LCC 36 London County Council. ANNUAL REPORT OF THE COUNCIL, 1927. Vol. III. PUBLIC HEALTH. (Including the Reports for the year 1927 of the County Medical Officer of Health and School Medical Officer, Main Drainage and Housing.) 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.I, Agents for the tale of the Publication of the London County Council. 1928. No. 2588. Price 2s. 6d. London County Council. ANNUAL REPORT OF THE COUNCIL, 1927. Vol. III. PUBLIC HEALTH. (Including the Reports for the year 1927 of the County Medical Officer of Health and School Medical Officer, Main Drainage and Housing.) CONTENTS. Chapter I. REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH FOR THE YEAR 1927. Vital Statistics— Page Population—Marriages—Births—Deaths—Infant Mortality 6 Infectious Diseases— Smallpox 7 Measles—Whooping-cough—Scarlet Fever—Diphtheria 10 Diarrhoea and Enteritis—Typhoid Fever—Anthrax 11 Plague and Cholera—Typhus—Cerebro-Spinal Fever—Poliomyelitis— Polioencephalitis—Encephalitis lethargica—Influenza 12 Tuberculosis Cancer 16 Statistical Table 23 Administration— Common and Seamen's Lodging Houses—Homeless Persons—Verminous Lodgers 24 Housing Acts Statistical Information 25 Sanitary Officers, Milk and Dairies Act 27 Venereal Diseases 28 Tuberculosis 30 Dispensaries (Analysis of Returns) 32 Laboratory Work 36 Midwives Acts and Children Acts 39 Mental Deficiency Act, 1913 43 Blind Persons Act 44 Chemical Branch 46 Observations of Visibility and Actinicity 49 Chapter II. REPORT OF THE SCHOOL MEDICAL OFFICER FOR THE YEAR 1927. Staff—School Buildings 51 Results of Medical Inspection 55 „ „ Higher Education Institutions 61 Dental condition of school children 63 Health of leavers—Insufficient sleep 67 Following-up 69 Chronic Invalidity 72 Medical Treatment 73 Rheumatic Children 81 Personal Hygiene Scheme 89 Physical Education (Teaching of Hygiene) 90 4 Page Co-operation with Official and Voluntary Agents 99 Open-air Education 106 Employment of Children—Nursery Schools116 School Meals 131 Infectious Disease Control132 The Treatment of Crippled Children147 Defective Children167 Examinations of Employees in the Education Service and Scholars 171 Statistical Tables.—I. Inspections—II. Defects—III. Exceptional Children —IV. Treatment of Minor Ailments, Visual Defects, Defects of Nose and Throat, Dental Defects, Uncleanliness172 Chapter III. Public Health—Tuberculosis—Venereal disease—Infant life protection— Health propaganda—Lying-in homes—Midwives—Homeless persons— Lodging houses—Offensive businesses—Cowhouses—Milk—Infectious diseases—Smoke nuisances 177 Chapter IV. Main Drainage 186 Chapter V. Housing 193 London County Council. ANNUAL REPORT OF THE COUNCIL, 1927. VOL. III—PUBLIC HEALTH. CHAPTER I. REPORT OF THE COUNTY MEDICAL OFFICER FOR THE YEAR 1927. By F. N. Kay Menzies, M.D., F.R.C.P. (Ed.), D.P.H., F.R.S.E., County Medical Officer of Health and School Medical Officer. Introductory Note. The two annual reports, to which this note forms the introduction, deal separately with the health circumstances of the population of London as a whole and with the health of the school-child approached individually and regarded apart. It might be thought that this year a disproportionate amount of space had been allotted to one of these two aspects of a subject which, broadly regarded, is in purpose and effect indivisible. During the present year, however, it has been thought less necessary to enlarge upon the administration of the general public health services, because some of these services have been very extensively dealt with either in recent annual reports or as separate monographs. In this latter category may be included, e.g., sewage disposal, common lodging houses, venereal disease and tuberculosis. Again, the school medical service, joining hands with social agencies, is more intimately in touch with the domestic lives of the people and, in this way, exercises a material influence on the general public health. Friendly and intimate talks to parents on the health of their children, the subject which is nearest to their hearts, is a most potent factor for good. Since the advent of medical inspection in London two generations of scholars have come within the purview of the school medical service, the outlook of the child has been broadened in every way, and the resulting reflex action upon the parents has undoubtedly improved the home environment. It would be invidious to choose among the manifold activities of this vast social service, but, in the present report, special attention has been directed to rheumatism and other crippling physical defects of childhood. The problem of the nursery school, too, has been discussed at a length merited by its importance. The Council has very good reason to be proud of its organisation for the amelioration of the life of the child. Everywhere the young life is aided by willing hands. Administrators, teachers, doctors, nurses, organisers and voluntary care committee workers, all unite to assist the parents in the endeavour to guide the child along the way of life that leads to useful citizenship. The physically defective, the blind, the deaf, and the feeble-minded child is afforded every possible opportunity to reduce his handicap in competition with his more fortunate brother in the struggle for existence. Voluntary agencies are associated with the school organisation in the supply of clothing, boots, spectacles, etc., where they are needed. The lighter side of life is not neglected, playground classes and healthy entertainments are provided in the intervals of school work. School journeys and visits to places of interest aid in the acquisition of knowledge and the cultivation of powers of observation. Athletic sports, cricket, football, netball, hockey, teach comradeship and team work, and elementary schools are beginning to have traditions and heroic ideals in the same way as the older public schools. Such a school fellowship may well be the foundation of a life-long trust, a memory, and an incentive. (6) 1000—(0.12940—7«i)—6.7.28—15435 6 Vital Statistics. Population. 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 1927 to have been 4,550,000, including 9,000 non-civilians. The estimated populations of the metropolitan boroughs in 1927 are shown in table on page 23. While the population of London has remained about four-and-a-half millions since 1901. the birth-rate has fallen continuously and, as a consequence, the child population of London has decreased considerably, the proportion of children under fifteen years of age having fallen from 30 per cent. in 1901 to 26 per cent. at the last census. On the other hand, the proportion of persons over thirty-five years of age increased from 32 per cent. to 40 per cent. There is no sign of arrest in the accelerated rate of decline in births and, assuming the present decrease, both of births and of infantile mortality, to continue until the next census, the children under fifteen years of age will by then form less than 20 per cent. of the total population, while the proportion at higher ages will be still further increased. The effect of these changes in the age-constitution of the population upon housing requirements in London is to increase the demand for tenements and part houses. Assuming that the number of married and widowed women may be taken as a broad indication of the number of family units, there has, since 1901, been an increase in the number of units of over 110,000 in a practically stationary population. Marriages. The marriages registered in London during 1927 numbered approximately 41,301 or 18.2 per thousand of the population, the rate for each of the preceding three years being 17.2. Births. The births in London during 1927 numbered 73,263 as compared with 78,825 in the preceding year. The birth-rate was 16.1 per thousand as against 17.1 for 1926 and 17.9 in 1925. The lowest birth-rate recorded in London was that for the year 1918, when the effects of the war were at their maximum. In that year there were 70,976 births, this being only 2,287 less than in 1927. In the last quarter of 1927, the births fell below the lowest number recorded for this quarter even during the war. The decrease in the number of births in London since 1921 has averaged about 4,000 annually. In 1901, when the population was about the same, the births exceeded those of last year by 57,829. The birth-rate for each metropolitan borough will be found in the table on page 23. The deaths in the civil population of London during 1927 numbered 55,170, giving a death rate of 12.1 as compared with 11.6 in 1926 and 11.9 in 1925. The distribution of the deaths by ages in 1927 and recent preceding periods is shown in the following table:— Year. 0— 1— 2— 5— 10— 15— 20— 25— 35— 45— 55— 65 + All ages. 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 1927 4,357 1,181 1,152 788 527 992 1 254 2,420 3,620 6,434 9,073 23,372 55,170 The increase in the number of deaths in London during 1927 over that in the two preceding years was almost entirely due to the influenza epidemic at the beginning of the year which resulted in a considerable increase in the mortality at the higher ages. Associated with this epidemic there was, as in other years an 7 increase in the deaths from diseases of the respiratory system and of the heart. An increase occurred in the deaths from nephritis, but, on the other hand, the deaths from diarrhoeal diseases were considerably below the average. Fatal street accidents continued to increase in number, the total being 669 in the 52 registration weeks of 1927 against 656 in 1926. Among children under 15 years of age, however, the deaths, numbering 149, were less by 14 than in 1926. The death-rates from all causes and from certain specified causes in each metropolitan borough and in London as a whole will be found in the table on page 23. The weather in 1927 again favoured infant life, the deaths under one year of age per 1,000 births being 59. which is the lowest rate recorded in London. It will be seen from the following table that the principal cause of the low rate was the decreased mortality from diarrhœa, due to a cool summer. Cause of Death. 1911 to 1914. 1915 to 1918. 1919 to 1922. 1923 to 1920. 1923. 1924. 1925. 1926. 1927. Measles 3.40 3.84 1.64 2.02 0.96 3.37 0.87 2.88 0.63 Whooping-cough 3.63 4.45 2.50 2.60 2.23 2.30 4.58 1.29 3.08 Influenza 0.27 1.10 0.81 0.38 0.20 062 0.38 0.34 0.46 Tuberculosis 3.40 3.20 1.52 1.26 1.21 1.20 1.48 1.14 1.05 Bronchitis 6.41 6.72 4.42 2.91 2.43 3.62 3.02 2.59 2.12 Pneumonia 12.28 14.96 12.60 11.51 9.07 14.13 12.27 10.59 11.37 Diarrhoea 24.28 16.10 12.16 9.36 9.07 7.89 9.72 10.78 6.97 Premature birth 18.16 17.42 17.00 14.74 14.66 15.89 14.31 14.11 13.94 Congenital defects 14.69 14.66 11.26 8.39 8.80 7.96 8.70 8.12 7.17 All causes 108 103 79 65 61 69 68 64 59 Infectious 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 23. During 1927, five cases of smallpox occurred within the adminstrative County Smallpox, of London, of which two proved fatal. Enquiry showed that, including one of the fatal cases, two were definitely unvaccinated, one was vaccinated for the first time after being infected but in time to modify the attack, another (aged fifty-four years) was vaccinated in infancy, and the remaining case (aged forty years) which terminated fatally was said to have been vaccinated but no scars were discernible. An outbreak in Hendon which occurred in March-May apparently originated from some unrecognised source in London. About this time outbreaks of smallpox occurred on board vessels coming through the Mediterranean from the East. In one case a smallpox patient was transferred to the Port of London's Smallpox Hospital at Denton from a ship (s.s. Nankin) which arrived at Gravesend from India on the 7th March, 1927. In another instance a passenger on board the P. & 0. liner, s.s. Rawalpindi, developed smallpox and was transferred to hospital at Gibraltar, where she died on the 13th March, two days after being landed. Many of the passengers on this vessel came to London, and the ship's surgeon developed smallpox in Wimbledon, and was removed to hospital on the 31st March, 1927. A case of smallpox also occurred at Gravesend at the end of March in the person of a waterside labourer working on ships coming into the Port of London. These facts are significant when considering the outbreak in Hendon and London which comprised thirteen cases (including four in London), of which seven were fatal. The outbreak is of special interest as it illustrates in a special degree two most important factors associated with the spread of smallpox, i.e. (1) the danger of the unrecognised mild case, diagnosed as chickenpox, which gives rise to secondary fatal cases; and (2) infection by fomites and the need for such persons as laundry workers being adequately protected by vaccination. 8 The history of the outbreak is briefly as follows: —A commercial traveller (A.M.), aged forty-seven years (vaccinated in infancy), living in Golders Green, who represented a firm of coal merchants in Paddington, and whose business necessitated frequent calls in the East end, fell ill on the 25th March, 1927, and four days later deve'oped a rash which was considered to be that of chickenpox. Subsequently, his wife (vaccinated in infancy) and daughter (aged sixteen years, unvaccinated) fell ill and developed rashes on the 9th April and the 13th April respectively; they were both admitted to a Hampstead nursing home under the impression that the disease from which they were suffering was chickenpox. Suspicion of smallpox was not entertained until 23rd April, when the Medical Officer of Health of Hampstead was called in, with the result that both patients were diagnosed as suffering from confluent smallpox. The daughter died in the Metropolitan Asylums Board Smallpox Hospital, Long Reach, Dartford, to which both patients had been removed. Further examination of A.M. revealed that he had had smallpox, and that he had not completely recovered. Another unvaccinated daughter, aged eight years, was also found to be suffering from the disease. They were both removed on the 24th April to the Middlesex County Council Smallpox Hospital at Yeading. As a result of the discovery of these cases four others were detected among the workers at the laundry to which the linen of the aforementioned family had been sent to be washed ; their rashes having appeared on the 21st April (two cases), 26th and 27th April respectively. A baby of one of these patients, prematurely born during the early stage of illness of the mother, also developed a smallpox rash (4th May) seven days after birth. Only one of the laundry workers who developed smallpox had been vaccinated and then only in infancy. Four cases connected with the laundry workers proved fatal, including the baby and its mother. The five cases, described below, occurred in London whilst the Hendon outbreak was in progress, and in the absence of the discovery of definite sources of infection, could only be regarded as having originated directly or indirectly with the Hendon cases or with some other missed case or cases which gave rise to or was associated with that outbreak. (1) A.N., a female, aged forty years, stated to have been vaccinated although no scars were discernible, was the daughter of the proprietress of an apartment house in Hampstead in close proximity to the nursing home where two of the Hendon cases were treated before they were recognised as smallpox {vide supra). Her rash appeared on the 5th May, but the case was not discovered until the 7th May, when she was removed to hospital. She died four days later. Although no direct association could be established it may be assumed that her infection was derived in some way from the nursing home. (2) On 10th May, C.R.. a male, aged twenty-nine years, unvaccinated, living in Poplar, was found to be suffering from smallpox, the rash having appeared on the 7th May. He had been moving about freely up to the time the nature of his illness was discovered, but the fact that no secondary cases resulted was no doubt largely due to the prompt action of the Medical Officer of Health of Poplar, who arranged for about two hundred and seventy persons to be vaccinated in connection with the occurrence of this case. The patient recovered after having had a severe attack. The source of infection was not elucidated, but it was significant that the man was infected during the time the Hendon cases were occurring. (3) C.S., aged twenty-nine years, living in Hackney, brother-in-law to C.R., mentioned above, was removed to hospital on the 19th May whilst he was under observation as a contact. The rash did not appear until the day following his removal to hospital, i.e., probably before he was infectious. He was primarily vaccinated on the 10th May as a contact of C.R., and his illness was modified in consequence. 9 (4) The fourth case in this series occurred in the Metropolitan Asylums Board Eastern Fever Hospital. The patient, an unvaccinated male child, aged four years, was admitted to the hospital on the 31st March, 1927, with whooping cough. On the 17th May he was transferred to the South Wharf Receiving Station on suspicion of smallpox. The diagnosis was confirmed, and the child was taken to Long Reach Hospital, where he died on the 23rd May. The infection in this case must have been contracted in the hospital, probably from some unrecognised case in a visitor, but the actual origin was never traced. (5) The fifth London case was imported from the North of England. A male vagrant, P.R., aged fifty-four years, vaccinated in infancy, tramped from Yorkshire to London, and was discovered in the Paddington Casual Ward on the 14th June to be suffering from smallpox. He had had a noticeable rash for seven days when detected. The case was very mild and typical of those which have been occurring in the provinces for the past few years. Up to the end of 1927, London remained singularly free from the invasion of smallpox from the provinces, in spite of the increasing number of cases which had been occurring in the Midlands and North of England, as will be noted in the following table:— Year. England and Wales (including London). London. Cases. Deaths. Cases. Deaths. 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 5,365 9 10 1 1926 10,141 11 (See note below) 5 1 1927 14,787 5 2 Note.—During 1927, there were 49 deaths in England and Wales in which smallpox was mentioned as a primary or contributory cause of death. In 13 of these smallpox is stated to be a contributory or secondary cause of death. In the remaining 36 cases smallpox is entered on the death certificate as the sole, primary or immediate cause of death or as a morbid condition giving rise to the immediate cause of death (for further particulars see the Annual Report of the Chief Medical Officer of the Ministry of Health for 1927 on the "State of the Public Health" when published). In last year's annual report it was stated that it was "hardly reasonable to assume that the Metropolis would remain free indefinitely." The early experience of 1928 has lent weight to that statement, for in the first three months about fifty cases of smallpox have occurred in London, mostly among the vagrant or indigent class, whilst as many have been reported in the surrounding counties. The outbreak or ginated in a casual ward at East Preston, Sussex, where a tramp was admitted in December, 1927, in a collapsed condition, having tramped from Lincolnshire. He was not recognised as suffering from smallpox, but a fortnight later about a dozen cases were discovered in the casual ward, and it was only then that the nature of the illness of the earlier admission was detected. In the meantime, large numbers of tramps had scattered over the countryside and many of them were incubating smallpox, with the sequel already stated. The outbreak is still in progress at the time of going to press, and a fuller report will be published in the annual report for 1928. The special danger to London of this mild type o smallpox, apart from the suffering, disorganisation and expenditure of time and money inherently associated with an outbreak of this disease, is the recurring risk o the introduction of the severe form of the malady from the Mediterranean or the Eastern Hemisphere, side by side with 'he benign form. It is only necessary to compare the mortality in the "Hendon" outbreak, i.e., thirteen cases with seven deaths (over 50 per cent. mortality), with that in the provinces (see table above), to realise the anxiety which 10 would be caused if the hemorrhagic form of the disease invaded London whilst an outbreak of the benign type was in progress. Owing to the difficulties which have arisen from time to time, consequent upon the differential diagnosis of smallpox, the Metropolitan Asylums Board revised their arrangements for the removal of patients, and the following procedure was adopted in December, 1927. (i) When the Board receive an application from a medical practitioner for the removal of a patient who is certified by the applicant to be suffering from smallpox, the Board will forthwith send to remove the case, at the same time notifying the medical officer of health of the borough of the application by the quickest available means. (ii) The Board's medical superintendent at South Wharf will, as soon as practicable, inform the borough medical officer of health of his view of the case, and, if he is unable to confirm the diagnosis but desires to retain the case at South Wharf for observation purposes, the borough medical officer of health will be given facilities for seeing the patient if he desires to do so. (iii) When the Board receives an application from a medical practitioner for the removal of a case which the applicant is not prepared to certify definitely, but which he regards as doubtful, the applicant will be referred to the borough medical officer of health and the case will not be removed until a definite certificate is forthcoming, or the medical officer of health applies for the case to be admitted for observation. 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 in connection with the diagnosis of suspected cases of smallpox. Finally, it must be emphasised once again, that the only bulwark against the invasion of smallpox is vaccination, and until the population as a whole is more adequately vaccinated, the risks of smallpox spreading in London will continue to arise from time to time, and in addition to the suffering and loss of life, vast expenditure of time, labour and money, which could be more usefully directed into other more profitable channels for the benefit of the public health, will continue to be expended in the Sisyphean labour of attempting to prevent a disease which would be non-existent in a properly vaccinated community. Measles was epidemic during the winter of 1927-28. The deaths in 1927 numbered 181, of which 130 occurred in the last quarter of the year, when the rapid increase in the deaths gave warning of the approaching winter epidemic. The deaths in successive four-weekly periods in the epidemic of 1927-28 compare with the corresponding figures for that of 1925-26 as follows:— Years. October to December. January to April. Total (28 weeks.) 1927-28 5 41 83 163 200 362 322 1,176 1925-26 38 84 133 216 196 205 167 1,039 While the deaths in the present epidemic exceed those recorded in 1925-26, they are below the number in the epidemic of 1923-24, when in the corresponding 28 weeks 1,309 deaths occurred. The death-rates in the metropolitan boroughs are shown in the table on page 23. There were 548 deaths from whooping-cough in London during 1927, the disease being epidemic during the winter months. An increased incidence was anticipated in view of the unusually low mortality in the preceding year when the deaths numbered only 231. The distribution of the mortality in the various metropolitan boroughs is shown in the table on page 23. There were 13,178 cases of scarlet fever notified in 1927 (52 weeks), the corresponding figure for 1926 being 12,293. The attack-rate was 2.9 per thousand, Procedure for removing cases of smallpox. Measles. Whoopingcough. Scarlet Fever. 11 as compared with 2.7 in 1926. The deaths numbered 63, giving a death-rate of .01 per thousand, while the case mortality was .5 per cent., compared with .7 per cent. in 1926. An exhaustive report upon administrative practice in the control and treatment of scarlet fever prepared by Dr. Allan C. Parsons, with the assistance of a committee of medical officers of the Ministry of Health, has been issued by the Ministry, being No. 35 of their series of Reports on Public Health and Medical subjects. Sir George Newman, in a prefatory note, refers to the need for a reconsideration of the use to which isolation hospitals are put, in view of the changes both in incidence and fatality which have occurred in recent times. The Ministry's committee conclude that "under present conditions and on general public health grounds, too many beds in fever hospitals are being reserved for scarlet fever patients, and that some of these beds could be more profitably used for the isolation and treatment of patients suffering from infectious diseases of more importance than scarlet fever at the present time." The notified cases of diphtheria numbered 12,183 in 1927 (52 weeks) as compared Diphtheria, with 13,526 in 1926. This gives an attack-rate of 2.7 per thousand, as compared with 2.9 in the preceding year. During the first three quarters of the year the notifications were below those for the same quarters of 1926, but in the last quarter the notifications increased considerably and exceeded those of the last quarter of 1926 by 202. The increase is still being maintained. There were 397 deaths in 1927, as compared with 547 in 1926. The remarkable decrease in diphtheria case-mortality referred to in last year's report and associated with earlier and more general use of diphtheria anti-toxin prior to admission to hospital, was similarly maintained in 1927, the case-mortality being 3.3 per cent., as compared with 3.9 in 1926, and with an average of 7.4 in 1919-1922, the four years preceding the issue of the Ministry of Health's memorandum on the subject. Diarrhœa and enteritis caused 556 deaths among children under two years Diarrhœa of age in London during 1927, this being 7.59 per thousand births. The corresponding and enteritis, rate in 1926 was 12.03. There were 261 notifications of puerperal fever and 892 of puerperal pyrexia Puerperal in 1927 (52 weeks). The puerperal fever case-rates per 1,000 births in each metro- fever and pyrexia politan borough are shown in the table on page 23. The mortality from puerperal fever is much lower in boroughs with poorer-class populations than in those occupied largely by the well-to-do. In the five years, 1921-25, the average number of deaths in the aggregate population of Bermondsey, Bethnal Green, Finsbury, Stepney and Shoreditch was .88 per 1,000 births, as compared with l.80 in the boroughs of Hampstead, Kensington, Lewisham, Stoke Newington and Wandsworth. There is some correlation between the incidence of maternal mortality and the percentage of illegitimate births, a closer correlation with the percentage of domestic servants and closer correlation still with the percentage of single women between 20 and 25 years of age. In 1927 the London mortality from puerperal fever among single women was 3.22 per 1,000 births, as compared with 115 per 1,000 births among married women. For other accidents of child-birth the figures were 2 93 and 146 respectively. It would add materially to the value of the statistics of maternal mortality if the deaths of married women were stated as a rate per 1,000 legitimate births, and of single women as a rate per 1,000 illegitimate births. In the medical press references have recently been made to the increase of abortion among married women. It is probable that one of the factors in the present unsatisfactory position with regard to maternal mortality, in spite of improvement in administration measures, is the increased burden of motherhood resulting from present economic conditions. 12 Typhoid There were 322 notifications of typhoid fever in London in 1927 (52 weeks), fever. as compared with 302 in 1926. The deaths in the calendar year numbered 30, the mortality being lower than that recorded in any previous year in London. In thirteen instances, two or more cases were notified from one house or institution. Eight cases of paratyphoid B were notified from a training college in Westminster in October, but inquiry failed to establish definitely the source of infection. Four cases occurred in Bedford College, St. Marylebone, among a party of Canadian teachers who had the use of the College during their visit. From the period of incubation it was clear that they could not have been infected in London. All the cases were mild. There was one instance of three cases in one house and ten of two cases. In addition two concurrent staff cases occurred in each of three hospitals. Seven fatal cases were not notified. Three of these occurred in mental hospitals situated outside the County ; of the four remaining cases, three were diagnosed post-mortem, and in the other case typhoid fever was entered on the death certificate as a secondary cause of death. Anthrax. Five cases of anthrax were notified in London during 1927, but two of these were not confirmed. During the first week of January four cases of anthrax occurred in connection with the Zoological Gardens. All of the patients, one of whom lived outside of London, were men who had been engaged in handling the carcases of two elephants which had died at the Zoo. The nature of the illness which caused the death of the elephants was not recognised until after the men were infected, and efforts, by the Zoo authorities, to trace the origin of the animals' infection were unsuccessful. Owing to the prompt administration of anti-anthrax serum, all the men had fairly mild attacks and recovered. A prophylactic dose of serum was also given to 29 other persons who had been in contact with the carcases and no further cases occurred. Plague, No cases of plague, cholera or typhus fever occurred in London in 1927. cholera and Typhus fever Cerebro- Ninety-five cases of cerebro-spinal fever were notified during the year, and in 10 spinal fever. cases the diagnosis was revised. Of the remaining 85 genuine cases, 51 (60 per cent.) proved fatal. In addition, 22 fatal cases which had not been notified under the Public Health (London) Act, 1891, were recorded in the Registrar-General's death returns making a total of 73 fatal cases for the year. Poliomyelitis Eighty-nine cases of poliomyelitis or polioencephalitis were notified during the encephalitis. year, of which 81 were regarded as genuine. Of these 12 (15 per cent.) proved fatal. In addition five fatal cases, which had not been notified, were discovered through the medium of the Registrar-General's death returns. A report on the treatment of children who are suffering from defects following poliomyelitis appears on page 154 of this report. Encephalitis 149 cases of encephalitis lethargica were notified, of which 114 are regarded as lethargies., genuine. Of these 49 (23 per cent.) had proved fatal up to 31st March, 1928. In this connection it is impossible to show a true mortality for this disease as death often does not take place until two, three or more years after the onset. In addition to the notified cases, 23 deaths were recorded amongst non-notified cases. A record of the deaths due to encephalitis lethargica during the period 1919-1926 was given in the annual report for 1926. Table of age incidence (actual cases). Age periods. Under 3. 3-5. 5-10. 1020. 2030. 3040. 4050. 50-60. Over 60. Total. Cerebro-spinal fever 57 10 13 9 10 4 2 1 1 107 Poliomyelitis and polioencephalitis 34 16 10 14 4 1 2 — — 81 Encephalitis lethargica 2 2 9 27 29 11 23 18 16 137 13 Table of yearly prevalence (notified cases). Year. 1915. 1916. 1917. 1918. 1919. 1920. 1921. 1922. 1923. 1924. 1925. 1926. 1927. Cerebro-spinal fever 627 425 390 218 197 154 103 86 65 93 93 83 93 Poliomyelitis and polioencephalitis 97 190 59 50 96 49 57 40 111 116 55 95 86 Encephalitis lethargica — — — — — 140 233 66 98 600 293 224 142 Encephalitis lethargica and its distressing sequelae, which have been frequently After effects and fully described in previous annual reports and elsewhere, continue to present of encephali-tis lethargica medical and social problems which still defy solution. From the medical point of view it must be frankly stated that patient investigation and research have brought us no nearer the secret of the cause or cure of the disease. From the social viewpoint there still remains a long-felt need of making provision for institutional treatment of those unfortunate adult patients whose mental, moral or physical deterioration, resulting upon an invasion of this disease has unfitted them for normal domestic and social life. Suitable cases under the age of 16 years are catered for at the Metropolitan Asylums Board's Northern Hospital, Winchmore Hill, on which comment is made in Chapter II, the report of the School Medical Officer. A review of the work carried out at this institution is contained in the printed report of Dr. G. A. Borthwick, the Medical Superintendent, which was adopted by the Metropolitan Asylums Board on the 10th December, 1927, describing the second year's working of the unit. It is true that the modification of the Mental Deficiency Act in 1927 may have some effect in securing the admission to mental hospitals or otherwise bringing under supervision those patients whose intelligence or moral outlook has so degenerated as to bring them within the scope of the new Act. This Act widens the definition of a mental deficient to include those persons whose mental deficiency arises before the age of eighteen, whether due to inherent causes or induced by disease or injury, whereas in the previous Act it was necessary to show that mental deficiency had existed " from birth or an early age." It was thus impossible to certify many cases of mental deficiency due to encephalitis lethargica. The recommendations in the report of Dr. G. A. Borthwick on the encephalitis lethargica unit at Winchmore Hill referred to above (see the report on the subject in Chapter II.) make it clear that, whilst the experience gained in regard to children shows that no positive curative results can be expected, many cases show considerable improvement, and that the unit has justified its existence, if only as a clearing house and observation station, where patients suffering from the charateristic physical disabilities, including the paralysed and Parkinsonian cases, may receive skilled attention and where children, whose mental condition unfits them for ordinary outside life, may be kept under observation. The need for making similar provision for adults who are affected applies with equal force. For the past three years the Council's public health department has concentrated upon following-up every known surviving case of the disease, whether notified or not. Enquiries are made at frequent intervals, as far as possible not less often than every six months, and in connection with these enquiries very valuable assistance has been rendered by the medical officers of health of the metropolitan boroughs in regard to adults and children under school age, as well as by the children's care organisers and the school medical service in regard to school children. As a result it has been possible to show the proportion of disability among a very large number of survivors. A table was given in last year's annual report which reflected the position as it was in 1926. This year a further table is submitted which, though 15435 B 14 including much of the information in last year's table, treats the subject from a somewhat different viewpoint, and, in addition to classifying the cases into juvenile and adult groups, indicates the year of onset and differentiates between the sexes. It refers to 528 cases in which it has been possible to obtain sufficiently up-to-date reports on which to draw conclusions as to the present condition of the patients. Many other cases have come under observation during the period covered, i.e., 1925-27, but owing to death, to the want of recent reports, or to their having moved or otherwise been lost sight of, it is not possible to include them in the analysis. The cases which first came under observation during 1927 either by notification or otherwise are not included, as it is now fully realised that some time must elapse before any statement as to recovery or otherwise is of any value. A variable interval frequently intervenes between the acute attack and the onset of the sequelae, characterised by more or less normal health, and this has accounted for the seeming paradox that cases reported to have completely recovered have later developed the well-known and distressing after-effects. The table on page 15 contains a good deal of hitherto unpublished information which, but for want of space, would justify considerable comment. Readers, however, may draw their own conclusions. With regard to the figures in brackets in the fourth column of each section, which denote the number of patients admitted to mental hospitals or correctional institutions such as reformatory and industrial schools, etc., it may be mentioned that 76 cases (46 males and 28 females) have been treated at West Park Mental Hospital and 28 (23 males and 5 females) at the Manor Mental Hospital, Epsom. Influenza. The deaths from influenza during 1927 numbered 1,815, as compared with 806 in 1926. Influenza had assumed epidemic form in most parts of Europe at the beginning of the year, and in London the mortality reached a maximum towards the end of January, the deaths in the last week of that month numbering 252. As in previous epidemics, the deaths from pneumonia, bronchitis and other respiratory diseases, as well as from diseases of the heart, increased considerably during the epidemic. The mortality at ages over 75 was considerably higher, relatively, than in the epidemic of 1922. Tuberculosis. The deaths from tuberculosis of the respiratory system in London during 1927 numbered 4,140, giving a death-rate of 0.91 per thousand living. Deaths from other forms of tuberculosis numbered 640, as against 691 in 1926, the death-rate being 0.14. The increase in mortality for pulmonary tuberculosis occurred in the first quarter of the year and is thus associated with the epidemic of influenza during the winter. The annual deaths and death-rates from phthisis, distributed for sex, in recent years have been as follows:— Period. Deaths. Death-rates. Males. Females. Total. Males. Females. Total. 1919-21 2,786 2,109 4,895 1.36 0.87 1.10 1922-24 2,685 1,917 4,602 1.27 0.78 0.01 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 1927 2,521 1,619 4,140 1.20 0.66 0.91 The number of notifications of tuberculosis received in London boroughs during 1927 (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 8,777. The cases of pulmonary tuberculosis numbered 15 15435 TABLE showing the present conditions of 528 cases of encephalitis under observation during 1925-1927 (the figures in brackets denote the number of the " mental cases " which have been dealt with at mental hospitals or correctional institutions). Year of onset. NOTIFIED CASES. NON-NOTIFIED CASES. Under 16 Years of Age. Over 16 Years. Under 16 Years of Age. Over 16 Years. Stated to have recovered. Still affected. Paralysed (including Parkinsonism) Mentally or morally affected. Stated to have recovered. still affected. Paralysed (including Parkinsonism) Mentally or morally affected. Stated to have recovered. Still affected. Paralysed (including Parkinsonism) Mentally or morally affected. Stated to have recovered. Still affected. Paralysed (including Parkinsonism) Mentally or morally affected. Before 1918 M. — — — — — 1 1 — — 1 1 — — — — — F. — — — — — — — — — 2 — 2 (1) — 1 1 — 1918 M. — — — — 1 2 1 1 1 2 — 2 (2) — 5 2 4 (3) F. — — — — — — — — — 2 — — — 1 — 1 (1) 1919 M. — — — — — 2 — 2 (2) 1 2 — 2(2) — 2 1 — F. — — — — — — — — — 2 — — — 1 1 — 1920 M. — — — — 1 4 1 3 (2) — 4 — 4(3) ] 5 5 1(1) F. — 1 1 — — 2 1 1(1) — 1 — 1(1) — 2 1 — 1921 M. 1 1 — 1 (1) — 2 — 1(1) 2 k 2 1 — — — — F. 3 — — — 3 2 1 2 (1) 1 4 — 1(1) — — — — 1922 M. — — — — — — — — — 1 — — 1 2 2 1 (1) F. — — — — 2 1 1 1 2 1 1923 M. 1 — — — — 2 — 1 3 3 — 1 1 4 3 1 (1) F. 2 1 1 1 1 4 2 2(1) 2 1 — 1 — 1 1 1924 M. 26 10 2 1 16 16 10 7(4) 15 6 4 2(1) — 8 3 5 (5) F. 11 11 1 2(1) 16 17 12 1(1) 8 5 2 1 5 4 1925 M. 7 2 1 1 22 13 6 3(3) 8 4 1 1 3 2 — F. 5 — — — 19 16 8 1(1) 5 — — — 1 1 — 1(1) 1926 M. 15 1 — — 14 6 4 3(1) 3 4 — 1 — 1 1 F. 3 1 1 — 11 6 2 — 2 1 — — 1 1 1 Not M. — — — — — 2 — — 4 4 — 4(3) — 33 3 30 (27) known F. — — — — — 2 2 — 3 3 — 1(1) — 22 1 21 (20) Total M. 50 14 3 3(1) 54 50 23 21(13) 36 36 8 18(11) 3 63 21 43(38) F. 24 14 4 3(1) 52 50 29 7(5) 22 21 2 7(4) 2 37 11 24 (22) Grand Total 74 28 7 6(2) 106 100 52 28 (18) 58 57 10 25(15) 5 100 32 67 (60) 102 cases 206 cases 115 cases 105 cases 308 cases 220 cases ♦ The sequelae have bseu broadly classified into "paralysed" and "mentally affected" in the two adjoining columns, but only in respect of cases where specific information has been received. A single case exhibiting both symptoms would appear in both columns. b 2 16 6,860, and other cases 1,917. The following is an analysis of the notifications in London during 1927 (52 weeks):— Form of tuberculosis notified. Sex. Notifications 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. 4 29 71 67 297 466 812 822 792 368 134 3,862 F. 4 28 69 103 455 557 813 483 283 132 61 2,988 Other tuberculosis M. 30 179 240 155 118 74 86 49 32 18 7 988 F. 21 144 184 128 99 94 114 36 29 19 20 888 All forms of tuberculosis M. 34 208 311 222 415 540 898 871 824 386 141 4,850 F. 25 172 253 231 554 651 927 519 312 151 81 3,876 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. — 3 5 8 1.013 3,400 F. — 2 2 701 1,970 Other tuberculosis M. — 13 8 21 75 558 F. 1 12 7 20 64 488 All forms of tuberculosis M. — 16 13 29 1,088 3,958 F. 1 14 7 22 765 2,458 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. 2 7 7 8 10 24 89 85 90 63 33 418 F. 3 5 3 8 24 42 65 53 39 22 25 289 Other tuberculosis M. 20 41 28 13 10 2 10 4 5 4 7 144 F. 13 39 26 17 13 11 17 9 6 6 9 166 All forms of tuberculosis M. 22 48 35 21 20 26 99 89 95 67 40 562 F. 16 44 29 25 37 53 82 62 45 28 34 455 The returns received under the Public Health (Tuberculosis) Regulations, 1924, from the Medical Officer; of Health of the metropolitan boroughs show that there were 39,633 cases of pulmonary tuberculosis (22,655 males and 16,978 females) and 15,867 cases of other forms of tuberculosis (8,368 males and 7,499 females) on the registers of the metropolitan boroughs at the end of 1927. Cancer. There were 6,774 deaths from cancer in 1927, as compared with 6,720 in 1926 and 6,628 in 1925, the death-rate per 1,000 living being 1.49, as against 1.46 and 1.44 in the two preceding years. In view of the fact, to which attention was drawn in last year's report, that an actual decrease in cancer mortality had occurred in London during the past ten years among women, it appeared desirable to direct closer consideration to the London cancer mortality, since it is generally acknowledged that London in respect of facilities for diagnosis is in advance of the rest of England and Wales, and for this reason any variation in the mortality rates may have special significance. Mr. B. E. Spear has accordingly made further analysis of the London mortality from the purely statistical standpoint, the questions considered being the relative incidence 17 upon the two sexes according to site of attack, the contrasts in incidence and sexratio of cancer mortality among persons born in successive decennia, and the influence of social condition upon mortality and locality of growth. If the deaths from cancer in London during the period 1911-20 be grouped Sox incidence according to locality of the fatal growth, it is found that cancers of which the male mortally mortality greatly exceeds that among females are located in a well-defined and quite limited area of incidence, namely, the part of the alimentary tract which is above the diaphragm. The figures relating to this group of cancers are as follows:— Site of Cancer. Death-rate per million living 1911-20. Site of Cancer. Death-rate per million living 1911-20. Males. Females. Males. Females. Lip 8 1 Pharynx 18 4 Tongue 82 6 Larynx, throat 42 5 Tonsil 12 1 Neck 19 3 Mouth 23 2 Œsophagus 106 16 Jaw 26 8 Total 336 46 On the other hand, the localities in which the female mortality is markedly in excess also comprise a special group, namely, the reproductive system, the figures being as follows:— Death-rates per million living. Males. Females. Breast 2 Breast 227 Prostate 30 Ovary, Fallopian tubes 38 Testis 6 Uterus 230 Penis, Scrotum 8 Vagina, Vulva 14 Total 52 Total 509 In the whole of the remaining localities of attack the incidence upon the two sexes may, relatively to the above marked divergences, be regarded as practically equal, as will appear from the following table:— Site of Cancer. Death-rate per million living. Males. Females. Rodent ulcer and remainder of upper alimentary canal 60 41 Stomach 214 153 Intestines 111 142 Rectum and anus 115 87 Liver 87 105 Other localities below diaphragm 106 94 Boner,, lymphatic glands, skin, etc 49 34 742 656 In the decennial period 1911-20 the annual average mortality from cancer in London per million living was, for males, 1,130, and for females, 1,211; and the above tables show that on the basis of sex ratio of mortality the localities of primary growth may be divided into three well-defined groups, the first (Group I.) comprising the upper alimentary tract with remarkable excess of male mortality; the second (Group II.) the reproductive system with correspondingly marked female excess; and the third (Group III.) all other cancers, with approximately equal sex incidence of mortality. The three groups into which fatal cancers have been classed on the basis of sex-ratio of mortality also exhibit points of contrast in respect of the age-distribution 18 of deaths; the mortality from Group II. cancers among females falls considerably earlier in life than that in other groups, while the excess of male mortality in Group I. is relatively higher at middle age. The mortality in Group III., on the other hand, has a very similar age-distribution in both sexes. See Section A of diagram on p. 19. (The Group I. female deaths and Group II. male deaths are not shown, as they are relatively negligible.) The relationship between Groups I. and II. in regard to age-incidence of cancer mortality suggests the possibility that the higher mortality from Group II. cancers among women at the earlier ages may be a determining factor in the extent of the excess of mortality from Group I. cancers among males; for, if the earlier mortality among women has proportionately reduced the number of those with a tendency to cancer, the survivors later in life, even if equally exposed to carcinogenic conditions, will respond less to them than the male survivors of the same age. This raises the question of the influence of constitutional predisposition to cancer, or cancer diathesis ; and if this is the governing factor, there would be grounds for qualifying the hypothesis which naturally suggests itself that some particular male habit is responsible for the higher mortality for Group I. cancers among men. Unfortunately, complete data to establish a complementary relationship between the excess of female Group II. cancers in earlier life and the excess of male Group I. cancers, among survivors from the same stock, are not available in London, as the tabulation of deaths according to locality by age and sex was not made before 1911, or before 1901 in England and Wales. There are, however, certain features of the cancer mortality of all sites which bear upon this possibility. mortality in In thereport of the County Medical Officer for 1923, page 38, the London cancer different mortality-rates are shown for eight successive equidistant three-year periods from generations 1850-62 to 1920-22 inclusive, per thousand living at different age-periods for both sexes. In the following table these death-rates are rearranged in such a way as to enable the mortality in successive periods of life among persons born in the same years to be readily followed. In column (1) the death-rate among persons who were born between 1805 and 1817 is shown as they passed through the successive ageperiods, 35-45, 45-55, 55-65, etc., and in column (2) similar figures axe shown in respect of persons born ten years later, and so on. Age period. Males London mortality from cancer per 1,000 living among persons born in 1805-17 1815-27 1825-37 r 1835-17 1845-57 1855-67 1865-77 1875-87 (1) (2) (3) (4) (5) (6) (7) (8) 35— .21 .28 .31 .39 .52 .45 .48 .50 45— .73 .91 1.20 1.65 1.72 2.09 2.01 55— 1.86 2.55 3.60 4.34 5.27 5.70 65— 3.81 5.58 7.47 9.13 10.05 75— 5.35 8.26 10.51 12.49 Females. 35— .86 .85 1.02 1.10 1.08 .92 .89 .77 45— 1.97 2.04 2.35 2.57 2.58 2.34 2.30 55— 3.42 3.74 4.31 4.68 4.62 4.52 65— 4.82 5.92 6.94 6.98 7.21 75— 6.81 8.64 9.37 10.60 It will be noted that there is a clear indication of a maximum mortality having been attained among females born between 1835 and 1857, so far at any rate as they can at present be followed, i.e., up to the 65th year of age; and, notwithstanding the wide variation in the male mortality, the relative incidence at each age-period is much the same in each column, that is to say, for each generation; among females the variation in mortality is not so great, but here, also, there is similar relative movement in each separate age-period. The female mortality for cancer is shown to be definitely declining in London among the survivors of those born since about 1851, while among males there is 19 20 evidence of a pause in the remarkable increase shown to have occurred among those born between 1805 and 1867, and some indication of an approaching decline. An erroneous idea of the incidence of cancer in the population may easily be derived from considering death-rates at ages, for while the death-rate at 75-85 years of age may be as much as 10 or 12 per thousand living, the population surviving to this age is relatively quite small. Actually more than one-half the total cancer deaths occur at working ages, i.e., before 65 years of age. In order to make the facts shown by the figures in the above table clearer, then, the rates have been applied to a life-table population, that is to say, a hypothetical population in which the number of persons aged, say, between 75 and 85, in relation to those of, say, 35-45, is so adjusted as to eliminate the effects on the age-constitution of the population of migration and changes in birth-rate. The results are shown in the following table, giving in ten-year age-groups the deaths which would have occurred in a life-table population of one million persons over 35 years of age, and also the percentage of such deaths occurring at each age-period. Calculated deaths from cancer in London in a standard (life-table) population among persons born in— Age period. 1805-17. 1815-27. 1825-37. 1835-47. 1845-57. No. Per cent. No. Per cent. No. Per cent. No. Per cent. No. Per cent. Males— 35— 69 4.9 92 4.6 102 3.9 128 3.9 170 4.6 45— 204 14.8 254 12.8 335 12.7 461 14.2 481 13.0 55— 396 28.2 543 27.4 767 29.0 925 28.4 1,123 30.3 65— 490 34.9 718 36.2 961 36.3 1,174 36.0 1,293 34.9 75— 244 17.4 377 19.0 480 18.1 571 17.5 640 17.2 Total 1,403 100.0 1,984 100.0 2,645 100.0 3,259 100.0 3,707 100.0 Females— 35— 283 11.3 278 9.9 334 10.3 360 10.4 354 10.2 45— 550 22.1 570 20.3 657 20.3 718 20.8 721 20.8 55— 729 29.2 797 28.5 918 28.4 997 28.8 984 28.5 65— 620 24.9 762 27.2 893 27.7 898 26.0 928 26.8 75— 311 12.5 395 14.1 428 13.3 484 14.0 472 13.7 Total 2,493 1000 2,802 1000 3,230 1000 3,457 1000 3,459 1000 The male deaths between the ages of 35 and 85 years are shown to have more than doubled in the course of forty years, from 1,403 among those born in 1805-17, to 3,707 among those born in 1845-57 ; yet the percentage of total deaths at the various age-periods remains practically unchanged throughout. Among females the increase during the same period is considerably smaller, from 2,493 to 3,459, but again the percentages at age-periods are very similar. but again the percentages at age-periods are very similar. The age-distribution of deaths among females differs considerably from that of males ; and if the percentages given in the table are differenced the following figures are obtained :— Age period. Percentage of deaths in successive age-periods. Female excess ( + ) or deficiency (—) among persons born in 1805-17. 1815-27. 1825-37. 1835-47. 1845-57. 35— +6.4 +5.3 +6.4 +6.5 +5.6 45 +7.5 +7.5 +7.6 +6.6 —7.8 55— +1.0 +1.1 — 0.6 +0.4 —1.8 65— —10.0 —9.0 — 8.6 —10.0 —8.1 75— —4.9 —4.9 — 4.8 —3.5 —3.5 From such methods of statistical analysis as have been applied to the figures, it appears that the relative excess of mortality at the earlier ages among women can be definitely assigned to the cancers of Group II., the reproductive system. 21 Notwithstanding the special conditions of life attendant upon motherhood, Cancer there is no excess of mortality from cancer of the reproductive system among married mortality in relation to women, the total mortality in a million of the London standard (life-table) population civil between 35 and 85 years of age during the decennium 1911-20 for the Group II. condition, cancers, being among married and widowed women 1,389, and among single women 1,465. When, however, the Group II. cancers are considered according to locality of growth in relation to civil condition, remarkable differences of incidence are found. From Section B of the diagram on page 19, it will be seen that among married women cancer of the uterus causes nearly twice as many deaths as among the same number of single women, and that the position is reversed in cancers of the remaining sites of the group. Figures obtained for the years 1921-26 indicate that the excess among married and widowed women of uterine cancer is limited to the cervix, but no data are available for the period 1911-20 in regard to this. If, however, it were possible to transfer deaths from cancer of the body of the uterus from the upper curves of Section B to those for the breast, ovary and vagina below, the contrast in mortality according to civil condition would be still further emphasised. In the lowest division of Section B of the diagram, the age-distribution of the total mortality from Group II. cancers is shown to be approximately the same for the two classes of civil condition. The conclusion suggested by the data is that exposure of the cervix to specific carcinogenic conditions associated with primary conception does no more than determine the locality of attack; so that, again, diathesis appears to be the controlling factor. It has not been possible hitherto to examine the relationship between social Cancer conditions and the mortality of cancer by locality of attack as the necessary data mortality in relation to have not been available for each metropolitan borough. The following observations social are based upon figures which have been supplied by the Registrar-General relating condition, to the six years, 1921-26. For the purpose of contrast in social condition or environment, two groups of boroughs have been selected, one, representing the better-class population, comprising Hampstead, Lewisham and Wandsworth, with a total population in 1921 of 588,654 (Group A), and the other, the boroughs of Bermondsey, Bethnal Green, Finsbury, Shoreditch and Stepney, with a population of 666,590, representing the poorer classes (Group B). In the latter group there is a higher proportion of Jewish residents among whom the mortality from cancer is thought to be relatively lower than in the general population ; there are also far more aliens in this group than in Group I., and this fact also tends to qualify any but broad deductions from the data. The calculation of corrected mortality figures for each borough, according to site of primary growth, must be deferred until the results of the next census are available for the purpose. As the number of deaths for most of the single localities is insufficient to give representative rates for such relatively small populations, the localities for which figures have been obtained are grouped so as to approximate to the groups formed for the purpose of the analysis of cancer mortality by sex-ratio in London in 1911-20. Thus cancers of the lip, tongue, larynx and oesophagus are taken to represent Group I., the localities of the alimentary tract above the diaphragm; while cancers of the breast, uterus and ovary represent Group II., the female reproductive system. The figures illustrating the contrasting incidence by social condition of the Group I. cancers, inter alia, in the standard (life-table) population of one million persons over 35 years of age are as follows:— 22 Sex and Group. Lip, Tongue, Larynx, (Esophagus. Stomach. Intestines. Liver. Other sites. All cancers. Males— Group A 679 702 1,028 234 1,190 3,833 Group B 825 1,010 1,103 263 1,225 4,426 Females— Group A 87 433 737 285 1,877 3,419 Group B 77 722 694 299 1,725 3,517 It will be seen that cancers of the upper alimentary tract among males are more frequent among the poorer class, the excess being about 22 per cent., while the excess in cancer of the stomach is even greater, i.e., nearly 44 per cent. These results agree with the observations of Dr. T. H. C. Stevenson in a paper read before the Royal Statistical Society on 21st February, 1928 ("The Vital Statistics of Wealth and Poverty"), in which he showed from consideration of the statistics of male occupational mortality in England and Wales that the mortality for these cancers among males increased progressively with descent in the social scale. Although the figures for females are very small, they indicate, on the other hand, a higher incidence in the better-class population of cancers of the upper alimentary tract; but there is an even greater excess than among males of cancer of the stomach among women of the poorer areas, amounting to nearly 67 per cent. above that in the better-class districts. Cancer of the upper alimentary tract appears, therefore, to be influenced by sex, and cancer of the stomach by social condition. It should be noted that the cancers taken to represent Group I. only include about one-half the total cancers of the upper alimentary tract. The similar figures for the cancers of Group II. (reproductive system) for females are as follows :— Group and Civil Condition. Uterus. Breast. Ovary. Total. Single woman— Group A 295 893 255 1,443 Group B 436 838 175 1,449 Married and widowed— Group A 597 710 129 1,436 Group B 675 534 101 1,310 The figures show that the married and widowed women of the better-class area, Group A, where the fertility rates are lower, have a higher mortality from cancer of the breast and ovary and a lower mortality from uterine cancer than among the poorer and more fertile class represented by Group B. There is some excess in total mortality from cancers of the reproductive system among the married and widowed women of Group A, but among single women despite differences in locality of growth, the total mortality in the two classes of population is much the same. Conclusion. From this analysis of the incidence of cancer mortality in the London population it appears:— (i) That among persons over 35 years of age the movements of the mortality from 1850 onwards are, in the main, correlated with the year of birth and not with progressive changes in conditions of life. (ii) That, assuming the same correlation to hold in the future, the female mortality-rate will continue to decline, while that of males will increase further for some time. (iii)That these variations in the total cancer mortality rates, considered in conjunction (a) with the complementary relation of the male excess of cancer of the upper alimentary tract to that of the female cancers of the reproductive system, and (b) with the contrasts in age-incidence of cancers of the reproductive system by locality of growth among single and married women, respectively, are consistent with the hypothesis that a cancer diathesis is the dominating factor in the mortality from carcinoma in the general population, and 23 Vital statistics for the several metropolitan boroughs and the County of London in the year 1927. (Rates per 1,000 of civil population.) Metropolitan boroughs. (Arranged in topographical order.) Estimated civil population, 1927. Births. Deaths. Infant ity (per 1,000 births). Measles Scarlet fever. Diphtheria. Whooping cough. Typhoid fever. Diarrhœa and Enteritis, age 0-2 (per 1,000 births). Phthisis. Pneumonia. Bronchitis. Cancer Notified cases of Infectious disease, (a) Scarlet fever. Diphtheria. Typhoid feyer. Erysipelas. Puerperal fever (per 1,000 births). Cerebro spinal fever. Acute pneumonia. Western. Paddington 142,700 15.6 13.6 79 .04 .02 .08 .27 .01 7.2 .67 1.28 .69 1.73 2.25 2.60 .11 .63 3.15 .02 2.04 Kensington 176,500 15.0 13.8 67 .01 — .06 .08 — 10.9 .65 1.19 1.03 1.84 1.51 2.22 .06 .33 1.13 .03 1.36 Hammersmith 132,800 15.6 13.0 61 .02 .01 .08 .03 — 11.1 1.20 .97 1.01 1.55 2.35 2.78 .08 .32 3.38 — 1.11 Fulham 161,900 15.1 11.4 68 — .01 .07 .05 .01 .9 .82 .90 .61 1.41 2.22 2.42 .07 .36 6.98 .05 1.92 Chelsea 63,690 13.4 14.1 76 .05 — .06 .09 .02 16.4 .93 1.16 .50 2.21 2.11 2.00 .09 .28 8.20 .03 2.46 Westminster, City of 136,500 10.1 12.4 69 .01 .01 .07 .05 .01 8.5 .73 .90 .68 1.79 1.12 1.23 .16 .26 4.27 .01 .47 Northern. St. Marylebone 103,500 13.3 12.2 59 .09 .01 .12 .11 .02 9.5 .73 1.01 .83 1.49 1.73 1.59 .16 .35 1.46 .02 .45 Hampstead 86,160 11.9 12.2 52 .02 .01 .02 .05 — 6.8 .44 .70 .59 1.86 1.59 .91 .10 .21 3.90 .03 .64 St. Pancras 212,800 15.5 12.3 62 .02 .01 .03 .16 .01 8.2 .93 .97 1.12 1.39 2.49 1.83 .10 .47 6.68 .01 1.41 Islington 334,300 17.5 12.4 55 .09 .03 .07 .14 — 7.2 .96 1.21 .94 1.39 2.73 2.16 .03 .42 5.64 .02 .98 Stoke Newington 52,130 14.0 12. 2 66 .02 — .10 .10 — 2.7 .79 .92 .59 1.40 2.64 2.04 .04 .25 1.37 — .63 Hackney 224,700 15. 7 11.6 64 .02 .02 .12 .12 .00 9.6 .81 1.09 .60 1.34 4.37 2.87 .06 .21 2.55 .01 .42 Central. Holborn 42,209 12.0 12.6 38 — — .02 .12 — 9.9 1.21 .85 1.59 1.18 1.43 1.31 .10 .52 5.95 — 1.16 Finsbury 75,500 19.1 13.4 51 .04 .03 .07 .23 — 7.6 1.36 1.15 1.25 1.40 3.23 2.70 — .57 4.86 .03 1.14 London, City of (b) 13,291 8.7 11.5 104 — .08 .08 — — 8.7 .90 .90 .30 2.03 2.87 1.36 — .30 — — .83 Eastern. Shoreditch 105,700 20.7 12.5 74 .08 .03 .11 .24 .01 10.1 .88 1.34 .90 1.27 3.60 4.43 .04 .59 5.96 .01 2.80 Bethnal Green 117,900 20.0 11.4 58 .03 .03 .14 .23 .01 10.2 .98 1.12 .81 1.29 5.13 4.10 .06 .68 2.98 .04 1.91 Stepney 250,880 18.3 11.8 68 .04 .02 .08 .18 .01 13.7 .94 1.20 .74 1.39 4.06 3.49 .11 .57 3.27 .02 1.39 Poplar 167,000 19.8 11.8 66 .05 .01 .10 .20 — 10.6 .97 1.21 .78 1.45 4.86 2.56 .03 .57 2.12 .02 3.25 Southern. Southwark 184,250 19.0 13.4 61 .15 .01 .11 .16 .01 7.4 1.07 1.19 1.09 1.41 2.93 4.20 .05 .57 3.43 .03 1.69 Bermondsey 121,000 19.9 12.9 62 .09 — .12 .10 .01 5.4 1.22 1.32 .93 1.45 4.98 3.99 .01 .21 3.33 .02 1.04 Lambeth 307,700 16.2 12.6 55 .08 .01 .12 .10 .01 6.8 .92 .94 .70 1.70 2.20 2.52 .07 .42 4.44 .02 1.61 Battersea 169,000 16.6 12.2 54 .01 .02 .15 .09 — 2.5 .89 .73 .92 1.49 2.49 4.47 .05 .46 3.58 .05 2.58 Wandsworth 342,700 13.5 11.4 53 .01 .01 .07 .08 .01 4.1 .87 .67 .78 1.46 2.39 2.23 .09 .36 2.59 .02 2.03 Camber well 271,100 15.6 11.5 53 .05 .02 .08 .11 .00 5.7 .93 .96 .79 1.33 2.40 2.81 .04 .43 1.66 .01 .76 Deptford 113,800 16.8 11.5 58 — .02 .12 .10 .02 4.2 1.05 1.05 .76 1.49 3.50 3.60 .09 .63 .53 .02 1.73 Greenwich 101,920 16.4 10.9 53 — .02 .11 .16 .01 5.3 .79 .73 .73 1.30 4.77 4.42 .07 .63 2.97 .02 1.43 Lewisham 188,600 15.1 11.0 46 .01 .02 .08 .04 .01 3.2 .93 .77 .85 1.54 3.26 1.81 .07 .29 2.11 .01 1.16 Woolwich 140,770 15.5 10.6 42 .01 — .07 .07 — 2.2 1.05 .67 .81 1.49 2.99 1.75 .06 .44 3.58 .02 2.11 London 4.541.000 16.1 12.1 59 .04 .01 .09 .12 .01 7.6 .91 1.00 .83 1.49 2.91 2.69 .07 .43 3.57 .02 1.49 (a)Five cases of smallpox occurred during the year, one (fatal) in Hampstead, three in Hackney (one fatal) and one in Poplar. (b)Including Inner and Middle Temples. 24 thus that the solution of the cancer problem may ultimately be found to depend upon the detection and modification of the cancer diathesis. It is worthy of note in connection with these conclusions that most of the deaths from malignant disease in the earlier years of life are due to sarcoma. Below the age of 20 years, 96 per cent, of the total cancer deaths in London during 1902 —1910 were due to sarcoma ; while at ages over 35 years, to which the above conclusions relate, 93 per cent, of the deaths from malignant disease were due to carcinoma. The cancer deaths under 20 years of age may therefore be taken to be representative of the mortality from sarcoma, and although the figures, even for tenyear periods and for England and Wales as a whole, are relatively very small, they indicate that the variations of mortality from sarcoma since 1850 are rather more closely correlated with contemporary conditions than with year of birth. Common and seamen's lodging houses. Administration. The supervision of the 164 common lodging houses licensed by the Council under the L.C.C. (General Powers) Act, 1902, entailed 7,469 day visits and 287 night visits by the inspectors. The supervision of 31 seamen's lodging houses licensed under the Merchant Shipping Act, 1894, entailed 750 visits by day and 45 by night. 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.I., price Is. 6d. Census of homeless persons. A census of homeless persons in London was taken on the night of Friday, the 18th February, 1927. 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 rather cold. Only five persons (two males and three females) were found sheltering under arches or on staircases. In the streets 68 males and 28 females were found, as compared with 76 males and 24 females in 1926, and 296 males and 76 females in 1914, on the occasion of previous censuses. In the common lodging-houses, 14,724 persons were accommodated as compared with 14,593 in 1926 and 20,173 in 1914, before the war. In the free shelters and labour homes not licensed, 646 males, 134 females and 22 children were accommodated as compared with 647 males, 125 females and 20 children in 1926. 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 777 (764 males and 13 females), the largest number recorded at any census since 1912. At London Rowton Houses, 5,042 men were accommodated and there was one vacant bed. Verminous lodgers in common lodging houses. 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. There are no figures available as to the actual number of lodgers cleansed, but a considerable improvement has been noted with regard to verminous conditions in such houses. Housing Acts, etc. An improvement scheme, under Part II. of the Housing Act, 1925, was made by the Council and submitted to the Minister of Health for approval, in respect of an area in the Metropolitan Borough of St. Marylebone, known as the Carlisle Street area, comprising some eight acres, on which stood 310 dwelling-houses, together with a few warehouses, etc., and having a population of about 2,832 persons. The approval of the Minister of Health has, during the period under review, been given to the Basing Place and Blue Anchor Lane improvement scheme and the China Walk (Lambeth), and Hatfield Street and Hankey Place (Southwark) 25 COUNTY OF LONDON. Statistics of the administrative work carried out during the year 1927. Sanitary Authority. Cowsheds. Slaughterhouses. Offensive Trades. Observations. Smoke nuisances. Notices. 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. authorised. No. of inspections. Intimations. Complaints. Houses licensed. Authorised lodgers. Persons. Rooms or premises Tenement houses extra supply. No. on register. No. of inspections. No. on register. No. ol inspections. No. of places. No. of inspections. Adults. Children. After infectious diseases. For vermin. City of London - - - - - - 135 2 11 - 1 455 40 1,008 Always - - 271 284 43 41 841 1,596 Batteraea - - 2 288 3 4 11 7 11 - 3 201 252 4,364 1,974 171 20 131 492 149 574 99 329 Bermondsey - - - - 14 55 30 7 6 5 3 1,197 141 - 1,698 444 - 200 662 114 207 119 501 Bethnal Green 11 54 2 104 9 116 14 6 - 1 6 395 36 - 1,263 365 - 253 772 170 361 187 580 Camberwell 1 12 2 185 10 25 151 15 18 - 5 438 28 3,476 2,987 239 - 450 1,095 361 497 174 204 Chelsea - - 2 62 - - 17 - 6 - 2 172 - 1,023 293 131 - 75 88 28 31 76 76 Deptford - - 2 78 6 24 33 3 5 - 6 1,154 - - 1,359 151 - 179 294 187 250 52 75 Finsbury - - 1 75 3 72 52 4 16 3 2 470 19 5 691 53 3 160 178 99 122 203 234 Fulham - - 2 191 - - 340 - 7 - 2 87 11 - 1,212 58 135 113 92 247 191 112 225 Greenwich 1 4 3 37 3 4 31 3 35 - 2 90 6 875 943 12 1 123 132 158 151 59 59 Hackney 5 61 15 526 19 33 574 20 22 1 4 313 58 2,764 2,604 476 1 366 1,382 263 412 157 215 Hammersmith - - 7 591 2 30 129 29 16 2 1 292 118 2,655 829 28 39 86 1,530 171 205 130 510 Hampstead - - 1 48 - - 1 - - - - - 4 1,063 - 26 26 62 163 71 86 67 145 Holborn - - 1 7 - - 241 2 8 - 13 948 93 - 484 46 2 129 98 42 311 255 437 Islington 1 10 13 710 19 64 232 10 60 - 23 830 12 5,035 3,089 25 55 540 900 238 78 440 430 Kensington - - 5 282 1 - 486 3 7 — 7 362 171 3,905 915 407 98 146 653 163 114 - - Lambeth 2 6 9 162 4 48 74 74 74 - 3 477 - - 7,255 464 104 490 2,940 168 504 198 396 Lewisham 3 24 8 566 - - 24 - - - - - - - 1,425 46 - 137 350 - - 114 243 Paddington 1 12 3 206 1 65 378 - 13 - 3 165 11 - - 110 - 101 425 127 200 112 302 Poplar 4 35 7 17 7 25 19 26 40 7 6 498 110 1,302 1,811 200 - 268 356 117 272 313 1,753 St. Marylebone 1 26 1 84 3 66 246 7 7 - 4 756 3,435 2,724 614 454 13 109 340 118 192 286 947 St. Pancras - - 5 132 1 48 255 3 24 2 2 78 1,322 5,540 1,095 82 216 209 774 327 290 380 456 Shoreditch 2 21 1 26 2 13 7 3 - - 4 284 - - 1,049 25 10 28 1,315 126 256 190 689 Southwark - - 4 88 4 8 4 2 . 3 1 22 2,322 1,067 3,443 5,634 627 27 348 1,878 139 278 346 1,384 Stepney 22 65 1 1 53 140 176 36 30 8 24 3,351 455 - 2,207 86 - 409 1,574 252 447 392 579 Stoke Newington 1 1 4 65 - - 8 2 6 - - - 1 1,581 351 110 - 61 54 26 63 31 36 Wandsworth 1 12 7 446 7 170 96 26 23 3 1 69 260 - 3,270 552 - 245 1,022 451 278 267 1,135 Westminster - - - - - - 2,057 29 79 - 6 1,745 351 1,069 894 57 22 507 636 148 121 450 930 Woolwich 9 239 7 25 - - 155 - - - 10 365 54 2,231 964 43 - 93 677 136 359 140 858 Total 65 583 115 4,962 171 1,040 5,976 319 523 33 165 17,514 8,059 14,063 46,910 5,488 776 6,289 21,356 4,637 6,891 6,290 15,344 Note.—In the columns above a dash signifies a nii return. Common lodging houses licensed by the Council (i.e., excluding those in the City of London) number, 164; lodgers, 17,059; visits—day, 7,469, night, 287 prosecutions, nil. Seamen's lodging houses, licensed number, 31 ; Poplar, 6 ; Stepney, 25; lodgers, 1,061. Visits—day, 750; night, 45; prosecutions, 6 ; penalties and costs, £46 5s. 0d. Prosecutions—Water Supply : Hammersmith, 1. Kensington, 1. St. Marylebone, 1 ; St. Pancras, 3 ; Milk shops : Fulham, 8 ; St. Pancras, 17; Southwark. 4. Ice Cream Premises : Hackney, 2. 26 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 unlit for habitation. In borough. Occupied by the working classes. Under P.H. Act. Under Housing Act. Kcpresen tations. Closing orders. Demolition orders. Complaints or illness. House to house. Instances found. No. remedied. No. on register. No. of inspections. No. illegally occupied. No. closed or otherwise remedied. Erected during year. In course of erection. No. made. No. of houses. No. made. No. determined. No. made. No. of houses demolished Intimation. Statutory. In pursuance of orders. Voluntarily. By owners. By L.A. City of London 1,932 1,015 417 223 225 161 - 138 138 - - - 1 1 74 354 - 128 24 - - - - - - 28 Battersea 27,901 25,010 4,312 1,058 3,229 925 392 3,193 442 - 1 1 7 7 85 125 - 90 13 - - - - - - 26 Bermondsey 18,221 18,071 5,383 3,908 2,168 498 5,133 2,168 3,796 6 1 1 2,763 400 220 450 5 139 25 - - - - - 163 7 Bethnal Green 18,497 18,497 6,462 859 6,085 4,421 - 7,559 - - - - - - 170 947 - 34 44 - - - - - - - Camberwell 42.523 34,016 4,525 520 4,633 1,611 2 4,281 - - - - 326 79 240 265 - - - 1 125 - - - - 27 Chelsea 11,710 2,498 941 187 886 216 - 436 - - - - 3 3 140 140 - - - - - - 2 - - 3 Deptford 18,122 - 2,968 2,895 3,378 199 - 3,378 - - - - Many cases 5 *— - - - - - - - - - - - Finsbury 10,889 - 1,366 - 2,079 367 - 2,079 - - 4 4 13 13 869 4,383 - 45 50 1 1 1 - - - - Fulham 25,979 - 3,071 225 2,073 325 50 1.890 27 1 2 2 - 44 - - - 128 187 - - - - - - - Greenwich 17,089 M'j'rity 968 52 1,120 147 - 1,367 - - 1 1 58 5 119 249 - 183 94 - - - - - - 4 Hackney 35,145 14,280 6,554 845 5,207 1,655 - 5,595 - - 10 6 221 25 117 46 - 25 6 - - - - - - 11 Hammersmith 19,338 12,500 5,871 237 3,232 1,200 - 3,216 - - 1 1 73 58 2,495 - 523 732 4 7 7 - - - - Hampstead 13,071 approx. one-hall 743 - 940 494 - 554 - - 35 35 40 3 491 1,309 - - - 4 4 4 - - - - Holborn 3,473 8,571 553 - 515 77 - 515 - - - 15 - - - - - - - - Islington 45,250 tenemts 28,600 8,498 1,296 4,666 513 1 6,105 - - 10 10 24 24 1,011 4,283 - t'n'm'ts 195 78 - - - - - - 49 Kensington 30,574 9,278 2,930 2,139 3,335 849 21 3,209 6 4 50 50 88 78 3,608 8,549 - 38 - - - - - - - - Lambeth 42,607 - 9,421 395 5,012 3,560 481 4,908 459 - 5 5 42 42 - t'n'm'ts 408 150 - - - - - 3 12 Lewisham 34,420 - 2,385 1,377 1,900 399 - 2,133 - - 1 1 62 9 6 42 1,528 - - - - - - - - Paddington 17,000 9,100 2,443 - 2,691 697 436 1,327 349 - 2 2 17 5 1,406 6,926 - - - 1 6 4 1 - - 4 Poplar 23,248 23,000 6,304 668 4,993 1,782 - 5,144 - - - - 26 11 36 69 - 147 - - 2 - - - - St. Marylebone 19,287 8,226 2,478 984 1,869 95 - 1,982 - - 8 1 192 192 1,070 10,833 - 40 - 1 310 - - - - - St. Pancras 25,216 16,000 4,273 310 3,170 1,809 244 3,972 234 - - - 19 15 1,459 5,243 - - - - - - - - - - Shoreditch 14,029 13,129 6,621 2,756 5,736 1,235 - 5,736 - - 2 2 172 85 303 1,281 - 184 36 - - - - - - - Southwark 19,050 14,034 10,523 4,210 10,499 3,277 2,483 10,710 10710 - - - 79 79 623 623 - 37 16 - - - - - - - Stepney 38,408 31,731 8,010 6,435 13,343 8,462 - 10,245 - - 8 6 87 62 2,639 2,625 - 119 305 - - - - - - 1 Stoke Newington 8,618 3,976 843 129 8771 100 - 1,791 - - - - 1 1 100 115 - - - - - - - - - - Wandsworth 73,017 48,148 8,288 1,435 4,600 560 - 10,756 - - 11 14 252 176 265 458 - 988 Not known - - - - - 6 32 Westminster 25,321 - 1,461 819 1,088 33 - 1,040 - - 31 27 46 32 155 1,278 2 - 118 1 20 - - - - - Woolwich 28,707 24,150 3,481 2,672 3,513 863 3 3,290 - - 11 3 130 27 327 380 - 1,033 462 4 4 3 - - - 36 Total 708,642 363,830 122,093 36,334 103,062 36,530 9,246 108,717 16161 11 203 181 4,744 1483 18,585 51,778 7 6,027 2,349 17 477 21 3 - 172 196 Note.—In many cases, it has been impossible to take effective action in the matter of overcrowding owing to the shortage of houses. * New register in course of preparation. Prosecutions—Houses Lei in Lodgings: Holborn, 1; Kensington, 15; Poplar, 1; Shoreditch, 4; St. Marylebone, 3; Westminster, 4. „ Overcrowding: Camberwell, 1; Fulham, 1; Hammersmith, 6; Holborn, 1; Kensington, 9; Westminster, 2. 27 improvement scheme. The former scheme provides for the accommodation of some 756 persons, and the latter 3,350 persons. The subjoined Table shows the number of sanitary officers and health visitors employed by the sanitary authorities in London :— Sanitary Inspectors. Male. Female. Health Visitors. Whole time. Part time. Whole time. Part time. Whole time. Part time. City of London 23 - 1 - - - Battersea 11 - - 2 7 2 Bermondsey 14 - - - 8 - Bethnal Green 11 - - - 12 - Camberwell 11 1 2 - 3 - Chelsea 4 - 1 - 1 - Deptford 8 - - - 6 - Finsbury 7 - 1 - 5 - Fulham 9 - 1 - 6 - Greenwich 5 - 1 - 10 - Hackney 18 - 2 - 16 - (including 2 Tuberculosis visitors) Hammersmith 9 - 1 - 3 - Hampstead 7 - 1 - 3 - Holborn 3 - - 1 1 1 Islington 20 - 2 - 9 - Kensington 11 1 5 - 4 - Lambeth 16 - 2 - 4 - Lewisham 10 - 1 - 9 - Paddington 9 - 2 - 2 - Poplar 10 - 1 - 9 - St. Marylebone 8 3 - 3 4 4 (including 1 Tuberculosis visitor) (including 1 Tuberculosis visitor) St. Pancras 15 - 1 6 18 6 Shoreditch 12 - - - 8 - Southwark 12 - 1 - 10 - Stepney 18 - - - 11 - Stoke Newington 2 (8 months only) 1 - (4 months only) 1 3 - Wandsworth 14 - - - 7 - Westminster, City of 11 - 1 - 7 - Woolwich 10 - 1 2 6 3 London County, 1927 318 6 28 15 192 16 Sanitary Officers. Milk and Dairies (Consolidation) Act, 1915. Samples of milk forwarded to London from places outside the County are now taken and examined under the provisions of the Milk and Dairies (Consolidation) Act, 1915. In 1927, 2,305 samples from milk consigned to London railway termini from 32 counties were submitted for bacteriological examination. In the case of 1,969 samples, the bacteriological examination was completed, and of these 154, or 7-8 per cent, yielded tubercle bacilli as against 4-5 per cent, in 1926. In accordance with the provisions of the Milk and Dairies (Consolidation) Act, 1915, information is 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. 28 From the copies of reports forwarded by the county medical officers of health, it would appear that 59 cows had been found to be affected with tuberculosis and were slaughtered under the Tuberculosis Order, 1925. In the case of 311 samples, it was reported that the injected guinea-pig had succumbed to an acute intercurrent infection by some organisms other than tubercle contained in the milk. As it seems possible that the death of the guinea-pig is caused by lethal organisms in the milk caused by dirty conditions either of the cow's udder or in the cowshed, the County Medical Officers of Health are now notified of the circumstances in order that they may take such action as they think desirable. In accordance with the instruction of the Mental Hospitals Committee, 25 samples have been taken during the year of the milk from the cows at the mental hospitals. Of these, four have been found to be tubercle infected. In each case the herd at the farm whence the milk emanated has been inspected by the Veterinary Inspector. In one instance, a cow which he considered tubercular and isolated for slaughter, subsequently died of pulmonary haemorrhage. In another instance, a cow found on post-mortem examination to be tubercular was slaughtered a few days before the Veterinary Inspector's visit. In the case of the remaining two samples, which emanated from the same herd, the inspector failed to detect any evidence of tuberculosis. Three cows, however, had been slaughtered shortly after the taking of the samples. The cows in the London sheds are inspected under the provisions of Section 27 of Part V. of the Council's (General Powers) Act, 1904, and Part IV. of the Milk and Dairies Order, 1926. The Veterinary Inspector makes a routine quarterly inspection of the cows at each cowshed. 367 inspections were made for this purpose during the year, and 8,125 examinations made. No case of generalised tuberculosis was detected, but in 116 cases other unhealthy conditions were found. Venereal Diseases. The number of new cases of venereal disease dealt with by the hospitals under the London and Home Counties Scheme during 1927 was 18,801, of which 6,095 were syphilis, 12,496 gonorrhoea, and 210 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 1,077 more than in 1926. Year. Syphilis. Gonorrhœa. Soft chancre. Non-venereal. Total. 1926 5,738 11,683 303 8,988 26,712 1927 6,095 12,496 210 10,16 28,965 Increase + or decrease — +357 +813 -93 +1,176 +2,253 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. Year. Syphilis. New cases. Soft chancre. Gonorrhœa. Total venereal 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 1920 3,725 2,013 301 2 8,825 2,858 12,851 4,873 1927 3,886 2,209 203 7 9,637 2,859 13,726 5,075 29 Importance is attached to the necessity of securing the regular attendance of patients at the clinics, more especially in the case of gonorrhcea, 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 767,278, and the ratio of attendances to venereal cases is in the proportion of 40 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 Ratio of attendances. country. Comparative figures for the eleven years during which the scheme has been in force are shown in the following table:- Year. New cases. Total. Attendances. In-patient, days. Venereal. Non-venereal. 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 1927 18,801 10,164 28,965 767,278 112,413 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. Another point worthy of note is the total number of examinations made of pathological specimens. Comparative figures for the eleven 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 1927 107,512 27,046 Pathology and bacterio- logy. The continued 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 arsenobenzene compounds for the treatment of their private patients. The number of medical practitioners availing themselves of this 15435 C 30 service is now 446 as compared with 108 at the end of 1917, the first year of the operation of the Scheme. Hostel tion. 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 1927, the number of patients dealt with at these institutions from the areas in the Scheme was 282, the aggregate number of days in residence being 26,422. 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 32 and 33. Afterhistories of tuberculous patients. An investigation has been made into the after-histories of adult and child patients treated in residential institutions during the year 1921. In each case the survey is the first made on a five-yearly basis, which is regarded as more satisfactory for assessing the value of residential treatment than the three-year basis formerly taken. Survey of the 1921 group will continue to be made after each subsequent period of five years, and the same course will be adopted as regards patients discharged during 1922 and each year thereafter. By this means comparative results of considerable value will be built up from year to year. Adults. The number of adult cases investigated was 3,178, which included 223 surgical cases. The records show the following results :— *Class. Total. Alive five years after discharge. Dead. A 468 83.5% 16.5% B 1 330 61.5% 38.5% B 2 1,299 34.0% 66.0% B 3 858 3.7% 96.3 % Surgical 223 73.5% 26.5% * The classification adopted throughout this article is as follows:—A, cases in which tubercle bacilli have not been demonstrated in the sputum; B, cases in which tubercle bacilli have been demonstrated in the sputum (Bl, early cases; B2, moderately advanced cases; and B3, advanced cases). Particulars obtained as to the fitness for work of the 1,230 surviving adult patients who were discharged from treatment in 1921 show that out of a total of 594 A and B 1 cases, 68 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: B.2, 40 per cent.; B.3, 25 per cent.; and surgical, 71 per cent. Of the total number of 1,230 in all categories, 57.5 per cent. were at work, 4.4 per cent. were fit for work, but were unemployed, 37.5 per cent. were unable to work (including cases receiving further residential treatment) and the condition of the remaining .6 per cent. was unknown. Children. The particulars obtained as to the after-histories of children discharged in 1921, relate to 522, of which 333 are pulmonary and 189 non-pulmonary. The mortality records show that 259 pulmonary and 153 non-pulmonary cases are still alive. The percentages are as follows :— Class. Pulmonary— Total. A live, five years after discharge. Dead. A 271 90% 10% B 1 11 44.5% 55.5% B 2 18 50% 50 % B 3 33 3% 97% 31 Class. Non-pulmonary (Surgical)— Total. Alive five years after discharge. Dead. Hip 45 71.1% 28.9% Spine 37 75.7% 24.3% Other bones 35 88.6% 11.4% Glands 59 93.2% 6.8% Other parts 13 53.8% 46.2% Of the 259 surviving pulmonary cases 68 were at school and 148 at work, and of 153 surviving non-pulmonary cases 71 were at school and 58 at work. Artificial light treatment. Arrangements were made by the Councd in 1926 for an experimental scheme to be put into operation which would enable the metropolitan borough councils to utilise as part of the tuberculosis dispensary schemes the facilities for artificial light treatment at certain hospitals and centres throughout London approved by the Minister of Health and the Council. Since the inception of the scheme the Council has approved proposals submitted by nineteen borough councils for utilising the facilities available under the scheme. From the information obtainable it would appear that the number of cases treated under the scheme has been small and that the results have been variable and speaking generally have not been encouraging. The scheme has been extended for another year. At the same time the experience gained so far indicates that under certain conditions and in certain subjects the application of ultra violet light appears to be a valuable method of treatment for non-pulmonary tuberculosis, but that the best results can generally be obtained in residential institutions, wherein it forms part of the scheme of treatment of the disease and is one of the many associated methods of treatment. It is not necessary in this report to refer to the question of the settlement of tuberculous persons in suitable employment after leaving sanatoria as this subject has been exhaustively dealt with in a special report which was presented to the Public Health Committee in December, 1927, and published by the Council (Publication No. 2545 ; price Is.) Employment of tuberculous persons. Reference was made in last year s report to the handicraft class for dispensary patients which had been successfully initiated by the Lewisham Tuberculosis Care Committee. The tuberculous patient who is unable to obtain employment is in danger of becoming a victim to depression, and the handicraft class is an excellent means of providing new interest and occupation. The Council has intimated to the borough councils its sympathetic interest in such ventures and expressed the hope that classes similar to the Lewisham class might be opened in other parts of London. Classes have been started in Kensington, Stepney, Wandsworth and Westminster. Handicraft classes for dispensary patients. The Tuberculosis Care Committees have continued their excellent work of advising and assisting tuberculous patients. Reports received in the ordinary course of administration indicate that much useful work is done in an unobtrusive way, e.g., children are adequately provided for during the absence of the mother under sanatorium treatment, help is secured for families during the absence of the breadwinner, employment is obtained for patients after treatment, and in numerous other ways, which cannot be visualised by statistical reports, much benefit has accrued to patients and their families as the result of the activities of these committees. Tuberculosis Care Committees. Between 1915 and March, 1925, the contributions received from parents and guardians of children dealt with under the tuberculosis scheme were paid into the "Tuberculosis Contributions Fund." Since April, 1925, the balance in the fund has been used with the co-operation of the Invalid Children's Aid Association for boarding out children living in contact with cases of advanced pulmonary tuberculosis. In addition, in a few cases where it was not possible to make other arrangements, children have been boarded out in order to enable their mothers to accept institutional treatment. There is no doubt as to the benefit derived by the children in the clean, healthy surroundings of the country away from overcrowded homes 15435 C 2 Boarding-out scheme. 32,33 Tuberculosis Dispensaries—Analysis of Returns, Jan.-Dec., 1927. Borough and Dispensary. On Dispensary Register, 1-1-27. Transferred during 1927 from other areas and lost sight of cases returned Examined for first time during 1927. (а) New cases excluding contacts. (б) Contacts (printed in italics). Total number (including contacts) under dispensary supervision during 1927. Removed from Dispensary Register during 1927. On Dispensary Register on 31-12-27. Total attendances. Visits to homes for dispensary purposes by No. of specimens of sputum examined. Diagnosis completed. Under observa tion. Pulmonary. NonPulmonary. Doubtfully Tuberculous. NonTuberculous. Total. (a) Cured. (b) Diagnosis not confirmed or nonT.B. (printed in italics). (a) Transferred to other areas or lost sight of. (b) Died (printed in italics). Diagnosis completed. Under Observation. Adults. Children. Adults. Children. Adults. Children. Adults. Children. Adults. Children. Tuberculosis Officer. Dispensary Nurse. Battersea 876 243 20 144 6 18 16 67 52 179 115 408 189 1,935 18 100 897 82 4,180 167 5,434 535 3 7 19 65 105 75 124 727 111 Bermondsey 1,156 42 58 90 8 13 18 161 57 73 62 337 145 2,291 72 103 1,174 40 4,247 209 3,873 798 13 9 215 316 228 325 805 97 BethnalGreen 612 10 13 73 6 9 8 34 6 232 124 348 144 1,389 10 77 596 9 3,676 161 2,404 707 1 1 3 3 115 139 118 144 629 68 Camberweil 2,003 45 23 224 6 36 37 96 40 338 333 694 416 3,884 87 148 1,979 33 7,587 692 7,087 1,113 36 7 21 12 219 408 283 420 1,462 175 Chelsea 192 30 10 47 19 4 197 278 263 282 897 9 21 199 16 3,307 46 3,131 341 1 30 89 31 89 630 22 Deptford 729 60 27 113 4 8 8 145 87 67 89 333 188 1,515 45 181 603 104 3,577 177 4,512 856 2 1 20 42 39 74 61 117 489 93 Finsbury 432 27 16 60 4 3 5 6 90 49 159 58 880 6 36 460 13 4,107 417 2,777 455 20 1 1 3 67 96 90 98 307 58 Fulham 1,117 54 23 129 7 30 25 28 9 320 331 507 312 2,552 72 302 902 13 4,836 592 5,422 885 5 4 10 9 177 274 192 287 1,181 82 Greenwich 607 21 13 71 7 10 7 12 11 77 78 170 103 1,314 29 647 31 6,061 204 3,880 150 17 1 1 4 9 12 152 204 179 221 545 62 Hackney 1,188 20 41 156 2 16 18 73 20 243 173 488 213 2,334 16 190 1,128 45 6,505 237 4,331 1,028 3 1 1 20 9 148 202 171 213 834 121 Hammersmith 660 26 26 147 4 14 13 17 3 197 127 375 147 1,408 25 46 720 24 2,631 158 4,547 507 7 1 1 1 2 58 104 66 108 507 86 Hampstead 225 23 24 41 1 5 1 8 6 48 38 102 46 495 2 74 204 11 1,184 8 1,243 271 2 5 3 24 41 31 44 185 19 Holborn 191 1 8 40 2 3 5 15 2 13 1 71 10 345 12 45 178 2 874 65 1,165 201 2 4 1 28 26 34 27 86 22 Islington 1,187 62 68 275 6 17 11 26 10 254 91 572 118 2,438 29 136 1,275 29 8,891 599 6,011 973 25 1 3 2 7 3 189 201 224 207 766 203 Kensington 1,222 31 9 90 4 6 19 55 17 136 115 287 155 2,141 251 208 846 13 2,927 83 2,350 499 1 1 4 4 2 188 237 193 244 756 67 Lambeth 1,508 157 35 367 9 42 46 134 34 576 258 1,119 347 3,686 77 252 1,592 111 9,735 431 5,062 1,444 20 4 2 35 24 220 215 277 243 1,450 204 Lewisham 851 18 47 146 4 16 16 13 9 141 125 316 154 1,573 9 61 901 5 2,889 306 2,189 164 7 1 1 1 79 98 87 100 481 116 Paddington 983 45 56 131 1 17 89 164 167 208 211 520 468 2,532 3 148 1,102 50 11,745 611 4,708 839 3 2 15 37 58 168 177 210 250 1,167 62 Poplar* 958 52 6 110 5 7 13 27 34 396 388 540 440 2,293 82 63 943 49 5,622 189 7,997 2,173 8 7 1 2 8 9 90 172 107 190 1,046 110 St. Marylebone 228 106 14 73 4 2 4 76 52 35 16 186 76 755 3 24 285 101 3,449 170 1,325 240 4 20 58 28 35 52 93 312 30 St. Pancras 734 73 59 179 3 7 18 107 25 117 139 410 185 1,659 7 212 758 127 5,094 133 5,279 917 6 2 9 7 41 133 56 142 475 80 Shoreditch 567 34 29 71 4 4 2 12 4 135 95 222 105 1,280 5 98 558 29 5,809 377 2,744 706 28 1 1 1 2 133 157 163 160 525 65 Southwark 588 41 10 164 12 12 45 28 15 160 60 364 132 1,500 42 142 580 51 5,543 45 3,429 527 3 2 3 1 7 130 219 134 231 573 112 Stepney 1,552 85 46 248 29 9 28 84 35 280 193 621 285 3,650 75 109 1,691 80 8,376 280 5,266 1,833 11 8 4 4 20 26 436 552 471 590 1,576 119 Stoke Newington 221 5 9 44 1 2 4 22 7 22 5 90 17 433 2 38 221 14 1,110 49 732 271 1 2 2 2 30 54 35 56 134 24 Wandsworth 1,262 73 45 206 2 16 15 60 18 215 451 497 486 2,884 165 76 1,192 22 5,720 386 5,067 2,087 22 1 2 3 5 201 287 227 294 1,244 185 Westminster 711 1 7 140 5 15 16 5 3 61 52 221 76 1,149 2 128 679 2 2,627 149 4,875 172 5 3 1 1 28 95 37 96 303 35 Woolwich* 1,790 19 7 193 15 19 21 41 19 401 381 654 436 3,194 534 198 1,155 19 5,014 523 4,802 598 1 3 2 4 137 141 140 148 1,173 115 Totals 24,353 1,404 749 3,772 161 356 508 1,535 746 5,211 4,378 10,874 5,793 52,406 1,660 3,245 23,465 1,125 137,323 7,464 111,642 21,290 242 34 28 48 267 328 3,435 4,851 3,972 5,261 20,368 2,543 * In the case of Poplar and Woolwich the numbers on the dispensary register on 1st January, 1927, are revised figures, and in the case of Poplar the apportionment between "Diagnosis completed " and "Under observation" is approximate. 34 in which they were living in close contact with advanced consumptives. During 1927, 208 applications were received and 146 children accepted, the remaining 62 being withdrawn or unsuitable. At the end of the year 53 children were being maintained under this scheme. The fund is also used for defraying the travelling or incidental expenses of children, providing surgical appliances required by children after discharge from institutional treatment and for supplying clothing in certain cases to children under the tuberculosis scheme. Tuberculosis, residential treatment. The following table indicates the number of applications from adults for residential treatment during each of the last five years:— Applications for first period of treatment. Applications for further treatment. Total applications. Ex-Service. Civilian male. Female Ex-Service. Civilian male. Female. 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 1927 63 2,119 1,819 417 727 622 5,767 Of the 5,767 adult cases recommended for residential treatment during 1927, only 32 were subsequently withdrawn, 5,205 were accepted and 530 were not accepted. The 5,205 cases were disposed of as follows : (a) 1,309 were passed for admission to "observation" beds in order to determine "diagnosis" or "suitability for sanatorium treatment"; (6) 3,896 were admitted direct to sanatoria or hospitals. Of the foregoing accepted cases, 320 for various reasons failed to enter institutions and 59 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 1,284 patients were discharged from "observation beds" and their classification was as follows (the corresponding figures for 1926 in pulmonary cases are also given) :— Pulmonary. 1927. 1926. Group A 355 (36.30%) 352 (37.65%) Group B1 60 ( 6.13%) 58 ( 6.20%) Group B2 484 (49.49%) 413 (44.17%) Group B3 79 (8.08%) 112 (11.98%) Total pulmonary cases 978 935 Surgical cases 18 13 Total diagnosed as tuberculous 996 948 For definition of classification see footnote on page 30. In the remaining 288 cases the diagnosis of tuberculosis was not confirmed. Of the 996 cases definitely diagnosed as tuberculous, 761 pulmonary cases were sent to sanatoria, 50 to institutions for advanced cases, 15 died in the "observation" hospitals, 15 cases were transferred to surgical institutions, and 155 were discharged home or arrangements made for them independently of the Council's Tuberculosis Scheme. The total number of adults admitted to institutions during 1927 was 5,311 as against 5,203 in 1926. 1,841 were under treatment at the commencement of the year, so that the total number of adults treated in 1927 was 7,152 as against 6,871 in 1926. The number under treatment on 31st December, 1927, was as follows (the corresponding figures for the previous year are shown in brackets ):— Discharged soldiers. Civilian adults. Totals. Voluntary institutions 129 (104) 507 (421) 636 (525) Metropolitan Asylums Board 37 (55) 1,273 (1,261) 1,310 (1,316) Total 166 (159) 1,780 (1,682) 1,946 (1,841) 35 The immediate results of the treatment of patients discharged on completion of courses of treatment during 1927 are indicated below. The figures in brackets are those for the previous year. 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. Immediate results of treatment. Classification. Surgical. Totals. A. Bl. B2. B3. Quiescent 181 (135) 73 (42) 51 (29) — (—) 83 (81) 388 (287) Much improved 352 (349) 168 (215) 1,021 (1,093) 45 (29) 205 (265)1,791(1,951) No material improvement 122 (102) 12 (38) 1,152 (1,473) 549 (422) 77 (56) 1,912 (2,091) Died in institutions 5 (4) — (2) 46 (50) 460 (395) 18 (11) 529 (462) Totals 660 (590) 253 (297) 2,270(2,645) 1,054(846) 383(413) 4,620 (4,791) With regard to children, the number recommended for treatment under the Council's Tuberculosis Scheme during each of the last five years was 865 in 1923, 1,019 in 1924, 1,025 in 1925, 1,163 in 1926, 1,190 in 1927. 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 arrangements have been made for the immediate admission to residential institutions of children suffering from tuberculous of the hip, spine and other joints. Of the 1,190 children (i.e., patients under 16 years of age) referred to the Council in 1927,1,164 were accepted for treatment, 26 were not accepted or were withdrawn ; 30 of the accepted cases for various reasons failed to enter institutions after acceptance. There were 202 children under treatment in voluntary institutions and 678 in Metropolitan Asylums Board institutions on 1st January, 1927 (total 880) and 1,048 children were admitted during the year, making in 1927 the total number of children treated 1,928 as against 1,874 in 1926. The number of children under treatment on 31st December, 1927, was 884, distributed as follows :— Metropolitan Asylums Board Institutions 664 Voluntary Institutions 220 The condition of the children under 15 years of age who were discharged from residential institutions in 1927 is indicated in the following table (children of 15 vears of age are included with adults owing to requirements of the Ministry of Health). The figures in brackets are those for 1926 :— Immediate results of treatment. A. Classification. Surgical. Totals. Bl. B2. B3. Quiescent 72 (83) ] - (1) 1 (2) - (-) 360 (245) 433 (331) Much improved 83 (62) 1 (2) 5 (14) - (2) 224 (260) 313 (340) No material improvement 19 (25) 1 (-) 6 (3) 7 (27) 27 (40) 60 (95) Died in institution 1 (3) - (-) 2 (-) 7 (14) 18 (20) 28 (37) Total 175 (173) 2 (3) 14 (19) 14 (43) 629 (565) 834 (803) In addition to the foregoing arrangements for residential treatment of tuberculous children the Council has established six open-air day schools for children 36 suffering from pulmonary tuberculosis or else from tuberculous glands with no open wounds who do not appear to require treatment in residential institutions. One additional school will be provided in 1928. The work of these schools is dealt with in the section of this report dealing with the school medical service. Diphtheria. Report of the Bacteriological Laboratory. To meet all the requests for bacteriological investigation, heavier than in any previous year, a total of over 13,800 of various tube and plate culture media, some 2,800 more in number than in 1926, were prepared by the two laboratory assistants. A total of 11,020 throat and nose cultures from 10,745 children were examined, yielding morphological diphtheria bacilli (K.L.B.) in 1,021, or 9.26 per cent. From 40 chronic carriers K.L.B. were isolated in pure culture, and sent to the Clinical Research Laboratories for the virulence test by animal inoculation. 28 cultures were reported non-virulent, and 12 virulent. Ringworm. Hair specimens from 1,872 children were examined and in 653 (34 8 per cent.) parasitic fungus was found.* Consultations Consultation visits at the request of medical officers of health and private practitioners to assist in the diagnosis, particularly of encephalitis lethargica and epidemic cerebro-spinal fever, were paid by Dr. J. A. H. Brincker or Dr. J. G. Forbes. Encephalitis lethargica.—Of seven cases in which encephalitis was regarded at consultations as not improbable, lumbar puncture was performed in one and four were confirmed by the subsequent course. But in two cases removed later to hospital for observation and operation, the disease proved to be cerebral tumour, one case being cerebral syphilis, now recovered. Three cases of suspected encephalitis, not supported at consultation, were due to neurosis and temporary indisposition in two; the third case on removal to hospital was found to be suffering from paratyphoid fever. Cerebrospinal fluids. Cerebrospinal meningitis.—One case of fulminating form was confirmed as due to the meningococcus by lumbar puncture and examination of the cerebrospinal fluid. Removal to hospital eventually resulted in complete recovery. One case of suspected cerebro-spinal fever was recognised at consultation as German measles. For help in diagnosis, particularly of notifiable diseases, such as cerebro-spinal meningitis, encephalitis and poliomyelitis, 122 specimens of fluid obtained by lumbar puncture from 109 cases were examined and reported on (as compared with 103 specimens from 93 cases in 1926). These included fluid from 46 cases at St. James' Hospital, Balham, 45 cases at the Fulham Hospital, 16 cases at the Highgate Hospital, and 2 cases seen in consultation at the patients' homes, which may be grouped as follows:— 1. Encephalitis lethargica,—19 specimens of fluid from 17 cases with the provisional diagnosis of this condition. The subsequent course of the 17 cases showed that only five were suffering from encephalitis in acute or chronic form. 2. Tuberculous meningitis.—Examination of the fluid was of assistance in the diagnosis of 19 cases, from which 22 specimens were sent. Tubercle bacilli were found in 14 of the 19 cases, i.e., 73.5 per cent., including one in doubt, in which histological section of post mortem material from the brain showed abundant tubercle bacilli. 3. Cerebro-spinal meningitis.—16 specimens of fluid from 12 cases were examined, and the diagnosis was made on the cytological and bacteriological changes found, including the presence of the meningococcus in film or culture. 4. Other forms of meningitis.—Of 12 specimens from 11 cases of acute meningitis, the organism found was identified as the pneumococcus in five, streptococcus in two, and in the four others, B. influenzae, pneumobacillus, diplococcus crassus, and staphylococcus aureus respectively. * See page 145 of this report. 37 In one case of serious meningitis (set 18), the possible consequences of postbasic meningitis in early life, and in one case diagnosed as chronic pachymeningitis following head injury, the fluid showed little change other than some increase in protein content. 5. Mastoid diseases and otitis media.—14 specimens of fluid from 10 cases were examined. Of 8 cases which eventually recovered, the fluid was normal in five; but in three there was marked meningeal reaction, as shown by the increase in protein and presence of polymorphocytosis, but cultures were sterile. One of these was complicated by tetanus (B. tetani was cultivated from the ear discharge sent to the Clinical Research laboratory), and another by cerebellar abscess relieved by operation. Recovery followed in both cases. In two cases which proved fatal from acute meningitis and cerebellar abscess, streptococcus was cultivated from the cerebrospinal fluid. 6. Cerebral lesions.—19 cases—(1) General paralysis of the insane (G.P.I.), and other syphilitic manifestations affecting the brain, e.g., arteritis and hydrocephalus. In five cases, aged 27 to 48 years, the cerebro-spinal fluid yielded positive Wassermann reaction (by tests carried out at St. Thomas's Hospital), excess of protein and globulin, and increase of lymphocytes. (2) Cerebral arteriosclerosis (non-syphilitic)—Showing but little change in the fluid, except occasional increase in protein. Seven cases of altered mental states arterial thrombosis, haemorrhage, or embolism. (3) Cerebral tumour—3 cases. (4) Concussion with right hemiparesis—one case. (5) Epilepsy—two cases. (6) Psychosis—cerebral degeneration. Normal cerebro-spinal fluid. 7. Diseases affecting the spinal cord and nerves.—Five cases in which the fluid was found normal, viz.:—Disseminated sclerosis (2), Tabes dorsalis (1), Peripheral neuritis (1), Hysterical paraplegia (1). 8. Meningismus.—Twelve cases with symptoms of meningeal irritation suggesting meningitis, in which the fluid proved normal and recovery followed. These included six cases of pneumonia or broncho-pneumonia, two cases of acidosis and cases of pericarditis, malnutrition and diarrhoea. 9. Conditions not associated with disease of the central nervous system in which the fluid was found normal—two cases of influenza, two cases of nephritis, one case of miliary tuberculosis, and tuberculous disease of the knee joint, but no meningitis. (1) Sputum—Eight specimens; tubercle bacilli found in five. (2) Conjunctival discharge from infants under observation for ophthalmia neonatorum—five cases. Gonococcus not identified. (3) Urine.—10 specimens examined. (4) Vaginal discharge.—Gonococcus not found—one case. (5) Fceces from a case of dysentery—B. dysenteriae (Flexner) and Morgan's bacillus (No. 1) isolated in pure culture. (6) Bacteriological examination of skin and wound of a midwife and two cases of Pemphigus—Yielded staphylococcus only. (7) Blood examination—Complete counts and haemoglobin estimation of four cases showed nothing abnormal in two and anaemia in two. (8) Histological examinations of post-mortem material (sent from hospitals) of cerebral and cerebellar tissue; included one case of tuberculous meningitis and one of cerebellar abscess. Miscellaneous examinations. Special investigations of swimming bath water were carried out during the course of the summer and early autumn months. In all, a total of over 100 samples were examined bacteriologically from (1) five open air baths and one covered bath of the fill and draw supply, (2) seven natural or artificial swimming ponds, (3) two open Swimming baths 38 air and one covered swimming bath supplied with filtration disinfection and aeration plant (Turnover Company, Belfast). The examination consisted of counts per cubic centimetre of the bacterial colonies obtained after 48 hours' plate culture on agar at 37 deg. C. from -1 to "5 cubic centimetres of the water, and included tests* for the presence of Bacillus Coli Communis in samples of 1 c.c. to 10 c.c.'s. I.—Fill and draw supply baths—without any process of filtration or purification by chemical means. 1. Open-air at Eltham, Mill wall, Victoria Gardens, Woolwich, Southwark Park, and Tooting. Average and Total. Average of Counts. B. Coli. present. Five baths. 42 samples ex- 950 colonies per c.c. In 1 c.c., 19 samples, amined between 31st Highest count, 20,000 per c.c., In 5 c.c., 10 samples. May and 21st October). lowest, 1 per c.c. In 10 c.c., 3 samples. No B. Coli., 10 samples. 2. Covered school bath at Gray-street, Blackfriars. Number of Colonies per c.c. Presence of B. Coli. (i.) Tap supply before inflow, 1, May 11th 4 In 5 c.c. (ii.) Main supply at bath inflow, 1, May 11th 31 In 5 c.c. (iii.) Fresh filled bath before use, 3 examinations 95 Average. In 1 c.c. in one. May 9th and 30th, July 4th. In 10 c.c., in one. Absent in one. (iv.) Bath water during use, 3 examinations. May 11th June 1st 65,650 Average. In 1 c.c., in three. July 6th II.—(ii.) Natural and artificial bathing ponds at Clapham Common, Highgate, Hampstead, Victoria Park, Plumstead, Brockwell and Ken Wood. Average of counts. B. Coli present. Seven ponds. 13 examinations between 1,250 bacteria, per c.c. In 1 ex., in 11 samples. May 2nd and October 4th. Highest, 14,000 per c.c. In 5 c.c., in 1 sample. Lowest, 6 per c.c. In 10, c.c. in 1 sample. III.—Swimming baths supplied with means of water purification by filtration, chlorination and aeration—installed with Turnover Company's plant (Belfast)— 1. Open-air. Bath. No. of examinations. Average No. of Highest. Lowest. B. Coli. present. Colonies per c.c. Peckham 17 (May to October) 50 500 0 No B. Coli in 12 (Below 10 colonies in specimens. 10 out of 17 In 10 c.c. in 2. specimens.) In 1 c.c. in one specimen of October 18th, when plant not working. Highbury 9 (June to October) 10 13 4 No B. Coli in 4, present in 5 c.c. in one when plant not work- 2. Covered. ing. Gt. Smith 14 (April to August) 350 3,500 0 No B. Coli in 13' street (10 colonies and under present in 5 c.c* 10 in 9 specimens). Total. Three baths, 150 No B. Coli in 29. 36 specimens. B. Coli in 5 c.c. in 2. B. Coli in 10 c.c. in 3. * The standard adopted by the Bathing Committee of the American Public Health Association (1923 and 1925) requires that:— (1) Not more than 1,000 organisms in 24 hours' growth at 37 deg. C. shall be found in more than 10 per cent, of samples. (2) Not more than two out of five samples of 10 c.c. on the same day shall show the presence of B. Coli. 39 Midwives and Maternity Homes Acts, 1902 to 1926, and Children Act, 1908. There are over 5,000 duly certified midwives with London addresses, of whom 870 gave notice of intention to practice within the County during the whole or part of the year, as compared with 868 in 1926. About 17.4 per cent, of the midwives with London addresses are in actual independent practice in the County, the remainder acting mostly as general or monthly 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. With regard to these, it may be noted that E. 27 of the rules of the Board provides that the rules, other than rule 22 (2), shall not apply to certificated midwives exercising their calling in poor law institutions "under the supervision of a duly appointed medical officer," interpreted by the Board as a resident medical officer. The attention of poor law institutions where the medical officer is non-resident has been drawn to this decision. The work of inspection is carried out by four women assistant medical officers, who pay special visits to midwives where cases of a septic nature or persistent high temperature or inflammation of the eyes occur. The midwives are also given advice on any point of difficulty that may arise in connection with the work. Every effort is made to ensure that the educative side of the inspectorial work is maintained. 2,014 visits were paid this year, as compared with 2,145 in 1926. Midwives. New rules made by the Central Midwives Board have been approved by the Ministry of Health and came into operation on 1st January, 1927. The variations and additions to the old rules deal with :—(1) the standard of efficiency of candidates for examination as midwives; (2) the placing of names upon, and removal from, the roll of midwives; (3) ante-natal notes; (4) duties to patients; (5) certain alterations in the wording of notices to be sent in by midwives; (6) modifications necessary to bring the rules in line with (a) the Ophthalmia Neonatorum Regulations, 1926; (6) the Puerperal Fever and Puerperal Pyrexia Regulations, 1926; (c) the Midwives and Maternity Homes Act, 1926. C.M.B. Rules Seventy-seven infringements of the rules of the Central Midwives Board were reported during the year, as compared with 88 during 1926. Of these, 41 were slight and dealt with by means of verbal caution; while 29 cases were of a more serious nature and were dealt with by a written caution. With regard to the remaining cases, four midwives were interviewed by the Committee,and personally cautioned. One case was reported to the Central Midwives Board who postponed sentence and asked for periodical reports on the midwife's conduct and methods of practice. Infringements of C.M B. rules. Nineteen midwives were suspended from practice, with a view to the prevention of the spread of infection, and in 13 cases compensation was authorised. Midwives are now, under the Midwives Act, 1926, entitled to reasonable compensation for suspension from practice. 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 child-birth except under the direction and personal supervision of a registered medical practitioner, unless the case is one of sudden or urgent necessity. During the year, eight enquiries were made into such cases, as compared with 11 in 1926. In six cases no further action was taken, and in two cases a verbal or written caution was administered. Suspension of midwives. The Births and Deaths Registration Act, 1926, came into force on 1st July, 1927, and 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. During the year, there were 486 still-births reported by midwives in their practice, as compared with 720 in 1922, 582 in 1923, 594 in Still-births. 40 1924, 510 in 1925 and 513 in 1926. Of those cases reported this year, 257 were males, and 227 females, while of two the sex was not stated ; 279 of the still-births were reported as macerated, 201 not macerated, and in six the condition was not stated. Puerperal fever. In 1926 reference was made to the fact that the Ministry of Health had in that year promulgated regulations with regard to puerperal fever and puerperal pyrexia. Previously puerperal fever was a notifiable disease, but the new regulations required that the form of certificate contained in Part I. and II. of the first schedule of the regulations shall be used in future by medical practitioners for notifying cases of puerperal fever. There were 267 cases of puerperal fever reported during the year, as against 337 during 1926. Of these, 40 cases proved fatal, as compared with 90 in 1926, a case mortality of nearly 15 per cent., as compared with 26 per cent, the previous year. In addition, the Registrar-General recorded 23 deaths from puerperal sepsis, which were not certified as fever, as compared with 30 the previous year. The distribution of the notified cases with the mode of delivery was as follows, deaths being shown in brackets:—Medical practitioners, 93 (16); Certified midwives, 70 (9); Medical practitioners and certified midwives, 2 (0); Hospitals and Poor Law Institutions, 71 (11); Medical students, 7 (0); Cases of miscarriage or abortion where no attendant was engaged, 23 (4); Uncertified women, 1 (0); total, 267 (40). Puerperal pyrexia. 892 notifications of puerperal pyrexia were received during the year, as compared with 308 in 1926; 37 of the cases proved fatal, distributed as follows, deaths being shown in brackets:—Medical practitioners, 246 (15); Certified midwives, 186 (8); Medical practitioner and certified midwife, 1 (0); Hospital and midwife, 1 (1); Hospitals and Poor Law Institutions, 392 (9); Medical students, 21 (0); Cases of miscarriage or abortion where no attendant was engaged, 40 (4); Uncertified women, 2 (0); no information, 3 (0); total, 892 (37). Twenty-four of those cases, with eight deaths, were subsequently notified as puerperal fever, and are, therefore, shown in both tables. Enquiry was made during the year into the causation of cases of puerperal pyrexia:—186 cases were analysed, the most frequently attributed causes being as follows:—influenza, 35; respiratory system, 20; sapraemia, 20; retained membranes, etc., 9; urinary infection, 8; pelvic infection, excepting sapraemia or septicaemia, 7; breast inflammation, 6; digestive system, 5; phlebitis, 5; there was no diagnosis in 35 cases. Medical aid. The Rules of the Central Midwives Board enumerate certain emergencies for which a midwife is required to advise in writing that medical aid be summoned, and must 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 1927, 6,622 notices were received, as compared with 6,910 in 1926. The estimated number of confinements conducted by midwives in independent practice is about 34,000. It would therefore appear that medical aid was necessary in about 19.5 per cent, of the cases, as compared with 17.5 per cent, during 1926. Ophthalmia neonatorum. New regulations with regard to the treatment and notification of ophthalmia neonatorum came into force on 1st October, 1926, making it no longer obligatory for a midwife to notify a case to the local sanitary authority. This duty is now placed solely upon the medical practitioner. In a memorandum issued by the Minister, a suggestion appeared 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 summoned by a midwife to attend a case of ophthalmia neonatorum, and the Council agreed to adopt the suggestion. 1,300 notices were received during the year with regard to medical aid summoned for inflammation of the eyes of infants, as compared with 1,282 notices in 1926. In addition, 65 other cases occurred in which either medical aid was not called in by the midwife or she failed to notify the Council that she had done so. Of these 41 1,365 cases, 488 cases proved to be ophthalmia neonatorum, as compared with 413 in 1926. 326 other cases that did not occur in the practice of midwives were also notified, making a total for the year of 814 notified cases of this disease. The percentage occurring in the practice of midwives was nearly 60 per cent., as compared with 59 per cent, in 1926. All the cases that occurred in the practice of midwives were investigated, and it was found that 475 were completely cured and 5 died, 2 cases could not be traced owing to removal of parents. Impairment of the vision of one eye occurred in 6 cases; in addition there was impairment of vision of one eye in a case not notified as ophthalmia neonatorum. 61 cases received in-patient hospital treatment at St. Margaret's Hospital, as compared with 57 cases during 1926. Classes for the post-graduate instruction of midwives have been carried on by the Council for some years past. This year a number of demonstrations at institutions were arranged, as in 1926, and were well attended. Lectures were also given at yarious institutions, and appeared to give great satisfaction. It may be noted that a letter was received from one of the lecturers who had been giving demonstrations during the past few years to the effect that he observed a distinct improvement in the appreciation of the importance of ante-natal work. In order to assist in the training of pupils a supply of ante-natal cards is furnished to any institutions at which there are pupils, so as to improve them in midwifery work, particularly with regard to ante-natal examinations. Training of midwives. Outbreaks of pemphigus neonatorum occurred during the year, the total number of cases being 251, as compared with 140 in 1926. In view of the fact that the cause of infection in the cases has been so obscure, an arrangement was made for a special enquiry to be carried out by Dr. Christabel Eyre, who formed the following conclusions. (1) The diagnosis of pemphigus neonatorum (bullous impetigo contagiosa) was confirmed in all but 3 cases. (2) The disease appears to be very highly contagious. The eight Chelsea cases, three Deptford cases, two in Lambeth and three in Stepney, can be tiaced to one source of infection in each group. In all these cases the infection was probably carried by the midwife. The other cases appear to be isolated ones. (3) In all but two cases examined there was no likelihood of there having been infection from the mother, either through ante-natal vaginal discharge, puerperal sepsis, or any evident impetigo or sores. The cleanliness of home surroundings did not appear to influence the severity of the disease. Contacts were found suffering from impetigo in 2 cases. (4) In 20 cases noted the average period after birth at which the outbreak appeared averaged 6-7 days, and the average duration of the whole of the cases appears to have been from 10 days up to 3 weeks. (5) In only two cases did grave constitutional disturbance ensue, although in many cases the extent of the lesions was great. In only one case did' death ensue, therefore the present outbreak may be considered to be of a mild form. (6) In six cases where the serum from unbroken blebs was bacteriologically examined the staphylococcus aureus was found in pure culture. (7) The organism appears in many cases to escape all ordinary destructive measures, and it is therefore recommended that special attention be paid by the midwife in contact with a case, to extra details such as the handle of her bag, the gloves she has worn to and from the case, her fountain pen, etc., in addition to the thorough disinfection she normally undergoes. (8) The regulations at present enforced by the Council, so far as the midwife is concerned, appear to deal as adequately as our present knowledge permits with the probable sources of infection. The notification is very prompt, and the midwives are alive to the great importance, both of early diagnosis and very careful personal disinfection once the diagnosis is established. With a view to bringing the disease more prominently to the notice of midwives the Board issued a free pamphlet for distribution by local supervising authorities to midwives practising within their various districts. Copies were sent by the Council to all London midwives. Pemphigus neonatorum. 42 Conference at Central Midwives Board Hall. In the last few years it has been the custom for a conference to be held between members of the Central Midwives Board and representatives of local supervising authorities, with a view to considering whether any alteration is necessary in the rules, and generally to clear up any points of doubt. A conference was held on 2nd November, 1927, and the two proposals put forward by the Council were (1) that the Board should give a definite ruling as to whether it does or does not require a daily attendance by a midwife, and (2) that the duration of the stages of labour be re-inserted in the Midwives' Register. Neither of these suggestions, however, was adopted bv the Board. Maternal mortality, The Council has been exercised with regard to maternal mortality in the practice of certified midwives, and has therefore prepared a report which indicates that there has been scarcely any decrease in the rates of maternal mortality for years past. It is hoped that a tightening up of the rules, together with an improved class of midwife, may result in improvement in the future. Further investigations into the subject of maternal mortality in midwives' practices are at present proceeding. Midwives and Maternity Homes Act, 1926. Part I. of this Act amends the Midwives Acts, 1902 and 1918 in various particulars. It makes the payment of compensation compulsory when a midwife has been suspended from practice with a view to preventing the spread of infection. Formerly this was optional on the part of the local supervising authority. As this duty is now obligatory on the Council, the payments will rank for grant under the Maternity and Child Welfare Act, 1918. The Act also provides a limitation of time, viz., two months from the date of his first visit, within which a medical practitioner must submit his claim when called in by a midwife in a case of emergency. 3,535 claims were submitted during the year 1927, and the total amount involved was £3,012 11s. 0d. About 25 per cent. of this amount will, it is estimated, in due course be recovered from patients. Lying-in homes. The powers of the Council with regard to the registration of lying-in homes are included in Part 4 of the London County Council (General Powers) Act, 1921. By-laws under the Act have been made in pursuance of Section 18, and these are being duly carried out by the keepers of lying-in homes, and are of great assistance to the Council when any complaint is made with regard to the home. Children Act, 1908. The powers of the Council under the Children Act, 1908, Part 1, with regard to infant life protection, were fully indicated in the Annual Report for 1921. The work of inspection is carried out by 14 qualified nurses acting as infant life protection visitors, and enquiries with regard to unnotified infants and other irregularities arc made by male inspectors attached to the department. Nurse infants kept under specified unsatisfactory conditions may, under Section 5 of the Act, be removed to a place of safety. In London the poor law institutions are so used. During the year four nurse infants were so removed, the same number as in 1926. The Council is permitted by the Act to grant total or partial exemption from inspection in cases where circumstances appear to warrant such a course. No application for exemption was made during the year 1927. The homes where nurse infants are kept are from time to time visited with a view to ascertaining whether the sanitary condition of the premises is satisfactory. During 1927, 841 reports, as compared with 870 in 1926, were made. The premises were found to be satisfactory in 553 cases, as compared with 498 in 1926. Sanitary defects were discovered in 107 homes, as compared with 165 the previous year, while overcrowding was reported in 85 homes, as compared with 111 in 1926. In ten homes overcrowding and sanitary defects were found, as compared with 22 in 1926. In 86 cases no action was taken owing to the removal of the infant prior to the visit of the inspector. In addition, 308 special enquiries into various irregular conditions have been made and the necessary action taken. Should a case of serious sanitary [defect be detected the attention of the Borough Council is drawn thereto. In some cases 43 it has been possible by a rearrangement of the accommodation to secure an improvement, but in others this has not been so, and the foster parents have in such cases been urged either to return the infant in their charge to its parent or to obtain other and more suitable accommodation. The lack of suitable housing accommodation has added to the difficulty in dealing with these cases. Advantage is taken of the local infant welfare centres to advise foster mothers with regard to weak or ailing children. The visitors watch such cases and see that the treatment advised is carried out. If the visitor is doubtful as to whether progress of the infant is good, the matter is formally reported with a view to an inspection by one of the Council's Medical Officers. The practice has worked very satisfactorily for some years now, and is of assistance to the visitors. When the nurse infant reaches the age of 7 years he ceases to be under the Act, but as he usually attends school from the age of 5 years, the additional advantage of supervision by the school medical service is available for him from that age. During 1927 there were 34 deaths of nurse infants, as compared with 26 in 1926. Inquests were held in 14 cases, as compared with 9 in the previous year. In 10 cases the verdict was death from natural causes, as compared with 6 in the previous year, and in 4 cases, accidental death, as compared with 3 in the previous year. No blame was attached to the foster mother in any of the cases. The Adoption of Children Act, 1926, came into force on 1st January, 1927. The Act provides that infants (under the age of 21 years) who have never been married may be legally adopted, the parents relinquishing all rights and responsibilities, which are thereupon assumed by the petitioners. Application may be dealt with by a High Court, a County Court, or a Court of Summary Jurisdiction. Any of these Courts may make an interim order, fixing a probationary period during which the applicant may have the custody of the child, or may give a full adoption order. Section 8 (3) of the Act enables the Court to appoint some person or body to act as guardian ad litem 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, may authorise the authority to incur any necessary expenditure. At the request of the Secretary of State for the Home Department, the Council on 8th March. 1927, agreed for an experimental period of one year to act as guardian ad litem of infants under the Act when so requested by County Courts and Courts of Summary Jurisdiction. During the period from that date, up to 14th December, 1927, 88 cases relating to children coming under Part 1 of the Children Act, 1908, were before the Courts. In the joint report presented to the Council on 8th March, it was agreed that the Medical Officer through the infant life protection visitor should deal with such cases. Of these 83 full adoption orders were made, three interim adoption orders, one application was withdrawn, and one adjourned. The officers have been of considerable assistance to applicants in connection with the filling up of the forms to be submitted to the Court. This has assisted the Courts and has been a boon to many petitioners. When the petitioner for the child proposed to be adopted resides outside the Administrative County of London the information as to any details necessary has been readily furnished by the local authorities for that area, and the Council in return has furnished information to local authorities outside the London area. Reference is made earlier in this report to the fact that the Court may authorise any public body to incur any necessary expenditure. Up to the present time, however, the out-of-pocket expenses during the year have been trivial. Mental Deficiency Act, 1913. On the 31st December, 1927,4,801 cases were being dealt with at the expense of the Council. Of these, 2,762 were in institutions; 48 under guardianship; 1,964 under supervision; and 27 in places of safety waiting other action. During the year 702 cases were examined with the following results :— Adoption of Children Act, 1926. 44 Type. Idiot. Imbecile. Feebleminded. Not defective. Insufficient evidence. Males 9 122 202 16 1 Females 11 101 215 24 1 Totals 20 223 417 40 2 Details with regard to certain children who were examined, between the age of 7 and 16 will be found on page 161, referring to the work of the School Medical Service. Occupation Centres. In 1923, ten Occupation Centres were opened and operated under the proviso that 75 per cent. of the cases on the roll of each centre shall be cases which have been placed under Statutory supervision. At the beginning of the year under review there were nine Occupation Centres, but one of these was closed on the 12th April, 1927. Provision has been made for the employment of guides where necessary, in order to convey the children to and from the Centres. A special visit was made to the Agnes Western Centre (St. James's Hall, Collier Street, Pentonville Road) by Dr. Carleton Williams, who reported that there were 20 children on the roll. The average attendance was said to be 18, though 19 children were actually in attendance on the day of the visit. The children had dinner at the Centre at a cost of 4d. per head, which was contributed by all the parents without demur, except that in two cases of great poverty the sum was fixed at 2d. The children were seen at dinner, the food was good and in general the table manners were admirable. Cleanliness and tidiness were noteworthy and the sense of propriety was such that a boy with a dirty nose was immediately noticed and attended to by the others. Each child had a tooth brush kept for him and a pair of shoes, and each one washed his or her hands before dinner. The improved behaviour of these boys and girls was found to be highly appreciated by the parents. The contrast in appearance, cheerfulness, and behaviour with those left at home was very striking. The time-table included drill and games in a garden-space behind the hall, handwork and speech training, and Dr. Williams was shown some excellent samples of simple handwork in mats. Blind Persons Act, 1920. During the year 98 persons over school age were seen. Of these, 50 males and 16 females were found to be capable of benefiting by training, and 18 males and 13 females were rejected, either because they were not certifiable as blind within the meaning of the Act, or were physically unfit for training. One case was referred for re examination at the end of a further period of three months. Advice was given as to the trades in which the persons should severally be trained, having regard to the prospects of future employment. Definition of blindness. In the report for last year, reference was made to Circular (681) issued in March, 1926, by the Ministry of Health, indicating that the Ministry did not deem persons, whose visual acuity, after correction of refractive errors, was greater than 6/60 (Snellin), to be blind unless the defect of eyesight included such special conditions as a great contraction of the field of vision. In April, 1927, the Ministry issued a further Circular (780) drawing attention to certain exceptions to the strict numerical standard, and emphasising that only visual conditions should be taken into account, and that other infirmities and occupation conditions should not be considered. The Circular further directed that all applications, made to the Ministry, for approval of new entrants to a grant-aided service for the blind should be accompanied by a medical certificate giving (i.) the degree of visual acuity in each eye of the new entrant, (ii.) the nature and extent of the visual defects present, and (iii.) a definite opinion, formed after due consideration of all the visual conditions, that the person is too blind to perform work for which eyesight is essential. 45 Dr. A. C. Williams has made an analysis of the medical findings in 100 applicants for training under the Blind Persons Act, 1920. Under this Act training is provided in certain circumstances for those who are both blind within the definition and capable of making use of the training. In London, candidates are examined by the Consulting Ophthalmologist who certifies blindness according to the standard laid down by the Ministry of Health. There is also an examination of the general bodily and mental condition to determine whether good use can be made of the training, or whether such severe disabilities are present which would render training useless. An analysis of 100 recent cases shows that the causes of blindness were :— Optic Atrophy, 15; Choroido-Retinitis, 9; Retinitis-Pigmentosa, 3; InterstitialKeratitis, 12; Irido-Cyclitis, 5; Ophthalmia-Neonatorum, 11; Lenticular Affections (mainly Cataract), 10; Affections of the Cornea other than I.K., 8; Congenital Malformation, 9 ; Miscellaneous, 18. The last group includes results of accidents and extreme refractive errors. Many of those found to be not certifiably blind belong to this group. The total number accepted as " blind " by the Ministry of Health was 89, four of these only after special consideration. Eleven candidates had too much vision to come within the provisions of the Act. At the general medical examination the number of persons having physical or mental defects in addition to the blindness was strikingly large—32 per cent., or nearly 1 in 3. Physical defects and general disabilities are particularly common in those whose vision in itself does not make them "too blind" to perform work for which eyesight is essential, and some candidates have evidently hoped that the presence of combined defect would cause them to be accepted for training, although they had a visual acuity above the certifiable standard. Circulars 681 and 780 of the Ministry of Health, however, emphasise the rule that only the visual condition should be taken into account, and other mental or bodily infirmities should be disregarded so far as action under the Blind Persons Act is concerned. Often more than one defect was found in one person, so that the total number of defects was 43. The physical defects were :— Serious diseases of the nervous system, 2; Surgical defects, 6; Anaemia, 2; Weak heart, 1; Debility, 1; Rhinitis, 1; Prurigo, 1; Haemophilia, 1; Bronchitis, 1; Pyorrhœa (severe), 4; Rheumatism, 1; Gastritis (severe), 1. There were in addition 6 cases of marked deafness. Also noted were 15 cases of mild mental abnormalities (dullness, neurosis and mental instability). Mental dullness and inertia occurred especially in candidates who came from poor law institutions, though not of a type that would be a permanent or insuperable bar to training. Careful watch was kept for cases of mental deficiency and several detailed examinations were made for this purpose. Although no certifiable cases were found among those given here, one or two defectives had been found on other occasions and handed over to the care of the mental deficiency authority. Two cases of paralysis and one of severe gastritis were rejected on medical grounds. Eight cases passed as fit for training had disabilities needing special consideration, such as old dislocation of forearm necessitating light work ; rheumatism needing avoidance of damp in training ; chronic bronchitis for which work had to be chosen where there would not be much dust. In several instances of remediable delect treatment was advised and obtained. Miss Jones, Secretary of the Metropolitan and Adjacent Counties' Association for the Blind, has kindly supplied a detailed list of the results in the 86 cases who were sent on as certifiably blind and physically fit for training. Of these 71 are doing well, or at least promising, two are under treatment recommended, and 13 are failures. Of the unsuccessful cases, seven failed on social or temperamental ground, e.g., "parents opposed training," "man refused to continue training." Six failed 15435 D Analysis cf condition found at examination. 46 on health grounds; three of these became insane and are now in mental hospitals, one is reported to have broken down with "nerves," one to have skin trouble and one to have undefined ill health. It is noteworthy that in four of the six who failed on grounds of health, blindness was due to optic atrophy. With the other classes of blindness only two out of 70 failed on account of health. It is well known that optic atrophy is usually a feature of cerebral disease and may be accompanied by more general damage. Out of 15 cases in the group under review four were unfit for training on medical grounds and eleven were fit for training. The six cases noted as deaf, including one deaf and dumb, are all doing well in a special class at Leatherhead. This result is very satisfactory. It might have been thought that the combined defect would cause great difficulty, but when the conditions are recognised and dealt with, the difficulty is found to be comparatively slight. Work of the Chemical Branch, 1927. The work of this branch is carried out at tour 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 kmds examined during the year totalled 5,240, an increase of nearly 11 per cent, on last year, and a considerable amount of work of an advisory character 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 533 Coals (Ash tests, etc.) 18 Coke 20 Disinfectants 19 Drugs 35 Feeding Stuffs and Fertilisers 17 Foods, groceries, etc. 810 Gases 26 Meals (School) 13 Metals 13 Milks 1,519 Oils, Greases, etc. 209 Paints and Colours 331 Petroleum and Paraffin 188 Soaps, Shampoo Preparations, etc. 39 Rainwater 107 River waters 509 Ordinary water 27 Waters from softening plant 508 Water and deposit (bathing lakes) 168 Miscellaneous 105 Fire-resisting materials and appliances. Considerable attention has been devoted to the testing of fire-resisting materials such as woods and composite materials consisting of asbestos mixtures or similar substances enclosed between sheets of wood or metal. Two general types of test have been evolved: (a) beam breaking tests based on the time elapsing before a beam of defined dimensions heated by a standard flame beneath it, breaks under the downward stress of a given weight, and (b) thermal conducting tests, in which a block of wood of defined thickness is heated on one side to 1,500 deg. F., and the rate of rise of temperature of the far surface is determined. The electric furnace, the thermo-electric thermometers and the beam breaking apparatus used in this test have been made in the laboratory. This work is still going on, and other means of testing fireproof materials are being tried. In connection with the examination of fusible metal-soldered links for automatically shutting ventilators on the outbreak of fire, the possibilities of making more fusible metals than those in common use were investigated. It appears that no alloy melting below 72.5 deg. C. can be made from ordinary metals without the addition of mercury. Building materials. Mortars and other building materials have been examined either as to compliance with the by-laws or as to general fitness for use by tests to suit the special requirements of each case. Brittle fibres. Among other matters of interest a rope which broke under the weight of one man within a week of passing the tensile test used by the Fire Brigade was found 47 on examination to contain very brittle fibres which had evidently been in contact with sulphuric acid or an acid salt. The roots of certain trees in two parks, which had been observed to be in a moribund condition were found by micro-chemical examination to contain relatively large proportions of iron (as tannate or gall-tannate) compared with those of unaffected trees. The iron probably reached the roots as acid sulphate washed out by rain-water from the ashes used in making up adjacent dry playgounds. The soil in both cases was deficient in lime. It was advised that limestone or chalk should be laid under clinker whenever trees were near these playgrounds. Moribund condition of trees. Several leadless paints were submitted to exposure tests and analysis. The behaviour of these paints on exposure depends largely on the medium used. If this is impenetrable to water the probability of failure under adverse conditions of exposure is lessened. It is of interest to note that such chemically inert substances as chromium oxide (green) and the oxides of titanium and antimony (white) were among the materials examined. In some cases the medium with which these were associated was of so poor a character that the paint was unsatisfactory as a protective coating. Leadless paints. A very unusual case ot displacement ot walls by the growth ot a tungus was observed at one of the Council's housing estates. A large growth, brownish in colour, with a strong distinctive odour, a dry leathery outer surface, and a yellow spongy interior, was found in the two-inch cavity of an eleven-inch hollow brick wall. When examined, microscopically, the mass was found to consist of interwoven mycelia, which shed abundance of spores when torn apart. Through the kindness of Dr. Ivimey Cook, the growth was submitted to Miss Wakefield, of the Herbarium, Kew, who identified it as the giant puff ball Lycoperdon giganteum, a plant of some interest, inasmuch as the dried fungus has been used as tinder, and the spores as a styptic powder. Only one other case of this fungus growing in a dwelling had come under notice at Kew. The puff balls were growing from the ground beneath the drawing-room floor, and the workmen who took up the floor thought they had found a heap of skulls. Miss Wakefield stated that the mycelium must have travelled from the ground in both cases. As it appeared that there was a risk of further growth from fruit bodies present in the cavity between the bricks it was recommended that all places which had been opened should be well sprayed with a solution of 2 per cent, copper sulphate and 2 per cent, ferrous sulphate (blue and green vitriol) or with Bordeaux mixture. It was suggested, also, that places which had not been opened could be sprayed by piercing a hole and inserting a tube with holes on the circumference near to the inner end and forcing the liquid through these holes. The very wet season was probably largely responsible for this very unusual fungoid invasion. Growth of fungus— L.C.C. Housing Estate The chemist has given evidence at two inquiries into death from carbon monoxide poisoning attributed to water heaters in bathrooms. One of the appliances used was of a kind which, although thermally efficient, was, from its construction, and from lack of provision of ventilation into the outside air, inherently dangerous. The other was of fairly satisfactory design, and provided with ventilation but an unfortunate combination of circumstances led to a fatality. Coroners' inquests— Bath heating appliances. Ten samples of coke from various gas companies and merchants were examined for water content. This was found to vary from 0.78 per cent, to 23.16 per cent. The amount lost by mere exposure to air in a dry place for ten days closely approximated to the total water content, showing that the greater part of the water in the coke is merely adherent and is not true moisture "or absorbed water. This was confirmed by the fact that exposure to a saturated moist atmosphere in no case led to an absorption of as much as 1.0 per cent. of water by air-dried coke. It was found that air-dried coke drenched with water and allowed to drain for a few minutes would take up from 9 to 15 per cent, of water- It is clear from these experiments 15435 D 2 Water in coke. 48 that whilst the water content of coke immediately after quenching or after storing in the open may be even higher than 20 per cent., the natural moisture of this material is of the order of 1 per cent. Coke stored under cover should not contain much more than this small amount. Vitamins in It was found that although the proportion of fat-soluble vitamin in butter and ranrjjanno. simj]ar fats is too small for the now well-known colour test wTith dehydrating agents to give definite indications, the separation of the unsaponifiable matter of such fats furnished a suitable means of concentrating the vitamin. Comparative tests with various margarines showed that a sample said to contain irradiated ergosterol gave marked indications with the colour test, whereas ordinary vegetable margarine gave no indication. Th'ame The systematic examination of the river Thames was continued during 1927, at points from Waterloo Bridge to the Edinburgh lightship. The daily examination of the rivei water showed that the heavy rainfall and great fresh-water flow during the year had the effect of keeping the proportion of salt water in the river much lower during the latter half of the year than in 1926. Notwithstanding this, the condition of the river as to dissolved oxygen was much the same as in 1926, until October, when an appreciable improvement was observed in the reaches towards the middle of the county. Outfalls At the outfall laboratories, systematic daily examinations of the sewage, reac hing the outfalls and the resulting effluent and sludge as well as of the water of the river Thames at both high and low tides have been continued. The systematic analyses of samples in connection with the working of the outfalls have also been made at these laboratories in addition to the research work undertaken in connection with activated sludge. Biological ^ During the year, research on this subject has been continued. Another system sewage60 °f mechanical agitation different from that which had given very satisfactory results has been investigated and found to be less suitable for the Council's purposes. The phenomenon known as " bulking " has occurred, and is being investigated in order to discover, if possible, the cause and means of restoring bulked activated sludge the properties of rapid sedimentation and nitrifying power which it has lost. The difficulties arising from " bulking " have from time to time been experienced wherever " activated sludge " treatment has been adopted, and although it presents no difficulties which cannot by proper means readily be overcome, its investigation promises improved methods of dealing with the problem based on definite knowledge of the controlling circumstances. Investigation has also been started into the digestion of sludge and the resulting combustible gases evolved in this process. Greenwich The routine chemical examination of samples in connection with water softening, station boiler waters, and condenser leakages at the power station has been continued throughout the year. A large number of testings of coal used at the power station and at other depots of the Council has been made, as well as of a considerable number of paints for iron work at the station. An investigation of the deterioration of turbine oils under continued use was carried out in part here, and in part at the central laboratory. Other matters connected with the working of large turbo-generators have been investigated. Bathing At the request of the Parks Committee an exhaustive investigation was under- open-air1 taken, during the bathing season, of the waters and deposits in various baths in swimming the Council's parks and open spaces. Special attention was given to two baths which baths. had been fitted with filtering plant and a similar bath not so fitted. The deterioration of water in a bath begins as soon as the bath is used. However clean the bathers may be, each contributes somewhat to the contamination of the water. This effect is cumulative unless, indeed, the volume of water is so great relative to the number of bathers that natural purification will always go on as rapidly as contamination. This could never happen in an artificial bath used to a reasonable 49 extent. Besides contamination due to bathers, sunlight acting on bicarbonate waters of the kind supplied to London will lead to the development and growth of myriads of microscopic green algæ which themselves colour the water, and which cause large amounts of insoluble carbonate of lime to separate as mud, causing turbidity or sediment, according to the amount to which the bath is being used. The turbidity soon becomes sufficient to make it impossible to see anything or anyone much under the surface of the water. Filtration, combined with the use of coagulants and bleaching powder, intelligently used, has a markedly beneficial result so far as the physical, biological and chemical character of the water is concerned. It has been found that very frequent renewal of water in baths not fitted with filters may be avoided by adding copper sulphate—less than one part per million— to stop the growth of algae and subsequent chlorination to sterilise or partially sterilise the water. Although this treatment is better than none at all, and cheaper than very frequent renewal of water, it cannot be considered as more than a palliative. In the course of this work it was sought to ascertain the average contamination introduced by a bather by comparative analyses before and after use of the water of a small swimming bath at a school. Having regard to the respective weights and surfaces of the children using the bath and of adults it would appear that a not very clean adult would contribute while in the bath about 0.8 gramme (say 12 grains) of nitrogen in all forms and 1.4 grammes of chlorions. It is probable that the preliminary use of a shower bath and other precautions would reduce this amount appreciably. In last year's report there was some account and discussion of observations made in the years 1923-6 of the horizontal range of visibility in all directions from the Fleche at County Hall. It was noted that while the seasonal changes in visibility and actinicity are due largely to natural conditions lying wholly outside human control, there can be no question that coal smoke is an important and aggravating factor in screening actinic light and intensifying the obscuration to which London is subject by reason of its situation in the valley of a large river. Early in 1927 comparison showed that the range of visibility in the Thames estuary was very much greater than from the County Hall on the same day. A series of observations was therefore made from the sludge ship used as a laboratory for river examination, of the most distant objects visible in all directions at midday. As the movements of the ships are regulated by tide it is impossible to obtain regular daily observations at any one place, but by selecting a few places whence well-defined distant objects can be seen under good conditions a fair number of continued observations were made. Those taken off Southend have been chosen as representing a place well away from London yet fully subject to meteorological variations due to the river itself. When observations taken at approximately the same time of day at Southend and County Hall are compared it is seen that at the former place the areas of visibility are approximately circles centred on the place of observation. The County Hall diagrams show in most cases not only a smaller range of visibility but a lessened visibility in the direction towards which the wind is blowing. The summer results so far as can be judged do not suggest the probability of any great systematic difference, but from October to December it is evident that a cause which has reduced the visibility at County Hall to a mile or less (rather more in October) has had very little effect on the Southend results, which show as good visibility on some days in December (8-10 miles) as in the summer. It may be noted that on December 28th, after the great snowstorm of Christmas, Ashdown Forest was clearly visible from Co'dharbour, more than 25 miles away, at midday, whilst the average range of visibility at County Hall was only a mile. It is remarkable that the actinic value as measured by Watkin's "Bee" meter was not usually higher at places down the river than at County Hall, notwithstanding the materially wider range of visibility. Observations of visibility and actinicity. 50 The greater visibility and the absence of "bulging" in the diagrammatic records in the lower estuary are significant. Traditionally the Thames estuary is a region of mists and fogs, but their effect on observed visibility is much less than, judged by the standard of London observations, might have been anticipated. It appears evident that the lessened visibility in London is due rather to special local conditions of smoke and dust than to its geographical position in this region of mist and fog. But just because the London atmosphere is so much worsened by the smoke and dust and grime so abundantly in evidence, the hope for improvement is the better grounded. That clearer, cleaner, brighter atmosphere is a hygienic need of the great metropolis scarcely needs stating. It is, therefore, a matter for unqualified satisfaction that the widespread efforts to improve the physical conditions of the London atmosphere will not be wholly thwarted by the natural circumstances of its geographical position. The following diagram shows the mean of visibility based on observations made simultaneously from the Fleche of the County Hall and from the deck of a vessel off Southend, respectively. (Observations from the County Hall are represented by a solid line, those from off,Southend by a broken line.) 51 CHAPTER II. REPORT OF THE SCHOOL MEDICAL OFFICER FOR THE YEAR 1927. By F. N. Kay Menzies, M.D., F.R.C.P.(Ed.), D.P.H., F.R.S.E., County Medical Officer of Health and School Medical Officer. Staff. The organisation of the medical staff under the Medical Officer of Health and School Medical Officer approved by the Council on 25.1.27 embraces five divisions of work. Of these division II. is wholly, and divisions IV. and V. partly, concerned with school medical work. Division II. (Senior Medical Officer, Dr. C. J. Thomas) includes the medical inspection of school children (including secondary and trade schools); medical and dental treatment and cleansing of school children ; open-air, etc., schools. The staff in this division comprises 1 Chief Aurist (Dr. A. G. Wells, Principal Assistant Medical Officer), 1 part-time Consulting Dental Surgeon (Dr. A. Livingston), 1 part-time Principal Assistant Medical Officer (Dr. B. Tchaykovsky), 7 Divisional Medical Officers, 23 Assistant Medical Officers, 2 half-time Assistant Aurists, 14 Assistant Medical Officers (6 sessions a week), 38 Assistant Medical Officers (3 sessions a week), 25 temporary Medical Officers (part-time) for 111 sessions a week, 8 Medical Officers (part-time) at open-air and tuberculous schools, 265 Surgeons and Anaesthetists at treatment centres, 60 Inspecting Dentists (part-time). Division IV. (Senior Medical Officer, Dr. F. C. Shrubsall) includes medical examination of scholarship candidates, etc., reference cases, Mental Deficiency Act, special schools, Blind Persons Act. The staff allocated to this division includes 2 part-time Consulting Surgeons (Mr. P. M. Yearsley and Mr. K. J. Acton Davis), 1 part-time Ophthalmic Consultant (Mr. N. Bishop Harman) and 2 Divisional Medical Officers. Division V. (Senior Medical Officer, Dr. J. A. H. Brincker) deals with infectious disease administration, bacteriology, diagnosis of smallpox, plague, cholera, etc. In this division is 1 Principal-assistant Medical Officer (Dr. J. G. Forbes) and 1 Medical Consultant (Dr. W. McC. Wanklyn). The school nursing service (Division II.) includes one Superintendent of School Nurses, 6 Divisional Superintendents and 350 Nurses. 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. Of the 23 new schools and enlargements, providing about 12,000 places, and the 18 cases of school modernising to be completed under the three years' programme of 1925-1928, all, it is anticipated, will be completed by 1st September, 1928. The reduction of classrooms to the " 40 and 48 " basis has now taken place in 81.9 per cent, of cases—i.e., 10,465 out of 12,671 classrooms in provided schools are on the reduced basis, and 2,792 out of 3,521 classrooms in non-provided schools. For the 10,000 new school places projected under the new three-year programme, 1927-1930, already 21 out of 38 sites required are cleared and available for building, and three schools are in process of being built. There were 40 complaints in regard to sanitation and hygiene of schools investigated by the medical department during the year. These related in 7 cases to defective lighting, 5 to ventilation, 3 to defective heating, 8 to sanitary offices and nuisances from smells, etc., 1 to presence of vermin, 6 to provision of desks, desking, Progress of improvement programmes Complaints of sanitation. 52 medical rooms, etc., 3 to defective playgrounds and 7 arose out of special investigations in connection with the control of infectious diseases. Childhood is naturally a time of freedom and activity. Civilisation has, however, decreed that in the preparation for life, children during considerable portions of their time shall be disciplined and confined to sedentary occupations. It is because of this fundamental divergence of physiological and conventional needs that the school desk question can never satisfactorily be solved. One after another new types of desks have been evolved only to prove in practice not to fulfil the hopes which have been held out of perfect result. It is not good physiology for children to remain seated at a desk for the greater part of a morning or afternoon, and the most perfect adaptation that could be possible of desk and seat to anatomical measurements of a particular child could not ensure throughout a session that the children would maintain correct postures. School hygienists have, therefore, almost given up devising and discussing desks in order to direct their attention to curricula which give more freedom to the child by reducing length of individual lessons, by providing frequent opportunity for relaxing and stretching muscles by play intervals and corrective exercises and by promoting active rather than passive means of teaching and training. There has been, however, during the past year a recrudescence of attention to the subject and the medical staff has been consulted on many interesting points in relation to desks and desking in the elementary schools. The London dual desk has proved in practice to give as good results as can be obtained, provided we admit that there must be desks at all. The reason why the London dual desk has given such satisfaction is undoubtedly not only because the internal measurements and relations of the parts are well designed in correspondence with physiological needs, but, also, because some 20 years ago, on the advice of the medical officer, no less than seven graded sizes were adopted to be supplied to the schools. Desks and desking. The London dual desks. The various types of desk which are in use, together with the height of seat and lower edge of desk from the ground respectively are enumerated in the following table:— Desks. Height of seat. Inches. Height of front of top. Inches. Clark's A. 17½ 31 B. 16 27 C. 14 23 K.G. 11 20 B. Pattern 1. 16 26½ 2. 14 24 3. 13 20 K.G.4. 11 29 K.G.5. 10 18 A. Pattern 1. 16 29 2. 15 27 3. 14 25 4. 13 23 5. 12 21 6. 11 20 K.G.7. 10 19 D. Pattern 1. 16 29 2. 15 27 3. 14 25 4. 13 23 5. 12 21 6. 11 20 K.G.7. 10 19 53 Formerly the desks were supplied with foot-rests, but the medical officer many years ago recommended that the supply of foot rests to desks should be discontinued. As a result the new pattern desks do not have foot-rests, and where head teachers have requested it, foot-rests have been removed from old pattern desks. It is also usual when second-hand desks are reissued from the supplies department to remove the foot rests. At the instance of certain head teachers, during the past year, the question has been reconsidered. Dr. Nairn Dobbie, who undertook to examine anew the problem of foot-rests, wrote the following review, and, as a result, it was decided to adhere to the policy of dispensing with the rests. "Following requests from the head teachers of Blackfriars (B.) and Pritchard'sroad (I.) schools, that foot-rests should be replaced on all desks, these schools were visited, the head teachers interviewed, and the classrooms and children inspected. "Arguments advanced by the head teachers fall under five headings. (1) Footrests give an alternative physiological position for the feet. (2) The feet while on foot-rests are off the floor giving freer circulation of air and consequent quicker drying of damp footwear. (3) The feet being oil the floor there is less noise. (4) Foot-rests ensure a better position of the children for writing, etc. (5) Foot-rests strengthen the desks. "With regard to: (1) The distance between the front of the seat and the floor being the same as that between the front of the seat and the foot-rest does give an alternative position for the feet, but even in the absence of foot-rests many alternative positions for the feet can be obtained by flexion and extension at the ankle joint without much relative change in the sitting position, and this actually takes place in all children in virtue of the physiological demand for movement, and even when foot-rests are in position the children only use them for a few consecutive minutes. Where the desk actually fits the child the foot-rest as such has no disadvantage from this single aspect, but many observations in different schools show that only in a minority of cases are the desks suited to the children. When the seat is too high, the child supports the legs by flexing them under the seat and resting on the toes, or slipping forward on his seat he rests his heels or feet on the floor; in either case the foot-rests are useless. When the seat is too low the foot-rest prevents the child from stretching his legs so that his knees come in contact with the locker of the desk; the foot-rest in this case is a distinct disadvantage. The practical difficulties of suiting the desks to the children are, that in the boys' department at Pritchard'sroad school, the average difference in height between the shortest and the tallest boys in each of the classrooms was 12 inches, and although the desks may be arranged to fit individual children at the beginning of each term, absences and the necessity for placing exceptional children, e.g., dull of hearing, near-sighted, etc., in certain positions in the classroom, coupled with the practical difficulty of shifting heavy dual desks, has the effect of largely negativing the original arrangement of desks for the children. "(2) Theoretically the feet being raised from the floor by foot-rests ensures a freer circulation of air and quicker drying, but even where foot-rests are, the feet are seldom on the rests for more than a few consecutive minutes, and in the absence of foot-rests the feet rest alternatively on the toes, soles and heels, and keep in no one position for long, so that the presence of rests does not necessarily quicken the drying of damp footwear. "(3) Children shift the position of their feet every few minutes and appear to have an instinctive tendency to kick anything and everything above the floor level so that foot-rests would seem to be a possible factor in noise production. The very scarcity of complaints from teachers of increased noise by removal of rests indicates that this aspect is not of serious moment. "(4) During the act of writing the body bends forward and balance and comfort are maintained by bringing the legs and feet under the seat, more particularly is this The question of foot-rests. 54 the case when the seat and desk are not accurately designed for the particular child, so that foot-rests are not helpful when working on the desk. " (5) In theory an additional cross member for the brackets should strengthen the structure, but reference to the stores department shows that the absence of foot-rests does not in practice alter the breakage rate of desks. " Foot rests form an ideal dust trap and the dust cannot be removed except by shifting the whole desk, and in every instance where foot-rests were examined there was an appreciable amount of dust underneath the rest and out of all proportion to the dust found elsewhere in the room, and this consideration from a hygienic standpoint makes these adjuncts undesirable. " These considerations seem to indicate that foot rests are unnecessary and undesirable, and bear out the School Medical Officer's recommendation of 20 years ago that the supply of foot-rests to desks should be discontinued." The supports of the dual desk being of cast-iron are brittle, and the supplies department has been much concerned over the cost of repairs and renewals owing to breakages occurring when the desks are moved for cleaning purposes. Hitherto, although sought, a satisfactory substitute has not been forthcoming; now, however, supports of steel have been devised, and my opinion was desired, by the Education Officer, upon a pattern desk with steel frame, which was submitted. At the same time my opinion was asked upon the width of the seat. The following embodies my reply to these questions:-"In reply to your memorandum, I beg to state that the sample desk with steel standard has been seen by the officers in my department. Their report is that in all respects but one the desk is quite as satisfactory as that with cast-iron standard. " The one defect is that in this particular sample the space between the seat and the lower edge of the back rest is insufficient, so that the latter does not clear the bony pelvis ; this makes the desk uncomfortable and would lead to unsatisfactory postures. If this defect is remedied it is considered that the desk with steel standard will be quite as satisfactory from the physiological point of view as the present desk with cast-iron standard. "I understand that my opinion is desired upon the question of the width of the seat. The width of the seat of the sample desk (8 inches) is identical with that of the present standard dual desk. Theoretically this is too narrow, it is generally considered by physiologists that the seat should be wide enough to support twothirds of the thigh, and according to this the width of the seat should be 11 inches in a desk in which the height of the seat above the ground is 16 inches. "It is, however, my opinion that no desk can be devised that is perfect according to physiological standards, and I imagine that when the present width was adopted the advisers of the Council had in mind that an ample range of sizes of desks was being adopted. If the height of the seat is so adapted to the scholar that his feet rest squarely on the ground, the objections to a narrow seat lose much of their force. Increasing the width of the seat would involve either an increased over-all measurement from back to front or a much greater projection of the seat forward under the desk. In the former case we should be led on to the consideration of the shape and floor space of classrooms, in the latter to the difficulties that would arise in getting in and out of the desks. " I imagine that the present dimensions of the desks are the result of compromise and represent what is practically attainable rather than what is theoretically desirable." Although the range of sizes of dual desks in the London schools is so ample as to afford an opportunity for all children to be seated in desks which correspond in size to their needs, it must be confessed that a very large number of misfits are found. Particularly is this seen in the upper standards where the range of difference in height of the children may amount to as much as eighteen inches. Steel versus cast iron framing. Necessity of supervision in regard to suitability of desk to child. 55 It would be more satisfactory if a rule were adopted making head teachers responsible as soon as possible after the educational year has begun and promotions have been made, for parading the children in each class, dressing them according to size, and seeing that by exchange of desks between the classrooms all children are seated in desks which suit them. The single rule that needs to be remembered is that the height of the desk seat above the floor should correspond as nearly as may be with two-sevenths of the child's stature. More significant than the question of modification of school desks is the revolt against desks altogether, which is gradually gathering head, and has taken especially the form of the substitution of tables and chairs, an experiment which is being watched by the medical staff with much interest and sympathy. This reform is generally to be welcomed as it is a move towards greater freedom. The desk with fixed seat is rigid, and the occupant is completely without control over this important part of his environment. The provision of separate and movable chairs at once introduces the factor of control, and gives an increase of freedom which is an almost incalculable boon. Already the babies' classes in the infants' departments have been equipped with tables and chairs instead of desks. The provision of practical workrooms with the necessity for flat, instead of sloping, surfaces has caused the provision of tables and chairs to be used for the older children, and now it has been decided experimentally to equip a number of schools throughout with similar furniture. An opinion was sought in regard to the number of standard sizes of tables and chairs required and the dimensions these should take. Based on the observation that, while dual desks are rigid and non-adaptable, any moderate inconvenience arising out of difference in height of table and chair is immediately corrected by the alteration of the distance of chair from the table, the advice was given that it was unnecessary to have so many as seven standard sizes. Moreover, if for instance four sizes of tables and four sizes of chairs were adopted, no less than sixteen combinations would be possible (though not all of them would be practically useful). In the first instance, in order to gain experience therefrom, it has been advised that foui sizes each of tables and chairs should be supplied for general use throughout boys' and girls' departments experimentally equipped and that the dimensions should be as given in the following table:— Tables and chairs instead of desks. Sizes of tables and chairs already supplied. Table. Height of top. Inches. Chair. Height of seat. Inches. Practical workroom 29 17½ Do. do. 27½ 16 Babies' rooms 18 9 and 10½ Special schools 20 12 Junior classes 24 15 Sizes now recommended— I 20 12 II 23 14 III 27½ 16 IV 29 17½ The Results of Medical Inspection. The number of children inspected in the three statutory age groups in the elementary schools during 1927 was 193,876, being 10,180 more than in the year 1926. They include 77,989 entrants, 56,017 at age eight, and 59,870 at age twelve. The increase in numbers was due to the fact that none of the age groups this year included children born in the years 1916, 1917 and 1918, when, owing to the absence 56 of all able bodied men at the war, the birth rate was so remarkably affected. Furthermore, 60,297 children were inspected in detail in the term before they were due to leave school (i.e., approximately the age of fourteen). 38,029 children not falling in the above age groups were specially inspected at the instance of care committee workers, school teachers, head teachers, or attendance officers, and an additional 44,365 children in connection with school journeys, open air classes, camp schools, and so forth. A further 1,950 children were inspected in the statutory age groups in special schools. The grand total of children medically inspected in 1927, therefore, was 338,517, being 8,122 more than in the year 1926. The number of children previously found ailing who were re-inspected was 193,260, an increase of 2,078 over the previous year. These re-inspections are not included in the totals shown above. There was no disturbing factor during this year, such as epidemic prevalence of measles, or the general strike of 1926, and the immense work which the above figures represent was carried through smoothly and satisfactorily. Parents are invited to attend all routine inspections. In 64.4 per cent, of invitations, a parent responded. Parental attendance is poorest when elder boys are being inspected, only 32.5 per cent, responding in the case of leaver boys, who hate to have their mothers dancing attendance upon them at school. On the other hand, in the case of entrant infants, parental attendance rose to 88 per cent. Refusals to allow children to be examined are very few in number. During the year 1927, the parents of 151 (186) children refused to allow them to be examined by the Council's assistant medical officers. Of these objections 17 (14) were subsequently withdrawn, and in 5 (12) cases the medical record cards were filled up by a private medical practitioner. The figures in brackets indicate the corresponding figures for 1926. Applications were received during the year from other local authorities for the medical record cards of 483 children who had left London and removed to other areas. These requests were received from numerous authorities throughout England and Wales. Of the cards asked for, 316 (or 65.4 per cent.) were sent; of the remainder, in 47 (or 9.9 per cent.) instances the children had not been examined, 95 (or 19.7 per cent.) could not be traced, and 25 (5.2 per cent.) belonged to other neighbouring authorities, i.e., Willesden, East Ham, etc. 111,978 children in the four age groups were referred for treatment for various ailments. The proportion referred of those inspected was 44 per cent., compared with 42 per cent, in 1926. Out of the 111,978 children, however, 78,492 were referred with or without some other defect, on account of dental decay, the chief scourge of child life in England. The analysis of the results of medical inspection immediately following will be limited to the three statutory age groups, in order to facilitate comparisons with previous years. The returns this year show that the children in the schools are better nourished than they have ever been before. 10,318 children in the three age groups were found to be under-nourished. This is 5.3 per cent, of those examined, compared with 6.2 per cent, in 1926 and 6.3 per cent, in 1925. The absence of industrial strife throughout the year has assisted to make this improvement possible. Girls at each age are found to be better nourished than boys; for this no reason can be assigned other than that girls are constitutionally more resistant to depressing influences than boys ; this is an old established fact of medicine and is shown alike in the greater mortality of boy babies and the greater incidence of rickets on boys than on girls. At the medical officer's suggestion Mr. T. E. Grier, the head teacher of the Winstanlev Road Council school (boys' department), Clapham Junction, arranged for continuous weighings to be made throughout the year of 40 boys of each age Attendance of parents. Refusals of parents to submit children for medical examinatioin. Requests from other local authorities for medical record cards Children referred for treatment. Results of medical inspection. Nutrition. Weight records. 57 group in the school. The results are so interesting and suggestive that the records are reproduced here in graphic form. The monthly averages are plotted from January, 1927, to January, 1928. The expected features of such a record are well brought out, including (1) the prepubescent rapid acceleration in weight of the boys at the ages of twelve and thirteen years as compared with the slower and more regular increase of the younger boys, (2) the already known phenomenon of acceleration in weight increase during the early autumnal period with retarded increases in the winter and spring months—that is well shown in each age group. In addition, this chart is remarkable because it includes one group of boys born or conceived before the war, and two groups of boys born in the two first post war years. The chart is arranged in such a way that in each group the records at the extreme right hand (e.g., January, 1928) are of boys who are at the same age and phase of growth as those in the group next above charted on the extreme left of the chart (January, 1927). If all things were equal the termination of each curve on the right should coincide exactly with the commencement of the curve next above on the left. This holds with the 1917, 1918 and 1919 groups but fails with the 1915 and 1916 and 1920 groups; but while the 1915 and 1916 groups fall off from the groups above them the 1920 varies in the other direction, i.e., exceeds the 1919 group. It is impossible to avoid the inference that these variations are the effect of circumstances connected with the war. The following is a tentative explanation. The London birth rate in 1914 was 24.3 per 1,000 living, but had fallen in 1918 to 16.0 per 1,000. This fall was of course due to the fact that a very large number of potential fathers were absent on military duty. In fact, every able bodied man 58 was so engaged and the population was being recruited by the remaining male population who were nearly all of C.3 classification. Already in 1915, the birth rate had fallen from 24'3 to 22'6 per 1,000. The first men to go were those of the very best physique and probably by 1916 all the men of fine physique had been drafted into the services. When conscription was introduced, the standard of physique accepted for the Army was greatly lowered, and it is probable that the population was already being recruited solely from inferior physical types in 1916. So that after the first considerable drop in the physique of the fathers in 1914 and 1915, there was no further lowering of the physique of children born during the war. In 1920, the birth rate went up again to 26.9 per 1,000 living, and the chart shows that Winstanley Road boys born in that year are better in physique than those of the war years. The birth rate went up of course solely because the male population had been demobilised to their homes and amongst them were the remnants of the men of fine physique who were drafted into the army during the first two years of the war. Continued improvement is shown in the personal cleanliness of the children. In 1913, only 67.2 per cent, of the older girls were in a clean condition as regards verminous infestation of the hair compared with 87.3 per cent, of the boys. Since that time a continual warfare has been waged against verminous conditions in the schools by the school nurses and teachers, with the result that every year a better result has been obtained. In 1916 and 1917 the percentage of girls in whom no trace of nits or vermin was found at medical inspection had risen to 70, in 1920 the figure had reached 75, by 1923 it had climbed to 80, in 1924 to 82.5, in 1926 to 88.1. In 1927, the percentage of heads completely free from nits or vermin in the twelve year old girls has reached 89.5 compared with 96.1 per cent in boys. The improvement thus shown has gone steadily on and is in the main due to the incessant work of the school nurses in inculcating hygienic habits. No doubt the prevailing fashion of short hair for girls is more hygienic and has facilitated the great strides that have taken place recently, Out of 193,876 children examined, only 158 are found with vermin of the body compared with over 4,000 out of the 197,000 examined in 1913. The condition of the children's teeth continues to afford ground for the greatest concern. That the school dental service has been successful in mitigating the results of dental decay and has greatly improved the condition of children's mouths on leaving school is not a matter of question. In 1913, 50 per cent, of twelve year old boys and 47.6 per cent, of girls of the same age were noted by the school doctors as presenting dental decay, while 10 per cent, of the boys and 8.6 per cent, of the girls had very extensive caries with septic mouths. In 1927, the returns of twelve year old children show that 29.4 per cent, of the boys and 27.7 per cent, of the girls had dental caries, while 2.7 per cent, of the boys and 2.3 per cent, of the girls had extensive caries with septic mouths. But this amount of improvement had already been obtained some two or three years ago, and there is at present no progress being made. Meanwhile, there is no improvement shown in the dental conditions of children entering school; they even appear to be worse. In 1913, the school doctors found 37.8 per cent, of boy entrants and 37.0 per cent, of girl entrants to have dental caries, while 10.1 per cent, of boy and 9.8 per cent, of girl entrants have already very severe caries with septic mouths. In 1927, 48.3 per cent, of boy entrants and 49 3 per cent, of girl entrants had dental caries, and no less than 15.3 per cent, of boys and 15.2 per cent, of girls had extensive caries with oral sepsis when they first came to school. The school dental service gets to work at once upon this mass of diseased conditions, with the result which has been detailed above, but it is no wonder that it has come to a halt in improvement when each year a fresh and increasing load is thrown upon the staff employed. Further information on the effect of the work of the school Cleanliness. Dental decay, 59 dental service is given in the special account of the investigation by Dr. Livingston in a later section. 12,810 children in the statutory age groups were referred for treatment for enlarged tonsils and adenoid growths, as compared with 10,168 in 1926, and 12,876 in 1925. The number referred is 6.6 per cent, of all examined. Entrant infants show the highest percentage of severe tonsillar and adenoid enlargements, 9.7 per cent, of boys on entering school being referred for treatment, while the corresponding percentage of twelve year old boys was 3.1 As in the case of dental decay, here again, the school medical service inherits as a result of pre-school conditions a large amount of disease, for investigation has shown that, in the great majority of cases, the unhealthy condition of the throat dates back to an early age and is already established before school attendance is commenced. Considerable difference is noted in the proportion of children referred for treatment for unhealthy throats by the different medical officers, but as conditions are, 6.6 per cent, does not appear an undue proportion to refer. Unhealthy throats with enlarged tonsils are noted in a much greater number of children than are referred for operation, and these children are kept under observation. It is, moreover, reported that considerable numbers of these children whose parents have been informed of their condition, although the school doctors have not advised immediate operation, nevertheless undergo operation between inspection and re-inspection, the parents taking independent advice and submitting their children for operation at hospitals or by other agencies outside the Council's scheme. The prejudice remarked a few years ago against operation for these conditions has now disappeared, owing largely to the improvement in the arrangements under which the operations are carried through, and the pressure upon the facilities provided has become very acute in consequence of the eagerness which the parents evince to follow the advice given. Otorrhoea (or running ears) was discovered in 2,463 children, a number which is slightly less in proportion than in previous years. Defect of hearing was recorded in 868 children (0.4 per cent.), and is again a reduction upon previous findings. Enlarged glands of the neck are caused in children by numerous unhealthy conditions of the nose, throat, scalp, face and mouth, and especially by septic teeth. The number of non-tuberculous children with enlarged glands recorded was 10,181, being 5.3 per cent. In the previous year, 1926, the percentage was 5.2. Here again the highest incidence was amongs the entrant infants, the proportion falling steadily during school life. 51.1 per cent, of boys and 52.9 per cent, of girls at age eight failed to pass the test for normal vision; the corresponding figures for 1926 were 51.9 per cent, and 54.7 per cent, for boys and girls respectively. Amongst twelve-year-old children, 43.2 per cent, of boys and 46.6 per cent, of girls failed, corresponding with 42.2 per cent, and 46.3 per cent, in the previous year. While a larger proportion of the children attain normal vision at the age of twelve years than at the age of eight, the number with severe defect increases between those years, At age eight, among boys 17.7 per cent, have severe defect, which is increased to 20.4 per cent, at age twelve; amongst girls, 18.4 per cent, at the earlier age with severe defect, increased to 21.5 percent, at age twelve. Owing to increased attention to sight saving in the schools, the prohibition of sewing in poor light, and modification of the curriculum in favour of those with poor sight, the much severer incidence of visual defect upon girls than boys is no longer so marked as it was before school medical inspection became general. 4,599 (2.4 per cent.) were reported to have functional or organic heart defect compared with 4,783 (2.6 per cent.) in 1926. The older girls continue to present the signs of heart strain in excess (3.3 per cent, as compared with 2.4 per cent, of boys at the same age). Anaemia was recorded in 3,930 children (2 per cent.), an improvement upon the previous year, when 2.4 per cent, were found anaemic. Tonsils and adenoids. Ear disease and hardness of hearing. Enlarged glands. Defect of vision. Heart defects and anaemia. 60 6,451 children were found with non-tuberculous lung defect, being 3.3 per cent, against 34 per cent, in the previous year. The incidence upon entrant children is far higher than at other ages. The great proportion of lung troubles which comprise a mild bronchitis associated with rickets are found to a greater extent amongst entrant boys than any other group. Pulmonary tuberculosis, definite and suspected, was reported in only 106 children, and other forms of tuberculosis in 152, in each case being less than 1 in 1,000 of those inspected. On the other hand, 367 children inspected as special cases were notified as tuberculous (definite or suspected). 101 children in the three age groups were recorded as epileptic, 185 as suffering from chorea and 146 with paralysis. Signs of rickets were noted in 1,242 children (0.6 per cent.); naturally the greatest number being in entrant infants; the proportion of entrant boys with definite rickets being reported as 1.3 per cent, of the total examined. It must be remembered that school medical inspection is a practical institution introduced for practical purposes. It has to be carried through with a due regard to economy of time and under conditions which are vastly different from the consulting room of the specialist. Refined diagnosis of disease is therefore not to be expected or required, nor is it necessary to record minute departures from the normal resulting from past illness or from congenital causes. The chief function of inspection is to draw attention to those defects which require immediate treatment, to divergences from health which require skilled investigation by others than the school doctor himself and to the beginnings of disease, which, left disregarded, may develop into serious illness threatening the life or working capacity of the child in later life. Had a school doctor unlimited time to give to each individual child, and were his aim merely to add to scientific knowledge, the number of children, particularly entrants, in whom, by careful investigation, signs of past rickets could be ascertained would be very greatly increased. Distinction, therefore, must always be drawn between the results of routine medical inspections and those of scientific surveys, and it will prove futile to base comparison between one part of the country and another upon the returns of medical inspection unless the survey in each case is carried on under uniform direction and with agreed standards of observation. Deformities other than rickets were recorded in 2,599 children in the age groups (1.4 per cent, of all examined). Of these 931 related to spinal curvature with incidence especially marked, as usual, upon the older girls. These curvatures are chiefly postural in nature and, for the most part, are such as can be corrected by appropriate exercises daily carried out in school. 29,981 boys and 30,316 girls were inspected immediately before leaving school as an additional group. Not only is the examination of this group of great importance in relation to the after-care conference and the placing of children in occupations suitable to their physical condition, but it also gives the final result of the efforts continued throughout school life to prevent, ameliorate and remove those physical defects which will prove a handicap to the child in later life. The school care committees pay special attention to the examinations of these children and, in their case, concentrate especially upon intensive following-up, for no further opportunity can arise to exert their influence. Even these results, therefore, cannot reveal the whole of the remedial work which is effected by the school organisation, since the children leave school before they can be re-inspected, and the final result of the last intensive efforts be ascertained. The leaving children prove from the returns made to be better nourished than any other age group, only 4.5 per cent, of boys and 3.7 of girls being undernourished. In cleanliness and personal hygiene they are superior to the twelve-year-old group, 91.9 per cent, of the girls having their hair completely free from trace of verminous infestation. Their dental condition Lung defects Tuberculosis. Nervous diseases. Deformities. Other deformities. The health of the leaving child. 61 is slightly better than that of the twelve-year-old children, and therefore better than that of any other age group amongst school children. Visual acuity also is slightly superior, both in boys and girls, to that of the tweleve-year-old group, owing no doubt to the provision of spectacles as the result of the detection of their visual defect at the tweleve-year period. Generally, also, defects requiring medical attention are fewer than at any other period in school life. 2.7 per cent, of boys aged fourteen and 3.5 per cent, of girls required operation for tonsils and adenoids, compared with 6.6 per cent, at all other ages, and 3.1 per cent, of boys and 4.1 per cent, of girls at age twelve. They present less otorrhœa, less external eye disease, less anaemia and less lung defect than any other age group, and less defect of hearing and heart defects than the twelve-year age group. The one and only condition which showed an adverse balance in the case of the leavers as compared with the others was spinal curvature amongst the girls, which was found in 1.3 per cent, of the fourteen-year-old girls, as against 1.1 per cent, of the twelve-year-old girls. Altogether, therefore, the fourteen-year-old group emerges from the scrutiny as the healthiest by far of all the age groups, and testifies to the great benefits which have followed the installation of medical inspection and children's care in school. While the routine inspections comprise all children, whether well or ailing, children specially examined are those who are brought before the doctor as obviously suffering. The children suffering from such condition as scabies, ringworm of the scalp, impetigo, corneal ulcer, tuberculosis, epilepsy and chorea found amongst special cases greatly out-number in each case those found suffering from the same diseases in all the routine age groups combined. Considerable numbers of children, too, with defective vision, hardness of hearing, anaemia, and nasal obstruction, whose condition has attracted the attention of the teachers, are thus brought specially to the school doctor's notice at these inspections, which are of the utmost value, and indeed essential to the well-being of the schools. All pupils at secondary schools are examined in detail at the ages of twelve and fifteen, while the health of each pupil at other ages is reviewed and the pupil medically examined if this is considered advisable. 4,608 boys and 4,684 girls in secondary and trade schools were examined in detail and 182 male and 953 female students in training colleges were also medically inspected. Of pupils who had been found defective 2,163 were re-inspected, including 803 pupils with defective vision, 130 with nose and throat defects, 60 with eye or ear disease, 759 with defective teeth and 603 with other ailments. Only one pupil (a boy) was found with pediculi, although 42 male and 69 female pupils were found to have nits. Of boys in secondary schools 16.5 per cent, and of girls 18.7 per cent, are wearing glasses, but in the training colleges over 25 per cent, of students are found to wear spectacles. Of boys in secondary schools 1.9 per cent, have serious dental decay, although another 24.5 per cent, have less serious dental caries. Amongst girls 2.3 per cent, have serious dental caries, and in addition 21.6 per cent, have some dental decay. Amongst students in training colleges serious dental decay was found in 5 male but only 2 female students, being 2.7 per cent, and 0.2 per cent., respectively, of. the number examined. In both male and female students another 10 per cent, were found to have slighter degrees of dental caries. Flat foot was reported in 2.4 per cent, of secondary school boys and ill 15.4 per cent, of girls, while spinal defects were found in 1.4 per cent, of boys but 18.9 per cent, of girls. The high proportion of minor deformities returned in secondary school girls is to be explained on the ground that the slighter, as well as the more serious deviations 15435 e Visual acuity. Other defects. Special inspections. Medical inspection of pupils at secondary schools. 62 from the normal are especially noted in the girls' schools, in all of which are appointed gymnastic mistresses, who pay special attention to the physique of individual pupils, although it is probable, too, that the incidence of more serious deformities is greater upon girl than boy pupils. Our memories, statistics and photographic records which have been preserved testify alike to the very great improvement which has taken place in the health, physique and appearance of the London school child during the past 30 years, and more particularly since 1907, when medical inspection of school children became obligatory by the passing of the McKenna Act. Professor F. G. Parsons, F.R.C.S., in his presidential address at the Anthropological Section of the British Association for the Advancement of Science, which met in Leeds in September, 1927, founded many of his deductions upon the examinations made by him of the children in the elementary and secondary schools of the London area. In the course of his address he said:— "That there is indeed much to show is clear enough to anyone who has walked the streets of London or of any of our great cities for half a century with open eyes. How seldom nowadays do we see the poor little half-starved bodies, so common thirty years ago, shivering, coatless and bootless, in the depth of the winter ; their miserable little limbs maimed by rickets, their ears streaming with matter from middle-ear disease, and their eye-lids red with ophthalmia. We know, thank God, that these are fast becoming things of the past; indeed the modern medical student thinks himself lucky if he sees a single case of rickets, about which his text-book has so much to say. "Bad teeth, adenoids, septic tonsils and glands in the neck, unfortunately, are still common enough, but slowly and surely these are being conquered, and are bound to be swept away before long; for all this improvement is gathering speed as it rolls on, and each year has rather more to show than that which went before. "I have been visiting lately a number of London County Council schools in order to see something of the physical characteristics of the rising generation, and I find that, even in the poorest districts, the children are, upon the whole, cheerful and fairly healthy, and a wonderful understanding exists between them and their teachers, who as a class are far above the pedagogues under whom I sat as a boy; while in the secondary schools, particularly in the healthier districts, such as Plumstead and Eltham, the physical beauty and perfect health of the boys and girls contrast very favourably with anything that our most expensive public schools have to show. It is true that I am speaking from the examination of only five thousand out of more than a million London children, and may have to modify my opinion as time goes on; but what I have seen fills me with hope for the future, and never again shall I grudge any taxes which I may be called upon to pay for education, since I realise that, under the cloak of education London at least is doing its utmost to change a C.3 into an A.I population." Medical inspection in 1927 reveals that the continuous struggle with the causes of suffering amongst school children is having most hopeful results. Although the incidence of dental decay is as wide as ever, the school dental service has succeeded in averting the worst consequences to the great majority of the children during school life. In the " Michael Faraday " school, at which the first dental inspection was made by Mr. C. E. Wallis, there were in 1906, amongst children aged eight to twelve, 95 per cent, with gross dental sepsis and neglect of oral hygiene. In this school Dr. A. Livingston, in 1927, using the same standards and pursuing the same methods as Mr. Wallis, found that these conditions were reduced to about 4 per cent, of the children. This result, however, has only been obtained by the exercise of the most strenuous efforts of the school medical service and the school care committees, with great expenditure of time and money. Summary of the present condition of the children as shown by medical inspection. 63 With longing eyes the school medical service is looking to the Government Dental Decay Committee to find the means by which the torrent of dental disease may be stemmed at its source, and to the efforts of child welfare and maternity centres, whereby, maybe, it will at some time be ensured that the teeth of the children when formed in the gums during infancy will be strengthened to resist caries and the burden of curative and palliative work, the brunt of which falls now almost alone upon the school medical service, will be lightened. In other respects also the returns show that as the children in school grow older the incidence of defect decreases, and the school-leaving child is healthier and stronger in every way than the child who enters. London children in 1927, as the figures show, are better nourished, better cared for in personal cleanliness, and in better health generally, than in any year within memory. This is due to the cumulatve effect of wise social measures for children's care which have been introduced during the past twenty years, and have been carried out with devotion alike by officials and voluntary workers fired by the great enthusiasm which the love of children cannot fail to engender. The results already obtained afford sure ground for hope for the future of the race. Fourteen hundred years ago the children of the south-eastern part of England were famed throughout the civilised world for their beauty, their health and their physique. The industrialisation and urbanisation of the 19th century, combined with the pursuance of the policy of laissez-faire, sadly obscured the beauty of the race's childhood. We are new in the process of emerging from that nightmare. Given dwellings into which sunlight and air can enter, knowledge which will enable them to choose right ways of living and opportunities for play and recreation in the free and open air, the race will once again bloom as formerly in health and physical excellence. Good housing, better education, playing fields, these three are the dominant needs of the child and parent of England's great metropolis. Already and increasingly, going into our schools, the improving appearance of our London children brings back the echo of the words of Pope Gregory, "Non Angli sed Angeli." Dental Condition of School Children. In the year 1906 the late Mr. C. E. Wallis, a man actuated by a sincere wish to help mankind, especially those in poor circumstances, wrote a report to the Council upon the state of the mouths and teeth of the school children in the Council's care. This was the first detailed dental investigation made of London elementary school children. His examination was no mere casual glance, but an exact and careful investigation of the teeth, gums, tonsils, throat and glands in each case, aided by dental mirrors, probes and spatulae. At the "Michael Faraday" School, Walworth, he so examined 245 children, who showed an average per child of 7.4 carious teeth; 9.3 per cent, suffered from abscesses of the jaw-bones, many discharging pus; 16.7 showed chronic pharyngitis; 29 per cent, chronic enlargement of the tonsils; while no less than 61 per cent, had enlarged sub-maxillary lymphatic glands; 37 per cent, of the children were anaemic. In his report he said—" The most striking feature observed is the neglect of dental cleanliness, and absence of any evidence of dental treatment, beyond a few instances in which teeth have been extracted or broken. Only 3 of these 245 children possessed tooth brushes, and showed signs of having used them regularly, and these three were practically free from caries. Bacterial deposits, tartar, remains of food and every degree of malodorousness and sepsis were evident. Many children were suffering from undue retention of temporary teeth." Mr. C. E. Wallis then described briefly the results of such foul mouths on the general health, and the undermining of the child's natural resistance to disease. At the same time Dr. Wm. Hunter, of Charing Cross Hospital, was showing scientifically that local concentrated sepsis caused anaemia, and that removal of local sepsis cured this 15435 e 2 Dr. Livingston's report upon the " Michael Faraday" School. 64 and many other complaints, while Dr. C. J. Thomas was fully investigating the general health of the school child. Whereupon, step by step, sometimes inch by inch, the Council with a devoted and not numerous band of doctors and dentists, a nurse or two, and keenly interested lay workers, began the creation of that dental service which now treats 125,000 children yearly and performs operations totalling half a million, of which 60,000 are performed under an anaesthetic. From one dental surgeon the number has increased to 86; from one chair in a corner of a borrowed room the accommodation has increased to 61 dental treatment centres, practically the whole of the County of London being covered. Where the population is most numerous as in Islington,. Hoxton and Finsbury, there are found centres correspondingly numerous. It is the Council's legitimate enquiry as to whether these centres, dental surgeons, and in fact the whole organisation, are benefiting the children ; whether this service is adequate ; whether the efforts made are palliative only, or whether dental and oral sepsis is being relieved and prevented. It has been one of the objects of the last year's work on the part of the Council's consulting dental surgeon, to answer these questions. As the "sample" school, "Michael Faraday" stands in Walworth now as then, and as the neighbourhood has not greatly changed, nor the inhabitants, save by the passing of time, in JuneJuly, 1927, Dr. A. Livingston carefully examined the children of the same age groups as those examined by Mr. C. E. Wallis, using the same schedules with the exception that it is now necessary to add two columns, to show teeth treated. The result is given below, the figures of 1906 being in italics. Table A. Approx. Age. Born in. No. examined. Carious teeth temporary. Carious teeth permanent. Average per child carious teeth. Purulent alveolar abscess Sinus or Fistula. Chronic Pharyngitis. Enlarged tonsils. Enlarged submaxillary glands. Anæmia. Teeth treated. Temporary. Permanent. Temporary. Permanent. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) BOYS. 9 1897 45 318 99 7.1 2.2 9 8 3 40 3 None None 8-9 1919-18 31 63 32 2.0 1.0 2 3 14 13 13 84 11 10 1896 43 225 107 5.2 2.5 3 1 8 37 8 None None 10 1917 39 55 38 1.4 0.99 3 1 12 18 14 123 17 11 1895 37 141 113 40 30 3 8 9 35 4 None None 11 1916 37 24 26 0.65 0.70 1 5 12 10 9 156 45 12 1894 39 62 158 1.6 4.0 1 9 22 39 7 None None 12 1915 44 22 64 0.50 1.4 4 3 10 6 8 186 38 GIRLS. 9 1897 44 251 112 5.7 2.5 4 7 14 36 39 None None 9 1918 31 56 26 1.8 0.84 5 1 13 10 4 114 9 10 1896 37 155 96 4.2 2.6 3 6 16 31 27 None None 10 1917 37 48 37 1.3 1.0 4 1 6 8 6 114 35 Totals 245 1,152 685 4.6 2.8 23 39 72 218 88 None None 219 268 223 1.22 1.02 19 14 67 65 54 877 155 NOTES.—It will be observed that the children recently examined were born during the war. The numbers in the classes in the youngest age group reflect the birth-rate decline of the later war years. Under "enlarged tonsils" is included a slight or moderate enlargement. Under anæmia is here included maldevelopment, which is strikingly noticeable in the children born in 1917-18-19. The figures for 1906 are in italics. 65 Table B (Boys). No. of children. Bom in Carious temporary teeth. Carious permanent teeth. Alveolar abscess, sinus, fistula, gingivitis, malocclusion. Chronic pharyngitis. Tonsils. Submaxillary glands. Anæmia maldevelopment. Teeth treated. No treatment. Permanent. Temporary. Very septic. Very septic. Severe enlargement. Mod. enlargement. Slight or normal. Sever? enlargement. Slight enlargement. Moderate. Slight. Fillings. Extrac tions. Fillings. Extrac tions. 44 1915 16 6 59 5 16 3 3 7 34 3 3 3 5 18 20 2 184 1 never required treatment. 1 never treated. 37 1916 23 1 23 3 1 5 4 8 25 3 7 6 3 30 15 1 151 1 never treated. 39 1917 55 — 38 — 4 1 5 7 27 5 13 1 13 9 8 1 122 — 30 1918 61 - 30 - 2 3 5 9 16 10 3 5 8 6 5 — 84 — 1 1919 — 3 — 2 — — — — — — - — - — — — 4 — 151 155 10 150 10 23 12 17 31 102 21 26 15 29 63 48 4 545 1 never required treatment. Totals. 165 160 48 47 44 111 549 2 never treated. 325 660 4.3 215 4.3 1.5 per child average. per child average. 5.8 Table B (Girls). 1 1915 — 2 - - - - - - - - - - 1 — — — — - 36 1917 42 4 26 11 5 1 2 4 30 6 2 - 5 30 5 — 114 1 never treated. 31 1918 39 17 24 2 5 1 3 10 18 9 1 2 2 5 4 — 114 4 never treated. 68 81 23 50 13 10 2 5 14 48 15 3 2 8 35 9 - 228 5 never treated. Totals. 104 63 19 18 10 44 228 167 272 2.5 4.0 per child average. teeth per child average. 66 The most striking difference is seen in the most relevant columns (6) and (7) of Table A. Without any exception in any age group, the incidence of caries per child is markedly less now than in 1806. Especially is this to be seen in the younger children's temporary teeth, a fall from 7.1 carious teeth per child to 2.0 carious temporary teeth per child. A second very marked difference is seen in the permanent teeth of the elder children. Instead of a progressively increasing amount of caries of teeth that must last a life-time, which in 1906 amounted to at least 4 at the twelfth year, to-day caries is at least held back at the eleventh and almost held back at the twelfth year. The lymphatic glands under the lower edge of the jaw-bone are the drains for toxins and micro-organisms from the teeth. In column (11) is seen the past and present state of these glands. In 1906, scarcely a child without the glands choked and hard, working continuously to overcome the microbes and poisons. To-day only two children in every seven suffering in this way, and of those one child is to be found only by diligent search, for the amount of enlargement of the glands is often very small. We know now that these glands, poisoned and choked, are a ready soil for tuberculosis. Chronic sore throat, so frequently associated with inflamed gums, has fallen by 50 per cent.; there is a distinct decrease in anaemia (and maldevelopment) very especially among the girls, the incidence of enlarged tonsils remains the same. To sum up: the average number of carious teeth per child stands at 2.10 this year, as against 7.4 in 1906; and 4.71 teeth per child have been treated; 47 children (21.5 per cent.) were found completely free from any dental or oral disease; no diseasefree mouth was found in 1906. Also continuous chronic poisoning due to diseased teeth, as shown by the condition of the gland drains, shows a corresponding decrease. How far are the questions of the Council answered ? The children are receiving benefit to their health, locally as respects mouth and teeth, and generally the whole body; these factors must influence the mind. Practically no cases of the gross dental sepsis and neglect of oral hygiene of 1S06 were evident; at most, 4 per cent, as against 95 per cent, in 1906; there was only one case of "toothache"; the general bearing of the children was almost invariably bright, disciplined yet not oppressed, happy and clean. But to the second question so glowing an answer cannot be given. There still remains an appreciable amount of caries; of enlarged tonsils, and the after-effects of early dental disease, as shown by the remains of abscesses; some deformed jaws were seen, and inflammation of the gums, both of these latter the early causes of adult pyorrhoea. As was reported to the Council last year, we are the receivers of "damaged goods"; in the early years of the child's life at school we can only repair damage done before and after birth—while the child is at home. We treat only one half of the school population; parental ignorance, apathy, and sometimes even obstruction, prove the greatest obstacles to treatment of the other half. For the moment the service is just, and only just, meeting the demand; during 1926, of the children inspected dentally in London, noted as requiring treatment, 69 per cent, received dental treatment, a much higher figure than in the rest of England and Wales.* No regulation treatment other than "immediate" for deformed jaws and teeth is given at any centre, although it is known that much more of this exists than the dental hospitals can treat. With the increase of numbers seeking treatment, there must be " pari passu " an increase in staff and accommodation; as our children treated in the last twenty years in their turn marry and bring their children to the centre—willingly do they do this—so must we increase our centres, so that we may no longer receive "goods" battered beyond repair, but treat early to prevent decay and its consequences. *The figures given in Sir George Newman's annual report for 1926 of the percentage of children requiring treatment who received it are:—London, 69.7; counties, 56.7; boroughs,. 57.4; urban districts, 55.9 ; county boroughs, 55.4. 67 It is admitted that our treatment is still largely palliative; we are chiefly curing oral disease, and prevention in toto is still far off. Year by year the small fillings placed in permanent teeth increase in number, in spite of active parental stubbornness against " stoppings." So does the dental surgeon keep the life-time teeth sound, by preventing further spreading in the mouth of caries. By short talks to assembled parents and children (especially the elder girls) the dental surgeons attempt to point out the consequence of dental and oral disease ; and to instruct in a right hygiene and a right diet, and they persuade individual parents to accept treatment of their children. At the chair-side the instruction is continued. The Council may rest assured that though in these years much, and more, palliative treatment must be given, no opportunity is lost to instil the need for prevention and preventive treatment, in fact to teach the London child to chew sound food and keep clean his own teeth. Mr. Sowden Hills, one of the Council's inspecting dental surgeons has completed an investigation comprising a differential examination of the mouths of 6,968 children, of Jewish or English parentage. The results of this examination tabulated and plotted show that the incidence of dental decay as between the two races of children is not greatly different although it is well known that there are great differences in diet. However, there is a marked divergence beginning at about the twelfth year : the English boys showing an increase in the amount of decay, but the Jewish boys showing a decrease. Boys of this age are just about to enter one of the great periods of growth ; but, while of English boys, 35 per cent, have healthy mouths, at thirteen the percentage is fallen to 27 per cent. Jewish boys at eleven have, 33 per cent, of them, healthy mouths; at thirteen they are practically stationary with 32 per cent, of healthy mouths and teeth; Jewish girls show an increase in oral health during these years, 42 per cent, being sound at 13 years. It is thought these considerable differences, which later, accumulatively, must make for greater health and comfort and efficiency may be attributed to the great differences between the two races in diet and personal hygiene, as taught and governed by the parents. The health of the leavers traced through their school career. The children leaving school this year form the last group whose birth took place before the war. It is therefore of some interest to pursue the method of comparing the record of their inspection at various stages during their school life. Some of the more striking particulars are given in the accompanying diagram in which the progressive improvement in the health of these children while under the care of the education authority is shown. The close similarity of the diagrammatic representation of the incidence of enlarged tonsils and adenoid growths with that of catarrhal lung disease suggests a close connection in origin between these conditions. The excessive incidence of oral sepsis upon the younger age groups is associated with the condition of decay in which the deciduous or milk teeth are so often found, and the substitution among children of the method of suppuration for the natural method of aseptic absorption in the shedding of these teeth. Vide diagram, p. 68. Injurious effects of insufficient sleep. More than one of the school doctors has remarked during the year upon the " nervousness " of so many of the children. They assign this nervousness, varying from mere restlessness, to actual chorea, to lack of restful sleep at night. Dr. John Beadles, working in the south-eastern division, states: "Such cases often do not get to sleep until a much later hour than is right; this may be due naturally to other causes than nervous excitement at the time of going to bed ; but, whatever the cause may be, this want of sleep reacts badly on the nervous stability of the child." Dr. Mabel Russell, working in the schools of Chelsea, makes similar observations. She finds that it is of less importance to ask how many hours the child spends in Comparison of English and Jewish children. 68 Children born in 1913. Health progress during school life. (1) Entrance examination in 1918. (2) Intermediate examination in 1921. (3) Twelve years of age examination in 1925. (4) School leaving examination in 1927. Unclean heads. 12 3 4 Gross decay of teeth. 1 2 3 4 Tonsils and adenoids for operation. 1 2 3 4 Ear diseases. 1 2 3 4 Anæmia. 1 2 3 4 Lung disease. 1 2 3 4 bed than to ascertain the quality of the sleep, whether restful or disturbed. With the assistance of the head teachers of the girls' department in two typical Chelsea schools (The "Ashburnham" and the "Marlborough"), she has ascertained for all the pupils in the two departments the number of children in the family unmarried and living at home, and correlated this with the number of rooms occupied by the family. The result is given in the following table:— No. of children per family. 1 2 3 4 5 6 7 8 9 10 11 12 No. of rooms per family. 1 8 1 4 3 0 1 0 0 0 0 0 0 2 17 32 32 22 17 7 4 0 0 1 0 0 3 16 43 54 42 14 28 18 9 4 3 0 0 4 11 17 14 17 17 21 14 7 4 2 2 1 5 3 5 4 6 5 3 6 5 2 1 1 1 6 4 2 1 1 4 6 2 2 2 2 1 1 6+ Fifteen families. 69 Dr. Russell remarks that, in many cases, the conditions are such that restful sleep is almost impossible to obtain. Following-up. When it became incumbent by law in 1907 and 1908 for the Education Authority to assume responsibility for the feeding of necessitous children in the schools, and for the medical inspection of the scholars, the London County Council found that already voluntary agencies existed which were carrying out a great deal of the work. It was, therefore, determined that in no case where a voluntary society or institution existed would the Council supersede them ; further, that where insufficient provision existed, efforts should be made to induce voluntary agencies to step in and fill the gap. In practically all the schools of the London Education authority a voluntary school care committee has been established, and it is around these school care committees that the whole system revolves. Upon them have devolved some of the important powers enjoyed by the Education Committee, and they thus became responsible for the whole of the social service work of the schools. Consisting entirely of unpaid volunteers, these committees undertake the attendance with the doctor at the medical inspections, they are responsible for interviewing the parents, for following-up the defective children, for persuading the parents to send the children for treatment, for distributing vouchers entitling attendance at hospitals, and treatment centres, for assessing the amounts that parents should pay towards the cost and for permitting free treatment in cases of necessity. They decide which children should be fed at school, how much the parents should pay, and which cases should be fed free of cost to the parents. They also undertake the work of after-care; they hold a school-leaving conference at the school at which each leaving child is interviewed with his parents, having before them the head teacher's and the school doctor's reports upon the child; with the help of the agents of the local employment exchange, they decide which would be the best career for the child, and endeavour to see that he is placed in a suitable situation when he leaves. The children's care committees have been recently reconstituted. There are now 922 Committees and they cover the whole of the schools except five small non-provided and two special schools. The number of workers who are full members of committees is 5,105, and there are, in addition, 179 approved workers. The voluntary committees are under the direction of a corps of trained organisers who are salaried officers of the Council. The organisers are women who have taken degrees or diplomas in social science in the various Universities. They train new voluntary workers, and are available always to advise, assist and supplement the school care committees. The twelve district organisers direct the social services of the schools in the twelve educational districts, and each maintains a bureau for mutual exchange of information with all the voluntary and municipal social services in her district operating in other spheres than that of the school. In each of the five medical divisions there is a divisional treatment organiser with a staff of assistant organisers who attend at all the treatment centres and hospitals within the Council's scheme. They mark and regulate the attendance of the children, they inform the school care committees of failure to attend so that the latter can take action to secure regular attendance, they inform the care committees when children are discharged, and, above all, convey to the care committees the advice of the treating doctor in regard to action which should be suitably taken in the home. It must be recognised that what are "diseases" to the medical department are "symptoms" to the social service department. If even such a simple condition as chronic inflammation of the eyes exists in a school child, the real cause of chronicity is some defect in the home: there is parental ignorance, parental neglect, School Care Committees. Organising staff. 70 poverty or unsatisfactory housing conditions. Whatever the physician may do in the way of improving the child's eyes temporarily by medical treatment, so long as the real disease—a defect in the environment of the child—is left untreated, the chronic inflammation of the eyes will return again and again. Similarly, a child may be sent to a colony or sanatorium to recover from such diseases as rheumatism or tuberculosis, but these conditions reflect some fault in the home which is the true disease, and must be tackled by the social service department, while the child is still away. Otherwise, upon his return, he will again contract the disease, and all the time and money expended upon curing the doctor's disease will be wasted because the true disease—maladjustment in the home—of which even tuberculosis or rheumatism are only symptoms, has not been dealt with. Therefore the medical officer who sees in the detection and treatment of medical diseases the sole object and end of his endeavours will fail to perform really useful work. Even the occurrence of a minor ailment in a child should lead to an attempt to uplift the family or rather to assist the family to uplift itself. Many medical officers still need enlightment in this respect. The efforts of the physician or surgeon to cure the sickness of the child must be supplemented by the simultaneous efforts of the social workers to cure the environmental defects in the home itself. Perceiving the great results that flow from this combination of medical and social effort, many of the great voluntary hospitals not included in the Council's scheme proper have demanded the presence of care organisers without requiring any subsidy from the Council for the treatment of child patients, and both the hospitals themselves and the school service have greatly benefited by this extension of the scheme, in the shortening of the duration of treatment, and by "following up" in the home ensuring, so far as possible, its permanence when a cure has been effected. The formal reinspections in school of children previously found ailing make it possible to compile a statistical record of following-up. During the year the total number of children reinspected was 193,260. Of these 133,462 were primary reinspections, and 66,827 second reinspections, of children not discharged at primary reinspections. Combining the results of first and second reinspections in 1927 it is found that 76.4 per cent, of the children were discharged by the school doctors, the condition for which they were under observation having been dealt with. This is a better result than in the two previous years when the figure stood at 75.4 and 75.5 per cent, respectively. Ignoring dental defect the proportion of the children treated works out at 81.4 per cent. Somewhat better results were obtained in regard to dental treatment than in the previous year ; at first reinspections 50.7 per cent, still needed treatment in place of 53.1 per cent, in 1926 and 54.3 per cent, at second reinspections in place of 53.7 per cent. It is dental treatment which, of course, gives by far the most trouble in followingup. Attention was drawn to the number of refusals to obtain treatment reported at the dental inspection at a voluntary school in North St. Pancras on 19th September, 1927. The care committee secretary, who is also the head teacher in the infants' department, enquired into the reasons for refusal in each case with the following result:— Of 38 cases referred for treatment, 4 children were treated by a private dentist, 1 was treated, and 2 desired treatment at a treatment centre. There were 31 refusals and the following were the excuses given:—"teeth loose, father will remove them" (3 cases); "all teeth are sound" (3 cases); "not bad enough at present" (10 cases); some treatment effected, but completion refused (3 cases); "will not have fillings" (3 cases); refusal without reason (4 cases); treatment deferred (4 cases); "treated at home" (1 case). Thus the meagre result of this dental inspection was that only 7 out of 38 children who need skilled dental treatment show any signs of obtaining it. Co-operation of voluntary hospitals. Results of reinspections. A poor dental result. 71 Dr. Livingston reports on this statement;—"One objection stands out strongly, the parents stating that the teeth ' are not bad enough yet.' It appears to me that we must lay much greater stress upon the facts of dental disease and general health and mentality, and, accordingly, I am requesting the dental surgeons as I visit the centres, if they are inspecting, to give the parents and children a short address, but laying as much stress as possible upon diet and hygiene, dental ill-health and its disasters and the need for treatment." In contrast to this must be mentioned the case of another non-provided school, St. James', Rotherhithe. It was noticed that at this school apparently 100 per cent, of medical and dental treatment was obtained, and the school doctor was asked to explain how this was brought about. She produced the following letter from Mr. J. D. Steen, the head teacher, who is enthusiastic for the well-being of his boys, and, through his experience in the Army, has learnt the great benefits of sound dentures. It is a signal result and demonstrates how much can be done when a head teacher is in full sympathy with the medical work, and goes "all out" to ensure its success:— "With reference to your enquiry as to how I manage to have the treatment you prescribe carried out in every case, I wish to say that a great deal of the success is due to the kindly and sympathetic interest you yourself take in the boys and the great influence you have with the parents, and also to the invaluable help I receive from the school nurse. After your visits I set to work in this way:— 1. I get a list of all cases requiring treatment. 2. I ask the boys to get permission from their parents to have treatment carried out. I write for appointments for all those who get permission and see that the appointments are kept, if possible, when the day arrives. 3. When permission is not forthcoming I ask the mother to see me, and, if necessary, test the boy's vision, etc., in her presence. If this is not successful I ask the father to see me. Knowing the parents I adopt what I consider the best line of action in each case. Determination and perseverance win through. 4. I keep constantly before the boys the importance of good health and what neglect now will mean later on. They understand that good health comes first. 5. It goes a long way when I tell the boys that we are the best school in London for having the doctor's orders carried out, and when it comes to the last two or three cases the boys feel that they are the only blots on an otherwise clean sheet and the parents' indifference is thus overcome. 6. I do not let financial difficulties stand in the way, and, in spite of this fact, the parents as a rule pay the prescribed fee. 7. I get help for glasses from the Hospital Sunday Fund, but only in two cases lately have I had help from the Spectacles' Committee. 8. In the case of the dentist's annual visit we generally have between 60 per cent, and 70 per cent, sound teeth. Of those requiring treatment I make a list for each class and post it in the classroom. The classes compete as to which one will have all the names marked off first. I can get every case treated and in very few is any pressure necessary. "In conclusion, I may say that I do not at present know of a boy in the school who has an unsound tooth, and when you visit for reinspection during the present term you will again find 100 per cent, treatment carried out." Where there is persistent neglect to obtain medical treatment, if the condition is a serious one, particulars are forwarded to the National Society for the Prevention or Cruelty to Children in order that action may be taken under Section 12 of the Children Act. 742 children with 821 ailments were referred to the Society during the year:— Vision cases, 386; Teeth, 348; Otorrhoea, 34 ; other defects. 53. It is not the practice of the Council to refer for prosecution cases involving surgical How to obtain 100 per cent, efficiency in dental treatment. N.S.P.C.C. cases. 72 treatment, but in addition to the above figures, particulars of 117 children with enlarged tonsils or adenoids were reported to the Society for enquiry and following-up. Owing to the close connection of ear discharge with zymotic diseases, particularly scarlet fever, by an arrangement with the Metropolitan Ayslums Board cases showing symptoms of otorrhœa in certain of the fever hospitals are reported to me when the children are discharged. These children are examined at school, a further examination is made after an interval of six months and the cases are kept under observation until two consecutive reports are obtained to the effect that there are no symptoms of the disease. During 1927 the number of children of school age reported was 217; of these 83 had a first negative report and 38 two negative reports; 71 cases reported last year were also marked off. Seven cases still showed signs of the disease and these will be kept under observation. Otorrhœa after scarlel fever. Reinspections in 1927. First re-inspections of children found to need treatment at medical examinations. Class of ailment and number of cases reinspected. Treated by private doctor or dentist. Treated under Council's scheme. Treated at hospitals not under Council's scheme. Hecovered by home treatment. Improved, needing only observation. Still needing treatment. Cured. Not cured. Cured. Not cured. Cured. Not cured. Refraction, 22,529 130 43 5,352 2,368 497 381 1,926 3,654 8,178 6% .2% 23.8% 10.5% 2.2% 1.7% 8.5% 16.2% 36.3% Minor ailments, 183 68 2,998 966 536 334 3,006 1,595 2,379 12,065 1.5% .6% 24.9% 8.0% 4.4% 2.8% 24.9% 13.2% 19.7% Nose and throat 61 12 4,847 285 957 111 2,467 2,352 8,191 19,283 .3% .1% 25.1% 1.5% 5.0% .6% 12.8% 12.2% 42.5% Teeth, 64,836 1,281 408 20,062 795 1,273 219 6,969 976 32,853 2.0% .6% 31.0% 1.2% 2.0% .3% 10.7% 1.5% 50.7% Other ailments 341 153 51 87 1,943 1,697 4,126 4,089 2,262 14,749 2.3% 1.0% .3% .6% 13,2% 11.5% 28.0% 27.7% 15.4% Total, 133,462 1,996 684 33,310 4,501 5,206 2,742 18,494 12,666 53,863 1.50% .51% 24.96% 3.37% 3.90% 2.05% 13.86% 9.49% 40.36% Second re-inspections of cases not previously discharged. Class of ailment and number of cases reinspected. Treated by private doctor or dentist. Treated under Council's scheme. Treated at hospitals not under Council's scheme. He. covered by home treatment. Improved, needing only observation. Still needing treatment. Cured. Not cured. Cured. Not cured. Cured. Not cured. Refraction, 11,928 49 33 2,271 1,147 249 211 1,393 2,186 4,389 .4% .3% 19.0% 9.6% 2.1% 1.8% 11.7% 18.3% 36.8% Minor ailments 44 36 975 466 158 213 1,441 894 1,358 5,585 .8% .6% 17.5% 8.3% 2.8% 3.8% 25.8% 16.0% 24.3% Nose and throat 24 8 2,205 91 564 60 2,073 1,491 5,005 11,521 .2°/ .1% 19.1% .8% 4.9% .5% 18.0% 12.9% 43.4% Teeth, 29,723 601 220 6,989 348 572 115 4,184 556 16,138 2.0% .7% 23.5% 1.2% 19% .4% 14.1% 1.9% 54.3% Other ailments 80 64 78 110 724 878 2,361 2,437 1,338 8,070 1.0% .8% 1.0% 1.4% 9.0% 10.9% 29.2% 30.2% 16.6% Total 66,827 798 361 12,518 2,162 2,267 1,477 11,452 7,564 28,228 1.20% .54% 18.72% 3.24% 3.39% 2.21% 17.15% 11.32% 42.23% Chronic invalidity of school children. All chronic invalids amongst children of school age are notified by the attendance department to the school officer each month. A census of all children who have been out of school for three months is taken every November. In November, 1927, 73 there were 1,934 children who had been absent for over three months, 897 boys and 1,037 girls. Heart disease and rheumatism falls more heavily on the girls, especially at ages over 10. Only 27 children were noted as absent on account of ringworm. There is also a diminution in the number of cases of chronic ear disease, 55 against 68 and 71 in the two previous years, due probably to the larger number of cases treated by ionisation. The passing of ringworm as a serious cause of continued absence from school is one of the conspicuous results of the work of the school nurses in the schools. The rheumatic group of diseases remains by far the chief cause of chronic invalidity, and becomes more prominent each year owing to the elimination or mitigation of the effects of other causes through appropriate measures. The lessened number of children noted year by year as chronically absent from school is another proof of the improving health of the child population. Three months out-of-school cases—November, 1927. Reasons for absence (grouped) and percentage of total. Boys. % Girls. % Total. % Rheumatism, heart and chorea 191 20.5 317 29.6 508 25.3 Nervous disorders 107 11.5 100 9.3 207 10.3 Tuberculosis (pulmonary and others) 127 13.6 107 10.0 234 11.7 Anaemia and debility 62 6.6 73 6.8 135 6.7 Ringworm 11 1.2 16 1.5 27 1.4 Skin diseases (excluding ringworm) 29 31 34 3.2 63 3.1 Eye diseases 33 3.5 43 4.0 76 3.8 Infections diseases 46 5.0 54 5.0 100 50 Other defects 328 35.0 328 30.6 656 32.7 Total 934 - 1,072 — 2,006 — Comparison between 1927 and three previous years. Complaint. Children. Percentage ot total. 1924. 1925. 1926. 1927. 1924. 1925. 1926. 1927. Rheumatism, heart and chorea 672 614 537 508 25.02 24.71 23.98 25.32 Nervous disorders 288 268 249 207 10.72 10.78 11.12 10.32 Tuberculosis (all forms) 399 322 268 234 14.86 12.96 11.97 11.66 Anaemia and debility 201 196 169 135 7.48 7.89 7.55 6.73 Ringworm 85 81 27 27 316 3.26 1.21 1.35 Skin diseases (excluding ringworm) 78 72 62 63 2.83 2.90 2.77 3.14 Eye complaints 135 103 92 76 5.03 4.14 4.11 3.79 Infectious diseases (including encephalitis lethargica 98 92 103 100 3.65 3.70 4.60 4.98 Other diseases 732 737 732 656 27.25 29.66 32.69 32.71 Total (all complaints) Number of children 2,686 2.608 2,485 2,398 2,239 2,130 2,006 1,934 Medical Treatment. At the end of the year 1927 there were 12 hospitals and 68 centres included in the Council's medical treatment scheme 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:— Provision made in Numbers treated Numbers treated Ailment. 1927. 1927. 1926. Defective vision 36,150 40,293 37,985 Ear, nose and throat disease 15,120 18,176 16,168 Ringworm 1,312 644 844 Minor ailments 72,655 99,766 89,709 Dental defects 128,370 124,992 113,932 Total 253,607 283,871 258,638 74 The increase in numbers treated under the Council's scheme, it will be seen was 25,233. This very large increase, amounting to 10 per cent. on the previous year's total, shows how greatly the provision is appreciated by the parents and social workers. The new centres established during the year were:— New centres. (1) "The Downham," 397, Downham Way, opened 1st July, 1927, provides for 660 minor ailments and 1,540 dental cases annually. (2) "Eltham" Centre, 16, Park Place, Eltham, S.E.9, opened 28th November, 1927, provides for 660 minor ailments and 1,540 dental cases annually. (3) Plumstead Centre, 236, Plumstead High Street, S.E.18. A new dental centre for 1,320 cases annually, opened on 1st April, 1927. (4) Victoria Hospital for Children.—Agreement made with the hospital for the in-patient treatment of 440 cases per annum in respect of children requiring operations for enlarged tonsils and adenoid growths. The arrangement came into force as from 29th April, 1927. (5) The Wick School Treatment Centre, Riseholme Street, Hackney Wick, E.9.—Increased by the addition of an in-patient centre, began the operative treatment of enlarged tonsils and adenoids on 2nd May, 1927. Provision is made for 1,320 cases annually. (6) The Poplar School Treatment Centre, 69, East India Dock Road, E.14.— The new St. Margaret's Ward for the in-patient treatment of cases of enlarged tonsils and adenoids was opened on 12th May, 1927, and provides facilities for 2,200 patients per annum. Treatment of the several ailments. In the following statement the ailments are dealt with separately m the order suggested by the Board of Education. (a) Minor ailments.—99,766 children received minor ailment treatment, an increase of 10,057 on the number for 1926, and their attendances at the treatment centres for this reason amounted to the huge total of 1,575,757. In pursuance of the arrangement with the Metropolitan Asylums Board 115 children suffering from ophthalmia or interstitial keratitis were sent to White Oak Residential School, Swanley. Among these were 15 cases of trachoma and 13 cases of interstitial keratitis. (b) Ringworm.—The great reduction which has been brought about in the number of children suffering from ringworm of the scalp is reflected in the figures above given of the numbers treated, which were less than half of those for whom provision had been made on the basis of previous years. As this result is due to reduction in the numbers suffering, and not due to any failure to bring those suffering to treatment, it has been found possible to cut down drastically the provision necessary for the treatment of ringworm of the scalp during the ensuing year. (c) Visual defects.—40,293 children were dealt with under the Council's scheme for refraction, or 2,308 more than last year. It has been necessary to increase the provision in this respect partly owing to the refusal of the hospitals to deal with school children. Spectacles were prescribed in 28,726 cases and in 26,086 cases they were obtained, a percentage of 91.0. (d) Nasal and aural defects.—The total number of cases treated was 19,973, of which 18,176 were treated under the Council's scheme. 13,046 children received operative treatment at the treatment centres, and of these 9,504 were retained after operation under the in-patient scheme at the nine centres where this arrangement had been made. The extension of the scheme by the addition of four centres was forecasted in the last annual report. These new centres all began work during the year 1927. Further, an arrangement with the Mildmay Mission Hospital, Bethnal Green, for the in-patient treatment of 10 cases a week, commenced on the 11th January 1928. Including this centre a summary of the existing provision is given here. 75 Address of Centre. In-patient treatment began. Annual provision from 1.4.28. Number treated in 1927. Belgrave Hospital, Clapham-road, &.W.9 sept., 1922 500 349 Cyril Henry, 57, St. Mary-street, Woolwich, S.E. 18 1.1.1920 2,500 2,284 Hanover Park, 7, Hanover-park, Rye-lane, S.E.15 17.5.1926 2,200 2,344 Highgate New Town, Chester-road, Swains-lane, N.W.6 1.4.1923 1,980 1,638 Mildmay Memorial Hospital, Newington Green-road, N.l 12.11.1925 440 214 Mildmay Mission Hospital, Austin-street, Bethnal Green, E.2 11.1.1928 440 — Poplar Centre (St. Margaret's Ward), 69, East India Dock- road, E.14 12.5.1927 2,200 1,479 Princess Louise Hospital, St. Quintin-avenue, N. Kensington, W.10 8.12.1927 1,380 30 Victoria Hospital, Tite-street, Chelsea, S.W.3 29.4.1927 440 266 Wick, Riseholme-street, Hackney Wick, E.9 1.5.1927 1,320 900 Total 13,400 9,504 Centres for in-patient treatment of enlarged tonsils and adenoids. In respect of the treatment of otorrhœa at the special ionisation centres, Dr. A. G. Wells reports as follows :—" At the end of the summer term Dr. Friel, who had been giving 5 sessions per week asked to be released of 3 of them, and is now giving 2 only. Dr. Sandiford was appointed to take 3 sessions and has been at work since the beginning of the winter term. Treatment of Otorrhœa by ionisation, etc. " The work done by the aurists shows a small increase over that recorded in the previous year, 1926. The south-eastern district still has by far the largest 'waiting list,' and four sessions per week are being continued in this division, while the northwestern division is receiving two only. Further provision for ionisation is desirable in all divisions with the possible exception of the eastern division, but the divisions most in need of further sessions are the south-eastern and the south-western. The following tables show the particulars of the work in connection with the cases of ear discharge and deafness:— Cases of Otorrhœa. Division. No. of examinations. No. of cases examined. No. of new cases. Discharged at 1st examination. No. of lapsed cases. No. of relapsed cases. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Patients. Ears. Patients. Ears. S.E. 3,000 3,363 678 675 496 487 83 56 69 65 73 N.E. 2,286 2,936 610 578 517 477 77 85 91 99 121 E. 2,342 2,716 487 580 409 479 54 82 95 108 119 S.W. 2,545 2,992 613 736 436 537 65 61 75 73 78 N.W. 1,321 1,690 284 334 205 252 26 19 20 42 49 Totals 11,494 13,197 2,672 2,903 2,062 2,232 305 303 350 387 4 40 Deaf Cases. Division. Examinations. Cases. New cases. Cured. Improved. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. S.E. 197 334 31 54 21 40 7 8 5 9 N.E. 171 336 30 57 17 32 9 18 1 2 E. 97 170 20 34 16 27 9 17 3 6 S.W. 102 183 34 64 28 52 24 39 3 6 N.W. 30 56 12 20 11 18 5 10 5 10 Totals 597 1,079 127 229 93 169 54 92 17 33 76 Deaf Cases—continued. Division. Unrelieved. Discharged 1st examination. Lapsed. Relapsed. Still under treatment. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. S.E. — — 4 7 5 6 — — 21 42 N.E. 1 2 — — 6 11 2 4 16 31 E 3 5 — — — — — — — — S.W. 1 2 — — 5 8 3 3 18 34 N.W. — — — — — — — — 7 10 Totals 5 9 4 7 16 25 5 7 62 117 Analysis of Otorrhœa Cases. Causes of suppuration. Total ears. Cured. Referred for mastoid operation. Lapsed. Still under treatment. Acute otitis med. supp 70 50 10 — — Chronic ot. med. supp. due to— I. Tympanic conditions— (a) Tympanic sepsis 840 675 — — — (6) T.S. + granulations 259 153 3 — — (c) T.S. + Polypi 83 41 1 — — (d) T.S. + caries 28 7 2 — — (e) T.S. + other conditions 35 20 — — — II. Tympanic conditions + (a) Tonsils and adenoids 233 133 1 — — (b) Nose conditions 120 82 — — — (c) Mouth conditions 4 2 — — — III. Tympanic conditions + (a) Attic disease 218 87 32 — — (6) Mastoid disease (no operation yet) 334 33 184 — — (c) Mastoid disease (operation already done) 246 144 25 — — IV. Tympanic conditions+ (a) External otitis 30 15 — — — (b) Stricture of meatus 18 5 1 — — External otitis 50 32 1 — — Cause undetermined 2 1 — — — Total 2,557 1,485 260 350 462 " The above table shows a complete analysis of the otorrhœa cases seen by the aurists at all the special centres. It gives the cause of suppuration in each case ; the cause of chronicity; the number cured; the number referred to hospital for mastoid operation ; the number of lapsed cases, i.e., those that left school while under treatment or for some other reason were lost sight of; and the number still under treatment at the end of the year. From the figures given it will be seen that the percentage of cases ' discharged cured,' after deducting those that lapsed, is 67'2 per cent. This figure takes no account of the result of those cases which were operated on for mastoid disease, which are given later in this report. Including these the percentage is 77'9. This percentage of ' discharged cured ' cases is approximately the same as that obtained in 1926. " The following are the details of the work done at the After Care Clinic at Kentish Town, which embraces the after treatment of the mastoid operations done 77 at the Downs Hospital:—Ionisations, 1,436 ; Ultra Violet Irradiations, 1,224 ; Dressing, 2,242 ; Total attendances, 5,428. Chronic mastoid disease— Patients. Ears. Number of patients treated 324 375 (a) After mastoid operation 272 317 (b) No operation 52 58 Referred from Downs Hospital 221 249 Discharged from Downs Hospital in 1926 and treated in 1927 99 120 1927 cases— Discharged from Downs Hospital requiring no treatment 30 31 Treated L.C.C. clinic and discharged cured 6 7 Still having treatment at L.C.C. clinics 7 7 Treated at L.C.C. clinic and since lapsed 2 2 Treated Kentish Town and discharged cured 107 119 Still under treatment at Kentish Town 60 69 Treated Kentish Town and since lapsed 2 3 Referred back to Downs Hospital for further operation 4 6 Not yet attended Kentish Town 3 5 1926 cases continuing treatment in 1927— Discharged cured 72 86 Lapsed in 1927 7 9 Referred back to Downs Hospital 11 14 Transferred to L.C.C. clinic in 1927 9 11 Cases still having treatment L.C.C. clinic, 1927— Cases discharged cured 6 6 Referred back to Downs Hospital 2 2 No operation—-1927— Treated at Kentish Town and "discharged cured" 39 44 Still having treatment at Kentish Town 6 7 1926 cases— Having treatment in 1927 7 7 ' Discharged cured' in 1927 7 7 " A description of the new method of diastolisation was given last year. For Diastolisavarious reasons it has not been possible to make as extensive a test of this method of tiontreatment as was intended during the year, but the opinion formed and given in the last report seems justified by the further results obtained in a series of cases, the details of which are as follows. The series consists of 45 cases:— Nature of ailment. Before Diastolisation. After Diastolisation. Nasal catarrh 20 3 Hypertrophic rhinitis 25 12 (in less degree) Impaired nasal respiration 34 3 Frequent colds 18 5 Nasal discharge 27 7 Snoring 6 — "276 treatments were given in all averaging approximately 6 treatments per case. The result showed that 26 cases were completely relieved; 12 were improved; 3 showed no improvement; 3 were still under treatment and 1 case had lapsed. There seems to be no doubt that diastolisation is able to assist materially in the relief of these nasal conditions, so frequently found in children, and chiefly characterised by inability to perform the function of nasal respiration correctly, with its many sequelae. It is my hope to make a much more extensive use of this method of treatment during the ensuing year." Dr. Lewis reports upon the the practice followed at the new Wick Centre for operations upon children suffering from throat troubles. " Since the opening of the Wick Treatment Centre in May, 1927, the cases operated on for tonsils and adenoids numbered 896. It may be of interest to record the method and results. " As the result of observation of the method of preparation for operation in vogue at the Highgate centre, it was resolved at the onset to vary the procedure 15435 F Operative treatment of adenoids at the Wick treatment centre. 78 adopted there, which was an enema of soap and water on admission together with a hypodermic of atropine administered prior to operation. The enema especially tended to upset the digestion of the children afterwards and it was abolished. " The children treated at the Wick have no preparation beyond an instruction to the mother to give a dose of castor oil two days before admission. No hypodermic is administered. The children are operated on at 2.0 p.m., on the day of admission. The anaesthetic used is ethyl chloride (the best results are obtained when air is given with it by a small pump fitted on to the face-piece of the bag). Removal of the tonsils is done by the guillotine (reverse method) and the adenoids by a curette. " At this centre the children are given nothing but ice-cream for 24 hours after operation, a little bread and butter being allowed on the second day (when they are discharged) if they ask for it. Ice-cream is made at the Centre and has been found most admirable after-treatment. The children like it, it is easily and comfortably swallowed, and is very nourishing. It also simplifies the catering. "Of the 896 cases treated to the end of 1927—children of all ages between 5 and 14—only 4 have had serious complications. One case of endocarditis developed on the second day—ultimately discharged after a week. One case of severe hemorrhage which yielded finally to plugging and hemostatic serum. Two less severe cases both yielded to adrenalin douching. One case contracted broncho-pneumonia on the day of discharge and had to be retained in the Centre for a week but ultimately recovered. Two other children remained longer at the centre at parents' request owing to home conditions. Minor cases of hemorrhagic oozing were reported, but were all checked by sitting up in bed and spraying with adrenalin. "None of the children suffered from the gastric disturbances which are reported from other centres. These are probably due to the enemas given there, and for that reason are not used at the Wick. Only in one instance has an ' accident' happened on the operating table, and it is better to risk that than incur the risk of gastric shock which the giving of the enema often causes in young children." (e) Dental defects.—62 part-time inspecting dentists (51 men and 11 women) take part in the inspection of the teeth of children in the schools, and 2,025 sessions were devoted to this work. There are now 60 dental centres, not including Bushy Camp School, where dental treatment is provided separately for 1,540 children, and arrangements were made during 1927 at these 60 centres for the treatment of 126,830 children. In all 226,146 children were inspected by the school dentists and of these 158,456 (70 06 per cent.) were found to require treatment. 124,992 children were treated at the Council's centres. Dr. Livingston's report on the dental treatment. "The return of the dental treatment for the year ended 31st December, 1927, shows a considerable increase (11,060) in the number of new cases passing through the dental surgeons' hands. Keeping pace with the increase in new cases is an increase in the numbers of necessary extractions, more particularly of the temporary teeth, the actual figure being about 46,000, but it is pleasant to be able to record that the number of extractions of permanent teeth does not show a pro rata increase to the numbers of new cases treated. The number of fillings placed remains practically steady compared with 1926 ; there is a slight decrease in the number of other operations performed, such as the application of silver nitrate. There has been a consequent increase in the numbers of general anaesthetics administered keeping pace with the increase in the numbers of teeth extracted, and the natural parental demand for painless dentistry. "It is very interesting to compare the returns of dental treatment for the year ended 31st December, 1912, with the returns for the year 1927 just finished. The interval is 15 years; in 1912, the first year for which figures were set out according to the present method of returning, five centres had already been established and during that year two otheis began treatment. 9,799 new cases attended. For these children an average of 3.26 extractions were performed. 1.65 fillings were placed 79 and 0'23 other operations performed, making a total average per child of 5.14 operations. In this interval of 15 years it will be observed that the numbers of children attending as new cases have increased over twelve times, the centres multiplied ten times. The extraction performed per child remains at about the same figure, 324. Fillings have fallen however to 0 82 per child this year. Other operations also remain steady at just under 0.2. "Our reports and observations show that the new entrants in the schools are showing cases where caries is rampant in a very high degree. The state of the permanent dentition once the child comes under the assistance of the Council and the dental surgeons of the centres is made secure, and continues to be relatively secure, a state of affairs confirmed again by independent observation of children who have been treated under the Council's scheme. We can only attribute the incidence of caries of the temporary teeth to the greatly increased consumption of easily fermented carbo-hydrates. Children of six years of age, born in 1922, have suffered from the great decrease in the cost of sweetstuffs, white bread, flour and biscuits. These are at and frequently below relative pre-war prices. We are hoping that the continued educational efforts by doctors, dental surgeons and all interested in the little ones, propaganda directed especially towards those girls about to leave school—the potential mothers of London children—will result in a more lively interest and practice of oral hygiene and the consumption of a rational diet in a rational way. That this will in time result in a marked decrease in the consequences of caries, caries itself, and the need for treatment of our damaged goods, is borne out by the last column of the following table. Whereas in 1912 the dental surgeons were struggling to treat some seven decayed teeth per mouth, and succeeding in treating only five, to-day slightly more treatment per child is given than the known incidence warrants, a fact which may be accounted for by the treatment given to the gums in many cases." Comparison of Returns—Dental Treatment, 1912 and 1927. Year. No. of new cases. No. of attendances. No. of teeth or roots extracted. No. of fillings. No. of other operations. No. of general anæsthetics. Average number of operations per child. 1912 6 centres 9,799 14,664 32,057 3.26 extractions per child. 16,257 1.65 fillings per child. 2,373 0.23 other operations or treatments. 2,533 514 2.26 operations per child less than the known incidence of caries. 1927 61 (dental) centres 124,992 206,663 406,373 3.24 extractions per child. 102,712 0.82 fillings per child. 24,994 0.18 other operations or treatments. 63,635 424 0.85 operations per child more than the known incidence of caries. Following are the statistics referring to the work done at the Woolwich Remedial Clinic during 1927. Children referred to the clinic from school doctors, 84; infant welfare centre, 71; parents, 26 ; hospitals, 19 ; dispensaries, etc., 8; total, 208; number of attendances during the year, 6,732. Of the 208 children seen on reference, 166 were given treatment and the other 42, while not being recommended for remedial or massage treatment, were helped, 15435 2 Woolwich I.C.A.A. Remedial Clinic. 80 either (1) surgical instruments or splints supplied, (2) convalescence recommended, (3) instructed re home treatment, (4) referred to hospital, or (5) kept under observation at intervals. Number of old cases re-attended for treatment, 29. Defects.—The 195 children mentioned above (i.e., 166 new and 29 old re-attended) were suffering from the following defects. Spinal curvature—postural, 47; kyphosis, 12; lordosis, 2; kypho lordosis, 9 ; lateral curve, 8. Defective chest expansion, 10; infantile paralysis, 13; foot deformities—talipes varus and valgum, 22; flat feet, 9; bow legs (genu varum), 35; knock knees (genu valgum), 6; various, 22; total, 195. At the weekly medical visits 607 inspections were made, and decisions made as follows:—Treatment required, 153; treatment not required, 16 ; discharged improved, 102; to continue treatment, 142; to re-attend, 22; to be seen again after an interval, 77; referred for convalescence, 13; referred to hospital, 4; referred to own consultant (Mr. Roth), 24; forms and certificates filled up, 8; referred to Woolwich Treatment Centre, 4; examined re general health, 3; referred to solarium, 3; various, 36. Mr. Paul Bernard Roth attended monthly, and his advice in difficult cases is found invaluable. He is also in sole charge of the strictly orthopaedic cases. Classes for stammerers. Classes for Stammerers.—During 1927 the number of children in attendance at the centres for stammering children was 252. Of these 55 were discharged as cured, while 48 were discharged as provisionally cured. Six children were readmitted, having previously been discharged as cured. An investigation into the permanency of cure or improvement of children who have attended stammering classes was carried out by Dr. E. J. Boome and Dr. Nairn Dobbie. The cases included 49 children (43 boys, 6 girls), who have been discharged one year or more previouslv, as cured or much improved, from stammering classes in London. All except 3 of these children were personally interviewed and examined, and the following table shows the results obtained :— Original condition. Condition on discharge. Present condition on medical certification. Slight. A. Bad. B. Severe C. Cured. A. Much improved. B. Relapsed. C. Cured. A. Much improved. B. Relapsed. C. Unchan ged. D. Worse. E. Boys 1 20 22 28 14 1 20 17 5 ° 1 Girls — 3 3 6 — — 4 2 — — — Totals 1 23 25 34 14 1 24 19 5 0 1 Remarks.—24 out of 49 children followed up remain cured after a lapse of time of at least one year from discharge. There is tendency shown towards relapse in the other cases. 34 of the 49 were considered cured on leaving the class, and only 24 are now certified to be without any tendency to stammer. There is little doubt that a stricter classification was made during this investigation than upon discharge. Several children are included in class B who remain to all intents and purposes "cured"; and with the strict classification now adopted some of the 34 children placed in class A as "cured" at the time of leaving would have been placed in class B. The slight hesitancy shown by certain of the children upon which they have been classified as " B " in the present investigation does not appear to be different in character and degree to that shown by nonstammering children of nervous type. In fact they are still regarded as " cured " by parents and teachers alike. It follows, therefore, that although the figures as they stand are very satisfactory and show undoubtedly there is a good return as the result of the expenditure involved in maintaining the classes, a perusal of the case sheets will carry the conviction that the results are even better than is shown by the analysis of the figures. 81 Rheumatic Children. The arrangement by which the Council has become the organising authority for the care of rheumatic children was described in last year's report, and reference to subsequent and imminent developments is made in a later section of this report dealing with crippling defects in school children. From the commencement of the scheme in November, 1926, up to 31st December, 1927, a total of 535 nominations had been received for institutional treatment for rheumatism in childhood, and the following table shows how they have been dealt with up to 3rd January, 1928, in the face of, as yet, inadequate provision. Hospital. At present in hospital. Discharged from hospital Removed by parents against advice. Died in hospital. Total. Boys. Girls. Boys. Girls. Boys. Girls. Boys. Girls. Boys. Girls. Queen Mary's Hospital, Carshalton (sub acute beds) — 16 — 12 — 2 — 1 — 31 Do. (rheumatic fever unit) 6 4 — 5 — — — — 6 9 High Wood Hospital, Brentwood (sub-acute beds) 26 30 17 19 9 21 1 1 53 71 Cases treated 32 50 17 35 9 23 1 2 59 111 Refusal by parents after admission had been arranged 4 6 Children placed by I.C.A.A. and other organisations 40 92 Children nominated but considered unsuitable under the scheme 41 61 Cases on nomination list at present 39 82 Total number of nominations received 183 352 Careful enquiry is made not only into the medical aspects of each case, but also into the social and environmental conditions. Dr. J. Nairn Dobbie has made a minute and searching analysis of the particulars in 100 of the first cases, and the results are given in the following report. The immediate cause of rheumatism in children is not yet known, although its disastrous effects are painfully evident. While definitely affected rheumatic children must be treated, it is obvious that preventive measures must be adopted to control this menace which maims, cripples and cuts off so many young lives. Such measure can only be framed when the conditions surrounding the inception of the disease are known and clearly recognised. At the present time it is difficult, if not, indeed, impossible, definitely to diagnose rheumatism in the early stages. It would, therefore, seem reasonable to take a series of frankly declared cases and analyse the signs and symptoms, and then retrace them back along the paths of progression to their immediate beginnings, and at the same time attempt to evaluate the influences and observe the effects of heredity and of the sufferer's personal, social, and environmental standing, and by so doing arrive at some tentative conclusions. Such conclusions may be proved or disproved by applying them later to children showing prodromal features. For clarity and uniformity it is well to use terms which more or less define the various conditions seen. Sub-acute rheumatism will cover the insidious type in which there may be periods of minor febrile attacks or of indefinite pains and aches accompanied by weakness in the limbs with recurrent sore throats, headaches and night sweats, occasional swellings of the joints, fleeting skin rashes and emotional upsets, during which the child is capricious both in behaviour and in appetite, but seldom so ill as to be confined to bed. Dr. Nairn Dobbie's report on the analysis of 100 cases of rheumatism in children admitted under the Council's scheme. 82 Rheumatic fever is used to denote an acute definitely febrile attack, often ushered in by a sore throat with marked pain and swelling (rarely redness in children) in one or other joint, often moving to another joint, or, again, during such an acute febrile attack, the heart rapidly becomes involved, the acute stage lasting from a few days to a fortnight or longer, and when the child is so acutely ill that bed has to be resorted to. Chorea is so familiar, as regards clinical appearances, that it requires no detailed description. There is, of course, considerable overlapping of these three classes. Many subacute cases exhibit intermittent attacks of rheumatic fever and chorea. It is because of this fact that the inclusive term acute rheumatism has been so widely adopted, but in so far as a large number of sub-acute cases never show major attacks this term is unsatisfactory, as it leads to confusion in discussion, in statistical surveys, in notification, and in the practical assignment of rheumatic children to hospital beds. One hundred cases, which have been admitted under the Council's scheme, either to Carshalton or to High wood, in which Dr. Dobbie has personally visited the homes, and in which the heredity, social and environmental factors have been ascertained, have been selected for analysis. Thirty-one of these children were removed direct from the wards of one or other of the large general hospitals in London, 62 were in attendance at out-patient departments, 5 were under treatment by private practitioners, and 2 were apparently under no previous medical supervision. In no case was the primary diagnosis made by Dr. Dobbie, and in all the hospital cases where the heart was involved such cardiac conditions had been carefully interpreted by hospital physicians. A simple tabulation of the cases is as follows, the figures in brackets showing the number of attacks. Classification. Number of cases. Sub-acute cases 20 Attacks of rheumatic fever with no history of previous or subsequent sub-acute phase 6 (1) 2 (2) 2 (3+) 2 Attacks of chorea with no previous or subsequent sub-acute phase (1) 2 9 (2) 4 (3 + ) 3 Sub-acute phase with rheumatic fever 37 Sub-acute phase with chorea 19 Rheumatic fever, chorea and no sub-acute phase 1 Rheumatic fever, chorea and sub-acute phase 6 No previous history 2 At first an attempt was made to tabulate the choreic cases separately, but the whole history and clinical appearances (apart from the obvious choreic movements) was so similar to the other rheumatic cases that they have been included, since it is obvious that the twitchings of chorea are but a part of the whole clinical picture of rheumatism. It will be observed that chorea figures either as a separate entity or combined with other manifestations in 35 cases, that is, in over a third of this series, but this group of 100 patients is unduly weighted with advanced cases complicated by cardiac lesions, and in any random sample of early rheumatic cases it is possible that this proportion of chorea would be much reduced. In most of the nine cases of chorea and six cases of rheumatic fever there was a history of periods of ailing with occasional sore throats, headaches, night sweats, and other minor symptoms, but no history of pains. Thirty-seven of the cases were boys and 63 were girls. Choreic symptoms were present in 23 girls and 11 boys. This table shows 20 cases of accepted rheumatism in which no history of major attacks could be gathered, and also shows the marked overlapping of minor and major symptoms and signs, also of major attacks 83 interspersed with periods of recurrent minor symptoms. The rarity of rheumatic manifestation below the age of five years is well known, and no case under five years appears in this series, no doubt largely because these were clearly declared cases. The ages of the children are here classified. Years of age. V. VI. VII. VIII. IX. X. XI. XII. XIII. XIV. XV. Number of boys 1 3 5 0 4 2 8 5 5 3 1 Number of girls 1 3 8 4 3 5 13 9 8 7 2 Totals 2 6 13 4 7 7 21 14 13 10 3 The numbers are very small and the distribution is perhaps chance, but there does appear to be a small peak about seven years and a more definite peak at the 11-14 years' period. The duration of illness varied from a few months to over eight years, and the longer the duration of rheumatism the surer becomes the diagnosis, but the absence of symptoms prior to five years of age and the falling off in numbers between eight and eleven seems definitely against the argument that duration of illness was the deciding factor at all events in this seven year old peak. These children were recommended not only because beds were now available, but also because their several conditions were sufficiently urgent to indicate hospital treatment, and so it might well be that at these ages of physiological stress the natural resistance of the body to adverse circumstances is lowered and rheumatism gains sway. The main clinical conditions seen at examination are tabulated as under:— Average or better than average. Nutrition. Fair. Poor. Number of children 21 56 23 Fairthin. Darkthick. Unclassed. Sweating hands. Rashes. Nodules. Skin. Pallor. Number of children ... 89 78 13 9 53 7 7 Carious teeth. Swelling of joints. 1 to 3. 4+ Number of children 15 14 2 Tonsillectomy prior to symptoms. Tonsillectomy after symptoms showed. Tonsils. Nil. Enlarged. Number of children 17 43 16 24 Temperature. Pulse rate. Under 100. 100 or over. Up to 97. 97—99. Above 99. Number of children 37 63 49 30 21 Hearts. Nil. Suspicious. Definitely affected. Number of children 19 42 39 Only 21 of these children were thought to be of average or better than average nutrition. Seventy-nine were below average, of whom 23 were excessively thin. Pallor was noted in 89 cases. Its prevalence may possibly have influenced the skin classification, since 78 were thought to have fair-fine skins, often showing excessive, delayed or irregular response to irritation, e.g., demography in varying degrees was frequently present; cold hands and feet were not uncommon, as was the presence of chilblains; sweating of the palms of the hand was noted in 53 cases; and seven children showed rashes varying from irregular erythema of a nervous or sweating nature to a definite urticaria seen in two children ; erythema nodosum was not present in any of these children. Drs. Vincent Coates and R. E. Thomas, of Bath, have reported the high percentage of their rheumatic children showing nodules, and this feature was specially looked for. Slight irregularities, little striae and tiny millet seed-like nodules felt in the subcutaneous tissues over long bones, are a not uncommon feature in thin children generally, but their pathological significance is doubtful, and only definite 84 nodules varying in size from that of a lentil to that of a small bean were recorded in seven cases in this series. These were found mostly on the occiput, the back of the hands, and on the elbows. Six out of the seven were taken directly from hospital and all were in cases of the more acute type. This feature when seen appears to be matter of moment in rheumatism. Swelling of one or other of the joints, usually ankles, wrists or elbows, was present in 15 cases, and appears mainly at feverish or definitely febrile periods in the disease. Tonsillectomy had been performed in 16 children prior to, and in 24 children subsequent to, the history of onset, and enlarged tonsils were present in 43 children. The frequent presence or past presence of tonsils, mainly showing signs of chronic inflammation, is important, since the role played by these in the aetiology of rheumatism is still uncertain. The tonsils were seldom markedly enlarged, but often appeared small, and it may be that this small or buried type of tonsil is often missed. In almost all the cases, even when the tonsils were not enlarged, the pillars of the fauces were inflamed, the common appearance of the throat resembling that of a child with a "cold " though catarrhal exudations were seldom seen. An interesting point in this series was that the enlarged tonsils were seldom accompanied by adenoidal growths sufficient to be remarked, and the typical adenoidal facies was not noted in any one of these children. Nor was the presence of obviously enlarged cervical glands a feature; small palpable glands were certainly present in many of the thin children, but would appear more an expression of geneial ill nurture than of specific importance. In this connection it may be noted that catarrhal signs in any of the mucous membranes or of the lungs were especially absent. No child had conjunctival infection (two had keratitis of old standing) and in three only was there a history of bronchitis or recurrent nasal catarrh. One child had had a radical mastoidectomy and another had otorrhea when examined. It would appear that it is not the " catarrhal " child that is subject to rheumatism. Three children out of this series had been admitted to hospital with acute appendicitis. Two were operated on, one with a gangrenous appendix ; all three subsequently developed rheumatic fever. The above classification of pulse rates and temperatures is not sound, since the ages of these children varied between five and 15 years, and the pulse rate in younger children is normally quicker than in older children, and their temperatures vary more. The most that can be said is that in rheumatism pulse rates and temperatures show wide variations for little apparent cause. The interpretation of early cardiac involvement in school children was discussed in the London County Council Annual Report for 1924, page 77 ; for simplicity the present series was classed under three headings—Nil, suspicious and definitely affected. There were 19 cases in which nothing abnormal was found, and 42 cases with suspicious signs. Hearts were looked upon with suspicion when there was slight dilation, that is, the " left border cardiac dulness " was beyond the nipple line ; or, when there was a systolic murmur of indefinite origin at the apex ; or, variation in the tone, rhythm and force of the beats, sufficient to raise doubts as to their significance; or, any combination of these faults; 39 children had definitely and permanently affected hearts. No mention is made in the above table of the temperamental make up of these children, and it is scarcely necessary—the generally malnourished conditions of these children, coupled with the clear evidence of endocrine—sympathetic imbalance as shown by their circulatory inefficiency, which go hand in hand with the unstable type of child whose higher mental and affective attributes show just such inequalities as do the maladjusted physiological functions of the body—clearly shows that rheumatism either establishes or aggravates an already existing instability in children. In Dr. Dobbie's opinion it is the child of nervous type that provides the soil in which the seeds of rheumatism take root. 85 The intelligence and educational attainments of 21 convalescent rheumatic girls at High Wood were enquired into, and it was found that 16 were of normal intelligence but only one of them was educationally equal to her years, the others being retarded from one to three years. Three were of subnormal intelligence, and were three to four years behind with their education. Two were supernormal and educationally were equal to or better than their years. The intelligence of this group was roughly what we might expect from a random sample of normal children, but their educational attainments were distinctly inferior, and this inferiority was not wholly attributable to lack of schooling, but in large part due to the well known inferior educability of the unstable child. The picture of the unstable child outlined above is known to every clinician, and the gradation from this unstable state to that of frankly declared rheumatism is so insidious that the point when the one ends and the other begins is at present beyond the knowledge of the physician. In the absence of cardiac involvement, even with the clinical picture of the child clear before us, the diagnosis of rheumatism must largely rest on the history of the case, with, perhaps, other factors to be mentioned later. Histories personally collected from the parents are set out statistically. No pains. Recurrent pains. Complaints of tiredness and weakness. Recurrent sore throats. Night sweats. Definitely febrile and feverish attacks. 18 82 79 79 62 52 Twitchings. Swelling of joints. Headaches. "Always nervous." Night terrors, etc. 51 49 47 44 11 In the 18 cases where no history was obtained of pains, six had had rheumatic fever, nine had had chorea, one had had rheumatic fever and chorea, and two were diagnosed on the condition of the heart with no previous history; but in all these cases, except the last two, many of the other symptoms were recorded, e.g., " easily tired," repeated sore throats, headaches, feverish attacks, etc. The pains complained of varied in intensity from mere discomfort to acute agony in which the child screamed if touched. The majority of the parents agreed that there is more complaint of this symptom during wet and cold weather, and it is usually while these pains are present that the child feels lax and tired, with little inclination to go out or to do anything but mope about. The pains may come on every few days, but usually a period of a month or longer is interspersed, in some cases a year or longer has passed between these minor symptoms appearing. Sore throats may or may not coincide with these pains, but they most often do. Night sweats usually do, though many parents volunteered the information that the child has always perspired at night. Rheumatic fever and chorea are usually exhibited at longer intervals, and a point of interest not yet elucidated was that rheumatic fever appeared to be more prevalent in those children coming from the better homes. Fidgetiness and twitchings, not so pronounced as to be diagnosed chorea, is a common symptom or sign in the course of the subacute illness. That the incidence of rheumatism is heaviest in nervous children is indicated by the fact that 44 parents stated their children had been " nervous " all their lives. Night terrors, sleep walking and talking are reported in 11 children. Three had had enuresis, two were stammerers, and two were said to have squinted during minor attacks, and in another child a squint was the first sign of oncoming chorea. It may be of interest to note that three other children, not in this series, had been recommended for treatment as cases of chorea, and were found on examination to be mental defectives. The erratic movements had been present from birth, and were thought to be more the expression of a congenital lack of neuro-muscular coordination than the acquired manifestation of chorea. The presence of tics, oftrepeated seemingly purposeless movements of a particular group of muscles, is not uncommonly found in rheumatic children, and it would be interesting to know in what proportion of children with such tics is rheumatism actually present. 86 There was a history of epistaxis in three of these children. In one case the nose bleeding heralded an acute attack of pericarditis, and was a somewhat serious haemorrhage. Sickness, vomiting and digestive upsets are fairly common, especially during febrile periods, and although cardiac involvement is the most spectacular feature, the disease is too wide-spread throughout the body to leave other tissues and organs untouched—witness the nerve irritation in chorea and the tendency to serious exudations. These symptoms collectively form a syndrome, which with the clinical picture of the child outlined above, together form a silhouette sufficiently clear in most cases as to be unequivocal even in the absence of cardiac involvement. All pains in children are by no means rheumatic in origin, but pains fleeting from place to place, with occasional swelling of joints, with repeated sore throats and recurrent feverish attacks, etc., are undoubted manifestations of rheumatism. The following table shows the incidence of infectious diseases in these children :— Measles. Whooping cough. Chicken pox. Scarlet fever. Diphtheria. 70 32 24 9 6 This incidence is more or less what one might expect to find in any random sample of 100 normal elementary school children of these ages, and no evidence was found that any of these diseases played any part in establishing or in influencing the course of the disease. In six out of nine cases of scarlet fever there was a history of rheumatism prior to the scarlet fever, and cardiac involvement showed no heavier incidence in the children who had had scarlet fever or diphtheria. The incidence of rheumatism in children falls especially on the poorer classes. It is rarely seen in consultant practice, and it is a negligible factor in morbidity at preparatory and public schools, as Dr. L. R. Lempriere, school medical officer of Haileybury, who has collected statistics from many public schools, has shown. Yet he points out that the " nervous " type of boy is present in increasingly greater numbers in public schools, so much so as to reduce the standard of general fitness at these institutions. " Nervousness " in children may be the result of poor nurture or of illness, but in the majority of cases it is for the most part inborn. Who amongst us has not seen the parents in the child ? Already the pendulum is swinging back from the purely environmental explanation of every departure from the normal to include the older and broader view of inherited qualities, disposition or character, held through the ages. Aristotle said, " Men are called healthy in virtue of the inborn capacity of easy resistance to those unhealthy influences that may ordinarily arise—unhealthy in virtue of a lack of that capacity." Sir Archibald Garrod (B.M.J., Nov. 26, '27, page 967), stated a truism when he said, " It is an indisputable fact that some individuals are far more liable than others to suffer from particular maladies." Professor MacLean, of St. Thomas', and Dr. Hurst, of Guy's, have shown the familiar tendency to kidney, stomach and circulatory disorders. The rheumatic diathesis was firmly believed in up to the end of last century, and has not vet been discredited. The family histories of rheumatism of these 100 cases is tabulated below :— Father affected. Mother affccted. Both parents affected. Brother or sister. Parent and brother or sister. Grandparents uncles or aunts affected. Immediate family + collateral. No history. Number of children 12 28 3 8 15 11 35 23 66 In twenty-three no record of family history of rheumatism was obtained. Sixtysix showed a rheumatic incidence in one or more members, apart from the patient, in the immediate family, and in eleven other cases the incidence was traced only in near collaterals—grandparents, uncles and aunts. In thirty-five of these children, the family history included both the immediate family and the collaterals. In the majority of the adults the story of rheumatism dated back to their childhood and their then habitat was in many instances far removed from their present homes, so 87 that " location " in the sense, say, of a family all suffering from malaria does not count, further the question of contagion scarcely arises, the spacing and distribution of those affected showed no point in favour of such a conclusion. A further significant fact was that one father and three mothers and four brothers and sisters of these children are said to have died of rheumatic fever or from rheumatic heart disease, and all these four parents were under forty-five at the time of death. Inherited susceptibility of diathesis would thus seem to be another link in the chain that fastens down the rheumatic child. But a constitutional bias does not determine the onset. There must be some factor, a factor at present unknown, that ignites the tinder. The history of the illness outlined above leaves little doubt that rheumatism is an infective illness, but that the virus only establishes itself under certain conditions, partly caused by poverty. It is widely held that it is mainly among the decent poor that rheumatism flourishes and that the poorest of the poor escape. This belief follows the observations of many able physicians, but Dr. J. A. Glover has pointed out, that it may be those physicians working in hospitals in better class neighbourhoods seldom see the lowest grades of humanity at their clinics, and that only the more observant and more careful mothers bring their children to hospital. Subnormality of the children in very poor homes is so much the rule that often the parents do not realise that their children are ailing and so do not seek medical aid. The expectation of life of such children is small; only the fittest of them reach school age. Such as do are the gamins of the streets and spend their waking hours out of doors—perhaps meagrely clad, when wind and sun and air can play their beneficial parts—in contrast to the overdressed and muffled up children of parents toopolite to allow their children " on the street." Moreover, necessitous children receive wholesome school meals. Every school doctor knows the difficulty in getting slum children to go to residential and convalescent homes—such children used to the haphazard life of squalor and grime take badly to a regular and wholesome regime, and if sent on a country holiday as often as not they are removed by their parents or run away. In these hundred cases, thirty-five came from slumdom and fifty-three more were borderline slum dwellers. It is only by seeing the homes that any estimate may be given of the conditions. There are many areas of wretched old tumble-down dwellings where the inhabitants are decent working folks just as there are areas of good class terraced houses once the residences of the rich but now parcelled out in single or double rooms to thriftless, inefficient, often criminal and immoral people, whose presence and numbers renders such property insanitary in the widest sense. The following chart shows the number of rooms in each house and the number of people in each family, with, in the squares, the numbers of families occupying the house. Number in families. Number of rooms. 1 2 3 4 5 6 7 8 9 1 — — — — — — — — — 2 — 1 1 — — — — — — 3 2 2 1 1 1 — — — — 4 2 8 6 2 — — — 1 — 5 2 9 6 10 — — — — — 6 — 8 8 1 — — — — — 7 — 2 10 2 — — — — — 8 1 — 1 3 1 1 — — — 9 — 1 1 — — — — — — 10 — — 1 — 2 — — — — 11 — — — — — — — — — 12 — — — 1 — 1 — — — The figures in the columns 1 to 9 represent the number of families in each house. 88 This chart clearly shows the evidence of overcrowding, for it should be remembered that in almost every home up to three rooms the kitchen was also a bedroom, and in many of the larger houses this also was the case. Only seven out of the hundred occupied houses of five or more rooms, and at least one such house was a veritable slum dwelling. Moreover, the majority of these rooms were of tiny dimensions, often ill-lit and usually badly ventilated, the difficulty of conserving the heat of the body is usually solved not by exercise, suitable diet and clothing and the outdoor life, but by rigidly excluding " draughts " by keeping the windows closed and all cracks hermetically sealed by rags. The inhabitants of such homes seldom change their day underclothes for night attire, and as those of the rheumatic diathesis are prone to sweating, much chilling and interference of the heat regulating mechanism of the body is engendered. Some of their children could almost be recognised by the sour sweaty smell of their underclothes. The diet of these children was not considered. The conditions mentioned above are not peculiar to rheumatic families, and although controls were not kept for this series, visits to these homes gave the impression that the contiguous families were in similar situations. Over and above the personal visit of Dr. Dobbie to each of the homes of these children, trained care workers also visited and fully reported on the social and environmental conditions, and much valuable information was so obtained. When such conditions as dampness or sanitary defects were reported, action was at once taken through the local medical officer of health, and, in addition, other nuisances brought to light were remedied or ameliorated as far as was possible. The following table shows some of their findings :— Slum. Fair class homes. Good class homes. High lying site. Low lying site. Good. Home conditions. Fair. Poor. 35 53 12 27 73 25 44 31 Terraced or semi-detached Floor occupied by family and by vatient. Tenement. . Separate houses. Basement Ground floor. Between floors, j Vop floor. 64 33 3 11 23 47 19 Separate bed for patient. Length of residence in present home in years. Damp. Dry. Yes. No. 1 2 3 4 .5 + 49 51 37 63 10 8 5 6 71 It is seen that fifty-three of the houses are classed as fair, but in Dr. Dobbie's opinion they were in the main really semi-slum. Most of the crowded areas in London are low-lying, in fact there are few high-lying parts within the County, and these are mostly peopled by the wealthier classes. Dr. Jane Shrubsall, in 1913, and Dr. F. C. Shrubsall in 1925 plotted out the distribution of rheumatic cases and showed the heavy incidence along the old water courses; it is not surprising to find that seventythree of the houses of these children were low-lying, for it is mainly in such sites that the densest and poorest population is found. This, is however, not a fair sample in which to discuss the matter of site, as it is a selected and not a random sample. The home conditions were ere estimated not so much on the presence or lack of furnishings, as on the general impression of cleanliness and orderliness and hgyiene, and only twenty-five were considered to be good, forty-four fair, and thirty-one poor, and where such houses were classed as poor they were indeed poor, a monument to the ineffectiveness and inefficiency of the parents, inefficiency scarcely to be wondered at when we remember that many of these poor parents were themselves the crippled victims of rheumatism and or were constitutionally unable to face the exigencies of everyday life. Basements, ground floor and top floors, because of their greater liability to damp and cold, have been blamed as contributory factors, and they may very well be, but the proportion seen here is much what we would expect in any sample from such dwellings, for it must be remembered that in many of the poorer localities the houses are but two or three stories high, so that there does not appear to be any real inference to be drawn by these figures. Most of the sampled families lived in 89 tenements (sixty-four), which ranged from a few modern open building estates to almost derelict buildings, presenting features not unlike back-to-back dwellings, and so present considerable difficulty in classification. So it is with dampness, forty-nine houses were said to be damp, and the evidence varied from leaking roofs and damp walls to " some signs of dampness below the scullery basin." The writer's impression was that the actual dampness in most of the houses was of small degree. It has been suggested that washing and drying of clothes in the poorer homes might be the cause of humidity, if not of dampness, but in such homes washing of clothes is a somewhat rare event, and when it is done it is taken to the public baths in the perambulator and the drying is done in the yard, which, fortunately, exists in the great majority of London's poorest homes. On no home visit did the writer see the washing drying in the house. Thirty-seven children were said to occupy a separate bed, this, in many instances is an euphemistic way of explaining that the child slept on an orange box, or on the floor, or maybe on a convertible bed chair, in many of the other sixty-three cases the child slept either with parents or with brothers or sisters to the number of four or more. That the very poor do not readily or often shift their residence is evidenced by the fact that seventy-one families out of a hundred had been in the same house for five or more years. In summing up the environmental factors, it would appear that no one disadvantageous factor stands out, but rather that each and all of the concomitants of poverty, poor houses, dampness, unhealthy sites, overcrowding, lack of ventilation and of sunlight, poor feeding, poor clothing, irregular habits, etc., destructively converge on these unfortunate children who wilt along the lines their bias carries them, be it marasmus, rheumatism, tuberculosis, or the respiratory diseases generally. Personal Hygiene Scheme. The number of examinations made at rota visits by the school nurses during 1927 was 1,990,201. Verminous conditions were found in 261,135 cases (13.1 per cent.). This is a considerable improvement, as the percentage of verminous cases in 1926 was 15.6 per cent., while in the previous year it was 16.6 per cent. Particulars of the results of the cleansing scheme during the past five years are:— Year. Examinations at rota visits. Verminous conditions noted at rota visits. Per cent. Verminous children referred to centres. Subsequently cleansed by parents. Verminous children cleansed at centres. Scabies cases bathed at centres. 1923 2,052,904 371,790 181 79,702 26,469 53,233 2,935 1924 2,059,590 332,695 161 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 1927 1,990,201 261,135 131 97,586 27,031 70,555 2,609 In addition, the numbers of cases dealt with at the head cleansing centres during these years were—24,516 (1923); 23,986 (1924); 23,947 (1925); 23,645 (1926); and 25,693 (1927). Of the 261,135 cases in which verminous conditions were noted, 153,291 were found to have nits only. Instances in which vermin or flea bites were found amounted only to 5.4 per cent. of the total number examined. It will be observed from the above table that there has been an increase of 479 cases of scabies during 1927. The year has been an unfavourable one for skin diseases generally. Soabies. A new centre having been opened in the North Paddington district, the Council has now 11 centres for the treatment of verminous children, while there are agreements with 18 sanitary authorities and eight voluntary committees. During 1927 there Treatment centres. 90 were 97,586 verminous children whose condition was brought to the notice of the parents by advice cards. Of this number, 44,986 attended voluntarily for cleansing but in 27,444 cases it was necessary to serve, after a further examination, statutory notices in accordance with section 87 of the Education Act, 1921. Following the service of these notices, 7,093 children attended the centres voluntarily, but, of the remainder, 18,476 were found verminous and taken compulsorily by the nurses for cleansing. Of these, 395 were subsequently found to be verminous and police court proceedings were taken in 277 cases. The number of children conveyed by ambulances from outlying schools was 11,102, as compared with 9,637 in 1926. In order that conditions in the homes of children dealt with under the cleansing scheme might be remedied, the borough medical officers have been informed of such cases. Reports were received regarding 3,554 homes visited ; destruction or disinfection of bedding or disinfestation of homes was carried out in 2,412 instances. Although, in the remaining 1,142 cases, this action was not necessary, advice was given to the parents by the health visitors. The corresponding figures for 1926 were 5,514 homes visited, action taken in 1,117 cases. Use of public washing facilities. The arrangements for providing warm baths for children during school hours were continued during the year, parties of children being taken to public baths under the cars of school nurses. The number of baths given was 40,371, as compared with 31,499 in 1926. Physical Education. Physical Education and Teaching of Hygiene. In their report for the year ended July, 1926, the Organisers of Physical Education (Mr. A. H. A. Gem and Miss Grant Clark) give an account of the physical education activities in each branch of the education service. They refer to overshadowing in the past of general activities by mere postural training (or drill). Recently a progressive advance has taken place in securing a better balance of physical activities. The necessity for carrying out physical exercises in the open-air is being better appreciated and a number of infants' departments are now doing this with advantage. The Council decided to recommend all head teachers to increase the amount of time devoted to physical education which is at present hardly sufficient, especially in the standards. For organised games only 44'6 per cent, of available football pitches and 20'9 per cent, of net ball pitches are utilised. This is largely because the bulk of the schools are not sufficiently near a pitch to make it possible for them to take advantage of the provision. On the other hand very full use is made of swimming facilities, which are more equitably distributed throughout London, and approximately 55,000 boys and 35,000 girls attend each week in organised lessons. The very valuable work done by the various " Associations " organised by teachers for athletics and games outside school hours receives adequate recognition by the organisers and this work is of such importance that their report on this section is reproduced in full. Games and Swimming out of School hours. "The numerous all London and district Associations, which have been so painstakingly built up constitute a factor the importance of which it would be hard to over-estimate. It should always be borne in mind that this valuable work if done by a body of enthusiastic teachers who, week in, week out, from year to year give their own time to the various athletic activities of their boys and girls. Londor owes a debt of gratitude to these men and women for their splendid efforts. The organisers have always endeavoured to assist and keep in close touch with this work as it is felt that on the playing field and in the swimming bath a personal touch can be maintained with the teachers, which is bound to re-act favourably on the physical education of the children. It is proposed to give a rather more detailed account of the activities of the various London Associations than is usually the case, dealing with them in alphabetical order. 91 "London Schools' Athletic Association.—This Association has once again completed a most valuable year's work, and great credit is due to all concerned for the large amount of time given to fostering athletics among the children. Twenty-five district Associations, representing about 800 schools, are affiliated to the main organisation, and each one of these districts has held preliminary athletic meetings to select its representatives to compete in the London Finals. The standard of performance is steadily increasing, and it is now a comparatively common occurence to find new " records " established for the various events. The London Schools' Athletic Association would themselves be the first to maintain that their primary aim is not to break " records " but to interest as many children as possible in athletics—at the same time, when consistently better performances are put up, it does indicate that the general level of efficiency is mounting. "London Schools' Amateur Boxing Association.—The London Schools' Amateur Boxing Association is to be congratulated on the efforts it is making to foster good, clean boxing. Boxing, though it has some disadvantages as a sport, e.g., its lack of facilities for the cultivation of the team spirit, has great attractions for the older boys, particularly in some districts, and helps to foster self-discipline in those who practise it. The work of the Association will surely be continually directed towards getting the greatest number of boys to box—the production of champions is quite a secondary consideration. Championship meetings undoubtedly find the best boys, create interest, and cause many boys to take part. Several hundreds of boys boxed in the various competitions, and 833 actually took part in the four divisional meetings. "London Schools' Cricket Association.—The latest "all London" association to be formed is the body which controls the boys' cricket. Although last season was the first, yet much valuable work was performed, and the energies of those in control will increasingly be directed to strengthening the organisation of the game. It will be recollected that the Education Officer was in touch with the M.C.C. and other Clubs with a view to arranging that some boys should have a chance to play, after school, on really good grounds under expert coaching. After the preliminary arrangements had been fixed the London Schools' Cricket Association undertook the responsibility of organising the details of the scheme. Many clubs agreed to have parties of boys to their grounds several evenings a week, and to provide both facilities and coaching. On all sides the clubs have spoken most highly of the work and behaviour of the boys. The following extract from amongst many letters illustrates this point. Shepherd's Bush Cricket Club—"The boys behaved extremely well and seem to benefit by the coaching. They were very enthusiastic and eager to improve their cricket ability." It is gratifying to note that during the coming season at least four hundred boys will be receiving such instruction. Two very interesting fixtures have been arranged :— London Elementary Schools v. Eton. London Elementary Schools v. London Public Schools. "London Schools' Football Association.—This old established Association, has once again carried out a most valuable year's work, and not only is the strength of the association increasing but in many cases the districts and leagues are holding larger numbers in affiliation. The voluntary work of the teachers and secretaries of the local districts and leagues is admirable, and it is to be hoped that the younger teachers will come forward in increasing numbers to fill the gaps created by those retiring after many years' valuable work. The scheme whereby the London Schools' Football Association undertakes the allocation of pitches continues on the whole to work admirably. The shortage of well-conditioned pitches is, however, a matter of concern in some districts. The Association (which embraces some extra Metropolitan areas) now has well over one 92 thousand affiliated schools under its control—fifty-three of which are Central Schools—and the Honorary Secretary estimates that about one thousand four hundred teachers give their time freely and voluntarily for boys' football on Saturday mornings. "London Schools' Netball Association.—Netball is now the chief school game played by the girls, and where there is a large playground this can be catered for very successfully on the premises. Most schools, however, have not sufficient space to accommodate more than one game, which only includes fourteen players, and therefore during a class games period other organised games which can be played on smaller courts have to be employed. This necessitates that the majority of the actual netball coaching is done after school hours, and much time is given voluntarily by many enthusiastic teachers to the organisation, coaching and umpiring of the game. Last year, before the District Champion School teams were arrived at, 310 teams had competed, representing 2,170 players—this is only a small proportion of the total number of girls who play netball in the London Elementary Schools. Much credit is due to the London Schools' Netball Association and affiliated associations for their hard work during the past year. "London Schools' Swimming Association.—Owing to the General and Coal Strikes which took place last summer, several of the borough authorities found it impossible to heat the water in the swimming Daths, with the result that many schools discontinued their attendance for a while. Naturally this break has adversely affected the number of certificates gained—it speaks well, however, for the enthusiasm of the teachers and children that the drop is not greater. (a) Swimming.—The London Schools' Swimming Association report that 7,029 certificates were gained by the boys, and 6,990 by the girls—the figures for last year being 8,487 boys and 8,135 girls. The Hackney branch gained the greatest number of certificates with a total for boys and girls of 997, but if the reckoning is made on the average number of certificates per department, the Kensington branch heads the list with an average of 16'6. Rotherhithe New Road School claims the greatest number of certificates on the boys' side with a total of 72, whilst Greenwich Park Central heads the list for the girls with a total of 69. (b) Life-Saving.—The number of awards gained by the girls far exceeds those credited to the boys :— Boys. Girls. Total. Advanced Certificates 791 1,577 2,368 Elementary Certificates 1,424 2,198 3,622 Grand Total 5,990 The Hoxton branch gamed the greatest number of certificates with a total of 568. Rotherhithe New Road School headed the list for the boys in both elementary and advanced certificates, with totals of 82 and 68 respectively. The late headmaster of the school did much to further swimming amongst his boys, and his sudden death will be a great loss to the school for which he worked so hard. Fulham Central Girls' School gained the most advanced certificates with a total of 41, whilst Sirdar Road with a total of 46 headed the list of elemenatry certificates. Great credit is due to the London Schools' Swimming Association, and to the many affiliated branches, for a most successful and strenuous year's work." Health Classes. In many schools children found by the school doctors to have postural deformities, due to lack of tone of the muscular system, are formed into special classes which are drilled in appropriate exercises for twenty minutes each day. Such "health" classes have been established in thirty-five boys' and sixty-two girls' departments. The important factors in the success of these classes are that the children get a daily lesson in small classes taken by the most suitable teacher on 93 the school staff. In many cases they change into special clothing and as a rule are given extra milk. Dr. F. C. Lewis, the divisional medical officer in the northeastern division has taken a leading part in the promotion of these special classes, and the following is his report upon the year's work in his division:— During the year the health classes for children found by examinmg doctors to be suffering from postural curvature of slight extent, deficient chest expansion and general lack of muscular tone without obvious disease, have been continued in the following schools:—Buckingham Street (G.); Westbourne Road (G.); Moreland Street (G.); Sigdon Road (G.); Daubeney Road (G.); Mandeville Street (G.); Homerton Row (G.); Poole's Park (G.); The Forster (G.); Princess May Road (G.); Blundell Street (G.); Hungerford Road (G.); Winchester Street (B.); Vittoria Place (B.); Central Street (B.) (since discontinued); St. Peter's Italian (B.). Report by Dr. F. C. Lewis. " The classes have tended to vary somewhat in the work done owing to the supervision of the physical training organisers, and the tendency is more towards securing a freedom of movement and an exercising of all muscle systems. This is in contrast to the older methods of remedial and physical work, which aimed rather at precise movements and sustained positions. The whole tendency of recent physical training is in this direction, free movements of a rhythmic nature supplanting the more formal tables of the Swedish school. " This influence is already marked in some of the more recently formed classes, and is due to the difference in training of the teachers taking them. Of the results it is not so easy to speak at present. The children gain in alertness, but on the whole the gain in power of concentration and co-ordination is not so marked. Be this as it may, I have no hesitation in saying that the children in these health classes, after six months, nearly all show a great physical improvement in muscular tone and general nutrition. This alone is sufficient to improve, and in some cases to correct, the lesser degrees of postural defect. " The classes consist of 20-28 children, and the discharges and new admissions are about 50 per cent, during the year. The school doctors report an improvement in physique in all these children, whilst in many cases the mental improvement is also remarked on by the teachers. Again, it must be emphasised that the success of these classes depends entirely on the interest of the head teacher and of the teacher taking the class. The formation of such a class in a school involves extra work and adjustment of time tables to a considerable extent, whilst in addition there is the provision of suitable special class kit. The need for such classes in the boys' departments is, I think, less, and one class has fallen into abeyance (Central Street). There are certainly not the numbers of special postural defects noted by the inspecting doctors in the boys' departments as there are in the girls'." Attention has been paid to the question of the teaching of hygiene as the result of Sir George Newman's report on the Health of the School Child for 1926. Dr. F. H. Spencer, the Council's Chief Inspector of Schools, has reported as follows upon the general practice in London :— Teaching of hygiene. " At the end of last year I asked each district inspector to enquire, at the next ten or twelve schools visited, what provision was made for the teaching of hygiene in practice and theory. Inquiries were made in 199 departments, of which 101 were boys' departments and 98 girls' or mixed. This sample, as it comprises fairly large numbers and was chosen by the ordinary requirements of the inspectors' duties and with no reference to the subject under enquiry, may be taken as a fair one. The results have been ably summarised by Mr. Lilley in the succeeding paragraphs (2-8). Memorand urn by the Chief Inspector. 2. The information shows clearly that in a large majority of the schools visited, valuable work is being done in inculcating healthy habits. Cleanliness 15435 u 94 inspections form part of the daily routine in many schools, and in at least one case, time is allocated for this purpose on the time table. Marks for the individual, team or house are often awarded in connection with these inspections, and, in one case, are taken into account in connection with the prize scheme. A ' clean hands ' chart is used in one school; in several others, nit combs, soap, tooth brushes or tooth paste are on sale, and while the attendance of boys and girls at the local baths for a hot bath is very generally encouraged, in one case arrangements are made for regular attendance for this purpose. Exercises in breathing are taken in connection with Physical exercises and singing lessons, and use of the handkerchief taught. The importance of ventilation is shown practically by the generally prevailing practice of opening any window which may be closed at the beginning of the singing lesson, and of the physical exercise lesson if this is taken within the school building. The necessity for and value of certain types of food is practically demonstrated by the provision of milk and cod liver oil for delicate children. In many schools, too, the annual school journey becomes an occasion for the teaching of healthy habits. In poor neighbourhoods where footwear is defective, plimsolls or knitted shoes are available, and the children practically taught the danger of wet feet. In many class-rooms, coloured health mottoes are exhibited. In one girls' school a junior Red Cross branch of sixty girls of thirteen years' old has been formed, and the Red Cross code of health laws adopted. 3. The actual practice of healthy living given in these various ways, is often reinforced by talks given by head teachers at school assembly. Occasions present themselves, from time to time, which make such addresses necessary, but it is probably true that the subjects for these talks are not always chosen so as to form part of a definite course. The value of this incidental teaching would be enhanced by systematic planning, but, even so, its aim would be habit formation rather than instruction in definite health knowledge, though a special feature is made in many schools of imparting some such knowledge during ' health week.' 4. The inculcation of healthy habits of living is undoubtedly regarded as an important educational activity by London teachers, and is receiving its due share of attention in the elementary schools. The Chief Medical Officer's report, paragraph 78 (page 76) suggests that, for children under 11 years of age, a few minutes every day should be devoted to simple practical teaching directed to the formation of healthy habits. It may unhesitatingly be affirmed that this is now satisfactorily being done, and that there is no ground whatever for suggesting that regular and systematic education in regard to the practice of hygienic habits is neglected by London teachers. 5. Where the London practice does not go quite so far as the Chief Medical Officer would like is in regard to the instruction of children over 11 years of age. For these, the Chief Medical Officer says ' there should be systematic and interesting study and practice in hygiene as a definite subject of the time-table every week.' In the L.C.C. 1923 Memorandum on the Laws of Health, Preface, the statement appears ' Nor is it always possible to include hygiene as a separate subject of the curriculum.' Incidental teaching is recommended and ' especially during the last year of school life '—' one or two special lessons each term.' Apparently there is a distinct difference of official opinion as to the amount of attention that should necessarily be devoted to instruction in theoretical hygiene. 6. In regard to actual practice of teaching this subject in the schools, it may be stated that the Council's district inspectors visited 101 boys' or mixed and 98 girls' or mixed schools, and found that some instruction in hygiene is prescribed in the syllabuses for children over 11 years of age (i.e., Standard V, 95 or higher) in all these cases except 49 boys' and 9 girls' schools. In many girls' schools and a small number of boys' schools there is definite and regular teaching of hygiene throughout the last three years of the school life ; in some girls' schools and many boys' schools hygiene is prescribed as part of the science teaching in perhaps one class only. While, then, the amount of instruction varies very considerably from school to school, it is nevertheless true that, in about 70 per cent, of these 199 schools, the subject does figure, to a greater or smaller extent, in the syllabuses of instruction. Some syllabuses in use in boys' and in girls' schools are comprehensive ; and in some cases the teaching is imparted by a head teacher or a permanent member of the staff having special qualifications, such as a B.Sc. degree or a diploma of the Institute of Hygiene. 7. Under existing conditions there is clearly a divergence between boys' and girls' schools in regard to the extent of instruction imparted in theoretical hygiene. The position seems to be that hygiene is regarded by head teachers generally as part of the science teaching, and the time customarily allocated to science in elementary schools seldom exceeds 60 minutes a week. Now, while in girls' schools nature study, simple physiology, hygiene, first-aid and mothercraft are regarded as an appropriate group of ' science ' subjects, and the science time distributed more or less equitably among them, the prevailing tendency in boys' schools is to devote the science time very largely to nature study in the lower classes and to simple chemistry and physics in the upper classes. It may so happen, therefore, in a boys' school where quite good work is being done in science, there is little teaching of theoretical hygiene in the upper standards. 8. If the Chief Medical Officer's view be accepted that the practical instruction directed to healthy habit formation already efficiently given in London schools is not enough, and that theoretical as well as practical instruction should be given in hygiene, the question arises as to how time is to be found for this, especially in boys' schools. Is the time devoted to science, including hygiene, to be increased, or is the hygiene teaching to be given in place of some of the everyday chemistry and physics now being taught ? The schools will require a lead in respect of this point. Although, in the Board of Education's suggestions to teachers, the science course for pupils of 11 years and upwards contains a section on the elementary study of the conditions for the healthy growth of plants and animals, no reference in the section where this is elaborated is made to human hygiene. The issue by the Board of Education of a special handbook of suggestions to teachers on the teaching of hygiene is referred to by the Chief Medical Officer, and will be awaited with interest. " 9. It should be remembered that infant care is a subject of instruction at the domestic economy centres where a good deal of practical hygiene teaching also takes place. This, however, serves to emphasise the disparity between the treatment of the subject for boys and for girls. " 10. The Board are to publish ' forthwith ' a special handbook of suggestions to teachers on the Teaching of Hygiene (Report of the Chief Medical Officer, Board of Education, p. 77 to 80). I am loth to advise the addition of Hygiene ' as a definite subject of the time-table every week ' without further information about the Board's suggestions, though I am of opinion that greater definiteness and probably a more generous allocation of time should be given to the subject of hygiene, especially in boys' schools. The most practical course will be to await the issue of the suggestions and then to confer with representative head teachers on the steps to be taken." Hygiene. Junior Red Cross Organisation in elementary schools, In a number of elementary schools Junior Red Cross " Links " have been established. The following reports upon three of these " Links " in an Infants' 15435 G 2 96 department and in two Girls' departments have been made by Dr. Ethel Timon, and upon a " Link " in a Boys' department, by Dr. C. W. J. Ingham. Dr. Timon's report on Junior Red Cross Organisation at three schools. " The Junior Red Cross is a branch of the British Red Cross Society. It was founded in Canada about 1919, has now expanded to a membership of ten million, and has ' Links ' in thirty-seven countries. Its aim is to promote the general wellbeing of the children by instilling into them from a very early age the elementary principles of personal cleanliness and hygiene. "(i) West Square Infants' School.—I visited this school on the 10th February, 1928. This ' Link ' was formed two years ago. As each child applies for admission, the parent is given a card called ' Health Laws ' and is told that she is expected to co-operate in their observance. This card contains seven elementary rules of hygiene: (1) Wash the hands before meals. (2) Brush the teeth and hair night and morning. (3) Breathe through your nose. (4) Windows open night and day (5) Play in the open air as much as you can. (6) Early to bed—10 hours'sleep— and early to rise. (7) Wash all over with soap and warm water as often as you can. " Each child before becoming a member has to qualify by passing the school nurse's ' cleanliness test,' i.e., (1) Each boy and girl must have his or her own tooth-brush and handkerchief. (2) Short clean nails. (3) Clean hands. (4) Perfectly clean hair. (5) Must not bite nails. (6) Must be clean and tidy generally. " When this standard is obtained and maintained for one month a badge is presented. These badges cost two pence, and are proudly worn by the members. A card containing the names of the members hangs up in the classroom. The class mistress examines the children twice daily and notes conditions of hands, nails, necks, knees, boots and shoes as to their cleanliness and inquiries whether teeth have been washed night and morning. Any child found wanting in these respects has his or her badge removed and a red dot placed on the enrolment card after his or her name. Every child must show a clean handkerchief each morning and afternoon. To ensure this handkerchief drill is taken each morning and nose breathing also promoted. When the children all assemble in the hall at 10 a.m., the head mistress has a general survey as to personal hygiene—there is a general handkerchief display and further breathing exercises and handkerchief drill. From the earliest moment the children are taught to breathe through their noses. First they are taught how to clear the nasal passages. The children are lined up and made to blow into handkerchiefs five times, and following that they do deep breathing exercises for five minutes. " In addition to the inspections carried out by the class mistress, the head mistress from time to time carries out a personal inspection. This consists of inspection of general personal cleanliness during the course of which she notes the general health. If a child is noted as looking tired inquiries follow as to that child's bed-time hour, whether windows are kept open at night, etc. If necessary parent is sent for and advised. This inspection is followed by further handkerchief display, any child without a suitable handkerchief is questioned and if the explanation is not satisfactory the badge is removed until the defect is righted, every day for a week. At the close of each year the secretary of the Junior Red Cross Section attends the school and presents certificates to the children who have obeyed the rules and not had their badges removed during that time. " In addition to personal cleanliness the head mistress sees that the general rules of hygiene are carried out as far as school life is concerned. School windows are kept open as much as practicable. Play in the open air is encouraged to its fullest extent. Posters are displayed around the school illustrating the advisability of fresh air, of brushing teeth, and of other principles of hygiene and health. " In addition to hygiene and health the Junior Red Cross has special mottoes— ' Help the sick,' ' Serve one another.' The children are encouraged to live up to these. For this purpose all members collect tin foil which is sent to the London 97 hospital- also they are expected to do ' one good deed a day.' As a result of these practices the children are taught from the moment they enter school by example of their school companions, and the efforts of the teachers to observe the rules and mottoes of the Junior Red Cross, and as an ultimate result of this they not only improve their bodily health, but also are made conscious of their social duties towards others. It is more than remarkable to note the rapidity with which this scheme has shown fruit. The head mistress reports that the medical and dental inspections show an increasingly high ratio, and what is more pleasing is the zest which these tiny children sh ow towards helping the sick and the eagerness with which ' tiny mites bring tightly clutched in their hot little hands' scraps of silver paper. I think this movement does an enormous amount of good not only towards building up a healthy body, but what is equally important a healthy mind. " (ii) Harper Street Girl's School.—I visited Harper Street Girl's School on the 13th February. This school formed a ' Link ' of the Junior Red Cross Section in November, 1927. As in West Square each child before being admitted as a member has to pass the nurse's ' Cleanliness Test.' They are then given the ' Health Laws ' cards and are told that they are expected to observe the maxims thereon. Badges are issued at the cost of two pence each to those who are willing to observe the conditions of membership. The badges are liable to summary removal without refund of purchase money should the holder through fault of her own fail to satisfy the conditions of membership or ' come to grief ' at the periodical examinations of personal hygiene made by the school nurse, but may be returned when the cause of removal has been remedied and the delinquent's personal condition is satisfactory for one month. In the future the head mistress hopes to have issued from the Junior Red Cross, certificates which will be given to all members who have observed the conditions for a complete year. " Inspections are carried out twice daily by class mistress, and each child has a special book tabulated thus :—Date/ Teeth/ Hair/ Neck/ Ears/ Hands/ Nails/ Boots/ Handkerchief/. This book is marked by the teacher at each inspection and the marks obtained for each section are tabulated at the end of the week. Those who present unsatisfactory totals are reported to the head mistress and are liable to lose their badges. Handkerchief display and breathing exercises are taken every day, arid nose breathing encouraged. In addition to individual inspection by classmistress, the head mistress from time to time summons the whole or part of the school to the hall and conducts a ' surprise ' inspection. This inspection consists of general examination of personal cleanliness, and handkerchief display. Any child who appears tired or flagging is noted and questioned as to bed time hours and parent sent for and advised. The importance of fresh air is fully stressed by means of ' talks.' Girls are advised to keep their windows always open as much as possible. Drill and games are in the open whenever it is possible. " In this school also the children are encouraged to observe the ' mottoes ' set up by the Junior Red Cross section. Tin foil is collected and sold and the money together with the proceeds of a ' farthing collection ' is being accumulated with the intention of eventually endowing a cot at Guy's hospital. The ' good deed' is also encouraged. In addition to these a third principle—' Lets be friendly with other Nations'—is promoted by means of posters, and also by correspondence and exchange of calendars with schools of foreign nations and the colonies—also links of the Junior Red Cross section. In this school the ' link' is only in its infancy, being barely three months in existence. The head mistress later on hopes to institute classes in health and hygiene. " (iii) Priory Grove School, Girls' Department.—I visited this school on the 14th February, 1928. This school became a ' link ' of the Junior Red Cross, two years ago. The preliminary conditions of membership are identical with the other two 98 I mentioned above, except that badges are not issued, but the names of the members are entered on a special card hung in each classroom. "Similar inspections are carried out by the nurse, class mistress and head mistress. Certificates of merit are given after one year's membership to the satisfactory candidates. In addition to the small 'Health Laws' card which is given in this and the other schools a larger card called 'Health Guide' is distributed. This card deals in much greater detail with the ordinary principles of health and explains the reasons why the 'Health Laws' should be obeyed. It deals with cleanliness, necessity of fresh air, need of sunlight, exercise, rest, prevention of infection, proper posture and general physical fitness of mind and body. Similar mottoes are observed though in a different way. Instead of collecting tin foil, each member contributes to a fund which is used to buy presents each Christmas for the children of the Belgrave Hospital—'Help the sick.' Correspondence is also carried on with members in Canada and America. Each member sent a personal gift to some individual member in a school in Canada this Christmas and received a personal reply. In addition, classes in health and hygiene, elementary nursing and first aid have been started, and are progressing very satisfactorily. Infant welfare and infant feeding are laid stress upon by the class mistress. "The head mistress is delighted with the scheme and is of opinion that the members show remarkable development, mentally and physically. In support of this, she informed me that the school medical and dental inspections show a marked physical improvement, and in addition the girls' department has obtained the remarkable score of twenty-one scholarships at the last examination. She says this is a record for her area. I was much impressed with the keenness which the girls showed in carrying out all the requirements of the membership, and especially with the willingness with which they subscribed towards helping the hospitals, and also I think the introduction of the knowledge of healthy living and home nursing will do a very great amount of good in the future. It will be a step towards the removal of the ignorance of elementary infant welfare, which is, unfortunately, only too apparent in some of the homes of to-day. This must, in its turn, lead to a healthier and sturdier infancy in the future generations and avoidance of many of the complaints due to wrong, or failure to provide, treatment, with the inevitable result of an uplifting of the national health." Dr. Ingham's report on Webb-street school (Boys) "On 19th January I visited the boys' department of Webb Street school in order to get a personal insight into the methods of hygiene teaching adopted by the head master. The head master himself is keenly interested in the subject of 'School hygiene,' and personally directs his method of instruction. His line of attack on this subject does not so much follow in the way of teaching hygiene, but rather in encouraging the ordinary simple rules of health and cleanliness, inspecting the boys frequently and regularly, and seeing that these rules are properly carried out. For the sum of 5s. per annum the school is affiliated to the Junior Red Cross Society, and the boys are expected to follow all the rules suggested by this body. As each new boy is admitted to the department he is presented with a 'Health Laws' card supplied by the Society, and told that he is expected to follow the instructions thereon, in addition to keeping his personal hygiene in satisfactory condition. In addition to this a decorated card, much the same as a 'Roll of Honour,' is hung in every classroom, and as each boy qualifies his name is added to the roll. "When the scheme first started small tin badges were issued to each boy as soon as his personal hygiene reached the required standard, but as the badges had to be purchased at the cost of 2d., and as numerous cases of 'lost, stolen or strayed' occurred, the novelty soon wore off and the demand became so small that the badges were dropped and the decorated roll substituted. In the near future the head master hopes to appoint a 'hygiene prefect' for each class. This prefect will be 99 expected to see to the hygiene arrangements of his class, such as issuing the 'Health laws' cards, attending to the roll, and seeing that hands and faces are washed when necessary. "The head master carries out inspections twice daily himself. These inspections are of a very informal but effective nature. The head master stands at the top of the stairs each morning and afternoon, and as the school assembles, each boy on entering has to file past him. Any individual presenting dirty hands, face, knees, unbrushed hair, dirty boots or any other condition giving him an untidy or dirty appearance, is noted and explanations asked. Should these prove satisfactory he is sent to 'clean up,' if not he is duly warned, and, if this does not suffice, nemesis follows in due course. An ample supply of soap is always available in the lavatories, and toilet paper is manufactured from the waste paper of the school, so that no excuse will be taken of an inability to securing means of washing. "Strict attention is paid to carriage and position in class, and thus any tendency to faulty posture, whether due to any physical defect or merely habit, is quickly noted, corrected, or if necessary, brought to the notice of the school doctor. The importance of obtaining as much fresh air as possible is fully stressed. Organised games are indulged in seriously, and talks on 'health and fresh air' have already been given twice by the medical officers of the borough. In addition to this, the boys are encouraged, by means of talks and practical suggestions, to get away, as much as possible, from the slums of Bermondsey by taking long walks, aided by 'bus rides, where finances permit, into the outskirts of London. It is quite an easy matter to take some lunch with them and by this means they get what is the nearest approach to a day in the country. "The results of these practices were not hard to find. On walking casually through the classes, my visit, of course, being entirely unsuspected, not a dirty face, hand or knee was to be seen, nor was there any sign of dirty or torn clothes or footgear. Heads were all neatly brushed back, and in face, it was hard to believe that I was still in a school, possibly in one of the dirtiest and poorest slums of London, on any ordinary school morning and had not been suddenly transplanted into one of the model schools on the outskirts on a prize day morning. "As is inevitable, following practices of this sort, the boys' physical condition is of a high standard. The results of medical inspection show a comparatively low percentage of defects found, while the percentage of treatment obtained is exceptionally high. Omitting the hopping period in September, the average percentage of attendance during the winter term was 92 per cent. This exceptionally high attendance shows that notwithstanding bad environment and bad food, observance and encouragement of hygiene and simple health maxims helps enormously to build up a healthy body with a high resistance to disease, and I think that if the lead given by Webb Street were followed by all other schools, the immediate result would be the turning out of a school child healthier and more robust and in every way more fitted to combat the onslaught of diseases which to-day are filling special schools and institutions, and with the ultimate inevitable result of a healthier and happier nation." 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; 163,694 parents took advantage of the invitation, an increase of 13,332. A remarkably large proportion attended the inspection of the infants at entrance to school, in numbers 68,538, or 88 per cent. Refusals to submit children to routine inspection are almost negligible. Teachers. Generally speaking, cordial support is given by the teachers to the school medical service. It is this support which makes the scope of the school medical 100 work so far-reaching, for the head teachers of school departments wield an influence which extends far beyond the boundaries of the school walls, and when this influence is exerted in enthusiastic furtherance of the school medical work, no bounds can be assigned to its success, as is seen in the story of medical following-up at St. James (B.) school, Thurland Road, Bermondsey, told in a previous section. Attendance Officers. The habit of school attendance is now thoroughly ingrained. The work of the school attendance department becomes yearly more and more a branch of general social service. In the annual "scheduling," when homes are systematically visited and a census of all children taken, the attendance officers note all abnormal children, and pay special attention to those under school age. In particular they make special enquiry for all crippled children, however young; lists of these are furnished to the school medical department and all such children are thereby brought under the notice of the appropriate agency for following-up. Children who are chronically absent from school are presented when necessary for medical examination. Expedited reports are made in cases of rheumatism, tuberculosis of bones and joints, poliomyelitis, etc., to ensure that they are considered in connection with the various schemes for residential treatment. Special officers in the attendance departments assist the school care committees in following-up difficult cases of general neglect or neglect to obtain medical treatment. During the prevalence of measles preferential visits are made to the homes of younger children absent from infants' departments with a view of ascertaining the existence of measles and thereby giving the local medical officers early information where otherwise it would be lacking. The attendance officers serve the statutory notices in all cases where it is necessary to proceed on account of verminous conditions, and they collect the sums due from the parents in respect of medical treatment carried out under the Council's scheme. Voluntary bodies. The National Society for the Prevention of Cruelty to Children, the Invalid Children's Aid Association, the Children's Country Holiday Fund, the Save the Children Fund, the Shaftesbury Society, The Junior Red Cross, the London Spectacles Association and innumerable other societies for social service in London are intimately associated with the work of the School Medical Service. The definite place in the scheme which the N.S.P.C.C. fills has been detailed in the Section on "Following-up." The I.C.A.A. undertakes the supervision of all crippled children, procures convalescence for ailing children, and this year has entered into still closer relationship with the service in relation to the treatment and supervision of rheumatic children. The work of other societies and associations has been mentioned in various earlier sections. Voluntary hospitals. The remarkable appreciation increasingly shown by the authorities of the great voluntary hospitals of the Council's organisation of social services is demonstrated by the eagerness with which many demand the allocation to their out-patient departments of the Council's organisers who serve as the links between the activities of the hospital physician and surgeons and the social service in the homes and schools carried out by the voluntary care committee workers. The remarkable results of this association and co-ordination of effort will be gathered from the following detailed reports. Report of L.C.C. work at Guy's hospital during 1927. The assistant organisers of children s care committees have been working during the year in the orthopaedic, aural, skin, and eye department of the hospital as formerly. This "following-up" work is in connection with the care committees of London's elementary schools, and its object is to try to ensure regular attendance of those children who come to hospital for treatment, to see that the doctors' instructions are as far as possible carried out, and to form a link between the hospital and the school doctors. The number of children attending in the orthopaedic department is much the same as last year—about 498 children are coming at regular intervals for supervision and treatment, and many of these are also referred for massage and remedial exercises, and attend in the massage department very well on the whole. In the aural 101 ment 2,122 new children attended. The number who underwent operations for removal of tonsils or adenoids in the out-patient department was 487, and of the total number of children attending 1,020 were discharged well, and 241 were reported well by the care committees. The number of school children who attended the diphtheria carrier clinic was 68 (total number of attendances, 446). In the skin department, 988 children attended— 54 of these were suffering from ringworm of the head, and 38 from scabies. In the eye department, 1,587 children attended. A certain number of these was treated for external eye diseases, but the total number tested for glasses was 1,258. Of these, glasses were ordered for 960, the vision of 138 was found not to require correction, and 160 were advised to continue wearing the same glasses. The number of glasses known to have been obtained during the year is 929; this of course, includes some which were ordered in 1926. Many reports on children attending in other departments of the hospital have been obtained through the almoner. These are for the information of the school doctors or care committees, and are invaluable. London Hospital Children's department. The remarkable extension during the year of the work by the formation of a children's department at the London Hospital working in close relationship with the school medical service, is described in the following paragraphs : Council elementary school children attending this consultative department are either referred through the receiving room, transferred from other departments, or they come direct with a special card issued by the school doctor at medical inspections. The number of appointments kept of those made under the special scheme has been high, but should there be failures the care committee is notified, and a further appointment offered. Very few of the cases definitely referred by the school doctor fail to attend subsequently. For all cases sent under the special scheme the organiser has a following-up card and this is presented to the treating doctor with the "folder" or case paper which each child has in addition to his ordinary hospital "book." Information with regard to income, number in family, etc., is obtained by the representative of the Marie Celeste Samaritan Society, who is present at each session. The "folder" is never seen by the patient or parent. Each patient is weighed on every attendance, the medical history, diagnosis and prognosis of each case is entered on the "folder" by the doctor. The examination of each new case occupies from twenty minutes to half-an-hour. It is usual for all Council school cases to be seen by Dr. Maitland-Jones or Dr. Tallerman, his first assistant. At subsequent visits the children may be seen by either of these or a clinical assistant. New cases attend on Tuesdays and Fridays, old cases on Wednesdays, but special cases are also occasionally seen on Tuesdays and Fridays. Old cases are graded to attend at intervals during Wednesday mornings and everything possible is done to suit the convenience of the parents in this matter. The organiser as far as possible is with the doctor during the examination of each school child, but if more than one of our children is being examined at the same time the doctor discusses the case later with the organiser and she always has access to the "folders." The following-up work of this department has grown rapidly. In addition to the routine notification to care committees of attendances, failures and discharges, a good deal of special action has been necessary on cases, and, with the co-operation of care committees, head teachers and class teachers, a great deal has been done, especially on the "conduct" cases, enuresis cases and where some modification of school curriculum has been advised. Transfers to other departments also entail a great deal of cross reporting to other organisers in the office. The session at hospital usually lasts from three to four hours and the organiser is fully occupied during this time talking either to doctor or parents. The examination in the children's department is most complete and includes test for albumen, Wassermann and Yon Pirquet. 102 The following is an analysis of cases dealt with from January to December, 1927 — No. of new cases referred by school doctors 252 No. of new cases referred by the receiving room 505 No. of cases discharged or lapsed 305 Queen's Hospital Outpatients department. Since an assistant organiser was appointed to work in the out-patients department of the Queen's Hospital for Children, Hackney Road, in September, 1924, two others have been added, so that at least one session is worked with each of the surgeons and physicians, with the exception of one who has recently changed his day. Six sessions are devoted to the casualty department. This newest venture in the casualty department, begun in September, 1927, is proving useful as a measure of increased co-operation between the casualty or out-patients department and the school treatment centres. The numbers of new patients attending in the out-patients department are not high compared with those at treatment centres owing to the fact that every case has already been dealt with in the casualty department or specially referred by the school care committees or by other medical authorities for specialist advice. Eight new school cases at a medical session is about the average, and between 35 and 40 old cases, but the current file in the case of one physician alone is 500, and each child is kept under observation and reported upon periodically to the care committees. Two or three new school orthopaedic cases may attend per session, but the discharges are even fewer, so the file continues to increase slowly. There are some 280 current orthopaedic cases. The current vision file, which includes external eye cases, numbers about 550. The total attendance for school children for the first four weeks of the term beginning January, 1928, is—new cases, 49; old cases, 120; making a total of 168. Thirty-six pairs of glasses were ordered, and during the same period 38 pairs, most of them of course ordered before this time, have been obtained. The aural department remains fairly stationary at about 250 cases, as there are practically as many discharges each week as there are new cases. In the other surgical departments and in the skin department the position is similar. The casualty numbers are from 6 to 25 new, and 20 to 60 old cases each session, and there are over 500 on the current file already. In the out-patients department the assistant organiser's work consists chiefly in following up the cases, keeping the honorary secrtaries of the care committees informed of new ones, the non-attendance of old ones and inviting their co-operation in getting them back for treatment. The reports on home conditions are frequently required by the doctors, particularly in cases where medical treatment fails to bring about the desired result. A large number of rheumatic children is dealt with, and it is necessary for the assistant organiser to impress upon the parents the importance of regular attendance even though the patient seems better. In the orthopaedic department, particularly the importance of regular attendance has to be pressed. The orthopaedic surgeon says gratefully that now "he never loses a case," and though this is not literally true, the action of the care committees and the friendly talks to parents at the hospital have resulted in much improved attendances. In the vision department it has been found a great boon to have a responsible officer to see that the children have the glasses ordered and to ensure the attendance of cases due to return in three to six months. Owing to the following up done in all departments attendances are much more regular and the treatment recommended by the specialists is thereby proving far more effectual. It should be mentioned how extremely courteous the surgeons and physicans have been since the L.C.C. scheme started, and they have expressed their appreciation of the work done from time to time. The care committees also find it extremely 103 useful to have reports on their special cases, and they have always been most kind in dealing with requests for reports from the hospital. In conclusion, comment should be made on the attitude of the parents. It is realised that they have come to regard the organisers as their friends to whom they may always appeal for advice about their troubles, or problems connected with their homes and children, and earnest endeavour is made to deal with their difficulties sympathetically. Middlesex Hospital. The arrangements for an assistant organiser to attend the aural sessions at the Middlesex Hospital was started in May, 1925, and figures are attached shewing the number of attendances made by children from Council elementary schools until the end of 1927. There was a slight increase in the work during the last year when the average number of new cases per session was 10.2 as against 9.2 in the previous years. Procedure at the hospital. The children attending the hospital can be divided into three groups: 1. Referred by private doctors with letters; 2. Attending with M.O., 49; as the result of medical inspections in school; 3. Brought by parents who suspect ear, nose or throat trouble. The last group has to be examined first in the ordinary out-patient department by the casualty surgical officer, who refers the children to the aural surgeon if necessary. There are usually four surgeons present at a session. A patient with a letter from a private doctor is seen by the honorary visiting surgeon, other new cases by the aural registrar. Old cases, unless specially told to see the honorary visiting surgeon, are seen by one of his assistants. The Council's organiser sees all patients in the waiting room and makes a record card for each child attending a Council school, as far as possible before the session starts. During the session she remains in the room and interviews each parent after the surgeon has examined the child. She notes the dates of all operations and arranges for the district nurses to visit the homes. In-patient treatment. A certain number of tonsil and adenoid cases is referred for admission on account of:—1. Bad home conditions; 2. The state of the child's general health; 3. Distance from home. Such cases are marked by the surgeon, A—urgent; B— fairly urgent, or C—can wait, according to urgency, and are sent for by the secretary as vacancies occur. There is, however, a long waiting list, therefore cases marked ' C" have to wait for several months. Patients remain in from one to six days, according to the nature of the case. Charge for treatment. All patients are registered by a member of the almoner's staff, who takes notes of their circumstances. A charge of 6d. per attendance is made where circumstances are favourable, but those who cannot afford this are admitted free. This charge covers medicine, etc., but not X-ray or operation. All operation cases see the almoner for assessment before leaving the hospital. A breathing exercise class is held at the hospital twice weekly. A certain number of children is referred to this class after an operation for the removal of tonsil and adenoids. Occasionally a child is sent who does not need an operation, but has acquired the habit of breathing wrongly. The parents are present, and are instructed how to supervise the exercises to be done at home. Twenty attendances complete the full course, but patients who lives at a distance are frequently asked to attend once only for instruction in the correct method of breathing. Reference to this class varies with the surgeon. The number of cases referred in the years 1925-6-7 was 30, 54 and 94 respectively. Endeavour is made to keep in touch with these cases, but it is difficult owing to the way the records are kept. On two occasions, Mr. Somerville-Hastings has asked for the attention of Dr. Sikes to be drawn to the way children were being taught to breathe in certain schools. In both cases Dr. Sikes visited the school himself and went into the matter with the head teacher. 104 A speech clinic has lately been started under the supervision of an expert in voice production. This is primarily intended for the benefit of adult patients who have had serious throat operations, but a Council elementary school boy was recently referred for stammering and is attending twice weekly. Although the numbers are not large there is a good deal to be done in connection with this hospital, and the work of the organiser is much heavier than it would be for an equivalent number of cases at a school treatment centre. The cases are followed up as after all aural sessions, but very few forms can be used, therefore the correspondence is heavy, and two whole mornings have to be given to attendance at the sessions. In six cases, Mr. Somerville-Hastings advised admission to an open-air school. These cases were referred to Dr. Sikes, who arranged for special examination. In four cases the recommendation was endorsed and the children have been admitted, three to St. Pancras open-air school and one to St. James' Park open-air class, the remaining two were found to be unsuitable for admission. No definite steps can be taken to increase the number of children attending, as it was made quite clear when the scheme started that no effort must be made to force up the attendances. It is, however, undoubtedly, of value to have a representative in the hospital, as otherwise the care committees would not receive reports of undoubted utility. The almoner and her staff are most friendly and consult the organiser from time to time about difficult cases attending other departments, and any special schools spectacle cases are passed on to her. Other hospitals. The children's care organisation also works in close co-operation with several of the other hospitals by correspondence between the almoners and the district organisers. At Great Ormond Street the cases dealt with comprise (1) rheumatic children attending the hospital, who have been followed-up by the care visitors and home reports submitted for the inspection of the treating physicians ; (2) children operated upon at the hospital for enlarged tonsils and adenoids upon whom home reports have been furnished to the hospital. These are classified into satisfactory and unsatisfactory home conditions, and the majority of the latter has been admitted to the wards. Similar work has been carried out in connection with the Royal Free Hospital, the Royal Northern Hospital, St. Bartholomew's Hospital, the City Road Chest Hospital, and St. Thomas' Hospital. Official bodies—The M.A.B. Very intimate associations exists between the work of the school medical service and that of the Metropolitan Asylums Board. In addition to the joint action taken in providing residential treatment for tuberculous children and those suffering from poliomyelitis, the M.A.B. puts at the disposal of the Council's school medical service numbers of beds at Swanley for children suffering from ophthalmia of certain kinds, including blepharitis, corneal ulceration, trachoma and interstitial keratitis, and at the Downs hospital for mastoid operations upon intractable ear conditions, while at Highwood and Queen Mary's hospital, Carshalton, over a hundred beds are now available for rheumatic children and ample provision is in preparation. Notifications are made to the school medical officer of children discharged from the Board's fever hospitals who have suffered from otorrhœa so that they may be kept under observation. Infant Welfare Centres. In a number of instances the work of school medical treatment is carried on in the same premises as that of the infant welfare centres. London Federation of Infant Welfare Centres. An Infant Welfare transfer card was adopted as a result of a conference with the London Federation of Infant Welfare Centres in 1920. This card is being used by some 40 centres in London and has been adopted by the borough councils of St. Pancras, Finsbury, Shoreditch, Stepney, Bermondsey, Camberwell, Greenwich and Stoke Newington—Shoreditch alone using some 3,000 cards a year. Tuberculosis Dispensaries. The scheme for mutual interchange of information and transfer of child patients between the school medical service and the local tuberculosis dispensaries continues 105 to function in a satisfactory way. Dr. Chaikin in the eastern division gives the following account of this side of the work:— "When tuberculosis dispensaries in London came into being a degree of contact was established between them and the school medical service. Children were sent to these institutions for an opinion and it became possible to obtain reports. Cooperation developed subsequently when the tuberculosis officers nominated for observation to the divisional medical officers "unsatisfactory" children, so called because either their past medical history or their physical state at the time, not necessarily definitely tubercular, rendered them unsatisfactory, and called for periodical special supervision. It was considered that these children could, conveniently, be examined by the school doctors and by their withdrawal temporarily from the dispensaries relieve the tuberculosis officers for other duties. At this stage contacts were not included. The time came when, with the growth of co-operation between the London County Council and the borough councils, it was arranged that children of school age who were contacts with sufferers should be reported to the divisional medical officers by the tuberculosis officers for observation, and, in doing so they were requested to state on the form M.O. 333 whether they were "satisfactory" or "unsatisfactory." An important feature of the scheme was that it embraced children contacts who had failed to attend the dispensaries for examination. From 1923 it has been the rule that the children nominated should be weighed periodically and re-examined by the school doctors at intervals of six months, in unsatisfactory cases, and nine months in "satisfactory" cases, and to be reported back to the tuberculosis officers when further observation appeared unnecessary. In the light of further experience the scheme was somewhat modified subsequently, in respect of "satisfactory" contacts, by the examination of selected children only, such as, where the original case might be infectious and where the home conditions are unsatisfactory or where medical treatment is indicated. There are five tuberculosis dispensaries in this division. Three of these are in Stepney, one in Bethnal Green, and one in Poplar. 3,809 children were reported contacts for observation by the tuberculosis officers during the five years: 1,138 in 1923; 950 in 1924; 726 in 1925; 445 in 1926; and 410 in 1927, up to November 18th. The high figure in 1923 included children from previous years, and the numbers in 1926 and 1927 show a decline of nearly 50 per cent, in comparison with 1924. This is due to a decrease in the number nominated from the Whitechapel and Poplar dispensaries. The following table of notified cases of tuberculosis of all ages in the respective boroughs can be given here:— Tuberculosis (all forms). Cases Notified, 1923-1927. 1923. 1924. 1925. 1926. 1927. Bethnal Green 323 254 243 211 151—3 quarters. Poplar 405 358 346 365 247—3 quarters. Stepney 594 590 605 531 288—2 quarters. In all three boroughs the numbers notified in 1926 are less than in 1923. The difference is most marked in Bethnal Green. The number of contacts reported to the school medical service for observation cannot be said to have a direct ratio to the number of notified cases, as the tuberculosis officers may retain some of them for observation and the number of children in families varies. "Unsatisfactory" children, contacts or not, numbered 917, and there were 2,416 "satisfactory contacts." 476 children, whose parents refused to bring them to the dispensaries, were reported, and, with few exceptions, examined by the school doctors. Every case on notification by the tuberculosis officer has been reported to the care organisation with a view to any required action being taken. 106 The period of observation, reckoned from the date of the first to the date of the last examination by the assistant medical officers, varied according to necessity from one to three, or even more years, and in every instance, where observation has been completed, the form M.0.333 has been returned to the tuberculosis officer, so that a re-nomination could be made. An analysis of 500 cases in respect of the period of observation shows the following:— Years. -1 1 - 2 2 -3 3 -4 4 Died. Refused examination. Number 381 34 63 6 5 0 1 0 1 9 Percentage 76.2 6.5 12.6 1.2 1.0 — 0.2 — 0.2 1.8 Open-air Education. The provision for Open-air Education during the past year included six day open-air schools for non-tuberculous children, accommodation, 1,200; seven-day open-air schools for tuberculous children, accommodation, 540; five country or seaside convalescent camp schools, accommodating 484 children for short periods, providing for about 4,700 children annually; and 151 open-air classes in parks or playgrounds in connection with ordinary elementary schools, providing for about 4,000 children. Day open-air schools. The five established open-air schools for non-tuberculous children at Aspen House (Brixton), Brent Knoll (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. In addition, the school at Holly Court (Hampstead), with accommodation for 130 children, was opened on 18th July, 1927. This school occupies an ideal site, overlooking the Heath, and placed under the direction of Mr. Williamson, transferred from Bow Road, has made a most auspicious beginning. Preparations are in hand for the establishment of three further open-air schools at Upton House (Hackney), at Du Cane Road (Hammersmith), and on the new housing estate at Downham (Lewisham). Aspen House open-air school. Aspen House was opened on the 23rd November, 1925. The head master, Mr. I.G. Jones, in his report to the Managing Committee in November, 1927, gives the following account of the activities followed in the open-air and the general medical arangements:— "In a new school of a type such as ours splendid opportunities are afforded for manual work, and it has been our aim in woodwork to employ boys in the making of articles necessary for the conveniences of the children and for improving the equipment of the school. Although our classrooms are open-sided shelters which cannot be closed, yet it is much pleasanter to work in the open-air without a roof overhead whenever possible. We were thus faced with the necessity for 'stands' for open-air class sites and for providing raised paths in wet weather. Eighty large duckboards or wooden slats were made; measured and cut by the bigger boys and nailed together by the smaller ones. Frames were made for iron scrapers, and these were found invaluable in the early months of the school's existence. Coat-racks, toothbrush racks, soap boxes, carrier boxes with handles for gardening purposes (usable instead of wheelbarrows and much more serviceable), provided opportunities for the initiative of the boys, for the use of an assortment of tools and for learning to make simple joints. In addition, the boys realised that they were partaking in efforts toward the improvement of their school. Later, work which required more skill and accuracy, was attempted, and among the tasks undertaken was the making of clog stands, a bird table, a sunshine recorder and stand, moulds for concrete work, a sundial, and bathroom equipment." 107 Dr. J. G. Duncan reports:—"The school which was opened in November, 1925, has now completed its second year. During the first year it was frequently difficult to persuade parents to allow their children to attend the open-air school, more especially if they lived some distance away. The prejudice has now almost entirely disappeared. In fact, many of the parents have applied for admission for their children, and there are several instances of two members of the same family being in attendance. The children themselves enjoy the life thoroughly and seldom wish to return to the ordinary school. "The weather conditions, unfortunately, have not been favourable during the year. There were 152 fine days and 74 wet days. It was possible for the children to rest outside on 143 days. Visits were paid to the school for medical inspection every fortnight, and every child was examined once a term. In the case of the more delicate children, examinations were made more frequently. "In 1927 there were 199 children in attendance. Of these 65 were admitted during 1927 and the remainder were those who had been in the school from 1925 or 1926. 51 children left during the year. The reasons for leaving school were—over age, 19 ; elementary school, 25; left (left district, parents' request, etc.), 7. The number remaining was 148. The average length of stay was twenty months. Children remaining in attendance (148). Children who left during 1927 (51). Much improved. Improved. No change. Total. Fit. Much improved. No change. Total. Anaemia and glands 5 6 2 13 — — — — Anæmia 49 24 6 79 24 4 3 31 Enlarged glands 5 2 1 8 6 — 28 Debility and malnutrition 10 9 6 25 — — — — Fibrosis 5 2 1 8 — 2 — 2 Bronchiectasis 1 1 — 2 — — — — Suspected phthisis 3 2 — 5 2 1 — 3 Old pleurisy 1 — — 1 — — — — Pneumonia and empyema 1 — — 1 — — — — Asthma 2 1 — 3 — 1 — 1 Tubercular contact 1 1 — 2 — — — — Tubercular bone (quiescent) 1 — — 1 — — — — Tubercular peritonitis (quiescent) — — — — 1 — — 1 Tubercular hip (quiescent) — — — 2 — — 2 Malnutrition — — — 2 — — 2 Nephritis after diphtheria — — — — ] — — 1 Totals 84 48 16 148 38 8 5 51 "Many of the children made remarkable progress during the time they were in attendance, and notes on one or two examples are given here. Boys—(1) G.E. was admitted suffering from marked anæmia and enlarged glands. His father had been in a sanatorium with phthisis, and two brothers were in attendance at P.D. schools suffering from healed tubercular disease of joints. In two years he had gained 14'4 kgs. and was in excellent health. (2) J.S. before admission had been at Margate for a year suffering from tubercular peritonitis. In ten months he had gained 8.2 kgs. and there were no signs of disease. His general condition was very good. Girls—(1) D.J., five children in the family had died of tuberculosis and this girl had been under observation at the tuberculosis dispensary for suspected phthisis. In two years she had gained 10 kgs. and was in excellent health. (2) M.D. was under treatment for suspected phthisis. For the first ten months she gained very little weight but during the following year she gained 7 kgs. Her general health was good and there were no signs in the lungs. 108 There was a family history of tuberculosis ascertained in 42 cases and 25 children had themselves either been in a sanatorium or had been under observation at the tuberculosis dispensary. The children were weighed once a month and their heights were taken once in three months. They are weighed wearing one garment only, and in this way it is possible to get accurate weights throughout the year. Average gain in weight : boys 4.1 kgs., girls 4.495 kgs. It is worthy of note that many of the children have lost weight during the Christmas and Summer holidays, but in all cases have soon made this up when they returned to school. It is also noticed that children who are irregular at school for reasons other than illness invariably lose weight. In wet weather the children bring dry stockings with them and are provided with school clogs. Their stockings and wet garments are dried in the special drying room. There are now facilities for regular bathing and each child is bathed once a week. The children look forward to their baths and thoroughly enjoy them. During the very cold weather at the end of the year it was thought advisable to discontinue them, much to the disappointment of the children. These regular baths are of great value in training the children in a cleanly and hygienic way of life. " The dietary is liberal and of excellent quality and the menus are varied. Each child is now having a pint of milk daily, and the more delicate ones are allowed an extra half pint. Butter and fresh-vegetables are given and fresh fruit is allowed at least three times a week. During the autumn the children fared exceedingly well in this respect as there was a splendid crop of apples and pears in the garden. There were no cases of chilblains during the year. The incidence of infectious disease was less than in the elementary schools and the common " cold " caused very little absence. "The cases which do very well are all cases of anaemia and enlarged glands, healed tubercular peritonitis, asthma uncomplicated by bronchitis, and fibrosis of the lungs. The children who showed nervous symptoms, e.g., marked restlessness and inattention, feverish attacks, night terrors, all did well with one exception, and in this case the home was at fault. The cases which do not make satisfactory progress are cases of bronchitis, asthma complicated by bronchitis, and children who show a rheumatic tendency. "There is still difficulty in getting parents to allow the children to remain after they reach the age of 14. In some cases this is very desirable if the improvement is to be maintained. The nights spent at home in bad housing conditions nullify in large measure the good which has been done during the day. Many of the children come from very poor neighbourhoods and several members of the family sleep in one room, more often than not with the windows shut. Late bed-time is another difficulty, and it is even difficult to get some of the careful mothers to see the necessity for early bed-time. At the admission examinations the parents are instructed re clothing, diet and bed-time and every effort is made to get treatment for defects (e.g., carious teeth, tonsils, etc.) completed before admission. It is desired to try the experiment of a sunshine class for the coming summer. Negotiations are still proceeding for acquiring the adjoining land, and this would prove a suitable site for such a class. Hitherto this additional benefit has been unattainable owing to the lack of playground accommodation. Physical exercises and practical and manual occupations are carried out in the open-air. The results from an educational point of view are also satisfactory. The children showed a considerable improvement in attention and mental alertness." Brent Knoll open-air school. The tenure of Birley House having terminated the school was transferred to Brent Knoll, Forest Hill, on 26th April, 1927. Dr. C. E. Thornton, in his report, states that the average number on the roll was 137, and the average percentage attendance 80. Infectious disease, as usual at open-air schools, caused very little 109 trouble, only 11 cases being reported, viz., mumps, 5; varicella, 2; scarlatina, 1; measles, 2; ringworm, 1. Amongst 129 children examined only 64 had definite physical signs of ill-health, viz., debility, anaemia, cardiectasis, 41; neurosis, 5; bronchial and pulmonary catarrh, 15; enlarged glands, 3. Regarding the number of children who presented no physical signs of illness, Dr. Thornton discusses the question whether the best use is made of the school. He points out the disinclination to admit children under 10 years of age and generally to admit children with defects which will lead to some irregularity of attendance, and draws attention to the clash of medical and scholastic views of the desirable candidates for admission. Further, he comments on the difficulty which must be experienced in refusing admission to apparently healthy children who have returned from convalescence or belong to tuberculous families, submitted by hospitals and tuberculosis dispensaries. Stowey House openair school. At Stowey House Open-Air School there are in attendance 170 boys and 100 girls. 75 boys left at Easter, all but three being fit. Of the 95 remaining, one had attended for four years, seven for three years, 34 for two years and 53 for one year. Of the 100 girls 52 were first-year, 20 second-year, 18 third-year and 10 fourth-year pupils. Comparing boys and girls it was noted by Dr. Slowan that girls appear to have done better than boys, 93 per cent. showing improvement as against 76 per cent. of boys. Generally satisfactory increases in physical measurements were noted throughout the age groups at the school. One girl is mentioned who made the phenomenal gain of 12 kgs. (26½ lbs.) in the year ; she was 11 years of age and suffered from fibrosis of the left lung. Convalescent camp schooJs. The arrangements for country holidays for debilitated children nominated by the school doctors comprise:— (1) The King's Canadian Camp School at Bushy Park with places for 300 boys. (2) The Wanstead House School at Margate for 60 girls. (3) The Barham House School at St. Leonards for 64 girls. (4) An arrangement with the Shaftesbury Society to take 30 girls at the Russell-Cotes Home, Parkstone. (5) An arrangement with the "Save the Children Fund" authorities by which the London School Organisation sends girls to Fairfield House, Broadstairs, with places for 50 girls. These institutions receive 3,000 boys and 1,580 girls annually, and the children without any break in their education are enabled to get the benefit of a country or seaside change which is so desirable. Bushy Park. The period of stay at Bushy Park was extended during the year to six weeks (instead of one month) for all boys during the winter months. Dr. Lee reports only one case of infectious disease during the year—which is very remarkable amongst so many as 3,000 boys who are constantly changing. The boys are very happy and once they get over the pangs of home sickness enter into the life and games of the school with great delight. The work done by the master responsible for physical exercises is excellent, and with boys interested in their own physical development very fine results are obtained in spite of the shortness of the stay. Wanstead House. Dr. McCombe states: "I am pleased to report again that this school has once more justified its existence. The famous Margate air, combined with adequate rest, a plentiful supply of suitable well-cooked food, and careful supervision together have worked wonders for the children who have passed through the school. 538 children were admitted between January and December, 1927, of these only 13 were confined to bed, and were as follows: One case chicken pox, noted second day after arrival, isolated 3 weeks; one case scarlet fever, diagnosed 5 days after arrival, sent immediately to Haine Isolation Hospital, Kent; eight children in bed over two days with colds; one case eczematous impetigo on admission; one child abscess 15435 H 110 on chin ; one child was in bed for 3 days and was operated on for appendix abscess after returning home. "The average gain in weight was 2.2 kgs., the highest gain being 6 kgs. One child lost a few ounces." Barham House. The head mistress of Barham House has paid great attention to the improving of the physique of the children. In 1924 the weight increase was an average of 1 lb. 10 ozs. a month, in 1926 it was 2 lbs. 5 ozs.; but between October, 1926, and November, 1927, the average was 4 lbs. 3 ozs. The great improvement in this respect dates from the moment when cod liver oil was administered as a routine measure to all the children, the dietary and regime in these respects having remained unaltered. Many delightful letters are received from the parents and the children after their return to London. Dr. F. C. Lewis reports on this institution as follows: "During the year, 511 children (all girls with the exception of one batch of 64 boys from Hamond-square in June) were sent to the school. These children, with the exception of four batches of 32 from schools in other divisions, came from the Shoreditch schools and stayed for four weeks at Barham House. Even during the winter months, when the facilities of the camp school for out-door work and play are very limited, the children came back noticeably improved in colour, energy, and general health. In most instances, too, there was a gain in weight. "After a good deal of controversy, permission was obtained for the girls to have 'sun-bathing' in a specially designed costume whilst at St. Leonards, and whilst the weather was such that very little opportunity offered, in August and September the girls were taken out into the garden and given 20 minutes in the full sun. (Parental consent was first obtained, but this was only withheld in 3 cases and in each of these cases the children were very sorry it had been.) The girls from St. John's-road—who were the first to be allowed 'sun-baths' at Barham House—put on an average of 2½ lbs in the month, exceeding the average of all previous batches. It is hoped to extend this experiment in 1928 for the provision of an open-air class room should render possible a more extended period of sun-bathing. "No ill effects were experienced, but the local medical officer was exceedingly cautious over the experiment, keeping the children moving during the exposure. To get the full effect of sun exposure, I think it essential for the patient to be stationary. It is hoped this year to get a more complete set of observations made, with a colour test on selected cases." Fairfield House, Broadstairs. The children at Fairfield House stay as a routine for three months. The girls who were admitted in January, 1927, have been followed up by the school care committees after their return with the following results:— School. Reason for admission. Weight. Care Committee Report. Going. Returning. Essendine Road (G.). Ivy L. (14) Nutrition 3. Delicate girl. Under observation at tuberculosis dispensary. Has occasional enlarged cervical glands. St. lbs. st lbs. Mother satisfied on Ivy's return. Girl has steadily improved. Her hair has completely grown again. Now at work, earning 10s. a week, apprenticed to firm of mackintosh makers. Very grateful for benefit derived from Fairfield House. 5 5 5 12.3 Sirdar Road (G.). Louise R. (14). Nutrition 2. Enlarged thyroid scoliosis, anæmia, debility. 6 13½ 7 10.3 Returned greatly improved. Unfortunately soon after starting work was sent on a message and lost her way. Wandered for ten hours, returned exhausted, and was in bed for a fortnight. Lost a lot of weight, but is now better. Sleeps and eats well, but is very nervous. 111 [$###]School. Reason for admission. Weight. Care Committee Report. Going. Returning. St. Thomas R.C., Fulham. Alice B. Nutrition 3. Pale. st. lbs. st. lbs. Has improved wonderfully by her stay at Broadstairs and has grown a good deal. Her appetite is good and she sleeps well. 5 6½ 5 10.11 The Marlborough Chelsea. Violet S. (-.5.13). Nutrition poor. Anaemic, some glandular enlargement. Has been to Hayling Island, but retrogressed since return. 5 10½ 6 10.13 Returned greatly improved in health. Report in April was "very much improved, has gained 14 lbs.," and this improvement has been fairly well maintained. Her teacher finds her brighter and more alert than before she went away and altogether she is in better health than she has been for a long time. Hettie W. (-.7.15). Nutrition poor. Anæmic, bad colour; very run down. 4 5¼ 5 210 Showed very little improvement on her return. Dr. Russell reported still very anaemic—continue milk. She is now under treatment for rheumatism. Home conditions fair; father in regular work. Nellie H. (-.9.13). Nutrition poor. Debility and anaemia. Pre-tubercular. Just returned from Bournemouth. Medical Officer's report there, "result disappointing." 3 13½ 4 4.8 Benefited very much by her stay. Report at medical inspection in April was "very much improved." Mother states improvement on the whole has been maintained. Gladys C. (-.10.16). Nutrition poor. Anaemic and lifeless. Has had enlarged glands. Heart slight dilatation, no strenuous games. 4 0½ 4 6 Benefited greatly. Dr. Russell pleased with her on her return and allowed her to resume games and drill. Improvement maintained and child now in good health. K ingwood Road, Fulham. Phyllis L. (13.5.16). Nutrition 3. Enlarged submaxillary glands. Debility and anæmia. 3 3 12.3 On return her improvement was remarkable, but it was not maintained. She had a bright colour and looked brighter, but she is now pale and round shouldered. Worries a good deal about lessons and before school examination is nervous and sick. Said to sleep well. St. Francis B.C., Kensington. Louise W. Nutrition 2. Nervous. 7 1½ 7 11.13 Quite a different girl since her return. Instead of being nervous, thin and pale, she is now robust, perfectly composed, happy and contented. I see her every evening in our club and cannot believe she is the same child. Addison Gardens. Rose P. Nutrition 2. Nervousness. Talks in sleep. Very thin. 5 2½ 5 11.5 Very much better for her stay. School doctor saw her in May and considered her condition satisfactory. Head teacher reports that her work this term has been good and that she is bright and keen about her lessons. Mother is pleased. Occasionally Rose has a bad night, but this is the exception and on the whole she is very well. 15435 H 2 112 [$###]School. Reason for admission. Weight. Care Committer Report. Going. Returning. Amberley Road. Ada W. Nutrition 3. Pallor. Scoliosis. Very poor condition. Is in remedial exercises class and has milk in school. Rt. conjunctivitis (needs treatment). st. lbs. 8t. lbs. As regards her work she always has been keen and alert, but she seems to have gone back a little, probably due to different teaching for three months. As regards health, there is no marked improvement. Very thin and pale. Some days better than others. Sleeps and eats well. Probably three months was not long enough to make an impression on her health. 3 7½ 3 11.15 St. James the Less. Sadie C. Nutrition 3. Subject to chest colds frequently. Debility; suitable for three months' stay. 3 2½ 3 5.14 Returned home much better. Appetite good. Mentally no change, but teacher and mother think she is rather brighter. St. Mary Magdalene's, Paddington. Jane P. Nutrition 3. Pale; undersized; backward. 5 6 5 13.11 Jane looks very well and mother is very satisfied. The girl eats and sleeps well and is putting on weight. She is quite bright. Further report.—It is really wonful how she has improved. Senior Street School. May C. Nutrition 3. Under observation at tuberculosis dispensary. Very poor condition. 5 11 6 8.1 A marked improvement in both children. The head teacher of the school speaks highly of the change in them, both physically and mentally. The mothers were also delighted, though Mrs. M. Maud M. Nutrition 3. Very poor general condition. 4 7¾ 5 3.8 regretted that Maud had not quite kept up her bonny appearance on return to the basement in which they live. It would seem that it was thoroughly worth while in both cases. St. Paul's, Paddington, S. Maisie S. Nutrition 2. Pallor; growing fast; badly needs sea air. 5 4½ 6 2.4 Maisie is now working at Whiteley's learning dressmaking. She is much better and stronger since her stay at Broadstairs. The mother is very thankful for all that was done. Our Lady of Dolours, Paddington, N. Kathleen T. Nutrition 2. Pale; tired looking; has had prolonged otorrhea and recurrent styes. Three months' stay advisable. 5 10¼ 6 3.14 The head teachers says that Kitty seems to have benefited very much, looking stronger, fatter, and appearing to have more vitality. The mother says Kitty is very well, that she eats and sleeps satisfactorily, and has no more trouble with her ears, and altogether is keeping very fit at present. Open-air classes. Good work continues to be done in open-air classes attached to the ordinary schools. Some of these classes held in parks resemble very closely open-air schools on a small scale. The number of such classes held during 1927 was 151. Of these 12 were of Type A (for debilitated children contributed by several schools), 35 of Type B (for debilitated children from one school only), 50 of Type C (consisting of an ordinary class of an elementary school meeting constantly in the open air) and 54 of Type D (consisting of an open-air station used in rotation by all or several of the ordinary classes of an elementary school). 113 Reports on 33 open-air classes were sent in by the visiting medical officers, out of which the following report by Dr. Miriam Lawson on a contributory (Type A) class held in Clissold Park is selected as an example giving an account of a successful undertaking in open-air work. Report on Clissold Park Open-air class. An open-air class was held in Clissold Park from May to October, 1927. It was disbanded at the end of September owing to the bad weather conditions. The class consisted of 39 children of varying ages from 9 to 13, drawn from seven schools comprising 21 boys and 18 girls. The place chosen is one of London's most beautiful parks, and it is eminently suitable for such a purpose. It is large, quiet in the daytime and not too sheltered by trees, while for the children, the wallabies' pen and the artificial waters are a never failing attraction. The bandstand in which the classes are held is not without its disadvantages, but with improved screening would be satisfactory even in such a bad summer as that of 1927. It is well raised off the ground, but in bad weather the wind and rain blow through the gap which exists between the roof and the top of the canvas curtains. Beds were provided and blankets were obtained, so that the children could rest daily. Two of the three essentials, rest, fresh air, and good food, were thus obtained, and after the first visit milk was obtained for each child daily, thus taking a step in the direction of the third essential. Some dinners were also obtained. Games and physical exercises were organised in the park. The majority of those attending suffered from general debility (22). Other types were as follows in order of numbers : anaemia (6), bronchitis (5), asthma (3), otorrhœa (1), T.B. gland (1), T.B. peritonitis (1) and morbus cordis (1). The class was medically inspected in May, in July, and twice in September. Inspections were carried out in a room provided by arrangement with the management of the refreshment rooms. The height, weight and chest expansion were measured before each inspection. The average gain in weight for the whole class was l.4kgs., and the gain in height 3.1 cms. For boys the average was weight 1.2 kgs.; height 3.7 cms. For girls the average was weight 1.6 kgs., height 2.3 cms. Average increase in chest expansion, whole class 2 cms., girls 2.3 cms.; boys 1.84 cms. From this it may be seen that girls increase in weight more than boys. This may be accounted for by the fact that the average physique or standard of health in this class was better in the case of girls than in that of the boys, and increase of weight is, therefore, more rapid in cases which are better equipped. This is borne out also by the results of cases with serious physical debility, e.g., asthma. Of three cases one lost weight (1 kg.), one remained stationary, one gained 1 kg The following table gives some idea of progress made:— A. Definite improvement. B. Slight improvement. C. No improvement. 0/ /o 0/ /o 0/ /o Girls 75 25 0 Boys 57.1 23.8 19.1 Taking the types of defect the following results are obtained:- A. B. C. A. B. C. Anæmia and debility (27) 17 8 2 Otorrhœa (1) 1 — — Bronchitis (5) 5 — — Morbus cordis (1) — — 1 Asthma (3) 0 2 1 T.B. peritonitis (1) 1 — — T.B.C. gland (1) 1 — — In spite of the decidedly adverse weather conditions, this class has done more than justify its existence. The children were physically much below the average at the commencement, and the improvement in intelligence and alertness was as noticeable as the improvement in physical condition. There was a very good tone about this class, and a sense of enjoyment and keenness which was very creditable to the teacher. 114 It would seem that asthmatics do not benefit to any great extent, and it was found that any children with a tendency to rheumatic pains developed such pains with any bad weather. Bronchitis cases, anaemias and the " town child " did very well. The question of attendance of children of rheumatic tendency at open-air classes and their fitness for open-air life is one frequently raised. The more experienced medical officers instinctively exclude such children. Dr. Lawson refers to recurrence of pains from time to time in such children under open-air conditions. References to rheumatic children in other reports bear this out:— "Rheumatic cases show no improvement either in nutrition or of their symptoms." Dr. Dorothy Mcintosh, Mantle Road (Girls) Open-Air Class. "One boy has had a slight return of chronic rheumatism." Dr. E. Johnson, the Latchmere (Boys) Open-Air Class. "Five rheumatic children show improvement in their general condition, but continue to have rheumatic pains at times." Dr. K. F. Butterfield, Athelney Street (Girls) Open-Air Class. "The child has developed tonsilitis (probably rheumatic) and I have recommended her withdrawal." Dr. W. J. Morrish, the Furzedown (Girls) Open-Air Class. On the whole, London experience suggests the inadvisability of including rheumatic children amongst other delicate children undergoing open-air treatment. They do not improve in the remarkable way that children do who are tuberculous in tendency or who are anaemic and debilitated without rheumatic symptoms. Open-air schools for tuberculous children. In addition to the provision for treatment of tuberculous children in residential institutions, the Council continued the use of the 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. After the summer recess an additional school, Geere House, at Stepney Green, accommodating fifty children was opened, making a total of six open-air schools. Arrangements were also completed before the end of the year for the opening in January, 1928, of a new school at Fort Road, Bermondsey, with accommodation for 125 children. Admission to the schools is granted on a certificate of a medical officer of the Council, and preference is given to children returning home after a period of treatment in a sanatorium. To such children the opportunity of remaining under regular medical supervision and of enjoying the advantages of open-air life has proved of considerable value. Children who are not considered to be in need of residential treatment, although tuberculous, have also derived benefit from their attendance at these schools. The six schools:—Grove Hill Road (Camberwell), Elizabethan (Fulham), Geere House (Stepney), Kensal House (Paddington), Springwell House (Battersea), Stormont House (Hackney), have together accommodation for 415 children. The number on the roll on 31st December, 1927, was 464, and the average attendance for the year ending 31st March, 1927, was 342. Excluding Geere House Open-Air School, for which the figures are availabie for one term only, 154 children were admitted to the five other schools during 1927, whilst 163 were discharged. Of the latter, 26 were transferred as fit for elementary schools, 66 were fit for work, 35 were transferred to institutions for residential treatment for tuberculosis or admitted to hospitals for various reasons, 25 moved away, 6 were transferred to special schools and 5 were discharged for other reasons. In 1925 vocational classes were started at Springwell House and Stormont House Open-Air Schools with the object of providing training likely to be of service to the children in obtaining employment. At Springwell House School two classes are in operation, one for boys and girls in commercial training which includes shorthand and typewriting and general office routine, and the other for girls in millinery and lingerie. From the commencement of the classes in November, 1925, up to the 115 end of the year 1927, ten boys and seven girls had obtained certificates of proficiency in shorthand, and one boy and one girl certificates in typewriting. The vocational class at Stormont House School is in needlework. Instruction is also given in gardening and carpentry, but these do not rank as vocational subjects. There is now definite evidence that the vocational classes are instrumental in helping pupils to obtain situations in occupations in which they have received training. It is reported that five boys and five girls went straight into offices from Springwell House School, and enquiries indicate that all are doing well. Nine girls entered the needlework trade from this school and five from Stormont House School. With regard to the gardening classes, a full-time instructor is employed at Springwell House School. The reports received from the medical officer of the school indicate that while the training given is of value educationally, there is the greatest difficulty in making use of it as a means of livelihood in London. The following extract from a report by the medical officer of the Stormont House School is of interest:— "My attention has been drawn to the marked improvement in the children after a short period at the school, more particularly to their obviously happier mental state, but also in a lesser degree to the improvement in their general health. I could not convince myself that this was entirely due to the change of environment, and I therefore interviewed the parents in a number of cases in order to obtain their views on the subject. " As you are aware, the type of child we get at Stormont House is usually rather backward from an educational standpoint compared with the average child of his own age in the elementary school, due to enforced absence from school through sickness. In the elementary school he is probably at the bottom of the class, with the result that a sensitive child develops a sense of inferiority, becomes miserable and unhappy, and his general health suffers in consequence. He soon begins to dislike school and stays away on the slightest pretext, with the result that he still further loses ground and a sort of vicious circle is set up. At Stormont House a child meets others in the same backward state as himself, and so less attention is drawn to him in this respect. He soon begins to regain confidence in himself, the result being that he is happy and contented and his general health improves accordingly." Holidays of children it the country and seaside. A census taken by the education officer gave the number of children in boys' and girls' departments of elementary schools who were taken to the country or seaside during the year. With the exception of those who went with their parents or relations, the medical department was concerned with each group in various ways. Return of pupils (other than infants) attending Elementary (excluding Special Schools) who, in 1926, spent a holiday away from London. Agency promoting the holiday. No. of pupils who spent holiday away from London. Total of columns (2)—(4). Number of pupils shown in column (5) whose absence from London fell within the normal school holidays. Holiday of 7 days duration. Holiday of 8-14 days' duration. Holiday of 15 days' duration and over. (1) (2) (3) (4) (5) (6) 1. Children's Country Holiday Fund 211 20,682 1,110 22,003 17,144 2. Any other organisations taking children away for holidays 1,332 5,800 2,228 9,360 4,549 3. Boy Scouts, Girl Guides, etc. 3,154 6,930 908 10,992 8,386 4. School Journey Scheme 391 10,638 852 11,881 1,080 5. Hop-picking and fruit-picking season arrangements 909 2,102 16,837 19,848 1,901 6. Parents or relatives 40,050 50,839 33,353 124,242 81,742 7. Pupils sent to residential open-air schools — — 4,449 4,449 549 Totals 46,047 96,991 59,737 202,775 115,351 116 During the summer term the school nurses pay particular attention to those children who are being taken away by the Children's Country Holiday Fund and other organisations, in order to ensure their cleanliness and freedom from parasitic conditions. Attention was specially shown to the children who go hop-picking with their parents, and an instruction has been issued by the Education Committee that children going hop-picking during 1928 shall be medically examined, as far as possible, before and after the event, in order to ascertain the effect upon them physically. School journeys, 1927. During the year 1927, 480 school journeys were held. The children taking part in them were examined by the school doctors in 479 cases before departure and in one case after return. In all 15,971 children were examined. Of these 160 (or 1 per cent.) were certified as unfit to take part in the journeys. They were rejected on various grounds, i.e., suffering from tonsilitis (17), otorrhoea (19), high temperature (10), personal hygiene (8), infectious disease (suffering and at home) (16), etc. A number of children was rejected provisionally on account of detective personal hygiene, but were subsequently passed as clean. Employment of School Children. The applications during the year 1927 for medical certificates in connection with the employment of school children out of school hours under the by-laws numbered 4,161, of whom 4,101 were boys and only 60 girls. The nature of the work for which certificates were granted was for boys (girls in brackets):—Delivery of milk 294 (1); delivery of newspaper 2,459 (24); carrying of parcels, etc. 625 (1); in a shop 344 (4); in a coal yard 4 (0); industrial work at home 1 (0); homework away from home 22 (4); as a messenger 57 (0); not stated 108 (2); in more than one occupation 27 (0). Certificates were refused on medical grounds in the cases of 83 boys and 4 girls ; in 118 cases the certificates were granted subject to medical treatment being obtained and in 60 further cases other conditions were imposed, whilst in 102 cases the reason for the issue of the conditional certificate is not known. In 14 cases the provisional certificates were withdrawn on account of the noncompliance with the conditions under which the certificate was issued. The medical reasons for withholding certificates included:—rheumatism 4, dental disease 8, visual defect 9, heart defect 12, throat troubles 7, anaemia and malnutrition 7, scoliosis 2, enlarged glands 1, ear disease 4, vermin and sores 1, recent operation 1, bronchitis 2, hernia 1, nervous disease 1, osteomyelitis 1, eczema 1, tuberculosis 1, undue fatigue 3, general debility 3. Theatrical children. Under the rules for certification of those employed in stage entertainments, 217 children were seen and kept under observation during the year, of whom 61 were boys and 156 girls. Five children were rejected on medical grounds; three boys who were presented for one particular play had been selected obviously because they appeared to be ill and haggard—these boys required convalescent treatment in place of employment on the stage; one girl with an abscess on the neck who wished to take part in a pantomime in the provinces was unfit to travel, and one girl only out of 217 children was rejected for verminous conditions. Nursery Schools. Report by Dr. Ballard and Miss Stevenson, District Inspectors of Schools, and Dr. McVail, Divisional Medical Officer. Introduction.—This report is based on the inspection of the nine nursery schools in London, the four in Manchester and the three in Bradford. As we had no reason to think that the few isolated nursery schools in other parts of the kingdom differed essentially from those we had already seen, we refrained from paying them a visit. The varieties of nursing schools.—There are many ways of classifying nursery schools. For administrative purposes the most important distinction lies between the provided and the non-provided. The majority are non-provided—all but one in London, all but one in Manchester, and all but two in Bradford. The school building affords 117 another basis of classification. The bulk of the schools are held in adapted houses. It is not always, however, a dwelling house that has been adapted. In one instance, the Jellicoe Nursery School in Gospel Oak, it is a garage, and in another, the Collyhurst Nursery School in Manchester, it is a series of army huts. Five only have been built specifically for nursery school purposes—the two McMillan Schools, the Children's House in Bow, the Rommany Road School in Gipsy Hill and two of the schools in Bradford. Lastly we may classify nursery schools on the ground of the facility they offer for open-air pursuits. At the one extreme stands the Rachel McMillan School where the garden is the essential factor and the structure consists of sheds which cost more for plumbing than for building, and at the other extreme stands theEncombe Place Nursery School, Salford, where the house is the essential factor and the only open-air space for the disporting of sixty children is a sort of platform no larger than an ordinary dining table. We may point out, however, that all the superintendents we saw regarded open-air instruction as the ideal, and indoor instruction as always a second best, to which they were driven, permanently by stress of circumstances or temporarily by stress of weather. Size of the school.—When nursery schools were first established in 1918 the prevailing opinion was that they should be small. A school of 40 was considered quite large enough. The Board of Education, in the regulations which they published in 1919, laid down 40 as the ideal number ; but they went on to say that " they would not refuse to consider proposals for a nursery school providing for as many as 80 or 100 children, but in no case should the number exceed 100." And even at the present day most nursery schools are small. If we leave out the McMillan School, we find the numbers in London Schools varying from 25 to 70, in the Manchester schools from 30 to 60, and in the Bradford schools from 60 to 80. Since those early days, however, opinion has been veering round. The ideal nursery school is now considered to be a large one. The main objection to the large nursery school was neither social nor scholastic; it was medical. The large school was regarded as a breeding place for infectious diseases and a centre from which they were spread. The larger the school the greater was supposed to be the danger. Experience has shown these fears to be groundless. An examination of the following table will show that infectious diseases are not more frequent in a large nursery school conducted on open-air lines, like the Rachel McMillan with an average attendance of 220, than in a small school like the Mary Ward Nursery, with an average of 15, or the Goldsmiths' with an average of 22. Percentage of cases of notifiable infectious diseases. Percentage non-notitiablc. Average attendance, 1925-26. Goldsmiths' 14 18 22 Jellicoe — 104 27 Kilburn Union Jack 4 — 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 The medical objection having been overcome, the advantages of the large school over the small came clearly into view. It is easier to organise, it affords more numerous social contacts, it involves less strain on the individual teacher and finally, it is cheaper. The functions of the nursery school may conveniently be discussed under the three heads : physical, social and scholastic. 118 The physical aspect.—The nursery school differs from the ordinary school in the emphasis placed on mere physical well-being. While other schools are primarily concerned with the children's minds, nursery schools are primarily concerned with their bodies. Hygiene is regarded as vital and fundamental, and it is only when the conditions of personal cleanliness, of wholesome feeding and of healthy physical growth have been abundantly secured that attention is paid to the strictly social and intellectual side of the school programme. The range of ages for the nursery school is from two to five. The schools, however, were not originally meant for all children of that age, but only for those who came from ill-conditioned homes. As for the level of living below which nursery schools are desirable and above which they are unnecessary, that is a matter on which there has been (and perhaps can be) no agreement. But, wherever the level, it is clear that the strongest claims are those of the most neglected children and that the proper place for the first nursery schools is the slums. Nearly all nursery schools provide a mid-day meal and keep the children on the premises all day. The only exception we discovered was the Ardwick Nursery School, Manchester. The Superintendent, who lived quite close to the school and was well familiar with the homes, contended that it was a higher achievement to induce the mothers themselves to provide their children with a wholesome midday meal decently served than to relieve the mothers of that responsibility. In the majority of nursery schools, however, the higher achievement is impossible. Indeed the mere fact that it is impossible is the main justification for the school. Another debatable question is that of bathing. Should the children be bathed at the school or should the Superintendent insist on the children coming to school clean from top to toe ? The sensible reply seems to be that the children must be clean at all costs, that the parents should be induced to do their part as far as the conditions of the home permit, and that the nursery school should make up the deficiency. In no schools need all the children be bathed; in no schools need none of them be bathed. The bath and the water should always be there for those who need them. Leaving debatable territory we find certain practices common to all nursery schools. Chief among these are: inspections by the school doctor at least once a term, daily visits by the school nurse, the systematic weighing and measuring of the children, extreme vigilance in the detection and isolation of cases of infectious illness and the keeping of medical record of each individual child. All the children sleep during the early part of the afternoon. Each is provided with his own comb, towel, tooth-brush and drinking mug. One of the main advantages of the nursery school is the opportunity it offers for the early detection and treatment of defects of the respiratory tract and the sense organs. Bad teeth, septic tonsils, adenoids, defective vision and running ears can much more easily be dealt with if they are taken in the early stages. A large proportion of the children who enter the nursery school suffers from rickets. If it is an open-air school the rickets rapidly disappear. The need for preventive and remedial measures before the child reaches the compulsory school age is clearly set forth in the following extract from the last report of the Council's School Medical Officer:— "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." 119 A more comprehensive and detailed account of the medical service as it bears on the nursery school is given in Appendix I. by Dr. McVail. The same author reports in Appendix II. an inquiry into the physical results of attendance at nursery schools. The social aspect.—The social function of the nursery school is two-fold. It trains the child in right personal and social behaviour and so fits him to be later a useful member of the community; and it exerts, through the children, an influence for good on the standards and ideals of the home. In addition to providing the right environment for the little child, the nursery school gives him companions of his own age, and skilled and sympathetic adults who have the time and the knowledge to train him in good habits. In the best nursery schools two characteristics are conspicuous ; first, the activity and independence of the children in helping themselves; and secondly, the pleasure and capacity they show in helping others and taking their share in doing work for the school. They learn to wash and dress themselves, to dust, wash dishes, serve and carry food, put away their possessions and look after pets with a care and a sense of responsibility that surprise their own mothers. They learn to give and take, to carry on their own pursuits without interfering with others, to be good-tempered and truthful. The trustful and friendly attitude of the nursery school child is a delightful result of the understanding sympathy with which the schools are directed. The potential underdog, rebel or anarchist, can all be recognised among the entrants to the nursery school, but it is seldom they are not transformed into orderly, active and happy citizens of their community. In most of the nursery schools we found that the bond between the teacher and her nursery survives the children's transfer to other schools and that many of the children who, it must be remembered, leave at five years of age, return to the school sometimes for many years for play hours, club gatherings or merely to see tneir old teacher. In one school a lending library was established which boys and girls, even up to 15 and over, continued to use; in another, children who returned for play hours became later Brownies and Girl Guides, Wolf Cubs and Scouts, and in another boys passed on into gymnastic and billiard clubs. The nursery school is usually, indeed the first, of a series of friendly and educative social groups which carry the child through childhood and adolescence to adult age. The Children's House at Bow, though of recent origin, is a centre of many such social activities. Further, through the children, the influence of the school reaches the parents. Though in two of the schools visited a Fathers' Club has been formed, it is naturally the mothers who manifest the keenest interest in the activities of the nursery school. In practically all the schools, Mothers' Clubs or Guilds have been formed. The primary aim is to establish friendly relations with the mothers and so to secure their co-operation in the work of the school. The social and friendly character of these gatherings is emphasised, but, directly or indirectly, the mothers gain through them a fuller knowledge of their children's needs and possibilities. Open days are sometimes held, and, in one school in Bradford, the mothers are allowed to come in pairs to spend a day in the school as spectators of their children's activities. We have much evidence of the value of such extensions of the school's influence. The gratitude of the mothers is shown in many ways, most often by help given in washing overalls and school linen. In one school a mother made the overalls, in another a mother acted as cook to the country cottage party, in another a group of mothers collected money towards an extension of the school building. 120 Where this spirit prevails the home life must be raised to a higher level. Indeed we have some ground for thinking that the nursery school educates the mothers almost as much as it educates the children. In Bradford an interesting experiment in the training of elementary school girls has been initiated by co-operation between the Lilycroft Nursery School and the Lilycroft Mixed School. As part of their Domestic Science Course, the girls of the leaving class attend the nursery school in rotation for one half-day a week during their last school year, in the morning one week, in the afternoon the next. Thus they see the greater part of the day's activities from 8.30 a.m. to 5 p.m. and take part in all but the actual teaching and medical treatment; and these they observe. They have the added dignity of a uniform, a note-book, a special corner as nursery "Big Sister" to the babies. Who can doubt that this practical experience will help them, not merely in their everyday duty of "minding the baby," but in later years when they themselves become mothers ? To sum up, in looking back over our series of visits, we feel that the nursery school is an institution of peculiar value in our industrialised society and that the multiplication of such schools would not merely set the children on the right way to healthy development of all sides of their nature, but would raise the general level of family life. We feel too that the influence of the nursery school flows directly from the superintendent, whose personality and outlook are all important and who, to meet all the claims made upon her, needs many qualities of mind and heart. The scholastic aspect.—We assume that it is now fully recognised that a nursery school is a school as well as a nursery; that the child's mind needs the ministrations of a teacher just as much as his body needs the ministrations of a nurse—in a word, that his mental habits are just as important as his physical habits. The training influences at work in the schools seem to derive from two sources, Froebel and Montessori. Where the influence of Froebel is strongly marked, as in the Notting Hill and Somers Town Nursery Schools, much importance is attached to play, story-telling, singing, dancing, nature study and handwork. The teacher takes up a prominent role and class teaching is the normal mode of instruction. Where the Montessorian influence is dominant, as in the Rommany Road Nursery School, the emphasis falls on individual work, free discipline, sense training and the use of didactic apparatus. The teacher is an observer and a guide, and the children are allowed, within certain limits, to follow their own pursuits. In the best schools, however, the method is eclectic; it is a selection of the best in both systems. We are glad to report that in none of the schools did we find any attempt to teach the three R's. The pursuits that seemed to us the most profitable were rhythmic movements, speech-training and handwork. A ready response to rhythm was almost universal. From the age of two onwards the children showed a manifest delight in all forms of dancing and singing and even reciting. It was the rhythm rather than the melody of music that seemed to appeal to them; it was the rhythm rather than the meaning of nursery rhymes that engaged their attention. A nursery rhyme enabled them to dance, so to speak, with their vocal organs. The manual activities were, rightly, of the simplest and most primitive kind. Digging in sandpits, building with large wooden blocks, putting Montessori apparatus to non-Montessorian purposes were the main occupations. Drawing with crayons on brown paper was sometimes attempted, but more for the joy of doing something than for delight in something done. The least satisfactory of the three was speech-training. We regard the cultivation of clear speech, if not of standard speech, as one of the main duties of the nursery school. And in some schools this duty was carried out with remarkable success. Little Yorkshire boys would tell us that they had "three coops of cocoa and one plate of coostard." The vowels were a little queer, but the consonants 121 were impeccable. Few schools rose to that standard of clearness and intelligibility. Few schools realised the full importance of first of all getting all the children to be communicative and then of getting them to acquire habits which ultimately lead to gracious speech. Staffing.—The Board recognise three grades of nursery school teachers—(i) superintendents, (ii) adult assistants, and nurses, (iii) probationers. It is rightly contended that " the work of a superintendent of a nursery school necessarily demands a high standard of capacity and a varied experience, both personal and professional." The experience of the last decade has convinced all who are closely concerned with nursery school work that the superintendent should possess a teacher's certificate, and be specially trained for nursery school work; and that the adult assistants should have at least the latter qualification. Some might be stronger on the nursing side others stronger on the teaching side; but all should have an ad hoc training. It was obvious to us that the services of the superintendent of a small school are exacting and nerve-racking. She is on duty all day. Even during the sleeping hours she cannot afford to be off guard; there are always some children claiming her attention. Her duties, carried out in a narrow environment, with a constant round of tiresome ministration, demand a large fund of patience, cheerfulness and good humour. And her health sometimes breaks down. One of us, who has kept the nursery schools of London under observation for nine years, has had the constant change of superintendent forced upon his notice. The period of her rule is generally brief. The strain upon her nerves tends to produce the very attitude of mind which is least desirable in a nursery school. She cannot stay away and rest, for the school cannot go on without her. This is true of the small nursery school only. The larger the nursery school the less obvious is the nervous strain. The remedy seems to lie in the free interchange of teachers between nursery schools and other schools. After a change of work the nursery school teachers can come back refreshed and strengthened. When she arrives at the period of life when attention to the needs of very young children is too exacting and burdensome, she can pass on to more congenial work among older children. We must, however, emphasise the need for special training for all who undertake to serve in a nursery school. To be specially drawn to this work is agood beginning, but it is not enough. The nursery school teacher must not only be a lover of children, but a knower of children as well, and a knower of all the factors that make for health, growth and happiness. The training of nursery school teachers—We were everywhere met with the complaint that it was difficult to secure good nursery school teachers. The ordinary teachers lacked the necessary knowledge of nursing and child hygiene; the nurse lacked the power to inculcate good social and intellectual habits. In the early days of nursery schools the teachers nearly all came from the Froebel Institute. They were excellent in their way, and, after a little experience, made admirable superintendents. But the Institute, good as it is for kindergarten teachers, does not pretend to train specially for nursery school teaching. This source of supply has since been supplemented by three others: (1) certain training colleges that undertake to give a special course in nursery school work, (i) the Mather Training College in Manchester, (iii) the McMillan Training Centre in London. The first source has never been very plentiful and is apparently drying up. Indeed, the training colleges seem to be making more and more provision for the teaching of seniors and less and less provision for the teaching of juniors. The Council's inspectors who select teachers for the List of First Appointments have no difficulty whatever in securing girls' teachers. The supply is superabundant. But the supply of infants' teachers, comparable in quality with the girls' teachers, 122 has been gradually falling off for some years and is now far short of the demand. This bias towards senior work seems to be partly due to the development of advanced courses in secondary schools and the desire of students to pursue their advanced studies with a view to becoming specialists ; partly to the fact that the course for the teaching of juniors lies on a distinctly lower intellectual level that the course for the teaching of seniors ; and partly to the feeling that there is a wider professional field for the teacher of seniors than there is for the teacher of juniors. It follows that the more intellectual and the more ambitious students choose the senior course. We venture to think that the training colleges themselves are not free from blame in this matter. They themselves specialise in everything except education, We mean that the course of study they offer in English, in history or in geography gives the student more intellectual grist to grind than the course in pedagogy. It is true that the Board of Education have given but little guidance in this subject and that there is no recognised and authoritative body of doctrine that it is desirable for all teachers to know. But it is not difficult to devise a professional course comprising those special studies which centre round the child, his health and his development—studies for which the term paidology is, perhaps, the most fitting. And though this is but a portion of a wider field of educational theory and practice, it is a very important portion and for the nursery school teacher the all-important portion. Yet no training college adequately provides such a course. The Gold smiths' College undertakes to do so and has a small nursery class attached to the College, but only a small and diminishing number of students take the course. The same seems to be true of the Darlington Training College. Neither of these gave any teachers to the nursery schools or nursery classes we inspected. The Mather Training College in Manchester has for some time ceased to exist as a separate institution, and now forms part of the City Training College, which has been preparing about a dozen nursery school teachers a year. But the City Training College itself is coming to an end at Christmas, and we are left with only one effective source of supply. This source of supply is the irregular training college at Deptford—a training college without a home or resident tutors—a college which is recognised temporarily from year to year, and that for only ten students. But the college has the essential things. It has a model nursery school on the spot where observation and practice are constantly going on. And it has the nursery school spirit. Teachers interested in this work come to Deptford as to a sort of Mecca from all parts of England (and Scotland) and find that they get something there which they cannot get anywhere else. The best nursery schools we saw in the North were conducted by McMillan trained teachers, and the best premises we saw were based on the McMillan model. We consider, therefore, that there is an urgent need for the establishment of a training college whose primary function is the training of nursery school teachers. It should provide a course in paidology which would be sufficiently comprehensive to serve as a diploma course for third-year students; it should serve as a centre for research and instruction in all that bears on the welfare and nurture of the young. Nursery classes.-—The only new thing we saw in the North was the nursery class. It is Manchester's way of solving the problem of the education of children under five. A nursery class is a glorified babies' class. It is a babies' class wth some, but not all, the amenities of a nursery school. It differs from the babies' class in having smaller numbers and in providing each child with a towel, a toothbrush and a drinking cup. It differs from the nursery school in not including children between two and three years of age, in not providing a mid-day meal and in not having a helper. The children are unselected, the doctor's visits are less frequent, and the school hours are shorter. There is, moreover, the important administrative difference that the nursery class forms part of the elementary school and comes under 123 the elementary school regulations, while the nursery school is no part of the elementary school system and is subject to a separate code of rules. Manchester has at present about 170 infant schools, and within those schools it has 49 nursery classes, some schools having one, a few having two, and about three-quarters of them having none. A nursery class is sometimes formed by splitting up a large babies' class. From a babies' class of 50 or 60 two nursery classes of 25 or 30 each are formed. The maximum roll is 30. It is allowed to reach 35 when a special kind of helper, known as a "student nurse," is allocated to the class. A student nurse is a bursar who teaches half time and attends a secondary school the other half. Her ultimate objective is nursing, not teaching. The success of these classes seems to be largely dependent on the teacher. Where she combines special aptitude with special training she does well; where one of these qualifications is absent, her work falls below the level which it is reasonable to expect from so propitious an arrangement and so generous an equipment. The nursery class raises the important question of the relation between the nursery school and the infant school. The relation between the nursery school and the infant school.—It seems rational to think that the nursery school finds its proper place within the infant school system, and ultimately, no doubt, that will be its fate. But it is doubtful whether the time is yet ripe. It is necessary for the nursery school to develop its own methods and create its own tradition. For it may be regarded as a means of reforming the infant school; and, indeed, the whole scheme of elementary education. If this view is well founded it is best for the nursery school to delay its entry into the infant school until it has a chance of assimilating it. At present it would stand a far greater chance of being itself assimilated. It is not merely true of the infant school, but of all schools short of the University that the influences that make and mould the curriculum and the methods of instruction flow from the higher schools to the lower. The consequence is that the education of the younger pupils has suffered too much from academic and bookish traditions. The nursery school is a means of counteracting this influence by turning the current, by extending upwards its own influence of health and kindliness and joyous spontaneous pursuits. It is true that much of this spirit already pervades our infant schools. It abundantly pervades the best of them. And we believe that already, if the schools and the special teachers be wisely chosen, experiments in the way of nursery classes may profitably be made in London. The effect on the subsequent school career.—It is not easy to estimate, with any approach to exactitude, the intellectual advantages of attendance at a nursery school. The main impediment is that nursery school children are a selected group. The poor are chosen rather than the well-to-do, the sickly rather than the strong. They are, on the whole, below the average in social status and in physical health. And even if their native intelligence is not also below the average, its development is hampered by factors which are only partly under the control of the nursery school. An attempt was made by one of us to trace the subsequent school careers of all the children who had left the Notting Hill Nursery School within the last five years. It was found that they all had held their own in school studies and pursuits. The educational tests that were given them indicated that they were at least up to the average in their school work. Although they entered the elementary school at the age of five with no formal knowledge of reading and number they soon caught up with those children who had had an early training in these subjects. The invariable verdict of the teachers concerned was that the nursery school children were alert and eager to learn, that they were well behaved and equipped with habits and attitudes which made for progress and happiness in the school. The teachers much preferred to get the children from the nursery school rather then straight from the homes. 124 Conclusions and recommendations.—(1) The nursery school fulfils a valuable function in modern life and its development in number and in efficiency would prove a great social boon. (2) It may be regarded as a partial compensation for an unsatisfactory home. It mitigates some of the evils arising from poverty and overcrowding. (3) It fulfils functions which the infant school, as at present constituted, either imperfectly performs or does not perform at all. (4) The need for the school is greatest where the mothers go out to work, or where the children have insufficient light, air, exercise, facilities for washing and wholesome food. (5) A large nursery school can be more economically and more efficiently conducted than a small one. (6) The more closely the school approaches an open-air school the better. (7) The "adapted house " type is far inferior to the shed-and-garden type. (8) The staff is quite as important as the premises; while the superintendent alone need have a teacher's certificate, she and all her assistants should be specially trained for the work. (9) If there is to be a development of nursery schools the problem of securing specially trained teachers becomes urgent. There is at present only one good source of supply and even that is precarious. (10) It seems desirable that the nursery schools should, for the present, be independent of the elementary school. When, however, it has established its own methods and its own tradition it might then enter into the infant school system with some likelihood of reforming that system. (11) Where nursery schools are impossible, nursery classes constitute a secondbest reform in the same direction. Experimental nursery classes may profitably be established in a number of the London infant schools. Section 19 of the Education Act, 1918, which came into force on 8th August, 1918, reads as follows :— (1) The powers of Local Education Authorities for the purpose of Part III. of the Education Act, 1902, shall include powers to make arrangements for— (а) Supplying or aiding the supply of nursery schools (which expression shall include nursery classes) for children over two and under five years of age or such later age as may be approved by the Board of Education ; and (b) Attending to the health, nourishment and physical welfare of children attending nursery schools. Indications are given in the annual reports of the Chief Medical Officer of the Board of Education that primarily nursery schools are intended for children from unsatisfactory homes who are thus in peculiar need of a different and better environment and training. This principle is laid down in the report of 1916 and maintained in the 1919 report, which, after quoting the section of the 1918 Education Act dealing with nursery schools, goes on to say:— "Nursery schools are therefore concerned mainly with children living in the poorer districts of large towns where housing conditions are unsatisfactory, overcrowding common, infant mortality high, an environment, in short, where many factors of healthy nutrition are certainly absent and where the resistance of the body to the onset of disease is not likely to be strengthened. The primary duty of nursery schools is nurture, the care of the health of the children and the prevention of future disease." In 1922 we are informed from the same source that 80 to 90 per cent. of children are born healthy, yet 30 to 40 per cent. of children admitted to school at five years of age have physical defects which could either have been prevented or cured. In 1925 the report states that the chief causes of ailments amongst school Detailed report on the physical aspect of the nursery school by Dr. McVail. 125 entrants are those dependent upon (1) faulty nutrition; (2) infective processes; and (3) unhealthy domestic surroundings. Examples of the first are anaemia, skin affections, eye diseases and rickets; of the second ear disease; and of the third uncleanliness and forms of skin disease. As regards changes in the physical defects of entrants within the previous ten years, the conclusion, broadly speaking, is that there is not much evidence of substantial improvement, although, judging from heights and weights, it may be inferred that the general physique of young children on admission to school is slightly better in the post-war years than immediately before the war. The need for linking up the work of infant welfare centres, nursery schools and the school medical service is emphasised and attention called to the wide field for preventive medical acitivity during the period of attendance at the nursery school. Briefly, the functions of the nursery school, regarded from the medical standpoint, are to provide children of two to five with an environment which is suitable for healthy growth and which it is impossible for them to obtain in the homes from which they come, to furnish them with abundance of light and air, to provide them with nourishing and adequate food, to attend to ailments at the earliest possible moment and to train them in hygienic habits. The physical results of attendance at nursery schools are discussed in a separate report. Details as to prevailing conditions in London, Manchester and Bradford are given below. Age.—The following table gives the percentage of children at dmerent ages in the nursery schools of London, Manchester and Bradford, respectively:— Place. Present No. on roll. Percentage of children aged[/##] 2 3 4 5 6 London 573 25 36.5 32 6 0.5 Manchester (returns obtained from two schools only) 82 22 36.5 33 8.5 0 Bradford 236 27 41 30 2 0 The figures are very similar for the three cities, about a quarter of the children in the nursery schools being two years of age. Attendance.—In London with a roll of 566 children (year ending March, 1927) the average attendance is 82 per cent. In Bradford with a roll of 236 the average is 70 per cent. In Manchester, where returns were obtained from three schools with a roll of 146, the average is 83 per cent. The attendances vary considerably. In St. Ann's, at Bradford, where the children are exceptionally poor, there is an attendance of 85.7 per cent., whereas in the same town Lilycroft and Princeville Schools, with a much better class of child and much better premises, have 63 per cent. and 58.5 per cent, respectively. Similarly, in London very poor schools such as the Rachel McMillan and Children's House, have attendances of 88 per cent., and 87 per cent. respectively, whilst Goldsmiths' College Nursery School, with a specially good class of child, has 69 per cent. Selection.—Most schools have a waiting list from which children are selected as vacancies arise. In some, for example, the Rachel McMillan and Notting Hill, children are chosen mainly on grounds of health. At Collyhurst (Manchester) all children are selected by the doctor at the Infant Welfare Centre, most being rickety or otherwise debilitated, though a few only—children who suffer from solitude at home—are also sent. Only children have likewise had some preference at the Mary Ward, though the tendency there now is to select on grounds of poverty. At Goldsmiths' College School delicate children with delicate mothers have priority. At Kilburn Union 15435 I 126 Jack, children of three and lour years old are preferred to infants of two, the reason being that the stairs are steep and falls are not uncommon. At the Children's House selection is made from families in the immediate neighbourhood who associate themselves with other interests connected with the school. At Rommany Road the poorest children and those whose mothers work outside are chosen. At Ardwick (Manchester) children are as a rule taken in turn on the waiting list, though very dirty children are refused. A few schools have almost no waiting list, and children are taken as they apply. Accommodation.—Types of building are very varied, schools built for the purpose being naturally the most satisfactory. Two Bradford schools (Lilycroft and Princeville) are amongst the best. These are of open-air type with large verandahs roofed with glass and gardens of good size. Rommany Nursery School is also an excellent building of open-air type with all modern requirements. The Rachel McMillan, with its six open-air shelters and attractive gardens, is also admirable. The Children's House (Bow) with a spacious schoolroom, roof playground and large open-air shelter is a bright spot in a slum neighbourhood. Of the adapted buildings one cannot speak so highly, though the best use is made of accommodation in many respects unsuitable. Most are ordinary dwelling houses and stairs are a difficulty with little children who require constant supervision in going up or down to their cloakrooms and lavatories. Also the rooms are frequently too small and freedom for exercise is impeded. Sanitary conveniences are sometimes unsuitable both in type and situation. The Kilburn Union Jack School is an example of the worst type of accommodation. This is a three-storey and basement house, the ground and first floors being used by the children. The schoolroom, also used for meals and sleeping, is reached by steep and narrow stairs from the ground floor cloakroom. There is no hot water supply, and the only cold water tap is in the kitchen. For washing the children all water requires to be carried thence to the ground floor cloakroom. A very tiny garden is practically never used owing to difficulty with stairs. Actual floor space per child for play, meals and sleeping, but excluding cloakroom and kitchen accommodation, varies from about 15 square feet at Kilburn Union Jack and the Ardwick (Manchester), to 32 square feet at the Jellicoe, and 38 at the Mary Ward, the Board of Education's requirements being not less than 12 to 15 feet. In open-air schools cubic space is, of course, of less importance than in converted dwellings. Without open-air conditions a room of the usual height with only 15 square feet per child tends to be unpleasantly stuffy during the rest period in the afternoon. A bald statement of floor space is misleading in other respects. At the Mary Ward, for instance, with 38 square feet per child, the space is so cut up into small rooms that children have less freedom for games and exercise than in a single spacious room at the Children's House, where the floor space is about 29 square feet per child. A disadvantage, however, of a single room for all purposes is that new two-year-olds are often very noisy, and, especially during the rest period, it is advisable to have a room for their own use. For that reason part of the large single schoolroom at Rommany Road has been partitioned off by sliding doors. The heating and lighting of playrooms are generally good and open fires are invariably protected by guards. As regards cloakroom accommodation, pegs are as a rule placed too close and clothing overlaps. Most cloakrooms have some heating arrangements, but a few are still lacking in that respect. Sanitary accommodation is, as a rule, sufficient, though sometimes inconvenientlv situated and of unsuitable type for children. Nearly all schools have provision within the building. 127 Playgrounds are generally adequate, exceptions being at Kilburn Union Jack, the Ardwick (Manchester) and Encombe Place (Salford), where there is little or no room for play outside. At the Jellicoe and Somers Town the playgrounds, though made good use of, are rather small. The Rachel McMillan, Rommany, Goldsmiths', Mary Ward and the two open-air schools at Bradford are examples of schools with specially good outdoor space. Playgrounds should be an essential for all nursery schools. The betterment in the health of children transferred at the beginning of this year from old premises without a garden in Rommany Road to the present open-air building with a good garden in Gipsy Hill, has been remarked by all connected with the school. A defect in the accommodation of some nursery schools is the want of a room recognised for isolation purposes. Medical inspection and treatment.—Every school has a doctor who visits regularly for medical inspection. The doctor for the provided schools is appointed by the Local Authority. Voluntary schools as a rule have a private doctor living close at hand, though the Rommany, Goldsmiths' College and Rachel McMillian (both voluntary and L.C.C.) are inspected by a Council officer. In most schools children are inspected once a term and in none less than once in nine months or a year, special cases being examined more frequently. At Collyhurst (Manchester) an open-air school for delicate children, the doctor visits fortnightly, each child being inspected every two months. Treatment for teeth, tonsils and minor ailments is nearly always obtained from school clinics, and general medical treatment from hospitals or private doctors. Most schools are near institutions where sunlight treatment is obtainable and few are without some cases undergoing such treatment. In London the school doctor, beyond advising as to cod liver oil, Parrish's food and the like, does not treat. At Collyhurst he also directs a masseuse who visits the school four afternoons a week. At St. Ann's, Bradford, general medical treatment is prescribed at school. Nearly all schools have a nurse who visits daily or, exceptionally, at longer intervals. A small minority have no nurse. In these cases a member of the staff with some nursing experience undertakes the duties of inspection of the children for cleanliness and infectious disease. At Collyhurst the school nurse visits for four hours every morning. In the event of an outbreak of infectious disease a doctor inspects immediately, and the visits of the school nurse are, if necessary, increased. Most nursery schools are near a clinic where medical advice on a doubtful case can at once be obtained. In London the special measles scheme is put in force when advisable. When ill, children from the Rachel McMillan Nursery School are visited at home by members of the staff who see that medical treatment and even coals and blankets are provided if necessary. In some other schools the sick are visited by the school nurse. School meals.—The rule is to provide milk and a biscuit or rusk shortly after the school opens in the morning and a two-course dinner at mid-day. Two exceptions are the Rachel McMillan School, which gives three meals a day (breakfast, dinner and tea), and the Ardwick (Manchester), where no dinner but only morning milk is provided. At the Goldsmiths' College School dinner is given only when the college is in session. At Collyhurst (Manchester), all children have, in addition to dinner and milk, cod liver oil twice daily. At the Rachel McMillan all have cod liver oil in winter and about a third in summer. At other nursery schools it is given mostly on the doctor's recommendation. Dinners are practically always well cooked, nourishing and varied. At London Schools they are cooked on the premises, or in the case of the Mary Ward, in the kitchen of a P.D. School close at hand. At two Manchester schools cooking is done 15435 I2 128 on the premises and at the third in an adjoining building. At Bradford food is sent in asbestos cases from the Municipal Central Depot. The weekly charge for food varies from 1s. 6d. to 3s. or 3s. 6d., most schools charging 2s. Necessitous children may have the payment wholly or partly remitted, though in London nearly all pay something towards their meals. At St. Ann's (Bradford) 30 or 40 children on a roll of 84 have them free. General.—At practically all nursery schools children have their own towels and tooth brushes. Combs are also provided, either one for each child or a common supply disinfected after use. Hair brushes are less frequently provided. The various articles are either named, numbered or distinguished by means of a picture. Children are supposed to brush their teeth daily, but in some schools this practice has, in the case at least of the two-year-olds, been given up. At Lilycroft (Bradford) the Superintendent found that whenever personal supervision was for a moment relaxed the babies used their tooth brushes for smoothing their hair. At another school whilst the teacher supervised the brushing of teeth at one end of a row of infants seated on the floor those at the other end sucked their tooth brushes, interchanged them, rubbed them on the cloakroom floor and then sucked them again. Unless in very favourable circumstances it seems much safer to give two-year-olds a piece of raw apple after their food than to insist on the brushing of teeth at school. Stretchsr beds with blankets, also in some cases sheets and pillows, are provided at all schools. Children sleep for 11/2 to 2 hours after their mid-day meal, some in the schoolroom and some in shelters in the playground when these are available. For children from slum homes this period of rest in a quiet and well-ventilated room is invaluable. From most nursery schools in London and Manchester children are taken by the staff to the country for a holiday in summer, the period varying from one to six weeks. Some schools take practically all the children each year, whilst others select a special group. Enquiry into physical results of attendance at nursery schools by Dr. McVail. An enquiry made by Dr. McVail into physical results of nursery schools falls into two sections, namely:— (i) A comparison between the health on admission to elementary schools of children previously in attendance for a year or more at a nursery school and that of ordinary entrants ; and (ii) The physical condition of individual children on entering and on leaving the nursery school. Comparison of nursery school transfers and other entrants to elementary schools. Investigation was made regarding 100 children who had within the past three or four years left the Rachel McMillan Nursery School (Deptford) and the Notting Hill Nursery School, 58 children being followed up from the former and 42 from the latter school. For admission to both these schools debilitated, rickety and badly nourished children have preference. Of children at the Rachel McMillan Nursery School some 80 per cent. at entrance have signs of rickets and about one third come from homes of a single room. The Notting Hill children also are selected on grounds of health. The 100 children are now in attendance at representative elementary schools near the respective nursery schools, namely, Clyde Street, Creek Road and Hughes Fields in Deptford, and Saunders Road, Sirdar Road and St. James' Norland C. of E. in Notting Hill. From their medical record cards at the elementary schools details were obtained as to the physical condition of the 100 children as entrants. Similar details were obtained regarding 100 controls, each control having been born in the same month and year as a child in the nursery school group. The two groups were weighed and measured at the time of my visits and their heights and weights are strictly comparable. As regards the general physical condition, the nursery school children were on an average somewhat older than the controls when first examined at the 129 elementary school owing to the fact that children at nursery schools remain there as a rule until five years old, whereas other infants may enter at three or four. The following table gives particulars as to the general physical condition, height and weight of nursery school children and controls respectively:— Group. No. of children. Nutrition. Teeth. Tonsils. Glands. 1 2 3 1 2 3 Slight. For treat ment. Nursery school 100 19 77 4 60 31 9 28 6 10 Controls 100 17 82 1 56 25 19 34 8 6 Group. Anaemia. Heart. Lungs. Shin. Eye. Ear. Deformities. Other. Aver, height. Aver, weight. Nursery school 4 2 9 3 2 4 1 116.2 21.59 Controls 4 4 17 3 3 4 3 1 115.3 21.22 It is seen that in spite of the fact that delicate children are selected for both the Rachel McMillan and Notting Hill Nursery Schools after attendance there they are in almost all respects somewhat better than the controls. As regard nutrition, an exception is noticed, for whereas 19 nursery school children are well nourished as compared with 17 controls, four nursery school children are under-nourished as compared with only one control. In the poorest schools the most poorly nourished in the two groups were nursery school children. Concerning teeth, only nine nursery school children had three or more decayed teeth as compared with 19 controls. As regards tonsils and adenoids, 34 nursery school children as compared with 42 controls showed signs of defect. Considering the facilities for operative treatment in connection with the nursery schools a better result might have been anticipated. That the more serious cases do, however, receive treatment from the nursery schools is indicated by the fact that none of the children who had attended there were suffering from otorrhœa or deafness, whereas of the controls three had otorrhoea and one had slight deafness. In addition, the figures for catarrhal lung conditions, also frequently associated with adenoids, bear out the above statement, as only nine nursery school children as compared with 17 controls were so affected. On the other hand glands were slightly enlarged in ten nursery school children as compared with six controls. As regards cardiac affections, the nursery school group contained two cases of functional disease whereas three controls had functional and one organic disease. Other defects varied only slighty in the two groups. With reference to height and weight, the nursery school children averaged 0.9cm. and 0'37 kilos more than the controls. The difference is slight, but, remembering the original handicap of the nursery school children, it is not insignificant. Concerning the physical condition of individual children on entering and leaving the nursery school, records of some fifty children were last year obtained from the Rachel McMillan Nursery School. These show conclusively the beneficial results of the regime there, associated as it is with good food, fresh air, cleanliness and medical treatment on diseased and debilitated babies. At the Rachel McMillan School conditions are specially advantageous for the poor in that the hours are longer {8 a.m. to 5.30 p.m.) than at other schools, the institution is run on open-air lines and three meals a day in addition to such extras as cod liver oil are provided. Physical condition of children entering and leaving nursery schools. The following cases are illustrative:— (1) D.M. (M.) born 13.10.20, admitted 27.8.23. On admission at 2 10/12 years child was considerably under weight and unable to walk owing to marked rickets of the legs. Was sent to hospital where irons were obtained. He received cod liver oil and malt at school and dental treatment at the clinic. At six years old he was well nourished and above average weight, the deformity of the legs was very slight and irons had been discarded. 130 (2) J.T.P. (M.), born 22.2.21, admitted 19.2.23. Family history of tuberculosis. Child on admission at two years old was thin and starved looking and suffered from severe rachitic bowing of the legs. He received sunlight and dental treatment and was given cod liver oil at school. At six years old he was of fair nutrition and colour and muscular tone were satisfactory. The deformity of the legs was greatly improved. (3) T.F. (M.), born 21.6.18, admitted 30.8.21. On admission at three years old child was considerably under weight, had dental caries and suffer 3d from muscular weakness of the heart, being subject to fits of extreme pallor. Dental treatment was obtained and he rapidly improved. On leaving the nursery school the heart was normal and weight above the average. (4) R.E. (F.), born 10.12.17, admitted 5.20. The youngest of twelve children Father and sister died of pulmonary tuberculosis. A brother and two sisters have different forms of tuberculosis. On admission at 21/2 years child was extremely delicate. Suffered from enlarged tonsils which were operated upon and otorrhoea which was successfully treated at the clinic. Whilst at the nursery school she was also treated for defective vision. At five years old she was a sturdy and well-built child, decidedly above the average weight. (5) C.R. (M.), born 23.4.21, admitted 23.4.23. A bad home. Mother goes out to work and father drinks. Before admission to the nursery school the child lay on his back all day in an empty house, a neighbour bringing him a bottle twice a day. At two years old he was thin and badly nourished and unable to walk owing to marked rickets. He was given cod liver oil at school and in nine months he had gained two kilos in weight. For many weeks he received at the clinic treatment for impetigo which recurred at every holiday. Dental treatment also was received. At four years old the father removed him to an elementary school. He was then of fair nutrition and walked well. (6) J.O. (M.), born 6.11.20, admitted 4.23. On admission child had bad otorrhoea which had commenced in infancy. For this he was referred to the Council's ear specialist who treated him by ionisation. The condition was cured, and at five years old he was in excellent health. Dental treatment also was obtained from the nursery school. (7) D.C. (F.), born 7.9.20, admitted 14.1.24. On admission at 21/3rd years child was pale and had poor peripheral circulation. She suffered from enlarged tonsils and infantile paralysis of the right leg which she dragged on walking. She has had regular treatment at hospital for the paralysis and now walks well. Her tonsils have been operated upon and her general condition is good. (8) L.L. (F.), born 15.6.20, admitted 11.23. On admission at 31/3 years old child had rachitic deformity of the legs, bronchial and nasal catarrh, and she suffered from diabetes. She was kept under regular hospital treatment for diabetes and dental treatment was given at the clinic. The catarrhal conditions ceased, her rachitic deformities considerably improved, and at six years old she was a tall and well-nourished child. (9) M.R. (F.), born 14.6.21, admitted 17.9.23. Belongs to a delicate family. Father died of tuberculosis and brother is at an open-air school. Home conditions are bad. On admission at 21/4 years old child had rachitic deformity of the chest and distended abdomen. She was given cod liver oil at school and sent to a clinic for heliotherapy. Although still delicate she had considerably improved at six years old. (10) L.W. (F.), born 11.6.21, admitted 20.6.23. On admission at two years old child had bad rickets of the legs, sores on the skin and otorrhoea. Dental and aural treatment were obtained at the clinic. At six years old she was free from otorrhoea and the rachitic deformities had practically disappeared. She was then a fine child, well-nourished and of good colour. 131 The above cases, many others similar to which could be cited, require little comment. By dietetic, sunlight and general hygienic treatment nearly all cases of rickets are cured without either instruments or operation and suffering is therefore minimised; otorrhoea is treated early and continuously until cure is effected; special attention is paid to the diet of the debilitated; clothes are given to the needy, and when sick at home children are visited by members of the staff of the school. Milk, meals and cod liver oil. The total number of samples of milk analysed was 1,483. Of these 60 (4.04 per cent.) were unsatisfactory, 1.01 per cent. containing added water and 3.03 per cent. showing a deficiency of fat. The maximum addition of water in any one sample was 6.3 per cent. whilst the greatest abstraction of fat was 48.3 per cent. It is to be noted that in general, the quality of the milk supplied shows much improvement when compared with the previous year's supplies. Of the meals supplied to the children at various centres, 13 samples were examined in the Council's central laboratory, and, where necessary, attention was called to the need for an increase in the protein content or the calorific value. Supervision of dietaries. Meals of milk or cod liver oil are extensively supplied in school to debilitated children on the school doctor's advice. Dr. Chaikin has supplied the following note upon the extent of this work in the Eastern division. " Special sessions are allotted in the Assistant Medical Officer's rotas each term for the inspection of children receiving milk, and malt and oil meals. The number of sessions thus allotted during 1927 is here detailed: E lamination of children in receipt of milk meals and cod liver oil. Spring. Summer. Autumn and Winter. Sessions 136 129 132 Part Sessions 64 60 65 "A card (M.T. 56) is filled up by the school doctor when a child is recommended for milk, or malt and oil. The children are examined each term, and the following entries made on the cards: (1) weight and height; (2) recommendation as to continuance or discontinuance of milk, or malt and oil; (3) information as to reason for non-examination (e.g., gone to another school, left school, etc.). "These records are used as the basis for determining the necessity for the allocation of special sessions and for close 'following up' of children who fail to attend for medical examination. "The following table shows the numbers of children recommended for milk and oil and malt meals by the assistant medical officers in this division at three periods of 1927, together with the numbers of new and discharged cases:— Term. Current cases at beginning of term. New cases during term. Cases discharged during term (i.e., milk discontinued). Left, etc. Not traceable. Spring 6,032 1,010 446 180 234 Summer 6,180 933 382 347 270 Autumn and Winter 6,103 1,400 488 380 260 "The number of current cases at the beginning of the Spring term, 1928, was 6,420." Special enquiries. Assistance has continued to be given to the special committees of the Board of Education. In the earlier part of the year a number of measurements were taken for the Board's Anthropometrical Committee, and the investigation of changes of vision during early life has continued to be carried out for the Board's committee of enquiry into visual defect. 132 Accounts of various special researches made independently by the staff during the year are given under their appropriate headings. Amongst them are Dr. Nairn Dobbie's investigation into footrests on school desks (p. 53), Dr. Mabel Russell's investigation into conditions of sleep of elementary school children (p. 67), an investigation into the after history of children who have been treated for stammering by Dr. E. J. Boome and Dr. Nairn Dobbie (p. 80), Dr. Livingston's investigation into the present condition of children's mouths in regard to oral sepsis and dental decay (p. 63), an investigation into the progress of myopia under sight-saving conditions (p. 168), by Dr. Elizabeth McVail, and investigations into the physical results of attendance at nursery schools also by Dr. McVail (p. 128), and an analysis of the results of institutional treatment of rheumatic children by Dr. Nairn Dobbie (p. 81). Introduction. Infectious Diseases (Schools). The school has been so frequently accused of constituting one of the most important factors in the spread of infectious disorders that it will not be inappropriate in this report to endeavour to correct a misconception which has for so long persisted in the public mind. It would be idle to deny that occasionally illnesses are contracted by children through association with their school fellows, whether in school or during playtime, or whilst going to and from school, through unrecognised cases, or thoughtlessness of parents in sending their children to school whilst ailing, but the risks of infection, induced by the compulsory aggregation of children for the purpose of school attendance, have been so greatly minimised in recent years by a well-organised system of medical inspection and supervision, by the increasing activities of the school nursing service and by a more enlightened understanding and closer co-operation of the teaching staff in applying modern elements and principles of preventive control in the schools, that it is now safe to say that the school child of to-day is more guarded and sheltered from risks of infection whilst actually in attendance at school than he is in his social and domestic life. The child is compelled to attend school at the age of 5 years, and many commence their school life before the compulsory age of attendance, namely at a period when the susceptibility to many of the infectious ailments is at its highest. This want of immunity is especially marked during the earlier years of school life, and, ipso facto, it is during these years that infectious diseases exact their toll; they would do so whether the children attended school or not, and under modern social conditions of a large town there is little doubt that the opportunities of infection are far greater out of school. It must also be borne in mind that children only spend 5 hours of the day in school, during which time they are under strict supervision. Teachers are under an obligation to report to the school medical department every case of exclusion or absence from school on grounds of infection, and these are reviewed daily by the responsible medical officer, who takes immediate action if there is the least indication of spread of the more serious infections, such as diphtheria and scarlet fever, among the children. The classes in the school affected are medically examined, any suspicious cases are excluded for medical advice and treatment, the facts are reported to the medical officer of health of the borough for domiciliary enquiry, and all precautionary measures are taken. The services of school nurses are utilised in advising the teachers in regard to local outbreaks of the less important diseases, such as mumps, chickenpox, etc. With regard to measles, a rigid system of control is exercised whereby, in co-operation with the local sanitary authorities, every effort is made to prevent the serious complications and mortality arising during epidemics of the disease, which appear with regularity every two years. This scheme was fully explained in last year's annual report. School teachers are provided with handbooks showing the periods for which children suffering from the various infectious diseases, or living in houses where 133 infection exists are to be excluded from school; these handbooks also contain general advice on how to deal with individual cases under normal circumstances, and rules with regard to reporting exclusions from school. It has been deemed necessary to make these prefatory comments on the relationship between school attendance and the spread of infectious illness, because many parents, and in some cases even their medical advisers, have been wont to blame the school when local outbreaks of diphtheria, scarlet fever, or other illnesses occur. The fact that closure of school premises as a means of checking the dissemination of infection has for so many years past been abandoned by most public health authorities of the larger towns as a result of experience of its futility, and that the Ministry of Health generally discourages such action in the "Joint Memorandum on Closure of and Exclusion from School," are sufficient arguments against the " ostrich " policy of school closure. Having regard to the increasing amount of supervision now exercised, the tendency in recent years has bean in the direction of reducing the number of exclusions owing to contact with infectious illness in the home. A scheme has been in force for some time past in residential institutions, from which children attend the Council's schools, and where it is ascertained that proper medical observation is maintained, relaxation of the rules with regard to the exclusion of children from school is permitted when cases of scarlet fever or diphtheria occur at the institution. In other words, where proper vigilance obtains both at the school and in the home, the exclusion of healthy contacts should be unnecessary. It is hoped that the time will arrive when similar principles will be able to be extended without undue risk in certain cases to private families, thus avoiding a very large amount of loss of attendance at school and interference with the children's education. It is now generally recognised by those best qualified to judge that the commoner infections are spread by personal contact, namely by " droplet infection " through the medium of coughing, talking, sneezing, etc. The responsibility of school classrooms per se, by the retention and persistence of the materies morbi on the furniture or in the air of the room, may be regarded as negligible, subject of course to the proviso that proper air space, ventilation and cleanliness are always needed on general hygienic grounds alone. Applications for the disinfection of classrooms and the use of disinfectants in the school are, therefore, consistently discouraged, save in exceptional circumstances. A retrospect of 1927 reveals once again that the disease which still causes the greatest difficulty and anxiety is diphtheria. The persistent prevalence of this disease in recent years is causing public authorities no little concern. The average number of cases reported annually as occurring among London County Council school children during the fourteen years 1906-19 was 2,846. During the eight years, 1920-28, the average number was 5,198. It is true that the latter period contained the two years when both diphtheria and scarlet fever, especially the latter, assumed epidemic proportions, but even if these two years were taken out of account, the average annual number of cases reported was 4,848. It is specially noteworthy, however, that whilst the incidence of scarlet fever has declined to normal dimensions, the rate of fall in the prevalence of diphtheria has been much less marked, and during the past three years the general prevalence has almost equalled that of the epidemic years of 1920-21. Taking the general population during the fifteen years, 1911-25, London headed the list of diphtheria attack rates in the populous towns of Great Britain. It is to be feared that no satisfactory explanation is forthcoming to account for the preference of diphtheria for London, if such be the case. At the same time, the fact must not be lost sight of that in London, owing to the large number of hospitals and the completeness of its medical services, it is probable that greater facilities exist for bacteriological examination, and that the number of cases which 134 are notified purely on bacteriological evidence or on slender clinical grounds unduly swell the notification figures. Whatever the explanation, however, the need for combating diphtheria is one of the paramount problems with which the public health administration of London is faced. The London County Council is endeavouring through its school medical service to deal with the question of diphtheria carriers, undoubtedly a potent factor in the spread of the disease, by arranging with certain general hospitals to treat such cases intensively in special clinics, for there is no doubt, on all the evidence available, that the persistence of the carrier state is maintained by pathological conditions of the throat or nose which require special attention by operative interference or otherwise. Another more important line ot attack, and one which holds out more promise than any other method of prevention, is active immunisation. Already this measure is being carried out in certain London boroughs on a limited scale, but until the general body of the public is properly informed as to the advantages of these means for protecting its children from attack and until, as a result of widely directed propaganda, the public claims the right of having its children so protected, it cannot be expected that any material effect will be observed on the incidence of diphtheria. This subject is dealt with more fully on page 135. There was a rise in the prevalence of scarlet fever in 1927, but this disease continues to be mild in type, and it has been decided by the Metropolitan Asylums Board, after conference with the Ministry of Health, the Society of Medical Officers of Health (Metropolitan branch) and the Council, that in the matter of hospital accommodation, preference will be given to measles when the supply of beds in fever hospitals is uneaual to the demands. The numbers of cases of infectious diseases reported by the teachers as occurring among school children during the course of the year, compared with similar figures in the preceding four years, are shown below:— Disease. Diphtheria. Scarlet fever. Measles and German measles. Whooping cough. Chicken pox. Mumps. Scabies. Ophthalmia. Ringworm. 1923 3,985 4,824 13,784 7,304 13,849 7,916 1,110 1,881 1,935 1924 3,696 6,093 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 1927 5,097 6,498 8,119 8,387 17,358 13,876 820 492 831 Sohoolinspec tions in connection with infectious illness. 1927. Strict supervision of children attending the Council's schools is exercised and the visits of assistant medical officers and/or school nurses are paid to schools where cases of infectious illness have occurred among the pupils with a view to ensuring, as far as possible, that all sources of infection are eliminated in order that healthy children may continue to attend school without risk of infection due to school attendance. The following table shows the numbers of schools visited and the numbers of children examined in connection with investigations into the occurrence of scarlet fever and diphtheria in the Council's schools during 1927:— Diphtheria. Scarlet fever. Division. No. of visits. No. of depts. visited. No. of schools visited. No. of children examined. No. of visits. No. of depts. visited. No. of schools visited. No. of children examined. E 69 44 40 6,943 94 65 54 10,122 N.E 81 51 44 8,596 81 64 50 10,077 N.W 122 72 66 9,928 63 46 39 6,069 S.E 124 83 69 10,090 79 64 54 10,232 S.W 137 84 68 14,487 58 44 38 8,603 London 533 334 287 50,044 375 283 235 45,103 135 In addition to investigations by medical officers, valuable work was done by school nurses in following up the medical officers' visits for scarlet fever and diphtheria, as well as in connection with minor infectious ailments. For example, the services of the school nurses were utilised for advising head teachers and examining suspects in a large number of schools where outbreaks had occurred, as follows:—mumps, 160 schools; chickenpox, 154; whooping cough, 17; impetigo, 8: ophthalmia, 3. The part played by the school nurses in the control of measles is dealt with on page 143. Although in 1927, the prevalence of diphtheria showed a slight diminution, 5,097 cases having been reported as occurring among school children, as compared with 5,634 in the previous year, the consistently high incidence in the last few years has been causing no little anxiety, especially as local reports have suggested from time to time that the disease has been exhibiting a specially virulent type of illness. During the year 287 schools were visited owing to outbreaks of diphtheria in the localities concerned, involving 533 visits by assistant medical officers, whilst in a number of these schools a nurse was also in attendance daily during the outbreak, with a view to advising the head teachers and swabbing suspects. In the course of these investigations and during ordinary medical inspections, etc., 11,020 swabs were bacteriologically examined in the Council's pathological laboratory, of which 1,021 showed the presence of micro-organisms indistinguishable from B. Diphtheria, and the remainder were negative. These 1,021 positive results related to 748 children, of whom 253 were officially notified as cases of diphtheria. In 40 cases which yielded several successive positive results, tests were made for the virulence of the micro-organisms and 12 of them proved to be virulent, whilst 28 were avirulent. These latter cases were readmitted to school without further treatment. With a view to the more intensive treatment of diphtheria carriers, the Council, in November, 1926, sanctioned an arrangement with Guy's Hospital for dealing with such cases at a special clinic attached to the hospital. This clinic was commenced as an experiment for one year with a view to the observation and treatment of those difficult cases of children, who, though harbouring virulent diphtheria organisms in their throats and/or noses, and therefore potentially infectious cases, are nevertheless immune to diphtheria and do not suffer the usual clinical symptoms of the disease. They are therefore unsuitable tor admission to the M.A.B.'s infectious hospitals, and for years the problem of treating these cases effectively, both in the interests of the individual carrier and their associates, whom they are likely to infect, has proved very difficult. Medical practitioners have neither the facilities nor the requisite experience to give proper attention to such cases, and it frequently happens that the affected children are sent back to school with medical certificates to the effect that they are in good health, no attempt having been made to provide treatment. These certificates cannot be accepted unless they are based upon bacteriological examination, and the refusal to admit the children naturally meets with resentment on the part of the parents, who do not understand the position ; unnecessary friction is thus engendered, whilst the unfortunate children concerned remain untreated. In many such cases the parents decline to allow the children to be re-swabbed or subjected to any kind of treatment, and, apart from the risks of spread of disease, considerable loss of school attendance is thus entailed. In one case quite recently the affected child with her brothers and sisters were excluded from school for several months, merely because the parents refused to allow them to be examined until they were finally induced to give their permission after a threat of prosecution for non-attendance at school. Even the general hospitals are at a loss to know bow to deal with these cases. It is a common practice for diphtheria carriers to be taken to a general hospital, where they wait in the ordinary out-patients' department at a grave risk of spreading diphtheria, and steps have been taken to obviate this practice as far as possible. Usually the only action taken at the hospital is to swab the child ; it frequently Diphtheria. 136 happens that a negative result is obtained and the child returns to school only to be re-excluded on a further positive bacteriological finding in the Council's laboratory. The whole position is a very difficult one, and the only solution presenting itself at present is to concentrate upon the treatment of these cases in special clinics at certain hospitals in different parts of London. It must be borne in mind that there are different varieties of so-called carriers of diphtheria germs. Some of them are harbouring harmless micro-organisms indistinguishable from true diphtheria, as seen under the microscope, but their toxicity can only be determined by a test for their virulence. Children are allowed to return to school when the test has proved that the germs are not virulent. Those carrying virulent germs capable of conveying disease to a susceptible child are excluded for treatment. Some, again, known as "passive" carriers, are themselves immune to the disease, but through casual infection they carry the germs in their throats or noses for quite a short period ; these quickly clear up with mild antiseptic gargles, etc. On the other hand there are numbers of children who suffer from various abnormalities of the throat or nose, such as enlarged tonsils and adenoids, ear discharges, ulcers and inflamed mucous membranes due to miscellaneous causes, who are capable of carrying and manufacturing the germs for long periods ; these children constitute the real danger if they remain untreated. It has been found from time to time that such cases, after tonsillectomy or other appropriate surgical treatment has been carried out, lose their capacity for carrying diphtheria germs. In this connection it is germane to quote from the annual report of Sir J. Robertson, the medical officer of health of the City of Birmingham for 1926. A good deal of work has been done in connection with the subject of diphtheria and the carrier problem in Birmingham, and Sir J. Robertson in his report states, inter alia, as follows— In our experience the persistent carrier is nearly always the possessor of enlarged or unhealthy tonsils and/or adenoids. * * * * Tonsillectomy and the removal of adenoids would appear to be a method of great value in the clearance of the obstinate carrier of diphtheria bacilli of proved virulence. As perhaps might be expected, clearance is more readily obtained of organisms from the throat than the nose. The large surface presented by the nasal mucosa for the lodgment and growth of diphtheria bacilli makes for difficulty in clearance by any means—surgical or otherwise. Nevertheless, the removal of the adenoid pad must tend to cut short the supply of organisms from the post-nasal space. Although no clinical method is uniformly successful, it may be said that the rational surgical treatment of the naso-pharynx is a great advance upon the extremely unsatisfactory methods—antiseptic sprays, bacteriological dyes, and diphtheria vaccines—hitherto available for the attempted clearance of the convalescent diphtheria carrier. There is no doubt that the chronic carrier of organisms of proved virulence is at present an important factor in the spread of infection and must be considered in quite a different category to the casual or transient carrier of harmless diphtheroids. It is important wherever possible to secure the bacteriological clearance of these chronic carriers. But important as he is in the spread of infection at the present time, he might be rendered relatively or even absolutely unimportant by the active immunisation against diphtheria of children of susceptible ages. The chronic carrier of virulent diphtheria bacilli who is always himself immune to the disease, can do no damage amongst a population which has also been rendered actively immune. The tragedies of the late case of diphtheria coming under treatment only when anti-toxin even in the largest doses can be of no avail will then cease to occur. 137 At Guy's Hospital clinic 115 children had been dealt with up to 31st December, 1927. Of these, 56 were able to return to school in less than four weeks, 32 in four to eight weeks, 13 in eight to twelve weeks, 9 in twelve to sixteen weeks, and one child was under treatment for nineteen weeks, but this case was complicated by chorea and the child was admitted to a Poor Law hospital. The remainder were still under treatment. There is no doubt that the existence of this clinic has satisfied a long-felt want and that much benefit has been derived from the special treatment of the children concerned and the minimising of risk of spread from such cases. But the clinic only serves a circumscribed area in South-east London, and more of these clinics are required in other parts of London if this important problem is to be properly faced. With this object in view the Council has authorised the extension of the scheme of treating diphtheria carriers in special clinics attached to certain other general hospitals in order that the facilities shall be available over a wider area, and negotiations to this end are proceeding. Schick test and active immunisatioi against diphtheria. The Council has had under consideration from time to time during the past few years the subject of the Schick test and active immunisation against diphtheria, and references to this preventive measure has appeared in previous annual reports. The most recent evidence on the subject is contained in a report, published in March, 1927, by the Medical Research Council, by Dr. J. Graham Forbes, one of the principal assistant medical officers of the Council. The Medical Research Council, in a preface to this report, state that it contained a comprehensive survey of this method of diphtheria prevention practised upon a large scale for the past ten years in America, and to a much less, though growing, extent in Great Britain. In July, 1927, it was referred to the Public Health Committee to report as to the need for taking fresh measures to combat diphtheria, in view of the aforementioned evidence published by the Medical Research Council, and the following extract from the report of the Public Health Committee, submitted to the Council on 20th November, 1927, which was adopted, is quoted in full, as it indicates what attitude the Council is taking at present with regard to the question of active immunisation, especially in relation to school children. In the report the subject is dealt with under main heads as follows:— "(1) Evidence available with regard to the value of the Schick test and active immunisation against diphtheria.—The results of his (Dr. Forbes') enquiry show unmistakably that diphtheria in London has a higher rate of incidence and of mortality than in almost any other European capital, and a higher rate of both than in any other large city in Great Britain. The large body of evidence already available leaves no doubt that the disease and its often fatal consequences may now fairly be called avoidable. The experience already gained during recent years and in so many places imposes upon every public health authority the responsibility of giving serious consideration to the provision of means now available for protecting life, and especially young life, from the menace of a disease whose prevalence and malignancy have been increasing of late years, and seem more likely to increase still further under present conditions than to diminish. At the same time, it should not be overlooked that an important part of this provision is the necessity for making the facts clearly known to all parents, and for instructing them as to the means open to them for the safeguarding of their children." In his report for 1925, the chief medical officer of the Ministry of Health says:— "For several years careful observation has been made of the use of the Schick test and of immunisation against diphtheria. ... As a result of improvement in material and technique, this method of prevention has now passed beyond the experimental stage, and is widely regarded as the best way of protecting against this disease. In my annual report for 1924 its appropriate use was advocated and local education authorities, hospital authorities and those in charge of maternity and child welfare centres were recommended to consider its adoption in suitable 138 circumstances. The experience of the year has, I think, justified this recommendation. ... As antitoxin has proved itself the best method of treatment, so immunisation appears to be our best prophylactic." The above-mentioned authoritative views form, to a large extent, the justification upon which such action as has been taken by public health authorities in this country has been based. As regards actual experience of active immunisation in this country, where it has been adopted in a particular area, the number of children immunised in proportion to the number of susceptible children is so small, and the period during which this preventive measure has been employed, so short, that any marked variation in the incidence of diphtheria can hardly be expected. On the other hand, there is strong evidence that where the population of institutions, such as the staffs of fever hospitals, residential schools and the like, have been immunised, a marked diminution in the incidence of diphtheria has followed. There is, as yet, however, insufficient evidence to demonstrate the effect, as regards the incidence of diphtheria, upon any given community, even if the whole or the great majority of the child population were actively immunised, because, so far as can be ascertained, there is no place in the world where active immunisation has been carried out with such completeness as to render it possible to draw any justifiable and certain conclusion. In New York and other large American towns immunisation has been carried out on a wider scale than elsewhere. In New York City over 600,000 children were tested, and over 400,000 children were immunised between 1916 and 1926. The child population of New York City, i.e., those of school age and under, is about 1,650,000. Coincident with these immunisations there occurred a decline in diphtheria mortality, for whereas the average number of diphtheria deaths for ten years previous to 1919 was 1,337, the corresponding figures for 1924,1925 and 1926 were respectively 715, 663 and 477. A corresponding decline was observed in other American cities. The conclusion must not, however, be drawn that the decline was entirely due to the immunisations which had been carried out, although they may have exerted some influence, because (a) after the period of cyclic prevalence which had been experienced in preceding years, the incidence of the disease would normally be expected to fall, and (b) the proportion of children immunised could not be expected to make any very marked difference in the epidemicity of the disease. That there is real need for caution in ascribing the remarkable diminution in the prevalence of the disease in New York between 1924 and 1926, to active immunisation alone, becomes clear from the fact that during the first six months of 1927, there has been a notable rise both in the incidence and mortality from diphtheria in New York City, no fewer than 8,596 cases, with 435 deaths, having occurred up to the end of June, 1927.* It is stated that the evidence, so far provided by results in America, points to an effective protection for at least six, and possibly ten, years. According to authoritative American observers, as a result of observation over periods ranging from 3 to 6 years, no child who received the full immunising course, and had given a Schick negative reaction, subsequently contracted diphtheria. Having regard to all the evidence so far available, which is set out in extenso in the report published by the Medical Research Council, and to the pronouncements of the Ministry of Health, there can be no reasonable doubt that active immunisation is now regarded by many prominent members of the medical profession as a valuable preventive measure. *The total number of cases reported as occurring in New York City during the whole of 1927 was 14,778 as compared with 7,367 in 1926; 9,051 in 1925; and 9,687 in 1924; whilst 716 cases (approx.) proved fatal in 1927 (figures for preceding years are shown in context above). 139 London holds an unenviable position both in Great Britain and the whole of Europe as regards the incidence of, and mortality from, diphtheria. During the 15 years, 1911-25, the average attack rate from this disease in London was higher than in any other large city in Great Britain. At the same time it must be borne in mind that the statistical records of notified cases of diphtheria in London tend to exaggerate the actual incidence of clinical diphtheria, as experience has shown that since the introduction of bacteriological aids to diagnosis of this disease, many doubtful cases, with little or no clinical evidence of diphtheria, are notified on bacteriological evidence alone, although the notification and removal to hospital of diphtheria "carriers," in more or less normal health, is officially discouraged. This tendency to notify cases on slender clinical grounds, if a bacteriological examination reveals the presence of the diphtheria micro-organism, is necessarily greater in a place like London where bacteriological facilities are more readily attainable. On the other hand, it must be remembered that bacteriological assistance in diagnosis has been invaluable in discovering many mild anomalous cases, frequently mistaken for tonsilitis, which in pre-bacteriological days were overlooked until the later symptoms of paralysis supervened. There is a further aspect of the question to be noted, namely, that a substantial proportion of cases notified as diphtheria prove, in the light of subsequent observation, not to be diphtheria. Of the 12,478 cases of diphtheria notified in London in 1925, 11,613 were admitted to the Metropolitan Asylums Board's hospitals, and in 2,366 of these cases, i.e., 20 per cent., the diagnosis proved to be erroneous. To what extent similar considerations apply in other large towns in England and Wales cannot be generally stated, but in Birmingham, during 1925, 1,999 cases were admitted to hospital as diphtheria, and in 290 (14 per cent.) of these, there was no evidence, on admission, either of clinical or bacteriological diphtheria. As regards average death rates during the 15 years 1911 to 1925, London occupied the fourth place in the order of the large towns in Great Britain. Talcing the large capital towns of Europe the death rate in London from diphtheria in 1924 (the latest for which the figures are available) was exceeded only by Edinburgh and Rome. There is no doubt, however, that in London, as elsewhere, the mortality from diphtheria has been markedly reduced since the introduction of antitoxin treatment, and that greater promptitude in the application of this form of treatment is bound to exert a progressively beneficial influence. (2) By what means and under what circumstances the new measure of prevention should be employed, if considered desirable.—This is a question for consideration, not only by the Council, but by all public health authorities in London. There is no doubt that diphtheria is attended by most fatal consequences under the age of five years, and, therefore, the problem of immunisation is primarily the concern of the metropolitan borough councils. The Westminster City Council and the Battersea, Camberwell, Deptford, Hackney and Holborn Metropolitan Borough Councils have initiated centres providing facilities for this purpose, and in several other metropolitan boroughs the matter is under consideration.* The extent to which the facilities for immunisation are made use of in the six boroughs mentioned is directly proportionate to the amount of propaganda and education of the parents which has been carried out. It would appear desirable that all public health bodies, both voluntary and public, including hospitals, provided they are persuaded as to the soundness of the measure, should assist the borough councils, as far as possible, by the dissemination of authoritative information on the subject. On the question whether the Council should supplement the efforts of the metropolitan borough councils by undertaking the immunisation of school children, we are informed that facilities, though at present very limited, already exist for *Stoke Newington, Marylebone, Poplar, Finsbury, and Wandsworth Borough Councils have since established immunisation centres. 140 school children to be tested and immunised in certain of the boroughs, and that these facilities will doubtless be considerably extended in the near future. It would appear desirable that those parents who desire that their children should be protected by immunisation should be given every opportunity of satisfying their wishes. In this connection we have considered a suggestion that as an experiment, in connection with selected schools at which the diphtheria incidence is high, facilities should be provided for the contacts of diphtheria cases to be inoculated as a preventive measure, with a view to accumulating information as to the results over the next two or three years. If immunisation were carried out in selected schools on the lines suggested, it would need to be conducted over a fairly wide area, e.g., a whole borough, before any reliable results on the local incidence of diphtheria could be demonstrated. If a few isolated schools were selected for the purpose it is doubtful whether any sound conclusions could be drawn from the effect upon the incidence of the disease, owing to fluidity of the school population, and to the fact that in the present state of public knowledge on the subject, the proportion of parental consents would not be sufficiently high. The prevalence of diphtheria fluctuates, both as regards time and place, and the disease attacks certain districts, remaining prevalent therein for varying periods, in some cases for two or three years, and then by the very process of natural immunisation through actual association with the disease—known as the "salting" of a community—the incidence dies down, only to transfer its activities to another district where it goes through a similar process. Active immunisation, as now carried out, produces by scientific means the same process of "salting" a community as would happen by natural means in a district where the disease prevails for any length of time, except that the artificial method of immunisation confers protection in a much shorter time than nature, unaided, takes to effect the same object, and thus tides over the susceptible period of a child's life. (3) To what extent and by what means, if any, the Council should carry out or assist in propaganda on the subject.—We are informed that the Education Committee have already given faciliies for the use of the school organisation in three boroughs (Holborn, Deptford and Camberwell) in the distribution of leaflets, prepared by the borough medical officer of health on the Schick test, and that these facilities will be extended to any other metropolitan boroughs in which it is decided to adopt measures of immunisation. The facilities provided by the school organisation afford a simple and inexpensive method of providing information for those parents who desire to be informed on the subject. (4) Whether any steps for the prevention of diphtheria among school children can usefully be taken by the Council, apart from measures already adopted in the school medical service.—The Education Committee have recently had under consideration the difficulty of dealing with diphtheria "carriers" who are responsible for spreading the disease. A special clinic has been held at Guy's hospital, at the Council's request, for more than a year with very satisfactory results, and in order that London may be properly provided with such facilities, inquiries have been undertaken with a view to the establishment of clinics of this kind at other hospitals suitably situated geographically. (5) Conclusion.—It is important to bear in mind that in London the metropolitan borough councils are the local authorities statutorily responsible under the Public Health (London) Act, 1891, for the prevention of infectious disease, although the Council has certain definite responsibilities in regard to the health of school children. The cardinal fact remains, however, that measures for the prevention of the spread of infectious diseases, such as diphtheria, are primarily the duty and responsibility of the metropolitan borough councils. 141 So far as the Council is concerned, we are of opinion that in the present state of knowledge it would be premature for the Council to introduce any measure of active immunisation among school children, even on a limited scale, until further experience is gained. The Education Committee concur in this view. Close observation will continue to be kept on the results of the new method of prevention where it has been adopted, and we have given instructions for a further report to be submitted to us on the subject in a year's time." Scarlet fever. During 1927, 6,498 cases of scarlet fever were reported as occurring among children attending the Council's schools, and 235 schools were visited from time to time by the Council's medical staff in connection with outbreaks of this disease ; these visits were supplemented where necessary by the attendance of school nurses for the purpose of "following-up." At these inspections over 45,000 children were examined. Scarlet fever has been very mild in type for some years past, with the result that a large number of ambulant and unrecognised cases occur, thus increasing the difficulty of control. Many of these cases are exceedingly difficult to diagnose, and there is no doubt that many of the spurious rashes met with are actually attributable to scarlet fever, whereas they pass under the names of other exanthems such as rubella, morbilli, fourth disease, epidemic roseola, etc. Rubella especially occupies a prominent place in the differential diagnosis of scarlet fever. Dr. G. E. Friend, the medical officer of Christ's Hospital published in the Lancet of 11th February, 1928, a very interesting account of a number of outbreaks of various exanthemata, in which he describes very fully the differing characteristics of each, and leads up to the conclusion that there are, in addition to the classic type of scarlet fever, two additional strains which he refers to as para-scarlet A and para-scarlet B. The latter type, he states, is very benign, corresponding to the milder form of scarlatiniform rubella (the epidemic roseola of Dukes), and only needs rest in bed during the period of the rash, with mild treatment, whilst para-scarlet A may be either benigr or severe ; it may even assume a fulminating or malignant form. Whilst he states that scarlet fever and para-scarlet A may be taken together, the complications of the 'para' forms differ markedly from those commonly associated with scarlet fever Dr. Friend summarises the importance of distinguishing these diseases from one another as twofold:— "(1) Neither scarlet fever, the para forms, nor rubella protect against each other, and a wider recognition of their separate nature will help to prevent the admission of the 'para' forms into hospital with cases of scarlet fever. "(2) Recognition will facilitate the early discharge of the para B and the mild cases of para A from hospital. There are few, if any, medical officers who would regard it as safe or expedient to liberate a case of scarlet fever, howeve mild, under four weeks, while the majority of cases of para A and all of para B can be discharged to ordinary life with perfect safety in two weeks. This is important on the grounds of finance, public opinion and school management." Further investigation into this suggestion of the differing types of scarlet fever and their distinguishing characteristics from other exanthemata would thus appear to be desirable from every point of view, and it remains to be demonstrated whether the observations of medical officers of fever hospitals bear out the conclusion arrived at by Dr. Friend. The tendency of both scarlet fever and diphtheria to persist for a number of years in certain localities has been observed for some time past, and the following table is shown to illustrate this phenomenon. The statistics cover a period of five years (1923-27). It will be noted that both diseases favoured the poorer class and more densel populated areas, namely the East End, especially Shoreditch and Bethnal Green and the riverside districts on the South, notably Bermondsey, Southwark, Greenwich 15436 k 142 Deptford and Battersea, whilst in the North, Hackney and Finsbury are prominent though to a somewhat less extent. A specially marked feature is the low prevalence of both diseases in the West and North-west areas as regards both scarlet fever and diphtheria. In these districts the overcrowded and insanitary neighbourhoods are surrounded by better class residential property and more sparsely populated areas, which provide a sluice against the tide of infection. The table also demonstrates that scarlet fever and diphtheria definitely tend to run together. In considering the densities of population in the various boroughs regard must be paid to the fact that in some boroughs more or less extensive, areas are not residential, such as in the case of Bermondsey where the docks cover a wide tract of land ; if allowance is made for these unoccupied spaces the actual density of population in Bermondsey is in the neighbourhood of 200 persons per acre instead of 79. Again, in other boroughs, like Lambeth, certain quarters are densely populated whilst in other parts of the borough good class residential property prevails, thus providing a diluent to reduce the general density of the borough taken as a whole. The parallelism of movement of diphtheria and scarlet fever prevalences during the period 1901-1918 was discussed and illustrated in the annual report of the County Medical OAS 'er for 1918 (pages 47 and 48). In the following statement of case-rates per thousand of population relating to the past five years, local rates which are in excess of the corresponding rate for London as a whole in each year are shown in heavy type. District. 1923. 1924. 1925. 1926. 1927. Average (5 years). S.F. Diph. S.F. Diph. S.F. Diph. S.F. Diph. S.F. Diph. S.F. Diph. West— Paddington 2.22 1.52 1.95 1.89 1.81 2.30 1.37 318 2.25 2.60 1.92 2.30 Kensington 1.21 1 .39 1.79 1.27 1.49 1.66 1 .67 2.40 1.51 2.22 1.53 1.79 Hammersmith 1.83 1.74 1.77 1.98 2.17 1 .55 2.07 1.90 2.35 2.78 2.04 1.99 Fulham 289 1.71 2.21 1.60 2.41 1.66 1.90 211 2.22 2.42 2.33 1.90 Chelsea 1.71 1.52 1.33 1.24 1.33 2.66 1.76 311 2.11 2.00 1.65 2.11 Westminster, City of .88 .69 1.47 1.69 1.47 2.07 .88 1.51 1.12 1.23 1.16 1.44 North— St. Marylebone 1.19 1.24 1.72 1.18 1.64 1.25 117 1.84 1.73 1.59 1.49 1.42 Hampstead 2.13 1.22 1.82 1.17 2.03 1.80 1.29 2.03 1.59 .91 1.77 1.43 St. Pancras 2.24 2.41 3.49 2.85 3.02 3.26 2.00 2.43 2.49 1.83 2 65 2.56 Islington 3.22 2.65 3.15 2.51 3.37 2.70 2.98 2.19 2.73 2.16 3 09 2.44 Stoke Newington 1 .33 1.08 1.66 1.96 1.30 1.40 3.66 1.59 2.64 2.04 2.12 1.61 Hackney 1.99 2 35 2.32 242 2.31 2.90 3.31 2.84 4.37 2.87 2.86 2.68 Central— Holborn 2.47 2.33 2.08 1.64 2.11 1.90 2.00 1.74 1.43 1.31 2.02 1.78 Finsbury 2.36 4.04 2.85 2.51 3.67 3.27 3.27 2.39 323 2.70 3 08 2 98 City of London 2.84 1.31 .94 .72 1.77 1.40 2.89 3.71 2.87 1.36 2.26 1.70 East— Shoreditch 3.72 3.40 3.45 3.63 4.53 4.11 4.01 3.53 3.60 4.43 3.86 3.82 Bethnal Green 2.61 4.10 3.53 4.73 2.78 4.16 3.92 5.40 5.13 4.10 3.59 4.50 Stepney 2.03 2.41 2.21 2.20 2.34 2.54 3.75 3.01 4.06 3.49 2.88 2.73 Poplar 1.74 2.19 2.91 2.40 2.80 2.18 4.00 2.97 4.86 2.56 3.26 2.46 South— South wark 2.19 411 2.81 4.18 3.93 4.80 2.56 5.02 2.93 4.20 2.92 4.46 Bermondsey 2.70 4.84 3.20 4.39 2.91 4.36 3.51 5.82 4.98 3.99 3.46 4.68 Lambeth 2.71 1.89 3.04 1.94 3.35 2.67 2.41 2.32 2.20 2.52 2.74 2.27 Battersea 252 2.52 2.32 2.53 3.22 2.66 3.60 3.52 2.49 4.47 2.83 3.14 Wandsworth 1.72 1.10 2.47 1.36 2.33 2.23 1.89 2.29 2.39 2.23 2.16 1.84 Camberwell 1.90 3.17 2.17 3.00 3.26 3.36 3.06 3.86 2.40 2.81 2.56 3.24 Deptford 3.01 3.53 2.52 3.04 2.47 5.03 3.41 4.94 3.50 3.60 2.98 4.03 Greenwich 2.11 2.12 2.82 3.07 2.96 4.23 3.60 4.88 4.77 4.42 3.25 3.74 Lewisham 2.16 1.58 1.96 .98 2.04 1.32 2.55 2.10 3.26 1.81 2.39 1.56 Woolwich 2.11 1.06 2.87 1.37 2.47 2.09 283 2.55 2.99 1.75 2.65 1.76 London County 2.21 2.26 2.50 2.30 2.66 2.72 2.68 2.95 2.91 2.69 2.59 2.58 143 The number of cases of measles, viz., 8,119, reported as occurring among pupils attending the Council's schools during 1927 was the lowest on record. It is true that the period corresponded with the trough of the measles wave, following the epidemic of 1925-6, but with the exception of 1921, when 8,317 cases were reported, no such low prevalence has been experienced since 1906 when the number of cases of measles among school children was first recorded. Mcasles. Measles has, within recent years, tended to become more explosive in its epidemic phases and outbreaks occur at more regular intervals, namely every two years. These periodic prevalences last about six months. Owing to exhaustion of susceptible material for attack the disease then becomes quiescent during an approximate period of eighteen months, when it commences to become active again. Apart from immunisation by means of serum from convalescents, every known method of control has been attempted with a view to checking its spread during these epidemics, but so far without success. Unfortunately these explosive outbreaks have always been accompanied by a high mortality and within recent years it has been the object of the Council, in co-operation with the metropolitan borough councils, to concentrate more upon preventing the complications of the disease which are the real cause of the deaths and extensive injury to health which follow in the wake of an attack of measles if proper medical attention and efficient nursing are not provided at an early stage of the illness. The scheme of control was fully set out in last year's annual report and it was then stated that attention during the next epidemic, which was due towards the end of 1927, would be directed towards the provision of home nursing or isolation hospital accommodation as regards the more overcrowded and insanitary areas, where medical advice is not usually sought and where nursing arrangements in the home are impracticable. The earlier the knowledge of cases of measles becomes available, the sooner may assistance be offered in the matter of home nursing and the greater the chance of averting complications. The epidemic, which was due in November, 1927, commenced almost in the week it was expected, for towards the end of that month the disease commenced to show signs of considerable activity judging from the number of cases reported from the schools. The scheme of control was put into force early in December. Plans had been fully prepared for classifying the schools according to the average social class of the children attending, and when the epidemic commenced the school nurses were drafted in the first place into those schools which were situated in overcrowded and badly housed areas, as soon as measles appeared therein, for the purpose of supervising the children and ascertaining in co-operation with the school attendance officers which of the absentee children were likely to be suffering from or developing measles, and with a view to informing the borough medical officer of health in such cases, so that he in turn might arrange for removal of the patients to hospital or for a district nurse to be provided, according to circumstances. It was already stated in the report of 1926 that the Metropolitan Asylums Board had undertaken to give preference to the admission of measles cases over scarlet fever cases, into their hospitals if the supply of beds was insufficient to meet the requirements for both diseases. At the end of 1927 the children being treated for measles in the M.A.B. hospitals numbered 1,063. During the epidemic which is now in progress, a new feature, which constitutes a definite step in advance, was introduced in connection with the propaganda for impressing upon parents the seriousness of measles and the need for obtaining early medical advice. It has for long been realised that one of the chief obstacles towards the efficient control of measles is the nonchalant attitude of parents generally toward the disease, and the tendency to regard it as a minor ailment of childhood which is unavoidable and therefore "the sooner it is over before Johnny goes to school the better." This lamentable, but unfortunately general, view of the matter among the poorer classes especially has been responsible for innumerable domestic tragedies. 15435 K 2 144 Measles is most dangerous during the second and third year of life and is a disease from which children should be protected as far as possible up to at least five years of age, the compulsory age of school attendance, and if attacked, should receive skilled medical or nursing attention. As an indication of the success with which the problem of mortality from measles has been combated by public health authorities in London in recent years the following table is quoted as indicating that whilst the incidence of the disease has remained more or less stationary, the number of deaths has progressively declined during the past twenty years and especially in the last decade. As measles is only notifiable in ten London boroughs and then only in a limited capacity, no statistics can be given of the number of cases occurring in the whole population, but the cases reported among school children, as shown in the table, may be taken as a reflex of the general incidence for purposes of comparison. Quinquennium. No. of cases reported nmong school children. No. of deaths (all ages). 1908-12 116,921 10,197 1913-17 112,185 8,040 1918-22 110,650 4,818 1923-27 117,151 3,170 Whooping cough. The number of cases of whooping cough reported from the schools during the year was 8,387 as compared with 5,534 in 1926. The incidence in preceding years will be found in the table on page 134. More than half the total cases for the year occurred in the period January to March. The school nurses visited seventeen schools where outbreaks occurred for the purpose of observation and of advising head teachers. Chiokenpox. There was a considerable rise in the number of cases of chickenpox reported as occurring among school children during 1927, namely 17,358 cases as compared with 12,769 in 1926. Figures for previous years will be found in the table on page 134. The prevalence of this disease necessitated the school nurses visiting 154 schools for the purpose of examining the children and giving advice. Mumps. 13,876 cases of mumps were reported by head teachers during the year as compared with 11,897 in 1926 (see table on page 134). This disease has been more than usually prevalent during the past four years, 50,410 cases having been reported as compared with 33,829 in the preceding four years 1920-23. During the year 160 schools were visited by school nurses in connection with the prevalence of the disease. Ophthalmia. The continuous decline of cases of ophthalmia among school children is eloquent of the useful work which is being carried out in connection with the medical treatment of minor ailments in school children. Only 492 cases were reported during the year as compared with 606 in 1926, 882 (1925), 1,101 (1924) and 1,881 (1923). The disease was most prevalent in Bermondsey where 107 out of a total of 492 for all schools were reported. Poplar had 68 cases, Stepney 57, Islington 43, Lambeth 48, Bethnal Green 29 and Shoreditch 21. Ringworm and favus. Ringworm continues to decline as will be noted in the table below. Year. Fresh cases. Cured cases. Cases outstanding at the end of the year. Percentage of cures effected by X-ray treatment. 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 1919 3,447 3,103 1,259 57 145 Year. Fresh cases. Cured cases. Cases outstanding at the end of the year. Percentage of cures effected by X-ray treatment.[/$$$] 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 1927 896 868 249 76 During 1927, of the specimens of hair stumps sent in by the school nurses, 1,872 were examined in the Council's laboratory and of these 653 contained ringworm fungus (550 small spore and 94 large spore) and 9 proved to be favus. Three fresh cases of favus were discovered during the year, whilst 5 cases remained uncured, making a total of 8 cases under treatment, all of which were cured during the course of the year. It has been recognised for some time past that ringworm is a generic title for a variety of skin affections which are due to different forms of fungus, which, although related, are quite distinct from each other, just as the tea rose, for example, is different from the rugosa. One form of ringworm can only be produced by the same species of fungus. In this connection valuable observations have been made during the past year. The fungi of ringworm may affect either the hairy scalp, the beard or the smooth skin. From a school point of view scalp ringworm is by far the most important variety, and adults, except those coming from a tropical country, are generally immune from the disease. The consequent inflammation or dermatitis of these fungi may differ in various individuals, depending not only upon the fungus but on the age of the person or on special peculiarities generally referred to as " idiosyncrasies." These parasitic affections may be manifested by a superficial scaly patch, or they may produce eczematous, pustular or granulomatous lesions. Two years ago Dr. J. A. H. Brincker, when investigating an outbreak of ringworm in a girls' residential school in the country affecting some 30 of the girls, found three entirely different types of fungus—the conclusions arrived at were that there were at least three different sources of infection. Recognition is due to Messrs. J. G. Hare and P. Tate, of the Molteno Institute for Research in Parasitology, Cambridge University, for the identification and classification of ringworm specimens from London school children, and a short summary of their report is here given. The fungi producing this group of skin diseases belong to the botanical class called Fungi Imperfecti and to the natural order Thallospirales. To this group also belong other fungi, notably the monilias which are known to produce disease in the human being. The ringworm fungi generally belong to two sub-orders of the Thallospirales, namely— I. True Thallospirales.—The pityrospirum or bottle bacillus which produces a disease simulating ringworm; it also affects the skin, nails and hairs, often producing a bulbous swelling, at which the hair splits or breaks off; this is known as Trichorexis nodosa. A case of persistent affection of the nails produced by this fungus was demonstrated in one of the children attending a school in Fulham. II. Sub-order Arthrospirales—(&) Favus types.—These are produced by the genus Achorion. In London school children only one species has been identified, (b) Large Spared type.—This variety is produced by the genus Trichophyton, which produces 17 per cent. of all the cases in London schools. Four species have been identified, namely—T. crateriformi, 41 per cent. of all large spore. T. acuminatum. 146 33 per cent. of all large spore. T. sulphureum, 17 per cent. of all large spore. T. violaceum, 9 per cent. of all large spore. This is a very rare species, (c) Small spored type—(microsporon).—This genus is by far the most common fungus in London and is responsible for 78 per cent. of all cases of ringworm of the scalp. It is a fungus which very rarely attacks adults or the smooth skin even of children. It is important that this latter consideration should be borne in mind as it is not uncommon for school teachers or others to allege that they have contracted ringworm from a school child, whereas on investigating the matter, it is trequently found that the disease from which the aggrieved person is suffering is not ringworm at all. The following species of small-spored ringworm (microsporon) have been identified in London school children—M. audouini, 89 per cent.; M. felineum, 2 per cent.; M. Lanosum, 2 per cent.; M. velvetium, 4 per cent.; other species so far unidentified but different from those mentioned, 3 per cent. Miscrosporon audouini is by far the most common species of fungus which affects London school children. It is responsible for over 70 per cent, of all the cases coming under observation. During the past year a portable apparatus for the purpose of assisting in the diagnosis of difficult cases of ringworm has been installed in the mcdical examination room at County Hall. This apparatus is similar to the type employed for the therapeutic use of artificial sunlight. A screen of Wood's glass is interposed between the ultra-violet rays and the object for diagnosis. By this means only rays of a certain wave length are allowed to pass, and these rays, by their property of fluorescence throw all diseased hairs into prominence. It is an apparatus specially designed for diagnosis and not for treatment, and as such should prove to be of value in children's institutions. Epidemic jaundice. An outbreak of cases of jaundice among school children attending Fircroft Road L.C.C. School, Tooting, was investigated by Dr. C. A. Thornton, one of the assistant medical officers. In all, 13 cases appear to have occurred, mostly in April and May. The history of the symptoms appears to have been almost identical in all cases, viz., a sudden onset with no premonitory symptoms, vomiting, anorexia, rapidly followed by jaundice with clay-coloured stools and dark (sometimes " black ") urine. The jaundice persisted from one to four weeks. There were no sequelae or complications. As this outbreak was not reported immediately, there was no possibility of suggesting that the urine should be tested for the presence of leptospira icterohcemorrhagica. Such a test must be made in the early stages of illness with any prospect of isolating the organism. No evidence of contact infection could be traced. In seven of the cases there were brothers or sisters (in one instance there were six) but only in one family was there a second case, and there was three weeks' interval between them. There was also no evidence that diet had any causal influence on the occurrence of the cases. Epidemic catarrhal jaundice has frequently been associated with outbreaks of influenza, and is regarded by some authorities as being one of the protean manifestations of influenza. In this outbreak there were no cases of influenza at the school, although it had been prevalent earlier in the year. A similar outbreak among school children occurred in the Camden Town area of St. Pancras during October and November. Several schools were affected. Dr. Sowden, the medical officer of health, stated that the urine had been examined in several cases for the leptospira icterohcemorrhagica. but with negative result. He attributed the outbreak to ordinary catarrhal jaundice. The standard of health of the children in the Council's residential, special and industrial schools and places of detention, has, so far as infectious diseases are concerned, been very good on the whole. At Homerton Deaf School, Penn, Bucks, there was a small outbreak of German measles limited to four cases. At Clapham Residential special and industrial schools and places of detention 147 Park (M.D.) School (Girls) five cases of scarlet fever and three cases of diphtheria were reported ; the children were all swabbed on two occasions in connection with the occurrence of diphtheria but no "carriers" were discovered. In view of the prevalence of the disease in the locality, the cases were no doubt imported. An outbreak of influenza, comprising 27 cases, occurred at Portslade Industrial School between the 13th and 24th January, and all the twenty-seven boys attacked recovered within a week of the onset of illness. The Treatment of Crippled Children* The Annual Report of the Chief Medical Officer of the Board of Education (1926), page 25—contains a statement to the effect that London is an area without an orthoptedic scheme. Moreover, it is clear that the Chief Medical Officer is of the opinion that, for this reason, London children are at a disadvantage compared with certain other areas. It is, of course, true that the Council has not promulgated what might be called an orthopaedic scheme, in the sense in which these words could be correctly applied to the Council's Tuberculosis or Venereal Disease schemes ; but, on the other hand, it would be grossly wrong, and indeed, unjust, to suggest that, because there is no formal scheme, therefore the Council has neglected its duty to the crippled children of London. The truth is that, for many years past, the Council, through the Education and Public Health Committees, has given careful and continuous study to the provision of adequate measures for the prevention and treatment of all those conditions which lead to the crippling of children. In this connection, it should always be borne in mind that the various disorders which give rise to crippling may, and in fact frequently do, arise before the commencement of school life, and from this it follows that any adequate measures taken to prevent, limit, or cure crippling, must extend downwards into the pre-school age, and upwards throughout the period of adolescence. It must also be remembered that, although the Council is the Education Authority for London, yet it is not the Local Authority under the Maternity and Child Welfare Act. Despite this obvious disadvantage, the fact remains that the Council has always endeavoured to explore the whole area of crippledom, regardless of age limits, and has gradually promoted suitable arrangements to provide for any deficiency wherever it is found to exist. Sir George Newman in his Annual Report for 1926 discusses at some length the conditions which should be observed in any orthopaedic scheme. They are as follows:— (1) The ascertainment of the number of cripples in each area, the cause, and the nature of their defects. (2) The provision of remedial facilities. (3) Arrangements for following up, re-education and after-care. (4) The prevention of crippling. These conditions are met in London in the following manner:— (1) In the London School Medical Service it is the routine practice for every child in attendance at school to be thoroughly examined by competent school doctors, some of whom hold important appointments as members of the Medical and Surgical staff of the principal voluntary hospitals. If crippling conditions of any kind appear to be present, such children are at once referred for further specialist investigation and treatment. Moreover, all children out of school for more than a very brief period are periodically reviewed. For this purpose, medical reports are obtained as to the reasons for absence, and, where necessary, special medical examinations are made, in order to ensure that they are receiving proper medical supervision and care. Not only does this procedure apply to children of school age but, in addition, the school attendance officers are instructed by the Education * See Appendix, p. 176. 148 Officer to bring to the notice of the School Medical Officer any child, under school age, believed to be suffering from any crippling condition. Inasmuch as the school attendance officers are so frequently in the homes of the children of London for the double purpose of "scheduling" and of securing school attendance, it is found in practice that they perform an extremely useful public, as well as personal, service by constantly bringing to the notice of the School Medical Officer, children of both school and pre-school age who are in need of skilled medical advice and supervision, many of whom are suffering from (or at any rate may well become candidates for) crippling conditions. In those cases where provision for treatment is not available through the Council, steps are at once taken to bring such cases to the notice of appropriate agencies, e.g., the Invalid Children's Aid Association, etc. Immense pains are taken from time to time to keep all hospitals and hospital staffs (including almoners) fully informed of the various facilities for treatment provided by the Council and they are urged to make the fullest and earliest possible use of these facilities. (2) The Council, by arrangement with various bodies (e.g., the Metropolitan Asylums Board and a large number of voluntary hospitals), is able to provide special facilities in cases of tuberculosis, poliomyelitis, encephalitis, venereal diseases, certain ear diseases, epilepsy, ophthalmia, and rheumatism, quite apart from the ordinary facilities available through voluntary institutions or the Poor Law Guardians. It also arranges as an education authority for the admission of certain children, not provided for under the foregoing, to residential hospital schools where treatment can be combined with education. These facilities provide for children of all ages, from new born infants to the end of the school life. Indeed, they go further for, as regards some of the conditions, notably tuberculosis and venereal diseases, the facilities for adequate treatment extend to adults. On the occasion of all medical inspections, steps are taken through the Care Organisation to secure treatment for children who attend P.D. special schools or who are nominated for examination with a view to admission to such a school. It almost invariably happens that such children are, or have been in attendance, at one of the departments of a general or special hospital, so that for any necessary action to be taken they are, in the first instance, referred back thereto to secure continuity of treatment and after care. Should the case, however, be one for which arrangements could be made for more rapid admission to residential treatment, steps are immediately taken to urge the medical or other officer concerned to submit an application to the Council for such treatment. (3) All children who have received residential treatment under any of these arrangements are specially examined on, or soon after, discharge, in order to determine the most suitable type of school for their further education. Following up for the purpose of advice to the family or other social or economic reasons is carried out by the members of the care organisation, in association with the Invalid Children's Aid Association or other bodies or by the tuberculosis care committees of the several boroughs. The preliminaries of re-education will usually have been carried out before the child leaves the hospital or hospital school. In those cases where regular attendance at a physical education department of a hospital is required for a further period, such arrangements can usually be made or the child may attend a clinic or massage centre. For obvious reasons, it is preferable that each patient should remain under the supervision of the surgeon who originally undertook the case. In the special schools the children are under the continuous supervision of the Council's orthopaedic consultant as well as of the certifying officers. Later on, at the end of the school period, if the child leaves school for the physically defective, further after care visiting and placement is undertaken by the After Care Association for Blind, Deaf and Crippled Children. The Association's reports* are annually summarised in the reports of the * See pages 164-165. 149 School Medical Officer. This following up extends to the age of eighteen years or, in many instances, for a longer period. In the case of tuberculosis, the care committees may continue supervision for any period required. It has been found, however, with the increasing efficiency and early age of treatment that numbers of children are enabled to return to the ordinary schools, when any subsequent after care would follow the ordinary channels, or may be deemed no longer certifiable before passing the age of sixteen, and so are eligible to leave school for employment. The details are given on page 158. In the case of each leaver, a form is filled for the guidance of the after care workers, showing what occupations would be less desirable and what attitudes and movements impossible. (4) With a view to the prevention of crippling every effort is made to ascertain the existence of cases of tuberculosis, poliomyelitis, rheumatism, and the like, at the earliest moment, in order that offers may be made of residential treatment; and it may be well to emphasize here the fact that there is no limit placed by the Council upon the duration of such residential treatment, except the opinion of the medical officer in charge of the patient. These facilities for residential treatment under the Council's various schemes have, as already explained, been frequently brought to the notice of all hospitals and other agencies. In those cases where the diseases are notifiable, steps are taken in co-operation with the borough medical officers of health, to follow up the patient from the date of notification in order to ensure at least the offer of appropriate treatment under the best conditions possible. The general arrangements for medical inspection and treatment; the provision of meals ; open air schools ; artificial light treatment, and the general rise in standard of living, have checked many deficiency diseases ; while the causes of infection are reduced both by early treatment and the greater cleanliness of food, dwellings and persons. As was clearly shown by the photographs published in last year's annual report, the physical condition of the London school children has enormously improved in recent years, while the reduction of crippling must be evident to all who can recall the streets of the poorer parts of London some thirty to forty years ago. Details of scheme. Tuberculosis of Bones and Joints.—In London it is found in most cases that the affected child has attended first as an out-patient in the surgical or the special orthopaedic departments of the various general or special hospitals, and that it may subsequently have been admitted as an in-patient. Very few cases of tuberculosis of bones or joints attend, in the first instance, at the tuberculosis dispensaries. Consequently, applications for residential treatment are mostly received by the Council from the voluntary general or special hospitals. In the case particularly of the out-patients, hospitals have been urged to apply to the Council for residential treatment at the earliest possible moment, and many applications are made nowadays by telephone message, the necessary papers being forwarded later. All applications must be made on the prescribed forms, Form A (the clinical record), and Form B (the environmental record). Subsequently, a home enquiry form is obtained, giving the economic circumstances, and all cases are considered for assessment. Procedure by the Council on receipt of applications.—On receipt of the Forms A and B, or on receipt of a telephone message in urgent cases, arrangements are made by the Council for the immediate admission of the patient to a residential orthopaedic institution. All urgent cases, i.e., cases of tuberculosis of spine, hip or major joints are admitted within a few hours of application to an orthopædic hospital, such as Queen Mary's, Carshalton, or Princess Mary's at Margate. Less urgent cases are transterred within a few days. No cases are kept waiting for admission more than a few days. 150 List of Institutions.—The institutions to which children suffering from surgical tuberculous affections are sent and the number of beds occupied in each on 31st December 1927, are as follows:— Institutions. Occupied beds. Institutions. Occupied beds. Metropolitan Asylums Board— Orthopaedic Hospital, Brockley-hill 13 Queen Mary's Hospital 248 Heatherwood Hospital, Ascot 25 Princess Mary's Hospital 181 St. Nicholas, Pyrford 10 Millfields 38 Sevenoaks Hip Hospital 9 Alexandra Hospital 35 St. Vincent's Hospital 6 Lord Mayor Treloar's Hospital, Alton 33 In addition some ten to fifteen children, who were in the convalescent stage, were accommodated in St. Andrew's Home, Hayling. A few cases in the above institutions were suffering from surgical tuberculosis of other parts than bones and joints. Admissions and discharges.—The number of children dealt with during the years 1925 and 1926 was:— 1925. Tuberculosis of glands. Tuberculosis of bones and joints. Number in on 31st December, 1924 132 493 Number admitted during 1925 184 311 Number discharged during 1925 192 255 Number remaining on 31st December, 1925 1926. 124 549 Number in on 31st December, 1925 124 549 Number admitted during 1926 249 277 Number discharged during 1926 211 279 Number remaining on 31st December, 1926 162 547 Duration of treatment.—Children remain in residential institutions as long as treatment is required. Periodic progress reports, generally three monthly, are sent to the Council. All the institutions are periodically visited and the children seen by one of the Council's surgical consultants (Sir Henry Gauvain and Mr. Acton Davis). After Care.—About ten days before the discharge of a patient from a residential institution the medical superintendent transmits to the Council the discharge report and notes concerning the case. These are sent on by the Council to the borough medical officer of health who brings the case to the notice of the tuberculosis care committee. The Invalid Children's Aid Association is represented on each committee. Supervision after discharge from hospital.—The arrangements for supervision of the patient after hospital treatment depend to some extent upon the source from which the patient came to the Council; e.g., some return to the direct supervision of the hospital surgeon in London from whom the patient originated; others continue under the supervision of hospital where the patient was treated, e.g., Alton and Heatherwood patients attend at regular intervals at Farringdon Road Dispensary, while certain of the Metropolitan Asylums Board patients attend at the Board's Out-patient Clinic at Kentish Town. The supervision of children at their homes is carried out with remarkable efficiency by the Invalid Children's Aid Association. Repairs of splints or new apparatus required after discharge from residential institutions can be provided under arrangements made between the Council and the Invalid Children's Aid Association. The net cost is borne by the Council after assessment of the parent. All children of school age on discharge from hospital, and before returning home, are seen by the Council's medical officers at the County Hall as to their suitability for attendance at schools for physically defective children or at elementary schools. 151 Results of treatment.—During the past year all the children who had been discharged from treatment in the year 1921, were reviewed, and the results are shown in the following table : Location of disease. Died within 5 years. Well and at school. Well and at work. Fit for work but unemployed. Keeping well. No information as to employment. Unfit for work, or condition unsatisfactory. Undergoing further residential treatment. Total. Surgical— Hip 13 18 10 1 -+ 2 1 45 Spine Other bones and 9 16 9 2 - 1 - 37 joints 4 18 10 - 3 - - 35 Glands (including peritoneum) 4 18 25 3 3 2 4 59 Other parts ... 6 1 4 - 1 1 - 13 Total 36 71 58 6 7 6 5 189 Percentage 191 37.5 30.7 3.2 3.7 3.2 2.6 100 It is well worthy of note that no less than 60 per cent. of the children, who were suffering from surgical disease of the hip or spine, showed only slight or no deformity or limitation of movement. Duration of treatment.—The average duration of treatment in days was:— Location of Disease. Survivors. Fatal Cases. Hip 555 490 Spine 479 492 Other bones and joints 298 534 Glands 217 68 Other parts 268 460 Poliomyelitis. Since September, 1924, by arrangement with the Metropolitan Asylums Board, 50 beds have been available at Queen Mary's Hospital, Carshalton, for the treatment of cases of poliomyelitis, up to 15 years of age, 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 for resulting deformities. Attention is concentrated on the re-education of the muscles, whilst splints and other orthopaedic appliances are supplied as required. Children are also given ordinary school lessons pari passu with the medical treatment. Steps have been taken to make these facilities widely known to the medical profession, including the surgical staffs of the voluntary hospitals in London, with a view to ensuring that cases are recommended for treatment while in the early stages of the disease. While all certifying officers visiting special and ordinary schools are instructed to draw attention to any children needing further treatment, an agreement has been arrived at with the Metropolitan Asylums Board to secure the admission of all cases of poliomyelitis which the Board is required to accommodate in the acute stage of the disease, into one hospital, viz., the Western Fever Hospital, and the Board has arranged for the hospital to be visited regularly by an experienced consultant surgeon for the purpose of advising as to the best methods of treatment. Cases are transferred from this hospital to Queen Mary's Hospital, with the parents' consent, as soon as the case has reached the second stage of illness. From September, 1924, to the end of 1927, 108 cases have been admitted (including three re-admissions) to Queen Mary's Hospital, and 61 have been discharged (including two deaths and three redischarges), leaving 47 under treatment on 31st December, 1927. The duration of stay ranges from a few months to over two years. Cases are only admitted by application of the Council's medical officer of health. Every notified case is reported by medical officers of health of the metropolitan 152 boroughs on special enquiry forms. These cases are followed up and, at the end of three months, institutional treatment at Queen Mary's Hospital is offered. If the parents' consent is obtained, an application form is filled up by the medical officer of health concerned, and, if approved by the Council's medical officer, the form is sent to the Metropolitan Asylums Board and the child is admitted within a day or two. A similar procedure is adopted with regard to any non-notified cases which come to light and those cases in which application is received from a voluntary hospital. When the children are discharged the medical notes on the case are sent by the medical superintendent of Queen Mary's Hospital to the Council's medical officer of health, who communicates them in turn to the voluntary hospital which the patient attended prior to admission and to the medical officer of health of the borough concerned. The children are specially examined to see if attendance at a day (P.D.) school is desirable. There is no doubt that the scheme has been successful in the amelioration of the crippling conditions resulting upon poliomyelitis, and even greater success will be accomplished as hospitals, medical practitioners and others concerned become more familiar with the facilities available and earlier attention is drawn to such cases with a view to the prompt and appropriate treatment in the early and acute stages of the illness. For this purpose the Council places at the disposal of the medical profession the services of its expert medical staff for assistance in early diagnosis. Special care is taken in following up to see that all children who have suffered from poliomyelitis wear suitable apparatus for such periods as the surgeons who have had charge of their cases deem necessary, or, if splints have been omitted and there appears to be any further risk of seeondary deformity or weakness, that the case shall be reconsidered. The continued use of splints. London has been criticised in the report of the Chief Medical Officer of the Board of Education from the standpoint of the relative number of children who leave the special schools wearing apparatus up to the date of departure. It should be recognised, however, that it is only those who are severely crippled who are admitted to the P.D. schools. It is also the fact that in London there is a large body of expert orthopaedic opinion which holds that apparatus should be worn as a precautionary measure for a considerable period after discharge from hospital, more especially in those cases where the wearing of such apparatus does not increase the social disability of the sufferer. Surgeons holding this view recommend children to continue to wear apparatus while at school. This advice applies, not only to cases of infantile paralysis, but also, and perhaps even more so, to cases of bone and joint tuberculosis. There are fashions in orthopaedic surgery as in other matters and sound arguments may be put forward by each side in support of the varying opinions held on this point. In any event the fact remains that some surgeons aim at so managing their cases that apparatus shall be abandoned at the earliest moment while others prefer that its use shall be continued for prolonged periods. The surgeons in question, on either side, are of the highest eminence, attached to the best known hospitals in this country, and each of them can and do put forward specific cases in support of their respective views. The system of following up adopted by a public authority to secure treatment does not provide for taking sides in a clinical dispute on differences of method of treatment, though the officers by drawing the attention of surgeons to after-results may frequently provide valuable information which ultimately may or may not influence surgical opinion. The fashion in any area may, however, seriously influence the proportion of the children in any given number of schools who wear apparatus. In London, with the number of hospitals available, there are examples of all varieties, and it may be that, in certain parts of the county, where the children tor the main part attend hospitals at which the orthopaedic surgeons prefer the apparatus to remain, there will be more cases at the age of fifteen years wearing such apparatus 153 than in other areas where the children attend hospitals at which the surgeons prefer removal at an earlier age. In provincial cities there is, naturally enough, a comparatively small number of orthopaedic surgeons, and the views of the leading surgeons on such a point are likely to dominate much more strongly the general practice. If it should so happen, therefore, that comparison is made with a city in which the more general practice is to abandon apparatus, London must, of necessity, show a higher proportion of apparatus cases. A statement as to the number of leavers still wearing apparatus, expressed as a percentage of the total numbers in attendance at special schools, affords but a slender basis for criticism, unless the proportion of those attending the schools who suffer from ailments which have never required the use of apparatus is also given, and is of a comparable order. A more correct figure is the number of those who have needed apparatus and have been so far cured as to be able to discard it. There is no reason to doubt that conservative surgery and operations for the restoration of function and stability are as much in evidence in London as elsewhere. In this connection, it should also be remembered that there may be certain districts in which the proportion of children wearing no apparatus is greater for the simple reason that the defects have not been consistently and continuously treated at all owing, perhaps, to the absence of special interest in orthopaedic work among the surgeons of the local hospitals or, simply because there are no means by which the children are assisted to obtain the necessary appliances. This is not the case in London, where the vast majority of children receive treatment and are placed in a position to earn a livelihood without handicap or undue strain and have been protected, so tar as is possible, throughout their school age. There is always a certain number of instances in which parents decline operative treatment, however advisable, and wander from hospital to hospital in search of some surgeon who will accept their views as to non-operative treatment. Most usually compulsion cannot be applied to these, for the parents are able to show in the end that they are acting under some form of medical sanction and so claim that this action is bona fide for the benefit of their child. Comparing the present situation with that at the beginning of the century, there can be no question of the beneficial effects of the steady campaign in favour of early treatment, and the small number of cripples to be seen in the streets in comparison with those in certain other areas is eloquent testimony to the effectiveness of the social service rendered in connection with education. The chronic manifestations of encephalitis lethargica are of a protean order and include those showing moral, intellectual, emotional and metabolic changes, and Encephalitis lethargica. lastly, there are the neurological types among which may be mentioned the cases exhibiting the Parkinsonian syndrome as well as those developing contractures and wasting of various muscles, and palsies of miscellaneous description. It is among the last mentioned group that orthopaedic treatment and care are required. Since November, 1925, by arrangement with the Metropolitan Asylums Board, 100 beds have been provided for children between the ages of 3 and 16 years, suffering from the sequelae of encephalitis lethargica. They are admitted for observation and treatment to the Northern Hospital, Winchmore Hill. The treatment necessarily varies according to the type of case, but all facilities are provided by the Board at the hospital for correctional treatment of cases of muscular unrest, hypertonicity or contractures of muscles and for Parkinsonian rigidity. The treatment includes massage, gymnastics, electrical therapy, artificial sunlight, etc., whilst splints and surgical footwear are supplied where required. Ordinary school lessons and instruction in various kinds of handwork are also given. Between November, 1925, and 31st December, 1927, there were 169 cases (including 11 readmissions) dealt with at this institutional unit, and 98 have been 154 discharged, leaving 71 under treatment at the end of 1927. One child died a few days after discharge during an “access of rage” and another child who was suffering from severe Parkinsonian rigidity died in the institution from broncho pneumonia. The duration of stay ranged between a few months to nearly two years, but in 35 cases the children were withdrawn by their parents against medical advice. The procedure in regard to ascertainment is similar to that obtaining in the case of poliomyelitis. Every notified case is reported by the borough medical officer of health on a special enquiry card to the Council's medical officer of health, and, in addition, large numbers of non-notified cases come to light through various channels of information. The majority ot these latter cases have not been diagnosed in the acute stage and are only discovered when the later manifestations appear. A comprehensive system of following-up by the school medical service in regard to school children, and through the agency of the borough medical officers in regard to all other cases, has been instituted. Applications for admission to the Northern Hospital are accepted from the Council's medical officer of health or the boards of guardians. Usually the children are examined for suitability for admission by one of the Council's medical officers, and where a child is considered suitable and the parents consent has been obtained an application form is sent to the Board. If the Board's neurologist endorses the application the child is admitted as soon as a vacancy occurs. In considering the outlook with regard to these difficult cases, both from the mental and physical aspect, and the need for continuing the institutional treatment, it will be appropriate to quote from the last report of Dr. G. H. Borthwick, medical superintendent of the Northern Hospital. He states:— “The experimental unit has not been productive of any positive curative results, but it has proved very valuable as an observation station where cases may be investigated and classified. “It has even been very valuable as an institution for housing both those children whose physical disabilities require skilled attention and those whose mental condition is such that they are unsuited to the ordinary outside life. “There is very little hope that patients suffering from the many after effects of encephalitis lethargica will ever, generally speaking, be cured, for evidence shows that the nerve cells attacked by the virus are irretrievably damaged. “It may be possible in a minority of cases to educate other cells to function in the place of the old ones, but this will be a very long task involving months and may be years of patient endeavour. “Whilst I cannot whole-heartedly recommend the Board to continue the section as an experimental unit with the hope of ultimately curing patients suffering from post encephalitis lethargica, yet the absolute necessity of housing these difficult and pitiful cases, either from a mental or physical point of view, is perhaps sufficient justification for carrying it on.” Again, writing on the subject of the neurological types, Dr. Borthwick states that the outlook of patients suffering from Parkinsonism is grave, and that, although under careful treatment many ot them tend to remain stationary, it is impossible to say that they will not deteriorate. He thinks that the hospital school is best for these patients and, as their capacity for movement is so reduced, that they should be dealt with in separate wards away from the naughty and restless children. Severe and bedridden cases require skilled hospital treatment where provision can be made for keeping up their interests through the medium of sight and hearing. Dr. Borthwick also points out that the patients showing paresis only have improved, but that cases of definite paralysis have not yielded well to treatment. They require skilled attention along ordinary orthopaedic lines, combined with the provision ot surgical boots and splints. Operative measures are also indicated in certain cases, 155 although the difficulty of knowing whether a local paralysis may not increase must he considered before an operation can be performed. On their discharge from Winchmore Hill all children are examined by one of the Council's certifying officers in order that the question of school attendance may be considered, A certain number of those who have been crippled by the disease have been found suitable for attendance at P.D. schools provided the condition is not accompanied by serious disorderly conduct. Severe cases of advanced Parkinsonism are unfitted for any form of education and certain of the conduct cases have been dealt with under the Mental Deficiency Act or in some instances under the Lunacy Acts. Others are able to continue under close observation in ordinary or special day schools but their future is very uncertain. The Council has contracts with the managers of the colony schools for epileptic children at Chalfont, Lingfield and Much Hadham, by means of which it provides for the education and necessary treatment of those whose parents are willing for them to leave home and who are of the necessary mental grade to profit by instruction. The available number of places is likely to increase in the future so that the chief difficulty is not so much the question of accommodation as of the disinclination of the parents and their medical advisers to allow the children to leave home for treatment at an early stage at which the prospects of improvement are much greater. During the year 1927, some 86 children were being maintained in these special residential schools for epileptic children. Rheumatism, chorea and their sequelae. As was pointed out in the Report for the year 1926, a definite start has been made in the provision of treatment for this insidious yet serious disorder. Up till then all that could be done was to secure that a suffering child was under medical treatment either by a private practitioner, at a hospital, or the like, a few being dealt with through the I.C.A.A. while rheumatism supervisory centres were just coming into existence. Since that date a considerable advance has been made in the provision of institutional accommodation by the Metropolitan Asylums Board. Cases are admitted thereto, on the nomination of the Council's medical officer of health, after the case has been investigated by members of the Council's medical staff, home circumstances ascertained, and the consent of the parents obtained. The accommodation provided consists of 66 beds at Queen Mary's Hospital, Carshalton, 84 beds at High Wood Hospital, Brentwood, and 77 beds for convalescent rheumatic cases at the Downs Hospital, Sutton, and Queen Mary's Hospital. The Metropolitan Asylums Board is also pressing forward with plans for additional buildings at Queen Mary's Hospital which will provide 350 more beds for rheumatic children at that hospital. Children who have failed to be admitted, owing to lack of accommodation, have been assiduously followed up jointly by the school medical service and the Invalid Children's Aid Association, and the best that is possible has been done for these children. Co-operation with the medical officers of the metropolitan boroughs has been established. In Kensington and Paddington rheumatism in children has been made a notifiable disease. In every case where the condition of the home of a rheumatic child, dealt with under the scheme, in relation to dampness or overcrowding, etc., seems to have a bearing on the aetiology of the disease, the medical officer of health is communicated with, while the child is still away, with a view to improving the home conditions before the child returns from the residential hospital. While the provision of beds has been proceeding much attention has been focussed upon the question of the rheumatic child generally. Opinion, both on the part of professional men and laymen, has been crystallising in favour of the establishment of local rheumatism supervisory centres to which parents of children suspected to be rheumatic or requiring observation for rheumatism might bring them periodically to receive advice upon their management. At such centres also it is probable that the earliest symptoms would be more likely to be detected, and, in addition, the need 156 for any special measures in regard to prolonged residential treatment or admission to special schools could be impressed upon the parents. In London the school doctors are paying special attention to rheumatism, a register of all cases has been established, school supervision is being carried out, and residential accommodation for acute and sub-acute cases is being organised. What is now chiefly required is the development of local supervisory centres. Already in the north-western division of London three rheumatism supervisory centres have been established, viz., in Paddington, Marylebone and Kensington. During the coming year it is hoped that five more centres will be established in connection with hospitals or treatment centres in the four divisions in which no provision of the kind as yet exists. All children discharged from residential treatment will be specially considered from the standpoint of the advisability of their further education in special day schools while continued supervision will be ensured. Other physical defects. Tuberculosis, poliomyelitis, encephalitis, epilepsy and rheumatism are the main causes ot crippling in childhood. There remains for consideration the comparatively small group in which the condition results from trauma, congenital defect or vascular lesions, such as hemiplegia. In the case of congenital defects or vascular lesions, in which there are mental changes as well as physical disabilities, the machinery of the Mental Deficiency Act can often be utilised to secure adequate and prolonged treatment. In the case of combined defect in which it is often found that, although neither mental nor physical defect alone would prohibit instruction in a school, the two together render this impracticable, the difficulties of obtaining sanction under regulation 5 are very great. Perhaps this difficulty may be reduced by the provisions of the Mental Deficiency Act of 1927. So far as traumata, congenital defects and miscellaneous causes of physical disability are concerned, it has been found that the ordinary resources of the voluntary hospitals, coupled with existing day school accommodation, are in the main adequate. When necessary, however, the Council as an education authority makes arrangements for maintaining or contributing to the cost of maintenance and education of a child in a residential hospital school where education may be continued while the child receives the necessary surgical treatment. Children are admitted to residential schools for the physically defective who are in need of prolonged or continuous treatment which would prevent attendance at a day P.D. school, but who could be educated at a residential school while receiving such treatment. As regards children at the orthopaedic hospitals, the Special Services Sub-Committee recently decided:— (a) That the authorities of the orthopaedic hospitals be informed that the Council, as education authority, cannot see its way to accept liability for the education and maintenance of children at the residential school carried on in the hospital whose stay at the hospital was likely to be less than three months. (b) That no action be taken to obtain the admission of children to the residential school carried on in the hospital who are normally in attendance at ordinary elementary schools. (c) That arrangements be made for the admission to the school of children on behalf of whom applications are received from the hospital authorities in the undermentioned cases, subject to the stay at the hospital being likely to exceed three months, at the cost stated below:— (1) Cost of education only in cases where children are normally in attendance at day schools for the physically defective. (2) Cost of education and maintenance in cases where the physical defect is such that the children are unable to attend day schools for the physically defective, but are not unable to benefit by the instruction given in the hospital school. 157 During the year 1927, 28 children were thus dealt with at the following hospitals and schools, viz:— Halliwick Cripple Home 1 Royal National Orthopadic Hospital 9 Heatherwood Hospital, Ascot 1 St. Andrew's Home 8 Hermitage Schools, Chailey 1 St. Michael's Convent of Mercy 1 Lord Mayor Treloar's Hospital, Alton 1 St. Vincent's Home, Pinner 5 National Children's Home 1 Defective Children. The total number of examinations conducted under the Education Act during the year was 25,672. 5,348 examinations with a view to admission to special schools were conducted. Admission examinations. 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. Vision B. G. Blind School. Myope class. Swanley. B. G. B. G. B. G. B. G. B. G. B. G. 518 577 14 21 147 151 53 56 270 298 34 51 — — Deaf school. Hard of hearing class. B. G. B. G. Hearing 207 189 42 29 34 40 129 115 2 5 — — P.D. 801 738 P.D. school. Open-air school. 150 163 102 84 — — B. G. B. G. 536 483 13 8 M.D. school. B. G. M.D. 1,231 947 481 372 617 467 70 52 63* 56* Epileptic colony. B. G. Epileptic 63 77 23 14 16 29 24 34 — — 2,820 2,528 1,343 1,174 1,182 1,072 | 232 226 63 56 5,348 2,517 2,254 458 119 * Of these 52 boys and 49 girls were imbecile; 6 boys and 5 girls were idiots; and 5 boys and 2 girls were feeble-minded. Examinations were also conducted in 76 cases with a view to ascertaining their fitness for education in Industrial or Reformatory schools, with the following results:— Recommended for Boys. Girls. Total. Reformatory school 18 3 21 Industrial school 31 2 33 M.D. industrial school 13 2 15 Dealt with under M.D. Act by being sent to institutions 5 2 7 67 9 76 The Special schools were visited at least once a quarter and every child present Rota visits was seen at least once during the year, the total examinations amounting to 19,513; to the in addition 735 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 for similar reasons. 15435 l 158 As a result of the visits and re-examinations the following re-classification took place : 31 were transferred from schools for the physically defective to schools for the mentally defective; 2 from schools for the partially blind to schools for the mentally defective; 1 from a school for the deaf to a school for the mentally defective; 3 from schools for the mentally defective to schools for the deaf; 6 from schools for the hard of hearing to schools for the deaf; 1 from a school for the physically defective to a school for the hard of hearing; 1 from a school for the deaf to a school for the hard of hearing; 65 were excluded as imbecile; and 59 were invalided on medical grounds. Children admitted to P.D. 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 65 36 101 Heart disease— Cerebral paralysis 12 7 19 Congenital 30 32 62 Various paralyses 24 20 44 Acquired valvular 109 150 259 Tuberculosis of bones and joints 147 95 242 Acquired non-valvular 31 47 78 Other diseases 36 57 93 Congenital deformities... 25 12 37 Other deformities 57 27 84 536 483 1,019 There were also 681 cases returned on improvement to elementary schools or, when over 14 years of age, excluded as no longer certifiable ; the details are as follows : R.= Returned on improvement to Elementary Schools. E. = Over 14 years of age, excluded as no longer certifiable. Special schools.—Physically defective, R. 146, E. 265; Mentally defective, R. 19, E. 178; Blind, R. 0, E. 3; Deaf, R. 1, E. 1; Mvope and Partially Blind, R. 3, E. 37 ; Hard of hearing, R. 14, E. 14. Total, R. 183, E. 498. De-certification 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 fourteen and sixteen years. The following is a table relating to different conditions for the year 1927. Defect. Cases passed no longer certifiable. Cases passed fit to return to elementary school. Heart 94 21 Rheumatism 3 10 Tuberculosis 61 29 Infantile paralysis 47 10 Rickets and deformities from this cause 11 30 Various traumata 13 9 Congenital deformities 13 5 Non tuberculous arthritis and synovitis, including pseudocoxalgia 2 10 Miscellaneous—Nervous conditions, ataxia, etc 7 5 Chorea 9 13 Anæmia 1 2 Bronchiectasis — 1 Osteomyelitis 4 1 265 146 An analysis has also been made of the 499 cases for admission to special (P.D.) schools, in which the children were either returned to elementary schools or invalided. 159 The particulars for the year 1927 are set forth in the following statement:— Returned to Returned to Condition from which child was or had been suffering. elementary schools. Invalided. Condition from which child was or had been suffering. elementary schools. Invalided Tuberculosis, actual or bus pected of bones, joints glands, etc. 17 11 Kidney disease — 4 Skin conditions — 1 Peritonitis 1 — Congenital deformities .. 19 6 Various chest conditions, bronchiectasis, empyema, etc. 6 8 Rickets and deformities from this cause 10 1 Fragilitas ossium 1 3 Infantile paralysis 21 14 Osteomyelitis 6 2 Cerebral paralysis 1 22 Various traumata 13 5 Epilepsy 4 1 Heart, congenital 13 14 Encephalitis lethargica 2 4 Heart, valvular 46 33 Pseudo-hypertropic muscular dystrophy - 1 Heart, non-valvular 35 22 Anæmia 15 1 Miscellaneous—Nervous conditions, ataxia, etc. 49 18 Rheumatism and chorea 54 15 313 186 Residential schools. There are 10 residential schools (3 industrial, 2 for blind, 2 for deaf, 1 for defective deaf, 1 for mentally defective boys and 1 for mentally defective girls) with a total accommodation for 712 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, 586 boys were admitted to Pentonville Road Place of Detention and 249 girls and infants to Ponton Road Place of Detention. Dr. F. C. Shrubsall's report on the ascertainment of the mentally defective. The work of the Council as a local education authority relative to mentally defective children may perhaps be viewed in a more interesting perspective in connection with the action taken by the Council as a local control authority, since any children who are found to be, or are suspected to be, mentally defective while of tender years may again come to notice during school ages, while those who are ascertained later must, ex-hypothesi, if rightly certified under the definitions of the Mental Deficiency Acts, have been defective during their school age, even if their conduct was such that their defect was not noticed at that time. Under the relevant Acts the duty of ascertaining and providing for the mentally defective under the age of seven years, and over the age of sixteen, rests with the Council as a local control authority, while between the ages of seven and sixteen years the duty rests with it as a local education authority. From the date of the coming in force of the Act of 1913, the duty of ascertainment of defectives of all ages has been assigned by the Council to the officers of the public health department, a procedure which provides for a uniformity of standardisation which could not be secured easily in any other manner. The conditions bringing cases to notice naturally differ in these groups as do the powers for dealing with them. There is a slight degree of overlapping in the younger cases between the education and control authorities, for though the duties of the education authority in reference to mentally defectives are limited to the period between seven and sixteen years of age, their general duties as an education authority commence at an earlier age, and a defective child may come to notice as soon as the period of compulsory education commences, if not as soon as voluntary attendance at an elementary school is permissive. The special importance of the school in the scheme of general ascertainment depends on the fact that its activities cover a cross section of practically the entire child population. During the year the cases which had been referred and dealt with under the Mental Deficiency Act during the two previous years, 1925 and 1926, have been analysed to show the relative importance of the different sources of information:— Cases under the age of seven.—During the two years referred to, 125 cases were 15436 L2 160 reported to the local authority under the Mental Deficiency Act, the sources being as follows:— London Authority for Mental Welfare, 38; Poor Law authorities, 8; Miscellaneous sources, 38; Through school medical service, 41. Miscellaneous sources include parents and friends of alleged defectives, private medical practitioners, hospitals, charitable organisations, infant welfare centres and the like. The importance of the latter as sources of information is gradually increasing. Forty-one cases came to notice in the course of school medical work, but the children being under the age of seven years, their names could not be sent forward by the Education Committee as in need of institutional treatment or guardianship, and the children were therefore dealt with as if notified from any ordinary source, which meant in practice that it had to be shown in some way or another that they were so far neglected as to render them subject to the Act. As a consequence of this it will be realised that a number of cases come to notice in which the children are undoubtedly mentally defective, but owing to the relatively satisfactory nature of their home conditions they are not subject to be dealt with, at any rate under the age of seven years. The provisions of the Mental Deficiency Act, 1927, enabling local authorities to deal with the cases of children with respect to whom a notification has been made by the parent or guardian that the child is in need of care or training which cannot be provided in his home, may enable a somewhat larger number to be provided for in future years, though it is more probable that parents would desire to retain young children below the school age in their homes unless their presence was obviously detrimental to the other members of the family, or there were some special circumstances such as employment of both parents. During the two years the certifying and enquiry officers of the public health department investigated the cases of 317 children, 107 of which had been brought to notice from miscellaneous sources, the London Authority for Mental Welfare and the Poor Law, and 210 which were discovered through the schools or the school attendance department. Of those the following were the gradings:— Mentally defective in the sense of the Education Act and possibly feeble-minded, 144 ; Imbecile, 162 ; Idiot, 11. Of the first group, 66 were invalided with a view to re-examination on attaining the age of seven years, and 38, all of whom were six years of age or over, were recommended for immediate admission to mentally defective special schools. Of the 106 imbeciles who came to light from the school organisation, only 41 were deemed subject to action under the Mental Deficiency Act, and action was taken in due course. In 65, circumstances were such as to preclude action, so that they were invalided from school attendance until the age of seven years, when a re-examination will take place with a view to notification. The ages at which these cases came to notice were as follows:— Ages —1 1+ 2+ 3+ 4+ 5+ 6 + Numbers 0 5 15 18 37 117 126 The proportion of idiots and imbeciles was greater in the earlier years. It is clear that these figures, particularly those relating to ages below the school attendance period would not represent the total number of defectives for the community but, from the returns of the Metropolitan Asylums Board, it appears that a considerable number of cases are admitted to their institutions, particularly to the * Fountain Mental Hospital, during the age period in question from other sources than * Note.—It is understood that in December, 1927, there were in the Fountain Mental Hospital 183 cases placed under the Mental Deficiency Act, and 341 cases placed there under other provisions, Children while in Poor Law institutions, do not without special exception come within the purview of the authority for mental deficiency whether on the general or the educational side 161 the Mental Deficiency Act. The removal of these cases diminishes the number which might otherwise come to the notice of the education authority at the commencement of the period of compulsory education. It also appears that the cases which come to notice at an early age contain a large proportion of cases in which the amentia is of a secondary character. The following statement shows the relative frequencies of different types of defect in children under seven years of age who have been ascertained by the certifying officials of the Council:— Primary amentia, 60.2 per cent.; Epilepsy, 8.2 per cent.; Paralysis, 6.8 per cent.; Cretin, 0.8 per cent.; Mongol, 18.2 per cent.; Micro-cephalic, 4.2 per cent.; Hydro-cephalic, 0.8 per cent.; Blindness, 0.8 per cent. From the age of seven to sixteen years preliminary ascertainment is conducted under the aegis of the Education Authority and the bulk of the cases which come to the notice of the control authority in this period are derived from this source. A small number comes to notice from the police courts or industrial schools under section 8 or section 9 of the Mental Deficiency Act. Such children or young persons have, however, most often been known previously and ascertained to be mentally defective so far as the Education Acts are concerned. The general procedure under the Education Act is that a statutory examination is conducted of every child nominated by the school attendance officers as not being in attendance, or by head teachers and school doctors in conjunction, as not making adequate progress in school, although minor physical defects have been dealt with so far as possible. In the year 1927, the nominations numbered 2,178, and showed the following results after examination:— Returned to elementary school, 1,084 ; Invalided temporarily with a view to re-examination, 122 ; Deemed suitable for admission to a school for the mentally defective, 853 ; Notified under the Mental Deficiency Act as—Imbeciles, 101; Idiots, 11 ; Feeble-minded, 7. The special schools are visited regularly and every child present is seen at least once during the year, the total number on roll of the M.D. Schools being 5,998. The doctor's examinations at rota visits to these schools, in 1927, amounted to 8,076. Special examinations were made of children already on the rolls for application for non-enforcement of attendance, as a result of which some 65 children who had been in attendance for varying periods of one to three years were excluded as imbecile. No particular difficulty arises at the earlier age periods, but towards the end of the time difficulties may arise regarding the children who have appeared sufficiently intelligent to derive some benefit from education in an ordinary school, but who have proved incapable, generally on account of temperamental difficulties or lack of control, of facing the conditions of the world when commencing employment at the age of fourteen years. Since they are over the age of compulsory school attendance it would not seem that school attendance could always be enforced de novo at a special school, yet if not in attendance at a special school they cannot be notified by the Education Committee as being about to be withdrawn or discharged from a special school under section 2 (2)6 of the Act. The machinery of notification as cases of special circumstances is very cumbersome, and it seems to be a matter of doubt how far it can be employed; the procedure may possibly be rendered easier by the Mental Deficiency Act, 1927. Steps are taken to secure the special examination of every child brought before a juvenile court who is known to have attended a special (M.D.) school, or to have been nominated at any time for a statutory examination with a view to such admission if necessary. In 1927, 76 children were so examined and, in consequence, 15 were recommended for admission to a special (M.D.) industrial school, and 7 for transfer to an institution under the Mental Deficiency Act, the action being taken under section 8. In the case of children who have been sent to certified industrial or reformatory schools, but who, while there, prove incapable of deriving proper benefit from training 162 because of mental defect, steps are taken for their ascertainment and, should they be certified under section 9 of the Mental Deficiency Act, and the necessary order issued by the Secretary of State, they are transferred to certified institutions under the Act. During the year seventeen children or young persons were so dealt with. Defective delinquent children were found to be rather above the average of other defectives, though scarcely to the extent which excluded the possibility of random sampling. The types of misconduct which appeared to be particularly associated with defective delinquents were, wandering and being beyond control. Of these offences it was noted that wandering provided the maximum number of lower grade cases. When the age of fifteen and a half years is reached, the case of every child in school attendance is reconsidered with a view to deciding whether his or her name should be notified to the local control authority. At this stage attention is paid, not so much to educational attainments as to the prospects of the individual being able to obtain suitable employment and to live harmoniously in the world. Reports on each child are obtained from the certifying officer, from the head teacher, and from the visitors of the London Association for Mental Welfare. These visitors subsequently carry out after-care amongst those ex-pupils of special schools whose names are not notified, or statutory supervision in the case of those whose names have been notified and in whose case supervision is thought by the local control authority to provide adequate care and protection for the moment. The number of cases recommended for notification with a view to possible institutional treatment or guardianship in 1927 was 123. It must be noted that, up to the end of 1927, only the names of those children in whose case the local education authority was of opinion that institutional treatment or guardianship would be beneficial could be thus notified. In future, under the Act of 1927, it will be possible to notify the names of those for whom statutory supervision is deemed desirable. Those children whose names are not so notified receive after-care supervision until the age of eighteen years, the necessary duties being carried out by the London Association for Mental Welfare. With a view to comparing the features of those whose names are notified and those who are referred for special after-care only, Dr. Carleton Williams has analysed the records of a random sample of 100 children approaching sixteen who had been recommended by head teachers and others as needing to be dealt with under the Mental Deficiency Act, and of another equally unselected group of 100 children who were not so recommended. In each case a note was made of the mental age, while the educational level, stability of character, capacity for handwork and home conditions, were graded in their groups to which marks I to III were assigned (mark III being the best, and mark I the lowest). The existence of any serious physical defect was also remarked. The results are set out in the following tables:— Mental age. Mental age. 10. 9. 8. 7. 6. 5. Average mental age. Numbers recommended for guardianship or institutional care 3 34 28 20 14 1 7.9 Numbers not so recommended 8 45 32 12 3 — 8.4 Gradations. Whether recommended or not recommended for institutional care. etc. Educational attainments. Stability. Handwork. Home control. Recommended. Not. Recommended. Not. Recommended. Not. Recommended. Not. Mark III 27 39 21 63 17 46 23 77 Mark II 22 34 49 36 50 47 43 21 Mark I 51 27 30 1 33 7 34 2 Average mark 1.8 2.1 1.9 2.6 1.8 2.4 1.9 2.8 163 Twenty-one children presenting material physical defects were recommended for guardianship or institutional care, and six were not so recommended. It will be seen that the difference between the two groups is greatest in the matter of stability, and in the home conditions ; the difference in the mental ages is not so great as might have been expected, showing that among M.D. children intelligence is not the greatest factor in making institutional care or guardianship necessary. The reason for the recommendation was lowness of mental grade in only 20 out of the 100 cases. More frequently it was instability of character or poor home conditions, often a combination of the two. Marked incapacity for handwork was sometimes given as a reason, but educational failure, in the narrower sense, was never suggested as a ground for institutional treatment. In twenty-one cases after-care was deemed necessary largely on account of combined defect, there being physical illness, such as paralysis and epilepsy in addition to the mental deficiency. There was a difference between the sex incidence in the two samples, there being sixty-one girls and thirty-nine boys in the group of those recommended for institutional care, as against forty-four girls and fifty-six boys in the group from those not so recommended. This is due to the fact that feeble-minded girls are more likely to be exposed to moral danger. Cases over the age of sixteen years.—During the two years (1925 and 1926), 625 cases were notified for ascertainment from the sources mentioned:—London Association, 138; Poor Law, 79; Police Courts (Section 8), 139 ; Prisons (Section 9), 10; Education Committee, nil; miscellaneous sources, 259. Miscellaneous sources include—parents and friends of alleged defectives, private medical practitioners, general hospitals, London Lock Hospital, relieving officers, charitable organisations rescue workers, police court probation officers, etc. On investigation of these 625 cases, it was found in 88 instances that either the individual was not defective, or that the evidence available was insufficient to bring him within the provisions of the Mental Deficiency Act, or that the person was both defective and psychotic and better suited for treatment in a Mental Hospital. The cases investigated during the period were graded as:—Moral imbeciles, 6; feeble-minded, 497; imbecile, 33; idiot, 1. The ages at the time of notification in quinquennial groups being— Ages. —20. —25. —30. —35. —40. —45. —50. Imbecile 14 6 5 1 1 3 3 Idiot — 1 — — — — — Feeble-minded 279 112 45 28 14 10 9 Moral imbecile 4 1 1 — — — — In 49 cases the individual, although defective, was not subject to be dealt with under the Act. It is thus evident that the bulk of the cases come to notice within the first decade after the termination of school life. The most important single group is made up of delinquents. In later years the position is complicated by the fact that the individuals may not only be suffering from a condition of mental defect from an early age, but also, in many instances, from degeneration due to their mode of life. An enquiry made some years back into the special circumstances of delinquents showed that the type of offence was, to some extent, associated with the degree of mentality. Wandering was often due to faulty orientation and lack of ability on the part of the subject to ascertain his whereabouts, or to take the necessary measures for returning home. Many cases of indecent exposure were due to sheer lack of appreciation of their surroundings and of ordinary social conventions, rather than of a deliberate desire to give offence. The average mental age found for defective delinquents who have committed particular types of offence agrees almost exactly with similar figures published by Dr. Norwood East from a totally independent source of investigation. 164 Investigation of the emotional stimuli showed that there was a distinct relationship between instability and delinquency, but it appeared that the capacity for employment was more closely correlated with stability than with intelligence or with mechanical attainments. Enquiry into the schools attended by adult defective delinquents charged in London showed that 45 per cent, had attended special (M.D.) schools, of the others, some had passed their school days before the special school system was fully established, many had come into London from the provinces, and certain others had had sufficient intelligence to pass through school harmoniously but had proved unable to fend for themselves in the world. The proportion of the total of defective delinquents to the total of ex-scholars of special schools is very small, and testifies to the stabilising effect of the character training in these schools and the value of the trade education for the elder boys and girls. All mentally defective persons placed under statutory supervision are visited by the officers of the London Association for Mental Welfare, who report regularly to the Council on the matter. These reports are always read and initialled by a senior medical officer, who thus keeps himself in constant touch with the changes in their condition and sees, where any change takes place, that the necessary recommendations are made to the Mental Hospitals Committee. The general effect of the work undertaken by the London County Council as the Mental Deficiency Authority, apart from the Education Authority, is shown by the following data classified in sex, as to cases either under supervision, or, in institutions on 31st December, 1927— In institutions, M. 1,356, F. 1,406 ; under supervision, M. 917, F. 1,047; under guardianship, M. 28, F. 20; in places of safety, M. 12, F. 15. After careers of children formerly attending special schools. Return for year ended December 31st, 1927, 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 1909 who have left special (mentally defective) schools and who have been on the books of the association as “after-care” cases 583 502 1,085 2. Number of these who— (a) Have since died 1 1 2 (6) Are known to be incapable by reason of mental or physical defect of undertaking employment 18 34 52 (c) Have been subsequently dealt with under M.D. Act 18 7 25 3. Number employed in— (a) Industrial or manual occupations (i.e., factory work, and trade or part of a trade) 359 234 593 (b) Agricultural or rural occupations 4 — 4 (c) Domestic occupations (i.e., servants sleeping in or out, lift boys and those “helping at home” 22 156 178 (d) Commercial (i.e., shop assistants or selling behind a counter), professional (or Army and Navy), clerical (office boys and girls) 9 2 11 (e) Blind alley or other precarious occupations (i.e., van boys, newsboys, errand boys or girls selling from a barrow) 85 9 94 4. Judged to be employable but out of work 46 47 93 5. Number whose careers have not been traced or who have left the neighbourhood 21 12 33 Total analysed under headings 2, 3, 4 and 5 583 502 1,085 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, 1927. 165 Placed by the Association. Placed by other means. Total. Blind. Deaf. Crippled. Blind. Deaf. Crippled. 1. (a) Industrial or normal occupations 3 74 411 9 44 511 1,052 (6) Domestic 1 1 4 4 11 38 59 (c) Commercial 0 0 18 0 0 114 132 (d) Blind Alley 2 0 12 2 4 106 126 Total 6 75 445 15 59 769 1,369 2. (a) Who have died since Blind. Deaf. Crippled. Total. 19 19 (6) Are known to be incapable by reason of mental or physical defect of undertaking employment. 6 122 128 (c) Are in attendance at an institution for further education and training. 5 16 41 62 3. Who have left London and cannot be traced — 2 33 35 4. Whose applications have been withdrawn, who refused openings or were unsatisfactory. 5 5 69 79 5. Not yet placed 3 8 73 84 Total 13 37 357 407 Statement of the number of children notified during 1927 by the local education authority to the local authority under the Mental Deficiency Act, 1913. Diagnosis. 1927. Boys. Girls. Idiots 5 5 Imbeciles 79 73 Moral imbeciles — — Feeble-minded— *(a) — — *(b) 49 74 *(C) 2 5 Total 135 157 * (a) Feeble-minded children notified under Article 5 of the Mental Deficiency (Notification of Children) Regulations, 1914 (i.e., children in respect of whom the Board's formal certificate (Form 308 M.) has been issued). (b) Feeble-minded children notified under Article 6 of those Regulations (i.e., children who, on or before attaining the age of 16, were about to be withdrawn or discharged from a special school), and (c) Feeble-minded children notified under other Articles. Mr. Yearsley's report on deaf children The medical work of the Special Schools for the deaf is under the charge of Mr. Yearsley, who reports that, as a result of examinations of the school children submitted to him during the last twenty years, he has formed the opinion that there has been a slow, but steady, increase in the efficiency of the treatment of deafness. This is most marked in the case of children suffering from middle ear suppuration, less progress having been made in cases where the condition arises from other causes. Analysis of cases of deafness. Out of 161 cases of deaf and hard of hearing children seen during the year, 12 had been dealt with in previous years ; in the 149 new cases, the causes of the deafness could be classified as follows :— Cause of deafness. Boys. Girls. Totals. Congenital 21 19 40 Acquired 51 52 103 Doubtful 3 3 6 75 74 149 166 Discarding the doubtful cases (two of them probably instances of sporadic deafbirth), there remain 143 cases in which the cause of deafness was undoubted or could reasonably be surmised. It is to be noted that the relation of the congenital cases to the acquired are 28 and 72 per cent. respectively, showing that superior methods of investigation have changed the statistics of some half century ago and fulfilled the prophecy of Mygind that in course of time it would be found that congenital cases formed less than, instead of more than, half the total number. The congenital cases were:— Boys. Girls. Totals. Per cent. True hereditary deaf-birth 8 6 14 35.0 Sporadic deaf-birth 13 13 26 65.0 21 19 40 Analysis of the acquired cases gives the following results:— A.—Meningitis— Boys. Girls. Totals. Per cent. 1. Epidemic cerebrospinal 1 2 3 2. Influenzal 1 — 1 3. Causes not ascertained 4 1 5 8.8 B.—Infectious diseases— 1. Scarlet fever 3 7 10 2. Measles 7 4 11 3. Diphtheria 1 2 3 4. Pertussis 2 — 2 5. Influenza — 1 1 6. Mumps 2 — 2 7. Encephalitis lethargica — 1 1 290 C.—Other infectious diseases— 1. Pneumonia 2 — 2 2. Chorea — 1 1 3. Congenital syphilis 1 2 3 5.8 D.—Primary middle ear disease— 1. Middle ear catarrh 11 19 30 2. Middle ear suppuration 11 12 23 3. Middle ear suppuration, results of 1 — 1 52.4 E.—Injuries 4 — 4 4.0 It may be noted that there are fewer cases this year to be ascribed to nervous diseases and more in which deafness has been a sequel of infectious disease. Blind children. The following table shows the number of children certified as blind during the decade commencing with 1918:— 1918. 1919. 1920. 1921. 1922. 1923. 1924. 1925. 1926. 1927. 69 83 74 89 88 59 84 70 33 35 As the decrease during the last two years is out of proportion to that of the general child population, the numbers for the last six years have been reviewed in three groups of two years, in order to note the nature of the defects to which the blindness has been attributed. dness has been attributed. The particulars are set out below:— (1) Injury or destruction (surface)— 1922-3. 1924-5. 1926-7. (a) Ophthalmia neonatorum 12 20 10 (6) Phlyctenular keratitis 9 13 8 (2) Inflammation within the eyeball or optic nerve— (a) Interstitial keratitis and iritis 27 25 7 (6) Disseminated choroiditis and optic atrophy 22 18 12 (c) Injuries 1 4 — (d) Buphthalmia or congenital glaucoma 3 4 1 (e) Macular defects 2 1 — (f) Congenital nystagmus 18 9 6 (g) Double detachment of retina — 1 — 167 (3) Congenital defects 1922-3. 1924-5. 7. (a) Albinism 16 11 2 (6) Defects of the crystalline lenses 11 12 6 (c) Varied defects of the globes 25 29 16 (4) High myopia 1 7 — 147 154 68 It would appear that a considerable part of the decrease is in those cases in which blindness is associated with venereal disease, and may be due to the great improvement in supervision and treatment brought about by means of the London and Home Counties Scheme for the diagnosis and treatment of venereal disease, also by the Council as a Midwives Act Authority. Part of the recent decrease is due to the change in the definition of blindness brought about by the limitations introduced by the Ministry of Health under the Blind Persons Act, 1920, whereby blindness for this purpose is limited to those cases which have a vision of 5/50 or less, or great contraction of the field of vision which renders a person too blind to perform work for which eyesight is essential. In consequence of this, a certain number of cases which, in former years, would have been sent to schools for the blind are now sent to schools for myopic children. It would appear to be premature to state that the figure for the blind will remain at 35, or under, per year, but there are no evidences of the probability of any substantial increase. Myopic pupils at secondary schools. The Council on 19th January, 1926, approved a scheme for the award of special scholarships at secondary schools for pupils who are successful at the ordinary scholarship examinations, but do not pass the medical examination owing to defective vision, and also to assist pupils from myope schools who have shown evidence of exceptional ability and who are more suited for a secondary school course than trade training provided that the parents accept full responsibility for the risks involved in training. Special classes for such pupils were instituted in September, 1926, at Raines Foundation School for boys, and the county secondary schools, Clapton and Peckham, for girls. The regulations for the care of myopes, given in the Council's annual report for 1926, are carefully observed. Dr. McVail reports as follows on these classes:—The total number of children now being taught under sight saving conditions is 37 (32 girls and 5 boys). Of these, 32 hold Council awards and the remaining 5 are fee payers. None have more than seven dioptres of myopia in the better eye, the majority ranging between four and six dioptres. For those with lesser degrees the regulations are to some extent modified. All are inspected at school every six months, and although a much longer time must elapse before any definite opinion can be formed as to the results of secondary school education on the eyes of myopes, the scheme has so far been successful. In most cases the myopia has, within the year, remained practically stationary, and in no case has there been any significant increase. Even under sight-saving conditions some children head their forms, and the social benefits derived are equally desirable for children whether their aim is scholastic or nonscholastic. The main difficulty has so far been concerned with home occupation. No home lessons are allowed, but some children, mostly of high ability, admit to reading at home. Myopic children in secondary schools are not the only offenders in using their eyes for close work when unsupervised, and attention is not infrequently drawn to children in ordinary myope classes who read or do cross-word puzzles at home, though the temptation is greater among the more intelligent. Teachers are largely instrumental in devising suitable home occupations. For instance, at Peckham the holiday task for myopes was the collection of picture post cards. These were neatly pasted into albums with an inscription in chalk below each picture. At the same school cameras, instead of books, have been proposed 168 as prizes to the myopes as an inducement for them to go out of doors. When children with small degrees of myopia are allowed a specified amount of reading at week ends, books with large and clear print are selected from the library by the head mistress. It is hoped, that by means such as the above, the eyesight of the myopes will be preserved and that advantage only will result from the scheme. As abovementioned, medical inspection is regularly and frequently carried out, and any child showing evidence of progressive myopia would be promptly detected. Observations on Myopic Children in Sight Saving Classes. General. Enquiry has within the past eighteen months been made made by Dr. McVail, into the progress of myopia in children in attendance for over three years at sight saving classes. The number of cases investigated was 150, and the average time for which records were obtained was 4'8 years, this period occurring between 5 and 14 or 15 years of age. The myopia was in each case measured from the glasses worn at the beginning and at the end of the period. Myopic children are, as a rule, examined at Council clinics or at hospitals every six or nine months, and the glasses worn may be taken as some indication of the progress of the myopia. Doubtful cases, or those where the child had not attended an eye department regularly, were omitted. The glasses in some instances showed a slight decrease in strength at the end of the period. Such cases were included in the enquiry, the total decrease being subtracted from the total increase. Number of children. Total increase in myopia both eyes added. Total decrease in myopia both eyes added. Years. D spheres. D cylinders. D spheres. D cylinders. 150 387 105.25 49.75 47.5 718 Deducting the decrease, the remaining increase is 337.25 D spheres and 57.75 D cylinders in 718 years, or 0.47 D sphere and 015 D cylinder per year (both eyes added). Taking the mean of the four meridians of the two eyes, the average increase is 027 dioptre per eye per year. It is unfortunately impossible to compare this very slight increase with that of myopic children who are not taught under sight saving conditions, as all with five dioptres or so of myopia in the better eye are admitted to special classes when the defect is discovered, as a rule about seven years of age. Possibly the findings as estimated by the glasses are somewhat lower than they should be. Minus lenses of high degree are expensive, and the tendency probably is for the oculist to advise change as seldom as practicable. Even, however, if the increase found were doubled, the indications are that with proper precautions myopia in children of school age is, as a rule, only slightly progressive. Cases in which decided advancement occurred even at sight saving classes are discussed later. Physical condition. The following table gives details as to the nutrition, teeth and tonsils of 104 of the 150 myopes, the remainder having either left school or been absent when visited:— Number of children. Nutrition. Teeth. Tonsils and adenoids. 1. 2. 3. 1. 2. 3. Slight. For treatment. ted upon. 104 14 75 15 72 28 4 21 9(+ 3 already operated upon) 32 The percentage of under-nourished children is about two and a half times as great as amongst the ordinary school population. Children of all ages from nine to fourteen years are included in the above table, and the condition of the teeth probably differs little from that of normal children. Nearly all with sound teeth had received treatment, some several times. 169 As regards tonsils and adenoids, in addition to the 30 children found to have these conditions, 32 had already been operated upon. A few had had two operations, two were awaiting a second operation, and one a third. The percentage of myopes even now requiring operation (12 in 104) is twice as great as amongst ordinary children. Family history. A definite family history of myopia was obtained in 27 of the 104 children. In eleven cases, one of the parents was affected; in 14 cases, one or more brothers or sisters had attended or were still at a myope class; and in two cases both a parent and a brother or sister were affected. In seven other cases a family history of myopia was probable. Position in family. The following table shows the position in the family of 148 myopic children belonging to 125 families:— Position of myopic children in family. Number of children in family. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 1 12 9 11 7 5 2 1 0 0 0 0 2 8 9 3 5 2 1 1 0 0 0 3 6 3 5 2 2 0 0 0 0 4 6 4 1 3 1 1 0 0 5 5 5 2 1 1 0 0 6 3 2 1 0 0 1 7 2 2 1 0 1 8 3 1 1 0 9 0 4 0 10 1 1 11 0 Total 148 12 17 26 19 24 15 13 9 4 6 3 It would appear that first children are rather more liable to be myopic than second, and second than third, and also that in the largest families (8 to 11 children) the greatest proportion of the myopes are amongst the last born, but the figures are inconclusive. The numbers are small, and as regards the largest families there is another fallacy. Although the first sight saving class in London was started in 1908, it is only within the past ten years or so that there has been considerable extension of these classes and that a serious attempt has been made to rope in all high myopes. In a family of ten, where the youngest child is now of school age, it may be that older members of the family were also myopic but attended ordinary schools and are not therefore included in the table. The following diagram shows in detail the position of myopes in 29 families of three and over, where either more than one child attended a myope class, or where other members of the family wore glasses. In each column the top circle indicates the first child and the lowest the last born. Black circles indicate children in a myope class and concentric circles those wearing glasses, but not in attendance at myope classes. Many of these cases, particularly 13, 16, 17, 18, 19, 25, 26, 27 and 29 show grouping of the myopic children in one part of the family. In some instances where only one child was at a myope class the history was given that the next child in the family wore glasses. This occurred in cases 10, 12, 14, 21 and 24. In cases 18, 20, 24, 26, 27 and 29 the myopic children and those wearing glasses tended to be grouped towards the end of large families. The actual examinations were confined to children in the special classes, and the glasses of others were not tested. From the histories given, myopia could only be suspected, and the fact that children in proximity to the myopes frequently wore glasses is given merely as a matter of interest and as a ground for future enquiry. In some instances there is no sign of grouping. Case 11 shows myopia in the 1st, 3rd, and 5th, the 2nd and 4th being normal; in case 15 the myope was the 5th 170 and the only other child wearing glasses was the 1st; in case 22 the myope was the 4th, and the only other child with glasses the 2nd. In case 9, the first child was an imbecile and the 5th an infant, so that the whole family might possibly be myopic, and in case 23 the 7th child was an infant so that here again almost the whole family might be myopic. The tendency to grouping of children within the family is very interesting and suggests that in some families there is a genetic factor causing myopia in consecutive children, though in others there is no such evidence. Increase of myopia. Twenty-two of the 104 children showed a mean increase of over 0.5 dioptre a year. Of these, the increase in 13 cases was from 0.5 to 0.75 dioptre; in six, from 0.75 to 1; in two, from 125 to 15; and in one it was 1.75 dioptres per year. A noteworthy feature is the large proportion of children, 17 out of 22 or 77 per cent., as compared with 55 per cent in the group with an increase of less than 0 5 dioptre a year, who had enlarged tonsils and adenoids at the time of the inquiry or who had already had them operated upon. Of eight who had had an operation, one child was awaiting a second, another still had catarrh and mouth breathing, a third had some enlargement of the tonsils, and a fourth had had an operation both before school age and at ten years old. Two others had not had tonsils and adenoids removed untilten. The remaining two had had operations at six and showed no signs of recurrence. Deducting these two, in 15 out of 22 or 68 per cent, of the cases, tonsils and adenoids were a factor possibly operative in the increase of myopia during the periods spent at sight saving classes. Eight of the 22 or 36 per cent, had a definite family history of myopia as compared with 23 per cent, in the group with the lesser increase. Nearly always this wasassociated with other possible causes such as tonsils and adenoids, the one exception being the case which showed the greatest increase (1.75 dioptres per year) where it was the only factor known. It is noteworthy that of nine children whose increase per year was over 075 dioptre, six had a definite family history of myopia. As regards position in the family, 26 per cent, ranged from 6th to 10th, as compared with 13 per cent in the group with the lesser increase. 171 Seven had a history of anaemia, debility, frequent bronchitis, glandular trouble or otorrhæa during their time at sight-saving classes, and one had had a bad accident necessitating a stay of several months in hospital. In the group with the smaller increase the percentage with similar defects was little less. Two of the 22 had malnutrition, and two had very bad teeth. Examinations of Employees in the Education Service and Scholars. 6,964 entrants to the permanent service and candidates for the award of scholarships presented themselves for examination during the year. scholarships presented themselves for examination during the year. The following table indicates the numbers submitted for each grade and the results of the examinations:— Status. Number examined. Number fit. Number rejected. Number who withdrew after being referred for remediable defects or were not due for re-examination until the end of the year. Male. Female. Male. Female. Male. Female. Male. Female. Permanent service 353 450 336 432 6 5 11 13 Teaching awards 236 906 228 840 1 16 7 50 Scholarships— Myopes 3 11 3 11 — — — — Others 2,623 2,475 2,571 2,439 30 13 22 23 Total *3,215 *3,842 3,138 3,722 37 34 40 86 7,057 6,860 71 126 * Including 26 permanent service cases (7 M., 19 F.), 56 teaching awards (8 M., 48 F.), and 11 scholarship (3 M., 8 F.) referred from 1926. The causes of rejection were mainly defects of vision, unsatisfactory general health and morbid conditions of heart. The total number of examinations was 8,496 an increase of over 3 per cent, when compared with the previous year. Some of the candidates were referred for one or more remediable defects. Cases specially referred. Special cases are referred for medical opinion. Particulars in regard to these cases are set out in the Annual Report of 1925. The number of examinations made was 3,887, an increase of 20 per cent, on 1926. The major part comprised teachers, of whom 671 were men and 2,874 women. In connection with sick leave 2,067, or 61 per cent., of the teachers were over 40 years of age. Physical education of teachers. During the year all applicants for the admission to the Council's course of physical education were examined, the number being 515, a slight increase on the previous year. Of this number, 35 were rejected. Accidents and sudden illness at County Hall. The arrangements made m 1922, whereby medical aid could be given in the event of cases of accident or sudden illness at the County Hall, were continued in 1927, and aid was rendered and advice given in 401 cases. Generally the cases were of a minor character, but of the 39 cases of injury one was serious and resulted from the fall of a workman from a trestle. 172 TABLE I. Medical Inspections, 1927. (a) ROUTINE INSPECTIONS. (b) OTHER INSPECTIONS. Age group. Boys. Girls. Total. Boys. Girls. Total. Entrants 39,199 38,790 77,989 Special inspections* (1) (2) 19,044 18,985 38,029 Age 8 28,452 27,565 56,017 23,784 20,581 44,365 Age 12 29,949 29,921 59,870 Re-inspections — — 193,260 Leavers 29,981 30,316 60,297 Total— Elementary schools 127,581 126,592 254,173 Special Schools 1,087 863 1,950 * (1) Special cases where individual notes are made. (2) Cases seen en masse where individual notes are not made unless the child requires treatment or observation, e.g., camp school nominations, school journey children, employment cases' etc. (infectious disease contacts are not included in this figure). TABLE II. (a) Defects found at Medical Inspections in 1927. ELEMENTARY AND SPECIAL SCHOOLS. Disease or defect. Routine inspections. Special inspections. Defects. Defects. Requiring treatment. Requiring observation. Requiring treatment. Requiring observation only. E.S. S.S. E.S. S.S. Malnutrition Skin— 857 13 991 3 446 237 Ringworm—Head 10 1 — 47 25 Body 67 1 2 — 17 4 Scabies 101 3 — — 270 131 Impetigo 449 3 3 — 520 63 Other disease (non-tubercular) 1,111 3 115 — 876 116 Eye— Blepharitis 1,112 5 92 1 349 28 Conjunctivitis 339 6 22 1 291 18 Keratitis 2 — — — 16 7 Corneal opacities 26 — 6 — 57 17 Defective vision (excluding squint) 20,873 156 6,485 88 3,520 376 Squint 1,795 10 460 — 637 63 Other conditions 258 2 61 — 200 24 Ear— Defective hearing 467 19 244 6 363 180 Otitis media 1,939 30 594 2 908 247 Other ear disease or defect 785 2 208 — 300 64 Nose and throat— Enlarged tonsils 10,057 38 8,307 29 2,630 561 Adenoids 1,269 11 682 1 581 69 Enlarged tonsils and adenoids 3,370 20 840 3 897 50 Other conditions 1,289 15 478 1 545 158 Enlarged cervical glands (non-tubercular) 705 5 2,335 7 261 216 Defective speech 116 — 208 4 136 72 Teeth, dental disease 78,492 448 1,146 2 5,354 92 Heart and circulation— Heart disease—Organic 43 — 116 1 10 5 Functional 27 1 379 1 3 7 Not stated 204 1 3,817 19 445 989 Anæmia 1,340 18 1,093 3 1,046 332 Lungs— Bronchitis 1,441 4 1,852 10 463 238 Other non-tubercular 282 1 967 3 211 356 173 Disease or defect. Routine inspections. Special inspections. Defects. Defects. Requiring treatment. Requiring observation. Requiring treatment. Requiring observation only. E.S. S.S. E.S. S.S. Tuberculosis— Pulmonary—Definite 9 — 13 — 32 3 Suspected 25 — 65 — 54 102 Non-pulmonary—Glands 40 — 23 — 40 14 Spine 2 — 11 8 5 Hip 1 — 9 1 13 10 Bones and joints 3 — 7 — 13 4 Skin 11 1 4 — 3 3 Other forms 7 — 12 — 40 23 Nervous— Epilepsy 49 1 53 6 173 89 Chorea 94 — 87 — 248 165 Paralysis 46 2 39 1 209 122 Other conditions 146 1 195 1 Deformities— Rickets 87 — 42 — 55 22 Spinal curvature 745 9 329 5 163 51 Other 484 5 331 1 154 58 Other conditions 3,158 16 1,388 4 3,928 1,285 (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 77,989 13,707 17.6 Age 8 56,017 12,105 21.6 Age 12 59.870 12,880 21.5 Leavers (age 13¾) 60,297 11,057 18.3 Total Elementary Schools 254,173 49,749 19.6 Total Special Schools 1,950 370 19.0 TABLE III. Exceptional Children in London in 1927. 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 132 128 260 Attending public elementary schools — 1 1 At other institutions — — — At no school or institution 7 5 12 (ii.) Suitable for training in a school or class for the partially blind Attending certified schools or classes for the partially blind 397 500 897 Attending public elementary schools 6 3 9 At other institutions — — — At no school or institution 5 3 8 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 332 287 619 Attending public elementary schools — — — At other institutions — — — At no school or institution 5 8 13 15435 M 174 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 81 94 175 Attending public elementary schools 8 10 18 At other institutions — — — At no school or institution — — — Mentally defective. Feeble-minded (cases not notifiable to the Local Control Authorities) Attending certified schools for mentally defective children 3,313 2,479 5,792 Attending public elementary schools 5 7 12 *At other Institutions 310 180 490 At no school or institution 69 54 113 Notified to the Local Control Authority during the year Feeble-minded 51 79 130 Imbecile 79 73 152 Idiots 5 5 10 Epileptics. Suffering from severe epilepsy Attending certified special schools for epileptics 56 30 86 In institutions other than certified special schools 38 25 63 ‡‡Attending public elementary schools 1 2 3 Suffering from epilepsy which is not severe At no school or institution 89 87 176 Attending public elementary schools— Ordinary 298 275 573 Special 64 47 111 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 of Education 39 81 120 At certified day open-air schools 104 82 186 At other institutions 2 4 6 At no school or institution 21 19 40 Non-infectious but active pulmonary and glandular tuberculosis At sanatoria or sanatorium schools approved by the Ministry of Health or the Board of Education 92 132 224 At certified residential open-air schools — — — At certified day open-air schools 157 123 280 At public elementary schools 80 41 121 At other institutions 5 7 12 At no school or institution — — — Delicate children (e.g., pre- or latent tuberculosis, malnutrition, debility, anæmia,etc.) At certified residential open-air schools 2,962 1,494 4,456 At certified day open-air schools 859 576 1,435 At public elementary schools 3,830 3,622 7,452 At other institutions 74 30 104 At no school or institution 134 142 276 Active non-pulmonary tuberculosis At sanatoria or hospital schools approved by the Ministry of Health or the Board of Education 389 325 714 (Note.—Cases of more or less quiescent tuberculosis attend the special day cripple schools) At public elementary schools 56 46 102 At other institutions 1 — 1 At no school or institution 23 15 38 Crippled children (other than those with active tubercu¬** lous disease), e.g., children suffering from paralysis, etc., and including those with severe heart disease At certified hospital schools 14 21 35 At certified residential cripple schools 17 8 25 At certified day cripple schools 2,060 2,044 4,104 At public elementary schools 1,055 1,290 2,345 At other institutions 285 301 586 At no school or institution 177 258 435 * Some of these may have eomc 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 Colonv. ** These figures include about 1,000 children suffering from non-pulmonary tuberculosis more or lessquiescent, or from the after-effects of such disease. 175 TABLE IV. Defects treated during 1927. 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. Tota . Skin. Ringworm—Head 644* 224 868† Ringworm—Body. Scabies 1,432 2,609 Impetigo 1,177 Other skin diseases Eye disease. (External and other, but excluding eases falling in Group II.) 99,766 1,572 103,947 Ear disease. 2,609 Cases in which operative treatment (e.g., mastoid operations, etc.) is given are excluded. Miscellaneous. (Minor injuries, brusies, sores, chilblains, etc.) 103,019 1,796 104,815 * 550 by X-Ray. † 660 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) 38,000 1,593 41,886 Other defect or disease of the eyes (excluding those in Group I.). 2,293 (estimated) Children for whom glasses were prescribed under Council's scheme 28,726 „ who obtained or received glasses under Council's scheme 26,086 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. 13,046 *1,797 14,843 5,130 19,973 * 105 by private practitioners, 1,692 at hospitals. 15435 M 2 176 Group IV.—Dental Defects. (1) Number of children who were— (a) Inspected by the Dentist—Age Groups— 5 years and under 7,474 11 years and under 38,776 6 „ „ 32,945 12 „ ,, 8,717 7 „ ,, 44,320 13 „ ,, 12,760 8 „ „ 9,741 14 „ over 5,763 9 „ ,, 30,941 10 „ ,, 34,700 226,146 (b) Found to require treatment, 158,476 (70.06 per cent.). (c) Actually treated, 124,992 (including (d) ). (d) Re-treated as the result of periodical examination, 3,830 (2) Half-days devoted to—Inspection, 2,025. Treatment, 16,577—Total 18,502. (3) Attendances by children for treatment, 206,663. (4) Fillings—Permanent teeth, 72,825. Temporary „ 29,887—Total 102,712. (5) Extractions—Permanent teeth, 52,221. Temporary „ 354,152—Total 406,373. (6) Administrations of general anesthetics for extractions, 68,217. (7) Other operations—Permanent teeth! Temporary Total 24,994. Group V.—Cleanliness—1926. (a) Average number of visits per school made during year by school nurse, 6. (b) Examinations of children in the schools by school nurses, 1,990,201. (c) Instances of uncleanliness, 261,135. (d) Children cleansed under Council's arrangements, 105,570. (e) Cases in which legal proceedings were taken, 277. APPENDIX. In his report for 1926 on "The Health of the School Child," p. 25, the Chief Medical Officer says:— "In London, where roughly 95 per cent, of children admitted to cripple schools attend hospital regularly during school life, we find that in seven ordinary cripple schools subjected to scrutiny 260 children left in the year ending 30th June, 1926, and that of those 93 (35.7 per cent.) were still wearing apparatus on leaving. There are no doubt circumstances in London which make this figure substantially higher than in some provincial cities." "In Liverpool, for instance, 46 out of 293 (15.7 per cent.) crippled children leaving school during the same period were wearing apparatus." ". . . speaking broadly, the new orthopaedic surgery ought now to be able to restore the bodies of these children without a high percentage of ' leavers ' having to wear surgical apparatus." Since pp. 147-153 of this report were written an analysis has been made by the Council's Medical Officers of the number of children aged 14 and upwards wearing splints in the cripple schools of Birmingham, Liverpool and Manchester, and a comparison of those of the same age wearing splints in eleven London cripple schools. There were in Birmingham 46 children aged 14+ ; of these, 20, or 42 per cent., wore apparatus. In Manchester, 16 children aged 14 + were seen, and of these 8, or 50 per cent., wore apparatus. In Liverpool, 78 children aged 14+ were seen, and of these 35, or 44-9 per cent., wore apparatus. In London, 312 children, that is, all aged 14 and upwards in eleven cripple schools have been examined. Of these 102, or 32-6 per cent., were wearing apparatus. In the three provincial cities, out of 140 children, 63, or 45 per cent., were wearing apparatus. Amongst the children seen, however, there were very many admitted to cripple schools who had not suffered from any disease which would, in any circumstances, require the wearing of surgical apparatus. Only two diseases were found which, to any extent, cause crippling of a nature likely to require the wearing of surgical apparatus. These are surgical tuberculosis and infantile paralysis. A fairer method would be to limit the comparison to children suffering from these diseases. In Liverpool, there were 48 children aged 14+ suffering from these diseases, and 35 (72 per cent.) were wearing apparatus. In the three provincial cities combined there were 76 children suffering from surgical tuberculosis or infantile palsy, and 55 (72-3 per cent.) were wearing apparatus. In London, there were 161 children suffering from surgical tuberculosis or infantile palsy, and of these 90 only were wearing apparatus, or 54-9 per cent., while 61 (37-9 per cent.) who had at one time worn apparatus had discarded it. These figures appear to show that the new orthopedic surgery is more successful in London than elsewhere, if the comparison is strictly confined to those diseases which are capable of being 'dealt with by surgical methods. 177 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 piovision of residential treatment required through a public authority (other than poor law guardians) and Exchequer grant of 50 per cent, is paid on the Council's approved expenditure. The metropolitan borough councils provide or arrange for the provision of dispensary treatment and the Council contributes 25 per cent, of the approved cost, the Exchequer contributing 50 per cent. Various particulars in regard to the work done under the scheme are given in Chapter I of this volume (pp. 14-16 and 30-36). Special inquiry was made into the work carried on at the Cambridgeshire Tuberculosis Colony, Papworth Hall, where treatment, training and employment are provided for tuberculous patients. The Council came to the conclusion that enterprises of this kind, while extremely interesting and valuable, could not ofler a solution, generally applicable, of the difficult problem of providing suitable employment or occupation for urban tuberculous persons after discharge from sanatoria. The Council decided to support a request of the National Association for the Prevention of Tuberculosis to the Minister of Health for an authoritative inquiry into the working of tuberculosis schemes throughout the country. For the purpose of forming a more reliable opinion as to the value of residential treatment for tuberculosis, it has been decided to make surveys at five-yearly intervals of the condition of persons discharged from treatment. The first of these surveys was made in respect of adults and children discharged in 1921. The tuberculosis 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. The Council has decided to admit reasonable expenditure on sputum flasks and paper handkerchiefs for the purpose of its grant. Arrangements have been approved for the post-graduate instruction of tuberculosis officers and the provision of "refresher" courses for tuberculosis health visitors and nurses. The experimental arrangements in connection with the dispensary service for treatment in suitable cases by artificial light in out-patient departments of approved hospitals and other centres were continued for a further period of one year from 1st April, 1927. The scheme for the diagnosis and treatment of venereal diseases in the county provides for the participation of certain authorities near London in the facilities afforded by selected hospitals for the pin-pose. The arrangements for 1927 provide for free treatment and diagnosis for in-patients and out-patients at 24 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. In pursuance of the policy followed in the development of the scheme all-day clinics have been established at five of the hospitals referred to and arrangements have been approved for the provision of an all-day clinic to serve the Western district of the county. 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 oi Venerea disease * 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. 2C35. Price 6d. 178 cost, salvarsan or its substitutes. The Council makes direct payments to hospitals for salvarsan or its substitutes supplied to medical practitioners in London. 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 percent, by the Council and the participating authorities according to the user of the facilities available. Details of cases treated in 1927 and preceding years are given in Chapter I, pp. 28 and 29. The Council's venereal diseases scheme provides 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 usefullv be directed through official channels. Rescue and preventive work. 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. The after-care of girls suffering from venereal disease is receiving special consideration. The Council obtained powers in 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. Under these powers the Council proposes to arrange for the circulation from time to time, as may be deemed desirable, amongst the medical officers of health of the metropolitan boroughs and medical practitioners, etc., in London, of medical information which it will be difficult for them to obtain in a comprehensive form without considerable study and research, and for the issue to the press on special Infant life protection. occasions of carefully considered statements as to any epidemic diseases. 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 1927, 3,184 nurse-infants and the premises of 2,350 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:— Year. Infants removed from foster-mothers. Exemptions. Deaths. Infringements discovered. Cautions. Prosecutions. Convictions. 1921 20 3 42 1 302 285 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* 26 214 210 4 3 1927 4 — 3* 222 217 5 5 * 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, and suggested various amendments which they considered to be 179 needed. 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. In view of this proposal the Council decided to take no further action to secure effect being given to its resolution of 18th May, 1920, as to the registration of persons receiving nurse-infants and of an nil infants 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 1926, 266 premises were on the register, 15 were added during the year, and 36 entries were removed (owing to discontinuance of user, removal, etc.), leaving a net total of 245 on the register at the end of 1927. Twelve premises carried on by registered medical practitioners were exempted during the year. The Nursing Homes Registration Act, 1927, received Royal Assent on 22nd December, 1927. The Act comes into operation on 1st July, 1928, and as from that date repeals Part IV (Lying-in Homes) of the London County Council (General Powers) Act, 1921, requiring the registration of lying-in homes in the County of London, and provides generally that a nursing home, viz., any premises used or intended to be used for the reception of and the providing of nursing for persons suffering from any sickness, injury or infirmity, including a maternity home, cannot be carried on unless it is registered in accordance with the provisions of that Act. Census of homeless persons. Particulars are given in Chapter I. (p. 24) of the result of the census of homeless persons taken in February, 1927. 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; 1926, 103; and 1927, 101. 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 £3 189. 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. 61 1 1926 164 16,997 1 1 £2 2s. 2 1927 164 17,059 nil nil nil 1 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 county, and a report thereon was prepared by the Medical Officer of Health.* On 1st March, 1927, a report † on the whole question was submitted to the Council, when it was decided to continue the course of action taken by the Council in the performance of its duties as the licensing authority for common lodging houses in the County of London and in regard to the character, standard and adequacy of the accommodation in common lodging houses and kindred institutions. *Common Lodging Houses and Kindred Institutions. Report by Medical Officer of Health, 1927. No. 2489. 1s.6d. †Common Lodging Houses and Kindred Institutions. Proceedings of the Council on 1st March, 1927. No. 2491. 6d. 180 Seamen's lodginghouses. 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 1,002 7 7 £41 8s. — 1926 34 1,073 1 1 £5 2s. 1 1927 31 1,061 6 5 £46 5s. — Offensive businesses. The following table gives particulars of licensed slaughterhouses, knackers yards and registered offensive 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 1927 115 4 171 Section 56 of the London County Council (General Powers) Act, 1927, which came into operation on 1st July, 1927, empowers the Council when sanctioning the establishment anew of an offensive business under section 19 of the Public Health (London) Act, 1891 to grant the sanction for such period as may be specified therein and to extend such period from time to time. Previously no limit could be set for the period for which the sanction held good. The Council on 26th July, 1927, decided to exercise the powers conferred upon it by this section. During 1927 sanction was given in five cases to the establishment anew of the business of a dresser of fur-skins and also to the establishment anew of the business of a slaughterer of poultry, a fellmonger, a soapboiler and a tripe boiler. The numbers of cowhouses licensed bv the Council in the past five years were as follows 1923, 98; 1924, 89; 1925, 84; 1926, 75; 1927, 65. Under the Milk and Dairies (Consolidation) Act, 1915, which came into operation on 1st September, 1925, and superseded as from 1st September 1926 Part IV. of the London County Council (General Powers) Act, 1907, samples of milk coming into London from places outside the county are taken and examined. Information is 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. In 1927, 2,305 samples from milk consigned to London railway termini from 32 counties were submitted for bacteriological examination. In the case of 1,969 samples, the bacteriological examination was completed and of these 154, or 7 8 per cent., yielded tubercle baccilli as against 4.5 per cent, in 1926. During the year 25 samples of milk were also taken from the Council's mental hospitals, 17 of which proved, on examination, to be free from tubercle baccilli. Four were found to be tubercle-infected. The herds at the hospitals from which the samples emanated were inspected but only in one case was it necessary to isolate a cow for slaughter, although in three cases cows had been slaughtered before the veterinary inspector's visit. A post-mortem examination of one of these cows revealed a state of advanced general tubercle. Cowhouses, Tuberculous milk. 181 During 1927, 367 inspections were made of the cows in London cowsheds, and the total number of examinations made was 8,125. No case of generalised tuberculosis was detected, but in 116 cases other unhealthy conditions were found. During the year the Council again considered the need for the provision of additional accommodation for the treatment of rheumatic children. Acute cases of rheumatism in children are treated in children's hospitals and general and special hospitals, but there was evident need for more accommodation for convalescent cases. The Metropolitan Asylums Board was asked as to the prospects of such accommodation being provided and, after being supplied by the Council with particulars of the needs, has decided to provide additional permanent accommodation of 350 beds at Queen Mary's Hospital, Carshalton, for children of both sexes suffering from sub-acute rheumatism, the later stages of acute rheumatism, rheumatic chorea and rheumatic carditis, including recurrent attacks. Consideration was given to the need for taking fresh measures to combat diphtheria in view of the recent evidence published by the Medical Research Council contained in a report* by Dr. J. Graham Forbes, a principal assistant medical officer in the public health department. The method of prevention referred to in the report is that known as the "Schick test" for ascertaining whether or not a person is immune from diphtheria, and with it is associated a method of "active immunisation " by the injection of toxoid-antitoxin mixture for persons found to be susceptible. The evidence showed that in London as elsewhere the mortality from diphtheria has been markedly reduced since the introduction of antitoxin treatment. The metropolitan borough councils are the local authorities statutorily responsible in London for the prevention of the spread of infectious disease such as diphtheria although the Council has certain responsibilities in regard to the health of school children. Certain metropolitan borough councils have initiated centres at which facilities for immunisation are available and in other boroughs the matter is under consideration. The Council came to the conclusion that in the present state of knowledge it would be premature for it to introduce any measure of active immunisation among school children, even on a limited scale, until further experience is gained. The matter will be considered again in a year's time. Representations were made by a number of metropolitan borough councils, supported by the Metropolitan Boroughs' Standing Joint Committee to the Council, asking it to promote legislation requiring compulsory registration with the sanitary authorities of ice cream makers and vendors and their premises. Powers had been granted by Parliament to certain provincial corporations in regard to the registration of premises used for the manufacture and sale of ice cream and it appeared desirable that registration should be required in London so that the sanitary authorities might have complete information as to where ice cream and similar commodities are being made, stored and sold and thus be in a position to exercise their existing powers for securing that proper conditions are observed at premises on which ice cream is manufactured, etc. The Council accordingly decided to apply to Parliament to require that any premises used or proposed to be used for the manufacture for sale, storage for sale or sale of ice cream or other similar commodity in the administrative county of London (except premises occupied as a factory or workshop, respecting which notice is required under section 127 of the Factory and Workshops Act, 1901, and premises used as a hotel, restaurant or club) should be registered with the sanitary authority. The latter premises were omitted as the position of premises of this kind is usually well known to the sanitary authority. The Council decided to take in hand the revision of the by-laws made under section 39 of the Public Health (London) Act, 1891, relating to the construction of water closets, etc. Urinals are not mentioned in this section and it appeared *Medical Research Council. The Prevention of Diphtheria, by Dr. J. Graham Forbes, M.D., F.R C.P., D.P.H., 1927. His Majesty's Stationery Office, 2s. net. Rheumatism. Diphtheria. Ice cream. By-laws as to waterclosets, etc. 182 desirable that by-laws should be made governing their position and construction. The Council decided to make application to Parliament to provide for the extension of the application of section 39 to urinals and also of sections 40, 41 and 42 which confer powers on the sanitary authorities in regard to the examination of water closets, etc., and non-compliance with the by-laws relating thereto. In July, 1924, the Council considered the question of the disposal of house and other refuse from London and certain out-county districts in so far as it affected the development for residential and industrial purposes of lands on the northern bank of the river Thames below Barking Creek. The Council's chief interest in the matter was as owner of the Becontree Housing Estate, but general considerations of public health and other interests of the Council made the cessation of dumping on the marsh lands abutting on the tidal waters of the Thames a matter of supreme importance. The Council called the attention of the Minister of Health to the matter and informed him that it considered this dumping in the vicinity of Becontree and other neighbouring areas under development for residential and industrial purposes constituted a menace to public health and asked him to investigate the whole matter with a view to guidance to the various authorities concerned as to future arrangements for dealing with such refuse. In 1925, the opportunity again arose of raising the question with the Minister, who then promised to arrange for a technical investigation to be made by an officer of the Ministry into the technical aspect of the problem of refuse disposal. As the unsatisfactory conditions referred to still continued the Council in July, 1927, again drew the Minister's attention to the matter and asked him to hold a public inquiry for the purpose of arriving at the most satisfactory solution of the problem of dealing with the refuse. 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 Refuse disposal. Midwives. 183 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. The Births and Deaths Registration Act, 1926, which came into force on 1st July, 1927, requires inter alia that the birth of every still-born child shall be registered Any certified midwife who was in attendance at the birth or who has examined the body of the child is required to give a certificate, for production to the Registrar for the sub-district in which the birth takes place, to the effect that the child was not born alive. Notifications by midwives of intention to practise during the year 1927 numbered 823; of intention to practise for specific periods less than a year, 26; and of having acted in specific cases, 21. During the year the Council reported to the Central Midwives Board that one prima facie case of malpractice, negligence or misconduct on the part of a certified midwife had been established. The Board found certain of the charges to be proved but postponed sentence with a view to further consideration on receipt of reports from the Council as to the conduct and methods of practice of the midwife at the end of three, six and nine months. In seven other cases of infringements of the rules of the Board which did not appear to be sufficiently serious to warrant submission to the Board, the midwives were cautioned by the Council to observe strictly the rules of the Board in their practice. From time to time women whose names have been removed from the Midwives Roll make application to the Central Midwives Board for the restoration of their names to the Roll. The rules of the Board require that such applications must be supported by the certificate of the local supervising authority of the district in which the applicant was resident at the time when her name was removed from the Roll and, if at the time of her application, she be resident in another district, then by the certificate of the local supervising authority for that district also. Generally speaking, when a midwife is removed from the Roll, the local supervising authority entirely loses touch with her and is not in a position to give a certificate which can be of value. Two such cases were considered during the year, and in the absence of any knowledge of the applicants since the removal of their names from the Roll, the Council felt itself unable to give certificates in support of the applications. 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. From 1st April, 1927, to 31st March, 1928, the Council's expenditure under section 14 of the Act of 1918 was approximately £4,060, the sums recovered during the same period amounting to £966 approximately. During the year 1927 the Council suspended 19 midwives from practice for short periods to prevent the spread of infection, and awarded compensation amounting to £126 10s. 4d. 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 popidation at the last census, and the Council's proportion for the vear 1927 was £528 12s. Proceedings as indicated below were taken by the Council during 1927 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 Smoke Nuisance. 184 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. Nine prosecutions were instituted against railway companies; 9 convictions were obtained, penalties and costs amounting to £27 lis. being imposed. Two prosecutions were instituted in respect of smoke nuisance from road locomotives; 2 convictions were obtained, the penalties and costs imposed amounting to £1 10s. 6d. 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—17. Prosecutions—9. Convictions—9. Total of fines and costs imposed—£27 lis. (2) Road locomotives:—Nuisances reported—12. Prosecutions—2. Convictions—2. Total of fines imposed—£1 10s. 6d. (3) Premises :—Reports made as to alleged nuisances—244. Cases in which legal proceedings were taken by metropolitan borough councils as the result of such reports—nil. The Diseases of Animals Acts, 1894 to 1927, the object of which is the suppression of contagious diseases in animals, naturally do not affect London so much is they do 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 1927 the incidence of the principal animal diseases so far as London is concerned was as follows:—Glanders, including farcy, nil; swine fever, 4 outbreaks in which 314 animals were involved; anthrax, nil; parasitic mange, 65 outbreaks involving 127 animals; foot and mouth disease, nil. During the year the Islington Metropolitan Borough Council asked the Council to support an application made by it to the Minister of Agriculture and Fisheries for the extension of the application of the Anthrax Order, 1910, made under the Diseases of Animals Acts, so as to cover all animals. Under that Order, the expression "Animals" is defined as meaning cattle, sheep and goats, and all other ruminating animals, and swine, horses, asses, mules and dogs. The Order contains many stringent provisions, with a view to preventing the spread of the disease, and requires the local authority to destroy all affected carcases and to cleanse and disinfect at its own expense all stables and buildings in which an animal has died or been slaughtered and everything used for or about any diseased animal or carcase. It occasionally happens that animals other than those specified in the above-mentioned definition contract anthrax, for instance, lions and other carnivorous animals. Recently, two elephants in London contracted the disease. In such cases, the local authority has no control over the carcase, and in some instances the owners have removed the skin and other valuable portions of the animal for preservation. It is extremely important that in a case of such a serious disease as anthrax, which is communicable to man, the carcase should be entirely disposed of without undue cutting or dismemberment. Having regard to the extreme danger attendant upon the handling of infected carcases, the Council on 1st March, 1927, decided to support the application of the Borough Council. Swine fever has been very prevalent throughout Great Britain during the past few years and 4 outbreaks were dealt with in London during the year. During 1927 no fewer than 20;683 swine were examined at feeders' premises. 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 Diseases of Animals. Anthrax, Swine fever. Rabies. 185 muzzling regulations, the Council made new regulations requiring the wearing of collars by dogs while on a highway. Under these regulations, 25,942 dogs were seized by the prjlice during 1927. Of this number, 7,381 were claimed by their owners and the remainder were sent to the Dog's Home for sale or destruction. Three cases of suspected rabies in London were reported during the year but the post-mortem examinations made by the veterinary inspectors failed to reveal evidence of disease, the suspicious symptoms being proved to arise from other causes. 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 1927, the returns of cases in London showed a slight increase. The following figures relate to 1927:—Outbreaks, 65; horses affected, 127; infringements, 14; written cautions sent, 9; cases referred to solicitor, 5; convictions, 5; penalties and costs, £35 8s. For the purposes of comparison, it may be pointed out that the number of outbreaks in 1926 was 57, affecting 91 horses. 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 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. 12 infringements of the Order were dealt with by means of written cautions. In consequence of an outbreak of foot and mouth disease at Neasden, Middlesex, the Minister of Agriculture and Fisheries made an Order on 7th January, 1927, declaring a district within a radius of 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 modified on 29th January 1927, and London was released from movement restrictions. In consequence of another outbreak at Enfield, Middlesex, a similar Order was made on 5th October 1927, which included the portion of the County of London north of the river Thames, but London was again released from restriction on 19th October, 1927. In the case of both outbreaks, 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 39 infringements of the Foot and Mouth Disease (Infected Areas Restrictions) Order of 1925, 37 of which were dealt with by means of written cautions. Cases referred to solicitor, 2; convictions, 2; penalties and costs £20 3s. 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 1927 numbered 3,016, the animals examined being—horses 3,209, cattle 55,574, sheep 92,050, swine 46,553, making a total of 197,386. There were 19 infringements, 18 written cautions, 1 case of legal proceedings and 1 conviction with a penalty and costs amounting to £15 5s. During the year an application for financial aid towards the cost of rebuilding and equipping the Royal Veterinary College was considered. As there was no provision in the three years' educational programme for such a grant, and as there Parasitic mange. Foot and mouth disease. Enforceme of orders. Rebuilding of Royal Veterinary Colloge. 186 did not appear to be any power under the Diseases of Animals Acts to give financial aid, the governors were informed that the Council was unable to accede to their request. During the year the Minister of Agriculture and Fisheries issued an Order, entitled the Transit of Animals Order, 1927, together with an amendment thereof, dated 9th May, 1927, which came into operation on 1st June, 1927. This Order consolidates and amends the provisions of the Animals (Transit and General) Order of 1912, and its amending Orders relating to the transit of animals by land in Great Britain, and by sea between ports in Great Britain, Ireland, the Channel Islands and the Isle of Man, and coastwise in Great Britain. The necessary steps were taken to bring the provisions of the new Order to the notice of the persons concerned. Those provisions of a general character relating to diseases of animals which were formerly included in the Order of 1912 have been embodied in a new Order entitled the Animals (Miscellaneous Provisions) Order of 1927, which came into operation on 1st June, 1927. This Order contains a new provision which empowers an inspector of the Ministry or the local authority to require special disinfection of slaughterhouses in particular cases with a view to preventing the spread of disease. The necessary steps were taken to bring the provisions of the new Order to the notice of the persons concerned. Article 2 (1) of the Markets, Sales and Lairs Order, 1925, provides that lairs which adjoin market premises and are used for the reception or temporary detention of animals offered for sale must be paved in accordance with the requirements of that Order and licensed by the local authority concerned. The Council was satisfied that these conditions have been complied with in connection with the lairs adjoining the Metropolitan Cattle Market, Islington, and the necessary licence was accordingly granted authorising the use of the lairs as from 1st July, 1927. CHAPTER IV. MAIN DRAINAGE. The district drained by the London main drainage system has an area of nearly 152 square miles with an estimated population of 5,624,900. This includes an area of nearly 36 square miles, with a population of 1,009,500 outside London. When the district of Walthamstow is incorporated in the area served by the system in accordance with the provisions of the London County Council (General Powers) Act, 1925, nearly 7 square miles, containing a population of over 125,500 will be added. The quantities of sewage, etc., dealt with during 1927 were as follows:— Sewage treated— Million gallons. Northern outfall 63,151.5 „ (daily average) 173.0 Southern outfall 36,678.2 „ (daily average) 100.5 Sludge sent to sea— Tons. Northern outfall 1,796,500 „ (daily average) 4,922 Southern outfall 851,300 ., ,, (daily average) 2,332 The sludge vessels made 1,831 trips and travelled altogether 202,300 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 Trannsit of animals. Disinfection of slaughterhouses. Markets. Sales and Lairs Order. 1925. Drainage area and statistics. Sewage treatment. 137 of apparatus. 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. The existing experimental plant reached an ultimate capacity of about 150,000 gallons of sedimented effluent a day. At other places activated sludge plants were working on quantities far beyond those dealt with in the Council's experimental plant and the Council authorised the Main Drainage Committee to make a further inspection of sewage works at provincial towns or districts. The Committee visited the sewage works- of the Birmingham, Tame and Rea District Drainage Board and those of the Corporations of Coventry and Reading. 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 1927 amounted to £264 0s. 11d. The re-organisation of the Council's fleet of sludge vessels has been completed and the fleet now consists of five vessels, namely, the Bazalgette (commissioned in 1887 and re-conditioned in 1921) of 1,000 tons capacity, and the Henry Ward (commissioned in 1923), the J. 11. Hunter (commissioned in 1924), the G. W. Humphreys (commissioned in 1925), and the John Perring (commissioned in 1926), each of about 1.500 tons capacity. During the year the Henry Ward became due for her first quadrennial survey by Lloyd's, and the work entailed was carried out at a cost of £1,480. The J. H. Hunter, the G. W. Humphreys and the John Perring underwent their annual overhauls at a total cost of £2,450. The water supply for the boilers of the sludge vessels consisted of hard water, and means were taken within the boilers themselves by treatment with chemicals to prevent the formation of scale. This method is much less satisfactory than separate treatment of the water in a softening plant. The water softening plants at the two outfalls is therefore being connected with the supply tanks for the sludge vessels, including the necessary pumps, at a cost estimated at £850. The pinnace Boqie, which is used by the superintendent of the sludge vessels, has been overhauled and equipped with an internal combustion engine at a cost of £456. The repainting and decorating of the workmen's cottages at the outfall has been undertaken, the Council having on 14th September, 1927, accepted the tender of Messrs. George Eaglen and Son, Bow, E., amounting to £372 for the work. Arrangements at an estimated cost of £160 have been made for the provision of a separate cabin adjoining the flushers' mess room, in which they can dry and store their working clothing. The screening of the sludge produces a large amount of solid matter and a contract was entered into with Mr. C. W. Parker, Bradwell-on-Sea, Essex, for the removal of the refuse upon payment by the Council at the rate of 6s. a ton. The estimated cost of this work is £1,560. A footpath ran from Gallions 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 has now been closed to the general public, but is available for use by all authorised persons to and from the outfall. Deposit of sludge at sea. Sludge vessels. Northern outfall. 188 A thoroughfare, known as Jenkin's-lane, runs through the Council's land at the Northern outfall to the foot of the Northern outfall sewer embankment, where it ends. The principal use of the lane is made by employees coming to their work at the Northern outfall and to the Beckton works of the Gas Light and Coke Company, and other persons having business at these places. To obtain access to the Company's works it is necessary to cross the sewer embankment. The Barking Town Urban District Council ran a tramway as far as the sewer embankment at a loss, and alternative means of conveyance by omnibus being available in connection with the construction of the East Ham and Barking by-pass arterial road, the district council desired to discontinue the working of the trams on this line. An essential condition to the provision of an omnibus service was the widening of Jenkin's-lane and the Council agreed to surrender the necessary land for the widening of the lane to 36 feet. The overhaul of the main beam engines and pumps at the Southern outfall 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 machinery in rotation. Up to date, the work has cost approximately £12,200. 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 tender, amounting to £4,111 8s. 9d., submitted by D. G. Sommerville and Company, Limited, Grosvenorplace, S.W., for the work was accepted on 28th October, 1926, and the work is proceeding. The accommodation for sludge separated from sewage in the precipitation channels at the Southern outfall consists of a large underground store capable of containing 10,000 tons. This arrangement compared unfavourably with that in operation at the Northern outfall, and on the average each cargo of sludge sent to sea from the Southern outfall contains 6½ tons less solid matter than from the Northern outfall, with the result that more water is sent to sea than should be necessary to dispose of the sludge. The Council has therefore decided to erect overhead sludge tanks at the Southern outfall similar to those at the Northern outfall. The estimated cost of the work is £21,000. The undermentioned tenders have been accepted: The Horseley Bridge and Engineering Company, Limited, Tipton, Staffs, for the supp'y and erection of overhead tanks, £12,769 16s. 3d.; The Demolition and Construction Company, Limited., London, S.W., for the construction of foundations, £2,293 7s. 6d.; Ham, Baker and Company, Limited, Birmingham, for the supply of sluice valves £680 19s.; and the Sheepbridge Coal and Iron Company, Limited, Chesterfield, for the supply of piping, £3,611 18s. 9d. The workmen's cottages at the outfall are being repaired and repointed at a cost of about £240, and repairs to the pier carried out at a cost of about £520. A new office has been erected at the outfall for the use of the superintendent of the sludge vessels at a cost of £270. Sand washed down the sewers accumulates at the outfall and in the adjacent sewers in large quantities. The cost of disposing of this amounts to £1,055 for the year. 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 continuation of the overhaul of the gas engine plant. The total cost of the work up to 31st December, 1927, has been £2,345. The apparatus screening the sewage flowing to the Worthington engine house, now known as the Gwynne engine house, has proved unsatisfactory, owing to the greater efficiency of the new plant, and the accumulation of rags and other debris in the pumps has necessitated the frequent stopping of the pumps and the removal of the accumulations by hand labour. In order to obviate the trouble, the Council decided to instal a new screen of improved type and this is being fitted at a cost of £2,000. Southern outfall. Abbey Mills pumping station. 189 Also it was ascertained that the old de-oiling and water softening apparatus was unable to cope with the increased load, with the result that oil found its way into the boilers in such quantities as might cause damage. It was therefore decided to instal a new independent de-oiling apparatus and to modernise the existing water softening plant by the addition of new chemical mixing apparatus. The estimated cost of these works is £1,100. The Channelsea River, a tributary of the River Lee, flows along the eastern side of Abbey Mills pumping station and the adjoining land which is also the Council's property. The river bank is known as the Long Wall. The condition of the wall has rendered repairs urgently necessary, and these have been undertaken at a cost of £1,038. The brickwork of the boilers at Deptford pumping station has been repaired at a cost of £255. The cost of overhauling the engines at the station for the year ended 31st December, 1927, amounted to about £430. A defective nest of tubes in the fuel economiser is being renewed at a cost of about £490. The pump chamber at Heathwall pumping-station disclosed the percolation of water and the walls of the chamber have been treated in order to prevent such percolation at a cost of £190. In order to ensure a sufficient and continuous supply of cooling water at Shad Thames pumping station, it has been necessary to instal a duplicate system for the purpose, and this has been carried out at a cost of £156. Owing to the development of defects in a cylinder of one of the old engines (No. 3) at the station, the cylinder is being renewed at a cost of about £320. From time to time subsidences have occurred in roadways on the sites of shafts sunk in connection with the construction of the Southern outfall sewer No. 2 and the Southern high-level sewer No. 2, due to the consolidation of the material used for filling in the excavations. Further subsidences occurred during the year in Prioloroad and Kinveachy-gardens, Greenwich, and Clarendon-road, Lewisham, and they have been made good at a cost of £250. An order has been made by the Council under the provisions of section 137 of the Metropolis Management Act, 1855, vesting in the Council the new sewer constructed on behalf of the Lambeth and Wandsworth Metropolitan Borough Councils in Brixton-hill and Streatham-hill, and the local sewer in Water-lane, Brixton, between the new sewer and the Council's EfEra sewer. The construction of the underground station and passages and new escalators at Piccadilly-circus necessitated a diversion of the Council's main sewer in Shaftesbury avenue which resulted in the discontinuance of the sewer as a main sewer for a length of about 230 feet. A short length of the sewer (about 26 feet) was required for the drainage from certain gullies and a house drain, and this length will be maintained bv the Westminster Citv Council as a local sewer. Deptford pumping station. Heathwall pumping station. Shad Thames pumping station. Outfall, intercepting and main sewers. Repairs, etc., have been carried out during the year to intercepting and main sewers as follows:— Approximate cost. £ Fleet Sewer 2,810 Hackney Brook Sewer 2,210 King's Scholars' Pond Sewer 4,460 London Bridge Sewer 260 Eastern Counties Sewer 252 Northern Outfall Sewer Embankment 265 Ranelagh Relief Sewer 3,830 RatclifE Highway Sewer 2,545 15435 N 190 Appropriate cost. £ Regent-street Sewer 3,570 Wick-lane Sewer 280 Northumberland-street Sewer 915 Falcon Brook Sewer 467 EfEra Sewer 2,481 EfEra Branch Sewer 318 Southern High Level Sewer No. 1 Extension 672 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 bv the Council's staff. The cost of this work in 1927 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 during times of heavy rainfall. The scheme, which is described in the Annual Report for 1920 (Vol. III., 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 and the north-western storm relief sewer. 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) the north-eastern storm relief sewer completed in September, 1924 (£700,000), the Beverley Brook relief culvert completed in September, 1926 (£38,450) and the Lewisham Branch sewer completed in October, 1926 (£246,656). 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 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 at an approximate cost of £60,000. Abbey Mills pumping tation nlargemenb 191 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 pumping station and the general flood relief scheme of 1919 provided 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 enlargement of the station was practically completed. Isle of Dogs 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. The installation of the machinery was well advanced at the end of the vear. Shad Thames pumping station. The scheme of relief sewers in Lewisham and Woolwich is described in the Annual Report for 1923 (Vol. III., p. 128). One of the sewers in question, namely, 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 Chalton), was completed during the vear at a cost of £207,562. Storm relief sewers in Lewisham and Woolwich. The scheme also provided for two branches of the Lewisham branch sewer to Hither-green and Lee-green respectively. Serious complaints had been made in recent years of flooding in the neighbourhood of Hither-green, and the development of the Council's Downham housing estate will, to some extent, increase the present demand on existing sewers at Hither-green. A desirable improvement in the local sewers in the district also depends upon the construction of the branch sewer to Hither-green, and the Council therefore decided to undertake the construction of the sewer at an estimated cost of £57,000. The tender, amounting to £53,004 13s. 5d., submitted by Messrs. Kinnear, Moodie and Company, Victoria-street, S.W.I, for the construction of the sewer was accepted on 26th Mav, 1927. Northwestern storm relief sewer. The north-western storm relief sewer extends 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 is connected with the Ranelagh sewer in Shirland-road, Kilburn, and runs to the nearest point on the Thames, at Hammersmith, connecting with various main sewers on the way. Branch sewers connect the new sewei with the middle level sewer in Ladbroke-grove, and with the Wood lane sewei at Wormwood Scrubs. A connection has also been made with the new pumping station at Hammersmith. Altogether the construction of about 5£ miles of sewer is involved, the approximate cost being £527,000. The principal sewei has been constructed for a length of about 2£ 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. The works are complete and the sewer was in full use in September, 1927. Southwestern storm relief sewer. The south-western storm relief 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 sewer from Effra-road to Nine Elms was completed in March, 1926. The question of extending the sewer southwards was considered, but storm relief works were more urgently reauired elsewhere, and were given preference. To give relief to an area where 15435 N2 192 floodings occurred and which would have been served by the extension of the southwestern storm relief sewer, the Council decided upon the construction of a short length of sewer between existing local sewers in Robson-road and Chestnut-road, Norwood, at an estimated cost of £700. The Streatham and Balham storm relief sewer was constructed in 1912. It receives the overflow of the main and local sewers at Tooting Bec-road, and discharges into the River Graveney at Colliers-wood. An extension which would tap the main sewer further along its course and increase the usefulness of the sewer was omitted in 1912. In order to relieve floodings in Balham and to increase the usefulness of the sewer, the Council decided to proceed with the construction of the extension of the sewer to Ritherdon-road, a length of about 400 yards, at an estimated cost of £12,000. The tender, amounting to £10,207 5s. submitted by Mr. Harold E. West, Westminster, S.W., for the construction of the sewer was accepted on 17th June, 1927. As a result of further study of the problem of floodings in London, 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 Coldbath-street area of Greenwich. Both these works are nearing completion. For the relief of floodings in the Bow district the gradient of the Eastern Counties sewer is being improved and re-inverting is also being carried out. The cost of the work is estimated at £5,000. A rainstorm of remarkable severity occurred in the afternoon of Monday, 11th July, 1927. The area most seriously affected was a comparatively narrow strip extending from Streatham through Hammersmith into Hampstead and Holloway. Heavy rain began in Balham High-road about 2.45 p.m. and reached Waterlow Park, Highgate, about 3.50 p.m. and lasted about 2 hours. The maximum recorded fall was at Hammersmith pumping station, where the total fall measured 2.65 inches. At places and at periods during the storm, the rainfall was intense. At several places rain fell at an equivalent rate of 3 inches an hour and over, while at Balham High-road 11 inches of rain fell in 18 minutes, equivalent to the rate of 5 inches an hour. A rough approximation shows that more than a million tons of water fell in two hours in the Royal Borough of Kensington and the Metropolitan Boroughs of Hammersmith, Fulham, Hampstead, and part of Wandsworth. Rainfall of such intensity is unusual, and there is no record of any fall in London of such intensity for so long a period. During the storm many sewers were gorged with water, and the street and other gullies could not pass the water as it fell, and floodings occurred. Storm relief works comprised in the scheme submitted to the Council on 22nd July, 1919, which had been completed at an approximate cost of £2,500,000, were in operation, and large quantities of water were discharged by these means. Otherwise the floodings would have been much more serious. The discharge of sewage from Leyton into the London main drainage system, which was authorised by the London County Council (General Powers) Act, 1925, commenced on 9th August, 1927. Streatham and Balham storm relief sewer extension. Further works for relief of flooding. Storm on 11th July, 1927. Out-county drainage. 193 Section 69 of the Metropolis Management Act, 1855, provides that no local sewer shall be made without the approval of the Council. During 1927 the construction or reconstruction of 192,549 feet of local sewers of-various sizes has been sanctioned. Local 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 or any such sewer diverted except with the Council's consent. During 1927 the Council save its consent in 20 such cases. Buildings, etc., over sewers. A request was submitted by the Amalgamated Engineering Union on behalf of engineers employed in the Council's main drainage service, that in view of the special character of the service if should be recognised as distinct from other sections of the service, and that the men in engineering trades employed therein should be paid a minimum wage of £4 4s. a week, and that shift workers in these trades should be paid at the rate of time-and-a-third. The men in question receive 11s. a week more in war wages than was normally paid in outside engineering shops. They also receive other benefits, including medical attendance, sick pay, superannuation, holidays, etc. Mechanics employed on shift work receive special allowances amounting to 3d. an hour or 4d. an hour at Deptford and North Woolwich pumping stations where the Council has not provided quarters. In the circumstances it was felt that the conditions under which the men worked did not warrant any further alteration in rates of pay, and the request was not granted. staff. 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 Council'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 duties of the Council. The contributions payable by the State towards the cost of the construction of houses, both by local authorities and private enterprise are subject to revision every two years. Particulars of the reductions made by the Housing Acts (Revision of Contributions) Order, 1926, in the amounts of the State grants in respect of houses not completed before 1st October, 1927, are given in the Annual Report for 1926 (vol. III., pp. 175-6). The next review is due to take place after 1st October, 1928. Revision of State contributions. Consequent upon the issue of the above-named Order, the Council, on 15th February, 1927, decided to reduce its rates of contribution towards the cost of houses provided by the City Corporation and metropolitan borough councils and by private enterprise, in corresponding proportions to the reductions in the Revision of scheme of financial assistance by the Council, 194 State grants. The Council's contributions towards housing schemes of the City Corporation and metropolitan borough councils are limited to approved cases, and are supplemental to the State grants which are paid direct to those authorities. As regards houses provided by private enterprise, the total amount of the grant in aid in each approved case is made direct by the Council, and the State contribution is subsequently recovered from the Government, the net expenditure by the Council being the difference between the Council's grant and that made by the State. Particulars of the revised scale of grants by the Council and by the State in respect of houses (which include flats or tenements) not completed before 1st October, 1927, are as follows :— Nature of grant. Grant in respect of each house. Statgrant. Council's grant. A. Housing, etc., Act, 1923. (i.) Grant to City Corporation and metropolitan borough councils. (ii.) Grant to purchaser or builder of new house for own occupation. (iii.) Grant to person or bodies maintaining houses for letting at approved weekly rent. B. Housing (Financial Provisions) Act, 1924. (i.) Grant to City Corporation and metropolitan borough councils. (ii.) Grant to public utility societies, or the like, maintaining houses for letting, subject to the "special conditions" prescribed by the Act. £4 a year for 20 years. £4 a year for 20 years. £4 a year for 20 years. £7 10s. a year for 40 years. £7 10s. a year for 40 years. Not exceeding £2 a year for 20 years (supplemental to State grant). Lump sum of £50 (including State grant). £6 a year for 20 years (including State grant). Not exceeding £1 17s. 6d. a year for 40 years (supplemental to State grant). Not exceeding £9 7s. 6d. a year for 40 years (including State grant). On 4th May, 1927, the Council decided, at the request of the Minister of Health, not to issue certificates of qualification for grant in future in respect of houses provided by private enterprise, the freehold cost or selling price of which exceeded £600, exclusive of the amount of the subsidy. The maximum selling price previously approved by the Council with the consent of the Minister was £650, exclusive of subsidy. Maximum selling price of houses. Up to 31st December, 1927, the Council had approved proposals submitted by private builders for the erection of 2,617 houses and flats to qualify for subsidy on completion, 438 of which will be maintained for letting. The number of houses approved during the year was 266. Houses approved for grant. Certificates of personal qualification to receive the promised subsidy were issued during the year to prospective owner occupiers of 307 houses included in those mentioned above, the total number of personal certificates issued since the inception of the scheme un to 31st December. 1927. beine 1,802. Legislation. The power conferred on the Council under Section 39 of the London County Council (General Powers) Act, 1926, 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, has been extended by Section 60 of the London County Council (General Powers) Act, 1927, so as to include buildings, outside as well as inside the County of London, subject to a proviso that no such building shall be erected by the Council outside the county, except with the consent 195 of the council of the borough or district concerned. The section also confers a similar power on metropolitan borough councils in connection with all housing schemes within their respective boroughs. The Council is empowered by Section 92 (1) (6) of the Housing Act, 1925, to guarantee the repayment to building societies of the amounts advanced by them for the building or acquisition of houses, the construction of which was commenced after 25th April, 1923. It was thought that an extension of this power might be useful, and the Council decided on 21st July, 1927, to promote legislation in the session of 1928 to obtain authority to guarantee such repayments to building societies also in respect of houses commenced on or before 25th April, 1923. Since the war, the Council has, up to 31st December, 1927, completed 24,085 houses and flats. The houses and flats completed during the year 1927 totalled 8,201. Altogether since the completion of the first dwellings in 1894, the Council has provided 34,070 tenements and houses and three lodging-houses with 1,880 cubicles, The total estimated population of the Council's dwellings on 31st December, 1927, was about 150,000 persons. 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. The programme of work in hand is very considerable, comprising the erection of about 18,000 additional houses under Part III. of the Housing Act, 1925, apart from the rehousinsr reauired under slum clearance schemes. Houses, etc. completed. 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 contributions 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 13 in number, and include 23 separate areas comprising 99.47 acres. The displacement of 28,513 persons of the working classes is involved and rehousing accommodation for about an equivalent number has to be provided, of whom not fewer than 19,870 have to be accommodated within the limits of the improvement areas. Clearance schemes. Particulars of housing schemes carried out or in process of execution by the Council during the year under Part III of the Housing Act, 1925, 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 2,770 acres, and was purchased with the aid of compulsory powers obtained in 1920. The development of the estate is being carried out by C. J. Wills and Sons, Limited, on a cost basis with a variable fee to the contractor. Several sections of the estate have been completed and others are in process of development. On 17th May and 26th July, 1927, the Council approved capital estimates of £1,270,000 (subsequently reduced to £1,115,000) and £1,450,000 (subsequently reduced to £1,190,000), for the development of two further sections of the estate, to be known as the Dagenham (No. 9) (1,946 houses and flats) and the Dagenham (No. 11) (2,072 houses and flats) sections, respectively. At the end of the year, about 12,188 houses on the estate had been completed, about 2,232 were in course of construction, and orders had been issued to the contractors for the erection of about 1,072 others. The estate is capable of being developed to the extent of a total of about 26,000 houses and flats, with a total population of about 130,000. During the year an additional site on the estate was sold to the Church of England authorities for the erection of a church, and an option was granted to a Jewish religious body to purchase, for the erection of a permanent synagogue, a site already leased to them for the erection of Becontree 196 a temporary building. Two further sites were sold to the Essex County Council, one for the extension of an existing school, and the other for the erection of a new elementary school. A site was also sold to the County of Essex Territorial Army Association for the extension of their drill hall. A site was also leased to the County of London Electric Supply Company, Limited, for the erection of a transformer station. Other sites were let on building lease for 99 years, for the erection of shops and residences for doctors and a dentist. The Council, on 11th October, 1927, decided to repurchase from the Ilford Corporation one of two sites in Becontree sold in 1922 for the erection of elementary schools, the Corporation being satisfied that one site only was sufficient to meet the requirements of the portion of the estate in the borough of Ilford. In connection with a proposal of the Dagenham Urban District Council to widen and make up Chequers-lane, which affords the only means of approach from the estate to Dagenham Dock station, the Council, on 28th June, 1927, decided, subject to the consent of the Minister of Health, to make a contribution of £1,000 towards the cost of the work. The Minister has withheld his consent, pending enquiries as to the willingness of the owners of adjoining land and others who would benefit by the improvement to contribute towards the expenditure. To enable the Dagenham Urban District Council to effect an improvement at the junction of Heathway and Goresbrook-road, a small piece of the Council's land was surrendered for addition to the public way. On 26th July, 1927, the Council decided to invite by public advertisement offers for leases of five sites at Becontree for the establishment of licensed refreshment houses, on the lines of the "Fellowship Inn" at Bellingham (if the necessary licences could be obtained), with special forms of control and management, for the supply of food and alcoholic and non-alcoholic liquors, on conditions, among others ,that the houses should be available for the general entertainment and refreshment of the population, and that the persons employed on the premises should not have any direct pecuniary interest in encouraging the sale of alcoholic liquor. It is proposed to surrender or to transfer the licences in respect of the four existing beerhouses on the estate as and when the new premises, which are intended to take their place, are completed and opened for business. The offers received were under consideration at the end of the year. Further consideration was given during the year to the question of the present unsatisfactory system of dumping London refuse on the north bank of the River Thames, in the vicinity of Becontree, and on 26th July, 1927, the Council passed a resolution urging the Minister of Health to hold a public inquiry for the purpose of arriving at a solution of the problem. The Minister, while fully appreciating the importance of the subject, was of opinion that the holding of a public inquiry would be inexpedient, as the subject formed part of the larger problem of the disposal of refuse from London generally, which was at the moment under investigation by his department. The Minister gave an assurance that the investigation should be proceeded with as rapidly as possible. A tenancy of about 4½ acres of land has been granted at a nominal rent to a sports and social club formed by the Council's employees on the estate, and on 13th December, 1927, the Council decided as a special case and without creating a precedent, to make a grant of £150 to the club towards the cost of laying out the land and of the necessary equipment. The houses so far erected at Becontree are lighted by gas, but permission was granted during the year to the County of London Electric Supply Company, Limited, to wire existing houses for electric lighting, the charge to the tenants for the current supplied to be through prepayment meters. The question of arranging for new houses on the estate to be lighted by electricity was under consideration at the end of the year. 197 The London and Home Counties Traffic Advisory Committee, at the request of the Minister of Transport enquired into the adequacy of travelling facilities to and from East London. Immediately on the publication of the report, in November, 1926, the findings of the Committee were considered by the Council. The Advisory Committee expressed the opinion that the transport requirements of the present and prospective residents on the Becontree estate should be further investigated, and that the Council and the railway companies concerned should be invited to explore jointly the practicability of providing additional travelling facilities either by the construction of new branch lines and/or by the provision of facilities for the extension of train services from the District Railway along either of the lines serving the estate. Representations were accordingly made by the Council to the Minister of Transport and to the London, Midland and Scottish Railway Company as to the urgent need for improving the travelling facilities on the Southend and Tilbury lines from Barking and the Council expressed its willingness to participate in a conference if convened, under the auspices of the Minister, to explore the situation. The suggested conference did not eventuate, but an opportunity of raising the question of improving the travelling facilities on the Southend and Tilbury lines occurred in connection with the London, Midland and Scottish Railway Bill, 1927. On the motion for the second reading of the Bill in the House of Commons on 21st March, 1927, the case of the Council and of other authorities was put and an undertaking in the following terms was given by Mr. E. B. Fielden, on behalf of the company:— (1) The Company would, within two years (i.e., by March, 1929), put forward proposals for improving the service, and, if necessary, promote a Bill to give effect to them. They would not pledge-themselves to any particular scheme, as other interested parties had to be consulted, but their officers were considering all aspects of the matter, including electrification. (2) On the completion of the re-signalling of the line between Barking and Bow (to be completed, it was hoped, in the summer of 1927), six additional trains would be rim in the summer of 1927 during the "peak" hours, all of which it was hoped would stop at Becontree. (3) The Company were fully alive to the importance of the population at Becontree and would undoubtedly have in mind the requirements of Becontree. The Company fully admitted that the requirements were not satisfactorily met by the existing service. The position is being carefully watched by the Council with a view to securing that the undertaking given on behalf of the Company shall be implemented in due course. The total area of Bellingham (Lewisham) is 252 acres, and, under the mam contract, completed in 1923, for the development of the portion of the estate devoted to working-class dwellings (176½ acres), 2,096 houses and flats have been erected. A few vacant plots have been left, on which it is now proposed to erect 32 additional houses. The portion of the estate south of Southend-lane, at present used as a golf course, has been reserved with a view to the erection by private enterprise of houses of a higher value than those usually provided by the Council. Bellingham. The housing estate at Downham (Lewisham and Bromley), which is about 522 acres in extent, was acquired under compulsory powers. The estate is being developed by Holland and Hannen and Cubitts, Limited, under a cost contract with a variable fee to the contractor. On 5th April, 1927, the Council approved a capital estimate of £810,000 to cover the cost of about 1,266 houses and flats on the Verdantlane (No. 4) section of the estate. Subsequently the Council, on 26th July, 1927, approved a capital estimate of £710,000 for the development of the remaining section of the estate, known as the Grove-park (No. 5) section, by the erection of 1,132 houses and flats. Downham.. 198 At the end of the year about 3,225 houses had been completed, and over 2.624 houses were in course of construction. The houses already built include No. 165, Downham-way, the 17,000th dwelling provided by the Council since the war. This house was opened by Her Majesty the Queen on the occasion of a visit of Their Majesties the King and Queen to Downham, on 19th February, 1927. A tablet commemorating the event has been affixed to the house. The Council, on 22nd November, 1927, decided, after offers had been invited by public advertisement, to let on building lease (subject to a ground rent and the payment of a premium), for 99 years, to Barclay, Perkins and Company, Limited, a site at Downham for the erection of a licensed refreshment house, on the special lines of those proposed at Becontree (see p. 196). During the year a site on the estate was sold to the Roman Catholic Church authorities for the erection of a church and elementary schools, and another site was sold to the Wesleyan Methodist Church authorities for the erection of a church. Sites were let on building lease for the erection of shop premises, and a house was also let for use as a school medical treatment centre. Roehamptor estate. Roehampton estate, Wandsworth, was acquired in 1919, and the development of the area of about 93 acres allocated for the erection of 1,212 working-class dwellings was completed during the year. The remainder of the estate has been leased for the erection of houses of a higher value. White Hartlane estate. Part of White Hart-lane estate, Tottenham, was developed before the war, and since the war 1,237 houses and flats and 11 shops have been erected by the Council. The development of the estate has now been completed with the exception of one small plot of land. During the year the last remaining shop site was let on a building lease for 99 years. Watling estate. The development of Watling estate (390 acres), un the east side ot luigware road, Hendon, which is being carried out by C. J. Wills and Sons, Limited, under a cost contract with a variable fee to the contractor, was commenced early in 1926. By 31st December, 1927, there were 1,373 houses and flats completed and occupied, and 1,194 others were in various stages of construction. The estate, when finished, will comprise 4,018 houses and flats. About 75 acres of land on the west side of Edgwareroad have been acquired by the Council, but no definite decision has yet been arrived at with regard to its use or development. During the year the Council sold three sites on the estate for the erection of churches, one to the Plymouth Brethren, another to the Wesleyan Methodist Church authorities, and the third to the Westminster Diocesan Trustees. Other sites were let on building lease for 99 years for the erection of shops or business premises, and a site was let on lease for 99 years to the Hendon Electric Supply Company, Limited, for the erection of a transformer station for the supply of electricity to shop premises on the estate. A site in Watling-avenue was also let on lease for 99 years to a doctor for the erection of a residence and surgery, and a house was sold to the Hendon Urban District Council for the use of the schoolkeeper of the elementary school to be erected on an adjoining site sold to the district council for the purpose. During the year the Council entered into an arrangement with the Hendon Urban District Council for the Council to collect the rates with the rents of houses at Watling estate, subject to an allowance to the Council of 21 per cent, of the amount of rates so collected. The lay-out plan has been designed to allow of the retention of most of the trees, and some of the finest of these are situated on land which will become the central open space of about 12 acres. A careful examination of all the trees was undertaken during the year and expenditure, not exceeding £300, was sanctioned for the work of preserving as many trees as possible, including necessary lopping and trimming. In connection with the proposal of the Middlesex County Council to widen certain 199 portions of Edgware-road to 100 ft., the Council, on 13th December, 1927, decided to surrender certain strips of land for addition to the public way. Lastelnau estate, Barnes (51½ acres), was purchased under compulsory powers obtained in 1925. A supplementary Order for the compulsory acquisition of about 2J acres, at the rear of 125 Castclnau, was made by the Council on 8th March, 1927, and confirmed by the Minister of Health on 6th May, 1927. Portions only of this land were required for the development of the estate, and an arrangement was accordingly made for an exchange of lands, involving the land actually needed by the Council and certain small portions of the land belonging to the Council which could be disposed of without detriment to the development of the estate. During the year a site on the estate was sold to the Surrey Education Committee for the erection of an elementary school. Castelnau estate. The estate is being developed on a " value-cost " contract, by Henry Boot and Sons (London), Limited, on their pier and panel system of concrete construction. At the end of the year 101 houses had been completed and the remaining 544 were in various stages of construction. One of the recommendations (xv.) of the Royal Commission on Cross-River Traffic in London, relating to western exits from London, contemplates the construction of a new arterial road across the estate. In order, therefore, to facilitate the construction of the arterial road in the event of the scheme being proceeded with, either in the near future or ultimately, arrangements have been made for the houses along one of the roads across the estate, which nearly coincides with the route of the proposed arterial road, to be set back so that at a future date the width of the road can be increased to 80 ft, without involving the demolition of any buildings. Old Oak estate, Hammersmith, was partly developed before the war, and on the remaining land 736 houses were completed before 1927. On 10th May, 1927, the Council decided to allocate 14 of the houses on the estate to rehouse about 87 persons of the working classes displaced in connection with the improvement of the southern approach to Lambeth bridge and the extension of the London School of Economics. During the year a site on the estate was let on lease for 99 years to Suburban Social Clubs, Limited, for the erection of a club and institute. No objection will be raised bv the Council to a club licence for the new premises. Old Oak estate. Wormholt estate was partly developed by the Hammersmith Metropolitan Borough Council, and the remainder (68 acres) was purchased by the Council for £58,500. The site adjoins the Council's Old Oak estate, with which it will be combined for purposes of administration. Wormholt estate. On 26th July, 1927, the Council approved a supplemental capital estimate of £60,000 to cover the cost of 48 additional houses and 60 flats in three-storey buildings, making a total for the estate of 771 lettings. The estate is being developed under a "value-cost contract," by Wilson, Lovatt and Sons, Limited. At the end of the year 369 houses had been completed. Nearly all the houses have been allocated for a term of years to meet the special needs of individual metropolitan borough councils, subject to payment of annual contributions under agreements in pursuance of section 14 of the Housing (Financial Provisions) Act, 1924, as mentioned in the Annual Report for 1926 (p. 181). During the year agreements were entered into for the allocation of 100 houses to each of the Finsbury, Hampstead, and Paddington metropolitan borough councils, and with the Westminster City Council for the allocation of 50 houses on the same terms as in previous similar cases The arrangement previously entered into with the St. Marylebone Metropolitan Borough Council for the allocation to it of a total of 200 houses on the estate was modified during the year so as to limit the number of houses to 100. During the year a site on the estate was let on building lease for 99 years to a doctor for the erection of a private residence and surgery. 200 Arrangements were made during the year with the Hammersmith Metropolitan Borough Council to wire the houses on the estate for electric lighting, free of cost to the Council, the borough council's charges to be collected with the rents of the houses and paid in bulk to the borough council, less 5 per cent, to cover the cost of collection. The Council also accepted the offer of the Gas Light and Coke Company to supply a gas installation for cooking and heating purposes (with a gas lighting point in the kitchenette), subject to a payment by the Council of £1 a tenement. Western-avenue, one of the proposed arterial roads from London, crosses the estate from east to west. On the transfer of the housing estate to the Council it was decided to construct the road at once to the full width of 100 feet throughout. To enable this to be done it was necessary to acquire at the eastern end of the road a small portion of the White City grounds, and an arrangement was accordingly entered into with the owners of the White City to obtain vacant possession of the land required for the sum of £400. The work of constructing the portion of the road through Wormholt estate is being carried out by the Hammersmith Metropolitan Borough Council, the Council paying its appropriate share of the cost oi the work. 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, and confirmed by the Minister of Health, with slight modifications, on 13th May, 1926. On 12th April, 1927, the Council decided to make a compulsory order for the acquisition of a further 71½ acres of land in the urban district of Carshalton for addition to the estate. After a local inquiry the Order was confirmed by the Minister of Health, on 18th July, 1927. The Council on 22nd November, 1927, approved a capital estimate of £5,000 for survey work, including the sinking of trial borings, and other preliminary expenses in connection with the development of the estate. Preliminary lay-out plans for the development of the first section of the estate are in course of preparation, and arrangements are in progress with the local authorities concerned for the drainage of the estate. Arbitration proceedings in respect of the purchase of a large part of the estate were pending at the end of tli e vftiir 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, was sold during the year to the Sutton Dwellings Trust for the erection of tenement dwellings and cottages. The Council is thereby relieved of the heavy capital expenditure which this very substantial addition to the provision of housing accommodation in London involves. Application will probably be made in due course by the Trustees for a grant from the Council under the Housing (Financial Provisions) Act, 1924. Clearance schemes. Particulars are given below of the various schemes being carried out by the Council for the clearance and reconstruction of unhealthy areas under Part I. or Part II. of the Housing of the Working Classes Act, 1890, or Part II. of the Housing Act, 1925. Tabardstreet, etc., scheme. The Tabard-street, etc., scheme deals with the Tabard-street and Grotto-place areas, Southwark, and the Crosby-row area, Bermondsey, comprising in all about 18| acres. The clearance of the three areas involves the displacement of 4,550 persons of the working class, and the Council is required under the confirming Order, as amended by the modification Order issued by the Minister of Health in July, 1926, to provide rehousing accommodation for not fewer than 3,580 persons, of whom not fewer than 2,580 are to be rehoused on the Tabard-street area. Accommodation has been provided on the main portion of the Tabard-street area, known as Tabard Garden estate, for 2,380 persons in seven blocks of dwellings and one cottage. Two 201 further blocks with accommodation for 236 persons will be erected on an adjacent site in Law-street included in the scheme. The remainder of the rehousing accommodation will be provided on East Hill estate, Wandsworth. On 8th February, 1927, the Council accepted the tender of Sir. R. J. Rowley, amounting to £1,562, 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. During the year arrangements were made for the Southwark Metropolitan Borough Council to carry out, on a cost basis, the paving, etc., works in connection with the widening of a portion of Tabard-street, in connection with the scheme. Ihe Brady-street scheme relates to an area ot about 7 acres in the metropolitan borough of Bethnal Green. About 1,865 persons of the working classes will be displaced, and accommodation has to be provided for 1,600 persons on the cleared site (to be known as Collingwood Estate), and for 265 persons elsewhere. Accommodation for 1,127 persons has already been provided under the scheme, and on 29th March, 1927, the Council approved a capital estimate of £23,430 for the erection on the area of a further block of dwellings (Codrington House), comprising 44 tenements of the normal type with accommodation for 264 persons. The tender of Rowley Brothers, Limited, amounting to £21,241, for the work, has been accepted, and the building is due to be completed in April, 1928. Brady-street scheme. During the year the Uouncil accepted the oner ot the Joethnal Green Metropolitan Borough Council to instal electric lighting in the tenements in Codrington House and of the Gas Light and Coke Company to instal gas for cooking purposes only, in each case free of cost to the Council. Arrangements were also made during the year tor che ±5ethnal Ureen iVietropolitan Borough Council to carry out at actual cost the paving works in connection with the widening to 40 feet of Bath-street. Ihe scheme lor dealing with the Ware-street area (to be known as Whitmoreestate), Hoxton (8£ acres), involves the displacement of about 2,648 persons of the working classes, and the Council is required to provide rehousing accommodation for that number, of whom not fewer than 2,160 are to be accommodated within the area. Up to the end of 1926 rehousing accommodation for 768 persons had been provided on the area and elsewhere. Ware-street scheme. During 1927 three further blocks of dwellings (Horner Houses), which are of the simplified type, comprising 80 tenements with accommodation for 376 persons, were completed. On 31st March, 1927, the Council approved a capital estimate of £29,560 for the erection of three additional blocks of dwellings, comprising 66 tenements (48 of the simplified type and 18 of the normal type), with accommodation for 328 persons. The building work, which was commenced in August, 1927. is being carried out by Rowley Brothers, Limited, as an extension of their contract for the erection of the three Horner Houses completed in 1927. During the year the Council decided to enter into an agreement with the lessee of a timber yard on the area, whereby the Council was able to acquire part of the site of the yard required in connection with the redevelopment of the area without payment of heaw trade compensation. 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 Dickens estate. About 1,660 persons of the working classes will be displaced, and accommodation has to be provided for this number of persons, of whom not fewer than 1,000 are to be accommodated within the area. Hickman's folly scheme. During 1927 arrangements were made for the Bermondsey Metropolitan Borough Council to pave, at the cost of the Council, certain strips of land in the area to be added to the public way. 202 Bell-lane and Ellen-street scheme. The Bell-lane and Ellen-street scheme provides for the clearance and reconstruction of two areas known as the Bell-lane area, Spitalfields (4 acres) and the Ellenstreet area, St. George-in-the-East (1| acres). 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. During the year a small plot of surplus land in the Bell-lane area was sold for the purpose of enlarging the yard of the adjoining licensed premises. Arrangements have been made for the paving works in connection with the widening and extension of Shepherd-street into Wentworth-street, in the Bell-lane area, to be carried out by the Stepney Metropolitan Borough Council at an approved schedule of charges. Prusom- street scheme. The Prusom-street scheme, which deals with an area about 8½ acres in extent, in Wapping, to be known, when re-constructed, as Wapping Estate, involves the displacement of 2,601 persons of the working classes. Rehousing accommodation has to be provided for an equal number of whom not fewer than 1,000 are to be accommodated on certain defined lands within the area. One block of dwellings, known as Willoughby House, with accommodation for 184 persons, was completed in 1926. On 28th June, 1927, the Council approved a capital estimate of £42,172 for th< erection on the area of blocks 2 to 5 of dwellings, to be known as Chancellor Flinders, Frobisher, and Franklin Houses. The buildings have been designed t( contain 96 tenements of simplified type, with 264 rooms, to afford accommodatior for 528 persons. The tender of Canonbury Construction Company, Limited amounting to £38,661, for the building work was accepted, and at the end of th( year the work of erecting the buildings was well advanced. During the year an agreement was entered into with the owners of two public houses immediately adjoining the area for an exchange of lands to facilitate th< execution of the scheme. Watergate- street scheme. The Watergate-street scheme deals with an unhealthy area in Deptford and Greenwich, known as the Watergate-street area, about 7| acres in extent. The area adjoins and will form part of an existing housing estate, known as Hughes Fields estate. The confirmation Order requires the Council to provide rehousing accommodation within the ar:a for 1,927 persons. The first two blocks of dwellings, to be known as Blake and Hawkins Houses, with accommodation for 396 persons, were completed during the year. During the year the Council accepted the offer of the South Metropolitan Uas Company to instal, free of charge to the Council, gas for lighting and other purposes in the dwellings to be erected on the estate. Arrangements were also made with the contractors for the erection of Blake and Hawkins Houses for the provision of new railings and certain paving work, etc., in connection with an enlargement of the yard of Drake Buildings on the adjoining estate, and also for certain modifications to be made in the boundary railings of Blake and Hawkins Houses. Baker's-alley, Birchfieldstreet and Bromleyplace scheme. During the year the block ot dwellings on the iSirchneld-street area, known as Birchfield House, was completed, and arrangements were made with the Commercial Gas Company to instal gas for lighting and cooking purposes free of cost to the Council. On 13th December, 1927, the Council decided to sell to the owners ot a public house adjoining the area a plot of surplus land to add to the curtilage of the licensed premises. George'sroad and Brand-street scheme. The scheme for dealing with the two unhealthy areas, known as the George s road and Brand-street areas, Holloway (4| acres), involves the displacement of 1,320 persons of the working classes. Rehousing accommodation has to be provided 203 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. On the Brand-street area are to be two parallel blocks of dwellings, named Branston and Rollit houses, containing flats for 292 persons. These buildings include eight shops and between them is a garden space. One block was finished in 1927, and the other was nearing completion at the end of the year. On 17th May, 1927, the Council approved a capital estimate of £2,000 in respect of preliminary expenses in connection with the erection of two blocks of dwellings, one of the normal and one of the simplified type, on the George's-road area. The buildings will comprise 134 tenements with accommodation for 744 persons. During 1927 the Council agreed to set back the line of the proposed dwellings fronting on George's-road, in the George's-road area, sufficiently to enable the road to be widened on that side to a width of 20 feet from the centre of the road to the forecourt wall, if so decided at a later date. Arrangements were also made for the construction of a temporary roadway on the Brand-street area, for use pending the formation of the permanent diversion of Brand-street. The scheme for dealing with the Ossulston-street area, St. rancras (about 8 acres), which was confirmed by the Minister of Health in 1926, involves the displacement of about 2,557 persons of the working class and the confirming order requires that rehousing accommodation for not fewer than that number shall be provided within the area. The name Ossulston Estate has been selected for the area when reconstructed. Ossulston- street scheme. On 31st May, 1927, the Council approved a capital estimate of £4,000 for preliminary expenses in connection with the re-development of the area. The area naturally divides itself into three sections—the northern, between Hampden-street and Phcenix-street; the central, between Phoenix-street and Christ Church and its school; and the southern, between Christ Church and Weir'spassage ; and a scheme has been prepared for the erection of three blocks of dwellings, one on each of these three sections. The area is situated in a district which, by reason of its proximity to the centre of London, is rapidly becoming more and more industrialised, and, as sites available for housing accommodation are exceedingly scarce in the central districts of London, the scheme contemplates the erection of buildings beyond the height of five storeys usually adopted for the Council's working-class dwellings, in order that full advantage may be taken of the opportunity of housing the maximum number of persons. Due regard has been paid at the same time to hygienic considerations, and the buildings comprising the three blocks of dwellings will be varied in height from three to nine storeys so as to ensure a generous supply of light and air to the new accommodation. A model has been prepared indicating the general lines of the scheme for the erection of the main (southern) block, the buildings in which will introduce a number of special features. The central block, which will be the first to be put in hand, will vary in height from three to six storeys, and will contain 87 working-class tenements with accommodation for 550 persons and about 14 lock-up shops. Subject to terms of letting, provision is also made for a maternity and child welfare centre and for a meetingroom for the Salvation Army. On 19th July, 1927, the Council approved a capital estimate of £7,350 in respect of the construction of the foundations of the central block, and the tender of Gee, Walker and Slater, Limited, amounting to £3,422, for the work, was accepted. The work was commenced in October, 1927. During the year arrangements were made to utilise temporarily for rehousing families to be displaced from the area accommodation in the houses on the Twyfordstreet site, Islington, which was acquired by the Council for education purposes. 204 The area includes two fully-licensed public houses, and on 8th November, 1927, the Council decided to enter into agreements with the respective owners for the reinstatement of the premises on other sites in the area on the basis of an exchange of freeholds and the payment by the Council in each case of a sum of £7,500 towards the cost of building new premises. It has been decided, at the suggestion of the Minister of Health and the Minister of Transport, to set back the frontages of the dwellings to be erected in Ossulstonstreet so as to permit of the widening of that thoroughfare to a width of 30 feet from the centre of the existing street, should it be decided to carry out the widening at a later date. China walk, etc. scheme A scheme was made by the Council in 1925 for dealing with four unhealthy areas known as (1) the China-walk area, Lambeth; (ii.) the Hatfield-street and Hankey-place areas, Southwark ; and (iii.) the Wyndham-road area, Camberwell. The Council proposed as an integral part of the scheme to acquire for rehousing purposes certain lands, about 4 acres in extent, adjoining the Wyndham-road area and also a small site in Hankey-place, Southwark, but the Minister of Health objected, on legal grounds, to the inclusion of these properties in the clearance scheme. A favourable opportunity having offered, the Council acquired the former property by agreement under Part III. of the Housing Act, 1925, for the purpose of erecting dwellings to be appropriated in due course for rehousing purposes. The site in Hankey-place to which reference is made below was subsequently also acquired by agreement. The scheme was confirmed by the Minister of Health on 2nd May, 1927, with the omission of the properties referred to above. The scheme, as confirmed by the Minister, requires accommodation to be provided for 3,350 persons, of whom not fewer than 2,200 are to be accommodated within the areas included in the scheme, leaving a balance of accommodation for 1,150 persons to be provided elsewhere. Accommodation for 958 persons is being provided on Kennings Estate, Kennington, and the Council decided on 31st May, 1927, that the whole of this accommodation should be appropriated to the China-walk, etc., scheme. Wyndham road site. The name Comber estate has been selected for the new dwellings to be erected on the Wyndham-road area and the adjoining 4 acres of land acquired under Part III. of the Act of 1925. The Council, on 26th July, 1927, approved a capital estimate of £22,390 for the erection of the first block of these dwellings, and accepted the tender of Mr. A. T. Rowley, amounting to £20,490, for the building work. The building, to be known as Moffat House, will contain 42 tenements of the normal type with accommodation for 254 persons. Hankeyplace site. The property covering the site, about half-an-acre in extent, at Hankey-place, Southwark, which, as mentioned above, was omitted from the China-walk, etc., scheme, as confirmed by the Minister of Health, comprises a billiards hall (about J acre) and a disused burial ground (about £ acre). The property adjoins Tabardgarden estate, and it was very desirable that the Council should acquire it, as it might, if it passed into other hands, seriously affect the amenities of that estate. The owners were prepared to sell for £4,500, and the Council, on 13th December, 1927, approved a capital estimate of £5,000 for the purchase, including incidental costs. Church Army Housing, Limited, were desirous of developing the site of the billiards hall for the erection of working-class dwellings, and were prepared to take a lease of the site in question at a rent of £100 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. A similar arrangement, securing the clearance of a small insanitary area and the re-development of the site for housing purposes at small cost to public funds, was concluded with the same society, in connection with the development of the Weston-street site, Southwark, at the other extremity of Tabard-garden estate. 205 As the disused burial ground could not be built upon, the Council decided to appropriate it for the purposes of an open space. Ihe scheme made by the Louncil in iyzb lor the clearance of the Basing-place and Blue Anchor-lane areas, Camberwell (about 3 acres), was confirmed by the Minister of Health on 23rd September, 1927. The confirming Order requires that rehousing accommodation for 756 persons, which is the estimated number of persons to be displaced from the two areas, shall be provided by the Council in new dwellings to be erected on the Blue Anchor-lane area when cleared. The Basing-place area will not be used for housing. By the end of the year good progress had been made with the acquisition of property included in the scheme. Basing-place and Blue Anchor-lane scheme. In 1926 the St. Marylebone Metropolitan Borough Council intimated that it had decided to make a scheme under Part II. of the Housing Act, 1925, in respect of an area known as the Carlisle-street area. The borough council sought the Council's views with regard to a proposal that the scheme should be in respect of a large area about 15 acres in extent. The Council was of opinion that portions of this area were ripe for development and would require sooner or later to be dealt with, but was not convinced that the conditions in the area at that time were such as to justify an improvement scheme being undertaken by a municipal authority or priority being <;iven to the scheme over schemes for areas in other parts of London which were calling for attention. The Council considered, moreover, that if a scheme of this magnitude were undertaken by a municipal authority, it should be carried out as a county scheme under the Housing Act, 1925, but in view of the definite decision of the borough council to formulate a scheme, the Council hardly felt justified in opposing the proposal, provided that the scheme was limited in the first instance to the northern portion of the area. Carlisle- street scheme A drart scheme was subsequently prepared by the borough council for the portion of the area north of North-street, and was submitted in June, 1927, for the observations of the Council. In the following month the borough council, having further considered the matter, submitted that, as similar clearance schemes had already been undertaken by the Council, the Carlisle-street scheme, in view of its magnitude, was one of general importance to the County of London as a whole and should be dealt with by the Council as a county scheme. The Council was not unmindful of the fact that the borough council by actively initiating and publicly announcing the scheme had prejudiced the power of the Council to discriminate as to the order of priority in which large clearance schemes in London should be undertaken. As the borough council, however, offered to bear part of the cost, the Council consented as a special case and without creating a precedent, to undertake the Carlisle-street scheme. After negotiation, it was agreed with the borough council that the appropriate division of the annual loss involved in the scheme, including the loss on the new dwellings, whether within the area itself or elsewhere, should be 50 per cent to be borne by the Exchequer, 30 per cent, by the borough council, and 20 per cent, by the Council. The necessary official representation was subsequently made to the Council with regard to the area, which is bounded by the gardens of houses in Aberdeen-place, and by Fisherton-street, Luton-street, Carlisle-street, North-street, and Lyons-place. The total number of dwelling houses in the area is 310, about 30 of these having shops under them. There are also a few warehouses, stores, etc., and one fully licensed public-house. It is estimated that the displacement of about 2,832 persons; of the working class will be involved. The official representation excludes two nonprovided schools, one a Church of England school in North-street, and the other a Roman Catholic school in Richmond-street. The Council, on 20th December, 1927, passed a resolution to make the scheme above-mentioned, and approved a capital estimate of £160,000 in respect of the 10435 o 206 cost of acquisition and clearance. The scheme includes the whole of the represented area, with the addition, for the purpose of making the scheme efficient, of one house in Aberdeen-place, a vacant plot of land in Lyons-place, and the remainder of that thoroughfare. The total area included in the scheme will be about 8 acres. An agreement will be entered into with the St. Marylebone Metropolitan Borough Council to provide for the annual loss on the scheme, including the provision of rehousing accommodation to be shared, after allowing for the State contribution, in the proportion of two-fifths by the Council and three-fifths by the Metropolitan Borough Council. The scheme will be duly submitted to the Minister of Health for confirmation. E..st Hill estate. Last Hill estate, AVandsworth (8 acres), was purchased in 1924 for the purpose of providing accommodation for rehousing purposes in connection with the clearance of unhealthy areas. Accommodation for 3,254 persons in 13 blocks of dwellings will be provided on the estate, to be allocated to various clearance schemes as indicated in the Annual Report for 1926 (Vol. III., p. 189). By the end of the year, 11 blocks of dwellings of the normal type with accommodation for 3,014 persons in 492 tenements had been completed. On 19th .January, 1927, the Council accepted the tender of W. H. Wheeler and Company, Limited, amounting to £590, for paving the footways adjacent to the first seven blocks of dwellings ; and on 20th December, 1927, approved a supplemental capital estimate of £2,700 for paving the remaining footways and finishing the carriage ways adjacent to all the existing blocks of dwellings on the estate. On 4th May, 1927, the Council accepted the tender of Messrs. Alexander Hawkins and Sons, amounting to £875, for wiring and fitting block 11 for electric light. Hornsey-rise estate. I he ilornsey Kise 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. The estate, which comprises three blocks of dwellings (188 tenements) of the normal type of accommodation, was nearing completion at the end of 1927. Kennings estate. ivennings estate (White Hart-street site), Kennington (about zj acres), was taken on building lease for 120 years from the Duchy of Cornwall. It is being developed by the erection of seven blocks of dwellings to accommodate 958 persons in 169 tenements. The accommodation is to be utilised for rehousing purposes in connection with the China-walk, etc., scheme. Calstock House and Fowey House, of the simplified tvpe of accommodation, were completed during the vear. On 19th January, 1927, the Council accepted the tender of Mr. R. J. Rowley, amounting to £53,027, for the erection of blocks 3 to 7. These dwellings will contain 105 tenements of the normal type with accommodation for 670 persons. On 20th December, 1927, the Council approved a supplemental capital estimate of £375 for the erection of an estate workshop and store. The work will be carried out as an extension of the contract for the erection of blocks 3 to 7. Shore estate Shore estate (Well-street site), South Hackney (3 acres), was taken on building lease for 99 years from the Governors of St. Thomas's Hospital. On 26th July, 1927, and 11th October, 1927, the Council approved a capital estimate of £42,977 for the erection of the first two blocks of dwellings and the construction of a road through the estate. On the latter date, the tender of Rowley Brothers, Limited, amounting to £39,748, for the work, was accepted. These two blocks, of which one will be of the simplified and one of the normal type, will contain accommodation for 508 persons in 92 tenements. During the year offers were accepted of (1) the Hackney Metropolitan Borough Council to instal electric lighting in the tenements free of cost to the Council and (2) the Gas Light and Coke Company, to instal gas for cooking purposes, etc., at a charge of £1 a tenement. 207 Particulars of the rents fixed by the Council from time to time for its workingclass dwellings will be found in the annual reports for previous years. Weekly net rents (exclusive of rates and water charges) for further accommodation provided both at cottage estates and in block dwellings were fixed by the Council during the year as follows :— Rents. Cottage estates.—Becontree (sections 8, 9 and 10)—Houses—3 rooms, 10s. 6d. to lis. 6d.; 4 rooms (non-parlour), lis. to 14s. 6d.; 4 rooms (parlour), 12s. 3d. to 14s. 6d.; 5 rooms, 12s. 9d. to 14s. 6d. Flats—2 rooms, 8s. to 9s.; 4 rooms, 12s. Castlenau estate (643 houses)—3 rooms, 14s.; 4 rooms (non-parlour), 14s. 6d. to 17s.; 4 rooms (parlour), 16s. to 17s. 6d.; 5 rooms, 16s. 3d. to 18s. Downham (2,626 further houses and flats)—Houses—3 rooms, 12s.; 4 rooms (non-parlour), 12s. 6d. to 14s.; 4 rooms (parlour), 13s. 6d. to 15s.; 5 rooms, 14s. 6d. to 15s. 3d. Flats—2 rooms, 10s. to 10s. 6d.; 3 rooms, 10s. to 11s.; 4 rooms, lis. 6d. to 12s. YVatling estate (1,103 further houses and flats)—Houses—3 rooms, 12s.; 4 rooms (nonparlour), 12s. 6d. to 14s. 6d.; 4 rooms (parlour), 13s. to 15s. 6d.; 5 rooms, 14s. 9d. to 15s. 9d. Flats—2 rooms, 10s. to 10s. 3d.; 3 rooms, 10s. 6d. to lis. 6d.; 4 rooms, 12s. to 12s. 6d. White Hart Lane estate (304 further houses)—4 rooms (non-parlour), lis. 6d. to 12s.; 4 rooms (parlour), 13s. 6d. to 14s.; 5 rooms, 14s. to 14s. 6d. Wormholt estate (662 houses)—3 rooms, 12s.; 4 rooms (non-parlour), 13s.; 4 rooms (parlour), 14s. 6d. ; 5 rooms, 15s. 6d. Block dwellings.—Birchfield House—2 rooms, 5s. 6d. to 6s. 6d.; 3 rooms, 7s. 6d. to 9s. Dickens estate (Oliver House)—2 rooms. 8s. to 8s. 6d.; 3 rooms, 9s. 3d. to lis. 6d.; 4 rooms, lis. 6d. to 12s. 6d. East Hill estate (Plymouth. Falmouth and Newlyn Houses)—2 rooms, 9s. to 10s.; 3 rooms, lis. to 13s.; 4 rooms. 12s. 6d. to 14s. 6d.; 5 rooms, 14s. to 16s. 6d. Holland estate (Carter and Bernard Houses)— 2 rooms, 10s. to 10s. 6d.; 3 rooms, 12s. to 14s.; 4 rooms. 15s.; 5 rooms, 16s. 6d. Hornsey Rise estate (Ritchie, Goldie and Welby Houses)—2 rooms, 9s. to 10s. 6d. ; 3 rooms, lis. to 13s. 3d.; 4 rooms, 13s. to 16s.; 5 rooms. 16s. 6d. Hughes Fields estate (Blake and Hawkins Houses)—2 rooms, 7s. 6d. to 8s. 3d.; 3 rooms, 9s. 6d. to 10s. 9d.; 4 rooms, lis. to 12s.; 5 rooms. 13s. to 13s. 6d. Kennings estate (Calstock, Fowey, Helston, Liskeard, Landulph, Penmayne and Trematon Houses)— 1 room, 6s. to 6s. 6d.; 2 rooms, 8s. to 8s. 6d.; 3 rooms. 10s. to 10s. 6d. Ring Cross estate (Branston and Rollit Houses)—2 rooms, 9s. to9s. 6d.; 3 rooms, lis. to 13s. 6d.; 4 rooms, 14s.: 5 rooms, 15s. 6d. to 16s. 6d. Whitmore estate (Horner Houses, Blocks 3 to 5)—1 room, 5s. 9d. to 6s. 3d.; 2 rooms, 7s. 3d. to 7s. 9d.; 3 rooms, 9s. 3d. to 9s. 9d. Advantage was taken by the Council, in co-operation with the Holborn Metropolitan Borough Council, of the demolition and redevelopment of certain property adjacent to the Council's Shelton Street estate, to effect a widening of Macklin-street, Holborn. As part of the arrangement, a portion of the yard of the Council's dwellings was surrendered, with an appropriate financial adiustment to the housing account. Sheltonstreet estate During the year the Council made grants not exceeding £140 in all. out of interest on deposits paid by tenants on taking up tenancies, for prizes for the best kept gardens and window boxes on the Council's estates, and contributions to the local funds for judging the various competitions. The Council also made a contribution of £5 towards the iudeine expenses of the London Gardens Guild. Prizes for gardens and window boxes. The question of the use of electricity for domestic purposes on the Council s housing estates was again under consideration during the year. In the case of pre-war dwellings, the only estate, apart from the lodging-houses, at which electric lighting was installed in the first instance, was Totterdown Fields estate, Tooting. At ten estates developed partly or wholly since the war, including Becontree, Roehampton estate, Bellingham, Downham, White Hart-lane estate, Old Oak estate and Norbury estate, electricity was not installed for any purpose. Negotiations were, however, in progress at the end of the year with a view to electricity being Electricity for domestic purposes. 15435 o* 208 provided in new houses on sections of Becontree still to be developed. At Becontree, Old Oak estate, Hammersmith, Beachcroft buildings, Cranford cottages and Brookstreet dwellings, Limehouse, and the Council's dwellings in Poplar, electric lighting is being installed by the supply authorities in some of the existing houses and flats at the request of the tenants. At Watling estate, Kennings estate, Kennington, and Dickens estate, Bermondsey, the supply authority is wiring and providing one or more utility points in each house or tenement for electric lighting ; and at Whitmore estate, Hoxton, and AVhiston House, Shoreditch, electricity has been installed for lighting, and at the option of the tenants for cooking and heating. At Wormholt and Castlenau estates electricity is being installed for lighting in all the houses. At Castlenau estate a group of 57 houses has been wired for cooking and heating, as well as lighting, and a similar installation will be provided by the supply authority in any house at Old Oak estate if desired by the tenant. In these cases the tenants are able to hire at reasonable rents electric appliances, in the use of which the supply authorities undertake to give instruction. The experiment of installing electricity for cooking and heating as well as lighting, is being carefully watched by the Council with a view to the extension of the principle to other estates if it proves satisfactory. Staff. Ihe average number of workmen employed by contractors on the Council s housing development operations at the end of the year was about 11,280. About 534 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 138, and women workers, i.e. laundresses, bedmakers, etc., about 53. Local housing scheme— Vauban- street area. During the year the Bermondsey Metropolitan Borough Council submitted for the Council's approval a scheme for the clearance of an unhealthy area in the borough, about 4£ acres in extent, known as the Vauban-street area, which the borough council proposed to redevelop by the erection of cottages. The Council was of opinion that a site such as this, situated in a densely populated industrial district close to the centre of London, should be utilised to the fullest advantage. The proposal of the borough council to provide on the area a limited amount of accommodation in cottages would have had the effect of encroaching on the housing accommodation provided in other parts of London and would thereby diminish the number of dwellings available for the general needs of the County. The Council, therefore, felt itself unable to give its approval to the scheme being carried out on the lines proposed by the borough council, and suggested that suitable block dwellings hygienically arranged should be erected instead. Grants to Metropolitan Borough Council. During the year the Council agreed to make supplemental contributions from the county rate under section 2 (5) of the Housing (Financial Provisions) Act-, 1924, of £1 a year for 40 years in respect of each of 15 tenements erected by the Poplar Metropolitan Borough Council on sites in Bedford-street and Ford-street, Poplar; and also in respect of each of 1,216 houses erected by the Woolwich Metropolitan Borough Council on its housing estate at Eltham. Housing progress in Greater London. Returns as to the progress of housing in Greater London since the war are submitted to the Council periodically. The latest return brings the figures up to 31st December, 1927. The number of houses of all classes provided in 1927 in Greater London was 41,800. This is a much higher figure than for any previous year since the war, and, so far as can be judged from the statistics available, more than that provided in any year before the war. Of the 15,843 houses provided by local authorities in Greater London in 1927, more than one-half (8,201) were provided by the Council to meet the needs of the County of London only, which is a much larger number than in any preceding year. The total number of new houses and flats provided during the whole period from 1920 to 1927 inclusive was 159,037, which includes 55,610 provided by local 209 authorities. Of these 24,085 (8,401 within the County of London) were provided by the Council, 556 (336 within the county) by the City Corporation, 8,432 by metropolitan borough councils, and 22,537 by local authorities in the outer London area. Altogether 17,169 houses and flats were provided in the County of London by local authorities. In addition, 614 tenements were added by the conversion of old houses. A comparison of the new accommodation with the estimated increase in population, would, by itself, indicate that the arrears accumulated during the war and immediately after had been considerably reduced. There must, however, be taken into consideration the factor that the ratio of increase in the number of families had been in excess of the ratio of increase in population due to the fall in the average size of the family. This was a very serious factor in the increase of the demand for houses in the period 1911-21, and will still operate, though to what extent cannot be known until a fresh census takes place. Up to the end of the year, whilst it seemed that the pressure on accommodation had been greatly eased, there was no reason for thinking that the shortage of working-class accommodation had been entirely made good. The applications received daily by the Council for accommodation showed that there were still large numbers who could not obtain the accommodation they desired, this no doubt applying particularly to the poorer classes. The question of the continuance of the Rent Restrictions Acts engaged the attention of the Council during the year. It was felt that the disadvantages attending the continuance of the restrictions were many. On the other hand, there was the undeniable fact that the housing shortage had not been overcome, and it was realised that a heavy burden would be thrown on the Council as the principal housing authority in London by the dishousing of persons which would almost certainly take place if property were decontrolled. The Council, in the choice between two evils, came to the conclusion that on the balance the public interest would be better served by the continuance of the restrictions for a further period and the Govern ment was approached by the Council in the matter. The duration of the Acts, which were due to expire on 25th December, 1927, was extended for another vear. Rent Restrictions Acts—Continuance. One of the recommendations of the Royal Commission on Cross-River Traffic in London is referred to on p. 199 in connection with Castlenau estate. The other recommendations of the Commission have been considered by the Council from the housing point of view. It is, in the opinion of the Council, improbable that these recommendations, which are practically limited to proposals for cross-river facilities, would have a fundamental effect on the London housing problem generally, or would do anything appreciable to establish better communication between the centres of industry and undeveloped land in the suburbs suitable for housing purposes. Royal Commission on cross-rivei traffic in London. In view of the many requests for information as to the Council's housmg work which are frequently received from Government departments and municipalities, as well as from bodies and parties at home and abroad interested in housing questions, the Council has decided to issue a handbook containing particulars of the Council's housing activities up to the end of the year 1927, including particulars of schemes undertaken by metropolitan borough councils. It has also been decided to issue a separate folder map of Greater London with the Council's housing estates marked thereon and particulars of the estates printed on the back. A copy of the map is also to be included with the handbook, which will be placed on sale at the price of 2s. 6d. a copy. Both the book and the folder map will be ready for publication early in 1928. Housing handbook. The Council's action in earlier years with regard to workmen s trams at cheap fares was dealt with in the Annual Report for 1920 (Vol. I., p. 77). In the Annual Reports for 1923 (Vol. III., pp. 139-40), 1924 (Vol. III., p. 153), and 1926 (Vol. III., p. 192) particulars are given of the proceedings before the Railway Rates Tribunal Workmen s trains. 210 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. The Tribunal in its judgment adopted, with a few minor modifications, the proposals put forward by the railway companies for the standard charges to be made in respect of goods, ordinary passenger fares and season ticket rates. As regards workmen's fares the Tribunal approved a scale as follows :— For each return journey where the single journey does not exceed 1 mile 2d. For the next 3 miles or any part thereof Id. a mile. „ „ 6 „ „ „ ¾d. „ „ „ 10 „ „ „ ½d. „ For the remainder of the distance ¼d. „ The effect of this decision is to produce a considerable reduction in the schedule of workmen's fares proposed by the railway companies, though the standards art largely in excess of those submitted by the Council. The new scales of charges which come into operation on 1st January, 1928, are subject to revision at the enc of the first complete financial year according as they produce more or less than the standard revenue ascertained by the Tribunal. PUBLICATIONS OF THE LONDON COUNTY COUNCIL. The undermentioned Publications, issued by the Council, may be purchased through any bookseller, or from the Council's Agents, P. S. KING & SON, LIMITED, 14, GREAT SMITH STREET, WESTMINSTER, S.W.I, from whom a complete list of the Publications of the Council may be obtained. Annual Report op the Council. Issued annually in five volumes. Edition for 1926 , 8vo.:— Vol. 1. Powers and duties—Elections— Finance—Rating and Taxation—Public Protection—Traffic—Public Amenities —Miscellaneous Services. 2s. 6d. No. 25:«>. Vol. II. Mental Hospitals. Is. No. 2540. Vol. III. Public Health, Main Drainage and Housing. 2s. 6d. No. 2512. Vol. IV. Education. Is. No. 2536. Vol. V. Abstract of Accounts—Memoranda on Housing accounts and statistics—Index. 6d. No. 2582. Accounts in Abstract. Accounts of the Income and Expenditure of the Council from 1st April to 31st March. Is. Issued annually. 1926-7. No. 2567. London Statistics. Statistics relating to London and the public services therein, with certain statistics of the adjacent districts. Issued annually. Volume for 1925-26, 15s. No. 2538. Statistical Abstract for London. Comparative statistics for 10 years relating to parishes, metropolitan boroughs, poor law areas, electoral areas. Administrative County of London, Greater London, etc. —Education, rateablo value, lunacy, pauperism, fires, finance, population, rates, locomotion, etc. Volume for 1917-1926. 2s. 6d. No. 2555. 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 Domestic 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 Marine Aquaria. 3d. No. 2488. 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. Census, 1921. Report upon the statistics relating to Greater London contained in the various volumes of the Census of England and Wales. 1921. Is. No. 2550. Municipal Map op London, 1913. Coloured to show parks, traffic services, etc.* In 28 sheets; scale 6 inches to a mile. Is. 6d. a sheet; complete sets, including kev sheet, 35s. THE LONDON COUNTY COUNCIL GAZETTE. Issued weekly. Containing full particulars of Appointments, Contracts, etc. Price 2d. Annual subscription, payable in advance, 13s. post free. The Survey of London (a series ot volumes dealing both historically and architecturally with a number of London parishes!, 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. 485. 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. 22811. Vol. X. St. Margaret, Westminster. (Parti.). 42s. No. 2432 Vol. XI. The Parish of Chelsea (Part IV.), Royal Hospital., 42s. No. 2532. The University of London Press, Ltd., in association with Messrs. Hodderand Stoughton have issued a series of booklets, prepared by the Council, dealing in a popular way witl the principal services administered by the Council. The series, which is fully illustrated iiinliiHoic • The Londoner's Education. 9d. net. Housing. 6d. rfet. Parks and Open Spaces. Is. net. Fire Brigade. 6d. net. Public Health. 6d. net. The London Ambulance Service. 6d. net.