5 4 11 20 2 1 2 11 ... 4.6 West Thornton 806 11 3 1 46 30 75 28 3 15 12 ... ... 6 15 2 23.9 Whitehorse 716 13 19 ... 2 35 12 6 2 13 10 ... ... 2 28 1 12.1 Winterbourne 1054 21 7 1 55 39 45 58 2 3 5 ... ... 6 16 ... 24.8 Woodside 958 8 1 ... 54 30 92 53 3 12 1 ... ... 5 14 ... 24.8 Heath Clark 427 4 ... ... ... ... ... ... ... ... ... ... ... ... ... ... 0.9 John Ruskin 398 3 ... ... ... ... 2 2 ... 1 ... 1 ... 1 ... ... 1.7 Lady Edridge 342 1 1 ... ... ... ... ... ... ... ... ... ... ... ... ... 0.6 St. Christopher's 112 2 1 ... ... ... 2 ... ... 3 1 ... ... ... ... ... 4.5 St. Giles 118 3 1 ... ... ... 2 ... ... 1 2 ... ... 1 2 ... 5.1 Myopic Class 32 ... 1 ... ... ... ... ... 1 1 1 ... ... ... 1 ... 3.1 Addington St. Mary's 95 7 1 ... ... 20 18 ... 2 1 4 ... ... 4 5 1 47.4 All Saints' 344 2 32 1 5 3 0 0.8 1 Arch. Tenison's 366 1 1 1 2 7.8 1 Christ Church 421 13 4 1 5 8 1 1 18 3 1 y 14.7 1 Holy Trinity 251 4 2 3 15 12 1 3 11 7 6.4 1 Parish Church 533 2 1 3 13 16 2 4 10 1 / 10 14.9 1 St. Andrew's 416 6 3 1 11 31 3 3 3 \i 0.4 St. Joseph's 232 ... ... ... ... ... 1 ... ... ... ... ... ... 1 ... ... 22.7 St. Mark's 163 8 1 ... 13 10 5 ... 1 2 5 2 4 10 10 ... 22.7 St. Mary's 375 7 10 ... 5 3 6 1 1 6 2 ... ... ... 8 ... 8.5 St. Peter's 124 ... ... ... ... ... 1 ... ... 2 ... ... ... ... 4 ... 0.8 St. Saviour's 275 4 3 ... 7 3 4 1 ... 4 ... 1 ... ... ... ... 8.0 Shirley 194 1 ... ... 1 13 2 ... ... 1 ... ... ... ... 3 ... 8.8 St. Michael's 229 2 ... ... 2 ... ... 1 ... ... ... ... 1 2 ... 2.2 Selhurst Grammar 929 5 1 ... ... ... ... ... ... ... ... ... ... ... ... ... 0.6 St. George's 85 3 2 ... ... ... 26 1 2 2 1 ... ... ... 2 ... 37.6 Cypress 281 4 1 ... 36 18 94 29 2 2 ... ... ... 2 15 ... 64.8 Totals 467 213 8 763 553 931 593 95 291 352 18 6 146 537 20 275 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 Cypress (64.8) and St. Mary's, Addington (47.4), due chiefly to Whooping Cough and Chicken Pox; next were St. George's (37.6) and Gonville (33.0), due chiefly to Mumps and Chicken Pox. The lowest incidence was in Selhurst Grammar (0.6). Scarlet Fever. Four hundred and sixty-seven cases were notified from the schools, 141 more than in 1936. Purley Oaks (35), Elmwood and South Norwood (25) had the most cases. Diphtheria. Two hundred and twelve cases were notified from schools. This was 67 more than in 1936. The Kingsley with 64 cases and Duppas with 25 cases, had the highest individual numbers. Mumps. Five hundred and ninety-three cases were notified from schools. Ecclesbourne (76) and Beulah (75) had the highest individual numbers. Chicken Pox. Nine hundred and thirty-one cases occurred in schools and were notified therefrom, 80 less than last year. Cypress (94), Woodside (92), West Thornton (75), Sydenham (68), and Elmwood (59) showed the highest incidence. Whooping Cough. Five hundred and fifty-three notifications were received from schools, 287 less than in 1936. The highest numbers for individual schools were: Winterbourne (39), Whitehorse (35), and Portland (32). Measles. Seven hundred and sixty-three cases occurred in schools. Those showing the highest incidence were Kensington (86), Kingsley (78), Norburv Manor (67), and Portland (65). 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 led to a higher incidence of all the common infectious diseases in these schools than occurred under the former arrangements. 276 FOLLOWING UP There are 22 Health Visitors, who devote 5/11ths 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 periodical 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 49 Total Visits to School Departments re Cleanliness 465 Number of children inspected for cleanliness (first inspection) 59,696 Number of children inspected (subsequent inspections) 2,410 Number of children found unclean (first inspection) 1,511 (1,813 occasions of infestation) Number of occasions in which children found unclean (subsequent inspections) 2,410 In addition, 1,474 " other visits " to schools were made. Home Visits. Concerning defects found at routine medical inspections 1,826 Subsequent visits re defects found at routine medical inspections 807 Visits re special cases 794 Visits to dental cases 121 Visits in connection with infectious cases and other visits (including 116 visits concerning uncleanliness) 14,447 277 These figures show an increase of 3,788 in the number of children inspected for cleanliness; a decrease of 938 in visits paid in connection with infectious cases and other visits for miscellaneoua reasons, an increase of 47 in the following-up visits to dental cases; a decrease of 378 in visits to special cases; an increase of 97 In the visits made regarding defects found at routine medical inspections, and an increase of 14 in the home visits regarding unclean liness. TREATMENT. The Work of the School Clinics. Table XIII. Summary of Attendances. 1937. 1936. Increase or Decrease. Minor Ailments Clinics 11042 13765 — 2723 Inspection Clinic 1872 1732 + 140 Dental Clinics 19225 14749 + 4476 Ophthalmic Clinic 3562 3493 + 69 Orthopaedic Clinic 1465 2055 — 590 Remedial Exercises Clinic 8474 8813 — 339 Nose and Throat Clinic 1220 1388 — 168 Ionization Clinic 424 316 + 108 Rheumatism Clinic 438 618 — 180 47722 46929 + 793 The Minor Ailments Clinics. Clinics are held each morning at Lodge 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, 822 children made 3,101 attendances, and at the Duppas School 817 children made 3,552 attendances. 278 Table XIV. Complaint. 1937. 1936. Cases. Attendances. Average No. of Attendances, per case. Cases. Attendances. Average No. of Attendances, per case. Ringworm of Scalp 6 20 3.3 9 15 1.7 „ Body 13 55 4.3 32 166 5.2 Scabies 72 358 5.0 62 267 4.3 Impetigo 203 909 4.5 305 1811 5.9 Other Skin Diseases 119 394 3.3 214 675 3.2 Otorrhoea and other Ear defects 243 881 3.6 305 1394 4.6 External Eye Disease 276 1946 7.1 328 2981 9.1 Miscellaneous 1639 6479 3.9 1574 6456 4.1 2571 11042 4.3 2829 13765 4.9 From this Table it is seen that the average number of attendances per child decreased from 4.9 to 4.3; the total attendances decreased by 2,723, and the number of individual cases by 258. Adenoids and Enlarged Tonsils. During 1937, 124 cases of tonsils only, 16 cases of adenoids only, and 347 cases of adenoids and enlarged tonsils, a total of 487 cases, were recommended for treatment. In 408 cases the Local Education Authority was requested to arrange for the operation. There were 80 sessions at the Croydon General Hospital. The work is done by a rota of 4 general medical practitioners working in pairs, as surgeon and anaesthetist, for periods of 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. 408 children were operated upon, a decrease of 72 on 1936. 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. Children admitted to Mayday Hospital are kept for a minimum of 5 days in hospital. All children are conveyed home by ambulance. In all there were 222 non-attendances. 279 Of the 408 children operated on 231 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, wae 57 per cent, compared with 47 per cent, in 1936. 55 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. 52 were operated upon in Mayday Hospital. The Inspection Clinic. 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. 1,872 attendances were made by children during the year, an increase of 140. Treatment of Visual Defects. Table XV. Number of defects dealt with. Spectacles prescribed. Spectacles 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. 1 Errors of Refraction— Elementary Schools 1114 26 1140 745 26 658 26 Secondary Schools 182 22 204 134 22 124 22 1296 48 1344 879 48 782 48 This Clinic showed an increase upon 1936 of 233, 280 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 Todd at the Croydon General Hospital; (b) The Remedial Exercises Clinic held in St. Andrew's Hall, Pump Pail; (c) The St. Giles' School, Addington. Table XVI. Spinal and Other Remedial Clinics. 1937. 1936. Attendances. sessions Av. att. Attendances. Sessions. Av. att. Spinal 2,735 540 5.1 2,734 553 4.9 Massage 172 172 1.0 176 176 1.0 Flat Feet 1,587 206 7.7 1,520 190 8.0 Breathing 2,792 261 10.7 2,996 287 10.4 7,286 1,179 7,426 1,206 St. Giles' School, Addington. Total number of female patients 38 Total number of male patients 16 Total number of attendances 1,188 Total number of sessions 199 Average attendance per session 6 No. of cases still under treatment 23 Complaints. Male. Female. Total Spastic Diplegia 4 1 5 Kyphosis 1 1 2 Hemiplegia 1 1 2 Infantile Paralysis 3 2 5 Paresis 1 - 1 Post. Op. Tonsils and Adenoids 1 1 2 Scoliosis 5 9 14 Knock-knee and Flat-foot - 5 5 Muscular Dystrophy - 1 1 Lordosis - 1 1 Total 16 22 38 381 THE SCHOOL DENTAL SERVICE. Report on the Inspection and Treatment of Children Attending the Public Elementary and Central Schools, and of Scholarship Children Attending Secondary Schools in 1937. The dental staff consists of four full-time dental officers. There has been no addition in personnel during the year. The work of the Dental Service consists chiefly in the inspection and treatment of all children attending the public elementary and central schools, and of scholarship children attending the secondary schools. In addition, treatment is provided for patients referred under Maternity and Child Welfare, Tuberculosis, and Mental Deficiency schemes. The clinic at the Waldrons, Duppas Hill Lane, has now been operating for over a year and the results justify its existence. There are now two branch clinics, the other being in the South Norwood district. The wide area covered by the town, and the very real danger to children of traffic if they have to travel long distances to a clinic, makes the foundation of further brancn clinics a matter requiring attention. Many children in the Shirley area have to travel over three miles to the clinic, and those who live at Addington have a journey of over four miles to the Lodge Road Treatment Centre which is the nearest to schools in these areas. An additional clinic to serve these growing districts is urgently required together with the necessary staff to work them. The average number of children served by each dental officer is approximately 6,000. This 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. In consequence, children can only be inspected once in eighteen months. It is very undesirable as defects that are neglected for eighteen months may require more extensive treatment and the number of visits needed to complete treatment is considerably increased. There has been considerable progress in the orthodontic scheme. The number of cases on the register has increased from 702 to 874, Parents are particularly keen on this treatment and no branch of the dental service is more appreciated. Further details of this service are given elsewhere. 282 Inspection. 108 sessions were devoted to school inspection, this being an increase of 8 on the toal for 1936. The age groups dealt with were 6, 7, 8, 9, 10, 11, 12, 13, and 14 years for re-inspection ; 5 and 6 year old entrants, and the whole of the children attending Central Schools. The dental officers have been unable to inspect all the children and provide treatment for every child requiring it Out of 26,200 attending the public elementary and central schools, 17,747 were inspected and 13,498 referred for treatment, compared with 18,316 inspected and 13,250 referred for treatment in the previous year. The number inspected in 1937 was fewer than in the preceding year because there was a considerable number of cases awaiting treatment at December 31st, 1936, which had to be completed before inspections for the year could be started. This batch of untreated cases was considerable because many more children were inspected towards the end of 1936 in readiness for treatment by the additional dentist who commenced his duties towards the end of the year. Other reasons for the drop in the number of children inspected were: the increase in the percentage of children referred for treatment, and that many of the children have required several attendances to complete treatment. The percentage of children suffering from dental disease was 76 as against 72 in 1936; the highest recorded except in 1924 when it was 82. The following table shows the percentage of children referred for treatment since 1924. Year 1921. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 1937. Percentage of children referred for treatment 82 75 68 61 61 63 63 66 68 72 72 69 72 76 This decided increase in the number of children referred for treatment means that 15 per cent, more children required treatment in 1937 than in 1928. This table cannot be construed as showinc a marked deterioration of the teeth but rather as provinp that infrequent inspections are not able to control dental disease. The number inspected represents 68 per cent, of the total school roll as compared with 70 per cent, in 1936. The sessions devoted to inspections totalled 108, and approximately 167 children were inspected per session as agaist 183 in the previous year. The total number of children with healthy dentitions was 9,443. This figure represents 4,249 found healthy at dental inspections and 5,194 rendered artificially sound through treatment at clinics. 283 There appears to be very little difference in the percentages of boys and girls with sound teeth up to the 11 year old age group, but from the 12 year old group upwards more girls have healthy teeth than boys. Treatment. The aggregate of the treatment sessions was 1,551 as against 1,179 in 1936. The total number of children treated during the past year was 10,404 compared with 6,899 in 1936, an increase of 3,505. Treatments completed totalled 5,194. The total number of fillings in permanent teeth was 8,603, which is an increase of 2,349 on last year's total, and fillings in temporary teeth numbered 923 as against 399 in the previous year. The sum-total of all fillings was 9,526. This is an improvement in the number of conservative treatments upon last year. The ratio of inspection sessions to treatment sessions was 1:15 compared with 1:8 for the whole country. All cavities prepared for synthetic porcelain fillings were lined with cement before the insertion of fillings. In practically all silver amalgam fillings the cavities were also lined with non-conductive cement. Whether a cavity is lined or not before the insertion of the filling material only one filling is recorded. The number of fillings per 100 children treated was 91 in 1937, compared with 90 in 1936. The number of permanent teeth extracted per 100 children treated was 28 in 1937, as against 32 in the previous year. Under the heading of "other operations" a great deal of conservative work has been done. These treatments totalled 4,061 which compares favourably with 3,542 in 1936. Tn this total is included 1,627 zinc oxide dressings, 123 dressings inserted in temporary teeth, 163 applications of silver nitrate, 44 gum treatments, 294 scalings, capping of exposed nerves, temporary cement fillings and 29 root fillings in anterior teeth. Special treatments included the fitting of two porcelain crowns, the splinting of two fractured centrals, extirpation of nerves under local anaesthesia, 7 cases of fraenectomy, and the insertion of 8 vulcanite dentures to replace upper incisors lost through caries or traumatic injury. Extraction of Teeth. The number of permanent teeth removed because of their carious condition increased from 2,182 in 1936 to 2,946 in 1937. Those extracted for orthodontic purposes totalled 65. There was 284 also an increase in the number of extractions of temporary teeth from 9,785 in 1936 to 12,025 in 1937. As 3,505 more children were treated in 1937 the increase in dental extractions is to be expected. Local anaesthesia was given on 3,570 occasions as against 3,074 in 1936, for the extraction of teeth, also for the preparation of painful cavities. Nitrous oxide was administered on 2,640 occasions, as compared with 2,075 in 1936. At the Lodge Road Treatment Centre "gas" is administered by the dental officers who devoted 94 sessions to this work. At the Selhurst and Waldrons Clinics, "gas" is administered by medical officers and 97 sessions were set apart for this purpose. Special Cases. The number of special forms issued by head teachers was 2,384, as against 2,057 in 1936. There has unfortunately been an increase in the number of "specials" but until there is sufficient staff to enable every child to be inspected annually and treated if required the number of "specials" will not be substantially reduced. Children who would have been called up as routine cases, had they been inspected, have been unable to wait for the inspection and consequently have been compelled through pain to seek treatment. Refusal of Treatment. In 1937, 42.5 per cent, of parents who were offered treatment for their children did not consent to clinic treatment. A small percentage would probably obtain private treatment but the majority would only visit a private practitioner in case of "toothache." The present acceptance rate of 57.5 per cent, is slightly lower than the average for the country but it nevertheless provides more work than the present staff can accomplish. It is, therefore, important that the dental officers should not waste precious minutes treating "refusal cases" when they suffer from toothache. As much of the dental officers' time and energy as possible should be conserved ,in treating those children whose parents have consented to routine treatment. For several years past it has been the practice to eliminate from the scheme, as far as is practicable, children whose parents have refused treatment of the permanent teeth for three consecutive years. At one time head teachers were sent lists of names of such children with instructions not to issue emergency forms to the children concerned, but owing to insufficient clerical staff it was found impossible to continue this useful method of restriction. 285 It would appear from records of refusal cases that the number increases after the age of 10 years. In an attempt to counteract this the method suggested by Dr. Weaver of the Board of Education might be tried. Dr. Weaver suggests that parents should be asked at the time of the first examination of children, to accept regularly conservative treatment during the whole period of school life, and that such cases should receive first claim on the services of the school dental officer on the grounds of economy and efficiency. Those parents who did not so agree would be given to understand that their children could only receive such attention as was possible after the first claims had been dealt with. There would appear to be no difficulty in explaining such a position to parents and securing their support, or otherwise, at the time of the first inspection of their children. Malocclusion and the Premature Removal of all the Deciduous Molars. The majority of the 5 and 6 year old have very carious and septic teeth which are beyond any form of conservative treatment and therefore have to be extracted. When the dental officer examines many of these children he is confronted with two possible lines of treatment: either to remove an aching tooth and leave the other carious teeth until they give trouble or to extract all the molar teeth and so give the patient a clean mouth. In view of the fact that septic teeth may give rise to a considerable amount of ill-health the latter method of treatment is to be recommended as the risk of subsequent malocclusion is not so important as the risk of illhealth through retained septic teeth. In 1936 the incidence of malocclusion was 4.99 per cent, of the total number of children inspected, and in 1937, 3.2 per cent The information obtained from these surveys does not appear to support the contention held by some dentists that the premature extraction of temporary teeth (specially the molars) increases the incidence of malocclusion in school children. The clinical examination of cases does, however, suggest that the early loss of the deciduous teeth produces special types of deformity. One of the Assistant Dental Officers investigated a number of cases in which all the temporary molars had been lost at an early age and he found that there was definite evidence that certain types of malocclusion were associated with the premature extraction of the temporary molars. The deformities appear more pronounced if seen before the eruption of the six year old molars. When the molar teeth are extracted in a child of five years practically all the stress of mastication is taken by the four canines, which is a very 286 fortable position for the child to bite and soon there is a tendency for one of the canines, usually an upper one, to move lingually, distally, or labially, which allows the jaw to swing to one side and produce a "cross-bite," with interlocking of incisors. It would seem that a certain amount of malocclusion could be prevented by extracting the two lower canines at the time the molars are removed, or by stoning off the tips of the canines. The results of this investigation emphasise the need of orthodontic clinics as a part of the school dental service. The types of irregularities described are of course sometimes found in dentitions which have not been mutilated, and it is possible that some cases of malocclusion in which the premature extraction of the teeth has been thought to be the cause, may not in fact have been the etiological factor. Further investigation is, therefore, necessary with controls in cases where irregularity exists but with all the teeth present; those in which the molar teeth were removed in early life but with no subsequent malocclusion, and lastly where there has been premature extraction of the temporary teeth and irregularity is present. Attendances and Charges For Treatment. The total number of attendances for the year was 19,225 as against 14,749 in 1936. The charge for treatment up to August 29th, 1937, was 8d. per attendance and 2s. for each "gas" administration. It was considered that the attendance fee did in certain cases create a difficulty for some of the indigent parents, who although they were entitled to free treatment were too reticent about their straightened circumstances to acquaint the dental clinic of their position, and paid when they could not afford it, while others may have adopted the extreme attitude of not consenting to treatment because they could not pay the fee and did not wish to disclose their inability in regard to payment. In the light of this information it was decided to have a flat Fate charge of 1s. for one year's treatment (dating from the day of the first attendance). The fee for each "gas" administration is 2s. as before. Whilst the initial fee of Is. is higher than the attendance fee previously charged, it is in the ''long run'' cheaper for the parents since each child makes at least two attendances for completion of treatment. It is the opinion of all the dental officers that this charge has already resulted in an improvement in the attendances and the considerable increase during the last quarter of 1937 would suggest that parents appreciate the new system of payment. The sum of £590 18s. 8d. was received in payment for treatment, and £4 1s. 9d. was received from the voluntary box contributions. 287 Cases X-Rayed. Cases referred to Mayday Hospital numbered 84 as compared with 50 in 1936. 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 cases X-Rayed included those suffering from traumatic injuries of incisor teeth, those who had undergone root canal treatments and in other cases for obtaining the relative positions of the roots of teeth before orthodontic treatment. It would be of great assistance to the dental officers if a dental X-Ray apparatus was installed at the Lodge Road Treatment Centre. The Treatment of Scholarship Children. Scholarship children are treated at all the clinics and the following is a summary of the work. Attendances 400 Gum Treaitment 2 New Cases 93 Scallings 6 Fillings—permanent 308 Gas Cases 22 Extractions—permanent 88 Local 10 ,, temporary 14 Cases Completed 77 Dressings 135 Root Fillings (anterior teeth) 2 The majority of the children require a large amount of work to be done and many attendances are necessary to complete the treatment. The incidence of dental disease in the children examined is very high, and it would appear from experience gained in the treatment of scholarship children that it is eminently desirable that opportunities for inspection and children, if required, should be provided for all pupils attending secondary schools. In many instances the teeth of the scholarship children were found to be much worse than those of children attending the public elementary schools. Dental Propaganda. The Dental Board of the United Kingdom kindly sent a demonstrator to visit some of the schools and give a talk to the children. The demonstrations and talks were given to approximately 3,000 children attending the senior schools. The following schools were visited, viz., Waddon Senior Mixed, Croydon British Senior Girls, Parish Church Boys, Purley Oaks Senior Mixed, St. Andrew's Senior Mixed, Davidson Senior Boys and Senior Girls, Portland Senior Boys and Senior Girls, Whitehorse Manor Senior Boys, Lanfranc Senior Boys and Senior Girls, and St. Michael's Girls. 288 At the routine inspections the dental officers gave talks to parents at the end of the inspections. During the year 19 talks were given and 529 mothers attended. The health visitors have rendered great assistance in carrying out lioxne visitations. Inspection and Treatment of Special Schools During the year St. Luke's Special School for Partially Sighted Children, St. Giles' School, Addington and St. Christopher's Special School were inspected. The children attending the Grangewood Centre were also examined. The acceptance rate for those referred for treatment was as follows: St. Luke's School, 52.9 per cent; St. Giles' P.D. School, 75.4 per cent.; St. Christopher's, 59.6 per cent., and Grangewood Occupation Centre. 52.2 per cent. The children attending these schools have their mid-day meal at the school and facilities are provided for the brushing of teeth particularly after eating. The present method of hanging up the toothbrush to dry after use in a position where it is exposed to dirt and dust is not very satisfactory. Dental Treatment and School Attendance. When the dental officer advises as part of the subsequent treatment that the child should not go back to school to complete that school session, but should either remain at the clinic or return to his home, an attendance mark is allowed for that session. In order that the head teacher may know that this advice has been given if a child does not return to complete the session a distinguishing mark is made on the appointment card which the child can show to the teacher at the next attendance. This procedure applies to the morning or afternoon session but not to both Orthodontic Treatment. The total number of children treated since the inception of the scheme in 1931 is 874. Of this total, 637 have been treated by special appliances and 237 by extraction of permanent teeth. The number of such teeth extracted for the purpose of relieving overcrowding was 65. The sessions devoted to orthodontia totalled 47 as compared with 43 in 1936. Extra verbal appointments reached a total of 1,620, as against 1,501 in 1936. Out of 17,747 children examined 585 or 3.2 per cent, were found to be suffering from malocclusion. It would, of course, be impossible to treat such a number and only those with marked deformity have been referred for treatment. The number of forms issued to parents was 248. During the year 361 removable and two fixed appliances were fitted. 289 The time devoted to orthodontia is restricted to one session per week, which is shared by two dental surgeons. With so little time for this work it is necessary to have these sessions as free as possible for new cases, or cases under treatment which require new impressions for further appliances. This is achieved by giving verbal appointments for those cases requiring minor adjustments of appliances after the work of the routine sessions is completed. Some of the cases treated have been those of mouth-breathing, and in most instances this has been of dental origin. In certain cases these patients have been supplied with oral screens,and special lip exercisers to improve the muscle tone of the lips, and to encourage normal breathing. Very often this treatment runs concomitantly with the wearing of special appliances. The Education Committee has approved that orthodontic treatment may be undertaken for children of indigent parents without charge, the cost of 15s. for each child being borne by the Committee. Summary of Work Done at the Selhurst Road Clinic. (Opened April, 1930). 1937. 1936. Attendances 5,100 4,798 Extractions 4,244 3,864 Fillings 2,483 2,160 Patients Treated 2,435 2,310 Other Operations 1,280 1,045 "Gas" Cases 634 613 Local Anaesthesia 1,491 1,219 Cases Completed 1,693 - Sessions held: Inspection 27, Treatment 430, Gas 43. Average attendance at this clinic 11.8. Summary of Work Done at the Waldrons Clinic. (Opened November 10th, 1936). 1937. 1936. Attendances 4,161 470 Extractions 2,831 143 Fillings 3,054 350 Patients Treated 2,046 116 Other Operations 756 31 Scalings 101 11 "Gas" Cases 556 4 Local Anaesthesia 640 30 Cases Completed 1,379 - Sessions held: Inspection 27, Treatment 355, Gas 43. Average attendance at this Clinic 11.7. 200 Conservative Treatment for the Deciduous Dentition. Although the number of fillings in deciduous teeth increased from 399 to 923, it should not be deduced from such an increase that the policy of the service in other years, of restricting the number of conservative treatments to those teeth in which the prognosis of completed work can be almost guaranteed, has been abandoned, but rather that there has been a greater number of mothers who sought treatment for their children during pie-school years and desired the treatment to be continued. As these children had had considerable treatment before commencing school the amount of work to be done was small, since the teeth had been kept in good order through attendance at child welfare clinics. The mothers who had exhibited such keenness in the dental welfare of their children have been encouraged to write for six-monthly inspections and it is as a result of these re-examinations that more fillings were inserted in the temporary teeth as compared with the previous year. The present difficulty of conservative treatment for the temporary teeth of school entrants would be considerably diminished if there was an adequate service of inspection and treatment for all pre-chools children. If such a service was given to all young children, and provided there was a high acceptance rate on the part of the parents it would be possible to insert many more satisfactory fillings (because defects would be seen when small) and to extract fewer teeth. The existence of such a service would not be a success unless it was utilised to the full. There would have to be sixmonthly inspections for all the children and continuity of treatment, if required. A great argument in favour of nursery schools is that they would provide an excellent opportunity for proper dental supervision of young children. Dental Defects. year (1) Number of children who were— 1936 (a) Inspected by the Dental Officers: — Aged 5—6 1,025 Total : 17,747 1,210 „ 6-7 1,733 1,726 „ 7-8 2,070 1,798 „ 8—9 2,046 2,058 „ 9-10 1,895 1,919 „ 10—11 1,633 2,070 „ 11-12 1,617 2,112 „ 12-13 1,778 1,815 „ 13-14 1,951 1,939 „ 14-15 1,335 1,248 15 up 664 421 Specials 2,384 2,057 20,131 20,373 291 (b) Found to require treatment 15,882 15,307 (c) Actually treated 10,404 6,899 (2) Half-days devoted to inspection. 108 100 Do., treatment 1,651 1,179 Do., adminstration 12 18 Do., gas administration— (by dental officers) 94 91 (by medical officers) 97 52 Do., orthodontia 47 43 1,909 1,483 (3) Attendances made by children for treatment 19,225 14,749 (4) Fillings—Permanent teeth 8,603 6,254 —Temporary teeth 923 399 9,526 6,653 (5) Extractions—Permanent teeth.. 3,019 2,182 —Temporary teeth12,025 9,785 15,044 11,967 (6) Administrations of general anaesthetics for extractions 2,640 2,075 (7) Administrations of local anaesthetics for extractions 3,570 3,074 (8) Other operations— Permanent teeth 3,940 3,542 Temporary teeth 121 34 4,061 3,576 EAR CLINIC. This Clinic is held at weekly intervals at Lodge Road Treatment Centre, for school children and children under school age. Cases are referred for treatment to the clinic mainly by the Assistant School Medical Officers and the Medical Officers of the Infant Welfare Centres, and are seen by appointment. The treatment advised and administered at the weekly Ear Clinic is continued where deemed necessary at daily intervals through the agency of the Minor Ailments Clinics. The early investigation of children with discharging ears and the subsequent 292 frequent treatment by thorough cleansing of the ears is most important in the prevention of deafness in later years. 1937. 1936. The Number of Sessions held 45 41 No. of first attendances 66 62 No. of re-attendances 372 254 Total number of children who received treatment or were investigated (10 cases being carried over from 1936) 76 62 These 76 cases were classified into three main groups:— 1937. 1936. Group 1.— No evidence of otorrhoea past or present, or deafness of more than a trivial or temporary nature 12 8 Group 2.— Deafness only. Some of these were due to old otitis media 7 9 Grouf 3.— Otorrhoea, active, quiescent or cured 57 45 The following is a brief summary of the action taken in the cases classified in these Groups:— Group 1.— 12 cases. In the majority of these cases the only defect found was an accumulation of wax blocking the meatus; all symptoms clearing up after the wax had been removed by syringing. Group 2.— 7 cases. Three were catarrhal in type and fit to attend the ordinary school. Of these, two were referred for breathing exercises and one called for no special treatment. Three were due to old otitis media, of which two improved with breathing exercises and one improved but is still under treatment with Eustachian Catheterization. Group 3.— 57 cases. (a) Found dry and requiring no treatment 9 (b) Found dry but recommended for necessary treatment such as tonsillectomy 4 (c) Active cases of otorrhoea 44 293 These 44 oases of actively discharging ears were treated as follows:— Eight were ionized of which five cleared up, three after one application, one after two applications, and two after three applications. Two did not respond to treatment, both were referred to Croydon General Hospital, one with chronic mastoid infection, and one with nasal obstruction requiring adenoidectomy. Thirty-three were treated with insufflations of iodized boracic powder, several of these having had preliminary treatment with glycerine and carbolic drops, and where granulations were present, these were cauterized with silver nitrate applications. Of these cases twelve were dry and healed, and completed treatment; fourteen were dry but still under observation; and seven were improving but still under treatment. Three were referred to Croydon General Hospital with chronic mastoid infection, mastoidectomy was performed and they still are under hospital treatment. The results of the year's work have been very successful, particularly those cases of otorrhoea treated with iodized boracic powder. Many of the cases of otorrhoea referred to the Clinic have been of long standing, with foul smelling discharges and unhealthy granulations surrounding the perforation of the drum. These cases with constant thorough cleansing and insufflations of iodized boracic powder rapidly lose their offensive character, the middle ear becomes much more healthy in appearance and in the majority of cases the discharge completely ceases. The insufflation powder used is 0.75% Iodine in Boracic Powder. The cases for ionization treatment are somewhat limited, and require careful selection, being in the main the chronic catarrhal discharges; suitable cases respond well to treatment. RHEUMATISM CLINIC. The Rheumatism Clinic is concerned with the diagnoser supervision, advice and re-examination of cases of juvenile rheumatism. Treatment of cases is not undertaken at the Clinic, but arrangements are made through it for the appropriate treatment to be administered. In the active and acute stage of the disease, children are referred for Hospital in-patient treatment, or, where home conditions are favourable, for domiciliary treatment by the patients' own doctor. 294 The mild and potential cases benefit greatly by a period of convalescence at Coombe Cliff Convalescent Home. With extra rest, a nourishing and well-balanced diet, and supervision under satisfactory hygienic conditions, the rheumatic symptoms frequently clear up. For other suitable cases extra nourishment in school, such as milk or cod liver and malt, are provided. Cases of fully developed chronic valvular heart disease, who are medically unfit to attend a public Elementary School, are recommended to St. Giles' School for Physical Defectives. The accommodation here was extended during the year. Children who have recently been discharged from hospital or convalescent home following a rheumatic attack, or children whose hearts are affected and might be injured further by undue exertion, are excluded for a suitable period from partaking in games, drill or school swimming. It should be emphasised, however, that both from the mental and physical well-being of the child, it is inadvisable to limit normal activities more than is absolutely necessary. Children in whom rheumatic manifestations are quiescent and who have a mild fully compensated cardiac lesion, and others in whom a systolic murmur is purely functional, may be turned into introspective invalids by exclusion from the normal school routine. 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 new cases attending the Clinic have continued to be inspected by a Sanitary Inspector, and notices are served on the owners for any necessary repairs; or the family recommended for consideration for a Council house. Rheumatism is an insidious disease. Acute rheumatic fever is far less common that the vague joint pains or mild chorea so frequently met with. The mild form, in which there are only vague joint pains or mild muscular twitching, may cause irreparable cardiac damage if neglected or overlooked; it is for this reason, and because relapses are common, that the constant supervision afforded by the Clinic is so necessary. One clinical note may be of interest; children who complain of pains around the knees and back of thighs following exercise and in whom the heart is unaffected are probably non-rheumatic. A simple test helps to demonstrate this. If such a child be asked to bend down and touch its toes, in most cases it will fail to 295 perform this action by as much as six or twelve inches. The child will complain of pain in the muscles above the knees, and the hamstring muscles at the back of the thighs will be found, on the child's bending forwards, to be shorter than normal and tightly stretched. This condition of short hamstring muscles occurs in rapidly growing children, where the rate of growth of the thigh bone has outstripped that of the muscles, it usually becomes compensated in a year or so, but it accounts for a number of cases referred as suspected juvenile rheumatism. Difficult and severe cases have been referred to the OutPatients' Department at 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 can be readily obtained. The total number of children whose names were on the "live" register at the end of 1937 was 614. Table XVII. Cases Examined at Rheumatism Clinic. 1935. 1936. 1937. Primary 160 154 187 Re-examinations 246 407 479 406 561 666 Rheumatic 143 (89.4%) 145 (94.2%) 158 (84.5%) Non-Rheumatic 17 (10.6%) 9 (5.8%) 29 (15.5%) 160 154 187 Classification of Rheumatic Cases— Primary. Re-examination. Sex—Males 83 (52.5%) 223 (46.6%) Females 75 (47.5%) 256 (53.4%) Total 158 — 479 Age when Examined— Ages 5 6 7 8 9 10 11 12 13 14 15 Primary 19 30 10 12 25 18 13 15 12 2 Re-examinations 3 26 32 34 46 58 79 55 94 40 1 296 The fact that the attendance at the Clinic has greatly increased during the past three 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 I.— Symptoms referring to the digestive system and intestinal tract, e.g., abdominal pains, constipation and lack of appetite 35 cases Group II.— Symptoms suggesting the presence of toxaemia, e.g., aching limbs, lassitude, headache 148 cases Group III.— Symptoms suggesting a disturbance of the nervous system, e.g., irritability, disturbed sleep, nocturnal eneuresis, fidgetiness 46 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). 1936. 1937. Mild and Potential 119 (82.1%) 120 (76.0%) Definite Active 16 (11.0%) 23 (14.5%) Definite Quiescent 10 (6.9%) 15 (9.5%) 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 : 158 cases. Rheumatic Pains 124 (78.5%) Rheumatic Fever 11 (7.0%) Chorea 12 (7.6%) Carditis, Definite 13 (8.2%)* *Slight 8 (5.1%) *Marked 5 (3.2%) Carditis, Suspected 1 (0.6%) Tonsillitis 8 (5.1%) 297 Rheumatic Fever Oases. There were 11 children who gave a definite history of Rheumatic Fever. Of these, 6 had sound hearts, and 5 had definite carditis. Chorea Cases. There were 12 cases of Chorea. Of these, 3 had definite carditis, 4 slight or suspected, and 5 sound hearts. Family Histories. In the case of 35 families (22.2 per cent.), either the father or the mother had had rheumatic fever, chorea or juvenile rheumatism. In 7 other cases (4.4 per cent.) a history of rheumatism was obtained in near relatives of the parents. In the case of 24 children (15.2 per cent.) their brothers or sisters gave a similar history of rheumatic manifestations. Skin Conditions. Recorded in 157 cases. Fair 85 (54.1%) Dark 72 (45.9%) Moist skin and a history of liability to sweating was recorded in 33 cases. A history of flushing and rashes in 38 cases. Nervous Conditions. Recorded in 158 cases. Children recorded as highly strung ... 86 (54.4%) Headaches 77 (48.7%)* *Occasional 72 (45.6%) *Frequent 5 (3.2%) Night terrors, etc. 44 (27.8%)† †Slight 42 (26.6%) †Severe 2 (1.3%) Enuresis 18 (11.4%) Twitchings 41 (25.9%) Often a combination of more than one of the above symptoms was manifested. Catarrhs. A history of various catarrhs, not tonsillitis, was reported in 4 cases (2.5 per cent.). 296 Tonsillectomy. Operation reported in 45 cases (28.5 per cent.). Re-Examinations. Four hundred and seventy-nine re-inspections were carred out. In 7 (1.5 per cent.) of these the conditions had become worse; 15 (3.1 per cent.) was considered to be non-rheumatic; 49 (10.2 per cent.) stationary; 207 (43.2 per cent.) were definitely improved; and 201 (42.0 per cent.) quiescent. Environment and Other Conditions in Rheumatism Clinic Cases. Reported in 142 cases. Wards.— Cases were drawn from all Wards in the Borough with the exception of South. Woodside 5 Thornton Heath 12 \ddiscombe 4 Bensham Manor 8 South Norwood 6 West Thornton 10 Upper Norwood 19 Waddon 37 Norbury 5 East 6 Whitehorse Manor 13 Central 2 Broad Green 9 Addington 6 Housing Conditions— Drainage of Subsoil and Condition of Houses. One hundred and fourteen of the houses were sufficiently drained and 20 were well drained; in 8 drainage was problematical. Mouses which were perfectly dry and did not show any signs of dampness numbered 57, whilst 72 showed traces of damp; 11 were damp; two houses were specified as very damp. Aspect. The aspects of the houses were as follows:— 161 cases reported. S.E. 21 S.W. 36 E. 14 N.E. 15 N.W. 26 S. 22 N. 18 W. 9 The bulk of houses in which cases occurred were ordinary terrace houses (101), 37 were semi-detached, and 3 were detached houses: definite overcrowding was found in two families. 299 Economic Status. The economic status of the families from whom patients were examined was as follows:— Poor in 14; average working class, 82; better working class, 34; clerical work, 8; and superior, 4. The interior home conditions were classified as follows:— Clean, 92; moderately clean, 41; superior, 5; unsatisfactory, 5. 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. Nine 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, 6 boys and 1 girl. Barclay Blind School, Brighton, 2 girls. Abbotskerswell, Devon, 1 boy. Sunshine Homes, East Grinstead, 2 boys. St. Luke's Special School For Partially Sighted Children. During the year this school was much improved and enlarged. At the end of the year there were 36 children in attendance. Of these, 27 were cases of myopia and 9 were non-myopes. 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 physical exercises, suitably restricted for certain children, are in regular use, with a noticeable improvement in carriage and posture. New permanent premises have been erected on the old site, consisting of a Hall, two classrooms, staffroom and medical inspection room, and were opened on the 3rd September, 1937. Deaf Children. Twelve boys and 4 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, 9 boys and 4 girls; Balham Lr.C.C. Day (Deaf) School, 1 boy, at Hearoville Road; Anerley Deaf School, 2 boys; Royal West of England Institution for the Deaf, Exeter, 1 boy. 300 Epileptic Children. Three girls are resident at the Lingfield Epileptic Colony; 1 girl at Chalfont Epileptic Colony. 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; 5 boys at Besford Court, Worcestershire; 1 girl at Allerton Priory, Liverpool ; and 1 boy at Trenmar Lodge, London. Physically Defective Children. The Education Authority have, in addition to the 85 children accommodated at St. Giles' (Physically Defective) School, crippled children in the undermentioned special schools:— The Heritage Craft School, Chailey, 3 boys and 3 girls; St. Catherine's, Yentnor, 1 boy; Lord Mayor Treloar Hospital, Alton, 1 boy; St. Vincent's Orthopaedic Hospital, 3 boys; Victoria Home for Crippled Children, Bournemouth, 1 boy. The Committee also maintained 1 girl at West Wickham Heart Home, a special school for cardiac cripples. An extension of the St. Giles' School, to accommodate 90 delicate children, was opened on the 18th October, 1937, and at the end of the year 74 children were in attendance at this section of the school. The total accommodation of St. Giles' School is now for 174 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. Cured. Improved. Ceased attend, lon-cooperatn. Referred psych, trt. Still Attending. Stammer 5 2 2 2 5 Lalling, Lisping 4 ... ... ... 6 Undeveloped Speech ... ... 2 ... 3 Cleft Palate 1 ... 2 ... ... Aphaisic ... 1 ... ... ... Malformed Palate ... ... ... ... 1 Cases Discharged. Speech now normal 11 Non-co-operation of parents 7 For psychological treatment 5 301 SCHOOL CAMPS AT PILGRIM FORT, CATERHAM. School camps were held, as usual, during the summer months at Pilgrim Port, Caterham, which is situated about 800 feet above sea level. At the beginning of this year a new cookhouse was built and equipped with a large coal-burning range and, at the same time, a heating stove was installed in the hall which is used for lessons and as a dining room. A new scheme, whereby the arrangements for caretaking and catering are controlled by the Education Committee, has been adopted. The Fort has accommodation for 40 children to camp at one time and, in cases where one school is unable to provide this number, two schools combine, each sending a party of 20. There are about 20 weeks in the year during which it is practicable to send school parties to Pilgrim Fort, but school holidays fall during six of these. In 1937, 15 weekly camps were held; Croydon school camps during 11 weeks, a Sheerness school party, and children from the Public Assistance Committee's Homes during the other 4 weeks. The following is a list of the Croydon schools which sent parties to Pilgrim Fort, with the number of children from each school:— Ashburton Senior Mixed (Boys) 44 Kingsley Senior Boys' 42 Kingsley Senior Girls' 48 Oval Senior (Boys) 40 Oval Senior (Girls) 41 Portland Senior Girls' 43 South Norwood Junior Boys' 40 Sydenham Junior Boys' 40 Tavistock Senior Boys' 44 Waddon Senior (Boys) 35 Waddon Senior (Girls) 41 458 On each occasion, two teachers were in charge. All the children in School camps are medically examined before proceeding to the Fort and the blankets in which they sleep are disinfected each week. During the year several Scout groups and other organisations also camped there for week-ends, thus bringing the season's total of visitors up to 650. 302 JUVENILE EMPLOYMENT RETURN. The following numbers of children were examined by the medical officers during 1937 as to their fitness to follow the parttime employment indicated. There.has been an increase of 21 in the delivery of goods for shopkeepers; no change in the delivery of newspapers, and a decrease of 12 in the delivery of milk:— 1937. 1936. 1935. 1934. 1933 Delivery of Goods for Shopkeepers 172 151 208 96 105 Delivery of Newspapers 245 245 285 190 163 Delivery of Milk 31 43 42 34 24 448 439 536 320 2S2; Thirty-nine girls were medically examined, and subsequently licensed by the Education Authority to take part in public entertainments. THE PROVISION OF MEALS AND MILK AND COD LIVER OIL AND MALT. The arrangements for the provision of meals for necessitous children have been continued during the past year. Children are now provided with free dinners at the Domestic Subjects Centres of the following schools:— Davidson, Ecclesbourne, Elmwood, Ingram, Kingsley, Sydenham, Tavistock and Waddon. Milk and cod-liver oil and malt have also been provided in school for children suffering from malnutrition. Recommendations for extra nourishment are made by the School Medical Officers, Teachers, School Enquiry Officers and Care Committees. 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. 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 Board, some 14,500 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. 1937. No. of Children who received Free Dinners 464 524 ,, Free Dinners provided 53,633 67,357 303 No. of Children who reoeived, on the recommendation of the School Medical Officer:— Pints. Pints. Free Milk 161—16,876 656—56,375 Milk (part payment) 30—2,941 32—1,722 Milk (whole payment) 15—1,987 56—2,705 Issues. Issues. Free Malt 37—4,069 192—15,011 Malt (whole payment) 45—5,178 74—3,377 (N.B.—Milk and malt and oil given on the recommendation of the School Medical Officer are supplied free of cost; voluntary pay men ts, however, are accepted from the parents.) The amounts supplied, as will be seen from the figures, shows a very substantial increase on 1936. The Committee continued, during the Easter, Whitsun, Midsummer and Christmas Vacations, to provide 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, 7,175 bottles being sold during twenty-five days; 1,488 bottles were supplied during the five days of the Easter Vacation, and 1,424 during ten days of the Christmas Vacation. All the milk supplied is Pasteurised milk, and the sources of supply are subject to the approved 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. ST. CHRISTOPHER'S SPECIAL SCHOOL I am indebted to Mr. H. J. Edmonds, the Headmaster, for the following report. The School continues to make steady progress in all subjects, especially in the teaching of reading. The year opened with 126 children on the school roll. During the year, 33 children were admitted, and 29 left, giving the number on the Register on December 31st, 1937, as 130. In this connection, it is very gratifying to note the high percentage of attendance. The children come from all parts of the Borough, many are poorly clad, and some leave their homes daily at 8 a.m. and yet the percentage of attendance for the year is 88. 304 Very definite progress has been made with Physical Training. Many of our children are not strong, unhappily, and exercises have to be very carefully graded, and weakly children constantly supervised, yet of all lessons, the Physical Training one is the most popular. That this training is beneficial is clearly to be seen by the improved carriage and bearing of the children. The teaching of Woodwork is making great strides, and the senior boys have made some very creditable models. It is hoped, shortly, to extend the handicraft side of the school by teaching boot-repairing and tailoring. It may be asked, perhaps, "What are the aims of the School?" Briefly put, they are to overcome the child's sense of inferiority, which every new entrant has, and to so equip him, that, on leaving he is able to obtain a situation and keep it, thus, not becoming dependent on his parents or the community. It is interesting to note, that during the last 7 years ended 31st December, 1937, 77% of the school leavers obtained, and still hold, regular employment. The thanks of all interested in the School, must be given to the Education Committee for providing such excellent mid-day meals, which are much appreciated by the children, and which certainly improve them physically. I must not conclude this report without placing on record the kindly interest shown, and the help given by the staff and scholars of the John Ruskin School. PHYSICAL TRAINING IN SCHOOLS. Detailed reports have been presented by the Assistant Education Officer and Inspector and the Organiser of Physical Training to the Education Committee, and the following is only a precis of the reports. Boys. Unsettled weather during the early part of the year interfered with physical work out of doors, especially with organised games, which are often carried on at some distance from the schools. In spite of this handicap, physical training was carried on steadily in all Departments. All Junior Departments followed the methods set out in the 1933 Syllabus for Physical Training; some Senior Departments 305 used the Reference Book of Physical Training as a source of material. Junior Departments have a daily lesson in Physical Training; Senior Departments do not achieve this owing to the longer period of the lessons. All Senior Departments and Selective Central Schools, with the exception of two Non-Provided Schools, have now at least one teacher who has had special training in the use of portable apparatus. Every such Department is equipped with apparatus and the equipment of Junior Schools on lines suggested by the 1933 Syllabus is now complete. Many teachers attended special courses in Physical Training, Sword and Morris Dancing, Swimming, and other forms of physical activity. The past year was the most successful in the history of the Borough so far as swimming was concerned. The teams representing Croydon gained many successes in the London Swimming Association's Galas. These successes only emphasise the good work done in all Senior and Junior Departments. The number of beginners' certificates gained remains at a high level. The accommodation at the Baths is now fully utilised. With the present facilities for teaching swimming, very little further advance is possible. During the year shoes have been provided to all Departments for the use of those children whose financial circumstances made it impossible for them to provide their own footgear. Additional playing field facilities have been obtained in the Kingsley area. This supplies a long-felt need in that particular district. Nearly every Department holds its own Sports Day and its own Swimming Gala, when parents have an opportunity of seeing the results of the physical work done in the Schools. The Croydon Schools' Athletic Association has continued its excellent work. Inter-School competitions in cricket, football, boxing, swimming, and general athletics have been carried on throughout the year. Parties for Country Dancing and Sword and Morris Dancing have also been arranged. The organisation and supervision of these inter-school activities are undertaken by the teachers voluntarily in their own free time and is worthy of the highest praise. 306 Girls. (Selective Central, Senior and Junior Mixed, Senior and Junior Girls', Infants' and Special Schools). The year 1937 brought many important schemes forward in connection with Physical Training—schemes which will ultimately have far reaching effects in the health and development of all children, and others, with whom the Local Education Authority has to deal. The Government Scheme was embodied in a White Paper on Physical Training and Recreation, in February, 1937 (No. 5364) and was followed by the Physical Training and Recreation Act, 1937, in July. The suggestions of Circular 1445, issued by the Board of Education in 1936, have been carried out as far as possible, especially as concerns the Elementary Schools. There is, whenever possible, a daily period of organised physical activity— physical exercises, organised games, swimming, dancing and athletics included. The provision of gymnasia, shower baths and changing rooms is included in the plans for the rebuilding of the Lady Edridge Selective Central and the Purley Oaks Senior Schools. The new building at St. Luke's Special School, opened during the year, is supplied with changing rooms and showers, also, a satisfactory supply of hot water is included in all new and re-conditioned schools. In connection with Circular 1450, all schools were supplied during the year with a certain number of gymnastic shoes for use in Physical Training lessons, for those children whose parents were unable to provide them. This has overcome much of the difficulty experienced by children unable to take part satisfactorily in agility movements and general activities, owing to unsuitable footwear. It has been a pleasure to see the obvious joy of many children able to enter fully, for the first time, into the jumping and vaulting exercises and games which form such a valuable part of the modern physical training lesson. The majority of children now make a definite effort to remove superfluous clothing for the physical training lessons, though the habit of changing into special clothing is not yet practicable owing to lack of changing room accommodation. For this reason the provision of special kit for physical training has not yet been considered. All Selective Central, Senior and Junior schools, with one exception, sent classes to the Baths during the Summer season. This year, for the first time, the Senior schools were given the 307 option of sending a limited number of children weekly throughout the winter months and girls from fifteen schools are attending. The high standard of swimming achieved in the past has been well maintained throughout the year. In addition to the Inter-Schools Gala, held in July, School galas were arranged by 17 schools. Playing Field or Recreation Ground accommodation is now available for all Central and Senior departments and for all Junior departments except 8. The year was a bad one from the point of view of using the fields regularly, owing to the wet and inclement weather experienced during the Spring and late Autumn, but all teachers are convinced of the benefits that the children derive from playing in the freedom of well cut grass fields with beautiful surroundings. Sports afternoons, Physical Training Displays and Inter-House Tournaments proved popular and at least 40 of these events were held. Folk Dancing was carried on as usual. The Folk Dance Section of the Croydon Schools' Sports Association arranged a Coronation Festival of Folk Dancing, in Ashburton Park, on Saturday, May 29th, when over twelve hundred children took part in the dancing. School Journeys were taken by girls from various schools to Weymouth, Seaford (2), Cromer, Isle of Wight (4), Switzerland, Germany and Paris. Four Girls' schools sent parties to camp at Pilgrim Fort. Corrective Classes, for girls with faulty posture, were continued in seven schools. The following Teachers' Courses were arranged during the year-— Course of Scottish Country Dancing. ,, ,, Senior School Physical Training. ,, ,, Dances suitable for Infants. ,, ,, Folk Dances of Many Lands. Five teachers attended the E.H.A. Physical Training Vacation School at Scarborough, in August. A Play Leadership Demonstration, arranged by the Croydon Playing Fields Associaton, in conjunction with the Central Council of Recreative Physical Training and supported by the Croydon 308 Education Committee, was held at Duppas Hill on Monday evening, July 12th, when the work of Play Leadership was successfully demonstrated with a large number of children. No report on Physical Training would be complete without mention of the valuable help rendered by those organisations which cater for the children out of school hours, especially that of the Croydon Schools' Sports Association, with its sections for Swimming, Netball, Athletics and Folk Dancing, which continues to co-operate in every way for the physical welfare of the children. INSTRUCTION IN SPECIAL SUBJECTS. In the time-table for the year commencing 1st August, 1937, 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). Ingriam (Domestic Science and Homecraft). Sydenham (Cookery, Homecraft and Domestic Science). Special Rooms or Centres reserved for School named— Ashburton (Domestic Science). Benson (Domestic Science). British Girls, Polytechnic (Domestic Science). Davidson (Domestic Scienoe). Eoclesbourne (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 Scienoe). 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. 309 Causes of Death in Children of School Age. Taking the school population as 25,704, the death rate per 1,000 in school children was 1.98. There were 51 deaths in children of school age; those caused by Infectious Diseases, 10 ; Pneumonia, 6 ; Tuberculosis, 6 ; Influenza, 3 ; Diseases of the Digestive System, 2 ; Diseases of the Respiratory System, 2 ; other defined causes, 22. In the Infectious Diseases Group the causes were: Diphtheria, 7 ; Typhoid Fever, 2 ; and Whooping Cough, 1. Among other causes of death were violent deaths (accidents), 4; Rheumatic Fever, 3; Meningitis, 3; Mastoiditis, 2; and Nephritis, 2. SECONDARY SCHOOLS. The usual arrangements for the medical examination of secondary school children were continued in 1937; 1,850 children were examined, 759 of whom were boys and 1,091 girls. Table II. of Appendix gives the detailed findings. 123 boys (17.5 per cent.) and 211 girls (19.3 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. 1937. 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. 1931 ... ... ... ... ... ... ... 2 45.5 38.0 ... ... ... ... 1930 ... ... ... ... ... ... ... 2 50.5 56.1 ... ... ... ... 1929 ... ... ... ... ... ... ... 5 49.5 54.9 51.0 62.5 48.0 54.5 1928 ... ... ... ... ... ... ... 7 55.8 70.2 57.5 73.7 57.5 61.2 1927 17 56.5 77.9 58.4 87.8 54.5 68.1 39 56.7 77.7 58.8 92.9 54.0 63.7 !926 136 56.5 79.0 60.4 98.3 53.2 66.6 116 57.1 80.7 60.5 114.5 53.2 62.4 1925 95 57.7 85.5 61.3 101.1 54.2 71.5 169 58.3 84.8 61.7 112.5 54.4 63.8 1924 92 59.4 88.6 63.3 105.6 55.0 73.5 255 60.0 97.7 64.5 124.1 56.5 76.0 1923 163 61.9 100.9 65.9 126.5 57.9 80.2 255 61.7 104.2 65.7 137.5 58.1 83.3 1922 169 64.4 114.4 68.4 137.2 58.3 88.1 146 62.6 108.1 65.9 128.1 59.7 90.2 1921 83 66.4 127.6 70.1 153.4 62.5 104.6 103 63.9 118.1 67.0 152.8 60.1 92.4 1920 19 68.0 129.7 70.5 147.2 66.2 110.4 22 64.7 130.1 67.2 156.6 62.7 110.5 1919 2 71.5 143.5 ... ... ... ... ... ... ... ... ... ... ... C.—Children Found to Require Treatment. Number of individual children found at Routine Medical Inspection to require treatment (excluding Nutrition, Uncleanliness and Dental Diseases). For Defective Vision For all other conditions Group. (excluding squint). recorded in Table IIa. Total. Total 193C. Entrants 4 493 494 596 Second Age Group. 168 262 408 391 Third Age Group... 221 215 413 295 Total (Prescribed Groups) 393 970 1,315 1,282 Other Routine Inspections i 20 27 46 19 Grand Total ... 413 997 1,361 1,301 Total visits to Elementary Schools: 569. 311 Table I. MEDICAL INSPECTIONS OF CHILDREN ATTENDING PUBLIC ELEMENTARY SCHOOLS. A.— Routine Medical Inspections. Number of Inspections in the prescribed Groups Year 1937. Year 1936. Entrants 3,115 3,230 Second Age Group 2,405 2,398 Third Age Group 2,090 1,605 Total 7,610 7,233 Number of other Routine Inspections 245 79 Grand Total 7,855 7,312 B.— Other Inspections. Number of Special Inspections 5,383 5,604 Number of Re-Inspections 12,399 12,122 Total 17,782 17,726 312 TABLE II. A.— Return of Defects found by Medical Inspection in the Year ended 31st December, 1937. 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 obser vation, but not requiring Treatment. (i) (2) (3) (4) (5) Skin— (1) Ringworm : Scalp ... ... ... ... (2) Body 1 1 ... ... (3) Scabies 9 ... 1 ... (4) Impetigo 4 1 ... ... (5) Other Diseases (Non-Tuberculous 9 5 5 ... Total (Heads I to 5) 23 7 6 ... Eye— (6) Blepharitis 13 6 ... 1 (7) Conjunctivitis 1 ... 1 1 (8) Keratitis ... ... ... ... (9) Corneal Opacities ... 1 ... ... 10) Other Conditions (excluding Defective Vision and Squint) 8 ... 3 1 Total (Heads 6 to 10) 22 7 4 3 (11) Defective Vision (excluding Squint) 413 98 68 2 (12) Squint 80 46 13 ... Ear— (13) Defective Hearing 9 8 4 3 (14) Otitis Media 13 9 ... ... (15) Other Ear Diseases 12 5 4 1 Nose and Throat— (16) Chronic Tonsillitis only 113 445 7 14 (17 Adenoids only 16 28 2 2 (18) Chronic Tonsillitis and Adenoids 333 271 28 5 (19) Other Conditions 111 91 9 4 (20) Enlarged Cervical Glands (Non-Tuberculous) 8 44 2 8 (21) Defective Speech 12 6 7 3 Heart and Circulation— Heart Disease : (22) Organic 42 151 4 12 (23) Functional 2 69 ... 3 Anaemia 66 60 1 6 313 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 12 43 ... 5 (26) Other Non-Tuberculous Diseases 8 19 1 3 Tuberculosis— Pulmonary: (27) Definite ... ... ... ... (28) Suspected 8 19 1 ... Non-Pulmonary : (29) Glands 4 4 ... 1 (30) Bones and Joints ... ... ... ... (31) Skin ... ... ... ... (32) Other Forms ... 2 ... 1 Total (Heads 29 to 32) 4 6 ... 2 Nervous System— (33) Epilepsy 7 ... 1 (34) Chorea i'i 40 3 4 (35) Other Conditions 9 106 4 16 Deformities— (36) Rickets 1 1 ... ... (37) Spinal Curvature 67 35 13 1 (38) Other Forms 106 63 18 4 (39) Other Defects and Diseases (excluding Uncleanliness and Dental Diseases 52 63 15 9 Total 1,555 1,747 214 111 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 3115 165 5.3 2472 79.4 472 15.1 6 0.2 Second Age-group 2405 195 8.1 1970 81.9 238 9.9 2 0.1 Third Age-group 2090 215 10.3 1696 81.1 167 8.0 12 0.6 Other Routine Inspections 245 28 11.4 201 82.0 16 6.6 ... ... TOTAL 7855 603 7.7 6339 80.7 893 11.3 20 0.3 314 TABLE III. Return of all Exceptional Children In the Area. Children Suffering from Multiple Defects. Number of children suffering from combination of defects 3 BLIND CHILDREN. A blind child is a child who is too blind to be able to read the ordinary school books used by children. In this Section only children who are so blind that they can only be appropriately taught in a school for blind children are included. At Certified Schools for the Blind. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 12 ... ... 1 13 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. 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. ... 39 16 ... ... 55 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. 15 ... 15 PARTIALLY DEAF CHILDREN. Only children who can appropriately be taught in a school for the partially deaf are included. At Certified Schools for the Deaf. At Certified Schools for the Partially Deaf. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 3 ... 8 ... ... 11 315 MENTALLY DEFECTIVE CHILDREN. Feeble-Minded Children. Mentally Defective children are children who, not being imbecile and not being merely Jull 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. 141 1 8 5 155 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 instruction in Special Schools for physically defective children. A. Tuberculous Children. In this category are placed only cases diagnosed as tuberculous and requiring treatment for tuberculosis at a sanatorium, a dispensary, or elsewhere. Children suffering from crippling due to tuberculosis which is regarded as being no longer in need of treatment are recorded as crippled children, provided that the degree of crippling is such as to interfere materially wi th a child's normal mode of life. All other cases of tuberculosis regarded as being no longer ip need of treatment are recorded as delicate children. I— Children Suffering from Pulmonary Tuberculosis. (Including pleura and intra-thoracic glands.) At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 8 6 ... 1 15 316 II.— Children Suffering from Non-PulmonAry Tuberculosis. (This category includes tuberculosis of all sites other than those shown in (1) above. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 12 11 ... 4 27 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. 63 23 ... ... 86 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 sufficiency severe to interfere materially with a child's normal mode of life, i.e., children who generally speaking are unable to take part, in anv 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. 49 16 6 9 80 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. 41 14 2 2 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. M.D. and Epilepsy 1 ... ... ... 1 M.D. and Cripple 1 ... ... ... 1 M.D. and Blind ... ... 1 1 317 TABLE IV. Treatment Tables. Group I.—Minor Ailments (excluding Uncleanliness, for which see Table VI). Number of Defects treated, or under treatment during the year. Disease or Defect. (1) Under the Authority's Scheme. (2) Otherwise. (3) Total. (4) Skin— Ringworm-Scalp: (i) X-Ray Treatment 2 ... 2 (ii) Other Treatment 6 ... 6 Ringworm-Body 13 ... 13 Scabies 72 ... 72 Impetigo 202 ... 202 Other Skin Disease 119 ... 119 Minor Eye Defects— External and other, but excluding cases falling in Group II 238 ... 238 Minor Ear Defects 269 ... 269 Miscellaneous— Minor Injuries, Bruises, Sores, Chilblains, etc. 1616 ... 1616 Total 2537 ... 2537 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) 1114 26 1140 Other defect or disease of the eyes (excluding those recorded in Group 1) ... ... ... Total 1114 26 1140 No. of Children for whom spectacles were (a) Prescribed 745 26 771 (b) Obtained 658 26 684 318 Group III.—Treatment of Defects of Nose and Throat. NUMBER OF DEFECTS. Received Operative Treatment. Received other forms of Treatment. Total number treated. Under the Authority's Scheme, in Clinic or Hospital. By Private Practitioner or Hospital, apart from the Authority's Scheme. Total. (1) (2) (3) (4) (5) (i) (ii) (iii) (iv) (i) (ii) (iii) (iv) (i) (ii) (iii) (iv) 3 22 376 ... 19 2 30 2 22 24 406 2 ... 454 (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. (i) Residential treatment without education. (ii) Non-residential treatment at an orthopaedic clinic. (iii) Number of children treated 24 16 314 328 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 1025 1733 2070 2046 1895 1633 1617 1778 1951 1999 17747 (b) Specials 2384 (c) Total (Routine and Specials) 20131 (2) Number found to require treatment 15882 (3) Number actually treated 10404 (4) Attendances made by children for treatment 19225 (5) Half-days devoted to: (7) Extractions: Inspection 108 Permanent Teeth 3019 Treatment 1551 Temporary Teeth 12025 Total 1659 Total 15044 (6) Fillings: (8) Administrations of general anaesthetics for extractions 2640 (9) Other Operations: Permanent Teeth 3940 Permanent Teeth 8603 Temporary Teeth 923 Temporary Teeth 121 Total 9526 Total 4061 TABLE VI.—Uncleanliness and Verminous Conditions. (i) Average number of visits per school made during the year by the School Nurses 9.7 (ii) Total number of examinations of children in the Schools by School Nurses(primary) 59696 (subsequent) 2410 iii) Number of children found unclean 1511 (iv) Number of children cleansed under arrangements made by the Local Education Authority 161 (v) Number of cases in which legal Droceedines were taken: (a) Under the Education Act, 1921 — (b) Under School Attendance Byelaws ... 319 SECONDARY SCHOOLS. Year ended 31st December, 1937. Table I. RETURN OF MEDICAL INSPECTIONS. A.—Routine Medical Inspections. Year 1937. Year 1936. Age 11 or under 352 361 12 270 341 13 305 108 14 394 185 15 351 268 16 147 187 17 29 41 18 or over 2 17 Total 1,850 1,508 B.—Other Inspections. Year 1937. Year 1936. Number of Special Inspections 256 59 Number of Re-inspections 860 364 Total 1,116 423 Visits to Secondary Schools 104 84 320 SECONDARY TABLE II.—A.—Return of Defects Found by Medical Inspection in the Year Ended 31st December, 1937 Routine Inspections. Number of defects. Special Number Inspection of deaths. DEFECT OR DISEASE. 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 12 19 ... ... Uncleanliness. (See Table IV.—Group V.) Skin— Ringworm : Scalp ... ... ... ... Body ... ... ... ... Scabies ... ... ... ... Impetigo ... ... ... ... Other diseases (non tuberculous) 5 ... ... ... Eye— Blepharitis 1 1 ... ... Conjunctivitis ... ... ... ... Keratitis ... ... ... ... Corneal opacities ... 1 ... ... Defective vision (excluding squint) 175 101 6 ... Squint 8 8 1 ... Other conditions ... ... ... ... Ear— Defective hearing 3 1 ... ... Otitis media 1 1 ... ... Other ear diseases ... ... ... ... Nose and Throat— Enlarged tonsils only 11 56 ... ... Adenoids only ... 1 ... ... Enlarged tonsils and adenoids 14 8 ... ... Other conditions 5 5 ... ... Enlarged Cervical Glands (Non Tuberculous) ... 4 ... ... Defective Speech 1 ... ... ... Teeth—Dental Disease 11 2 ... ... Heart and Circulation— Heart Disease— Organic 4 63 ... ... Functional ... 13 ... ... Anaemia 3 18 ... ... Lungs— Bronchitis ... 2 ... ... Other non-tuberculous diseases ... 4 ... ... Tuberculosis— Pulmonary— Definite ... ... ... ... Suspected ... 4 ... ... Non-pulmonary— Glands ... 1 ... ... Spine ... ... ... ... Hip ... ... ... ... Other bones and joints ... ... ... ... Skin ... ... ... ... Other forms ... ... ... ... Nervous System— Epilepsy ... 4 ... ... Chorea ... 20 ... ... Other conditions ... ... ... ... Deformities— Rickets ... ... ... ... Spinal curvature 44 21 ... ... Other forms 41 32 1 ... Other Defects and Diseases 5 15 ... ...