LCC 35 London County Council. ANNUAL REPORT OF THE COUNCIL, 1926. Vol. II. MENTAL HOSPITALS AND MENTAL DEFICIENCY. Published by the LONDON COUNTY COUNCIL, And may be purchased, either directly or through any Bookseller, from P. S. KING AND SON, Limited, 14, Great Smith Street, Victoria Street, Westminster, S.W.1. Agents for the sale of the Publications of the London County Council, 1927. No. 2540. Price 1s. London County Council. ANNUAL REPORT OF THE COUNCIL, 1926. Vol. II. MENTAL HOSPITALS AND MENTAL DEFICIENCY. 526 - (0.12365 - 76a)—28.11.27—14837 CONTENTS. page Chapter I. Position, powers and duties of the Council in regard to the care of the mentally afflicted 3 Chapter II. Report of the Mental Hospitals Committee for the year ended 31st March, 1927 3 Chapter III. Eighth annual report of the Council to the Board of Control as to the performance of duties under the Mental Deficiency Act, 1913, for the year ended 31st December, 1926, with financial statements for the year ended 31st March, 1927 25 Appendices. I.—Financial statement showing the cost of administration of the Mental Deficiency Act during the year ended 31st March, 1927 39 II.—Return of expenditure (and cost a head) during the financial year ended 31st March, 1927, on maintenance of defectives at institutions provided by the Council 40 London County Council. ANNUAL REPORT OF THE COUNCIL, 1926. CHAPTER I. During the year ended 31st March, 1927, the position, powers and duties of the Council in regard to the care of the mentally afflicted have not been altered. A full list of these powers and duties will be found in Vol. I. of the Annual Report for 1926, pp. 29 and 30. CHAPTER II. Report of the Mental Hospitals Committee to the London County Council. 1. This report, for the year ended 31st March, 1927, is the tenth annual report of the Committee to which, under section 35 of the London County Council (General Powers) Act, 1915, stand referred all matters relating to the exercise by the Council of the powers of a visiting committee under the Lunacy Acts. It is the thirtyfifth annual report upon the administration of the London County Mental Hospitals.* Scope of the report. 2. During the period covered by this report meetings have been held as follows:—Mental Hospitals Committee. 12; visiting sub-committees of mental hospitals (ordinarily fortnightly, one meeting being held to transact general business and the next to discharge patients and to make statutory inspections), 242; other sub-committees (dealing with matters arising from the Council's administration of the Lunacy Acts), 48. Meetings. 3. On our representation the Council has secured the insertion in its General Powers Act, 1926, of a provision that after the triennial election of members of the Council the Mental Hospitals Committee and their sub-committees shall continue in office until the first meeting of the new Mental Hospitals Committee. Committee and subcommittees— Period of office. 4. We have to record with regret the death on 13th November, 1926, of Mr. A. E. Smith, J.P., who had been a co-opted member of the Mental Hospitals Committee since March, 1925. The service which Mr. Smith was able to render during the period of his membership was of great value and was appreciated highly by his colleagues. Death of a member of committee. Accommodation. 5. On 1st January, 1927, the accommodation at the London County mental hospitals, according to the requirements of the Board of Control as to bed space, was:— Accommodation. *It should be observed that a few of the matters dealt with in this chapter, e.g., under the section relating to superannuation acts, have an application wider than the mental hospital service and concern also the service under the Mental Deficiency Act, which, strictly, is matter for the following Chapter III. 4 Table 1. Mental hospital. Beds. Males. Females. Total. Banstead* 842 1,121 1,963 Bexley 1,015 1,071 2,086 Cane Hill 846 1,270 2,116 Claybury 924 1,229 2,153 Claybury Hall (for private cases only) 64 — 64 Colney Hatch 1,006 1,473 2,479 Hanwell 1,006 1,322 2,328 Horton 271 1,655 1,926 Long Grove 1,063 1,005 2,068 West Park 1,128 968 2,096 Ewell Colony† 329 100 429 Total 8,494 11,214 19,708 Total (excluding Claybury Hall) 8,430 11,214 19,644 *Temporarily reduced while certain wards are undergoing reconstruction. tAccommodation in use at 1st January 1927, by the Ministry of Pensions, for cases of mental disturbance occasioned by war service, and therefore not available for the Council's patients. The figures given here represent the allocation of the accommodation before the occupation of the Colony by the Ministry commenced. See statement in paragraph 7. 6. Comparison of this table with the corresponding table in the last annual report (Annual Report of the Council, 1925, Vol. II., p. 4) shows an increase in the total measured accommodation of all the hospitals of 354 beds (192 male and 162 females). This is due mainly to the completion of the additional wards for female patients at West Park mental hospital and to the re-occupation, following reconstruction, of certain of the male wards at Banstead mental hospital. 7. Occupation of the Ewell Colony was resumed by the Council on 1st February, 1927, on its vacation by the Ministry of Pensions and its accommodation (429 beds) will be utilised for the reception of 100 male and 329 female patients. The use of the greater portion of the accommodation for female patients (reversing the allocation which obtained before the Ministry's occupation began) is necessary to meet the greater requirement at present for beds for female as compared with male patients. The arrangement so to use the Colony is subject to further consideration at the end of two years. This variation in the use of the accommodation at the Ewell Colony converts the increase in accommodation for male patients (see para. 6) into a decrease of 37 beds but increases the additional female accommodation to 391 beds. The Colony though originally provided for the accommodation of epileptic patients can no longer be reserved entirely for that class of case, but has to serve, for the present at least, for the reception of other types of mental disorder. 8. When the structural alterations at Banstead mental hospital have been completed the measured accommodation at the London County mental hospitals, including Ewell Colony, will be as follows:— Male. Female. Total. Banstead 1,110 1,387 2,497 Bexley 1,015 1,071 2,086 Cane Hill 846 1,270 2,116 Clay bury 924 1,229 2,153 Colney Hatch 1,006 1,473 2,479 Hanwell 1,006 1,322 2,328 Horton 271 1,655 1,926 Long Grove 1,063 1,005 2,068 West Park 1,128 968 2,096 Ewell Colony 100 329 429 8,469 11,709 20,178 5 9. These totals will be increased by the numbers of beds which will be provided as the result of the structural alterations and additions, now in hand or in active preparation, set out hereunder:— Male. Female. Total. Erection of male villa at Colney Hatch mental hospital 40 0 40 Structural alterations to provide for better classification at: Cane Hill mental hospital — 10 10 Claybury mental hospital — 43 43 Erection of nurses' villa at Horton mental hospital, setting free, for the use of patients, accommodation in wards originally provided for patients but at present used for nurses — 120 120 40 173 213 Upon completion therefore of the various structural alterations and additions now in hand or contemplated (as above), the number of beds in the mental hospitals will be 8,509 for male, and 11,882 for female patients, a total of 20,391. 10. The numbers of patients resident on 1st January, 1927, were Patients— Number resident. Table 2. Mental hospital. Males. Females. Total. Banstead 845 1,131 1,976 Bexley 1,054 1,118 2,172 Cane Hill 883 1,255 2,138 Claybury 940 1,289 2,229 Claybury Hall (private patients only) 57 — 57 Colney Hatch 1,005 1,546 2,551 Hanwell 1,046 1,379 2,425 Horton 270 1,671* 1,941 Long Grove 1,091 1,029 2,120 West Park 978 781 1,759 Ewell Colony† — — — Total 8,169 11,199 19,368 Total (excluding Claybury Hall) 8,112 11,199 19,311 * Includes 131 patients in the private wards. † Accommodation in use at 1st January, 1927, by Ministry of Pensions. 11. A comparison of table 1 with table 2 shews that at all the London County mental hospitals except West Park the number of patients was in excess of the measured accommodation. There were, however, at West Park mental hospital 150 vacant beds for male and 187 for female patients, 337 in all. 12. The statutory returns made to the Board of Control by the London Boards of Guardians, taken with other available information show that on 1st January 1927, the Council was responsible for finding accommodation for 19,807 insane persons, who were housed as follows:— Patients for whom the Council was responsible. Table 3. Males. Females. Total. Parish patients in London County mental hospitals 7,061 10,759 17,820 Parish patients maintained by the Council in other mental hospitals under contract 85 389 474 Parish patients in the mental hospitals of other counties and boroughs under arrangements made by guardians 30 94 124 Total Parish patients 7,176 11,242 18,418 14837 B 6 Table 3—continued. Males. Females. Total. Private patients at Horton mental hospital - 131 131 Patients in various London County mental hospitals on the private list (Lunacy Act, 1891, section 3), including ex-soldiers classified as "service" patients and private patients 1,008 239 1,247 Total Private patients 1,008 370 1,378 Criminal lunatics in various London County mental hospitals chargeable to the Prison Commissioners 11 — 11 8,195 11,612 19,807 The sub-totals in the last column, printed in italics, appear again in Table 5. [This table does not include male private patients at Claybury Hall, but it does include female private patients at Horton mental hospital, all of whom have London settlements and are received at a low charge, so that probably, if they were not dealt with thus, the Council would have to provide for them as parish cases. This is true also of the "private list" cases, all of whom are admitted in the first instance as parish cases and also of the majority of the "service" cases.] Parish patients. 13. The number of parish patients accommodated in London County mental hospitals on 1st January, 1927, exceeded by 462 (238 males, 224 females) the number so accommodated on 1st January, 1926. This increase is accounted for chiefly by the opening of further wards at West Park mental hospital. The number of London patients accommodated in out-county mental hospitals, under arrangements made by London boards of guardians, i.e., patients admitted to out-county mental hospitals but subsequently found to be chargeable properly to London parishes or unions, was 14 less on 1st January, 1927, than on 1st January, 1926, viz., 124 as against 138. During the year 1926 the number of such patients transferred from outcounty mental hospitals to London County mental hospitals was 99. Patients boarded out. 14. The number of patients boarded out under contracts made between the Council and out-county authorities was, on 1st January, 1926, 380 (35 males, 345 females). During the year 1926, a contract, dated 29th December, 1925, with the West Riding mental hospital for the reception of 50 London female patients became effective and a contract for the reception of 50 female patients at the Three Counties mental hospital was extended to cover from 11th April, 1926, the reception of 50 male patients also. Additional contracts were entered into for the maintenance, one at the Hants County mental hospital and one at the Ipswich Borough mental hospital, of two London female patients whose relatives lived near the respective institutions. A contract with the Derby County mental hospital for the reception of 15 female patients expired on 13th December, 1926. The contract with the East Riding mental hospital was renewed for a further term from 6th February, 1926, but the number of patients to be received was reduced from 70 females to 40 females. During 1926, 139 London patients were sent to outcounty hospitals under reception contracts, viz., 57 males and 82 females, 17 (1 male and 16 females) died, 5 (4 males and 1 female) were discharged, 1 male was transferred to the service class, thus ceasing to be chargeable to London, and 22 (1 male and 21 females) were brought back to London County mental hospitals. There has been therefore a net increase during the year of 50 males and 44 females, making the total number boarded out at 1st January, 1927, 474 (85 males, 389 females). 7 15. At 1st January, 1927, the contracts in force were as follows:— Contracts, Table 4. Mental hospital. Number contracted for. Charge a head a week provided for in the original contract. Charge a head a week from 1st January. 1927. Date of commencement. Full term of contract. Date of expiry. City of London M. F. £ s. d. £ s. d. Years. 35 5 1 5 0 1 8 6 1st July, 1923 5 30th June, 1928 (or earlier by six months' notice). Hants County - 1 1 8 0 1 8 0 15th April, 1926 5 14th April, 1931 (or earlier by three months' notice during last four years). Ipswich Borough - 1 1 8 0 1 8 0 22nd June, 1926 5 21st June, 1931 (or earlier by three months' notice during last four years). Leicester City - 115 1 6 10 1 9 9 16th July, 1924 5 15th July, 1929 (or earlier by three months' notice). Monmouth County - 90 1 5 4 1 2 8½ 8th January, 1924 3 *7th January, 1927 (or earlier by three months' notice). Oxford County - 20 1 6 10 1 8 0 3rd September, 1923 5 2nd September, 1928 (or earlier by three months' notice during last four years). Three Counties 50 50 1 8 7 1 8 7 11th April, 1926 2 10th April, 1928 (or earlier by three months' notice). Yorks, East Riding - 40 1 5 6 1 5 6 6th February, 1926 3 5th February, 1929 (or earlier by three months' notice). Yorks, West Riding - 50 1 6 0 1 6 0 29th December, 1925 2 28th December, 1927 (or earlier by three months' notice). *This contract has been renewed for three years for reception of 70 female patients at a charge of £1 2s. 8½d. a week. 16. The following table shews the total number of lunatics for whom the Council has been responsible to find accommodation on 1st January, in certain years since 1890*:— Number of patients to be provided for. Table 5. Date. Parish and county patients. Chargeable to Prison Commissioners. Patients on private list, etc., and private patients at Horton. Total. Increase. Decrease. 1st January— 1890 10,100 4 - 10,104 - — 1900 15,061 17 107 15,185 5.081(a) - 1910 19,288 39 587 19,914 4,729(a) — 1920 16,243 7 1,046 17,296 - 2,618(b) 1921 16,557 40 1,219 17,816 520 — 1922 17,085 36 1,228 18,349 533 — 1923 17,343 15 1,142 18,500 151 — 1924 17,725 10 1,183 18,918 418 - 1925 17,653 10 1,397 19,060 142 — 1926 17,876 13 1,419 19,308 248 — 1927 18,418 11 1,378 19,807 499 — (a) In each year of these decennia there was an increase. The average yearly increase was, from 1890 to 1900, 508, and from 1900 to 1910, 473. (b) During the first 5 years of this decennium there was an average annual increase of 162, the next four years (1916-1919) showed decreases averaging 1,078 a year, the last year (1920) showed an increase of 70. Patients — increase in numbers. 17. The increased number of patients for whom the Council on 1st January, 1927, was responsible to find accommodation was 499. The number of additional rate-aided patients was 542, but there was a diminution of 41 in the number of private patients, and a decrease of 2 in the number of patients chargeable to Prison Commissioners. In considering table No. 5, reference should be made to tables Nos. 9 to 12 inclusive, and to the corresponding tables in the annual report for 1925. It * The figures for each year up to 1915 will be found in the Annual Report for 1915-1919 (Vol. II., p. 15) and for 1916-1919 in the Annual Report for 1921 (Vol. II., p. 6). 14837 b 2 8 will be seen that the number of recoveries for 1926 was slightly less than that for 1925, as also was the number of deaths:—711 recoveries in 1926 as against 717 in 1925, and 1,300 deaths in 1926 as against 1,327 in 1925. The total number of admissions, both direct and indirect, for 1926 was 3,951, as against 3,622 for 1925, an increase of 329, while the total number of discharges was 1,596 for 1926 as against 1,389 for 1925, an increase of 207. The increase in the total number of patients for whom the Council is responsible is due obviously to the inevitable accumulation in the Council's mental hospitals of chronic patients, for whom discharge is not practicable. Insane persons within the knowledge of public authorities, 1890-1927. 18. Details of the total number of lunatics (excluding male private patients at Claybury Hall) under the care of public authorities in London responsible for dealing with them are as follows*:— Table 6. Date. Lunatics under reception orders in County or Borough mental hospitals. Lunatics in M.A.B. mental hospitals. Lunatics in workhouses or with relatives and friends. Total number of lunatics. Annual increase or decrease of Lunatics under reception orders. Total number of lunatics. 1st January— (i.) (ii.) (iii.) (iv.) (v.) (vi.) Increase Decrease Increase Decrease 1890 10,104 5,566 692 16,362 - - - - 1900 15,185 5,770 562 21,517 5,081 — 5,155 - 1910 19,914 6,676 413 27,003 4,729 — 5,486 — 1920 17,296 5,291 328 22,915 — 2,618 — 4,088 1921 17,816 5,385 326 23,527 520 - 612 - 1922 18,349 5,320 298 23,967 533 - 440 - 1923 18,500 5,101 279 23,880 151 — — 87 1924 18,918 5,148 312 24,378 418 — 498 — 1925 19,060 4,976 294 24,330 142 — — 48 1926 19,308 4,975 245 24,528 248 - 198 - 1927 19,807 4,817 239 24,863 499 - 335 — Net increase in 37 years 9,703 8,503 Average increase per annum 262 229 Metropolitan Asylums Board's accommodation. 19. Table 6 shows that the total number of London lunatics under reception orders increased in the year by 335. Actually the London County Council had to provide for 499 additional cases (see table 5), but the cases looked after by the Metropolitan Asylums Board decreased by 158 and there were 6 fewer patients for whom the guardians provided care, either in the infirmary or workhouse or through friends and relatives of the patient. The reduction in the number of the Metropolitan Asylums Board's cases probably is not unconnected with the use of a considerable section of the accommodation originally provided by the Board for "chronic, harmless lunatics," for the reception of cases of mental defect. This arrangement (to which further reference is made in Chapter III., paragraph 33) has been of real service to the Council in connection with the administration of the Mental Deficiency Act, nevertheless it has cast upon the Council the responsibility of providing a greater proportion of the total accommodation which is required for the insane. At the same time we are given to understand that the Metropolitan Asylums Board have not had to refuse applications made by Boards of Guardians for the admission of chronic, harmless lunatics, such as the Board may receive. There is no doubt a tendency on the part of the parish relieving officers to apply directly to the Council for vacancies for all classes of patients who have to be dealt with under the Lunacy Acts, and it is often difficult to suggest that a "chronic" case is not really suitable for care in the wards of a County mental hospital. Certainly * Figures for 1890-1915 and 1916-1919 are given in the Annual Reports for 1915-1919 (Vol. II., p. 16) and 1921 (Vol. II., p. 7). 9 the mere fact that the case is "chronic i.e., that it offers no prospect of speedy recovery, if at all, is not in itself sufficient to indicate that the case is one for the Metropolitan Asylums Board; the case to be eligible for one of the Board's mental hospitals must also be "harmless" to himself and others, in other words, the kind of case which might lawfully be detained in a workhouse, the Board's accommodation being, in effect, centralised workhouse accommodation. Even cases of chronic senile dementia can be, and often are, so troublesome that care in a County mental hospital is fully warranted. And it would seem that the provision made under the Mental Deficiency Act is, by now, having some effect in withdrawing from the operation of the Lunacy Acts cases of congenital deficiency, for whom before 1913 a mental hospital (probably one of the Board's hospitals) furnished the only possible refuge if institutional care, outside a workhouse, was needed. 20. During 1926, 22 male and 11 female patients of a kind eligible for detention in the Metropolitan Asylums Board's mental hospitals were transferred from London County mental hospitals to the Board's care. Of those patients, two females were returned during the year, having proved, after transfer, to be unsuitable for the Board's institutions. In addition to these retransfers the London County mental hospitals received by transfer from the Board's institutions, 11 male and 33 female patients. Applications for admission. 21. The applications for beds for cases of lunacy received from the relieving officers in the County of London and dealt with during each month of the period 1916-1927 are shown in table 7 below. This table is interesting because it gives some indication whether there is any actual increase in the incidence of mental unsoundness in the county. The figures give the total applications made each month, of which a certain number (between 5 and 6 per cent.) is usually withdrawn for one reason or another. The figures therefore do not represent the total number of cases certified. It will be noted that the applications exceeded the previous year's figures by 16. Last year there was an increase of 143 over the year previous. Applications for beds. Table 7. 1916-17 1917-18 1918-19 1919-20 1920-21 1921-22 1922-23 1923-24 1924-25 1925-26 1926-27 April 272 238 282 303 294 242† 267 263 243 256 297 May 294* 275 313 347* 303 324* 337* 328 265 329 270 June 291 314* 271 314 347* 274 275 303 265 266 304 July 260 314* 316 327 308 323 272 333* 338* 340* 340* August 264 250 259 317 292 263 300 297 252 238 265 September 225 247 256 265 261 257 282 238 237 273 267 October 226 233 286 270 298 287 233† 278 275 287 245† November 242 200† 343* 217† 231† 242† 261 289 236† 228† 276 December 222† 242 242† 228 287 286 291 256 300 294 295 January 267 279 297 316 302 278 286 297 297 248 320 February 248 248 253 286 279 252 287 266 266 314 253 March 252 300 289 336 292 280 302 211† 275 319 276 Total 3,063 3,140 3,407 3,526 3,494 3,308 3,393 3,359 3,249 3,392 3,408 Monthly average 255 261 283 293 291 275 282 280 270 282 284 * Highest in each year. †Lowest in each year. Readmissions. 22. The total number of patients who were readmitted to the London County mental hospitals during the year ended 31st March, 1927, after having previously been discharged "recovered" from one or other of the London County mental hospitals was 318. Of this number 83 were readmitted within twelve months of the date of their discharge. Former patients readmitted, after being discharged "recovered." 10 23. Statistics as to recoveries and readmissions during the past 32 years are as follows :— Table 8. Mental hospital. Patients discharged "recovered" between 1895 and 1926. Number of such patients readmitted to any London mental hospital up to 31st March, 1927. Percentage of readmissions in col. (ii) to discharges "recovered" in col. (i). Number of patients in col. (i) readmitted to any London mental hospital within twelve months of their discharge up to 31st March, 1927. Percentage of readmissions in col. (iv) to discharges "recovered " in col. (i) (i.) (ii.) (iii) (iv.) (v.) Banstead 5,293 1,697 32.06 634 11.97 Bexley (from 19th September, 1898) 3,073 825 26.84 287 9.33 Cane Hill 3,850 1,265 32.85 429 11.14 Claybury 6,275 1,911 30.45 710 11.31 Colney Hatch 4,752 1,484 31.22 527 11.09 Hanwell 5,310 1,767 33.27 640 12.05 Horton (from 3rd March, 1902—out of use from May, 1915, to November, 1919) 1,588 417 26.25 133 8.37 Long Grove (from 18th June, 1907) 1,847 457 24.74 170 9.20 The Manor (from 8th June, 1899—out of use from July, 1916, to March, 1919; disused entirely as accommodation for cases of insanity since January, 1922) 742 206 27.76 69 9.29 Ewell Colony (from 19th August, 1903 —out of use since June, 1918) 104 16 15.38 7 6.73 West Park 186 44 23.65 20 10.75 Total 33,020 10,089 30.55 3,626 10.98 24. Records have been kept of readmissions since 1895 and the figures relating to the five hospitals which were in existence then are quite consistent. From these it appears that of the discharges "recovered" more than thirty per cent. have relapsed sooner or later after discharge and about 11 per cent. within twelve months after discharge. Admissions, Deaths and Discharges. Admissions. 25. The following tables give particulars of the admissions, deaths and discharges during 1926. In tables 11 and 12 are statistics of the death and recovery rates:— Table 9. Hospital. Admissions—1926. Total number under treatment, 1926. Direct. Indirect Total. (i.) (ii.) (iii.) (iv.) M. F. Total. M. F. Total. M. F. Total. M F. Total. Banstead 140 231 371 176 10 186 316 241 557 977 1,612 2,589 Bexley 153 206 359 11 11 22 164 217 381 1,218 1,328 2,546 Cane Hill 138 191 329 5 1 6 143 192 335 1,026 1,438 2,464 Claybury 140 225 365 36 7 43 176 232 408 1,188 1,515 2,703 Colney Hatch 143 237 380 10 7 17 153 244 397 1,155 1,763 2,918 Hanwell 229 142 371 9 14 23 238 156 394 1,237 1,528 2,765 Horton 1 167 168 16 32 48 17 199 216 285 1,853 2,138 Long Grove 176 137 313 4 6 10 180 143 323 l,260 1,171 2,431 West Park 300 253 553 80 307 387 380 560 940 1,368 955 2,323 1,420 1,789 3,209 347 395 742 1,767 2,184 3,951 9,714 13,163 22,877 11 Table 10. Discharged (excluding transfers to other mental hospitals, but including cases sent for further carein institutions of the M.A.B.)—1926. Hospital. Recovered. To care of friends on undertakings under sec. 79 of the Lunacy Act, 1890. Relieved or not. improved, otherwise than under col. ii. Total discharges. Died, 1926. (i.) (ii.) (iii.) (v.) M. F. Total. M. F. Total. M. F. Total. (iv.) M. F. Total. Banstead 21 56 77 15 28 43 29 49 78 198 56 87 143 Bexley 37 73 110 24 25 49 33 36 69 228 75 77 152 Cane Hill 35 46 81 5 14 19 11 22 33 133 73 83 156 Claybury 45 70 115 2 5 7 51 36 87 209 74 94 168 Colney Hatch 11 29 40 23 47 70 28 54 82 192 76 99 175 Hanwell 52 19 71 10 13 23 28 28 56 150 81 74 155 Horton — 39 39 1 14 15 2 29 31 85 11 91 102 Long Grove 34 41 75 12 20 32 19 28 47 154 67 44 111 West Park 55 48 103 25. 27 52 52 40 92 247 89 49 138 290 421 711 117 193 310 253 322 575 1,596 602 698 1,300 Discharges and deaths. * "Relieved" or "not improved" for the purpose of this table includes discharges to a workhouse (including an institution provided by the Metropolitan Asylums Board), discharges of patients whom it is intended to deal with under the Mental Deficiency Act, discharges of alien patients fcr repatriation, discharges of private patients by order of a relative or the person making payment for maintenance (Sec. 72, Lunacy Act, 1890), discharges following escape if a patient is not recaptured within 14 days (and, occasionally, on the expiration of a reception order which is not continued as provided for by sec. 38 of the Lunacy Act, 1890), as well as discharges (made by order of visitors) of patients who. though not recovered, can be cared for outside the hospital, but in whose cases undertakings under sec. 79 of the Lunacy Act, 1890, are not given. Table 11. Hospital. Remaining on registers 31st December, 1926. (i.) Average daily number on registers, 1926. (ii.) Percentages of recoveries on total admissions, 1926. (iii.) M. F. Total. M. F. Total. M. F. Total. Banstead 845 1,131 1,976 746 1,201 1,947 6.64 23.23 13.82 Bexley 1,054 1,118 2,172 1,047 1,105 2,152 22.56 33.64 28.87 Cane Hill 883 1,255 2,138 880 1,244 2,124 24.47 23.95 24.17 Claybury 997 1,289 2,286 1,000 1,277 2,277 25.56 30.17 28.18 Colney Hatch 1,005 1,546 2,551 1,003 1,526 2,529 7.18 11.88 10.07 Hanwell 1,046 1,379 2,425 1,033 1,375 2,408 21.84 12.17 18.02 Horton 270 1,671 1,941 269 1,652 1,921 — 19.59 18.05 Long Grove 1,091 1,029 2,120 1,087 1,027 2,114 18.88 28.67 23.21 West Park 978 781 1,759 1,001 607 1,608 14.47 8.57 10.95 8,169 11,199 19,368 8,066 11,014 19,080 16.41 19.27 17.99 Cases under treatment. Recovery rate. Table 12. Hospital. Percentage of total recoveries on direct admissons, 1926. (i.) Percentage of recoveries yielded by direct admissions on the direct admissions. (ii.) Percentage of deaths on average daily number on registers, 1926. (iii.) M. F. Total. M. F. Total. M. F. Total. Banstead 15.00 24.24 20.75 6.42 9.52 8.35 7.50 7.24 7.34 Bexlev 24.18 35.43 30.64 9.80 18.44 14.76 7.16 6.96 7.06 Cane Hill 25.36 24.08 24.62 7.97 12.04 10.33 8.29 6.67 7.34 Claybury 32.14 31.11 31.50 19.28 6.66 11.50 7.40 7.36 7.37 Colney Hatch 7.69 12.23 10.52 2.79 3.37 3.15 7.57 6.48 6.91 Hanwell 22.70 13.38 19.13 14.84 6.33 11.59 7.83 5.38 6.43 Horton - 23.35 23.21 - 9.58 9.52 4.08 5.50 5.31 Long Grove 19.31 29.92 23.96 10.22 8.75 9.58 6.16 4.28 5.25 West Park 18.33 18.97 18.62 9.66 8.30 9.04 8.89 8.07 8.58 20.42 23.53 22.15 10.35 9.16 9.69 7.46 6.33 6.81 Recovery rate — Death rate. 12 Analysis of statistics. 26. The hospitals with the highest numbers of direct admissions were West Park (as would be expected, in the hospital most recently opened), Colney Hatch, Banstead and Hanwell. Including the indirect admissions, the hospitals with the highest total number of admissions were West Park, Banstead, Claybury and Colney Hatch. Those, however, with the greatest number of patients under treatment were Colney Hatch, Hanwell, Claybury and Banstead. The hospital with the lowest number of patients under treatment was Horton, and here the total number of admissions, both direct and indirect was also the lowest. 27. The hospital with the highest number of discharges "recovered" was Claybury, followed by Bexley, West Park, and Cane Hill. The hospitals with the lowest number of discharges "recovered" were Horton, Colney Hatch, Hanwell and Long Grove. With the discharges "recovered," however, should be considered also discharges under section 79 of the Lunacy Act, 1890, to the care of friends, and discharges of patients as "relieved" or "not improved." On the total number of discharges, West Park is highest, followed by Bexley, Claybury and Banstead. There is, as might be expected, a rough relation between the totals of admissions and discharges, and the highest total numbers of discharges were found at those hospitals which had the highest total numbers of admissions. 28. The hospitals with the highest death rates in proportion to the average daily numbers resident were West Park and Claybury with 8.58 per cent. and 7.37 per cent. respectively. The death rate is usually influenced by the number of admissions. The lowest was Long Grove with 5.2 per cent. 29. The percentage of recoveries on the total admissions for all the mental hospitals was 17.99 per cent. for the year, as against 19.79 per cent. for the previous year, and the percentage of deaths on the total average daily number on the registers during the year was 6.81, as against 7.06 in the previous year. Classification and chargeability of patients. Patients on the "private list." 30. The usual enquiries have been made as to all patients in respect of whom it appeared likely that there were means, and 140 patients have been found entitled to be classified as private patients in accordance with section 3 of the Lunacy Act, 1891, the cost of maintenance being recovered from the patients' estates or secured by undertakings to pay on the part of relatives or friends. 31. The following statement shows the action taken in regard to the classification of patients during the year ended 31st March, 1927:— Table 13. Number of patients on private list (Lunacy Act, 1891, sec. 3) on 31st March, 1926 374 Number of patients transferred to private list during the year ended 31st March, 1927 140 514 Of these were— re-transferred to parish list 21 discharged 73 died 30 removed to The Hall, Claybury hospital (males) 3 removed to private ward, Horton hospital (females) 26 removed to private institutions 4 transferred to private (service) class 1 158 Number of patients on private list on 31st March, 1927 356 13 These were located at Banstead (9m. 14f.), at Bexley (13m. 31f.), at Cane Hill (12m. 30f.), at Claybury (23m. 20f.), Colney Hatch (14m. 21f.) at Hanwell (12m. 24f.), at Horton (60f.), at Long Grove (23m. 26f.) and at West Park (10m. 14f.). 32. Patients who are chargeable to the county are those who have not acquired a poor-law settlement in any parish of England and Wales or who have no status of irremovability from any such parish, All patients when first received into the mental hospitals are prima facie chargeable to the union or parish from which they are sent. The parish authorities in the case of a patient who is found not to be settled in or irremovable from their parish may give notice to the local authority (the Council) of intention to obtain an order of a justice to adjudicate the chargeability to the county. All such cases are enquired into by the chief officer of the mental hospitals department, and where settlements can be found elsewhere steps are taken to get the notices withdrawn. The attention of the parish authorities is also drawn to cases in which, from information obtained, it would appear that patients might be chargeable to out-county parishes. County patients. 33. The chief officer makes enquiries as to the ability of all patients, who are chargeable to the county, to reimburse either wholly or in part the expenses of their maintenance. 34. Inquiries have been made as to settlements of all patients concerning whom the London boards of guardians have given notice of their intention to obtain orders adjudicating the chargeability of the patients to the County of London, with the result that 71 new notices were received, giving, with 4 cases standing over from last year, a total of 75 cases to be dealt with. In 18 cases settlements were found and the notices were withdrawn, in 45 cases orders were made on the County of London, and 4 cases are still under consideration. Chargeability of County patients. 35. The 45 patients adjudicated to the county appeared to belong to the following countries: Ireland, 13; Scotland, 6; Ceylon, 3; India, 3; Russia, 3; England, 2; France, 2; United States of America, 1; Asia Minor, 1; Australia, 1; Czecho-Slovakia, 1; Cyprus, 1; Egypt, 1; British Guiana, 1; Norway, 1; Sweden, 1; Switzerland, 1 ; West Indies, 1; Unknown, 2. 36. The number of patients chargeable to the county, as compared with the total number chargeable to London boards of guardians and to the county, for whom the Council was providing accommodation at the commencement of 1927, and of previous years, was as follows *:— Table 14. Date, 1st January. Chargeable to the County. Chargeable to London boards of Guardians and the County. Date, 1st January. Chargeable to the County. Chargeable to London boards of Guardians and the County. 1890 532 10,100 1922 448 17,085 1900 510 15,061 1923 459 17,343 1910 564 19,288 1924 478 17,725 1915 555 20,882 1925 491 17,653 1920 424 16,243 1926 515 17,876 1921 436 16,557 1927 525 18,418 37. It will be observed that since 1920 the numbers of patients chargeable to the county and to London boards of guardians have shown a tendency to increase slightly. In 1890 the number of patients chargeable to the county amounted to 5 per cent. of the total; in 1900 it had fallen to 3.2 per cent., and is now only 2.7 per cent., This is evidence of the careful investigation always made in cases which boards of guardians seek to make chargeable to the County of London. * Figures for 1890-1899, 1901-1909, 1911-1914 and 1916-1919 are given in tho Annual Report for 1921 (Vol. II., p. 9). 14837 C 14 Service patients. 38. The following table gives particulars of ex-soldier patients at each of the London County mental hospitals during the year ended 31st March, 1927:— Table 15. Admission of patients with previous military service. Patients classified as "service" patients during the year. Discharged or transferred after classification as "service" patients. No. died. "Service" patients remaining at 31st March, 1927. Under section 91 of Army Act. Under summary reception orders. Transferred from other mental hospitals. Banstead - 40 45 10 5 2 118 Bexley 3 62 4 8 6 6 80 Cane Hill 1 27 - 5 4 11 89 Claybury — 29 3 13 10 3 146 Colney Hatch — 21 2 2 4 3 80 Hanwell 1 63 4 8 4 - 119 Horton — — — — — - — Long Grove — 71 1 12 12 3 135 West Park 2 34 8 24 6 1 38 Ewell Colony — — 1 — — - 1 Total 7 347 68 82 51 29 806 39. The number of patients with previous military service admitted under summary reception orders (i.e., through poor law parishes or unions) was 69 less than the number so admitted during the previous year. Every such case is considered by the Ministry of Pensions, with a view to "service" classification should the Ministry be satisfied that the mental disability is due to or is aggravated by service during the Great War. The number of such cases to receive "service" classification during the year ended 31st March, 1927 was less by 24 than the corresponding number for the year ended 31st March, 1926. Alien Lunatics. Alien lunatics. 40. There has been no change since the date of the last annual report in the arrangements made for the deportation of alien lunatics. 41. During the year ended 31st December, 1926, 120 alien patients were admitted to London County mental hospitals chargeable to London parishes or unions and there were, in addition, 632 already in residence on 1st January, 1926. Of this total number of 752 patients, 2 have been deported under the provisions of the Aliens Act, 4 have been discharged to friends for repatriation, 22 have been transferred to other mental hospitals, 51 have died, and 35 have been discharged either "relieved" or "recovered," 114 in all, leaving 638 in residence on 31st December, 1926. 42. The nationalities of these 638 patients were as follows: American (Latin), 2; American (U.S.A.), 13; Armenian, 2; Asiatic, 1; Austrian, 23; Belgian, 7; Bulgarian, 1; Chinese, 9; Czecho-Slovak, 6; Danish, 3; Dutch, 12; Egyptian 2; Finnish, 2; French, 55; German, 78; Greek, 5; Hungarian, 6; Italian, 61; Lithuanian, 2; Norwegian, 3; Persian, 2; Polish, 58; Portuguese, 1; Roumanian, 6; Russian, 239; Serbian, 1; Spanish, 8; Swedish, 6; Swiss, 17; Syrian, 1; Turkish, 4 ; Unknown, 2. Encephalitis Lethargica. Encephalitis lethargica. 43. The research work upon post-encephalitis cases, and the administration of special treatment to such cases both at West Park mental hospital and also at The Manor certified institution are being continued. 15 The Mental After-Care Association. 44. This Association has continued to give valuable assistance in connection with patients discharged or allowed to be absent on trial. Mental After-Care Association. 45. The arrangement whereby a payment of two shillings and sixpence is made in respect of each patient dealt with by the Association on the grant of leave of absence on trial under section 55 of the Lunacy Act, 1890, has been extended to apply to those cases in which services have been rendered by the Association, in connection with applications made for the discharge of patients under section 79 of the Lunacy Act, 1890. 46. During 1926-27 the following cases were helped by the Association in the manner indicated:— Home visits. Placed in cottage, homes. Placed in situations. Old cases, i.e., before 1926, helped in various ways. Banstead 129 12 16 5 Bexley 43 15 9 3 Cane Hill 26 4 2 2 Claybury 141 28 14 16 Colney Hatch 8 10 7 7 Hanwell 104 14 12 16 Horton8510114 Long Grove 10 9 4 2 West Park 91 21 19 9 Maudsley—132— Totals 637 136 96 64 Except for the payments indicated, the Association is entirely dependent on voluntary subscriptions and a number of the mental hospitals have been enabled to contribute to the Association's funds by making articles for sale and as a result of entertainments. Queen Adelaide's Fund. 47. Grants have been made from this private fund during the year, for the relief of deserving patients upon their discharge "recovered" from the mental hospitals. The number of cases in which grants were made at each of the London County mental hospitals during the year ended 31st March, 1927, and the amounts expended were as follows:— Queen Adelaide's fund. No. of patients receiving grants. Total Amount of grants. M. F. Total. M. F. Total. £ s. d. £ s. d. £ s. d. Banstead 6 9 15 15 0 0 22 0 0 37 0 0 Bexley 1016 26 37 15 0 79 5 0 117 0 0 Cane Hill 10 9 19 22 0 0 30 10 0 52 10 0 Claybury 21 13 34 64 10 0 38 5 0 102 15 0 Colney Hatch 1 4 5 3 0 0 21 0 0 24 0 0 Hanwell 21 4 25 45 4 0 7 10 0 52 14 0 Horton — 6 6 — 21 13 0 21 13 0 Long Grove 8 2 10 24 8 6 3 5 0 27 13 6 West Park 5 8 13 13 0 0 23 5 0 36 5 0 82 71 153 224 17 6 246 13 0 471 10 6 Royal Commission on Lunacy and Mental Disorder. 48. This Commission, appointed by Royal Warrant of 25th July, 1924, has now concluded its sittings, which extended into the year under review, and has presented its Report. Report of Royal Commission. 14837 O 2 16 Stricture and scope. 49. This document is in three parts, the first, which deals with the procedure of the Commission, refers to the evidence taken, both oral and written and to the institutions visited and to the manner of visitation. The second part treats of the legal and administrative aspects of the questions arising as to the certification, detention and care of the mentally afflicted, and opens with an historical survey of these questions, followed by an outline of the existing system accompanied by criticisms and proposals relating to its various aspects, grouped under the headings of certification, detention, care, private institutions and public authorities, both local and central. In the third part the conclusions and recommendations of the Commission are summarised under the same heading as appear in the scheme of classification adopted in the second part of the report. Action taken on the Report. 50. the Keport, during the year under review, was being considered by a special sub-committee whom we have appointed to consider as to the administration of public mental hospitals. Nursing service in mental hospitals. Nursing service— Report of Departmental Committee. 51. The same Sub-Committee also has been considering, under reference from us, the proposals made in the report of the Departmental Committee appointed to enquire into the nursing service in County and Borough mental hospitals, which was issued in 1924. Contributions to medical literature. Contributions to medical literature. 52. Contributions to medical literature have been made by members of the medical staff of the London County mental hospitals during the year ended 31st March, 1927, as follows:— Dr. G. A. Lilly, deputy medical superintendent, Banstead mental hospital, in collaboration with Dr. E. L. Hopkins, third assistant medical officer, Hanwell mental hospital. "Journal of Mental Science," January, 1926.—" A note on the Wassermann Reaction in the Blood Serum of Male admissions at Hanwell Mental Hospital." Dr. D. R. Alexander, second assistant medical officer, Bexley mental hospital, in collaboration with Dr. Golla, director of the Pathological Laboratory, Maudsley hospital. "British Medical Journal," 2nd October, 1926.—"The Value of Malarial Therapy in Dementia Paralytica." Dr. G. F. Peters, third assistant medical officer, Cane Hill mental hospital. "Journal of Mental Science," April, 1926.—" Unexpected Fits." Dr. G. R. A. de M. Rudolf, fourth assistant medical officer, Claybury mental hospital. Proceedings of the Royal Society of Medicine, 1926, xix. (Section of Tropical Diseases and Parasitology, p. 27).—" Some Aspects of Therapeutic Malaria." (This work gained the Gaskell Prize and the Gold Medal of the Royal Medico-Psychological Association.) In collaboration with Dr. J. C. Ramsay, eighth assistant medical officer, Claybury mental hospital. "Journal of Tropical Medicine and Hygiene," 1927, xxx. 1.—"Enumeration of Parasites in Therapeutic Malaria." In collaboration with Dr. R. J. B. Marsh, eighth assistant medical officer, Claybury mental hospital. "Journal of Tropical Medicine and Hygiene," 1927. xxx, 57.— "Some Observations upon Carbohydrate Metabolism in Malaria, with special reference to the effect of Insulin and Glucose upon Benign Tertian Malaria." Lt.-Col. J. R. Lord, medical superintendent of Horton mental hospital. "Journal of Mental Science," July, 1925, and April, 1926.—"Some Psychological Reflections." "Journal of Mental Science," October, 1926.—" Philippe Pinel." "Journal of Mental Science," (special number), August, 1926.—" The Clinical Study of Mental Disorders." "Mental Hospitals and the Public." (Messrs. Adlard and Son, Ltd.) Dr. W. D. Nicol, second assistant medical officer, Horton mental hospital. "Journal of Mental Science," October, 1926.—" Clinical Aspects and Results of the Malarial Treatment of General Paralysis." Dr. P. K. McCowan, second assistant medical officer, West Park mental hospital. "Journal of Mental Science," October, 1926.—" The Physico-psycho-galvanic Reflex in the Neuroses and Psychoses. (This essay gained the Bronze Medal of the Royal MedicoPsychological Association). In collaboration with Dr. J. S. Harris, senior assistant medical officer, Maudsley hospital. "Journal of Medical Science," January, 1927.—" Chronic Epidemic Encephalitis." 17 In collaboration with Dr. J. S. Harris and Captain S. A. Mann, chief assistant to the pathologist, pathological laboratory, Maudsley hospital, "The Lancet," 17th April, 1926.—"Blood Sugar Studies in Encephalitis Lethargica." "Medical Journal," 1st May, 1926.—" Hyoscine in Post Encephalitis Lethargica; with special reference to its influence on Carbohydrate Metabolism." Farming Operations. 53. The special sub-committee appointed to consider and report on the whole question of the farming operations at the institutions under our direction, referred to in previous annual reports, have continued their work during the past year. The Ministry of Agriculture very kindly arranged again for two of their inspectors to visit, and report upon all the farms. The reports received have been of great assisttance, and a number of suggestions, notably those as to the purchase and feeding of cattle have been adopted. Farming operations. 54. In the official farm accounts ot the London County mental hospitals no charge is included for rent, rates and taxes, tithes, repairs and insurance of buildings, produce sent into the institutions is credited at rates approximately 20 per cent. below the market prices published by the Ministry of Agriculture, and milk supplied is credited at 20 per cent. less than current contract prices. As thus kept, the farm accounts for the year 1925-26 give a total debit balance of £4,633, as against £3,044 for the previous year. This increase can be fully accounted for by the deficit at one mental hospital (Claybury) where an outbreak of swine fever occurred. 55. "Trading" accounts for some of the institution farms have been submitted to us by the comptroller in respect of the years 1924-25 and 1925-6. Arrangements are being made for similar figures for all the institution farms to be prepared in future years. These accounts differ from the official accounts by the inclusion of hypothetical charges, fixed by the valuer, for rent, rates and repairs, and of interest at 5 per cent. on the working capital, i.e., the amount of stock on hand. The cost of special allowances to working patients is included, but no charge is made for patients' labour owing to the varying conditions, which make it impossible to fix any reliable figure for this. Produce is credited at full market value. 56. Comparing the "trading" accounts with the official accounts, in respect of those institutions for which "trading" accounts have been prepared, it appears that a deficiency is replaced by a credit balance. It is perhaps unnecessary to discuss this result more fully here: we propose, however, to continue to compare accounts prepared on a "trading" basis, with the official accounts. Woman Gynæcologist. 57. The Council has authorised on our suggestion the appointment, as an experiment for one year, at Horton mental hospital, of a woman medical officer with special experience in gynaecology. Massage treatment of patients. Woman gynæcologist. 58. On our recommendation the Council has increased the establishment of staff at each of the large London County mental hospitals by one trained masseuse (full time or part time, as may be found necessary), the appointment being made on an unestablished basis. Massage treatment Occupational Therapy. 59. The Council on 16th November 1926, authorised the continued employment as an experiment of a part-time woman occupations officer at each of the London County mental hospitals until 31st March, 1927. It has been found that Occupational therapy. 18 the work done by these officers is of great value, and justifies full-time appointments. The Council has accordingly, on our recommendation, increased the recognised staff of each of the large London County mental hospitals from 1st April, 1927 by one woman occupations officer, the appointment to be made in an unestablished capacity. Works of improvement. etc., at mental hospitals. Structural alterations and additions. 60. Alterations and additions to the buildings and fittings, and other structural works which have been carried out at certain of the mental hospitals are set out below. The statement does not include minor works carried out at small cost:— Banstead mental hospital. Bath in cowman's cottage £41 19 9 Adaptation of bowling alley to form shoemaker's shop 179 1 8 Poultry shed 128 8 9 Fencing at Fairlawn 186 8 0 Alteration at tinsmith's shop 67 10 0 Master keys in locked boxes 11 12 10 Conversion of nurses' rooms in A2 and A3 into clinical rooms 14 4 7 Bull yard enclosure 11 15 2 Messroom and bath at gasworks 79 14 9 Water supply to cattle troughs on Downs 10 14 3 Modernisation of blocks J and K 8,768 18 11 Rppapering and painting cowman's cottage 19 7 2 Fixing gas cooker in medical superintendent's house 11 17 11 „ kitchener „ „ „ 37 13 0 Repairs to deputy medical superintendent's house, including water system 122 10 7 Welding No. 6 boiler 16 18 0 Wringing machine in foul laundry 129 12 4 Conversion of serving hatchway to doorway in K2 ward 26 2 8 Relining copper in kitchen 81 15 5 Bexley mental hospital. Installation of baker's oven in general kitchen 940 12 7 Installation of slipper baths in female general bathroom 167 17 10 Enclosing and fitting doors to steam heated cupboard in general kitchen 23 12 6 Alterations to farm bailiff's house 45 1 2 Additional lavatory accommodation for female visitors 27 14 6 Observation windows in 24 side room doors 17 8 2 Renewal of flooring, etc., in padded room 71 15 0 Shelving in clerk's office storeroom and stationery cupboard in clerk's office 16 10 3 Renewal of washing machine in general laundry 161 2 1 Screen to divide L ward and sanitary annexe for L ward 183 7 10 New operating theatre 314 13 0 Additional shed for poultry 157 8 9 Cane Hill mental hospital. Laundry—re-arrangement of general wash-house 587 10 11 Laundry—alterations to foul wash-house 40 4 7 Kitchen—additions and alterations106 4 9 Electric power supply 77 13 11 Cinematograph 451 8 11 Bakery motor and counter shafting 50 1 10 Radiators in H block, female 393 19 4 Connecting up sewer to local authority's system 1,425 15 11 Radiators in nurses' recreation room 98 0 1 Lockers for staff clothing sent to laundry 26 16 5 Additional W.C.'s for C ward, male 317 4 10 Verandah at G ward (male) extension 124 17 10 Potato peeler, main kitchen 117 5 7 Claybury mental hospital. Poultry house, erection, etc. 224 3 6 Airing court paths—re-arrangement 96 16 1 19 Claybury menial hospital—continued. Isolation hospital—conversion of locks £14 15 4 Farm, draining ditch 23 0 9 Alteration of slipper bath in El ward 19 10 8 Boiler in former steward's house 15 7 5 Bedside tables and lockers (part only) 197 8 6 Electric lights in N1 ward 12 11 1 Letter boxes (27) 17 0 1 Equipment of clinical examination room, M and N blocks 39 8 2 Moving small greenhouse 17 7 10 Conversion of six doors at piggeries 11 19 8 Colney Hatch mental hospital. Bakery, dough-mixing machine 180 11 8 Renewing floor of recreation hall 149 7 6 Greenhouse and forcing pit 319 18 1 New bathroom, male division 868 7 3 Overhauling dome of main tower 114 7 0 Improving ventilator to laundry ward dormitory 132 12 2 Alterations to villa 6 55 3 9 Washhand basins in lecture room 24 19 0 Hoffman steam press 89 13 10 Two hot water boilers in nurses' home and boys' villa 30 4 10 Improving lighting and ventilation in main stores 63 12 6 Hanwell mental hospital. Provision of special overflow and mixing valves to two baths for continuous bathing 44 17 1 Single rooms, heating, additional work 122 3 3 Provision of additional doorway in gallery of No. 7 male ward 27 12 3 Lighting certain single rooms 19 16 4 Alterations to structures and strapways, etc., for new washing machine and hydro-extractor in laundry 53 10 0 Cupboard in laundry for storage of towels 19 17 2 Glass panels in doors of clinical examination rooms in wards 31 5 5 Enlarging window, fixing shutter and frame No. 1 single room of No. 3 female ward 18 13 9 Warren farm house, sub-division into two separate residences 210 0 8 Provision and fixing of lift in medical superintendent's house 49 8 5 Warren farm, fire hose and appliances 24 0 2 Thirty gas-heated ovens and hot carving tables in wards 457 2 3 Single rooms, glass panels in doors 191 17 11 Dental surgery—No. 21 female ward (adaptation) 31 13 5 Radiator in No. 20 female ward store room 11 14 9 Alterations to No. 1 female ward 577 13 0 Matron's quarters, alterations 184 14 11 Warren farm, field gates (2) 15 10 0 Warren farm, fencing public footpath (fields 311 and 327) 50 19 0 Warren farm, fencing public footpath (field 328) 10 19 9 Grills for windows of nursing staff bedrooms 122 17 3 Canal boundary wall, doorway 41 17 1 Wood sashes in lieu of iron sashes in assistant matron's quarters22 18 2 Six gates for fencing across footpaths at Warren farm 12 12 2 Warren farm house, necessary repairs, and putting in good condition 211 6 6 Relaying tar-paving in No. 1 male court 104 17 2 Supply and erection of dough kneader 329 6 10 Renewal of kitchen range at gate porter's quarters (West) 16 9 5 Repairing damage done by motor lorry to south pier No. 1 female court 11 2 8 Supply and erection of two boiling pans115 2 0 Renewal of floor boarding in No. 16 male ward 77 11 7 Renewal of tell-tale clocks 156 5 0 Horton mental hospital. Alterations, farm building 972 3 0 Fume cupboard, pathological laboratory 11 11 4 Mosquito-proofing rooms in isolation hospital 29 16 11 20 Horton menial hospital—continued. New road, south boundary £134 7 9 Shed, dispensary stores 29 8 3 Lavatory basin and electric wall plugs, isolation hospital 19 14 8 Fencing meadows 191 19 6 Water supply to meadows 97 18 1 Alterations to boundary fence 27 18 8 Power-driven flour hoist at bakery 54 6 5 Hot water boiler at medical superintendent's house 16 13 7 Removing kitchener and installing modern stove, Shrubbery house 24 6 9 Cupboards in laundry 14 12 2 Three loose boxes at farm 227 14 6 Slop sink in ward 3 24 14 1 Long Grove mental hospital. Power refrigerator plant, provision (part of estimated cost £900) 76 10 11 Farm fencing 9 15 10 Letter boxes in wards 20 5 6 Conversion of window to door, matron's sitting room 11 16 10 New boiler feed pump 129 15 6 West Park mental hospital. Isolation hospital, adaptation for induced malarial treatment 49 19 5 Seat in airing court, El and E2 wards 12 14 1 Concrete bases for dustbins 17 2 11 Maudsley hospital. Pipe coils in ward side rooms 10198 Slop sink in corridor lavatory for use of domestic staff 19 16 8 Gas fires in clinical assistants' and medical officers' dining rooms 13 19 10 Matters affecting individual hospitals. 61. In the following paragraphs we refer in detail to certain matters which affect, in particular, individual hospitals. Banstead Mental Hospital. Modernisation of wards. 62. The modernisation of the large chronic blocks, (three male and five female), has been proceeded with; work on two blocks, J and K (male) has been completed and that on blocks M (male) and B (female) is in progress. The female blocks C, D, E and F remain to be dealt with. Renewal of steam boilers. 63. In our last report we made reference to the need for renewal of the steam boilers at the hospital. One new boiler has been installed and a contract has been entered into with Messrs. John Thompson (Wolverhampton) Limited, for the installation of three others. The total cost of the four boilers is estimated at £9,850. Legacy. 64. A legacy of £100 has been left to the hospital by the sister of a patient. Bexley Mental Hospital. Purchase of land. 65. An offer made by the owner of the Baldwyn's estate to sell approximately 14 acres of land to the Council, at £100 an acre was, on our recommendation, accepted and the purchase has been duly completed: possession was taken on 11th February, 1927. The land will be added to the hospital farm. Cane Hill Mental Hospital. Lease of land. 66. A lease has been granted to H.M. Government of a plot of land 70 feet by 130 feet, on the hospital estate, for a term of 99 years at an annual rental of £30, to provide a site for a post office telephone exchange. Cinematograph. 67. A cinematograph apparatus has been installed in the hospital, and the first performance was given on Saturday, 27th November, 1926. 21 68. The connection of the hospital buildings with the local authority's sewer Sewage was completed on 6th January, 1927, and the former system, which obtained for disposal. 43 years, of distributing sewage, after treatment, over the farm land has been discontinued. Claybury Menial Hospital. 69. The new admission villa for 43 female patients, the erection of which has been authorised, is in course of construction. Female admission villa. 70. Structural alterations to provide for improved classification of patients have been completed at M and N blocks and are in process of being carried out at block C. A plan of alterations for a similar purpose at block S has been approved by the Minister of Health and the work is about to be put in hand. Colney Hatch Mental Hospital. Ward improvements. 71. We have had under consideration the question of the water supply, which is provided at this hospital by a well. Although the volume of water in the well has been diminishing during the last twenty years, we are advised that the yield probably will be maintained for some years to come, though it may be necessary either to deepen the well or to make alterations in the pumping apparatus. The position is being kept under observation. Water supply. 72. The new admission block for 40 male patients (the erection of which has been authorised), is in course of construction. Hanwell mental hospital. Male admission block. 73. An agreement has been completed between the Couucil and the Metropolitan Water Board for the supply of water to Warren Farm, an estate purchased for addition to the hospital during 1925. Warren Farm estate. 74. A scheme has been put in hand for remodelling the drainage from buildings on the Warren Farm estate. Until recently the sewage there has drained into a cesspit. Arrangements are being made to connect the drainage system with the sewer of the Southall-Norwood Urban District Council. Horton Mental Hospital. 75. To enable the Epsom Urban District Council to widen the road at the corner of Long Grove Road and Horton Lane, with a view to minimising the risk of accident from fast moving traffic, a small piece of land, about 640 square feet, forming part of the Horton mental hospital estate, has been surrendered to the Epsom Urban District Council, in consideration of the payment by that Council of the sum of £10. West Park mental hosvital. Road widening 76. The last four blocks of the hospital, viz., A. B, C and D, have now been completed and only the chapel remained unfinished at the end of the period covered by this report. Completion of works— hospital and chapel. 77. A contract for the provision of an organ for the chapel has been placed with Messrs. H. Willis and Sons and Lewis and Co., Ltd., of Liverpool, whose tender (£780) was the lowest. The Maudsley Hospital. Organ for chapel. 78. The Maudsley Hospital has now commenced its fifth year of work and continues fully to prove the utility and value of such an establishment for the treatment of cases of early mental breakdown and incipient mental disorder. Full details of the year's work are given in the Annual Report of the medical superintendent, which will be issued as a separate document. Work of the hospital. 22 Number of cases under treatment. 79. The hospital was opened on 1st February, 1923, and hitherto reports have dealt with yearly periods to 1st February, 1926. In this and future reports the period dealt with will end on 31st December in each year. The number of patients treated at the hospital during the eleven months ended 31st December, 1926, were made up as follows:— Out-patients. Numbers treated. Disposed of in out-patient department durins period from 1.2.26 to 31.12.26 Admitted to w ards from out-patient department, during period from 1.2.26 to 31.12.26. Still attending on 31.12.26. M. F. T. M. F. T. M. F. T. M. F. T. Number carried over from year 1923-24 8 4 12 4 3 7 — — — 4 1 6 Number carried over from year 1924-25 8 7 15 3 6 9 — — - 5 1 6 Number carried over from year 1925-26 51 67 118 31 52 83 10 7 17 10 8 18 Number registered during period from 1.2.26 to 31.12.26 443 620 1,063 243 338 581 139 244 383 61 38 99 Total number 510 698 1,208 281 399 680 149 251 400 80 48 128 Inpatients. Males. Females. Total. In hospital on 1.2.26 52 96 148 Admitted from out-patient department during period from 1.2.26 to 31.12 26 149 251 400 Admitted otherwise during period from 1.2.26 to 31.12.26 40 109 149 Total 241 456 697 Discharged 180 344 524 Died 4 16 20 Total 184 360 544 Remaining in hospital 31.12.26 57 96 153 Lectures in psychological medicine. 80. We have authorised a further course of post-graduate lectures in psychological medicine, at the hospital, subject to the conditions applicable to the previous courses. This will be the tenth course held at the hospital. Accommodation. 81. The Board of Control have agreed to recognise, as additional accommodation at the hospital, 16 beds to be placed on the bridge verandahs connecting the ward blocks. The bridges are being enclosed, and in one case widened, to render them suitable for this use. Ewell Colony. Ministry of Pensions occupation. 82. The lease of this institution to the Minister of Pensions was not renewed after 31st January, 1927, upon which date possesion was resumed by the Council (see par. 7). Use of accommodation. 83. As previously stated in this report (see par. 7), the Colony will be utilised at present for receiving cases of lunacy suitable for treatment in the villa accommodation provided and the position will be reviewed at the end of two years, i.e., in January, 1929. Admission of patients. 84. The Colony was re-opened for the admission of patients on 21st February 1927. During the period covered by this report admissions were limited to transfers from other institutions and recent cases were not received. 23 Housing of Staff. 85. A plot of land of about 13½ acres on the Council's estate at Epsom has been sold to the Epsom Urban District Council for £3,600 for the purposes of a housing scheme, on the understanding that of the houses to be erected (approximately 120), one-third, i.e., 40, shall be allotted during the first five years, for occupation by married employees of the London County Council working at institutions on the Horton Estate. Housing of staff. Staff. 86. The established staff of the mental hospitals department (including the staff at the central offices), numbered, on 31st March, 1927, 597 officers, 3,335 nurses (male and female) and 921 employees of various grades. Number. 87. Dr. L. H. Wootton, deputy medical superintendent of Colney Hatch mental hospital, who was seconded to be medical superintendent of the Ewell Colony, under the Ministry of Pensions, has been seconded to act further in a similar capacity in the Council's service for a period of two years from 1st February, 1927, the date of resumption of occupation of the Ewell Colony by the Council. Changes in medical staff. 88. Dr. J. S. Harris, a fourth assistant medical officer at West Park mental hospital has been appointed senior assistant medical officer at the Maudsley hospital to succeed Dr. W. S. Dawson, who has been appointed professor of psychiatry in the University of Sydney, New South Wales. 89. Mr. Peter Dickson, after a period of service in an acting capacity, was, as from 1st April, 1926, appointed to be chief assistant in the mental hospitals' engineers' department. 90. We have consented to the acceptance by Miss M. M. Thorburn, R.R.C., matron of Horton mental hospital, of an invitation to serve for two years on a panel of examiners for the diploma in nursing, recently instituted by the University of London, subject to such service not interfering with her official duties as matron. Matron acting as examiner. Asylums Officers' Superannuation Act, 1909, and Asylums and Certified Institutions (Officers' Pensions) Act, 1918. 91. We continue to deal with matters under these statutes by virtue of powers delegated by the Council. Superannuation acts. 92. During 1926-27 sixty-four superannuation allowances were granted, to the amount of £7,505 8s. 7d. a year. Allowances granted. 93. In two cases where application had been made for the addition of years of service under section 2 (3) of the Act of 1909, it was decided that no action should be taken. Additional years of service. 94. In four cases contributions towards pensions granted by the Council have been claimed from the authorities of other institutions from which the pensioners had removed after at least two years' service ; the contributions as agreed amounted in total to £48 8s. 6d. a year. Contribution by the Council towards a pension granted by another authority to an officer who had removed from the Council's service was agreed at the rate of £60 17s. 11d. a year. Contributions by other authorities. Contribution by the Council. 95. The sum of £149 3s. 2d. overpaid to a pensioner who was formerly a stoker at Hanwell mental hospital, has been written off as irrecoverable. Irrecoverable overpayment 96. Claims made by one hundred and eight officers and employees for repayment of superannuation contributions under section 10 (1) of the Asylums Officers' Superannuation Act were allowed. The total amount so repaid was £1,193 8s. 8d. Repayment of contributions. 97. In fifteen cases the application for return of contributions could not be acceded to owing to the circumstances in which the services of the applicants had been terminated. 98. One hundred and thirty applications from female officers and employees leaving to be married, for return of their contributions, as permitted by section 24 Gratuities. 10 (2) of the Asylums Officers' Superannuation Act of 1909, were granted. The sums returned amounted in total to £2,970 16s. 7d. 99. The Council granted, under section 4 of the Act of 1909, gratuities to the widows of two members of the established staff who had died from illness while in the service and who had served for at least 10 years, and in whose cases it was medically certified that had they survived their illnesses they would have remained permanently incapacitated for further asylum duty, and therefore that had they retired at the date of death they would have been entitled to pension. The aggregate of these gratuities was £288 7s. 4d. Deceased pensioners. 100. Nine persons in receipt of pensions under these Acts died during the year 1926-27. Sanction to remove. 101. Written sanction to remove, under section 6 of the Act of 1909, was given to three officers and employees who were transferring to the services of other asylum authorities. 102. The income and expenditure on maintenance account upon mental hospitals, etc., during the year ended 31st March, 1927, is shown in the following table in comparison with the amounts for the previous ten years :— Year ending 31st March. Income. Expenditure. Year ending 31st March. Income diture. £ £ £ £ 1917 662,312 674,237 1923 1,508,039 1,381,656 '918 670,079 736,347 1924 1,330,068 1,391,237 1919 753,767 889,012 1925 1,349,319 1,468,820 1920 1,270,666 1,314,295 1926 1,473,076 1,565,089 1921 1.868,646 1,641,962 1927 1,644,339 1,581,075 1922 1,872,482 1,564,770 Income and expenditure. Income and expenditure. Statement of accounts. 103. A detailed statement of the accounts for the year ended 31st March, 1927, is shewn with other accounts of the Council in the published abstract of Accounts (see Vol. V.). Cost of maintenance. Cost of maintenance. 104. The charge made by the Council to London boards of guardians at 31st March, 1926, for the maintenance of parish patients in the mental hospitals was 26s. 10d. a head a week. This charge was increased from 1st April, 1926, to 28s. 7d., at which figure it stood at 31st March, 1927. 105. As the charges for in-county parish patients have exceeded the limit of 14s. a week, prescribed by section 283 of the Lunacy Act, 1890, the same charges have been made for patients chargeable to out-county parishes. Charges for private patients. 106. The charge made at Horton mental hospital for female private patients in the private ward, which at 31st March, 1926, was 35s. a head a week, was increased from 1st April, 1926 to 36s. 2d. a head a week. 107. At Claybury Hall the charge made for male private patients, which, at 31st March, 1926, was 56s.aweek forthose having a London settlement, and 59s. 6d. a week for out-county patients, has remained unchanged throughout the year. Private list" cases. 108. The charges for "private list" cases (those admitted chargeable to a parish, who, having a settlement in or status of irremovability from a London parish, are able to pay the full cost of maintenance or perhaps a little more, as a contribution to capital expenses which are not included in cost of maintenance) have been at the minimum, the charge current for parish patients, and, at the maximum, 4s. 1d. a week in excess of that charge. H. F. Keene, Chief Officer. R. Dunn Gardner, Chairman. 23 CHAPTER III. Ninth Report of the London County Council to the Board of Control. (This chapter contains the report in respect of the year ended 31st December, 1926, which the Council is required to make by No. 28 of the Mental Deficiency Act Provisional Regulations, 1914.) Administrative arrangements. 1. The Council's administrative arrangements for the discharge of its duties under the Mental Deficiency Act, 1913, through the Mental Hospitals Committee, remain as described in previous reports (see Annual Reports for 1915-19, Vol. II., p. 29, and 1920, Vol. II., p. 17). Committee and SubCommittees. 2. During 1926, meetings of the Mental Hospitals Committee and of subcommittees wholly concerned with work under the Mental Deficiency Act have been as follows :—Committee, 12 ; managing sub-committees of certified institutions for the mentally defective, 59 ; other sub-committees and Cases Section, 28. Meetings. Staff. 3. Administrative and executive work continues to be divided between the Mental Hospitals Department and the Public Health Department, in accordance with the scheme detailed in the first annual report (see Annual Report for 1914, vol. II., p. 280). The comptroller of the Council collects contributions towards the Council's expenses of maintaining defectives in institutions (and in some instances towards the Board of Control's expenses of maintaining defectives in a State institution) and the solicitor, in certain cases, takes steps to enforce payment of arrears. (For particulars as to collection of contributions, see pars. 68 and 69.) Departmental arrangements. 4. On 31st'December, 1926, the staff authorised for employment in the Mental Hospitals Department entirely upon work connected with the administration of the Mental Deficiency Act was:—1 senior assistant; 2 assistants, first class ; 4 assistants, second class; 5 assistants, general grade ; 2 enquiry officers (nonpensionable). In the Public Health Department at the same date the staff engaged entirely for work under the Act was 3 women inspectors. Staff employed for central administration. Ascertainment. 5. The Council's duty to ascertain what persons in London are defectives within the meaning of the Act and are subject to be dealt with under the Act has been discharged as fully as possible. 6. During the year, following certain representations made by the Board of Control, opportunity was taken to review the methods which the Council employs in respect of the ascertainment of defectives in London, and the conclusion was formed that the existing machinery for ascertainment (which is referred to in some detail on pp.31 and 32 of Vol. II. of the Council's Annual Report for 1915-1919), and the manner in which it was being employed were adequate to secure that ascertainment in London was being carried out as fully and as accurately as it was reasonable to expect. Machinery for ascertainment. 7. Restrictions imposed by the Board of Control whereby, of the cases ascertained, none but those deemed to be "urgent" as defined by the Board of Control should be dealt with in institutions, are still in force. Urgent cases. 26 Cases ascertained. 8. The cases of whom the Council received information during the year ended 31st December, 1926. were :— Source of information. Miscellaneous sources. London Association for the (are of the Mentally Defective. Education authority. Poor-law authorities. Charged with offences before a court of criminal jurisdiction (Sec. 8). Criminal cases. Industrial schools (Sec. 9). Total. Prisons (Sec. 9). 190 95 £80 40 83 9 28 730 Employment of the London Association for the Care of the Mentally Defective. Supervision. 9. Arrangements for the supervision in their own homes of those persons ascertained to be defective and subject to be dealt with, for whom this measure appears to provide adequate protection or for whom no better means of care can be furnished, continue to be made through the London Association for the Care of the Mentally Defective. For the financial year ended 31st March, 1927, the Council has paid to the Association £1,917, an increase of £177 upon the payment for the previous year, which was necessary to meet normal salary increments for the Association's staff and to cover the cost of increased administrative expenses at the Association's head office in respect of occupation centres (see paragraph 13 and onwards). The amount of £1,917 includes consideration for services rendered by the Association in furnishing (i.) reports upon the home circumstances of the relatives of defectives required by the Visitors of certified institutions in which London cases are maintained, to enable the Visitors to perform their duties under section 11 of the Act, and (ii.) reports as to the progress of defectives who may be absent in London on licence from certified institutions, with a view to ultimate discharge. Enquiries made for visitors of institutions. Enquiries as to progress ot defectives on licence. Method of payment of errant to the London association. 10. In order to avoid the necessity for occasional bank overdrafts, involving payment of interest which must add to the general expenses of the Association, arrangements have been made for payments on account of the Council's grant to the Association to be made monthly in advance. Friendly visitation or after-care 11. Friendly visitation has again been afforded by the Association in suitable cases for defective persons resident in London, after discharge from institutions or guardianship. No payment is made by the Council for this work as the cases are no longer "subject to be dealt with" under the Act. Cases supervised 12. At 31st December, 1926, the number of cases under statutory supervision in London was 1,856 (854 males and 1.002 females). Continuation of the scheme of "occupation centres." Provision of occupation centres. 13. The use of "occupation centres." i.e., centres organised by voluntary effort, with financial assistance from the Council and the Board of Control, which mentally defective children who are unfit for attendance at special schools may attend otherwise than compulsorily for simple occupational training, details of which are given in the Annual Reports for 1923 (Vol. II., pp. 19-21) and 1924 (Vol. II., pp. 27-28), has been continued and developed during 1926. Centres in use, and attendances. 14. The following table gives particulars of the centres of which use has been made by the Council during the year, and of attendances made thereat by " recognised " cases, i.e., by defectives who are under statutory supervision and are not more than 16 years old (or, in some special cases, 18 years). These are the cases for whom the centres are primarily intended, and in respect of whom the Council makes a financial contribution to the expenses of the centres, and at least 75 per cent, of the places available at each centre are reserved for such cases. The centres are under the management of the London Association for the Care of the Mentally Defective, except the " Agnes Western " and Willesden centres which are 27 trolled by the Central Association for Mental Welfare and the Willesden Association for the Care of the Mentally Defective respectively; but all arrangements (including the financial arrangements) in respect of the "Agnes Western" centre are made for convenience through the London Association. The Willesden centre provides for children residing outside the London county area, but it has been found convenient for a few isolated London cases to attend there, and the figures as to Willesden given in the table relate only to these cases:— Sessions Average number on roll Average Centre. Address. a daily attendance. week. Hackney Infants' Class Room, Dalston Congrega10 27 17 tional Church, Middleton-road, Dalston " Agnes Western" St. James' Parish Hall, Collier-street, Isling10 16 11 ton Whitechapel Christchurch Hall, Hanbury-street, Spital5 15 11 fields Southwark St. John's Parish Hall, Bedford-street, 5 20 13 Southwark Poplar St. Frideswide Club House, Follett-street, 5 18 12 East India Dock-road Bethnal Green* St. Margaret's House, Old Ford-road, 5 11 7 Bethnal Green Lambeth (a) Pelham Hall, Lambeth Walk. 3 24 13 Battersea (a) Congregational Church Small Hall, Batter- 2 20 12 sea Bridge-road Deptford (6) St. Paul's Institute, High-street, Deptford 3 11 9 Woolwich (6) St. James' Parish Hall, Burrage-road, S.E. 2 17 11 Willesden Pember Hall, Pember-road, Kensal Green 5 2 1 Total — 181 117 *See paragraph 15. (a) and (6)—These centres are grouped, i.e., are open for a combined total of five sessions weekly, each group of two sub-centres counting for grant as one centre. 15. In the last Report (Vol. II., p. 32, par. 13), reference was made to the provision of whole day centres and to a reorganisation which had been effected to secure a better distribution of centres in localities where they were most needed. At the end of the Christmas term, 1926, the Bethnal Green centre was closed, on account of a decline in the attendances there, and arrangements were made for the Lambeth and Battersea centres to provide five sessions a week each (instead of three and two sessions a week respectively). " Wholeday " centres and re-distribution of other centres. 16. The grant made by the Council to the Association in respect of occupation Guides, centres covers the provision at each centre of one guide (except at the Hackney centre, which has two), to assist certain of the defective children who otherwise could not be counted upon to make regular attendances. During 1925, a supplementary payment was made to cover the cost of additional guides, and this payment was continued during 1926; 16 additional guides, escorting 54 defectives, were thus employed. The cost of the additional guides' wages, fares, etc., during the twelve Cost, months ended 31st March, 1927, was £350, which amounts to approximately 6 1/2d. a school day for each of the 54 children dealt with. The arrangement to provide additional guides is being continued during 1927. 17. The basis of payment by the Council to the London Association for the Care of the Mentally Defective for the use of occupation centres during the year ended 31st March, 1927, was at the rate of £143 a year for each of the seven part-time centres, or groups of centres, except the Hackney centre, in respect of which the Council paid the actual net cost of operating it (after allowing for income) not exceeding £465 a year. These payments were slightly in excess of those made during the year 1925-26. The increased grants were necessary chiefly to meet increased rent Payment for use of centres. 28 which had to be paid by the Association for premises used as occupation centres. The grant in respect of the "Agnes Western" centre was at the rate of £143 a year; the extra cost of its development to whole-day use was met from voluntary sources. Payment to the Willesden Association for the use of their centre at Kensal Green was made at the rate of £5 a year for each London case received there. Results. 18. During 1926 the work of the centres proceeded satisfactorily. Efforts were made to sustain and improve attendance with some success. There was a noticeable improvement in the children who attended at the centres, and their parents cooperated well with the supervisors. The children's handwork improved in quality and it was possible to effect sales of work at most of the centres. Singing, toy bands, games, etc., are carried on at each centre, and definite training is given in light domestic duties and in hygiene. Attendances. 19. The attendance at occupation centres of cases approved by the Council, though it showed during 1926 an average increase of 9 over the average for 1925, still, at the end of the year, left something to be desired. No doubt better attendance could be effected if more guides were provided, as very few parents, however willing, are able to give up the greater part of a morning or afternoon to accompany their children to and from a centre ; but it is questionable how far the further expenditure which would thus be entailed would be justified by final results. Conclusions. 20. It would seem that the provision of occupation centres can do much to assist children who are the subjects of statutory supervision; but the cost is somewhat high (say, £15 103. a year for each case dealt with—taking the average of actual attendances), having regard to the improbability that, in the absence of facilities for attendance at an occupation centre, the more costly alternative of institutional care would necessarily have to be resorted to for most of the cases who do attend. Without doubt, the relief afforded by occupation centres to overtaxed parents is appreciated, though the Act of course makes provision primarily for the benefit of defectives and not of the relatives who are responsible for caring for defectives while they are able to do so. So long as occupation centres are to do real good, it seems that a number of small centres, conveniently placed for the attendance of individual cases and making provision for individual care in small classes, is necessary; this need contra-indicates what otherwise might be the more economical possibility of fewer and larger units, centralised, at which work could be done on a larger scale at a diminished cost per head. Continuance of arrangement. 21. The arrangement for the provision of occupation centres, is to be continued during 1927. Use of guardianship. Guardianship. 22. During 1926, the use of guardianship as a means of providing suitable care and control for certain defectives was further developed. Experience has shown, however, that in many cases detained in institutions who have improved so much that care under the supervision of an individual guardian may be beneficial, possibly as a stage towards yet further relief from personal control under the provisions of the Act, it is inadvisable to apply immediately for varying orders providing for guardianship, but that it is wiser to arrange that the defective concerned shall, in the first place, proceed on leave of absence, with a view to guardianship later on if he or she should prove suitable. The advantage of this tentative step is that it permits readily of recall to institutional care if the experiment of personal guardianship does not in fact give the result which was anticipated. Number of cases under guardianship 23. During the year, 13 additional cases were placed under guardianship. On 31st December, 1926,21 males and 19 females were maintained under guardianship. Of these, 11 males and 2 females were in village homes in Sussex, placed through the agency of the Guardianship Society of Brighton; 2 males and 11 females were in institutional homes in or near London; and 8 males and 6 females were under the guardianship of parents or near relatives. (See Annual Report for 1925, Vol. II., p. 33.) 29 24. The guardianship scheme established by the Central Association for Mental Welfare, some details of which were set out in the Annual Report for 1925 (Vol. II., p. 33, pars. 22-24), was brought into operation during 1926. In each instance the London cases placed through the Association's agency were females, and proceeded in the first place on leave of absence from certified institutions. The prospective guardians who have been provided are in the district of Letchworth (Herts). Difficulty is experienced by the Association in finding persons suitable and willing to undertake the guardianship of male defectives. Guarardianship scheme of Central Association for Mental Welfare. 25. On account of this difficulty the Council agreed to payment being made at a rate not exceeding 20s. a head a week for any male defectives who might be placed through the Association's agency, instead of at the rate of 15s. a head a week, which had previously been agreed upon. (See Annual Report for 1925, Vol. II. p. 33, par. 23). Basis of payment. 26. The Council has agreed to pay to the Central Association, monthly in advance, at the rate of £5 a head a year in respect of the upkeep of outfits provided for London defectives, placed through the Association's agency, in addition to not more than £10 a head for the provision or completion of initial outfits. Mabys Association. 27. Experimental arrangements were made with the Mabys Association for placing suitable female defectives for whom the Council is responsible, under guardianship or under care while absent on licence from certified institutions with a view to guardianship, at the Association's Home at Battersea, upon payment by the Council, for each case so placed, at the rate of 25s. a week, inclusive, subject to the deduction of any wages received by a defective who might be placed in daily domestic service while under the Association's care, less a reasonable allowance of pocket money. Mabys Association. Provision of care in institutions. (a) Accommodation under contract. 28. During the year 1926, the Council was still obliged to make use of accommodation which it had been able to secure under contract to enable it to make provision for those ascertained cases of mental defect for which supervision or guardianship does not make sufficient provision. The following table shows the number of cases for which accommodation was being provided thus at the end of 1926 :— A\ccommodat,ion in institutions under contract. Institution. Fe- Males. males. Institution. Fe- Males. males. Metropolitan Asylums Board Certified Institution 504 406 National Institutions for Persons Requiring Care and Control:— Stoke Park Colony, Bristol 28 56 Whittington Hall 5 St. Mary's Home, Alton, Hants — 17 Crathorne, Finchley 9 Etloe House, Leyton — 24 Pield Heath House, Hillingdon — 2 St. Francis' School, Buntingford 4 — St. Joseph's Home, Sudbury, Suffolk — 1 Western Counties Institution, Starcross 1 Girls' Training Homes, Clapton — 4 Walsham How Home, stow— 20 Cumnor Rise Home, Cumnor, Berks — 2 Helping Hand Home, Upper Hollo way — 14 Pontville, Ormskirk, Lanes. ... 1 — PrineessChristian'sFarmColony, Hildenborough, Kent ... 1 8 Dovecot, Knotty Ash, Liverpool — 1 The Home, Everton Terrace, Liverpool — 1 House of Help, Bath — 2 Prudhoe Hall Colony, Prudhoe- on-Tyne — 1 Plumstead Institution (Woolwich Guardians) 12 5 Eagle House Hostel, Mitcham — 11 Royal Earlswood Institution, Redhill 7 4 Ellen Terry Home, Reigate — 2 St. Teresa's, Lewisham — 11 Besford Court, Worcester 3 — Girls' Village Homes, side — 4 Littleton House, Girton 1 — Total 562 605 30 Charges made for maintenance 29. The class of patient received and the charges* made for maintenance were:— Institution. Religion. Class of defective received. Charges. By contract. Supplemental payments. Maintenance (a week). Burials. Outfits. Maintenance a week) Burials. Outfits. Besford Court, Worcestershire Roman Catholic Feeble-minded males, high grade £80 a year £10 £10 £10 a year — — Bigod's Hall, Dunmow, Essex Roman Catholic Males (imbeciles and feeble-minded) up to age of 16 11/6 £5 — 6/- — — Crathorne, Finchley. Protestant Mothers (feeble-minded or moral imbeciles) and their children (no child retained over 7 years of age) 11/6 £5 £3 5/6 — £3 Cumnor Rise Home, Oxford Church of England Feeble-minded females from 14 years (epileptics and fallen women not taken) 12/- £5 £5 4/- - - Dovecot, Knotty Ash, Liverpool No restriction High-grade feeble-minded females, from 16 years £34 a year £4 — £31 a year £6 - Durran Hill House, Carlisle Roman Catholic Feeble-minded females aged 16 and over (criminals and fallen women not accepted) 11/6 £5 5/- - - Eagle House Hostel, Mitcham No restriction. Feeble-minded women of high grade 20/(a) £5 £5 Temp. reduction 1/- - £7 (for those enter- domes- t ic service) Royal Earlswood Institution, Redhill No restriction. All grades, both sexes Not exceeding £63 a year. N ecessary expenses. £5 Ellen Terry National Home for Blind Defective Children, Reigate No restriction Imbecile and feebleminded blind children up to age of 12 years £90 a year £5 £5 — — — Etloe House, Leyton Roman Catholic Feeble-minded females from 16 years of age 11/6 £6 £6 5/6 - - Girls' Training Homes Clapton Protestant Feeble-minded females (trainable) from 8 years upwards 11/6 £6 £5 6/- — £2 Girls' Village Home. Barkingside (Dr. Barnardo's Homes) No restriction Feeble-minded and imbecile girls 14/- £10 — — — — Helping Hand Home, Cathcart Hill, N. No restriction Feeble-minded females, preferably from 16 years 11/6 £3 £4 and allowances for upkeep 6/- - £4 and allowances for upkeep House of Help, Bath. Church of England Feeble-minded females 12 /6 £5/5/- £3 4/- — £2 * Most of the charges specified in the contracts are on a pre-war basis, and are supplemented by additions paid under the authority of the Minister of Health as shown in the table. (a) Less earnings of patients which are pooled and refunded proportionally to local authorities. 31 Institution. Religion. Class of defective received. Charges. By contract. Supplemental payments Maintenance (a week). Burials. Outfits. Maintenance (a week) Burials. Outfits. Littleton House, Girton No restriction Feeble-minded males .. £72 16s. a year £510/- £8 - — — Metropolitan Asylums Board Certified Institution—Sections at: Darenth, Kent Caterham, Surrey I^eavesden, Herts Fountain, Tooting No restriction All grades, both sexes Actual cost, viz.:— 26/3 28/3½ 29/2 36/5½ Reason- able expenses - - - - Pield Heath House. Hillingdon, Middlesex Roman Catholic Females, feeble-minded and moral imbeciles (tractable cases up to age 16) 11/6 £7 - 5 /6 - - Pontville, Ormskirk, Lanes. Roman Catholic Feeble-minded males, between 5 and 16 years 12/- £5 — 8/- — — Princess Christian's Farm Colony, Hildenborough, Kent No restriction High grade cases, both sexes 12 /6 £4 £5 3/6 £1/10/- £2 Prudhoe Hall Colony, Prudhoe-on-T yne No restriction All grades (including epileptics), both sexes 15/- £4 £5 7/2 £1 £1/10/- St. Francis' School, Runtingford, Herts Roman Catholic Educable males 11/6 £7 - 6/- — — St Joseph's Home, Sudbury, Suffolk Roman Catholic Feeble-minded females aged 16 to 20 11/6 £6 - 3/- — — St. Mary's Home, Alton, Hants. Church of England Females over 16, who might have had illegitimate children 14/- — £5 3/6 - — St. Teresa's, Lewisham Roman Catholic Feeble-minded females over the age of 16 years †22/6 £5 £5 - - - Stoke Park Colony, Bristol, and Whittington Hall, Chesterfield Protestant All grades, both sexes (males, only such as can be dealt with by a female staff) High-grade cases 10/6 £3 — 7/7 3/6 — Low grade cases:— 14/- £3 - The Home, Everton Terrace, Liverpool. Protestant Females, feeble-minded and moral imbeciles, over 16 years 15/- £8 £5 1/ - - Walsham How Home, Walthamstow Church of England Females, feeble-minded and moral imbeciles 12/- £3 — 5/6 — - Western Counties Institution, Starcross No restriction High-grade cases, both sexes Actualcost plus 2/6 a head a week as "overhead " charge, viz.:— 23 /1 £5 — - — — Woolwich Guardians' Institution, Plumstead No restriction All grades (adults), both sexes (Actual cost) Institution. 20/5.85 Infirmary 51 /5-02 Not to exceed £6 - - - - † Subject to variation with the approval of the Minister of Health. 30. During 1926, seventeen of the institutions named in the foregoing table were visited by members of the Mental Hospitals Committee on behalf of the Council and the patients who were being maintained there at the Council's charge were seen. In addition seven other institutions named in the table were visited on the Council's behalf by local visitors of the Central Association for Mental Welfare. In each instance satisfactory reports were made by the visitors. Visitation of "eontract" it stitutions. 32 Besford Court. 31. Three institutions appear for the first time in the table, contracts with the managers of these institutions for the reception and maintenance there at the Council's expense of suitable cases, as accommodation may be available, having been entered into during 1926. Besford Court, near Defford, Worcestershire, is certified under the Mental Deficiency Act to accommodate 37 male defectives, and is also certified Littleton House. by the Board of Education and the Home Office. Littleton House School, Cambridge is managed by the Littleton House Association, is certified under the Mental Deficiency Act to accommodate nine male defectives, and is certified also by the Board of Education. The Girls' Village Home, Barkingside, Essex, one of Dr. Barnardo's Homes, is certified to accommodate 150 female defectives who must be residents of the village home, ascertained to be defective after admission there. Barkingside Home. Kensington Poor Law Institution. 32. The Kensington Board of Guardians found that they could not arrange for an extension of the agreement between them and the Council for the reception of defectives at the Marloes-road institution after 2nd April, 1926, and the agreement therefore terminated on that date, and the Council's cases were removed elsewhere. Metropolitan Asylums Board. 33. The accommodation provided by the Metropolitan Asylums Board has continued to be of great value during the year under review. Originally provided for the reception of chronic harmless lunatics, since its approval for use for the reception of cases of mental defect it has served a most useful purpose as part of the total accommodation available for this class of patient, though the result necessarily has been to diminish the total accommodation available for London cases dealt with under the Lunacy Acts. During the year the Board undertook to provide vacancies at an average rate of 30 a month for suitable defectives to be maintained at the Council's expense. The Council was able to use all the vacancies allotted at a rate, on the average, of 25 a month. It is understood that in allotting these vacancies the Board have decided to refuse any longer to admit to their institutions defectives chargeable to out-county authorities, but that there is still in the Board's care a considerable number of out-county cases admitted during earlier years under arrangements made with the approval of the Minister of Health. If and when these authorities can make other provision for their cases, valuable accommodation of which London naturally would expect to have the advantage may become available. Salvation Army. 34. Arrangements were made for the use by the Council of institutions (lying-in homes, etc.) provided by the Salvation Army for the accommodation, either as in "places of safety" or on licence from certified institutions, of mentally defective women found to be pregnant, until after their confinement, upon payment by the Council, for each case so placed, at the rate of £1 a week, and of an additional charge of £2 for the expenses of the confinement. (b) Accommodation -provided by the Council. 35. This has continued to be provided at (i.) The Manor, Epsom (488 male and 565 female defectives of all classes); (ii.) the South Side Home, Streatham Common, S.W. (80 females, higher grade cases); (iii.) Brunswick House, Mistley, Essex (50 males, higher grade cases); and (iv.) Farmfield, near Horley, Surrey (85 adult or adolescent males of criminal experience or intractable disposition). The accommomodation at these institutions continues to be reserved exclusively for London cases. A statement of expenditure on the administration of these institutions is given in Appendixes I. and II. Number of cases accommodated. 36. At 31st December, 1926, the four institutions were practically full, except for a few beds for female children at The Manor, Epsom.. The Manor, Epsom, school department. The Manor. 37. The number of children in the school department at The Manor has continued to increase. The average attendance at school during the year ended 31st March, 1927, was 153, an increase of 16 on the average for the previous twelve months. As 33 from 1st April, 1926, the school department was recognised as a grade III. special school, and the salary of the head teacher was increased from that date, to the rate for a head teacher of a grade III. special school, on the scale applicable to the County of Surrey provided in the Burnham Award of 29th March, 1925, on teachers' salaries. The employment in the school, as from 1st January, 1927, of a fourth assistant teacher was authorised 38. Authority was given also for the employment as an experiment, for twelve months from 1st April, 1927, of two visiting teachers (one for drill and organised games, and one for singing), each for not more than two sessions of two hours each in any one week. Visiting teachers. 39. The industrial department has continued to be an important feature of the activities of The Manor. During the twelve months ended 31st December, 1926, the sale of articles made in the workshops realised £2,242, as compared with £1,844 during 1925, £1,200 during 1924, and £663 during 1923. The various occupations of the patients remained as detailed in the Annual Report for 1925 (Vol. II., p. 37). Industries. 40. The following new works at The Manor nave been authorised. ana put in hand, viz., enlargement of the recreation hall; additional accommodation for the house steward's clerical assistants and other minor improvements in the stores: additional pig-sties and a shelter, to enable pig-breeding to be undertaken. New works, 41. As from 1st April, 1926, the designation of the senior assistant medical officer at The Manor was altered to that of " deputy medical superintendent." Assistant medical officer. 42. Authority was given for the employment of an additional assistant clerk the clerk's office, with effect from 1st April, 1927. Additional staff. 43. The boy scout troops and the girl guides companies at the Manor are still valuable factors in the training, discipline and recreation of the better class of patients. They are mostly accommodated in separate villas known as the scouts' and guides' lodges, and they receive special training and privileges. The guides' lodge serves a useful purpose in the preparation of suitable female patients for domestic service outside the institution. The designation of the senior nurse who acts as captain of the girl guides and also has charge of the general workshop, was altered to " workshop charge and guides' captain," as from 1st April, 1927. Soouta and guids. 44. A number of medical officers from the capitals and great cities of the world visited The Manor during March, 1926, in connection with arrangements made under a scheme initiated by the League of Nations. Visit of foreign delegates. Farmfield. 45. The use of Farmfield, Horley for the accommodation of adult and adolescent male defectives of criminal experience or intractable disposition was developed to its fullest capacity during 1926. At the end of the year there were 83 patients in residence (accommodation for 85 cases is provided) and 14 patients were absent on licence. Farmfield, Horley. 46. The effect of the training and discipline afforded upon a particularly difficult type of defective has been most marked, and the existence of Farmfield for the accommodation of such cases has enabled the Council to keep its other certified institutions, and also "contract" institutions, free from the undesirable influence of adult male defectives of criminal experience and intractable temper. Progress. 47. Considerable progress has been made with industries, and use has been made as far as possible of the local labour market to find opportunity for placing defectives in employment outside the institution, but under the supervision of its superintendent. Industries. 48. At the end of 1926 proposals for extending Farmfield to provide additional accommodation for patients were under discussion. Proposed extension. 49. Some spare land, adjoining one of the blocks, has been allocated provide 33 garden allotments for patients. to Garden allotments. 34 Cottages for married staff. 50. Owing to the difficulty experienced by certain married members of the staff at Farmfield in obtaining suitable accommodation in the neighbourhood for themselves and their families, it was decided to erect six cottages on the Farmfield estate, for occupation, at an agreed rent, by married employees. Patients' dietary. 51. A scale of diet for patients based on that for patients at Brunswick House, Mistley, with certain modifications, has been adopted for use at Farmfield in substitution for a provisional scale which has been followed experimentally since the opening of the institution. Laundrywork. 52. Arrangements have been made for some of the patients laundry work to be done in the institution by patients' labour, instead of by a contractor. This arrangement has resulted in a considerable financial saving. New works. 53. The following new works at Farmfield have been authorised and put in hand, viz., conversion into workshops of a detached building containing cells which were provided for refractory patients when the institution was in use as a home for inebriates; provision of external sanitarv accommodation. Brunswick House, Mistley — Purchase of freehold. Brunswick House. 54. The freehold interests in Brunswick House, Mistley, and the cottage adjacent thereto which is used as a residence for the superintendent of the institution have been acquired by the Council. Proposed extension. 55. Consideration has been given to a scheme for an extension of Brunswick House in order to accommodate an additional 25 patients, and for the alteration of the existing buildings to give improved kitchen and bathroom accommodation. Patients' dietary. 56. The diet scale for patients at Brunswick House has been varied by an increase in the issue of fresh fish. Scout troop. 57. The boy scout movement continues to exercise a beneficial influence on the patients. The scout troop has been extended from 12 to 18 members. South Side Home, StreathamUse as a hostel. South Side Home. 58. It was decided to use the South Side Home, Streatham, as far as possible as a hostel for patients suitable for trial in domestic service outside the institution, under circumstances which would allow of their being supervised by the superintendent, with a view perhaps to final discharge from institutional care at a later date. For this purpose patients who have improved under care in other institutions may be transferred to the South Side Home, where the residential neighbourhood affords opportunities for placing patients locally. At the end of 1926, 10 patients had been placed thus, either in residential or in daily domestic service. Allotments. 59. The Council s tenancy of land used as allotments for cultivation by patients at the South Side Home was terminated during 1926, as the land was required for building purposes. Girl guides. Visiting chaplain. 60. A hut has been erected for the use of the girl guides. 61. The Rev. W. J. Latham, M.A., the Vicar of Immanuel, Streatham Common, who held the chaplaincy of the South Side Home, having resigned the living, his successor, the Rev. W. F. Leadbitter, B.A., was appointed to be visiting chaplain of the institution, with effect from 1st October, 1926. Need for further accommods¬. tion. (c) Prospective accommodation. 62. In addition to the proposals to extend Farmfield and Brunswick House (referred to in paras. 48 and 55), consideration was given during 1926 to the possibility of providing further accommodation to meet immediate and prospective demands. At the end of the year, however, definite proposals had not been agreed upon. 35 Legal proceedings. 63. It was necessary, during 1926, to institute legal proceedings, under section 56 of the Mental Deficiency Act, against a man who had cohabited with a female patient while she had absconded from private care to which she had been licensed from The Manor, Epsom, with the result that she had become pregnant. After three hearings at the police court, during which the patient, who was a difficult witness, modified statements which she had made previously on the strength of which proceedings had been commenced, the defendant was committed for trial at the Central Criminal Court, where the Grand Jury, after hearing each of the witnesses, ignored the bill, and the defendant was discharged. Legal pro jeedinga. Method of dealing with cases of mental defect. 64. The London County Council considered representations made by the Worcestershire County Council during 1926 that, in view of the increasing number of mentally defective persons in the country, and the heavy and necessarily increasing cost of maintaining and extending institutions for the mentally defective, His Majesty's Government should be urged to take such compulsory measures as it might deem best to prevent the spread of mental deficiency, by sterilisation, by compulsory segregation or otherwise. The Council, on representations made by the Mental Hospitals Committee, decided (i.) that there were too many practical difficulties in the way of resorting to surgical sterilisation as a prophylactic against mental deficiency, and (ii.) that compulsory segregation was already available in certified institutions for necessitous cases, and that there did not appear to be any serious justification of the opinion that the effect of institutional treatment was usually unsatisfactory. Sterilisation and compulsory segregation. Sexual relations as a ground for dealing with cases of mental defect. 65. Having regard to the difficulty so often experienced in determining that there are grounds for the compulsory detention in an institution of a mentally defective person who has been in close association with a person or persons of the opposite sex, or who might be contemplating matrimony, in spite of the fact that unless institutional care is provided the person in question will in all human probability beget children who will themselves be defective, representations were made to the Board of Control on 12th May, 1926, that, in the Council's opinion, nothing short of a definite strengthening of the existing law would make it possible for a local authority to secure the custodial care of a mentally defective person solely on the ground that he or she was behaving in such a way as to render it likely that mentally defective children would be begotten. Sexual relations of defectives. Departmental Committee on sexual offences against young persons. 66. Consideration was given to the following recommendations relating to the treatment of the mentally defective contained in the report of the Departmental Committee appointed, in July, 1924, by the Home Secretary to collect information and to take evidence as to the prevalence of sexual offences against young persons :— (27) That the words "from birth or an early age" and "from an early age" should be deleted from section 1 (c) and 1 (d) respectively in the Mental Deficiency Act, 1913. (28) That, after conviction, but before sentence, the Bench shall remand, for a mental examination and report, all cases of indecent exposure, all sexual offenders previously found guilty of an indecent offence, and all cases in which the Court suspects mental disease, disorder or defect. Sexual offences. 36 (29) That all Courts shall make arrangements for the services of a mental expert to be at their disposal. (30) That those who commit repeated indecent offences against young persons shall be subject to prolonged detention in suitable institutions. The Council, on 27th July, 1926, recorded the following opinions upon the recommendations which are set out above:— (i.) That, so far as the amendments of the statutory definitions of mental defect recommended by the Departmental Committee were concerned, these were to be objected to on the ground that the amendments went much beyond the end which the Departmental Committee appeared to have in view. (ii.) That there would seem to be no objection to recommendation No. 28. (iii.) That recommendation No. 29 was, for all practical purposes, effective at present in London. (iv.) That, as regards recommendation No. 30, it would be advisable that the suggestion should be considered by Parliament on its merits, rather than that an endeavour should be made by some very general extension of the scope of the Mental Deficiency Act or by some administrative departmental regulation to secure that such cases were dealt with under that Act—unless they were cases in which mental defect was found within the meaning of the Act. New Bil. Mental Deficiency Act (Amendment) Bill. 67. Except upon one minor point, the Council expressed its approval of the Mental Deficiency Act (Amendment) Bill, a Government measure which passed the House of Lords during 1926 and was introduced later in the House of Commons, only to be dropped in December, 1926. Contributions towards expenses of maintenance of defectives in institutions or under guardianship. Number of oases under contribution and amounts collected. 68. The following statement shows for the year ended 31st December, 1926, bow the Council discharged the duty of making recovery, where possible, of such contributions as were available in relief of the expenses of maintaining defectives in institutions or under guardianship:— (1) Cases under contribution. (2) Total sura accrued. (3) Total sura collected. (4) Percentage of (3) to (2). (5) Sura written off. (6) Sum outstanding. 1,340 £. s.d. 9,144 0 5 £. sd. 8,350 19 11 91-3 £ s.. d. 233 16 0 £ s. d. 559 4 6 Legal proceedings to enforce payment. 69. Legal proceedings had to be taken during the year for the recovery of payment from persons liable to contribute with the following result:— In 14 cases, orders made to pay amounts totalling:— 4 cases adjourned upon undertaking to pay being given. In 2 cases, amounts paid at Court before proceedings, totalling :— 1 case adjourned, contributor unemployed. Arrears. Costs. Arrears. Arrears. Costs. Arrears. £ 109 s. 10 d. 8 £ 2 s. 15 d. 0 £ 19 s. 13 d. 0 £ 5 s. 18 d. 0 £ 0 s. 6 d. 0 £ 6 s. 13 d. 0 London cases granted leave of absence from certified institutions with a view to ultimate discharge. Cases granted leave of absence on trial. 70. The following statement furnishes some interesting particulars as to London cases to whom leave of absence from certified institutions has been granted with a view to ultimate discharge. 37 Nome of institution. On leave of absence on 1/1/20. Granted leave of absence during 1926. No. of licences revoked during 1926. No. of cases on licence whose orders were discharged during 1926. No. of cases on licence transferred to guardianship. Died whilst on leave during 1926. No. of cases still on licence on 31/12/26. M. F. M. F. M. F. M. F. M. F. M. F. M. F. The Manor, Epsom 33 22 20 21 15 10 1 1 — — — — 37 32 Farmfield, Horley 5 14 3 1 15 Brunswick House, Mistley 7 5 — 2 - 3 — — — — — 7 — South Side Home, Streatham 3 - 5 - - - - — - - — - 8 "Contract" institutions 13 18 17 12 4 4 3 0 3 0 — 1 20 25 Total 58 43 56 38 24 14 8 1 3 — — 1 79 65 195 38 9 3 1 144 71. The proportion borne by the number of cases to whom licence was granted with a view to ultimate discharge to the total number of cases receiving institutional care was about 1 to 12½. This proportion is considerably higher than during 1925, when it was about 1 to 15. Nineteen per cent, of the cases on licence failed to make good during 1926, and the licences had to be revoked. In 1925 such cases amounted to 20 per cent. 72. The policy of granting leave of absence in suitable cases with a view to ultimate discharge is advocated by the Board of Control and was developed so far as was possible during 1926. The results of this policy during the year were much the same as during 1925, and the observations set out in the last Annual Report (Vol. II., p. 39, par. 53) apply with equal force. Statistics. 73. In the absence of any directions by the Board of Control as to the form in which statistics required by No. 28 of the Mental Deficiency Act Provisional Regulations, 1914, shall be submitted, the Council submits the following tables, which continue, for the year ended 31st December, 1926, the information tabulated on p. 40 of the last Annual Report (Vol. II.) :— Statistics of cases dealt with. Sources from which information has been received of cases of alleged mental defect. Source of information. Period. From 1.4.1914 to 31.12.1926. g 1926 only. London Association for the Care of the Mentally Defective 865 95 Local Education Authority 3,899 280 Poor Law Authority 393 40 Police authority (Section 8) 747 88 Transfers from Prisons (Section 9) 146 9 Transfers from Industrial schools (Section 9) 350 28 Miscellaneous 1,658 190 Total number of oases of which information was received 8,058 730 Action taken on above cases. (a) Position at 31st December, 1926, with regard to the 8,058 oases referred to in the first column of the preceding table— Detained— In institutions provided by the Council 1,302 In institutions under contract 1,167 Under guardianship 41 In places of safety awaiting the presentation of a petition for an order 24 Total number of cases detained 2,534 38 Under statutory supervision 1,856 Still under consideration 145 Total remaining on the active list 4,535 Removed from active list— Died 502 Discharged from institutional care 243 Removed to a mental hospital under Lunacy Acts 178 Removed to a State institution (violent or dangerous cases) 46 Dealt with through the Poor Law 579 Ascertained not subject for action 1,975 3,523 Total 8,058 (b) Summary of action taken during the year 1926 :— Placed in institutions provided by the Council 141 Placed in institutions under contract 257 Placed under guardianship 12 Placed in places of safety until the presentation of a petition for an order 68 Placed under statutory supervision 362 Discharged from institutional care 31 Removed to a mental hospital 21 Removed to a State institution 10 Dealt with through the Poor Law 52 Ascertained not subject for action 194 Died 48 Financial statement. Financial statement. 74. No. 28 of the Regulations provides also for the submission of financial statements for the year ending 31st March. Such a statement (prepared by the Comptroller of the Council) showing the cost to the Council of the administration of the Mental Deficiency Act, 1913, from 1st April, 1926, until 31st March, 1927, forms Appendix I., and particulars of the Council's expenditure on the maintenance of defectives in its own institutions are given in Appendix II. 39 APPENDIX I. Financial statement showing the cost of administration of the Mental Deficiency Act during the year ended 31st March, 1927. £ s. d. £ s. d. £ s. d. Expenditure— (1) Ascertaining numbers, supervising and dealing with defectives— (a) Salaries, etc., of officers 12,914 16 10 (6) Travelling expenses 285 14 2 (c) Costs and charges in legal proceedings 52 4 1 (d) Temporary detention in places of safety, cluding expenses of conveyance, removal,etc. 1,731 7 3 (e) Grants to voluntary societies 3,557 10 5 (f) Other expenses (stationery, furniture, office expenses, etc.) 3,801 12 11 22, 343 5 8 (2) Institutional treatment under contract— (a) Accommodation and maintenance 72,971 9 9 (b) Conveyance, removal, etc 380 10 5 (c) Other expenses 107 4 4 73, 459 4 6 (3) Guardianship— (a) Maintenance 1,566 18 3 (6) Conveyance, removal and other expenses 149 6 2 1,716 4 5 97,518 14 7 (4) Maintained in institutions provided by the local authority— Brunswick House, Mistley 3,330 19 6 South Side Home, Stroatham (a) 5,493 13 7 The Manor, Epsom 88,125 6 10 Farmfield, Horley (a) 11,9289 18 4 108,879 18 3 206,398 12 10 1 ncome. Contributions towards maintenance of defectives and costs recoverable 9,161 8 5 Superannuation contributions, Central Office staff 1 19 0 Charges to staff in Council's institutions for board and lodging, superannuation contributions, and miscellaneous income— South Side Home 889 5 - Brunswick House 657 13 7 The Manor 11,676 11 8 Farmfield 1,938 17 4 15,162 7 7 Grant from Board of Control (6) 91,232 8 2 115,558 3 2 Net cost to the Council 90,810 9 8 (а) Including debt charges. (b) Including gratuities in respect of criminal defec tives. 40 APPENDIX II. Return of expenditure (and cost per head) during the financial year ended 31st March, 1927, on maintenance of defectives at institutions provided by the Council. Heading. Cost per patient weekly. Brunswick House. South Side Home. Tho Manor. farmfield. Number of patients (average) 49-4 78-4 965-2 801 Salaries and wages (excluding farm and repairs)— s. d. s. d. s. d. s. d. Medical staff 10.9 4.9 11.8 7.0 Other institution staff 9 11.2 10 10.6 12 9.3 22 0.3 Superannuation, insurance and 2.2 1.4 1.4 3.6 ling expenses of staff 11 0.3 11 4.9 13 10.5 22 10.9 Less income from staff for board, lodging, etc. 1 7.5 3 6.5 3 1.4 5 4.8 Net cost of staff 9 4.8 7 10.4 10 91 17 6.1 Provisions (including staff meals and net cost of farm produce, if any) 6 8.9 6 9.9 6 2.0 10 2.7 Clothing and staff uniforms 1 7.8 (a) I 6.4 (a)l 6.9 (a) 2 2.5 Medical requisites and drugs 0.5 1.7 1.7 1.4 Fuel, light and water 1 0.5 2 0.0 3 4.2 4 9.8 Washing and cleaning materials, etc. 2 3.3 6.1 7.5 1 8.4 Furniture and bedding 1.5 (a) 6.0 (a)l 61 4.6 Removals, burials, etc. 0.7 0.3 0.4 2.3 Rates, taxes, and insurance 4.7 9.0 11.9 1 7.9 Stationery, postage and sundries 4.8 3.6 (a) 4.6 6.4 Miscellaneous 3.9 1.6 (a) 3.0 3.8 Rent of land and buildings 9.3 3 6.3 - 5-6 Debt charges—interest and redemption 10.0 - 5 5.6 Repairs and upkeep of buildings, etc. 7.5 1 3.3 1 4.6 (a) 3 6.7 Additional equipment and special expenditure 2.2 5.1 10.1 10.7 24 0.4 23 1.4 31 6.4 49 6.9 Less miscellaneous income (other than for maintenance of patients) 3 3.1 7.1 1 1.9 1 8.8 Total cost per patient weekly 20 9.3 22 6.3 30 4.5 47 10.1 Brunswick House. South Side Home. The Manor. Farm field. Total. Actual figures used in preparing above table— £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. Gross expenditure (6) 3,301 11 7 5,449 10 11 87,208 10 7 11,481 9 11 107,441 3 -- Less income other than contributions towards maintenance of patients (6) 628 5 8 845 2 4 10,759 15 5 1,490 8 11 13,723 12 4 Net expenditure at institutions 2,673 5 11 4,604 8 7 76,448 15 2 9,991 1 - 93,717 10 8 (а) Including cost of materials for industries. (b) The figures are less than those shown in Appendix I., as to meet the requirements of the Board of Control only the net financial result of the farming operations is included for cost purposes and superannuation contributions are deducted from wages. The net expenditure is the same in both tables. PUBLICATIONS OF THE LONDON COUNTY COUNCIL. The undermentioned Publications, issued by the Council, may be obtained through any bookseller, or of the Councils Agents, P. S. KING & SON, LIMITED, 14, GREAT SMITH STREET, WESTMINSTER, S.W.I. Annual Report of the Council. Issued annually in five volumes. Edition for 1925, 8vo.:— Vol. 1. Powers and duties—Elections— Finance—Rating and Taxation — Public Protection — Traffic—-Public Amenities— Domestic and Miscellaneous Services. 2s. 6d. No. 2457. Vol. II. Mental Hospitals. Is. No. 2458. Vol. III. Public Health, Main Drainage and Housing. 2s. 6d. No. 2470. Vol. IV. Education. Is. No. 2471. Vol. V. Abstract of Accounts and Index. 6d. No. 2508. Accounts in Abstract. Accounts of the Income and Expenditure of the Council from 1st April to 31st March. Is. Issued annually. 1926-7. No. 2600. London Statistics. Statistics relating to London and the publio services therein, with certain statistics of the adjacent districts. Issued annually. Volume for 1924-25, 15a. No. 2464. Statistical Abstract for London. Comparative statistics relating to Parishes, Poor Law Areas, Metropolitan Boroughs, Electoral Areas, Education, Rateable Value, Lunacy, Pauperism, Fires, Finance, Population, Rates, Locomotion, etc. Volume for 1916-1925. 2s. 6d. No. 2479. Horniman Museum. "From Stone to Steel." Handbook to the cases illustrating the Ages of Stone, Bronze and Iron. 6d; No. 2203. " Ascent of Man." Handbook to cases illustrating structure of Man and the Great Apes. 6d. No. 2009. Handbook to the Cases illustrating the Evolution of Domestio Arts. Part I. 6d. No. 2350. Do., do. Part II. 6d. No. 2277. Handbook to the Cases of Freshwater Vivaria and Aquaria. 3d. No. 2336. Handbook to the Cases illustrating Locomotion in Animals. 2d. No. 2269. Handbook to the Cases illustrating Simple Means of Travel and Transport. 6d. No. 2392. Handbook to the Cases illustrating the Defences of Animals. 6d. No. 2414. Electricity Supply, 1924-25, with two maps. 5s. No. 2486. Municipal Map of London. Prepared from the 6-ft. Ordnance Survey, revised to 1913 and coloured to show tramways, underground railways, omnibus routes, parks, etc. In 28 sheets, on a scale of 6 inches to a mile (880 feet to an inch). Is. 6d. a sheet; complete sets, including key sheet, 35s. THE LONDON COUNTY COUNCIL GAZETTE. Issued weekly. Containing full particulars of Appointments, Contracts, eto. Price 2d. Annual subscription, payable in advance, 13s. post free. The Survey of London, fully illustrated, is published by B. T. Batsford, Ltd., 94, High Holborn, W.C., as follows :— Vol. I. The Parish of Bromley-by-Bow. 10s. 6d. No. 486. Vol. III. Parish of St. Giles-in-the-Fields (Part I.), Lincoln's Inn Fields. 21s No. 1488. Vol. IV. The Parish of Chelsea (Part II.). 21s. No. 1584. Vol. V. The Parish of St. Giles-in-the-Fields (Part II.). 21s. No. 1663. Vol. VI. The Parish of Hammersmith. 21s. No. 1778. Vol. VII. The Parish of Chelsea. (Part III.). 21s. No. 2065. Vol. VIII. The Parish of Shoreditch. 42s. No. 2180. Vol. IX. St. Helen, Bishopsgate. (Part I.). 42s. No. 2280. Vol. X. St. Margaret, Westminster. (Part I.). 42s. No. 2432. The University of London Press, Ltd., in association with Messrs. Hodderand Stoughton, have issued a series of booklets, prepared by the Council's staff, dealing in a popular way with the principal services administered by the Council. The series, which is fully illustrated, includes:- The Londoner's Education. 9d. net. Housing. 6d. net. Parks and Open Spaces. Is. net.. Fire Brigade. 6d. net. Public Health. 6d. net. The London Ambulance Service. 6d. net. A complete list of the Publications of the Council may be obtained of P. S.King & Son, Limited, 14, Great Smith Street, Westminster, S.W.L London County Council (Staand) ?>0/ 2. Naee LCC 35 London County Council. ANNUAL REPORT OF THE COUNCIL, 1926. Vol. III. PUBLIC HEALTH. (Including the Reports for the year 1926 of the County Medical Officer of Health and School Medical Officer, Main Drainage and Housing.) 1000—(0.11717—76A)—14.6.27—14172 CONTENTS. Chapter I. REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH FOR THE YEAR 1926. Vital Statistics— Page Population—Marriages—Births—Deaths—Infant Mortality 5 Infectious Diseases— Smallpox 7 Measles—Whooping-cough—Scarlet Fever—Diphtheria 12 Diarrhoea and Enteritis—Typhoid Fever—Anthrax 14 Plague and Cholera—Typhus—Cerebro-Spinal Fever—Poliomyelitis— Polioencephalitis—Encephalitis lethargica 15 Influenza 18 Tuberculosis 18 Cancer 27 Statistical Table 28 Administration— Common and Seamen's Lodging Houses—Homeless Persons—Verminous Lodgers 29 Statistical Information 30 Housing Acts—Sanitary Officers 31 Venereal Diseases 33 Tuberculosis 34 Dispensaries (Analysis of Returns) 36 Poliomyelitis 41 Laboratory Work 42 Midwives Acts and Children Acts 48 Mental Deficiency Act, 1913 52 Blind Persons Act 53 Chemical Branch 54 Observations of Visibility and Actinicity 57 Chapter II. REPORT OF THE SCHOOL MEDICAL OFFICER FOR THE YEAR 1926. Staff—School Buildings 63 Results of Medical Inspection 71 „ „ Higher Education Institutions 77 Following-up 78 Chronic Invalidity—Medical Treatment 81 Rheumatism in Childhood 88 Work of the School Nurse 90 Personal Hygiene Scheme 96 Open-air Education 97 4 Page Physical Training 107 Co-operation with Official and Voluntary Agents 112 Employment of Children—Nursery Schools 116 School Meals 119 Infectious Disease Control 119 Defective Children 134 Examinations of Employees in the Education Service and Scholars 151 Special Enquiries—Canal Boat Children—Lupus Class 153 Statistical Tables.—I. Inspections—II. Defects—III. Exceptional Children —IV. Treatment of Minor Ailments, Visual Defects, Defects of Nose and Throat, Dental Defects, Uncleanliness 155 Chapter III. Public Heatlh—Tuberculosis—Venereal disease—Infant life protection— Health propaganda—Lying-in homes—Midwives—Homeless persons— Lodging houses—Offensive businesses—Cowhouses—Milk—Infectious diseases—Smoke nuisances 160 Chapter IV. Main Drainage 168 Chapter V. Housing 175 London Country Council ANNUAL REPORT OF THE COUNCIL, 1926. VOL. III—PUBLIC HEALTH. CHAPTER I. REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH (Dr. F. N. KAY MENZIES) FOR THE YEAR 1926. Vital Statistics. The population of the County of London at the census of 20th June, 1921, was 4,484,523, including members of the Armed Forces in London but excluding Londoners on active service elsewhere. It is estimated by the Registrar-General that the population, with residence in London at the date of the census, was about 4,524,000, allowance being made in this estimate for persons absent on holiday when the census was taken. The Registrar-General estimates the total population in the middle of 1926 to have been 4,615,400, including 10,000 non-civilians. The estimated mid-year populations of the metropolitan boroughs in 1926 are shown in the table on page—. Population. The Registrar-General's estimate of the population of London in 1926 allows an increase of 91,400 in the County population in the five years since the last census. During this period the births have exceeded the deaths by 165,500, so that there has been a loss by the excess of emigration over immigration of about 74,000 persons. The marriages registered in London during 1926 numbered approximately 39,670 or 17.2 per thousand of the population, this being the same as in 1925 and 1924. Marriages. The births in London during 1926 numbered 78,825 as compared with 82,401 in the preceding year. The birth-rate was 17.1 per thousand as against 17.9 in 1925, and 18.6 in 1924. The decrease in the number of London births is shown in the following table:— Period. Average annual births. 1901—05 129,522 1911—15 109,184 1921—25 90,766 Births. The continued fall of the birth-rate cannot but give rise to concern, both in local administration and in national affairs, for the empty cradles of to-day mean empty schools to-morrow and later on empty workshops. In this connection, however, some comfort may be derived from the fact that Dr. Greenwood in "Metron" (vol. 5, No. 2) estimates that at the census of 1931 the population under 5 years of age in England and Wales will be in excess of that enumerated at the last census. On the other hand, Dr. T. H. C. Stevenson, in introducing a debate on "The Laws Governing Population" before the Royal Statistical Society in December, 1924, observed, that "it seems very probable that the momentum of the present fall may carry us to a considerably lower level than any yet attained," and the seriousness of the position lies in the fact that whatever steps may be taken to arrest the fall will be slow in their operation. The following is a brief review of some of the causes which are thought to have played a part in bringing about the decline of the birth-rate. Decline of birth-rate. In the early part of the last century children of parents of the poorer class were employed when only six or seven years of age in machine minding and in coal mines, etc. In 1816 their employment for more than twelve hours (excluding meal times) was made illegal, but this enactment applied only to cotton mills. In 1833 children Causes of decline. Decrease in wage-earning of children. (5) 6 under thirteen were not allowed to work more than eight hours per day, while under the Factory Acts of 1874 no child under ten years of age was allowed to work in a factory. In 1871 the first Elementary Education Act came into force and had an immediate effect upon the value of children of the poorer class to their parents as a means of supplementing the family income. The continuous decrease in the employment of children is evident in the census figures of occupation. In the census of 1901 we find that only 1.3 per cent. of the children under thirteen years of age were returned as occupied. Effect of Factory and Education Acts. The birth-rate in England and Wales reached its maximum in the seventies, and has since continuously declined. One of the factors in this decline has no doubt been the reduced value of the child to parents of the poorest class, which is also the most prolific class of the population. The effect of the later age of wage-earning among children brought about by the Elementary Education Acts and Factory Acts is also shown in the marriage-rate. The children brought within the scope of compulsory education by the Education Acts, who previously had had, little or no schooling (we are again dealing principally with children of the poorest class), were between five and thirteen years of age, or nine years of age on the average, and they came to the age of marriage some ten or twelve years later. It would be expected on comparing these youths with those of the same age in years prior to the Education Acts that they would not have attained the same skill and wage-earning power in their trade or occupation, nor would they be comparatively so well developed physically. The decline in the marriage-rate among young women under twenty-one years of age, dating from about 1883, may be thus accounted for, and no doubt gave an additional impulse to the rate of decline in the birth-rate. From 1883 down to about 1910 the birth-rate in England and Wales declined pari passu with the decrease in the percentage of women under 21 years of age among the married in each year; but after 1910, and down to the present time, the birth-rate and marriage-rate part company. The percentage of minors among women married ceased to decline and has even increased, but it is interesting to note that the birth-rate has not followed, on the contrary, the fall has been accelerated. Housing shortage and increased cost. Owing to the shortage of houses the accommodation on the Council's estates is rationed, and a married couple without children is not allowed to have more than a two-room tenement. On post-war estates the weekly rent of these tenements is about 13s. A married couple with two children may have a three-room tenement, for which the rent is about 16s., while where there are more than two children a fourroom tenement is allotted, for which the rent is about 19s. Since between 25 and 30 per cent. of the rent represents rates, it will be seen that the parents of more than two children pay from 5s. to 6s. a week in respect of rates. Although the principle of abatement of taxation in respect of wife and children is recognised in income tax assessment, relief of this kind does not reach the poorer class of the population. Two children per married pair only suffice to maintain the family, but, since there are many childless couples, it is the family of more than three children to which we must look, even only to maintain the existing population. One way of eking out the family income open to these families is that of taking in lodgers, and statistics collected some years ago show that many families of the poorer classes in London made a regular practice of so doing as a means of supplementing their earnings. In this direction it is suggested that municipal authorities might do much by building houses specially designed for the accommodation of large families and so arranged as to allow of one or more lodgers being taken. A difficulty frequently met with, more especially among the lower middle class, is the objection on the part of landlords to children. "No children taken" is more frequently met with as a stipulation nowadays than ever before. There is something to be said for the landlord's position since the cost of repairs is likely to 7 8 be increased in a bouse full of children. If, however, the landlord were entitled to make some deduction from the rates, in respect of premises, occupied by parents with children, his attitude would no doubt be changed, and it might even result in preference being given to such tenants. The birth-rate for each metropolitan borough will be found in the Table on page 28. The London birth-rate since 1840 is shown in the diagram on page 8. Deaths. The deaths in the civil population of London during 1926 numbered 53,476, giving a death-rate of 11.6 as compared with 11.9 in 1925 and 12.2 in 1924. The distribution of the deaths by ages in 1926 and preceding years is shown in the following table:— Year. 0- 1— 2— 5- 10— 15— 20— 25- 35- 45— 55— 65 + All ages. 1911-14 l1,968 3,546 2,716 1,421 846 1,088 1,299 3,525 5,292 7,142 8,328 18,221 65,392 1919-22 7,836 2,131 1,919 1,376 853 1,175 1,318 3,103 4,238 6,414 8,265 19,828 58,456 1923 5,615 1,373 1,276 860 638 1,016 1,220 2,474 3,737 5,985 8,105 19,692 51,991 1924 5,904 2,164 1,863 817 709 1,015 1,225 2,514 3,770 6,265 8,582 21,059 55,887 1925 5,599 1,427 1,371 816 647 1,091 1,235 2,531 3,618 6,034 8,500 21,722 54,591 1926 5,067 1,479 1,302 819 554 929 1,199 2,397 3,511 6,038 8,639 21,542 53,476 The year of lowest death-rate in London was 1923 when, as will be seen, the deaths numbered 1,485 less than in 1926. The excess in 1926 is greatest at the higher ages and is almost entirely accounted for by the increased mortality from diseases of the heart and circulatory system and cancer. At younger ages an excess in the mortality at ages from 1 to 5 years is due to the epidemic prevalence of measles during the winter of 1926. Among other causes of death which have increased since 1923 are deaths caused by vehicular traffic, which in 1926 numbered 656 (52 Weeks) as against 453; among children under 15 years of age the deaths increased from 146 to 163. The death-rates from all causes and from certain specified diseases for each metropolitan borough and for London as a whole will be found in the Table on page 28. The annual death rates in London since 1840 in relation to the mean of the rates for the last 86 years are shown in the diagram on page 8. Infant mortality. The year 1926 was generally favourable to infant life, the winter being mild and the summer temperate. Deaths under 1 year of age per thousand births were 64, this being the lowest rate recorded with the exception of that for 1923. In the following table the deaths under 1 year of age per thousand births from the principal causes of infant mortality are shown for 1926 and preceding years:— Cause of Death. 1911 to 1914. 1915 to 1918. 1919 to 1922. 1923 to 1926. 1923. 1924. 1925. 1926. Measles 3.40 3.84 1.64 2.02 0.96 3.37 0.87 2.88 Whooping-cough 3.63 4.45 2.50 2.60 2.23 2.30 4.58 1.29 Influenza 0.27 1.10 0.81 0.38 0.20 0.62 0.38 0.34 Tuberculosis 3.40 3.20 1.52 1.26 1.21 1.20 1.48 1.14 Bronchitis 6.41 6.72 4.42 2.91 2.43 3.62 3.02 2.59 Pneumonia 12.28 14.96 12.60 11.51 9.07 14.13 12.27 10.59 Diarrhoea 24.28 16.10 12.16 9.36 9.07 7.89 9.72 10.78 Premature birth 18.16 17.42 17.00 14.74 14.66 15.89 14.31 14.11 Congenital defects 14.69 14.66 11.26 8.39 8.80 7.96 8.70 8.12 All causes 108 103 79 65 61 69 68 64 Infections Diseases. The attack-rates and death-rates of the principal infectious diseases in London and the constituent boroughs are shown in the table on page 28. Smallpox. During 1926, nine cases of smallpox were notified in London, of which four proved to be wrongly diagnosed, leaving five actual cases of which one died. In addition, there were two cases (one fatal) in Willesden, just over the county border, 9 one of whom infected three of the cases which occurred in London. The seven cases may be classified in two unassociated groups of five and two respectively, both of which derived the infection from Paris. Enquiries with regard to the condition of vaccination of the patients showed that one of the cases, a male, aged fourteen years, had never been vaccinated until five days before his rash appeared—i.e., too late to afford protection. The ages of the other six patients ranged between 32 and 64 years, and only one had been vaccinated since infancy-i.e., 26years before his illness, and he suffered a mild attack. The history of the two groups of cases is as follows:— Group I (five cases).—On the 5th September, 1926, a man (M.F.), aged 43 years, and his wife (R.F.), aged 44 years, arrived in London from South Africa, having travelled overland, via Paris. On the 7th September they went to an hotel in St. Marylebone. The following day (8th September) M.F. fell ill, and he consulted a doctor on the 12th September, a rash having appeared in the meantime. The doctor formed the opinion that he was suffering from chicken-pox. As subsequent developments proved, M.F. was then suffering from smallpox. Between the 8th and 12th September, when medical advice was sought, he attended the local Jewish synagogue on two occasions, and on the 18th September, the Day of Atonement, he was at the synagogue practically all day. It appears that after the 12th September his movements were somewhat restricted at the hotel, and, on this account, he and his wife removed, on the 19th September, to a nursing home for chronic cases and convalescents in Willesden, where they would have greater freedom. Between this date and the 23rd September their movements were uncontrolled, and they visited, among other places, theatres and restaurants in the West End, a tourist agency (daily to collect mails), wholesale and retail firms of various kinds, as well as private houses. On the 24th September, Mrs. R.F. fell ill with severe pains in the back, followed by headache, vomiting and sleeplessness. A rash appeared two days later. On the 29th September, Dr. Buchan, Medical Officer of Health of Willesden was called in to see the case in consultation with the medical attendant, and he found that the woman was suffering from hæmorrhagic smallpox. Enquiries by Dr. Buchan elicited the foregoing particulars regarding the husband's illness, and he concluded that M.F. must have been infected in Paris. Both the man and his wife were at once removed to Kingsbury Smallpox Hospital, where Mrs. R.F. died the same night. She had not been vaccinated since infancy. Her husband was vaccinated in infancy and revaccinated about 1900. Dr. Buchan forthwith informed Dr. Porter, Medical Officer of Health of St. Marylebone, in whose district the hotel at which the patients stayed is situated, whilst Dr. Tate, County Medical Officer of Middlesex, informed the County Medical Officer of Health of London. The following day was spent in making enquiries at the hotel, examining contacts and taking the necessary precautionary measures. One of the chambermaids (I.T.), aged 32 years, was found to be ill with a temperature, and Dr. Porter, in consultation with Dr. Wanklyn, notified the case (30.9.26) as one of smallpox, as a precautionary measure, and had the patient removed at once to the Metropolitan Asylums Board receiving station, North Wharf, where subsequently an eruption appeared, which proved to be symptomatic of smallpox. It was fortunate that this patient was removed before she became infectious. She had not been vaccinated since childhood. It was also ascertained the same day that a charwoman (L.W.), aged 42 years, employed at the hotel and living in Lambeth, had been absent ill for a few days. Dr. Priestley, Medical Officer of Health of Lambeth, was at once informed and, on visiting the woman (30.9.26) found that she was suffering from smallpox, the rash having appeared two days previously. She was immediately removed to North Wharf, and subsequently to Long Reach Hospital, where the rash became confluent, and she died a week after her admission to hospital. She had not been vaccinated since infancy. 10 A page boy (W.S.), aged 14 years, employed at the hotel, was also found by Dr. Porter to be suffering from a sore throat, and was removed to hospital as a precaution (1.10.26). Some days after his admission a meagre and not very characteristic rash appeared, and it was eventually decided that the case was one of mild smallpox. The boy was vaccinated for the first time on the 1st October, and the vaccination did not properly take. No further cases occurred, and it was due to the energetic administrative action taken, including the supervision and vaccination of large numbers of contacts, that the disease did not spread. Group II (two cases).—As in the case of the Group I. outbreak, the infection originated in Paris, but there was no association between the two groups, except as regards the common source of infection. The first patient (A.D.), who had not been vaccinated since infancy, was a woman, aged 52 years, who spent most of September in Paris, where there was an outbreak of smallpox of a severe type, and returned to London on the 25th September. She felt unwell on the 6th October, and attended the Royal Northern Hospital the following day, when she was so ill that she was admitted as an in-patient. On the 8th October a rash appeared, and on Saturday, the 9th October, she was isolated in the hospital on suspicion of smallpox. A consultation was held that day, and Dr. Wanklyn was called in on Monday, the 11th October, when the patient was declared to be suffering from a severe attack of confluent smallpox. She was at once removed to North Wharf, and vaccination of all contacts at the Royal Northern Hospital was commenced the same evening. All the visitors to the hospital during the week-end, 9th to 10th October, were regarded as contacts, and their names and addresses, together with those of all patients who were discharged from the hospital after the 8th October, were communicated to the medical officers of health of the districts concerned. A secondary case occurred in the person of an in-patient at the hospital (S.S.), a female, aged 64 years, occupying the next bed to the patient (A.D.). S.S., who had not been vaccinated since infancy, was re-vaccinated with other contacts on the 11th October. Her rash appeared on the 20th October, and she was removed to the Metropolitan Asylums Board receiving station the following day. The attack was modified as a result of her re-vaccination. No further cases occurred. Miscellaneous Cases and Supervision of Contacts.—From time to time cases of smallpox occur outside the county area, in which the patient has passed through or visited London during the infectious period. Similarly it frequently happens that smallpox contacts from other parts of the country, or from abroad, come to visit, or to stay in, London. In every case the Council's public health department keeps in close touch with their movements, and co-operates with the medical officers of health of the metropolitan boroughs and extra-metropolitan authorities with the object of preventing spread of the disease. A fatal case of smallpox occurred in January, 1926, at the Hague among a party of South African students (55 males and 78 females) who were touring the Continent. The patient was infected in Paris. All members of the party were vaccinated before they left Holland, and they arrived in this country on the 31st January. They came to stay at an hotel in St. Pancras, where they were kept under daily observation for 12 days prior to their departure. The situation was complicated by an outbreak of German measles among them whilst they were at the hotel, but no further case of smallpox occurred. In June, 1926, a girl (E.B.), aged 20 years, journeyed from South Shields to Limpsfield, Surrey, via London. She fell ill with headache, shivering and vomiting on 6th June, the day before she left South Shields, where several cases of smallpox had occurred in the street where she lived. She arrived at King's Cross Station on the 7th June feeling somewhat better, and was there met by an employee of the 11 Industrial Welfare Society, who escorted her by taxi-cab to the head office of the Society, and from there to Victoria Station en route to Oxted and Limpsfield. It was not until the 10th June (three days later) that a rash appeared, and smallpox was not suspected until the 12th June, when she was removed to hospital on the advice of the Medical Officer of Health of Godstone Rural District Council. She had never been vaccinated. The occurrence of this case involved the following up and vaccination of large numbers of contacts, both in and out of London; fortunately no further cases resulted. Apart from the cases previously mentioned as having been infected in Paris, no case of smallpox occurred among the many passengers and members of the crew of smallpox infected vessels who came to London. In every case these persons were followed up by the medical officers of health concerned, and vaccination was advised where necessary. Provincial Smallpox.—The continuous menace to London represented by the progressive spread of smallpox in the Midlands and Northern Counties in recent years, which has now extended to South Wales, is a matter for brief comment, inasmuch as, whilst this prevailing mild type of disease has now been affecting the provinces, mainly in the mining and industrial areas, for a matter of five years, it has not, except in one or two isolated instances, been introduced into London. How long London will continue to escape epidemic prevalence is a matter upon which no definite opinion can possibly be expressed, but there is no doubt that, as in the case of the provinces, the decline in vaccination in London is a matter for serious concern, and unless the prevalence in other parts of the country abates, it is hardly reasonable to assume that the Metropolis will remain free indefinitely. It is, therefore, absolutely necessary that all public health and hospital authorities, medical practitioners, as well as the public, should be made to realise fully the menace to the public health which exists to-day from the high proportion of the unvaccinated section of the population. The following table, which is a continuation of a similar table which has appeared in recent annual reports, is presented for purposes of comparing the number of cases of smallpox in London and the rest of the country in the past sixteen years:— Year. England and Wales (including London). London. Cases. Deaths. Cases. Deaths. 1911 289 23 72 9 1912 121 9 4 1 1913 113 10 3 — 1914 65 4 2 - 1915 93 13 11 3 1916 159 18 1 — 1917 7 3 — — 1918 63 2 35 — 1919 311 28 24 6 1920 280 30 18 4 1921 336 5 2 — 1922 973 27 65 20 1923 2,504 7 11 1 1924 3,797 8 4 - 1925 5,351 6 10 1 1926 10,141 11 5 1 The Council has continued to place at the disposal of medical officers of health of the metropolitan boroughs and certain of the Home counties and extra metropolitan authorities the services of its expert medical staff for the diagnosis of suspected cases of smallpox. 12 Measles. Measles was epidemic during the winter of 1926 and caused 933 deaths, giving a death rate of .20 as compared with .07 in 1925. The death-rates in the metropolitan boroughs are shown in the table on page 28. Whoopingcough. There were 231 deaths from whooping-cough in London during 1926, the lowest number recorded in any year except 1923, when there were 432 deaths. The death-rate was 0.5 per thousand as compared with .19 in 1925. Scarlet Fever. There were 12,293 cases of scarlet fever notified in 1926 (52 weeks), the corresponding figure for 1925 being 12,215. The attack-rate was 2.7 per thousand, the same as in 1925. In the rest of England and Wales the corresponding figures were 2.1 and 2.3 respectively. The deaths numbered 83, giving a death-rate of .02, the same as in 1925. Diphtheria.. The notified cases of diphtheria numbered 13,526 in 1926 (52 weeks) as compared with 12,472 in 1925. This gives an attack-rate of 2.9 per thousand as compared with 2.7 in the preceding year. The London attack-rate is considerably higher than that for the rest of England and Wales, which was 1.3 per thousand. Of the total cases, 6,832, notified in 1926, 51 per cent., were among children aged 5 to 15, while the deaths were 209, giving a case-mortality for this age period of 3.1 per cent. The total deaths numbered 547, the death-rate being .12 as against .11 in 1925. Diphtheria case- mortality. The case-mortality from diphtheria has decreased remarkably since 1922. Before the introduction of antitoxin in 1894 the case-mortality was between 22 and 23 per cent. The subsequent decrease is shown in the following table giving the average rate in four-year periods:— Period. Case-mortality per cent. Period. Case-mortality per cent. 1895-98 17.8 1911-14 7.0 1899-02 12.2 1915-18 7.4 1903-06 9.2 1919-22 7.4 1907-10 8.7 1923-26 4.7 In the seven years 1916-22 little tendency to decline can be found, the average annual case-mortality being 7.42 per cent. but the extent of the subsequent reduction is apparent from the following table in which the average rate for 1916-22 is compared with the annual rate for each year since this period:— Year. Case-mortality per cent. Average case-mortality, 1916-22. Reduction in casemortality. 1923 1924 1925 1926 5.78 5.27 3.95 3.89 7.42 7.42 7.42 7.42 1.64 2.15 3.47 3.53 In order to illustrate the effect of this decrease in case-mortality, the deaths which would have occurred on the rate of the preceding seven years is compared with the actual deaths in 1923-26 in the following table:— Year. Cases notified. Calculated deaths (7.42 per cent.) Actual deaths. Reduction in deaths due to decreased case-mortality. 1922 1923 1924 1925 1926 15,247 10,301 10,684 12,472 13,526 1,131 764 792 925 1,003 1,129 595 564 493 526 2 169 228 432 477 The deaths given in this table relate to a year commencing one week later than that to which the notified cases refer, to allow for the lapse of time between notification and death. The table shows that the deaths in 1926 were reduced by nearly one-half and that the total reduction in deaths in the four years 1923-26 amounts to 1,306. 13 In the autumn of 1922 the Ministry of Health issued a memorandum on the supply and administration of diphtheria antitoxin in which the following paragraph occurs:— "It cannot be too strongly emphasised that early administration of antitoxin not only reduces the mortality from diphtheria, but causes the disease to run a milder and shorter course; while by lessening the period of the patient's infectivity to others it reduces the period of occupation of a bed in an isolation hospital. It is thus an important measure in the interests of economy as well as of the public health. It should be the aim of every medical practitioner so soon as on clinical evidence he has diagnosed diphtheria either to have the patient removed forthwith to an infectious diseases hospital or himself to administer an adequate dose of antitoxin." And further:— "Once the decision is made on clinical grounds that the case is one of diphtheria, antitoxin should be given forthwith without waiting for the report of the bacteriological examination." In June, 1923, a letter was addressed by Dr. Caiger, Chief Medical Officer of the infectious hospitals service of the Metropolitan Asylums Board, to the Medical Press, in which, again referring to the paramount importance of giving antitoxin in the early stages of the disease, it is mentioned that, of 150 cases of diphtheria which proved fatal in one of the fever hospitals of the Board in 1922, no less than 46 or 30 per cent. died within 24 hours of admission, and 17 more, or 42 per cent., within 48 hours. Dr. Caiger says:— "In view of the almost invariable success of antitoxin, if administered in the early stage of diphtheria, and the comparative harmlessness of the remedy, even should its use subsequently prove to have been unnecessary, this record must be regarded as nothing short of deplorable." And further:— "The most frequent source of delay in treatment is the fatal practice of awaiting the result of bacteriological examination before deciding to give antitoxin or sending the case into hospital if serum were to be given to every case of suspected diphtheria at the earliest possible moment before being sent into hospital, such action on the part of the certifying practitioner would be warmly welcomed." The Board recommended on 28th July, 1923, that the Ministry of Health should consider the question of making it obligatory on the part of local authorities to keep a stock of diphtheria antitoxin from which medical practitioners could be supplied on request. It is the practice in metropolitan boroughs to keep a supply of antitoxin at the Town Hall. It may be advisable for the authorities concerned to consider the desirability of utilizing other public places as accessory sources of supply of antitoxin more especially in those districts in which the Town Hall is not equally accessible to all parts of the borough. In considering the reduction in the case-mortality shown to have occurred, it is of interest to note that, in the autumn of 1910, an order was issued by the Local Government Board "sanctioning" the provision by sanitary authorities of a temporary supply of diphtheria antitoxin, and, although no marked reduction in casemortality is apparent in the figures for 1911, in the two following years a reduction occurred similar to that above recorded in recent years, but the reduction was not maintained. A comparison of the incidence and fatality of diphtheria in the less densely populated boroughs, which are also largely occupied by the well-to-do class, with the densely populated and poorer boroughs of London shows that the incidence in the poorer boroughs among children below five years of age is nearly three times that in 14172 b Incidence in relation to density of population. 14 the better class area. Comparing the death-rate, it is found to be much higher proportionately in the poorer classes below two years of age, when it is more than three times as great, but, on the other hand, between five and fifteen years of age there is a higher mortality in the better class areas. Apparently the higher rate of incidence in the earlier years in the poorer boroughs has produced a greater degree of immunity from the more severe type of disease. In respect of case-mortality there is not very much difference between the two classes of population up to five years of age, the advantage being with the poorer class districts; but again at the age of five to fifteen the case-mortality is in excess in the better class districts, being nearly twice as great. The figures, which are shown in the following table relate to the period 1921-25. The less densely populated boroughs of Group I comprise Hampstead, Lewisham and Wandsworth, while Group II comprises Bermondsey, Bethnal Green, Finsbury, Shoreditch and Stepney:— Age period. Case-rate per 1,000 living. Death-rate per 1,000 living. Case-mortality per cent. I. II. I. II. I. II. 0—l 1.6 5.2 0.2 0.8 15.3 15.4 1—2 4.1 15.0 0.6 1.9 14.1 12.6 2—5 8.8 21.1 1.0 2.0 11.5 9.3 0—5 6.2 15.9 0.7 1.7 12.1 10.5 5—15 6.6 8.2 0.4 0.3 6.3 3.8 Diarrhoea and Enteritis. Diarrhcea and enteritis caused 948 deaths among children under two years of age in London during 1926, this being 12.03 per thousand births. The corresponding rate in 1925 was 10.79. Outbreak of diarrhœal disease in Poplar. An outbreak of illness of a diarrhœeal character occurred in Poplar in July, the days of chief intensity being the 11th and 12th, when 114 cases occurred, out of a total for the month of 238. The cases mostly occurred in a circumscribed area between the Poplar Gas Works and East India Dock. The outbreak was investigated by Dr. George C. Hancock, C.B.E., on behalf of the Ministry of Health. No evidence was found involving the food supply and the bacteriological results in that respect were negative. The incidence was greatest among women and children, and it was found that samples of drinking water taken in the invaded area gave very unfavourable results on bacteriological examination by Dr. Scott in the Ministry of Health's laboratories. Investigation showed that it would have been possible under certain conditions of pressure for polluted water from the Gas Works to be forced back into one of the Metropolitan Water Board's mains on the area of the outbreak. (Ministry of Health: Reports on Public Health and Medical Subjects, No. 41). Typhoid fever. There were 302 notifications of typhoid fever in London in 1926 (52 weeks) as compared with 395 in 1925 (52 weeks). The deaths in the calendar year numbered 31, the mortality being lower than recorded in any previous year in London. In 19 instances two or more than two cases were notified from one house, as compared with 24 in 1925. Five cases occurred in a household occupying a tenement in Stepney, fried fish being the cause of infection suggested. Four cases occurred in two instances, one in Hampstead where a carrier was implicated and one in Bethnal Green where the first case was not recognised as typhoid fever until three others had occurred. There were four instance of 3 cases in one house and twelve of 2 cases. Eleven deaths from typhoid fever were not notified. Seven of these occurred in mental hospitals situated outside the County; Of the 4 remaining cases one was diagnosed post-mortem and in three typhoid or paratyphoid fever was certified as a secondary cause of death. Anthrax. During 1926, seven cases of anthrax, of which one proved fatal, occurred in London. The infection was attributable in five instances to the handling of foreign hides, and, in one case, to feathers which were imported from China. In the fatal 15 case, a baby aged one year, living in Paddington, the diagnosis was confirmed by inquest and bacteriological examination, but no light was thrown on the source of infection. No cases of plague or cholera occurred in London during 1926. No cases of typhus fever occurred in London during 1926. Plague and cholera. Typhus fever During the year 1926 there were 93 cases of cerebro-spinal fever notified, of which 16 were not regarded as genuine cases. Of the 77 actual notified cases, 54 (70 per cent.) proved fatal. In addition, 23 fatal cases which had not been notified under the Public Health (London) Act, 1891, were discovered through the Registrar General's death returns, making a total of 100 actual cases of the disease, with 77 deaths. Cerebrospinal fever. During 1926, 97 cases of Poliomyelitis and Polioencephalitis were notified and of these 14 were not regarded as genuine, making a total of 83 actual notified cases for the year. Of these 8 proved fatal. In addition, 2 deaths from the disease were recorded by the Registrar-General amongst non-notified cases. Poliomyelitis and polioencephalitis. The slight rise in the incidence of this disease as compared with the previous year, when 55 cases were notified, was due to a mild recrudescence which occurred unusually late in the year and lasted till the middle of December. This rise was preceded by outbreaks in various parts of the country, notably at Broadstairs and other parts of Kent and Leicester. In several instances it was ascertained that London patients were probably infected in these areas. It is surmised that in certain cases the infection was imported from Brittany, where a severe type of poliomyelitis was prevalent during the late summer. Incidence and Mortality.—During 1926, 231 cases of encephalitis lethargica were notified, and in 58 cases the diagnosis was subsequently revised. Of the 173 actual notified cases, 68 (39 per cent.) proved fatal. In addition, 22 fatal cases, which had not been notified under the Encephalitis Lethargica Regulations, were recorded in the Registrar-General's death returns. Several of these cases had their onset in previous years. Encephalitis lethargica. Table of age incidence (actual cases). Age periods. Under 3. 3-5. 5-10. 1020. 2030. 3040. 40- 50. 50-60. Over 60. Total. Cerebro-spinal fever 64 5 10 7 11 - 1 2 - 100 Poliomyelitis and polioencephalitis 18 15 20 13 12 4 2 1 — 83 Encephalitis lethargica 7 12 18 24 40 22 22 29 21 195 Table of yearly prevalence (notified cases). Year. 1914. 1915. 1916. 1917. 1918. 1919. 1920. 1921. 1922. 1923. 1924. 1925. 1926. Cerebro-spinal fever 73 674 432 430 265 199 164 109 86 70 97 95 93 Poliomyelitis and polioencephalitis 93 97 197 53 53 96 65 59 40 112 116 55 97 Encephalitis lethargica Not notifiable till 1st January, 1919. 86 149 243 72 101 605 304 231 The subject of encephalitis lethargica from the point of view of its effect upon the juvenile section of the population and the arrangements made for the institutional treatment of children under the age of 16 years, is dealt with in my report as the School Medical Officer. The incidence of this disease, however, is by no means limited to the younger section of the community, as the following table, shewing the age incidence of actual cases notified since 1919 (allowing for revision of diagnosis), clearly demonstrates. This table will also be of interest as indicating the mortality 14172 b 2 16 at the different age periods and the distribution of the disease as regards sex during the seven years (1919-1925). Non-notified cases are not included in the table. Age and sex distribution of incidence and mortality (1919-1925.) Age periods. 0-5 5-10 10-15 15-20 20-25 25-35 35-45 45-55 55-65 65-75 75 & over Totals Cases M. 50 63 100 92 56 82 88 77 49 9 6 672 F. 27 56 56 88 69 86 103 101 42 20 5 653 Total 77 119 156 180 125 168 191 178 91 29 11 1,325 Deaths M. 24 13 15 26 13 19 42 43 32 7 4 238 F. 15 16 15 24 16 27 48 53 23 16 4 257 Total 39 29 30 50 29 46 90 96 55 23 8 495 Percentage case-mortality (approx.) M. 48 21 15 27 23 23 48 56 63 78 67 35 F. 56 29 26 27 23 31 45 52 55 80 80 39 Total 51 24 19 27 23 27 46 54 59 80 73 37 This is the first occasion on which a table giving a summary of the age and sex distribution of encephalitis lethargica, both as regards cases and deaths, for the whole period during which the disease has been notifiable, has been presented in the annual report. The table is of interest as demonstrating the following points:— (i) Although encephalitis lethargica is a disease which affects all ages, it has a definite preference for children and adolescents between the ages of 10 and 20 years, and more especially for those in the age group 15-20 years. (ii) Whilst there is little appreciable difference in the incidence as between males and females at all ages, the former being slightly in excess, there is a preponderance of males over females in the age groups 0-5 and 10-15, although the mortality is higher among females at these ages. These facts are borne out by the greater number of applications on behalf of boys suffering from aftereffects for admission to the Northern Hospital, Winchmore Hill. (iii) The case mortality rate for the 7-year period was 37 per cent. There was greater liability to death among children under 5 years of age and among adults from the age of 35 years, and after this age the death-rate increased progressively. The lowest mortality occurred in the age period 10-15, years which comes within the period of highest susceptibility. In a report on 301 cases of encephalitis lethargica in Sheffield in 1924 recently issued by the Medical Research Council (Special Report Series No. 108) the following broad conclusions were drawn:— 1. Statistical estimates of the incidence and fatality of Epidemic Encephabtis should be accepted with reservation, owing to the occurrence of unrecognised mild and abortive cases. 2. The evidence already available as to increased susceptibility to infection in males, and increased liability to death in females is confirmed by the Sheffield figures. 3. There is an increased susceptibility to infection in males between the ages of 15 and 30 years. 4. There is no evidence which establishes any relation between the disease and social conditions, such as overcrowding, poverty or insanitary conditions in dwellings. 5. There is no evidence of any association with topographical considerations, or with the supply of water, milk, or any other form of food. 17 6. There is no reliable evidence that the disease is spread by direct contact, nor any data for computing an incubation period if infection does take place. It is of interest to compare these conclusions with the above table representing 1,327 cases, i.e., over four times as many as those on which the Sheffield conclusions were based. It will be noted that the deductions as regards paragraphs (2) and (3) correspond broadly with the London figures, except that on the larger number of cases the difference in the incidence and mortality as between males and females is not very marked, and also that the preponderance of male cases ceases to be a special feature after the age of 20 years or thereabout. In this connection it is appropriate to quote a passage in the Sheffield report dealing with the greater susceptibility of males in the earlier years of life, which reads as follows:—"These figures are too small to form the basis of any general conclusions, butif confirmed by larger statistics, it suggests a greater susceptibility to infection in the central nervous system of the male as compared with the female during the period when sexual maturity is achieved and most active." Interpreting the London figures, it would appear that the balance in favour of male cases is most noticeable during the period of puberty and whilst sexual maturity is in process of being formed rather than when it has become achieved. With regard to the conclusions (4), (5) and (6), of the report quoted above, it may be stated that, generally speaking, the experience in London conforms with that of Sheffield. On the question of leakage in the notification of cases it is estimated that in London the number of cases which escape notification exceeds by about 50 per cent. the number which are officially notified. Sequelœ.—An account of the sequelae of encephalitis lethargica appeared in the annual report for 1925 (p. 109). In order to show the effects of the disease in the year 1926 upon those who survived attacks during the seven-year period 1919-1925, the following table is presented:— Notified. Non-notified. Under 16 years. Over 16 years. Total. Under 16 years. Over 16 years. Total. 1. Total number of cases (1919-25) 448 1,112 1,560 — — 2,000 (circa) 2. Not confirmed as genuine cases 60 175 235 — — — 3. Fatal* 111 (5) 384 (31) 495 (36) 26 74 100 4. Now apparently well 119 254 373 39 ? ? 5. Slight sequelae, not interfering with occupation, schooling, etc. 23 38 61 14 ? ? 6. Suffering from sequelae which partially interferes with occupation or schooling 38 62 100 45 ? ? 7. Wholly incapacitated 75 105 180 150 ? ? 8. No. among (6) and (7) showing conduct changes 60 54 114 64 ? ? 9. No. among (6) and (7) showing Parkinsonism 23 31 54 7 ? ? 10. Untraced 22 94 116 - - - *The figures in parentheses denote the number of deaths among patients in which the cause of death was registered as being due to some morbid condition other than encephalitis lethargica. The need for further residential accommodation.—The limited accommodation at the Metropolitan Asylums Board's Hospital, Winchmore Hill, i.e., 100 beds, while perhaps adequate as a clearing house for juvenile cases of chronic epidemic encephalitis, falls far short of the actual needs as regards the permanent care of individual sufferers. To what extent the provision will be met by the new Mental Deficiency Bill, if it becomes law (see p. 133), is doubtful, but in any case there remains the problem of dealing with older persons. Applications are constantly being received for the 18 residential treatment of adults, and similarly there has been a considerable demand from extra-metropolitan authorities for the treatment of persons resident outside London. Special mention should also be made of those cases discharged as being unlikely to benefit by further treatment and those discharged as being over age. Such cases, combined with those for whom there is insufficient accommodation, whether juvenile or adult, present a serious problem, both from a social and public health point of view. On the other hand, the establishment of such an institution as the Winchmore Hill unit has shown that much can be accomplished in mitigating the results of "pathological delinquency" by the early and continuous medical observation and treatment of the children in a well-conducted institution. "Whether the effects of such treatment will be permanent in cases which have been discharged as definitely improved has yet to be established, but in a number of cases the improvement has been sustained for several months. Similarly, whether institutional treatment for adolescent and adult cases would effect an amelioration of their condition is an experiment which has yet to be made, but there is no doubt with regard to the need for such an experiment, if only for the purpose of the classification and subsequent disposal of the patients. A further important reason for extending the provision of residential treatment of these cases lies in the need for supplementing the present knowledge of the disease in its various phases by scientifically studying its later manifestations at close quarters and so applying the knowledge thus gained to the practical treatment of the disease generally. This point of view is emphasised in the report by the Medical Research Council referred to above, in regard to 301 cases of the disease in Sheffield, in the following passage:— "These critical studies of a local epidemic of the disease, and the close and sustained observations of the individual cases of illness throughout their course which are here recorded, have clear value for all whose business it is to be concerned with the disease and its treatment. They do not, however, nor do the careful and prolonged laboratory investigations which have been coupled with them, throw new light upon the problems of its causation, or give any guidance towards effective preventive control. This malady, choosing its victims at random as it now seems to us, has caused and is causing in all classes some of the most poignant among the tragedies of disease. Our only hope of overcoming it lies in the acquisition of more knowledge, and we can only expect to attain this by the sustained and patient prosecution of further studies of the kind now presented." Influenza. The deaths from influenza during 1926 numbered 806, the maximum mortality being recorded in the 14th week, when 74 deaths occurred. In last year's annual report an analysis was shown of the periodicity of influenza prevalences in London since 1890, according to which a prevalence was to be expected about the 3rd week of 1927. Influenza became epidemic at the end of 1926 and reached a maximum mortality in London in the 4th week of 1927, when the deaths numbered 252. The table of periodicity referred to shows that while there has been no epidemic with a maximum on the 4th week of the year, there have been three reaching a maximum in the 3rd week and two in the 5th week, the interval to the next following epidemic being from 54 to 69 weeks. In the present case, where the maximum falls on the 4th week, the table of periodicity suggests the probability of an epidemic in April, 1928, having a maximum about the 13th week of the year. Tuberculosis. The deaths from tuberculosis of the respiratory system in London during 1926 numbered 4,066, giving a death-rate of 0.88 per thousand, corresponding figures for 1925 being 4,361 and 0.95 respectively. Deaths from other forms of tuberculosis numbered 691 as against 796 in the preceding year, the death-rate 19 being 0.15 per thousand of the population. The deaths and death-rate from tuberculosis of the respiratory system by sexes in recent years have been as follows:— Year. Deaths. Death-rates. Males. Females. Total. Males. Females. Total. 1919 2,945 2,252 5,197 1.47 0.94 1.18 1920 2,675 2,000 4,675 1.29 0.82 1.04 1921 2,737 2,076 4,813 1.32 0.85 1.07 1922 2,841 2,047 4,888 1.35 0.84 1.08 1923 2,586 1,846 4,432 1.23 0.75 0.97 1924 2,629 1,857 4,486 1.24 0.75 0.98 1925 2,571 1,790 4,361 1.21 0.72 0.95 1926 2,474 1,592 4,066 1.16 0.64 0.88 The number of notifications of tuberculosis received in London boroughs during 1926 (52 weeks), after correction of the figures within each Metropolitan borough by the exclusion of cases notified as primary but subsequently found to have been previously notified, was 9,188 as compared with 9,661 in 1925 (52 weeks). The cases of pulmonary tuberculosis numbered 7,093 and other cases 2,095, the corresponding figures for last year being 7,554 and 2,107. The following is an analysis of the notifications in London during 1926 (52 weeks). Notification of tuberculosis. Form of tuberculosis notified. Sex. Notihcations on Form A. (Total of primary notifications received in London boroughs, other than elementary school cases, infra.) 0- 1-5-10- 15-20- 25- 35- 45- 55- 65+ Total. Pulmonary tuberculosis M. 9 42 106 92 305 480 884 824 785 |400 126 4,053 F. 4 25 80 113 421 554 824 473 318 144 65 3,031 Other tuberculosis M. 36 222 292 145 120 79 80 53 35 17 12 1,091 F. 22 162 216 128 107 100 110 51 29 25 10 960 All forms of tuberculosis M. 45 264 398 237 425 559 964 877 820 417 138 5,144 F. 26 187 296 241 528 654 934 524 347 169 75 3,991 Form of tuberculosis notified. Sex. Notifications on Form B. (Primary notifications of cases discovered through medical inspection in elementary schools.) Notifications on Form C (Secondary notifications from institutions receiving cases.) 0- 5- 10+ Total. Poor Law. Other. Pulmonary tuberculosis M. 1 3 1 5 1.058 3,621 F. — 1 3 4 678 1,856 Other tuberculosis M. - 11 8 19 121 581 F. 3 10 12 25 89 501 All forms of tuberculosis M. 1 14 9 24 1,179 4,202 F. 3 11 15 29 767 2,357 In addition to the primary cases notified on forms A and B shown in the above tables, a number of cases came to the knowledge of Medical Officers of Health otherwise than by notification. These figures include cases not notified before death:— Form of tuberculosis notified. Sex. New cases of tuberculosis coming to knowledge otherwise than by notification on forms A and B. 0- 1- 5- 10- 15- 20- 25- 35- 45- 55- 65 + Total. Pulmonary tuberculosis M. 4 9 8 7 17 28 86 77 75 57 31 399 F. 5 6 6 6 17 36 69 48 31 23 13 260 Other tuberculosis M. 19 42 34 16 9 5 12 6 7 6 5 161 F. 13 52 25 13 14 12 13 10 6 11 6 175 All forms of tuberculosis M. 23 51 42 23 26 33 98 83 82 63 36 560 F. 18 58 31 19 31 48 82 58 37 34 19 435 20 Under the Public Health (Tuberculosis) Regulations, 1924, the Medical Officers of Health are required to prepare, from the register of notified cases of tuberculosis, a quarterly return showing the number of cases on the register at the commencement and at the end of the quarter, and the number added to and removed from registers during the same period. The returns under this order received from the several metropolitan boroughs, show that at the end of 1926 there were 40,205 cases of pulmonary tuberculosis (23,027 males and 17,178 females) on the Registers of the Metropolitan Boroughs and 15,762 cases of other forms of tuberculosis (8,293 males and 7,469 females). Mortality from pulmonary tuberculosis among adults. In comparing the incidence of phthisis in different populations, too little attention has been paid to the relative health of the populations concerned. The simplest and most obvious measure of the health of the population is afforded by the death-rate from all causes, especially when consideration is being given to the mortality amongst adults. It has been shown in earlier reports of the County Medical Officer of Health that the mortality from tuberculosis is intimately associated with "social condition." The mortality-rate from phthisis in London boroughs of the poorer class in the ten years, 1901-1910, was two or three times greater than among boroughs of better class populations. It might from this be supposed that there are some particular conditions prevailing among the poorer classes which are specific factors in phthisis causation, such as, increased risk of infection due to overcrowding; insanitary conditions generally; or intemperance, etc. It will, however, be seen from the accompanying table that when the mortality from phthisis is stated as a percentage of the deaths from all causes at each age period, much of the difference between the three groups of boroughs of different social circumstance disappears. Group I contains boroughs with a large proportion of well-to-do residents; Group II. is an intermediate group approximately to the London average, and Group III represents boroughs of the poorer classes. The rates are per 100,000 living in each age-group:— Phthisis death-rate in Group. Phthisis per cent. of all causes. Age period.I. II. III. I. II. III. Males. 5-15 11 14 17 5 5 6 15-25 107 105 132 35 33 35 25-45 219 271 341 33 36 37 45-65 03 398 513 14 16 19 Total of Rates 640 788 1,003 87 90 97 Total, GroupI=100 100 123 157 100 104 112 Females. 5-15 21 23 27 9 8 9 15-25 67 80 105 32 32 34 25-45 112 144 207 25 26 29 45-65 123 154 224 8 9 10 Total of Rates 323 401 563 74 75 82 Total, Group I=100 100 124 174 100 103 112 In the comparison of phthisis mortality rates in groups of London boroughs, arranged according to "social condition," two points require to be borne in mind. In the first place, the proportion of persons suffering from phthisis who will be able to leave London and take up permanent residence in a more suitable locality must necessarily be greater in the better class boroughs and, as a consequence, the deathrate of the group which includes these boroughs will be relatively understated. Also, 21 where deaths occur among persons removing from London to institutions or nursing homes outside the County, the deaths are transferred back to London, and the proportion of persons able to afford such institutional treatment is necessarily greater among boroughs of the better class, although, as will be seen from the following table, the administration of the Council's Tuberculosis Scheme has considerably modified the relation between the better class and poorer boroughs in this respect:— Increase, per cent., by transfers. Period Boroughs largely occupied by Boroughs largely occupied by well-to-do. poorer class. 1911-13 6.7 1.4 1919-21 5.6 1.5 1923-25 1 4.9 3.0 The second point is that the earning power of workers stricken with phthisis is at once reduced so that there is a tendency for such persons to drift downwards in the social scale; and the last stage of self-support is represented, in a number of cases, by housing accommodation of the poorest type, including common lodginghouses. No recent records are available in regard to the mortality among the occupants of common lodging houses, but figures abstracted in 1906-8 show that a considerable proportion of the deaths in certain boroughs occurred among persons whose last known address before admission to institutions was a common lodginghouse. In Holborn such deaths formed 29.0 per cent. of the total; in Westminster, 18.5; and in Stepney 16.9. The percentage of the total deaths in London which occurred in the common lodging-house population at ages 45-55 was 6.3; ages 55-65, 10.6, and 65-75, 12.2. The heavy incidence of phthisis upon this class is shown by the following comparison of the percentage of phthisis deaths to deaths from all causes in the male common lodging-houses population and in London as a whole for the year 1905:— Population: 25- 35- 45- 55- 65+ Common lodging-house population 54.3 52.9 48.3 30.8 11.2 London County 39.9 31.0 23.0 11.9 2.7 In the annual report of the County Medical Officer of Health for 1909, page 58, it is shown that the graduation of phthisis mortality according to "social condition" in London is similar to the graduation of the London phthisis death-rate in successive decennia. Similar figures for the age-groups with which we are mostly concerned here and for more recent years are shown in the following Table, where the phthisis mortality is also shown as a percentage of the deaths from all causes. It will be seen from the latter figures that the difference in phthisis incidence in successive decennia is almost completely correlated to the change in the general death-rate Phthisis death-rate per 100,000 living. Phthisis, per cent. of all causes. Age period. 1881-90. 1891-00. 1901-10. 1881-90. 1891-00. 1901-10. Males— 5-15 27 19 15 6 5 5 15-25 172 146 120 36 35 34 25-45 444 377 291 39 36 36 45-65 516 482 419 17 16 16 Total of Rates 1,159 1,024 845 98 92 91 1901-10=100 137 121 100 109 101 100 Mortality in successive decennia. 22 Phthisis death-rate per 100,000 living. Phthisis, per cent. of all causes. Age period. 1881-90. 1891-00. 1901-10. 1881-90. 1891-00. 1901-10. Females— 5-15 42 32 26 9 8 9 15-25 142 107 87 36 32 32 25-45 286 221 156 33 29 26 45-65 228 201 164 10 9 9 Total of Rates 698 561 433 88 78 76 1901-10=100 161 129 100 116 102 100 Relation of mortality to urbanisation. Differences in the incidence of phthisis mortality, similar to those found in populations of differing social circumstance, and in successive decennia, are also found in populations living in different classes of area, and here again the variations are correlated to the deaths from all other causes. The facts are broadly illustrated in the diagram on the next page. The upper parts of each section of this diagram show phthisis death-rates (1) according to social condition; (2) in successive decennia; and (3) according to class of area of residence. In the lower part of the diagram the phthisis death-rates are shown as a percentage of deaths from all causes for each age. It will be seen that in all three sections the divergence between various groups of population shown in the upper part of the diagram are almost eliminated in the contours shown below them. The diagram relates to males only, but the female rates give similar results. It will be noticed that both when figures relating to successive decennia are considered, and those relating to different groups of population, there is not an exact parallelism between the variation of the phthisis death-rate and the death-rate from all causes. One finds that the phthisis deaths in the poorest of the social groups and in earlier decennia and also in the more urbanised districts are all relatively higher than the corresponding deaths from all causes in these groups of population. This points to the fact that, although in general the phthisis mortality responds to the same conditions as those which determine the general death-rate, there is some condition which is specific to the phthisis mortality. Nutrition the chief factor. From the clinical point of view, Osler tersely sums up the position with regard to phthisis thus ("Principles and Practice of Medicine," page 332): "The cure of tuberculosis is a question of nutrition; digestion and assimilation control the situation; make a patient grow fat and the local disease may be left to take care of itself." It will, therefore, be expected that any conditions which affect the nutrition of the general population will have a somewhat greater effect relatively upon the phthisis death-rate than on the death-rate from other causes. This fact is well illustrated in the exceptional conditions which obtain in war, famine or other adversity, when the phthisis death-rate will be found to be still more increased proportionately, while, on the other hand, in times of prosperity and improved food supply a relatively greater decrease is found to occur. It is of interest to recall in this connection the experience of this country and all the European countries which were involved in the Great War (1914—18). Types of phthisis. A remarkable difference is found in the age-incidence of phthisis in London compared with that of Ireland on the one hand and of coal miners on the other, (see diagram on page 24, where the phthisis death rates per thousand living at certain age periods are shown for each of the three populations). These three populations were taken by the late Dr. Brownlee as typifying three different kinds of phthisis. Ireland representing what he called the "young adult type," London the "middle-age type" and the coal-miners the "old age type." But as has been observed above, a consideration of the phthisis death-rate which does not take 23 24 25 into account the corresponding figures for all other causes of death may lead to erroneous conclusions. If the phthisis deaths are calculated as a percentage of the deaths from all causes the resulting curves, also shown in the diagram on page 23, exhibit little difference from one another. The young adult, middle-age and the oldage phthisis types have disappeared. The greatest proportion of phthisis deaths is shown to occur at about the same age in all three groups. A consideration of the age-distribution of deaths among common lodging-house inmates in conjunction with the high mortality from phthisis after the age of 45 in London as compared with England and Wales suggests the possibility that some part of the London mortality at the higher ages is due to causes other than any particularly adverse effects of the London environment upon health. A comparison of the mortality of London children with that of children in England and Wales as a whole shows that at school ages the death-rate in London from phthisis is lower than that of England and Wales. In 1921-25 the average death-rate from phthisis at ages 5-15 in England and Wales was 164 per million as compared with 140 in London. There is in this fact prima facie evidence against any assumption of specific tubercular environment. Some part of the lower mortality among the London children may no doubt be due to the fact that deaths among London children attending special schools outside the County are not transferred back to the London population as are the deaths among London children occurring in institutions situated outside the County; but the proportion of such untransferred deaths must be quite small and hardly sufficient entirely to account for the unfavourable position comparatively of England and Wales as a whole. In the case, then, of children, or more generally of persons under 20 years of age, the highly urbanised environment of London does not appear to involve any higher mortality from phthisis. It may well be that some explanation of the high London mortality is to be sought in the nature of the changes in the London population which have been going on for many years past. London attracts the young adults of both sexes and many of them on marrying move out of the county, especially north of the Thames. It is found, by use of the London life-tables, that if there had been no outward movement among natives of London, there would have been enumerated in 1911 at the age of 35 to 45 about 325,000 males of London birth, whereas of the total male population of this age in 1911 the Census shows that only 171,787 were born in London, so that 153,213 or nearly one-half of the males of London birth had moved from the County. The proportion is about the same for females. It is generally contended that the migrating population of young ages is mainly drawn from the healthier young adults. On this assumption the immigrants would be a selected population with a low mortality rate, but it is an observed fact in actuarial experience that the initial advantage possessed by a selected population disappears in the course of time, so that at the end of 15 or 20 years there is little difference between the mortality of the selected population and that of the average. The immigrant population, therefore, at about 45 years of age will largely have lost their initial advantage and, perhaps, being unaccustomed to the London environment, even compare unfavourably with the native-born population of the same age; but if the emigrant London population is selected, the residuary population must have a higher mortality than the average, and it is probable that those emigrating do not take with them any relative who is accommodated in a London institution. It may thus be, that London is charged with a number of paupers, mental defectives, etc., which is out of proportion to the surviving population of later ages resident within the County boundary upon which mortality-rates are calculated. In this connection it is worthy of note that the proportion per thousand of population who are inmates in lunatic asylums in London is twice as great as in England and Wales, and so also is the proportion per thousand of population accommodated in poor law institutions, and the majority of these inmates are of high ages. Effect of population movements on mortality 26 That the growth of the areas immediately adjacent to the County of London has largely been due to the outward movement of the London population is exemplified by reference to the population of the County of Middlesex, which in 1871 was 242,374, while in 1911 it had increased to 1,126,465. The census of that year shows that of this population, 32 per cent, were Londoners by birth, and a considerable proportion of the remainder must necessarily be children of Londoners. A discussion of the outward movement of the London population will be found in the County Medical Officer of Health's report for the year 1913, pages 2 and 3, where it is shown that, as a result, there has been a loss of population of the younger ages in London north of the Thames. This outward movement represents a continuous loss for many years past of the young and progressive element of the population of the county, and the loss of this "selected" element may, as suggested, be accountable for some part of the excess of the phthisis mortality in the residual London population at the higher ages. In the following table the phthisis death-rates for both sexes together for London and Middlesex in the period 1920-22 are compared. The rates are per 100,000 living at each age :— The increase in recent years of phthsis among young women. Excess of Age-group. Middlesex County. London County. London rate. Excess per cent. 15-25 191 239 48 25 25-45 235 293 58 25 45-65 207 339 132 64 65+ 94 215 121 129 Attention was drawn in the annual report of the County Medical Officer of Health for 1922 (p.11) to the remarkable increase which had occurred in the mortality from phthisis among young adults. especially among young women, and the figures there given are reproduced here, together with the corresponding rates for the past three years, which show that the increased rate is still maintained. The rates shown are per 100,000 of population. Period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75Males- 1900-02 51 15 17 82 172 260 443 519 427 317 131 1911-13 37 15 17 72 148 208 320 360 364 263 150 1920-22 16 5 14 84 151 151 210 261 235 168 82 1923-25 11 5 15 75 147 154 198 225 202 141 57 Females- 1900-02 42 23 32 76 97 150 251 214 166 121 77 1911-13 32 15 35 81 96 117 159 153 127 113 66 1920-22 18 9 31 111 131 114 111 96 81 81 53 1923-25 13 8 25 106 126 109 90 80 68 50 33 Figures subsequently available relating to England and Wales show that an increase has also occurred in the country as a whole. The increase is greater in London than in the aggregate of urban and of rural districts in England and Wales. The figures for the periods 1911-13, 1920-22 and 1923-25 for ages 15 to 25 for females in the three classes of population (deaths per 100,000 living) are as follows :— Period. London. England and Wales. Urban Districts. Rural Districts. 1911-13 89 107 103 106 1920-22 122 122116 116 Increase 33 15 13 10 „ percent. 36.9 13.8 12. 6 9.2 A short life-.able for females of England and Wales for the period 1911-20 shows that the amount of migration among young women has changed somewhat from that found in the decennium 1901-10, but such changes as have occurred will not 27 support the hypothesis that diminished migration is the reason for the change in phthisis mortality among young women. A fact which appears definitely to dispose of any question of migration as the particular cause in the case of young women is that there has been a similar increase in the number of new cases of phthisis notified in London. Phthisis was not made compulosrily notifiable until 1913, and, in the first years of notification, "primary" cases did not all represent new cases; but it is reasonable to assume that the excess of primary cases in the early years relatively to later years was proportionately the same for each age-group; and in the following Table the total primary notifications between the ages 5 and 65 are taken as 1,000 for each group of years shown in order to enable the figures for the early years of notification to be used. As a check upon the result shown by the notifications, a similar procedure has been adopted with the deaths for the same period. It will be seen that the two sets of figures show very similar results. Correction has been made for changes in the population in each age-group from one period to another. Primary cases of pulmonary tuberculosis, Females. Deaths from pulmonary tuberculosis, Females. 5-15 15-25 25-15 45-65 5-65 5-15 15-25 25-45 45-65 5-65 1913-14 186 258 327 229 1,000 67 239 323 371 1,000 1915-19 173 295 328 204 1,000 77 295 324 304 1,000 1920-22 133 358 329 180 1,000 58 352 328 262 1,000 1923-25 101 394 330 175 11,000 54 378 324 244 1,000 To facilitate the consideration of this table, it may be observed that had the incidence or mortality from phthisis decreased equally in each age period, the proportion of cases and deaths in each age-group would have remained the same for each of the periods shown. The Table shows that the change in the incidence and death-rate at ages 15 to 25 have been different from that at other ages, and the table given on the preceding page shows that this difference is due to an actual and not a relative increase in phthisis among young women of this age-period. It would seem, therefore, to be clear that we are confronted with an actual increase in the incidence of phthisis among young women, and it will be inferred from the Table given on page 26 that the causes to which this increase is due commenced to operate before the War, while the percentages in the Table on page 22 appear to indicate that the change even dates back as far as the 'nineties. In this connection, it is noteworthy that it was about this time that women began to take up business pursuits as a means of livelihood, and, in the course of time, they have considerably displaced men in certain occupations and thereby reduced the wageearning power of men in certain occupations. This change appears also to have influenced to some extent their early marriage. The census of 1881 shows that, of women between the age of 20 and 25, 31.6 per cent. were married. Thereafter the percentage falls continually up to 1911, when it was 21.8 per cent. In 1921, however, there was an increase, as the figure then rose to 25.0 per cent. It 'will be noticed that, after the age of 25, when a far greater proportion of women are married, there is little evidence of increased incidence of mortality through phthisis. It is difficult to estimate to what extent the considerable employment of women during the Great War, together with the great loss of life amongst young men of marriageable age, are also factors in this connection. Cancer. There were 6,720 deaths from cancer in 1926 as compared with 6,628 in 1925, the death-rate per thousand being 1.46 as against 1.44 in 1925, and 1.21 in the ten years 1911 to 1920. In the Annual Report of the County Medical Officer of Health Vital statistics for the several metropolitan boroughs and the County of London in the year 1926. (Rates per 1,000 of civil population.) Metropolitan boroughs. (Arranged in topographical order.) Estimated civil population, 1926. Births. Deaths. Infant mortality (per 1,000 births). Measles Scarlet fever. Diphtheria. ing cough. Typhoid fever. Diarrhœa and Enteritis, age 0-2 (per 1,000 births). sis. Pneumonia. Bronchitis. Cancer. Cases of notifiable Infectious disease. (a) Scarlet fever. Diphtheria. phoid fever. Erysipelas. Puerperal fever (per 1,000 births). Cerebro spinal fever. Acute pneumonia. Western. Paddington 146,700 15.4 12.7 86 .23 .01 .14 .06 .01 25.2 .70 1.00 .75 1.67 1.37 3.18 .08 .52 6.22 .03 1.78 Kensington 179,800 15.1 12.8 61 .14 .02 .12 .04 .01 13.6 .72 .98 .94 1 .91 1.67 2.40 .17 .38 3.32 .02 .82 Hammersmith 134,400 16.3 11.4 65 .17 .01 .10 .08 - 9.1 .93 .82 .72 1.68 2.07 1.90 .06 .22 3.21 .01 .75 Fulham 164,300 16.3 10.8 66 .29 .02 .09 .06 - 12.7 .96 .83 .54 1.62 ] .90 2.11 .05 .48 5.63 .02 1.79 Chelsea 64,820 13.3 12.6 65 .25 .02 .09 .12 .02 17.4 .85 1.00 .59 1.80 1.76 3.11 .03 .53 4.65 - 2.21 Westminster, City of 138,400 11.3 11.7 61 .17 - .65 .01 .01 9.3 .85 .95 .63 1.52 .88 .1.51 .07 .29 2.50 -l .50 Northern. St. Marylebone 105,800 12.8 13.0 85 .31 .01 .09 .09 - 14.0 .94 1.06 .87 1.67 1.17 1.84 .10 .41 8.12 .02 .84 Hampstead 87,530 12.3 10.6 60 .10 .01 .10 - .01 5.6 .58 .72 .42 1.54 1.29 2.03 .14 .24 3.72 - .65 St. Pancras 216,400 16.7 12.4 75 .30 .01 .06 .11 .00 14.1 .84 .82 1.16 1.45 2.00 2.43 .06 .38 3.87 .01 1.29 Islington 339,200 18.5 12.1 69 .21 .04 .09 .08 .00 12.3 .85 1 .26 .74 1.36 2.98 2.19 .05 .35 4.31 .02 .74 Stoke Newington 53,080 15.6 11.1 49 .11 - .09 .02 .02 6.0 .96 .53 .58 1.85 3.66 1.59 .11 .36 9.67 .02 .42 Hackney 22.500 17.3 10.8 59 .05 .02 .11 .02 .02 18.0 .81 .85 .67 1.40 3.31 2.84 .04 .26 7.36 .01 .22 Central. Holborn . 43,200 12.4 12.1 90 .14 .02 .09 .02 22.4 .60 .90 1.55 1.46 2.00 1.74 .12 .32 3.75 .05 .91 finsbury 77,550 20.6 12. 9 69 .27 .03 .06 .06 10.0 1.15 1.07 1 .33 1.28 3.27 2.39 .03 .53 1.88 .01 1.11 London, City of (b) 13,520 8.0 11.0 65 - - - .07 .- 18.5 .67 .59 .44 1.78 2.89 3.71 .45 - - .67 Eastern. Shoreditch. 107,400 23.3 12.2 68 .26 .04 .12 .01 .01 10.4 1.28 1.14 .98 1.17 4.01 3.53 .06 .49 4 .01 .04 2.60 Bethnal Green 119,600 20.9 11.7 72 .36 — .18 .03 .01 15.2 1.02 1.08 .87 1.20 3.92 5.40 .12 .68 2.81 .03 1.90 Stepney 255,400 19.7 11.9 66 .26 .04 .13 .03 .02 18.6 1.05 1.25 .88 1.23 3.75 3.01 .14 .54 3.18 .02 1.04 poplar 169.000 21.9 11.5 71 .23 .02 .013 .06 .02 16.4 .80 1.21 .95 1.29 4.00 2.97 .03 .42 3.56 .02 3.16 .Southern. Southwark 188,600 20.2 13.0 70 .28 .02 .17 .03 .02 13.4 1.12 1.08 1.00 1.38 2.76 5.02 .05 .39 5.00 .04 1.40 Bermondsey 123,100 20.7 12.1 56 .19 .04 .34 .01 9.0 1.15 1.05 .80 1.28 3.51 5.82 .02 .24 3.53 .04 .92 Lambeth 311,000 17.2 11.7 55 .21 .01 .14 .07 .01 8.8 .87 .98 .67 1.60 2.41 2.32 .03 .31 6.36 .02 .71 Battersea 171,900 17.3 11.4 62 .25 .01 .12 .08 .01 9.4 .82 .86 .76 1.53 3.60 3.52 .02 .43 3.71 .01 2.25 Wandsworth 342,100 14.3 10.6 64 .16 .01 .08 .05 - 6.3 .72 .65 .60 1.45 1.89 2.29 .06 .32 3.49 01 1.45 Camber well 275,400 16.6 11.2 66 .18 .02 .21 .03 - 10.9 .92 .83 .89 1.46 3.06 3.86 .05 .44 3.72 .01 .64 Deptford 115,700 18.2 11.3 56 .27 .01 .16 .04 .02 9.0 .79 .93 .72 1.37 3.41 4.94 .02 .50 5.23 .02 .158 Greenwich 103,300 17.7 11.0 62 .14 .02 .12 .04 .01 9.2 .91 .87 .79 1.21 3.60 4.88 .0 7 .63 4.89 - 1.15 Lewisham 187,800 15.4 10.1 43 .10 .02 .06 .05 .01 4 9 .72 .85 .68 1.37 2.55 2.10 .08 .30 1.74 .01 .88 Woolwich 141,900 16.8 10.2 43 .08 .03 .07 .02 .01 5.3 1.04 .57 .73 1.39 2.83 2.55 .06 .33 1 .63 .04 1.99 London 4,605,400 17.1 11.6 64 .20 .02 .12 .05 .01 12.0 .88 .94 .79 1.46 2.68 2.95 07 .39 4.24 .02 1-22 (a)Five cases of smallpox occurred during the yrear, two in St. Marylebone, and one each in St. Pancrs, Lslington and Lambeth The Lambeth case proved fatal. (b) Including inner and Middle Temples. go 29 for 1923, page 38, it was shown that in the past 20 years the female mortality at ages below 65 years has decreased, while above that age the rate of increase has diminished. The facts are the more remarkable when it is borne in mind that it is just during this period the greatest improvement in the means of diagnosis has occurred. Much of the increase shown in the annual rates since the beginning of this century does not represent actual increase in the incidence of cancer, but it is the result of the increased proportion of persons of higher age in the London population, which has in recent years been further accentuated by the rapid decrease in the birth-rate. It is found that when allowance is made for the change in the age constitution of the population which occurred in London between the census of 1911 and that of 1921, the number of deaths among females actually decreased, while the male rate only slightly increased. Under section 37 of the London County Council (General Powers) Act, 1907, the medical officer or any person provided with his authority (in writing) may examine the person or clothing of any inmate of a common lodging house where they have reason to suspect that such person or clothing is verminous or in a foul and filthy condition. Verminous lodgers in common lodging houses. The "worker" is generally clean as far as regards body vermin. The main sources of difficulty are the shabby genteel man and the tramp. There are no figures of the actual lodgers cleansed, but the attached table shows the improvement in London, and the improvement amongst the lodgers is even more than among the population generally (the figures for children are not included). Not only are the figures less, but those actually dealt with are far less verminous. 14172 c Administration. The supervision of the 162 common lodging houses licensed by the Council under the L.C.C. (General Powers) Act, 1902, entailed 9,607 day visits and 348 night visits by the inspectors. The supervision of 35 seamen's lodging houses licensed under the Merchant Shipping Act, 1894, entailed 784 visits by day and 64 by night. Common and seamen's lodging houses. A comprehensive report on common lodging houses, with special reference to the accommodation for women, was prepared in December, 1926, and is obtainable at the Council's publishers, P. S. King and Son, 14, Great Smith Street, Westminster, S.W. 1, price 1s. 6d. A census ot homeless persons in London was taken on the night of Friday the 19th February, 1926. The area covered extended over the whole of the county, except such of the outlying portions as are not usually the resort of such persons. The night was fine and very mild. Only 3 persons (all females) were found sheltering under arches, or on staircases. In the streets 76 males and 24 females were found, as compared with 76 males and 37 females in 1925, and 296 males and 76 females in 1914, on the occasion of previous censuses. In the common lodging houses 14,593 persons were accommodated as compared with 14,425 in 1925 and 20,173 in 1914 before the war. In the free shelters and labour homes not licensed, 647 males, 125 females and 20 children were accommodated as compared with 448 males, 118 females and 23 children in 1925. The number of persons in casual wards and in the hostel under the auspices of the Metropolitan Asylums Board on the night in question was 668 (661 males and 7 females), the largest number recorded at any census since 1913. At London Rowton Houses, 5,043 men were accommodated, and there were 10 vacant beds. Census of homeless persons. co o COUNTY OF LONDON. Statistics of the administrative work carried out during the year 1926. Sanitary Authority. Cowsheds. Slaughterhouses. Offensive Trades. Smoke nuisances. Common lodging houses. Cleansing of persons and rooms. Water supply Milkshops. Ice cream premises. Restaurants and Eating Houses. No. licensed. No. of inspections. No. licensed. No. of inspections. No. lioensed. No. of inspections. Observations. Complaints. Notices. Houses licensed. Authorised lodgers. Persons. Rooms or premises. Tenement houses extra supply. No. on register. No. of inspections. No. on register. No. of inspections. No. of places. No. of inspections. Adults. Children. After infectious diseases. For vermin. City of London — 7 * — — 85 7 7 1 455 33 951 — — — 334 356 61 43 806 654 Battersea 1 12 2 271 3 10 59 2 2 3 201 229 4,371 2,354 162 31 131 731 148 451 99 295 Bermondsey - - - - 13 26 13 - - 3 1,197 182 - 1,818 411 8 206 761 92 197 135 546 Bethnal Green 11 40 3 312 9 2 22 - - 6 395 20 - - 302 - 244 809 164 367 182 583 Camberwell 1 16 2 195 11 27 67 5 5 5 438 42 3,247 3,587 187 2 440 1,435 346 486 165 224 Chelsea - - 2 133 - - 11 2 - 2 172 — 1,157 279 83 1 76 183 59 65 76 76 Deptford - - 2 76 6 14 — 2 4 1,089 — 2,068 1,591 143 15 163 272 165 235 98 172 Finsbury - - 1 65 3 31 28 18 2 2 470 30 3 996 103 5 153 177 115 129 209 226 Fulham - _ 2 117 - — 228 10 7 2 87 1 — 1,224 76 96 112 116 216 131 103 1,168 Greenwich 2 4 3 24 3 2 23 11 1 2 90 3 758 1,153 22 7 112 116 154 154 60 64 Hackney 5 79 16 469 19 40 544 29 29 4 313 80 1,435 1,826 560 6 216 1,264 268 557 117 267 Hammersmith - - 7 510 2 56 103 15 13 1 292 78 2,521 665 27 38 84 1,577 171 224 128 444 Hampstead - -__ 1 50 — — 1 1 — — — 3 1,087 — 72 26 63 174 69 88 61 104 Holborn - 1 6 - — 340 7 6 12 920 164 — 223 134 6 124 157 64 185 235 198 Islington 2 25 13 716 19 60 121 52 2 22 767 6 4,634 3,442 91 57 496 792 238 136 430 467 Kensington - - 5 326 1 43 340 3 3 7 362 146 4,197 1,285 432 134 131 636 169 183 Not st ated Lambeth 2 9 10 180 3 36 58 58 58 4 415 — — 2,637 361 53 485 2,910 170 510 180 - Lewisham 6 60 8 534 - — 12 — 2 — — — — 1,322 81 — 142 360 Not s tated 98 196 Paddington 1 10 3 200 1 65 104 13 2 3 165 10 3 Not stated 154 2 97 404 152 206 114 364 Poplar 6 35 8 14 7 18 7 56 27 6 499 76 1,523 1,467 239 — 120 414 124 205 177 128 St. Marylebone 1 21 1 96 3 70 453 4 4 5 763 3,651 2,973 802 722 18 144 340 118 200 296 1,092 St. Pannras 1 33 5 151 1 71 288 20 15 2 78 1,065 5,332 1,124 79 170 212 824 339 379 375 201 Shoreditch 2 17 2 10 3 95 25 3 3 4 281 — — 936 279 18 270 1.454 132 276 178 429 South wark - - 4 70 2 8 8 3 — 21 2,311 1,045 3,396 3,009 1,656 33 374 1,739 152 456 353 1,412 Stepney 23 59 1 1 56 178 152 29 25 25 3,595 462 — 1,655 732 3 436 1,273 265 464 321 631 Stoke Newington 1 - 4 107 - — 49 8 1 — — 1 1,395 363 119 — 62 50 26 30 31 31 Wandsworth 1 12 8 340 8 113 30 23 12 1 69 203 — 4,560 593 — 248 2,176 394 361 250 1,069 Westminster - - - - - - 2,490 62 26 5 1,619 233 920 919 13 44 496 854 141 102 444 826 Woolwich 9 261 7 28 — — 20 1 1 11 379 23 2,273 720 51 2 87 1,061 222 497 72 442 Total 75 693 128 5,001 173 951 5,695 442 235 163 17,422 7,786 44,244 39,957 7,884 775 6,256 23,415 4,734 7,317 5,793 12,309 Note.-In the columns above a dash signifies a nil return. * Continuous supervision during slaughtering. Common lodging houses, licensed number, 163; lodgers, 17,422; visits—day, 9,607, night, 348; prosecutions, 1; penalties and costs, £2 2s. 0d. Seamen's lodging houses, licensed number, 35 ; Bermondsey, 4 ; Poplar, 6 ; Stepney, 25 ; lodgers, 1,079. Visits—day, 784 ; night, 64 ; prosecutions, 1 ; penalties and costs, £5 2s. od. , Prosecutions—Smoke Nuisances: Hackney, 1; Poplar, 2. Water Supply: Hammersmith, 1; Kensington, 8; St. Pancras, 4. milkshope: Fulham, 2; St. Pancras, 2. Restaurant and Eating Houses : Greenwich, 1 ; Westminster, 1. Slaughterhouses: Shoreditch, 1. Offensive Trades : Shoreditcli, 2. 31 Persons cleansed (figures abstracted from local reports). Borough Council. 1907. 1908. 1924. 1925. Borough Council. 1907. 1908. 1924. 1925. Battersea 504 1,006 311 261 Lambeth - - - - Bermondsey 48 69 72 78 Lewisham - - - - Bethnal Green 6 — 1 7 Paddington — — 20 9 Camberwell 231 1,124 72 62 Poplar 764 876 136 69 Chelsea — — 4 10 St. Marylebone 8,592 11,304 4,387 3,978 Deptford — — — — St. Pancras 1,373 1,417 1,172 1,130 Finsbury 34 9 5 10 Shoreditch 7 — — — Fulham — — 7 5 Southwark 22 39 842 1,066 Greenwich — — 15 8 Stepney — 58 449 420 Hackney 148 225 50 77 Stoke Newington — 65 1 1 Hammersmith — — 40 90 Wandsworth 3 12 15 180 Hampstead — — 4 4 Westminster — 5 61 117 Holborn 254 226 124 124 Woolwich 62 101 27 29 Islington 9 8 10 23 Kensington — — 130 109 Total 12,057 16,544 7,955 7,867 Details as to the progress made with the several represented insanitary areas Housing and the housing schemes undertaken by the Council will be seen on reference to ActsChapter III. The Table on page 32 is in a somewhat different form from that adopted in previous years and now gives a general survey of housing conditions in London and the action taken with reference thereto by the metropolitan borough councils under the Housing Act, 1925, and the Public Health (London) Act, 1891. Detailed inspection of the premises subject to the bye-laws regulating the Poultry business of a slaughterer of poultry have been completed, and the number of such slaughtering. premises entered upon the Council's register in now 61. The subjoined Table shows the number of sanitary officers and health visitors Sanitary employed by the sanitary authorities in London :— Officers Sanitary area. Sanitary inspectors. Male. Female. Health visitors. Whole time. Part time. Whole time. Part time. Whole time. Part time. City of London 24 — 1 — — — Battersea 11 — — 2 8 2 Bermondsey 13 — — — 8 — Bethnal Green 11 — — — 11 — Camberwell 11 — 2 — 3 — Chelsea 3 — 1 — 4 — Deptford 8 — — 1 5 1 Finsbury 7 — 1 — 5 — Fulham 9 — 1 — 6 — Greenwich 5 — 1 — 9 1 Hackney 18 — 2 — 13 — Hammersmith 9 — 1 — 3 — Hampstead 6 — 1 — 3 — Holborn 3 — — 1 1 1 Islington 20 — 2 — 10 — Kensington 11 2 5 7 9 — Lambeth 16 — 2 — 4 — Lewisham 9 — 1 — 8 — Paddington 10 — 2 — 2 — Poplar 10 — 1 — 9 — St. Marylebone 8 3 — 2 4 4 St. Pancras 15 — 1 6 19 6 Shoreditch 12 — — - 6 —. Southwark 12 - 1 - 10 - Stepney 18 — — — 11 — Stoke Newington 2 1 — — 3 — Wandsworth 13 — — - 6 — Westminster, City of 11 — 1 - 7 - Woolwich 10 — 1 2 6 2 London County, 1924 315 6 28 21 193 17 Three of these are employed by a Local Health Society, which is subsidised by the Borough Council. 14172 CO to Borough. No. of houses. No. of houses inspected. No. of notices served. No. of houses repaired or nuisances remedied under P.H. Act. No. of houses repaired under Section 3 of Housing Act. Underground rooms. Overcrowding. Houses let in lodgings. No. of houses closed by owner. No. of houses for the working classes. Houses unfit for habitation. In borough. Occupied by the working classes. Complaints or illness. House to house. Under P.H. Act. Under Housing Act. Representations. Closing orders. Demolition orders. No. illegally occupied. No. closed or otherwise remedied. Instances found. No. remedied. No. on register. No. of inspections. Erected during year. In course of erection. No. made. No. of houses. No. made. No. determined. No. made. No. of houses demolished. Intimation. Statutory. By owners. By L.A. In pursuance of orders. Voluntarily. City of London 1,957 1,040 587 321 167 243 — 181 181 — — — 3 3 119 442 — 6 24 — — — — — — 19 Battersea 27,847 24,956 6,728 676 2,679 720 60 2,773 61 2 - - 5 5 85 15 - 28 tnmts. 22 - - - 1 - - 29 Bermondsey 18,252 18.102 6,039 5,405 1,733 322 4,723 1,733 3,941 5 1 1 - - 223 446 5 - 57 2 164 1 - - 102 14 Bethnal Green 18,497 Nearly all 6,672 1,014 6,712 5,323 - 8,394 - - - - ? 2 170 933 - 48 - - - - - - - - Camberwell 42.476 36,380 2,982 2,217 7,106 2,147 62 5,199 1 — 3 3 151 50 297 271 — ? ? 2 122 — — — — 8 Chelsea 11,566 2,501 1,426 Not 826 214 - 374 — — 2 2 9 9 Not s tated — 5 flats — 1 78 34 - - - - Deptford 18,122 16,300 1,237 stated 3,176 4,025 214 - 4,025 - - - - - 2 253 506 - - - - - - - - - - Finsbury 20,005 20,005 1,522 - 2,279 445 - 2,279 - - 4 4 15 15 919 3,954 — — 15 tnmts. 4 4 4 — — — 4 Fulham 27,040 20,265 2,130 223 2,153 336 2 3.072 1 1 1 1 61 32 —— — — 36 flat - - - - - - 7 - Greenwich 16,910 M'j'rity 884 — 1,249 213 - 2,000 - — — — 1 1 112 137 — 65 150 - - - - - - 3 Hackney 35,136 14,273 6,385 849 5,441 1,564 - 5,125 - — 6 - 139 20 71 72 — 57 10 9 132 — 1 - - 8 Hammersmith 18,815 12,000 6,347 214 3,322 953 - 2,697 - — 3 3 66 31 — - — 202 188 - - - - - - Hampstead 12,978 6,489 414 — 836 640 - 836 - — 34 10 2 2 - - - - - - - - - - - Holborn 3,473 8,571 tenemts 982 - 543 76 - 543 - — 2 2 4 4 577 871 — — 15 tnmts. — — — — — — — Islington 45,000 28,500 8,702 1,397 4,797 581 1 4,797 - — 10 10 26 26 1,011 3,480 l 409 24 - - - - - - 19 Kensington 30,089 9,239 2,588 2,168 4,232 1,101 37 4,187 21 5 24 22 94 65 3,768 10,630 — 30 flat,' 5 cots. 14 flats 1 1 1 — - — - Lambeth 42,607 31,955 12,083 414 5,835 3,901 413 5,878 442 1 7 7 29 29 — — — 207 138 — - — — - - 4 Lewisham Not s tated 1,410 1,296 1,734 350 - 1,734 - — 1 1 127 34 4 29 — 739 Not stated 1 1 1 — 1 —. — Paddington 17,000 9,100 2,531 — 1,750 699 457 11,281 360 — 3 2 21 9 1,406 6,635 — — - — - — 2 - — - Poplar 23,248 23,000 7,703 579 5,112 2,502 — 5,168 — — — — 19 — 13 107 — 96 103 - - - - - - - St. Marylebone 19,341 8,232 2,977 1,326 1,060 157 — 2,062 - - 12 12 6 6 - - - 20 46 - - - - - - - St. Pancras 25,216 16,000 4,438 708 3,736 1,710 447 3,494 409 - - - 19 16 721 3,547 - - - - - - - - - - Shoreditch 13,900 13,000 6,372 3,203 6,213 1,511 — 6,213 — - 1 1 191 74 307 978 - 48 152 - - - - - South wark 20,506 14,032 8,855 4,328 10,267 3,112 1 101 10,577 7 1 — — 29 29 274 274 — 32 - 9 9 — - - - - Stepney 31,673 31,673 8,160 5,216 15,138 7,923 — 13,582 — — 10 8 63 45 2,645 4,514 — 46 119 flats — — — — — 176 Stoke Newington 8,607 3,976 954 280 661 Not stated — 1,234 — — — — 1 1 92 181 — — — — - — — 2 Wandsworth 71,718 47,160 11,779 1,674 5,428 750 — 13,200 — — 15 9 222 32 265 632 1,954 180 9 12 12 - - 1 6 Westminster 27,352 11,376 1,412 555 1,074 43 — 1,053 - - 2 - 59 32 13 83 - - - 1 3 - - - - 3 Woolwich 27,685 23,153 3,543 3,214 3,819 1,327 4 3,580 - — 6 2 278 17 325 374 — 219 615 4 4 4 — — — 21 Total 677,016 451,278 127,842 40,453 109,927 39,077 7,307 127,272 5,424 15 147 100 1,640 589 13,670 39,111 6 4,252 1,872 36 530 57 4 1 110 316 Note.—In many cases, it has baen impossible to take effective action in the matter of overcrowding owing to the shortage of houses. In addition, 1,684 notices were served under bye-law. Prosecutions—Houses Lei in Loi'jinjs: Hilbjrn, 4; Kensington, 9(3; Paddington, 11 ; Poplar, 1 ; Shoreditch, 20; Stepney, 2. ,, Overcrowding : Fulhu.m, 1 ; Hammersmith, 2 ; Holborn, 1 ; Konsington, 1 ; Shoreditch, 1 ; Woolwich, 2. 33 Venereal Diseases. The number of new cases of venereal disease dealt with by the hospitals under the London and Home Counties Scheme during 1926 was 17,724, of which 5,738 were syphilis, 11,683 gonorrhoea, and 303 soft chancre. Comparing these figures with those of the previous year it will be observed that the total number of new cases dealt with is 222 more than in 1925. Year. Syphilis. Gonorrhoea. Soft chancre. Non-venereal. Total. 1925 5,902 11,321 279 8,680 26,182 1926 5,738 11,683 303 8,988 26,712 Increase+ or decrease +362 +362 +308 +530 The distribution of new cases of venereal disease between the sexes is shown in the following table, the figures for the preceding years being given for comparison. It will be seen that in the case of syphilis the figures for 1926 are the lowest recorded since the scheme first came into operation. New cases. , Total venereal Year. Syphilis. Soft chancre. Gonorrhoea. cases. M. F. M. F. M. F. M. F. 1917 4,427 3,351 199 11 3,830 1,207 8,456 4,569 1918 3,764 3,002 116 13 4,844 1,940 8,724 4,955 1919 6,394 3,391 463 18 10,441 2,440 17,298 5,849 1920 6,988 3,579 766 25 10,669 2,427 18,423 6,031 1921 5,088 3,100 458 13 8,573 2,136 14,119 5,249 1922 4,207 2,600 309 12 8,233 2,402 12,749 5,014 1923 4,497 2,631 311 4 9,043 2,520 13,851 5,155 1924 4,174 2,452 301 4 8,565 2,785 13,040 5,241 1925 3,556 2,346 268 11 8,464 2,857 12,288 5,214 1926 3.725 2,013 301 2 8,825 2,858 12,851 4,873 Importance is attached to the necessity of securing the regular attendance of patients at the clinics, more especially in the case of gonorrhoea, and efforts to secure the requisite provision of facilities for intermediate treatment at times other than during the hours of the clinic are meeting with considerable success. A number of patients still fail to complete the full course of treatment considered necessary before final discharge, due in no small measure to the false impression that a cure has been effected on the disappearance of outward signs of the disease. The need for improving conditions likely to cause patients to discontinue attendance at the clinics or to transfer them from one clinic to another continues to receive careful attention. The total attendances were 687,075, and the ratio of attendances to venereal cases is in the proportion of 38 attendances to each new case. This figure shows a considerable advance over that for previous years and is noteworthy when it is borne in mind that in those countries where venereal diseases are compulsorily notifiable, the ratio of attendances to new cases has never been greater than the figures which are shown for London under the voluntary system adopted in this country. Comparative figures for the ten years during which the scheme has been in force are shown in the following Table :— Ratio of attendances. 34 New cases. Year. Attendances, In-patient days. Venereal. Non-venereal. Total 1917 13,025 2,360 15,385 120,659 63.923 1918 13,679 2,693 16,372 169,485 66,095 1919 23,147 5,118 28,265 307,722 73,211 1920 24,454 6,592 31,046 464,033 81,612 1921 19,368 6,050 25,418 496,209 79,692 1922 17,763 5,950 23,713 529,003 112,564 1923 19,006 6,644 25,650 555,509 106,662 1924 18,281 7,292 25,573 589,002 102,456 1925 17,502 8,680 26,182 646,131 102,454 1926 17,724 8,988 26,712 687,075 101,735 Attention is also drawn to the very large number of non-venereal patients who present themselves for examination. This appears to indicate quite clearly that the general public is appreciating more and more the efforts which have been and are being made to spread far and wide a knowledge of the serious nature and grave after effects of the venereal diseases. Pathology und bacteric logy. Another point worthy of note is the total number of examinations made of pathological specimens. Comparative figures for the ten years are shown in the following Table :— Year. Pathological examinations. For treatment centres. For private practitioners. 1917 13,988 3,649 1918 25,973 6,380 1919 51,554 10,464 1920 58,920 14,027 1921 66,134 18,472 1922 74,022 19,836 1923 69,784 24,403 1924 79,005 24,797 1925 106,064 26,346 1926 100,543 27,565 The increased use made by medical practitioners of the facilities for the examination of pathological specimens is highly satisfactory. Under the Scheme, medical practitioners who fulfil certain conditions are entitled to free supplies of the approved arseno-benzol preparations for the treatment of their private patients. The number of medical practitioners availing themselves of this service is now 439 as compared with 108 at the end of 1917, the first year of the operation of the Scheme. Hostel accommoda- A The necessity was recognised from the outset for accommodation where young women and children under treatment could be lodged during the period of infectivity. Certain hostels managed by or independently of hospitals have received grants in aid for this purpose, and experience has proved the value of these hostels for the more efficient treatment of certain cases and for preventing the spread of disease. During the year 1926, the number of patients dealt with at these institutions from the areas in the scheme was 298, the aggregate number of davs in residence being 24,603. Tuberculosis dispensary service. The Council s Tuberculosis Scheme. Detailed information has been furnished by the Metropolitan Borough Councils as to the work of the tuberculosis dispensaries, including particulars as to the numbers of new cases and " contacts " examined and the number of home visits, etc. This information is summarised in the Table on pages 36 and 37. Afterhistories of adult tuberculous p&titntB. An investigation has been made into the after-histories of adult patients treated in residential institutions during the year 1922. The results do not reveal any marked difference as regards mortality percentages, etc., from those ascertained in connection with previous similar enquiries. 8-5 Particulars obtained as to the fitness for work of the 1,510 surviving patients who were discharged from treatment in 1922 show that out of a total of 563 A and B1 cases, 63 per cent, were at work, and this must be regarded as a satisfactory testimony to the value of sanatorium treatment when applied to cases in the early stages of the disease. The percentage at work in the other categories is as follows :— B2, 23-6 per cent.; B3, 16-7 per cent. ; and surgical, 56-5 per cent. These results are better than might have been anticipated. Of the total number of 1,510 in all categories, 48-6 per cent, were at work, 5-6 per cent, were fit for wTork, but were unemployed, 43-7 per cent, were unable to work (including cases receiving further residential treatment) and the condition of the remaining 2-1 per cent, was unknown. In a previous report (1924) reference was made to investigations which had been carried out into the question of the use of artificial light for the treatment of tuberculosis. The opinion was expressed that the value of such treatment in suitable cases was proved, but that the knowledge and experience available was insufficient to define accurately the limits of usefulness of this form of treatment. Artificial , light treatment. Arrangements have accordingly been made by the Council tor an experimental scheme to be put into operation which will enable the Metropolitan Borough Councils to utilise as a part of the tuberculosis dispensary services, the facilities for artificial light treatment at certain hospitals and centres throughout London, approved by the Minister of Health and the Council. During the year 1926 the Council has approved proposals submitted by ten borough councils for utilising the facilities available under the scheme. In. view of the shortness of the time during wThich the Scheme has been in operation and the present limited scope of the arrangements it has been decided to extend the experiment for another year. It is probable that a number of other metropolitan borough councils will wish to participate in the scheme during the coming year. The question of the employment of tuberculous persons continues to receive unremitting attention. In the competition of the labour market the tuberculous patient is always at a disadvantage as compared with the healthy person and his difficulties are intensified in conditions of wide-spread unemployment, such as prevail at the present time. Nevertheless the tuberculosis care committees continue to do useful work in assisting patients to get in touch with employers who can offer suitable employment. Employment of tuberculous p. rsons. This work has been facilitated by the institution of a scheme of co-operation between the Employment Exchanges and the tuberculosis dispensary service with a view to enlisting the aid of employers of labour. Arrangements have been made, subject to the concurrence of the patients, for the tuberculosis officers to furnish medical certificates as to the degree of fitness of patients for employment. Reference may here be made to the useful work carried on by the Central Fund for the Industrial Welfare of Tuberculous Persons at the Spero Leather Workshop, Hatton Garden. At this workshop about twenty-five tuberculous ex-service men, most of whom have first received a period of treatment for tuberculosis and training in leatherwork at King George V Sanatorium, Godalming, are engaged in the manufacture of leather goods. The men work under regular medical supervision at the workshop and their cases also receive special attention from the tuberculosis officers and the tuberculosis care committees. A second scheme devised on similar lines has been launched by the Central Fund at the Spero Firewood Factory, King's Cross. Here about twenty ex-service pensioners are at work, chopping and bundling firewood. It may be mentioned that the Council has been able to assist this venture by placing with the Committee of the factory a large order for firewood for use in the Council's institutions. Mention may also be made of an experiment which has been successfully tried of employing four tuberculous patients in the Council's Parks. The men engaged were selected after consideration of reports from the tuberculosis officers. As a result Tuberculosis Dispensaries—Analysis of Returns, Jan.-Dec., 1926. Borough and Dispensary. On Dispensary Register, 1-1-26. Transferred during 1026 from other areas and lost sight of cases returned Examined for first time during 1926. (a) New eases excluding contacts. (b) Contacts (printed in italics). Total number (including contacts) under dispensary supervision during 1926. Removed from Dispensary Register during 1926. On Dispensary Register on 31-12-26. Total attendances. Visits to homes for dispensary purposes by No. of specimens of sputum examined. Diagnosis completed. Under observa tion. Pulmonary. NonPulmonary. Doubtfully Tuberculous. Non1 Tuberculous. Total. (o) Cured. (») Diagnosis not confirmed or nonT.B. (printec in italics) («) Transferred to other areas or lost sight of. «>) Died (printed in italics). Diagnosis completed. Under Observation. Adults. Children. Adults. Children. Adults. Children. Adults. Children. Adults. Children. Tuberculosis Officer. Dispensary Nurse. Battersea 843 301 11 147 6 15 23 94 73 171 131 427 233 2,027 39 90 876 243 4,686 142 5,294 1,504 3 2 1 1 9 12 71 113 84 128 679 100 Bermondsey 1,221 12 36 116 5 6 27 131 58 68 61 321 151 2,117 82 95 1,156 42 4,680 119 3,913 968 2 14 11 S6 263 100 276 639 103 BethnalGreen 856 13 7 89 1 16 13 33 11 251 106 389 131 1,604 9 313 612 10 4,027 153 1,587 772 3 1 9 3 82 110 94 114 578 82 Camberwell 2,003 54 11 256 8 48 33 176 28 473 460 953 529 4,225 101 158 2,003 45 8,574 1,203 6,310 1,930 3 1 5 11 3 186 467 200 475 923 1,744 174 192 30 3,434 41 3,531 374 Chelsea 443 17 10 41 2 53 5 105 121 199 129 1 32 1 1 2 1 43 77 46 79 639 29 729 60 3,777 132 4,515 1,179 Deptford 918 32 12 94 6 8 8 175 125 38 114 315 253 1,676 121 122 1 32 13 26 74 58 88 566 78 432 27 4,387 409 2,799 408 Finsbury 426 10 5 40 3 4 9 4 6 70 42 118 60 850 9 19 16 2 1 6 4 13 78 111 99 132 301 62 Ftilham 1,125 43 15 150 15 14 34 72 52 215 248 451 349 2,388 42 136 1,117 54 5,156 411 5,355 810 5 2 1 7 2 10 142 236 150 255 932 107 Greenwich 529 16 9 59 19 9 13 5 9 114 76 187 117 1,343 635 16 607 21 6,034 191 4,404 148 22 6 2 3 2 .5 209 236 235 250 64 Hackney 1,764 22 29 160 5 9 24 61 18 253 191 483 238 2,987 11 455 1,188 20 7,257 260 3,673 1,087 9 2 1 3 11 5 195 225 216 235 1,197 116 Hammersmith 802 22 11 125 3 22 23 13 3 133 94 293 123 1,344 65 66 660 26 2,850 188 3,942 513 8 2 1 1 1 35 45 44 49 454 73 Hampstead 200 10 77 52 3 3 4 4 43 41 102 48 549 36 61 225 23 1,154 1,308 301 8 1 3 4 3 48 45 61 51 181 23 Holborn 292 1 5 30 3 1 4 5 6 4 4 7 44 17 425 1 75 194 1 872 73 1,140 176 2 5 21 35 29 37 147 7 Islington 1,168 9 34 268 5 28 20 36 15 260 90 592 130 2,410 47 120 1,187 62 10,038 588 2,316 968 20 3 4 7 9 170 264 200 277 814 180 36 co Kensington 1,258 45 49 133 7 7 13 61 21 107 87 308 128 2,293 107 92 1,222 31 3,517 98 2,344 501 1 3 5 12 231 253 236 269 761 77 Lambeth 2,100 54 35 305 12 42 37 79 17 665 303 1,091 369 4,052 48 213 2,101 157 9,522 396 4,515 1,385 40 6 3 5 17 10 131 185 191 212 1,315 188 Lewisham 768 7 45 153 4 16 18 21 8 104 100 294 130 1,426 19 56 851 18 3,073 335 2,244 120 4 1 3 3 69 102 73 109 389 93 Paddington 852 25 66 130 2 21 57 104 44 88 97 343 200 1,883 10 84 983 45 11,670 688 3,725 338 13 1 3 35 18 20 171 136 205 192 685 76 Poplar 930 16 49 130 10 10 17 62 102 297 302 499 431 2,337 44 45 967 190 5,521 184 8,597 2,065 12 2 2 6 13 13 147 217 174 238 1,001 90 St. Marylebone 339 32 12 63 3 2 2 48 25 36 15 149 45 664 11 25 228 106 3,316 212 1,242 230 3 3 2 9 25 16 29 28 59 265 29 St.Paneras 590 73 48 163 5 10 11 88 31 86 117 347 164 1,396 10 118 734 73 4,533 145 4,580 804 6 o 1 8 6 41 no 55 119 410 51 Shoreditch 530 13 2 107 5 4 9 19 5 111 48 241 67 1,159 11 15 567 34 6,086 367 2,705 620 21 1 3 3 7 102 169 127 179 430 102 Southwark 561 60 5 170 7 19 27 25 11 163 52 377 97 1,331 111 46 588 41 5,106 46 3,927 550 1 1 1 2 2 62 162 65 166 447 98 Stepney 1,395 96 21 255 18 15 19 97 34 353 361 720 432 3,698 56 61 1,552 85 8,896 241 6,129 1,912 12 7 6 3 19 28 433 526 470 564 1,839 105 Stoke Newington 221 3 9 38 1 2 3 15 10 26 6 81 20 394 5 36 221 5 1,183 47 521 252 1 2 3 25 29 28 32 107 20 Wandsworth 1,703 53 60 256 21 24 19 160 02 90 151 530 253 3,193 102 108 1,262 73 5,992 341 5,429 1,865 8 1 250 335 258 336 1,487 161 Westminster 683 1 2 139 1 8 7 1 76 50 223 59 1,130 253 104 711 1 2,697 46 4,144 223 27 3 5 37 90 67 95 61 Woolwich 2,121 35 12 204 24 14 20 80 41 387 408 685 493 3,690 99 49 2,210 21 7,314 511 3,624 412 5 2 1 3 5 144 184 152 192 1,162 149 Totals 26,611 1,075 687 3,873 198 380 496 1,722 823 4,787 3,879 10,762 5,396 53,514 1,197 2,810 25,375 1,514 145,352 7,567 103,813 22,405 2,53 45 31 106 211 229 3,251 4.828 3,745 5,208 20,090 2,498 38 of a year's experience of the scheme it would appear that the value of these men's work does not exceed three quarters of that of an ordinary park labourer. Authority has been given for the number of tuberculous men employed in the Parks to be increased to twelve, but future appointments will be limited to employees and exemployees of the Council. Tuberculosis Care Committees. The successful working of the Tuberculosis Scheme is enhanced by the unobtrusive, but efficient, work of the Tuberculosis Care Committees and their voluntary workers. The value of the work is often not realised as it is rarely reported officially. The difficulties of tuberculous persons, great as they are, would be much greater were it not for the valuable work of the Care Committees in enlisting on their behalf the assistance of all available official and voluntary agencies. The sympathetic friendship of the Care Committee Visitors and their personal interest in the problems and distress of a family are welcomed and frequently many visits to the home are necessary to solve these difficulties. Handicraft class for dispensary patients.—As a result of the initiative of the Lewisham Tuberculosis Care Committee a handicraft class has been held at the dispensary which is attended by about eighteen patients of both sexes who have been specially selected by the Tuberculosis Officer. The class has been approved by the Council's Education Committee under the arrangements for conducting classes in connection with clubs and social agencies and the salary of the instructress is paid by the Council. No cost falls on the dispensary service. The handicraft at present practised is the making of leather goods. The scheme is not intended primarily to provide patients with a means of earning but rather to give them a new interest and to afford them some occupation. There is evidence that the class is serving a useful purpose and is psychologically advantageous to the treatment of the patients. Boarding-out of contact cases. In April, 1925, a scheme was put into operation for removing children from heavily-infected and overcrowded homes in which a member of the family was suffering from advanced pulmonary tuberculosis. Up to 31st December, 1926, 688 applications were received, and 324 children boarded out. The remainder were withdrawn by their parents or were found to be unsuitable. Most of the homes from which the children are drawn are economically much below the average as a result of the illness in the family, and many of the children are badly dressed and cared for. In addition to the great physical benefit obtained for the children by removing them from close association with advanced consumptives, there is a great gain, morally and socially, derived from their residence, even though it be but temporary, in clean, healthy homes in the country. It is not possible to make a definite statement of the physical benefit gained by the children, as they are not ailing when sent away, but there is no doubt that their general health improves and that their resistance to infection is increased. Tuberculosis, residential treatment. There has been a steady increase in the number of applications for the residential treatment of adults under the Council's Tuberculosis Scheme during the last few years. This may be attributed in part to the activities of the tuberculosis dispensary service and in part also to the pressure for the provision of residential accommodation other than in Poor Law infirmaries for advanced cases. On the other hand, as was to be expected, the number of new cases accepted by the Ministry of Pensions for the first time as suffering from tuberculosis due to war service is a steadily declining figure. The following table indicates the figures for the last five years :- Applications for first period of treatment Applications for further treatment. Total Civilian Civilian applications. ex-Service. civilian' male Female. ex-Service. civiliam male female. 1922 415 1,597 1,338 801 .347 397 4,896 1923 373 1,730 1,561 748 381 330 5,123 1924 363 1,823 1,705 714 560 469 5.634 1925 381 1,929 1,829 598 605 527 5,869 1926 128 2,262 1,864 478 693 582 6.007 39 As a result of the growing demand for beds for the more advanced cases, the accommodation for this class has been supplemented by the Metropolitan Asylums Board at a hospital at Grove Park, Lee, containing 151 beds for men and 171 beds for women, of which 11 beds for men and 12 beds for women are reserved for surgical cases. The surgical beds are used partly for observation purposes to determine the suitability of patients for treatment at such institutions as St. Luke's Hospital, Lowestoft, so as to avoid the occupation of surgical beds in sanatoria by chronic hopeless cases instead of cases where the prognosis is favourable. It should be noted, however, that most of the institutions used by the Council for " advanced " cases are not entirely reserved for this class. The accommodation and equipment are so arranged as to permit of the effective treatment of a proportion of moderately advanced and even early cases. This, to some extent, obviates the depressing atmosphere resulting from the congregation of large numbers of hopeless cases. Of the 6,007 adult cases recommended for residential treatment during 1926, 5,323 were accepted, 45 were subsequently withdrawn and 639 were refused. The decision in 114 of these cases was made after examination of the patients by medical officers of the Council. The 5,323 cases were disposed of as follows :— (a) 1,329 were passed for admission to " observation " beds in the first instance to determine diagnosis or suitability for sanatorium treatment; (b) 3,994 were passed for direct admission to sanatoria or hospitals. Of the foregoing accepted cases, 421 for various reasons failed to enter institutions and 77 were awaiting vacancies at the end of the year. The cases referred to "observation" hospitals were generally (1) patients in whom the diagnosis of tuberculosis was doubtful; (2) acute cases; and (3) patients with well-marked symptoms whose suitability for sanatorium treatment could only be satisfactorily determined after a period of observation in hospital. During the year 1,288 patients were discharged from" observation beds" and their classification was as follows. The corresponding figures for 1925 in pulmonary cases are also given :— Pulmonary 1926. 1925. Group A 352 (37.65%) 374 (34.82%) Group B1 58 ( 6.20%) 66 ( 6.15%) Group B2 413 (44.17%) 465 (43.30%) Group B3 112 (11.98%) 169 (15.73%) Total pulmonary cases 935 1,074 Surgical cases 13 31 Total diagnosed as tuberculous 948 1,105 For definition of classification see table below. In the remaining 340 cases the diagnosis of tuberculosis was not confirmed. Of the 948 cases definitely diagnosed as tuberculous, 687 pulmonary cases were sent to sanatoria, 107 to institutions for advanced cases, 13 died in the "observation" hospitals, 4 cases were transferred to surgical institutions, and 137 were discharged home or arrangements made for them independently of the Council's Tuberculosis Scheme. The total number of adults admitted to institutions during 1926 was 5,203 as against 4,934 in 1925. 1,668 were under treatment at the commencement of the year so that the total number of adults treated in 1926 was 6,871 as against 6,557 in 1925. The number of adults under treatment on 31st December, 1926, was as follows (the corresponding figures for the previous year are shown in brackets) :— 40 Discharged soldiers. Civilian adults. Totals. Voluntary institutions 104 (154) 421 (560) 525 (714) Metropolitan Asylums Board institutions 55 (83) 1,261 (871) 1,316 (954) Total 159 (237) 1,682 (1,431) 1,841 (1,668) The immediate results of the treatment of patients discharged on completion of courses of treatment during 1926 are indicated below. For the purpose of this table patients of 15 years of age are regarded as adults, owing to the "age" division of patients required for the purposes of the Ministry of Health, although treatment for them was arranged in institutions for children. Classification. Immediate results of Surgical. Totals. treatment. A. B1. B2. B3. Quiescent 135 42 29 - 81 i287 Much improved 349 215 1,093 29 265 1,951 No material improvement 102 38 1,473 422 56 2,091 Died in institutions 4 2 50 395 11 462 Totals 590 297 2.645 846 413 4.791 A"are cases in which tubercle bacilli have not been demonstrated in the sputum, B1 are early cases, B2 are moderately advanced cases and B3 are advanced cases. With regard to children, the number recommended for treatment under the Council's Tuberculosis Scheme during each of the last five years was 972 in 1922, 865 in 1923, 1,019 in 1924, 1,025 in 1925, 1,163 in 1926. The increase from 1924 onwards may be attributable partly to the fact that cases formerly sent to Metropolitan Asylums Board institutions through the Poor Law Guardians are now referred to the Council, partly to the increased facilities for prompt treatment now available under the Council's Tuberculosis Scheme and partly to the additional cases dealt with directly by the Council owing to the termination of the agreement with the Invalid Children's Aid Association for the "Convalescent" treatment of tuberculous children. There is now no waiting list, either for 'pulmonary or surgical cases in children. In dealing with surgical cases it was found that there was great need for expediting the admission to residential institutions of children suffering from acute conditions, e.g., from tuberculosis of the hip, spine and other joints. By arrangement with the Metropolitan Asylums Board it is now possible for the Council to secure the admission of these cases immediately to Queen Mary's Hospital, Carshalton, or Princess Mary's Hospital, Margate, and the authorities of certain voluntary institutions, for example, Lord Mayor Treloar's Hospital for Cripples, Alton, and Heatherwood Hospital, Ascot, are also co-operating with the Council in bringing these cases under prompt treatment. The attention of the staffs of the Metropolitan hospitals has been drawn to these facilities and they have been invited to report to the Medical Officer of the Council by telephone on such cases coming under their notice. Arrangements have been made for the immediate admission direct from the hospitals to one of the institutions mentioned of all cases so reported. In fact it may be stated that practically all serious cases of surgical tuberculosis in children are now dealt with under these special arrangements. Of the 1,163 children {i.e., patients under 16 yearsof age) referred to the Council in 1926, 1,137 were accepted for treatment, 26 were not accepted or were withdrawn; 55 of the accepted cases for various reasons failed to enter institutions after acceptance. There were 182 children under treatment in voluntary institutions and 610 in Metropolitan Asylums Board institutions on 1st January, 1926 (total 792) and 1,082 children were admitted during the year, making in 1926 the total number of 41 children treated 1874 as against 1,661 in 1925. The number of children under treatment on 31st December, 1926, was 880, distributed as follows :— Metropolitan Asylums Board Institutions 678 Voluntary Institutions 202 The condition of the children under 15 years of age who were discharged from residential institutions in 1926 is indicated in the following table (children of 15 years of age are included with adults owing to requirements of the Ministry of Health):— Classification. Immediate results of Surgical. Totals. treatment. A. B1. B2. B3. Quiescent 83 1 2 - 245 331 Much improved 62 2 14 2 260 340 No material improvement 25 - 3 27 40 95 Died in institution 3 - - 14 20 37 173 3 19 43 565 803 Since 1916 tuberculous children who could be satisfactorily treated in "convalescent" institutions have been sent away through the Invalid Children's Aid Association with the financial assistance of the Council in the form of grants representing roughly 75 per cent. of the net cost to the Invalid Children's Aid Association. These grants have been paid out of a special fund known as the "Tuberculosis Contributions Fund" into which contributions made to the Council by parents towards the cost of sanatorium treatment of their children were paid. This arrangement had to be terminated in consequence of a decision of the Treasury, conveyed to the Council by the Ministry of Health, on 10th February, 1926, that as from 1st April, 1925, parents' contributions in respect of sanatorium treatment were to be paid into the County Fund in relief of the cost to the Council of such treatment. The agreement with the Invalid Children's Aid Association for dealing with convalescent cases was formally terminated at 31st July, 1926, but the Association completed treatment for the children who had been sent away before that date and who were not then fit to return home. During the transition period between 1st April, 1925, and 31st October, 1926, the grant to the Invalid Children's Aid Association for " convalescent " cases was met from the County Fund. It has been arranged that the balance of the Tuberculosis Contributions Fund remaining at 31st March, 1925, amounting to some £18,000, shall be used for ancillary purposes connected with the treatment of tuberculosis which are not provided for in the scheme of the Council. These include such items as the supply and repair of surgical appliances required for tuberculous children who are receiving out-patient treatment, clothing required to enable children to go away to sanatoria or to return home, and the boarding-out of children living in overcrowded conditions with persons suffering from advanced tuberculosis. This work continues to be undertaken by the Invalid Children's Aid Association. In addition to the foregoing arrangements for residential treatment of tuberculous children the Council has established five open-air day schools for children suffering from pulmonary tuberculosis or from tuberculous glands with no open wounds who do not appear to require treatment in residential institutions. Two additional schools will be provided in 1927. The work of these schools is dealt with in the section of this report dealing with the school medical service. Poliomyelitis. By an arrangement with the Metropolitan Asylums Board 50 beds are available at Queen Mary's Hospital, Carshalton, for the treatment of cases entering upon the second stage of the disease (deemed for this purpose to be three months after onset) and also of those requiring correctional operations from resulting deformities. 42 The cost of treatment is borne by the Metropolitan Asylums Board, but certain cases are assessed and the amount collected as contributions, less a small charge for the expenses incurred in collecting, is handed over to the Board. This arrangement has been in force since September, 1924. Up to 31st December, 1926, 59 cases have been sent to Carshalton for treatment. Steps have been taken to bring these facilities to the notice of the surgical staff of all Voluntary Hospitals in London, with a view to ensuring that cases are recommended for treatment while in the early stages of the disease. Report on the Diagnostic and other work of the Bacteriological Laboratory. During 1926 a total of 11,125 specimens of material sent for bacteriological, microscopical or bio-chemical report were examined, as compared with 10,710 in 1925. In addition, special investigations included :— (a) Milk.—A full inquiry as to the cleanliness and bacterial content, chemical analysis and microscopical examination of 68 samples of milk supplied to the Claybury Mental Hospital—the subject of a detailed report to the Hospital Committee on 19th April, 1926. (b) Swimming-bath Water.—Quantitative bacteriological examinations were made of 42 samples of water from the four swimming baths at Peckham Park, Highbury Fields, Tooting and Southwark Park, taken in the course of ten visits paid during the months of July, August and September, for the purpose ef comparing the degree of bacterial pollution of water treated by filtration, chlorination and aeration in the baths supplied with the special plant of the Turnover Filter Company at Peckham Park and Highbury Fields, with that of untreated water contained in the baths at Tooting and Southwark Park, where renewal of water is the only means of removing bacterial impurity. The comparison from the bacteriological standpoint was entirely in favour of the use of the filter plant. Particulars were included in a combined chemical and bacteriological report made to the Parks Committee (No. 416) on 28th January, 1927. To meet the requirements of all the bacteriological work involved, a total of close on 11,000 tubes of serum and other media and over 80 plates of various culture media (a larger number than in any previous year) were prepared by the two laboratory assistants. imary of I. Diphtheria.—A total of 9,039 cultures from throat and nose swabs, over 1,000 ,lne more than in any previous year (in 1925, 7,910), were examined, yielding 766 or s. 1 8-5 per cent, in which the diphtheria bacillus was found, 22 or -3 per cent, reported as " suspicious," and 8,251, or 91-2 per cent, negative results. The average number of cultures examined daily amounted to close on 29, and the largest number in one single day, 105 ; in one month (December), 1,304. These examinations were the outcome of 433 visits during the year, paid by school doctors or nurses to separate departments of 233 schools, in the course of which some 47,000 children were examined (as compared with 43,000 in 1925), mainly in the boroughs of Southwark, Bermondsey, Camberwell, Deptford and Wandsworth, south of the river; Islington in the north, and Bethnal Green and Stepney in the east end. In all, 569 new " carriers " of the diphtheria bacillus were identified bacteriologically in 1926. In addition, the importance of ascertaining the virulence of diphtheria cultures from certain selected chronic carriers among the school children, involved the work of obtaining the diphtheria bacillus in pure growth by repeated sub-culture, in 110 cases. Of the pure cultures, thus isolated and sent to the Clinical Research Association for the necessary animal inoculation tests, 73, an unusually high proportion, were reported virulent and 37 avirulent. In the case of the latter, known to be harmless and incapable of causing clinical diphtheria, it was therefore safe to allow 43 the immediate return to school of the children concerned. Reference is made in my report as the School Medical Officer to the arrangements with the authorities of Guy's Hospital for treatment of the chronic virulent carrier, a problem which has for so long defied solution. II. Ringworm.—out of selected samples of hair from 1,954 children, examined for ringworm fungus in 1926 (as compared with 2,642 examinations in 1925), a total of 1,253 were negative, 10 unidentified fungus, and 691 positive (35 per cent.), as against 40 per cent, positive in 1925. The varieties of fungus identified in the 691 positives were :—Small spore (Microsporon Audouini) 84 per cent., large spore (Megalosporon Endothrix) 13-4 per cent, and 2.6 per cent. Favus (Achorion Schoenleini). III. Cerebrospinal fluid.—As an important aid to the clinical diagnosis of notifiable and other diseases of the central nervous system, the routine examination during 1926 was undertaken of 103 specimens of cerebro-spinal fluid from 93 cases, 68 of these were sent from the Fulham Hospital, 25 from St. James' Hospital, Balham, 4 from Highgate Hospital and 6 from private patients. A detailed account of the significance of the cytological, chemical and bacteriological changes affecting the cerebro-spinal fluid, and the value attaching to them in the differential diagnosis of encephalitis, the different forms of meningitis, including cerebro-spinal and tuberculous, and of various cerebral lesions, has appeared in previous Annual Reports, and therefore the points already discussed need not be repeated. The specimens examined may be grouped under the following headings based on the ultimate diagnosis of the several cases :— 1. Encephalitis Lethargica.—Five specimens from five cases (ages 4, 6, 8, 24 and 63 years) in which, by the absence of any marked departure from the normal, the laboratory examination confirmed the original diagnosis in three, and contraindicated the suggested diagnosis of meningitis in two—subsequently supported by post-mortem examination in three fatal cases, and by the further course in two cases, which made apparent recovery. Encephalitis lethargica. 2. lubercutous Meningitis.—18 specimens of cerebro-spinal fluid were examined from 18 patients, whose ages ranged from 9 months to 59 years—five being under 5 years, three aged 5-10 years, seven aged 10-20 years and three aged 26, 53 and 59 years. Sex incidence was evenly distributed. The duration of illness from onset of symptoms to death was stated in 16 cases, to be three weeks in seven; two to three weeks in three ; and one to two weeks in six. The provisional diagnosis suggested in hospital was tuberculous meningitis in nine cases, meningitis (?) in three. Encephalitis, uraemia, meningeal haemorrhage and meningismus were diagnosed respectively in four cases. No diagnosis was stated in two cases. Characters and composition of the eighteen specimens of fluid were as follows :— Tuberculous meningitis. Naked eye appearance.—Slight turbidity in 11, clear in 5, blood-tinged in 2, fine clot formation in 14. Cytology.—Marked lymphocytosis in all, cell counts in three specimens showed 104, 150 and 370 cells per c.mm. Tubercle bacilli.—Were identified in film preparation from the clot or cell deposit in fifteen specimens or over 83 per cent. Chemical composition.—The protein content was in excess of the normal (•01 to -02 per cent.) in all, ranging from -04 to 1-8 per cent, with an average of 42, and excess of globulin was also invariable. Dextrose was not quantitatively estimated, but was roughly determined to be below the normal (•7 per cent.) by the amount of reduction of Fehling's fluid, as absent in five, very faint trace in six, faint trace in five, and definite trace in one specimen. Chlorides in three specimens amounted to -64, -64 and -58 per cent. 44 In eight cases consent for post-mortem examination was obtained, and the typical appearances of tuberculous meningitis were found. The identification of tubercle bacilli in the fluid of 15 cases during life had however already definitely established the diagnosis, and in the remaining three, in which bacilli were not found, the diagnosis was on the whole in favour of tuberculous meningitis from the high lymphocyte and protein content, but remained doubtful until verified by postmortem examination. Cerebrospinal meningitis. 6. Cerebrospinal Meningitis.—1,5 specimens of fluid were examined from seven patients; one aged 20 and the others aged six or under, in whom the diagnosis of meningitis had already been made in hospital, but information as to the type of infection could only be provided by bacteriological examination. The characters of the fluid in the acute stage were distinctive, showing marked turbidity, heavy deposit of polymorph cells, with the presence of gram negative diplococci in film preparations of the cell deposit, and the meningococcus was obtained in pure culture in three of the cases ; the remainder proving sterile. The protein content ranged from .13 to .75 per cent. yielding an average of .32 per cent., and globulin was present in marked excess. Dextrose was usually absent; in three cases there was a very faint reduction of Fehling's fluid—chloride estimation in three specimens amounted to .7, .58 and .64 per cent. In the later stages of the disease, which resulted in recovery after three months in two cases, polymorph cells were replaced by lymphocytes, and only a very few degenerate meningococci were visible, whilst cultures proved sterile. In the five fatal cases, death occurred 6 days, 16 days, two months and three-four months after first onset of symptoms. Post-mortem examination, which was allowed only in one case, showed typical cerebro-spinal meningitis, and diagnosis of the other cases was based on the result of examination of the cerebro-spinal fluid. The meningococcus (diplococcus intracellularis meningitidis of Weichselbaum) is held responsible for two types of meningeal infection. The one known as cerebrospinal fever or meningitis or "spotted fever" may occur (1) in epidemic form, and was notably prevalent during the early period of the war twelve years ago among both the civil and military population; or (2) sporadically, giving rise to isolated cases in non-epidemic times ; characterised by sudden onset and not uncommonly the appearance of hemorrhagic spots or rash; occasionally fulminant and fatal in 24 to 48 hours, or lasting one to two or more weeks, with a high case mortality (50 to 80 per cent.) and showing at post-mortem examination extensive exudate of purulent lymph over the membranes covering the vertex and base of the brain, involving also those of the spinal cord. This type was present in three of the seven cases above mentioned ; two proved fatal in six and sixteen days ; one made good recovery and was discharged from hospital three months after the first onset of illness. The other type of meningitis caused by the meningococcus has long been known as post-basic meningitis (as described by Gee and Barlow in 1878 and later by Stills in 1898) and is non-epidemic. It attacks chiefly young children or infants under the age of two years, afEecting the membranes at the base of the brain and giving rise to a characteristic condition of head retraction (cervical opisthotonos). Its duration may extend to several weeks or months resulting in eventual recovery, and if not fatal may be followed by hydrocephalus and blindness with consequent arrest of cerebral development. In this group the other four cases investigated are to be classed ; one, aged 6, was discharged from hospital greatly improved three months after the first symptoms appeared; one aged 3i and two aged 10 months, died after two or three months' illness. Meningitis; other form 4. Other form of meningitis include the types of intection caused by pyogenic and other organisms than the tubercle bacillus and meningococcus. Nine specimens of cerebro-spinal fluid from eight cases were examined and showed marked turbidity 45 with heavy deposit of pus cells and gram-positive cocci, also heavy protein content, varying from .05 to 1.44 per cent. (average .43 per cent.), marked excess of globulin, and total absence of dextrose. Chlorides estimated in two cases amounted to .85 and -64 per cent. Cultures yielded streptococcus in four, pneumococcus in two cases and a diphtheroid bacillus in one and staphylococcus in one. In both pneumococcal and streptococcal types of infection there was evidence of a primary inflammatory focus in the middle ear, either acute or chronic, extending to the mastoid bone or sphenoidal sinus, with the additional complication, in three cases, of cerebral abscess. In the case of staphylococcal meningitis, invasion of the meninges had followed an intracranial haemorrhage, the result of fracture of the skull from a fall six days previously. Mention may here be made of two cases, one of chronic middle ear disease and mastoid infection, the other of infection of the frontal sinuses, in which symptoms of meningeal irritation were present. The cerebro-spinal fluid, however, which in both cases proved to be normal, contra-indicated the existence of meningitis. Complete recovery followed. 5. Gross Cerebral Lesions. (1) Cerebral hoemorrhage.—Six cases (four male, two female, aged 51, 52, 60, 62, 65 and 69) in which the cerebro-spinal fluid was normal in composition or contained the products of extravasated blood, and yielded on centrifugation evidence of blood serum in the yellowish supernatant fluid with very high protein content and excess globulin, but low leucocyte count, pointing to absence of inflammatory reaction. In these cases the application of special tests for the Wassermann and colloidal benzoin reactions afforded means of determining whether the arterial degeneration responsible for the haemorrhage was due to a syphilitic arteritis or not. Of five specimens so tested, the reactions were negative in four and positive in one. Three of the six cases proved fatal and three were discharged much improved. Gross cerebral lesions. (2) Cerebral arteno-sclerosis and thrombosis.— Vascular degeneration of tiie cerebral blood supply, a condition showing itself usually in later middle life and known as cerebral arteriopathy, may cause obstruction to the circulation in the brain, which may be partial, intermittent, or complete, and result in altered mental or physical states, according to the particular regions of the brain affected; to be differentiated from a haemorrhagic lesion due to actual rupture of a blood vessel with destruction of brain tissue by the extravasated blood, commonly occurring in the path of the upper motor tract and causing sudden paralysis or hemiplegia. In five cases of cerebral arteriopathy, specimens of cerebro-spinal fluid were examined and showed no change from the normal, except for a high protein content in two cases. Moreover, the negative Wassermann and colloidal benzoin reactions obtained, contra-indicated the possibility of syphilitic arterial disease. In two of the cases of cerebral thrombosis, there was interference with the blood supply of the motor area and consequent hemiplegia, which proved fatal in one, and was followed by partial recovery in the other. In the remaining three cases altered mental states were prominent features, attended by some loss of power of one side-terminating fatally in one case, and in the other two resulting in partial recovery, or a state of dementia necessitating removal to a mental hospital. (3) Tumours of the brain, (i.) Glioma of the occipital lobe.-Girl, aged 7, with symptoms suggestive of meningitis, developing a month after an attack of measles. The cerebro-spinal fluid showed no abnormal change other than slight increase in protein content and globulin, relatively few cells and those chiefly lymphocytes; findings, which were equally consistent with cerebral tumour, abscess, or encephalitis, but clearly contra-indicated meningitis. Death occurred a fortnight after the first onset of cerebral symptoms and at post-mortem examination a gliomatous tumour with central necrosis was found occupying the right occipital lobe. 14172 D 46 (ii.) Multiple tuberculous tumours of the brain and general miliary tuberculosis.— Girl, aged 15, with symptoms of meningeal irritation of six weeks' duration, the diagnosis of which rested between tuberculous meningitis, cerebral syphilis and cerebral tumour. From examination of the cerebro-spinal fluid on two occasions it was possible to exclude both meningitis and cerebral syphilis. The slight increase in the protein cell content, lymphocytes and endothelial cells, were consistent with cerebral tumour. Diagnosis, however, remained in doubt until death occurred four months after the first onset of symptoms, and it was only at post-mortem examination that the precise nature of the lesions was discovered, as above recorded. (4) Cerebral abscess was found post-mortem in four cases as a secondary complication to middle ear disease and associated with meningitis in three cases, and chronic empyema in one case. The cerebro-spinal fluid in each case gave evidence of an acute infection by the presence of pus cells in large number, high protein content, globulin excess, and absence of dextrose. Culture yielded streptococcus in two cases, a. diphtheroid bacillus in one, and staphylococcus in one case. (5) General paralysis of the insane.—Examination of the cerebro-spinal fluid established or confirmed the diagnosis in twelve cases of this type of cerebral degeneration. In all the fluid was clear and colourless, and yielded a lymphocyte cell count almost invariably in excess of the normal (15 per cm), ranging between 10 and 40 per cm, but in one case reached as high as 144—the average of eight cases being 24 per c.mm. The protein content was increased, ranging from .03 to .12 per cent, averaging .062 per cent.; there was marked excess of globulin, and dextrose was invariably present in amount slightly above normal. In confirmation of the neurosyphilitic nature of the disease were the consistently positive Wassermann and colloidal benzoin reactions, in close agreement with each other in each case. The former, carried out and reported on by the courtesy of the Pathological Department of St. Thomas' Hospital; the latter tests being performed as a routine measure in the Council's laboratory. The twelve patients, with one exception, were all males, whose ages ranged between 36 and 61 years, and averaged 48 years. Owing to their mental condition, nine of the twelve were transferred from the Poor Law hospital to various Mental Hospitals. The remaining three, however, improved sufficiently under treatment to be discharged to their homes. In two of these cases the symptoms pointed to advanced renal disease, and uraemia was suggested as a possible diagnosis, but was contra-indicated by the fact that the chloride and urea contents of the cerebro-spinal fluid proved to be within normal limits in each case. (Chlorides .58 and .64 per cent, and urea .11 per cent.)—subsequent improvement followed. (6) Other conditions of cerebral degeneration (non-syphilitic).-In 7 other cases of mental disorder the cerebro-spinal fluid was found to be normal-the absence of excess in protein and globulin and the low cell content (3 to 10 per c.mm.) together with negative Wassermann and colloidal benzoin reactions contra-indicated neurosyphilis. The patients, with one exception, were males, six of whom were aged thirty to fifty-five years, and were suffering respectively from epilepsy, mania, or paralysis agitans; in two cases the mental states were diagnosed as due to Alzheimer's disease, a condition in which diffuse overgrowth of the neuroglial connective tissue of the brain (gliomatosis) is described. One patient, a boy of 11 suffered from epileptic mania. In none of the seven cases was it possible to associate an attack of encephalitis lethargica in the past with the development of the various mental states concerned. (7) Diseases of the spinal cord.—The cerebro-spinal fluid of six adults (three male and three female) aged 34 to 69 years, suffering from inflammatory and degenerative lesions, showed the following changes :— (i.) Disseminated sclerosis (3 cases). One fatal, two showed some improvement. 47 Low cell content—protein .02 to .05 per cent. No excess of globulin. Dextrose normal trace. Negative Wassermann and colloidal benzoin reactions. (ii.) Acute transverse myelitis (two cases, both fatal). Slight increase in cell content including polymorphs. Protein .15 and .08 per cent. and excess of globulin—in favour of an inflammatory lesion, and the negative reactions contra-indicated neurosyphilis. (iii.) Compression paraplegia (one case, fatal). Normal fluid. (8) Meningismus.—In six children under the age of six years, and one aged 11, the provisional diagnosis of meningitis was corrected by examination of the cerebrospinal fluid, which in each case showed nothing abnormal by the subsequent course. The symptoms of meningeal irritation, described as meningismus, were attributable to pneumonia or broncho-pneumonia, and in one case rickets with abscess of the lung— five of the children recovered and two died—post-mortem—no evidence of meningitis. (9) General conditions.—In four adults, aged 30 to 60 years, whose conditions had been diagnosed respectively as due to uraemia, neurosyphilis, cerebral tumour and myelitis, the cerebro spinal fluid proved to be normal and the reaction tests for neurosyphilis were negative. The final diagnosis in three cases was either neurasthenia or malingering, the conditions being purely functional as opposed to organic disease. In one case suffering from chronic nephritis in which the cerebrospinal fluid showed no evidence of uraemia, death occurred as the result of cellulitis and septicaemia. Conjunctivitis (Oupntnaimia).Slide preparations from eye cuscnarges of new born infants sent for examination by the Council's assistant medical officers in charge of midwives. 14 specimens examined. In two gonococci were identified, two were reported as "suspicious," and 12 showed a variety of cocci and bacilli but no gonococci. (2) Vaginitis.—Out of 4 specimens of vaginal discharge, two showed the presence of gonococci. (3) Sputum.—4 specimens examined, three showed tubercle bacilli. (4) Urine.—4 specimens examined for albumin and casts. (5) Blood.—Complete counts of two adults were made :— (i.) A school teacher (A.S.), suffering from sarcoma of the lymphatic glands, which proved fatal a year later. (ii.) Miss W. slight degree of anaemia. Miscellaneous examinations. During 1926, in response to requests from borough medical officers of health and general practitioners and to assist by consultation or lumbar puncture in the diagnosis of such notifiable diseases as encephalitis, poliomyelitis and cerebro-spinal meningitis, visits were paid by Dr. J. A. H. Brincker or Dr. J. G. Forbes to 22 private patients in the following boroughs : Kensington (6), Westminster (3), Islington (3), Woolwich (2), Hampstead, Marylebone, Hammersmith, Southwark, Poplar and Bethnal Green (one in each borough), and two cases were seen in consultation with medical officers of the Ministry of Health. 1. Encephalitis lethargica was suspected or provisionally diagnosed in eleven patients (eight female and three male), nine being adults, aged 15 to 63 years, and an infant of one year. At consultation (1) two were regarded as suffering from post-encephalitic sequelae with moral or mental deterioration; (2) five were diagnosed as probable encephalitis but, on removal to hospital, the subsequent course of two of these showed their conditions to be due to cerebral tumour in one and acute endocarditis in the other. In the three other cases, recovery followed and no sequelae have developed and their condition, though at the time of consultation suggestive of an attack of encephalitis, remains open to doubt. In four cases the temporary diagnosis of encephalitis was definitely rejected, and their state was recognised as due 14172 d 2 Consultation visits. 48 to debility from overwork at school, cardiac syncope and concussion, hysteria, and in the fourth case the clinical condition pointed strongly to cerebral tumour, opinions which subsequently proved correct. (2) Poliomyelitis was suspected in five patients and confirmed at consultation and by subsequent events in two, one of whom recovered and the other continues in statu quo. In the other three, opinion was given against poliomyelitis in favour of neuritis in two, since recovered, and the third, a child of two, when removed to hospital was found to be suffering from acute pneumonia. (3) Meningitis—six consultations. Whereas cerebro-spinal meningitis was suspected in each case, that diagnosis was not supported at consultation or as the result of lumbar puncture. It was possible to determine that four patients were suffering from other forms of meningitis; in two, as a complication of middle ear disease and mastoid inflammation, the other two respectively, acute pneumococcal meningitis and tuberculous meningitis. In one patient the normal cerebrospinal fluid clearly contra-indicated meningitis and the symptoms pointed to intracranial pressure by cerebellar tumour or cyst; sudden death occurred two days later, but post mortem examination was refused. The acute condition of the sixth case of supposed cerebro-spinal meningitis was held at consultation to be due to influenza, from which the child, aged 4, soon recovered. Midwive8. Midwives Acts and Children Acts. Duly certified midwives with London addresses exceed 5,000 in number, of whom 868 gave notice of their intention to practise within the County during the whole or part of the year, a decrease of 33 on last year's figures. About 17-3 per cent, of the midwives with London addresses are in actual independent practice in the County, the remainder acting mostly as monthly or general nurses under medical supervision. Practising midwives, other than those who work entirely in hospitals or infirmaries under medical supervision, are subject to inspection by the Council's officers, with a view to ensuring that a proper standard of efficiency is maintained. This work is carried out by four women medical inspectors, who pay special visits to midwives having cases of a septic nature or persistent high temperature or inflammation of the eyes. Advice is also given by the inspectors on any point of difficulty arising in connection with the work: 2,145 visits were paid by the inspectors this year, as compared with 2,384 the previous year. Infringement of O.M.B. rales. 88 infringements of the rules of the Central Midwives Board were reported during the year, of which 50 were slight, and therefore dealt with by means of a "verbal caution; 25 cases were of a more serious nature, and were dealt with by a written caution. Of the remaining 13 cases, 11 midwives were seen by the Committee, and 8 of them cautioned, the other 3 being reported to the Central Midwives Board ; the hearing of two cases was adjourned by the Committee. Of the 3 cases reported to the Board, one was cautioned; in the other cases the Board postponed sentence and asked for periodical reports on the midwife's conduct and methods of practice. Eleven midwives were suspended from practice with a view to the prevention of the spread of infection, and in 6 cases compensation was authorised. One midwife applied for a certificate in support of her application to the Central Midwives Board for the restoration of her name to the Midwives' Roll, but this was refused. The Midwives Act, 1902 (section 1 (2)), as amended by the Midwives and Maternity Homes Act, 1926, makes it an offence for any uncertified person to attend women in childbirth except under the direction and personal supervision of a registered medical practitioner, except in sudden or urgent necessity. During the year 11 inquiries were made by the inspectors into such cases, in 8 of which it was decided to take no further action; 2 were dealt with by a verbal or written caution and one woman was prosecuted and bound over in the sum of £20. 49 During the year there were 513 still-births reported by midwives in their practice. The figures for previous years were : 1921, 684; 1922, 720; 1923, 582; 1924, 594; 1925, 510. Of these infants 272 were males and 235 females, and 6 not stated. Of the 513 still-births, 272 were reported macerated, 227 not macerated, and in 14 cases the condition was not stated. Still-births. it, may De noted that section 7 of the Births and Deths Regisiranon act, 1926, which will come into force on the 1st July, 1927, requires that the birth of every still-born child shall be registered by the registrar in a register of still-births containing the heads of information prescribed in the First Schedule of the Act. 337 cases of puerperal fever were reported during the year, as against 316 the previous year. 90 cases proved fatal, as compared with 78 the previous year, a case mortality of over 26 per cent, as against over 23 per cent, the previous year. In addition the Registrar-General recorded 30 deaths from puerperal sepsis, which were, however, not notified as puerperal fever. The distribution of the notified cases was as follows •— Puerperal fever. Delivery conducted by Cases. Deaths. (а) Medical practitioners 127 33 (б) Certified midwives 81 14 (c) Medical practitioner and certified midwife 8 2 (d) Hospitals and poor-law institutions 81 30 (e) Medical students 10 2 (/) Cases of miscarriage or abortion where no attendant was engaged 26 8 (g) Uncertified women 3 - (h) No information 1 1 Total 337 90 Regulations were made by the Minister of Health during 192b making Puerperal Pyrexia a notifiable disease. The Order which came into force 1st October, 1926, defines the disease as" any febrile condition (other than a condition which is required to be notified as Puerperal Fever under the Infectious Disease (Notification) Acts) occurring in a woman within 21 days after childbirth or miscarriage in which a temperature of 100-4 deg. Fahrenheit (38 deg. Centigrade) or more, has been sustained during a period of 24 hours or has recurred during that period." Puerperal Fever has been notifiable throughout the country since the Infectious Disease (Notification) Extension Act 1899, but notification of the disease has been far from complete, with the result that statistics are inaccurate and misleading and measures for the prevention and effective treatment of the condition have been seriously hampered. The main reason for the comparative failure to notify is that Puerperal Fever is ill-defined and not a specific disease comparable with Scarlet Fever or Diphtheria. The Medical Officer of a Local Sanitary Authority is required to send a copy of every notification received from a medical practitioner to the County Medical Officer within 24 hours of its receipt. In London the Borough Medical Officers are also required to send a copy to the Metropolitan Asylums Board within 12 hours. The number of notifications will it is anticipated be numerous, but the great importance of securing adequate treatment in the early Stages of puerperal infection is regarded as outweighing any objection to the notification of a certain amount of minor illness which gives no cause for anxiety. 308 notifications of puerperal pyrexia were received, 12 of which proved fatal; the distribution is as under :— Delivery conducted by Cases. Deaths. (а) Medical practitioners ... ... ... ... ... ... ... 83 7 (б) Certified midwives ... ... ... ... ... ... ... ... 58 2 (c) Medical practitioner and certified midwife ... ... ... ... 5 1 (d) Hospitals and poor-law institutions ... ... ... ... ... 137 — (f) Medical students ... ... ... ... ... ... ... ... 5 — (/) Cases of miscarriage or abortion where no attendant was engaged ... 20 2 308 12 Puerperal pyrexia. 50 13 of these cases, with 3 deaths, were subsequently notified as puerperal fever, and are, there fore, included in both tables. Medical aid. In certain emergencies specifically enumerated in the Rules of the Central Midwives Board a midwife is required to advise in writing that medical aid be summoned, and must also see that such help is summoned and obtained. The notice is sent to the doctor, and a copy must be forwarded to the local supervising authority. During 1926, 6,910 notices were received, as compared with 7,034 in 1925. Assuming that approximately 40,000 confinements were conducted during the year by midwives in independent practice, it appears that medical aid was required in 17.5 per cent. of the cases, nearly the same percentage as in the preceding year. Ophthalmia neonatorum. Great stress is laid by the Council on the due observance by midwives of the Rules of the Central Midwives Board with regard to inflammation of the eyes. However slight the inflammation may be, it is the duty of the midwife to summon medical aid, and as soon as the notice is received at this office the case is followed up by one of the medical inspectors. Notice is also sent by the medical inspector to the borough medical officer, so that the health visitor may continue to keep observation on the child after the midwife has left the case. Most valuable assistance is also given by the Voluntary Nursing Associations in cases where domiciliary treatment is necessary. During the year the Minister of Health decided to issue new Regulations with regard to the treatment and notification of Ophthalmia Neonatorum. The new Regulations which came into force on the 1st October, 1926, make it no longer obligatory for a midwife to notify a case. This duty is made the sole responsibility of the medical practitioner in charge of the patient. The midwife must, however, forward a notice of sending for medical aid to the local supervising authority. The reason for this alteration is that the system of dual notification by midwives and medical practitioners had in some instances resulted in complete failure to notify. An obligation is also laid upon the Medical Officer of Health of a Local Sanitary Authority to forward a copy of every notification that he receives to the County Medical Officer of Health within 24 hours after the receipt of the notification. In London the Borough Medical Officers are also required to send a copy of the notification to the Metropolitan Asylums Board within 12 hours. A memorandum on the new Regulations was issued by the Minister of Health in which he indicated the necessity for close co-operation between the Local Supervising Authority under the Midwives Acts and the Local Sanitary Authority where the former authority is not also the Maternity and Child Welfare Authority and the Local Sanitary Authority, and he indicated the method he considered would best bring about the desired result. Steps have been taken in the direction indicated. The Minister further suggested that the Council should consider whether they should not refrain from exercising their power of recovery from the patient's representative of the fee paid to a medical practitioner called in under Section 14 of the Midwives Act, 1918. The Council decided to adopt the suggestion of the Minister. 1,282 notices were received from midwives during the year with regard to medical aid summoned for inflammation of the eyes of infants, as compared with 1,284 in 1925. In addition, 60 other cases occurred in which either medical help was not called in by the midwife or she failed to notify the Council that she had done so. Of these 1,342 cases, 413 proved to be ophthalmia neonatorum, as compared with 422 in 1925; 278 other cases that did not occur in the practice of midwives were also notified, making a total for the year of 691 notified cases of this disease. The percentage occurring in the practice of midwives was 59+, as against 60+ in 1925. All the cases that occurred in the practice of midwives were investigated by the inspectors, and it was found that 404 were reported as completely cured, while 4 died. Impairment of the vision in one eye occurred in 2 cases, whilst in 3 51 instances the result could not be ascertained owing to the removal of the patients. 57 cases received in-patient hospital treatment at St. Margaret's Hospital. In past years classes have been arranged for the instruction of midwives, and were well attended. In 1924, 1925 and 1926, classes both for general midwifery subjects and also ante-natal work were held. The Central Midwives Board has made new Rules which came into operation on the 1st January, 1927. The variations and additions deal with the standard of efficiency of candidates for examination as midwives, and other matters designed to improve their midwifery. Several outbreaks of Pemphigus Neonatorum nave occurred in the practice of London midwives during the year, the total number of cases being 140. The outbreaks have caused considerable anxiety as the source of infection in the various cases is often obscure. Generally, however, the disease has been of a mild form. pemphigus neonatorum. This Act which provides for the amendment of the Midwives Acts 1902 and 1918 in certain particulars and for the registration and inspection of maternity homes, came into force on the 4th August, 1926. Part I. of the Act deals with the amendment of the Midwives Acts. Midwives and Maternity Homes Act. 1926. the Second Part of the Act has reference to the registration and inspection of maternity homes. As the registration of such homes is regulated by the London County Council (General Powers) Act 192, so far as London is concerned, the 1926 Act does not apply inasmuch as Section 14 (3) provides that "nothing in this Act shall affect the provisions of any local Act.” The by-laws made under section 18 of the L.C.C. (General rowers) Act, 19-1, are being carried out by the keepers of lying-in homes, and are of assistance to the Council in dealing with any complaint that may be made with regard to the home. Lying-in homes. The powers of the Council under the Children Act, 1908 (Part 1), with regard to infant life protection are fully indicated in the Annual Report for 1921. The work of inspection is carried out by 14 visitors and two male inspectors. Nurse infants who are being kept under specified unsatisfactory conditions, may under powers given by the Act be removed to a place of safety—i.e., in London to Poor Law institutions. During 1926, 4 nurse infants were so removed, as compared with 3 in the previous year. The Act permits the Council to grant total or partial exemption from inspection in cases where the circumstances appear to warrant such a course. One request for exemption was received during the year and partial exemption was granted. Children Act, 1908. All the homes in which foster children are kept are visited with a view to ascertaining whether the sanitary condition of the premises is satisfactory. During 1926, 870 reports, as compared with 947 during 1925, were made. The premises were found to be satisfactory in 498 cases the same number as the previous year. Sanitary defects were discovered in 165 homes as compared with 242 the previous year, while overcrowding was reported in 111 homes as compared with 141 in 1925. Overcrowding and sanitary defects were found in 22 homes as compared with 16 the previous year. In 74 cases no action could be taken owing to the removal of the infant prior to the visit of the inspector. In any case of serious sanitary defect the attention of the borough council was drawn to the defect. A rearrangement of the accommodation has in some cases enabled an improvement to be effected, but in others this has been impossible and the foster mothers have in such cases been urged either to obtain more suitable accommodation or to return the infant to its parent. As will be obvious, the lack of suitable housing accommodation has added to the difficulty of dealing with such cases. The help of the local infant welfare centre is sought in the case of the illness of an infant, and where a foster mother has charge of a weak or ailing infant she is 52 urged to take the infant to the centre and follow the skilled advice given there. The visitors are instructed to watch such cases with a view to seeing that the treatment is carried out. Whenever a visitor is doubtful as to the progress of an infant the matter is reported with a view to an inspection being made by one of the Council's medical officers. This practice has worked very satisfactorily and has been of great assistance to the visitors. A nurse infant ceases to be under this part of the Act at the age of seven years, but as the child usually attends school from the age of 5 years it has from that age the additional advantage of supervision by the school medical service. The number of deaths of nurse infants during 1926 was 26, as compared with 38 last year, while inquests were held in 9 cases, as compared with 16 in 1925. The verdict in 6 cases was death from natural causes, and in 3 cases accidental death. Adoption of Children Act. In past reports reference has been made to the question of adoption of infants. A committee was appointed by the Home Secretary to examine the problem of child adoption from the point of view of possible legislation, and at the request of that committee evidence was submitted on behalf of the Council. The Committee issued reports of its findings and a draft Bill to give effect to them. This Bill passed its final stages in 1926 and came into force on 1st January, 1927. It provides that infants (under the age of 21) who have never been married may be legally adopted, the parents relinquishing all rights and responsibilities, which are thereupon assumed by the adopters. The courts authorised to deal with applications under the Act are the High Court, or at the option of the applicant, and subject to rules which may be made by the Lord Chancellor, any county court or court of summary jurisdiction within the jurisdiction of which either the applicant or infant resides. Upon any application for an adoption order, the court may postpone the determination of the application, and may make an interim order (which is not an adoption order) giving the applicant custody of the infant for a period not exceeding two years by way of a probationary period. Section 8 (3) of the Act reads as follows:— For the purpose of any application under this Act and subject to any rules under this section, the court shall appoint some person or body to act as guardian ad litem of the infant upon the hearing of the application with the duty of safeguarding the interests of the infant before the court, and where the body so appointed is a local authority the court may authorise the authority to incur any necessary expenditure, and may direct out of which fund or rate such expenditure is to be defrayed, but nothing in this section shall be deemed to authorise the court to appoint a local authority to act as guardian ad litem of an infant except with the consent of that authority. The concluding words, necessitating the consent of an authority to its being made guardian ad litem, were included at the suggestion of the Council. Mental Deficiency Act, 1913. On the 31st December, 1926, of the 4,390 cases being dealt with at the expense of the Council there were—In institutions, 2,469; under guardianship, 41; under supervision, 1,856; in places of safety waiting other action, 24. There remain 3,669 out of the total number 8,059 of cases of alleged mental defect, of which notice has been received since the Act came into operation. These cases include 447 in which no action could be taken; 1,528 ascertained not defective, not subject or not to be London cases; 579 dealt with through the Poor Law; 969 removed from the register (died, discharged or removed to mental hospitals or state institutions) 53 and 146 still under consideration. During the year 781 cases were examined with the following results:— Type. Male. Female. Total. Idiot 11 15 26 Imbecile 112 106 218 Feeble-minded 225 245 470 Moral imbecile 4 2 6 Not defective 14 38 52 Insufficient evidence 2 7 9 Total 368 413 781 In addition to the foregoing, certain cases were examined while still of school age, and are recorded on a later page. The Occupation Centres opened in 1923 were continued throughout the year and, as in the past year, the Council made provision for the employment of guides, where necessary, in order to convoy the children to and from the centres. Occupation centres. Dr. Fairfield has analysed the notes of the cases of those women dealt with under the Mental Deficiency Act who have at some time given birth to one or more illegitimate children. They are 32 in number. 23 women had given birth to one child. 4 „ „ „ „ „ two children. 4 „ „ „ ,, „ three children. 1 „ „ „ „ „ nine children. Defectives who have given birth to illegitimate children. The total number of children born was 47. Although most of the births are very recent, 16 of the 47 children are already dead. Of the 32 women, two are married, but both of the latter group have had illegitimate children. One of them is the mother of nine children. She evaded recognition during school days, married, had eight children, six of whom died, two being saved by the care of relatives. After her husband’s death she gave birth to an illegitimate child, who died of venereal disease. Her two surviving children are mentally defective as was the only one of the seven deceased children who survived infancy. The history of the 32 mothers shows that seven came from provincial schools (one being a Special School), and 24 from London Schools. Of the latter, 13 were educated in ordinary elementary schools and only 11 had been to Special schools for defective children. Five of the 11 left school before the Mental Deficiency Act came into being, one being at school when the disaster happened. In one case, a petition to put the defective in an institution had been dismissed by the magistrate; in two cases, the names had been notified by the Education Committee, the girls leaving school at 16. In two cases, the girls were under voluntary supervision. Blind Persons Act. The Council’s scheme for carrying out the provisions of the Blind Persons Act, 1920, set out in previous reports, was continued throughout the year, during which 96 persons over school age were seen. In the Act, blindness is defined as being “ too blind to perform work for which eyesight is essential.” This definition appeared, however, to permit of too wide an interpretation, and in order to standardise the work throughout the country, the Ministry of Health in March, 1926, issued Circular 681, in which they indicated that they did not deem persons whose visual acuity, after correction of refractive errors, was greater than 6/60 (Snellen) to be blind unless the defect of eyesight included such special conditions as a great contraction of the field of vision. In consequence of this interpretation of the definition, the Special Committee on the Welfare of the Blind directed that any cases which the Medical Officers considered as blind within the meaning of the Act, whilst not complying with the limitation laid down by the Ministry of Health Definition of blindness. should be the subject of a detailed report. 5 of these special cases have been dealt with. Including these, 56 males and 20 females were found to be capable of benefiting by training, and advice was given as to the trades in which the persons should severally be trained, having regard to the prospects of future employment. 11 males and 9 females were considered to be unfit for training. Work of the Chemical Branch, 1926. The work of this branch is carried out at four laboratories, viz.: the Central Laboratory at County Hall and the Laboratories at the Northern and Southern Outfalls and the Greenwich Power Station. Central laboratory. Samples of various kinds examined during the year totalled 4,723 and a considerable amount of work of an advisory character, involving much consideration, was carried out. The samples were submitted by other departments of the Council for examination as to their compliance with specific requirements or their suitability for various purposes. The following table shows the number and description of samples examined at the Central Laboratory:— Building Materials 387 Paints and Colours 364 Coals 12 Varnishes and Dryers 28 Disinfectants 23 Petroleum and Paraffin 157 Drugs 33 Soaps, Shampoo Preparations, etc 42 Feeding Stuffs 14 Rainwaters 96 Foods 653 River waters 519 Meals 11 Water and deposit from bathing lakes 45 Metals and Assays 17 Ordinary waters 25 Milks1,371 Water-softening samples 533 Oils 230 Miscellaneous 136 As an example of the investigations carried out and of their practical bearing and consequential economic effect on the Council's services the following inquiries are of interest. The examination, by special physical tests simulating conditions of user of the paints and varnishes, afforded data which resulted in an improvement in the specification and thereby effected a considerable financial saving. A cable of simple construction, intended for wiring dwellings erected by the Council, was sent for examination, with a view to ascertaining whether such a cable could safely be embedded in the plastering of the walls without protective sheathing. Tests showed that the rubber-like coating was physically and chemically of a durable nature, and was entirely suitable for the purpose indicated. Special examinations were also made under the provisions of the Building Acts, in connection with which tests were made, under standardised conditions, of the fire-resisting properties of such materials as wire-armoured glass and a variety of woods, of which the properties had not previously been investigated. Greenwich Power Station laboratory. The work of the laboratory at the Greenwich power station comprises:-(i.) The daily examination of samples of water and materials with a view to the control of the water-softening plant, the blowing-down of boilers, the detection of condenser leakage, and advice on Such matters as the purity of condensed water supplied to the station batteries; (ii.) the sampling, preparation and examination of samples of coal used both at the power station and at other works of the Council, such as the main drainage outfalls and pumping stations, the preparation and examination of samples of fuel, ashes, etc.; and (iii.) investigations on matters affecting the operation of the station plant. Additional work was involved owing to the difficulty of obtaining coal from normal sources. River Thames. The systematic examination of the river Thames was continued in 1926, at points from Waterloo bridge to the Edinburgh lightship, which is in the vicinity of the discharge area for sludge from the Council's outfalls and for waste matters discharged by other bodies. 55 Provision was made for additional treatment of sewage at the outfalls, but it was not found necessary to resort to such treatment. At the outfall laboratories systematic daily examinations of the sewage reaching the outfalls and the resulting effluent and sludge, as well as of the water of the river Thames at both high and low tides, and other analyses in connection with the working of the outfalls have been continued. Much attention has also been given to chemical work relating to fuel economy and systematic examinations of fuel, feed-water, etc., are now made on lines similar to the work at Greenwich power station. In addition much experimental work needed to throw light on matters connected with the river, and Sewage treatment, has been undertaken at these laboratories. Outfalls. The frequent occurrence of supersaturation with dissolved nitrogen of water in the River Thames and its estuary has been the occasion of some investigation in the river itself as well as in the laboratory. The anomalies observed in the estuary made it desirable that some information as to the proportion of nitrogen found in solution in the open sea should be obtained. A consideration of results obtained on the water of the North Atlantic by one of the oceanographic expeditions of the nineteenth century had raised the expectation that the dissolved nitrogen in water some distance from the coast would vary very little from saturation, and the occasion of the delivery of the S.S. “ John Perring ” seemed to promise an opportunity for elucidating the point. By the kindness of the builders of the “ John Perrin,” I was enabled to detail one of the chemical assistants to make investigations on the voyage of the ship from the Clyde to Erith, and, as a result of this opportunity, it was ascertained that (1) Supersaturation with dissolved nitrogen occurred at all points of observation from the Clyde to the Thames. It was, however, present in lesser degree than had been observed in the neighbourhood of the Black Deep. (2) The explanation of this phenomenon cannot be the same as that to which is to be ascribed its persistent recurrence in considerably higher degree at places such as Erith. There can be little doubt having regard to the distribution, amount and other facts elucidated as to the excess of free nitrogen in river water in the neighbourhood of the outfalls that its origin is to be found in the breakdown of nitrogenous organic matter discharged as sewage into the river. (3) It has not hitherto been generally recognised that the most valuable constituent of sewage, the nitrogenous organic matter, when discharged as at the Council's outfalls into estuarine waters, becomes largely resolved into its elements. The world's stock of combined nitrogen by this process of dissolution into free elemental nitrogen and simple compounds of other elements is thereby depleted to the very serious extent which the vast quantities represented involve. (4) Nor can there be much doubt that similar processes are at work in respect of the sludge discharged into the Sea at the Black Deep. But that the excesses of nitrogen observed in the estuary are to be ascribed wholly to this cause is disproved by the findings on the voyage from Greenock to London. For this reason the observations are valuable. A new and so far inexplicable phenomenon has to be recorded, while a tentative view as to the part played in the final stages of sewage disintegration—the end changes—in their effect upon the gaseous content of marine waters, has to remain in suspense until further knowledge justifies a conclusion. Gases dissolved in sea and estuarine waters. During the year, various minor, but important, matters have been investigated, such as the effect of adding activated sludge in successive increments to the liquid to be treated ; the effect of variations in depth of tanks used for treatment and the immediate results of mixing activated sludge with effluent from the sedimentation channels. Incidentally it was found that no advantage was obtained in treatment by Biological treatment of sewage. 56 successive additions of sludge and the quality of effluent was not affected by very considerable differences in depths of diffuser tanks. It was, however, discovered that a stable liquid could be produced by mere admixture and subsequent sedimentation of highly activated sludge and effluent. The conditions under which this result can be assured are being still further investigated. An important experiment with a system of mechanical agitation different from that referred to in previous reports is now in progress at Crossness. The public health problem arising from the fact that the area and population now served by the Council's main drainage system will be increased in the near future, will necessitate consideration. Bathing lakes, openair swimming baths and paddling: ponds. Many examinations of the water of open-air swimming baths, bathing lakes and paddling ponds were made during the bathing season of 1926. The most important part of this work was an investigation, extending over some months, of the results obtained in two baths by the use of a filtration and chlorination plant. The results of these investigations will be set out in the ensuing report. In one of the parks in South London a paddling pond had been cleaned and refilled with water from the mains. Within a fortnight it was reported that the water was bright red. Microscopical examination showed that an abundant growth of the red form of protococcus (var hcematococcus) had caused this visitation, of which perhaps Egypt affords the earliest recorded instance. A small dose of sulphate of copper successfully killed the organism, which did not reappear. River Lee. The condition of the river Lee continued to be unsatisfactory. Towards the end of July, after heavy rains, the Navigation Cut from Tottenham Lock downwards was in a foul condition, chemical analysis showing the water to be badly polluted, whilst abundant ocular evidence testified to the very unsatisfactory state of the river bed. Masses of putrefying debris were brought to the surface by the copious evolution of gas from the bed, and passing barges almost grounded on the black mud which they brought up in black clouds as they passed. This stream is still used by the rowing clubs of East London, who continue to put out crews, notwithstanding the very great sanitary and aesthetic disadvantages of the river in its present condition. The natural stream which forms the eastern boundary of the county at Hackney Marsh is in a dirty condition. It would appear that substantial improvements in the waters of the tributary brooks, and extensive dredging are needed to restore the stream to a good condition. River Wandle. I he effect on the water of the river of the improved treatment of sewage from the districts included in the operations of the Wandle Drainage Board has been the subject of some investigation. The results of examinations made in January, July and October show that the effluent discharged at the outfall near Earlsfield Station does not differ greatly in its degree of purification from the river water with which it mixes and which, although in a moderately good condition, has already received much pollution. The effect of the effluent as now discharged on the water immediately below the outfall is not great and the condition of the river from the outfall down to the Thames does not appear to have given rise to offence. Disposal of house refuse Reference was made in two previous reports to an experiment conducted at the Ebury Bridge depot of the Westminster City Council on the storage of house refuse after the removal of large matters and comminution of the finer and softer matters remaining. The heap thus obtained was kept under observation and the changes going on in it were the subject of chemical and biological examination. Briefly, the effect of storage is that considerable bio-chemical changes characterised by a very marked rise of temperature go on. Much of the organic matter is 57 converted by oxidation and other changes into carbon dioxide and marsh gas which were identified and determined in the air drawn from depths of 1 foot 6 inches and 3 feet below the surface. In this process of mineralisation the greater part of the organic nitrogen is retained by the mass. Several species of plants grew freely on the surface of the heap and much of it was disposed of as a top dressing for grass in London parks. Observations of visibility and actinicity. Of the environmental conditions affecting health and well-being there are none to which greater importance can be attached than those which are comprehended in the atmospheric complex. Little understood in their mode of action they are a common circumstance operative over considerable areas and affecting vast numbers of persons. Of recent years attention has more particularly been paid to atmospheric pollutions and especially as they affect the air of cities. Coal smoke and the other products of combustion from the domestic and the factory chimney, dust and grit emitted into the air from industrial processes and from the grind and attrition inseparable from the activities of a great city have each received a large measure of attention and become the subject of systematic record. Some years ago the Council sanctioned the keeping of observations asked for by the Advisory Committee on Atmospheric Pollution and a considerable amount of work in this connection has been done and the results forwarded to the Advisory Committee. Occasion was taken to expand some of these observations in directions more immediately bearing upon health and the results are now presented for the first time. The Flèche of the County Hall afforded an excellent view-point from which to measure horizontal visibility as it was affected by the varying seasonal and other conditions of the London atmosphere. Record was also made of the actinic power of the light, a property which to an increasing degree is recognised as having a direct and very important bearing on health. At 10 a.m. and at noon, G.M.T., these observations have been systematically recorded on each week-day since September, 1923. One fact comes out clearly as a result of the three years' records when the data are distributed and compared according to season. The summer months are the period of greatest horizontal visibility at noon in London, the mean range being 5.6 miles for the months of June, July, and August, as compared with a range of 2.5 and 2.6 miles respectively for the spring and autumn months. The winter mean is only 0.9 of a mile. Generally speaking, low visibility is associated with low actinicity of the light. Measured by actinometer and expressed as the number of seconds taken to turn a standard paper to a given tint, the mean figures are summer, 17 seconds, and spring and autumn, 36 seconds and 38 seconds respectively and winter, 63 seconds. If the individual months are taken, comparison shows the same close correspondence—see Table II. No correlation appears to be established when comparison is made with the amounts of deposits collected in the rain gauges which are a measure of the impurities washed out of the atmosphere by rainfall. This method of measuring atmospheric impurities is open to many disturbing factors and cannot be relied on as an index of suspended impurities in the atmosphere at times other than those immediately preceding rainfall. The automatic filter records made by Dr. Owen’s instrument (a means of separating the finer particles yielding varying shades of blackness to the paper through which the air is filtered) on the other hand, show a very close correlation both to the data of visibility and of actinicity. The summer months yield much the lowest figure of blackening; the averages being for summer 0.6, spring and autumn, 1.0 and 1.1 respectively, and winter, 1.4. 58 This close correspondence between visibility, actinicity and atmospheric impurity as measured by filtering definite volumes of air through standard filtering paper is illustrated by a comparison of the mean monthly figures for the three years—see Tables I, II and III, and graphs on pages 59-61. Table I. Showing mean daily radius of visibility during the respective months of the period September, 1923, to August, 1926. The observations were made at midday from the Flêche of the County Hall. Spring. Summer. Autumn. Winter. Starch. April. May. June. July. August. Sept. Oct. Nov. Dec. Jan. Feb. 1923–4 — — — — — - 5.7 2.7 0.9 0.6 0.7 0.8 1924-5 1.2 1.8 6.2 5.3 7.1 7.0 4.8 1.6 1.0 0.8 0.8 1.1 1925-6 1.2 1.4 3.5 4.6 4.1 3.8 4.5 1.5 1.0 0.8 0.8 1.3 1926 1.7 1.9 3.8 6.2 5.5 6.9 — — - - - — Table II. Showing mean of the time, in seconds, required to produce a standard tint, using Watkins “Bee” meter. The means are based on daily observations made at mid-day with a north exposure, and are those of the respective months during the period September, 1923 to August, 1926. Spring. Summer. Autumn. Winter. March. April May. June. July. August. Sept. Oct. Nov. Dec. Jan. Feb. 1923.4 — - — - - - 18 23 45 45 52 54 1924.5 43 24 14 8 10 12 15 50 67 80 84 44 1925.6 55 28 15 17 18 21 35 42 51 79 69 63 1926 60 43 36 27 23 15 - - - - - - Table III. Showing the mean of the daily deposit as recorded by Dr. Owen’s Automatic Filter Recorder during the respective months of the period September, 1923, to August 1926. Spring. Summer. Autumn. Winter. March. April. May. June. July. August. Sept Oct. Nov. Dec. Jan. Feb.' 1923-4 - - - - - - 1.1 1.3 1.2 1.2 2.3 1.7 1924-5 2.0 1.4 1.0 0.8 0.7 0.6 - 1.2 1.6 2.1 1.7 1.0 1925-6 0.9 0.8 0.7 0.6 0.6 0.6 0.5 0.9 1.1 1.3 0.9 0.9 1926 0.7 0.6 0.6 0.5 0.6 0.6 - - - - - - A distant object is seen and distinguished from Surrounding objects only if the light which reaches the observer's eye from it is sufficiently different in intensity or colour. If the illumination of the object is very poor it will be indistinguishable from its surroundings. If the object is surrounded by or seen against a light haze it is more likely to be seen if dark or in silhouette. If between the observer and the object there is a haze, dark or light, this will by mere obscuration and scattering of the rays reduce the visibility of the object. Atmospheric pollution may, therefore, decrease visibility either by decreasing the illumination due to the sun’s rays or by interposing a more or less turbid layer of air between the object and the observer. The most striking feature of the observations is the great seasonal range in Mean of visibility based on daily observations from the Flèche of the County Hall. The mean is that of the three respective months in each of the three years, September, 1923, to August, 1926. 60 Graphs showing the seasonal relationship between certain meteorological phenomena, represented by the mean of observations in the respective months during the period, September, 1923, to August, 1926. SPRING SUMMER AUTUMN WINTER 61 Graph showing radius of visibility during (1) a fine summer day, (2) a fair winter day, and (3) a misty winter day. 62 visibility and in the actinic power of the light. The average area of visibility in London at mid-day is no less than 50 times greater in the three summer months, June to August, than it is during the three winter months, December to February, and about five times greater than it is during the three months of spring and autumn respectively. The actinic power of the light is more than three times greater in the summer than in the winter months, and about twice as powerful in summer as in the spring and autumn months. The deposit from dust and tarry matter by filtration of the air through white filter paper during the winter months gives an average tint nearly three times darker than the corresponding average for the summer months, while the average of the spring and autumn tints is nearly twice as dark as the average of those of the summer. While these seasonal changes in visibility and actinicity are due largely to natural conditions lying wholly outside of human control, there can be no question that coal smoke which is the main factor in the varying seasonal changes in the filter tint is an important and aggravating factor in the screening of actinic light and in intensifying the obscuration arising from the seasonal atmospheric changes to which London is subject by reason of its situation in the valley of a large river. This is strikingly borne out by a consideration of the changes in shape of the area of visibility. It is traceable in the composite diagrams, which give the averages of the monthly or quarterly observations when considered in conjunction with the averages of the direction of the wind, and is distinctly to be observed in the daily charts in which wind direction is simultaneously recorded. The bulges of extended visibility in one direction or another are generally towards the quarter from which the wind is blowing. In a great city like London it is obvious that the smoke screen will be densest in the direction of its drift, and that visibility should be limited in such a region is only what might be expected. 63 CHAPTER II. REPORT OF THE SCHOOL MEDICAL OFFICER (Dr. F. N. KAY MENZIES) FOR THE YEAR 1926. Staff. The staff engaged in the work of the school medical service includes, in addition to the School Medical Officer, who is also the Medical Officer of Health, one Senior Medical Officer giving his whole time to the work, one Senior Medical Officer supervising the work of special schools in addition to the general work of Mental Deficiency, one Principal Assistant Medical Officer for infectious diseases,* one Principal Assistant Medical Officer (whole time) for supervision of aural diseases with two Assistant Aurists (part time), five Divisional Medical Officers supervising the work in the five divisions into which London is divided for school medical purposes, one Divisional Medical Officer dealing with infectious diseases, two Divisional Medical Officers dealing with special schools in addition to the general work of Mental Deficiency, 24 Assistant Medical Officers (full time), 14, Assistant Medical Officers (part time, each for six sessions a week on yearly engagements), 34 Assistant Medical Officers (part time, each for 3 sessions a week on yearly engagements), and part time temporary Medical Assistants on special authorities giving 112 sessions a week. There are in addition one Principal Assistant Medical Officer (part time) for secondary schools and four Consulting Medical Officers (part time) for aural, ophthalmic, orthopaedic and dental matters. The school nursing service includes one Superintendent of School Nurses, six Divisional Superintendents and 328 Nurses. It is with deep regret that I record the deaths of Dr. Helen B. Hanson, Assistant Medical Officer, and Mr. C. E. Wallis, Consulting Dental Surgeon, both of whom had been associated with the school medical service almost from its beginnings. School Buildings. Under the “40 and 48” scheme, the Council pursues a steady policy, not only of provision of places by means of new schools and enlargements, but also of modernisation of old schools, and by these means the sanitary condition of provided schools is steadily being improved. It is anticipated that in the three years’ period 1925-1928, there will have been completed 23 new schools and enlargements providing 12,000 places and 18 of the older schools will have been modernised. In addition to the above, a sum of £36,000 is included in the programme in respect of minor structural improvements in schools not at present to be dealt with under the “40 and 48” scheme. During 1926, 83 complaints or questions in regard to the sanitary conditions of schools were dealt with in the public health department. Of these 13 were questions relating to the provision of a medical room in schools, 27 complaints arose in connection with special investigations into outbreaks of infectious diseases at or in the neighbourhood of schools, and the remainder in regard to, natural lighting (6), artificial lighting (2), ventilation (6), presence of vermin (6), sanitary conveniences (6), drinking water (2), desking (1), heating (10), and nuisance from adjoining premises (4). Special attention was paid during the year to the schools which are mechanically ventilated and to the use of dustless oils on the floors of ordinary schools. A group of schools bunt between 1898 and 1902 was equipped with the “plenum” system, whereby air is forced into the schools by means of large fans. The air is screened, moistened, heated, and distributed to the halls and classrooms by ducts. The plenum system of ventilating and heating. *At the reorganisation of the public health department on the 25th January, 1927, the Council resolved that as from the 1st April, 1927, this position be regarded as that of a Senior Medical Officer having control of the whole of the work, both clinical and administrative, relating to infectious disease. 64 The air escapes from the rooms by a separate system of exit ducts. The system makes it necessary that all windows should be kept tightly sealed, and doors throughout the buildings must remain closed, particularly the main outer doors of the departments. A certain number of complaints has been received from teachers working in the schools concerned, but in almost every instance the complaints have been directly caused by defects which it has been possible to rectify. On the whole the complaints have been relatively few in number and less serious than the complaints arising in schools naturally ventilated erected during the same epoch. From some of the “plenum” schools there has never arisen a complaint in all the years during which they have been established. Much investigation and research has been carried out by the Council's officers on the conditions in the mechanically ventilated schools. The first scientific observations on the physical conditions of the atmosphere in these schools were made in 1903. The introduction by Dr. Haldane of a ready means of estimating the amount of carbon dioxide in .the air made it possible to take a large number of accurate observations in a short space of time. The mechanically ventilated schools were visited and compared with neighbouring schools which are naturally ventilated. It was found that, judged by the amounts of respiratory impurity in the air during occupation, the “plenum” schools were very distinctly superior to the ordinary schools. It is true that the “plenum” schools differed amongst themselves in efficiency. While for instance at the “John Ruskin” and at Cassland-road, the air was found on all occasions in a satisfactory condition, at Christian-street and at Old Montague-street, the respiratory impurity at times mounted above the margin which is considered permissible. This is owing to the fact that in the latter schools the exit ducts are especially narrow, so that while all the doors in every department are shut,satisfactory ventilation is maintained, but when the doors are opened in one department for children to go out to play, or for any other purpose, the system is short circuited and the full measure of air does not reach the other departments. Even when thus temporarily upset, owing to opening of doors, however, the air in these schools, judged by the carbon dioxide present, was no worse than in the ordinary schools. In 1911 the medical officer (Education) in conjunction with the Council's chemist, made a comprehensive series of observations at Commercial-street School, one of the schools ventilated on the “plenum” system, where complaints had at that time found expression. A neighbouring elementary school, Chicksand-street, was used as a control. It was found that, judged by the amount of carbonic acid present in occupied classrooms, the air was superior in the “plenum” school at all points to that in the school naturally ventilated. It was considered, however, that the air, although sufficient in amount, was delivered too hot and dry to the classrooms, and suggestions were made for improvements to the installation with a view to overcoming this fault. For four years between 1914 and 1918 a comprehensive research was carried out upon “plenum” ventilated schools by one of the officers of the public health department. The schools investigated were Berner-street, Christian-street, Commercial-street, and South Hackney Central. The factors investigated comprised: (1) heat, (2) humidity, (3) odour, and (4) air currents. Many thousands of observations were made, and the results were uniformly in favour of the mechanically ventilated schools as far as the physical factors enumerated above are concerned. On many other occasions observations have been made during the past 22 years, although not upon so elaborate a scale as those described. The figures and diagrams relating to these observations are not reproduced in this report, but always the tests have shown that the “plenum” schools have the advantage over ordinary schools in regard to the sufficiency and purity of the air supplied, so far as these can be gauged by mere physical measurements and considerations. 65 It may be asked, if the air in the “plenum” schools is sufficient in quantity and pure in quality, why do teachers sometimes complain? There are two factors to be considered, one physiological and the other mental. The physiological effect upon the occupants of a building which is warmed solely by heating the entering air is a somewhat enervating one. In ordinary life the musculature of the body is kept in a condition of “tone” by innumerable stimuli to the skin, arising from frequent small alterations of temperature of the air and by the little eddies and currents of air to which our bodies are exposed under natural conditions. When these stimuli are absent, as they largely are in the “plenum” schools, there is some loss in muscular tone, and consequently a diminution in alertness; the atmosphere is a drowsy one. This is the main objection to the “plenum” system of ventilation and heating. The ideal conditions for health are those that ensure sufficient warmth received by radiation through an atmosphere relatively cool. The reverse of these conditions holds when the sole source of heating a room is the entering air. It is probable that the objections made by certain of the teachers working under the system are due to mental effects produced by the physiological reaction described. To this must be added the “caged-in” feeling which many experience in a room in which it is impossible to open the windows, a feeling which amounts to a mild form of what is termed in medical textbooks, “claustrophobia.” Enthusiasts for the open-air life can never be happy under these conditions. The following letter was written in 1912 to my predecessor by Dr. Garnett, who was then Education Adviser to the Council. “I enclose a little memorandum which I prepared for the Education Officer on the ventilation of Commercial-street School. I do not want to trouble you with any of the mechanical details, but I should be glad if you would consider the following problem on the physiological and psychological basis. ”Under medical advice the Council is providing not only open-air schools but open-air classes in the London playgrounds, and while in some schools these classes are provided alike for strong and weak children, in other schools it is the anaemic children who are specially selected to attend such classes. We appear, therefore, to assume that, provided a child is warmly clad, the variable conditions to which he is exposed in the open air are conducive to health. “At the other extreme of our system we have the mechanically ventilated school, in which no window may be opened because it disturbs not only the ventilation of the particular room, but of all other rooms in the circuit, and doors can only properly be opened provided that there is a second door closed before reaching the open air. In a mechanically perfect system of forced ventilation the air may be uniformly distributed among the occupants of the room without any sensible draught, and the full amount which the most extreme hygienist can demand may be supplied at a perfectly uniform temperature, and always with the same pre-determined degree of humidity. As far as known chemical, physical and mechanical conditions are concerned, the system may be assumed to be perfect, and the occupants of the rooms are exposed throughout the whole day to precisely the same conditions in all these respects, and there is no demand made upon any of the regulating machinery of the body to alter the adjustments pertaining to surface evaporation, subcutaneous circulation and the like, while such machinery would be constantly called upon for re-adjustments when the body is exposed to the ordinary conditions of open air life. “Between the purely natural conditions of life out of doors and the apparently perfect conditions of living in a tube with an ample supply of pure air, we have the ordinary conditions of natural ventilation in which there are considerable differences of temperature and hygrometric conditions within the 66 same room, while there are great differences between the rooms and the corridors, and the amount of carbonic acid present may be two or three times that to be found in the open air, but may it not be contended that, when we are not dealing with the hospital ward, but with the problem of rearing a number of young people so as to be vigorous in body and alert in mind, the very imperfect but varying conditions incidental to a moderately efficient system of natural ventilation provide better conditions than a chemically, mechanically and physically perfect system or forced draught? “If this is not the case, why is the open air regarded as so hygienic? Does anyone believe that the difference is merely due to the amount of poisonous matter in the atmosphere of an ordinarily well ventilated room? There may be in the outer air actinic rays about which we know little, and which are incapable of penetrating glass, and these may be entirely absent in our closed classrooms. The rays which gradually turn to a violet colour the window glass of a century ago through the liberation of metallic manganese within the glass may be rays of this kind. On the other hand, it may be the constant adaptation of the body to varying conditions which constitutes the major part of the health giving influences of the open air. My main point is, ought we on the one hand to be running open air classes, and on the other to be adopting a system of forced draught and closed windows? The two appear to be very inconsistent.” This letter is worthy of being put upon record if only for the remarkable insight which enabled Dr. Garnett to suggest the existence of actinic rays which cannot penetrate glass, which might have a decided effect upon health. At that time nothing was known scientifically of the effect of ultra violet rays upon health. It is only in the past six years that the very important and definite health giving properties of these rays have been demonstrated, and it is the fact that they are obstructed by ordinary glass. The memorandum to which Dr. Garnett alluded in his letter, contained the following paragraph relating to the complaints of the teachers:— “I do not think that teachers will ever take kindly to the “plenum” system. In the first instance, any system of heating by warm air is unpleasant. It causes a deposit of the solid particles in the air on all surfaces which are cooler than the air itself, and gives a sense of stuffiness. For comfort the air should be colder than the furniture and walls of the room. This gives a feeling of crispness to the air, which is experienced to perfection in the sunshine of a high mountain. “In the second place, I think that in a building in which the windows can never be opened to admit the fresh air directly from the outside, a nervous depression is produced. I do not think that the supply of chemically pure air, perfect as regards its hygrometric condition and its temperature, in a closed building would ever have the health giving effect of open air life, at least as far as its effect on the nervous system is concerned. “In the third place, it is very much open to question whether there is not a considerable refreshment when different parts of the room are at slightly different temperatures whereby eddy currents are naturally produced. In a room which is heated entirely by air at a uniform temperature, there is liability to a production of the sense of lassitude and oppression which would be at once relieved either by opening a window or coming to the front of a bright fire. I am not in a position to explain all these phenomena on physiological grounds.” It will be seen that the opinion which the medical staff has independently formed coincides with that of Dr. Garnett, and an attempt has been made to give the physiological explanation which Dr. Garnett felt himself unable to do. 67 Although the chief objection to the “plenum” system is that the heated entering air is made the sole means of warming the school and its occupants in winter, there are some other objections to the system as applied in the London schools. For instance, the designer of the system was so obsessed by the “plenum” idea, that in some of the schools he even went out of his way in order to resort to devices which obstructed the outflow of air in order to produce a “plus” pressure inside the building. In these schools there is frequent trouble through inefficient working of the system whenever the doors are opened in any department, as an outrush of air takes place, which short circuits the supply to other departments. It is only in the winter, when heating is necessary, that the chief condition of objection exists. During the summer months, when the system is working properly, the physical conditions connected with the air supply are unexceptionable. One hot afternoon in July this year, two of the mechanically ventilated schools were visited. At Commercial-street the conditions were most pleasant, an abundant supply of cool washed air was being delivered to the classrooms, and a feeling of relief was experienced on gaining the inside of the building from the hot, dusty and odoriferous street. Proceeding directly on the same afternoon from Commercialstreet to Old Montague-street, another mechanically ventilated school, the conditions in the boys’ and girls’ departments were found most oppressive and unsatisfactory, and it was a relief to escape from the classrooms into the corridors again. In the infants’ department, however, the atmosphere was very pleasant and satisfactory and the reason for the stuffiness in the boys’ and girls’ departments was apparent. The main doors of the infants’ department stood widely open, with the result that more than its due share of air was being pumped through this department, while the other departments were short circuited, and starved of their due supply. This same inattention to the rules was noticed in this school 23 years ago, when the first observations were recorded. It will be gathered that, although objections can be urged against the “plenum” system, it also has its advantages. Emphatically, judged by purely physical considerations, the system is capable of giving better results than are obtained in most naturally ventilated schools. The honours boards of the schools concerned bear testimony to the fact that the educational progress of the children is not affected, and there are in some of the schools teachers who have worked in them continuously for upwards of twenty years, who are in first rate physical condition, and in the best of health. In every school the opinion of the teachers is divided in regard to the merits of the system, but there was certainly more objection in Old Montague-street, for instance, than at Commercial-street. In the latter school, the system is of very great advantage in view of the generally polluted atmosphere surrounding the school. In Old Montague-street and Christian-street schools there are original defects of construction, to which reference has been made in the body of the report, which make it difficult to keep the system in a reasonable state of effective working. It is understood that the Old Montague-street school is shortly to be given up. The conclusion to be drawn is that no case can be made out for the general “scrapping” at present of the schools worked upon this system. A dust-allaying oil was applied to some of the floors of nine schools during the Christmas vacation at the end of 1924, and the experiment was watched on behalf of the public health department by Dr. J. Nairn Dobbie. The dust in schools comes mainly from three sources—(a) Dust carried by the air; (b) dust carried in by the boots and clothing of the school population; (c) dust from the wear and tear of furniture, fitments, floors, walls, chalk, etc. The use of dustless oils on school floors. The amount of dust varies as the weather is wet or dry, as to the presence or absence of factory and tenement chimneys and the direction of the prevailing wind— the surface of the surrounding streets, and the nature of their paving—type and 68 amount of traffic, whether horse or mechanical. In crowded and poor neighbourhoods more dust is found, and the poorly-clad and ill-shod children carry more dust in their clothes and boots; other things being equal, the newer the school the less the dust. Dust particles are composed of organic and inorganic material, and range in size from minute indeterminate nuclei to easily recognised pieces of wool, cotton, feathers, horse dung, vegetable spores, siliceous and sooty particles, etc., and being relatively much greater in bulk, attract micro-organisms and form a nidus for their preservation and growth. The effect of the dust-allaying oil is to leave a fine film of oil on the surface of the floor. This weights dust particles falling on it and so prevents their rising into the air. At the same time, the flooring becomes darkened, while the surface is made more slippery and tends to stain absorbent materials which come in contact with it. As will be readily understood, such slight slipperiness and the tendency to stain gradually pass off as the oil is absorbed by the wood and gets worn off the surface; so too does the effect of allaying the dust, though the dust-allaying properties of the preparation were still efficient at the end of the three months’ trial. The condition of the wooden floor prior to the application determines the resulting colour, and to a certain extent the slipperiness. When the flooring was new and clean, a pleasing dark reddish-brown colour resulted and the slight slipperiness present was in the direction of the grain of the wood, and was not of great account, but when the flooring was old, uneven and dirty, the resulting colour was distinctly drab, and had a damp greasy appearance which has a depressing effect on many teachers, while the resinous knots which stand out do not absorb the oil, and form points of great slipperiness. That less dust is found in the treated rooms was the unanimous verdict of all the teachers, school keepers and cleaners; from personal observation there was less dust on window ledges, tops of cupboards and on light-shades, etc., in the treated rooms than in the untreated rooms; pieces of white paper were experimentally exposed for varying periods in comparable places in treated and untreated rooms, and invariably the treated rooms showed a thinner layer of dust, many teachers stating they could leave books and papers exposed in the treated rooms without fear of their being soiled by dust; a few stated that their hands and faces and linen were cleaner at the end of the day; several who were subject to sore and irritating conditions of the throat and nose stated they had found much improvement since their rooms had been treated. The amount of dust raised in sweeping the treated rooms was markedly less, in spite of the fact that in oiled rooms a hard bass broom is used as against the soft hair broom used in the untreated rooms. The heavier hard bass broom entails much harder work on the cleaners, but the majority of those questioned preferred sweeping the treated rooms on account of the lessened dust. The dust in these rooms instead of rising in the air is pushed along in pellet form in front of the broom. At the first visit to some of the schools pieces of absorbent materials—cloth, papers, etc.—were placed on the floors of treated rooms and when slight pressure was applied faint oily stains resulted. Towards the end of the term this soiling effect had almost passed off. Many of the scholars’ paper-covered books showed oily stains as the result of lying on the treated floors, and two sewing mistresses found that any materials which fell on the floor became soiled, while two drill instructresses prohibited the girls from sitting or lying on the hall floor from fear of soiling their clothing. Slipperiness was most apparent in the early part of the term—that is, shortly after the application of the oil. Fifty-three teachers out of 66 stated that the floors were more slippery. One infant in Hackford-road fell while drilling and fractuied his left femur; several cases of minor sprains and accidents were reported, and 69 several teachers complained of having themselves fallen. The danger points seem to be the knots, which stand out in old and uneven flooring. All the head teachers and assistants to the number of 66 were asked their opinions on the question of dust; whether they liked the colour, was the floor more slippery, was there any soiling, and for any further observations. Sixty-six replied there was definitely less dust; the advantages being variously stated as keeping the place cleaner; the atmosphere was sweeter, and not the same tendency to become stuffy; books and materials kept cleaner; faces, hands and even linen were cleaner at the end of the session; freedom from throat, nose and chest trouble. Sixteen stated that they preferred the new colour (these largely in schools where the flooring was comparatively new and clean before application); 36 expressed themselves as indifferent to the colour; 14 stated they disliked the colour for varying reasons—“too drab and depressing,” “looks damp and greasy,” etc.; 53 stated that the floor was more slippery, especially just after the floor was treated. Eighteen teachers stated that there was some soiling of the scholars’ clothes and material and books which came in contact with the floors. No complaints had been received from parents as to any accidents from slipping or about soiling the children’s clothes. It is perhaps well to bear in mind that dark clothing is mostly worn during the spring term, and so minor stains would not so readily show up. Sixty-two teachers stated that the advantages definitely outweighed the dis-advantages. No appreciable odour could be detected from the treated floors. Bacteriological plates containing gelatine and agar, suitable culture media for many micro-organisms, were exposed in Virginia-road and Burrage-grove. In each of these schools two rooms, comparable in every respect—size, exposure, floor level, etc., were chosen, one having been treated and one not. Three experiments in each school were carried out. In the first experiment a series of gelatine and agar plates were exposed in the two rooms, while the boys were told to sit quietly. In the second experiment another series of plates were exposed after the boys had stamped their feet, and so raised the dust from the floors. In the third experiment immediately after cleaners had swept out the two rooms the plates were exposed. All the plates were then incubated, agar for 24 hours and gelatine for 48 hours, and the number of growths or colonies of micro-organisms were counted. The results are tabulated below :— N.T. = Not treated. T.= Treated. Virginia-road. Number of colonies on Time of Agar. Gelatine. exposure. Experiment I. N.T. 31 64 10 mins. T. 21 41 10 „ N.T. 76 98 20 „ T. 40 48 20 „ Experiment II. N.T. 179 400 10 mins. T. 129 115 10 „ N.T. 262 600 20 „ T. 149 252 20 „ Experiment III. N.T. 75 327 10 mins T. 10 34 10 „ N.T. 100 364 20 „ T. 28 50 20 „ Burrage-grove. Number of colonies on Time of Agar. Gelatine. exposure. Experiment I. N.T. 12 14 5 mins. ..T. 6 11 5 „ N.T. 21 21 10 „ T. 16 17 10 „ Experiment II. N.T. 154 149 5 mins. T. 89 129 5 „ N.T. 181 252 10 „ T. 132 202 10 „ Experiment III. N.T. 183 Numberless 5 mins. T. 22 30 6 „ N.T. 222 Numberless 10 „ T. 44 53 10 „ 70 In each case it is seen that the number of colonies is much less in the treated rooms, and markedly so after the cleaners have swept out the rooms. The percentage attendance of the scholars and staff in the treated schools was collected for the January-March period in the last three years, and compared with similar figures for neighbouring untreated schools. Factors other than dust have such a preponderating influence at this time of the year that no conclusions could be drawn as to the part played by a less dusty atmosphere on the health of the school population. In the case of Stowey House open-air school, the outside pavilions are mainly used by the children on inclement days, and for feeding and resting in, so that such disadvantages as slipping and staining of clothes do not call for comment, while the lessened dust from the treated floor is the important factor. The head teacher and assistants were unanimous that there was less dust in the sheds. It might even be suggested that the boots and shoes of the children by getting an oily film treading from the prepared floors, would act beneficially by preventing their feet from getting damp on leaving the sheds. There is no doubt that the use of the dust-allaying oil definitely lessens the dust, and produces a cleaner, sweeter and more healthy atmosphere than obtains under the usual methods of periodical scrubbing and daily sweeping as carried out generally in the schools. On the other hand, a disadvantage is that the oiled floors necessitate extra care, owing to the slippery surface, and make it impossible to use the floors to the same extent for physical exercises owing to soiling of garments which come into contact with the oil. In view of the encouraging nature of the reports, it was decided to make a much more extended experiment. In 126 departments in 56 schools the oil has been used throughout the year 1926. At the end of the year a total of 281 departments in 118 schools were being treated. Financially the method proves that a saving can be effected compared with the cost of ordinary cleansing. A summary of the opinions of the head teachers of the 126 departments has been made by the Education Officer and is here reproduced:— Department. Report improved cleanliness. Report less cleanliness. Do not regard slipperiness as serious drawback Regard slipperiness as serious drawback Do not regard risk of soiled clothing as serious drawback. Regard risk of soiled clothing as serious drawback. Consider advantages outweigh disadvantages. Consider disadvantages outweigh advantages. Wish to continue use of oil. Do not wish to continue use of oil. Boys’ 44 1 42 3 41 1 43 2 43 2 (No opinion expressed 3) Girls’ 31 1 24 7 27 5 28 3 29 3 No opinion (No opinion expressed 1) expressed 1) Mixed 12 — 8 4 11 1 12 — 12 — Infants’ 34 — 23 9 23 11 28 4 28 4 (No opinion (No opinion (No opinion expressed 2) expressed 2) expressed 2) Special 3 — 3 — 2 — 3 — 3 — (No opinion (expressed 1) Totals 124 2 100 23 104 18 114 9 115 9 (No opinion (No opinion (No opinion (No opinion expressed 3) expressed 4) expressed 3) expressed 2) This shows that the head teachers in 115 out of 126 departments wish to continue the new method. On the whole, there is a strong preponderance of opinion that the two chief drawbacks (slipperiness and soiling of garments) are not serious enough to weigh against the increased freedom from dust which is obtained. It is proposed to extend the treatment to 100 further schools in London. 71 The Results of Medical Inspection. The number of children in the three statutory age groups inspected in the elementary schools during 1926 was 183,696, being 14,006 less than in the year 1925. They included 74,948 entrants, 44,195 children at age eight, and 64,553 children at age twelve. The inequality in the magnitude of the groups reflects the alterations of the birth rate just before, during and subsequently to the war. 2,025 additional children were examined in their age groups at special schools. Furthermore, 6.3,099 children were inspected in the term before they were due to leave school (i.e., approaching the age of 14). 38,753 children were medically examined in 1926 as special cases not falling in the above age groups, being presented to the doctors by care committee workers, school nurses, head teachers and attendance officers, either because there were indications of failing health or because they were absent from school. An additional 42,822 children were inspected in connection with school journeys, open-air classes, camp schools and so forth. In all, therefore, 330,395 inspections of children were carried out during 1926, compared with 316,722 inspections in 1925. The additional numbers are due to the fact that the examination of children about to leave school was carried out completely in 1926 whereas in 1925 the examination of this additional age group was not undertaken until the year was already advanced. The number of children previously found ailing who were re-inspected in 1926 was 191,182, a very considerable increase beyond the number in 1925 which was 159,388. These reinspections are not included in the totals shown above. Altogether the volume of primary work of inspecting and reinspecting children in the elementary schools, therefore, was considerably increased in 1926. 103,717 children in the four age groups were referred for treatment for various kinds of ailment. These included dental conditions. The proportion referred for treatment of those inspected was 42 per cent., compared with 429 per cent, in 1925. The percentage referred for treatment in the three statutory age groups was 43'8, and this is identical with the percentage of the previous years. A large number of the children were referred for treatment for dental conditions. The exclusion of dental cases reduces the percentage referred for treatment to 193. For the purposes of comparison with former years, the analysis of the incidence of the various ailments which immediately follows will be limited to the three statutory age groups, the condition of the leaving children being left over for a following section. Defects found. 11,391 children in the age groups were found to be under nourished. This is 6" 2 per cent, of the number inspected compared with 6'3 per cent, in 1925. This result is very remarkable, considering the widespread unemployment during a year which was more overshadowed by industrial troubles than any other year in history. Although it is true that during inspections it did not appear that there was any noticeable falling away in the physical condition of the children, yet we were quite prepared for at least a fractional rise in the proportion of under nourished children as the result of the whole year's working when reduced to statistical form. That nothing of the kind has taken place is a testimony to the efficiency of the measures which have been introduced of late years to safeguard the health and well being of our children. These measures stood the strain of the great war, and they have proved themselves effective in dealing with the strains, perhaps even greater, which have been the war's aftermath. The worst group from the point of view of nutrition is that of the eight-year-old boys, 8*2 per cent, of whom appeared to be undernourished, compared with 6" 6. per cent, of the girls of the same age. In an earlier repoit (1923) it was pointed out that there is a special syndrome of conditions which presses most hardly upon boys of this age. This syndrome expresses itself in grave dental decay leading to oral sepsis with enlarged cervical Nutrition. 72 glands and under- nourishment. The greater neglect of attention to the teeth in boys than in girls is the reason for the especial incidence of ill-health in this group, although it may be that as boys appear to be more susceptible to rickets in infancy there is greater mischief wrought amongst them in the way of dental decay through defective structure of the teeth at an early age. Cleanliness. The ministrations of the school nurses pursued without intermission over many years have completely revolutionised the conditions of the children in regard to personal hygiene. When the first tentative work in this direction was undertaken about 1902, a very shocking state of affairs was revealed. Over three-quarters of the girl pupils were found to be infested with head lice and the presence of body vermin was very common. For some years now, thanks to the work of the nurses in the schools and at the cleansing stations, body vermin have become very rare, and during the past year only 258 children out of 246,795 examined were found infested with them. Verminous conditions of the head have proved less tractable, especially in the case of girls. Nevertheless, remarkable strides have been made, and the process of improvement shows no sign of slackening during the past year. In 1913 only 67.2 per cent, of the older girls in the schools were found without traces of verminous infestation of the hair. In 1916 and 1917 this percentage had been raised to 70, in 1920, the figure reached 75, by 1923 it had climbed to 80, in 1924 to 82-5, in 1925 to 85.2, and in the present year to 88' 1 This progress is very encouraging, the nearer one comes to perfection the rule is the harder progress becomes, but no slackening is apparent in the above figures, and if the present rate of improvement could be maintained, a few more years would see the virtual extinction of the head louse in London as well as that of the body louse. Dental decay. The dental condition of the entrant infants shows little alteration. 46 per cent, have manifest decay, and 15 per cent, have severe caries with inflamed and septic gums. These figures have remained practically constant for several years. Dental inspection and treatment at school has produced a very definite improvement in the dental condition of the older children, as will be seen in the following table relating to the twelve-year-old boys and girls :— Dental conditions found at medical inspection in children at age 12. 1913. 1917. 1921. 1925. 1926. 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 Boys 50 40 10 55.2 38.6 6.2 60.3 35.7 40 69.2 28.0 2.8 70.9 26.3 2.8 Girls 52.4 39 8.6 56.4 381 5.5 63.5 33.3 32 70.2 27.5 2.3 72.4 25.3 2.3 (1) Represents teeth apparently sound. (2; Represents caries, but not extensive. (3) Represents considerable caries (4 or more teeth decayed) and oral sepsis. Thus in 14 years the improvement is such that one-fifth more of the school population now leave school with good teeth than was formerly the case. But this represents the result of the work of an organisation which is almost entirely remedial and only to a minor degree preventive. The figures for the entrant infants show that no diminution in the incidence of dental caries is taking place and all that we have so far been able to accomplish is to keep its ravages to some extent in check during school life. The teeth of the children with whom the school dental service has to deal are already to a great extent preformed (although not necessarily erupted) before the children come to school. The work of Mrs. Mellanby for the Dental Decay Committee suggests that impropei feeding and hygiene in infancy affects the structural integrity of the teeth, and this renders the teeth more prone to decay or, at any rate, makes the spread of decay more rapid when it starts. The widespread and, indeed, almost universal incidence of caries is nothing less than a calamity which has overtaken the human race. Viewing it from a broad 73 biological standpoint, one must be impressed with the fact that the mammalian teeth, which have been inherited by man from progenitors who needed instruments to wrest a precarious livelihood by gnawing fibrous roots or tearing raw flesh, are no longer needed to do the work for which they were originally destined. The earlier inventions by man, such as the art of cooking, and the later developments of civilised customs, have resulted in an abundance of foods which require scarcely any mastication at all. The teeth have lost their survival value. Although the teeth of puppies may be rendered badly shaped and imperfect in structure by repeating in them the usual dietetic regimen of human babies, it is impossible to induce in them dental caries at will. One cannot help thinking that modern man has lost an hereditary factor, "Resistance to Caries," much in the same way as certain lands of wheat have lost an hereditary factor, "Resistance to Rust."No other organ in the body shows such a universal tendency to decay as do human teeth; they stand apart, and their especial vulnerability must be recognised as a phenomenon sui generis. Only by the exercise of constant and unremitting care can the ravages of dental decay be kept within bounds. The school medical service is playing its part in this campaign, keeping the teeth of the children under constant supervision and inculcating at all times the necessity for dental cleanliness. There should be even more attention paid to regular organised and definite instruction on the care of the teeth in schools. What is equally needed, however, now is the instruction of the mothers on the proper feeding of infants in order to ensure that when the teeth are being laid down in the jaws during babyhood the elements necessary for strengthening them are abundantly present. 10,168 children in the statutory age groups were referred tor treatment for enlarged tonsils or adenoid growths as compared with 12,876 in 1925 and 8,944 in 1924. Of these 10,168 children, 5,724 were entrant infants amongst whom the greatest proportion of diseased throat conditions is always found. The diminution in the total number of children referred for operation is due in some measure to the smaller number of children comprised this year in the entrant group. The percentage of children referred for treatment in the age groups was 5.5 compared with 6.5 in 1925. Tonsils and adenoids. Though some of the variations from year to year in the number of cases of tonsils and adenoids found is to be explained by alterations in the age constitution of the children inspected, it is also probable that the prevalence of these conditions is connected with climatic conditions and with the incidence of particular infectious diseases predisposing to catarrh. Hence there are times of serious pressure on the treatment centre alternating with periods of comparative remission, and the arrangements must possess a certain amount of elasticity which it is not easy to ensure. Otorrhcea (or running ears) was found in 2,564 children or 1'4 per cent, of routine examinations. This is identical with the findings of the previous year. Defective hearing was reported in 869 children or 0 5 per cent, being a slight improvement on previous findings. Ear diseases. In view of the suggestion which has been made that children suitable for hard of hearing classes are unduly retained or overlooked in the elementary schools, special instructions were issued to the school doctors to guard against any possibility of this happening. Deaf children. The present instruction to the school doctors on this point is as follows:— "It is essential that at all examinations an estimate should be made of the acuity of hearing of children inspected and when any doubt arises a special test should be made and the result recorded. When selecting suitable children for nomination for hard-of-hearing classes, and in recording all cases of deafness, an estimate of hearing should always be given. The forced whisper should be used, and in each case the distance at which the child responds to the test should be entered on the medical record card. It is necessary to nominate deaf children 74 as early as possible, as there is no lower age limit for their attendance at deaf schools. In the case of all children with hardness of hearing the question of the need for special education should be considered at the earliest moment in addition to the question of treatment, and the head teacher should be asked to fill up form M.O. 51 and to forward it to the school medical officer at the County Hall. "In order that there should be no possibility of delay in obtaining consideration for hard-of-hearing children the following rules should be carried out by the doctors in the schools :— (1) During re-inspections at each school the school doctor should set apart a definite time for reviewing all children in the school who are known or suspected to be hard of hearing. (2) All such children should be carefully tested by the forced whisper test. The children tested should be classified as follows :— A.—A child who responds at 20 feet should be regarded as normal. B.—A child who responds at distances between 6 and 20 feet should be regarded as slightly hard of hearing—to be watched. C.—A child who responds only at distances below 6 feet in the better ear should be considered hard of hearing (or deaf). The forced whisper should be made at the end of an ordinary expiration. Numbers like ninety-seven, eighty-three, etc., or words such as 'banana,' 'potato,' 'tobacco,' may be used. The child should not be in a position to watch the doctor's lips during the test and should be requested to repeat the words heard. (3) The same test should be made in the case of children found to be hard of hearing during routine medical inspection. (4) In every case the result of the test should be recorded on the forms in the following way, e.g.:— F.W. at 5 feet—H. of H. F.W. at 10 feet—slightly H. of H. (5) All children falling into category C above should be nominated for special examination. The school doctor should forward the medical cards to the Divisional Medical Officer and the head teacher should be asked to fill up form 51 and to forward it without delay to the School Medical Officer. But children approaching the leaving age should not be nominated unless the deafness is very pronounced, e.g., F.W. at 4 feet or worse. (6) All children falling into category B, should be kept under observation. (7) In each succeeding term all the children previously found to be deaf or hard-of-hearing should be tested, together with any children who may have been suspected to have become hard of hearing in the meanwhile, and the results of the test recorded. " Any difficulties experienced in carrying out the above instructions should be at once reported to the divisional medical officer." In spite of the special attention directed to the detection of deafness, fewer cases were notified as a result of medical inspection. There appears therefore to be no ground for any apprehension that deaf or hard of hearing children fail to be detected at medical inspections. Enlarged glands of the neck. Enlarged glands of the neck (non-tuberculous) were noted in 9,637 children or 5"2 per cent. In 1925 the percentage was 4.78 per cent. There has been a gradual increase during recent years in the number of children reported with enlarged glands. The incidence is heaviest upon entrant infants (7.3 per cent, in boys and 63 per cent, in girls) and least upon the oldest children (3.4 per cent, in boys and 3.3 per cent, in girls). Although the number of children noted to have enlarged cervical glands has increased, the number referred for treatment shows no similar increase. 75 756 children at routine inspections were referred for treatment in 1926 as against 783 in 1925. It appears, therefore, that the increase in the numbers noted is due to the doctors notifying to a greater extent the slighter degrees of enlargement. 51.9 per cent. of 8-year-old boys and 54.7 per cent. of 8-year-old girls failed to pass the test for normal vision. While the figure for girls is the same as last year's, the boys show a distinct improvement. In the 12-year-old group 42.2 per cent. of boys and 46.3 per cent. of girls failed. Here the percentage closely approximates to that of last year. The proportion of children with more serious defect (V =6/12 or worse) was as follows:—8-year-old boys 18 per cent., girls 18.5 per cent; 12-year-old boys 19.9 per cent; girls 21.5 per cent. Owing to the excessive amount of visual defect amongst Jewish boys, arrangements were made with the Jewish Health Organisation of Great Britain for their better supervision, particularly in regard to the Jewish classes in the evenings. A closer co-operation has now been effected and the names of Jewish children attending myope schools, together with those of other children with the more serious degrees of defective vision, are now being regularly transmitted to the Jewish Health Organisation in order that the special regime insisted upon during compulsory school hours may so far as is possible be followed during the hours of voluntary study at other times Visual defects. 4,783 or 2.6 per cent. of the children inspected were reported to have heart defects, functional or organic. Last year 2.71 per cent. were reported. The older girls continue to show the greatest amount of heart strain (3.4 per cent.) Anaemia was reported in 4,338 children or 2.4 per cent.; this compares favourably with the previous vear when 2.75 per cent. were recorded as anæmic. Heart defects and anaemia. 6,236 children or 3.4 per cent. were recorded with lung affections other than tuberculosis. It is the entrant infants who suffer by far the most highly. The condition is almost always bronchitic and is associated in all probability with mild degrees of rickets. The fact that entrant boys are more prone to bronchitis than the entrant girls supports this view. The incidence was slightly less than in 1925. 5.7 per cent. of entrant boys were bronchitic as against 2.9 per cent. of 8-year-old and 1.7 per cent. of 12-year-old boys. Lung disease. Pulmonary tuberculosis was detected in only 102 children (0.1 per cent.) and other forms of tuberculosis in 126 children. It is thus now quite rare to find tuberculosis at routine medical inspection in school. It is satisfactory to note that children suffering from more serious diseases such as tuberculosis are detected and dealt with as they arise and do not remain overlooked in school, waiting until the time comes for their routine inspections in the age groups. Tuberculosis. 106 children were found to be epileptic, 191 children were found with signs of chorea, and "paralysis" (mostly old cases of poliomyelitis) was found in 173 children. The cases of infantile paralysis were found chiefly amongst the entrant infants. Nervous diseases. There has been year by year a rapid diminution in the number of children reported with rickets. 1,118 were reported in 1926, the figures being for the previous three years: 1,320 in 1925, 1,786 in 1924, and 1,975 in 1923. Naturally most cases are reported in entrants, and it is the entrant boys that suffer most severely. During the year the work of Dr. M'Gonigle, in Durham, has attracted attention. He has shown that when the signs of old rickets are especially sought there are at all ages many more children than is commonly supposed in whom it can be decided that some degree of rickets has been suffered. Applying his methods in London it is found that the remains of the milder degrees of rickets can be detected in a much larger proportion of children than are reported by the school doctors at medical inspections, although the incidence of rickets in London is far less than in Durham. There is no particular point in searching for and recording M'Gonigle's signs in Deformities. 76 the routine medical returns, as they consist in small aberrations which at the time of examination will pass unnoticed unless especially looked for; they require, and indeed can receive, no remedial action, and tend rapidly to disappear during school life. Their importance lies in the demonstration that, while serious rickets has become very much less prevalent than formerly, there still remains a large proportion of the children whose nutrition during early infancy, long before school life has been entered upon, has been prejudicially affected by improper feeding, absence of sunlight, defective ventilation and general neglect of hygiene. The opinion is growing that this widespread deleterious influence is more important than was suspected. Hitherto we have been accustomed to worry only about the more serious degrees of rickets, to congratulate ourselves because they are rapidly becoming rarer and to comfort ourselves with the assurance that during school life the bony deformities resulting tend to disappear. But now it is beginning to be perceived that it is not alone the bony structures, upon the maldevelopment of which the diagnosis of rickets mainly depends, that suffer, but also the general constitution of the child to a greater degree than was formerly imagined. The number of entrants to school who have bronchitic signs has been remarked upon, and in these reports it has always been considered that this excess of bronchitis has been connected with a rickety constitution. But we are now beginning to see more clearly that the care and management of the infant children before school age is the most fundamental of all the influences which affect the health and physique of the children. The school medical service inherits children whose constitution has been already compromised. The great scourge of dental caries which takes such a preponderant place in the anxieties of the school medical service can only be mitigated when the children are allowed by proper management and care in the pre-school years to have from the beginning teeth well formed and strong to resist decay. The macroscopic effects of rickets disappear, but are we certain that the microscopic effects do not remain ? In the case of the teeth there is evidence to show that it is the case that they do remain. It is even being suggested now that the incidence of adenoid growths and enlarged tonsils is chiefly upon children whom painstaking investigations will show to have suffered from rickets in infancy, if only to such minor degree as not to have occasioned remark or discovery. More and more it is borne in upon us that the part of the school medical service must remain to a large degree remedial rather than preventive, and we must look for the lightening of its burdens to preventive work which must be done at the earliest ages long before school life commences. Other deformities. Deformities other than those having their origin in rickets were reported in 2,722 children, of these 1,010 were spinal curvatures. 378 of these were found in the older girls, being twice the incidence upon older boys. They consist chiefly in postural lateral curvature of the spine, which by appropriate exercises in school can generally be corrected without recourse to further treatment. The health of the child leaving school. In 1925 at the urgent request of the local associations of care committees and other interested bodies, the examination of all children about to leave school which had for some years been in abeyance was restored. In 1926 the whole of the school leavers were inspected comprising 31,301 boys and 31,798 girls. On the whole the results of this inspection are very satisfactory. They demonstrate that during the last two years of school life there is a special intensification of effort to get defects remedied before the children leave school and to fit them as far as possible for industrial life. Enlarged tonsils and adenoids were reported in 5.8 per cent. of the boys as compared with 7.2 per cent. at age 12, and in the girls in 6.9 as compared with 8.9 per cent. Poor nutrition was reported in 4.9 per cent. of leaving boys compared with 6.7 at age 12, and in 43 per cent. of girls compared with 6.3. 77 Deficient cleanliness was found in 9.9 per cent. of leaving girls compared with 11.9 at age 12. Defective teeth were recorded in 28.6 per cent. of leaving boys compared with 29.1 at age 12 and in 28.6 per cent. of girls compared with 27.6. Very severe degree of dental defect was reported in 2.2 per cent. of leaving boys and 2.1 of leaving girls compared with 2.8 and 2.3 respectively at age 12. 615 per cent. of leaving boys had normal vision against 57.8 per cent. at age 12 and 566 per cent. of girls against 53.7. In almost every other circumstance the leaving were superior to the 12-year-old children. There was less otorrhœa, less anaemia and even in the case of postural curvature of the spine there was no increase in the incidence on girls of 14 compared with those of 12. Very valuable work is done at special inspections. Children flagging in energy or absent from school for illness are brought before the school doctor at the first convenient opportunity. 38,753 children were inspected outside the age groups in 1926. Amongst them were 853 cases of malnutrition, 314 of scabies, 3,799 of defective vision, 566 squint, 1,067 external eye disease, 1,267 of discharging ears, 1,706 of anaemia, 429 of tuberculosis actual or suspected, 314 of epilepsy, 498 of chorea, 421 of paralysis, etc., and 522 of deformity. In many of these conditions the cases found at special inspections outnumbered all the cases detected at all the age group inspections lumped together. Special inspections. The survey of the statistics of medical inspections shows that, while there is still much leeway to be made up, while still many children leave school with defects unremedied, there is year by year a notable improvement; this is especially marked in the case of personal hygiene, dental conditions and visual defect. It also shows that much of the defect is due to causes over which the schools can have no direct control, and that these causes operate most profoundly upon the infant child in the pre-school years. The net results. The records show an improvement in the health of the children during school life and an intensification of the activities of children's care in the two years immediately preceding the school leaving age. The school medical service is a receiver of damaged goods and spends most of its time and energies in patching them up. What is now required is an intensification of social effort directed to the care of the infant in arms and the toddler before school age, so that children shall come to school in the beginning with constitutions unimpaired and with bodies attuned to receive the mental, moral and physical education which it is the primary function of the school organisation to impart. Medical Inspection of Pupils at Higher Education Institutions. All pupils at secondary schools and technical institutes are seen by the school doctor annually, but the complete schedule of examination prescribed by the Board of Education is only filled in on entrance and at the ages of 12 and 15. In all, 6,429 male and 7,072 female pupils were seen by the school doctors during 1926. In addition, 2,425 pupils who were under observation for defects were reinspected. The number of male pupils inspected at the age of 12 was 1,300; of these 94 (7.2 per cent.) were below normal in nutrition and one was found in an emaciated condition. Some degree of dental caries was found in 294 (22.6 per cent.), severe dental caries in 31 (2.4 per cent.), 341 (26.2 per cent.) failed to pass the vision test, of these 179 (13.7 per cent.) had more serious visual defect; 6 boys had ear disease; 13 defective hearing; 6 speech defects; 31 defects of heart and circulation; 57 (4.4 per cent.) were anæmic, 9 had defects of the lungs; 9 of the nervous system; 14 of the spine; 53 (4.1 per cent.) were flat footed. At age 15,1,632 pupils were fully examined. 85 (5.2 per cent.) were below normal 14172 F 78 in nutrition, while 3 pupils were suffering from malnutrition; dental decay was present in 374 (22.9), being of serious degree in 37 (2.3 per cent.); 528 (32.3 per cent.) failed to pass the vision test and 281 (17.2 per cent.) had more serious visual defect; 246 (15.1 per cent.) were wearing glasses; 12 had ear disease; 14 defective hearing; 17 speech defects; 45 defects of circulation; 38 (2.3 per cent.) were anæmic; 9 had lung defect; 5 defects of nervous system ; 22 spinal defect; 33 were flat-footed. Of female pupils in secondary schools, 1,000 were examined in detail at age 12. 115 (11.5 per cent.) were below normal in nutrition; 8 were not satisfactory in cleanliness, though pediculosis was completely absent in all girls examined; 188 (18.8 per cent.) had caries of the teeth, of these 13 had severe caries; 82 (8.2 per cent.) had nose and throat defects; 320 (32.0 per cent.) failed to pass the vision test, of these 162 (16.2 per cent.) had serious visual defect; 140 (14.0 per cent.) were wearing spectacles; 8 had ear disease; 10 defective hearing; 1 speech defect; 29 defects of circulation; 28 anaemic; 8 lung defect; 13 defects of nervous system; 137 (13.7 per cent.) spinal defects; 162 (16.2 per cent.) were flat-footed. At age 15, 1,491 female pupils were examined; 102 (6.8 per cent.) were below normal in nutrition and one was suffering from malnutrition; 34 (2.3 per cent.) were not satisfactory in cleanliness; 301 (20.2 per cent.) had dental caries, of whom 15 (1 per cent.) had serious decay; 74 (5 per cent.) had nose and throat defect; 523 (35 per cent.) failed to pass the vision test of whom 296 (19.8) had more serious visual defect; 290 (19.4 per cent.) were wearing glasses; 17 had ear disease; 17 defective hearing; 4 speech defects; 44 defects of heart and circulation; 68 (4.6 per cent. were anaemic; 12 had lung defects; 24 defect of nervous system; 263 (17.6 per cent.) had spinal defect; 160 (10.7 per cent.) were flat-footed. Comparison of health of male and female pupils. At either age, male pupils appear better nourished than female pupils; both boys and girls attain a high standard of personal hygiene, and in one case alone was pediculosis found and that in a 12-year-old boy. Dental caries is more prevalent in boys than in girls; visual defect, on the other hand, is more prevalent in girls than boys; spinal defect (chiefly due to bad carriage and posture) and flat foot are recorded much more frequently in girls than in boys. Progress in health during secondary school life. Nutrition improves in both sexes while at the secondary school, dental caries shows a little increase amongst the girls; vision deteriorates considerably and many more are wearing glasses at the older ages; together with the deterioration in vision goes an increase in defects of posture. The traditional physique of the student, bespectacled with narrow chest and a stoop, is evidently still the fate of a large proportion of the pupils at institutions for higher education. Following-up. In the normal case the mother of the child attends the inspection of her child at school. If a defect requiring treatment is found, the care committee representative who is also present at the inspection discusses with the mother there and then ways and means of obtaining treatment. If the mother has no private medical attendant or is not in a position to pay for private attendance and the case is one suitable for treatment under the Council's arrangements, a voucher is applied for entitling the mother to attend a treatment centre. Should the appointment made not be kept, the care committee representative is advised, who visits the parent, ascertains the reason for non-attendance and if the parents consents applies for a new appointment. If the parent does not attend the inspection, the school nurse visits and delivers an advice card signed by the school doctor, which states the defect and urges the necessity for treatment. The representative of the care committee follows this up and if the parent is unable to secure treatment herself a voucher is applied for if the parent consents. Many parents readily take advantage of the facilities provided; this is well seen amongst the children who win scholarships; it is now extremely rare to find 79 at the scholarship examinations children whose parents have neglected to obtain treatment for the ailments which have been pointed out at school medical inspection. There remains, however, a certain number of parents obstinately refusing to take the necessary steps to obtain treatment. Head teachers and care committee workers do their best to persuade and many cases are referred to the special officer, but too often no result of intensive following-up is obtained. In the last resort, such cases are referred to the N.S.P.C.C., and prosecution may follow. 714 cases were reported to the Society in 1926, including 354 vision and 319 dental cases. In practice, however, prosecution can only be successfully carried through when children are already suffering by the development of a disease, and great care has to be exercised in submitting cases for prosecution. For it is not by threats or coercion that lasting good can be brought about. All is hopeless unless the whole-hearted interest and co-operation of the parents are engaged. It is the slow process of enlightenment which alone will eventually solve the problem. It is most encouraging to note that the younger mothers who were still at school when the school medical service was instituted are much readier than the older ones to agree to medical and dental treatment when required. As these replace the present generation of mothers the efforts of the school medical service as a preventive force will at last be rewarded. It is in regard to the treatment and prevention of dental decay that the greatest ignorance and prejudice still exists. Six months after pointing out the need of dental treatment at medical inspection there are still 41.7 per cent. of children needing treatment in respect of whom no steps have been taken by the parents despite all efforts to induce them. Even less notice is taken of the dental inspections. The following is an example of the replies received:— "I desire my daughter's teeth to remain as they are; the same Power that placed them there will make due change when necessary." Other reasons given by parents to the visitors for not obtaining dental treatment are the following: "Second teeth never come if the first are removed," "Shock was so great in another child that it brought on scarlet fever," "Bad teeth run in the family," "When the teeth ache they can come out," "His father has had toothache all his life, so the child will have to put up with it," "As the teeth never ache and the child does not complain, the treatment cannot be urgent," "He won't go and I can't make him," "Is the child mine or the L.C.C.'s?" "Won't have the child's mouth pulled about," " I do not agree with stoppings," " What was our teeth given us but to eat with, and you wants to draw them," " I'll take her to a proper dentist when her teeth ache." The formal reinspections in school of children previously found defective in any way make it possible to compile a statistical record of following up. During the year 192,035 reinspections were made, being 28,308 more than in 1925. 121,228 of these were primary reinspections and 70,807 were second reinspections of children not discharged at primary reinspections. (The London system is to allow a term to elapse between the discovery of the defect before the primary reinspection is made, and to earmark the unsatisfactory cases at the primary reinspections for a second reinspection after the lapse of another full school term.) Combining the results of the first and second reinspections, it is found that in 1926, 75.4 per cent. of the children needing treatment eventually obtained it. This is practically identical with the figure of 1925 which was 75.5 per cent. Ignoring dental defect, the proportion of children treated works out at 80.7 per cent., which is again practically identical with the figure of the previous year (80.3). Of the cases treated, 78.1 per cent. were dealt with under the Council's scheme, 7.1 per cent. were treated by private practitioners and 14.8 per cent. at hospitals and institutions not coming within the Council's scheme. 14172 F 2 80 There is a steady drift year by year of children from the voluntary hospitals to the treatment centres. This movement is accounted for partially by the popularity of the treatment centres, but still more by the policy of some of the hospitals who seek to relieve the pressure on their out-patient departments by diverting children who apply to them for treatment to the Council's centres. Thus, for instance, taking at random the year 1919 for comparison with the year 1926, in the former year 14.3 per cent. of total refractions were done at hospitals outside the scheme, while in the latter year 11.4 per cent. only were so done. Similarly with operations for tonsils and adenoids, in 1919 of all operations 24.3 per cent. were carried out at voluntary hospitals while in 1926 only 17.6 per cent. were credited to these. Taking again the same two years for comparison in the effectiveness of following up: the proportion of children at first reinspections found to have neglected to get treatment for defective vision was 42.6 per cent. in 1919 as against 36.9 per cent. in 1926; the proportion who had failed to get treatment for tonsils and adenoids in 1919 was 46.3 as against 41.7 in 1926; for dental decay neglect to obtain treatment was found in 52.2 per cent. in 1919 as against 53.1 per cent. in 1926. Here, again, we see how much harder it is to persuade parents to obtain dental treatment than anything else. Reinspections in 1926. 1st Reinspections. Class of ailment and number of cases reinspected. Attended by doctor. Treated under Council's scheme. Treated at other hospitals. Not treated, but recovered. Not treated. Improved. (For observation only). Not treated. Still needing treatment. Cured. Not cured. Cured. Not cured. Cured. Not. cured. Refraction 19,157 108 62 4,361 2,049 515 338 1,600 3,050 7,074 .6% .3% 22.8% 10.7% 2.7% 1.8% 8.3% 15.9% 36.9% Minor Ailments 10,946 215 56 2,391 877 419 292 2,633 1,588 2,475 2.0% .5% 21.9% 8.0% 3.8% 2.7% 24.0% 14.5% 22.6% Nose and throat, 18,762 84 13 4,106 262 845 112 2,666 2,840 7,834 .4% .1% 21.9% 1.4% 4.5% .6% 14.2% 15.2% 41.7% Teeth, 57431 1,359 468 15,918 784 772 168 6,176 1,283 30,503 2.4% .8% 27.7% 1.4% 1.3% .3% 10.8% 2.2% 53.1% Other ailments, 14,932 346 163 700 638 1,201 1,183 4,174 4,213 2,314 2.3% 1.1% 4.7% 4.3% 8.0% 8.0% 28.0% 28.2% 15.4% Total 121,228 2,112 762 27,476 4,610 3,752 2.093 17.249 12.974 50,200 1.7% .6% 22.7% 3.8% 3.1% 1.7% 14.3% 10.7% 41.4% 2nd Reinspections. Class of ailment and number of cases reinspected. Attended by doctor. Treated under Council's scheme. Treated at other hospitals. Not. treated, but recovered. Not treated. Improved. (For observation only). Not treated. Still needing treatment. Cured. Not cured. Cured. Not cured. Cured. Not cured. Refraction, 13,263 58 33 2,405 1,247 323 250 1,397 2,351 5,199 .4% .2% 18.1% 9.4% 2.4% 1.9% 10.6% 17.8% 39.2% Minor Ailments 5,661 50 43 973 553 177 184 1,302 861 1,518 .9% .8% 17.2% 9.8% 3.1% 3.2% 23.0% 15.2% 26.8% Nose and throat, 11,466 26 11 2,117 130 464 60 2,176 1,625 4,857 .2% .1% 18.4% 1.1% 4.0% .5% 19.0% 14.2% 42.5% Teeth, 31,484 776 262 7,253 415 418 98 4,734 636 16,892 2.5% .8% 23.1% 13% 1.3% .3% 150% 2.0% 53.7% Other Ailments, 8,933 106 97 348 406 584 698 2,773 2,506 1,415 1.2% 1.1% 3.9% 4.6% 6.5% 7.8% 31.0% 28.0% 15.9% Total, 70,807 1,016 446 13,096 2,751 1,966 1,290 12,382 7,979 29,881 1.4% .6% 18.5% 3.9% 2.8% 1.8% 17.5% 11.3% 42.2% 81 Chronic Invalidity in Children of School Age. The attendance officers furnish each month a return of the children who have been absent from school for a period of over three months. A register of all such children is kept in the public health department, and this affords the most complete information that we have in regard to the extent and causes of chronic invalidity in children. Inquiries are instituted to ascertain that the children are receiving adequate treatment and to see that steps are taken to ensure return to school if the child be fit or education in a special school if that be deemed advisable. In November of each year a census is taken of the children then out of school for over three months. In November, 1926, the number on the list was 2,130 compared with 2,398, 2,608 and 2,683 in the three previous Novembers. The following table gives details of the cases for the last four years:— Complaint. Rheumatism, heart and chorea Nervous disorders Tuberculosis (pulmonary and other) Anaemia and debility Ringworm Skin complaints (other than ringworm Eye complaints Infectious diseases Other diseases All diseases (total No. of cases) Total No. of children out of school Children. 1923. 1924. 1925. 1926. 652 672 614 537 274 288 268 249 462 399 322 268 184 201 196 169 145 85 81 27 66 76 72 62 112 135 103 92 67 *98 *92 *103 764 732 737 732 2,726 2,686 2,485 2,239 2,683 2,608 2,398 2,130 Percentage of total. 1923. 1924. 1925. 1926. 23.92 25.02 24.71 23.98 10.05 10.72 10.78 11.12 16.95 14.86 12.96 11.97 6.75 7.48 7.89 7.55 5.32 3.16 3.26 1.21 2.42 2.83 2.9 2.77 4.11 5.03 4.14 4.11 2.46 3.65 3.7 4.6 28.02 27.25 29.66 32.69 * Including encephalitis lethargica. Rheumatism, heart disease and chorea are responsible for 537 cases or nearly 24 per cent. of the total, the rheumatic group of cases thus easily topping the list of causes of chronic invalidity in children, tuberculosis for 268 or 12 per cent., while anæmia, debility and lung disease (pre-tubercular cases) account for 367 or 16 per cent. 103 or 4.6 per cent. of the cases were absent as a result of infectious disease, including the sequelae of measles, scarlet fever and diphtheria, and cases of encephalitis lethargica. Cases of ringworm are gradually disappearing from these lists owing to the much larger proportion of cases submitted to X-ray treatment. The figures for the years 1921-1926 were 231, 200, 145, 85, 81, 27. Among older girls the incidence of heart disease is twice that among the older boys, but taken generally the figures relating to long absences show that both among boys and girls the younger ages provide the greater number of cases. There were 570 boys and 611 girls recorded from 5—9 years of age and 401 boys and 548 girls from 10—14. The higher incidence of infectious disease on the younger children and the fact that children are not admitted to special schools under the age of 7 to some extent account for the higher proportion at the earlier ages. There were 24 children suffering from the effects of encephalitis lethargica. Medical Treatment. The growth of the medical treatment scheme from its beginning in 1910 was reviewed in the annual report for the year 1925. At the end of the year 1926 there were 12 hospitals and 64 centres, in addition to the dental centre at Bushy Camp School. The provision made for the several ailments and the numbers treated. during the year were as follows:— 82 Defective vision Ear, nose and throat disease Ringworm Minor ailments Dental defects Total Numbers provided for (1926). 34,830 14,680 1,574 70,675 125,950 247,709 Numbers treated (1926). 37,985 16,168 844 89,709 113,932 258,638 Numbers treated (1925). 36,356 15,066 1,167 88,447 112,964 254,000 The excess of numbers treated in some departments over the provision made, was made up partly by larger numbers seen per session than the agreements provided for, and partly by the sanctioning of additional sessions for which provision was made in the estimates when pressure upon the accommodation became apparent at certain centres. The very remarkable diminution of children suffering from ringworm is a great testimony to the value and efficiency of the work of the nurses in the schools coupled with adequate provision for treatment. The new centres which have been opened during the year are:— (1) "The Elizabeth Bullock," 376, Wandsworth Road, S.W.8, opened 1.4.26, provides for 660 minor ailments and 1,540 dental cases annually. (2) Pentonville Centre, 11, Cynthia Street, Finsbury, opened 30.11.26, provides for 660 minor ailments. (3) Lewisham Minor Ailment Centre (an addition to the Dental Centre at 72, Lewisham Park) opened 31.8.26. provides for 660 minor ailments. (4) The "Hanover Park" Centre, Rye Lane, Peckham, opened 17.5.26; provides for the in-patient treatment of 1,760 children operated upon for enlarged tonsils and adenoids. (5) The "Prunella" Centre, 29, Cable Street, E., opened 1.1.27, provides for 1,540 dental cases. (6) The Hoxton Centre, 48, Hoxton Street, N.l, opened 1.1.27. An additional department provides for 440 cases of ear, nose and throat diseases. In the following statement the ailments are dealt with separately in the order suggested by the Board of Education. (a) Minor ailments.—89,709 children received minor ailment treatment, an increase of 1,262 on the number for 1925. In pursuance of the arrangement made with the Metropolitan Asylums Board, 127 children suffering from contagious ophthalmia or interstitial keratitis were sent to White Oak Residential School, Swanley. Among these were 20 cases of trachoma and 17 cases of interstitial keratitis. (b) Visual defects.—37,985 children were dealt with under the Council's scheme for refraction. Spectacles were prescribed in 26,718 cases, and 23,593 cases (88.3 per cent.) were obtained. (c) Nasal and aural defects.—The total number of cases treated was 17,783, of which 16,168 were treated under the Council's scheme. 11,550 children received operative treatment at the treatment centres, and of these 6,210 children were retained after operation under the in-patient scheme at the five centres where this arrangement has been made. The extension of the scheme by which it is intended that all operation for throat disease shall be dealt with by in-patient provision is being steadily forwarded. This scheme began tentatively in January, 1920, at the Cyril Henry Centre, Woolwich, handed over to the Council for maintenance, as a memorial to her son, by Lady Henry. The Belgrave Hospital adopted the practice towards the end of the year 1922, retaining the children for at least three nights. Later the Highgate New Town Centre was built and equipped in modern fashion by Mr. and Mrs. R. Kohnstamm in memory of their sons lost in the war. In-patients have been received here since 1st April, 1923. During the past year, on 17th May, a centre was opened at Hanover Park, Peckham, and temporary 83 arrangements with the Mildmay Hospital have been in force since November, 1925. A summary of the existing provision is here briefly given. In-patient Annual Number Address of Centre. treatment begun. provision. treated in 1926. Belgrave Hospital, Clapham-road, S.W.9 September, 1922 500 475 Cyril Henry, 57, St Mary's-street, Woolwich, S.E.18. 1st January, 1920 2,500 2,501 Hanover-park, 7, Hanover-park, Rye-lane, S.E.15 17th May, 1926 1,760 1,251 Highgate New Town, Chester-road, Swain's-lane, 1st April, 1923 1,760 1,672 N.W.6. Mildmay Hospital, Newington Green-road, N.l 12th November, 12 a week up 311 1925. to 31/3/26. 5 a week from 1 /5/26. Two further centres, at 69, East India Dock Road, Poplar, and the other at Riseholme Street, Hackney Wick, are in hand, and it is hoped will shortly be opened. These will provide for 2,200 children and 1,320 children annually respectively. As regards West London, it is understood that the Princess Louise Hospital, North Kensington, will be able to accommodate 500 Council patients per annum from next September onwards, and arrangements are being made for 440 children a year to be treated as in-patients at the Victoria Hospital, Tite Street, Chelsea. When these arrangements come into operation the total provision made for in-patient treatment will approximate somewhat closely to the estimated requirements, namely. about 11,000 patients per annum. The following are the statistics relating to work done under the new scheme from 1st January to 31st December, 1926, distinguishing between children suffering from otorrhœa and purely deaf children. Otorrhœa. Purely deaf children. Patients. Ears. Patients. Ears. Attendances 10,258 11,906 807 1,259 Cases examined 2,077 2,540 155 280 New cases examined 1,812 2,286 102 183 Cases lapsed 266 317 25 48 „ discharged at first examination 330 425 4 8 „ discharged cured 1,295 1,498 77 139 „ improved — - 10 16 „ relapsed 334 364 9 15 „ unrelieved — - 7 10 ,, still under treatment on 31st December, 1926. 830 1,014 65 118 Report of Dr. A. G. Wells on the treatment of discharging ears. In comparing the results of the past year with those of 1925, it will be seen what a great improvement there has been in the percentage of successful cases. Whereas in 1925 the " discharged cured cases show 45.7 per cent. for discharging cars, 1926 shows 67.3 per cent. Also, while in 1925 the "discharged cured" cases show 22.7 per cent. for purely deaf patients, and 5.2 per cent. improved, and 10.7 per cent. unrelieved; the results for 1926 are "discharged cured" 59.9 per cent.; improved 6.9 per cent.; unrelieved 4.3 per cent. The past year shows the highest percentage of successful cases since the ear scheme has been in operation. There is, however, an explanation which may account for the considerable increase over the year 1925. Until the beginning of 1926 the principal centres obtained their cases mainly through the "treatment centre" doctors. For the most part these were cases which had been receiving treatment at the treatment centre for varying periods, and which did not seem to respond to the treatment given. They were, in consequence, referred for further advice and treatment. This meant that in the main the cases which were referred were the more difficult ones, and usually not "early" cases. Since the beginning of 1926 another plan for the supply of cases has been adopted. This consists in taking a The table below shows a complete analysis of the work done:— Total cases. Cured. Lapsed. Sent to hospital. Still under treatment. Causes of suppuration. Acute Supp. Otitis media 2 2 — — — Chronic Supp. Otitis media due to: I. Tympanic conditions only— (a) Tympanic sepsis only 611 454 10 1 146 (b) T.S.+granulations 182 106 10 1 65 (c) T.S.+polypi 23 9 3 — 11 (d) T.S. + caries 8 6 1 — 1 (e) T.S. + other conditions 27 18 — — 9 II. Tympanic conditions+ (a) Tonsils and adenoids 59 45 3 1 10 (6) Nose conditions 41 23 — 1 17 (c) Mouth conditions — — — — — III. Tympanic conditions+ (a) Attic disease 216 60 19 31 106 (6) Mastoid disease (no operation) 164 6 8 97 53 (c) Mastoid disease (operation already) 53 32 2 5 14 84 Ionisation. centre and working through all the cases at that centre and then passing on to another centre and doing the same again. In this way it is possible to deal with all types of cases, early as well as late, easy as well as difficult, and no doubt this method is largely responsible for the high percentage of successes in the year 1926. This latter plan has the advantage of rapidly clearing the centres that are being worked through, but the disadvantage of not finding it possible to work through all the treatment centres in the year with the present staff, viz., three aurists. It is quite clear that it will be necessary to increase the number of aurists, if the "ear" cases are to be dealt with adequately. Although the rule is to work through the treatment centres consecutively, nevertheless any "urgent" or "special" cases referred are seen as well. This plan will be continued through 1927, by the end of which time we shall be able to form a better opinion as to the relative merits of the two methods. In the treatment of cases by ionisation, the same plan has been followed during the past year as in 1925, viz., the cases selected have not been limited to those obviously suitable, but many doubtful and difficult cases have also been treated by this method, with or without the assistance of other forms of treatment, and these are embraced in the results recorded below. Naturally, the effect of including these cases is to reduce the percentage of successful results, but on the other hand quite a fair number are eventually cleared up, and are thus saved from the necessity of a mastoid operation. Of the 454 cases which were still under treatment at the end of 1925, 87 were found to be quite healed without any further ionisation in 1926. These should be added on to the number of "discharged cured" cases for 1925, but this could not be done at the time the last report was written, since these cases were not examined until early in 1926. The two instruments which are working from batteries instead of the main current, viz., those at Popham Road treatment centre and at Breakspears Road, have done well to last without renewal of batteries since April, 1925, and still show no signs of running out. A fair number of repairs to "ear pieces," "indifferent electrodes," "leads," etc., have had to be executed during the year, but this is inevitable in spite of fair treatment and care. The upkeep in running costs spread over the year is negligible. The total number of ears ionised was 1,392. The total number "discharged cured" 762. The number which lapsed from various causes 57. The number referred to hospital for operation 137, and the number still under treatment at the end of the vear was 436. 85 Causes of suppuration. Total cases. Cured. Lapsed. Sent to hospital. Still under treatment. IV. Tympanic conditions+ (a) External otitis 2 - - - 2 (6) Stricture of meatus 2 — — — 2 External otitis 2 1 1 — — Cause undetermined — — — — — Totals 1,392 762 57 137 436 From this table it will be seen that the percentage of successful results for the whole of London was 57 per cent., with 436 cases still under treatment on the 31st December, 1926. Tympanic sepsis cases show 75 per cent. cures. The following are the percentages for the various divisions:— N.W. Lissonia 68.3% with 37 still under treatment on 31 /12/26. Kenley-st. 37.1 % „ 39 „ „ „ „ N.E. 60.7% „ 65 „ „ „ „ E. 47.4% „ 139 „ „ „ „ S.E. 50.9% „ 93 „ „ „ „ S.W. 67.9% „ 63 „ „ „ „ The low percentage at Kenley Street treatment centre is due to the large number of attic disease cases in which an attempt has been made to cure without operation. Children requiring operation for mastoid disease are admitted by special arrangement with the Metropolitan Asylums Board to the Downs Hospital, and on their return are kept under observation at the Board's After-Care Clinic at Kentish Town. Patients. Ears. Number of patients referred from Downs Hospital to Kentish Town 262 306 ,, referred from Downs Hospital 1925 continuing treatment in 1926 70 94 Total 332 400 1926. - - Number discharged from Downs Hospital requiring no treatment 36 43 ,, discharged from Downs Hospital, treated at L.C.C. clinic and cured 6 8 ,, discharged from Downs Hospital still under treatment L.C.C. clinic 8 8 „ treated Kentish Town and discharged cured 101 115 „ still under treatment at Kentish Town 99 120 „ lapsed 6 6 ,, referred back to D.H. for further operation 6 6 1925. Number treated Kentish Town and discharged cured 58 79 ,, transferred to L.C.C. clinics 9 11 ,, lapsed in 1926 3 4 Total number of mastoids cured in 1926 159 191 During the past year (in April) ultra violet ray irradiation was introduced at Kentish Town as an adjuvant in the treatment of ears. The instrument used was a Tungsten arc lamp. Though many cases appeared to respond and benefit from this treatment, more experience is required before anything of definite value can be said on the matter. During the year 1,329 irradiations were employed. Details relating to the Downs Hospital and the After Care Clinic, Kentish Town. Another method of treatment introduced during the year is diastolisation. This treatment, which is not practised in England, was introduced in France by Dr. Gautier of Paris, and is extensively used in the Paris clinics on the school children. It is employed in cases of defective nasal respiration, particularly those due to hypertrophic rhinitis and the like. The instruments employed are graduated hollow bougies of rubber, shaped to the exact contour of the nasal canal. These are connected by a nozzle and indiarubber tubing to a "pear" by means of which the bougies may be inflated and deflated. By a combined "to and fro" movement of the bougie and a simultaneous inflation and deflation, the treatment is accomplished. Diastolisation. 86 Briefly, the effect is to produce a decongestion of the congested and inflamed mucous membrane with its condition of stasis and tumefaction. Great success is claimed by those French surgeons who are employing the treatment, and our observations and experience tend to confirm these claims. Out of a series of 35 casesall suffering from deficient nasal respiration of marked degree accompanied by symptoms of snoring, mouth breathing, inability to blow the nose, nasal discharge, deafness, frequent colds, etc., and showing various grades of nasal catarrh, different forms of rhinitis and other pathological conditions of the nose, 24 cases were completely relieved, 7 were greatly improved and the remainder showed some degree of improvement. The benefit derived was not confined to the local condition of the nose, but was seen in the general condition of the child. Those who in addition had discharging ears, appeared to derive benefit in this direction also, as was evidenced by the rapid cessation of the discharge in several cases, during the administration of the treatment. These nasal conditions are very frequent and very intractable and this method appears to give fair promise of supplying the solution to the problem. A special report on this subject will be made at a later date after further experience in the treatment. Each of the main clinics is now supplied with a set of the apparatus required. Inspection of treatment and operating centres. On the whole, the staff of operators at the tonsil and adenoid clinics is the best that we have had. There is a fair amount of difference in the skill of the various operators and the standard of excellence in some cases is very high. Various of the minor ailments centres have also been visited and the nurses instructed in the treatment of ears. This work is sometimes done very inefficiently, owing firstly to lack of knowledge and training (the work being by no means simple) and secondly to the lack of suitable equipment. When possible it would be desirable to increase the number of ionisation centres and also to increase the present staff of assistant aurists. It has already been stated that 87 ears of the 168 still under treatment at the end of 1925 were found to be well without any further treatment in 1926. This gives the percentage of successes in cases of tympanic sepsis as 85 per cent. in 1925. The exact percentage for 1926 cannot be known until the result of these "stand over" cases, numbering 146 at the end of 1926, is recorded. The percentage of cases completed during the year is 75 per cent. for tympanic repsis. The full result when known will probably exceed the percentage for 1925. (d) Dental defects—58 part-time inspecting dentists were engaged in examining the teeth of children in the schools, and 2,029 sessions were devoted to this work. There are now 58 dental centres, not including Bushy Camp School, where dental treatment is provided separately, and arrangements have been made at these centres for the treatment of 124,410 children. In all 237,022 children were inspected by the dentists, and of these 163,422 (68.95 per cent.) were found to require treatment. 113,932 children were treated at the Council's centres. The special difficulties in regard to dental treatment are dealt with in the section on following up. The agreed number of ten new cases at each dental session presupposed a normal distribution of the types of defect. With the enlargement of the scheme year by year, there is more difficulty found in ensuring this normal distribution. It is necessary with extended provision to rely more upon those parents who do not appreciate the advantages of regular dental attention to their children than it was in the earlier stages of the development of the scheme. So many parents cannot see the benefit of the "stitch in time," and wait until toothache or failing health brings home to them the necessity for treatment. Hence the scheme becomes weighted by the lag of advanced cases of dental decay and the school dentists find it impossible to deal with so many as ten new cases at a session, owing to the increased proportion of children requiring more extensive treatment. The amount of dental 87 work done by the dentists at a session is not diminished but even increased, although the number of "cases" dealt with at a session is slightly reduced. It is probable that the increase of the charge from 1s. to 2s. was a factor which tended to delay the appearance of children for dental treatment at the earliest stages. The Council during the year agreed that where "slight treatment only" was given the charge should be reduced to 1s. This arrangement came into force after the summer holidays and during the winter term the number of children returned as "slight cases only" was 1,995. The experiment was tried from May to September, 1926, of holding an evening dental session once a fortnight at the Hoxton centre, for the convenience of mothers who were unable to take their children for treatment during the day. In spite of the efforts of the care committee workers in the district, the number of cases which attended these sessions showed that there was no very great eagerness on the part of the parents to avail themselves of the special facilities. In fact, the percentage of appointments kept at these evening sessions was actually lower than the percentage of those kept at the morning sessions. In the circumstances, it is not proposed to arrange for anv further evening sessions to be held at the centre. Hoxton School Treatment Centre —evening dental session. (e) The results of medical treatment—It is clear that every nation, which hopes to maintain its place in the racial distribution of the world's peoples, must take an active interest in the welfare of its children. As a means to this end, education is a most potent factor, but education as ordinarily understood must be accompanied by education in the laws of health. Medical inspection has done much in directing attention to physical defect and wrong ways of living, but instruction in this manner is of little service unless remedial measures can be readily obtained. This was realised in the early days of inspection, and led to the growth of the medical treatment scheme which has for aim the provision of adequate facilities for every child needing treatment. When it is realised that annually more than a quarter of a million children are treated, in the vast majority of cases with the active co-operation of the parents, it will be seen that the scheme is an essential public service, and we must press steadily forward to its completion. It is something gained that the children of to-day are brighter, happier, and better in health than those of a former generation. Moreover, it is an investment wherein the dividends are only deferied, for undoubtedly the community will benefit by a healthier adult population with the concomitant results of increased working ability and lessened time-wastage due to the early breakdown of the human machine. The total cost of this great service is inconsiderable, amounting to less than a three-half-penny rate or, in other words, not as much as ten shillings per child per annum during the nine years of school life, and it may be expected that there will be a return for this outlay in much greater measure during each of the succeeding fifty vears of working life. Dr. Kidner, Divisional Medical Officer, supervises this Remedial Clinic of the Woolwich Invalid Children's Aid Association, which is subsidised by the Council under the treatment arrangements. The following is his report for the year:— "For the whole of the year this Clinic has had the advantage of monthly visits from Mr. Paul Bernard Roth, who acts as consultant in difficult cases attending the remedial clinic, in addition to his complete charge of orthopaedic cases which formerly were under hospital surgeons in Central London. The great advantage to Woolwich children is that if any operative treatment is necessary Mr. Roth makes arrangements to take the case into the Miller Hospital where he is orthopaedist, and uniformity of treatment is thus secured. As an instance of the value of such a clinic of close cooperation with the hospital may be mentioned the wryneck cases. Three children, since Mr. Roth's appointment, have been operated upon for this condition, the scars being almost undetectable, and have attended the clinic for massage and exercises to complete the cure. Previously great difficulty was experienced,both inpersuading Woolwich Invalid Children's Aid Association Remedial Clinic. 88 the parents and in securing facilities for the operation, without which our massage and exercises were almost entirely valueless. "The following paragraphs summarise the work done at the clinic during the year: "The total number of children referred was 234, including 117 boys and 117 girls. Of these, 186 received treatment, and 48 were referred to other agencies for the supply of surgical instruments, convalescent treatment, instruction in home exercises, or hospital treatment. The attendances numbered 6,815. During the year 118 cases were discharged—8 as cured, 38 much improved, and 72 improved. "The defects treated may be classified as follows, the first figure representing the new cases, whilst the figure in brackets represents the numbers remaining over from the previous year: Postural defects, 42(9); lateral curvature, 11(12); kyphosis, 13(10); kypho-lordosis, 5(1); lordosis, 2(0); depressed sternum, 0(1); deficient chest expansion, 10(6). "Cases referred for massage, etc., were: Infant paralysis, 9(12); club foot, 4 (4); knock knee, 5(5); bow legs, 26(8); other effects of rickets, 17(2); flat feet, 17(5); fractures, 9(1); wryneck, 0(2); injuries, 4(8); muscular weakness, 16(2); deformities, 2(0); chronic constipation, 4(0); rheumatism, 2(0); synovitis, 0(2); Erb's palsy, 2(1)." Classes for stammerers. During 1926, 266 children passed through the stammering centres; of these 59 were discharged cured, 29 were discharged provisionally cured. The term "provisionally cured" covers the class of child who might stammer under stress, but whose confidence has so far been re-established as to justify removal from the classes. Ten children who were under observation as having relapsed during the year were brought back into the classes for further treatment. The class at the Jews Free School is carried on under excellent conditions. Most of the boys are already attending the school and can be followed up and returned for treatment if necessary without any difficulty. The Headmaster of this school writes: "I should like to take this opportunity of saying that the training received in the stammering class has in many cases proved most effective and, in some cases, positively astonishing. One of my boys who was a bad stammerer before attending the class, gained a first prize in an elocution competition and shows no signs of defective speech." The instructress at this class, Miss M. A. Richardson, reports that she recently saw nine of the boys who formerly attended this class and that nearly all of them are continuing to practise the exercises and were eager and interested when shown any alteration or improvement of exercises, evolved since they had been in the class. Miss Richardson adds that they were "all keen to show how well they could talk and to tell of occasions when speaking was now easy where it has previously been difficult or impossible." Rheumatism in childhood. The very important question of rheumatism in childhood was fully dealt with in last year's annual report. Rheumatism is the only widespread menace to the school child's health in which the power of appropriate administrative action is still lacking. It now takes first place as the cause of chronic invalidity in childhood, not because it has increased in incidence or severity, but because, while administrative measures have diminished other scourges, such as tuberculosis, and have supplied the means of appropriate action in individual cases, the fortress of rheumatism stands where it did, unmenaced and unsubdued. The statistical records of the school medical work show that in 1919, 20.5 per cent. of the chronic invalidity in London school children was due to tuberculosis and 14.5 per cent. was due to rheumatism; in 1926 only 12 per cent. was due to tuberculosis, while 24 per cent. was due to rheumatism. These figures are staggering. But it must be reiterated that they are not due to an increase in rheumatism. They 89 are in fact a great testimony to the efficacy of the administrative measures possible in the case of tuberculosis and the thoroughness with which they have been applied. In reviewing the individual records of chronic invalidity, the majority of the cases of tuberculosis are "satisfactory," that is, the medical officer is satisfied that the best possible measures are being exerted for the children; if a tuberculous case is not "satisfactory," he knows exactly what to do, the machinery is there ready at hand, he has only to press a button, so to speak, for it to be set in motion and the only sand likely to get into the machine is parental objection due, in the majority of cases, to affection blinding the mother to the best interests of the child. Even in these cases there is a "second best" line of administrative action which is open. But in rheumatism the case is quite the reverse. In only a small proportion of the children can the individual cases be written off as "satisfactory." Case after case is revealed of sub-acute rheumatism, chorea or rheumatic heart disease, which the medical officer cannot mark "satisfactory." He knows that the best possible is not being done for the child, but he is helpless. There is no button to push; there is no machinery to work; there is no provision in existence adequate to the needs. There remains the duty of providing special school accommodation for children who are crippled with heart disease on account of earlier rheumatism. Out of 1,083 children seen for admission to physically defective schools in London in 1926, 327 were suffering from non-congenital heart disease. As rheumatism is almost the only cause of acquired valvular heart disease in childhood, it is thought that many, if not the majority of these children could be saved from crippling if adequate means existed for dealing with rheumatism similar to those available for tuberculosis. Fortunately instructed opinion is now alive to the necessities of the case. As the result of conferences among the Ministry of Health, the Metropolitan Asylums Board and the Council, additional provision was established for rheumatic children at Queen Mary's Hospital, Carshalton, in November, 1926. The scheme provided for the provision of a rheumatic unit of 60 beds, and embraces five clauses, as follows:— (а) That in admitting cases to these 60 special beds, preference will be given to children received directly from out-patient departments of selected London Hospitals or from the homes of the children. This restriction is important if research work of the kind proposed, and for which the unit is instituted, is to be undertaken. (b) That the final decision as to the suitability or otherwise of cases for admission shall rest with the medical superintendent of the hospital or his representatives. (c) That the London County Council will be promptly informed of the admission and of the discharge of each patient and will be furnished with particulars as to the condition of each patient od discharge. (d) That the London County Council will be informed in writing by the medical superintendent of the clinical character and type of case suitable for the specific purpose of the unit, in order that if the County Council know of such cases, at home or elsewhere, they may be in a position to recommend them for examination by the medical superientendent or by one of his representatives for decision as to admission. (e) That, apart from the 60 beds of this unit, the Board will do all that is practicable by the special allotment of other convalescent beds at Queen Mary's and the Downs Hospitals to accommodate (if desired by the London County Council) cases of acute rheumatism at a later stage of the disease. It was decided that cases of primary acute rheumatism, with temperature and acute local manifestations and excluding chorea were suitable for the "unit." Under clause (e) 16 more beds were placed at the Council's disposal at Queen Mary's Hospital for sub-acute cases (including chorea) but confined to girls only. 90 Up to the end of February, 1927, the number of children admitted to the rheumatic unit was 17. The beds for sub-acute cases were all filled by December 14th, 1926; since that date there have been 17 urgent applications for admission of sub-acute cases in girls lor whom it has been possible to provide for only two by an extension of the 16 beds at Carshalton to 18. In November, at the time the additional provision was made at Carshalton, an index of children suffering from rheumatism reported to the public health department was commenced, and at the present date (25.2.27) the index contains 1,314 names. The need for further accommodation is now fully recognised and measures are being concerted for the provision of further beds on a substantial scale with the least possible delay. Measures for concerted action in cases of rheumatism between the Council's care organisation and various hospitals are mentioned in the section in co-operation with the voluntary institutions. Notice should here also be taken of the establishment in Paddington under Dr. Reginald Miller of a "Rheumatism Supervisory Centre" at the Paddington Green Children's Hospital. The centre is intended to meet the need shewn by rheumatic cases for careful supervision during periods of apparent quiescence to prevent the development of heart disease. "The plan adopted is to supervise the care of the children when apparently well by periodical examinations, and to instruct the parents in writing to consult their usual practitioner or hospital should fresh symptoms or rheumatism supervene. Treatment at the centre itself is only given in urgent cases. In this way it is hoped that the centre will form a useful link between practitioners, the school medical service and the hospitals, for the benefit of the patients. Further, instruction is given to parents in the care of rheumatic children." As a development of the Paddington system, the Ministry of Health has agreed to the making of acute rheumatism in childhood a "notifiable disease" in the Borough of Paddington under the Public Health Act. The experience of the year has demonstrated anew how small a part in relation to the whole problem of rheumatism in childhood is played by the onset of acute rheumatic symptoms. There is a very large number of children in the schools with a rheumatic tendency. They suffer from symptoms too slight to be noticed, or for alarm to be aroused, if noticed by the parents. They have recurrent attacks of sore throat, complain of vague growing pains and present unusual pallor; that is all. In a great number of cases nothing further supervenes. In others the jerky movements of chorea come on, especially in the spring time. In still others the school doctor is shocked to find at a routine examination that there is a heart murmur showing that the valves of the heart have been quietly attacked by the disease and the child now has a serious defect which, in all probability, will remain with him for the rest of his existence, crippling his usefulness and curtailing his expectation of life. It is this quiet, unsuspected onset and the impossibility of predicting who, amongst the large number of children who suffer from recurrent sore throat and vague pains in the limbs, are those that will later show the more serious symptoms of rheumatism which make the disease so baffling, and render it in the highest degree unlikely that compulsory notification will give any real assistance in solving the administrative problem. It is through closer attention to the early and in themselves unimportant symptoms, through the development of "supervisory centres," and through the provision of sufficient beds assigned to children, who require long periods of rest under observation, that the prevention of the more serious and disabling manifestations of rheumatism must be sought. The Work of the School Nurse. The obvious improvement in the condition of the children in elementary schools during the past twenty years is very largely to be ascribed to the quiet and unobtrusive 91 a group of boys at a bermondsey school in 1894. Boys of the same age at the same school in 1924. 92 A ciass in an infants' school in southwark thirty years ago. The corresponding class in 1924. 93 but steady and persistent labours of the school nurses. The photographs of children reproduced on pp. 91-92 form a record which shows how striking is the improvement in appearance, in personal neatness, and in carriage, which has taken place. Quite definite medical conclusions can be drawn from the photographs referred to. It must strike everyone that the children in the later photographs are brighter and more intelligent in appearance, infinitely better cared for and happier looking. As seen by the medical eye, the following differences are observed. Taking the group of boys on the foremost page, the earlier photograph presents great inequality in physical condition, the types ranging from robust to very ill nourished, while the later photograph shows a set of boys of average nutrition without any of the inequalities of the former group. Carriage and posture are deplorable in the earlier photograph, slack and loose postures predominating; in the later photograph the evidence of physical training is very apparent in the improved carriage and alert appearance. A very striking medical point is the absence of mouth breathing in the later group, while in the earlier group two of the nine boys are mouth breathers. In the groups on page 92 similar observations can be made. In the 1894 group grave inequalities in nutrition are apparent, while all the children but one in the 1924 group appear very well nourished. Carriage and posture are greatly superior in the later group, and while mouth breathing is common in the earlier group, it is quite absent in the lower group. In these photographs also the contrast in strain as shown by the facial muscles is very marked. In the earlier group there are at least eight children who would at once be called out on cursory inspection for medical examination, while in the lower group there is only one. Taken as a whole the photographs show the attainment in the later groups of a higher cultural level and the response to the influences making for better care and improved physique is well illustrated. The first school nurse was appointed in 1901. At that time ringworm was very prevalent in the area and accounted for such a large proportion of chronic absence from school that a nurse was appointed for the sole purpose of following up children suffering from the disease. She was, in fact, called a "ringworm nurse." Although the work of the school nurses has now been extended over a wide domain, the following figures relating to ringworm prevalence testify to the results which attended the nurses' efforts in the restricted sphere in which the school nurses were originally employed. Cases carried Cures forward effected Fresh Cured to new by X-ray. Year. cases. cases. year. %. 1911 6,214 5,872 2,458 30 1912 5,311 5,131 2,204 37 1913 5,573 5,257 2,277 44 1914 4,449 4,904 1,638 50 1915 3,747 3,928 1,334 47 1916 3,115 3,081 1,232 51 1917 2,814 2,964 992 53 1918 2,639 2,555 979 51 Cases carried Cures forward effected Fresh Cured to new by X-ray. Year. cases. cases. year. %. 1919 3,447 3,103 1,259 57 1920 3,983 3,856 1,332 56 1921 3,473 3,765 999 61 1922 2,766 2,918 818 65 1923 2,322 2,395 705 69 1924 1,724 1,924 482 70 1925 1,518 1,611 373 71 1926 1,029 1,141 228 76 The deplorable condition of many of the children when the nurses were first appointed can be judged from a quotation from a report by Dr. J. Kerr, formerly Medical Officer to the School Board for London, who stated: "When I first went round London schools in 1902, nearly every school had from 4 to 6 children, the back of whose heads was crusted with a thick mass of scabs, exudation and lice." That such conditions are now non-existent may fairly be attributed to the nurses' work in the schools. School nurses and the cleansing scheme, etc. 94 By September, 1904, the School Board and the Council, as its successor, had appointed 11 nurses whose duties specifically included the supervision of personal hygiene of the children. The school nurses at that time worked under great difficulties. There was then no explicit statutory sanction for dealing with conditions of personal uncleanliness, and the nurses were compelled to carry out their duties in face of much opposition from irate parents. As many as 50 or 60 indignant parents attended on occasions at the schools to interview the nurse in the discharge of her duties ; riots and assaults were not unknown and it is a tribute to the patience and tact of nurses and teachers over a period of years that a very strict and comprehensive scheme is now in operation with very little opposition from the parents of London school children. During this period there is no doubt that a great change has taken place in the attitude of parents. Formerly looked on as almost an inevitable accompaniment of indifferent home conditions and unsatisfactory cleansing arrangements at home, the campaign has demonstrated that these conditions can be eradicated in many cases if enough attention is given to the trouble. Further the children of those early years are the parents of to-day and they have had brought to their notice during their own school life the advantages and desirableness of endeavouring to maintain a high standard of cleanliness. It is also probable that prevailing hair fashions have made it somewhat easier to detect the trouble in its early stages. An encrusted head is now never seen in the schools, a child with body lice but rarely, and, although the nurses' examinations show that about 15 per cent. of the children are still classed as "verminous," this figure is only obtained by including children many of whom have a few nits only, and on whom no actual live vermin are seen. (About two-thirds of the children now classed as verminous are noted as having nits only.) With the passing of the Council's General Powers Act, 1907, and the Children Act, 1908, the Council was given powers to arrange for the compulsory cleansing, under certain conditions, of verminous school children. Previous to the passing of these Acts, and subsequent to 1904, the Council had sought, and obtained, the cooperation of several of the borough councils in the direction of cleansing the bodies and clothing of verminous children. These arrangements were, however, on a voluntary basis and invited the parents to avail themselves, free of charge, of the facilities for bathing and disinfestation provided by the borough councils at their stations which had been erected under the Cleansing of Persons Act, 1897. The Council in 1910 itself established and equipped three cleansing centres and it was at these three stations that arrangements were made for the compulsory cleansing of children in accordance with the powers conferred on the Council by the Children Act. These arrangements were later extended by agreement with the various borough councils, so that by the year 1911 a fairly comprehensive scheme was in operation for practically the whole of London. In the case of the three Council stations referred to above, the influence was restricted to schools in the vicinity, but the inclusion of the borough centres in the "compulsory" part of the scheme rendered it possible to frame a scheme whereby practically every school was systematically inspected and brought into touch with a remedial centre. These arrangements remain substantially as they were in 1911; alterations have from time to time been made in the agreements with the boroughs (more particularly in the direction of enlarging the stations) and, as occasions demanded, the Council itself established more centres to deal with those districts where there was pressure or a gap in the borough scheme. In the earlier years it was necessary to build up a scheme whereby verminous bodies and clothes could be dealt with at the same time as verminous heads, but it became evident that children with verminous bodies and clothing were being eliminated, following in the wake of the class of child with encrusted heads. In order better to deal with the cases where infestation was 95 confined to nits only, in 1920 the Council decided that special arrangements should be made for the treatment of such children in premises apart from the ordinary cleansing centres, and to this end arrangements have been made with several voluntary committees for the treatment of these cases of slight infestation. It has always been the policy of the Council to secure the co-operation of the parents in this important work, and the use of the Council facilities has only been offered as an alternative to home treatment. Up to 1920 the practice of cutting the hair, which before this time was the only method known of eradicating the trouble satisfactorily, caused much dissatisfaction and elicited great opposition from parents. This practice was, however, the outcome of a magisterial decision that if it was impossible to cleanse the hair properly without cutting the hair, the hair must be cut, or it would follow that any subsequent proceedings against parents would fail, inasmuch as the Council had not "properly" cleansed the hair in the first place. Increasing attention had been given during the war years to the methods of cleansing, and in 1919, by collaboration of the Council's chemical and nursing staffs, a special preparation was brought into use and proved so successful that it was possible to cleanse the most verminous of heads at a single sitting. At the same time, a special type of metal comb was introduced which was found to be extremely effective. These innovations completely altered the position, as it was no longer found necessary to cut the hair to effect a proper cleansing, and from 1920 onwards the practice of cutting of the hair no longer found a place in the Council's cleansing scheme. The agreements made between the Council and the borough councils (local sanitary authorities) for the use of the cleansing stations are not the only means of co-operation which the borough councils have extended to this work. Powers were given to these authorities in 1904 for cleansing, purifying or destroying articles certified as filthy, dangerous or unwholesome, and for compelling the stripping and cleansing of verminous dwellings. The cleansing scheme provides that local boroughs should be notified of all cases of children bodily infested, and of persistent cases of head infestation. Thus, whilst the school child is being dealt with under the cleansing scheme, the local sanitary anthority is given the opportunity of dealing with other members of the family, the bedding and clothing, and also with the actual dwelling. Returns are received from the local sanitary authorities showing the work done by them under this heading, and are referred to in the annual reports of the school medical officer. It was found that certain difficulties had arisen owing to differing interpretations of the powers under the Act of 1904, and, arising out of a conference of the Council and borough councils, it was decided that application should be made to Parliament to strengthen the powers of the borough councils in dealing with verminous bedding and clothing, etc. Extended powers were subsequently given in the General Powers Act of 1922. The officers upon whom falls the responsibility for the working of the cleansing scheme are the school nurses. The school nurse arranges for the various advice notices to be forwarded to parents. It is she who is called upon to support her finding in the face of protests from the parents. She must deal with the parents, firmly yet tactfully. Important records have to be kept by her in case she should be called by the magistrates to give evidence in the courts. As she has a certain number of schools in her care, in which she examines at least once a term all the children (there is no statutory provision for the exemption of any child from personal hygiene inspections), she is called upon to undertake many duties in her stride. Enquiries as to outbreaks of infectious diseases, the visiting of homes for the giving of advice, or for ascertaining the reasons of absence, are made by the school nurse She assists the school doctor in the swabbing of "contacts" with cases of diphtheria. 14172 G 96 In the course of her inspections she must be always on the lookout for rashes, sore throats, cases of ringworm, scabies or other skin affections, and for children who are suffering from ear discharge, sores or other minor ailments. She notes children who may need convalescent treatment such as that given at the Council's residential open air schools. Lastly she assists in the routine medical inspections, prepares the children therefor, carries out the preliminary vision testing and the actual weighing and measuring. Should the school doctor desire to draw particular attention to a child who needs medical treatment and whose parents are not present at the inspection, it is the nurse's duty to visit the home and explain the necessity of dealing with the matter. The human side of the cleansing work has not been forgotten by the nursing staff. For many years the school nurses have themselves organised a voluntary Cocoa Fund, out of which is provided for the children attending a cleansing station a cup of cocoa after the cleansing. The contributions to this Fund are mainly derived from the various social events held by the nurses throughout the year. In all phases of the Council's school medical work, the school nurse is an essential factor upon whose efforts depend the successful working of the arrangements. Personal Hygiene Scheme. The number of examinations made at rota visits during 1926 by the school nurses was 1,840,106; verminous conditions were present in 288,721 instances, or 15.6 per cent., as compared with 16.6 per cent. in 1925, and 16.1 per cent. in 1924. The results of the work under the cleansing scheme for the last five years are:— Verminous Verminous Subsequently Verminous Scabies Exanimations conditions Per children cleansed children cases Year. at rota noted at cent. referred to by cleansed at bathed at visits. rota visits. centres. parents. centres. centres. 1922 2,158,100 405,335 18.7 73,800 26,031 47,769 3,944 1923 2, 052,904 371,790 18.1 79,702 26,469 53,233 2,935 1924 2,059,590 332,695 16.1 74,643 22,012 52,631 2,155 1925 1,937,588 323,020 16.6 88.859 27,647 61,212 2,077 1926 1,840.106 288,721 15.6 96,426 31,116 65,310 2,130 In addition to these figures, the numbers dealt with at the head cleansing centres during the past five years were 24,637 (1922), 24,516 (1923), 23,986 (1924), 23,947 (1925), and 23,645 (1926). Of the total number of 288,721 where verminous conditions were noted, 174,697 were noted as infested with nits only. Cases where actual vermin or flea bites were noted amounted to less than 6.2 per cent. of the number of examinations. Scabies. Little difference is noted in the number of cases of scabies treated at the centres as compared with 1925, but towards the end of 1926 and at the beginning of 1927, a slight rise in the numbers attending the centres was apparent. Treatment centres. The Council has 10 centres available for the treatment of verminous children and has agreements with 18 sanitary authorities and 7 voluntary committees for the use of their premises for the work. In addition a new Council centre will shortly be available for the North Paddington district, and an agreement is pending with a voluntary committee for the use of part of the committee's premises in Stepney as a head cleansing centre. Cleansing scheme. Under the Council's cleansing scheme there were, in 1926, 96,426 verminous children whose condition was brought to the notice of the parents by means of advice cards and who were referred to the cleansing centres for following up. Of this number 42,571 attended voluntarily at the various centres for cleansing, but in 25,688 cases it was necessary to serve, after a further re-examination, statutory notices in accordance with Section 87 of the Education Act, 1921. Following upon these notices, 6,712 children attended the centres voluntarily for cleansing, but of 97 the remainder, 16,027 were found verminous after a still further examination, and were taken compulsorily by the nurses for cleansing. Among the latter, 592 were subsequently found to have relapsed, and police-court proceedings were instituted in 413 of these cases. A brief description of the operation of this scheme and the methods adopted for cleansing at the various centres was given in the last annual report. Two motor vehicles are available for conveying children to the centres from outlying schools. The number of children thus conveyed in 1926 was 9,637, as compared with 7,865 in 1925. As in previous years, the borough medical officers were informed concerning children dealt with under the Council's cleansing scheme, in order that the home conditions might be remedied under the General Powers Act, 1922. During 1926, reports were received in regard to 5,514 homes visited; out of this number disinfection or destruction of bedding or disinfestation of homes were carried out in 1,117 instances. In the remaining 4,397 instances, although disinfestation or destruction of bedding was not needed, in many cases advice was given to the parent? by the health visitors. In 1925 the corresponding figures were 1,949 homes visited, action taken in 785 cases. In certain boroughs, parties of children are taken during school hours, under the charge of school nurses for warm baths at the public bathing establishments. In 1926 the numbers of baths thus given were: Camberwell, 2,727; Kensington, 7,811; Lambeth, 4,906; Shoreditch, 6,023; Stepney, 7,283; St. Pancras, 2,749; total, 31,499. This scheme is very popular with children and teachers and constant are the demands to increase the quota of children. The following is taken from a letter by a head master of a school in St. Pancras:— Use of public washing facilities by school children. "I wish to make application for further baths for the children attending this school. The number allocated is totally inadequate Under present conditions two vacancies have to be balloted for, and so keen is the desire on the part of the boys that it has now to be considered a privilege to go to the baths." Open Air Education. The provision for open air education for London includes at present:— Five day open air schools for non-tuberculous children; accommodation 1,070. Five day open air schools for tuberculous children, accommodation 365. Five country camp schools, accommodating 484 children for short periods, providing for about 4,700 children annually. 137 open air classes in connection with ordinary open air schools providing for 5,480 children. Here also must be mentioned the Rachel McMillan camp school for children aged 2.5, special notice of which will be found under the heading "Nursery Schools." The five established open air schools for non-tuberculous children at Aspen House (Brixton), Birley House (Forest Hill), Bow Road (Poplar), Shooter's Hill (Woolwich), and Stowey House (Clapham Common) have continued open throughout the year with the exception of the normal school holidays. Very good results continue to be obtained. The 1925-28 programme provided for three new day open air schools, one in each year of the triennium, with accommodation in each for 130 children. Sites have been visited and earmarked for these schools, and preliminary plans have been drawn up. Preparations for the opening of Holly House (Hampstead) as an open air school are well advanced, and this school will be opened in 1927, to the great advantage of a large district in North London which has hitherto been without this much needed provision. Day openair schools. On the completion of the programme for the triennium there will be 8 open air schools for non-tuberculous children providing accommodation for 1,330 children. 14172 G 2 98 It is proposed to open one further open air school in 1928-29, bringing up the accommodation to 1,860 in nine schools. Attention has been given during the year to the question of the subsequent history of children who have passed through these schools. Shooter'shill open-air school. Mr. Hugh Broughton, the Head Master, of Shooter's Hill open air school, which has been in existence for 18 years, has kept records of old pupils, and recently stated that "we have been getting into touch with former scholars, in order to ascertain whether the benefits conferred by the school have persisted when the boys and girls have gone out into the world. So far exactly 200 have been traced, and it is remarkable that among them there is not a single case where the old weakness has returned after the doctor has certified fitness to leave the school. Their occupations are as follows:—factory workers (unskilled or semi-skilled), 40; skilled manufacturing trades, 26; shop assistants and managers, 37; domestic service and nursing, 17; building trades, 9; drivers, roundsmen, messengers, 20; clerical work, 14; at home (some married), 12; army, navy, merchant service, 9; abroad, 7; to higher education, 6; temporarily unemployed, 4; total, 200. "The records prove that the children leave the school prepared, both by educational attainment and physical condition, to face competition from the product of ordinary schools, and further than that, not only do they secure good health while in the school, but also they learn how to keep their health when school days are over. "The accompanying letter addressed to me from an old scholar admirably illustrates the lasting qualities of the benefits the children receive:— "'It was by an accident that I should be sitting by a fire somewhere in Australia when by chance I picked up a paper which turned out to be the Kentish Independent, and read an article which referred to my old school, and the good work it has done since its foundation, and also its figures of healthy workers who were once weak and delicate children. Well, Sir, I for one, owe my health and strength to that school. When I was there the head master was Mr. Turner, and my teachers were Miss Taylor and Miss Bayne. I quite remember how thin and ill I was after my operations, in fact I was nicknamed "Skinny," and I appreciate now what they did for me. I have never had a day's illness since I left that school, which is ten years ago this year. What a difference ten years make. I am now 23 years old, and my health has never been better. I am, I suppose, what you would call in the prime of life, but it is hard to say if I would have been the same had there been no open air school. Well, Sir, I am now managing a Fuel Depot, which is heavy work, but I am quite capable of doing it. I should like to be put on the Old Boys' Roll, and when I return to England, which I hope to do in two years, I hope to visit the old school again. (Signed) L. F. C.' " After history of children who have attended Stowey House openair school. 25 children who had left Stowey House three years, selected at random, were followed up and their present position in regard to health and occupation ascertained. 12 of the children were boys and 13 girls. Of the 12 boys, three are still at elementary schools, to which they returned on leaving the open air school, eight are in wage earning industrial occupations at which, on the whole, they are doing well, and one is a bugler in the Royal Engineers at Aldershot. The trades of these eight boys are: tailoring, 2; mason, 1; shop boys, 3; milk roundsmen, 1; printers, The health of 9 of the boys is very satisfactory, and of the other 3 fairly satisfactory. Of the 13 girls, 2 have died, 1 was taken ill immediately after leaving school, where her health had been greatly improved, and she died in the infirmary of kidney 99 disease; the other girl, who also greatly improved during her stay at school, died three years after leaving, of tuberculosis. Of the other 11 girls, 1 is at the ordinary elementary school but is not in robust health, and the home circumstances are very poor; 10 are in wage earning occupations, 3 in the clothing trades, 2 in domestic service, 2 in factories, 1 in a shop, 1 at a printers, and 1 at a bookbinders. The health of these 11 girls is very satisfactory in 6 cases, in the other 5 not so satisfactory, but in 2 of these the health is generally good, but is temporarily affected at the time of the enquiry. Unsuitable occupation is a depressing feature in some of these cases, including one suffering from tuberculous gland, who is employed at a feather bed factory. In these cases attempts have been made to find more suitable occupations, but the difficulty is to find occupations out of doors with prospects that appear satisfactory to the parents, who generally insist upon girls following occupations in which the parents are themselves engaged or interested. Many of the children are now in robust health and in 13 cases out of the 25 the parents spontaneously affirm that going to the open air school was "the making of the children," and converted them from chronic invalids into healthy normal children. The following are extracts from some of the reports:— (1) "The mother considers that the improvement in the girl's health, due to her attendance at an open air school, has been permanent; she continues to keep very well and has grown into a fine big girl." (2) "Mrs. S. was averse to sending Harry to Stowey House open air school, and gave way only because a certain Mr. B., who works with her husband, urged her to do so because Stowey House had been the making of his boy, who was also one who would never eat anything. Mrs. S.'s own words, oft repeated during the course of conversation, were: 'I can't be glad enough I sent him.' " (3) "Mrs. P. is of opinion that the time spent at the open air school brought about a great improvement in his health—formerly he was listless—never had the energy to play or do anything after school hours—now she states he is a fine big boy, full of energy and enjoys everything." (4) "Her mother reports that Leah has kept in splendid health since leaving the open air school. She considers it is nothing short of a miracle that Leah has been able to do as much as she has done." (5) "She has had no illness during these two years, and her mother volunteered the information that her greatly improved health was owing to the year she had spent at Stowey House." In the cases which have not done so well, two influences stand out as of especial importance in depressing health and undoing the good obtained at the open air school. These are in the first place unsatisfactory home conditions and in the second place unsuitable employment. It is noteworthy that the after history of the girls is much less satisfactory than that of the boys, and this is probably due to the confined lives of the girls both at home and in their occupational pursuits. The length of stay of individual children in the day open air schools is another question which has received attention recently. In order to preserve some sort of educational continuity it has been the practice to consider the question of fitness for leaving the open air school only once in the year; so that at the commencement of the school year all those considered fit to return to ordinary school leave in a body, and the vacancies created are filled up by the most suitable children from the waiting list which has been accumulating throughout the year. It must be conceded that from the point of view of the teachers and organisation of the school this plan is of great advantage, as it enables the head master to classify the children into Period of stay in open-air schools. 100 suitable groups in regard to ages and sex, which remain practically undisturbed throughout the year. From the medical point of view, however, the plan has its disadvantages, as children urgently requiring open air education may have to wait several months before admission. This would be avoided if the children in open air schools were reviewed from the point of view of fitness to leave each term instead of annually as at present. The head master of Bow Road open air school, which has been in existence for five years, has supplied the following tables showing the length of stay of children at this school in periods which are multiples of six months. Time in the school. Number of children. (1) (2) Stayed 6 months or less 32 8 „ between 6 months and 12 months 43 17 ,, ,, 12 ,, 1½ years 59 46 ,, ,, 1½ years and 2 ,, 26 20 ,, ,, 2 ,, 2½ ,, 24 15 ,, ,, 2½ ,, 3 ,, 17 9 ,, ,, 3 ,, 3½ ,, 20 12 ,, ,, 3½ ,, 4,, 6 6 ,, ,, 4 ,, 4½ ,, 2 2 Bow-road open-air school. "The numbers in the first column include children who have left the school from all causes. In the early years we had many children enter who were nearing the school leaving age and that is the explanation of why we have had rather a large number who left after only six or twelve months' stay. "It is far more valuable, I think, to take the lengths of stay of those children who entered the school delicate and weie passed out by the school medical officer certified fit to leave."These are set out in the second column in the above table. "Another valuable table, especially in its lower lines is that showing the lengths of time the children who are now in the school (and therefore not yet certified fit) have been in attendance. It will be seen that we have 27 children who have been in the school more than three years." Time in the school. Number of children. Admitted less than 6 months ago „ between 6 months and 12 months ago 32 50 (Accommodation increased 30 places, 4/26) ,, ,, 12 ,, 1½ years ago 24 ,, ,, 1½ ,, 2 28 ,, ,, 2 ,, 2½ 4 ,, ,, 2½ ,, 3 23 (Accommodation increased 30 places, 4/24) ,, ,, 3 ,, 3½ 9 ,, ,, 3½ ,, 4 8 ,, ,, 4 ,, 4½ 5 ,, ,, 4½ ,, 5 5 188 Aspen House open-air school. Another question, which is anxiously put by authorities who wish to institute an open air school for the first time, is " to what extent is it possible in England, owing to weather conditions, for classes to be held outside the classroom? "The Head Master of Bow Road has also supplied the answer to this question. He states that, over a period of five years, lessons have been taken entirely outside on 1,008 days, inside the classrooms on 125 days, and partly out and partly in on 95 days. Children rapidly become acclimatised to open air conditions, and fears expressed in many quarters on this score prove in practice to be unfounded. Aspen House school was opened on 23rd November, 1925, in extremely severe weather, and some doubts were held as to the advisability of this. A careful selection of the children was carried out, and Dr. Duncan, the school doctor, reports that although many 101 of the children come from poor and overcrowded homes none of them suffered. The average gain in weight of the children was twice that of children of the same age distribution in the ordinary schools, and the gain is greater in the winter than in the summer. In spite of inadequate clothing in many cases, not a single child suffered from chilblains. The utilisation of natural sunlight as a healing agency is making headway m the open-air schools. In the following report Dr. W. J. M. Slowan recounts the experience gained in 1926 of this method of treatment at Stowey House open-air school:— Sun Classes at Stowey House open-air school.—The sun-treatment this year shows a further extension, inasmuch as in addition to two classes of boys there was for the first time on record a class of girls enjoying the benefits of this latest development in the regime of the open-air school. Through the foresight and enthusiasm of the headmaster a special part of the garden had been cleared and prepared during the winter months, and here, secluded by natural and artificial contrivances, the girls of the sun-class enjoyed an eagerly desired and much envied segregation. No ill results attended the experiment, hazardous as it seemed to the anxious mother who, hoping there would be no fatal cases, reluctantly consented to her daughter joining the class. Girl's class.—The class consisted of 42 girls aged from 9 to 12 years. Of these, 23 browned normally, 2 excessively, 12 slightly, and 5 not at all. Of these five three cases of malnutrition were very often absent occasionally for long periods, a fourth also suffering from malnutrition, was a freckler, and the fifth a very weakly child suffering from malnutrition, anaemia and enlarged glands. None of these five improved. Seven other girls, suffering from malnutrition and enlarged glands, showed little or no improvement in relation to the condition of defect. The remaining thirty girls all showed considerable improvement in physical condition ; anaemia, as is usual, disappeared, and in quite a number of cases enlarged glands diminished in size. Of the two lung cases, one with indefinite signs showed great improvement, the other— fibrosis—was a non-browner and frequently absent and showed no improvement at the end of the class. The average gain in weight was kg. 1.7, maximum kg. 3.5 minimum kg. 0.3; average gain in height was cm. 2.3, maximum cm. 4.0, minimum cm. 1. Senior boys' class.—This consisted of 39 boys, aged 12½—14 years. Of these, 15 browned normally, 9 excessively, 11 slightly, and 4 not at all. Of these four, three were cases of malnutrition and showed no improvement, two of them gaining only kg. 0.1 in weight. The fourth was interesting as proving an exception to the rule about freckles not benefiting by sun-treatment. He was a case of enlarged glands and proved to be a freckler; he did not brown in the slightest degree and he made the greatest gain in weight in the class, kg. 6, and improved greatly in general condition. Five others—four enlarged glands and one malnutrition—showed little or no improvement, one of them gaining only kg. 0.6, although he was one of the nine who browned excessively. The amount of browning apparently does not always indicate the amount of improvement in physical condition. The remaining 30 boys all improved, all anaemias disappeared—as in the girls' class—and in many cases enlarged glands diminished in size. One case of fibrosis of lung improved both in general health and as regards the lung condition. The average gain in weight was kg. 2, maximum kg. 6, minimum kg. 0.1; the average gain in height was cm. 3, maximum cm. 5, minimum cm. 1. Junior boys' class.—This consisted of 35 boys aged 8.12 years. Of these 10 browned normally, 9 excessively, 14 slightly, and 2 not at all. Of these two, one suffering from malnutrition showed no improvement. The other, a case of enlarged glands, proved to be a freckler, and, in contradistinction to the boy in the senior class, gained only kg. 0.6 instead of kg. 6.0 in weight. In spite of this, however, his general condition was good at the end of the treatment, and his enlarged glands had disappeared. Four others showed no improvement, (1) fibrosis and malnutrition, (2) Sun classes at Stowey House open-air school. 102 enlarged glands and bronchitis, (3) enlarged glands and malnutrition, (4) enlarged glands, this last being one of the best browners, although he made the smallest gain in weight in the class, kg. 0.4. The remaining 29 improved, anaemias as usual disappearing and in many cases enlarged glands diminishing in size. The average gain in weight was kg. 1.8, maximum kg. 3.8, minimum kg. 0.4. The average gain in height was cm. 2.3, maximum cm. 5, minimum cm. 1. Comparing the three classes, it is to be noted that speaking generally the boys biowned better than the girls. The greatest average gain in weight and height was found, as was to be expected, in the senior boys' class, weight kg. 2, height cm. 3. The classes of junior boys and girls of corresponding ages showed practically similar results: boys' weight, kg. 1.8, height cm. 2.3, as compared with girls' weight kg. 1.7 height cm. 2.3. In the main, however, there is little difference in the three classes. Apart from the physical results, in all classes the improvement in vivacity, brightness and general alertness was most noticeable and seems to justify the proposal that the whole school next summer should, if possible, be so organised as to be able to enioy and derive benefit from the sun-treatment. Tuberculosis open-air schools. In addition to the provision for treatment of tuberculous children in residential institutions, the Council continued the use of five open-air schools specifically for children notified under the Tuberculosis Regulations, 1912, as suffering from tuberculosis of the lungs or of glands with no open wounds. The children are admitted on the certificate of the medical officer of the Council, and preference is given to those returning home after treatment in a sanatorium, and to such children the opportunity to remain under regular medical supervision and to still enjoy the advantages of open-air life has proved to be of great value. At the same time attendance at the open-air school has been found to be very beneficial to children, who though tuberculous have not been considered to be in need of residential treatment. The five schools—Camberwell, Elizabethan, Kensal House, Springwell House, and Stormont House, have together accommodation for 365 children. The number on the roll on 31st December, 1926, was 426, and the average attendance was 342. During 1926 there were 153 children admitted and 154 discharged. Of the latter, 47 were fit for elementary schools, 66 were fit for work, 17 were transferred to institutions for residential treatment for tuberculosis, and 16 were admitted to hospitals for various reasons, 8 moved away, 1 was transferred to a special school, and 1 child died. At Springwell House School vocational classes were started in November, 1925, with the object of providing training of a kind likely to be of service to the children in obtaining employment. It is found that there is less objection on the part of the parents to the children remaining at the school until the statutory leaving age of 16 years, on account of the practical value of the training. Two classes are in operation, one for both sexes in commercial training which includes shorthand, typewriting and general office routine, and a class for girls in millinery and lingerie work. Up to the present 6 certificates in shorthand have been gained by the boys, and several children have obtained situations mainly on account of the training given at the school. The time that has elapsed since the inception of this vocational training scheme is not long enough to form a definite opinion on its work, but there is evidence that the training is of assistance in enabling the children to obtain emolovment. Camp Schools. It is anticipated that two additional open-air schools will be available in 1927, one at Stepney Green accommodating 50 children, and the other at Fort Road, Bermondsey, with accommodation for 125 children. Camp schools provide residential accommodation for elementary school children who require a country holiday on health grounds. They comprise:— (1) The King's Canadian Camp School, at Bushy Park, for 300 boys, taking over 3,000 boys annually. 103 (2) The Wanstead House School at Margate for 60 girls, taking 480 girls annually, (3) The Barham House School at St. Leonards for 64 girls, taking 600 gills annually. (4) An arrangement with the Shaftesbury Society to take 30 girls at the Russell-Cotes Home, Parkstone; provides for 240 girls annually. (5) An arrangement with the "Save the Children Fund" authorities by which the London school organisation sends girls to Fairfield House, Broadstairs; provides for 200 annually. The last is a new addition during the year to this type of institution and is maintained by voluntary funds, no part of the cost falling upon the rates. The period of stay of children at the schools has again come under review during the year. The length of stay has been a varying one in the different schools; at the King's Canadian camp school the stay is four weeks; at Wanstead House six weeks, at Barham House four weeks, and at the Russell-Cotes Home six weeks. In his annual report for 1924, Sir William Hamer quoted a special investigation on the physical results of a visit of 30 girls to the Russell-Cotes Home from 24th July to 30th August. The results were remarkable and uniformly excellent on the general health of the girls. The average increase in weight over five weeks was 5 lb. 7.78 oz., a most satisfactory result. Practically the same results are obtained in the six weeks period of stay at Wanstead House. Sir William Hamer stated that he had no reservation in his opinion that the short term period is a most economical and successful way of improving the health and physique of the particular class of child in London in whose interests it was devised. It is true that the medical officers and the workers of the administrative staffs at the various homes are generally unanimous in recommending a longer stay. No doubt this opinion is chiefly based upon interest in the children under their charge, but it must also be remarked that the frequent changes of children cause the officers more anxiety and trouble. An extension all round of the time of stay to three months would reduce by much more than one half the number of children now being dealt with under the present arrangements. So much benefit is undoubtedly obtained from the stay of six weeks that it may not be said there is sufficient justification for doubling the length of stay, and thus halving the number of children who would be able to take advantage of the present arrangements. It will be remembered that when the Council surveyed the arrangements to be made for open-air education, it was decided that the numerous voluntary convalescent homes which exist catered fairly satisfactorily for the child who required prolonged convalescent treatment, but that there was a class of child requiring a short holiday under camp school conditions for which there was no provision made, and the "camp schools" as they were originally called, were brought into existence to serve the need of this class. A wholesale extension of time would approximate the Council's residential open-air schools more to the convalescent home type, and there would be an encroachment on the field of voluntary effort, which it is the policy of the Council to assist. At the present time it is possible to give an extension of stay in particular cases upon the advice of the local medical officer ; but in view of the administrative difficulties raised by last moment extensions of stay, involving disappointment to candidates prepared to go on a particular date, it has been necessary to keep such extensions down to a minimum. In these circumstances, it would appear that the six weeks' period is the best for this type of school. It will be seen from the statement at the beginning of this report, that at two of the three homes to which girls are sent, the period is six weeks, while at one (Barham House) the period is only four weeks. This distinction was made because Barham House, at first, was used partly as a school journey centre and partly as a 104 school for children requiring a holiday on medical grounds. At the King's Canadian School, Bushy Park, the period of stay is also four weeks. There is no reason why a distinction should be made between the length of stay for boys and girls, but it could hardly be recommended that it should at once be raised to six weeks at this school, inasmuch as thereby some 1,200 boys annually would be deprived of the opportunity of obtaining a needful holiday. It must be pointed out, however, that although Bushy is very popular in the summer, and little difficulty is experienced in keeping the accommodation used to its fullest extent at that period of the year, it is very difficult in winter. A majority of parents object to their boys going away in the winter months, and during this time a very great strain is placed upon the medical and organising staffs in preparing sufficient boys to utilise the accommodation to its full extent, owing to the fact that a very much larger number of boys needs to be examined and followed up than eventually is prepared to go. During the winter months the absence or short duration of sunlight, and the long evenings curtailing the period of the day which can be spent in open air conditions also make the month's stay much less valuable in a curative sense than the corresponding length of time in the summer. It was therefore suggested to the Council that during the five months from 1st November to 31st March, the length of stay at the King's Canadian camp school should be extended to six weeks, and during the period from 1st April to 31st October it should remain as at present, viz., one month, and this suggestion has now been adopted. The following reports for the year on Wanstead House, Barham House and The King's Canadian school, Bushy, have been contributed by the local officers in the case of Wanstead House and Bushy, and by Dr. F. C. Lewis in the case of Barham House. The report on the Bushy Park school deals with the results of special physical exercises which form a feature of the regime. Dr. MeCombe's report on Wanstead House. "It is a pleasure to be able to report a comparatively clean bill of health— especially as there have been epidemics in the locality. "Out of 534 children who have attended during the year, 1926, only 17 have been confined to bed by illness. Of this 17, only one child was in bed for longer than four days—the majority of cases being mild tonsilitis. The other case was a girl who developed chicken-pox two days after arrival, but precautionary measures were immediately taken, and there was no further outbreak. "One child returned to London suffering from impetigo on the scalp which was noted a day or two after arrival, and, in spite of very careful nursing and supervision, persisted during her stay. "The average gain in weight for the year was 2.3 kgs.=5 lbs. (during a 6 weeks' stay). The highest individual gain=7.4 kgs." Dr. Lewis's report on Barham House. "I have to report that during the year a total of 638 children were admitted to the camp school in parties of 64 at a time. Each party stayed approximately four weeks. Of these, 442 came from Shoreditch schools, the remaining 256 children coming from the eastern and north-west divisions. Hamond Square, the school which originally had the prior claim on Barham House, at the request of the donor (Mr. G. Rainey), contributed a batch of 64 girls in April and 64 boys in August. This latter was the only batch of boys using the school. "The general condition of the children on return was markedly improved, especially during the spring and summer months. Regular food, regular supervision of personal hygiene, and the change from the homes of Shoreditch in most cases brought about a real gain in weight as well as an improvement in general health. The popularity of the camp school is shewn by the number of children who come forward clamorous for a second visit. "As the result of the parties being largely girls, the difficulties of enuresis have declined, and no case was sent home on that account. But with personal hygiene the difficulties have increased, and, in spite of all precautions, three or four dirty 105 heads were reported from each batch. This will continue until it is found possible to despatch the children in the afternoons, when a morning visit to the Cleansing Station should dispose of the inevitable effects of dirty home conditions. We have refrained from sending any cases with a marked rheumatic tendency to St. Leonards in the winter and autumn months. Such cases do not improve at the seaside in cold weather, but bronchitis and general debility cases always seem to benefit." "During the year, 3,130 boys visited the school. Of these, 1,338, or 42.7 percent., received remedial treatment during their stay. Improvement was noted not only in the correction of the physical disability for which the boy was primarily treated, but in an even more marked degree, an increase in weight and activity ensued. The average increase in weight in the 25 days was 2.9 lbs., whilst the increase in activity and general fitness, although not recordable in figures, was most noticeable by comparing a new class with one in its fourth week. The cases treated were of the same nature as in previous years, and again the system of giving individual treatment to the more urgent cases and treating the remainder in small groups was retained. "Treated individually.—Kyphosis, 134; lordosis, 28; scoliosis, 51; deformed thorax, 8; old poliomyelitis, 5; treatment after fracture, 2; round shoulders, 5; massage, 4; total, 237. "Treated in small groups.—Bad carriage, 83; flat chest, 456; poor breathing, 75; general anaemia, 487 ; total, 1,101. "Owing to the large number of cases of flat foot, country dancing and boxing exercises have been introduced, but it is difficult to say at present how far this will be successful in checking or correcting the complaint, owing to the short time we have the bovs here." Mr. Devonshire's report on Bushy Camp School. The Fairfield House residential open air school was opened at Broadstairs on 5th October by the "Save the Children Fund." It has accommodation for 50 girls, and is organised on lines similar to the Council's Wanstead House school, Margate, except that the children will stay for longer periods (probably about three months). The first party for admission was selected by the school care committees, and the necessary medical examinations were arranged through the Council's school medical service. The Council has agreed to authorise the use of the school medical service and school care committees in connection with the selection and examination of the children for future admissions to Fairfield House, provided no additional expenditure is thereby incurred to the Council. Fail-field House residential open-air school. The following extracts from letters quoted verbatim show how greatly the parents appreciate the advantages gained by a stay at the residential open air school, even when it is limited to four weeks' residence. Catford.—"I am writing to see if you could grant Ronald another two weeks at Bushy. I went to see him on Saturday last and found him looking so happy and ever so much better in health he looked. I could hardly believe my own eyes to see such a change. I was more than pleased. I don't know if I am asking too much, but I was told that children do stay longer sometimes. I should be ever so thankful if he could." Hackney.—"On Saturday last my wife visited my son at the school, and was very much surprised (and needless to say pleased) at the great alteration in his health and appearance, for which we are very thankful, as he has always been a very delicate boy. Please don't think we are greedy, as I know there are many others waiting to go, but he asked his mother, and again in his letter this morning if he can stay on a little longer? Is this possible? I should be ever so grateful and willing to contribute a small amount towards his upkeep." Lambeth.—"Just a few lines to let you know that my son, James, arrived home 106 quite well and happy. I don't know how to thank you and all those who have taken care of my boy whilst at Bushy. He says one and all were very nice to him —he did not want to come home. Well, sir, I thank you one and all for your kindness towards my boy." Stoke Neurington.—" Allow me to express to you and your staff my deep appreciation (even if somewhat belated) of the benefits which my son derived from his stay at the above school. The three weeks' stay under your care have made a great, and I trust, lasting improvement in him." Westminster.—" I went to visit my son on Saturday at Bushy School. I was so pleased at the improvement in him, I am writing to ask you if there is any possibility of his having an extension. He is so happy, he would very much like to stay longer. I am given to understand he is due to leave on Saturday, the 11th, so if you can help me in this at all, I shall be pleased to hear from you." Putney.—"Will you accept my grateful thanks to you and your assistant masters for all the kindness shown to my son, Edwin, whilst he was staying at your school. I think it is a wonderful place for boys who are not quite as strong as they ought to be, and I do feel I would like you to know how grateful I am to you all, as he is never tired of talking about it. I did not like the idea of his going at first, but I feel now that I have done a great thing for him in letting him go. I think he must have enjoyed every minute of his stay by the way he talks about it all." Hammersmith.—"I am writing to tell you of the very great satisfaction I feel regarding my son's stay at Bushy. He has returned very much improved in many ways; before going to Bushy his health was the cause of much anxiety. The improvement in this alone is very marked, he is now quite robust, and full of life and energy —he is also brighter and more manly. I am sure you will be glad to know he still enthusiastically carries out the "Bushy" ideals, i,e., strips for what he calls "The Bushy Wash" instead of the "Cat's Lick" which I am afraid most schoolboys indulge in if they can. In many other ways it is noticeable that the training he has received whilst in your care has made a lasting impression. Upon the occasion of the visit to the school we were much struck by the wonderful organisation—we found everything there that a boy could possibly want to make him happy, or that his health and well-being require. We would like to offer to you, Sir, and to the gentlemen who so very ably assist you, our heartfelt thanks, and very best wishes for the continued success of the school." In view of the difficulty found in London in securing suitable sites for open-air schools, the policy has been pursued of extending wherever possible the principle of holding open-air classes in connection with the elementary schools. Prior to the 1925-28 programme, 97 open-air classes had been authorised, accommodating approximately 3,800 children. Provision was made in the current programme for a progressive increase to 117 classes in 1925-26, 137 in 1926-27, and 157 in 1927-28, bringing the total accommodation of playground and park classes up to 6,200. Although it is becoming increasingly difficult each year to find new and suitable sites, it is proposed to extend them further by making provision for ten additional classes in 1928-29, and ten more in 1929-30, thus bringing the total number of places to about 7,000. The Elementary Education Committee on March 9th, 1926, authorised 124 open-air classes to be held from April 13th to October 22nd, 1926, in connection with ordinary elementary schools, in addition to 5 similar classes maintained all the year round. On subsequent dates 9 additional classes were approved. Of the summer classes 51 were arranged to occupy sites in parks or open spaces, and the remainder for playgrounds either at ground level or on the roofs of schools. These classes were distributed among the four usual types of open-air class as follows:— Open-air classes. 107 Number of classes. Parks or open spaces. Playgrounds. Type A.—Delicate children from a group of schools 8 1 Type B.—Delicate children from a group of classes in same school 18 15 Type C.—An ordinary class 14 38 Type D.—Ordinary classes in rotation 11 28 51 82 Reports were received from the school doctors on 35 of these classes. In all the reports but one satisfactory improvement in the health and physical condition of the children is noted. The less favourable report is upon the West Square Infants' playground class, where the site is not very suitable owing to its being shut in and getting no sun. Special note is taken of the excellent results at many of the classes, especially those which are held in parks and open spaces away from the schools. Freedom from infectious diseases and colds, satisfactory increase in weight and in physical measurements, including chest expansion, anaemia cured or improved in many children, improved tone of the heart, improved posture and gain in alertness are all points which recur frequently in the reports. Especial mention may be made of the all-the-year-round class at St. Giles-inthe-Fields, where many anaemic children were quite restored to health, of the Rotherfield-street (B) class held in Waterlow Park, where special note is made of the increase in chest expansion of the boys, the Farncombe-street (B) class, where very marked improvement took place, both mentally and physically, the Nightingalelane (R.C.) class, where the improvement in practically all the children was very obvious, and the St. Peter's (G. and I.), Vauxhall, where the class was held in the Kennington-park bandstand, and where the majority of the parents wrote to the head mistress to say how much they appreciated the improvement they had noticed in their children's appetite and general health. Although children are not selected on account of health for participation in school journeys, the increasing numbers of children who in this way receive a country holiday must be noted with interest and satisfaction by the school medical service. The duties of the service in connection with this movement are by no means negligible. Applications were received in 1926 for the help of the school doctors in connection with 396 school journeys and about 12,550 children were inspected. Of these, 71 were regarded as unsuitable to accompany the parties; in some cases these children were either suffering from contagious diseases or susceptible of communicating such diseases to others. As the school organisation is involved and the success of a journey is completely destroyed by an outbreak of infection while away from home, or indeed even by the development of an acute illness in a single member of the party, the overhauling of the children by a doctor immediately before the expedition starts is a procedure which should never be neglected. Physical Training. Mr. A. H. A. Gem, the Organiser of Physical Education, reports that teachers are still in good numbers taking steps to make themselves more intimately acquainted with modern requirements. Real progress has been made in the organisation of games for the older boys; team-work and the house-system are being progressively developed. Further differentiation between the physical training of the younger and older children is desirable. Miss G. S. Clark, the organiser of physical training for girls and infants, points out that the work is not in general sufficiently progressive throughout a school, exercises which form the basis of the work in the lower classes still being taught in the higher ones. At present the majority of the children in the School journeys. 108 elementary schools have three lessons per week of twenty minutes' duration. Swimming is taken in addition to this by children from the higher classes during the swimming season, and the same children frequently have one extra period for games. Generally the children in the lower classes at present are inadequately treated in regard to periods of physical training. Instruction in swimming is in London taken very seriously, and the arrangements for tuition during school hours are effectively supplemented by the London Schools' Swimming Association. During 1925, as many as 8,487 boys obtained the Association's Certificate for 100 yards and 8,135 girls qualified for the 50 yards' certificate, 1,594 boys and 2,475 girls obtained the elementary, while 1,167 boys and 1,774 girls obtained the advanced certificate in life saving. The question of the precautions that are necessary, particularly amongst elementary school girls participating in swimming races under intense competitive conditions, was discussed in my annual report for 1925. During the past year occasion was taken by some of the assistant medical officers to visit some of the swimming competitions organised by the London Schools' Swimming Association. Dr. Nairn Dobbie attended the St. Pancras Swimming Gala, held on September 22nd (girls) and September 23rd (boys). He examined the condition of a number of boys and girls before and after the races, particularly in relation to their circulatory reactions. The following tables give the results of his observations:— Boys. Age. Temperament. Distance of a.b. from middle line. Pulse rate before race. Pulse rate after race. Pulse 2 min. after race. Distance in lengths. Time and nature of meal. (1) A. Y., 24.10.12 Bright 2¾ in. 88 140 reg 100 reg. 2 1 p.m.—glass of milk. (2) D.H., 14.12.12 Placid 2¾ in. 104 148 sl. irr. 112 reg. 1 12 noon—soup, bread and butter. (3) F.A., 1.5.13 Bright 2¾ in. 80 144 si. irr. 108 sl. irreg. 3 12 noon—liver, bacon, bread and butter. (4) C.P., 8.6.13 Placid 2¾ in. 88 136 reg. 104 reg. 2 12.30—potatoes and tomatoes. (5) W.L., 12.6.14 Bright 2¾ in. 108 144 irr. 112 sl. irr. 1 1.15 — milk pudding. (6) R.B., 21.5.15 Rather nervous 2¾ in. 96 Breathing laboured 164 marked irreg. 120 irreg. 1 12.45—stew. (7) R.C., 15.2.15 Bright 2¾ in. 96 144 reg. 100 reg. 1 1 p.m.—potatoes and greens. (8) E.B., 15.2.15 Bright 2¾ in. 104 152 marked irreg. 116 still irreg. 1 12 noon—milk pudding. (9) G.H., 25.5.13 Bright 2¾ in. 88 132 reg. 92 reg. 2 12.30—broth, bread and butter. (10) G.T., 28.5.13 Bright 2¾ in. 100 140 sl. irr. 112 irreg. 1 12 noon—cold meat, bread and butter. (11) F.E., 6.12.15 Anxious 2¾ in. 96 Breathing laboured, 160 marked irreg. 124 still irreg. 1 12.30 — glass of milk. Nutrition—First 8 good; last 3 average. Physique—First 8 good; Nos. 9 and 10 average (slim); No. 11 small. Skin—Fine throughout. Heart—Normal throughout. 109 Girls. Age. Temperament. Skin. Distance of A.B. from middle line. Pulse rate before race. Pulse rate after race. Pulse 2 min. after race. Distance. (1) K.L., 2.10.12 Bright Fine 2¾ in. 116 160 irreg. br. marked 128 reg., br. faint 2 lengths. (2) M.G. (1) 23.5.13 Bright Fine 2¼ in. 108 156 extra systoles 120 reg. 2 lengths. (3) H.M., 17.10.13 Bright Fine 2½ in. 120 164 irreg. 124 reg. 1 length. (4) A.O., 16.2.14 Bright Fine 2¼ in. 120 160 sl. irreg. 132 reg. 1 length. (5) G.A., 18.11.14 Placid Rough and dry 2¾ in. 92 132 reg. 120 reg. 1 length. (6) G.G., 11.9.14 Bright Fine 2\½ in. 104 156 irreg. 124 still irreg. 1 length. (7) G.W., 14.10.14 Bright Fine 2½ in. 96 148 reg. 108 reg. 1 length. (8) F.H., 7.3.15 Bright Fine 2¼ in. 108 160 irreg. 140 still irreg. 1 length. (9) E.B., 5.4.15 Placid Fine 2¾ in. 88 120 reg. 88 reg. 1 length (a trained swimmer who won 3 races). (10) L.H., 1.11.12 Nervous Mottled 2½ in. 96 156 irreg. systolic br. 116 irreg. 1 length. (11) G.T., 29.6.13 Somewhat placid Mottled 2i in. 100 160 irreg. breathing laboured 120 still irreg. 1 length. (12) M.G. (2), 20.9.14 Rather nervous Mottled 2¾ in. 112 164 marked irreg. breathing laboured 140 still irreg. after 5 min. 1 length. (13) M.C., 2.2.15 Anxious Fine — 124 164 marked irreg. 92 after 5 min. 1 length. Nutrition—First 9 good; Nos. 10-13 average. Physique—-Nos. 1-7 and 9, good; Nos. 8 and 10, small; Nos. 11-13, average. Heart—No. 1, Funct. syst. bruit at apex; Nos. 11 and 12, A.B. diffuse and slapping; No. 13, A.B. diffuse. The pulse-rate prior to the race showed more uniformity among the boys when the rates lay between 88-108 as against the girls 88-124. In only 4 of the boys was the pulse-rate 100 or more, while 9 girls showed a high rate. Excitement largely accounts for this all-round increase of pulse-rate, and the comparatively higher rates in the girls indicates a relatively higher susceptibility to the effects of excitement in them. There is normally a definite physiological increase of pulse-rate in pubescent girls, so that the normal rate may be somewhere near 100, which, of course, does not account for the high rates seen here. This higher susceptibility to the effects of excitement in girls seems to be borne out by the fact the average rise in rates following the races is lower in girls (47.5) than is the average rise in boys' pulse rates (51). If anything, this indicates that the reserve forces of the heart have already been called into action prior to the actual contest, a surmise which is proved by the average slower rate of fall (32) in the girls than in the boys (36.7) two minutes after the race, thus exemplifying the physiological law that the greater the fatigue of any organ, the longer time such organ takes to recuperate. In one girl's case, M. G. (2), the pulse-rate was 140 five minutes after the termination of the race. She appeared to be cold and was shivering, and was really the only child seen who perhaps was not suited by build or nature to take part in such a contest, although no harm came to her, for she was seen some time afterwards and was then warm and happy. A very interesting result was the high jump of the pulse-rate in the three girls of poor circulation, L. H. (60), G. T. (60), and M. G. (52), and in the high jump of 110 the two boys who were rather highly strung, R. B. (68), and F. E. (64). In thesecases, too, the breathing was laboured and their pulse-rates were relatively high at the end of two minutes following the race. High variability in pulse rate is almost always (apart from diseased states) indicative of lack of nervous control and is found in those most easily fatigued. Dr. Jas. Kerr states "For practical purposes, physique as determined by efficiency is nervous capacity to maintain respiration and circulation normally." Although these children did not show up so well as the other better conditioned children, yet their reactions were well within the range of normality, since the pulse-rate following exertion may show a rise of 100 beats per minute and in the untrained may not return to the normal rate for half-an-hour or more. The irregularity in cardiac rhythm following the events was of a type commonly seen in ordinary children. It varied in rate with the respiration, the rate quickening in inspiration and slowing during expiration and was equally present in girls and boys and appeared to vary also with the pulse rate, the higher the rate the greater the arrhythmia. In M. G. (1) (girl) the irregularity noted appeared to be due to extra systoles, but this was not noticeable two minutes later, and did not seem to be of any moment. The systolic bruit heard in L. H. (girl) after her race may have been due to physiological dilatation though no proof of this was found since the area of cardiac dullness was not mapped out. The longer length of some of the races did not apparently make much difference in the respiratory and circulatory reactions. If anything, the boys swimming the longest distances showed up best; either the mere adding of distance within the limits seen did not call for greater response, or the boys taking part in such contests were more fit, or perhaps more accustomed to swim such distances. Experience and training certainly lighten the burden. The girl E. B. stated she had been specially trained by an expert. She certainly had the decided advantage of a good physique and was in excellent general condition, quiet, confident and unruffled by excitement. When seen, she was taking part in her third race; she won all these and took part in a fourth, a team race. Her movements were slow, methodical and rhythmic, with an overhead movement of the arms and a "crawl" action of the legs and feet, the rolling action of which was similar in effect to the method of propulsion in sculling a boat with one oar over the stern. Her actions seemed automatic in their rhythm, the maximum effect was obtained without waste of energy, either nervous or physical. On the conclusion of the race she was the least distressed of all the competitors examined, and her pulse returned to the normal within two minutes. The times taken by the boys and girls in the finals were kindly supplied by Mr. A. B. Woodbury. Best time. Worst time. Novices (Boys over 13) 30 secs. 33 2/5 sees. 1 length. (Girls over 13) 36 2/5 „ 43 2/5 „ Scratch (Boys under 12) 25 „ 34 4/5 „ „ (Girls under 12) 35 „ 43 „ „ Scratch (Boys 12—13) 24 3/5 „ 28 1/5 „ (Girls 12—13) 31 4/5 „ 37 1/5 „ Scratch (Boys 13—14) 54 4/5 „ 66 4/5 „ 2 lengths. (Girls 13—14) 71 1/5 „ 92 It will be seen that the time taken by the best boy is better than the time taken by the best girl in each race over the same distance. The better muscular development and stronger frame, coupled with perhaps a temperamental advantage and the traditional habit of greater indulgence in games enables boys to make a better performance than girls of the same age. Conclusion.—Adolescent girls are mentally and physically rather more unstable than boys of the same age. This inequality has lessened within recent years (largely due to their greater indulgence in games). Instability of much degree, unless that 111 of a temporary nature following illness, is not usually manifested for the first time at adolescence. There is a definite clinical syndrome, easily recognised, in those of a highly strung nature. The prowess of children showing this syndrome seldom entitles them to represent their class or school in athletic contests. The healthy adolescent heart is capable of doing everything demanded of it. Evidence of poor circulation, mottled skin, blue hands and face, etc., is the most important single clinical sign of inability for effective adaptation to emotional and physical strain. Competitive games and athletics, including swimming, are as important for girls as they are for boys to ensure full development of mind and body along the right lines. Regulation of the time, quantity and quality of a meal prior to any contest is necessary. Particularly in swimming competitions there should be close supervision of the temperature of baths and water, and of the time children are undressed prior to entry into the water. Dr. F. C. Lewis, the divisional medical officer, reports as regards his division:— "The school medical staff have attended most of the swimming galas and preliminary competitions in the north-eastern division during the past season. As a result of my own observations and the reports of Dr. Raffle and Dr. Porter, I should like to offer a few points for your consideration. The strokes taught by the swimming instructors are varied. They apparently always commence with the ordinary breast stroke. This is undoubtedly the best and least exhausting for both boys and girls, but is seldom used by competitors in the races. The strokes used are (1) the trudgeon stroke, an overarm stroke with a scissors action of the legs. This is strenuous as, unless the breathing is properly taught, there is a tendency for the breath to be held during a short race, either entirely or partially. The chest crawl, an over-arm stroke with a fast (optimum, 8 leg strokes to 2 arm strokes) paddle action of the legs from the knees. This is an extremly exhausting stroke for young children, and the only cases requiring medical attention at the competitions were for children under 12 and 13 who had used this stroke. The reason for the collapse, which in one instance was severe enough to need strenuous restoratives, was in all cases insufficient aeration, due to the face (nose and mouth) being practically under the water during the race when the crawl stroke is used. I may mention that practically all winners in the competitions, at any rate amongst the boys, used this stroke only, so that it is obviously the fastest. What would seem to be indicated is that the crawl stroke certainly (and possibly the over-arm trudgeon also) should not be allowed to be used in races in which the competitors are under 12 years old. The strain, both cardiac and muscular, is too severe to be borne safely by young children, and in view of the danger of collapse, due to partial asphyxia, it should be prohibited in school organised competitions before the age of 12. The trudgeon, if more care is devoted to the proper teaching and management of breathing, is far less objectionable, as the mouth and nose should be well out of the water as each arm is brought forward. In a fast crawl this is impossible, the body and face lying practically prone on the water during the whole of the race. It was the unanimous opinion of all the school doctors in attendance at these competitions that the crawl stroke should not be allowed in races for children under the age of 12." Health classes.—In many schools children, found by the school doctors to have postural deformities susceptible of improvement by directed physical exercises, are formed into special classes which are drilled in appropriate exercises for twenty minutes each day. Such "health classes" have been established in 34 boys' and 50 girls' departments. As the classes are small it is possible for the teacher to 14172 H Health classes. 112 give more individual attention to each child. All the teachers in charge have attended a special course at the Council's Physical Training College, under the immediate supervision of the Council's organisers of physical education. The results of this special concentration upon children who are the most in need of drill are excellent, but the difficulty of staffing in the schools makes extension of these classes a slow matter. The establishment of special health classes has been especially fostered by Dr. F. C. Lewis, the Divisional Medical Officer in the N.E. division. He reports that, in 1919, special remedial exercise classes were started in a few specially selected schools where a teacher on the staff was qualified by special training, combined with keenness, to take them. They were under the direct supervision of the physical training organiser of the area, and when they were comparatively few in number it was possible for the organiser herself to inspect them in conjunction with the assistant medical officer in charge. On the reorganisation of the physical training staff of the Council in 1924 it was found impossible for the organiser to supervise the classes herself and the character of the classes was slightly altered. At present there exist in the N.E. division 3 boys classes and 12 girls classes (3 of these are temporarily suspended) which are taken by teachers on the staff of the school who have attended a special course of lectures in physical training at the Council's school and who are approved as capable by the organiser (Miss GrantClarke). The selection of tables (progression of exercises given) is left entirely to the discretion of the teacher in charge of the class, whilst the physical defect for which the child was nominated to the class by the inspecting doctor is inspected every term by him. This alteration is reflected in the nomenclature of the classes. They are no longer styled "remedial classes," but health classes, and although the child with postural deformities (kyphosis, scoliosis, flat foot, etc.) is included as before, no specific exercises for these defects are given. Reliance is rather placed on carefully and regularly given free-standing exercises, with the addition of a few special balance exercises on forms. The classes are taken daily, and, in the case of the girls, in a suitable dress and foot-wear, in contrast to the routine physical training work of the schools. The size of the class is also limited to 20 or 25 scholars. If a criticism be allowed, the present system, whilst enabling a larger number of schools to start health classes, has somewhat impaired the corrective value, owing to the absence of special exercises designed to meet the requirements of children with postural defects. It has also widely increased the conditions which should render children eligible for the classes; whereas formerly the bulk of the cases showed actual spinal curves, there is now a large proportion with general stunting and poor development of physique admitted. The more severe cases of special deformity are referred to hospitals for exercises and massage, but the number of these is small. It would rather appear that the need for these classes is really a confession that daily physical exercise is needed generally throughout the schools, but that only in certain schools where there is a confident teacher and also a head who is willing to make the necessary arrangements, is it undertaken. What one would like to suggest is that in every school a certain number of children adjudged by the inspecting doctors to be in need of daily physical training should be in a position to get it. There should be a health class in every girls' department, with special kit and milk if necessary, instead of, as at present, only in schools where facilities exist. Co-operation with Parents, Teachers, School Attendance Officers, Official and Voluntary Bodies. Parents. The response of parents to the invitation to attend the medical inspection of their children continues to be satisfactory. 150,662 parents took advantage of the 113 invitation, i.e., 61 per cent. The percentage of parents present at the inspection of the entrants only was 87. The fact that in London so many parents see the school doctor and discuss with him the health of their children is of very great importance, for it represents by far the greatest and most successful educational influence in hygiene that has yet been brought into action. Refusals to submit children to routine inspection were encountered in 186 instances—less than one in 1,000. In 14 cases the refusal was withdrawn on further explanation, and in 12 instances the official record was filled in bv the family doctor. The teaching staff as a whole gives enthusiastic support to the school medical service. They not only notify to the medical officer every case of infectious disease or suspected infectious disease amongst the pupils or at the pupils' homes, but also issue the invitation to the parents to attend medical and dental inspections. Many teachers go far beyond the nominal duties in their devotion to the care of the children. In many instances they act as secretaries to the school care committees. Teacher. The attendance officers devote much time to assisting in the work of the school medical service. They confer with the medical officers in regard to children absent from school and make the necessary arrangements for them to be seen as special cases by the school doctors. Special officers in the attendance branch assist the school care committees in following up difficult cases where medical treatment is urgently required. During the prevalence of measles the attendance officers visit absentees in the infants' departments with a view to giving the local medical officers early information of cases which would otherwise remain unknown. They also serve the statutory notices under the Children's Act in all cases where it is necessary to proceed on account of verminous conditions. Another duty performed by them is the collection of sums due from the parents for medical treatment. It will be seen, therefore, that the attendance officer enters largely into all the schemes of welfare work for the school children, and is an invaluable ally of the school medical service. Attendance officers. The system of children's care in London has always, broadly speaking, been based upon the principle of co-operation with voluntary bodies working in the field of children's care. The bulk of the following up is carried out by the members of the school care committees, who number about 5,000. The school care committees decide whether the charges for medical treatment should be remitted in appropriate cases, and also whether children should be retained upon the list for school feeding. The medical practitioners in many districts provide and manage the school treatment centres, and one of their number usually gives his services as secretary of the centre. The District Nursing Associations have also been brought into the orbit of the school medical service. They supply the nursing staff at the treatment centres for the nursing treatment of minor ailments and the Council's agreements with them ensure the visiting of children in their homes when necessary. The Council's organisers of care committees maintain a close co-operation with all the voluntary institutions and associations dealing with school children, and have in many instances established a system of mutual registration. They are in close touch with the Invalid Children's Aid Association, one of whose members is invariably upon the school care committee at the schools for the physically defective. They are in close touch also with the National Society for Prevention of Cruelty to Children, which gives valuable aid in cases of neglect. It is impossible here to enumerate all the organisations, local and universal, with which co-operation is maintained. Voluntary bodies. As one example of the co-ordination effected by the children's care organisation of the Council all over London with countless institutions aiming at betterment, may be cited the case of the Hollington Club in Camberwell, whose description is given in the book "Medical Control on a Boys' Club," written by H. G. G. 14172 H 2 Hollington Club. 114 Mackenzie, Esq., D.S.O., M.D., published by Dent & Sons. Thus : (p. 15) " Conditions involving teeth, throat and ear and vision are referred to the district organiser of children's care work for the Camberwell and Peckham area. Deeply is the club indebted to Miss Burton for her willing and effective co-operation in these matters. The same rule applies to the later appearance of one of the above defects in a junior, however long the period since his admission may be." Again (p.33) "I think there can be no question that the remedial work carried out at the school dental clinics has made a more manifest advance in the last sixteen years than in any other department. I find that I have recommended 117 out of 558 juniors, inspected shortly after they had joined the club, for further attention. Most of these belong to the earlier half of the whole period, and it is no exaggeration to say that the number in need of treatment grows smaller every year. Indeed, a really bad mouth is now rare." Another book in the literature of practical social endeavour in London is "Child Life in Westminster," issued by the Save the Children Fund, and much is to be found in it concerning the relations of the school medical service to other organisations. Dealing with the efforts which have been made to realise the "Children's Charter," it states: "Of considerable excellence in quality, and, I imagine, more neaily adequate than anything else, is the school medical service So much is done. The amount of goodwill expended on the children is quite bewildering in the complexity and multiplicity of organisations. Inspectors, L.C.C. officers, voluntary workers vie with each other in effort. Welfare centres, school clinics, hospitals and homes, clubs for boys and girls—they seem so numerous that it is hard to believe any single child can be left out. And all these agencies reveal a growing volume of public opinion. A happier childhood is now the ideal of the nation." Metropolitan Asylums Board. Co-operation with the Metropolitan Asylums Board is maintained in cases of ophthalmia, mastoid disease, encephalitis lethargica and tuberculosis; in the appropriate sections of the report an account is made of the numbers of children dealt with under these headings. In addition, a special arrangement exists whereby children who have suffered from ear trouble while at the Fever Hospitals are notified, in order that they may be kept under observation by the school doctors. There were 162 children reported during the year, in four of whom otorrhcea was found to have recurred while attending school. Tuberculosis dispensaries. A complete system exists whereby co-operation in following up children who are attending school is effected with the tuberculosis dispensaries, and the mutual exchange of information is provided for between the school doctor and the tuberculosis officer by means of a special card. General and special hospitals. At many of the general and special children's hospitals the work of the school care committees has come to be greatly appreciated and, indeed, depended upon. Assistant organisers attend all the hospitals with which the Council has arrangements for the treatment of school children. In addition, three of the Council's assistant organisers spend their whole time in connection with Guy's Hospital, a similar number are engaged at the Queen's Hospital for Children; assistant organisers alsoattend the Middlesex Hospital and Shadwell Hospital for Children. The almoners of all the hospitals maintain a close correspondence with the care organisation. This great and growing system of close co-operation with voluntary institutions has produced a chain of linked activities which has been productive of the very best results. Guy's Hospital during 1926. At Guy's Hospital there was an increase in the number of school children at the hospital dealt with by the assistant organiser in the eye department; on the other hand, some decrease occurred compared with last year in the numbers of children treated in the other departments. The number of children seen in the ear, nose and throat department was 2,131, and 413 had operations for the removal of tonsils. 115 and for adenoids in the out-patient department. The number discharged cured was 777, and 375 were reported by the care committee as requiring no further treatment. The arrangement by which the Council's ambulance takes home the children after operation has been continued, and is found to work well. The number of school children under treatment and observation in the orthopædic department at the end of the year was 523. These children are visited by the care committees if any are overdue to return to hospital, and in most cases the visits result in reattendance. The checking of attendances in the massage department has been continued, and is proving to be of value. In the eye department 1,721 children attended, and glasses were ordered for 868. Of these, 759 are definitely known to have obtained glasses, and 102 children were tested, whose vision was found not to require correction. In the skin department 1,301 children were treated, 43 of these were suffering from ringworm of the head and 45 from scabies. The reports on children attending in other departments of the hospital which are so invaluable to care committees and which are obtained through the Almoner, have been many and various. This side of the work is increasing. There has been an extension of the work of the assistant organiser working in the ear, nose and throat department during the year. This organiser now attends the weekly clinic for reputed diphtheria carriers, which was started by the hospital in July, and she keeps the records of children attending there for the information of the school medical officer. At the London Hospital an important new departure has taken place whereby for the first time a Children's Consultation Department has been formed under the charge of Dr. Maitland Jones. A scheme of co-operation between the department and the school medical service has been instituted. The following figures relate to the attendances of London County Council children in the Children's Department from October 26th to December 23rd, 1926. 1. Number of L.C.C. children already in attendance, October, 1926 76 2. ,, of new cases referred from Receiving Room or transferred from other 95 department 125 3. „ of appointments made by school doctor under new scheme 37 4. „ of appointments kept 30 5. „ of cases discharged 10 6. Total number of current cases 191 London Hospital. There is an average attendance of 35-40 old cases each week. Great Ormond Street Hospital for Sick Children now refers children requiring operations for tonsils and adenoids to the Council's care organisation for reports upon home conditions, so that arrangements can be made in certain cases for the children to be kept in the hospital after operation. During the last three months of 1926, as many as 166 such enquiries were made. This hospital also maintained a close co-operation with the care organisation in all cases of rheumatic children. Special reports are provided from the hospital for the use of the school doctors, and a complete enquiry on home conditions is made by the school care committees and transmitted to the hospital. Great Ormond Street Hospital The Westminster Hospital also requires reports upon children suffering from enlarged tonsils and adenoids. These and other hospitals frequently refer special cases of difficulty to the care organisation, asking them to arrange for children to reattend at hospital for daily nursing treatment for otorrhœa, for provision of spectacles, for special feeding at school or for reports on home conditions. Westminster Hospital. In return the hospitals give information when asked on special cases which is of great help to the school doctors and the care organisation. Amongst the other hospitals with whom definite liaison and systematic exchange of information are Other hospitals 116 maintained through the almoners and the Council's care organisation are the West London Hospital, The Victoria Hospital for Children, St. George's Hospital, the Western General Dispensary, Paddington Green Children's Hospital, the Maida Vale Hospital for Nervous Diseases, St. Bartholomew's Hospital (aural department), Royal Northern Hospital, Royal Free Hospital, Victoria Park Hospital, the Miller Hospital, St. John's Hospital, St. Thomas's Hospital and South London Women's Hospital. Employment of School Children. The applications during 1926 for medical certificates in connection with the employment of school children out of school hours under the Bye-laws, numbered 4,251, of whom 4,191 were boys and only 60 girls. The nature of the work in the case of boys was delivery of milk 306, delivery of newspapers 2,522, carrying of parcels 586, in a shop 382, in a coal yard 5, industrial work at home 4, housework away from home 37, as a messenger 96, employment not stated 48, in more than one occupation 36, with a butcher 1. The 60 girls sought work in the delivery of milk 1, delivery of newspapers 33, carrying of parcels 5, in a shop 6, industrial work at home 2, housework away from home 6, as a messenger 1. Certificates were refused on medical grounds in the cases of 74 boys and 6 girls; in 262 cases the certificate was granted subject to medical treatment being carried out, and in 57 further cases other conditions were imposed. In two cases boys were subsequently found at medical inspection to be suffering from overwork and after enquiry their employment was terminated. In some of the cases where conditional certificates were issued they were subsequently withdrawn as the conditions were not complied with. Under the special regulations for the employment of children in public entertainments, 152 girls and 20 boys were examined and kept under observation during the year. Three girls were refused certificates on medical grounds, one on account of high myopia, one for anaemia and general debility and one for scabies. One boy with bronchitis was also rejected. 47 of the children were required to have medical attention; for personal hygiene 8, throat trouble 2, dental caries 14, skin disease 1, visual defect 13, nutritional disorders 8, orthopaedic attention 1. Nursery Schools. Nursery schools have been in existence in the London area for a considerable number of years, the oldest (Notting Hill) having been opened about 1908, and the Rachel McMillan three or four years later. In the beginning of 1917 a report by the school medical officer was presented to the General Purposes Sub-Committee, pointing out the advantages in poorer neighbourhoods of school attendance on the control of infectious disease, the particular benefit of nursery schools under the care of an experienced matron, and the desirability of having such schools under the education authority in order that advantage might be taken of existing clinics and other institutions. During the same year a conference, including education officers, head mistresses and medical officers, was appointed by the education officer to report upon the education of children under five. Their report, presented to the Education (General Purposes Sub-Committee) in September, 1917, dealt with various matters relating to nursery schools. In 1918 the Education Act (Section 19) gave powers to local education authorities to supply, or aid the supply, of nursery schools including nursery classes, for children from two to five, and to attend to their health, nourishment and physical welfare. Under this Section of the Act, regulations for nursery schools were issued by the Board of Education in March. 1919 (copy appended). 117 In June, 1919, six voluntary nursery schools were recognised by the Council under Section 19 of the Act, and within the next few months two more schools were included. In July, 1919, it was decided that where application was made by managers, arrangements should be made by the Council for the medical inspection and treatment of children attending these non-provided schools. In December, 1919, a report from the medical officer advocated nurses' daily visits to the schools. In February, 1922, it was resolved to continue such daily inspection. The Council, in March, 1920, decided to maintain as an experiment three nursery schools and one nursery class in existing public elementary school buildings and three nursery schools in detached buildings. Numerous schools and sites were inspected by the Council's officers, but, in consequence of the issue of Circulars 1185 and 1190, by the Board of Education, it was decided not to proceed with any of the six proposed nursery schools except the Council's portion of the Rachel McMillan nursery school. The position of the eight voluntary schools remained unaltered, and also that of the nursery class at Christ Church school, Hampstead, already established. (Closed 1926.) In November, 1923, Dr. Hogarth reported on the effect of nursery schools on the health of the children. The condition of children leaving the Hampstead and Somers Town nursery schools to enter infants' departments was found to be superior to that of the ordinary entrant. At the Rachel McMillan nursery school the weight of the six-year-old children was appreciably greater than that of six-year-olds who had been at Creek Road elementary school, in. the same neighbourhood, for three years. A proposal was made in 1924 for the establishment of six, and ultimately of 12, nursery classes in infants' departments in poor neighbourhoods. In October, 1924, the Central Care Sub-Committee considered the matter, but did not see their way to taking any action at that time owing to the policy of rationing expenditure. In February, 1920, it was estimated that the cost of maintaining an attached L.C.C. nursery school of 75 children would be £19 10s. per head, and of a detached L.C.C. school £20 10s. per head. The following table gives the average attendance and the percentage of cases of infectious diseases at the various nursery schools in London. At the time the Nursery Schools Regulations were issued the opinion was universally held that there were great advantages from the point of view of immunity from infectious disease in keeping their institutions small and isolated. Experience has, however, shown that relative freedom from infectious disease bears no relationship to the size of the school. The Rachel McMillan nursery school, with an average attendance of 220, comes out of a strict comparison maintained over a period of a year with as good a record as the schools with an average attendance of between 20 and 50. Percentage of I cases of Percentage Average notifiable non- attendance, infectious notifiable. 1925-26. disease. Goldsmith 14 18 22 Jellicoe 0 104 27 Kilburn Union Jack 4 0 23 Notting-hill 2 30 54 Rachel McMillan 4 30 220 Rommany-road — 58 26 Somers Town 2 7 42 Mary Ward 7 33 15 Children's House 4 25 23.5 118 Dr. B. J. O'Connor has submitted the following report upon the Rachel McMillan nursery school:— "I have had extended opportunities of observing the health of the children, and I am pleased to report a marked improvement in their physical and mental state. The pale, flabby, debilitated, often rickety child, so painfully noticeable on admission, has been replaced, after a period of attendance in the school, by a sturdy, happy, contented child; the dull and apathetic is no longer seen, and a bright, responsive child has taken his place. The children, judiciously dieted, are placed in most hygienic surroundings, their hours of sleep and education being carefully regulated; exercises in the form of play and exposure to the maximum amount of sunshine and fresh air are aimed at. "Among the results following this treatment, I must especially mention the remarkable reduction in the prevalence of catarrhal conditions of the respiratory tract and their injurious sequelse, proving, without doubt, that during the child's attendance in the school he has not only acquired increased resistance to disease, but very marked recuperative powers. In this connection it is interesting to read the remarks of the Chief Medical Officer to the Board of Education (Sir George Newman) in his Annual Report for the year 1925. 'At the Deptford McMillan nursery school an analysis of approximately 50 cases shows the beneficial effect of school life under open air conditions on the London slum child. Breathing exercises, massage and sunlight treatment are given in necessary cases, and the nasal catarrh prevalent among many of the children on admission clears up rapidly under good hygienic surroundings.' "The following figures show the comparative freedom from infectious disease in the school, further proof of the resistance conferred on the children by the healthy conditions under which they live. During the year 1926, out of a total number of 252:— The number of cases of scarlet fever was 6, or 2.38 per cent. ,, „ diphtheria „ 4, „ 1.58 ,, ,, measles „ 2, „ .79 „ „ „ „ chicken pox „ 15, „ 5.95 „ „ mumps „ 12, „ 4.79 "There have been no cases of scabies and only one case of ringworm; cases of impetigo, a fairly common skin affection among school children, were few, and cleared up promptly under appropriate treatment. These excellent results would not have been obtained without the co-operation of the principal, Miss Stevenson, and the staff of the nursery school, whose promptitude in reporting, and diligence in detecting suspicious symptoms have been most fruitful in preventing the spread of infectious disease. "Numerous defects have received treatment, including squint, enlarged tonsils and adenoids, carious teeth, middle ear disease, rickets, malnutrition, skin affections, etc. The average attendance at the school during the year 1926 has been:— Council section 104 out of total 112, or 92 6 per cent. Voluntary „ 126 „ „ 140, „ 90 „ Total 230 „ „ 252, „ 91 For the last three months of 1926 (October-December) the attendance has been:— Council section 99 out of total 112, or 89 per cent. Voluntary „ 129 „ „ 140 „ 92 „ Total 228 „ „ 252, „ 90 "I am of the opinion that the nursery school is conducted on sound health principles, that it forms the foundation of permanent good health and that it fulfils with conspicuous success the purposes for which it was established." 119 The Romany Road nursery school was transferred at. the beginning of 1927 from the Mission Hall in Romany Road to newly erected premises with accommodation for 40 in Gipsy Road. These premises are commodious and well arranged and are a great improvement upon the former arrangements. School meals. The systematic examination of samples of milk supplied to necessitous and other children has been continued during the year. The total number of samples analysed was 1,312. Of this number 101 (7.7 per cent.) were found to be " unsatisfactory," 66 (5.0 per cent.) containing added water and 35 (2.7 per cent.) showing a deficiency of fat. The maximum addition of water in any one sample was 20 per cent., whilst the greatest abstraction of fat was 70 per cent. Appropriate action was taken in all cases. In connection with the provisions of meals at Feeding Centres, 11 meals were submitted to examination in the Council's Central Laboratory, and when necessary attention was drawn to the need that existed for an increase in the nourishing and heat-giving constituents. Supervision of dietaries. The control of infectious diseases among school children. One of the problems with which the municipal authorities of large towns are concerned is the control of epidemic diseases, particularly as affecting children of school and pre-school age. The tendency, which has been growing for many years, in the direction of migration from rural parts and the smaller towns to the large industrial and commercial centres has intensified the problem, by contributing towards overcrowding, and by the influx of susceptible persons from the more isolated areas where zymotic diseases are not so common. This latter phenomenon has been particularly noted from time to time in connection with the opening of new housing estates around London, where in several instances outbreaks of diphtheria quickly follow upon the development of an estate, due, it is surmised, to carriers of the disease, who are immune, coming from congested areas and mixing with susceptible children from less populous districts. The year 1926 was chiefly marked by an increased prevalence of diphtheria, and the biennial outbreak of measles which commenced in the closing weeks of the preceding year. Scarlet fever showed a slightly increased incidence, whilst mumps and, to a less extent, chicken-pox were also prevalent. There was a considerable decline in the prevalence of whooping cough, and a further noteworthy drop in the number of cases of ringworm due to increased resort to X-ray treatment. The following table shows the incidence of the various infectious diseases reported by school teachers during the year as compared with the preceding four years. Whilst preventive medicine has made rapid strides in combating such gastrointestinal and insect-borne diseases as cholera, typhoid fever, yellow fever, malaria, plague, as well as small-pox, etc., there still remains a wide field for scientific study with a view to the reduction, both of incidence and severity, of those diseases conveyed through the respiratory channels, e.g., diphtheria, measles and whooping cough, and those affecting the central nervous system such as cerebrospinal fever, poliomyelitis and encephalitis lethargica, all of which still exact a heavy toll of life and suffering among young children. In this connection much has already been achieved as a result of investigation and research in recent years, and whilst it must be admitted that in regard to certain diseases measures of prophylaxis are still regarded as being in the experimental stage, one important discovery, namely the Schick test and active immunisation against diphtheria, is an established method of protection now being increasingly adopted.* *A full report on this question by Dr. J. G. Forbes will shortly be published by the Medical Research Council. Introductory. 120 Confident claims have also been made regarding a similar test in relation to scarlet fever, known as the Dick test, which is being applied in America and in certain parts of Great Britain, notably in Aberdeen, where the Schick and Dick tests, together with the resultant inoculations of immunising fluid, where necessary, are being simultaneously applied to young children. Similarly in regard to measles, active research in being carried on in numerous countries with a view to throwing further light on the aetiology of measles, and encouraging results have already been obtained in America and elsewhere, in dealing with measles, by the use of serum from convalescents and sheep, which has been found to have a definite prophylactic and therapeutic value, although its use is limited owing to the difficulty of obtaining the requisite supplies. After many years of endeavour to deal with epidemic diseases by means of the segregation of the sufferer in isolation hospitals and by improved methods of treatment, medical science and public health bodies are realising more and more the truth of the slogan that "prevention is better than cure," and whilst a definite measure of success has attended the patient work of the pathologist and clinician in this direction within recent times, in order that new discoveries mav be turned to good account the co-operation of the public must be secured, and this can only be effected by well directed and wise propaganda. The public must be made to realise that the utilisation of such protective and precautionary measures as are afforded by medical science against the epidemic diseases of childhood is a civic, as well as a parental, duty and should be undertaken in the interests of the individual and the community as a whole. Similarly, no effort should be spared to bring home to the minds of the public the fundamental precautions necessary in the case of dangerous infectious diseases of childhood, and the dangers associated with their neglect, as for example, the need for the earliest possible administration of anti-toxin by the doctor in the case of diphtheria, especially if there is any delay in removal to hospital, and the proper medical and nursing care in the cases of such diseases as measles and whooping cough, in order to prevent the fatal complications which, in the absence of adequate precautions, so frequently supervene. The enlightenment of the public should constitute the corner stone of all health campaigns, and especially with regard to those preventable diseases of childhood which are not only the cause of much suffering and mortality, but also affect the education of young persons, and thus interfere with their future careers. The following table shows the numbers of actual cases of infectious diseases reported by head teachers as occurring amongst school children during 1926, compared with figures for the preceding four years:— Disease. Diphtheria. Scarlet fever. Measles and German measles. Whooping cough. Chicken pox. Mumps. Scabies. Ophthalmia. Ringworm. 1922 5,641 8,026 34,385 10,340 8,213 4,207 1,570 801 2,488 1923 3,985 4,824 13,784 7,304 13,849 7,916 1,110 1,881 1,935 1924 3,696 5,093 35,946 8,404 11,826 15,424 920 1,101 1,558 1925 5,033 5,717 24,521 12,795 17,583 9,161 711 882 1,364 1926 5,634 5,872 34,778 5,534 12,769 11,897 694 606 937 School inspections in connection with infectious illness, 1926. The diseases referred to in the above table are dealt with individually in the following pages. Both diphtheria and scarlet fever are controlled in the Council's schools by means of the detection and exclusion from school of individual sufferers, suspects and contacts of actual cases. The policy of school closure has for long been abandoned and reliance is placed upon strict supervision and keeping the schools free from infection as far as possible. For this purpose school teachers are provided with a handbook of rules with regard to exclusion from school as well as general advice as to the elementary precautions to be taken, and where there is evidence that 121 infection is likely to spread the school is visited by one of the assistant medical officers, who makes the necessary investigations, examines the children, excludes any suspicious cases and reports, if there is any serious extension of the disease among the children, the medical officer's inquiries are supplemented by daily visits by the school nurse. These measures generally succeed in arresting the spread of infection. The number of schools which were visited by medical officers during the year, and the number of departmental visits in connection with local outbreaks of scarlet fever and diphtheria are shown below:— Diphtheria. Scarlet fever. Total. Division. No. of No. of No. of No. of No. of No. of No. of No. of No. of depts. schools children depts. schools children depts. schools children visited, visited, examined. visited, visited, examined visited. visited, examined. N.W. 87 51 7,570 27 22 2,116 114 73 9,686 N.E. 36 25 4,038 80 48 9,996 116 73 14,034 S.E. 150 66 15,721 93 56 9,665 243 122 25,386 S.W. 103 51 13,270 61 49 10,389 164 100 23,659 E. 57 30 6,732 50 35 7,512 107 65 14,244 Total 433 223 47,331 311 210 39,678 744 433 87,009 In addition to the inspections for scarlet fever and diphtheria referred to in the foregoing table, the medical staff also conducted special inquiries at certain schools owing to the prevalence of miscellaneous infections,e.g., skin ailments, eye diseases, etc. During the year the Council's public health inspectors carried out 27 special investigations at schools where the condition of the premises or environment were alleged to have been responsible for rendering children susceptible to infectious illness. The services of the school nursing staff were utilised for investigating and giving advice to teachers during the prevalence of minor infectious ailments and, in this connection, apart from the work of the nurses in connection with the measles scheme (see p. 127), 265 schools were visited from time to time (chicken pox, 104 schools; whoopine coueh, 18; mumps, 129: impetigo and eczema. 11; ophthalmia. 3). As has been noted on the previous page, 5,634 cases of diphtheria occurred among children attending the Council's elementary, special and secondary schools during 1926, an increase of 601 cases over the preceding year. In the annual report of 1925 it was shown how the incidence of diphtheria has progressively risen in the last three quinquennia. It was also pointed out that the inclusion of purely bacteriological cases in the notification figures may have partially accounted for this increase. There is, however, no doubt that there has been an intensification of diphtheria prevalence in the past five years, although fortunately the increased incidence is not reflected in the mortality figures, as will be noted in the following tabular statement showing the number of cases of diphtheria and the number of deaths from the disease among persons of all ages in London during the past three quinquennia;— Diphtheria. Diphtheria in London. Quinquennium. 1912—16. 1917—21. 1922—26. No. of cases of diphtheria (all apes) 41,710 56,005 62,278 No. of deaths from diphtheria (all ages) 2,892 4,151 3,330 Percentage mortality 6.9 7.4 5.3 Various hypotheses have been tentatively suggested by epidemiologists to account for these periodic outbursts of infectious illness, such as the appearance in the community of a fresh crop of "unsalted" or susceptible children, a cyclic exacerbation of virulence on the part of the particular micro-organism concerned, housing congestion, humidity, etc. In this connection the researches of Professor Topley on the subject of experimental epidemiology (see Lancet, 7th, 13th, 27th March, 1926) are of very great value and worthy of close study. 122 As regards diphtheria, the discovery by Klebs and Loeffler of the specific microorganism associated with the disease in 1884 was hailed with much satisfaction as constituting the dawn of a new era in the prevention of diphtheria, but, although it has certainly been of great assistance in enabling us to secure more efficient control over the disease in schools and similar groups of persons, and also in securing confirmation of diagnosis, it has certainly added to our difficulties by introducing the problem of the apparently healthy germ carrier and the method of his disposal and treatment. In this connection, it may be mentioned that arrangements were made during the latter part of 1926 with Guy's Hospital to treat a certain number of diphtheria carriers at a special clinic, under the supervision of Mr. Layton, the throat surgeon, and Professor Eyre, the bacteriologist. This clinic was opened in July as an experiment with a view to the more intensive study of the carrier question, and for the purpose of ascertaining whether by special treatment, including where necessary surgical interference, a speedy and reliable cure of chronic carriers could be effected. Up to the end of the year 33 children had been treated, including two cases notified and removed to hospital, and 24 were able to return to school cured. It is as yet too early to report upon the methods employed or the results obtained, but suffice it to say that the clinic has already proved of great value, and it is hoped that similar centres may soon be established in connection with other large hospitals, in order that a wider area may be covered. The clinic at Guy's Hospital has also been of service as providing a nucleus in London for the Schick testing and active immunisation of school children, this method of protection having been employed in a number of cases. If similar clinics were opened elsewhere, their establishment would be exceedingly valuable, not only for the treatment of carriers, but also for spreading the net of active immunisation over a wider area. The prevalence of diphtheria within the last few years should bring home to the minds of all public health authorities, especially in London where the epidemic prevalence has been experienced in a greater degree than other parts of the country, the urgent need for taking the fullest advantage of the new method of protection afforded by the Schick test and active immunisation. 223 schools were visited during 1926 by the school medical staff for the purpose of conducting inquiry into the occurrence of diphtheria amongst the pupils, entailing 433 visits or revisits to separate departments and the examination of some 47,000 children. The districts chiefly affected were Southwark, Bermondsey, Camberwell, Deptford and Wandsworth, south of the river; Islington on the north ; and Bethnal Green and Stepney in the east end. Altogether 9,039 bacteriological examinations were conducted in the Council's laboratory during the year in connection with visits to schools, swabbing of contacts of "carriers" or clinical cases in certain instances, 766 of which revealed the presence of diphtheria bacilli, the actual number of children affected being 569. Of these, 237 were removed to hospital after official notification by the Council's medical officers, private medical attendants or borough medical officers of health. The remainder were re-swabbed from time to time until negative results were obtained. The family contacts of "carriers" are excluded from school until they are found to be free from infection of diphtheria after bacteriological examination. Virulence tests have been restricted to the chronic carriers and certain special cases, and, out of 110 specimens, 73 were found to be virulent (including 3 teachers) and 37 were avirulent. Children found to be harbouring avirulent micro-organisms were allowed to return to school whilst the virulent "carriers" were re-swabbed from time to time and were excluded from school attendance until three consecutive negative results had been obtained. In 16 schools (including one secondary school) which have been affected in one or more departments by outbreaks of diphtheria, the special examination of the children by the school medical staff was supplemented by special visitation by the 123 school nurses for the purpose of keeping the children under careful supervision and swabbing where necessary. In certain of these schools the attention of the school nurses was confined to the selection of suitable cases for swabbing and to advising the head teachers as to exclusion or re-admission of the children. In the heavily infected districts, however, a more intensive scheme was put into force and no child who had been absent from school was allowed to resume attendance until proof had been obtained by bacteriological examination of freedom from infection of diphtheria. The schools were visited daily until the situation had improved and afterwards at fairly frequent intervals until the outbreaks had ceased. At the beginning of 1927, 9 schools (17 departments) were still being visited daily and the more intensive scheme was being applied in 4 schools (7 departments). Many of the school nurses have attained high proficiency in the technique of swabbing, and their work in dealing with diphtheria outbreaks has been of very great value. In one school alone (Tennyson Street school, Battersea) where between September, 1926, and the first week in February, 1927,52 cases of diphtheria occurred, 35 in the infants' department, 10 in the boys' and 7 in the girls' department, the school nurse swabbed some 800 persons, including school children, children under school age and in some cases the parents, and discovered 54 harbouring diphtheria bacilli; of these 35 were notified, mainly at the instance of the medical officer of health of the boroughs concerned and removed to hospital, although only one showed any clinical signs of diphtheria. The policy of notifying diphtheria carriers is of very doubtful value save in special cases, as for example, those occurring in residential institutions, and is discouraged by the Ministry of Health, for not only does it seem unwise to treat a physically healthy child in a fever hospital, but the effect upon the local inhabitants, who cannot be expected to distinguish between a clinical and a purely "bacteriological" case, tends to create undue panic; also the notification of such cases vitiates the statistical records and makes for artificially inflated epidemics. Furthermore, a diphtheria carrier being already immune to the disease will not develop clinical diphtheria. By way of further illustration, it may be mentioned that at another school (Keeton's Road school, Bermondsey), 58 cases of diphtheria occurred between September, 1926, and January, 1927, and similar action by the school medical service was taken as in the case of Tennyson Street school. Following upon a sudden outburst of 23 cases which were notified from the infants' department immediately after the mid-term holiday, Dr. Boome visited the school from time to time, and his inspections were supplemented by daily visits by the school nurse. In all, 23 children were found to be harbouring diphtheria germs, only 5 of whom were notified and removed to hospital. Following upon the vigorous action taken, the outbreak was reduced to a few sporadic cases between the middle of November and the Christmas holidays. The parents were kept informed of the action taken at the school, and by a judiciously worded circular sent out by the infants' head teacher, panic was allayed. There is no doubt that by the stringent supervision maintained and by securing the confidence and co-operation of the parents a more serious extension of the disease was averted. For reasons of space it is not possible to give a detailed account of the outbreaks at individual schools and the methods employed in combating the spread of infection, but experience has shown that where a nurse can be spared to visit the school daily and ensure the exclusion from school of all children who are likely to be foci of infection, the spread of diphtheria in the face of a threatening outbreak can be controlled with a considerable measure of success. There was a slight increase in the prevalence of scarlet fever among children attending the Council's schools, 5,872 cases having been reported, as compared with 5,717 in 1925. Figures for the preceding three years will be found in the table on page 58. The disease was most in evidence during the spring and winter Scarlet fever. 124 terms, the districts principally affected being Lambeth, Battersea, and Cainberwell in the south, and Islington, Bethnal Green, Stepney and Poplar, north of the river. The number of schools visited by the Council's medical officers for the purpose of conducting investigations into the occurrence of scarlet fever among the pupils was 213, entailing 311 departmental visits and the inspection of some 39,000 children. For many years past scarlet fever has, broadly speaking, been manifested by a benign type of illness. The mortality from this disease has been very much lower than diphtheria, measles and whooping cough as will be noted in the following table showing the deaths from the four most serious diseases of early childhood during the three quinquennia ending with the year 1925. Deaths. Quinquennium. Measles Whooping cough. Diphtheria. Scarlet fever. 1911—15 9,596 4,872 2,900 1,167 1916—20 5,830 4,010 3,624 701 1921—25 3,859 3,479 3,923 930 Total 19,285 12,361 10,447 2,798 The above figures fully justify the decision of the Metropolitan Asylums Board (referred to on page 129) to give priority to cases of measles during epidemics of this disease, when the number of beds available is insufficient to provide for the accommodation of both scarlet fever and measles. The etiology of scarlet fever was made the subject of a report by Dr. Forbes in the Annual Report of 1925 (pages 50-52) in which the role of the streptococcus in relation to throat infection and the transmission of scarlet fever and puerperal fever was discussed. Reference was also made to the Dick Test and SchultzeCharlton reaction. Since then no additional contributions of sufficiently outstanding importance have appeared to warrant further comment on this subject. At the time the annual report of 1925 was going to press an epidemic of measles was in full progress, although it had not reached its height, and in that report the subject was discussed from a general and historical point of view, in addition to those aspects which were of current interest at a time when the disease had invaded practically all parts of London. The general prevalence lasted from November, 1925, to April, 1926, and a review of the epidemic is now presented. Incidence. During the six months ended 30th April, 1926, 39,387 cases of measles were reported from the schools under the Council's jurisdiction, i.e., about 2,000 cases less than in the previous epidemic, 1923-24, when, during the six months ended 31st May, 1924, 41,261 cases were reported. The total number of cases occurring in the general population is not known, as measles is not a notifiable disease, and even if it were, large numbers of cases would doubtless escape notification. It has been, however, calculated that the total figure may be taken as somewhere between two and three times the number of those reported as occurring among school children. On this basis it is estimated that there were, roughly, between 80,000 and 100,000 cases altogether during the period in question. All parts of London were involved in the epidemic, although the disease was considerably more prevalent in some neighbourhoods than in others, as the table below demonstrates. The case rate in the more densely populated districts was, for the most part, lower than in the better class residential areas. The East End, for example, emerged with a considerably smaller ratio, as compared with boroughs like Hampstead, Wandsworth and Lewisham, as far as the school population is concerned. This is probably accounted for by the fact that children in the poorer districts contract measles and other infectious illnesses earlier in life, i.e., before they reach the age of compulsory school attendance. The following table shows the geographical distribution of 125 the disease month by month during the period November, 1925, to April, 1926, together with the rate per 1,000 of the school population. Numbers of cases of measles reported by head teachers:— School medical division and metropolitan boroughs. Nov., 4 weeks. Dec., 5 weeks. Jan., 4 weeks. Feb., 4 weeks. March, 4 weeks. April, 5 weeks. Total, 26 weeks. Approximate rate per 1,000 children in average attendance (1924-25). Rate per 1.000 above or below mean for London. N.W. Paddington 94 327 454 282 82 34 1,273 90 +22 Kensington 119 185 159 179 84 21 747 49 —19 Hammersmith 129 151 263 514 121 90 1,268 81 +13 Fulham 120 123 310 927 557 85 2,122 98 +30 Chelsea 4 93 140 223 44 10 514 76 +8 Westminster 3 20 101 242 322 40 728 71 +3 St. Marylebone 36 36 39 174 241 69 595 61 —7 Hampstead 2 26 53 324 209 60 674 123 +55 St. Pancras 35 166 195 638 470 254 1,758 67 —1 Total 542 1,127 1,714 3,503 2,130 663 9,679 78 +10 N.E. Islington 131 410 471 730 406 159 2,307 54 —14 Stoke Newington 38 26 49 161 80 21 375 78 +10 Hackney 191 397 333 349 236 91 1,597 53 —15 Holborn 1 26 51 123 70 5 276 69 +1 Finsbury 42 165 77 100 71 28 483 40 —28 Shoreditch 88 170 111 57 31 15 472 28 —40 Total 491 1,194 1,092 1,520 894 319 5,510 50 —18 E. Bethnal Green 197 261 198 271 195 137 1,259 60 —8 Stepney 308 441 280 233 219 158 1,639 38 —30 Poplar 132 232 184 201 130 82 961 38 —30 City of London 6 19 21 10 1 9 66 34 —34 Total 643 953 683 715 545 386 3,925 43 —25 S.E. Bermondsey 83 223 221 284 174 93 1,078 49 —19 Camberwell 329 896 536 597 407 90 2,855 76 +8 Deptford 228 328 183 221 154 55 1,169 82 +14 Greenwich 253 287 170 169 97 74 1,050 66 -2 Lewiaham 45 272 317 663 472 179 1,948 98 +30 Woolwich 397 376 201 196 109 92 1,371 70 +2 Total 1,335 2,382 1,628 2,130 1,413 583 9,471 74 +6 S.W. Southwark 115 316 408 837 319 67 2,062 66 —2 Lambeth 21 231 436 1,215 778 224 2,905 84 +16 Battersea 54 271 367 750 443 160 2,045 93 +25 Wandsworth 71 103 173 1,391 1,510 541 3,789 96 +28 Total 261 921 1,384 4,193 3,050 992 10,801 86 +18 Grand Total 3,272 16,577 6,501 12,061 8,032 2,943 39,386 68 - In the above table the figures relate to all departments of the schools, but the incidence of measles among children attending upper departments is more or less negligible, as the majority of children, probably about 90 per cent., have already suffered from the disease by the time they leave the infants' department. Consequently, the rate per 1,000 of cases occurring among children attending infants' 126 departments would be very much higher, viz., about 180 per 1,000, instead of 68 per 1,000, and the figure would be greater still among the babies' and junior classes. Epidemics of measles, which occur with regularity in London, roughly every two years, have been the subject of close study by the public health authorities, and all possible and practicable means have been explored for limiting the spread of the disease. Experience has shown that, in spite of all efforts, but little can be effected as regards checking the incidence of the disease when it becomes epidemic, although a good deal can be accomplished in reducing mortality. Whereas formerly class closure and the exclusion of susceptible children were resorted to when measles threatened to spread in a school, it was found that the interference with school attendance was not justified by the results which accrued in the prevention of spread. Every young child is susceptible to measles until protection is acquired by an attack of the disease, so that during the inter-epidemic periods the mass of susceptible material, augmented by the natural increase in births, accumulates until the proportion is ripe for the disease to spread. Were it not for the fact that measles is endemic in this country and that successive generations have become familiarised with the disease, the toll of life would be greater than it is. It is well known that where measles attacks a population unprotected by racial immunity, the death rate is very high, both among children and adults, as for instance when soldiers from the Antipodes and from the Highlands of Scotland were attacked during the war. Public health administration in London in recent years has been chiefly directed towards early treatment, the efficient nursing of cases and reduction in mortality. Mortality. As a consequence of the greater attention to these matters in recent years, the mortality due to measles has been greatly reduced, although the incidence has remained practically stationary, as the following table demonstrates:— Quinquennium. No. of cases reported among school children. No. of deatlis (all persons). 1911—15 116,754 9,596 1916—20 115,093 5,830 1921—25 116,956 3,859 During the epidemic of 1925-26 there were 1,034 deaths during the six months from November to April, inclusive, which represents a considerably lower mortality than in the 1923-24 outbreak, when, in the six months while the epidemic was in progress, viz., December to May, inclusive, there were 1,391 deaths. The consistency with which the mortality from measles is being reduced is indicative of the success of the measures which are being taken by the Council and the several metropolitan boroughs in their respective spheres of action. The monthly distribution of the 1,034 deaths was as follows:— November. December. January. February. March. April. Total. No. of deaths 66 159 216 196 205 192 1,034 As usual, the heaviest burden of fatalities occurred in the age group of one to two years, only 55 deaths in the school age period, and 5 deaths over school age having been recorded, as will be noted below:— Age groups. 1 year. 1—2 years. 2—5 years. 5—15 years. Over 15 years. No. of deaths 248 462 264 55 5 Immunisation against measles. As already stated (p. 120), active rest arch is being prosecuted in the direction of measles prophylaxis, and in this country the Ministry of Health, in conjunction with the Medical Research Council, have recently been engaged in the investigation of methods of active immunisation against measles which it is hoped will bear fruit in due course, but it is as yet too early to make any further statement in the matter. The measles scheme. In accordance with the decision of the Education and Public Health Committees in 1921, after conference between representatives of the Council and the several metropolitan boroughs, the measles scheme is put into force when the number of 127 cases of measles reported from the schools approaches a figure of about 1,000 per week, a point which was reached early in November, 1925. The scheme involves the utilisation of the services of school nurses, who visit daily the schools where measles is reported to have occurred, examine children in the classes affected, especially those under 5 years of age, send immediately to the divisional officer responsible for school attendance the names and addresses of all children absent without known cause, exclude from school all definite or suspicious cases of measles, informing the medical officer of health of the district where necessary, and generally give advice to the head teachers during the course of the outbreak. The attendance officers visit the absentees at once, and where cases of measles are discovered, a special form is despatched at once to the medical officer of health of the district. Head teachers are also required to report, in accordance with the usual rules, all known or suspicious cases at once on the ordinary notification form (Form 84), to the school medical officer, medical officer of health of the district, and the divisional officer. The object of the scheme is to expedite knowledge of the existence of cases of measles, in order that the borough medical officer of health may arrange for the home to be visited in the early stages of illness, and for the case to be removed to hospital or local nursing assistance supplied where necessary. The crucial period of measles is usually during the first week of illness. It is during this time when complications such as broncho-pneumonia, which are so dangerous to life, supervene, and it is, therefore, necessary so to organise the machinery of administration as to secure that a visit to a home is paid by the local health officers in this early period. Although very much has been accomplished in this direction since the existing measles scheme was introduced, the ideal has not yet been wholly attained. It was suggested by Sir William Hamer in his report on measles, in connection with the conference in 1921, that steps should be taken, if possible, to impose an obligation on parents to inform the head teacher of the school of the reason for a child's absence within 48 hours. The Council's solicitor, however, reported subsequently that the Council had no power to make, under Section 74 of the Elementary Education Act, 1870, or otherwise, a bye-law requiring parents to make such notifications. The Education Committee at that time, however, undertook to consider whether anything further could be done to secure the fuller co-operation of parents and guardians in that direction, but no specific proposals were made. If it is not possible to effect a compulsory measure requiring notification on the part of parents whose children are absent from school, an attempt can be made to secure the voluntary co-operation of parents in this matter during epidemics of measles, and for this purpose the advice on the measles warning card, which is already sent out to the parents of susceptible children in classes affected by measles is to be supplemented by some appropriate words urging parents to inform the head teacher at once if a child is absent with a supposed cold or symptoms of measles, during the prevalence of measles. It would also appear to be desirable for the borough medical officers of health to take similar action through their local machinery with regard to children under school age. The administration of the measles scheme involved a very large amount of work on the part of the school nurses, attendance officers, head office staff and others concerned. During the progress of the epidemic, much of the ordinary work of the school nurses, in connection with personal hygiene schemes and medical inspection, had to be suspended. The hours devoted by the nurses to measles work during the 17 school weeks the scheme was in operation were equivalent to the full time services of 28 nurses. Complaints were received from numerous sources of the suspension of the nurses' ordinary school duties, but it is hoped that, in future epidemics,this difficulty may be to some extent overcome, although it is obvious that emergency work of this nature must always take precedence over routine work. 14172 I 128 The following table shows the amount of work done by the nurses during the 17 school weeks the procedure was in force, and the results obtained:- Measles Scheme—17th November, 1925, to April, 1926 = 17 school weeks (approx.). Division. Schools at which scheme in force. Hours devoted to measles work. Definite cases excluded and reported to M.O.H. Suspicious cases excluded. No. of cases in col. (5) later proved to be measles. No. of absentees reported to D.S. Absentees in col. (7) proved definite cases of measles. (1) (2) (3) (4) (5) (6) (7) (8) N.W. 187 2,832 52 1,013 523 9,914 2,878 S.W. 175 2,119 79 759 414 6,511 2,478 S.E. 169 3,191 41 895 492 7,770 2,496 N.E. 124 1,739 60 336 119 2,508 680 E 104 1,580 104 250 82 4,243 1,142 Totals 759 12,189 =4,876 school sessions 336 3,253 1,630 30,946 9,674 Home nursing and hospital accommodation. The medical officers of health of the metropolitan boroughs are generally in agreement as to the usefulness of the scheme, and there is no doubt that the procedure has been of value in enabling them to secure knowledge of cases of measles and so assisting them in rendering any necessary assistance to the parents, either by way of home nursing or by removal of the cases to hospital. The metropolitan boroughs are empowered under the Maternity and Child Welfare Act, 1918, to provide nursing and medical assistance in the case of children under five years of age suffering from measles and certain other diseases dangerous to young life. They are also empowered to deal similarly with adults under Section 77 of the Public Health (London) Act, 1891. Medical officers of health receive information of the occurrence of measles from various sources, viz., the school organisation, infant welfare centres, health visitors and other health officers during the normal course of domiciliary visits, and in 10 boroughs by statutory notifications under local orders making measles a compulsorily notifiable disease. Compulsory notification on a larger scale has frequently been tried, but has as often been abandoned. There is considerable difference of opinion as to the value of such a measure as applied to measles, but the protagonists of the system contend that one of its chief advantages lies in the fact that, where a disease is compulsorily notifiable, it is regarded with greater seriousness by the parents, and is, therefore, valuable from an educational and propagandist point of view. The general view is, however, that sufficient means are available, through the school organisation and otherwise, for ascertaining the existence of cases, and that if all possible steps are taken to speed up the machinery, there is no need to supplement these sources of knowledge by statutory notification. As soon as a case of measles is reported to a medical officer of health, the health visitor makes domiciliary inquiries, and if nursing assistance is required in the home, a local nursing association, with whom the borough councils have working arrangements, sends a nurse to the home, or, if the home conditions are unsatisfactory and unsuitable for proper nursing, the case is removed to hospital if there is sufficient accommodation. Arrangements with district nursing associations to provide treatment in the homes are in operation throughout the London boroughs, although these facilities were more freely used in some boroughs than in others, possibly because in the latter there had been little demand owing to the mildness of the disease, or from other causes. In future epidemics much greater scope in the matter of hospital accommodation will be provided as, arising out of an informal conference at the Metropolitan Asylums Board, consisting of representatives of the Board, the Ministry of Health, L.C.C., and the Metropolitan Branch of the Incorporated Society of Medical Officers of Health, on 20th April,1926, it was agreed that it would be 129 highly desirable for all cases of measles recommended for removal by medical officers, of health to be admitted to the Board's fever hospitals, and that, when measles is epidemic, such cases shall generally be admitted to hospital in preference to scarlet fever, if the accommodation is insufficient to provide for all scarlet fever cases. This new scheme of hospital accommodation for measles was agreed to by the Metropolitan Asylums Board on 16th October, 1926, and received the sanction of the Ministry of Health. It is hoped that this extended hospital accommodation, supplemented where necessary by the existing scheme for the provision of nursing assistance in the home of the patient, will have the effect of reducing still further, in the next epidemic, the mortality and complications due to measles. It is important to emphasise that the whole scheme of dealing with measles, in the present state of our knowledge, is directed towards the prevention of mortality and those complications which produce such disabling effects in the sufferer, frequently resulting in prolonged attendance at hospitals, medical treatment centres, etc. Upon reviewing as a whole the subject of measles epidemics and the steps to be taken in the future to mitigate the serious results accruing therefrom, it is clear that the organisation of the public health services must be directed with due regard to the personnel available, and concentrated upon those areas in which the special need is acute. In the better class districts where the housing accommodation is such as will provide adequate means of home nursing and where, in most cases, private medical advice is sought, inquiry or assistance by public health authorities is generally unnecessary. Every effort should, therefore, be made to concentrate attention upon the overcrowded and insanitary areas where the housing conditions are unsatisfactory and where it is impossible to isolate or to nurse efficiently children who are suffering from measles. It is in these areas where the mortality and disablement during epidemics of measles occur. It has therefore been suggested to medical officers of health of the several metropolitan boroughs that they should classify their districts into three separate zones for measles purposes, namely:— Class I.—Streets or districts where there is little or no overcrowding, and where there is a satisfactory standard of living. Children suffering from measles in these districts would probably require no supervision or assistance from public health authorities. Class II.—Streets or districts where there is both overcrowding and lack of proper nursing facilities. Class III.—Very bad insanitary and slum districts where it is dangerous for children suffering from measles to remain at home. There should be no difficulty in a sub-division of this kind, as the medical officers of health of the boroughs already classify the houses in their districts in a similar manner in connection with the treatment of tuberculosis, and for other purposes. It will be the object of the Council, in future epidemics of measles, to supervise closely the schools attended by children in districts of Class II. and III. types with the object of detecting cases of measles in the early stages and to speed up the machinery for securing the earliest possible information of cases, in order that the borough medical officer of health may be in a position to obtain the early removal of cases to one of the Metropolitan Asylums Board's isolation hospitals for treatment or, where the medical officer of health considers that satisfactory isolation arrangements can be made at home, but where, for one reason or another, the parents are unable to provide adequate home nursing, to offer the services of a trained nurse during the early and critical stages of illness. Such a scheme would involve daily visits of inspection, not only to the homes of the children, but also to schools in the affected areas, and also perhaps to the infant welfare centres. As was previously pointed out, the normal staffs of the health services are insufficient to cope satisfactorily with an epidemic of measles if the work is to be carried out efficiently. For example, the services of school nurses 14172 I2 130 have been temporarily withdrawn from their ordinary work of personal hygiene and medical inspection during measles epidemics to the detriment of these important and essential services, and there is no doubt that the health services of the metropolitan boroughs have been similarly hampered during such epidemics, although it is the •custom in certain boroughs to appoint additional temporary nurses or health visitors for this purpose. In view of the fact that measles is a disease both of school and preschool age, although more dangerous to the latter class, the campaign against measles is the dual concern of the Council, as local education authority and of the several metropolitan borough councils, and in future epidemics the utmost resources of these public health services should be utilised in combating the disease. In 10 boroughs measles is a notifiable disease, with the approval of the Minister of Health, who only confirms such local Order if he is satisfied that proper arrangements have been made to "follow-up" cases of measles as they are notified, and to take such steps as are necessary with a view to the prevention of mortality and complications arising from the disease. In these boroughs the medical officer of health may desire to make his own arrangements without special assistance from the Council's school organisation. The next epidemic is due about the end of 1927, and the public health services of London should be prepared for the emergency when it arrives. For this purpose the Council is prepared to co-operate in the closest possible manner with the local sanitarv authorities through the school organisation. Whooping cough. There was a decline in the prevalence of whooping cough in the schools during the first ten months of the year, but during November and December the disease became somewhat more prevalent. The numbers of cases reported during the year were 5,534, as compared with 12,795 in 1925, 8,404 (1924), 7,304 (1923), 10,340 (1922). The school nurses visited 18 of the affected schools from time to time for the purpose of examining the children and advisinc the head teachers. Ringworm and favus. The decline in the number of cases of ringworm referred to in previous annual reports has been maintained. The careful supervision exercised by the school nurses is responsible for the early diagnosis of the disease and the prejudice of the parents against the application of X-ray treatment has now practically disappeared. A comparative table showing the results achieved in the years 1911 to 1926 is included in the section on the work of the school nurses (page 93). Allowing for the fact that a number of cases are unsuitable for X-ray treatment the percentage of cases treated and cures effected by this means is now highly satisfactory. During 1926, 1,950 specimens of hair stumps were examined in the Council's laboratory and of these 673 contained ringworm fungus and 18 proved to be favus. 8 fresh cases of favus were discovered during the year and 12 cases reported in 1925 remained uncured at the beginning of 1926. Of these 15 were cured and the remaining five were still under treatment at the end of the year. Chicken pox. The number of cases of chicken-pox occurring in London still remains high, 12,769 cases being reported from the schools during the year as compared with 17,583 in 1925, 11,826 (1924), 13,849 (1923), 8,213 (1922). The school nurses visited 104 schools specially affected for the purpose of examining the children and advising the head teachers. Mumps. 11,897 cases of mumps were reported as occurring amongst school children during 1926 as compared with 9,161 in 1925, 15,424 (1924), 7,916 (1923), 4,207 (1922). The school nurses visited from time to time 129 schools which were specially affected. Ophthalmia (blight, infective conjunctivitis). A further decline occurred in the number of cases of eye disease reported from the schools during the year, the number of children affected being 606 as compared with 882 in 1925, 1,101 (1924), 1,881 (1923), 801 (1922). The districts mostly affected during the years were the east end of London (Shoreditch, Bethnal Green, Stepney and Poplar), 211 cases, and Bermondsey, 108 cases. 131 Special attention is directed to the treatment of all cases of disease of the eyes through the Council's "treatment" scheme. The health of the children at the Council's residential institutions for children of school age was highly satisfactory as regards the incidence of infectious illness. Only a few sporadic cases of infectious disease occurred at one or other of these institutions. It is probable that in the few cases that occurred, the infection was introduced by visitors or that the patients were incubating the disease before their admission. Precautionary measures regarding isolation of the patients and close observation of the contacts were successful in preventing any spread of infection. Residential schools and places of detention. I he subject of encephalitis lethargica as a whole is reviewed in that section or the annual report dealing with the general public health. In view of the fact that this disease, as regards its sequelæ, presents a specially difficult problem in relation to children of school age, it will be appropriate to make reference to the subject in this section of the report. The number of children of school age notified during 1926 as suffering from encephalitis lethargica was 53, the total number of notifications for this disease among persons of all ages being 231. The following table presents an analysis of the notified cases between the ages of 3 and 14 years during 1926 as compared with 1925. It will be noted that the diagnosis of encephalitis lethargica in 10 cases was not confirmed. Of the remaining 43 cases, 15 died, and 8 were still suffering from the sequelæ of the disease at the time of the last report. With regard to the 15 children who were said to be apparently normal, it must be remembered that relapses are common and that frequently an intervening stage of normality occurs, after the acute stage, before the after-effects appear. In this connection it will be noted that in the 1925 figures, in which a sufficiently long interval has elapsed to allow of the sequelæ to become manifested, the number of children still suffering from after-effects exceeds the number of those apparently normal. Encephalitis lethargica ("Sleepy sickness"). Total notified. Apparently normal. Suffering from after-effects. Not confirmed as E.L. Fatal. No information. M. F. M. F. M. F. M. F. M. F. M. F. 1925 22 25 6 6 10 5 3 3 2 11 1 - 1926 36 17 10 5 6 2 6 4 10 5 4 1 In addition to the 53 notified cases during 1926, 107 cases under the age of 16 years, notified in previous years as encephalitis lethargica, came under observation or were investigated from time to time. Further, there were 134 non-notified cases in this age period on which one or more reports were obtained during the year, apart from those treated at the Northern Hospital, Winchmore Hill, to which reference is made later. These cases are classified according to the nature of the sequelæ in the following table. The various categories broadly conform with the classifications given in the report of the Metropolitan Asylums Board on the first year's working of the experimental unit at the Northern Hospital, and are as follows:— Mental.—Intelligence affected in a greater or less degree, ranging from mental hebetude to imbecility. Conduct changes.—These cases range between those showing excitability and emotional outbursts to those of the gross forms of delinquency exhibiting maniacal behaviour, pilfering, sexual perversity, etc. Parkinsonism.—A characteristic condition associated with muscular rigidity, slowness of movement, nodding head, dribbling, tremors, etc., resembling the paralysis agitans of old age. These cases vary from the mild Parkinson type to the helpless and bedridden case. Excito-Motor.—Includes cases exhibiting involuntary movements, coarse tremors, myoclonic spasms or twitchings, choreic or jerky action of the limbs, and muscular contractions, etc. 132 Paralysis.—This category includes the various cases of paralysis or paresis of one or more limbs or certain muscles, disturbances of the nerves affecting respiration, e.g., panting breathing, slow breathirtg, snorting, snuffles, etc., and speech, e.g., stammering, slurred, staccato or explosive speech. Sleep.—Cases which are manifested by an inverted sleep rhythm or by restlessness and noisy behaviour at night. In many cases the patients tear up the beclothes or are otherwise destructive. Miscellaneous.—Refers to various other physical or nervous manifestations not covered in the above categories. Sub-Normal.—Signifies that the patients, though not suffering from any very specific after-effects, are not as well as they were before their illness. Cases under observation during 1926. (Excluding cases dealt with at the Northern Hospital, Winchmore-hill.) Whether notified. Total No. of cases. Classification of sequelæ. Mental. Conduct. Parkinson. Excitomotor. Paralysis. Sleep. Miscellaneous. Subnormal. Apparently normal. Notified—107 cases— Sex M 69 16 14 4 3 8 11 8 5 28 F 38 5 11 2 2 3 3 5 5 12 Non-nolified—134 cases— Sex M 72 18 25 3 9 7 13 4 5 23 F 62 17 20 1 6 10 14 5 5 15 The experimental unit at the Metropolitan Asylums Board's Northern Hospital, Winchmore Hill, was opened in November, 1925, for the residential treatment and observation of children between 3 and 16 years of age suffering from the after-effects of encephalitis lethargica. The experiment is of great importance as it is the first attempt of the kind which has been made by a public authority to deal with these cases. Children are admitted on the application of the Council or the various Boards of Guardians. As soon as information of children suffering from the sequelæ of encephalitis is received from the various sources, i.e., medical officers of health, hospitals, school care committees, school medical service, etc., domiciliary enquiries are made through the care committees and particulars obtained on a report form. Arrangements are then made to examine selected cases at County Hall and the Metropolitan Asylums Board's admission forms are completed for suitable cases and forwarded to the Board. If the Board's neurologist approves, the children are admitted and the parents are asked to contribute toward their maintenance according to their means, the assessments for this purpose being made by the school care committees. The total amount of contributions thus collected is forwarded to the Board by the Comptroller. The Metropolitan Asylums Board's report on the first year's working of the unit demonstrates that the outlook in certain classes of case is hopeful, whilst in others there has been little or no response to treatment. It further indicates that the future purpose of the institution, apart from its usefulness in effecting definite improvement in the milder type of case, may well be that of a clearing house where patients suffering from the heterogeneous forms of the sequelæ of encephalitis lethargica may be observed, classified and allocated in the various ways, according to the nature of the defect. For example, it is suggested that the milder types of "mental" cases should be dealt with at a hospital school and, as they become 16 years of age, drafted to a residential colony, although, as is pointed out, there is at present no power to institute such a colony or detain the patients therein. The patients who could be certified either as mentally defective or insane can be dealt with under the appropriate Acts. At present a patient who exhibits mental symptoms, following encephalitis lethargica, can only be dealt with statutorily if 133 he is shown to be insane or mentally defective. These terms may be briefly defined as follows:— Insanity.—A "lunatic" is an idiot or person of unsound mind, and the term is capable of wide application. In practice he is only dealt with by the community if his conduct is persistently dangerous to himself and/or others. Lunatics are transferred to mental hospitals, and those whose condition is due to encephalitis lethargica, in London, are sent to West Park Mental Hospital. Mental deficiency.—In the case of the Mental Deficiency Act, it must be shown that there is a state of failure of development of mind which has existed from birth or an early age. In addition to this the affected persons must comply with certain postulates, namely, that they are neglected, criminal or inebriate, or, if of school age, that they are incapable of being educated in a special school. Some difficulty has arisen owing to the fact that the term "early age" is not legally defined, and although it has been the practice of the Board of Control to accept cases if the onset of the disorder arose during school age, some judicial authorities and some medical practitioners are not prepared to go so far. With a view of dealing, inter alia, with the difficulty of the term "early age," a Bill was passed in the Autumn Session of 1926 through the House of Lords to amend the Mental Deficiency Act. In this Bill it was proposed to define mental defectiveness so as to include all cases where there is a "condition of arrested or incomplete development of mind, whether innate or induced after birth by disease, injury or other cause." The Bill, however, lapsed in the Commons, and it is understood that a Private Bill will shortly be introduced substantially embodying the provisions of the Government Bill.* As regards patients exhibiting sleep disorders and the peculiar feature known as inversion of the sleep rhythm, the treatment at Winchmore Hill has effected considerable improvement. The neurological types have not on the whole responded materially to treatment. This category includes the Parkinsonian cases already referred to, those showing excito-motor phenomena (cases of muscular unrest) and the intermediary types exhibiting various kinds of paralysis or paresis and disturbances of the respiratory rhythm, speech changes, etc. The Board suggest that a hospital school for the milder Parkinsonian cases, and treatment in an infirmary ward or special hospital for the severer types, is indicated. It is further recommended that the severe cases of muscular unrest should be treated in an institution on the lines of the existing unit, their ultimate disposal depending on their physical and mental condition, and that the bedridden cases should be transferred to a hospital or infirmary if unable to be dealt with in their homes. It is pointed out that the paralysis cases, including those in which the respiratory rhythm and organs of speech are affected, have resisted treatment. The Board suggests that some of these cases might be dealt with in an ordinary special school if otherwise suitable, and that the severer types should be treated in the same way as the Parkinsonian group. It cannot be too strongly emphasised that the provision of this special unit at Winchmore Hill has materially assisted in the solution of the problem of the disposal and treatment of cases of chronic epidemic encephalitis. Admittedly the results as regards positive cures have not been as encouraging as had been hoped, but it must be remembered that the unit was experimental and the outlook when the scheme was inaugurated was very uncertain. One of the principal objects of the experiment was to provide residential treatment for cases which had not proved amenable to ordinary hospital treatment. *In the new Bill, which has passed the second reading in the Commons, "mental defectiveness" is defined as "a condition of arrested or incomplete development of mind existing before the age of eighteen years, whether arising from inherent causes or induced by disease or injury." 134 The appreciation of parents and the gratification expressed by hospital and other authorities for the opportunity of placing these difficult cases under residential medical care has fully justified the step taken. The Board have agreed to continue the experiment for a further period of one year from the 13th November, 1926. The following table gives an analysis of the admissions and discharges up to the end of 1926. As cases are received on the application either of the Council or Boards of Guardians they are allocated in the table accordingly:— Cases dealt with at the M.A.B.'s Northern Hospital, Winchmore Hill. Admissions and discharges. Councils cases. Guardians' cases. Total. M. F. Total. M. F. Total. M. F. T otal. Admissions 59 50 109 16 9 25 75 59 134 Discharges 17 15 32 7 2 9 24 17 41 Re-admissions 1 2 3 — — — 1 2 3 Still in hospital 43 37 80 9 7 16 52 44 96 The following table shows the conditions from which the children were reported, or found, to be suffering on their admission to the Northern Hospital. The information as regards the Guardians' cases is incomplete as the condition upon admission in many cases was not known to the Council. It must also be remembered that in many instances certain defects, e.g., tremors, twitchings, excessive salivation, etc., were intermittent, and may not have been noted at the time of examination. Condition. Notified. Non-notified. Total. Male. Female. Male. Female. Sleep disturbance 14 11 27 26 78 Mental— (а) Retardation or hebetude 14 4 24 20 62 (b) Lack of concentration only 4 3 4 2 13 Character changes 19 12 30 25 86 Emotional 2 3 5 5 15 Restless and fidgety 2 — 6 6 13 Parkinsonism 6 4 9 12 31 Paralysis of limbs 2 — — 1 3 Muscular weakness 1 — 2 3 6 Facial paresis— (а) Lack of expression 2 1 1 4 8 (б) Facial weakness 1 — 1 1 3 Dribbling 2 1 6 3 12 Speech defects 5 — 2 — 7 Tremors and twitching 3 1 4 3 11 Choreic movements 2 — 3 — 5 Irregularity in gait 2 1 4 4 11 Eyes— (а) Squint 2 3 — 1 6 (b) Ptosis — — 1 1 2 (c) Irregular movements — — —— 1 1 With regard to the discharged patients, considerable difficulty is presented in regard to those cases which, on account of their reaching the age limit, are no longer able to be accommodated at the Winchmore Hill unit. These cases, together with other adolescents and adults suffering from chronic epidemic encephalitis, for whom there is no accommodation at present available, present a serious problem. Admission examinations. Defective children. The total number of examinations conducted under the Education Act during the year was 25,867. 5,517 examinations with a view to admission to special schools, were conducted; this is an increase of 228 as compared with the examinations of 135 the previous year. The following table shows the number of children nominated for examination and the recommendations made:— Defect. Number nominated. Suitable for admission to Returned to elementary school. Invalided. Notified under M.D. Act. Blind School. Myope class. Swanley. B.G. B. G. B. G. B. G. B. G. B. G. B. G. Vision 48l 561 15 18 110 152 62 70 260 292 34 29 - Deaf school. Hard of hearing class. B. G. B. G. Hearing 342 356 36 32 57 78 242 238 7 8 — — P.D. school Open-air school B. G. B. G. P.D 737 796 530 553 13 11 108 137 86 95 — — M.D. school. B. G. M.D 1,221 895 481 346 632 473 43 44 55* 32* Epileptic colony. B. G. Epileptic 65 63 29 13 | 13 23 23 27 — — Total 2,846 2,671 1,333 1,273 1,255 1,163 203 203 55 32 5,517 2,606 2,418 406 87 *Of these 46 boys and 22 girls were imbecile; 7 boys and girls were idiots; and 2 boys and 3 girls were feeble-minded. Examinations were also conducted in 118 cases with a view to ascertaining the fitness of the children for education in industrial or reformatory schools. The special schools were visited at least once a quarter and every child present was seen at least once during the year, the total examinations amounting to 19,491; in addition 741 special examinations were made of children already on the rolls of special schools in connection with applications for non-enforcement of attendance at special schools, and similar reasons. As a result of the visits and re-examinations the following re-classification took place: 232 returned on improvement to elementary schools; 19 from schools for the hard-of-hearing and 1 from a school for the blind, to schools for the deaf; 3 from schools for the mentally defective, 1 from a school for the physically defective, and 1 from a school for the deaf, to schools for the hard-of-hearing; 3 from schools for the myopic to schools for the blind; 3 from the schools for the physically defective and 4 from schools for the blind, to schoolsfor the myopic; 18 from schools for the physically defective, 1 from a school for the hard-of-hearing and 4 from schools for the partially blind to schools for the mentally defective; 2 from schools for the myopic to schools for the physically defective; 59 excluded as imbecile; 72 invalided on medical grounds; and 537 over 14 years of age deemed to be no longer certifiable. Rota visits to the schools. The following statement shows the nature of the conditions found among the children certified as suitable for admission to physically defective schools at the admission examinations during the year:— Morbid condition. Boys. Girls. Total. Morbid condition. Boys. Girls. Total. Infantile paralysis 62 44 106 Heart disease— Congenital 20 29 49 Cerebral paralysis 6 12 18 Various paralyses 34 29 63 Acquired valvular 121 183 304 Tuberculosis of bones and joints 144 111 255 Acquired non-valvular 8 15 23 Other diseases 47 43 90 Congenital deformities 28 32 60 Other deformities 60 55 115 530 553 1,083 Conditions found at admission examinations. 136 Decertification of P.D. children. Owing to the improved facilities for treatment, especially for tuberculosis and paralysis, now available and a greater possibility of admitting to the schools certain cases of heart disease at somewhat earlier stages than was formerly possible, an increased number of children improve to such an extent that they are able to return from the Special (P.D.) schools to the ordinary elementary schools or are "no longer certifiable" as defective between the ages of 14 and 16 years. The following is a comparative table relating to different conditions for the years 1925 and 1926:— Defect. Cases passed no longer certifiable. Cases passed lit to return to elementary school. 1925. 1926. Total. 1925. 1926. Total. Residential schools. Heart 47 56 103 17 17 34 Rheumatism 2 6 8 4 2 6 Tuberculosis 68 49 117 33 24 57 Infantile paralysis 42 41 83 12 9 21 Various 40 41 81 89 50 139 Total 199 193 392 155 102 257 There are 3 residential industrial schools, 6 residential special schools (2 for blind, 2 for deaf, 1 for defective deaf and 1 for mentally defective) with a total accommodation for 676 residential and 222 day scholars. To each institution is allocated a medical officer and provision has been made for dental inspection and treatment. During the year 735 boys were admitted to Pentonville Road Place of Detention and 271 sirls and infants to Ponton Road. Standard of certification of children for admission to M.D. schools. During the year some attention has been paid to the question of the standard of the certification of children for admission to special schools for the mentally defective with a view to seeing whether any material change has taken place in recent years. The records of the mental ages of the children admitted between the years 1918 and 1926 inclusive have been taken out in three-year periods. The history of the certification is briefly as follows:— When the schools were first commenced in 1892 by the late School Board for London there were no statutory arrangements governing the conduct of such classes, admission to which was arranged by the inspectorate, any medical supervision being of a voluntary character. In 1898 the Medical Officer of that day was directed to supervise the classes and in the following year two part-time assistants were delegated the task of visiting the schools and examining entrants. After the passage of the Elementary Education (Defective and Epileptic Children) Act, 1899, the medical work was placed on a statutory basis from which time the records have been preserved. In the earlier years attention was principally paid to physical and particularly to neurological signs such as defective poise, twitchings, muscular overaction and the various stigmata as well as to the educational attainments or rather lack of attainments of the children in question. At that time the Superintendent of schools for physically and mentally defective children or one of her assistants accompanied the medical officer at his examinations and the selection was made on a joint basis. So far as can now be judged from the past records, some children were admitted and remained on trial for considerable periods who would now most probably be deemed imbecile, while there were others of a higher grade who, at the present time, would be likely to be regarded as merely dull and backward. Needless to say this latter class profited greatly by instruction in the special school as at each there was a full curriculum of manual occupation, and, for older children, trade instruction such as, at that time, could not be obtained elsewhere within the school system. The special schools have preceded trade and central schools. There is no question but that, at that time, the Special Schools were "schools of recovery" and that the term "mental defect" had not its present connotation ftiiggestive of a need for permanent care, supervision and control. The very extension 137 of the period of education by two years in the case of these children seemed to indicate hopefulness that additional instruction might lead to the establishment of working capacity and powers and of a harmonious self-control in the scholars. Gradually, in the years up to 1909, various tests of intelligence and capacity were being tried out but there was no established scale and each of the medical officers was making his own separate experiments and investigations. At this period nomination for admission was made almost entirely by the teachers of the ordinary schools. After the introduction of the system of general medical inspection under the Administrative Provisions Act, nominations from the teachers were supplemented by those from the school doctors. The numbers of admission examinations increased as did the provision of special schools. After 1909 the work of Professor Binet became known in England and the tests were tried out in some of the schools and .at admission examinations so that at about 1912 these tests became part of the recognised procedure of ascertainment. Between 1912 and 1914 data were accumulating to shew their value in distinguishing between the innately defective •children and the dull and backward children, and as a consequence the numbers of higher grade children admitted very materially diminished. The war caused a certain dislocation of the arrangements of classification owing to the frequent changes of medical officers necessitated and it seems probable that some higher grade cases may have been deemed backward and so not admitted, and that children of a lower grade were given rather lengthy trials in school; this being due to the fact that no one medical officer had the opportunity of seeing many of them for a sufficiently long period to form a definite opinion that mental progress had ceased. With the return of the regular staff, so that children could be kept under continuous observation, these lower grade children were combed out. From the end of the war onwards the standard of suitability for admission to special schools has been, broadly, that a child should have a mental ratio of between § and ^ the normal with some serious educational retardation, always supposing that retardation could not be explained on other than mental grounds. The following table shows the average mental ages of children admitted for each chronological age, arranged in three-year groups. From this it will be seen that the standard has remained practically constant in the last nine years:- Chronological age. Mean mental age. Chronological age. Mean mental age. 1918-19-20. 1921-22-23. 1924-25-20. 1918-19-20. 1921-22-23. 1924-25-26. 7 4.9 4.8 4.6 11 7.1 7.4 7.4 8 5.7 5.7 5.6 12 7.7* 7.5 7.6 9 6.3 6.5 6.4 13 8.2* 7.8 7.7 10 6.8 7.0 7.0 14 8.4* 8.1 8.2 * Including re-examination cases. In the early days of the Act, if it became necessary to enforce attendance, proceedings were taken before a Court whose decision on the facts was final. A judgment of the High Court, however, based on the Elementary Education Administrative Provisions Act, 1909, (Section 6), was that a Magistrate was bound to act on the certificate signed by a duly qualified practitioner approved by the Board of Education to the effect that the child was defective, and that a Magistrate was not entitled to form his own opinion or question the child in the case where a decision was not disputed. Later the position changed somewhat: by the Education Act, 1918, re-enacted in the Education Act, 1921, it was laid down that in a case of doubt as to whether a child is or is not defective or epileptic the matter shall be determined by the Board of Education. The final word on standardisation is thus in the hands of the Board. Dr. Boome has standardised certain tests which have been suggested for use in the examination of alleged mentally defective children by their application to Mental testa. 138 children in the Winstanley Road and Cork Street schools. The tests concerned (1) the knowledge of the animal from which certain forms of meat are obtained,. and (2) the power of telling the time supposing the hands of the clock are reversed. With the "animal and meat" test the children were given small slips of paper with the numbers 1, 2 and 3 written on them. The children were then asked to write one answer and one answer only against such number. They were then told to "write down the name of the animal which gives us" 1. Beef. 2. Mutton. 3. Bacon. Each question was asked twice. With the "clock changed hands" test the children were asked to try and picture the clock. Some further explanation was given, then they were told to "fancy the time with the hands changed places." Again only one reply to each of the three times set was required, viz., 12-20, 1-10, and 10 to 10. The tables appended show the percentages of successes in the various classes and ages. Age. Number tested. Percentage number of children passed. Animal tests. Changed hands tests. Beef. Mutton. Bacon. 12—20.1—10. 10 to 10. Boys. 14 35 80 71 68 63 46 54 25 92 92 100 84 60 72 13 35 80 71 68 63 46 54 56 94 84 89 82 71 79 12 40 73 43 63 45 30 37 38 75 56 72 70 45 61 11 38 66 45 55 32 26 32 38 82 63 82 63 61 56 10 35 66 46 49 31 20 26 45 80 71 82 38 34 43 9 30 67 60 53 33 23 20 36 25 36 50 36 19 25 8 14 43 30 57 7 0 7 16 50 44 16 12 12 37 Girls. 14 7 100 42 71 100 28 71 13 47 85 j 46 74 78 42 70 12 39 74 43 79 76 56 58 11 33 78 36 75 72 54 60 10 44 70 40 70 54 45 52 9 28 64 17 78 53 28 46 8 30 36 2616 1 166 10 It is interesting to note that beef is the best known and that bacon is better known than mutton. The relation to age was not very close and suggests that the test is one only applicable to children of 13 years and over. The "changed hands" test showed a more distinct relation to age, but the results indicate that it could only be employed for those at the end of the school period. Epilepsy. The school doctors are instructed to refer any well-marked cases ol epilepsy (especially those in which school attendance is interfered with) to the Head Office for consideration for a colony. The following report on seventy-three of the cases so referred has been made by Dr. Fairfield:— Returned to Day School (Elementary or M.D.) 25 Colony recommended 41 Consent given by parents 24 Consent refused by parents 17 (invalided) Unfit for Day School or Colony 7 (Too old, too young or deteriorating rapidly) 73 Admitted to Residential Colony in 1926 27 On waiting list December, 1926 17 139 Treatment. — No treatment, 12; private doctors, 10; hospitals, 46; not known, 5. In many of the cases the treatment was desultory, the child being taken to the doctor for a "bottle" when it has had a fit. A steady improvement is noted over previous years. Parents are beginning to understand the necessity for regular medical care in epilepsy and are less prone to rely on the child "growing out of the fits at seven or fourteen." No estimate could be formed of the efficacy of the treatment given, as these cases are ex hypothesi the failures of all methods. All except two were cases of idiopathic epilepsy. Conduct.—Fifteen out of seventy-three had reports of serious misconduct, either temporary or permanent. The records include two attempts to strangle younger brothers or sisters, persistent pilfering, attacks on adults with knives, dangerous spitefulness in school. Two factors are clearly at work in producing this situation. The first is the epileptic process itself, which is of the nature of a cerebral irritation and is notoriously apt to manifest itself in uncontrolled and impulsive actions. The mechanism is probably analogous to that which produces somewhat similar effects in encephalitis lethargica. In several cases in this series the misbehaviour is definitely associated with fits. G. P. came up with two reports. The one from a private doctor stated "has tried to strangle a girl with a noose and threw knives at people." Another from his teacher was uniformly laudatory—"the loveliest little boy in the school"—"quite a little gentleman"! G. P. turned out to be a quiet little fellow of eight whose life had been blameless except for this sudden outburst of violence and malice after a bad bout of fits. Another small terror of 6| was described as the "pest of the neighbourhood." His speciality was pelting the police with over-ripe oranges, pilfered from barrows— but he had also attempted to shave himself and the baby with his father's (nonsafety) razor. He, too, was docile and rational except when the fits were on him. The second factor making strongly for misconduct is lack of reasonable home discipline, which is very common in epileptic children. The parent is afraid to correct in any way, and the child learns to exploit its fits to attain its ends. Where school attendance is contra-indicated, the habits acquired in running the streets go to complete the deterioration of character. Examples of the grossly "spoilt" child are commonest among those who refuse colony treatment. Two children who had been for years out of school were thought at first to be either deaf or imbecile; it turned out they had simply learned to ignore the sound of the female voice. Another small boy had established a reign of terror over his family, his mother admitted he was bribed all day long to placate him. When his long-suffering father at last attempted to chastise him for ill-treating his sister, he ran to fetch a policeman, explaining to the astonished officer that he "had fits and must never be punished." The need of residential school care for such children is overwhelming. Heredity.—A return of the family incidence of epilepsy would need closer enquiry than it is possible to give in these cases. It was noted, however, that in the great majority of cases the history is negative as regards "fits." In only three instances did the parents admit the occurrence of fits in themselves after reaching adult life, and in only one case was the condition serious enough to interfere markedly with the daily work. The medical work of the special schools for the deaf is under the charge of Mr. Yearsley, whose report is summarised as follows:— Examinations at the County Hall.—There has been a great change in the work during the past year. The sittings have been 47, as against 24 during 1925, while the number of children examined was 763, as compared with 366 in 1925. The average number per sitting was 16.2 as against 15.2 in 1925. An analysis of the results of these examinations shows the change which has occurred in the nature Mr. Yearsley's report on deaf children. 140 of the work. In order that this may be the more apparent, the figures for the two years have been placed in parallel columns:— 1926. 1925. Fit for central school 4 4 Fit for elementary school 73 19 Fit for elementary school and treatment 53 Fit for elementary school front row190 88 Fit for elementary school front row and treatment 137 Fit for hard of hearing school 149 82 Fit for normal deaf school 68 87 Fit for defective deaf school 12 12 Fit for mentally defective school 18 13 Imbecile 2 4 Invalid 15 11 Advice given 42 45 763 366 It will be seen that the number of children seen in 1926 was nearly 400 more than in 1925, the reason being that a special endeavour was made to discover as far as possible the number of children affected more or less with deafness who were attending the elementary schools. A large percentage (59.9) of these were fit for an elementary school, either in their ordinary places or in the front row, with or without treatment in either case. A number of the cases fit for elementary school and treatment were cases of temporary deafness due to obstruction by wax. It will be noted that the percentage of children fit for deaf schools has fallen from about 27.0 to 10.5, while that of the hard of hearing has declined from 22.4 to 19.5. This is partly due to the greatly increased number of early deaf cases. Attention has, however, recently been drawn to the fact that the proportion between children passed for deaf and partially deaf schools has altered considerably during the past 16 years. The figures are as follows:— Between 1904 and 1909 the numbers passed as deaf were:— 1904 1905 1906 1907 1908 1909 32 60 114 129 96 93 Up to and including 1909 the figures include all degrees of deafness, and many of these would now be classed as partially deaf. The figures from 1910 to 1926 can be given separately for each class:— Tear. Deaf. Partially deaf. Tear. Deaf. Partially deaf. 191 125 41 1918 88 59 1911 120 9 1919 124 80 1912 111 34 1920 130 88 1913 148 84 1921 125 76 1914 122 60 1922 134 67 1915 135 62 1923 97 83 1916 83 67 1924 110 66 1917 95 66 1925 103 87 1926 68 135 The explanation of these figures is, perhaps, a little complex. In some ways it is more apparent than real. In the earlier years the attempts made to discover the partially deaf child were very limited, and hard of hearing schools were not opened all at once, but one by one and at varying intervals. The whole matter was, in a word, in an experimental stage, and consequently a number of children were sent to deaf schools who would probably now te judged to be more fit for hard of hearing classes. As time went on and the opportunities of studying the partially deaf child in contrast with his much more deaf or wholly deaf brother became greater, experience showed that the method of teaching in the hard of hearing centres, whereby teaching upon deaf lines was combined with practice among hearing children, was adapted to children much more deaf than was originally believed. Hence has arisen a tendency to pass children into hard of hearing classes who would 141 have been sent into deaf schools ten or twelve years ago. The advantage of this method appears to be two-fold, the children are educated more in a hearing environment and such as are found later to be too deaf for a hard of hearing class can be transferred to a deaf school without loss of special education, while it has the further advantage of being less costly. That the present treatment of ear, nose and throat conditions is vastly better than it was fifteen years ago is shown by the difference in the cases seen at the County Hall; but this is much more noticeable in the suppurative than in the non-suppurative diseases of the ear. In the latter there is grave necessity for improvement. Analysis of causes of deafness.—The number of hard of hearing, deaf and defective deaf children were 229. Of these 22 have been already seen and dealt with in former years, leaving 207 for analysis. These were as follows:— Boys. Girls. Totals. Congenital 24 12 36 Acquired 66 96 162 Doubtful 4 5 9 94 113 207 The doubtful cases—of which two were probably congenital, one was said to be due to the "shock of air-raids," and another (in a Russian child) to being "frightened by Bolsheviks"—may be discarded, leaving 198 to be dealt with. The congenital cases were 36 or 34.6 per cent. of all cases, and were made up as follows:— True hereditary deafness 4 Sporadic deaf birth 31 Aphasia 1 36 The family trees of the four cases of true hereditary deafness are in three instances examples of Mendelian inheritance, the recessive character breeding true. In the first two instances there is in each case a family history of deaf birth on both sides. In the third case a born deaf woman with a family history of deaf birth married a man whose deafness was acquired. 142 The following diagram shows the case of two brothers of a family with a history of deaf birth who were pure dominants; their marriages with normal women each resulted in deaf birth. The cases of sporadic deaf birth (31) and aphasia (1) presented no special points of interest. The deaf birth was arrived at by exclusion, and, in the absence of facilities for spcial tests, one can at present reach no further as to causation. The acquired cases, 162 in number, are as has been previously pointed out, of the greatest interest from the point of view of prevention. The following table gives details of these cases:— 1. Diseases of the nervous system— Meningitis— Boys. Girls. Totals. Epidemic cerebro-spinal 0 1 1 Measles 0 1 1 Traumatic 0 1 1 Causes not ascertained 2 1 3—6 2. Infectious diseases— Scarlet fever (suppuration) 4 5 9 Measles (suppuration) 2 2 4 „ (catarrhal) 4 3 7 „ (internal ear) 0 1 1 Diphtheria (suppuration) 0 4 4 ,, (catarrhal) 1 1 2 Pertussis (suppuration) 1 1 2 „ (catarrhal) 1 1 2 Influenza (catarrhal) 0 1 1— 32 3. Other infective diseases— Pneumonia (suppuration) 0 2 2 „ (catarrhal) 1 0 1 Congenital syphilis 1 6 7— 10 4. Primary ear diseases— Middle ear catarrh 18 38 56 „ suppuration 20 20 40 „ „ results of 7 6 13—109 5. Injury 4 1 5— 5 162 It is noteworthy that diseases of the nervous system account for only 3.8 per cent. of the acquired cases, a very great diminution, more apparent than real and probably due to the increased number of middle ear cases called up for examination. One case only was attributable to "spotted fever," a notable diminution, bearing out the remarks in last year's report concerning this disease. In 50 per cent. of the cases of meningitis there was no clue as to its causation. Of the infectious diseases there were 32 cases, or 19.8 per cent. of all acquired cases, as against 16.8 per cent. in 1925. As usual, the chief items are, in order of frequency, measles (37.5 per cent.), scarlet fever (28.1), diphtheria (18.7) and whooping cough (12.5). The preventabilitv of deafness in these cases is again well demonstrated. In 19 the deafness was due to suppuration, in 12 to catarrh. In the former the mastoid operation had been required four times on the right, once on the left, 143 and in five cases on both sides. In one case only was the deafness due to internal ear complications. Other infective diseases are represented chiefly by congenital syphilis, of which there were 7 cases, or 4.3 per cent. of all acquired cases. This is practically the same proportion as in 1925. Three cases of deafness due to pneumonia (two suppurative, one catarrhal), all preventable, are included in this section. The great majority of the cases in the partially deaf schools is drawn from these cases, included under the heading of primary ear diseases, the remainder coming from the infectious diseases class. They are, this year, all cases of chronic middle ear catarrh and chronic middle ear suppuration or its results. They numbered 114 in all, or 70.3 per cent. of all acquired cases. The cases of middle ear catarrh were 56, in which no less than 49 had undergone operation for tonsils and adenoids, some more than once. The cases of deafness due to middle ear suppuration or its results were 53, the number having had tonsils and adenoids removed being 19. In many the suppuration had begun in early life and the original cause could not be ascertained with certainty. In all probability, however, it had commenced in the course of an inflammation of the upper air passages. In one case it followed an operation for cleft palate. The mastoid operation had been performed 14 times, on one side in 9, on both sides in 5. Nine cases of deafness due to injury (5.5 per cent. of all acquired cases) were seen. In each instance the deafness followed a fall on the head. During the year under review the whole question of the cause of blindness, and the measures for prevention and treatment available, were considered in the light of the powers afforded in areas other than London by the Public Health Act, 1925. The most recent authoritative statement on the causes of blindness was contained in the report of the Departmental Committee of the Ministry of Health, many of the data of which were supplied by the Council's Ophthalmic Consultant. Causes of blindness and means for prevention. Age of incidence of the onset of blindness.—The following table contains the age of incidence of the onset of blindness:— Age. Per cent. Age. Per cent. Age. Per cent. 0—1 21.4 20—30 9.7 50—60 9.5 1—10 10.8 30—40 9.7 60—70 9.6 10—20 94 40—50 11.0 70 6.4 Apart from the initial crop the incidence appears to be fairly steady throughout life. Causes of Blindness.—These may be classified into six groups: Congenital defects; Inflammatory conditions of the surface of the eye; Inflammations inside the eye; Accidents, chiefly industrial; Myopia; Senile changes. These vary in their incidence at different age periods while the possible measures for prevention are also varied in character. The chief factors which lead to blindness are:— (1) Before the school age, congenital defects and ophthalmia neonatorum. (2) During the years of school life, inflammations, as a result of congenital syphilis, play a large part, as do some of the surface inflammations which are not connected with veneral disease, while myopia begins to be an effective agent. (3) In adult and middle life, accidents assume a prominent part in the causation of blindness, lesions resulting either from congenital or acquired syphilis continue to be important factors, while the loss of vision due to the secondary changes in the eyes of high myopes has usually made itself known by the end of this period. (4) After fifty, glaucoma and cataract which may be looked upon as largely senile conditions are the most important factors. Methods of prevention.—Under these must be considered both the prevention of the morbid condition responsible for the damage to the eye and the prevention, 14172 K 144 if possible, of actual blindness in the event of the eye becoming diseased. This latter consideration naturally overlaps with that of treatment. The various factors are considered in the above-mentioned order. Congenital defects.—Such conditions as imperfect eyes, congenital cataracts, dislocation of the lens, absence of the iris (the coloured part of the eye) or albinism are responsible for much visual defect and have been noted in some 20-30 per cent. of the children who have attended schools for the blind in different parts of the country. In some cases the defects tend to recur in families. No preventive measures for these conditions are known. At the most it can only be urged that in the case of familial defects the marriage of those affected should be discouraged. In a eugenic campaign, which is the only method at present available, education plays the main part. There is, however, little evidence that such conditions occur with greater frequency in any particular class of the community. Inflammatory conditions of the surface of the eye. The chief causes of this are— Ophthalmia neonatorum; purulent conjunctivitis of later years; phlyctenular (spring) keratitis; chronic inflammation of the eyelids and conjunctivas; trachoma. Ophthalmia neonatorum is probably the most serious of all the causes of blindness and is due to infection of the eyes by venereal discharges either at the course of birth or very shortly afterwards. The complete prevention of ophthalmia neonatorum would involve the prevention of gonorrhoea in the mother. Here education plays a part by encouraging higher standards. More directly, however, it may lead to the attendance of the mother at the ante-natal clinics of hospitals or welfare centres. In this event the existence of the condition would be ascertained in time to permit of such treatment, either at the ante-natal centre itself or at a clinic for venereal disease or by other means, as would greatly minimise the risks to the infant. The value of the ante-natal and welfare centres is impressed upon all students in the health courses in the Council's evening schools. Apart from this increased ante-natal care special care is taken to secure that all midwives appreciate the value of immediate attention to the eyes of new born infants and take all necessary measures recommended for this purpose. In this connection it may be noted that the Council has for many years arranged "refresher" classes at regular intervals for the further instruction of midwives in all districts of London. Ophthalmia neonatorum was made notifiable throughout England and Wales in 1914. Under the general order then made the disease was defined as "a purulent discharge from the eyes of an infant commencing within 21 days from the date of its birth." The order laid upon every certified midwife, who had reasonable cause to suspect that any child she was called upon to visit in her practice might be suffering from this condition, the duty of notifying the same to the medical officer of health of the local sanitary authority (in London, the borough council), unless the case had already been notified by a medical practitioner. Under the rules of the Central Midwives Board every midwife who attends an infant with any inflammation or discharge from the eyes, however slight, is required to obtain medical aid and to report to the local supervising authority (in London, the County Council) that she has so done. Owing to the duty of notification to the local sanitary authority being placed on two parties and the possibility of oversight resulting from either party thinking the other had carried out the duty, the Ministry of Health have under consideration a modification which would relieve the midwife from the obligation to notify under the regulations. That duty would then rest solely on the medical practitioner called in. The arrangements made by the Council, as the supervising authority, provide that on the receipt of a notice from a midwife that an infant has inflammation or discharge from its eyes, however slight, the home is visited by an assistant medical officer who assures herself that the child is under adequate medical care, and 145 wherever it seems necessary endeavours to secure its transfer to St. Margaret's Hospital, Leighton Road, which has been rendered available for opthhalmic cases under the arrangements between the Council and the Metropolitan Asylums Board which manages that institution. During 1925, 1,349 cases of inflammation of the eyes in infants attended by midwives were dealt with, of which 422 proved to be ophthalmia neonatorum. Of these cases 398 were completely cured, 14 died, impairment of the vision in both eyes occurred in one case, and of one eye in 3 cases, while in 6 the patients removed and the after results could not be traced. 65 cases received in-patient treatment at St. Margaret's Hospital. The Council's consulting ophthalmologist has pointed out the value of the methods introduced in recent years, for whereas in his first survey of the causes of blindness amongst the children attending the Council's schools for the blind the proportion ascribable to ophthalmia neonatorum exceeded 36 per cent., in his last survey the figure had fallen to 19 per cent. Purulent conjunctivitis of later years is due to a great variety of conditions, but for the most part cases follow attacks of the exanthemata, especially measles. The prevention of the conjunctivitis is therefore bound up with the prevention of the exanthemata themselves. Measles is no longer a notifiable disease, except in 10 metropolitan boroughs, but the arrangements made by the Council for the forwarding of information as to absences from school, due to this cause, to the medical officer of health of the borough and to the school medical officer have contributed to the control of this disease and its after effects. In periods of epidemic prevalence a limited number of beds are available at the fever hospitals of the Metropolitan Asylums Board, while there are schemes whereby in each borough nursing assistance may be available in the homes of the children where needed. Apart from cases occurring during the acute and infectious stages of the exanthemata the Council's scheme for medical inspection and treatment secures that any children attending school who have discharging eyes can be at once referred for treatment at treatment centres or hospitals. Phlyctenular conjunctivitis and blepharitis do not lend themselves to active preventive measures other than those which tend to raise the general standard of nutrition and cleanliness. Once the conditions have arisen children are referred for treatment at clinics, hospitals or minor ailment centres. There are arrangements whereby special cases are seen by the Council's ophthalmic consultant. By arrangement with the Metropolitan Asylums Board children in need of longer residential care are sent on the certificate of the Council's medical officer to Swanley, where they remain until relieved. In certain cases this may involve residence for prolonged periods. If necessary, a child may be sent more than once. This arrangement is. most effective and is being increasingly utilised by the hospital authorities of London. These disorders lead more often to impaired vision than to actual blindness. With regard to the cases treated at minor ailment centres to which allusion is made in the preceding paragraphs, it may be added that of the 88,000 cases dealt with at these centres during 1925, a large proportion were slight ailments of the eyes such as blepharitis, etc. Trachoma, an acute infection of the eye, conveyed by contagion, is one of the chief causes of blindness in some countries, but has in this country now become relatively rare, though it occurs in little epidemics after importation from without London, usually, it is believed, from the Continent. Children suffering therefrom are promptly admitted on the certificate of the Council's medical officer to the Metropolitan Asylums Board's institution at Swanley. Cases are usually detected! through the school inspection and treatment centres. Greater difficulties arise in the case of adults who may not seek treatment for some time, although they may be in an infectious state, of which the sufferer is probably unaware. Between 1903 and 1920 the proportion of trachoma cases among poor law children admitted 14172 k 2 146 to the Metropolitan Asylums Board's institution fell from 47 per cent. to 17 per cent. Since trachoma is usually introduced from abroad, the departmental committee pointed out that the first line of defence is in the examination of aliens at the ports, where there is, however, the difficulty of the absence of power to check the landing of affected transmigrants. Inflammations within the eye.—Of the causes of these conditions syphilis undoubtedly takes the leading place. Estimates have been made by different ophthalmic surgeons which show that it is responsible for some 30 per cent. of the cases of blindness in children and for between 7 per cent. and 15 per cent. of the cases of blindness in adults. The main line of attack is clearly that of the prevention of veneral disease in general. Once the disease has been acquired prompt treatment is the only preventive of the sequelæ. So far as children are concerned, it should be remembered that the existence of the congenital disease is first rendered evident by the occurrence of active manifestations when it is a matter of cure rather than of prevention. The great aim is to secure ante-natal treatment. This could be provided by close co-operation between the ante-natal centres and the V.D. clinics. At this stage treatment is most effective and usually cures the mother and protects the child. The scheme of the Council for the treatment of venereal disease provides all that is necessary, and the steady educational campaign which is being carried on simultaneously should effect, in time, a steady improvement. One of the sources of trouble, though a diminishing one, is the relinquishing of treatment by the patients before they are discharged as cured and by their failure to return at intervals for observation. So far as school children are concerned the scheme of medical inspection and treatment affords the opportunity of treatment for all affected at the V.D. clinics, etc., while once a child has been taken to a clinic the officers thereat use every effort to secure the examination of the whole family. Accidents.—The majority of these are of an industrial character, though London is not an area in which such conditions bulk largely towards the quota of the blind. The prevention of industrial blindness depends in the main upon the adoption of suitable precautions in the factories, a matter which is in the hands of the factories department of the Home Office. Myopia.—This is a congenital condition which is responsible for much defective vision. During early life the condition may increase in most individuals, but only to a harmless extent. In a certain number, however, it may increase rapidly and seriously. This increase is accompanied by a stretching of the coats of the eye which proceeds unevenly, so that in time the inner coat, which is the actual seat of the first of the processes which result in vision, may become detached with resulting blindness. This condition is known as detachment of the retina. When the eye is squeezed continuously, as it is in the convergence of the eye which accompanies looking at any object which is held close to the eye, it tends to elongate, and if for any reason the coats of the eye are soft this stretching may be extreme. The shortsighted naturally tend to hold objects close to their eyes and so have to converge the eyes to secure binocular vision. They thus increase the pressure and so tend to increase the stretching. The coats of the eye yield more readily in certain persons in early life so that at this time the risk of close work is greatest. Unfortunately the closest work done by a child is in such occupation as reading, writing and sewing, which form the largest part of the school curriculum. Hence the need for special educational methods for those who suffer from marked and progressive short sight. This has been fully recognised in London and the Council provides special sight saving (myope) schools for the purpose. The arrangements for detecting such children at medical inspections are elaborate and whenever a need for special care is evident, the children are examined by the Council's ophthalmic consultant who decides whether their transfer to the myope classes is needed. These arrangements have proved 147 very successful, and have been copied in many parts of the world. The aim is to tide the children over the dangerous period of early life and to discourage them from close work with their eyes. Should vision fail, despite these precautions, the children may be transferred for training with the blind. Senile conditions.—Insufficient is known as to the primary causes of these conditions to allow of their being included in the category of preventable disease. The greatest danger is the insidious nature of their onset which leads to delayed application for treatment. Facilities for the treatment of diseases and injuries to the eyes.—London is peculiarly well equipped in this connection. There are five large special ophthalmic hospitals as well as organised ophthalmic departments in all the large general and and children's hospitals. For purposes of refractions and for the treatment of minor ailments of the surface of the eye and the eyelids the Council has arranged for treatment centres. Special arrangements exist for the provision of glasses for children through the care committee organisation. In the case of adults who attend hospitals, there are, in most, if not all hospitals, arrangements whereby certain firms of opticians supply the glasses prescribed at reduced rates and assistance is given from time to time through various funds administered by the hospital almoners and others. The facilities for the prevention of blindness already in operation in the County of London, fulfil practically all the arrangements which would be likely to be available in any area in which a local authority adopted Section 66 of the Public Health Act, 1925. It would appear that the weak points affect adults rather than children, and are concerned not so much with any lack of facilities for treatment as with delay in their use owing to lack of appreciation of the gravity of the condition. The failure may be on the part of the patient, more rarely on the part of others. The most important element consists in education in the direction seeking advice whenever needed. In this respect London is relatively well situated. Myopes in secondary schools.—In the annual report for the year 1925 it was stated that the Council had decided that pupils who were successful in ordinary scholarship examinations, but who were discovered by the school medical authority to be suffering from myopia to a marked degree, should hold the awards at specially selected schools where arrangements were made on lines parallel to those which had proved successful in myopic and sight-saving classes in the elementary schools. It was also decided that where the school was more than 2 miles from the pupil's address an allowance should be made for travelling expenses over and above the ordinary maintenance grant. This is a very important advance in its practice of school hygiene. Hitherto, there has been no alternative in many cases other than to refuse an award on account of the pupil's unfitness from a medical point of view, and many bright pupils have thus been deprived of the advantages of secondary education. During the year arrangements have been made for female pupils to attend special sight-saving classes at the County Secondary Schools at Peckham and Clapton, and the subjoined statement has been prepared for the guidance of teachers in charge of classes. It has not yet been possible to form classes for male pupils but the matter is under consideration. Myopes in secondary schools. General.—(1) Myopes have frail eyes, overstretched and, therefore, weakened, and much care should be taken in their use, particularly during the period of growth. (2) Such children should not read or write for more than half an hour at a stretch, and the total time the eyes are so used should not exceed an hour and a half a day, and between each of the half-hour periods there should be an interval of at least an hour. (3) Homework and sewing are prohibited. (4) Myopes should not be allowed to stoop over their work nor to hold it close Statement for the guidance of teachers in charge of myope classes. 148 to their eyes, but should be encouraged to sit erect with their books propped up before them. The print should be large and distinct. Their writing must be done at arm's length. (5) The children must not work facing the light, which should always fall from the left side. When daylight is poor, blackboard work and handwork must be suspended, except such as can be done w:th the eyes shut. No reading or handwork may be done by artificial light. (6) The cultivation of thought and memory is of prime importance to these children. They should be helped to strengthen "association" memory, e.g., by mnemonics, and should be encouraged to invent mnemonics for themselves. (7) Since reading for long at a time is dangerous, and reading by artificial light more so, and since the temptation to read at home is severe, the school must cooperate with the home in providing interests and occupations for the hours of artificial light, e.g., knitting with the eyes shut, learning tunes, etc., from the gramophone, making relief maps on browD paper with plasticene or paste, gardening, being read to, "listening-in." (8) Frowning is a sign of strain. Any child noticed to be frowning should be told to close its eyes and rest a few moments. (9) It is essential that parents and friends of short-sighted children (and the children themselves) should be instructed that a secondary school regime is not for these children a step to a subsequent career of clerical or sedentary work, or any work requiring habitual close application, for such work is injurious to short-sighted eyes and risks serious breakdown. Particular.—(1) Physical exercises for myopes may include all those taught to normal children except such exercises as involve the body being fully bent downwards and forwards. All drill and dancing may be taught, but no jumping on both feet should be allowed. Skipping may be practised when this is done with regular alternation of the feet: skipping with both feet together must not be done. Swimming may be allowed, but not diving. Ball games may be played with a soft ball, but not in the company with normal children unless specially permitted by the school doctor: it must be remembered the short-sighted children see slowly, and so are handicapped and run an extra risk. Sufficient exercise should be taken to keep up the bodily health, but overstrain, such as may be involved in competitions, reacts injuriously upon the short-sighted eye and should be avoided. (2) Reading.—Books with small print should not be used. The book should be held at least 15 in. from the eyes, and at an angle of about 15° from the perpendicular. It should never be horizontal. For continuous reading or reference it should be placed on the special book-rest provided. Unblinking fixity of the eyes must be avoided, and rapid and frequent blinking encouraged. (3) Writing.—All writing should be done at arm's length, on the blackboard provided or paper pinned thereon. The letters must be 1 in. without tails, and the chalk marks must be thick and heavy, not spider lines. The blackboards should be used when the rest of the class are using rough note-books, class-work paper or doing any written work which is not for permanent record. The half-hour limit must be strictly observed, and it must be remembered that worry is to be avoided. Children who are bothered by the work in hand should be specially helped. In all written work neatness is of trime importance as an aid to clear seeing. A limited amount of written work may be done for correction, and is to be kept in portfolios. Probably two portfolios (large size) will be enough for each child, one for English, French and history, the other tor mathematics, science and geography. The size of the writing must be not less than ½ in. including the tails 149 of the letters, the sheet of paper must be pinned to the blackboard (not put on a table surface) and the writing done at arm's length. The limit is set by the 1½ hour total for reading and writing, and the best apportionment of the time in each dav will be arrived at after consultation between the mistresses teaching the Forms concerned. (4) Preparation periods and homework.—In some of the preparation periods these children will have special poetry lessons. In others where the work is not writing, the quick learners amongst the normal-sighted should be allowed to teach the lesson sotto voce to the short-sighted, working in couples. It is hoped that those at home will undertake a certain amount of such teaching, e.g., the scripture verses and poetry, by repetition; some history and geography, by reading through. (5) In ordinary lessons these children should be encouraged to listen with their eyes closed; they should have frequent questions to prevent their falling asleep. (6) In science lessons they may momentarily read the markings on glass cylinders, thermometers, balances, etc. If this is found difficult the short-sighted child must rely on its partner's readings. In botany no effort should be made to see nectaries or small structures, but large diagrams should be consulted and the children encouraged to exercise the imagination necessary to visualise details in their true proportion. (7) In singing lessons, the ruled music boards should be used for tests instead of manuscript books. As the word books may not be used, myopic children will have to sing to "la" except in so far as they pick up the words. (8) In handwork a beginning should be made with knitting. Girls who are accurate knitters should be set to produce as many garments as they can, gradually increasing their power of knitting without looking. Beginners must practice at once to obtain accuracy without looking. Wool rug work on canvas, raffia and cane work, netting and weaving are all suitable, and in them all the habit of feeling the process rather than seeing it should be cultivated. (9) In drawing plant form can be copied in brush work. Perspective and large groups can be done in charcoal on white paper or in white chalk on brown paper. Design with measuring should be attempted only on blackboard scale. The ordinary art desk is unsuitable. Careful enquiries have been made as to the most suitable occupations for children suffering from marked myopia, and the following suggestions are offered for the guidance of those concerned. The occupations are in two grades, the first selection (A) is mainly of the outdoor type, enabling the worker to be standing and moving—the general health is likely to be better for the freedom of movement enjoyed and with the improvement of general health the state of the eyes is likely to be benefited. The second selection (B) involves sitting and stooping to some extent and is therefore not so good for the body and the eyes. Occupations for myopes Boys. A. B. Nursery gardening Stick and pipe mounting. Messengers. Pipe makers. Insurance agents. Some branches brush making. Rent collectors. Basket making. Piano tuners. Artificial flower making. Poultry farming. Confectionery. Hawking or street trading. Boot mending. Travellers or canvassers. Metal punching. Shopwork under good conditions. Upholstery. Wire workerg (bird cages, etc.). Coffin making. Hotel and club servants (no lifting). Builder's merchant. Chemical soap and candle factories (wrappers Ironmonger. and packets). Tobacco stopping and cigar making. 150 Boys. A. B. Skin dressing and tanning. Veterinary assistants, zoo keepers. Animal Social and welfare workers (N.S.P.C.C., care and breeding. R.S.P.C.A., Y.M.C.A., etc.). Machine minders (layers-on in printing). School attendance officers. Theatre attendants, liftmen and door porters. Telephone operators (private firms). French polishers. Girls. A. B. Florists' work. Box making. Waitresses and stillroom workers. Envelope folding. Dairy shops. Show card mounting. Under nursemaids (no sewing). Some branches brush making. Light warehouse work (packing). Cork sorting. Helpers at schools for mothers. Cementing and black bordering. Helpers at special schools and dining centres. Stockroom work. Domestic service (place carefully selected). Artificial flower making. Hotel and club servants (no lifting). Fancy paper workers. Social and welfare workers (Y.W.C.A., Stationery trade. N.S.P.C.C., R.S.P.C.A., etc.). Cigar making and tobacco stripping. Telephone operators (private firms). Upholstery. Chemical soap and candle factories (wrappers Confectionery. and packers). Knitting factory. Skin dressing and tanning. Metal punching. Wire mattress weaving. Pipe makers and mounters. French polishing. Machine minders (layers-on in printing). Return for year ended December 31st, 1926, of the after careers of children formerly attending special schools for the mentally defective, apart from those whose names have been forwarded to the Local Control Authority for action under the Mental Deficiency Act, 1913. M. F. Total. 1. Number of children born in or subsequent to 1908, who have left special (mentally defective) schools and who have been on the books of the association as "after-care" cases 568 488 1,056 2. Number of these who— (а) Have since died 5 1 6 (b) Are known to be incapable by reason of mental or physical defect of undertaking employment 27 35 62 (c) Have been subsequently dealt with under M.D. Act 14 12 26 3. Number employed in— (а) Industrial or manual occupations (i.e., factory work, and trade or part of a trade) 307 198 505 (b) Agricultural or rural occupations 7 — 7 (c) Domestic occupations (i.e., servants sleeping in or out, lift boys and those " helping at home" 22 164 186 (d) Commercial (i.e., shop assistants or selling behind a counter), professional (or Army and Navy), clerical (office boys and girls) 9 5 14 (e) Blind alley or other precarious occupations (i.e.. van boys, newsboys, eirand boys or girls selling from a barrow) 86 3 89 4. Judged to be employable but out of work 76 52 128 5. Not seen either at home or employment centre, and position not known 4 7 11 6. Number whose careers have not been traced or who have left the neighbourhood 7 7 14 7. No action possible 4 4 8 568 488 1.056 After careers of children formerly attending special schools. After careers of children formerly attending special schools for the blind, deaf and crippled children (data furnished by the After Care Association for blind, deaf and crippled children), for the year ended 31st March, 1926. 151 Placed by the Association. Placed by other means. Total. Blind. Deaf. Crippled. Wind. Deaf. Crippled. 1. (a) Industrial or normal occupations 1 87 366 1 57 422 934 (6) Domestic 0 0 20 1 0 109 130 (c) Commercial 0 2 0 2 8 65 77 (d) Blind Alley 0 0 8 0 4 95 107 Total 1 89 394 4 69 691 1,248 2 (a) Who have died since Blind. Deaf. Crippled. Total. 1 23 24 (b) Are known to be incapable by reason of mental or physical defect of undertaking employment. 1 9 113 123 (c) Are in attendance at an institution for further education and training. 5 9 45 63 3. Who have left London and cannot be traced — — 2 2 4. Whose applications have been withdrawn, who refused openings or were unsatisfactory. 2 2 41 45 5. Not yet placed 3 6 66 75 Total 11 27 294 332 Examinations of employees in the Education Service and Scholars. The following table shows the number of persons who submitted themselves for examination during the year. These comprise entrants to the permanent service and candidates for the award of scholarships. Status. Number examined. Number fit. Number rejected. Number who withdrew after being referred for remediable defects or who were not due for reexamination until after the end of the vear. Male. Female. Male. | Female. Male. Female. Male. Female. Permanent service 438 648 421 622 8 5 9 21 Teaching Awards 301 928 251 848 41 21 9 59 Scholarships : Myopes 7 18 6 18 1 - - - Others 2,443 2,127 2,374 2,095 56 20 13 12 3,189 3,721 3,052 3,583 106 46 31 92 6,910 6,6 35 152 123 The causes of rejection were mainly defects of vision, unsatisfactory general health and morbid conditions of heart. The total number of examinations was 8,194. some of the candidates having been referred for one or more remediable defects. There are also referred to the public health department special cases in which medical advice is required. Particulars in regard to these cases are set out in the annual report of last year. The number of cases dealt with was 3,242. The major part of these was teachers of whom 525 were men and 2,310 women. In connection with sick leave 65 per cent, of the teachers were over 40 years of age ; this figure is an increase of 3 per cent, on that of the previous year. The report of last year contained the results of a preliminary survey of the infirmities which had led to a premature termination of the teacher's career, either by death or disablement. Continuing this survey special attention has been paid to those suffering from tuberculosis. During the five vears extending from the 1st Cases specially referred. Health ot teachers. 152 April, 1921, to the 31st March, 1926, there were 115 new cases of pulmonary tuberculosis (viz., 45 males and 70 females), the after-history of which may be outlined as follows:— Returned to duty 54 Appointments lapsed or resigned 30 Died 16 Still current at the end of the year 15 In these cases the length of service prior to the appearance of the illness was noted and arranged in five year intervals, viz.:— Tears of No. of Years of No of service. cases. service. cases. 1 to 5 years 40 20 to 25 years 10 5 to 10 21 25 to 30 3 10 to 15 20 30 to 35 3 15 to 20 16 35 to 40 2 The maximum number of cases fell in the second year of service. Analysing the 40 cases (12 male and 28 female) that occurred within five years of entering the service it was found that 20 were Londoners and 18 came from the country and the provinces, whilst the particulars of locality of birth and residence of the two remaining cases had not been recorded. From this it will be seen that the proportion is about equally divided and does not differ materially from that found among teachers in general. The greater frequency in the early years is also in agreement with the fact that the maximum incidence of the disease in the general population falls in the decade 20 to 30. One important factor in the case of the male teachers is the fact hat practically all had had war service The subjoined table shows in percentages the results from the early age group compared with those of the subsequent groups:— After-history. Date of onset. Early group (within 5 years). Other groups (from 5 years to 40 years). Resumed 55 42 Lapsed or resigned 25 27 Died 12.5 15 Current at end 7.5 16 During the year all applicants for the admission to the Council's Course of physical education were examined, the number being 508, an addition of 206 or 68 per cent, on the previous year. Of this number 55 were rejected. The arrangements made in 1922, whereby medical aid could be given in the event of cases of accident or sudden illness at the County Hall were continued in 1926 and aid was rendered and advice given in 313 cases. Generally the cases were of a minor character, but of the 45 cases of injury 8 were serious, being due to the fall of workmen from a scaffold erected in the ceremonial staircase for the purpose of renovations. Special enquiries. The available time for special enquiries has this year largely been taken up in giving assistance in the researches initiated by the Special Committees of the Board of Education. Doctors Parson, Kindness, Mcllroy and Brander have assisted in the enquiries of the Vision Committee, while Doctors Boome, Ingham and Nairn Dobbie have helped with the enquiries of the Anthropometric Committee. Details of other special enquiries made during the year are found under the appropriate headings in this report, amongst them are to be mentioned Dr. Dobbie's enquiries into school cleansing (p. 67) and into the effect of swimming contests on the circulation (p. 108), and Dr. Thomas' enquiry into the after-history of pupils at open air schools (p. 102). In last year's annual report, an account of the condition of canal boat children was given by Dr. Mabel Russell. Some further notes on the progress of these Physical education of teachers. Accidents and sudden illness at County Hall. 153 children, compiled by Dr. Russell, are reproduced here. Dr. Chaikin also contributes some notes upon the "Lupus" class in connection with the London Hospital. The number of canal boat children now upon the report of the barge class is 104, a notable increase during the year. Gentle and tactful handling has increased the confidence of the parents and no doubt is leading to the establishment of more civilised conditions. It has even been possible to induce some of the parents to be present at the medical inspections. This was accomplished by special efforts by the teaching staff, who visited the wharf in person, printed invitations having proved quite useless owing to the illiteracy of the people. Whereas in the case of asthma and bronchitis medical treatment is required for the children over a period of some months great difficulties arise, as although wbile the boat is moored at Paddington wharf hospital attendance can be secured, so soon as the boat starts on its voyage treatment is interrupted and may not be recommenced for from 4 to 6 months. In February the Council's sanction was received for a daily visitation to the class by the school nurse to carry out the treatment of minor ailments. 471 dressings have been carried out by the nurse. The nurse's greatest difficulty was to establish a sufficient degree of cleanliness of the parts affected in order to see what was wrong before dressing it. Kettles of hot water and small pails were obtained in which the children steeped their affected limbs or other parts until clean. Amongst the conditions mentioned were dog bites and especially septic places behind the knees due to the friction of the towing rope. Striving after cleanliness in this way has brought home to the children and their parents the need for personal hygiene and indeed there is a marked improvement in this direction. The children have become more humanised and the girls now come to school in tidy overalls and the boys even try to wear a collar, and all brush their hair. Vermin still give trouble, but the nurse has persuaded 12 children to go with her to the cleansing station and one or two mothers have come to the school and asked to be allowed to take their children voluntarily to the station, so that is a distinct advance. After much visiting and persuasion 16 children have attended a dental centre, and we now have about 20 children cleaning their teeth regularly. This is really rather wonderful because they had never even heard of such a thing as a tooth brush before. Of 31 entrants to the class medically examined 4 were suffering from debility, one from epilepsy, one from tonsils and adenoids, one from congenital eye defect and one from otorrhea. A dental inspection was held during the year with the results already detailed. The results of the medical work are on the whole very satisfactory; both teachers and nurse have worked with a will and they have gained the confidence of the parents, a big step with these somewhat primitive people, who are timid of interference and would be quick to resent it. Lupus vulgaris, or what is commonly called "lupus," is an afEection of the skin, caused by the tubercle bacillus, its usual onset being in childhood, very often attacking one cheek, although not limiting itself to the face, and sometimes selecting covered parts, in which case it is liable to spread considerably before attracting attention. Starting with what looks like a pimple, which does not disappear but persists with some scarring round it, when pressed with and seen through transparent glass (diascopy) it reveals the presence of parts having the colour of "apple-jelly" or "barley-sugar" "apple-jelly" nodules or "barleysugar" bodies of Sir Jonathan Hutchinson Ulceration and spread follow. It may extend into the nostrils and destroy the cartilage if near the nose, or may attack the orbit and eye if situated near. School Medical Inspection has done and can do a great service by early recognition of the disease and prompt recommendation for treatment—both Dr. Russell's report on canal boat children. Dr. Chaikin's report on the "lupus" class. 154. being essential to prevent spread, ulceration and disfigurement. School attendance is possible for slight cases under treatment, if the sore parts are dressed and covered with bandages, but where the disease is extensive and severe, exclusion becomes necessary. This is a guiding policy, but every case should be considered separately and in conjunction with the treating physician in regard to fitness or otherwise to attend ordinary school. Owing to the chronicity of the disease exclusion may be required for a long time. Several years ago there were, at the London Hospital in the Light Department, about twenty children undergoing treatment for lupus vulgaris, but unfit for school owing to the extent and severity of the disease, a number of whom had not attended for some years. There were, amongst them, children from different parts of the country, who had come specially to London for treatment and were boarded out by arrangements made by the Marie Celeste Society in connection with the London Hospital. They were not receiving education and were without the benefits of school teaching and social supervision. Dr. O'Donovan, under whose care the children were at the London Hospital, was anxious that a special class should be provided for them and brought the matter to the notice of Mr. Swann, with the result that a hospital class for children under treatment in the Light Department of the London Hospital and unfit for school was opened by the Council in April, 1925, in a portion of the premises once occupied by the Stepney Day Continuation School and placed under the headmastership of Mr. A. Sinclair, the Head Master of the Trafalgar Square school, and a class teacher, Miss Gilder. The Board of Education sanctioned the stay of pupils up to the age of sixteen. To fit in with arrangements for treatment at the London Hospital the girls attend in the forenoon and the boys in the afternoon. The educational attainments cf the children vary owing to their different ages, and the long periods of absence from school which have preceded their admission. Handwork enters largely into the curriculum. Mr. Sinclair reports that a total of 40 scholars have passed through since opening (18 boys and 22 girls) and the average time in the class per scholar is twelve months. When a child is suspended for a time from hospital treatment and returns home, a further attendance at the London Hospital is sometimes necessary and resumption at school. In any case the children leave at 16 years. The school has been a means of providing some education and social supervision for the children who, through absence from school for years, have been deprived of both. Their homes are as far distant as Harringay and Weymouth and the Isle of Wight and Bury St. Edmunds, and though they were boarded out in London and attended hospital half a day no school could receive them. They are medically inspected at school every term and treatment recommended if necessary. Medical inspection revealed a certain number with malnutrition, dental caries, tonsils and adenoids, and defective vision. Having regard to the sore condition of their skin a separate towel is provided for each child. The school is performing very necessary work, and though the number of children is small, the value of the school cannot be measured by the numbers, and there will be need for it as long as there are severe and extensive cases of lupus. 155 TABLE I. Medical Inspections, 1926. (a) ROUTINE INSPECTIONS. (6) OTHER INSPECTIONS. Age group. Boys. Girls. Total. Boys. Girls. Total. Entrants 37,526 37,422 74,948 (1) 19,873 18,880 38,753 Age 8 22,253 21,942 44,195 (2) 22,544 20,278 42,822 Age 12 32,591 31,962 64,553 Re-inspections — —. 191,182 Leavers 31,301 31,798 63,099 Total— Elementary schools Special Schools 123,671 1,127 123,124 898 246,795 2,025 * (1) Special cases where individual notes are made. (2) Cases seen en masse where individual notes are not made unless noted for treatment or observation, e.g., camp school nominations, school journey children, etc. (infectious disease contacts are not included in this figure). TABLE II. (a) Defects found at Medical Inspections in 1926. ELEMENTARY AND SPECIAL SCHOOLS. Disease or defect. Routine inspections. Defects. Special inspections. Defects. Requiring treatment. Requiring observation. Requiring treatment. Requiring observation only. E.S. S.S. E.s. s.s. Malnutrition 829 13 1,026 4 457 396 Skin— Ringworm—Head 11 — — — 51 22 Body 47 1 1 — 47 7 Scabies 102 — 2 — 237 77 Impetigo 380 1 7 — 484 26 Other disease (non-tubercular) 1,082 6 131 — 837 123 Eye— Blepharitis 1,026 7 80 1 327 28 Conjunctivitis 331 4 16 —. 324 36 Keratitis 5 — — — 24 4 Corneal opacities 21 1 5 — 79 17 Defective vision (excluding squint) 19,838 170 5,562 86 3,430 369 Squint 1,509 15 450 — 515 51 Other conditions 264 3 59 _ 201 27 Ear— Defective hearing 481 14 273 4 436 286 Otitis media 2,070 24 654 4 1,016 251 Other ear disease or defect 764 5 234 1 337 59 Nose and throat— Enlarged tonsils 8,098 42 7,340 18 2,173 548 Adenoids 1,266 11 679 2 580 67 Enlarged tonsils and adenoids 2,558 14 583 1 675 61 Other conditions 1,295 3 414 4 531 154 Enlarged cervical glands (non-tubercular) 756 6 2,298 4 251 286 Defective speech 113 1 195 _ 112 58 Teeth, dental disease 71,938 446 1,061 — 4,817 176 Heart and circulation— Heart disease—Organic 57 1 171 1 4 1 Functional 24 — 352 4 1 4 Not stated 184 I 3,928 21 429 902 Anæmia 1,429 14 1,146 3 1,254 452 Lungs- Bronchitis 1,428 7 1,629 1 540 214 Other non-tubercular 257 2 941 6 271 344 156 Disease or delect. Routine inspections. Defects. Special inspections. Delects. Requiriug treatment. E.S. S.S . Requiring observation. E.S. S.S. Requiring treatment. Requiring observation only Tuberculosis— Pulmonary—Definite 7 — 9 — 36 7 Suspected 40 — 42 — 59 142 Non-pulmonary—Glands 17 — 28 — 42 28 Spine 2 — 1 — 6 2 Hip 1 — 1 — 11 6 Bones and joints 8 — 9 — 13 6 Skin 9 — 1 — 16 16 Other forms 16 — 8 — 20 19 Nervous— Epilepsy 47 — 51 1 186 128 Chorea 102 1 81 1 326 172 Paralysis 33 4 59 — 259 162 Other conditions 122 1 192 1 Deformities— Rickets 91 — 41 — 52 19 Spinal curvature 737 3 364 2 180 63 Other 442 1 352 — 161 47 Other conditions 3,037 14 1,260 6 3.659 1,331 (b) Children found at routine medical inspection to require treatment (Excluding Uncleanliness AND Dental disease). Age group. Inspected. Found to require treatment. Percentage requiring treatment. Entrants 74,948 12,975 17.3 Age 8 44,195 9,418 21.3 Age 12 64,553 14,018 21.7 Leavers (age 133/2) 63,099 11,112 17.6 Total Elementarv Schools 246,795 47,523 19.3 Total Special Schools 2,025 369 18.3 TABLE III. Exceptional Children in London in 1926. BLIND (including partially blind)—- Boys. Girls. Total. (i.) Suitable for training in a school or class for the totally blind Attending certified schools or classes for the blind 145 137 282 Attending public elementary schools — — At other institutions At no school or institution — — 8 9 17 (ii.) Suitable for training in a school or class for the partially blind Attending certified schools or classes for the partially blind 370 483 853 Attending public elementary schools 5 5 10 At other institutions At no school or institution — — 6 4 10 Deaf (including deaf and dumb and partially deaf)— (i.) Suitable for training in a school or class for the totally deaf or deaf and dumb Attending certified schools or classes for the deaf 339 302 641 Attending public elementary schools — — — At other institutions — — — At no school or institution 10 7 17 157 Deaf—continued. Boys. Girls. Total. (ii.) Suitable for training in a school or class for the partially deaf Attending certified schools or classes for the partially deaf 80 78 158 Attending public elementary schools 10 7 17 At other institutions — — — At no school or institution 2 2 4 Mentally defective. Feeble-minded (cases not notifiable to the Local Control Authorities) Attending certified schools for mentally defective children 3,503 2,685 6,191 Attending public elementary schools 6 5 11 *At other Institutions 333 211 544 At no school or institution 47 49 96 Notified to the Local Control Authority during the year Epileptics. Feeble-minded 53 90 143 Imbecile 76 51 127 Idiots 10 7 17 Suffering from severe epilepsy Attending certified special schools for epileptics In institutions other than certified special 57 37 94 schools 33 25 58 ††Attending public elementary schools 6 1 7 At no school or institution 94 106 200 Suffering from epilepsy which is not severe Attending public elementary schools— Ordinary 275 264 539 Special 64 52 116 At no school or institution — — — Physically defective. Infectious pulmonary and glandular tuberculosis *At sanatoria or sanatorium schools approved by the Ministry of Health or the Board 55 71 126 At certified day open-air schools 92 73 165 At other institutions 2 2 4 At no school or institution 18 14 32 Non-infectious but active pulmonary and glandular tuberculosis ♦At sanatoria or sanatorium schools approved by the Ministry of Health or the Board 73 133 206 At certified residential open-air schoolb — — — At certified day open-air schools 137 109 246 JAt public elementary schools 54 48 102 At other institutions 2 4 6 At no school or institution 9 7 16 Delicate children [e.g., pre- or latent tuberculosis, malnutrition, debility, anæmia,etc.) At certified residential open-air schools 3,194 1,445 4,639 At certified day open-air schools 712 506 1,218 At public elementary schools 3,911 3,888 7,799 *At other institutions 70 35 105 At no school or institution 177 190 367 Active non-pulmonary tuberculosis *At sanatoria or hospital schools approved by the Ministry of Health or the Board 418 336 754 (Note.—Cases of more or less quiescent tuberculosis attend the special day cripple schools) At public elementary schools 47 55 102 At other institutions 3 — 3 At no school or institution 18 13 31 Crippled children (other than those with active tuberculous disease), e.g., children suffering from paralysis, etc., and including those with severe heart disease At certified hospital schools 15 16 31 At certified residential cripple schools 27 17 34 At certified day cripple schools 2,044 2,040 4,084 At public elementary schools 1,040 1,352 2,392 *At other institutions 269 239 508 At no school or institution 252 399 651 * Some of these may have come to the notice of the school medical officer, but have been dealt with throughout by the Guardians. † Discovered at medical inspections and referred for treatment. †† Awaiting admission to Colony. ** These figures include about 1,000 children suffering from non-pulmonary [tuberculosis more or less quiescent, or from the after-effects of such disease. 158 TABLE IV. Defects treated during 1926. TREATMENT TABLE. Group I.—Minor Ailments (excluding uncleanliness, for which see Group V.). Disease or defect. Defects treated or under treatment. Under Council's scheme. Otherwise. Total. Skin. Ringworm—Head Ringworm—Body. Scabies 1,269 2,130 844* 525 l,369† Impetigo 861 Other skin diseases Eye disease. (External and other, but excluding cases falling in Group II.) 89,709 1,436 93,275 Ear disease. Cases in which operative treatment (e.g., mastoid operations, etc.) is given are excluded. Miscellaneous. (Minor injuries, brusies, sores, chilblains, etc.) 2,130 92,683 1,961 94.644 ** 761 by X-Ray. †871 by X-Ray. Group II.—Defective Vision and Squint (excluding eye defects treated as Minor Ailments, Group I.). Defect or disease. Defects dealt with. Under Council's scheme. Otherwise. Total. Errors of Refraction (including Squint, but excluding operations for Squint) Other defect or disease of the eyes (excluding those in Group I.). 35,985 2,000 (estimated) 1,687 39,672 Children for whom glasses were prescribed under Council's scheme ,, who obtained or received glasses under Council's scheme 26,718 23,593 Group III.—Treatment of Defects of Throat and Nose. Number of defects. Received operative treatment. Received other forms of treatment. Total number treated. Under Council's scheme. Private practitioner or hospital. Total. 11,550 1,615* 13,165 4,618 17,783 * 134 by private practitioners, 1,4.81 at hospitals. 159 Group IV.—Dental Defects. 1) Number of children who were— (a) Inspected by the Dentist—Age Groups— 5 years and under 8,075 11 years and under 39,954 6 ,, ,, 40,010 12 „ 9,130 7 „ „ 33,615 13 „ 11,445 8 „ „ 9,191 14 „ over 6,263 9 „ „ 34,958 10 „ „ 44,381 237,022 (6) Found to require treatment, 163,422 (68.95 per cent.). (c) Actually treated, 113,932 (including (d) ). (d) Re-treated as the result of periodical examination, 17,798. (2) Half-days devoted to—Inspection, 2,029. Treatment, 17,380—Total 19,409. (3) Attendances by children for treatment, 192,502. (4) Fillings—Permanent teeth, 72,512. Temporary ,, 30,395—Total 102,907. (5) Extractions—Permanent teeth, 49,201. Temporary „ 308,586—Total 357,787. (6) Administrations of general anæsthetics for extractions, 58,076. (7) Other operations—Permanent teeth Temporary }Total 26,319. Group V.—Cleanliness—1926. (а) Average number of visits per school made during year by school nurse, 6. (b) Examinations of children in the schools by school nurses, 1,840,106. (c) Instances of uncleanliness, 288,721. (d)Children cleansed under Council's arrangements, 101,389. (e) Cases in which legal proceedings were taken:— (i.) Under the Education Act (Section 87), 413. (ii.) Under the School attendance By-laws, Nil. 160 CHAPTER III. PUBLIC HEALTH. Tuberculosis. The responsibility in London for the public provision of treatment for tuberculosis rests on the Council, which in 1914 prepared a comprehensive scheme, revised in October, 1922.* Under this scheme the Council arranges for the provision of residential treatment required through a public authority (other than poor law guardians) and the metropolitan borough councils provide or arrange for the provision of dispensary treatment. Various particulars in regard to the work done under the scheme are given in Chapter I of this volume (pp. 18-27 and 34-42). In order to provide more residential accommodation for advanced cases of adults suffering from tuberculosis, the Metropolitan Asylums Board has reconditioned its institution at Grove-park, Lee, accommodating upwards of 300 patients, for the reception mainly of advanced cases of both sexes. The question of the dietary of patients receiving treatment under the Council's tuberculosis scheme in sanatoria and hospitals was investigated and the Council came to the conclusion that the dietary was adequate and satisfactory. The dispensary service was the subject of special survey in 1920†. Recommendations for the development of the service are made to the metropolitan borough councils from time to time by the Council with the approval of the Minister of Health. In consultation with the Minister of Health the Council has approved of arrangements in several cases during the year for the post-graduate instruction of tuberculosis officers and similar arrangements have been approved in principle for the provision of "refresher" courses for tuberculosis health visitors and nurses. Under the Council's scheme, the contributions received from parents or guardians towards the cost of the residential treatment of children were, up to 31st March, 1925, paid into a fund, known as the Tuberculosis Contributions Fund, which was applied towards the provision of institutional treatment in certain cases, the boarding out of children from homes infected with tuberculosis, and the provision of clothing, surgical appliances, etc., the Invalid Children's Aid Association undertaking the necessary arrangements. Since 1st April, 1925, in consequence of a decision of the Minister of Health, such contributions are credited to the county fund, and, as in the case of contributions in respect of adults, the total amount received, less certain deductions, is divided between the Council and the Metropolitan Asylums Board on the basis of accommodation provided. The institutional treatment formerly provided by the Association is now carried out through the Council's schcme, and the accumulated balance in the Fund is being applied towards defraying the cost of boarding out children in suitable cases in which the home or other conditions render this desirable and of supplying clothing and surgical appliances. The Invalid Children's Aid Association has continued to undertake these arrangements on the Council's behalf. Arrangements were made in consultation with the Ministry of Health, under which metropolitan borough councils are enabled in connection with the tuberculosis dispensary service to secure the treatment in suitable cases of persons suffering from tuberculosis, by artificial light in out-patient departments of approved hospitals and other centres. The scheme was approved for an experimental period of one year from 1st April, 1926, in the first instance. * Scheme for the treatment of tuberculosis in London. No. 2183. Price 4d. † Tuberculosis in London. Report of the Public Health Committee. 1st July, 1920. No. 2035. Price 6d. 161 The scheme for the diagnosis and treatment of venereal diseases in the county 1 provides for the participation of certain authorities near London in the facilities afforded by selected hospitals for the purpose. The arrangements for 1926 provide for free treatment and diagnosis for in-patients and out-patients at 27 hospitals and for the reception of patients for treatment at seven hostels. Special provision has been made for the treatment of pregnant women and very young children. Practitioners secure, at the cost of the Council, scientific reports for diagnosis purposes on materials obtained from patients suspected to be suffering from venereal disease, and approved practitioners may obtain, free of cost, salvarsan or its substitutes. The cost of diagnosis and treatment at hospitals and hostels is borne as to 75 per cent, by the Ministry of Health and as to the remaining 25 per cent, bv the Council and the participating authorities according to the user of the facilities available. The Council makes direct payments to hospitals for salvarsan or its substitutes supplied to medical practitioners in London. Details of cases treated in 1926 and preceding years are given in Chapter I, pp. 33-34. Veneroal disease. The Cuouncil's s venereal diseases scneme provines in general terms for lectures and addresses to selected audiences, and for the publication and dissemination of information. The British Social Hygiene Council exercises on behalf of the Council certain of its powers relating to propaganda work. The Council undertakes publicity work which can most usefully be directed through official channels. A central council representing public authorities and voluntary agencies concerned in rescue and preventive work in London undertakes the co-ordination of rescue and preventive work among women and girls in London. The Council has four representatives on the central council. Rescue and preventive work. The Council obtained powers in the session of 1926 to enable it to undertake and contribute towards the cost of health propaganda work and also to enable the metropolitan borough councils to undertake such work. Health propaganda. Part I of the Children Act, 1908, provides that a person who undertakes for hire or reward the nursing and maintenance of an infant under the age of seven years apart from its parents shall, within 48 hours, give notice of such reception to the local authority (in London the Council), and empowers such local authority to fix the number of infants which may be kept in any dwelling. If an infant dies the foster-mother must notify the coroner within 24 hours, and the Council within 48 hours. At the end of 1926, 3,082 nurse-infants and the premises of 2,448 fostermothers were subject to inspection. Power is given to remove to a place of safety an infant in the charge of a foster-mother who is unfit to have the care of it owing to negligence, ignorance, inebriety, immorality, criminal conduct, or other similar cause. Similar action may be taken where the premises are overcrowded, dangerous or insanitary, or if the infant is being kept by a person or in any premises in contravention of the Act. The Act also empowers a local authority to exempt either partially or wholly premises which are so conducted as to render ordinary inspection unnecessary. Particulars of action taken in recent years are as follows:— Infant life protection. Year. Infants removed from foster mothers. Exemptions. Deaths. Infringements discovered. Cautions. Prosecutions. Convictions. 1921 20 3 42 302 285 26 26 1922 14 3 52 279 266 13 13 1923 6 3* 53 303 292 11 10 1924 7 4* 26 274 267 7 7 1925 3 1* 38 263 261 2 2 1926 4 1* 26 214 2110 4 3 * Partial. The Child Adoption Committee issued in April, 1926, their Third and Final Report dealing with questions relating to the amendment of Part I of the Children Act, 1908. The Committee expressed the opinion that no grounds had been shown 14172 L 2 162 for a marked change in the substance of the law, but suggested various amendments which they considered to be needed. The amendments proposed were such as to secure substantially many of the objects sought by the Council's resolutions of 18th May, 1920 (and referred to in the Annual Report for that year; p. 113), as to amendments which experience had shown to be necessary to remedy defects in the provisions of the Act. One important proposal was that notification of the reception of an infant must be given at least 48 hours before reception (instead of within 48 hours after, as at present), which would enable a local authority to intervene, if necessary, before the child is actually received. The Child Adoption Committee also proposed that the period during which a foster-child is under the supervision of the local authority should be extended by two years, i.e., from the age of 7 years to the age of 9 years. Having regard to the adequate school medical service in the County of London, it was not considered that any real advantage was likely to accure, so far as London was concerned, by the adoption of this proposal. On these and other points of a minor nature, arising out of the Child Adoption Committee's proposals, the Council's views were communicated to the Minister of Health, by whom they will receive consideration in connection with any amendment of the Children Act, 1908. Lying-in homes. The Council s powers and duties with regard to the registration and inspection of lying-in homes are described in the Annual Report for 1922 (vol. III., p. 104). At the end of 1925, 277 premises were on the register, 26 were added during the year, and 37 entries were removed (owing to discontinuance of user, removal, etc.), leaving a net total of 266 on the register at the end of 1926. Eleven premises carried on by registered medical practitioners were exempted during the year. Census of homeless persons, Particulars are given in Chapter I. (p. 29) of the result of the census of homeless persons taken in February, 1926. The total numbers of homeless persons found in the streets, on staircases and under arches at the censuses in recent years were:— 1915, 178; 1916, 44; 1917, 28; 1918, 9; 1919, 8; 1920, 51; 1921, 56; 1922, 112; 1923, 141; 1924, 82; 1925, 118; and 1926, 103. Common lodging- houses. Particulars with regard to common lodging-houses licensed by the Council are as follows:— Year. Houses licensed. Lodgers authorised. Prosecutions. Convictions. Penalties and costs. Cases of infectious disease 1921 181 18,503 1 1 £3 18s. 1 1922 178 17,948 1 1 £3 2 1923 175 17,700 5 5 £19 10s. 2 1924 174 17,519 nil nil nil 1 1925 168 16,930 3 3 £8 19s. 6d. 1 1926 | 164 16,967 1 I £2 2s. 2 A comprehensive investigation was undertaken during the latter part of 1926 into the question of the character, standard and adequacy of the accommodation provided in common lodging houses and other kindred institutions in the country. Under the powers conferred on the Council by Part V. of the London County Council (General Powers) Act, 1907, the Council has made and renewed agreements with certain metropolitan borough councils for the cleansing of verminous inmates of licensed common lodging-houses and their clothing. Seamen's lodging- houses. Particulars of seamen's lodging-houses licensed by the Council are as follows:— Year. Houses licensed. Lodgers authorised. Prosecutions. Convictions. Penalties and costs. Cases of infectious disease. 1921 51 1,287 13 11 £130 10s. 6d. 1 1922 44 1,170 1 1 — 1 1923 36 1,089 4 4 £40 1 1924 38 1,128 4 4 £14 3s. | 2 1925 33 1,092 7 7 £41 8s. — 1926. 34 1,073 1 1 £5 2s. 1 163 The following table gives particulars of licensed slaughterhouses, knackers Offensive yards and registered offensive businesses:— businesses. Year. Slaughterhouses. Knackers' yards. Offensive businesses. 1921 158 4 60 1922 153 4 60 1923 147 4 101 1924. 136 4 *230 1925 132 4 *209 1926 122 4 *165 * Inclusive of the businesses of a dresser of furskins and a slaughterer of poultry. During 1926 sanction was given in three cases to the establishment anew of the business of a dresser of fur-skins and in seven cases to the establishment anew of the business of a slaughterer of poultry. In .November, 1925, the Council made by-laws under section b of the Housing Act, 1925, with respect to houses intended or used for occupation by the working classes and let in lodgings or occupied by members of more than one family and the by-laws were submitted to the Minister of Health for confirmation. Various representations and objections were made to the Minister by metropolitan borough councils and other interested parties, and the Minister, on 5th March, 1926, confirmed the by-laws "except in so far as they apply to any lodging-house in which the tenant resides and not more than one family is lodged." Houses divided into separate tenements. Tne numbers of cownouses licensed by tne uouncu in the past five years were as follows 1921, 101; 1922,100; 1923,98; 1924,89; 1925,84; 1926,75. The Minister of Health issued a Milk and Dairies Order, dated 26th July, 1926, under Section I. of the Milk and Dairies (Consolidation) Act, 1915, which came into operation on 1st September, 1925. The Order revoked the Dairies, Cowsheds and Milkshops Orders of 1885, 1886 and 1899, and all regulations made thereunder by local authorities. Under the last mentioned Orders, by-laws were made by the late Metropolitan Board of Works requiring approval of any premises proposed to be used as dairies, etc. Before the Order was issued, it was represented to the Minister of Health that it was desirable that the Council should retain the power requiring the submission of plans of new dairies. The Minister did not, however, see his way to retain this power in the new Order, but an article has been included requiring a month's notice to be given to the sanitary authority of intention to occupy premises as a place for the keeping of milk. Cowhouses, Milk and Dairies Order, 1926. The Milk and Dairies (Consolidation) Act, 1915, provides lor the repeal at the expiration of one year from the date on which the Act comes into force of so much of any local Act as relates to any of the matters dealt with by any of the provisions of the Act of 1915. The Council's powers under Part IV. of the London County Council (General Powers) Act, 1907, relating to the taking and examination of samples of milk, therefore lapsed on 31st August, 1926. Information is now sent, immediately upon discovery of tubercle-infected samples of milk, to the medical officer of health for the county concerned, who is responsible for the examination of the cows at the farm whence the sample emanated. Arrangements are made in any special case for the Council's veterinary inspector to inspect a herd from which tubercle-infected milk has been sent to London. Under the powers conferred on the Council by Fart IV. of the London County Council (General Powers) Act, 1907, samples of milk forwarded to London from places outside the county are examined. In 1926, 2,184 samples from milk consigned to London railway termini from 31 counties were submitted for bacteriological examination. In the case of 1925 samples, the bacteriological examination was completed and of these 86, or 4 5 per cent., yielded tubercle baccilli as against 4 6 per cent, in 1925. In connection with these samples, the veterinary inspector visited Tuberculous milk. 164 44 farms and examined 1,067 cows up to the time the altered arrangements referred to above came into force. During the year it was found that 58 cows showed signs of tuberculosis or were otherwise unhealthy; one cow supposed to have been tuberculous had been slaughtered prior to the inspector's visit and the farmer undertook to have the animal removed. In addition, the inspector re-visited 367 farms, and inspected 6,689 cows up to September, 1926; all the animals examined at these revisits were found to be in a satisfactory condition with the exception of 26 which were unsatisfactory upon other grounds than suspicion that they were suffering from tuberculosis. In each instance the owner undertook to have the animal removed. An intimation was received from a cowkeeper of a case of suspected tuberculosis in one of his cows. The animal died before inspection, but a post mortem disclosed no traces of tuberculosis. During 1926, 341 inspections were made of the cows in London cowsheds, and the total number of examinations made was 6,196. No case of generalised tuberculosis was detected, but in 81 cases other unhealthy conditions were found. Midwives. The powers and duties of the Council in relation to midwives are contained in the Midwives and Maternity Homes Acts, 1902 to 1926. The last Act came into force on 4th August, 1926. Under the Midwives Act, 1902, the duties of the Council, as the local supervising authority for London, were chiefly disciplinary in connection with the conduct, professional or otherwise, of midwives or persons practising as midwives in London. The Council was also required to suspend from practice any midwife, if such suspension appeared to be necessary in order to prevent the spread of infection. The Midwives Act, 1918; passed to amend the Act of 1902, enlarged the Council's responsibilities, the chief alteration dealing with the provision of medical assistance for midwives. By section 14, midwives are required to summon medical aid in an emergency as defined by the rules of the Central Midwives Board. The fees of the medical man so called in are payable by the Council (in accordance with a scale fixed by the Local Government Board and amended by the Ministry of Health) which has power to recover them from the patient, her husband, or other person, liable to maintain her, unless it can be shown that such person is unable to pay the fees. This Act also empowered the Council to pay, if it thought fit, to any midwife suspended by it from practice to prevent the spread of infection, such reasonable compensation for loss of practice as in the circumstances might seem just. It also gave power to the Council to aid the training of midwives and to make grants for the purpose. The Act of 1926 amends the provisions of the Act of 1902 with regard to the practice of midwifery by uncertified persons, either male or female. It also repeals the discretionary powers conferred upon local supervising authorities in respect of compensation for loss of practice to any midwife suspended from practice to prevent the spread of infection, and entitles her to recover such amount as is reasonable in the circumstances of the case unless she herself had been in default. The Act confers upon local supervising authorities power, subject to the sanction of the Minister of Health, to make arrangements with pregnant women in their respective areas for the payment of agreed sums, in instalments or otherwise, to cover liability in respect of the fees of medical practitioners called in under the provisions of section 14 of the Act of 1918. Notifications by midwives of intention to practise during the year 1926 numbered 835; of intention to practice for specific periods less than a year, 20; and of having acted in specific cases, 13. During the year the Council reported to the Central Midwives Board that three prima facie cases of malpractice, negligence or misconduct on the part of certified midwives had been established. In all cases the Board found the charges to be proved. In one case the Board cautioned the midwife as to her future conduct, and in another, sentence was postponed with a view to further consideration on 165 receipt of reports from the Council as to the conduct and practice of the midwife at the end of three and six months. In the third case the midwife was severely censured, and the Council was asked to make reports upon her conduct and practice at the end of three and six months. The probationary period in this case was extended by three months for a further report from the Council. Owing to the difficulty of assessing the sums to be recovered from patients, their husbands or other persons liable to maintain them in respect of the fees of medical practitioners called in by midwives to the patients, the Council, in 1921, adopted a scale of assessments graduated according to net income, after allowing a deduction in respect of each maintainable child or other dependant. Difficulties were encountered in dealing with cases of inflammation of or discharge from the eyes of infants, particularly in relation to the obtaining of medical assistance. The reluctance on the part of midwives appeared in many cases to be due to the fact that they were unwilling to involve their patients in charges for medical attendance, and in many cases the midwives attempted to treat the eyes, notwithstanding the risk incurred by their so doing. From the infant's point of view, it is particularly important that skilled assistance should be available at the earliest opportunity as the disease may develop rapidly and lead to blindness. In the circumstances the Council decided, subject to the expenditure being approved by the Ministry of Health for the purpose of Exchequer grant under the Child Welfare and Maternity Regulations, to take no steps for the recovery of fees paid to medical practitioners called in to assist midwives in respect of such cases. The Ministry of Health approved the proposal. From 1st April, 1926, to 31st March, 1927, the Council's expenditure under section 14 of the Act of 1918 was £4,270, the sums recovered during the same period amounting to £1,190. During the year 1926 the Council suspended 10 midwives from practice and awarded compensation amounting to £43 l1s. Whereas expenditure incurred by the Council under the Midwives Acts ranks for State grant, at the rate of 50 per cent., the Maternity and Child Welfare Regulations expressly exclude payments in respect of suspensions from practice to prevent spread of infection. Having regard to the provisions of the Act of 1926, which entitle a midwife to recover compensation, as indicated above, the Council decided to approach the Ministry of Health with a view to the Regulations being amended to allow such payments to rank for grant. Courses of lectures and practical demonstrations in ante-natal and post-natal work and in general midwifery were arranged during the autumn and winter sessions. Under section 5 of the Act of 1902, as amended by section 2 of the Act of 1918, any adverse balance in the accounts of the Central Midwives Board is apportioned between the councils of the several counties and county boroughs in proportion to population at the last census, and the Council's proportion for the year 1926 was £484 10s. lOd. Further detads of the Council's work are given in Chapter I., pp. 48-51. Proceedings as indicated below were taken by the Council during 1926 with regard to smoke nuisance from railway and road locomotives, and some proceedings were also instituted by the sanitary authorities in respect of smoke nuisance from trade premises. As regards railway locomotives, section 114 of the Railway Clauses Consolidation Act, 1845, requires that every locomotive shall be constructed on the principle of consuming its own smoke, and section 19 of the Regulation of Railways Act, 1868, enacts that, if a locomotive fails to do this, the railway company shall be guilty of an offence. Eleven prosecutions were instituted againt railway companies; 11 convictions were obtained, penalties and cost amounting to £31 13s. being imposed. Three prosecutions were instituted in respect of smoke nuisance from road locomotives; 2 convictions were obtained, the penalties and costs imposed amounting to £1. Smoke Nuisance. 166 Particulars of the work carried out during the year in connection with the suppression of smoke nuisance are as follow:— (1) Railway locomotives:—Nuisances reported—11. Prosecutions—11. Convictions—11. Total of fines imposed—£20 3s. Total of costs imposed—£11 10s. (2) Road locomotives:—Nuisances reported—20. Prosecutions—3. Convictions—2. Total of fines imposed—£1. (3) Premises:—Reports made as to alleged nuisances—146. Cases in which legal proceedings were taken by metropolitan borough councils as the result of such reports—nil. In consequence of the coal strike, the railway companies, manufacturers and other persons experienced great difficulty in obtaining supplies of steam coal. A certain latitude was accordingly allowed during the year as regards emissions of smoke. The number of prosecutions in consequence less than in the preceding year. Diseases of Animals. The Disease of Animals Acts, 1894 to 1925, the object of which is the suppression of contagious diseases in animals, naturally do not affect London so much as the country. In London, apart from swine fever, attention is now principally directed to glanders, anthrax, rabies, parasitic mange and foot and mouth disease, diseases which are communicable to man. The Acts are supplemented by Orders issued by the Minister of Agriculture and Fisheries. During 1926 the incidence of the principal animal diseases so far as London is concerned was as follows Glanders, including farcy, nil; swine fever, 1 outbreak in which 24 animals were involved; anthrax, 1 outbreak involving 1 horse; parasitic mange, 57 outbreaks involving 91 animals; foot and mouth disease, nil. During the year there appeared to be some danger of the reintroduction of glanders into Great Britain through the importation of horses, ponies, etc. This trade had recently shown signs of revival, and there was reason to believe that, although imported horses were alleged to undergo veterinary inspection before being shipped from foreign parts, in some cases they were not subjected to the mallein test for the detection of glanders. Horses may be affected with the disease for some time without showing any external signs, but may nevertheless be capable of spreading infection. In the past many serious outbreaks of glanders have been caused by such animals and the Council has been put to heavy expenditure in respect of compensation of animals slaughtered. The last outbreak of the disease in London was in 1922. The matter is at present regulated by the Importation of Horses, Asses and Mules (Great Britain) Order of 1921, which empowers the Minister of Agriculture and Fisheries to require any horse brought to this country to be subjected to the mallein test on arrival. In order to perform the duty satisfactorily, considerable expenditure by the Government in connection with the provision and equipment of quarantine stations would be involved. It was understood that the Minister had under consideration the question of seeking parliamentary powers to permit of a charge for the testing and quarantine services being levied upon the importers of horses. It was felt to be a matter of paramount importance that there should be no recrudescence of the disease, and the Council, on 4th May, 1926, expressed the opinion that effective steps should be taken to secure that all horses, ponies, asses and mules imported into Great Britain should be subjected to the mallein test for glanders before being admitted into the country. A copy of the Council's resolution was forwarded to the Minister of Agriculture and Fisheries, who replied that he was fully alive to the necessity for guarding against the risk of the introduction of glanders by means of imported horses, and that he had under consideration the question of seeking new powers to require the detention of imported horses at the port of landing in this country with a view to the application of the mallein test before they were allowed to come into contact with home animals. It was added that a Bill embodying this proposal would come before Parliament in the session of 1926. It was, however, apparently not found possible to introduce such a Bill. 167 Swine fever has been very prevalent throughout Great Britain during the past few years and an outbreak was dealt with in London during the year. During 1926 no fewer than 17.285 swine were examined at feeders' premises. Swine fever. The Council is convinced that the most efficacious measures for stamping out hydrophobia are muzzling, the seizure of all stray dogs and the regulation of the importation of dogs. Under the Dogs Act, 1906, which revoked all then existing muzzling regulations, the Council made new regulations requiring the wearing of collars by dogs while on a highway. Under these regulations, 29,813 dogs were seized by the police during 1926 and 21,584 were destroyed. Rabies. On the outbreak of the Great War, the Order dealing with parasitic mange was temporarily suspended, with the result that the disease increased largely. The conditions under which trade horses are fed and worked in London, particularly during busy seasons, tend to encourage the spread of the disease. During 1926, the returns of cases in London showed a slight decrease. The following figures relate to 1926:—Outbreaks, 57 ; horses affected, 91; infringements, 11; written cautions sent, 8; cases referred to solicitor, 3; convictions, 3; penalties and costs, £38 5s. For the purposes of comparison, it may be pointed out that the number of outbreaks in 1925 was 73, affecting 106 horses. Parasitic mange. As the outcome of one of the recommendations of the Departmental Committee on Foot and Mouth Disease the Minister of Agriculture and Fisheries issued an Order, entitled the Movement of Animals (Records) Order, 1925, which had for its object the provision of a ready means of tracing animals which may have been in contact with diseased or suspected animals. The new Order, which came into force on 1st February, 1926, requires, with certain exceptions, records to be kept by any person who moves or permits any animal to be moved to or from any premises. Two infringements of the Order were dealt with by means of written cautions. Foot and mouth disease. In consequence of an outbreak of foot and mouth disease at New Maiden, Surrey, the Minister of Agriculture and Fisheries made an Order on 31st March, 1926, declaring a district within 15 miles of the infected place to be an " infected area " for the purposes of the Foot and Mouth Disease (Infected Areas Restrictions) Order of 1925. This area included the County of London. As no further case of the disease was disclosed the Order was withdrawn on 29th April, 1926. A further outbreak occurred at Southgate, Hertfordshire, and on 22nd September, 1926, an Order was made declaring a district within a radius of 15 miles of the infected place to be an " infected area." This area included the County of London, which was released from movement restrictions on 7th October, 1926. There was an outbreak also at Harmondsworth, Middlesex, as the result of which the Minister made an Order, on 4th November, 1926, declaring a district within a radius of 15 miles of the infected place to be an " infected area." This area included ten metropolitan boroughs. The portion of the County of London concerned was released from movement restrictions on 19th November, 1926. In the case of each outbreak, the necessary steps were taken to bring to the notice of the persons concerned the provisions of the Orders of which the effect is to prohibit the movement of animals out of the area and to permit movement within or into the district only under licence. There were 63 infringements of the Foot and Mouth Disease (Infected Areas Restrictions) Order of 1925, all of which were dealt with by means of written cautions. With a view to eliminating as far as possible the danger of the introduction into this country of foot and mouth disease by means of carcases imported from the continent of Europe, the Minister of Agriculture and Fisheries on 2nd June, 1926, made an Order entitled the Importation of Carcases (Prohibition) Order of 1926, prohibiting, with certain exceptions, the importation of such carcases. The necessary steps were taken to bring the provisions of the Order to the notice of the persons concerned. 168 To ensure that the requirements of the several Orders in force from time to time are being observed, and that the animals are not caused unnecessary suffering during transit and are free from signs of disease, the Council's inspectors pay numerous visits to railway wharves, depots, etc., where animals in transit are collected. The visits during 1926 numbered 2,852, the animals examined being—horses 1,955, cattle 49,343, sheep 80,697, swine 18,897, making a total of 150,892. There were 30 infringements, 26 written cautions, 4 cases of legal proceedings and 3 convictions with penalties and costs amounting to £11 4s. Enforcement of orders. CHAPTER IV. MAIN DRAINAGE. The district drained by the London main drainage system has an area of nearly 149 square miles with an estimated population of 5,480,000. This includes an area of nearly 32 square miles, with a population of 868,000 outside London. When the districts of Leyton and Walthamstow are incorporated in the area served by the system in accordance with the provisions of the London County Council (General Powers) Act, 1925, 11 square miles, containing a population of over 250,000, will be added. Drainage area and statistics. The quantities of sewage, etc., dealt with during 1926 were as follows :— Sewage treated—- Million gallons. Northern outfall 59,857.9 „ ,, (daily average) 164.0 Southern outfall 35,163.9 „ „ (daily average) 96.3 Sludge sent to sea— Tons. Northern outfall 1,650,000 „ „ (daily average) 4,521 Southern outfall 804,400 „ „ (daily average) 2,204 The sludge vessels made 1,724 trips and travelled altogether 190,380 nautical miles. For some years past experiments have been undertaken in connection with the biological treatment of sewage on the activated sludge basis, using various types of apparatus. The methods experimented with have comprised (i.) the diffusion of air through the sewage by means of porous tiles fitted in the bottom of the tank; (ii.) the agitation of the sewage by paddle wheels which constantly expose fresh layers of the sewage to the air; (iii.) spraying; and (iv.) the stirring of the sewage by means of vertical stirrers. The last-mentioned method was installed during the year. At an early stage the experiments established the fact that London sewage responded to treatment with activated sludge. Later experiments were directed towards the treatment of the effluent discharged into the river from the settling or sedimentation channels, and it has been found that effluent can be more expeditiously dealt with than crude sewage. The tanks have been altered from time to time and the quantities of liquid which can be dealt with have been largely increased. Sewage treatment. The solids, known as sludge, which are obtained from the sewage after sedimentation at the outfalls are conveyed to, and deposited in, the Black Deep in the Thames estuary. The Deep is also used by other authorities for the deposit of waste materials and the cost of buoying the deposit area is apportioned among the various authorities using it for that purpose. The Council's proportion for the year 1926 amounted to £308 5s. 8d. Deposit of sludge at sea. 169 The new sludge vessel, the s.s. John Perring, was launched at the yard of W. Beardmore and Company, Ltd., at Dalmuir, near Glasgow, on 26th February, 1926, and was commissioned on 26th April, 1926. The cost of the vessel was £51,630 17s. The fleet of sludge vessels now consists of the Bazalgette, commissioned in 1887 and reconditioned in 1921, of 1,000 tons capacity, the Henry Ward (commissioned in 1923), the J. 11. Hunter (commissioned in 1924), the G. W. Humphreys (commissioned in 1925), and the John Perring, each of 1,500 tons capacity, giving a total carrying capacity of 7,000 tons, as compared with 6,000 tons of the six old vessels. Two of the older sludge vessels, the s.s. Barrow and the s.s. Belvedere, were disposed of during the year to Messrs. G. B. Pas and Zonen, of Bolnes, Rotterdam, for £1,750 each. The annual overhaul of the s.s. Henry Ward, the s.s. G. W. Humphreys and the s.s. J. II. Hunter was undertaken at a total cost of £2,111 19s. 7d. Sludge vessels. Four new pumping engines and two surface condensing sets are being installed at the Northern outfall, at a cost of about £7,000. The construction of the foundations for the new machinery is being undertaken by direct employment of labour, at an estimated cost of £300. No proper messroom accommodation has hitherto been available for the workmen employed at the outfall, and a disused sluice house is being adapted for the purpose at an estimated cost of £550, to include lavatory accommodation and a locker-room. The repair of the pier at the outfall, which was seriously damaged by the s.s. Surrey, was carried out at a cost of £9,691 2s. 9d., the cost being recoverable under insurance policies. The general work of repairing the pier, which has extended over many years, was continued during the year at a cost of approximately £1,500. The screening of the sludge produces a large amount of solid matter, and a contract was entered into for the removal of the refuse, the estimated cost being £1,500. A footpath ran from Gal lions Station, North Woolwich, through the property of the Port of London Authority and the Gas Light and Coke Company to the Northern outfall. Underneath the pathway the rising sewer main from North Woolwich pumping station to the outfall had been constructed. The pathway is of considerable use to the Council, being the direct means of access to the outfall from North Woolwich and Gallions Station. The Gas Light and Coke Company obtained powers in the Company's Act of 1925 to close the path on the Company's property, and the Council secured the insertion in the Act of a provision preserving rights of passage to and from the outfall for all authorised persons and of reasonable access to the rising main. The Port of London Authority was desirous of closing the portion of the path running through its land, and assent was given, subject to the Authority entering into an agreement embodying terms to safeguard the Council's interests on lines similar to the protection afforded by the Gas Light and Coke Company's Act, 1925. Northern outfall. lne overhaul ot the main beam engines and pumps at the southern outtall has been proceeding continuously since 1915, when completion of the engines and pumps ' in the new engine house offered an opportunity for stopping the old machines in rotation. Up to date, the work has cost approximately £10,650. The roof of the main engine house, which was constructed in 1864, required to be renewed. The roof has a span of about 45 ft. 7 in., and it was decided that the new roof should be carried out in reinforced concrete. The cost of the work will be over £4,000. Baths have been installed in the staff quarters, at a cost of about £850. Repairs to the pier have cost £450, to the wharf wall £105, and to the bunkers of the main engine house, £250. Southern Dutfall. Apart from the work in connection with the enlargement of Abbey Mills pumping station which is referred to under the heading of " Flood relief works," the works undertaken at the station during the year included the overhaul, at an estimated . Abbey Mills pumping 1 station. 170 Deptford pumping station. cost of £2,000, of the gas engine plant. These engines are designed primarily for dealing with storm water or performing other intermittent work, but owing to the dismantling of the Worthington engines, which dealt with the sewage flowing from the Isle of Dogs, additional strain was thrown upon the gas engine plant. One of the mains through which sewage is pumped from the Gwynne engine house (formerly the Worthington engine house) into the northern outfall sewer was found to be fractured, and the cost of repair amounted to about £200. The cast-iron steam piping in the boiler house at Deptford pumping station was thirty years old and could no longer be relied upon. It was therefore decided to instal a complete new range of steel, piping and valves, at a cost of approximately £750. Two of the main engines are being overhauled, at a cost of about £300. Three of the bridges which carry the Northern outfall sewers over roads, etc., Outfall, intercepting and main sewers. have been repainted, at a cost of £],804 Is. 6d. The Southern high level sewer No. 2 passes under property belonging to the Guardians of the Poor of the Parish of Lewisham. The Guardians proposed to erect a nurses' home on their property, and it was necessary to undertake the strengtheningof the sewer under the buildings, at a cost of £600. The King's Scholars' pond sewer passes under Victoria-street, near Victoria Station. The sewer is an old one and the depth between the top of the sewer and the roadway is very small. The increasing weight of traffic necessitated the strengthening of the sewer, and the cost of the work, apart from the incidental cost of shifting pipes belonging to other authorities, has amounted to £1,188 16s. 8d. Main sewers generally possess storm overflows for the purpose of discharging storm water direct into the River Thames. Discharge may be controlled either by penstocks, which require to be opened by manual labour at the appropriate time, or by tidal flaps which open or close automatically when the pressure is greater internally or externally. Three main sewers, the Earl, Duffield, and Battle Bridge sewers, formerly operated by means of penstocks are being converted to the tidal flap system, at a cost of £2,500. A further portion of the Counter's Creek sewer, passing under the site of the proposed hospital for children in Wallingford-avenue, North Kensington, being no longer required for use as a main sewer, has been discontinued for that purpose. Repairs, etc., have been carried out during the year to intercepting and main sewers as follows :— £ Balham Sewer 944 Blackfriars Road Sewer75 East Boundary Sewer 1,938 Effra Sewer 500 Falcon Brook Sewer 500 Kennington Road Sewer 900 Hackney Brook Sewer 1,500 King's Scholars' Pond Sewer3,000 Ranelagh Relief Sewer 6.000 Ratcliff Highway Sewer 4,000 Regent Street Sewer 4,000 Northumberland Street Sewer 3,000 Wick Lane Sewer 2,500 The work of removing from the sewers deposits which accumulate there is one of considerable magnitude. For this purpose the county is divided into four districts, each district being made the subject of a separate contract. Contracts are based upon prices for the cartage and disposal of the deposit which is removed from the sewers by the Council's staff. The cost of this work in 1926 was approximately £3.400. Flood relief works. The Council on 22nd July, 1919, had before it a comprehensive scheme of works to mitigate floodings in various parts of London on both sides of the river Thames 171 during a time of heavy rainfall. The scheme, which is described in the Annual Report for 1920 (vol. [II., p. 121), specified seventeen works and the total estimated cost, based on pre-war conditions, was £2,467,150. The first work undertaken was the construction of the north-eastern storm relief sewer from Kelvin-road, Highbury, to the Thames at Shadwell, which was commenced in 1921. In order to provide additional employment the Council on various dates subsequently decided to accelerate the work on other portions of the 1919 scheme, particularly those which would provide work suitable for unskilled or partly skilled labour. The works selected were the improvement of the river Graveney, the Wandle Valley sewer, the Charlton storm relief sewer, flood relief works at Hammersmith, the enlargement of the Isle of Dogs and Abbey Mills pumping stations, the south-western storm relief sewer, storm relief sewers in Lewisham and Woolwich, the north-western storm relief sewer, and the installation of additional machinery at Shad Thames pumping station. All these works have been approved for grant by the Unemployment Grants Committee. A further item in the scheme, the construction of the Beverley Brook relief culvert, which was commenced in 1925, did not rank for Government grant. Of the 17 specified works included in the scheme of 1919, 12 have been completed or are in hand. The estimated final cost shows an increase of about 72 per cent, on pre-war figures. The completed works comprise the improvement of the river Graveney completed in January, 1923 (cost, approximately £200,000), the Wandle Valley sewer (first portion) completed in January, 1924 (£175,000), Charlton storm relief sewer completed in March, 1924 (£150,000) and the north-eastern storm relief sewer completed in September, 1924 (£700,000). Further particulars of these works are given in previous Annual Reports. Details of the schemes which were completed during the year under review or were still in hand at the end thereof are given below. The relief scheme tor the low-level area in West London of about 2,500 acres in Fulham, Kensington and Hammersmith, which provided for the construction of a sewer about a mile in length, having an outlet to the Thames near Hammersmith Bridge, and the erection of a new pumping station near the outlet, has been completed, at a cost of approximately £300,000. Flood relief works at Hammer- smith. The outlet trom Hammersmith storm water pumping station discharges into the River Thames at the Hammersmith Metropolitan Borough Council's wharf, near the pumping station. At the same wharf the borough council has an installation of pumps which draws water from the river for condensing purposes at the borough council's electricity generating station through inlet pipes laid in the river bed. Complaints were made by the borough council that the working of the pumps at the storm water pumping station caused the inlets to the condensing water pipes of the electricity generating station to become choked with debris stirred from the river bottom. Of the various alternatives considered for remedying the cause of complaint, that of altering the position of the inlets and modifying the methods of circulating the condensing water appeared to be the most satisfactory. After negotiations, the borough council agreed to accept, in full settlement of its claim, the sum of £5,000, from the Council towards the cost of the works nronosed. Hammersmith Pumping Station. The enlargement of Abbey Mills pumping station involves alterations in the Worthington engine house (now known as the Gwynne engine house), at the station, the installation of new pumping plant there, and the provision of additional boilers in one of the boiler houses and of supplementary plant. This work was completed in October, 1926, at an approximate cost of £60,000. Abbey Mills pumping station enlargement. In addition to the pumping carried out at Abbey Mills pumping station in connection with the drainage of the low-lying areas in Poplar and the Isle of Dogs, storm water from these areas is pumped direct into the Thames at the Isle of Dogs Isle of Dogs pumping station enlargement. 172 pumping station and the general flood relief scheme of 1919 provides for the enlargement of this station and the substitution of gas for steam power, at a cost of approximately £60,000. At the end of the year the installation of the machinery was well advanced. A penstock in Manchester Road, Isle of Dogs, which prevents storm water from flowing back from higher ground to the northwards when pumping is taking place at the Isle of Dogs pumping station a short distance away, could only be operated on the spot. Hydraulic apparatus is being installed, which will enable the penstock to be operated from the pumping station, at a cost of £420. Southwestern storm relief sewer. The south-western storm reliei sewer has been designed to assist the drainage of Clapham, Streatham, Brixton, West Norwood and Dulwich. It has been completed at an approximate cost of £300,000. If required, the sewer can be extended southward to relieve the Effra Branch sewer at West Norwood. The length from Effra Road to Nine Elms is 2§ miles, and in order to expedite the work it was made the subject of two contracts—(i.) between Effra Road and Clapham Road, completed in February, 1924 ; and (ii.) from Clapham Road to the Thames, begun in March, 1923, and completed in March, 1926. Storm relief sewers in Lewisham and Woolwich. The scheme of relief sewers in Lewisham and Woolwich is described in the Annual Report for 1923 (vol. III., p. 128). The construction of the Lewisham branch sewer (Bell-green, Lower Sydenham, to a junction with the southern highlevel sewer No. 2 near Court Hill Road, Lewisham), and of a branch sewer from Catford station has been completed. Owing to the nature of the ground encountered in the progress of the work it was decided to carry out the construction of the Lewisham branch sewer between George Lane and Court Hill Road in iron instead of brickwork, and to use compressed air in connection with this portion of the work. The additional estimated cost in this respect is £5,000. The construction of the Eltham sewer (from the junction of the Council's existing Eltham sewer and the local sewer in Eltham Road, near Eltham Green, to the southern high-level sewer No. 2 at Charlton), had not been completed by the end of the year. The approximate cost, of the two sewers is £524.500. Shad Thames pumping station. Shad Thames pumping station, opened in 1909, was designed to accommodate six pumping sets, but as a first instalment three only were put in. The flood relief scheme of 1919 included proposals for completing the equipment of this station. The second instalment, consisting of three engines and pumps, is being added at an approximate cost of £22,000. Northwestern storm relief sewer. The north-western storm relief sewer will extend from Kilburn to Hammersmith and has been designed to relieve floodings in Willesden, Paddington and North Kensington. The works comprise the construction of the principal sewer which will be connected with the Ranelagh sewer in Shirland-road, Kilburn, and will run to the nearest point on the Thames, at Hammersmith, connecting with various main sewers on the way. Branch sewers will be constructed to connect the new sewer with the middle level sewer in Ladbroke-grove, and with the Woodlane sewer at Wormwood Scrubs. A connection will also be made with the new pumping station at Hammersmith. Altogether the construction of about 5¼ miles of sewer is involved, the approximate cost being £527,000. The principal sewer is being constructed for a length of about 2¼ miles in tunnel, largely under compressed air, of cast-iron segments lined with concrete, including the connection from the Hammersmith Pumping Station to the Stamford Brook Sewer in King Street, Hammersmith. The remainder of the total length of about 5¼ miles, including the branch sewers named, has been constructed in brickwork in tunnel, except for two short lengths in cast-iron segments lined with concrete. The work was let in two contracts, one for the cast-iron sewers, and the other for the brick sewers. 173 The negotiations, for the most part abortive, with authorities outside London for contributions towards the cost of a relief scheme to deal with the overflowing of Beverley-brook are referred to in the Annual Report for 1924 (vol. III., p. 129). Negotiations, however, with the Barnes Urban District Council have been brought to a conclusion and the arrangement was ratified in the London County Council (General Powers) Act, 1924. The scheme involved is the construction of a culvert, not less than 8 feet in diameter, to draw off storm water from the brook at a point near Priest's-bridge, Upper Richmond-road, and to discharge it into the Thames by the most direct route. The approximate estimate of the cost is £39,500, towards which the District Council will contribute one-fifth or £8,000, whichever is less. Work was begun on 17th September, 1925, and was completed in September, 1926. Beverley Brook. Two storms of exceptional severity at certain places and during short periods occurred on 11th August and 1st September, 1926. The fall on the former date varied considerably. At the Isle of Dogs, .42 inches fell in five minutes ; at North Woolwich, .50 inches fell in 10 minutes ; and at a number of places rain fell during short periods at rates of 3 inches and 21 inches an hour. During the storm of 1st September, 1926, rain was general all over London, but was exceedingly heavy in the east and south-west districts. The maximum recorded fall was .90 inches in 20 minutes at North Woolwich, and at a number of places falls at rates of 2 inches and 1A inches an hour were observed. The heaviest falls approximated to high water in the River Thames, and little benefit could be derived from the low level storm outlets to the river. All the Council's pumping machinery available to meet the conditions of the storms was in operation, and with the new sewers and works comprising about 70 per cent, of the scheme submitted in 1919, undoubtedly prevented more serious floodings. Further work9 for relief of flooding. As a result of the study of the problem, several works not specifically included in the original scheme were found to be desirable. Two measures of relief which were relatively small were approved by the Council, and comprised a diversion of drainage from the southern outfall sewer No. 2 into the southern high-level sewer No. 2, at an estimated cost of £5,000 ; and a diversion of drainage from the Ravensbourne and Lee Green sewer into the southern outfall sewer No. 1, at an estimated cost of £1,000. The former work was rendered desirable owing to difficulty in dealing with water levels in the southern outfall sewer No. 2 in storm times, accentuated by the fact that a number of sewers draining higher ground discharge into the outfall sewer instead of the high-level sewer. The diversion of drainage from the outfall sewer into the high level sewer will obviate the necessity of its being pumped at the Southern outfall, and will tend to reduce the surcharging of the outfall sewer in times of storm. The connection between the Ravensbourne and Lee Green sewer and the southern outfall sewer No. 1 is designed to reduce the risk of flooding in the Cold bath Street area of Greenwich. Further works for the relief of flooding are under consideration The Annual Report for 1923 (vol. III., p. 129) describes the negotiations with the Lambeth and Wandsworth Borough Councils for the construction by the Council of a new 4-foot sewer in Streatham-hill and Brixton-hill at the joint expense of the borough councils in the proportion of two-thirds to Wandsworth and one-third to Lambeth. The new sewer, which has been completed, is vested in the Council, while the present local sewer in Streatham-hill and Brixton-hill will continue to be maintained by the borough councils. The cost of the new sewer amounts to £46,845 (for works only), and the work was approved by the Unemployment Grants Committee for the purpose of State aid. Sewer in Streatham hill and Brixton-hill. Enquiry was made of the Council whether it would be willing to receive into the London main drainage system the drainage of Barking and Ilford. In view of the enquiry being held by the Ministry of Health in connection with the drainage of London and adjacent areas, it was premature to consider the reception of the drainage of these^areas. Out-county drainage. 174 Insurance against fire. Main drainage properties were re-valued for the purpose of fire insurance at £472,620. Such properties include sludge vessels, structures, buildings and their contents, including machinery, except such parts as are underground and not liable to damage by fire. Local sewers. Section 69 of the Metropolis Management Act, 1855, provides that no local sewer shall be made without the approval of the Council. During 1926 the construction or reconstruction of 86,544 feet of sewers of various sizes has been sanctioned. Buildings, etc., over sewers. Under section 204 of the Metropolis Management Act, 1855, and section 68 of the Metropolis Management (Amendment) Act, 1862, no building or any other encroachment may be erected in, over or under any sewer vested in the Council except with the Council's consent. During 1926 the Council gave its consent in 12 such cases. Staff. Reductions in the wages of officers and crews on general trading vessels (home trade) of 10s. a week and 6s. 6d. a week respectively, as from 1st August, 1925, having been decided by the National Maritime Board, such reductions were applied under the arrangements in force to the officers of the Council's sludge vessels, and after a confirming decision by the Thames District Maritime Board to the crews of the vessels. Subsequently a demand was submitted, on behalf of the officers and crews, for the immediate restoration of the rates previously in operation and for the settlement of terms of a new agreement relative to this branch of the Council's service. Negotiations were undertaken, but on 29th December, 1925, the crew of one of the sludge vessels refused to proceed with the loading of the vessel and this lead was followed at intervals by the crews of the other vessels, and the journeys of the vessels ceased entirely on 1st January, 1926. The men refused the Council's offer, conditional upon immediate resumption of work, of (i.) the restoration of the cuts of 10s. to officers and 6s. 6d. a week to each member of the crews ; (ii.) the reference to arbitration of the question whether any further additions should be made ; and (iii.) immediate consideration by the Council of the methods by which wages in the sludge vessels should be fixed for the future. Agreement was reached on 6th January, 1926, at a conference held at the offices of the Ministry of Labour, upon the following conditions (i.) the restoration of the cuts ; (ii.) the reference to the Industrial Court for arbitration of the question of further additional pay to be retrospective to 1st August; (iii.) consideration by the Council of the methods by which wages in the sludge vessels shall be fixed in future ; (iv.) re-instatement of officers and men in former or equivalent positions ; and (v.) immediate resumption of work, without victimisation on either side. The service was re-started on 8th January, 1926. The hearing of the difference between the Council and its employees before the Industrial Court took place on 15th January, 1926, and the Court gave its award as follows : " 10. The Court, have carefully considered the evidence and contentions put before them and the admission by both sides that the work of the sludge vessels is a special service, and are of opinion that, having regard to the nature of the service, an advance, greater than the restoration of the ' cuts,' the reason for which has already been referred to, is justified. The Court award that, as from 1st August, 1925, an advance be made in the rates of officers of 12s. 6d. a week, credit to be given for all sums of 10s. a week already paid since that date; 9s. a week to all other ratings except boys, and 7s. 6d. a week to boys, credit to be given for all sums of 6s. 6d. a week already paid. The Court desire to point out that the advance given above is a general one and is to cover all the duties and services which have been enumerated in the contentions urged on behalf of the officers and crews." The total cost of the restoration of the cuts effected in August, 1925, and of the additional sums awarded by the Court amounted to about £3,400 a year. In the agreement of 6th January, 1926, above referred to, the Council undertook to consider immediately the methods by which wages in the sludge vessels service should be fixed in the future. The Council is in communication with the associations and unions concerned. 175 CHAPTER V. HOUSING. Prior to the passing of the Housing Act, 1925, which came into force on 1st July, 1925, and which reproduces in a consolidated form the permanent law relating to the housing of the working classes, the powers of the Council in this matter were derived from the Housing Acts, 1890 to 1924. The financial provisions of the Housing, etc., Act, 1923, and the Housing (Financial Provisions) Act, 1924, dealing with Exchequer contributions towards the cost of the construction of houses were not incorporated in the Act of 1925, but have been continued as separate enactments. These Acts were passed for the purpose of encouraging building in the immediate future, and are thus in the nature of temporary expedients. Particulars of the provisions of these Acts are set out in the Annual Report for 1924 (vol. III., pp. 142 and 143). Apart from administrative duties, the main divisions of the Counil's housing work are (i.) the provision of new dwellings to meet the need for additional accommodation, and (ii.) the improvement or reconstruction of unhealthy areas, including the provision of dwellings for rehousing persons of the working classes displaced. Powers and luties of the Council. Under the Housing (Financial Provisions) Act, 1924, the State contribution towards the cost of the erection of houses and the period for which such contribution is payable may be revised after 1st October, 1926, and in each second year afterwards The Act requires, however, that before such revision is made the Minister of Health shall consult the local authorities concerned. In this connection the Minister of Health held meetings on 17th June and 16th July, 1926, with the local representatives, when the question of expenditure allotted to housing and the costs of production was discussed. The Minister indicated the possibility that any houses completed by a certain date (being a date subsequent to 1st October, 1926) would be eligible for Exchequer contribution on the scale then in force, but that for houses completed after such date the State subsidy might have to be reduced. He stated that his review of the question would cover subsidies under both the Act of 1923 and the Act of 1924, but that grants in aid of slum clearance under section 1 (3) of the Act of 1923 would remain unchanged. At the second meeting the Minister himself was not present and discussions took place between the principal officials of the Ministry and the representatives of local authorities on the points previously raised by the Minister. Revision of State contribution. As a result of its consideration of the announcement made by the Minister the Council on 27th July, 1926, resolved that, in its opinion, the scale of Exchequer contributions towards the cost of the provision of houses under schemes promoted by London housing authorities under the Housing, etc., Act, 1923, and the Housing (Financial Provisions) Act, 1924, should remain unaltered for a period of two years from 1st October, 1926, but that the question of the revision of the scale after such period should be considered in October, 1927, by the Minister of Health in consultation with the local authorities mainly concerned. The resolution was duly submitted to the Minister of Health, who replied on 5th August, 1926, that it was the general policy of the Government to bring to an end the subsidies under the Acts of 1923 and 1924 as soon as practicable, although it was recognised that this could only be done' gradually and with sufficient notice to enable local authorities and those engaged in the building industry to accommodate themselves to the position, in order to avoid breaking the continuity of house production. The statutory review under the Act of 1924 fell to be made after 1st October 1926, and the Minister could not at that time say what reduction of subsidies, if any, might be made by Order under that Act. On 11th December, 1926, the Minister of Health made an Order entitled the Housing Acts (Revision of Contributions) Order, 1926, reducing the grants in respect of 14172 m 176 Contributions to schemes of metropolitan borough councils. houses not completed before 1st October, 1927, from £6 to £4 a year for each house for 20 years under the Housing, etc., Act. 1923, and from £9 to £7 10s. a year for each house for 40 years under the Housing (Financial Provisions) Act, 1924. The Order also provides that the maximum amount of the grants which may be made by the Council towards the cost of housing schemes undertaken by metropolitan borough councils shall be reduced from £3 to £2 a house a year for 20 years under the Act of 1923, and from £2 5s. to £1 17s. 6d. a house a year for 40 years under the Act of 1924. The Council in 1923 decided to supplement the State contribution towards housing schemes carried out by metropolitan borough councils under the Housing, etc., Act, 1923, but in view of the increased amount of the Exchequer grant under the Housing (Financial Provisions) Act, 1924, the Council did not at first think it desirable to make a similar supplemental grant under the latter Act, and this view was supported by a majority of the borough councils at a conference on the subject on 24th March, 1926. Owing, however, mainly to the increased cost of building and the rate of interest on borrowed money it became generally impracticable to restrict the loss to the rates on housing schemes in London to the amount (£4 10s. a house a year for 40 years) which was contemplated when the Act of 1924 was formulated. In these circumstances the Council decided on 20th July, 1926, to supplement the State grant in respect of future schemes of the City Corporation or any metropolitan borough council under the Act of 1924 which involve a charge upon the local rate exceeding £4 10s. a house a year for 40 years, by a contribution in suitable and approved cases of a sum from the general county rate not exceeding £2 5s. a house a year for 40 years. This maximum contribution, however, as indicated above, will be modified in the case of houses not completed before 1st October, 1927, in accordance with the provisions of the Housing Acts (Revision of Contributions) Order, 1926. Legislation. Section 39 of the London County Council (General Powers) Act, 1926, confers on the Council the power to provide and maintain in connection with any of its housing schemes in the County of London any building or part of a building adapted for use for any commercial purpose, provided that no such building shall be erected in any metropolitan borough except after consultation with the Council of the borough concerned. On 9th November, 1926, the Council decided to promote legislation in the session of 1927 to repeal this proviso, and extend the power of the Council to buildings outside the County of London, and also to obtain a similar power for the metropolitan borough councils in connection with any housing schemes within their respective boroughs. Clearance schemes— Trade compensation. A decision of considerable importance, affecting the general question of trade compensation in respect of properties required for clearance schemes under Part II. of the Housing Act, 1925, was given by the High Court during the year. The claim of Mr. G. J. Northwood, the lessee and licensee of the " Freemasons' Arms " publichouse, No. 45 Pereira-street, and the lessee of the adjoining premises, No. 47 Pereirastreet, in the Brady-street area, and the claim of Barclay, Perkins and Company, Limited, his mortgagees, were referred to arbitration. Both these premises were included in the Brady-street scheme on account of their sanitary condition, and not merely for making the scheme efficient. At the arbitration proceedings it was contended on behalf of the claimants that the compensation should include a sum for trade disturbance or loss of licence, and a special case was stated by the arbitrator for the decision of the High Court on this question. The decision of the Court was to the effect that the arbitrator was not entitled to award any sum for trade disturbance, loss of licence or trade fixtures ; that he was not entitled to award a greater sum than he otherwise would in respect of the site value of the premises because a portion of the premises was licensed for the sale of excisable liquors ; and further, that, apart from any question of the premises 177 being licensed premises, he was not entitled to award any compensation for trade disturbance or loss of trade. An appeal by the claimants to the Court of Appeal for the decision to be set aside was disallowed. During the year the Council had under consideration the question of the height to which habitable rooms in its houses should in future be constructed. In the County of London the question is governed by the London Building Act, 1894, which requires the height of habitable rooms to be not less than 8 ft. 6 ins. The Council had previously applied this standard to all houses on its estates, whether such houses were within the scope of the Act or not, but on 26th January, 1926, the Council decided to restrict the height of rooms in its houses outside the County of London to 8 feet in those districts where such a height was permitted by the local building by-laws. Height of rooms. Since the war the Council has, up to 31st December, 1926, completed 15,903 houses and flats, which contain a maximum accommodation on the basis of two persons a room for about 120,424 persons. The houses and flats completed during the year 1926 totalled 4,643 with accommodation for 34,650 persons. Altogether since the completion of the first dwellings in 1894, the Council has provided accommodation for about 178,728 persons in 25,874 tenements and houses and three lodging-houses with 1,880 cubicles. These figures cover the whole of the Council's housing operations for the periods mentioned, including rehousing in connection with schemes for the clearance of unhealthy areas and other public improvements. Houses, etc. completed. The programme of work in hand is very considerable, comprising the erection of about 15,000 additional houses under Part III. of the Housing Act, 1925, apart from the rehousing required under slum clearance schemes. The Minister of Health is empowered to make contributions from the Exchequer towards the expenses incurred by local authorities in carrying out improvement schemes under Part II. of the Housing Act, 1925, such contributions being limited to one-half of the estimated average annual loss. The Minister has intimated that he is prepared to consider proposals for the County of London involving contribution from the Exchequer amounting to £50,000 a year, and a comprehensive programme of slum clearance is being carried out by the Council. The schemes now in operation or about to be commenced are 12 in number, and include 22 separate areas comprising 91 acres. The displacement of 25,691 persons of the working classes is involved and rehousing accommodation for about an equivalent number has to be provided, of whom 17,470 have to be accommodated within the limits of the improvement areas Particulars of the schemes are given later. Unhealthy areas. Particulars of the Council's scheme for the administration of the subsidy provisions of the Housing, etc., Act, 1923, were set out in the Annual Report for 1923, Vol. III., pp. 132-3; for houses not completed before October, 1927, the amounts of the Council's contributions will be governed by the conditions of the State grant as modified by the Housing Acts (Revision of Contributions) Order, 1926. Up to 31st December, 1926, the Council had approved proposals submitted by private builders for the erection of 2,351 houses to qualify for subsidy on completion, the number of houses approved during the year being 679. Building grants. Particulars of the Council's housing operations during the year are as follows:— The estate known as Becontree, situated in the County of Essex between Chadwell Heath on the north and Ripple Road on the south, comprises about 2,768 acres, and was purchased with the aid of compulsory powers obtained in 1920. The development of the estate, which has been entrusted to C. J. Wills and Sons, Limited, on a cost basis with a variable fee to the contractor, is being carried out in sections, and is being proceeded with from three different directions—viz., the northwest, or Ilford section; the south-east, or Dagenham section; and the north-east, or Valence section. Becontree. 178 At the end of the year about 8,400 houses on the estate had been completed, about 1,600 were in course of building, and orders had been issued to the contractors for the erection of about 3,800 others. On 11th December, 1926, the Council approved a capital estimate of £1,250,000, for the development of a further section, to be known as the Valence (No. 10) section, by the erection of about 2,136 houses, of which about 186 will probably be of timber construction. During the year the Council also approved the erection of 68 additional houses on the Ilford (No. 5) section, and 100 additional houses on the Dagenham (Nos. 6 and 8 sections). During the year the Council fixed the weekly net rents (exclusive of rates and water charges) for accommodation on the Valence (No. 4) section, Ilford (No. 5) section, the Valence (No. 7) section, and the Dagenham (No. 6a) section. The range of rents is as follows:—Five-roomed house, 12s. 6d. to 13s. 6d.; four-roomed (parlour) house, 11s. 6d. to 14s.; four-roomed (non-parlour) house, 10s. 6d. to 12s. 9d.; threeroomed house, 10s. to 11s.; two-roomed flat, 7s. 6d. to 9s. 3d. The rents of 19 demonstration wooden houses were also fixed as follows:—Four-roomed house, 13s. 6d. to 14s. 6d.; three-roomed house 11s.; two-roomed flat with common basement, ground floor 12s., first floor 11s.; detached four-roomed house, with alcove and basement, 20s. The scheme for the development of Becontree provides for the preservation of rural belts along the western and southern boundaries of the estate, and during the year the Council decided to transfer about 35½ acres of this land, adjoining Goodmayes recreation ground, to the Ilford Urban District Council (now the Ilford Borough Council) to lay out and maintain for use for recreation purposes. About 7.89 acres of this will be set apart mainly for the use of a children's playing field and the remainder for general sports and recreation purposes. The Council also agreed to convey two parcels of land on the Valence section (24.64 acres) and one on the Dagenham section (38 acres) to the Dagenham Urban District Council for use in perpetuity as open spaces. As part of the arrangement the district council agreed to surrender whatever rights or interest it might have in part of Becontree Heath (3½ acres) which is required in connection with the development of the Valence (No. 10) section of the estate. On 2nd March, 1926, the Council agreed to an exchange of lands with the Barking Town Urban District Council whereby about 35½ acres of land belonging to the district council near the centre of the estate was conveyed to the Council in exchange for a piece of land about 41 acres in extent, in the extreme south-west corner of the estate, required by the district council for an extension of the adjoining cemetery. With a view to straightening part of the northern boundary of the estate an exchange of two small parcels of land of equal area was effected during the year. During the year the Council sold two sites to the Church of England authorities, one for £1,040 and the other for £900 for the erection of two churches, and two further sites were sold to the Essex County Council for £1,130 and £625 respectively for the erection of elementary schools. Other sites were let on building lease for 99 years for the erection of shops, and a site at the junction of Goresbrook-road and Heathway on the Dagenham section was let on lease for the erection of a cinematograph hall. A site of about 3 acres in extent at the rear of the houses in Broad-street was let on a 21 years' lease to the Heathway Lawn Tennis Club, and a site on the northern side of Becontree-avenue was let on lease to a medical practitioner for the erection of a house and surgery. The freehold of Valence House and grounds, together with two adjacent cottages, was sold to the Dagenham Urban District Council for £2,000 for use for municipal purposes. Arrangements were made during the year for the widening of Broad-street on the Dagenham section, the work being carried on by the contractors for the development of the estate at the cost of the Dagenham Urban District Council. 179 The Council on 9th March, 1926, passed a resolution that, in its opinion, the need for improved travelling facilities between London and Becontree was vital and urgent. Evidence in support of this resolution was given on behalf of the Council in March, 1926, before theLondon andHome Counties Traffic Advisory Committee which had been appointed by the Minister of Transport to enquire into the adequacy of travelling facilities to and from East London. A new station or halt has been provided at Gale Street, Becontree, on the Southend branch of the London, Midland and Scottish Railway, the necessary land for the purpose having been provided by the Council. The total area of Bellingham is 252 acres, and under the main contract, completed in 1923, for the development of the portion of the estate devoted to working-class dwellings (176½ acres) 2,090 houses and flats were erected. The six houses of the " Tibbenham " type erected on one of the few small sites remaining on the working class portion of the estate were completed during the year, and the weekly net rents (exclusive of rates and water charges) were fixed as follows:—Four-roomed (nonparlour) house, 11s. to 11s. 6d.; five-roomed house, 13s. 3d. Bellingham. The housing estate at Downham (Lewisham and Bromley) which is about 520 acres in extent, was acquired under compulsory powers. The estate is being developed by Holland & Hannen and Cubitts, Limited, under a cost contract with a variable fee to the contractor. On 23rd February, 1926, the Council approved a supplemental capital estimate of £147,750 to cover the cost of 241 additional houses on the Bromley-road (No. 1) section of the estate, making a total for that section of 2,419 houses at an estimated cost of £1,457,750. This estimate proved to be insufficient, and a supplemental capital estimate of £689,250 was approved by the Council on 20th July, 1926, to cover the additional cost of the 2,419 houses on the No. 1 section and also the development of the Whitefoot-lane (No. 2) section by the erection of 698 houses and flats. Subsequently the Council on 30th November, 1926, approved a capital estimate of £305,000 for the development of a further section of the estate, known as the Baring-road (No. 3) section, by the erection of 421 houses and flats. At the end of the year about 1,600 houses had been completed, and over 1,300 houses were in course of construction. Work on the No. 3 section had not been commenced. Downham. During the year a further contract was entered into with the London and Eastern Prefacto Company, Limited, for the erection of four additional houses (making 8 in all) of the Prefacto type of construction at Downham. The development of the Bromley-road (No. 1) section includes the provision of 24 three-storey buildings containing 72 flats, and the weekly net rents (exclusive of rates and water charges) of these were fixed during the year, as follows:—Ground and first floors—three rooms, 10s. 6d. and 11s.; four rooms, 12s. Second floor— three rooms, 10s. and 10s. 6d.; four rooms, lis. 6d. The weekly net rents of certain demonstration houses of different types of construction were also fixed as follows:—"Atholl," "Telford," "Weir" and "Wild" types (five rooms) 13s. 6d. a week ; "Prefacto" houses—four rooms, 13s., five rooms, 14s. During the year the Council allocated a site of about 2½ acres to the north of Downham-way for the erection of an elementary school, and a site of about 13,000 square feet at the northern junction of Bromley-road and Old Bromleyroad was let on building lease for 99 years at a rent of £150 a year for the erection of shop premises with dwelling accommodation over. On 21st December, 1926, the Council decided that offers should be invited by public advertisement for a 99 years' lease of a site at Downham for the erection of a refreshment house, on the lines of the " Fellowship Inn " at Bellingham, for the supply of food and alcoholic and nonalcoholic liquors, on conditions, among others, that the house should be available for the general entertainment and refreshment of the population, and that the persons employed on the premises should not have a pecuniary interest in encouraging the sale of alcoholic liquor. 180 Roehampton estate. The Council has agreed to surrender a strip of land at Downham for the widening of Baring-road. Roehampton estate, Wandsworth, was acquired in 1919, and an area of about 93 acres has been allocated for the erection of working-class dwellings. The development of the first section and a part of the second section has been completed by the erection of 792 houses, and the erection of 422 houses and administrative buildings on the remainder of the estate has been entrusted to C. J. Wills and Sons, Limited, on similar terms to those contained in their contract for the development of Becontree. White Hartlane estate. Of the 422 houses 335 had been completed at the end of the year. Part of the White Hart-lane estate, Tottenham, was developed before the war, and on the remaining land 839 houses and two shops were completed before 1926. On 9th February, 1926, the Council decided to let a contract for the erection of 9 shops with dwellings over on the Lordship-lane frontage of the estate, and on 15th June, 1926, the contract was extended to include the erection of 4 houses on a vacant site in Tower Gardens-road. The weekly net rents (exclusive of rates and water charges) of the flats over the 9 shops have been fixed as follows:—Five-roomed flats, 14s. 3d. to 14s. 6d.; four-roomed flats, 13s. On 27th July, 1926, the Council decided to accept the offer of John Laing and Son, Limited, for the erection of 300 houses on their "Easiform" system of concrete construction to complete the development of the estate. The prices range from £459 for a four-roomed non-parlour intermediate house to £561 for a five-roomed end house. The total estimated cost of the 300 houses is £175,000. A plot of land on the estate has been let on lease for 99 years to the British Master Method Syndicate, Limited, for the erection of 4 houses on their special system of concrete construction. Watling estate. The Watling estate, which is situated astride Edgware-road in the Hendon urban district, is being acquired partly through the exercise of compulsory powers and partly by agreement. On 23rd June, 1925, the Council made a compulsory order for the acquisition of about 118 acres of additional land for inclusion in the estate. The Order was duly submitted to the Minister of Health, and after a local inquiry the Minister, on 19th January, 1926, confirmed the Order, with the omission of about 16¾ acres of land belonging to the London Electric Railway Company. The Council, on 27th July, 1926, agreed to purchase two additional plots of adjoining land, comprising 2¼ acres for inclusion in the estate. The main portion of the estate, about 400 acres in extent, lies to the east of the main road at Burnt Oak on the Edgware extension of the London Electric Railway, and provision has been made for the erection of about 3,970 houses. Particulars of the contract entered into with C. J. Wills and Sons, Limited, for the development of the estate are set out in the Annual Report for 1925 (Vol. III., p. 193). By the end of the year about 900 houses and flats were in course of erection, and the weekly net rents (exclusive of rates and water charges) for the accommodation were fixed as follows Five-roomed house, 14s. 9d. ; four-roomed house (parlour type), 14s. 6d.; four-roomed house (non-parlour type), 12s. 6d. ; threeroomed house, 12s. ; four-roomed flat, 12s. and 12s. 6d. ; three-roomed flat, 10s. 6d. and 11s.; two-roomed flat, 10s. and 10s. 3d. During 1926 the Council sold a site for £1,000 to the Church of England authorities for the erection of a church. Other sites were let on building lease for 99 years for the erection of shops or business premises, and a site was also let on lease for 99 years to the Hendon Electric Supply Company, Limited, for the erection of a transformer station, etc., in connection with the supply of electricity to the estate. 181 Offers of the Hendon Electric Supply Company, Limited, and the Gas Light and Coke Company to instal respectively electricity for lighting and gas for cooking purposes, etc., in houses on the estate have been accepted. Castelnau estate, Barnes (51¼ acres), has been acquired under compulsory powers obtained in 1925. Castlenau estate. On 27th July, 1926, the Council approved a capital estimate of £456,372 for the development of the estate by the erection of 643 houses. The Council considered that this was a case in which, instead of following the usual course of inviting tenders, arrangements should be made with a firm of repute for carrying out the work on a cost price basis. Negotiations were accordingly entered into with the firm of Henry Boot and Sons (London), Limited, for the erection of the houses on their pier and panel system of concrete construction, and as a result an arrangement was agreed to as follows:— (1) The contract to be for the development of the whole estate, including the construction of roads and sewers. (2) The operations under the contract to be financed by the Council on an actual-cost basis. (3) The contractors to guarantee that the actual cost of the work to the Council will not exceed a measured value to be determined in accordance with a schedule of prices in the manner provided by the contract, and the guarantee to be secured by means of a bond in an amount of £30,000. (4) The contractors' fee to be 2½ per cent. on the amount of the measured value provided that, in the event of the cost being less than the measured value by an amount of more than 1 per cent. of the measured value, the fee shall be increased in accordance with a sliding scale. (5) The contract to contain a " break " clause to enable the contract to be determined by the Council before the completion of the work, if necessary. The order to commence was given on 17th September, 1926. Old Oak estate, Hammersmith, was partly developed before the War, and on the remaining land 724 houses were completed before 1926. The Coimcil, on 27th April, 1926, accepted the tender of Mr. A.T. Rowley, amounting to £10,223, for the erection of 14 houses on one remaining site, and the houses were nearing completion at the end of the year. On 21st December, 1926, the Council fixed the weekly net rents (exclusive of rates and water charges) for the 14 houses as follows : end houses, 14s. 6d. and 15s.; intermediate houses, 14s. Old Oak estate. The Wormholt estate was partly developed by the Hammersnuth Metropolitan Borough Council, and the remainder (66 acres) was purchased by the Council in 1925 for £56,000. During the year 1926 the Council agreed to purchase from the borough council two additional plots of land for £2,500 for inclusion in the estate. The site adjoins the Council's Old Oak estate, with which it will be combined for purposes of administration. Wormholt estate. The Council s intention in acquiring this site is to provide houses for assisting the metropolitan borough councils in the west of London to meet the special needs of their boroughs, subject to payment to the Council in respect of the facilities thus afforded. During the year the Council decided to enter into agreements under section 14 of the Housing (Financial Provisions) Act, 1924, with certain metropolitan borough councils whereby the Council undertook to allocate for a period of years, not less than 20 and not exceeding 40, a number of houses on the estate to families to be nominated by the borough councils, in consideration of a payment to the Council, for the period during which the right of nominating tenants continued, of such annual sum not exceeding £7 a house as might be determined by the Council when the houses were completed. The houses included in these agreements were as follows:—99 houses to the Council of the Royal Borough of Kensington, 100 houses to the Hammersnuth 182 Metropolitan Borough Council, and 200 houses to the St. Marylebone Metropolitan Borough Council. Negotiations were in progress at the end of the year with other metropolitan borough councils with a view to a similar allocation of the remaining houses to be erected. It is proposed to erect on the estate about 662 houses, and 60 flats in threestorey buildings. Offers to undertake the work on a cost basis with a variable fee or commission, on the lines of the contract for the development of Watling estate, were invited from five firms. As a result three offers were received and the firm of Wilson Lovatt and Sons, Limited, was entrusted with the work. The Coimcil, on 16th November, 1926, approved a capital estimate of £450,000 in respect of the 662 houses, the preparation of the estimate for the three-storey buildings being deferred for the present. St. Helier estate. A compulsory order for the acquisition of about 846 acres of land for St. Helier estate, situated mainly in the parishes of Morden and Carshalton, was made by the Council on 15th December, 1925. The Order was duly submitted to the Minister of Health for confirmation and after a local inquiry held on 11th February, 1926, the Minister confirmed the scheme, with slight modifications, on 13th May, 1926. At the end of the year the preliminary plan of development was in course of prepreparation. St. Quintinpark site. The Council on 12th October, 1926, decided to appropriate for housing purposes a site at St. Quintin-park, Kensington, originally acquired for purposes of the education service. The site, which is about eight acres in extent, is very openly situated and has a frontage of about 520 feet to Dalgarno-gardens, a 50 feet road, in which the sewers are already laid. It is bounded on the west by the public recreation ground known as Little Wormwood Scrubs, on the north by allotment gardens bordering the Great Western Railway, and on the east by land belonging to the Clement Talbot motor works. The land, which has a gentle slope towards the south, is practically clear of buildings and could appropriately be developed by the erection of tenement dwellings for the working classes. The total charge against the housing account in respect of the land is estimated not to exceed £15,500. No definite arrangements for the development of the site have yet been made. Tabardstreet, etc., scheme. The Order confirming the Tabard-street and Grotto-place, Southwark, and Crosby-row, Bermondsey, a scheme under Part I. of the HousingAct, 1890, comprising altogether about 18½ acres, required the Council to erect on the Tabard-street area dwellings for the accommodation of not fewer than 2,580 persons of the working class, and stipulated that such dwellings should include not fewer than 25 cottages to be erected upon the detached portion of the area between Law-street and Little Hunter-street. The clearance of the three areas comprised in the scheme involved the displacement of 4,550 persons of the working class, but on account of the considerable number of vacant rooms existing in the neighbourhood when the confirming Order was made and the amount of housing accommodation which was being provided by the Council for the county generally, the rehousing obligation under the scheme was limited to the provision of accommodation for 2,580 persons. Accommodation has been provided on the main portion of the area known as Tabard Garden estate for 2,388 persons in seven block dwellings and one cottage, but there are still more than 1,000 persons residing in old dwellings in the three areas comprised in the scheme. To find a solution of the difficulty of continuing the work of clearance, the Council on 22nd June, 1926, decided to apply to the Minister of Health for a modification of the original Order so as to enable accommodation to be provided under the scheme for rehousing 1,000 additional persons on such sites or site as the Minister of Health might approve, and to cancel the requirement that certain of the rehousing accommodation must be provided by the erection of cottages. On 10th July, 1926, 183 the Minister of Health issued an Order entitled the London (Tabard-street, etc.) (Housing of the Working Classes) Amendment Order, 1926, to give effect to the proposal. In place of the 25 cottages to be erected under the original scheme, the Council proposes to erect upon the detached portion of the estate in Law-street, two blocks of dwellings, of which one is to be of the normal five-storev type to accommodate 192 persons and the other of the simplified type of construction (particulars of this type of dwelling are set out in the Annual Report of the Council, 1925, Vol. III., pp. 189-90) to accommodate 144 persons. The weekly net rents (exclusive of rates and water charges) for accommodation at Strood House, a building of the simplified type of construction provided on Tabard Garden estate as part of the rehousing accommodation under the Hickman'sfolly scheme, have been fixed on the basis of the rents charged for accommodation on other parts of the estate—viz., Ground and third floors—Four rooms, 14s. 6d. to 15s. 6d.; five rooms, 17s.; First and second floors—Four rooms, 15s. to 16s.; five rooms, 17s. 6d. During 1926 a site on the estate was let on lease for 99 years at a rent of £100, for the erection of a hostel for women or married couples. On 9th November, 1926, the Council decided to invite tenders from selected firms for the erection on a strip of land in Manciple-street, of four lock-up shops and four workshops of an inexpensive character, for letting to small traders and shopkeepers occupying premises on the Tabard-street area. The Brady-street scheme, under Part II of the Housing Act, 1890, relates to an area of about 7 acres in the metropolitan borough of Bethnal Green. About 1,875 persons of the working classes will be displaced, and accommodation has to be provided for 1,600 persons on the cleared site and for 265 persons elsewhere. In part fulfilment of the rehousing obligation under the scheme, a block of dwellings known as Whiston House, containing 12 tenements to accommodate 90 persons, has been erected by the Council at Goldsmith's-row, Shoreditch, and 35 cottages with accommodation for 175 persons have been provided on a site at Walthamstow by the freeholders of a large part of the property required for the clearance scheme. The first block of dwellings (Bullen House) to be erected on the improvement area, named Collingwood estate, was completed in 1923, and the second block (Pellew House), which consists of 48 tenements, was completed during 1925. The third block (Fremantle House), containing accommodation for 294 persons in 48 tenements, was completed during the year under review. On 22nd June, 1926, the Council fixed the weekly net rents (exclusive of rates and water charges) for accommodation at Fremantle House as follows : Ground floor—Two rooms, 9s. ; three rooms, 10s. 6d. to 11s. ; four rooms, 13s. First and second floors—two rooms, 9s. 6d.; three rooms, 11s. to 11s. 6d.; four rooms, 13s. 6d. Third and fourth floors—three rooms, 10s. 6d. to 11s. 6d.; four rooms, 12s. 6d. to 13s.; five rooms, 14s. 6d. Arrangements for the erection of the fourth block of dwellings (Codrington House) were in progress at the end of the vear. Brady-streeb scheme. The scheme for dealing with the Ware-street area, Hoxton (8½ acres), under Part I. of the Housing Act, 1890, involves the displacement of about 2,648 persons of the working classes, and the scheme as confirmed by the Minister of Health requires rehousing accommodation to be provided for that number, of which not fewer than 2,160 are to be accommodated within the area. Rehousing accommodation for 378 persons has been provided in 72 three-storey cottage flats on White Hartlane estate, Tottenham. The first block of dwellings (Archer House) to be erected on the reconstructed area (to be known as Whitmore estate), with accommodation for 228 persons in 39 tenements, was completed in 1925. The extension of Archer House by the provision of 12 additional tenements (33 rooms) and the 14172 n Ware-street scheme. 184 erection of another small block, to be known as Arrow House, to contain 18 tenements (48 rooms) were nearing completion at the end of the year. On 20th July, 1926, the Council approved a capital estimate of £38,094, subsequently reduced to £32,149, for the erection of three further blocks of dwellings (Horner Houses). These dwellings, which are of the simplified type of construction, have been designed to contain 80 tenements, comprising 188 rooms with accommodation for 376 persons. Tenders were invited by public advertisement, and on 12th October,1926, the Council accepted the tender of Rowley Brothers, Limited, amounting to £29,589 for the building work. On 29th June, 1926, the Council fixed the weekly net rents (exclusive of rates and water charges) for accommodation in Arrow House, and the extension of Archer House, on the basis of the rents already fixed for the first portion of Archer House, as follows—Ground floor—two rooms, 9s. 6d. to 10s.; three rooms, 11s. 9d. to 12s. First and second floors—two rooms, 10s. to 10s. 6d.; three rooms, 12s. 3d. to 12s. 6d. Third and fourth floors combined—three rooms, 11s. to 12s. 3d. ; four rooms, 13s. 6d.; five rooms, 15s. 6d. In order to secure the site of certain licensed premises required for the redevelopment of the area the Council during the year arranged terms with the freeholders for the settlement of their claim on a re-instatement basis, subject to the consent of the licensing justices. Hickman's folly scheme. Another unhealthy area which is being cleared by the Council is the Hickman's folly area, Bermondsey (6 acres), to be known after reconstruction as Dicken's estate. About 1,660 persons of the working classes will be displaced, and the order of the Minister of Health confirming the clearance scheme requires the provision of accommodation for this number of persons, of whom not fewer than 1,000 are to be accommodated within the area. For the purpose of providing part of the rehousing accommodation required under the scheme, a block of dwellings (Strood House) has, as indicated above, been erected in Staple-street on Tabard Garden estate, Southwark. The first block of dwellings (Pickwick House), with accommodation for 302 persons in 52 tenements to be erected on the Hickman's Folly area was nearing completion at the end of the year. On 20th July, 1926, the Council approved a capital estimate of £19,330, subsequently reduced to £17,960, for the erection of a second block of dwellings (Oliver House) which will comprise 34 tenements, containing 96 rooms with accommodation for 192 persons. The offer of the contractors for the erection of Pickwick House to undertake the work as an extension of their existing contract at the rates and prices contained in the contract was accepted by the Council on 12th October, 1926. At the end of the year the work of excavating and concreting the foundations was proceeding. On the basis of the rents charged at the Council's Swan-lane dwellings, Rotherhithe, after making allowance for larger rooms, greater amenities and closer proximity to the centre of London, the Council on 20th July, 1926, fixed the weekly net rents (exclusive of rates and water charges) for accommodation at Pickwick House as follows:—Ground Floor—two rooms, 8s. to 8s. 9d.; three rooms, 10s. to 10s. 9d. First and second floors—two rooms, 8s. 6d. to 9s. 3d.; three rooms, 10s. 6d. to 11s. 3d. Third and fourth floors combined—three rooms, 10s. to 10s. 9d.; four rooms, 12s. to 13s.; five rooms, 14s. to 15s. During the year the Council accepted the offer of the Bermondsey Metropolitan Borough Council to instal electricity for lighting purposes and of the South Metropolitan Gas Company to instal gas for cooking and lighting purposes at dwellings on Dicken's estate, free of cost to the Council, the tenants to have the option of using gas or electricity for lighting. 185 A site on the estate has been let for 21 years at a rent of £20 a year to the Oxford and Bermondsey Boys' Club, for the purpose of erecting a semi-permanent building for use as a boys' club. During the year the Council decided to purchase one of the three licensed premises on the area and not to retain the licence, and in the case of another of these premises, the site of which is required for the redevelopment of the area, the Council decided to settle the claim of the freeholders on a re-instatement basis subject to the consent of the licensing justices. The Bell-lane and Ellen-street scheme under Part I. of the Housing Act, 1890, provides for the clearance and reconstruction of two areas known as the Bell-lane area, Spitalfields (4 acres) and the Ellen-street area, St. George-in-the-East (1½ acres). Under the scheme as confirmed, dwellings have to be provided for the accommodation of 1,705 persons of the working classes, of whom not fewer than 600 are to be accommodated within the Bell-lane area, and the remainder elsewhere. The name Holland estate has been selected for the area when reconstructed. The Council on 23rd February, 1926, approved a capital estimate of £39,495 for the erection of the first two blocks of dwellings on the estate (Bernard House and Carter House), comprising 60 tenements and 12 shops, and accepted the tender of Chessums, Limited, amounting to £36,216, for the building work. At the end of the year Carter House was nearing completion and the work on the foundations of Bernard House was in progress. Bell-lane and Ellen-street scheme. During 1926, the Council accepted the offer of the Stepney Metropolitan Borough Council to instal electric lighting to the dwellings on the estate, free of cost to the Council, and the offer of the Commercial Gas Company to instal gas for cooking purposes, etc., at a charge of £2 10s. a tenement. During the year the Council decided to enter into an agreement with the owners of a beerhouse in the Ellen-street area involving an exchange of lands and the rebuilding of the beerhouse. The scheme for dealing with the two unhealthy areas, known as the George'sroad and Brand-street areas, Holloway (4¾ acres), was confirmed by the Minister of Health on 31st July, 1925. Altogether, 1,320 persons of the working classes will be displaced, and the scheme requires the provision of rehousing accommodation for an equal number of persons of whom not fewer than 900 must be accommodated on the cleared areas. The areas when reconstructed will be known as Ring Cross estate. George'sroad and Brand-street scheme. The properties forming the George's-road area included in the scheme when confirmed consisted of two detached groups of houses about 60 yards apart, but the properties in the intervening space were subsequently purchased by agreement for the purpose of improving the area for redevelopment. On 20th July, 1926, the Council approved a capital estimate of £33,917, subsequently reduced to £30,873, for the erection of two blocks of dwellings (Branston House and Rollit House) on the Brand-street area. The dwellings have been designed to contain 48 tenements, comprising 146 rooms with accommodation for 292 persons, together with 8 shops. The tender of Messrs. R. Woollaston and Company, amounting to £28,642, 16s. 3d. was accepted for the building work, and at the end of the year the excavations and concreting for the foundations were in progress. The scheme made by the Council for the clearance of three insanitary areas in the metropolitan borough of Poplar, known as the Baker's alley (1⅓ acres), Birchfield-street (¾ acre) and Bromley-place (¾ acre), areas was confirmed by the Minister of Health, in 1924. The confirming Order specifies that accommodation for not fewer than 190 of the total of 740 persons required to be housed shall be provided on the Birchfield-street area. Bakei's-alley, Birch field- street and Bron place scheme. On 20th July, 1926, the Council approved a capital estimate of £19,677 for the erection of a block of dwellings on the Birchfield-street area to be known as Birchfield 14172 N 2 186 House. The dwellings will be of four storeys of the simplified type of construction, and will contain 40 tenements comprising 95 rooms with accommodation for 190 persons. The tender of Messrs. R. Woollaston & Company, amounting to £14,867 3s. for the building work was accepted, and at the end of the year the excavations and concreting for the foundations were in progress. Prusom- street scheme. The scheme made by the Council for dealing with the Prusom-street area in Wapping (8½ acres), as confirmed by the Minister of Health, involves the displacement of 2,601 persons of the working classes and the confirming order requires the provision of accommodation for an equal number, of whom not fewer than 1,000 are to be accommodated on certain defined lands within the area. Certain houses in Watts street and Old Gravel-lane which were of a slightly better class than the other property included in the scheme as submitted to the Minister of Health were omitted by the Minister on confirmation. The effect of this exclusion was to leave the Council with an irregularly shaped plot of land to be developed for housing purposes, and consequently negotiations were opened up with the owners of the property in question with a view to the Council pin-chasing the property, and on 19th January, 1926, the Council agreed to the acquisition of the property for a sum not exceeding £1,000. The name Wapping estate has been selected for the area when reconstructed. The first block of dwellings to be known as Willoughby House, containing 31 tenements with accommodation for 184 persons, was completed towards the end of the year. On 26th October, 1926, the Council approved a capital estimate of £1,500 for preliminary expenses in connection with the development of the remainder of the estate, and by the end of the year preliminary plans of blocks Nos. 2 to 5 had been approved and the working drawings were in hand. On the basis of the rents charged for accommodation at the Council's dwellings in Cable-street, Shadwell, situated about half a mile from Wapping estate, and after making allowances for amenities and the difference in the size of rooms, the Council, on 27th July, 1926, fixed the net weekly rents (exclusive of rates) for accommodation at Willoughby House according to the following scale:—Ground floor—two rooms, 7s. 6d. to 8s.; three rooms, 9s. 6d. to 10s.; four rooms, 12s. First and second floors—two rooms, 8s. to 8s. 6d.; three rooms, 10s. to 11s.; four rooms, 12s. 6d. Third and fourth floors combined—three rooms, 9s. 6d. to 10s. 9d.; four rooms, 12s. to 12s. 6d. Offers were accepted during the year of (1) the Stepney Metropolitan Borough Council to instal electric lighting free of cost to the Council in dwellings on the estate ; and (2) the Commercial Gas Company to instal a gas service for cooking purposes, etc., at a charge of £1 14s. a tenement. Owing to the extreme difficulty experienced in the clearance of the Prusomstreet area, the Council, on 29th June, 1926, decided to appropriate for housing purposes the disused casual wards in Raymond-street, originally acquired as a site for the erection of a new elementary school, and selected a site, comprising the northern part of the adjoining open space (Wapping Recreation Ground) for the erection of the new school. In consideration of the portion of the recreation ground to be surrendered for the erection of the new school, the Council decided to add to the open space a portion of the Prusom-street area of slightly larger area than that proposed to be appropriated for the school. It is proposed to erect on the Raymond-street site, a five-story block of tenement dwellings with accommodation for about 260 persons. This proposal has the advantage of providing housing accommodation on the area without involving any displacement of population. Watergate- street scheme. A scheme for dealing with an unhealthy area in Deptford and Greenwich, known as the Watergate-street area (7.38 acres) was made by the Council on 10th February, 187 1925. The scheme, which was confirmed by the Minister of Health on 5th February 1926, provides that accommodation for 1,927 persons, which is equivalent to the number to be displaced, shall be provided on certain specified portions of the cleared site. As the area adjoins an existing housing estate, known as Hughes Fields estate this name has been selected for the area when reconstructed, and the two estates will be combined for administrative purposes. The Council on 12th October, 1926, approved a capital estimate of £32,072 for the erection of the first two blocks of dwellings to be erected on the estate, to be known as Blake House and Hawkins House. The dwellings will contain 67 tenements comprising 198 rooms, with accommodation for 396 persons. The tender of J. E. Billings and Company, Limited, amounting to £34,980, for the building work, was accepted, and at the end of "the year the concrete foundations for Blake House had been completed, and the brickwork commenced. There are three licensed premises on the area. A proposal to deal with one of them by offering the owners an alternative site on the Council's housing estate at Downham had to be abandoned, owing to the refusal of the licensing justices to sanction the removal of the licence. It is hoped that the two other licences may be dealt with as redundant and referred to the compensation authority under the Licensing Act. The scheme includes four houses which the owners desired for the extension of their works. The houses being situated on the border of the area were not essential to the scheme, and on 14th December, 1926, the Council decided to permit the owners to retain the major portion of the site, on condition that they demolished the houses when they became vacant and paid to the Council a sum of £400 towards the loss involved in providing rehousing accommodation for the persons displaced. The scheme made by the Council in 1925 for dealing with the Ossulston-street area, St. Pancras, 8 acres, was confirmed by the Minister of Health on 27th April, 1926. The execution of the scheme will involve the displacement of about 2,557 persons, and the confirming order requires that rehousing accommodation for not fewer than that number shall be provided within the area. A large proportion of the property included in the scheme has been acquired and the question of the redevelopment of the area was under consideration at the end of the year. Ossulston- street scheme A scheme was made by the Council in 1925 for dealing with four unhealthy areas known as (i) the China-walk area, Lambeth, (ii) the HatfieId-street and Hankeyplace areas, Southwark, and (iii) the Wyndham-road area, Camberwell. The scheme was duly submitted to the Minister of Health for confirmation and a public local inquiry lasting five days was held into the proposals between 19th and 25th November, 1925. The scheme presented several points of difficulty and at the end of 1926 the final decision of the Minister was still awaited. China-walk, Hatfield- street and- Wyndham road scheme The Council included in the scheme for rehousing purposes certain lands, about 4 acres in extent, adjoining the Wyndham-road area and a small site in Hankey-place. Southwark. but as they did not form part of the unhealthy areas the Minister intimated that he could not see his way to allow them to be retained in the scheme. The former property consisted of three sites, between Camberwell New-road and Wyndham-road, Camberwell, comprising in one case parts of gardens and in the other cases the sites of small cottages with large gardens. In view of the Minister's objection, which was based purely on legal grounds, the Council decided on 21st December, 1926, to acquire this property, under Part III. of the Housing Act, 1925, instead of under the clearance scheme, with the object of providing dwellings to be appropriated in due course for rehousing purposes. The total cost of the acquisition of all interests, making good the boundaries, etc., is estimated not to exceed £21,000, which is the same figure as would have applied if the property were acquired under the clearance scheme. 188 The total extent of the areas as now proposed to be dealt with under the clearance scheme is about 10¾ acreas.. The Hatfield-street area (2¾ acres) is situated in a district which is rapidly becoming industrialised, and the Council has decided to devote most, if not all of the area for commercial purposes. It is proposed to utilise accommodation being provided by the Council at Kennings estate, Kennington, for rehousing the persons to be displaced. During the year the Council decided to enter into agreements with two commercial companies owning property in the area, which they desired to retain for the extension of their businesses. One of these companies, The Associated Iliffe Press, Limited, held the freehold of a large number of houses in the area, all let on short tenancies. Under the agreement the company will retain the sites of the houses and will pay to the Council £13,000 towards the cost of clearance and providing alternative housing accommodation elsewhere. To facilitate the clearance operations and to enable the transfer of the tenants to be effected, the Council will take over the property of the company at an early date, and will pay to the company a rent during the period within which the clearance of the land will be carried out. The agreement with the second company, J. Sainsbury, Limited, provides for the clearance of the company's lands in the area which they will retain, for the sale of an additional cleared site to the company for £1,050, for the payment to the Council of £3,000 in respect of part of the loss involved in rehousing the people to be displaced, and for the granting of an option to the company to purchase at fair market value an additional parcel of land when the lay-out of the area has been finally determined. Basing-place and Blue Anchor-lane scheme. An official representation under Part II. of the Housing Act, 1925, was made to the Council during the year by the medical officer of health of Camberwell with regard to two unhealthy areas known as the Blue Anchor-lane and Basing-place areas within the borough. The Blue Anchor-lane area, about 2 acres in extent, is situated near the junction of Rye-lane and High-street, Peckham. It is bounded on the north by the rear of houses in Goldsmith-road, on the south by the rear of properties in High-street, on the east by the rear of houses in Hardcastle-street, and on the west it has a frontage to Hill-street. The area is largely occupied by costermongers and street sellers. The site planning is bad and the planning of the individual houses is unsatisfactory. The houses are old, worn and damp. The Basingplace area, about one acre in extent, is situated between High-street, Peckham, and Yictoria-road, and comprises Basing-place, Paradise-place and Paradise-yard. The houses are old, damp and worn, and the site is badly laid out, with the residt that light and ventilation are considerably restricted. The Council being satisfied that the existing evils could only be remedied by the clearance and reconstruction of the areas decided on 27th July, 1926, to make an improvement scheme in respect of the two areas, and approved a capital estimate of £50,000 in respect of the cost of acquisition and clearance. The scheme includes 124 houses (4 of which have been added for efficiency purposes), one beer-house, a small mission room on the Basing-place area, a number of workshops, etc., and it is estimated that the displacement of about 756 persons will be involved. It will be possible to provide dwellings on the Blue Anchor-place area with accommodation for about 950 persons, in addition to a few lock-up shops. The scheme provides for the rehousing on that area of a number of persons not fewer than the number to be displaced under the scheme. The scheme was duly submitted to the Minister of Health for confirmation, and a public local inquiry into the proposal was fixed for 20th January, 1927. Westonstreet site. The attention of the Council was directed during the year to a block of dilapidated property comprising 11 houses occupied by about 110 persons, at the junction of Weston-street and Tabard-street, Southwark, about 50 yards distant from the 189 Tabard-street area. The property was vested in the Bridge House Estates Trustees, who were prepared to sell for £935, and the Council on 27th July, 1926, approved a capital estimate of £1,250 for the purchase, including the expense involved in connection with the removal of the tenants and incidental costs. Church Army Housing, Limited, were desirous of developing a site in this locality for the erection of working-class dwellings and were prepared to take a lease of the site in question at a rent of £50 a year, which represented the value of the land for housing purposes. The Council accordingly decided to enter into an arrangement with the society on these lines, thus securing the clearance of a small insanitary area and the redevelopment of the site for housing purposes at small cost to public funds. East Hill estate, Wandsworth (8 acres) was purchased in 1924 for the purpose of providing accommodation for rehousing purposes in connection with the clearance of unhealthy areas. The accommodation for 3,254 persons which will be provided on the estate has been allocated to various clearance schemes as follows : Hickman'sfolly, Bermondsey, scheme, 400 persons; Prusom-street, Wapping, scheme, 1,060 persons; Baker's-alley, etc., Poplar, scheme, 200 persons; Bell-lane, etc., Stepney, scheme, 750 persons; and Tabard-street, etc., Southwark and Bermondsey, scheme, 844 persons. By the end of the year the first eight blocks of dwellings with accommodation for 1,524 persons in 256 tenements had been completed. East Hill estate. The Council on 4th May and 21st December, 1926, approved capital estimates amounting to £141,759, for the erection of three further blocks of dwellings, consisting of 236 tenements with accommodation for about 1,500 persons, together with seven shops. The work of construction has been entrusted to J. E. Billings and Company. Limited, the contractors for the erection of the first eight blocks of dwellings, as an extension of their existing building contracts at the rates and prices contained therein. On the 12th October, 1926, the Council accepted the tender of Smethurst and Company (London), Limited, amounting to £2,067 6s. 6d., for wiring and fitting blocks Nos. 9 and 10 for electric light. The Council on 23rd March, 1926, fixed the following scale of weekly net rents for accommodation in block No. 6 (St. Ives House):—Ground floor—Two rooms, 8s. 6d and 8s. 9d. ; three rooms, 10s. 6d.; four rooms, 12s. First and second floors—Two rooms, 9s. and 9s. 3d. ; three rooms, l1s.; four rooms, 12s. and 12s. 6d. Third and fourth floors combined—Three rooms, 10s. 6d. and 12s.; five rooms, 13s. 6d. and 14s., and on 12th October, 1926, the rents for blocks Nos. 7 and 8 (Milford House and Brixham House) were also fixed as follows:—Ground floor—two rooms, 8s. 6d. to 9s.; three rooms, 10s. 6d. to lis.; four rooms, 12s. 6d. First and second floors— Two rooms, 9s. to 9s. 6d. ; three rooms, 11s. to 11s. 6d.; four rooms, 13s. Third and fourth floors combined—three rooms, 11s. to 11s. 3d.; four rooms, 12s. 6d. to 13s.; five rooms, 14s. The Council on 19th January, 1926, and 21st December, 1926, approved capital estimates amounting to £1,177 for the paving of footways adjacent to the first eight blocks of dwellings. The Council has taken on lease for 120 years a site of about 2.3 acres in area in White Hart-street, Kennington, the property of the Duchy of Cornwall, for the purpose of erecting dwellings to be utilised for rehousing purposes under the Chinawalk, etc., scheme (see above). Kennings estate. It is proposed to erect seven blocks of dwellings with accommodation for 958 persons on the site which when developed will be known as Kennings estate. On 20th July, 1926, the Council approved a capital estimate of £28,990 for the erection of the first two blocks of dwellings, to be known as Calstock House and Fowey House, comprising 66 tenements, containing 144 rooms with accommodation for 288 persons. 190 The erection of these two buildings was made the occasion for ascertaining definitely whether any economical substitute could be obtained for the type of brick construction usually adopted by the Council for block dwellings. Alternative designs were accordingly prepared ; one based on the normal method of brick construction, and the other specially adapted to the requirements of steel and concrete ; and for the latter design alternatives of (1) a steel frame with external walling entirely of concrete, and (2) a steel frame with external walling of concrete but with brick facing were included. In addition to the different methods of construction embraced by the drawings and specification, provision was made to enable prices to be submitted for the buildings if constructed of any special material such as reinforced concrete, or by any special method, the drawings in these cases being regarded as indicative only of the requirements as to equipment and accommodation. Tenders on this basis were accordingly invited by public advertisement, and, as a result 15 tenders were received for normal brick construction, 17 for steel and concrete construction, and 2 for reinforced concrete construction. The lowest tender received was for buildings of normal brick construction. In every case in which a firm had submitted prices, both for brick and steel frame construction, the price of brick construction was considerably lower. The tenders for steel frame construction showed a substantial reduction in every instance if brick facing, instead of concrete throughout, were used for the external walls. The lowest tender for brick construction (£21,752) was equivalent to about £151 a habitable room, for steel frame construction (£24,442) about £170 a room, and for reinforced concrete construction (£24,762), about £172 a room. The tender for buildings of the normal brick construction submitted by Mr. R. J. Rowley, amounting to £21,752, was eventuallv accepted. Hornsey-rise estate. The Hornsey Rise estate, Islington (3 acres), was purchased by the Council in 1925 and the accommodation for 1,168 persons which will be provided thereon has been allocated for rehousing persons of the working class displaced in connection with the acquisition of properties for the education service. Tenders for the erection of the first block of dwellings were invited by public advertisement, with the intention that the contracts for the three blocks should be let on the basis of the prices tendered for the first. The Council on 16th March, 1926. accepted the tender, amounting to £37,324 14s. 5d. for block No. 1, submitted by E. D. Winn and Company, Limited; and on the same date approved a capital estimate of £112,080 for the erection of the three blocks of dwellings to be known as Ritchie House, Goldie House and Welby House, respectively. On 9th November, 1926, the Council decided that electricity should be employed for general lighting purposes on the estate and that gas should be installed for cooking and heating and ancillary lighting for the use of tenants if desired. The wiring and fitting for electric lighting will be carried out bv and at the expense of the Council. Well-street site. The attention of the Council was directed during the year to a site at South Hackney, suitable for development by the erection of dwellings to be utilised for the provision of rehousing accommodation in connection with schemes for the clearance of unhealthy areas in East London. The site, which is about 3 acres in extent, lies in the quadrangle bounded by the gardens of houses in Well-street, St Thomas's-road, King Edward-road, and Shore-road. The site is about two miles distant from the Poplar areas, the Prusom-street area, Wapping, and the Bell-lane area, Spitalfields, and about a mile from the Brady-street area, Bethnal Green, and the Ware-street area, Hoxton, and is, therefore, very conveniently and centrally situated for rehousing purposes. The Governors of St. Thomas's Hospital, the owners of the property, while not prepared to dispose of the freehold, were willing to let the land on building lease for 99 years, at rents of £60 for each of the first and second years, £125 for the third year, and £150 for the fourth year, £175 for the fifth year and £250 a year subsequently. Part of the site was subject to certain leases 191 which had not expired, and when the Council, on 30th March, 1926, decided to take a lease of the site on the terms indicated, it also approved a capital estimate of £4,000 for obtaining possession of the whole site and for carrying out certain works (including the provision of boundary walls, etc., where necessary) consequent on severance. The site, which will be known as Shore estate, will be developed by the provision of 184 tenements with accommodation for 1,016 persons. On 11th May, 1926, the Council approved a capital estimate of £3,500 in respect of preliminary expenses incidental to the erection of the dwellings and at the end of the year working drawings for blocks Nos. l and 2 were well in hand. The Council having decided to adapt the upper floors of the disused fire-station at Shepherd's Bush for rehousing purposes, to be known as Bush Green House, accepted during the year a tender, amounting to £678, for the work of conversion. The cleaning and decorating work was carried out by direct labour at an estimated cost of £120. The ground floor and basement have been let for commercial use. Bush-green House. The Council's dwellings are built primarily to provide residential accommodation for persons of the working classes and the Council is satisfied that the dwellings are occupied by the class of persons for whom the accommodation is intended. The most numerous categories are clerks, labourers, transport workers and printers, while mechanics in various trades form a large proportion of the total. It has been found expedient, however, to allocate a few houses and tenements to medical practitioners, midwives, nurses and others, whose presence is essential to the wellbeing of the tenants on the estates. Some of these have been given preference on this account over the ordinary applicants for tenancies. Occupation of tenants— Rents. As the Council's post-war housing operations are subsidised out of public funds, persons to whom special facilities have been afforded to exercise a calling on the estate have been charged rents exceeding those ordinarily charged to the other tenants. The rents of premises let for purposes of a medical practice have, for example, been fixed at what may be described as a remunerative rent, that is to say, at an amount sufficient to cover all outgoings including debt charges, while in certain other cases preferentially accommodated rents have been charged on a lower scale but still exceeding the rents fixed by the Council for ordinary tenants. It is a condition of the ordinary tenancy of the Council's dwellings that the premises shall not be used for trade purposes. Some of the tenants, however, have utilised their address for receiving orders in connection with their business, and in a few cases it has been found that, in addition to the essential services mentioned above, some minor profession, e.g., music teacher, or work of a light character, such as dressmaking, is carried on. The question which was reviewed by the Council during the year, is one of some difficulty, it being necessary on the one hand to obviate hardship to the person in poor circumstances and on the other to ensure that public funds shall not be employed to subsidise profitable businesses or professions. In the circumstances, the Council decided on 9th March, 1926, that tenants belonging to the better paid professions, such as doctors, dentists, etc., should continue to pay a rent at least equivalent to the remunerative rent; and that in all other cases in which public indication given that any profession or occupation for profit was being carried on at or from the dwelling or in which the tenant was preferentially accommodated for the purpose of pursuing such profession or occupation, an addition of 10s. a month should be made to the normal subsidised rent. The position will be reviewed at the end of twelve months. During 1926 the charges for cubicles at the Council's lodging-houses, Carrington House and Parker-street House, were reduced by 1d. to l0d. and 11d. a night, respectively, with corresponding reductions for special cubicles and weekly tickets. Lodging house?. During the year the Council made grants not exceeding £100 in all out of the interest on deposits paid by tenants on taking up tenancies, for distribution to prize funds for the best kept gardens and window boxes on the Council's estates. Prizes for gardens and window boxes. 192 Selection of tenants. The Council had under review the results of the arrangement agreed to in 1924, as an experiment for one year, whereby a part not exceeding 50 per cent, of the new accommodation provided by the Council under Part III. of the Housing Act, 1890, was allocated amongst suitable applicants recommended by the metropolitan borough councils in proportions based upon existing conditions of overcrowding in such boroughs. Taking the total number of new houses which became available for letting in 1925, about 32 per cent. were let to applicants recommended by the borough councils. In addition a number of other cases of special hardship were accommodated so that, about 80 per cent. of the accommodation was preferentially allotted to families living in unhealthy or overcrowded conditions, leaving only about 20 per cent. to the ordinary applicants from the general list. Many of the families thus preferentially accommodated were very poor, and were found to have been living in only one room or two. Some had been registered for accommodation by the borough councils for a considerable period. In the past, experience showed that where poor tenants were placed in limited numbers amongst tenants of a better class, their home conditions improved, but when such a large proportion of the accommodation was let to tenants of this character the improvement was not so apparent. By continuing this policy the Council ran the risk of loss and general deterioration, and difficulty in preventing accumulation of arrears of rent. The allocation of houses to special hardship cases having reached an unduly high percentage, the Council, on 26th January, 1926, while continuing the arrangement with the borough councils, decided tc include all such cases preferentially treated in each borough in the quota allotted to the borough council, so that approximately 50 per cent. of the new accommodation provided by the Council should be available for the applicants to be taken from the general list. Staff. The average number of workmen employed by contractors on the Council's housing development operations at the end of the year was about 9,900. About 450 men were continually engaged during the year on works of maintenance and repair at the Council's dwellings and estates, while the local management staff, including superintendents, estate clerks, porters, etc., numbered about, 140. Workmen's trains, etc. The Council's action in earlier years with regard to workmen's trains at cheap fares was dealt with in the Annual Report for 1920 (Vol. I., p. 77). In the Annual Report for 1923 (Vol. III., pp. 139-40) particulars are given of the proceedings before the Railways Rates Tribunal at which representations were made by the Council on the subject of the charges to be made for workmen's fares and season tickets on London railways. During 1924 schedules of the standard charges proposed to be made by the companies in respect of the conveyance of passengers and goods were submitted to the Tribunal and formal objections to the proposals were lodged on behalf of the Council (Annual Report for 1924, Vol. III., p. 153). As a result of the Council's representations, the railway companies submitted forms of schedules of charges for workmen's fares and season tickets. The Council secured an amendment of the schedules submitted by the companies in regard to workmen's fares with the result that the schedules were approved by the Tribunal in such a form as to enable it at the proper time to consider the Council's suggestions in regard to the fixation of the actual fares to be charged. After the form of schedules had been settled the Tribunal proceeded to ascertain the standard revenue of the companies in 1913, and the next stage of the inquiry, which was commenced on 5th October, 1925, was to determine the estimates of railway working expenses after the fares and charges to be fixed by the Tribunal shall have come into operation. The Tribunal delivered its judgment on 30th December, 1926, provisionally determining the schedules of standard charges to be made by the railway companies in respect of goods, passengers, etc., which are to operate as from a date to be determined by the Tribunal (probably 1st January, 1928) upon finally fixing the charges. The effect of the judgment is being considered by the Council. Printed by Odhams Press Ltd., Long Acre, W.C.2.