Lcc 39 London County Council. ANNUAL REPORT OF THE COUNCIL, 1930. Vol. III (Part I). PUBLIC HEALTH (Report for the year 1930 of the County Medical Officer of Health). 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 Stbeet, Victoria Street, Westminster, S.W.I, Agents for the sale of the Publications of the London County Council. 1931. No. 2850. Price 1s. London County Council ANNUAL REPORT OF THE COUNCIL, 1930. Vol. III (Part I). PUBLIC HEALTH (Report for the year 1930 of the County Medical Officer of Health). 1000. (McC. 11G61-89)—24.9.31. CONTENTS. Page Vital Statistics— Population—Marriages—Births—Deaths—Infant Mortality 5 Infectious Diseases— Typhus—Smallpox—Chickenpox 6 Measles—Whooping-cough—Scarlet Fever—Diphtheria—Diarrhoea and Enteritis—Puerperal Fever and Pyrexia 8 Statistical Tables 10 Enteric Fevers—Anthrax—Cerebro-Spinal Fever—Encephalitis Lethargica—Polioencephalitis—Poliomyelitis 12 Influenza—Rheumatic Fever—Yellow Fever—Cancer 13 Tuberculosis 13 Administration— Common and Seamen's Lodging Houses 15 Homeless Persons 19 Verminous Lodgers 23 Milk and Dairies Act 23 Statistical Information 24 Sanitary Officers 26 Drainage By-laws 27 Venereal Diseases 28 Tuberculosis 32 Dispensaries (Analysis of Returns) 36 Laboratory Work 40 Mental Deficiency Acts 43 Blind Persons Act 48 Midwives Acts and Children Acts—Nursing Homes Registration Act— Adoption of Children Act 50 Chemical Branch 56 PREFATORY NOTE. The great access of work imposed upon the Council by the Local Government Act, 1929, has caused delay in the publication of the reports of the Medical Officer of Health. To minimise the delay the reports on (1) General Public Health Administration and (2) on the School Medical Service are being issued separately as Parts I and II of Volume III of the Annual Report of the Council, 1930. Part II has already been published. A separate volume containing the Report of the Medical Officer of Health on the Hospital and General Medical Services of the Council will also be issued (Volume IV). This volume will deal fully with the administration of the general and special hospitals, the London ambulance service, and the pathological services. London County Council. ANNUAL REPORT OF THE COUNCIL, 1930. VOL. III—PUBLIC HEALTH (Part I) REPORT OF THE COUNTY MEDICAL OFFICER FOR THE YEAR 1930. 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. Vital Statistics. The population of the County of London at the census of 20th June, 1921, was 4,484,523, including members of the armed forces in London, but excluding Londoners on active service and elsewhere. It was estimated by the RegistrarGeneral that the population normally resident in London at the date of that census was about 4,524,000, allowance being made in this estimate for persons absent on holiday when the census was taken. Population. The preliminary results of the census taken on the night of 26th April, 1931, give the enumerated population of London as 4,396,821 including 12,100 noncivilians. The estimated populations of the metropolitan boroughs in 1930, based upon the preliminary census results, are shown in the table on page 10, and the rates given in this Annual Report are calculated upon these figures. The marriages registered in London during 1930 numbered approximately 42,857, or 19.3 per thousand of the population, the rate for the preceding year being 19.1 Marriages. The births in London during 1930 numbered 69,447 compared with 70,089 in the preceding year. The birth-rate was 15.8 per thousand, as against 15'8 in 1929. This is the lowest birth-rate recorded in London, the number of births being fewer by 1,529 than in 1918, when the influence of the European War was at its height. The birth-rate for each metropolitan borough will be found in the table on page 10. Births. The deaths in the civil population of London during 1930 numbered 50,992 giving a death-rate of 116 per thousand, compared with 14.2 in 1929. Deaths. The distribution of deaths by ages in 1930 and recent preceding periods is shown in the following table:— Period. 0 - 1 - 4 _ 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 1923-26 5,546 1,611 1,453 828 637 1,013 1,220 2,479 3,659 6,080 8,456 21,004 53,986 1927-30 4,585 1,396 1,152 818 490 1,009 1,245 2,414 3,444 6,195 9,200 23,788 55,736 1928 4,879 1,556 1,278 863 484 1,042 1,215 2,362 3,375 5,869 8,705 22,267 53,895 1929 4,995 1,642 1,217 842 502 1,047 1,272 2,528 3,765 6,907 10,491 27,681 62,889 1930 4,109 1,205 963 779 447 956 1,237 2,347 3,015 5,571 8,529 21,834 50,992 6 It will be seen that the deaths in 1930 were considerably fewer than the figures for other years shown in the table. This was due to the comparative absence of epidemic diseases during the year and especially to the low mortality from influenza. As a consequence of the absence of any influenza epidemic and of a winter not marked by any abnormally severe weather mortality from diseases of the respiratory system was also very low. As compared with 1929 the only cause of death conspicuously higher was that of measles, which caused 1,027 deaths, as against 206 in 1929. Deaths attributed to alcoholism show a continuous increase in recent years, although still small in number. The deaths in 1930 were 22 compared with 15 in 1929 and 7 in 1926. There has, however, been a marked decrease in deaths attributed to cirrhosis of the liver. For the first time for a number of years the deaths due to street accidents show a tendency to decrease, the total being 822 for the 53 weeks of the year as compared with 814 for the 52 weeks of 1929; among children under 15 years of age the deaths decreased from 169 to 166. Infant mortality. 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 10. The conditions during 1930 were favourable to infant life, the deaths under one year of age per thousand births being 59, a rate which is equal to the lowest rate recorded in London, viz., that of 1927. It will be seen from the following table that one of the chief causes of the low rate was the decrease in mortality from respiratory diseases. Cause of death. 1911 to 1914. 1915 to 1918. 1919 to 1922. 1923 to 1916. 1927 to 1930. 1926. 1927. 1928. 1929. 1930. Measles 3.40 3.84 1.64 2.02 2.07 2.88 0.63 3.93 0.61 3.12 Whooping.cough 3.63 4.45 2.50 2.60 3.14 1.29 3.08 2.45 615 0.89 Influenza 0.27 1.10 0.81 0.38 0.48 0.34 0.46 0.23 0.96 0.26 Tuberculosis 3.40 3.20 1.52 1.26 0.89 114 1.05 0.95 0.77 0.79 Bronchitis 641 6.72 4.42 2.91 2.30 2.59 2.12 2.56 2.87 1.66 Pneumonia 12.28 14.96 12.60 11.51 12.10 10.59 11.37 13.03 14.15 9.85 Diarrhoea 24.28 1610 12.16 9.36 8.87 10.78 6.97 9.52 9.93 9.07 Premature birth 18.16 17.42 17.00 14.74 14.17 14.11 13.94 14.22 14.81 13.71 Congenital defects 14.69 14.66 11.26 8.39 7.38 8.12 7.17 7.60 7.65 7.11 All causes 108 103 79 65 64 64 59 67 71 59 Infectious Diseases. The notifications, attack-rates and death-rates for the principal infectious diseases in London and the constitutent metropolitan boroughs in 1930 are shown in the tables on pages 10-11. Typhus fever. Typhus.—During the year two cases of typhus were notified from Shoreditch and admitted to the Western Hospital. The diagnosis was, however, not confirmed by microscopical examination in either case and the patients were discharged. Smallpox and Chickenpox. Smallpox.—The mild type of smallpox which was experienced in London in the years 1928 and 1929 continued unabated in 1930. As in previous years many cases which had been missed owing to the benign character of the disease were discovered during the investigation into the secondary crops of cases to which they had given rise. A number of cases occurred at hospitals amongst both outpatients and in-patients, and several common lodging houses were affected. The vagrant class, however, was not specially involved. 7 The following table shows the notified cases which occurred during the year, and it will be observed that the disease was most prevalent in the Northern and Eastern districts. Metropolitan Borough Number of cases notified. Metropolitan Borough. Number of cases notified. West— East— Paddington 3 Shoreditch 788 Kensington 4 Bethnal Green 951 Hammersmith 21 Stepney 958 Fulham 7 Poplar 631 Chelsea — Westminster City 3 South— South wark 104 North— Bermondsey 47 St. Marylebone 6 Lambeth 46 Hampstead 3 Battersea 9 St. Pancras 175 Wandsworth 8 Islington 242 Camberwell 306 Stoke Newington 29 Deptford 48 Hackney 493 Greenwich 28 Lewisham 11 Central— Woolwich 10 Holborn 14 Finsbury 193 Total 5,149 City of London 11 Of the deaths referred to in this table, 10 occurred among patients from the administrative county of London. Smallpox Deaths, 1930. Borough. Age. Sex. Vaccinal conditions. Date of death. Certified cause of death. Shoreditch 10 years M. Unvacc. 12.1.30 I. (a) Encephalomyelitis. (6) Smallpox. Bethnal Green 11 years F. Unvacc. 1.3.30 I. (a) Pyaemia (cause not known). II. Smallpox, discrete modified. Bethnal Green 3 days F. Unvacc. 1.3.30 I. (o) Smallpox. (6) Prematurity. II. Jaundice. Poplar 45 years F. Infancy 24.2.30 I. (a) Mitral stenosis. (6) Pleurisy. II. Smallpox. Camberwell 7 months F. Unvacc. 11.4.30 I. (o) Bronchial pneumonia. (6) Pertussis. (c) Smallpox. Stepney 60 years F. Infancy 2.4.30 I. (a) Heart failure. (b) Cordiac-vascular degeneration. II. Smallpox. Stepney 46 years F. Infancy 12.4.30 I. (a) Myocarditis. (6) Cerebral thrombosis. II. Smallpox. Finsbury 4 weeks M. Unvacc. 22.4.30 I. (a) Smallpox. (6) Pyaemia. Islington 5 weeks F. Unvacc. 1.8.30 I. (a) Smallpox. (6) Pyaemia. Stepney 58 years M. (T) 31.10.30 I. (a) Myocarditis. II. Smallpox. During the year passengers and crews from ships from Bombay, Sydney, Yokohama and Hamburg, which had had cases of smallpox on board, arrived in London. No case of the virulent type of smallpox, however, occurred in London. 8 Chicken-pox was made notifiable in several metropolitan boroughs for varying periods, and at the end of the year was notifiable in Paddington, Chelsea, Westminster, Islington, Stoke Newington, Hackney, City of London, Bethnal Green, Stepney, Poplar, Lambeth, Deptford and Woolwich. Measles. The deaths from measles in 1930 totalled 1,027, compared with 206 in 1929. The deaths in successive four-weekly periods in the epidemic of 1929-1930 compare with the figures for the two preceding epidemics as follows:— Years. Oct. Nov. Dec. Jan. Feb. Mar. April May June Total. (36 weeks). 1929-30 10 24 50 91 133 243 269 189 50 1,059 1927-28 5 41 83 163 200 362 322 188 73 1,437 1925-26 38 84 133 216 196 205 167 84 27 1,150 It will be noted that the epidemic of 1930 was less severe than in 1928 and reached a maximum later than the epidemics of 1928 and 1926. Whooping cough. There were 128 deaths from whooping-cough in London during 1930 compared with 1,141 in 1929. The death-rate, 003 per thousand, was the lowest recorded in London. Scarlet fever. There were 16,699 cases of scarlet fever notified in 1930 (53 weeks), the corresponding figure for 1929 being 15,855 (52 weeks). The attack-rate was 3 7 per thousand as against 36 in 1929. The deaths numbered 112, giving a death-rate of 0'03 per thousand of population at all ages, and a case mortality of 0'7 per cent. Diphtheria. The notified cases of diphtheria numbered 13,411 in 1930 (53 weeks) compared with 11,788 (52 weeks) in 1929. This gives an attack-rate of 3'0 per thousand, as against 2.7 in the preceding year. There were 452 deaths, as against 350 in 1929. The case mortality was 33 per cent. The case mortality from diphtheria has fallen markedly since 1922, and in the report of the Medical Officer of Health for 1926, pages 12-13, it was suggested that the decrease was associated with the memorandum issued in the autumn of 1922 by the Ministry of Health stressing the importance of immediate use of antitoxin, further emphasised by a letter to the medical Press in 1923 making it clear that the late Metropolitan Asylums Board welcomed the use of antitoxin by the certifying practitioner before sending cases into a hospital of the Board. The increase in 1930, although very slight, may possibly indicate that the effect of the steps referred to—especially apparent during 1923, 1924 and 1925—has diminished. Diarrhoea and Enteritis. Diarrhœa and enteritis caused 687 deaths among children under two years of age, or 9.89 per thousand births. The corresponding rate in 1929 was 1096. Puerperal fever and Pyrexia. There were 293 notifications of puerperal fever and 740 of puerperal pyrexia in 1930 (53 weeks) compared with 312 and 758 respectively, in 1929 (52 weeks). The deaths from puerperal sepsis numbered 134, and from other accidents of childbirth 97; the deaths per 1,000 births 1.93 and 1.40, respectively; a total of 3.33. The death-rates from puerperal fever and other accidents of childbirth per thousand births in each metropolitan borough in the periods 1920-1927, and 19281930, together with the deaths in childbirth in 1930, are shown in the following table:— 9 Metropolitan Boroughs. Childbirth deaths per 1,000 births. Number of deaths in Childbirth. 1930. 1920-27. 1928-30. Puerperal fever. Other causes. Total. Puerperal fever. Other causes. Total. Puerperal fever. Other causes. Total. Western. Paddington 1.5 1.8 3.3 1.9 1.5 3.4 3 3 6 Kensington 1.9 1.7 3.6 2.5 1.3 3.8 6 — 6 Hammersmith 2.1 1.7 3.8 2.1 1.8 3.9 4 5 9 Fulham 1.9 1.6 3.5 2.9 1.3 4.2 9 5 14 Chelsea 1.9 29 4.8 21 3.0 5.1 2 — 2 Westminster 1.5 2.9 4.4 3.6 3.9 7.5 4 6 10 Northern. St. Marylebone 2.1 2.6 4.7 2.6 2.9 5.5 4 3 7 Hampstead 1.8 1.6 3.4 2.0 3.7 5.7 5 1 6 St. Pancras 1.4 1.7 31 0.7 1.5 2.2 . 4 4 Islington 1.4 1.5 2.9 1.8 1.8 3.6 10 9 19 Stoke Newington 2.5 1.9 4.4 1.7 3.5 5.2 1 2 3 Hackney 1.8 1.5 3.3 1.6 2.0 3.6 2 4 6 Central. Holborn 2.9 0.6 3.5 1.6 1.6 3.2 1 1 2 Finsbury 0.9 14 2.3 2.9 1.2 4.1 7 3 10 London, City of 2.0 1.0 3.0 0.8 — 0.8 1 — 1 Eastern. Shoreditch 1.1 1.2 2.3 1.5 1.5 3.0 4 3 7 Bethnal Green 0.9 1.6 2.5 2.0 0.8 2.8 4 — 4 Stepney 1.0 1.4 2.4 1.1 1.4 2.5 4 6 10 Poplar 1.2 1.7 2.9 0.9 1.5 2.4 4 — 4 Southern. Southwark 1.3 1.4 2.7 1.9 0.9 2.8 7 2 9 Bermondsey 1.1 1.8 2.9 1.3 1.7 3.0 5 5 10 Lambeth 1.8 1.3 3.1 1.3 1.5 2.8 7 7 14 Battersea 0.9 1.9 2.8 1.1 1.6 2.7 4 6 10 Wandsworth 1.6 1.7 3.3 2.1 2.3 4.4 7 12 19 Camberwell 1.7 1.5 3.2 2.5 1.6 4.1 15 5 20 Deptford 1.6 1.7 3.3 2.0 1.1 3.1 3 1 4 Greenwich 1.0 1.4 2.4 1.4 1.2 2.6 4 — 4 Lewisham 1.1 1.9 3.0 1.7 1.2 2.9 3 — 3 Woolwich 1.2 1.6 2.8 2.2 3.0 5.2 4 4 8 London 1.5 16 3.1 1.8 1.7 3.5 134 97 231 The deaths per thousand births, i.e., the maternal mortality, in 1930, are shown in the table on page 10, but owing to the smallness of the figures the death-rates for a single year may be misleading ; the relative mortality in the various boroughs can only be correctly inferred from rates covering a considerable period as, for instance, those shown in the above table for the eight years 1920-27. It will be seen during this period that the boroughs with the lowest maternal mortality per thousand births were Finsbury, Shoreditch, Greenwich and Stepney; and that the highest mortality occurred in Chelsea, St. Marylebone, Westminster and Stoke Newington, which have also the highest rates in the period 1928-30. There were 291 notifications of fevers of the enteric group in London in 1930 (53 weeks) compared with 351 in 1929 (52 weeks). The deaths in the calendar year numbered 26, as against 45 in 1929. This is the lowest number of deaths recorded in London from this cause. Enteric fevers. 10 Vital statistics for the several metropolitan boroughs and the County of London in the year 1930. (Rates per 1,000 of civil population.) Metropolitan boroughs. (Arranged in topographical order.) Estimated civil population 1930. (Provisional figures.) Births. (a) Deaths. Infant mortalty (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. Maternal mortality (per 1,000 births). Notified cases of infectious disease. Scarlet fever. Diphtheria. Typhoid fever. Erysipelas. Cerebro spinal fever. Acute pneumonia. Western. Paddington 141,400 15.2 12.8 78 .15 .01 .08 .03 .01 13.5 .74 .93 .37 1.97 2.78 2.54 2.67 .08 .52 .03 1.51 Kensington 175,200 14.7 12.8 69 .22 .02 .07 .02 .01 14.7 .80 1.00 .59 1.77 2.33 2.48 2.01 .19 .38 .02 1.26 Hammersmith 135,800 16.0 11.8 64 .23 .02 .15 .07 .01 101 .97 .84 .56 1.58 4.14 3.60 2.80 .04 .49 .02 1.18 Fulham 152,300 15.5 11.0 57 .18 .01 .13 .03 .01 12.3 .75 .81 .25 1.64 5.91 3.91 2.64 .08 .48 .03 1 .41 Chelsea 59,560 13.4 13.1 40 .14 .02 .08 .03 — 6.3 .93 .74 .47 2.20 2.50 2.23 1.80 .07 .50 .02 1.52 Westminster, City of 120,500 11.0 12.5 61 .15 .02 .04 .02 .02 3.7 .80 .88 .50 1.86 7.32 2.00 1.96 .14 .31 — .20 Northern. St. Marylebone 97,310 12.8 12.0 62 .36 .01 .12 .02 .01 11.2 .77 .82 .42 1.75 5.62 2.27 2.50 .15 .68 .04 .43 Hampstead 86,530 11.6 11.3 58 .04 .02 .02 — — 5.0 .44 .49 .45 1.81 5.99 2.46 1.14 .14 .33 — .69 St. Pancras 199,000 15.9 12.2 61 .15 .03 .15 .02 .00 14.2 .83 .81 .52 1.80 1.26 3.25 2.81 .04 .59 .03 .96 Islington 322,700 17.6 12.0 69 .46 .04 .11 .04 — 15.8 .84 .88 .51 1.44 3.34 4.00 3.80 .09 .58 .02 1.09 Stoke Newington 50,830 14.4 12.1 55 .22 .02 .02 — — 5.5 .67 .89 .30 1.48 4.10 3.08 2.48 .10 .68 — .41 Hackney 216,000 16.3 11.0 50 .21 .02 .16 .02 .00 7.4 .81 .71 .37 1.48 1 .71 4.49 3.32 .02 .48 .02 .41 Central. Holborn 36,200 11.2 13.5 89 .33 — .06 .03 — 12.3 1.10 .97 .83 1.91 4.94 2.53 2.26 .14 .84 — 1.36 Finsbury 70,540 18.3 13.2 64 .62 .01 .13 .08 .01 9.3 1.08 .87 .83 1.59 7.74 4.42 4.66 .07 .88 .01 1.51 London, City of (b) 10,270 8.8 13.5 44 — — .10 — .10 — .78 .78 .29 2.04 11.11 2.11 1.82 .19 .57 — .77 Eastern. Shoreditch 98,960 20.1 12.2 65 .50 .01 .20 .03 — 10.1 .88 1.08 .55 1.34 3.52 4.31 3.44 .04 .68 — .97 Bethnal Green 109,800 17.8 11.1 60 .34 .01 .13 .03 .01 9.7 .87 1.03 .47 1.37 2.05 4.84 3.97 .04 .80 — 1.31 Stepney 232,700 18.0 11.7 76 .22 .03 .12 .03 .01 23.7 .92 .98 .39 1.35 2.37 4.08 3.24 .05 .79 .03 1.51 Poplar 157,900 19.4 10.7 55 .19 .02 .11 .02 — 6.2 .84 .77 .30 1.34 1.31 3.98 3.73 .04 .68 .02 2.95 Southern. Southwark 175,300 17.1 12.7 57 .44 .02 .10 .06 .01 6.3 1.20 .91 .54 1.43 3.01 4.28 3.80 .01 .62 .03 1.87 Bermondsey 113,100 18.2 13.1 64 .53 .07 .11 .05 .02 7.3 1.18 1.12 .60 1.47 4.86 4.47 4.07 .04 .36 .04 1.07 Lambeth 295,400 16.1 12.0 57 .16 .04 .13 .01 .00 9.1 .94 .70 .36 1.73 2.94 3.80 3.25 .05 .52 .02 1.19 Battersea 160,700 16.5 11.5 55 .23 .01 .09 .04 — 7.9 .86 .63 .44 1.51 3.77 3.72 3.29 .04 .48 .01 2.28 Wandsworth 350,400 13.4 10.7 54 .14 .02 .08 .02 .01 6.6 .75 .54 .37 1.57 4.05 2.82 2.60 .07 .44 .01 1.46 Camberwell 254,300 15.0 11.0 52 .19 .02 .08 .03 .01 5.0 .87 .68 .50 1.60 5.25 3.92 2.36 .02 .53 .01 .70 Deptford 108,800 16.2 11.5 61 .22 .03 .04 .03 — 9.7 1.04 .67 .43 1.43 2.27 5.16 3.84 .02 .47 .02 .67 Greenwich 99,700 15.9 10.4 48 .21 .03 .13 .01 — 6.2 1.02 .65 .40 1.51 2.50 5.20 3.50 .07 .60 .01 1.32 Lewisham 215,000 14.6 9.5 43 .04 .03 .08 .04 .00 4.8 .74 .53 .33 1.45 .95 4.96 2.05 .07 .31 .03 .92 Woolwich 141,800 14.9 10.9 42 .11 .04 .04 .01 .01 4.6 1.06 .71 .43 1.42 3.66 4.32 3.41 .06 .52 .01 2.01 London 4,388,000 15.8 11.6 59 .23 .03 .10 .03 .01 9.9 .87 .78 .44 1.57 3.33 3.74 3.01 .07 .54 .02 1. 24 (a) The birth-rates are calculated on the total populations. (b) Including Inner and Middle Temple. 11 Number of cases of infectious disease notified in the County of London during the 53 weeks ended 3rd January, 1931. Metropolitan Borough. Anthrax. Cerebrospinal fever. Continued fever. Diphtheria (including membranous croup). Dysentery. Encephalitis lethargica. Enteric fever. Erysipelas. Malaria. Ophthalmia neonatorum. Pneumonia. Polioencephalitis. Poliomyelitis. Puerperal fever. Puerperal pyrexia. Scarlet fever. Small-pox. Typhus. Western— Paddington — 4 3 384 — 1 1 75 1 15 217 — 1 5 39 365 3 — Kensington — 3 — 358 4 2 34 68 3 11 224 1 1 8 24 441 4 — Hammersmith — 3 — 386 — 3 6 67 — 14 163 1 1 8 26 497 21 — Fulham — 4 — 409 — 1 13 74 2 20 219 1 1 17 35 605 7 — Chelsea — 1 — 109 — — 4 30 1 6 92 — — 7 9 135 — — Westminster, City of — — — 240 — 3 17 38 — 16 24 — 1 6 16 245 3 — Northern— St. Marylebone — 4 — 247 — 2 15 67 1 17 43 — 2 8 26 225 6 — Hampstead — — — 100 — 4 12 29 — 7 61 — 1 8 13 216 3 — St. Pancras — 7 — 568 1 3 8 120 2 32 194 — 1 19 51 658 175 — Islington — 8 — 1,246 — 2 31 190 1 65 359 — 5 33 88 1,311 242 — Stoke Newington — — — 128 — 1 5 35 1 4 21 — — 4 7 159 29 — Hackney — 4 — 730 — — 5 106 — 16 89 1 — 4 56 985 493 — Central— Holborn — — — 83 — 1 5 31 — 5 50 — 1 3 6 93 14 — Finsbury — 1 — 334 — — 5 63 — 28 108 — — 6 16 317 193 — London, City of — — — 19 — — 2 6 — — 8 — — 1 — 22 11 — Eastern— Shoreditch — — — 346 5 5 4 68 — 32 98 — — 6 23 434 788 — Bethnal Green — — — 443 1 — 5 89 1 21 146 — — 6 15 540 951 — Stepney — 8 2 767 — 4 13 188 1 29 358 — 1 13 18 964 958 — Poplar — 4 — 598 — — 6 109 — 42 473 1 2 9 8 639 631 2 Southern— Southwark — 6 — 677 25 2 2 111 1 28 334 — 1 15 41 762 104 — Bermondsey — 5 — 468 — 4 5 41 2 13 123 1 — 14 20 514 47 — Lambeth — 6 — 977 1 9 14 156 2 45 358 1 1 19 46 1,142 46 — Battersea — 2 — 538 — 3 6 78 2 34 373 — 1 9 21 608 9 — Wandsworth 1 5 1 925 2 4 26 156 2 32 519 1 2 17 26 1,004 8 — Camberwell — 3 — 611 — 2 5 137 1 19 180 — 3 17 39 1 ,012 306 — Deptford — 2 — 425 — 1 2 52 2 26 74 — — 9 10 571 48 — Greenwich — 1 — 355 — — 7 61 — 15 134 — 1 5 12 527 28 — Lewisham — 6 — 448 — 3 15 67 2 17 200 — — 12 19 1,085 11 — Woolwich — 1 — 492 l — 8 75 1 8 289 — 2 5 30 623 10 — London 1 88 6 13,411 40 60 291 2,387 29 617 5,531 8 29 293 740 16,699 5,149 2 Ages 0- — 24 — 321 — — 1 117 — 617 400 — 3 — — 142 83 — „ 1- — 21 — 4,241 1 6 11 90 — — 1,247 3 13 — — 4,393 402 — „ 5- — 10 1 5,052 3 7 34 75 — — 583 4 11 — 6,962 991 — „ 10- — 3 — 1,583 1 2 29 70 1 — 179 — 1 — 1 2,602 868 — „ 15- — 7 4 717 2 7 44 126 — — 300 — — 7 46 983 839 1 „ 20- — 10 — 591 2 5 48 119 — — 291 — — 77 173 644 510 — „ 25- — 7 1 564 7 11 46 215 15 — 495 1 1 139 405 626 534 — „ 35- — 2 — 224 4 3 40 370 6 — 576 — — 69 107 243 338 1 „ 45- — 4 — 84 1 7 22 458 6 — 554 — — 1 8 76 217 — „ 55- — — — 23 1 6 10 413 1 — 476 — — — — 19 203 — „ 65- — — — 9 — 3 5 226 — — 311 — — — — 8 53 — „ 75+ — — — 2 — 3 1 108 — — 119 — — — — 1 11 — Age not stated — — — — — — — — — — — — — — — — — — 12 Anthrax. Anthrax.—One case of anthrax, which proved fatal, was notified in London during the year. The patient was employed at a flour and grain wharf, and had no known contact with skins or furs. Cerebrospinal fever. Cerebrospinal fever.—During the year 1930, 88 cases of cerebrospinal fever were notified. The diagnosis was not, however, confirmed in 13 of these cases. Of the 75 actual cases 51 (68 per cent.) proved fatal. In addition 29 deaths were recorded by the Registrar-General of cases which had either never been notified or had been notified in 1929, making a total of 80 fatal cases for the year. Encephalitis lethargica. Encephalitis Lethargica.—During the year 1930, 60 cases of encephalitis lethargica were notified. Of these 15 were, however, not confirmed. Of the actual 45 cases 16 (36 per cent.) proved fatal. In addition 49 deaths were recorded by the Registrar-General of cases which had either never been notified or had been notified in previous years. There was thus a total of 65 fatal cases for the year. Provision for the treatment of post encephalitis lethargica is made at the Northern Hospital, Winchmore Hill, and accommodation, limited to 50 beds, is provided for adult patients. During the year 6 patients were discharged and there were 8 admissions. The whole of the accommodation was in occupation at the end of the year. Owing to the large number of patients waiting admission the Council has decided to increase the accommodation, and an additional 115 beds is being provided. Particulars of the children treated in the special unit at the Northern Hospital are given in the Annual Report of the School Medical Officer. A comprehensive survey of the experience gained in the treatment of post encephalitis lethargica is contained in reports by Dr. G. A. Borthwick, medical superintendent of the Northern Hospital, and Dr. F. L. Golla, director of the central pathological laboratory of the Mental Hospitals Department. These reports appear as a separate publication.* Poliomyelitis and Polioencephalitis. Poliomyelitis and Polioencephalitis.—During the year 1930, 29 cases of poliomyelitis and 8 cases of polioencephalitis were notified. The diagnosis was not, however, confirmed in 6 cases of poliomyelitis and one of polioencephalitis. Of the 30 actual cases, 4 proved fatal. In addition 7 deaths were recorded by the Registrar-General of cases which either had never been notified or had been notified in previous years, making a total of 11 deaths for the year. Special facilities are provided at the Western Hospital for acute cases and at Queen Mary's Hospital, Carshalton, for the residential treatment of children suffering from paralysis following poliomyelitis and polioencephalitis. During the year 3 children were admitted to the Western Hospital. Of these 2 were sent home and 1 was transferred to Queen Mary's Hospital, Carshalton. In addition 45 children (30 boys and 15 girls) were admitted to Queen Mary's Hospital, Carshalton; and there were 49 discharges (33 boys and 16 girls). The services of Mr. G. Perkins, F.R.C.S., and of Mr. W. H. Trethowan, F.R.C.S., are available in a consultative capacity at the Western and Queen Mary's Hospitals respectively. Notifications received in each registration year since 1920, excluding duplicate notifications and military cases:— Year. 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 Cerebrospinal fever 154 103 86 65 93 93 83 93 70 121 88 Encephalitis lethargica 140 233 66 98 600 293 224 142 100 92 60 Poliomyelitis and polioencephalitis 49 57 40 111 116 55 95 86 54 66 37 * Encephalitis Lethargica—obtainable from P. S. King & Son, Ltd., 14, Great Smith Street, Westminster, S.W.I. (No. 2811),price 6d. 13 The deaths from influenza during 1930 numbered 366 as compared with 3,118 in 1929. The mortality in 1930 was lower than that in any year since 1889. Influenza. The deaths in London from rheumatic fever in 1930 numbered 174, of which 72 were among children under 15 years of age. The corresponding figures in 1929 were 168 and 68 respectively. Rheumatic fever The following is an extract from the report of the Medical Officer of Health of the Metropolitan Borough of St. Pancras for the year 1930 concerning a case of yellow fever:— Yellow fever. "A death from this disease took place in the Borough during the year, and, as such an occurrence is so unusual in this country, inquiries were made as to the mode and source of infection. " The disease is endemic on the West Coast of Africa, and it has been generally assumed that it was transmitted only by the bite of the Yellow Fever mosquito, Edes Egypti (Stegomyia fasciata), but it is now known that other species of mosquito can carry the disease. " The case in question did not, however, originate in this manner; the deceased was a laboratory worker in a research institute in which an investigation concerning Yellow Fever had been going on for some time. " The virus was kept alive in monkeys (Macacus rhesus) which till recently were the only animals known to be susceptible to infection. " Early in the investigation one of the medical staff and his laboratory assistant contracted the disease in a mild form and both recovered. " Some time later another laboratory worker who assisted at a post-mortem examination on a monkey was infected ; this was a very severe case, but he also recovered. About 10 days later another of the laboratory staff was taken ill. How he contracted the infection was not traced, but it is supposed that he handled some contaminated apparatus. This patient was admitted to the Hospital for Tropical Diseases, Endsleigh Gardens ; the case was moderately severe, but recovery ensued. " During his stay in hospital, an examination of his blood was made by a member of the hospital staff, and this person also contracted Yellow Fever, but recovered. A blood examination of the last-mentioned case was also made, and the person conducting the examination contracted the infection, and this case proved fatal in five days, although convalescent serum was used on the first day. " These cases appear to show that the infection of Yellow Fever can penetrate through the unbroken skin, and that experimental work and the handling of instruments and apparatus contaminated with infected blood is extremely dangerous. " I am indebted for particulars of the above cases to Dr. N. Hamilton Fairley, O.B.E., Director of Pathology and Assistant Physician to the Hospital for Tropical Diseases; and Dr. C. M. Wenyon, C.M.G., C.B.E., Director-in-Chief of the Research Institute concerned. " After the occurrence of the last of the above-mentioned cases, it was decided to stop the investigation, the animal house, laboratory, etc., were thoroughly cleansed, and Dr. Wenyon stated work was no longer being done." There were 6,908 deaths from cancer in 1930 as against 6,865 in 1929, and 6,773 in 1928. The death-rate per thousand was 1.57. There was an increase of 99 in the male deaths and a decrease of 56 among the females. Cancer. Tuberculosis. The deaths from tuberculosis of the respiratory system in London during 1930 numbered 3,826, giving a death-rate of 0'87 per thousand living, the corresponding figures for 1929 being 4,230 and 0.96 respectively, and for 1928—3,985 and 0.89. The increased mortality in 1929 is associated with the influenza epidemic of that year. There were 526 deaths from other forms of tuberculosis in 1930 as against 584 in 1929, the death-rate being 0.12. Tuberculosis. The annual deaths and death-rates from pulmonary tuberculosis in recent years are shown in the table on the next page: 14 Period. Annual 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 1.28 0.78 1.01 1925-27 2,522 1,667 4,189 1.19 0.67 0.91 1928 2,356 1,629 3,985 1.14 0.68 0.89 1929 2,523 1,707 4,230 1.24 0.72 0.96 1930 2,304 1,522 3,826 1.13 0.64 0.87 The number of primary notifications in metropolitan boroughs during 1930 (52 weeks), after correction of figures within each metropolitan borough by the exclusion of cases notified as primary but subsequently found to have been previously notified, was 8,051, the corresponding figure for 1929 being 8,732. The following is an analysis of the notifications in London during 1930 (52 weeks ended 27th Dec.). 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. 3 28 58 70 321 509 822 674 684 408 139 3,716 F. 1 22 60 97 449 593 710 437, 945 146 62 2 822 Other forms of tuberculosis M. 20 119 191 85 85 84 74 39 29 23 15 764 F. 10 98 151 90 98 89 06 50 14 16 5 717 All forms of tuberculosis M. 23 147 249 155 406 593 896 713 713 431 154 4,480 F. 11 120 211 187 547 682 800 487 259 162 67 3,539 Form of tuberculosis notified. Sex. Notifications on Form B. (Primary notifications of cases discovered through medical inspection in elementary schools.) Notifications on Form C. (Secondary notifications from institutions receiving cases.) 0- 5- 10 + Total. Poor Law. Other. Pulmonary tuberculosis M. — — 1 1 1.423 2,915 F. — — 2 2 887 1,972 Other forms of tuberculosis M. — 9 4 13 112 519 F. 2 9 5 16 62 449 All forms of tuberculosis M. — 9 5 14 1,535 3,434 F. '2 9 7 18 949 2,421 In addition to the primary cases notified on forms A and B shown in the above tables, a number of cases came to the knowledge of medical officers of health, otherwise than by notification. These figures include cases not notified before death:— Form of tuberculosis notified. Sex. New cases of tuberculosis coming to knowledge otherwise than by notification on forms A and B. 0- 1- 5- 10- 15- 20- 25- 35- 45- 55- 65 + Total. Pulmonary tuberculosis M. 4 6 9 6 25 45 112 122 88 66 57 540 F. 3 5 14 13 421 62 102 79 41 34 15 410 Other forms of tuberculosis M. 9 34 29 21 22 27 18 13 15 8 3 199 F. 15 30 25 18 19 25 12 14 9 8 4 179 All forms of tuberculosis M. 13 40 38 27 47 72 130 135 103 74 60 739 F. 18 35 39 31 61 87 114 93 50 42 19 589 15 The source of information as to the unnotified cases shown in the above table was as follows:— Source of information. Number of cases. Pulmonary. Non -pulmonary. Death Returns from local Registrars 188 110 transferable deaths from Registrar-General ... 173 80 Posthumous notifications ... 78 44 "Transfers " from other areas 407 102 Forms C and D 102 42 Other sources 2 — The returns received under the Public Health (Tuberculosis) Regulations, 1924, from the medical officers of health of the metropolitan boroughs show that there were 31,008 cases of pulmonary tuberculosis (17,478 males and 13,530 females) and 11,879 cases of other forms of tuberculosis (6,211 males and 5,668 females) on the registers of the metropolitan boroughs at the end of 1930. Administration. The supervision of the 152 common lodging houses licensed by the Council under the London County Council (General Powers) Act, 1902, entailed 6,953 day visits and 182 night visits by the inspectors. The supervision of the 22 seamen's lodging houses licensed under the Merchant Shipping Act, 1894, entailed 629 visits by day and 30 by night. Common and seamen's lodging houses. Early in the last century it was increasingly felt that the men of the mercantile marine, not only needed protection afloat, but also ashore against the unscrupulous boarding house master, the crimp and the harpy. At first the protection developed along the lines of private enterprise, and in 1835 the Sailors' Home in Well-street was founded. This institution, much enlarged and brought up to date, still carries on a valuable work with its 220 beds and its manifold activities. A little later the position of the coloured man came to the front. Large numbers were landed in the port and not being re-shipped were found wandering about begging, many ultimately becoming chargeable to the guardians. To meet their needs the Asiatic Home in the West India Dock-road was opened in 1854. This, too, with its accommodation for 170, is still in existence, and is largely frequented by Lascars. Other nationalities were eventually catered for by the German Sailors' Home, and the Scandinavian Home. Formerly, the English sailer was to be found in the so-called boarding houses, of which there were large numbers in the streets and alleys adjoining the docks. Many drifted into common lodging houses, whilst others frequented small public houses and beerhouses, some of which provided dancing halls. Here his associates included thieves and prostitutes and before long the seaman generally found himself without money or belongings. Left destitute his only hope was the crimp, who found him a ship and some clothes, receiving in exchange an " advance note," the value of which was very considerably in excess of the services rendered. These scandals were brought to the notice of the Board of Trade and, in the consolidation of the Merchant Seamen's Acts by the Act of 1894, a group of sections under the heading "Protection of Seamen from Imposition " was included. Of these, section 214 gives certain local authorities, whose district includes a seaport, power to make by-laws for regulating seamen's lodging houses. In 1901, the Council, much concerned with the possibility of infection from plague and cholera being introduced from foreign ports, issued a circular to all known keepers of seamen's lodging houses stating that advantage had been Seamen's lodging houses.— Historical note. 16 taken of the powers granted by the Act of 1894, and that by-laws had been made. Before the close of the following year 97 houses were under inspection in the following districts:— Poplar 32 houses with 474 beds Stepney 64 „ „ 1,165 „ Woolwich 1 house „ 26 „ Provision was made under the by-laws for licensing, but this was optional, and it was not until 1907 that the first licence under these by-laws was applied for and granted to the German Sailors' Home. Considerable difficulty was experienced in enforcing these earlier by-laws. Many of the keepers were foreigners with a scanty knowledge of English. The houses were mostly let on weekly tenancies. There were constant removals, and the keeper was under no obligation to notify a change of address. The principal difficulty, however, was that many of the houses were old, worn out, and quite incapable of being reconditioned. The experience of these first few years showed that the only satisfactory method of dealing with the premises would be by way of annual licensing. After correspondence with the Board of Trade, new by-laws were approved on 1st January, 1910, and on 19th February of the same year, an Order in Council was issued making it an offence under a penalty not exceeding £100, to lodge seamen unless the premises were licensed by the London County Council. The first result of licensing was to reduce the number of houses from 80 to 37, some ceasing to exist because they were unfit, others, occupied by Chinese, because they were affected by the by-law prohibiting opium-smoking and gambling, and were closed for this reason. At various times difficulty was experienced in deciding what was a " seamen's lodging house." The Board of Trade was advised by the Law Officers of the Crown as follows :— "We do not think that the reception of a single seaman constitutes the house a seamen's lodging house within the meaning of the Act; there must be something in the nature of a course of business, and whether a house is a seamen's lodging house is a question of fact in each case." A little later a further point arose as to what constituted a seaman for the purposes of the by-laws, and, the old definition under which a seaman ceased to be a seaman after 4 weeks ashore, was amended as follows:— "Seaman means any male person other than the holder of a certificate of competency or service as master, mate or engineer in the merchant service, who is ordinarily employed in any capacity whatever aboard ship." The by-laws now in force date from 1917. During the War, owing to torpedoed crews being sent to London from all parts, and shipping being held up for considerable periods, the boarding houses became crowded with seamen of all nationalities. Many of them had to be housed and fed in common lodging houses and the cheaper hotels. After the Armistice, it was some years before things settled down. The depression in shipping and the objection of the trade unions to coloured seamen having preference over white, resulted in many hundreds of Arabs, Somalis, Malaysians and West Indians, being left derelict. Many were found in a starving condition ; the Council communicated with the Board of Trade, and whilst the official machinery was being set in motion, the British and Foreign Sailors' Society stepped into the breach and fed and housed them until they could be placed on board the ships provided for their repatriation. 17 With the exception of the Scandinavians and, previously to the war, the Germans, the housing of foreign seamen, Lascars, Arabs, and Chinamen particularly, has always been a serious problem There was difficulty with the Lascars in 1922, when for want of more suitable accommodation large numbers were housed in common lodging houses, including Carrington House, in Deptford. It was felt that much of this accommodation was unsatisfactory; not only was there no provision for the special preparation of their food, but there was no privacy for them when they wished to carry out their devotional exercises. It was no uncommon thing to find them praying in the common kitchen exposed to the ridicule of the other lodgers. The India Office was informed, and as a result increased use was made of the Asiatic Home. Since that date little difficulty has been experienced, owing first to the smaller number of Lascars now requiring accommodation and to the shipping companies taking greater advantage of the Asiatic Home. The Chinese problem has always been a serious one. In the earlier days it was mostly in connection with opium-smoking and gambling that difficulty was experienced, to-day it is associated with the fact that the Chinese restrict themselves to quite a small area, where the houses are old, worn and badly planned and practically all let at weekly rentals. Usually the reconditioning and the works asked for as health requirements are not particularly expensive or extensive, but owing to the construction and arrangement of the premises, the fire danger is a real one and, owing to the short tenancies, few keepers will risk the expenditure. Consequently, when from any cause there is a large number of Chinese seamen to be housed, the available accommodation is insufficient, and the residue drift into unlicensed premises. Since the introduction of licensing, nearly the whole of the convictions shown in the table (p. 18) have been for lodging seamen, generally Chinese or Arabs, in unlicensed premises. The advent of the Chinese seamen dates back some 50 years or more. First a store was opened in Limehouse Causeway, to be quickly followed by boarding house masters from Liverpool. The colony gradually increased and encroached on the surrounding streets, including Pennyfields, West India Dock-road and High-street, Poplar. In 1910, the estimated Chinese population was about 1,500. In 1913, there were 12 licensed premises and 42 other houses frequented by Chinese. By 1915, the licensed houses had dropped to 9, but the other premises had increased from 42 to 81. This maybe taken as the period when the colony was at its maximum, probably some 2,000. During the War, a large number left London to work on munitions and did not return when the War was over. Some went to Rotterdam and Amsterdam, others to Antwerp, from which places it was much easier to get boats, opportunities in London being very slight, although wages were higher. To-day there are only 3 licensed houses specially catering for Chinese, with accommodation for 40 persons. The total population of the Chinese colony to-day is perhaps 250. Of the unlicensed houses some are occupied privately, others are used as clubs, and some as Chinese stores. In 1913 it was felt that some additional powers for dealing with Chinamen were necessary, and it was suggested that certain areas should be scheduled by the Board of Trade, and that instead of the Council having to prove that any Chinaman in the area was a seaman, the responsibility of proving that he was not a seaman would rest on him. Since that date, however, the Aliens Act, which does not allow aliens to enter or remain in this country without registration with the police, has practically met the difficulty. At the same time the number of Chinese seamen using the port has materially diminished and to-day difficulty is experienced only occasionally when a crew is brought to London. Opium-smoking, at one time so prevalent in the Chinese quarter, has practically ceased in the lodging houses owing to the operation of the by-laws and of the Pharmacy and Dangerous Drugs Acts. 18 The table appended gives particulars of the number of seamen's lodging houses before and after licensing.became compulsory. There are several factors responsible for the reduction in the number of houses and beds. Among the principal are:— 1. The movement of the shipping industry eastward to West Ham and Tilbury. 2. The tendency towards shorter voyages, with the result that there is less money due when seamen land. This in turn has affected the old boarding house system, whereby an inclusive charge was made for board and lodging, and the men now prefer to buy their own food. 3. The improvement in travelling facilities which enables the seaman to keep more in touch with his home. 4. Certain areas in Greater London have not taken advantage of the powers conferred by the Merchant Shipping Act. The result has been that in one case at least a keeper refused a licence by the London County Council, as not being a fit and proper person for the purpose, removed beyond the county boundary and opened a Chinese boarding house. At one time trouble was experienced with houses accommodating Arab seamen, and, in consequence of inspections and prosecutions, the keepers of such houses also went outside the county. Seamen's Lodging Houses Governed by By-laws. Year. Houses. Lodgers. Day visits. Night visits. Convictions. Fines & costs. Before licensing. £ s. d. 1902 97 1,665 2,842 — — — 1903 102 1,748 1,956 4 1 1 16 0 1904 90 1,585 1,298 10 3 11 7 0 1905 77 1,509 1,509 15 5 9 13 6 1906 84 1,551 1,431 38 8 43 7 0 1907 82 1,550 2,169 70 7 38 19 0 1908 85 1,571 2,081 78 3 24 0 0 1909 80 1,524 1,983 84 6 15 0 0 After licensing. 1910 37 1,157 2,404 197 14 90 9 0 1911 36 1,173 1,465 204 6 52 13 0 1912 41 1,066 1,079 210 13 81 12 0 1913 44 1,120 1,814 237 4 29 16 0 1914 35 1,043 1,247 174 4 59 13 0 1915 43 1.186 1,660 255 8 76 16 0 1916 53 1,271 1,422 193 17 313 0 0 1917 57 1,461 1,637 142 6 97 0 0 1918 59 1,486 1,666 85 12 139 2 0 1919 57 1,381 1,542 76 17 118 2 0 1920 53 1,298 1,496 109 6 91 10 0 1921 51 1,281 1,387 146 11 130 10 6 1922 44 1,180 1,168 138 — — 1923 37 1,089 1,275 79 3 40 0 0 1924 38 1,128 1,086 97 3 14 3 0 1925 33 1,092 865 81 7 41 8 0 1926 35 1,079 784 64 1 5 2 0 1927 31 1,061 750 45 5 46 5 0 1928 27 1,044 813 32 5 21 7 0 1929 25 806 796 50 — 1930 22 864 629 30 2 13 8 0 The distribution of seamen's lodging houses in December, 1930, was Stepney, 19 houses, 784 beds ; Poplar, 3 houses, 80 beds. 19 Some attempt to classify the nationality of the seamen accommodated in the various licensed houses has been made in the following table, which must, necessarily, be regarded as approximate only:— Nationality. Houses. Beds. Nationality. Houses. Beds. British 9 22 604 Scandinavian 3 8 20 40 4 12 8 30 217 West Africans, etc. 2 3 9 220 6 4 34 Indian, etc. 2 170 174 19 4 Chinese 3 16 40 German 1 5 5 5 19 22 864 Russian, etc. 2 6 12 6 A census of homeless persons in London was taken on the night of Friday, 14th February, 1930. 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 cold with a north-east wind. Seven persons (males) were found sheltering under arches or on staircases. In the streets 47 men and 25 women were found compared with 22 men, 8 women and 1 child on the night of the census in 1929. In the common lodging houses 14,855 persons were accommodated compared with 14,648 in 1929. In the free shelters and labour homes not licensed, 631 men, 117 women and 18 children were accommodated compared with 700 men, 110 women and 24 children in 1929. The number of persons in casual wards and in the Metropolitan Asylums Board hostel on the night in question was 740 (724 males and 16 females). In London Rowton Houses, 5,014 men were accommodated and there were 26 vacant beds. Census of homeless persons. After the dissolution of the monasteries in the years 1539-1541 the care of the poor became a State problem and from the year 1601 onwards numerous laws have been passed dealing with this class of the population. In earlier years, vagrants were punished by whipping and branding, discharged soldiers were rewarded by a licence to beg, whilst poverty in general, when unrelieved by charitable effort on the part of the Church, or by private benevolence, was regarded as an offence. The present century, however, has seen a great advance upon these methods, and various Acts, such as the Workmen's Compensation Act, the National Health Insurance and various Pensions Acts, have paved the way to the Local Government Act of 1929, which, in its reform of the Poor Law administration, adumbrates the treatment of poverty as a social service. Among the evils of recurrent poverty, the attention of the Council was directed early in 1904 to the number of apparently homeless persons to be observed aimlessly wandering in the streets of London at night. A preliminary census undertaken by skilled observers on the night of the 29th January, 1904, showed that as many as 2,000 persons might be regarded as coming within this category. As the result of the experience then gained, an area was mapped out and used in 1905 roughly approximating to an ellipse, having its centre at St. Paul's Cathedral with a major axis of eight miles from east to west, and a minor axis of five miles from north to south. The same area was adopted in all future censuses so that the figures should Historical note. 20 be strictly comparable. The following table shows briefly the results obtained in the several years:— TABLE I. Showing the number of homeless persons found in the streets, and inmates of common lodging houses and casual wards on the night of the census. Persons. Persons. Year. Common Lodging Houses (Inmates) Casual wards (Inmates) Homeless. Total. Year. Common Lodging Houses (Inmates) Casual wards (Inmates) Homeless. Total. 1904 23,442 1,218 1,797 26,457 1919 12,336 50 8 12,394 1905 23,381 1,139 2,181 26,701 1920 14,333 88 51 14,472 1907 22,450 1,137 2,404 25,991 1921 14,090 188 66 14,344 1909 21,864 1,188 2,388 25,440 1922 13,076 289 112 13,477 1910 21,156 1,107 2,747 25,010 1923 13,891 400 141 14,432 1911 21,204 1,091 1,785 24,080 1924 14,165 429 82 14,676 1912 21,499 1,033 1,203 23,735 1925 14,425 503 118 15,046 1913 20,526 546 649 21,721 1926 14,593 668 103 15,364 1914 20,173 335 540 21,048 1927 14,724 777 101 15,602 1915 17,305 179 178 17,662 1928 14,738 835 78 15,651 1916 15,254 123 44 15,421 1929 14,648 860 31 15,539 1917 13,679 89 28 13,796 1930 14,855 740 79 15,674 1918 12,522 82 9 12,613 Note.—The area covered in 1904 was less than in later years—to be comparable with other years the figures in the " Homeless " column should be 2,000. Special circumstances in the earlier years of the record have a considerable bearing upon the results shown. In 1905 the Salvation Army was, at two shelters, feeding homeless persons at night. In 1907, the distribution of food on a large scale was continued on the Embankment. In 1909, the Salvation Army provided food and shelter in four institutions between the hours of 12.30 and 3.30 a.m. Sleeping accommodation was not provided. In the same year, moreover, the Church Army had leased a building where men were allowed to sit antecedent to performing their allotted task of wood-chopping in the King's Tents. In return for this labour they received food and a ticket for a bed in a common lodging house on the succeeding night. In the several years 1909-1914 a separate record was kept of the persons accommodated in shelters in this way, and if they are not included, the numbers of homeless persons given in the table for those successive years, will be reduced to 759 ; 969 ; 1,026 ; 983 ; 491; and 434. In addition to the philanthropic effort just described it was the practice for charitable associations to provide tickets for beds in common lodging houses free of charge, although it was never possible to obtain precise information of the extent of this alms-giving. It was commonly reported at the time that there was considerable traffic in these bed tickets, even in those obtained from the Church Army in return for labour. Thus, by fulfilling his task of wood-chopping valued at about 2½d., a man would receive two meals and a ticket for a bed. The ticket was worth at least 4d., being a reduction of 2d. on the usual charge of 6d. and, after disposing of it, the recipient could take his chance of a meal from the Salvation Army with three hours rest in a shelter, in this way providing himself with food, shelter and pocket money. It will be observed that the rapid reduction in the numbers of homeless persons in the years from 1910 to 1913 coincided with the restriction of the scope of charitable effort. It must not be too hastily assumed, however, that there was a causal 21 ship, because in the earlier years high numbers were obtained, although there was then no attempt at feeding vast crowds such as obtained later. The only conclusion that could be drawn at that time was that economic conditions were the most important factor. The Metropolitan (Casual Paupers) Order, 1911, had for its object the transfer of the twenty-eight casual wards of the metropolis to the Metropolitan Asylums Board. The Local Government Board, in forwarding the Order, pointed out that uniformity of administration was of the first importance, and suggested that experience might show a way to differentiate the occasional from the habitual vagrant. Following this change of administration, a scheme was evolved whereby the police in two central divisions were supplied with tickets for distribution to homeless persons. On presentation at an office on Waterloo pier these tickets entitled the possessor to a bed in a casual ward or shelter. During the month of November, 1912, of the 2,966 tickets distributed by the police, 2,608 were presented by the recipients at the office. Of the persons concerned, 595 were given tickets for charitable institutions, and 2.013 were given tickets for admission to casual wards. Actually 551, or nearly 93 per cent, of the first mentioned tickets were used, and 996, or just over 49 per cent, of the latter. These comparatively large figures were probably the result of curiosity, for later the numbers diminished rapidly. The homeless poor night office has since been transferred to 12, Northumberland Avenue, W.C.2, and is still in active operation. From the time of the inauguration of this scheme until February, 1914, the last enumeration before the war, the numbers continued to fall. On the last mentioned date, the homeless numbered 540, the occupants of casual wards were about one-third of the number accommodated at the time of the census in 1912, and the common lodging house inmates were some 1,300 fewer than in the earlier year. These results again were not entirely due to the operation of the scheme outlined in the preceding paragraph, because, as this scheme was based on the provision of shelter for all homeless persons either in the casual ward or common lodging house, the natural corollary would be an increase in the number of inmates of those institutions. Here again it could only be concluded that economic conditions were the determining factor. Very slight variations in the prosperity of the community have an immediate effect upon the casual worker, who lives from day to day, and has no reserve upon which he can rely in case of need. Severity of weather, trade depression in particular industries, strikes, even the transfer of contracts to other more distant localities, all exercise their influence in preventing him from obtaining work. Since the war, the common lodging house population has remained fairly stationary at a somewhat lower figure than 15,000, thus showing a considerable decrease upon the average nightly accommodation of about 25,000 at the beginning of the century. The Council's chief inspector reports that the major part of the 15,000 inmates is now composed of permanent lodgers as contrasted with the much greater number of casuals in the earlier years. Doubtless unemployment and sickness insurance benefits have played a great part in this change. War pensions, widows pensions, Rent Restriction Acts, and a more generous view of the people's needs in granting out-relief in money and kind have all contributed their quota towards the elevation of the standard of living. The real casual is now accommodated in the casual ward, and having regard to the increased numbers in this class, it is probable that they have never been regularly domiciled in London. The fact that there were only 16 women among them tends to confirm this view. The following tables compare the results obtained in the two years 1910 and 1930, and show details of the different groups of homeless persons, and their distribution in localities. 22 TABLE II. Showing the total number of persons who might be regarded as homeless because they were unable to pay for a bed. Description. 1910. 1930. Men. Women. Young persons Total. Men. Women. Young persons Total. Persons found homeless in the streets 732 220 17 969 54 25 — 79 Persons in casual wards 928 173 6 1,107 724 16 — 740 Persons in receipt of Poor Law relief in common lodging houses — — — * 247 26 — 273 Persons occupying free beds in common lodging houses (paid for by charitable associations) 368 80 — 448 123 16 — 139 Persons who were allowed to "sit up" in a shelter with or without food 1,561 — — 1,561 332 10 — 342 Persons who received food and a bed in return for a light work task 217 — — 217 296 — — 296 Persons in unlicensed houses where no charge is made 701 350 11 1,062 282 107 18 407 Persons in licensed houses where no charge is made 1,235 37 8 1,280 — — — † Total 5,742 860 42 6,644 2,058 200 18 2,276 * No figures available. † In 1905 it wag decided in the Courts that houses of this class could not be regarded as common lodging houses. Previously, certain houses of this type had been licensed. The licence was renewed until comparatively recently when the use of the premises was discontinued, and there are now no licensed houses where no charge is made. TABLE III. Showing the number of homeless persons distributed according to locality on 13th February, 1910, and 14th February, 1930. District. 1910. 1930. Men. Women. Children. Men. Women. Children. Embankment—awaiting distribution of tickets by eleemosynary institutions, e.g., the Salvation Army, etc. *1,450 — — 9 2 — Holborn, City and north and northeast 148 44 1 bov 14 4 — Central, Westminster, etc. 121 33 9 boys 24 9 — East, Stepney and east centre 199 88 1 girl 3 7 — Paddington, Kensington, Chelsea, Fulham and Hammersmith 95 19 1 2 1 — Waterloo, Lambeth and Battersea 149 35 — 2 1 — London Bridge, Elephant and Castle, and south-east ... 20 1 5 boys — 1 — Total 732 220 17 54 25 — In Table III. the 25 women in 1930 form a very high percentage of the total number when compared with the year 1910. The result of the observation of many years leads one to the conclusion that very few women are really homeless. The classification of women found in the street is most difficult, and no individual inquiry has ever been attempted. . Included among the 1,561 in shelters in Table II. 23 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. The exercise of these powers has undoubtedly contributed to the improvement noted with regard to verminous conditions in such houses. No formal action under this section was necessary during the year. Verminous lodgers in common lodging houses. Milk and Dairies (Consolidation) Act, 1915. The Milk and Dairies (Consolidation) Act, 1915, 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. Under the altered arrangements the Council substituted for the position of full-time veterinary inspector one of half-time temporary veterinary inspector, subject to periodical review, and has decided to continue his employment until 31st December, 1931. Tuberculous milk. Samples of milk forwarded to London from places outside the county are taken and examined under the provisions of the Milk and Dairies (Consolidation) Act, 1915. In 1930, of samples of milk consigned to London railway termini from 33 counties 2,557 were submitted for biological examination. In the case of 2,331 samples, the biological examination was completed, and of these 213, or 9.1 per cent., yielded tubercle bacilli, as against 7.5 per cent. in 1929. From the copies of reports forwarded by the county medical officers of health, it would appear that 106 cows from the herds concerned had been found to be affected with tuberculosis and were slaughtered under the Tuberculosis Order, 1925. In the case of 206 samples, it was reported that the injected guinea pigs had succumbed to an acute intercurrent infection by some organism other than the tubercle bacillus. In the case of 62 of these samples the Lister Institute reported that, in their opinion, the deaths of the guinea pigs were caused by infection conveyed in the milk. The facts relating to these cases also were referred to the county medical officers of health for them to take such action as might appear necessary. Replies were received in respect of 30 of these 62 samples, and in 16 instances conditions were found which might account for the early deaths of the guinea pigs. Conditions which contravene the provisions of the Milk and Dairies Order, 1926, are sometimes observed by the inspectors while engaged in milk sampling. Contraventions of the Order were noticed in several cases in regard to the cleanliness and condition of churns. Details of these cases were transmitted to the authorities concerned. In December, 1930, it was decided that six months notice, dating from 1st January, 1931, should be given to terminate the existing agreement with the laboratory where the samples had been examined and that the examination of such samples should be carried out in the Council's laboratories as from the 1st July, 1931. Previously a report had been submitted stating that the number of samples examined during recent years averaged 2,600 per annum involving an expenditure of approximately £2,000 yearly, and that arrangements could be made for these examinations to be carried out in the Council's recently acquired Southern Group Laboratory at the Park Hospital at a saving of apnroximatelv £650 per annum. Examination of milk. In the report above referred to attention was drawn to existing arrangements for milk sampling for tubercle at a number of institutions at which bovine animals were kept, transferred to the Council by the recent changes in local government. These arrangements varied considerably, and, in order to preserve uniformity, it was decided that the same procedure should be adopted in regard to sampling as obtained at the Council's mental hospitals. Transferred institutions. In compliance with the instruction of the Mental Hospitals Committee, the cows at the mental hospitals have been inspected quarterly by the Council's veterinary surgeon. In addition, samples of milk have been taken twice during the year Mental hospitals. 24 COUNTY OF LONDON. Statistics of the administrative work carried out during the year 1930. Sanitary Authority. Cowsheds. Slaughterhouses. Offensive Trades. Smoke nuisances. Common lodging houses. Cleansing of persons and rooms. Water supply. Milkshops. Ice cream premises. Restaurants and Eating Houses. No. licensed. No. of inspections. No. licensed. No. of inspections. No. authorised. No. of inspections. Observations. Intimations. Complaints. Notices. Houses licensed. Authorised lodgers. Persons. Rooms or premises. Tenement houses extra supply. No. on register. No. of inspections. No. on register. No. of inspections. No. of places. No. of inspections. Adults. Children. After infectious diseases. For vermin. City of London — — — — 10 16 55 1 6 — 1 477 130 1,103 all — — 273 223 9 9 867 993 Battersea — — 2 140 3 3 7 7 4 1 3 187 263 3,901 2,057 278 22 240 509 168 208 116 293 Bermondsey — — — — 13 45 55 13 5 3 3 1,188 49 — 2,110 589 9 280 568 121 191 119 553 Bethnal Green 11 31 2 208 9 115 66 4 5 1 5 366 690 2 1,922 324 — 260 698 151 347 187 589 Camberwell 1 23 2 181 10 30 178 11 32 3 5 438 55 4,064 4,410 435 16 430 1,456 235 239 172 198 Chelsea — — 2 30 — — 26 — 5 — 2 164 12 754 273 217 4 70 128 27 45 70 67 Deptford — — 2 255 6 1 24 — — 4 7 1,198 9 1,981 1,817 63 — 165 190 120 130 45 103 Finsbury — — 1 106 3 28 44 4 9 4 2 470 9 4 1,192 294 17 131 197 72 113 229 308 Fulham — — 2 113 — — 291 3 3 1 2 84 3 10 1,753 169 44 153 53 104 213 98 153 Greenwich 1 4 3 32 3 5 53 5 61 1 2 90 20 729 1,081 19 2 116 139 120 129 66 66 Hackney 3 33 12 444 16 31 1,304 29 36 5 4 307 138 2,313 2,980 411 3 428 1,400 225 292 215 191 Hammersmith — — 7 367 2 11 79 20 57 — 1 280 132 2,580 1,206 41 50 107 1,141 111 211 164 533 Hampstead — — 1 36 — — 1 — 1 — — — 4 692 — 31 10 67 178 54 116 61 87 Holborn — — 1 3 — — 107 3 2 — 12 835 270 — 600 119 2 126 94 30 54 249 384 Islington — — 13 716 18 73 128 18 93 2 21 775 78 5,492 4,713 103 96 420 702 250 121 461 479 Kensington — — 4 204 1 51 157 5 4 2 6 284 293 3,762 1,796 349 62 154 450 136 162 141 1,017 Lambeth 1 12 6 538 4 48 61 61 61 — 3 473 — — 6,103 702 46 614 3,069 226 843 200 217 Lewisham 1 2 8 785 — — 141 7 10 — — — — — 1,870 104 — 118 296 171 165 119 303 Paddington — — 2 306 1 60 186 1 15 — 3 234 30 3 norcrd 96 51 115 425 126 250 120 210 Poplar 3 20 7 52 7 6 61 13 16 5 6 636 112 1,192 1,746 97 1 118 267 112 251 792 1,986 St. Marylebone — — 1 50 3 56 297 — 6 — 4 739 3,472 3,335 1,032 391 9 113 326 68 120 386 859 St. Pancras — — 4 180 1 39 371 4 21 1 2 78 1,211 5,864 1,736 201 118 318 735 231 257 280 694 Shoreditch 2 31 1 5 2 8 748 11 3 1 4 284 6 — 1,999 31 35 273 863 96 226 189 456 Southwark — — 4 114 4 18 8 1 — — 20 2,353 1,301 3,316 7,716 907 6 367 1,774 176 704 376 1,504 Stepney 19 110 1 1 53 221 268 29 66 3 20 2,919 556 215 2,796 349 6 372 1,197 246 440 347 493 Stoke Newington — — 4 39 — — 13 1 19 — — — — 1,332 444 128 3 66 56 35 27 32 53 Wandsworth 1 24 6 735 2 5 47 6 31 1 — — 244 15 4,565 1,135 4 307 1,318 497 591 322 630 Westminster — — — — — — 755 16 31 2 6 1,750 520 380 744 71 21 177 314 76 44 1,153 1,596 Woolwich 7 109 6 21 — — 40 7 43 — 9 318 21 1,863 1,117 41 1 94 403 122 280 154 324 Note.—In the columns above a dash signifies a nil return. Common lodging houses licensed by the Council (i.e., excluding those in the City of London) number 152 ; lodgers, 16,450. Visits—day, 6,953, night, 182. Seamen's lodging houses, number licensed, 22 ; Poplar, 3 ; Stepney, 19 ; lodgers, 864. Visits—day, 629 ; night, 30 ; Prosecutions—Smoke Nuisances. Battersea, 1, £4 4s. Od. costs; Bermondsev, 2, (40s. and £10); Camberwell, 1, £3 3s. Od. costs; Kensington, 1, £1 (Order made prohibiting recurrence); Westminster, 2 (Orders made for abatements (1), £2 2s. Od. (1) £21 costs. Water Supply. Hammersmith, 4; St. Pancras, 2; Westminster, 1. Ice Cream Premises. Stepney, 2. Milkshops. Islington, 1 ; City of London, 2; Battersea, 3. 25 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, 1925. Underground rooms. Overcrowding. Houses let in lodgings. No. of houses closed by owner. No. of houses for the working classes. Houses unfit for habitation. Representations. Closing orders. Demolition orders. In borough. Occupied by the working classes. Complaints or illness. House to house. Under P.H. Act. Under housing Act. No. illegally occupied. No. closed or otherwise remedied Instances found. No. remedied. No. on register. No. of inspections. Erected during year. In course of erection. No. made. No. of houses. No. made. No. determined. No. made. No. of houses demolished. Intimation. Statutory. By owners. By L.A. In pursuance of orders. Voluntarily. City of London 1,793 890 183 195 172 38 77 360 — — 1 — 1 1 54 162 — — — — — — — — — 6 Battersea 27,947 25,058 6,639 1,052 3,312 1,341 15 3,555 311 1 ? 10 37 37 62 353 — 25 6 — — — — — 6 Bermondsey 18,596 18,450 6,227 3,343 3,403 1,148 1,016 3,403 1,015 1 1 1 1,408 206 55 173 — 41 146 9 203 — — — 24 Bethnal Green 18,497 Prac. all 7,820 546 5,800 4,018 — 6,203 — — — — — — 225 782 — 28 37 2 2 2 — — 2 2 Camberwell 42,492 33,992 4,684 998 4,580 1,604 30 5,165 — — 6 5 229 116 240 216 — fits 106 fits 342 — — — — — 80 26 Chelsea 11,777 2,434 849 166 630 219 — 377 — — — — 25 25 396 76 — fits 17 132 2 2 1 — — — 45 tnmts. Deptford 18,122 90% 2,430 1,755 3,458 1,078 42 3,820 35 — — — — 3 — — — !7 — — — — — — — — Finabury 10,889 prac. all 1,909 1,481 2,722 448 2,722 — — — — — — — 754 3,009 — 2 103 — — — — — 25 Fulham 24,385 prac. all 3,890 889 2,511 543 211 2,335 646 — 5 5 60 30 139 2,062 — fits 44 — — — — — — — — Greenwich 17,656 80% 1,260 208 1,363 172 — 1,701 — — 1 1 13 7 96 158 — 50 76 — — — — — 6 5 Hackney 35,514 14,710 7,071 66 5,090 1,206 — 5,285 — — 8 8 94 19 170 5 — fits 175 90 1 55 — — — — 34 hses18 Hammersmith 20,200 13,700 8,490 250 4,492 1,896 10 4,629 — — 10 9 89 75 2,495 — — 146 56 1 2 — — 1 4 3 Hampstead 13,260 approx one-half 1,068 1,295 1,198 787 44 1,007 — — 56 15 105 65 1,295 3,797 — — tnmts — 1 1 1 1 4 — — Holborn 3,473 8,571 937 621 479 86 2 479 2 — 23 7 14 6 493 824 — 15 — 12 12 9 — — — 29 tnmts — Islington 46,000 28,700 5,942 1,442 4,573 580 24 5,474 24 — 16 16 32 32 1,000 531 — 157 — 1 3 3 — — — 54 Kensington 35,296 9,857 3,469 1,050 2,701 565 188 2,641 180 9 34 34 25 20 3,111 9,580 — fits 558 4 — — 2 — — — — 24 Lambeth 42,607 — 13,072 362 4,188 435 362 6,132 449 1 6 6 — — — — 4 127 200 2 5 4 — — 4 — Lewisham 50,000 No rcrd 2,850 1,071 2,420 824 — 2,380 — — 7 4 46 16 4 24 — 183 approx 2 2 2 — — — — Paddington 17,000 9,100 2,084 — 1,148 485 489 1,547 416 — 5 4 * 2 1,406 7,055 — — — 1 1 1 1 — — — Poplar 24,013 23,000 approx. 7,423 1,063 5,158 1,780 — 4,406 — — 2 1 95 28f 114 1,181 — 116 — — — — — — — — St. Marylebone 19,567 8,579 about 2,257 995 1,570 49 — 1,521 — — 30 30 6 6 1,055 7,481 — fits 21 fits 12 — — — — — — — St. Pancras 25,216 18,000 6,718 880 3,140 1,338 580 3,047 512 1 5 4 23 17 2,125 3,358 — 155 143 5 15 — — — — — Shoreditch 14,026 13,126 6,023 1,997 5,126 1,126 — 5,126 — — many 2 136 92 402 799 — 54 55 — — — — — — 59 Southwark 26,496 14,610 7,465 791 8,043 3,721 2,403 6,917 1,546 — — — 32 32 357 357 — 93 86 — — — 1 2 2 — Stepney 38,534 32,035 9,686 7,839 13,947 7,047 2 13,625 1 1 18 12 80 43 2,602 2,817 — 20 54 — — — — — — 192 Stoke Newington 8,670 3,974 1,433 — 687 67 — 1,419 — — 1 1 1 1 100 57 — — — — — — — — — 9 Wandsworth 74,656 49,140 8,735 2,957 6,296 781 — 13,874 4 — 27 15 166 224 267 119 — — 72 4 160 — 1 — — 38 Westminster 25,321 6,694 2,245 853 887 58 6 871 5 — 16 10 55 16 386 1,463 1 160 fits 298 — — — — — — — Woolwich 30,253 25,500 4,813 2,351 3,549 1,004 — 2,772 — — 7 2 70 44 nt kept 532 — 490 30 5 5 5 2 6 4 36 Note.—In many cases, it has been impossible to take effective action in the matter of overcrowding owing to the shortage of houses. Prosecutions—Houses Let in Lodgings : Holborn, 4 ; Paddington, 14 ; Islington, 4 ; Kensington, 5 ; St. Pancras, 12 ; Stoke Newington, 1. Overcrowding—Hammersmith, 9 ; Hampstead, 2 ; Holborn, 1 ; Islington, 1 ; St. Pancras, 2 ; Kensington, 5. * Owing to existing social conditions official action was taken with regard to 9 cases only. f Includes 10 cases reported in 1929. Housing Acts. A full account of the action taken under the various Housing Acts will be found in Volume II of the Annual Report of the Council, 1930. 26 Sanitary Inspectors, 1930. District. Popula- tion (Census) 1921 Male. Female. Health Visitors. Whole time. Part time. Whole time. Part time. Whole time. Part time. City of London 13,709 23 — 1* — — — Battersea 167,739 11 2* 8 2* (• Act hot h as Sanita ry Inspectors and Health Vis itors.) Bermondsey 119,452 12 — — 10 — Bethnal Green 117,238 11 — — 12 — Camberwell 267,198 12* — 2† — 3 2† (Including 1 Food & Drug Inspector & 1 Food Inspector.) (The two Female Sanitary Ins pectors also act as part-time Health Visitors.) Chelsea 63,697 4 1 1* — (Excludi ng 3 Chelsea Health Society Visitors, subsidised by Council.) Deptford 112,534 8 — — — 8 1 Finsbury 75,995 7 — 1 — 6 — Fulham 157,938 10 — 1 — 7 — Greenwich 100,450 5 — 1 — 10* — 222,142 (Including 2 T.B. Visitors.) Hackney 19 — 1 — 15* . — (*Including 2 T.B. Visitors.) Hammersmith 130,295 11 — 1 — _ 4 — Hampstead 86,153 6 — 1 — 3 — Holborn 43,192 3 1* 1 1* (Acts both as Sanitary Inspector and Health Vlsitors.) Islington 330,737 19 — 2 8 — Kensington 175,859 11* (•Including 1 Food Inspector.) 7 7 Lambeth 302,868 16 — 52 — 6* — (Including 2 T.B. Visitors.) Lewisham 174,194 10 — 1 — 9 — Paddington 144,261 9 — 2 — 2 — Poplar 162,578 14* — 1 — 12* — (•Including 2 Meat A Food Inspectors.) (* Includes 3 T.B. visitors. E xcludes 9 Vol. Assoc . Health Visitors) (p lus 1 Sister in charge o f Light tre) totoal 28. St. Marylebone 104,173 8 3 — 3 4 4 St. Pancras 211,366 15* — 1* 5* 17 5* (Including 2 Food Inspectors and 1 Factory and Workshop Inspector.) (* Factory & Workshop Act.) (* Act both as Sanitary Inspectors and Health Vis itors.) Shoreditch 104,248 13 — — — 6 — South wark 184,404 13 — 1 — 10 — Stepney 249,657 21 — — — 11 — Stoke Newington 52,172 3 — — — 3 — Wandsworth 328,307 18 — — — 8 — Westminster, City of 141,578 12 — 1 — 8 3 Woolwich 140,389 11 — 1 2 8 — Total County of London 4,484,523 335 3 22 20 200 25 27 from the supplies given by the herds at each of the institutions under the direction of the Mental Hospitals Committee. In all, 83 samples were taken. Of these, 5 were found to be tubercle infected; in addition, in each of 10 cases, the guinea pig succumbed to an acute intercurrent infection and in the remaining 68 cases, tubercle bacilli were not detected. The percentage of samples found to be tubercle infected of the total number of completed examinations made was 6"85. Each of the herds at the four institutions (viz., Bexley, Claybury, Hanwell and Cane Hill) whence the 5 tuberculous samples emanated, was inspected. At Bexley, 2 cows were found to be suffering from tuberculosis and slaughtered and at each of the other three institutions (Clayburv, Hanwell and Cane Hill) one cow suffering from tuberculosis was slaughtered. The results of the routine inspections of the herds are shewn ir the following table:— No. of visits. No. of animals examined. No. of cows with T.B. (referred to above). No. of cows with other unhealthy conditions, (apart from T.B.). Cows. Bulls. Young stock. 45 2,613 12 67 5 30 The veterinary surgeon confers with the farm bailiffs when making the inspections and gives such advice as may be necessary. Improvements and alterations in the buildings, which add to the comfort of the animals and simplify and assist cleansing operations, have been carried out. The farm stock generally is kept at a high standard. Licensed cowsheds. The cows in the London sheds are inspected under the provisions of section 27 of Part V. of the London County Council (General Powers) Act, 1904, and Part IV. of the Milk and Dairies Order, 1926. The veterinary surgeon makes a routine quarterlv inspection of the cows at each cowshed. The results of his visits are shown below:— Number of visits to cowsheds 274 Number of cows examined 7,788 Number of bulls examined 7 Number of cows presenting unhealthy conditions 79 as follows— Giving tuberculous milk 5 (cows slaughtered voluntarily by owners) With atrophy of one or more quarters 32 With other defects 42 It is interesting to note that the number of licensed cowsheds in the county has diminished from 738 in 1888, the year of the Council's inception, to 50 in the year now under review. The existing premises are mostly situated in the metropolitan boroughs of Woolwich, Stepney and Bethnal Green, parts of Woolwich being of a more or less rural character, while in Stepney and Bethnal Green the sheds are necessary for the supply of milk to Jewish residents in accordance with the requirements of their religion. By-laws as to water closets etc. By-laws in substitution for the existing by-laws under section 39 (1) of the Public Health (London) Act, 1891, and section 24 of the London County Council (General Powers) Act, 1928, with respect to water closets, urinals, earth closets, privies and cesspools and the proper accessories thereof in connection with buildings were made and allowed bv the Minister of Health. In 1929 the Council made a revised code of by-laws regarding the construction of drains and the deposit of plans and particulars of proposed drainage works under section 202 of the Metropolis Management Act, 1855, and the Metropolis Management Acts Amendment (Bye-laws) Act, 1899. During the year under review these by-laws were confirmed by the Minister of Health, with certain modifications. By-laws as to construction of drains. 28 Venereal Diseases. In his annual report for the year 1916, Sir William Hamer, at that time County Medical Officer of Health, gave particulars of a scheme for the provision of the necessary facilities for the diagnosis and treatment of venereal disease which had been formulated as a result of conferences between representatives of the counties of London, Buckingham, Essex, Hertford, Kent, Middlesex and Surrey, and of the county boroughs of Croydon, East Ham and West Ham. The Local Government Board, in due course, signified its approval of the scheme, which came into operation on 1st January, 1917, and is known as the London and Home Counties Scheme. Hospitals.—The general and special hospitals undertaking in-patient or outpatient treatment and other work under the scheme at the end of 1930, were as follows:— General Hospitals.—St. Thomas's; Seamen's; Royal Free (women); Guy's; West London; Royal Northern; Middlesex; St. Mary's; St. George's; University College; Metropolitan; King's College; Albert Dock; Miller General; St. John's, Lewisham; Westminster. Special Hospitals.—South London Hospital for Women; St. Paul's; Great Ormond-street; Royal London Ophthalmic; Mothers' Hospital (Salvation Army), Lower Clapton-road, E.; Children's, Waddon. All-day clinics have been provided at St. Thomas's Hospital; St. Paul's Hospital; Guy's Hospital; West London Hospital; The London County Council (Whitechapel) Clinic and the Royal Free Hospital (women). The number of new cases of venereal disease dealt with under the scheme during 1930 was 16,707, of which 5,225 were syphilis, 11,123 gonorrhoea, and 359 soft chancre. Comparing these figures with those of the previous year, it will be observed that the total of new cases dealt with is 722 more than in 1929. Year. Syphilis. Gonorrhoea. Soft chancre. Non-venereal. Total. 1929 4,931 10,774 280 8,801 24,786 1930 5,225 11,123 359 10,162 26,869 Increase + or decrease — + 294 +349 + 79 +1,361 +2,083 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. New cases. Total Venereal cases. Syphilis. Soft chancre. Gonorrhoea. M. F. M. F. M. F. M. F. 1917 4,427 3,351 199 11 3,830 1,207 8,456 4,569 1918 3,764 3,002 116 13 4,844 1,940 8,724 4,955 1919 6,394 3,391 463 18 10,441 2,440 17,298 5,849 1920 6,988 3,579 766 25 10,669 2,427 18,423 6,031 1921 5,088 3,100 458 13 8,573 2,136 14,119 5,249 1922 4,207 2,600 309 12 8,233 2,402 12,749 5,014 1923 4,497 2,631 311 4 9,043 2,520 13,851 5,155 1924 4,174 2,452 301 4 8,565 2,785 13,040 5,241 1925 3,556 2,346 268 11 8,464 2,857 12,288 5,214 1926 3,725 2,013 301 2 8,825 2,858 12,851 4,873 1927 3,886 2,209 203 7 9,637 2,859 13,726 5,075 1928 3,433 1,837 229 6 8,249 2,647 11,911 4,490 1929 3,303 1,628 276 4 8,271 2,503 11,850 4,135 1930 3,389 1,836 347 12 8,620 2,503 12,356 4,351 With regard to the new cases of venereal disease, an attempt was made to ascertain whether the infection was of less or more than one year's standing in patients attending the clinics for the first time during the year 1930. The returns received 29 from the treatment centres showed that as regards syphilis in approximately 53 per cent, of the new patients, and in the case of gonorrhoea in 86 per cent., the infection had taken place within a year. Importance is attached to the necessity of securing the regular attendance of patients at the clinics, more especially in the case of gonorrhoea, and efforts to secure the requisite provision of facilities for intermediate treatment at times other than during the hours when the medical officer attends 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. Ratio of attendances. In past years the ratio of attendances has been stated as so many attendances to each new case of V.D. admitted to the clinics during the year. By this means an estimate, comparable year by year, is obtained of the efficiency of the work as measured by the continued attendance. For the year 1930, the total attendances of V.D. patients was 772,816 and the ratio of attendances of Y.D. patients to new V.D. cases was 46, compared with 44 in 1929 and 43 in 1928. Comparative figures for the fourteen years during which the scheme has been in force are shown in the following table:— Year. New Cases. Total. Attendances. In-patients 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 25,560 555,509 106,662 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 1928 16,401 9,595 25,996 763,535 65,106 1929 15,985 8,801 24,786 768,872 51,520 1930 16,707 10,162 26,869 836,219 51,216 Attention is also drawn to the very large number of non-venereal patients who present themselves for examination. This appears to indicate quite clearly that the general public is appreciating more and more the efforts which have been, and are being, made to spread far and wide a knowledge of the serious nature and grave after-effects of the venereal diseases. Pathology Eind bacteriology. Another point worthy of note is the total number of examinations made of pathological specimens. Comparative figures for the fourteen years are shown in the following table:— Pathological examinations. Year. From treatment centres. From 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 30 Year. Pathological examinations. From treatment centres. From private practitioners. 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 1928 107,410 29,785 1929 114,840 32,605 1930 125,177 33,309 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 preparations for the treatment of their private patients. The number of medical practitioners availing themselves of this service is now 492, compared with 108 at the end of 1917, the first year of the operation of the scheme. Venereal disease; hostel accommodation. From the outset the necessity was recognised for accommodation where young women 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 1930, the number of patients dealt with at these institutions from the areas in the scheme was 272, the aggregate number of days in residence being 30,362. Comparative figures for 1929 were 249 and 26,525. The hostels undertaking work in connection with the scheme for the year 1930, were as follows :— 22, Highbury-quadrant, N. (Royal Free Hostels Committee); 148, Lambethroad, S.E. (St. Thomas's Hospital); 80, Stockwell-park-road, S.W. (Southwark Diocesan Association for Preventive and Rescue Work); 35, Parkhurst-road, N. (West London Mission); 62, Regent's-park-road, N.W. (Royal Free Hostels Committee) ; Salvation Army Hostels, 122-124 and 126-128, Lower Clapton-road, E. Rescue homes. The desirability of maintaining treatment and observation of girls and women for whom residence in hostels has been provided during the acute stages of venereal disease, engaged the attention of the Public Health Committee of the Council during the year 1928. As a result, arrangements were made with the authorities of certain rescue homes, providing vocational training in domestic and other work, to receive young women and girls who, although requiring continued treatment and observation had been certified by the medical officer of a clinic as fit to reside in any institution without danger to other residents. These arrangements were completed in the autumn of 1928, but have not been utilised to the extent anticipated despite several circulars to V.D. clinics and hostels. During the year 1930 only five of the eleven beds available were occupied. The total number of days in residence was 500. The London County Council (Whitechapel) Clinic. On 1st July, 1930, the Venereal Diseases Clinic at the London Hospital, one of the institutions in the London and Home Counties Scheme, was transferred to the Council as an all-day clinic, and is now known as the London County Council (Whitechapel) Clinic. It remains open from 8 a.m. to 9 p.m., and provision for intermediate treatment is available daily, Sundays and Bank Holidays included, throughout the year. The premises are rented from the London Hospital, but the staff is appointed and the clinic maintained entirely by the Council. Under the directorship of Dr. T. Anwyl Davies, assisted bv a loyal and efficient staff, the clinic has been an unqualified success. During the first six months the number of female patients increased two fold and the regular attendance of all patients has considerably improved. 31 32 The total number of new patients in attendance during the six months ended 31st December, 1930, was 1,527 of whom 522 were not diagnosed as suffering from venereal disease. The number of attendances was 76,183, compared with 36,802 for the first half of the year before the clinic was maintained by the Council. Of the new patients 75.5 per cent, of the male and 63 per cent, of the female venereal cases were infections of less than one year's standing. When the Council assumed control the adaptation and equipment of the premises had not been completed, and considerable alterations had to be effected, including the provision of a laboratory for the pathological work. The total number of pathological examinations for the six months was 15,650, of which 8,192 were blood tests. For the convenience of private practitioners, arrangements were made for results of certain tests to be communicated by telephone within three hours of the delivery of specimens. Facilities for the study of venereal diseases are available for medical students and post-graduates, demonstrations being given every Wednesday from 2 p.m. to 4 p.m. The average number of students attending the weekly demonstrations during the last three months of the year was 21. On 31st December, 1930, the staff of the clinic was as follows :— One director, 2 senior and 2 junior medical officers, 2 clinical assistants, 1 pathologist, 1 sister, 3 nurses, 5 male attendants, 2 male and 2 female clerks, and 1 male and 1 female cleaner. The rapid and continued growth of the work has necessitated provision for the appointment of additional medical and nursing staff. The graph on page 31 shows the weekly attendances of patients both before and after the 1st July, 1930, when the clinic was taken over by the Council. The figures for the separate attendances made by male and female patients are not available for the first half of the year. The Council's Anti-Tuberculosis Scheme. Residential treatment. Residential treatment under the Council's tuberculosis scheme is provided for all tuberculous persons (adults and children) ordinarily resident in the County of London recommended by a public authority except those recommended for treatment under the Poor Law. The operation of the Local Government Act, 1929, transferred to the Council the responsibility of dealing with tuberculous persons formerly provided with residential treatment by boards of guardians. These were accommodated partly in the infirmaries, now organised by the Council as "general hospitals," and partly in voluntary institutions in the country. Those suffering from pulmonary tuberculosis in poor law infirmaries were accommodated in special wards and it is estimated that on an average about 1,250 beds were occupied. Those suffering from nonpulmonary tuberculosis were placed in the general surgical wards and a number of beds varying from 120 to 150 was devoted to this purpose. From the information available to the Council it would appear that on the average about 275 beds in voluntary institutions in the country were taken for their own cases by the various boards of guardians. Broadly speaking, patients who are likely to improve materially from residential treatment are dealt with under the Council's tuberculosis scheme, and those suffering from chronic disease without prospect of definite improvement and also patients acutely ill are accommodated in the Council's general hospitals. The first mentioned, if able to be up for eight or more hours a day are transferred to voluntary institutions outside London where grounds are available for their use. Among the advantages of the transfer of the poor law accommodation to the Council may be mentioned the additional facilities now available enabling the Council to distribute patients more 33 satisfactorily among suitable institutions having regard to their needs. Cases in institutions both under the Council's tuberculosis scheme and in the transferred poor law general hospitals are reviewed and interchanges are effected so that the accommodation at the disposal of the Council is used to the best advantage. The subjoined information concerns patients treated under the Council's antituberculosis scheme. The following table indicates the number of applications from adults for residential treatment during each of the last five years:— Year Application for first period of treatment Application for further treatment Total Applications ExService Civilian Male Female ExService Civilian Male Female 1926 128 2,262 1,864 478 693 582 6,007 1927 63 2,119 1,819 417 727 622 5,767 1928 33 2,125 1,839 345 760 633 5,735 1929 34 2,245 1,910 278 882 656 6,005 1930 19 2,331 1,814 204 943 667 5,978 Of the 5,978 adult cases recommended during 1930 for residential treatment, 76 were subsequently withdrawn, 4,894 were accepted and 1,008 were not accepted. The 4,894 cases were disposed of as follows:—(a) 1,241 were passed for admission to " observation " beds in order to determine "diagnosis" or "suitability for sanatorium treatment " ; (b) 3,653 were passed for admission direct to sanatoria or hospitals. Of the foregoing accepted cases, 328 for various reasons failed to enter institutions. The 1,008 cases not accepted under the scheme were generally cases of advanced disease of the type referred to above as having been formerly dealt with by boards of guardians. Since 1st April, 1930, many of these have been accommodated in the Council's general hospitals or, if ambulant, in voluntary institutions in the country under the arrangements for public assistance. 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, 1,195 patients were discharged from "observation beds"and their classification was as follows (the corresponding figures for 1929 are also given):— 1930. 1929. Pulmonary. Number. Percentage. Number. Percentage. Group A 292 35.39 294 34.54 Group B 1 28 3.39 42 4.94 Group B2 366 44.37 381 44.77 Group B3 139 16.85 134 15.75 Total pulmonary cases 825 100.00 851 100.00 Surgical cases 21 8 Total diagnosed as tuberculous 846 859 For definition of classification see footnote to the first table on page 38. In the remaining 349 cases the diagnosis of tuberculosis was not confirmed. Of the 846 cases definitely diagnosed as tuberculous, 579 pulmonary cases were sent to sanatoria, 58 to institutions for advanced cases, 17 died in the " observation " hospitals, 8 cases were transferred to surgical institutions, and 184 were discharged home or arrangements made for them independently of the Council's tuberculosis scheme. The total number of admissions to institutions during 1930 was 4,907, compared with 5,249 in 1929. At the beginning of the year 2,083 patients were under treatment 34 so that the total number of adults treated in 1930 was 6,990, compared with 7,169 in 1929. The number under treatment on 31st December, 1930, was as follows (the corresponding figures for the previous year are shown in brackets):— Ex-service pensioners for tuberculosis. Civilian adults. Totals. Voluntary institutions 50(70) 626 (645) 676 (715) London County Council institutions 22 (28) 1,319 (1,340) 1,341 (1,368) Total 72 (98) 1,945(1,985) 2,017 (2,083) The immediate results of the treatment of patients discharged on completion of treatment during 1930 and the two preceding years are indicated in the following table. All percentages are shown in italics. The upper line of italic figures under each classification heading indicates the percentage of cases falling within each horizontal classification group, and the second line of italic figures shows the percentage of cases falling under each vertical division into which results of treatment are classified. For example, 523 patients were discharged in 1928 with the disease "quiescent." Of these 275 or 52.6 per cent, were cases of pulmonary (Group A) tuberculosis. The total number of cases in this category was 745, and 275 of these or 36.9 per cent, were discharged as "quiescent." For the purpose of this table patients of 15 years of age on admission are regarded as adults, owing to the "age" division of patients required for the purposes of the Ministry of Health, although treatment for them was arranged in institutions for children. Classification. a B 1 B2 B3 Surgical. Totals. Immediate results of treatment. Quiescent Much improved No material improvement Died in institutions Totals 1928.1929.11930. 1928. 1929.l930. 1928.l929. 1930 1928. 1929. 1930 l928. 1929. 1930. 1928.l929.l930. 275 278 320 84 108 77 86 91 2001 — — — 78 92 105 523 569 702 52.6 48.9 45.6 16 .1 19.0 11.0 16.4, 15.9 285 — — — 14.9 16 2 14.9 100 100 100 36.9 40.6 47.0 38.2 51.2 46.4 3.8 3.9 9.1 - - - 21.6 22.7 25.7 11.4 12.3 15.7 371 315 243 1241 99 78 1.172 1,217 984 49 36 34 202 224 198 1,918 1,891 1,535 19.3 16.6 15.8 6.5 5.2 5.1 61.l 64.4 64.1 2.6 2.0 2.2 10.5 11.8 12.8 100 100 100 49.8 46.01 35.7 56-31 46-9J 47-0 51-7\ 51-9 45-0 4-9 3-7. 3-2 56.0 55-3 47-9| 41-7 40-9\ 34-2 91 85 105 12l 4 11 978 1,022 975 514 505 633 69 72 92' 1,664 1.688 1,816 5-5 5 0 5-8 •?, ■2 -II 58-8 60-5 53-7 30-9 30 0 34-9 4 1 4 3 5-01 100 100 100 12-2 12-41 U-4\ 5-51 1-9 t-6 43-lj 43-6 44-5 51-3 51-7\ 60-9 19 1 17-8 22-51 86 2 36-51 40-5 8 7 IS — — | — 30 13 30 440 436 373 12 17 16 490 473 432 1-6 1-5 3-11 — — . — 6 1 2-7 7-0 89• 8 92-2 86-3 2-5 3-6 3-7 700 100\ 100 1-1 10 1-9 — — I — ] 1-41 -6 1-4 43-8 44-6\ 35-9 3-3 4 2 3-9 70-7 70-3 9 6 745 685 681 220 211 166 2,266 2,343 2,189 1.0031 977 1,040 361 405 409 4,595 4,621 4,485 16'2 14 -8 15-2 4-8 4-6 3-7 49-3 50-7 48-8 21-8; 21-1 23-2 7-9 8-8 9-1 700 100 100 ioo ioo m ioo 700 loo ioo ioo loot too ion ioo ioo 100 ioo ion\ im 100 With regard to children, the numbers recommended for treatment under the Council's anti-tuberculosis scheme during each of the last five years were respectively 1,163 in 1926, 1,190 in 1927, 1,081 in 1928, 1,069 in 1929, 1,121 in 1930. In dealing with surgical cases, arrangements have been continued for the immediate admission to residential institutions of children suffering from tuberculosis of the hip, spine and other bones. Of the 1,121 children (i.e., patients under 16 years of age) referred to the Council in 1930,1,068 were accepted for treatment, 53 were not accepted or were withdrawn ; 27 of the accepted cases for various reasons failed to enter institutions after acceptance. There were 858 children under treatment at the beginning of the year, and 1,026 children were admitted during the year, making the total number of children treated in 1930 1,884, compared with 1,830 in 1929. The number of children under treatment on 31st December, 1930, was 890, distributed as follows:— London County Council institutions 642 Voluntary institutions 248 33 The condition of the children under 16 years of age (on admission) who were discharged from residential institutions in 1930 is indicated in the following table. The figures in brackets are those for 1929:— Immediate results of treatment. Classification. Surgical. Totals. A. Bl. B2. B3. Quiescent 123 (67) 2 (—) 5(1) — (—) 302 (331) 432 (399) Much improved 64 (89) 3(2) 13 (18) —(—) 178 (147) 258 (256) No material improvement 16 (20) l(-) 12(11) 7(14) 27 (25) 63 (70) Died in institution 3(3) —(—) -(1) 5(3) 19 (26) 27 (33) Total 206 (179) 6(2) 30 (31) 12 (17) 526 (529) 780 (758) l'apworth and Preston Hall Village Settlements The Council sends a number of patients to Papworth Village Settlement both under its anti-tuberculosis scheme and under the arrangements for public assistance. A careful selection is made with a view to the admission of patients most likely to be accepted by the authorities of the sanatorium for settlement in the colony. About 23 of the Council's former patients have been accepted as permanent employees of the industrial settlement. The serious problem is the patient who, after some 12 or 18 months' treatment and training, has small prospect of entering the settlement. As the colony is an industrial concern it is necessary that only the most efficient should be accepted for employment. To discharge patients after 18 months training is not only a disappointment to the patient but is a waste of time and money. The Council has accordingly recently entered into an arrangement with the authorities of the institution concerning those patients, who, although unlikely to be fully selfsupporting, are yet able to be of some commercial value. The arrangement is that the Council will pay the difference between the value of the patient as a wage earner and the cost of his maintenance, subject to periodical review of each case at intervals of a few months. There are some 23 patients now at the colony under this arrangement. A similar arrangement operated at the Preston Hall Village Settlement Burrow Hill Colony, Frimley, Surrey. In 1929 the Burrow Hill Colony, Frimley, Surrey, which belongs to the National Association for the Prevention of Tuberculosis, was re-organised into an institution for the treatment and training in gardening and clerical work of youths between the ages of 14 and 19 years. The scheme is that youths suffering from tuberculosis who need to remain under treatment for at least a year are sent to the colony and the Council has authorised the granting of a second year of training in cases where there are definite indications that prolonged residence is likely to be of special benefit to the boys, both as regards health and fitness for employment. The course of instruction at the colony has received the approval both of the Board of Agriculture and the Board of Education. The Council maintains an average of about 40 beds. Last year a scheme was adopted under which arrangements were made for special training in gardening of selected boys with a view to their subsequent employment in the Council's parks department as " improvers " after two years training at the colony. The first group of selected cases will be due for employment early in the year 1931. Tuberculosis dispensary service. Detailed information has been furnished by the metropolitan borough councils' tuberculosis dispensary service 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. The information is summarised in the table on pages 36 and 37. 36 Tuberculosis Dispensaries. Analysis of Returns, Jan.-Dec., 1930. Borough. On Dispensary Register, 1-4-30. Transferred during 1930 from other areas and lost sight of cases returned Examined for first time during 1930. (a) New cases excluding contacts, (b) Contacts (printed in italics). Total number (including contacts) under dispensary supervision during 1930. Removed from Dispensary Register during 1930. On Dispensary Register on 31-12-30. Total attendances. Visits to homes for dispensary purposes by No. of specimens of sputum examined. Diagnosis completed. Under observa tion. Pulmonary. NonPulmonary. Doubtfully Tuberculosis. NonTuberculosis. Total. (a) Cured. (6) Diagnosis not confirmed or non- T.B. (printed In italics). (a) Transferred to other areas or lost sight of (b) Died (printed in italics). Diagnosis completed. Under Observation. Tuberculosis Officer. Dispensary Nurse. Adults. Children. Adults. Children. Adults. Children. Adults. Children. Adults. Children. Battersea 906 41 30 162 5 13 21 61 32 190 110 426 168 1,724 27 122 915 56 3,621 133 4,292 1,305 — — — 2 1 6 49 95 50 103 508 96 Bermondsey 984 21 13 149 12 20 18 14 8 251 111 434 149 2,110 62 42 893 26 3,932 1,302 4,174 1,294 21 9 — 2 2 5 206 264 229 280 969 118 Bethnal Green 656 5 11 113 3 5 20 15 15 245 109 378 147 1,394 3 56 691 10 3,340 140 2,653 590 3 — — 3 7 9 70 105 80 117 557 77 Camberwell 2,140 22 33 202 7 11 19 92 11 273 140 578 177 3,657 33 109 2,196 30 5,509 747 7,963 1,192 50 3 6 4 40 15 221 368 317 390 1,137 152 Chelsea 205 5 18 66 7 9 14 6 2 231 195 312 218 924 11 44 241 9 3,089 61 3,238 287 3 — — — 1 — 71 91 75 91 592 27 Deptford 567 56 19 110 4 16 17 123 70 62 50 311 141 1,228 36 86 566 55 2,579 188 2,906 615 1 — — — 24 23 38 48 63 71 403 82 Finsbury 475 12 20 55 8 5 11 — 1 86 53 146 73 949 2 40 525 2 4,050 281 2,682 447 28 4 2 3 — — 100 86 130 93 332 48 Fulham 887 28 58 149 2 12 25 197 129 124 141 482 297 2,073 27 147 900 11 3,479 304 3,959 1,461 1 1 — 2 5 9 143 160 149 172 909 79 Greenwich 764 6 14 65 1 8 7 9 5 94 67 176 80 1,337 — 137 694 18 3,941 205 4,206 231 27 3 2 4 5 5 115 136 149 148 424 64 Hackney 1,156 12 58 169 9 29 28 45 13 337 197 580 247 2,546 18 141 1,219 10 6,354 284 3,302 1,230 3 — — 2 11 10 228 239 242 251 1,046 112 Hammersmith 793 10 36 137 6 28 17 7 — 188 80 360 103 1,584 12 50 896 9 1,996 142 4,869 463 16 1 1 2 — 1 123 138 140 142 538 79 Hampstead 168 14 15 31 — 5 2 27 5 51 28 114 35 394 3 40 164 7 934 10 1,326 93 4 — — — 11 3 14 16 29 19 126 18 Holborn 183 2 3 36 1 4 4 9 2 7 — 56 7 334 6 14 200 — 997 28 1,413 159 3 — — 2 — 1 46 31 49 34 98 16 Islington 1,370 21 44 261 12 31 33 28 2 231 85 551 132 2,570 14 184 1,471 13 8,353 452 3,352 992 59 4 2 4 — 3 203 177 264 188 705 183 ERRATA. The following amendments should be made in the table on pages 36-37:- (1) Date at head of columns 2 and 3 to read 1.1.30 instead of 1.4.30. (2) Italicised figure for Hampstead in column lb to read 1&2 instead of 126. (2) Figure for Lewisham in column 18 to read 977 instead of 976. (4-) Figure for new cases in Southwark in column 12 to read 10 instead of 19. (5) Figure for contacts in V/andsworth in column 11 to read 114 instead of 14. (6) Total 1950 figure in column 18 to read 24,471 instead of 24,4.70. 37 Kensington 804 10 102 118 11 19 19 98 18 99 49 334 97 1,770 45 109 843 34 2,807 89 2,600 503 2 — — — 2 4 207 208 211 212 653 86 Lambeth 1,569 66 25 292 15 31 21 46 23 460 110 829 169 3,328 50 194 1,594 85 7,923 666 5,617 1,181 33 7 2 1 33 23 296 275 364 306 1,209 196 Lewisham 939 3 59 180 3 10 14 14 3 129 73 333 93 1,629 42 63 976 — 2,580 283 1,924 206 4 — — — 2 1 69 126 75 127 425 122 Paddington 1,262 17 24 126 2 21 35 86 47 259 299 492 383 2,482 100 180 1,136 12 9,073 552 5,180 489 2 — — 7 9 14 149 123 160 144 984 70 Poplar 773 33 9 123 8 13 10 27 15 274 250 437 283 1,841 77 63 776 45 5,253 172 6,971 2,078 40 — — 6 6 14 112 128 158 148 798 82 St. Marylebone 412 88 20 68 4 8 6 92 24 26 7 194 41 838 2 34 461 89 2,224 118 1,557 218 3 1 1 — 8 29 18 23 30 53 219 33 St. Paneras 757 112 58 153 7 18 29 59 13 124 72 354 121 1,556 22 185 784 67 3,624 57 4,388 653 14 — — 2 12 — 47 79 73 81 395 103 Shoreditch 635 11 40 71 16 5 21 2 — 119 69 197 106 1,270 7 95 666 3 5,795 295 3,540 718 31 8 2 2 — 1 106 131 139 142 434 65 Southwark 568 48 22 196 13 19 30 42 22 89 19 346 75 1,401 54 100 651 39 4,283 41 3,656 436 13 — — 1 6 2 147 173 166 176 423 134 Stepney 1,652 100 33 221 12 18 27 120 29 274 119 633 187 3,351 49 114 1,652 124 5,906 171 4,645 1,063 11 7 3 2 19 10 302 392 335 411 1,308 104 Stoke Newington 214 7 24 48 2 4 12 16 5 60 36 128 55 548 3 40 250 5 1,231 81 916 353 1 — — — 2 — 56 61 59 61 234 16 Wandsworth 1,379 22 16 253 17 34 16 258 82 300 98 845 213 2,900 29 131 1,408 57 4,571 174 4,747 690 52 5 — 9 16 — 14 229 182 243 1,078 197 Westminster 638 5 20 197 4 26 18 9 — 46 29 278 51 1,047 6 178 647 9 2,272 82 2,967 225 3 — — 3 — — 21 28 24 31 137 70 Woolwich 1,010 3 11 173 13 15 22 92 31 323 297 603 363 2,312 36 59 1,055 24 4,657 479 5,321 732 2 — — — 6 2 160 152 168 154 1,042 96 Total 1930 23866 780 835 3,924 204 437 516 1,594 607 4,952 2,884 10,907 4,211 49,097 776 2,757 24,470 849 114373 7,537 106364 19,904 430 53 21 63 228 190 3,431 4,082 4,110 4,388 17,719 2,525 Total 1929 23,287 1,007 1,357 3,957 163 430 428 1,496 642 5,011 3,787 10,894 5,020 50,329 786 2,984 23,866 780 120661 7,193 100763 17,963 368 50 24 57 223 192 3.506 4,345 4,121 4,644 19,178 2,735 38 Following up of discharged cases. Adults.—Of the adult cases discharged from hospitals or sanatoria in 1924 the number investigated was 3,631, including 244 surgical cases. The following table shows the result of the enquiry and also (in brackets) the corresponding figures ascertained from last year's enquiry into the 1923 cases:— Classification. Total. Percentage alive five years after discharge. Percentage dead. A 440 (414) 75.9 (78.9) 24.1 (21.1) B 1 255 (284) 65.5(63.0) 34.5(37.0) B 2 1,871 (1,669) 32.3(32.5) 67.7 (67.5) B 3 821 (784) 4.4 (6.9) 95.6 (93.1) Surgical 244 (245) 75.4 (77.6) 24.5(22.4) * The classification adopted 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. B3.—Advanced cases. Particulars obtained in 1929 as to the fitness for work of the 1,324 surviving adult patients who were discharged from treatment in 1924 show that out of a total of 501, A and Bl cases, 65.4 per cent, were at work. The corresponding percentage for the A and Bl cases in the 1923 group was 69 4. The percentages at work in the other categories and also the corresponding figures for the 1923 group (shown in brackets) are as follows :—B2, 46.4 (47) per cent.; B3, 26.9 (31.5) per cent.; and surgical, 65.6 (63.1) per cent. Of the total number of 1,324 in all categories, 55.6 (57.5) per cent, were at work, 5.7 (7.8) per cent, were fit for work but were unemployed, 36.6 (35.8) per cent, were unable to work (including cases receiving further residential treatment). Children.—The particulars obtained as to the after histories of children discharged in 1924 relate to 559, of which 240 are pulmonary and 319 nonpulmonary. The mortality records are as follows. (The figures in brackets refer to last year's enquiry into the 1923 cases):— Classification. Total. Percentage alive five years after discharge. Percentage dead. A 113(136) 92.9 (88.7) 7.1 (11.3) B 1 3 (7) 100.0(71.4) — (28.6) B 2 22 (18) 22.7 (11.1) 77.3(88.9) B 3 37 (35) 2.7 (14.3) 97.3(85.7) Surgical 384 (278) 88.8 (89.9) 11.2 (10.1) The mortality rates of the non-pulmonary cases classified according to the location of the disease are as follows:— Total. Percentage alive five years after discharge. Percentage dead. Hip 69 81.2 (88.7) 18.8 (11.3) Spine 49 71.4(73.7) 28.6(26.3) Other bones 89 92.0 (98.4) 8.0 (1.6) Glands 149 95.3 (93.0) 4.7 (7.0) Other parts 28 92.9 (78.6) 7.1 (21.4) Of the 114 surviving pulmonary cases 27 were at school and 75 at work, and of 341 surviving non-pulmonary cases, 126 were at school and 174 at work. 39 In addition to the foregoing arrangements for residential treatment of tuberculous children the Council has established six open-air day schools with accommodation for 565 children suffering from pulmonary tuberculosis or from tuberculous glands with no open wounds who do not appear to require treatment in residential institutions. The work of these schools is dealt with in the school medical officer's report. Tuberculosis care committees. The valuable work of the tuberculosis care committees in arranging assistance for tuberculous patients and their families cannot be summarised statistically, but the effectiveness of the anti-tuberculosis scheme is in no small measure due to their co-operation. The scope of activity of the committees has widened considerably since the inception of the scheme and the quality of the work, which involves close co-operation with the various social agencies and public officials in the respective boroughs, is excellent. Assistance to patients in obtaining employment following residential treatment is a feature of the activities of the tuberculosis care committees. Employment. In view of the importance of this question a scheme was adopted in 1928 which provides for the training for nursing and domestic service of selected patients at King George V. Sanatorium after a period of treatment and special observation at Pinewood Sanatorium. Nine posts for nurses and nine for domestic servants are reserved for trainees who complete satisfactorily the course of training. Up to the end of the past year 24 patients have been sent to King George V. Sanatorium for training (including 11 previously accepted). Of the total, 17 have been employed on the nursing staff and 7 on the domestic staff. Breakdown in health requiring return to sanatorium has occurred in 3 cases. Three of the trainees left at their own wish before, and 3 after, the completion of the probationary period of six months under the scheme. Five others, although medically fit, were considered unsuitable for further employment. The remaining 10 of the trainees were still in the service of the institution at the end of 1930. The aggregate service of the 24 trainees has been 14 years and 5 months with a total duration of sickness, including illnesses from any cause, of 159 days, 71 of which were attributable to the three cases that relapsed. Boarding out of contacts, and supply of surgicAl appliances, etc. With the co-operation of the Invalid Children s Aid Association the scheme for the boarding out of children living in contact with cases of advanced pulmonary tuberculosis has been continued, and, in a few cases, where it was not possible to make other arrangements, children have been provided for in order to enable their mothers to accept residential treatment. The applications received during 1930 were 208, and 172 children were accepted, the remaining 36 being withdrawn or unsuitable. At the end of the year 89 children were being maintained under this scheme. The cost of these arrangements is borne by the Council. Arrangements were also made through the Invalid Children's Aid Association for providing children with surgical appliances after discharge from institutional treatment, and in 65 cases apparatus was so supplied. Formerly the cost of these instruments was borne from the balance of a fund known as the " Tuberculosis Contributions Fund " into which contributions made by parents towards the cost of their children's residential treatment under the Council's anti-tuberculosis scheme were paid prior to 1st April, 1925. Payments into this separate account are no longer made, as since 1st April, 1925, the contributions of patients towards the cost of their maintenance are paid into the County Fund. Handicraft classes. Among the activities of the tuberculosis care committees in several boroughs is included the organisation of the dispensary service handicraft classes, mainly for those who are unfit for ordinary employment. The funds for such classes are provided from voluntary sources, but it is the practice of the Council to provide and pay for the services of an instructor. Generally the goods made by the patients are either sold by them privately or by means of sales of work organised by the voluntary 40 care committees and the proceeds, after deducting the cost of materials are given to the patients. There is a total of 12 such classes in operation in London, with an average roll of about 18 members at each class. Report on the Work of the Bacteriological Laboratory. The work of the bacteriological laboratory during 1930 may be conveniently divided under the following headings :— (1) Diphtheria investigations (mainly in schools). Cultures from a total of 6,840 throat and nose swabbings of 6,268 individuals, chiefly school children, with a few cases of ear discharge were examined and reported on. They yielded 836 positive results showing the presence of micro-organisms morphologically indistinguishable from the diphtheria bacillus, including 215 which proved positive on re-examination—the net result being 621 positive results or 9.9 per cent, of those originally swabbed—including 7 cases of ear discharge. In 290 doubtful or negative cultures, a further re-incubation for 24 hours was given and yielded 36 (12.4 per cent.) in which positive results were obtained. There was therefore an inclusive total of 7,130 bacteriological examinations of both throat and nose cultures. In 51 cases, cultures were examined at the Southern Group Laboratory for virulence by animal inoculation and for confirmation of doubtful results. Nineteen were returned as virulent, and 11 as avirulent diphtheria bacilli. In 8 cases the diphtheria bacillus was not verified and in 13 case3 B. Hoffmann only was identified. Compared with 1929, there were nearly 1,300 more throat and nose swabbings from over 1,130 more individuals in 1930. (2) Throat examinations of maternity nurses for the presence of streptococcus hcemolyticus. Seventy cultures on blood agar were examined from 53 midwives or maternity nurses who were contacts of cases of puerperal pyrexia, as compared with 35 examinations from 24 nurses in 1929. Of the 53 nurses, 5 showed streptococci of the true haemolytic type—i.e., just under 10 per cent.—a proportion which has been stated to occur normally in any chance group of individuals. (3) Cerebrospinal fluid. Examination was made of 135 specimens, for help in diagnosis of . 127 hospital patients including 49 at the Fulham Hospital, 44 at St. James' Hospital, 21 at Highgate and 13 at St. Pancras Hospitals, compared with 103 in 1929. As the result of examination, or of the subsequent course of the cases, the specimens reported on fall within the following groups:— (A) Meningitis.—56 specimens from 52 cases :— (1) Tuberculous.—30 specimens from 28 cases. Tubercle bacilli were found in 16 specimens. (2) Meningococcal.—13 specimens from 11 cases. The meningococcus was obtained in culture from 4, and identified in films from the cell deposit in 13 specimens. (3) Pneumococcal.—In 5 specimens, the pneumococcus was found in culture and film preparation. (4) Streptococcal.—Streptococcus was obtained in film preparations, and in culture in 5 cases, and was associated in 3 cases with cerebral or cerebellar abscess. (5) Influenzal.—B. influenzae was isolated in culture, in 2 cases, as well as in film preparations from the cell deposit. (6) Staphylococcus pyogenes aureus, associated with cerebral abscess secondary to suppurative parotitis, was obtained in 1 case, in culture and film preparations. (7) Serous meningitis.—In 3 cases no organisms were found in film preparation from the fluid, or in culture, but the examination showed evidence of meningeal reaction, with increase of the cell and protein content—in association with pneumonia or other acute febrile condition. 41 In 1 case of tetanus, 2 specimens of the cerebrospinal fluid showed evidence of meningeal reaction to the intrathecal inoculation of antitetanic serum but without septic infection, the cerebrospinal fluid proving sterile, and recovery followed. (B) Cerebral lesions.—36 specimens classified under the following headings :— (1) Tumour.—8 specimens. Glioma or other form of neoplasm of the cerebrum and cerebellum—6 cases. Gummata—1 case, and tuberculoma 1 case. (2) Abscess.—Cerebral or cerebellar in 8 cases. One case associated with bronchiectasis; (4 complicated by streptococcal meningitis, 1 tv staphylococcal meningitis, and 2 also secondary to disease of the mastoid; included under sections A and C). (3) Hemorrhage.—7 specimens from 5 cases, of cerebral, or subarachnoid haemorrhage. (4) Encephalitis.—8 specimens from 6'cases—including 2 cases of encephalitis lethargica, one being a post-encephalitic condition, with hysteria. Two cases, as sequels of chickenpox, in brothers ; 1 case following mumps and 1 case occurring after vaccination against smallpox. (5) Cerebral degeneration.—Neurosyphilis (general paralysis)—4 cases. Polioencephalitis (myasthenia gravis)—1 case. Dementia—2 cases. (6) Cerebral arteriopathy.—Arterio-sclerosis—4 cases. Thrombosis with cerebral softening—1 case. (C) Lesions of the spinal cord.—10 specimens from 8 cases, of respectively :— (1) Acute meningo-myelitis. (2) Acute anterior poliomyelitis. (3) Erb's specific paraplegia, neurosyphilitic paraplegia, and tabes dorsalis. (4) Spastic paraplegia and hysterical paraplegia. (5) Endothelioma (tumour at the level of the 4th dorsal vertebra). (D) Inflammatory conditions of the ear, nasal and accessory sinuses.— 10 specimens from 9 cases :— (1) Chronic otitis media and mastoid disease, in 6 cases complicated by secondary meningitis or cerebral abscess in 4 cases. (2) Inflammation of the nasal, frontal or sphenoidal sinuses in 4 cases; complicated by meningitis in 1 case. (E) Meningismus.—Seven specimens which showed no departure from the normal composition, in cases with symptoms of meningitis, but subsequently proving to be cases of diarrhoea and bronchitis; adenitis; pneumonia; pyelitis; and rickets with convulsions. (F) Miscellaneous diseases.—16 specimens. Examination was made of cerebrospinal fluid in a variety of acute and chronic conditions, in which lumbar puncture had been performed ; but revealed nothing abnormal in the fluid ; therefore eliminating meningitis and neurosyphilis. Such cases proved eventually to be enteric fever, enteritis, smallpox, miliary tuberculosis, uraemia (chronic nephritis), arthritis and lymphangitis, valvular disease, broncho-pneumonia, Meniere's disease, and debility. (4) Ringworm examinations.—Out of 930 specimens of hair examined microscopically, 300, or 32 • 2 per cent., proved to be infected—238 with the small spore, and 54 with the large spore fungus, and 8 with favus. In 2 cases a positive opinion could not be given. (5) Miscellaneous examinations including slide preparations:— (i) from vaginal or urethral secretions, showing gonococci in 10 out of 20 films examined. (ii) Of secretion from the conjunctiva, showing gonococci in 1 out of 6 film specimens. 42 (iii) Of pus (a) from the umbilicus, and elbow, in 2 cases of pemphigus neonatorum showed staphylococcus and B. Coli. (b) from discharging sinus in the knee of an adult —staphylococcus aureus. No tubercle bacilli. (iv) Ten specimens of sputum. Tubercle bacilli found in 3. (v) Five specimens of urine for microscopical or chemical examination. (vi) Blood examination. Complete cell count showed no evidence of anaemia. (vii) Histological examinations (a) of material from the meninges and cerebral cortex of a case of post-basic meningitis; (b) tumour from patient in maternity home—fibro-angioma. (6) Water examinations.—Quantitative bacteriological counts of colonies per c.c. after 48 hours incubation at 37 degrees C. in agar plate culture—and demonstration of presence of coliform bacilli. (A) Tap water from— (i) Ponton Road Place of Detention. 130 colonies per c.c. No coliform bacilli in 10 c.c. (ii) Millfields Children's Homes. From 4,000 gallon tank supplied by well to :— (1) Pantry in Block "A"—18 colonies per c.c. Coliform bacilli in 0.1 c.c. (2) Scullery in Block "C"—10 colonies per c.c. Coliform bacilli in 1 c.c. (iii) Gray Street School, Blackfriars. Nine colonies per c.c. Coliform bacilli in 5 c.c. (B) Main supply— (i) Lyham Road School. No colonies in 1 c.c. No coliform bacilli. (ii) Millfields Children's Homes. One colony per c.c. No coliform bacilli in 10 c.c. Thames River Samples (18 examined). Date. Time. Place. Count of colonies per c.c. at 37°C. Presence of coliform organisms. 13th June, 1930 9.30 a.m. Teddington 45,000 In 1 /100 c.c. ,, ,, 1.25 p.m. Chiswick 24,200 In 1/100 and 1/10,000 c.c. ,, ,, 3.33 p.m. Hammersmith 48,000 In 1/1,000 c.c. ,, ,, 4.30 p.m. ,, 200,000 ,, ,, ,, 5.30 p.m. ,, 40,000 In 1/100 c.c. 23rd July, 1930 9.15 a.m. Teddington 21,000 In 1/10,000 c.c. ,, ,, 12 noon. Hammersmith 8,500 In 1/1,000 c.c. ,, ,, 1.45 p.m. ,, 10,700 In 1/10,000 c.c. ,, ,, 2.0 p.m. ,, 11,000 ,, ,, ,, 2.35 p.m. ,, 11,500 In 1/1,000 c.c. ,, ,, 2.45 p.m. ,, 10,000 In 1/10,000 c.c. 11th November, 1930 8.55 a.m. Teddington 25,000 In 1/100 c.c. not in 1/10,000 c.c. ,, ,, 11.40 a.m. Chiswick Eyot 12,000 ,, ,, 12.5 p.m. ,, 10,900 ,, ,, ,, 1.35 p.m. ,, 18,000 ,, ,, ,, 2.30 p.m. Kew Bridge 20,000 ,, ,, ,, 3.0 p.m. ,, 15,000 ,, ,, ,, 4.10 p.m. Richmond 50,000 In 1/1,000 and Bridge. 1/10,000 c.c. 43 Swimming Baths. Count of Colonies per c.c. Presence of coliform organisms. 9th May, 1930, Lyham Road 30,000 In 1/10 c.c. 16th May, 1930, Gray Street School, Blackfriars 40,000 ,, For use in bacteriological work, 7,500 serum tubes were prepared in the laboratory and 1,150 were obtained from the Belmont Antitoxin Establishment. In addition, about 10,000 c.c. of various nutrient media were made. Consultation visits.—In consultation with private practitioners, visits for help in diagnosis were paid to three patients, whose symptoms had suggested encephalitis, but who eventually proved to be cases of (1) tuberculous meningitis; (2) cerebral arterial degeneration with chronic nephritis; and (3) cerebral thrombosis. Mental Deficiency Acts, 1913-27. Cases dealt with by the Council. On 31st December, 1930, there were being dealt with by the Council 6,440 cases. Of these 3,712 were in institutions, 100 under guardianship, 2,592 under supervision and 36 in places of safety awaiting action. During the year 7,268 cases were examined; the figure includes 5,993 examined in connection with the investigation of the cases of inmates of mental hospitals and institutions formerly under the care of the Metropolitan Asylums Board, but in 456 cases of the latter, as inquiries into early histories had not been completed, analysis into classes had not been made by the end of the year. The results are as follows :— Class. Cases seen in ordinary routine. Cases seen in special investigation in county mental hospitals and institutions taken over during the year from other authorities. Males. Females. Males. Females. Idiot 11 13 191 179 Imbecile 127 90 874 850 Feeble-minded 525 425 1,133 908 Moral defective 3 — 4 — Not defective 40 41 450 948 Under investigation — — 248 208 Total 706 569 2,900 3,093 In the table showing the cases seen in the county mental hospitals it will be noted that large numbers are classified as " not defective." These numbers include the results of examinations at Tooting Bee Mental Hospital where the majority of the inmates are either those suffering from senility or chronic harmless insanity. In some instances, though the patients were of the " defective " type, it was not possible to establish a history prior to the age of 18 years. During the year special attention was paid to the period of life at which defectives were brought to notice and the following table gives an analysis of 2,416 cases :— 44 Cases in mental hospitals and cases not already certified in institutions taken over. Cases seen in the ordinary routine of work. Grade of defect. Males. Females. Males. Females. Under 7. 7 & under 16. 16 & over. Under 7. 7 & under 16. 16 & over. Under 7. 7 & under 16. 16 & over. Under 7 7 & under 16 16 & over. Idiot 5 22 16 1 15 7 5 5 2 9 4 — Imbecile 29 120 94 20 97 117 31 80 12 21 57 10 Feeble- minded 5 142 280 5 78 235 19 320 153 11 231 152 Moral defective — — 3 — — — — — 3 — — — Of the ordinary cases practically all the feeble-minded in the age group 7-16, and a proportion of those over 16, are cases which have been notified by the Education Committee on leaving special schools for the mentally defective. Fifty-four of the 81 cases examined and deemed not to be defective were over the age of 16 years. It will be noted that by far the greater number of those children who require to be dealt with before attaining the age of 7 years, are of the lower mental grades. The incidence of cases classified under clinical type as well as grade of defect is shown in the following table:— Clinical type of defect. Cases in mental hospitals and cases not already certified in institutions taken over. Cases seen in the ordinary routine of work. Grade of defect. Grade of defect. Idiot. Imbecile. Feebleminded Moral defect. Total. Idiot. Imbecile. Feebleminded Moral defect Total. Simple primary amentia 1 239 580 — 820 8 104 789 1 902 Mongolism 2 20 — — 22 2 41 1 — 44 Cretinism — 3 1 — 4 — 4 3 — 7 Hydrocephaly 2 9 2 — 13 — 1 1 — 2 Microcephaly 5 8 1 — 14 4 4 2 — 10 Post-encephalitic 1 4 6 — 11 — 3 13 2 18 Plegic 10 50 19 — 79 6 25 28 — 59 Plegic and epileptic 12 27 5 — 44 — 5 4 — 9 Epileptic 30 99 96 — 225 4 16 30 — 50 Traumata — 4 4 — 8 — 3 — — 3 Miscellaneous 3 14 31 3 51 1 5 15 — 21 Total 66 477 745 3 1,291 25 211 886 3 1,125 Causes assigned for mental deficiency. Dr. A. C. Williams has analysed 130 case histories of persons dealt with under the Mental Deficiency Acts, viz.: 80 feeble-minded and 50 imbeciles. The cases were not selected and thus the results despite the small numbers concerned give a fair idea of the usual course of events. The following are the causes suggested by parents:— In the Feeble-minded. Per cent. In thu Imbecile. Per cent. Inherited defect 2.5 — Alcohol and syphilis in life of parents 6.25 - Fright and worry in pregnancy 12.5 38 Illness and injuries in pregnancy 5.0 6 Difficult birth 2.5 6 45 In the Feeble-minded. Per cent. In the Imbecile. Per cent. Neglect at birth 1.25 2 Meningitis 1.25 2 Epilepsy 6.25 6 Other illnesses 3.75 2 Injuries in infancy 10.0 6 Air raids in infancy — 2 Nil 48.75 30 100.0 100 One of the striking features is that in 70 per cent, of the imbeciles the alleged cause depends on extrinsic factors, whereas in the feeble-minded the percentage is only 42-5. The difference seems to be in agreement with the fact, noted in last year's report, that the parents of imbeciles were often more intelligent than those of the feeble-minded. The percentage of cases in which fright and worry during pregnancy is given as the cause, is much higher in the imbeciles, 38 per cent, as against 12.5 per cent, in the feeble-minded. It is a specially common statement in the case of Mongol imbeciles. In the majority of cases the fright or shock was due to a serious cause, such as bombs or distress at the death of a near relative—occurrences which did not take place during previous pregnancies. On the other hand, it must be added, that in the majority of such cases it was reported that the mother was of a nervous disposition and sometimes the father was said to be " nervy." Against the probability of fright or shock during pregnancy being a common cause of defect, it must be remembered that of all the babies born during the air raids, no more than the usual percentage was defective. It is probable that these causes are not negligible, but that their significance has been enormously exaggerated. Illness and injury during pregnancy sound likely factors, but most of the cases resulting are of the type that occurs with inherited defect and the percentage is no higher among the imbeciles who would include nearly all the examples of secondary (i.e. non-inherited) defect. Difficult birth with instrumental delivery is recorded more frequently among imbeciles, but in only one case was there paralysis or epilepsy which might be anticipated as a concomitant effect of cerebral pressure. Meningitis is a real though not common cause producing a definite type of defect. Epilepsy may be a definite cause of mental deterioration. One case in this series was normal till 8, feeble-minded at 11, and completely imbecile at 15 ; but epilepsy may merely accompany or aggravate congenital mental defect. There are at least two examples of this. Other illnesses in early childhood have very little real significance. In the majority of cases there was evidence of pre-existing defect (e.g. a child had an illness at 3, but had never been able to speak). Air raids at the period of birth are among the causes that are similarly shown to have scarcely any significance in the causation of mental defect, though they, like some of the other influences, are possible causes of neurosis. Falls or blows on the head are often mentioned by parents, but in the cases here 46 cited the condition was ordinary primary amentia, whereas the mental disturbances caused by a fall are of a very different type. In the large proportion of the cases where no cause was suggested by the parents, there was evidence in the family history of an inferior or unstable stock, though rarely of certifiable mental defect or lunacy. Dr. Williams also finds that there is a larger proportion of congenital defects and abnormalities in imbeciles than in the feeble-minded, many of them being closely associated with the mental defect and denoting that the amentia is of a secondary type and not of the ordinary inherited variety, whilst acquired defects, however, are somewhat commoner in the feeble minded, viz. :— Congenital defects, etc. Imbeciles. Per cent. Feeble-minded. Per cent. Mongolism 24 1.2 Cerebral paralysis 14 6.2 Hydrocephalus 2 0.0 Epilepsy 8 11.0 Cleft palate 2 0.0 Congenital heart disease 2 0.0 Congenital blindness 4 0.0 Acquired defects. Heart weakness 0 2.5 Defective vision 2 7.5 Malnutrition, etc. 0 7.5 Other affections 0 3.75 Among other affections was that of a defective lad who had his arms severely bitten by a tame bear. In only one of all the cases in this series was it suggested by the parents that the practical inefficiency was due to physical causes and in fact on detailed examination, making full allowance for the physical disability, it was found that the mental defect was the real cause of the social failure. The previous educational history in these cases was as follows:— School. Imbeciles. Per cent. Feeble-minded. Per cent. No school 58 5.0 Institutions 4 2.5 Private school 2 o.o M.D. school 30 72.5 P.D., etc. 6 3.75 Elementary school 0 16.25 The great majority of the feeble-minded attended M.D. schools and the real proportion for London cases should be somewhat higher since those who had no schooling and those who were sent to institutions were children under 5, while several of the cases who had attended elementary schools had done so in areas where no special schools existed. There were in fact only three persons in this series of feeble-minded children who would not have been fit for special schools in London at the age of 7. The larger proportion of imbeciles had not attended any school; nearly one 47 third had been given a trial in M.D. schools and had there been found ineducable. It is worth noting that a certain type of private school receives children unfit for any schools belonging to an education authority, but the result is rarely satisfactory. Though there were no examples in the present group, there do occur, not infrequently, cases of children who have been deemed fit for special schools, being sent to private schools by the parents. The result is almost always a failure and the child ultimately goes to the special school, having suffered from the delay. The educational attainments of the feeble-minded were:— Per cent. Below standard 1 42 Standard 1 and 2 46 ,, 3 „ 4 10 ,, 5 2 The educational attainments of the imbeciles were usually nil and never beyond those of a small infant. None of the imbeciles in this series was employed, and action under the Mental Deficiency Act was usually needed because of the inability of the parents to care for them and supply their needs. None of the feeble-minded with mental ages of 8 or less had sufficient intelligence for employment, but those above the 9 year level failed in occupations mainly because of their unstable character and troublesome behaviour. Some of these and most of those above the 10 year level were not incapable of useful occupation, but needed care and control because of the character defect, sometimes entirely " for the protection of others." Occupation centres for children unfit for special schools. The London Association for Mental Welfare has organised occupation centres in various parts of London for the training of mental defectives who are incapable of benefiting by the curriculum of the special schools for mentally deficient children. Each of the ten centres was visited during 1930 by the school doctors, and a routine medical examination was made of those in attendance at the time of the visits. The number of children examined was 183 (103 boys and 80 girls). Their ages ranged from 6 to 17, but the majority were between 9 and 14. In the condition of their clothing, nutrition and the cleanliness of head and body they showed no signs of neglect and were up to the standard that obtains among ordinary elementary school children : 76 were noted as in need of medical or dental treatment—a percentage of 42, which is very little above that of children of the same age in elementary schools. Dental treatment was required in 57 cases, treatment for enlarged tonsils or adenoid growths in 7 cases, 10 had a marked squint, 4 suffered from skin disease and 13 had other defects, 2 of them being subject to fits. Apart from the cases of squint and dental defect there seems to be no undue incidence of disease among these children. The parents were invited to be present at the detailed examinations, and in 66 per cent, a parent attended—a similar proportion to that obtaining for children of the same age in elementary schools. It is evident that these children are well looked after at home and sent to the centres well fed and in a clean and tidy condition. The employment of guides has been sanctioned when necessary to convey the children between the centres and their homes and the Council has made a grant for this purpose. 48 Blind Persons Act, 1920. Blind training, etc. During the year, 429 persons over school age were seen. Certificates were furnished in the under-mentioned cases:— Males. Females. Training of the blind 56 25 Registration of the blind 114 134 Application for grant 6 6 Homes for the blind 1 2 Homeworkers 2 4 179 171 Twenty-nine males and 47 females were reported as being not blind within the meaning of the Blind Persons Act, 1920 and 3 cases were referred for re-examination, which will take place in 1931. Of the 81 persons in respect of whom certificates of blindness were furnished in connection with application for training, 6 (5 females, 1 male) were deemed to be unfit physically and one, a man, who was deemed to be blind, refused to submit to a physical examination. Certificates submitted by private or hospital doctors in 4 cases (3 male and 1 female) were accepted as furnishing satisfactory evidence of blindness. In 7 cases the applications for certificates of blindness were withdrawn. Of a series of 355 persons over 16 years old certified as blind within the past two or three years, 173 were male and 182 female. The series does not include children under 16 in attendance at schools for the blind. In the following table an attempt is made to classify generally the causes of blindness of 169 of the males and 170 of the females with relation to the age of onset, on approximation only, as in many cases only the end results of disease were present, and earlier histories were often extremely vague. Probably under heading III there are cases which should belong to other groups. The ages of onset were frequently difficult to ascertain with any exactitude and it may be that some should have been entered in a lower decade. The case of senile change entered in the decade 20 to 30 was that of a man of about 50 suffering from glaucoma, who gave a definite history of onset of blindness before he was 30. Causes of blindness. Age. I Congeni - tal defects II Inflammations of the surface of the eye. Ill Inflammations of the inside of the eye. IV Accident V Myopie. VI Senile change. Total. Percentage. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. Under 20 8 9 7 18 8 5 2 1 — 1 — — 25 34 14.8 20.0 20—30 — — 4 1 13 7 1 — 3 1 1 — 22 9 13 0 5.3 30— 40 — — 3 2 13 8 1 — 6 7 — — 23 17 13.6 10.0 40— 50 — — — 1 1 14 8 3 1 2 4 — 2 20 16 11.9 9.4 50— 60 — — — 1 1 7 4 1 2 2 6 1 — 12 13 7 1 7.6 60— 70 4 4 13 7 2 — 4 6 11 15 34 32 20.1 18.8 70_ 80 — — — 1 — 5 7 — 1 2 3 17 17 25 28 14.8 16.5 80— 90 1 1 — — — 1 7 16 8 18 4.7 10.6 90—100 — — — — — — — — — — — 3 — 3 — 1.8 Total 8 9 21 27 74 47 10 5 19 29 37 53 169 170 100 100 Percentage 4.7 5.3 12.4 15.9 43.8 27.7 5.9 2.9 11.3 17 0 21.9 31.2 100 100 — — 49 The following table gives in greater detail the causes of blindness in the total of 355 (173 males and 182 females). Disease. All ages from 16 upwards. No. Total. Percentage. Total. Percentage M. j F. M. F. M. F. + F. M + F. Congenital defects Microphthalmia 1 2 9 Buphthalmia 0 1 Congenital cataract 5 4 9 5.2 4.9 18 51 Albinism 3 1 Nystagmus 0 1 Inflammations of the surface of the eye Ophthalmia neonatorum (one + high myopia) 5 14 21 Interstitial keratitis (in one case one eye blind from accident) 8 4 Trachoma 3 4 30 12.1 16.5 51 14.4 Other corneal disease (two from exanthemata; one tuberculous; one a case of xerophthalmia; in one case one eye blind from accident) 5 8 Inflammations of the inside of the eye Iritis and irido-cyclitis (7 + interstitial keratitis; 2 + superficial corneal scars; 2 + choroiditis; one rheumatic; 2 tuberculous; one + detached retina; one + macular degeneration; one phthisis bulbi of unknown origin) 12 24 Choroido-retinitis and choroiditis (6 + interstitial keratitis; one + accident one eye; in 2 male cases the distinction from retinitis pigmentosa was uncertain 23 13 50 43.3 27.5 125 35.2 Retinitis pigmentosa 13 3 Optic atrophy (one + accident one eye ; one + high myopia) 25 6 Tay's macular disease 1 0 Other macular disease 0 1 Diabetic conditions (one retinitis; one cataract) 0 2 Retinitis (unclassified) 1 0 Angioma of retina 0 1 Accidents 10 6 10 6 5.8 3.3 16 4.5 Myopia (13 had history of accident) 20 30 20 30 11.6 16.5 50 14.1 Senile changes Cataract (8 + corneal scars ; 2 + macular degeneration; one + trachoma; 3 + accident to one eye; one + pallor of discs; in one case one eye was blind from smallpox; one case may have been diabetic) 21 44 38 57 22.0 31.3 95 26.7 Glaucoma (2 + accident to one eye; in one case one eye was blind from smallpox) 13 11 Macular degeneration 4 2 Total 173 182 173 182 100 10C 355 100 Comparing males and females, the percentage of blindness caused by congenital defect varies little. As to inflammations of the surface of the eye, the larger percentage in females (16.5) as compared with males (12.1) is mostly due to the greater number of cases of ophthalmia neonatorum in the former group. 50 Of blindness from inflammations of the inside of the eye, the larger percentage in males (43.3) as compared with females (27.5) is mainly accounted for by the greater number of cases of retinitis pigmentosa and of optic atrophy in men. Choroiditis and choroido-retinitis are almost twice as common in the males, whereas cases of iritis and irido-cyclitis, many of unknown origin and of doubtful classification, are twice as common in the female group. Blindness from accident is 2.5 per cent. commoner in the males and from myopia it is 4.9 per cent. commoner in the females. The larger percentage of blindness from senile changes amongst the females (31.3) as compared with males (22.0) must be at least partly due to the greater longevity of women. Midwives Acts, 1902 to 1926, Nursing Homes Registration Act, 1927, Children Act, 1908, and Adoption of Children Act, 1926. The Midwives Acts, 1902-1926 and the Rules of the Central Midwives Board regulating the practice of midwives provide for:— (a) Prevention of the practice of midwifery by unauthorised persons. (b) Training of midwives. (i) Lectures to pupil midwives. (ii) Post-certificate lectures to certified midwives. (iii) Grants for special instruction of midwives and midwife-teachers. (c) Supervision of the practice of midwives. (d) Suspension of midwives from practice on grounds of the possibility of spreading infection and compensation for loss of practice resulting from such suspension. (e) Payment of fees to doctors called by midwives to attend patients in cases of abnormality or emergency. (f) Payment of proportion of any annual deficit incurred by Central Midwives' Board. Midwives. There are approximately 5,000 certified midwives with London addresses, of whom 901 gave notice of intention to practise within the county during the year, compared with 828 in 1929, the remainder acting mostly as general or monthly nurses under medical supervision. Practising midwives, other than those who work entirely in poor law institutions and hospitals approved by the Central Midwives Board and under medical supervision, are subject to inspection by the Council's inspectors of midwives with a view to ensuring that a proper standard of efficiency is maintained. The work of inspection is carried out by four women assistant medical officers, who supervise the work of the midwives generally, give advice in regard to any difficulties that may arise in connection with their work and pay special visits where cases of a septic nature or persistent high temperature, inflammation of the eyes or blisters on the child occur ; 2,322 visits were paid this year compared with 2,285 in 1929. Infringements of C.M.B. rules. Infringements of the Rules of the Central Midwives Board to the number of 81 were reported during the year, compared with 104 in 1929. Of these 54 were slight and a verbal caution was deemed to be sufficient; 24 cases of a more serious nature were dealt with by a written caution, and 3 midwives were interviewed by the Committee and personally cautioned. Two midwives who were reported to the Central Midwives Board during 1929 weTe removed from the Midwives' Roll during the year 1930. Suspension of midwives. The Midwives Act, 1926, requires that in the case of midwives suspended from practice in order to prevent the spread of infection the local supervising authority must compensate such midwife for loss of practice by the payment of such amount as is reasonable in the circumstances of the case, provided that the midwife was not herself in default; 37 midwives were suspended from practice during the year 51 in order to prevent the spread of infection, and in 19 cases compensation was authorised. The total sum paid in compensation was £91 6s. 1Od. Uncertified persons. The Midwives and Maternity Homes Act, 1926, amended section 1 (2) of the Midwives Act, 1902, so as to make it an offence for any uncertified person to attend women in childbirth, except under the direction and personal supervision of a registered medical practitioner, unless the case was one of sudden or urgent necessity. During the year 9 enquiries were made into alleged infringements of this law, compared with 16 in 1929. Two women were prosecuted, one being fined £5 and the other £4. In 3 cases no further action was taken ; in 4 a caution was administered. Still-births. The Births and Deaths Registration Act, 1926, 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 by the first schedule of the Act. During the year there were 408 still-births reported by midwives in their practice, compared with 582 in 1923, 594 in 1924, 510 in 1925, 513 in 1926, 486 in 1927, 473 in 1928 and 413 in 1929. Of the cases reported this year 239 were male and 169 female; 233 were reported as macerated, 172 not macerated, and in 3 the condition was not stated. Puerperal fever. During the year 284 cases of puerperal fever were investigated, compared with 311 in 1929. Of these cases 62 proved fatal, the same number as in 1929, a case mortality of 21.8 per cent., compared with 19.9 per cent. in 1929. In addition, the Council was informed of 29 deaths from puerperal sepsis which were not notified as "puerperal fever," compared with 39 the previous year. The distribution of the 284 cases, with the mode of delivery, was as follows, deaths being shown in brackets:— Medical practitioners 88 (19); certified midwives 62 (11); medical practitioner and certified midwife 4 (0); hospitals and poor law institutions 72 (12); medical students 8 (4); cases of miscarriage or abortion where no attendant was engaged 44 (15); uncertified women 1 (0); not ascertained 5 (1). Total, 284 (62). Puerperal pyrexia. In July, 1926, the Ministry of Health made regulations requiring the notification of puerperal pyrexia, which is defined by the regulations to be "any febrile condition (other than a condition which is required to be notified as puerperal fever under the Infectious Diseases (Notification) Acts) occurring in a woman within 21 days after child-birth or miscarriage in which a temperature of 100.4° Fahrenheit (38° Centigrade) or more has been sustained during a period of 24 hours or has recurred during that period." The regulations were amended in 1928 and now require a medical practitioner to notify any such case on the approved form and transmit the notification to the medical officer of health of the district in which the patient is actually living at the time of notification. Any notification of a case in a London hospital must specify the place from which and the date at which the patient was brought to the hospital and must be sent to the medical officer of health of the district in which the said place is situated; 760 notifications of puerperal pyrexia were received during 1930, compared with 781 in 1929, and 52 cases proved fatal. Particulars of the attendant at the confinement are set out here, the deaths being shown in brackets:—Medical practitioners 150(11); certified midwives 154 (16); medical practitioner and certified midwife 2 (0); hospitals and poor law institutions 367 (21); medical students 25 (0); cases of miscarriage or abortion where no attendant was engaged 58 (4); no information 4 (0). Total, 760 (52). Twenty-eight of the cases, with 11 deaths, were subsequently notified as puerperal fever, and are therefore shown in both tables. Medical aid. The Rules of the Central Midwives Board indicate the emergencies for which a midwife must advise in writing that medical aid be obtained, and for which such help must be secured. A notice in the approved form is sent to the doctor, and then to the Council. In the year now under review 6,516 such notices were received, compared with 6,833 in 1929. The estimated number of confinements conducted by midwives in independent practice during the year was 29,000. This appears to indicate that 52 medical aid was necessary in about 22.5 per cent. of the cases, compared with 22.8 per cent. during 1929. Ophthalmia neonatorum. In 1926, regulations came into force rendering it no longer necessary for a midwife to notify a case of this disease to the local sanitary authority, this duty being assigned to the medical practitioner only. This, however, did not relieve the midwife of the necessity of sending a copy of her medical aid notice in all such cases to the Council. The Ministry of Health issued a memorandum in connection with the regulations, suggesting that the Council should consider whether it should not refrain from exercising the power of recovery from the patient of the fee paid to a medical practitioner summoned by a midwife in a case of inflammation of the eyes, and the Council decided that parents should not be asked to reimburse the Council for fees paid for such medical attendance. The number of these cases during the year was 789 and the amount paid to medical practitioners in respect of the cases was £716. Inflammation of the eyes. Notices. During the year 1,346 notices were received indicating that medical aid had been summoned for inflammation of the eyes of infants, compared with 1,333 in 1929; 23 other cases arose 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 1,369 cases, 321 proved to be ophthalmia neonatorum, compared with 415 in 1929; 293 other cases that did not occur in midwives' practices were also notified, making a grand total of 614 such cases during the year, the percentage occurring in the practice of midwives being 52.3 per cent., compared with 56.7 per cent. in 1929. All the midwives' cases were investigated, and it was found that 316 were completed cured, 2 were left with impaired vision one with both eyes affected and one with one eye only affected, 2 died of inter-current disease, and 1 could not be traced owing to the removal of the parents. Thirty-eight cases became in-patients at St. Margaret's Hospital, compared with 47 during 1929. Special provision is made by the Council at this hospital to deal with cases of this disease, including the admission of mothers with breast-fed children, and the results are most encouraging. Every effort is made to persuade parents of babies with serious ophthalmia to take advantage of this provision. Instruction of midwives. As in past years, courses of demonstrations and lectures by obstetrical specialists at convenient centres were provided for the post graduate instruction of midwives practising in London or Middlesex, the cost being shared by the two county councils in proportion to the the numbers of London and Middlesex midwives attending. Occasional special instruction by approved teachers was also arranged for the benefit of selected midwives. In April of this year the Central Midwives Board suggested that lectures to pupil midwives on the Rules of the Central Midwives Board and the relationship of the midwife to the various health authorities should be given by the medical officer of health of the local supervising authority. The Board approved the arrangements made by the Council for providing a course of two lectures by two of the Council's medical officers particularly associated with the supervision of midwives. Pupil midwives in training at the Council's hospitals and other institutions in London are admitted to the courses, the first of which was held in June, 1930, at the London Day Training College and was attended by 346 pupil midwives. The second course, given at the end of September, was attended by 178 pupils. A certificate of the attendance of a pupil at the course is signed by the Council's medical officer and furnished to the Central Midwives Board. This course of lectures is to be provided four times a year for the instruction of fresh pupils before each examination of the Central Midwives Board for candidates for admission to the Midwives Roll. Pemphigus neonatorum. During the year 79 cases of pemphigus neonatorum were reported, the same number as in the previous year. Maternal mortality. The arrangement made at the suggestion of the Ministry of Health whereby confidential reports are made on maternal deaths by medical officers of the Council 53 and are exchanged with the borough medical officers of health as described in my last annual report, was continued during the year. Payment of medical fees. The Midwives Act, 1918, imposed upon the Council the duty of paying the medical practitioners' fees when called in by midwives in cases of emergency. Reimbursement by the patient except in eye cases is also provided for. The Ministry of Health have laid down a scale of fees to which local authorities must adhere. The Midwives Act, 1926, fixed a limit of time, namely, two months from the date of the first visit, within which a medical practitioner must submit his claim. In pursuance of this provision, 51 claims amounting to £49 10s. were refused during 1930 ; 4,049 valid claims were submitted during the year 1930, compared with 3,904 in 1929, the total amount involved being £4,601 14s. 6d., compared with £4,290 8s. 6d. in 1929. Approximately 25 per cent. of the total amount of the claims was recovered from patients during 1930. Registration of nursing homes. The Nursing Homes Registration Act, 1927, came into operation on 1st July, 1928, and repealed Part II of the Midwives and Maternity Homes Act, 1926, and also so much of any local Acts as provides for the registration of maternity homes. The Annual Report for 1928 (Vol. III, pp. 53-54) indicates fully the powers of the Council under the Act. There is no reliable information as to the number of nursing homes in London in 1927, that is, before the Act came into operation. The total number of applications for registration as nursing homes approved by the Council since the Act came into operation is 372; the total number on the register on 31st December, 1930, was 271, showing that the number of registrations which have been cancelled since the Act came into operation is 101:35 of these cancellations which occurred during 1930 have been analysed; the causes were as under:— The home removed to other premises Use of the premises as a nursing home given up (two of which were definitely stated to be because the nursing home did not pay). Change of ownership (Death of the registered keeper was the cause in 6 of these and her ill health in 1.) No longer registrable (owing to the character of the work carried on) 2 13 19 1 35 The number of applications for registration dealt with in 1930 was 42. Of these 8 were withdrawn when the Council's requirements were notified to the applicants, and 2 of the remainder were refused registration. A nursing home is defined as "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 and includes maternity home." The definition of a maternity home is "any premises used or intended to be used for the reception of pregnant women or of women immediately after childbirth." Consequently such premises require registration as a maternity home even though the women go to some other place for the actual confinement. In administering the Act the Council has been guided generally by the following considerations:— Keeper.—The keeper must not be unfit either by reason of age or otherwise. A person under 21 years of age would be considered unfit; otherwise each case is considered on its merits. The keeper, if not "qualified" under the Act must nominate a person so "qualified " to superintend the nursing or to take charge of the home. Situation.—Two particular points arise as to unsuitability, i.e., propinquity of an offensive business or some special fire risk. Accommodation.—A minimum standard is laid down as to size of rooms (960 cu. ft. maternity, 800 cu. ft. surgical or medical, 700 cu. ft. senile infirm, 600 cu. ft. 54 ante-natal). The type of case which may be accommodated in each room is fixed, but rooms are not necessarily registered for one type of case only. Keepers are required to make satisfactory provision for the accommodation of staff. An isolation room is required in all maternity homes where two or more beds are provided in any one room. In surgical homes an isolation room is not required, but keepers must inform the Council as to the arrangement to be made in the event of a septic case arising in a room containing two or more beds. The provision of an operating theatre is not insisted upon in homes existing at the time the Act came into operation, where such did not exist, but a theatre is required in all new homes registered for surgical cases. The use for other purposes of rooms registered for patients is deprecated and the prior approval of the Council is required for any such use. Staffing.—No hard and fast rule is laid down as to the number of trained and untrained staff required. This will depend on the type or types and number of patients. Each case is considered on its merits, but in the ordinary mixed home, as a general rule, two day nurses and one night nurse are required for every six patients. A night nurse is always required when four or more patients are in the home or when any patient is acutely ill. Every endeavour is made to persuade keepers to employ the largest practicable number of trained staff. When the keeper of a maternity home is a midwife and has a district practice, satisfactory arrangements must be made for the care of patients during her absence on district work. Domestic staff must be employed in numbers adequate to the work to be done. Furniture and Equipment.—A minimum standard of equipment is laid down. The amount of furniture and equipment required depends to some extent on the type of home. Fire requirements.—Homes are inspected by officers of the architect's department and of the Fire Brigade and the necessary requirements are made to ensure the safety of the occupants of the premises. Inspection.—Premises are inspected by officers of the Council upon application for registration and as occasion requires after registration. The periods between such inspections vary generally from two weeks to nine months or even a year in the cases of very good homes. The work of inspecting the homes was divided among seven medical inspectors, who devoted altogether about twelve half-days a week to the work. Other inspections were made by sanitary inspectors and members of the staffs of the Council's architect and of the Fire Brigade. Administration.—Detailed reports on each application are submitted to the Public Health Committee and a considerable number of letters are sent to registered keepers concerning matters requiring attention. During the year under review three applications for registration were refused on the grounds (i) unsuitability of premises, (ii) unfitness of applicant and inadequate staffing arrangements and (iii) inadequate staffing arrangements. In 1930 the Council granted 118 exemptions from the provisions of the Nursing Homes Registration Act, 1927, in respect of premises not conducted for profit. These exemptions were for a period due to expire on 30th June, 1931, after which date the exemption may be renewed at the discretion of the Council from year to year. The homes have on the whole been satisfactory, and considerable improvement in the general cleanliness and orderliness and in the staff of the homes has been secured. There was, however, one serious complaint about the keeper of a nursing home during the year. As ill-health was pleaded, he was permitted to surrender his registration on giving an undertaking not to conduct a nursing home in London again. It is anticipated that improvement of the nursing homes will be maintained, 55 especially as the older homes gradually close or come under new management In the latter event they will be subject to re-registration and will be required to fulfil all the requirements for a new home. Maternity and childwelfare work by voluntary associations. Voluntary associations engaged in maternity and child-welfare work.—Under the Discontinued Grants Order 1930 made by the Minister of Health under Section 101 (6) of the Local Government Act, 1929, the Council is responsible for the payment of grants to 57 maternity and child-welfare associations. Similar grants are payable under the Order by metropolitan borough councils to certain child-welfare associations in their boroughs. The money for these grants is contained in the block grant payable by the Ministry of Health to the councils concerned. In deciding which authority shall pay the grant the Ministry appears to have been guided by the general principle that the Council should be responsible for payments to institutions dealing with maternity work and the welfare of mothers (which in certain cases also includes their babies) and with homes for healthy babies, whereas the borough councils should be responsible for the grant to those institutions dealing more particularly with child welfare. The amount payable by the Council is £33,064 per annum. These grants are only payable on the conditions (inter alia):— (i) That the Council is satisfied as to the efficiency of the maternity and child-welfare service provided by the association in respect of which the contribution is payable and that such service is being used by a reasonable number of those persons for whom it is provided; (ii) That no reduction or alteration of such service is made without the consent of the Council. It is necessary therefore that these associations should be inspected from time to time by the Council's officers. This work is carried out by the medical staff employed on work under the Nursing Homes Registration Act, while occasionally it also involves the employment of a sanitary inspector, who is detailed by the chief inspector from amongst his staff. Children Act, 1908. The Annual Report for the year 1921 indicated fully the powers of the Council under the Children Act, 1908, Part I, with regard to infant life protection. Fourteen qualified nurses carry out the work of inspection and act as visitors under the Act. Failure to comply with the law requiring notification within 48 hours of the reception of a child subject to Part I of the Children Act is a punishable offence. Special enquiries are made by male inspectors of the public health department when there is information or suspicion that the keeping of a nurse infant has not been reported to the Council. Caution, prosecution, removal of the child to a place of safety or other appropriate action follows. Newspaper advertisements of (or for) foster-mothers are followed up and there is extensive and constant co-operation with maternity and child welfare authorities in London and other parts of the country, the Metropolitan and other Police, the N.S.P.C.C., philanthropic societies, hospital almoners and other associations and persons concerned with matters affecting the welfare of children. The particular concern which the Council has shown for the safeguarding of foster children, who for the most part are illegitimate and the offspring of women in straitened circumstances, who cannot go to work until a home is found for the child, has resulted in a widespread expectation on the part of mothers and authorities or persons interested in them, that the officers concerned with the administration of Part I of the Children Act shall introduce applicants, whose necessity is usually very urgent, to suitable persons willing to receive the children for moderate payment. This onerous task, which entails responsibility quite beyond the provisions of the Children Act, is undertaken to the fullest extent compatible with discretion and with the degree to which the supply of foster mothers having suitable homes can meet the demand. 56 At the end of 1930 there were 1,773 homes under inspection, the number of nurse-infants therein being 2,548. Nurse infants who are kept under unsatisfactory conditions, which fall within the purview of Section 5 of the Act, may be removed to a place of safety. In London public assistance institutions are used for this purpose. During 1930 it was necessary to remove only 6 nurse-infants, compared with 18 in 1929. Five of the children were removed from one foster mother and 1 child from another. The Act permits local authorities to grant total or partial exemption from inspection where circumstances appear to warrant such a course, but no application for exemption was made during 1930. The homes where nurse-infants are kept are visited in order to ascertain whether the sanitary condition of the premises is satisfactory; 688 reports were made during 1930, compared with 761 in 1929. In 422 cases the premises were found to be satisfactory compared with 462 in 1929. In 101 homes sanitary defects were discovered, compared with 102 in 1929, while overcrowding was found in 84 homes, compared with 100 in 1929. Overcrowding and sanitary defects combined were found in 32 homes, compared with 14 in 1929. In 49 cases no action could be taken under the provisions of this Act owing to the removal of the nurse-infant prior to the visit of the inspector. Special inquiries were also made in 348 cases with regard to the condition of the premises, and the necessary action was taken in each case. In the event of a serious sanitary defect beingreported the attention of the local borough council is drawn thereto, and in some cases it has been found possible by rearrangement of the accommodation to secure improvement. In others it has not been possible and the foster parent has been urged to return the child in her charge to the parent or to obtain other and more suitable accommodation. Foster mothers are advised to attend local infant welfare centres with the children in their charge. In the event of a nurse-infant being weak or ailing the visitor carefully watches the case and sees that the treatment advised by the doctor is duly carried out. If doubt exists in the visitor's mind with regard to the progress of the the nurse-infant, one of the Council's medical officers attends and examines the child. During the year, 25 nurse-infants died, compared with 27 in 1929. In 7 cases inquests were held, compared with 8 in the previous year: a verdict of death from natural causes was recorded in 4 cases and in 3 cases accidental death. In none of the cases was blame attached to the foster mother. Adoption of Children Act, 1926. The Adoption of Children Act, 1926, provides for the legal adoption of infants. A court, upon the hearing of an application for an adoption order, may appoint some public body to act as guardian ad litem, with the duty of safeguarding the interests of the infant before the Court, and, where the body so appointed is the local authority, may authorise the authority to incur any necessary expenditure. The Council at the request of the Home Secretary has agreed to act as guardian ad litem of children who are the subject of applications for adoption orders in London. The Council's medical officer deals with those children who have been or are nurseinfants under the supervision of the public health department. During the year 1930 the total number of applications dealt with by this department was 60. The results of the hearings were as follows:—55 full adoption orders and 2 interim adoption orders made; 2 applications refused and 1 withdrawn. It is understood that the work of the Council's officers has been of assistance, both to the Courts and to the petitioners. Although the Court may authorise the public body, acting as guardian ad litem, to incur any necessary expenditure, the Council has decided not to make application to Court for payment, as the expenses are trivial. Work of the Chemical Branch. The work of the branch is carried out at four laboratories, viz., the central laboratory at County Hall, the laboratories at the Northern and Southern Outfalls and at Greenwich power station. 57 Central laboratory. A large proportion of the work performed at the central laboratory consists of the examination of samples of stores supplied under contract to the Council's many depots and stations. Specifications have been revised so as to bring them closely into touch with modern conditions and requirements and to ensure that the goods demanded shall, as nearly as possible, be in accord with the specification. Not only has the volume of analytical work greatly increased, but the entirely new duty of examining drugs supplied to the Council's hospitals, brought about by the transfer of functions under the Local Government Act, 1929, has been laid upon the branch. Examination of samples. The total number of samples examined in the central laboratory during E the year amounted to 8,014, and the following table shows their number and description:— Air 315 Meals 10 Building materials 128 Metals— Cement 322 Disinfectant 24 various 19 Driers 18 solder 20 39 Drugs and medical stores 576 Miscellaneous 114 Floor oils and polishes 9 Milk, condensed 8 „ for schools 1,690 Gas— „ „ hospitals 158 Dry cleaners 4 „ farm 10 Flue 775 779 Motor spirit 5 Greases 26 Insecticides 21 Oils— Fertilisers 48 lighting 39 320 Feeding stuffs 216 lubricating 233 painting 27 Foods, Groceries— miscellaneous 21 Baking powder 27 683 Oilman's sundries 8 Egg powder 12 Paints 420 Meat extracts 27 Shampoo preparation 3 Butter 8 Soap 123 Cakes, biscuits, bread 14 Tobacco 19 Cereals 47 Turpentine 15 Cheese 23 Water (softening treatment, County Hall) 153 Cocoa 46 Coffee and chicory 7 „ boiler 758 Custard powder 4 „ river 372 Flavouring essences 11 „ drinking 46 Fish 28 „ in-leakage 26 Flour 32 „ laundry 6 Jam and marmalade 122 Sewage 16 Jelly 9 Wax 4 Lard and dripping 16 Petroleum 117 Margarine 43 Rainwater, etc. (atmospheric pollution) 301 Miscellaneous foodstuffs 30 Mustard 12 Water from bathing lakes 3 Pepper and spice 7 Boiler deposit 1 Preserved meat 48 Other deposits 104 Sugar 62 Syrup and treacle 16 Vinegar 13 Yeast 19 Milk samples. Milk.—The total number of samples examined during the year was 1,858. Of these 1,690 were of milk supplied to children in the elementary schools, which is required to conform to the standard of 3.5 per cent. fat and 8.5 per cent. nonfatty solids, except during the months of March and April, when the fat must be not less than 3 per cent. The quality has on the whole been well up to the standard as regards composition, 7.1 per cent. only being below the standard due to deficiency of fat or containing added water. From the point of view of cleanliness, however, the standard was not so high—11.5 per cent. containing extraneous matter due 58 generally to careless handling, in allowing dust, etc., to fall into the milk, and in a few cases due to unhygienic conditions of milking, giving rise to contamination by manure. The contamination of milk by any form of dust or other extraneous matter is likely to affect the quality of the milk adversely by rendering it more liable to "sour" and it may be a source of contamination by pathogenic organisms. With this fact in view, any samples found to be contaminated only with traces of extraneous matter are reported as unsatisfactory, no matter what the composition of the milk may be. Of the milks found to be of unsatisfactory composition 98 were found to be deficient in fat (in one case, only 33 per cent. of the fat was present) and 23 contained added water, the maximum addition being 20 per cent. In addition to the above, 168 milk samples were examined—10 from farms belonging to institutions or schools, 140 from hospitals and institutions and 18 from mental hospitals. Of these 29 (17.3 per cent.) were found to be unsatisfactory. Samples of meals. Meals for necessitous children.—Ten samples of meals, other than "milk" or "oil" meals, supplied at feeding centres, were examined during the year and gave results which showed that the required food values were generally well maintained Water supply; private wells. Water supply—from private wells.—Samples of water from the following hospitals and institutions were analysed from time to time with a view to ensuring that the quality of water was satisfactory for drinking purposes:— Caterham Mental Hospital; Millfield Tuberculosis Institution, Rustington; Sidcup Residential School; Bethnal Green Hospital; Long Grove Mental Hospital; Hollesley Bay Colony; London Industrial Colony, Sutton; Horton Central Station; Lamorbey Residential School; St. Pancras (South) Hospital; Southern Hospital, Dartford; Waterloo House Institution; Hanwell Mental Hospital. The total number of analyses made was 45, and in 7 cases advice was given as to measures which should be taken to imprmrove the quality of the water in Question. Fertilisers and feeding stuffs. During the year 264 samples of fertilisers and feeding stuffs for cattle and poultry, have been examined in connection with the provisions of the Fertilisers and Feeding Stuffs Act, 1926, by the chemist, who is the agricultural analyst for those parts of the county which do not come within the purview of the City Corporation or the Port Sanitary Authority. The results of the analvses were:— Samples of feeding stuffs Complied with guarantee 88 Deficient 57 Constituents in excess of guarantee 53 Guarantee incorrect in form or no guarantee 16 216 Samples of fertilisers Complied with guarantee 18 Deficient 8 Constituents in excess of guarantee 20 Guarantee incorrect in form or no guarantee 2 48 Water softening. The proportion of samples not agreeing with the statutory statement was very similar to that of last year and shows clearly the necessity for the examinations performed under the Act. In the majority of cases the divergence from the limits allowed under the Act was comparatively small, but in a few cases the discrepancy was considerable. In one instance a sample sold as "nitrate of soda" consisted entirely of sulphate of ammonia. The general good effect of this Act and the earlier Acts which it replaces is shown in the very rare occurrence of impurity in feeding stuffs which 30 or 40 years ago were often grossly adulterated. Examinations of waters used for laundry purposes have been made and information given as to the amounts of soda-ash required for removing most of the soapdestroying constituents. 59 The waters used in the boilers at the pumping stations are softened by treatment with soda-ash and lime, so that the scale-forming constitutents, which are detrimental to the boiler itself and which prevent also the available heat of the coal from being utilized economically, are reduced to a minimum. Where the feed water is of practically constant hardness the "softening" is effected automatically, but examinations are made daily so that any necessary adjustment of the quantities of chemicals added may be made. At one station, where the feed water is taken from the river, the hardness varies considerably owing to tidal effect and automatic softening is not practicable. In this case samples are examined twice weekly and information as to the amount of chemicals to be added is supplied to the station. During 1930 an average hardness of 34.5 was reduced to 9.1 at this station, a reduction of about 74 per cent. Refrigerants. During alterations at an engine house at Abbey Mills pumping station trouble was experienced with water in the foundations. As the amount showed no signs of diminishing despite pumping, samples of the water were examined and it was found that its composition was not dissimilar from that of spring water found in the vicinity and did not resemble either land drainage or river water as was suspected. The question of the installation of multiple refrigerator systems in residential flats has been under consideration. It appears that the advantages of a central condensing plant for the refrigerant used are great, but it is evident that much care must be exercised in the choice of refrigerants. Methyl chloride, which presents some advantages, has been found to be very undesirable in domestic installations owing to its toxic properties being unaccompanied by any warning irritant smell. Other refrigerants, such as ammonia and sulphur dioxide, give a warning in this way when a leak occurs, but in a house pipes charged with these gases, on account of this liability to leak, must always be regarded as an added danger to the inmates of the house. River Wandle. An examination of this river was made by the chemist and a representative of the chief engineer. Both visual evidence and the chemical examination of samples collected at various points showed that this river, which is already contaminated when it reaches the county of London, continues to receive both domestic and industrial pollution on its course through the county towards the Thames. It is interesting to note that the late General Sir Desmond O'Callaghan in an autobiographical work (Guns, Gunners and Others, p. 254) refers to having obtained permission as a boy in the early fifties of last century to fish for trout in "The beautiful Wandle before ignorant savages turned it into a sewer." The question of the future treatment of the Wandle with a view to improvement is under consideration by the Council. Swimming baths (indoor). Two indoor swimming baths at Lyham Road (Brixton) and "Blackfriars" (Southwark) Schools were visited and comparative examinations made of the water used for filling the bath and that remaining after use when he bath was about to be emptied. Although the boys using both baths were very clean and apparently of clean habit in using the baths, the water after use in each case contained much matter in solution and suspension and was heavily contaminated with micro-organisms. This is the inevitable result of many persons bathing in water not continually sterilised. Experience with outdoor baths in the Council's open spaces has shown the great improvement following the installation of plant for filtration followed by chlorination. A clear, practically sterile, water can be maintained for months with large numbers of bathers using the baths with considerably less effective supervision than school children receive. Swimming baths(open air). For the purpose of ensuring that the water in these baths is reasonably clean and suitable from the point of view of freedom from suspended matter (green growth, etc.), the waters have been examined from time to time and advice given to the parks department as to the desirability of changing the water. In the case of the natural lakes and unfiltered swimming baths the standard of purity cannot, of course, 60 be as high as obtains in the baths where the water is filtered, but the water can be rendered reasonably safe from a health point of view by suitable chlorination. This does not, however, abolish the great disadvantage to feeble swimmers and nonswimmers of having a water which soon becomes turbid, because a drowning person might be unobserved, whereas in clear water he would be easily seen and probably rescued. In the case of the "filtered" baths, advice is given to the parks department on the control of the chlorination and filtration of the water. Greenwich power station. In addition to the sampling and examination of fuels for the tramways and other departments and the routine necessary for the maintenance of adequate control in the water system of the power station and in the combustion of the various fuels employed, the work of the Greenwich laboratory during the year has included the investigation of a number of corrosion problems, and considerable assistance has been given in connection with official tests on de-aerating plant and certain steam-raising units. The corrosion of iron work in contact with new flooring in the switch house was found to be due to the presence of chloride in the flooring composition employed and was remedied by replacing the material by a Portland cement mixture at the places of contact. Cases of corrosion in a boiler of the Council's sludge vessel the "John Perring" and in a Stirling boiler at the Northern Outfall works were also investigated at some length, and remedial measures were recommended which appear to have been effective in countering the corrosion troubles. Battcrsea and Fulham power stations. The possible effect of flue gases emitted from these stations upon the atmosphere of the surrounding districts has been under consideration, and observations, additional to those included under the general scheme of investigation of atmospheric pollution in which the Council and many other local bodies in Great Britain co-operate with the Department of Scientific and Industrial Research, have been made by order of the Public Health Committee at places in the county. The authorities responsible for both of the projected super-stations have been alive to the necessity of treating the flue gases with a view to the removal of sulphur acids and the reports of a committee presided over by the Government Chemist have shown that a measure of success has been achieved on a fairly large experimental scale. The possibility that the water used in washing the flue gases may have an unfavourable effect on the water of the Thames has been considered. The attention of the Port of London Authority has been directed to the matter and the Authority appears to have obtained reasonable safeguards. The chemist assisted by experimental work and attendance at conferences in the presentation of the Council's case against the proposals for the enlargement of the Fulham station, which was heard by the Electricity Commissioners in December, 1930. Outfalls. The regular examination of the sewage treated at the outfalls and of the effluent and sludge produced has been carried on since the present treatment was started in 1888 and 1890 respectively. At both outfalls the percentage of dry matter in the sludge was between 7 and 8, the difference being about 0.2 per cent. in favour of Barking. The dry matter in individual cargoes varied from 1.0 per cent. to 16.0 per cent. at Barking and from 0.8 per cent. to 13.9 per cent. at Crossness, the distribution of individual results being fairly uniform around the mean which in each case fairly represents the "mode" of its constituents. On comparing with results obtained in the earlier years of the outfalls it does not appear that the use of chemical precipitants produced a less watery sludge when allowance is made for the weight contributed by the precipitants themselves. River Thames. The examination of the water of the Thames near the outfalls, begun in 1885, and more extended examinations in the course of the sludge ships and at a few places above the outfalls have been continued. The condition of the upper reaches of the 61 tideway appears to be deteriorating. At the end of July when the weather was very hot the condition of the water of the river made it necessary to treat the effluent with ferrous sulphate. The weather conditions during August obviated the need for the continuance of the treatment, which accordingly ceased on 22nd August. Biological treatment of effluent. Good progress is being made with the construction of the additional sewage purification plant at the Northern Outfall, Beckton, which, it is hoped, will be put into use during the coming summer. This plant, designed on the experience gained during 10 years working of an experimental plant at Crossness, provides for the treatment of settled sewage in a series of aeration channels of novel type, followed by separation of the purified liquid from sludge, and reactivation of sludge by air blowing through diffuser tiles. The settled sewage will be taken from two of the existing precipitation channels, which for this purpose have been divided about three quarters of the way along their length by the construction across them of a weir chamber, and treated, with the addition of free humus, in a series of eleven two-tier channels, each 300 feet long. Circulation will be provided by motor-driven Hartley paddles fixed at each end of each channel. In passage from inlet to outlet of a channel, the liquid will flow six times from an upper to a lower, or from a lower to an upper compartment, a roof, as it were, of fresh air being kept in the lower compartments. The capacity of the aeration channels is 198,000 cubic feet. The mixture of sludge and liquid will flow for separation into sedimentation tanks, which are of two types:— (a) Three tanks of total capacity of 99,000 cubic feet, 29 feet deep, and each consisting of 4 inverted pyramids, arranged for central feed, peripheral discharge of effluent, and gravitational discharge of sludge from the bottom. (b) Three Dorr tanks of total capacity 97,000 cubic feet, maximum depth 10½ feet, in which the flow is through practically square tanks, with the effluent discharge over a weir along the top of the side opposite to the inlet, and the sludge induced to flow by a slowly rotating apparatus down the sloping bottom of the tank to the centre, from whence it is discharged by gravitation. The effluent from both sets of these tanks will be discharged through a culvert passing under the existing precipitation channels, and mixed with the ordinary effluent before discharge into the river. The humus, after discharge from the settling tanks, will be pumped into 4 humus reactivation channels, formed in the posterior portions of the existing Nos. 1 and 2 precipitation channels beyond the newly formed weir chamber. These channels are each about 290 feet long, and have a total capacity of 166,000 cubic feet. In each channel there will be 3 rows of air diffuser tiles, each row being placed in the bottom of a ridge running the length of the channel. Sludge digestion.—Work on sludge digestion on a laboratory scale has been carried out, mainly with a view to ascertaining the effect of temperature and of stirring on the period of digestion, and the volume, composition and calorific value of the gas evolved. Work at present in progress at a digestion temperature of 55°C has given variable results, but generally indicates a marked reduction in the digestion period, without such an increased gas production as would make good the additional heat requirements. The uncertainty of making deductions of value on the large scale from these experiments led to sanction for the construction of a large experimental sludge digestion unit. This will consist of a deep circular, concrete tank, of about 30,000 gallons capacity, roofed in, and provided with hot-water pipes for heating, and a stirring mechanism. Arrangements are made for sampling, and for temperature observations, at varying depths at the sides and in the centre, as well as accurate measurements of the influent and effluent sludge. Between the gas collector to the gas holder, provision is made for condensers, flame trap, meters and calorimeter. 62 A steam heated calorifier is to be used for heating the contents of the tank until the evolution of inflammable gas is established, after which a gas fired boiler will be used. With an experimental plant such as outlined above, information for guidance on the large scale will be obtained on such points as period of digestion, optimum temperature, heat requirements at different times of the year, net gas production, reduction in sludge solids and de-watering of the residual solids to be sent to sea. Precautions against explosions or poisonous gas in sewers. With a view to making it possible to detect certain poisonous or explosive gases in sewers by means of portable apparatus, several pieces of apparatus were examined with known mixtures of air and coal gas, etc., for the purpose of checking their reliability. Some were found to give quite accurate indications of the gas present, whilst others gave erratic results, which might lead to unnecessary panic or give a false sense of security. Generally speaking, these automatic devices are not sufficiently "fool-proof" and require to be manipulated by a man skilled in handling scientific apparatus. For purposes of detection only, the ordinary miner's testing lamp is more convenient in the hands of workmen than these more elaborate devices, and has been found useful when working in sewers. The matter of simple routine test in the interests of safety in sewers is under consideration. River subway tunnels. The systematic examination of the air in the river subway tunnels at Blackwall and Rotherhithe has been continued during the year. Previous investigations having shown that the worst conditions occur about 10 a.m. on weekdays, attention was concentrated on this period of the day, so that it must be emphasised that the following figures apply to the worst conditions normally occurring in the tunnels. At Blackwall the average carbon monoxide content of 104 samples taken at regular intervals during the year was 21.5 parts per 100,000, 39 of the samples exceeding the recommended maximum figure of 20 parts per 100,000. Twenty-four determinations of suspended matter gave an average figure of 6.2 on Owens' fog-shade scale, 10 of them exceeding the recommended limit figure of 6 (i.e., 1.92 milligrammes suspended matter per cubic meter of air). In Rotherhithe tunnel the average carbon monoxide content of 103 samples was 16.4 parts per 100,000, 25 of them exceeding the limit figure of 20. Twenty-six determinations of suspended matter gave an average of 7.3 on Owens' scale, 16 exceeding the limit figure of 6. An analysis of the results showed clearly that the carbon monoxide concentration tends to become much greater in summer than in winter; but the average suspended solids content of the air remained fairly constant. A further portion of the scheme for improving the ventilation of Blackwall tunnel, consisting of extraction fans working in No. 1 shaft, was brought into operation in September. Results obtained since then show a consequent improvement in the atmospheric conditions at that end of the tunnel, but the full effect cannot be judged until the scheme has been completed by the installation of the fans for blowing fresh air into the northernmost section of the tunnel. No alteration was made in the ventilation system at Rotherhithe during the year, but a scheme for improvement is being prepared by the chief engineer. British Engineering Standards Committees. The Council is represented by its chemist with other officers on two committees of the British Engineering Standards Association, one on the Sampling and Analysis of Coal and the other on Standard Definitions and Tests for Fire Resistance and Incombustibility. The proceedings of the former committee have continued over some years owing to the detailed nature of the problem involved and the necessity for co-ordinating methods recommended with the requirements and conditions of industry, but the proposed methods have been published in a tentative form and after consideration of criticisms offered, will be issued in final form. The publication of standard methods of sampling and analysis of coal, by a responsible association, should do much to induce confidence in foreign buyers of coal who are used to much more definite information as to the quality of fuel than satisfies buyers in this country. The Committee on Fire Resistance and Incombustibility has set forth for 63 comment draft definitions and methods of testing, which should help to clear up the rather vague application of terms concerning matters which may at times endanger human lives, and are of very great importance in connection with all fire risks from the point of view either of safety or insurance. Atmospheric Pollution Committee. The Council through its laboratory services makes a considerable contribution to the work of the Committee on Atmospheric Pollution of the Department of Scientific and Industrial Research. During the past years a process for determination of sulphur acids in air has been the subject of experiment and the details are now available. Results obtained at County Hall by this process show that London air may contain from 0.05 per million volumes of sulphur dioxide on a clear day, up to 0.52 in fog, and the data obtained were found valuable in connection with the presentation of the Council's case at the Fulham Power station inquiry. Visibility. Visibility.—Observations of visibility in all directions at midday from the fleche at County Hall were continued during 1930. As the results of 7 preceding years were available a reasonable comparison of the year's results with the average of preceding years was made. The average of the greatest distance at which known objects could be distinguished was calculated for each calendar month of the six years for quadrants embracing 45° on either side of each of the four cardinal points. The results show that visibility is greatest, on the average, at all times of the year in a southerly direction and markedly so from May to September, that visibility over the two quadrants centred on north and east respectively is low and very similar for the two quadrants, whilst the western quadrant occupies an intermediate position. The maximum distance of visibility in July or August is from six to eight times that during the months of lowest visibility, November to February. Compared with the averages of the preceding years, 1930 must be considered a year of good visibility, omitting the four months when the range of visibility is about one mile only, the northern visibility was below the average in March only, the southern in May and September only and the western in September only. The greatest excesses of 1930 over the seven preceding years were in the semicircle north-west to southeast, the increased southerly and westerly distances being less marked. INDEX. Subject. Page Adoption of Children Act, 1926 56 Anthrax 12 Bacteriological Laboratory 40 Births 5 Blind Persons Act, 1920 48 British Engineering Standards Committee 62 Cancer 13 Cerebro-Spinal Fever 12 Chemical Branch 56 Children Act, 1908 55 Common Lodging Houses 15 Cowsheds 27 Deaths 5 Diarrhoea 8 Diphtheria 8 Drainage By-laws 27 Encephalitis Lethargica 12 Enteric Fever 9 Fertilisers and Feeding Stuffs Act, 1926 58 Homeless Persons 19 "Homeless" (Historical Note) 19 Housing Acts (Statistics) 25 Housing Acts (see Volume II of Report) Infant Mortality 6 Infectious Diseases 6 Influenza 13 Marriages 5 Maternal mortality 9 Measles 8 Mental Deficiency 43 Subject. Page Midwives Acts 50 Milk and Dairies Act 23 Milk Sampling 57 Nursing Homes 53 Occupation Centres 47 Ophthalmia Neonatorum 52 Polioencephalitis 12 Poliomyelitis 12 Population 5 Puerperal Fever 8, 51 Puerperal Pyrexia 8, 51 Rheumatic Fever 13 Sanitary Officers 26 Scarlet Fever 8 Seamen's Lodging Houses (Historical Note) 15 Sewage Treatment 61 Smallpox 6 Subway Tunnels 02 Swimming Baths 59 Tuberculosis (Notifications) 13 Tuberculosis (Scheme) 32 Tuberculosis (Dispensary Statistics) 36, 37 Tuberculous Milk 23 Venereal Diseases 28 Visibility 63 Vital Statistics 5,10,11 Water Examination 42,50 Whooping Cough 8 Yellow Fever 13 LCC 39 London County Council. ANNUAL REPORT OF THE COUNCIL, 1930. Vol. III. (Part II). PUBLIC HEALTH. (Report for the year 1930 of the School Medical Officer) Published by the LONDON COUNTY COUNCIL, And may be purchased, either directly or through any Bookseller, from P. S. KING AND SON, Limited, 14, Great Smith Street, Victoria Street, Westminster, S.W.1, Agents for the Sale of the Publications of the London County Council 1931. No. 2851. Price 1s. 6d. [11720] London County Council. ANNUAL REPORT OF THE COUNCIL, 1930. Vol. III. (Part II). PUBLIC HEALTH. (Report for the year 1930 of the School Medical Officer.) CONTENTS. Page Staff—School Buildings 2 Results of Medical Inspection 3 Inspection in Higher Education Institutions 10 Following-up 11 Schools and Homes transferred from Poor Law Authorities 12 Chronic Invalidity—Employment of School Children 14 Medical Treatment—Dental Treatment 10 Stammerers' Classes 27 Personal Hygiene Scheme 29 Rheumatism Scheme 30 Special Inquiries—Basement-dwelling Children—Ophthalmia in Residential Institutions—Arachnodactyly 45 Supervision of Dietaries 54 Open-air Education 55 Convalescent Camp Schools 61 School Journeys 62 Nursery Schools 62 Child Guidance 63 Defective Children 67 Deaf Children 75 Residential and Industrial Schools 76 Examinations of Employees in the Education Service and Scholars 86 Infectious Disease in Schools 87 Statistical Tables.—I. Inspections—II. Defects—III. Exceptional Children —IV. Treatment of Minor Ailments, Visual Defects, Defects of Nose and Throat, Dental Defects, Uncleanliness 92 London Countg Council. REPORT OF THE SCHOOL MEDICAL OFFICER FOR THE YEAR 1930 By F. N. Kay Menzies, M.D., F.R.C.P. (Edin.), D.P.H., F.R.S.E., County Medical Officer of Health and School Medical Officer. Introduction. The regular work of the School Medical Service has continued uninterruptedly: a little advance here, another there, and throughout a continued and progressive development in almost every branch are to be noted. The health and physique of the London school child of to-day are infinitely better than were those of his parents; almost every year some improvement is shown in the figures relating to personal hygiene and in the nutritional index. In such a serious condition as discharging ears, marked improvement has been shown, whilst ringworm of the scalp, the bane of the pre-war school doctor, is rapidly disappearing. Even in the condition of the teeth where an enormous amount of leeway has to be made up, the figures concerning leaving children are beginning to show a lessening of the amount of decay. Reference is made later to the result of a special examination of the throats of representative five-year-old children. The naso-pharynx was found to be normal in only 17-4 per cent.: adenoids were present in 54.9 per cent, and in another 12.8 per cent, adenoids formerly present had been removed by operation. In connection with the same investigation it was found that only 4.7 per cent, of these children who were at the commencement of their school life were entirely free from dental caries. It is increasingly obvious that more must be done to improve the health of the "toddler," by which is meant the child of from two to five years of age. Progress in this direction is being made, so far as the Council is concerned, by the establishment of nursery schools, and, by other means, by the metropolitan borough councils who are the statutory authorities under the Maternity and Child Welfare Act. Efforts to persuade parents to obtain the necessary treatment for defects discovered at medical inspections are increasingly successful and this result has been attained not only by the provision of additional facilities for treatment but by the devoted work of the thousands of Care Committee voluntary workers, who carry the gospel of health into the homes of the people. The sections of this report which deal with the scheme for the supervision of rheumatic children and with the provision of open-air schools are well worth special study by all interested in the London school child As a valuable contribution to the study of juvenile delinquency the report of the Medical Officer supervising the Ponton-road place of detention has been included in full. The steps taken, so far as the School Medical Service is concerned, to deal with the serious outbreak of smallpox which occurred during the year are fully described. The most important development of the work of the School Medical Service during 1930 was in consequence of the transfer to the administrative control of the Education Committee of the twenty-three schools (including the training ship "Exmouth," transferred from the Metropolitan Asylums Board), provided by the several poor-law authorities of the County. The School Medical Service was faced with many unusual and difficult problems, some of which have not yet been satisfactorily solved, but certain administrative changes have already been effected which will, it is hoped, be of benefit to the children under supervision. Advantages to the School Medical Service are already appearing as a result of the transfer to the Council of the hospitals formerly controlled by the Guardians and the Metropolitan Asylums Board, e.g., arrangements are being made for certain operative work to be done for school children in these hospitals and for the School Medical Service to receive clinical notes concerning school children treated in certain hospitals. The work of the staff continues to be excellent and acknowledgment must be made of the enormous amount of valuable aid received by the members of the School 2 Medical Service from their colleagues in the Education Officer's Department, and from the various voluntary organisations concerned with the improvement of the conditions of child life in London. Staff. From 1st October, 1929, a reorganisation of the public health department was made upon the basis of three branches (i) special hospitals including control of the acute infectious diseases; (ii) general hospitals and district medical work transferred from the poor law guardians; and (iii) general public health administration including housing and the school medical service. Three principal medical officers were appointed upon the above-mentioned date to take charge of the three branches, viz., (i) special hospitals, etc., Dr. J. A. H. Brincker; (ii) general hospitals and poor law medical administration, etc., Dr. W. Brander; and (iii) general public health administration, Dr. W. A. Daley. With the exception of the administrative work in connection with infectious disease in schools which continues to be directed by Dr. Brincker, who is assisted by a principal assistant medical officer (Dr. J. G. Forbes), the work of the school medical service falls entirely in the branch directed by Dr. Daley and is organised in two main sections. One of these sections, of which the senior medical officer in charge is Dr. C. J. Thomas, embraces the medical inspection of school children, the medical and dental treatment and cleansing of schoolchildren, open-air schools and general school hygiene. For purposes of routine medical inspection, etc., London is divided into five divisions, north-west (divisional medical officer, Dr. A. W. Sikes); north (divisional medical officer, Dr. F. C. Lewis); northeast (divisional medical officer, Dr. G. Chaikin); south-east (divisional medical officer, Dr. H. R. Kidner); south-west (divisional medical officer, Dr. E. E. Argles). The remaining staff in this branch of the school medical work includes one principal assistant medical officer for aural work (Mr. A. G. Wells); seven part-time assistant aurists; one part-time consulting dental surgeon (Dr. A. Livingston); one parttime principal assistant medical officer (Dr. B. Tchaykovsky); one divisional medical officer for ophthalmic work, nursery schools, etc. (Dr. E. M. McVail); *21 whole-time assistant medical officers; 11 assistant medical officers giving six sessions a week; 44 assistant medical officers giving three sessions a week; additional temporary medical assistance for 132 sessions a week ; 10 medical officers (part-time) at open-air schools, etc.; 266 surgeons and anaesthetists at treatment centres; and 93 dentists at treatment centres, of whom 64 are employed as inspecting dentists in the schools. As mentioned in last year's Annual Report, Miss D. E. Bannon was appointed as matron-in-chief of the public health department on 1st October, 1929. Her duties include the superintendence of the school nursing staff in addition to the supervision and organisation of the nursing staff at the hospitals and institutions transferred under the Local Government Act, 1929. The school nursing service comprises six assistant, superintendents, 93 school nursing sisters and 260 nurses. The other section concerned with the school medical service (Dr. F. C. Shrubsall, senior medical officer) includes the medical examination at the County Hall of scholarship candidates, school teachers, etc., and the medical work in special schools and reformatories. Dr. Shrubsall also deals with the work under the Mental Deficiency Acts, the Blind Persons Act, and the medical examination of the Council's staff. In this section are included the services of a part-time consulting surgeon for aural disease (Mr. P. M. Yearsley); a part-time consulting surgeon for orthopaedics (Mr. K. J. Acton-Davis); a part-time ophthalmic consultant (Mr. N. Bishop Harman; two divisional medical officers (Drs. A. C. Williams and E. J. Boome); an assistant medical officer who is attached for half his time to Ponton-road place of detention. School Buildings. The 1927-30 programme adopted by the Education Committee provided for the completion of 10.140 new school places in 14 new schools, two enlargements, *Two vacancies and two medical officers temporarily seconded for work under the Mental Deficiency Acts. 3 and the modernising of 15 schools. At the end of 1930 out of 31 sites acquired, in 15 cases the new buildings have been opened, building operations are in progress on 7 sites, 6 sites are available for building and 3 sites are being cleared. Some delay in the carrying out of the programme has occurred owing to the new policy decided upon in relation to the grouping of schools on the basis of a break at 11+. This has delayed the modernising work more than it has the provision of new schools. During the period, the modernisation of three schools has been completed and, in four cases, the necessary alterations are being carried out. At the present time 94.7 per cent, of the classrooms are on the "40 and 48" basis as compared with 57 per cent, in April, 1924. In all new and remodelled schools provision is made for a medical inspection room. It cannot be said that the medical inspection rooms hitherto provided have given complete satisfaction. It is held that, in order that vision testing can be carried out with Snellen's types, all rooms used for medical inspection should measure at least 20 ft. in one direction. The result of this practice is to produce rooms which are long and narrow and the exigencies of school planning determine that the window should be at one end and the door at the other in almost every instance. If the rooms are placed near the school hall they are found to be noisy, if they are placed at a distance from the hall there is no convenient place in which parents and children may wait. It is probably not possible to solve the difficulties entirely but if a length of 20 ft. were no longer insisted upon more freedom would be acquired in planning the rooms, which could often be of a more convenient shape. A decision was made during 1930 by the Council to supply hot water wherever a medical inspection room was established in schools. In many of the older schools trough closets still exist but they are being dealt with steadily according to plan and are being replaced by modern fittings. The Council's architect has given particulars of 9 schools with which it is proposed to deal during the present year. The Results of Medical Inspection. The number of elementary school children inspected in the three statutory age groups (entrants, children aged 8 and children aged 12) during 1930, was 168,248, being 20,896 fewer than in 1929. The group of children aged 12, only numbered 42,548, the year of birth 1918, being one of abnormally low birth-rate. In addition 48,605 children were fully inspected in the term previous to that in which they were due to leave and 1,605 children in special schools were also inspected in their age groups. Age groups. The number of children not falling in the four age groups, referred lor examination for special reasons by care committee workers, teachers, school nurses, attendance officers, etc., was 36,803, while additional children to the number of 49,349 were inspected in groups in connection with school journeys, open-air classes, camp schools and so forth. Special inspections. The grand total of children inspected during the year amounted to 304,620. When it is considered that in addition 186,615 children under observation for previously recorded defect were re-inspected, it is evident that the total number of school children seen by the school doctors, during the year, forms a high percentage of the children on the school rolls. Every child in attendance is also inspected thrice annually by the school nurse. Total inspections. Parents are invited to all routine primary inspections but not always to special inspections and rarely in re-inspections. The proportion of parents responding to the invitation to be present was for the three statutory age groups, 74.8 per cent., which was a great improvement on previous years. In the case of entrant infants, the percentage of attendance of parents was 89. The interest now shown by the parents in the medical inspection of their children is very gratifying. It may be said that only the accident of sickness or pressing emergency prevents the parents of children from meeting the doctor at the entrant examination. Because it reaches practically the whole population there is probably no other influence which can B 1 Attendance of parents. 4 Refusals. compare in its educational effect upon the people, from the point of view of health, with the intimate talk with the school doctor, the child being present as an object more absorbingly interesting to the mother than any other could possibly be. Refusals of parents to submit children for medical inspection are so few in number as to be almost negligible. During the year 1930, the parents of 112 children (47 boys, 65 girls) refused to allow them to be examined by the Council's assistant medical officers. The figure for the year 1929, was 108. The 112 children were distributed in the divisions as follows:—N.E. 10, N. 16, N.W. 31, S.E. 25, S.W. 30. Ten of these objections were subsequently withdrawn and in nine other cases either medical record cards were filled in by a private medical practitioner or medical certificates as to physical fitness were produced. It is noticed that the number of objections received in the winter is larger than for the other terms, probably owing to the parents' fear that the children will "catch cold" when they are undressed for the medical inspection. Requests for medical cards. During the year 1930 various education authorities asked for the medical record cards of 439 children who had removed to areas outside London. It was possible to accede to the requests in 337 cases. Of the remainder it was found that 19 children had not yet been examined, while it was not possible to trace 70 cards. The remaining 13 cases related to the cards of children who were not attending school in the County of London. Children referred for treatment. The number ol children in the tour age groups rererrea tor treatment tor various ailments (including dental caries) was 94,388. The proportion referred of those examined was 43.5 per cent., a figure which has remained practically constant for several years. Analysis of results. The analysis of the results of medical inspection immediately following is limited to the three statutory age groups in order to facilitate comparison with previous years. The results of the Council's extra examination of leaver children will be considered separately. Nutritional condition. When the results of the year s inspections are known, the first figure eagerly examined is that of the nutritional state of the children. In 1930 the percentage of children returned as under-nourished was 4.8. This is easily the best gross figure ever obtained in London. In 1925, 6-3 per cent, were found to be under-nourished, in 1926 the percentage was 6.2, and in the successive years 1927-9 it was 5.3, 5.1 and 5.2. That this improvement is a true reflection of the condition of the children and not merely an apparent improvement shown as the result of accidental variation in the numbers of children seen in the different age groups, is proved by an examination in detail of the age and sex figures in each year. In each year. In the following table, in which appears the percentage of under-nourished children found in each year in each age and sex group, it will be seen that they all share equally in their contributions to the general improvement of the whole. 1925. 1926. 1927. 1928. 1929. 1930. Entrant boys 5.7 5.7 5.0 5.0 4.6 4.4 girls 5.0 4.8 4.0 41 4.0 3.5 Intermediate boys 8.5 8.2 7.3 6.7 6.7 6.3 ,, girls 7.2 6.6 6.1 5.2 5.2 5.1 12.year.old boys 6.5 6.7 5.4 5.3 6.0 5.1 12 „ girls 6.3 6.3 4.8 4.4 4.9 4.5 Total 6.3 6.2 5.3 51 5.2 4.8 Cleanliness. The most striking figures exemplifying the effect of the work of the school medical service generally are those relating to the personal cleanliness of the children. The index which has for many years been taken, in London, for comparison is the condition of the hair of the 12-year-old girls. In 1913, only 6.2 per cent, of the older girls were completely free from signs of verminous infestation. In 1916 and 1917 the percentage had risen to 70, in 1920 to 75, in 1923 it had climbed to 80, in 1926 to 88.1. In 1927 the percentage was 89.5 and in 1928, for the first time, the 5 90 per cent, mark was passed, the percentage actually being 91.5. This percentage was exactly maintained in 1929, and in 1930 has been again slightly improved upon, reading 91.9. The improvement in this one respect is to be taken, of course, merely as an index of all.round general improvement in personal hygiene and care, which figures for other age groups and other conditions fully bear out. Infestation with body vermin, which, in the early days of medical inspection was found in 3 to 4 per cent, of elementary school children, has now practically disappeared. In 1930, out of 168,248 children inspected, 248 children only were found with body vermin. Ringworm, which formerly was a condition very seriously interfering with school attendance, the numbers detected annually running into thousands, has now been reduced in the London elementary schools to a mere handful of cases per annum. The heaviest burden the school medical service has to bear is undoubtedly the poor condition of the children's teeth. It is probably not going too far to say that dental unsoundness is the most serious of all the conditions that not only menace but actually lower the state of the national health. Dental decay. The condition of the teeth of the entrant infants continues to give cause for great concern. In 1930, of the entrant infant boys, 47 per cent, showed obvious dental decay at medical examination, and of the entrant infant girls, 47.8 per cent, compared with 46.7 per cent, and 47.7 per cent, respectively in 1929. These figures are obtained as part of the result of the general medical examination. Closer examination with probe and mirror would reveal a still greater amount of dental caries. Owing to the extended (but not yet completed) provision made for the dental treatment of children during school life the dental condition of the older children has greatly improved during recent years. In 1930, of the 12.year.old boys, 26.9 per cent, and of 12-year.old girls, 24.7 per cent, were found by the school doctors with obvious dental caries, as compared with 27.1 per cent, and 24.4 per cent, respectively in 1929, 28.3 per cent, and 26.6 per cent, in 1928, and 29.4 and 27.7 per cent, in 1927. Each year therefore marks, with the exception of the girls in 1930, a slight but definite improvement. Altogether since 1913 the sum of improvement is very considerable indeed for in that year 50 per cent, of 12.year.old boys and 47.6 per cent, of 12.year.old girls had obvious dental decay. In 1913 care for the teeth had scarcely begun and only two or three dental centres existed as compared with the 65 school dental centres that now exist in London. In the statutory age groups, 11,291 children were in 1930 referred for treatment for enlarged tonsils and adenoid growths, or 6.7 per cent, compared with 7 per cent, in 1929 and 6.5 per cent, in 1928. The better facilities now existing for conducting operations no doubt influence the examiners in referring cases for treatment no less than the parents in following their advice. The entrant infants provide by far the greatest quota of children referred for operation for unhealthy throat conditions, viz., 10.3 per cent, of entrant boys and 9.2 per cent, of entrant girls, as against 5.4 per cent, of 8.year.old boys and 6 per cent, of 8.year.old girls, and 3.2 per cent, of 12.year.old boys and 4 per cent, of 12-vear.old girls. Enlarged tonsils and adenoid growth. In 1930 otorrhoea (running ears) was found in 1,673 children in the three age groups or 1.0 per cent. There has been a steady decline in the number of children with running ears. In 1927 the percentage found was 1.3 and in no year previous to 1930 has the proportion returned been less than 1 per cent. This gradual reduction of the number of children with discharging ears is of great importance as, of course, the condition, while a constant danger to the life of the sufferer, is also the chief precursor of chronic deafness arising in childhood. It is again the entrant infants who contribute the largest proportion of the children with discharging ears. While otorrhoea becomes less frequent as the children pass upwards through the school, defect of hearing becomes more frequent. This is because defect of hearing is generally a permanent and incurable condition and the numbers accumulate during school life: 453 children were detected with hardness of hearing or 0.3 per Otorrhoea and hardness of hearing. 6 cent., compared with 696 children or 0.4 per cent, in 1929, and 868 in 1927. Thus the number of children noted as hard of hearing at medical inspection has been almost halved in the last three years. This result both in improvement of discharging ears and in hearing capacity is undoubtedly due to the greater readiness to have the tonsils and adenoids treated, which has been such a marked feature during the last three or four years. Defect of vision. In the examination of vision glasses are worn if the children normally use them. In the 8.year.old group, 47.3 per cent, of boys and 48.2 per cent, of girls failed to pass the vision test in 1930. In 1926, the figures were 51.9 per cent, and 54.7 per cent, respectively, in 1927 they were 51.1 per cent, and 52.9 per cent., in 1928 46 .6 per cent, and 48.9 per cent., and in 1929 47.8 per cent, and 49.5 per cent. At age 12, of boys 40.3 per cent, and of girls 44.9 per cent, failed to pass the vision test, compared with 40.7 per cent, and 44.3 per cent, in 1929, and 41.2 per cent, and 44.9 per cent, in 1928. While boys show some betterment at this age too, the girls do not. The greater incidence of visual defect upon girls than upon boys has always been a feature of the results of school medical inspection. While in the younger girls there is a gradual approximation to the figures for boys, the difference is apparently growing at the older age owing to improvement in the boys not shared by the girls. Is this because the older girls must strain their eyes more at sewing and other fine tasks, or is it because the older girls are less ready than the boys to wear spectacles when needed ? Some indication of the answer to this question may be shown later in this report (p. 11). Heart trouble and anaemia. Heart defect (functional or organic) was reported in 3,390 children or 2 per cent. In 1928 and 1929 the percentage was 2.2 per cent. Older girls, as usual, present signs of heart strain in excess of older boys (2.8 per cent, as compared with 2 per cent.). Anaemia was recorded in 2,016 children, or 1.2 per cent. There has been a very rapid decline during the last few years in children so suffering. In 1926 the figure was 2.4 per cent., in 1927 2 per cent., in 1928 1.7 per cent., and in 1929 1.4 per cent. Healthier ways of living and, in particular, increasing use of the open.air by girls as well as boys, no doubt accounts for this improvement. Defect of the lungs. Lung detects were noted in 3,835 children (2.3 per cent.). Here, again, there has been a steady decline in incidence. In 1926, of the children examined, 3.4 per cent, were found with lung trouble, but each year since then they have been fewer. This, like the decline in anaemia, must be ascribed to healthier modes of life. Entrant infants continue to contribute the largest quota to those with lung defects, particularly the infant boys amongst whom 3.8 per cent, were noted, the cases being chiefly bronchitis of rickety origin. Tuberculosis. It is barely possible now for a child to be found in school at a routine inspection suffering from tuberculosis. Only 62 children were notified with pulmonary tuberculosis and 47 with tuberculosis of other organs than the lungs. These numbers were fewer than those of the previous year, which already had fallen far below the proportion of one in a thousand. Nervous diseases. Epilepsy was noted in 60 children, compared with 73 in 1929, and 97 in 1928; chorea in 186 compared with 178 in 1929, and 204 in 1928, and paralysis in 76, compared with 122 in 1929, and 125 in 1928. Rickets. The manifestations of rickets serious enough to be recorded, were found in 708 children or in 0.4 per cent. Here, again, is a measurable drop, as there were 1,097 (0.6 per cent.) recorded in 1929. The largest proportion of rickets is always found in entrant boys, being half as much again as in entrant girls. Other deformities. Other deformities than those due to rickets were recorded in 2,017 children (1.2 per cent.), the same proportion as in 1929. Spinal deformity accounted for 721 of the above, the older girls contributing a quota of 245, which was much larger than that of any other group and twice as large as that of the boys of the same age. Vaccination records, 1930 In view of the prevalence in London of small.pox, the Education Committee decided, during the year, that the school doctors should note in the records the existence of vaccination marks (which they cannot avoid observing) when examining 7 children. Such records were made in the two last terms of the year, and the results were as follows:— Percentage of Vaccinated. Entrant boys 50.6 50.3 „ girls 50.1 Intermediate boys 50.5 50.2 „ girls 49.9 12-year-old boys 54.9 56.2 girls 57.4 14-year-old boys 57.51 56.2 „ girls 58.9 58.2 About half the entrant children (ages 4-5) were found to have the marks of vaccination. Among the 14-year-old age group the percentage was 58. Either vaccination was more frequently carried out in 1916-17, when the older age group children were born, than it was in 1925-6, when the entrant children were born, or there were many cases of vaccination carried out after school age was reached. It is interesting to compare the numbers of entrants and leavers recorded as having vaccination marks respectively in the boroughs where smallpox had appeared in 1928, the first year of any considerable prevalence, when there were 296 notifications allocated as follows:— Wandsworth, 88; Poplar, 68; Lambeth, 53; St. Marylebone, 30; Southwark, 21; all other boroughs, 36. Percentage reported in 1930 as vaccinated. Entrants. Leavers. Wandsworth 61 61 Poplar 26 48 Lambeth 53 60 Marylebone 78 75 Southwark . 48 54 From this table it is seen that while in Wandsworth and St. Marylebone the proportion of children vaccinated does not alter much between the two groups, in Lambeth and Southwark the proportion of leavers vaccinated is somewhat higher than among entrants, while in Poplar it is nearly doubled. This indicates that when smallpox occurs in an area where vaccination in infancy is commonly neglected, a number of school children are given the protection of vaccination. Although the infants are found to be well nourished on entering the schools and compare favourably with other groups both in this respect and in that of personal hygiene, they present a large number of defects mainly due to defective surroundings and faulty nurture antecedent to school life: 47 per cent, of boy entrants have manifestly carious teeth as do 478 per cent, of girl entrants, while 14.8 per cent, have serious dental diseases compared with 6.8 per cent, of the 8-year-old children and only 1.8 per cent, of the 12-year-old children; 10.3 per cent, of entrant boys and 9.2 per cent, of entrant girls are referred for treatment for enlarged tonsils and adenoid growths, compared with 5.7 per cent, of the 8-year-old group and 3.6 per cent, of the 12-year-old pupils. The condi of the entrant infants. Other conditions in which the entrant infants suffer to a much higher degree than do the older children, are otorrhœa, lung trouble, external eye diseases and rickety deformities. Much light is thrown upon the condition of entrant infants in the second interim report of the Board of Education's Committee on Adenoids and Enlarged Tonsils. This report gives an account of an investigation into the association of rickets and dental diseases with adenoids and enlarged tonsils. It is not intended here to discuss the main purpose of the investigation and the Committee's findings upon the results, but to point out (which might easily be overlooked) that the statistics compiled by the Committee give very valuable information as to the condition of the entrant children. The children examined were unselected children, aged five, in the London elementary schools and the work was carried out mainly by medical officers of the Council: 1,638 five-year-old children were examined in 33 elementary schools by three medical officers who confined their examination entirely to the detection of nine bony abnormalities 8 commonly associated with rickets. The three medical observers worked independently but upon a common plan, which had been evolved in a previous short survey carried out in concert. The relationship between the type of school and the incidence of physical signs associated with rickets is shown by the Committee in the following table, the schools being classified in a descending scale according to social type as B-j-, B, B— and C. Schools. No. of schools. No. of children. No signs. Per cent. One sign. Per cent. Two signs. Per cent. Three or more signs. Per cent. B+ 4 197 44 22.3 50 25.4 52 26.4 51 25.9 B 12 586 84 14.3 142 24.2 149 25.4 211 36 0 B 5 267 26 9.7 64 24.0 72 27.0 105 39.3 C 12 588 51 8.7 94 160 148 25.2 295 50.2 Thus an intensive survey in which attention was concentrated solely upon the persistence of bony malformations associated with rickets, showed that in the London schools to.day amongst the children at five years of age, three or more signs of rickets are found in percentages varying from 25.9 in "fair" schools to 50.2 in" poor "schools. As rickets is pre.eminently a nurture disease, these results show how much is still required in both improvement of housing conditions and in training in motherhood. It may be objected that in the ordinary inspection of entrants only 0.75 per cent, of the entrants are recorded as having rickets, but these are the children who have marked outstanding manifestations of the disease calling for notice and for action, while the signs recorded by the special investigators are minor manifestations no longer necessarily of any importance except as signs of deficiency or default at an earlier stage. Another section of the enquiry consisted in the examination of as many of the same 1,638 children as possible by the Council's aurist, who made a digital examination of the naso.pharynx of 1,361 of the children. At the ordinary inspection the presence of adenoids is inferred from the symptoms and signs shown by the child and is not confirmed by digital examination. This section of the investigation is therefore of great importance as the actual incidence of adenoidal over.growth in unselected London children has never hitherto been established. Of the 1,361 children examined, 174 had already been operated upon for the removal of adenoids. Of the remainder the naso.pharynx was found normal in only 237 (17.4 per cent.), tonsillar enlargement with or without sepsis was found in 193 (14.3 per cent.) and tonsillar sepsis without enlargement and without adenoids in 10 (0.7 per cent.). Adenoids in some degree, with or without tonsillar enlargement, were present in 747 (54.9 per cent.). Including those whose adenoids had been removed, the proportion of unselected 5.year.old children in whom adenoids were or had been found, was 67.7 per cent. The extent to which resort is now made to operation upon enlarged tonsils and adenoids is shown by the fact that at age five 12.8 per cent, of the children in the schools have already had their adenoid growths removed. It is noteworthy that in contradistinction to the distribution of the signs of rickets, no greater prevalence of adenoids was found in the poorer schools ; in fact the proportion of children free from adenoids was highest in the poorest group of schools. The Committee, in order to be able to compare the results of digital examination with those of other investigations in which this method was not used, asked the Council's aurist to re.examine the children and to record only symptoms related by parent or teacher and those observed by himself without a digital examination ; 490 children were therefore re.examined at a date about a year subsequently to the first examination, 30 per cent, of the mouth breathers showed no signs of adenoids on digital examination, while of those showing extensive adenoids on digital examination only 29.3 per cent, were mouth breathers. It is therefore evident that the two methods of diagnosis result in the selection of two different series of children and that the results obtained are not comparable. 9 A third section of the investigation consisted in the ascertainment of the condition of the teeth, carried out by Mrs. Mellanby. Of the original 1,638 children, 1,293 were examined in this part of the investigation. The Committee presents Mrs. Mellanby's results in regard to caries in the following table, the figures 1—6 referring to the degree of caries, the figure 1 representing the least degree and the figure 6 the greatest degree of caries:— Schools. No. examined. Free from caries. Caries present. 2 3 4 6 6 Per cent. Per cent. Per cent. Per Per cent. Per cent. Per cent. B+ 147 9 61 5 3.4 21 14.3 8 5.4 15 10.2 17 11.6 72 49.0 B 480 31 6.5 7 1.5 47 9.8 29 6.0 80 16.6 45 9.4 241 50.2 B. 210 8 3.8 3 1.4 19 9.1 19 91 29 13.8 15 7.1 117 55.7 C 456 13 2.8 5 1.1 43 9.4 25 5.5 64 14.0 40 8.8 266 58.3 Total 1,293 61 4.7 20 1.5 130 10.2 81 6.3 188 14.5 117 9.0 696 53.8 Only 4.7 per cent, of the five.year.old children were found by Mrs. Mellanby (using probe and mirror), to be free from caries, and " much " caries ranged from 60.6 per cent, in the good schools to 67.1 per cent, of the children in the poorest schools. Mrs. Mellanby also recorded the degree of hypoplasia or defective structure of the teeth in the children examined by her. In no case did she, according to her standards, find a condition of normal structure, while the degree of hypoplasia, like the amount of caries and the incidence of rickety signs, though not so strikingly, was higher in the poorer than in the better schools. The Council has voluntarily instituted a routine fourth age group examination which takes place in the term previous to that in which the children are due to leave school. The results of this inspection are available at the school-leaving conference in connection with future employment and are of assistance in the choice of occupation. This examination is valuable too from a statistical point of view, as it gives a final verdict upon the results of the work of the school medical service. The health of the leaving child. The leaving children examined numbered 24,388 boys and 24,217 girls. They were found better nourished than any other group, only 3.7 per cent, of boys and 2.9 per cent, of girls being returned as under.nourished compared with 5.1 per cent, and 4.5 per cent, in the case of the 12.year.old group. The highest standard of personal hygiene is also found in this group, 97.5 per cent, of boys and 94.6 per cent, of girls being found scrupulously clean at medical inspection. The dental condition of the leaving girls was this year better than that of the 12.year.old girls, reversing the findings of last year, when there was recorded a slight falling off in the dental condition in the leaving girls. Visual acuity (as measured in school by Snellen's type test, with spectacles on if worn by the scholars) greatly improves between 12 and 14; 63.2 per cent, of boys in the leaving group and 59.3 per cent, of girls passing the test satisfactorily, as against 59.7 per cent, and 55.1 per cent, respectively among the 12.year.old group. The percentage of leavers referred for tonsillar and adenoid growths was 2.3 and 3.1 in boys and girls compared with 3.2 and 4.0 at 12 years. Otorrhcea was less frequent in the leaving group, while defect of hearing was, as last year, found in exactly the same degree in the leaving and 12-year groups. Anaemia and heart defect were distinctly less prevalent among the leaving children, both boys and girls. Among the boys the incidence of spinal and other deformities was also distinctly less, but among the girls these deformities were found in increased ratios. 10 The summary of these results shows therefore a very marked improvement in the condition of the leaving child, due largely to the intensive efforts of the teachers, care committee workers, doctors and nurses, during the last two years at school to fit their charges for the battle of life. That these efforts are proving increasingly successful is shown by the fact that the condition of the leaving children this year was also markedly better in every respect than the leavers of last year, and the latter, than those of the year before. The sole respect in which the condition was less satisfactory than in the 12-year group, was in the increase of spinal curvatures and other deformities, such as flat foot in the elder girls contrasted with an improvement in the boys. Great care is required in the case of girls from 12 to 16, who are growing rapidly, to correct faulty postures and give periods of recumbent rest. Girls are growing faster than boys at this age and should not be expected to vie with the latter in phvsical endurance. Special inspections. While the routine inspections comprise all children in certain age groups whether well or ailing, children specially examined are those who are brought before the doctor because members of care committees, teachers, school nurses or attendance officers are specially concerned about their health. These inspections are very valuable because they enable the more serious conditions to be detected at an early stage. Thus, amongst the 36,803 children especially examined, 774 cases of scabies were found, while among the 216,853 children in the age groups only 84 were found. Pulmonary tuberculosis definite or suspected was found in 160 children in the smaller special group, while only 65 children in the routine age groups were found similarly affected. Again epilepsy was found in 213 children in the special group as against 48 in the combined routine age groups, and chorea in 402 compared with 185. It thus comes about that serious departures from health are found much more often as a result of bringing the child especially to the notice of the doctor, than as a result of routine inspection. The children no longer wait until their age group routine examination is reached, and illnesses are detected and treated at an early stage. Conclusions. In 1930 it may be claimed that the physical state and comfort of the children of London are better than ever before as judged on the broad primary conditions of nutrition and personal hygiene. Although minor conditions of departure from health are rife, the major manifestations of disease are becoming more and more rare. The stringency of the times is not allowed even to a slight degree to affect the children prejudicially, but on the contrary, the condition of the children's health steadily improves. General. Medical Inspections in Higher Education Institutions. All pupils in the secondary schools and trade schools are examined in detail at the ages of 12 and 15 years, while the record of each pupil is reviewed at other ages and a medical examination carried out if this is considered advisable. Including examinations in training colleges 13,470 pupils were examined in 1930, an increase over the previous year resulting from the inclusion of certain aided institutions where previously no routine medical inspections had been carried out. In comparison with the children in the elementary schools, as might be expected, the secondary school pupils show superiority, although the disparity yearly grows less. In three instances, gross uncleanliness of person was found, one in a boy specially examined and two in girls of the fifteen-year-old group. Among 12-year-old boys, 76.5 per cent, were returned with sound teeth, but in those at 15 years the proportion fell to 71.1 per cent. Among 12-year-old girls, 79.5 per cent, were returned with sound teeth, but at 15 years the proportion was 76.7 per cent. Dental condition. Among 12-year-old boys, 69.7 per cent, were able to pass the vision test, but at 15 years the proportion had fallen to 67.6 per cent., although those wearing spectacles rose from 14 per cent, to 16.3 per cent. Among 12-year-old girls the proportion passing the vision test was 66.1 per cent, but at 15 this had fallen to 64.4 per cent. 11 although those wearing spectacles rose from 16 per cent, to 19.2 percent. The number of boy pupils with more serious defect of vision rose from 15.3 per cent, at 12 years to 19.1 per cent, at 15, and similar figures were found in the girls (15.4 per cent, and 19.5 per cent.). In these three years of secondary school life, therefore, there is measurable deterioration both in dental conditions and of vision. Considering that a higher proportion of girls than of boys wear spectacles and that the number wearing them increases between 12 and 15, and that notwithstanding this the visual acuity of the girls is markedly less than that of boys, while also visual acuity declines in boys during secondary school life, there appears to be no escaping the conclusion that education imposes injurious strain upon the eyes, greater in girls than in boys. Of the men in training colleges 70 per cent, were able to pass the vision test: 26.4 per cent, of those examined wore spectacles ; amongst the women 72.2 per cent, passed the vision test but 33.5 per cent, were wearing spectacles. Education and eye strain. As safeguards to the health of pupils, principals and parents should be alive to the necessity of regular visits to the dentist on one hand and, on the other hand, of protecting the eyes by the provision of spectacles to relieve strain and by avoiding prolonged periods of reading and close eye work without the necessary resting of the eyes at intervals. Following.up. The physical care of the children generally, including the following.up of those found defective at medical inspections, is entrusted by the Council to the school care committees, of which the number is now 920. The number of voluntary workers who are full members of a care committee is 6,167. The care committee work is directed by a staff of organisers numbering 149. The re.inspection by the school medical staff of children previously referred for treatment or placed under observation makes it possible to compile a statistical record of following.up. During 1930, 186,615 children were re.inspected, a decrease of 9,744 upon the previous year: 127,147 were first re.inspections and 67,401 were second re.inspections of cases not completely cleared up at the primary re.inspection which takes place about four to six months after the child first comes under notice as defective. Combining the results of first and second re.inspections it is found that 80.7 per cent, of children found ailing were finally treated or discharged as no longer requiring treatment. This result is better than that of the previous year and is the best result ever obtained. 1ST RE.INSPECTIONS, 1930. (Percentages are given in italic type.) Treated. Not treated. By private doctor. Under Council's scheme. At other hospitals. Treatment no longer needed (cleared up naturally). Observation only required (improved ). Treatment still necessary. Cured. Not cured. Cured. Not cured. Cured. Not cured. Refraction, 21,506 147 78 5,703 2,357 637 398 1,658 3,854 6,674 0.7 0.4 26.5 11.0 3.0 1.8 7.7 17.9 31.0 Minor ailments, 122 29 2,120 482 489 233 2,099 1,008 1,228 7,810 1.6 0.4 27.1 6.2 6.3 3.0 26.8 12.9 15.7 Nose and throat, 57 11 6,965 312 1,046 105 2,050 2,677 7,455 20,678 0.3 0.1 33.7 1.5 5.1 0.5 9.9 12.9 36.0 Teeth 64,102 1,352 309 24,984 823 1,978 194 5,001 966 28,495 2.1 0.5 39.0 1.3 3.1 0.3 7.8 1.5 44.4 Other ailments, 246 110 434 380 1,516 1,330 3,408 3,783 1,844 13,051 1.9 0.8 3.3 2.9 11.6 10.2 26.1 29.0 14.2 Total 127,147 1,924 537 40,206 4,354 5,666 2,260 14,216 12,288 45,696 1.5 0.4 31.6 3.4 4.5 1.8 11.2 9.7 35.9 12 2nd Re.inspections, 1930. Treated. Not treated. By private doctor. Under Council's scheme. At other hospitals. Treatment no longer needed (cleared up naturally). Observation only required (improved). Treatment still necessary. Cured. Not cured. Cured. Not cured. Cured. Not cured. Refraction, 13,612 61 46 2,741 1,364 337 257 1,245 3,125 4,436 04 0.3 20.1 10.0 2.5 1.9 9.2 23.0 32.6 Minor ailments, 39 20 737 228 184 141 920 597 709 3,575 1.1 0.6 20.6 6.4 5.2 3.9 25.7 16.7 19.8 Nose and throat, 21 6 3,218 117 577 81 1,708 1,594 4,421 11,743 0.2 0.1 27.4 1.0 4.9 0.7 14.5 13.6 37.6 Teeth. 30,781 765 162 10,115 361 979 110 3,176 488 14,625 2.5 0.5 32.8 1.2 3.2 0.4 10.3 1.6 47.5 Other ailments, 78 57 290 253 726 785 1,849 2,511 1,141 7,690 1.0 0.7 3.8 3.3 9.4 10.2 24.1 32.7 14.8 Total 67,401 964 291 17,101 2,323 2,803 1,374 8,898 8,315 25,332 1.4 0.4 25.4 3.5 4.2 2.0 13.2 12.3 37.6 Cases referred to the N.S.P.C.C. Where there is persistent neglect to obtain treatment, the case is referred to the N.S.P.C.C. to endeavour to persuade the parents to obtain treatment. In certain cases the Society takes legal proceedings under Section 12 of the Children Act. During 1930 there were 919 cases, with 1,027 defects, referred to the Society and included 496 dental defects, 298 vision defects and 84 nose and throat cases. Aural disease and scarlet fever. Owing to the close connection between certain infectious diseases and ear trouble an arrangement is made by which notification is made of any child who had suffered from ear discharge while in a fever hospital. The names of infants under school age are sent to the local medical officers for following up at the infant welfare centres whilst children of school age are examined every six months until two consecutive reports show that no further symptoms of the disease are present. In all, 332 cases were reported, 39 of which were referred to the borough councils or other local authorities. Of the cases followed up at school, 15 were found with otorrœha on the first examination by the school doctor. Seven of these had cleared up by the time of the second examination and 2 were still affected. Nine which were free from discharge on the first occasion were found to be affected at the time of the second examination. All these cases are being kept under observation until found to be clear, at two successive visits, at intervals of 6 months. Transferred schools and homes. Schools and homes transferred to the Council from former Poor Law Authorities. Under the Local Government Act, 1929, the under-mentioned 23 schools or children's homes were transferred to the Council and for administrative purposes were placed under the control of the Education Committee:— Former Name. North Surrey District School. North Surrey District Wainwright Home. West London District School. Kensington, Chelsea and St. Marylebone District School. Kensington, Chelsea and St. Marylebone Branch School, Marlesford Lodge. Lewisham Children's Home. Hampstead Cottage Home. Metropolitan Asylums Board Training Ship "Exmouth." New Name. Anerley Residential School. Wainwright Children's Home, Broadstairs. Ashford Residential School. Banstead Residential School. Hammersmith Children's Home. Cumberlow Lodge Residential, South Norwood. Erskine Hill Children's Home. Training Ship " Exmouth," off Grays, Essex. 13 Former Name. Central London District Schools. Shoreditch Cottage Homes. Islington Schools. Islington Receiving Home. Poplar Training School. St. Pancras Schools. Bethnal Green Children's Homes. Holborn Schools. Lambeth School. Hackney Children's Homes. Camberwell Scattered Homes. Bermondsey Schools. Greenwich Children's Homes. Stepney Jewish Homes. Stepney Homes. New Name. Hanwell Residential School. Hornchurch Children's Home. Andover Children's Home. Hornsey Rise Children's Home. Hutton Residential School, Essex. Leavesden Residential School. Leytonstone Children's Home. Mitcham Children's Home. Norwood Children's Home. Ongar Residential School, Essex. Peckham Children's Homes. Shirley Residential School, near Croydon. Lamorbey Residential School, Sidcup. Stepney Children's Homes. Stifford and Grays Children's Homes, Grays. The institutions transferred from the guardians or joint district managers are of varying type, some being on " barrack " lines, others being of the cottage home type, whilst from the Metropolitan Asylums Board, the training ship "Exmouth" (off Grays, Essex) was taken over by the Council. Education was provided for the children either (a) within the institutions themselves or (b) by attending neighbouring schools of the local education authority of the area where the school was situated, and in one case where education was provided within the institution, children from a nearby village attended the institution's school. Only 6 of these homes are situated in London the remainder being distributed in neighbouring counties, and in assuming control of these homes the Council became responsible not only for the education but also for the health and domestic arrangements of a "family" of over 7,000 children. Immediately the schools came under the control of the Council an enquiry into the hygienic and medical arrangements was made by Dr. J. L. D. Fairfield and Dr. Margaret Hogarth. At a later date (June, 1930) following on their reports, the Council arranged for a consulting podiatrist, Dr. Donald Paterson, to make a preliminary survey of the dietary and the arrangements for the general supervision (medical and nursing) of the children in these residential schools. Surveys of schools. Under the late authorities a medical officer had been appointed for each of the schools and in most of the schools the medical officer visited the school each day mainly to deal with ailing children but it was by no means universally the practice to undertake a complete inspection of the children at regular intervals. The sections of The Public Assistance Order, 1930, concerning residential schools and homes for children provide (1) that every infant under the age of 18 months shall be examined by a medical officer not less than once in every two weeks and (2) that every other child shall be examined by a medical officer not less often than once in every 3 months. Medical supervision. It was apparent that the medical inspection prescribed by the Order was not being carried out in every instance. Further there appeared to be need for some uniform method of recording these inspections (replacing the books, cards and case sheets of differing design formerly used), and to regularise the arrangements made for outside medical treatment when required. To discuss these and cognate matters the medical officers of these homes were invited to attend a conference at the County Hall in June, 1930. Having had the advantage of hearing the views of the medical officers concerned it has been possible to initiate a practical scheme for dealing with any contingencies that may arise and for conforming to the rules laid down by the Public Assistance Order. In the case of medical examinations the Education Committee with the concurrence of the Central Public Health Committee (in whose care the Council's administrative scheme places children in these schools under the age of 3) made the following recommendation:— (a) Every infant in the school or home under the age of 18 months shall have a complete stripped examination by the medical officer not less than once in every two weeks. 14 (b) Every other child under the age of three years shall have a complete stripped examination by the medical officer not less than once in every three months. (c) Every child over the age of three years shall be examined by the medical officer not less than once in every three months and shall receive a complete stripped examination once a year. Medical treatment. Operation cases. A standard medical card has also been adopted tor recording these examinations. With regard to medical treatment it became apparent from the beginning of the scheme that many of these children were in need of operations for enlarged tonsils and adenoids. An administrative arrangement was made whereby such cases could be operated on in the Council's general hospitals (formerly Poor Law infirmaries). The scheme was extended to embrace all operation cases including such cases as appendicitis, hydrocele, etc. For urgent operation cases reliance is placed upon the discretion of the local officers, who are advised to communicate directly (a) in London, with the nearest Council hospital and (b) outside London, with the local voluntary or public hospital. For cases in which this course cannot be adopted or is unsuccessful and for less urgent cases a "fixed point" has been designated in the general hospitals division of the public health department, it being the duty of the "fixed point" to allocate cases to appropriate hospitals. Medical treatment cases. For children requiring non.operative treatment, e.g., for rheumatism, tuberculosis, skin trouble, keratitis, and for infectious diseases the schools are instructed to communicate by means of the appropriate form, or in urgent cases by telephone, with the special hospitals division of the public health department who allocate beds and when necessary provide an ambulance for conveyance. (The ambulance service is also available for general hospital cases.) Otorrhœa. The medical officers of the institutions were invited to refer to the school medical officer any cases of otorrhcea in which advice was required, and evidence was soon forthcoming that many children in these homes were suffering from otorrhoea for which the ordinary syringing treatment given at the homes was not effective in providing a permanent cure. In dealing with these referred cases advantage was taken of the scheme already in existence for London school children generally, whereby such cases could attend at the Kentish Town clinic, for ionisation treatment under the case of the Council's chief aurist. This clinic is conveniently near to the Andover Children's Home (one of the transferred schools). Full advantage of this contiguity was taken and owing to the fluidity of arrangement possible now that all these homes are under one control, parties of children are temporarily lodged from distant homes at the Andover Home where they stay until further ionisation treatment bv the Council's aurist is no longer required. Vision treatment. One of the points brought up for discussion at the conference was the question of vision testing at the homes and the provision of spectacles. On enquiry it was found that at seven of the homes no systematic arrangements had been made iu this direction by the former authorities. This was rectified and arrangements are now made for an ophthalmic surgeon to visit each of these seven schools once every three months. Any prescriptions given are made up through the Council's supplies department. Dietaries. Dr. Donald raterson has submitted some valuable suggestions as the result of his visits to some of the schools. His investigations are not yet completed, but from the facts already obtained it appears to be desirable as an early measure of reform that a uniform dietary should be drawn up for all the schools. Chronic Invalidity. The school attendance department reports each month the names of all children who have become chronic invalids, absence from school entirely on account of illhealth for three months and upwards being taken as the criterion. Each year the number of sick children remaining on the list in the month of November is analysed in the medical department, and the result gives, in effect, a census of chronic invalidity. 15 The following tables show the number of children who had been out of school for three months or more in November, 1930, and comparative figures for the three previous years. The numbers remain fairly constant, but it may be noticed that the proportion of the total suffering from nervous disorders has steadily declined. The number of children absent on account of rheumatism and associated conditions, including heart disease, forms a very high proportion of the whole (32.8 per cent.), and the figures bring out in a startling manner how largely this group of conditions looms in the production of chronic ill-health in childhood (and, of course, afterwards). There were children absent in respect of epilepsy 50 cases (nervous disorders) and with encephalitis 12 cases (infectious diseases). Amongst "other ailments" were 122 children with respiratory diseases other than tuberculosis, 39 with ear diseases and 45 with infantile paralysis. Cases out of School for Three Months, November, 1930, compared with the Three Preceding Years. Cases. Percentage of total. 1927. 1928. 1929. 1930. 1927. 1928. 1929. 1930. Rheumatism, heart disease and chorea 508 681 680 678 25.32 30.95 30.77 32.82 Nervous disorders 207 199 148 99 10.32 9.05 6.70 4.80 Tuberculosis (pulmonary and other) 234 216 264 295 11.66 9.82 11.95 14.28 Anaemia and debility 135 141 105 129 6.73 6.40 4.75 6.24 Ringworm 27 17 22 22 1.35 0.77 0.99 1.06 Skin complaints (excluding ringworm) 63 56 58 49 3.14 2.55 2.62 2.37 Eye 76 62 84 72 3.79 2.82 3.80 3.49 Infectious diseases 100 106 85 73 4.98 4.82 3.85 3.53 Other defects 656 722 764 649 32.71 32.82 34.57 31.41 2,006 2,200 2,210 2,066 100.00 100.00 100.00 100.00 Wage.earning Employment of School Children. The applications during the year 1930 for medical certificates, in connection with the employment of school children out of school hours under the by.laws, numbered 4,030, including only 46 girls, compared with a total of 4,155 in 1929. The nature of the work for which certificates were granted was for boys (girls in brackets)—Delivery of milk, 209; delivery of newspapers, 2,343 [29]; carrying or delivery of goods or parcels, 605 [5]; in or in connection with a shop, 286 [7]; in a coal yard, 4; industrial work at home, 7; home work away from home, 19 [3]; as a messenger, 58 [2]; not stated, 24; 87 boys and one girl were granted certificates in respect of two or more occupations. Certificates were refused on medical grounds in the cases of 71 boys. In 200 cases the certificates were granted subject to medical treatment being obtained, and in 138 additional cases other conditions were imposed. In 11 cases the provisional certificates were withdrawn on account of the non.compliance with the conditions under which the certificate was issued. The number of children seen under the regulations for children employed in stage entertainments was 214, of whom 27 were boys and 187 were girls. Five boys were given certificates conditional upon treatment for defects (1 skin, 2 dental, 1 vision, 1 deformity); 26 girls were given conditional certificates (6 skin, 1 external eye disease, 7 vision, 10 dental, 2 deformity). Three children were rejected; one on account of skin disease, one on account of deformity, and one for neurosis; all three were girls. A condition of flat foot was frequently noticed in girls who were dancers: this condition at rest appears to be natural in such children, it disappears when the foot passes into activity and gives rise to no symptoms. Children employed in stage entertainments. 16 Medical Treatment. Two new medical treatment centres were opened ; one for minor ailments at the Bermondsey Medical Mission Hospital and one for minor ailments and dental surgery at the maternity and child welfare centre in North Hammersmith, so that at the end of 1930 the Council's scheme for the treatment of school children included 72 centres and 16 hospitals as well as the special dental clinic attached to the King's Canadian Camp School, Bushy. Camp School, Bushy. The following comparative table shows the provision made in 1930, and the number of children actually treated during the year and during 1929:— Ailment. Provision made in 1930. Number treated 1930. Number treated 1929. Defective vision 40,770 43,579 41,620 Ear, nose and throat 17,315 19,760 19,903 Ringworm 822 358 480 Minor ailments 76,980 101,298 98,023 Teeth 141,295 138,280 128,711 277,182 303,275 288,737 In order to provide the necessary elasticity in the arrangements a certain amount of money is allotted for additional services which can be applied to meet emergencies wherever they arise. Thus the number of children actually treated amounted to 26,000 more than were provided for in fixed contracts. Eye defects. During the year 43,579 children with eye detects were treated under the Councils scheme. This represents an increase of 1,959 over the year 1929. The majority of the cases were referred for refraction and during the year spectacles were prescribed in 30,087 cases; in 27,505 of these cases spectacles were obtained, a percentage of 91.4. Ringworm. The incidence of ringworm in the schools still continues to decline. The number of cases requiring treatment by X.rays during 1930 was only 358 compared with 480 in 1929. It has been thus possible to reduce still further the provision necessary for this form of treatment which formerly required the maintenance of a large number of centres. Minor ailments. For minor ailments 101,298 children received daily nursing treatment. This is an increase of 3,275 on the number dealt with during 1929. Ear, nose and throat defects. The number of children treated during the year 1930 in the throat departments of the centres was slightly less than during the preceding year, viz., 19,760 compared with 19,903. All cases under the Council's scheme requiring operations for enlarged tonsils and adenoids are now dealt with as in.patients, being kept at the centres or hospitals for two nights after the operation. During the year under review 16,215 children received operative treatment, an increase of 1,311 over the year 1929. It has been possible to provide adequate accommodation for in.patient treatment owing to the transference to the Council of certain general hospitals under the provisions of the Local Government Act, 1929. Provisional arrangements have been made at the Bethnal Green Hospital, the Norwood Children's Hospital and the Mile End Hospital. It is the experience at the general hospitals that more beds are available for this type of work in the summer months than in the winter. At the same time it is recognised that tonsillectomy is better undertaken in the summer than the winter. Endeavours are, therefore, being made to utilize as fully as possible the accommodation available at these hospitals during the summer months for throat operations on school children. Ionisation. The treatment of discharging ears by ionisation, and other methods, at special consultation centres has been further increased. One additional centre was established during the year raising the total number to nine. Mr. A. G. Wells' report on treatment of aural disease. Mr. A. G. Wells has submitted the lollowing report:— "This report comprises the work done by the special aural staff at present numbering seven (one whole- and six part-time), with their co-workers, the nurses and organizers at the "Ionisation" centres; a record and analysis of operations performed at the Downs Hospital, Sutton, on cases recommended for admission to the 17 hospital, by the aural staff; a record of the work done at the after-care clinic, Kentish Town, and certain work done in connection with aural cases of residential schools. The total number of sessions per week now given by the aural staff at the 'Ionisation' centres is 21. "The two following tables give certain particulars of the work at the 'Ionisation' centres, showing statistics for the separate divisions of London and for this report the divisions are named according to the arrangement which held prior to April last. Otorrhcea Cases. Division. No. of examinations made. No. of ears examined and treated. No. of ears cured. No. of ears not needing treatment No. of ears lost sight of. No. of ears relapsed. No. of ears still under treatment Children. Ears. E. 2,442 2,905 580 300 86 32 236 124 S.W 3,463 4,114 859 496 161 15 112 150 N.E 3,258 3,585 763 385 132 30 131 177 S.E 4,252 4,816 872 520 77 27 63 194 N.W 1,429 1,812 484 264 42 31 29 97 Totals 14,844 17,232 3,558 1,965 498 135 571 742 Deaf Cases. Division. No. of examinations made. No. of ears treated. No. of ears cured. No. of ears relieved. No. of ears unrelieved. No. of ears lost sight of. No. of ears relapsed. No. of ears still under treatment. Children Ears. E. 88 155 25 17 — 6 — 2 S.W 205 387 91 22 7 6 4 52 N.E 71 125 38 18 1 1 6 12 S.E 184 356 87 20 18 8 8 2 31 N.W 31 51 26 15 — 6 — — 5 Totals 579 1,074 267 92 26 26 9 14 100 Otorrhœa Cases Classified. Cause of suppuration. Total ears. Cured. Referred for mastoid operation. Lost sight of. Still under treatment Acute otitis suppuration 102 82 3 2 15 Chronic otorrhoea suppuration due to:— I. Tympanic conditions— (a) Tympanic sepsis 1,539 1,128 29 45 337 234 126 18 12 78 (c) T.S. and polypi 81 44 12 3 22 (d) T.S. and caries 11 1 3 — 7 (e) T.S. and other conditions 7 5 — — 2 II. Tympanic conditions+ (a) Tonsils and adenoids ... 302 218 — 18 f 6 (b) Abnormal nose conditions 71 50 1 7 13 (c) Abnormal mouth conditions 1 1 — III. Tympanic conditions + (a) Attic disease 116 42 29 9 36 (b) Mastoid disease (no operation yet) 137 5 99 8 25 (c) Mastoid disease (previous operation done) 349 169 22 25 133 IV. Tympanic conditions+ (a) External otitis (b) Stricture of meatus 42 1 33 1 2 4 3 External otitis 66 59 — 2 5 Cause undetermined 1 1 — — — Totals 3,060 1,965 218 135 742 18 "The last table relates to cases of otorrhœa only, all of which, needed treatment and shows the cause of the discharge in each case, the number cured, those referred for mastoid operation, those lost sight of and the number still under treatment at the end of the year. "The disparity in the numbers in the various divisions is due to the fact that more sessions are given in certain divisions than in others. "The percentage of 'cases' cured was 67.2. This is obtained by deducting both those which required no treatment and those lost sight of from the total number of ears examined and treated, and comparing the number 'cured' with this remainder. The average number of attendances 'per ear' works out about five throughout. The average number of examinations per session throughout the year was approximately twenty. The proportion of 'relapsed' cases was about one in every 51/2 ears. There are two main causes for relapse. Firstly, water, if allowed to get into the ear of a healed otorrhoea case, is most likely to be followed by a reinfection, whether the water is from a swimming bath or other source. Although parents and children are warned of this as a routine, nevertheless great carelessness seems to persist in this respect and many re-infections are directly traceable to the accidental or careless introduction of water into the ears. The second main cause is the condition of the nose. It is comparatively rare to find a child without some degree of nasal catarrh or rhinitis. This is due to persistent neglect of attention, over long periods of time, to nasal toilet. Large numbers of children from early years are not given handkerchiefs, and many of those who are in possession of one, do not use it properly. Not infrequently a child is found who not only does not know how to use a handkerchief but even how to blow the nose. This is, directly or indirectly, responsible for much suffering sooner or later, from various diseases of the upper respiratory tract and its appendages, e.g., nasal catarrh and rhinitis, adenoids and disease of the ears, including deafness and otorrhoea. Often in addition to these there are chest complaints. Here is a large field in which it is possible to improve the condition of affairs in a marked degree. "It would be a useful part of the school routine if teachers of all school classes occupied five minutes at the beginning and at the end of every session in instructing children in the use of the handkerchief (or its substitute), and in the correct way of blowing the nose. "Part of the five minutes should be used in instructing the children in correct nasal breathing, and an extension of breathing exercise time up to twenty minutes a day would be well worth the effort and time. "There would no doubt be a certain percentage of children who would be more intractable than the rest. For these it would be perhaps an advantage to institute special clinics where the children could attend for a course of diastolisation. This treatment was introduced in Paris about 1924 by Gautier; clinics were established where large numbers of school children are treated and great success is claimed by this pioneer. The method was introduced in London in a small way in 1925, and the results were sufficiently encouraging to justify a considerable extension. Dr. Clarke of the public health service in Liverpool and Dr. Bernveld of the public health service in Reading came to see this mode of treatment and, being impressed, introduced it in their own services with successful results. Attention in previous annual reports has been drawn to this method of treatment and the results obtained therefrom. "The second table details cases of deafness unaccompanied by otorrhoea. Of the 267 cases, only 92 were restored to approximately normal hearing, 26 had some degree of relief, 26 had no relief at all and 100 were still under treatment at the end of the year. If the above recommendations concerning nasal hygiene and treatment had been earlier in force many of these children would have escaped deafness, to their own advantage and to the advantage of the community upon whom they are a. burden. 19 "The third table gives a detailed analysis of all cases of otorrhœa requiring treatment and shows the various conditions of disease responsible for the ear discharge and the numbers suffering from each condition. It shows further the number of cases cured as the result of ionisation or other form of treatment; the number which had to be referred for mastoid operation; the number lost sight of and the number still under treatment at the end of the year. Study of this table shows that about half the total number of ears, viz., 1,539, are classified as 'tympanic sepsis' (uncomplicated). Further, the table shows that 29 of these were referred for mastoid operation. "Another point to be noticed is the large number of ears that had already had a mastoid operation at the time of presentation for treatment at the centre. A certain proportion of these had never healed since being operated on, but some of those enumerated had at some time cleared up and subsequently became re-infected. The two main causes of re-infection have already been pointed out and what was said concerning ears untreated by operation applies equally to ears which have been surgically treated. "Many children with (a) discharging ears, or (b) ears which at one time were discharging and have subsequently cleared up, are allowed to go to the swimming baths. In the case of discharging ears this should not be permitted, since in the first place it is objectionable and even dangerous to others, and secondly, it is adding further infection to an already infected ear; while in the case of ears that have recovered from their disease, water from swimming baths is almost certain to give rise to re-infection. Notifications are sent to head teachers in this matter, but notwithstanding this, cases frequently come under notice showing re-infection from this cause. "During the year 180 mastoid operations were performed at the Downs Hospital on children who were admitted on the recommendation of the aural staff of the school medical service. Downs Hospital. These 180 operations are in the table classified under eleven headings. The records of these cases have been followed from the day of their operation at the Downs Hospital through their 'after-treatment' periods, whether at the after-care clinic at Kentish Town or at the special aural clinics, and the following table shows the number (a) of each type of operation where complete healing took place during the year, and also (b) the number of each type of operation where the patient was still under treatment at the end of the year, together with the average length of treatment per case. Type of operation performed. Number of cases Average time per case in weeks (Healed). Number still under treatment at end of year. Average time per case in weeks (Unhealed) operated upon. healed. 1. Radical mastoid operation (without flap 74 43 25 31 313/4 2. „ „ „ (with flap) 20 18 201/3 2 21½ 3. „ „ with muscle graft 38 18 14 20 27½ 4. „ „ with skin pedicle 2 1 16 1 8 5. „ „ with wolf skin graft 1 1 26 — — 0.*Heath conservative mastoid 6 3 151/3 2 25½ 7. „ „ type (without flap] 14 13 21 1 40 8. Schwartz type with muscle graft 17 6 11½ 11 14½ 9. Epitympanic with muscle graft 5 — 5 5½ 10. „ 2 2 20½ — — 11. Heath conservative type with skin graft 1 — — 1 67 *There were six cases of this type done, but one case was lost sight of and therefore only five are shown in this table. "These 180 cases had this in common, they were all cases of chronic disease of the mastoid bone. In certain cases the indications for a particular type of operation were obvious, but in others it was not always easy to decide whether or not any form of radical operation should be performed. The fact, however, of these cases being of a fairly uniform type renders it possible to make some sort of comparison of the results of the various types of operations performed. o1 20 "Although the figures are small it would appear that the best results are obtained from the Schwartz type of operation with muscle graft in the conservative group, and with the muscle graft operation in the radical group. "This is the first year an analysis of this nature has been made, but it is intended to continue the plan in the future, and with greater numbers more evidence will be available. After-Care Clinic. The after-care clinic at Kentish Town is mainly concerned with the treatment of children discharged from the Downs Hospital after ear operations. The following particulars give some idea of the work done at this clinic last year:— Total number of ionisations 1,870 „ „ dressings 2,652 ,, ,, ultra-violet irradiations 477 Number of ears referred from Downs Hospital in 1930 187 „ „ „ „ 1929 and continuing treatment in 1930 53 240 Of these 139 ears were discharged from the clinic 'cured' ; _ 71 were still under treatment at the end of 1930; 2 could not be traced; 8 were re-admitted to Downs Hospital for further operation. The remainder either received treatment at the special aural centres, or else were healed when discharged from the Downs Hospital. The after-care clinic is also used for the purpose of examining and treating residential school children and other special cases referred from head office, etc. Residential schools. "Since the (Council has assumed control ot these schools it has been round that many children suffering from otorrhœa and nasal and aural defects were receiving unsuitable treatment or alternatively no treatment at all. "Several of these institutions have been visited and many of the children examined; 97 cases of discharging ears from these schools have attended the after-care clinic for treatment. "Of these 76 ears have been cured, 17 are still under treatment, and 4 were referred to the Downs Hospital owing to mastoid disease. In addition to the otorrhœa cases, 7 deaf children attended. Of these the hearing was restored completely in 5 cases, while 2 are still under treatment." Teeth. Dr. A. Living s ton. There was an increase of about 10,000 in the number of children treated for dental disease. Dr. Livingston, the Council's consulting dental surgeon, reports as follows:— " During the year 1930 the Council's inspecting dental surgeons found that 34.08 per cent, of the school children had completely healthy mouths and teeth, this is the highest proportion of oral healthiness yet found and is 2 per cent, better than the figure for 1929. The increased healthiness is specially notable in the permanent teeth, treatable when the child comes under the dentist's care at school; the temporary teeth are still too often found hopelessly decayed when the child is first admitted. In this connection the Norwood Dental Centre may be cited where it was found that the following fall in the numbers of permanent teeth extracted as unsaveable in each thousand cases may be represented as follows:— 1928 for 1,000 children 390 permanent extractions. 1929 280 1930 „270 "If 1,000 children be examined, and the total dental and oral disease be summed up, including gum inflammation, accumulated tartar, and other states as well as the more frequent simple caries and the unsaveable teeth, the oral defectiveness this year will be represented by the figure 4,079; this is the lowest representative figure in our records, contrasting markedly with 4,200 three years ago, and over 8,000 in 1912. "Turning to a more detailed review of the working of the Council's schemes, it is satisfactory to record that the actual increase in new cases admitted to the centres this year greatly exceeds the number expected under the local contracts, and 9,327 21 additional new cases were presented although 6,000 only were expected. For this the excellent and continuous work of the care committees is largely responsible; at the same time evidence is accumulating that dread of visiting the dental surgeon is diminishing. A total of 138,280 new cases was admitted to the dental centres under the Council's scheme; of these 40,209 at some time previously had been treated and discharged as completed cases. Compared with previous years the number of temporary teeth found unsaveable and therefore requiring extraction shows a very slight increase, while as pointed out above, there is a definite fall in the incidence of gross decay of the permanent teeth. Here it must be noted that the administration of anaesthetics has kept equal pace with the necessity for extractions, and the dental surgeons exercise the greatest care that operations shall be ' painless,' so assisting to overcome the dislike for dental treatment that is so widespread. "The dental surgeons placed in position, thus preventing further decay, a total of 115,904 fillings, and the average of fillings amounting to 892 for each 1,000 children treated is well maintained. "There was a slight but distinct fall in diseases of the gums. The use of the toothbrush, coarse diet, and general good hygiene, are helping to stem the tide of disease under this heading. "Although on the whole considerable improvement is reported, much remains to be done in the prevention of disease and in treatment of the mouth and teeth. More facilities are needed and it is still necessary to teach the parents the importance of healthy teeth to the whole organism of the child. Here it should be noted that another area—North Hammersmith—has been provided with a dental treatment centre during the year, and moreover, the Eastman Clinic of the Royal Free Hospital was opened late in 1930, to which the children of Prospect Terrace School and scholarship children generally are admitted. To this clinic also the Council's local centres are commencing to refer deformed mouths which are so frequent in England and for the correction of which the existing dental hospitals are severely overworked. "Three new dental centres will be brought into use in 1931, and will each provide much-needed accommodation." Testimony is not wanting to the improvement of the dental condition of young adults. Dr. Mary Kidd, contributing to the report of the medical officer of health of Hampstead for 1929, states: "I want to pay a tribute to the marvellous results that one is beginning to see now, of the dental treatment that has been bestowed so adequately and thoroughly on the London elementary school children in the last fifteen years or so. When I first took charge of the ante-natal clinics in 1918, the teeth of most of the expectant mothers were in a very bad state owing to decay and pyorrhoea. In their school days the dental inspection and treatment of school children in the elementary schools had scarcely been begun. In recent years we have seen a great change in the condition of the teeth of the young expectant mothers. Dental decay and oral sepsis are not nearly so frequently encountered as in the years 1918 to 1924. I attribute this to the fact that the young mothers we are dealing with now have mostly received dental treatment whilst at school." Again, in his inaugural address delivered as President of the Metropolitan Branch of the British Dental Association on December 11th, 1930, Mr. B. B. Samuel stated: "If one may make a general statement at this stage, it would be that the dental condition of children (at least in the London area) has very considerably improved during the last two decades. One no longer sees the large number of appalling carious dentitions in quite young children, and, at Paddington Green Children's Hospital, when such a case comes before us, my colleagues and I usually surmise correctly that the patient is from outer London. I feel that sufficient credit has not been given to the dentists employed by the London County Council for the interest aroused by them and by the workers at the various voluntary organisations, notably the school care committees and the pre-natal and maternity clinics. I think that the public, through these and other agencies, have now learnt something of the evils that may be expected from neglected teeth, and, more important still, the desirability of prevention has been rightly stressed." 22 The employment of "Dental Hygienists." The question of the training and employment of dental nurses or attendants is one which is at the present time much to the fore. The matter has been raised formally, firstly in the following letter from the Dean of the Royal Dental Hospital of London, School of Dental Surgery, University of London:— "The question of training women to act as Dental Nurses to do minor work under the conditions permitted in the Dentists Act, 1921, Section 1 (3) (c) has been considered by my Committee, and I have been invited to write and ask whether, supposing such women were trained, there would be any chance of your Council employing them in your Dental Clinics ? The work they could usefully be employed upon is auxiliary to that done by the Dental Surgeon, and must be under his (her) supervision, and would include the carrying out of simple cleaning of the teeth of children and propagating the principles of Dental Hygiene. "At the moment we have only heard of one or two centres in which such dressers are demanded and we feel that it would be unfair to permit candidates to undergo a somewhat lengthy and expensive training if there is no suitable avenue of subsequent employment. "Your Committee's consideration of this question would be of very great assistance, and I shall be glad if you will kindly let me know the result of its deliberations." Secondly, by the Manor Charitable Trust. A year ago it was agreed that the Manor Trust should take over as a voluntary service the dental oversight of the children in two elementary schools, viz., Gainsborough-road school and Berkshireroad school (Hackney South). The Manor Trust pointed out that there was a number of "dental hygienists" (or dental nurses) being trained in London at present, and the Trust is greatly interested in their future. The Trust adopted a proposal to bear the expense of the experiment, to engage six of these dental hygienists and with the consent of the Education Committee and the Board of Education to utilize them in selected schools in London or, failing London, in some other area, where they would confine themselves entirely to prophylactic and propaganda work. It will be observed that the letter of the Dean of the Royal Dental School refers to "dental nurses," while the Manor Trust speaks of "dental hygienists." The latter is an American term, but the underlying idea is the same. The question is undoubtedly of importance and merits earnest attention. It cannot be denied that the issues involved are controversial. The following is a short outline of the history of the movement:— 1. In America.—Dr. A. C. Fones of Bridgeport, Connecticut, started to train the first dental hygienists in 1913-14. The work of the hygienists attached to the Fones Institute consists in dental inspection of children in the schools, recording the results and giving prophylactic treatment. They work as a rule in pairs and their portable outfits are easily transferred from one school to another. When the equipment is fixed up, the hygienists take each class in the school in succession. Charts are made of each child's mouth, one for the parent and one as a permanent record in the files, showing the conditions found in the mouth over a period of years. In Bridgeport the mouths of 20,000 children are cared for by a corps of 26 dental hygienists, two supervisors and an assistant supervisor (who are also dental hygienists) and three women dentists. This system is now fairly widespread in America, and dental hygienists are trained in many centres. Naturally a movement such as this required careful regulation because of the possibility of abuse through the tendency of partially trained persons to take on duties and perform operations which they are not fully capable of carrying through successfully. Legislation, therefore, had to be brought about. The enactment setting out the law in America is contained in the Senate Bill No. 391. This permits any legally incorporated dental dispensary or infirmary to establish courses of study in oral hygiene for women students, and these may be graduated in one year as dental hygienists. Any licensed dentist, public institute, or school authority may employ such licensed and registered hygienists. They may remove lime deposits, accretions and stains from the exposed surfaces of the teeth, but they shall not perform any other operation on the teeth or tissues of the mouth. They may operate under the general direction and supervision of a licensed dentist, but nothing in the enactment may be construed as authorising any dental hygienist to perform any operation in the mouth without supervision. 23 In addition to the Bridgeport Institute there are other pioneer establishments in the United States that merit description. The Rochester (New York State) Dental Dispensary was founded in 1915 by Mr. George Eastman, who has furnished $1,800,000 for the purpose. At this dispensary, the education of the parents and children is regarded as being of even more importance than treatment. In 1916 a school for dental hygienists was erected for the purpose of educating young women to do prophylactic work in the public schools or in private dental offices. The Dispensary Authorities direct the prophylactic work which is done in the public schools by squads of licensed dental hygienists in charge of licensed dentists. The squads are provided with portable equipment consisting of chair, cabinet, engine instruments, sterilisers, etc. All the prophylactic work—cleaning of the teeth—is done in the schools. The " squad " visiting a school varies from six to fifteen operators, depending on the size of the school. (Note.-—It must be borne in mind that American schools are far bigger than schools in this country.) It is claimed that the benefits of the work are noticeable in the improved health of the children, and that Rochester occupies a unique position with reference to this work. Another famous American institution is the Forsyth Dental Infirmary for Children, Boston. The clinics here were in full operation in 1915. The aim of the institution is "to render serviceable the carious teeth of children; to teach the principles of mouth hygiene, and to make every effort to determine wherein lies prevention." Young women receive instruction in oral hygiene and render services in children's dentistry. Apparently, however, the public elementary and other schools of Boston are not open to the visits of the dental hygienists from the Forsyth Infirmary, and it is stated that in certain other cities where dental hygienists are trained, the school authorities have not thought it desirable to permit their activities within the schools. It has been necessary to set out in some detail the movement in America, for, undoubtedly, the urge at the present time taking place in London is due to the establishment in London of a replica of the Rochester (N.Y.) Dental Dispensary, in connection with the Royal Free Hospital. 2. In New Zealand.—Owing to the shortage of dental surgeons throughout the Dominion and the fact that the population is a very scattered one, it was decided, about 1920, to train young women to perform the necessary treatment which at the outset was to be confined to work on the milk dentition of the younger children. The dental nurses are specially trained by the Health Department solely for Government school dental work. The salaries of these trained dental nurses are less than half of those paid to dental surgeons. The training includes a two years' special course. They work without the continuous personal supervision of dental surgeons and they perform all operations usually carried out by the latter, including extraction and fillings. It is stated that their work has been successful and it is understood that, although they were primarily intended to work solely upon the milk dentition of younger children, the scope of their work has since been extended to cover similar operations upon the permanent teeth of older children. The conditions in New Zealand are, of course, exceptional, but such a scheme of dental practice by partially qualified persons would not be legal in this country. 3. In England and Wales.—During the war, and before the operation of the Dentists Act of 1921, there was a shortage of trained dentists and the Board of Education approved the employment of " dental dressers," who were able to assist the school dentist in his work. This was in accordance with the recommendations of the Departmental Committee appointed by the Lord President of the Privy Council in 1917. Such dental dressers were allowed to carry out inspection, fillings, extractions, etc., under the supervision of a dentist. Eight education authorities at one time or another took advantage of the Board's approval, viz : Sheffield (3 dental dressers), Derbyshire (5), Shropshire (4), Liverpool (5), Abertillery (1), Bristol (1), Nottingham (1) and Preston (1). The Dentists Act of 1921, however, placed restrictions upon the work which might be carried out by dental dressers or nurses, and the conditions defining the 24 legal position in this country at present are contained in Circular 1929 of the Board of Education which is here reproduced:— Performance of Minor Dental work by persons who are not Registered Dentists. "Local Education Authorities will find in the Appendix to this Circular the conditions which have been approved by the Minister of Health under Section 1 (3) (c) of the Dentists Act, 1921, for the performance, in connection with the School Medical Service, of minor dental work, under the personal supervision of a registered dentist, by a person who is not a registered dentist. A few Local Education Authorities have, under conditions approved by the Board of Education, already tried the experiment of employing the services of dental nurses or dental dressers to undertake minor dental work. If such Authorities desire, after the receipt of this Circular, to continue to employ any person who is not a registered dentist in connection with their arrangements for the dental treatment of school children, an intimation to that effect should be sent to the Board of Education, together with an assurance that the work will in future be conducted in strict compliance with the conditions set out in the Appendix. In the case of other Authorities desirous of employing on minor dental work under these conditions any person who is not a registered dentist, full particulars of the proposal should be submitted (on a Form 9a M.) for the approval of the Board of Education under Section 13 (1 )(b) of the Education (Administrative Provisions) Act, 1907, before any appointment is made. Appendix. Conditions approved by the Minister of Health under Section 1 (3) (c) of the Dentists Act, 1921, for the performance of Minor Dental Work in the School Medical Service of Local Education Authorities, under the Personal Supervision of a Registered Dentist, by a person who is not a Registered Dentist. The conditions on which a person who is not a Registered Dentist may perform minor dental work in the School Medical Service of Local Education Authorities under the personal supervision of a registered dentist are as follows:— 1. The approval of the Board of Education must be given to the employment in the School Medical Service of the person concerned, and such approval shall not be given unless the Local Education Authority undertake that the work done shall be limited to cleaning and polishing, applying or removing dressings or temporary fillings, charting, recording or work of like responsibility. 2. The person concerned must be either :— (a) a duly registered dental student who has received training for at least two years in dental mechanics and for at least six months in practical operative work; or (b) a person (called a Dental Nurse) who has received a course of instruction approved by the Minister of Health in a Dental School or Dental Clinic approved for the purpose by the Minister after consultation with the Dental Board ; or (c) a person employed at the date of the approval of these conditions on minor dental work in the School Medical Service under arrangements approved by the Board of Education. No dental student employed under paragraph 2 (a) of these conditions may be so employed for more than six months. 3. The registered dentist under whose personal supervision the work is performed:— (a) must always be present when operative work is being carried on ; (b) must not supervise more than two persons at one time if he himself is performing operative work at the same time, or more than six persons at one time if he himself is not so performing; (c) must prescribe the treatment to be given and inspect every case after treatment and be responsible for the efficient carrying out of the treatment." The issue of this Circular for the time being put an end to the employment of dental dressers by the local education authorities. 25 In considering the question it must be remembered that in London there has been a system of progressive dental care of the children which has been in operation for 18 years, and that there has never been experienced any shortage of dentists in London for the work. The school treatment centres to which dental departments are attached are provided by voluntary committees who appoint and direct the dentists employed; the Council reserves to itself the approval of the dentists and the right of inspection. Certain of the dental surgeons appointed for treatment by the dental committees are also appointed dental inspectors in the schools by the Council. At present there are 64 such dental inspectors, and there is provision (which is annually increased) for the treatment of 144,100 children per annum. All children in the schools are inspected by the dental inspectors at the ages of 6, 7, 9, 10 and 11 (in the other age groups they come under inspection by the school doctors). It has not always been possible in the past for the school dentist to complete his rota of inspections within the year, but special attention has been directed to this point and failure is now the exception rather than the rule. Parents are invited to the dental inspections and instruction in dental hygiene is given by the dental inspectors by lectures to the parents and by individual talks. The dental inspector is accompanied at his inspections by an assistant care organiser who undertakes some of the clerical work and the making of appointments at the dental centres. In the case where the parent does not attend, a form is forwarded, when treatment is required, for the parent's signature. Failure to respond is attended to by the members of the school care committees who are entrusted with the followingup of the cases. At the treatment centres the dentist is assisted by a fully trained nurse who is a member of the Council's school nursing staff. The London system of school dental inspection and treatment. The provision of facilities for treatment has hitherto almost equalled the desire of the parents to take advantage of them, but at the present time the educational advance as regards appreciation of the need of dental treatment is in some areas a little ahead of the provision. In these areas when the waiting lists become unduly long, they are reduced by the provision of additional sessions. The ideal of continuous dental treatment for all children needing it will eventually require the present provision in London to be very largely increased, but this will be one of the problems of the future. The provision of dental hygienists or dental nurses, whichever they are called, must be viewed from two aspects (1) in the treatment centres, (2) in the schools. Treatment Centres.—In the treatment centres the Council already provides fully trained nurses or nursing sisters, some of whom have been engaged in the work for many years. Their work is confined, however, to non-professional duties in the dental sense, i.e., the care of and sterilisation of instruments, holding the children, handing the instruments to the dentist, cleaning up, clerical work, etc. It is possible that if each dentist were provided with a dental hygienist, more professional help would be given and the dental work might be more expeditiously performed. It might be considered whether the school nurses should not be trained to do the more professional work. There is, as yet, no suggestion as to the salary a fully trained dental hygienist would command, but it is hardly likely to be so disparate from that of the school nurse as to effect any economy in this respect, and it must not be forgotten that the use of dental hygienists or school nurses for even minor dental work is almost certain to arouse opposition on the part of the dental profession. The presence of a fully trained nurse would still be necessary on "anaesthetic days." Schools.—In the schools the services of the dental hygienist would be mainly of a propagandist character, but only experience in this country can demonstrate either a positive or negative value. It must be pointed out that the "leakage" between inspection, and treatment is greater in the case of dental disease than in that of any other kind of ailment; that in spite of all endeavour, at the best, not more than 67 per cent, of children found on inspection to require dental treatment actually receive it; and that no means should be neglected which promise a more rapid improvement than at present obtains. It is probable that much of the difficulty experienced arises from the fears of the children 26 themselves, and it is thought that the prophylactic work of the dental hygienists in the schools would operate in the direction of overcoming these natural fears in regard to dental treatment. The effect of the entry of dental hygienists into the schools would also have to be considered upon several classes of individuals now engaged in the work including the teachers, organisers, and care committee members, school dentists, school nurses and school doctors. The effect upon the teachers.—The teachers at present carry out important propaganda work, they are charged with the duty of hygienic instruction and in some schools instruct the children in the care of their teeth by tooth brush parades and tooth brush drill, etc. Some teachers are enthusiastic, others less so. In at least one school in London where the head teacher is a super-enthusiast in the cause of dental hygiene there is a hundred per cent, efficiency. If this could be reproduced in every school the whole problem would be at once solved without the advent of dental hygienists. Would the teachers welcome this further invasion of the schools ? The question cannot be answered with certainty. On the ground of disturbance of school work, however, it is almost certain that there would be opposition in many places. It is probably the anticipation of this opposition which has prevented the dental hygienist from obtaining entry to the schools even in certain cities of the United States in which they received their training. The effect upon organisers and care committee members.—The dental hygienists would naturally usurp to some extent the functions of organisers and care committee members but especially that of the organisers, as they would be the natural accompanists of the dentists at the inspections. Would the care committee members welcome them ? Probably yes, if it could be shown that they are more effective in propaganda and if their prophylactic work could be shown to result in the prevention of decay. Incidentally it may be mentioned that it is the organiser and not the centre nurse who at present accompanies the dentist because the following-up of defect is in the Council's system carried out by the voluntary care committees and not by the paid professional staff. The effect upon the school dentists.—It is possible that, obeying the professional instinct, the school dentists themselves would prefer not to be placed in the invidious position of aiding a system not acceptable to the profession at large, although the Council of the School Dentists' Society has declared itself not inimical to the employment of dental hygienists on the Fones plan. The effect upon the school nurses.—The school nurses are the practical educators in habits of personal hygiene, including the hygiene of the mouth. Under a scheme initiated by Sir Cyril Jackson, who provided prizes for individual excellence in oral hygiene in schools, the school nurses acted as judges and much early educational work in this connection was carried out by them. As in the case of attendance at the dental centres, it may appear that if there is a place for dental hygienists in the schools it would be better, by training the school nurse, to combine in one individual the care of all aspects of personal hygiene than to multiply the different specialists and classes of persons visiting the schools. The effect upon the school doctor.—The school doctor at present takes a very prominent share in the propaganda work, especially as over 80 per cent, of the parents attend the inspection of the entrant children. Indeed in various ways so much propaganda is carried on that it is possible that the people who are not converted remain aloof from conviction rather than from ignorance. The dental hygienist, however, would in no way interfere with the school doctor's work. In the above considerations the propaganda side of the dental hygenist's work has been chiefly borne in mind, but the very important question of the prophylactic side of the work has not been given so much attention. If it can be shown that by the practical attention to oral hygiene—cleaning and polishing the teeth of the children in school, detecting at an early stage the beginning of caries, bringing home to the children their individual remissions in care, etc.—a considerable prevention of caries takes place and a considerable expenditure upon treatment is avoided, and 27 that there is 110 cheaper or so efficient a method of attaining this result, then the dental hygienist in some form must be provided. Some of the American reports are enthusiastic and the rapid extension of the dental hygienist movement in America would hardly have taken place unless the opinion was widely spread and strongly held that their work is good. On the other hand the same opinion might be held of our own system in England of which the results can by no means be held to be negligible. A letter which has been received by one of the Council's officers from the Director of one of the pioneer training schools for dental hygienists in America suggests caution. He states: "You ask as to the results. I think that the hygienist does some valuable work and that there is a great field for her in certain places. I do not think, however, that the hygienist will ever prevent decay of the teeth. I believe the cause of decay is of a more fundamental nature. Statistics indicate this since in spite of all our hygiene and reparative work, dental decay still exists to the extent of 95 to 98 per cent." The Council considered that the Dean of the Royal Dental Hospital School of Dental Surgery should be informed that the Council would not. at present contemplate the employment of dental nurses or dental hygienists as permanent officers in the Council's school dental service. It was considered worthy of trial to accept the services of the six dental nurses offered by the Manor Charitable Trust and the Council agreed to give facilities for this experiment, their work to be confined to propaganda and prophylactic work. Subsequently the Eastern Clinic was opened on 17th November, 1930, and with the consent of the Manor Trust three of the six dental nurses were appointed at this clinic to whom the Council agreed to assign the dental care of a neighbouring school (Prospect-terrace) on the same lines of voluntary service followed by the Manor Charitable Trust in the two Hacknev schools alreadv mentioned. The Council is bound by law to make a charge for treatment. The charge to the parent is fixed at 2s. for a major ailment, and after a fortnight's free treatment 1s. for a minor ailment until discharge. No charge is made for refraction which is held to be a form of " further inspection." Spectacles are paid for by the parents but assistance is given in necessitous cases by the London Spectacles Association working in conjunction with the school care committees. Concessions art allowed whereby for " slight treatment " of dental cases a charge of 1s. only is made and the school care committees are empowered to remit the charge altogether in any case where necessity is pleaded. The number of " slight cases " in which the charge was reduced for dental treatment was 10,897. The total amount recovered from parents during the year was £11,723 3s. 2d. By an arrangement with the Hospital Savings Association vouchers are accepted in lieu of payment of charges and the Fund pays to the Council the sum of £1,000 a year. The average cost per case has been worked out as follows for the current year:—Refraction and eye disease, 6s. 3d. ; ear, nose and throat defect, 17s. 2d.; minor ailments, 7s. 9d; X-Ray treatment of ringworm, 25s. 8d.; dental treatment, 7s. 2d. Notices setting out these costs are exhibited in the centres for the information of parents who desire to pay in full. Scholarship holders in secondary schools are treated on the same terms as elementary school children, but fee-paying pupils in these schools are required to pay the full charge as set out on the exhibited notices. Charges for medical treatment. Stammering Children. There are now eight centres for stammerers, a new centre at Amberley-road school (Paddington, N.) having been opened in August, 1930. During the year 320 children attended the centres ; of these 29 were discharged cured, 55 as provisionally cured, and 48, many of them greatly improved, left for various reasons. It is only quite recently that it has been realised that stammering is not due to an organic defect of the speech apparatus but should be classed as a nervous disorder, in many cases a disorder of the whole personality, affecting behaviour, temperament and outlook. In the child and to a greater degree in the adult the effects of this disorder are very noticeable. The sufferer may be irresponsible and unstable, irritable or excitable. He is often quick tempered or unruly, or, on the other hand, moody and reserved. Report by Dr. E. J. Boome. 28 The stammerer frequently has a neuropathic history or a constitutional tendency to this condition. He may have experienced a severe disturbance of the nervous system due to shock, accident or fright, e.g., one boy was pushed off a pier into the water by a rough companion, another set a room on fire. Some sufferers begin to stammer after the shock of an operation for the removal of tonsils and adenoids. Illness is a frequent determining cause, and in some cases it is the aftermath of scarlet fever or diphtheria. Again, in some cases, rheumatic fever or subacute rheumatism are factors in the causation. The common association of rheumatism with chorea, the greatest cause of inco-ordination in children, is well established. This connection is so close that cases of chorea have been sent to the centres as stammerers. In all these cases the fact underlying the muscular inco-ordination is the nervous instability so often found in rheumatic disorders. One of the most noticeable features of a stammerer is his strained and anxious expression. Even in repose this is seldom absent and it becomes intensified as soon as he attempts to speak. When he actually begins to speak, another characteristic exhibited by all stammerers to a greater or lesser degree is at once evident, namely, the muscular tension which is an outward and visible sign of mental tension. The latter is there all the time, but except to the initiated observer it is, perhaps, not so evident until the effort of speaking makes it so marked as to be unmistakable. In a severe case this hypertonicity will nearly always be accompanied by muscular spasm. The worst type from the point of view of treatment is the laryngeal spasm. This type takes longer to learn to relax and, therefore, to cure than any other. In the examination of persons suffering from cerebral paralysis, who are often of a very high mental grade, it was noticeable that general muscular spasm and athetosis was often aroused by attempts at utterance. This was especially so when the response required considerable mental effort. Thus it was more marked with the more difficult mental tests than with the easier ones. It should not be necessary to tell parents that fault finding or ridicule increase a stammer and yet this has to be done repeatedly, although it is not always the harassed mother with slender means and a large family who needs advice on this point. Investigation reveals a distressing number of parents holding a totally wrong view of the children they bring for treatment. As regards the patient, one of the symptoms of the inferiority complex is extreme self-consciousness. He blushes easily, is often emotional, sometimes almost hysterical, but worst of all is his acute sense of difference from his fellows, inseparable from his condition, unless the stammer is a very mild one. This feeling of inferiority or inadequacy will gradually colour his whole personality ; he does not confine it to speech ; he begins to doubt himself in other directions as well, e.g., his ability to do good work, or to establish contact with his fellows. In extreme cases he may go about with a hanging head, be unable to look people in the face and will avoid responsibility, preferring always to keep in the background. He is hypersensitive and in constant fear of ridicule. As Locke said in 1690 : " Defected minds, timorous and tame, and low spirits are hardly ever to be raised and very seldom attain to anything." This inferiority complex may be due, more especially in a child, to environment. Constant discouragement and fault-finding will gradually undermine self-confidence and a child whose manner, appearance or achievements are the subjects of continual adverse criticism can hardly fail to develop an inferiority complex. Stammering, then, is associated with a condition of instability of the nervous system and enuresis and delinquency. The relationship in the last-mentioned complaints has been attributed to the same cause. Dr. Verner Wiley made some notes on the signs of physical instability and the type of mental instability found in non-defective delinquents examined by him. His results, given in the School Medical Officer's Annual Report for 1929, page 82, show that of 401 cases at Pontonroad Place of Detention, 26, or 7.3 per cent., suffered from enuresis and six cases, or 1.7 per cent., stammered. In another group of 522 consecutive cases of stammerers 36, or 6.9 per cent., suffered with enuresis. 29 Treatment.—Many a stammer has been confirmed by the wrong attitude of parents and teachers towards it, whereas if rightly treated in the initial stage, it might never have developed. The prevention of undue excitement, plenty of rest and sleep, and above all, intelligent treatment of the child so that his attention shall not be focussed on his difficulties, are all simple preventive measures. Exercises based on principles of relaxation and rhythmic co-ordination are invaluable. They further the practice of ease and rhythm, and are the means of inducing confidence and mental relaxation. Voice production methods can do no harm to a stammerer if they do not draw attention to the mechanism, i.e., the breathing, or the action of the vocal cords. The husky or wrongly pitched voices so often found among stammerers will usually adjust themselves with the gradual release of the tension that is causing them. One of the most important elements in the treatment is relaxation. Muscular relaxation to begin with, leading as the patient progresses to mental relaxation. This should be the basis of all treatment. It is invaluable and indispensable. No treatment can have lasting results which does not enable the patient to acquire physical and mental repose. Lefthandedness and Stammering.—Miss M. A. Richardson conducted an investigation into the incidence of lefthandedness among normal speaking children in two elementary schools, and compared them with 522 stammerers, which gave the following results:— In school 1, among 280 non-stammerers 24 were lefthanded, or 8.57 per cent. In school 2, among 350 non-stammerers 26 were lefthanded, or 7.43 per cent. Of the 522 stammerers 23 were lefthanded, or 4.45 per cent. According to these figures, the number of lefthanded children among normal speakers would appear to be about double the number found among stammerers. But although 23 only were lefthanded, Miss Richardson found that 132 of the 522 had lefthanded relatives, which points to a possible connection between the lefthanded temperament and stammering. Personal Hygiene Scheme. The number of examinations made by school nurses at rota visits during 1930 was 1,862,374, and verminous conditions were found in 225,323 cases or 12.1 per cent., as compared with 12.4 per cent, of cases examined in 1929. Particulars of the examinations and the results of the cleansing schemes during the past five years are given below:— 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 and impetigo cases bathed at centres. 1920 1,840,106 288,721 15.6 120,071 31,116 88,955 2,130 1927 1.990,201 261,135 13.1 123,279 27,031 96,248 2,609 1928 1,850,152 233,108 12.6 119,241 26,236 93,005 2,820 1929 1,909,723 236,034 12.4 116,618 25,502 91,116 3,163 1930 1,862,374 225,323 12.1 117,814 26,590 91,224 3,462 Of the 225,323 cases in which verminous conditions were noted, 127,345 (56-5 per cent.) were found to have nits only. The Council has two " cleansing schemes " ; one in which only slight traces of infestation are dealt with at head cleansing centres; the other providing for the treatment of the more severe cases of infestation of persons and clothing and leading 30 up to court prosecutions where necessary. The latter scheme is worked from " bathing centres " provided by the borough councils or the Council itself; these centres are equipped with baths and sterilisers but the so-called " shampoo centres " have only provision for head cleansing and in some cases the work is carried out in a room in a medical treatment centre. The number of cleansing centres used is now 38; 11 being the Council's own centres, 18 are borough council stations, and there are 9 centres organised by voluntary committees (one of these at "Downham" was newly opened early during the year). The undermentioned cases were dealt with under the cleansing scheme for the more severe cases:— Number of advice cards issued to parents 90,322 „ children attending voluntarily at bathing centres 42,973 „ statutory notices served in accordance with Sec. 87 of the Education Act, 1921 23,097 „ attending bathing centres after statutory notices— (a) Voluntarily 4,915 (6) Compulsorily 15,844 ,, cases in which police court proceedings taken 300 Co-operation with the medical officers of the City of London and the metropolitan boroughs in remedying verminous conditions in the homes of children has been continued. Use of public washing facilities. The number of children attending for warm baths during school hours was 35,089 in 1930, as compared with 37,018 in 1929. The arrangements were during the year extended to the Borough of Fulham. Statistics. Rheumatism Scheme, 1930. Number of nominations 639 ,, children admitted to special hospitals 324 Cases seen by medical referee in voluntary hospitals 86 „ ,, „ in their homes 147 „ „ „ at supervisory centres 86 „ „ „ at County Hall 18 Reports made by care committees on home conditions 307 " Following-up " reports made by care committees 391 Cases seen at County Hall on return from hospital 210 Re-examinations by school doctors 505 Number of children attending supervisory centres for the first time 1,387 Total number of attendances at supervisory centres 6,070 Number of cases referred to Invalid Children's Aid Association 210 „ reports made by Invalid Children's Aid Association 194 „ cases reported to medical officers of health re dampness, etc. 39 „ cases reported to housing manager for better accommodation 28 Report on the rheumatism scheme. Dr. A. Banks Raffle. During 1930 certain changes took place in the organisation of the rheumatism scheme : 7 additional centres were brought into the Council's scheme for supervising rheumatic children, viz.:—East London Hospital for Children, Hammersmith School Treatment Centre, King's College Hospital, Putney School Treatment Centre, Royal Waterloo Hospital Supervisory Centre, St Marylebone General Dispensary and Woolwich School Treatment Centre. Of these the Hammersmith, Putney, King's College Hospital and Woolwich Centres did not exist before 1930, but the other three were working in co-operation with the Council's scheme although not subsidised by the Council. The two rheumatism supervisory centres at Paddington Green Children's Hospital and the Princess Louise, Kensington, Hospital for Children continue to co-operate with the school medical service. With the disappearance of the Metropolitan Asylums Board in April the co-operation which had obtained since 1926 came to an end. From April the beds required for the treatment of children suffering from rheumatism were supplied by the special hospitals division of the public health department. The change has proved of marked service to the scheme, for although the provision of hospital 31 modation falls far below requirements a step forward was made during the year in that more than fifty children received treatment at Carshalton or Brentwood than was the case in 1929. As in former years, the medical superintendents of Queen Mary's Hospital, Carshalton, and High Wood Hospital, Brentwood, have always shown themselves willing to help in providing, as far as was in their power, accommodation for children requiring immediate treatment either on account of the severity of their illness or because their home surroundings were unsatisfactory. Two advances have been made in the work of following-up children who have received hospital treatment for rheumatism. Before 1st April, 1930, when the Local Government Act, 1929, came into force, only a limited number of children with rheumatic affections, who had been admitted into the Metropolitan Asylums Board's children's hospitals through the local boards of guardians, were supervised under the scheme after their discharge. Now, however, by co-operation with the special hospitals division and the general hospitals division every rheumatic child recommended for treatment in a special hospital is known to the rheumatism section with the result that medical discharge reports are now received from the Downs Hospital, Sutton, and effect is given to recommendations concerning attendance at rheumatism supervisory centres or for examination for certification for attendance at a school for physically defective children. The children reported on are supervised in school in the same manner as those discharged from Queen Mary's Hospital or High Wood Hospital. The other advance is that the supervision of children who have received hospital treatment under the scheme has now also been extended to include the years immediately following their leaving school. From the information supplied by the returns of such supervision it will be possible to ascertain the effect of child rheumatism in adolescence, to estimate the handicap which the disease inflicts on the young worker, and to assure that the children are supervised or treated if this should be necessary after they have passed out of the care of the school medical service. The results of a few months' experience of this additional supervision are set out later. With the further provision of supervisory centres during the year the number of children dealt with is greatly in excess of former years : 1,387 children attended the centres during 1930, making 6,670 attendances. These centres are a vital part of the rheumatism scheme for they not only provide for the diagnosis and supervision of children who do not require a stay in hospital as part of their treatment but also select for the hospital beds available the most suitable cases. One of the most striking feature of the year's work has been the increase in the number of children who have been admitted to Carshalton or Brentwood on the recommendation of the medical officers of the supervisory centres. Such children have not had, as so many of those referred by the voluntary hospitals have, preliminary treatment in hospital, and not only is their need of accommodation in the Council's hospitals greater but also they furnish especially valuable information on the course which rheumatism takes in children. It is expected that further centres will be opened in 1931, adding to the framework which is being gradually extended throughout the Council's area, and on which will be built future developments of the medical and social work among rheumatic children. Work of supervisory centres. The number of children nominated for hospital treatment during the year was 639. The agencies nominating these children were:— Voluntary hospitals 303 Assistant medical officers and school care committees 173 Medical officers of supervisory centres 80 Invalid Children's Aid Association 37 Private practitioners 31 Other agencies 9 639 Nomination for hospital treatment during 1930. 32 It should be noted regarding the nominations by the Invalid Children's Aid Association that in addition to the figures shown above many of the cases notified by the voluntary hospitals are also notified by the Association, and other cases which have become more urgently in need of hospital treatment are re-notified by them. It would be unsafe to accept the nominations received during 1930 as representing the number of school children in London who need prolonged residential treatment for rheumatism. It is well known to the nominating agencies that the scheme has not unlimited beds at its disposal and they have, therefore, hesitated to send in the names of children except where real urgency occurred. The nominations were distributed as follows: Seasonal incidence. January 59 February 61 March 56 April 45 May 47 June 50 July 66 August 31 September 42 October 56 November 70 December 56 639 This distribution indicates the demand for beds throughout the year. The fall in the number of nominations during August and September is to some extent explained by the school holidays and by the cessation of the work of the rheumatism supervisory centres, but it is also due to the smaller amount of rheumatism which is present in the community during this season of the year. Of the 639 children nominated, 324 were admitted to hospital, either at Queen Mary's Hospital, Carshalton, or High Wood Hospital, Brentwood. There were comprised in this number 114 boys and 210 girls. Ages of children admitted to hospital. The ages of the children admitted to hospital were as follows:— Age. Number admitted to hospital. Age. Number admitted to hospital. 3 1 9 48 4 4 10 49 5 10 11 44 6 16 12 44 7 22 13 25 8 23 14 31 The condition of the 324 children admitted to hospital is set out in the following table:— Type of disease. Boys. Girls. No. of cases. Heart affected. Valvular disease of the heart. No. of cases. Heart affected. Valvular disease of the heart. Rheumatic fever 11 7 1 20 14 9 Sub-acute rheumatism. 70 50 18 125 40 30 Chorea ... 33 12 3 65 23 12 Total 134 69 22 210 77 51 Rheumatic nodules. Rheumatic nodules were present in 5 children (3 boys and 2 girls) admitted to hospital. Two were cases of chorea, one was rheumatic fever and the other two sub-acute rheumatism. In four of these children the heart was affected. 33 During 1930, 356 children were discharged from hospital (Carshalton 136, Brentwood 220), and 210 of these were examined at County Hall; 102 were considered to be physically fit for the full curriculum of an elementary school with the exception of swimming ; 61 were permitted to attend an elementary school, but drill and games were forbidden ; 43 were certified for schools for physically defective children, and 4 were held to be temporarily unfit for attendance at any school. Children discharged from Carshalton and Brentwood. Of the 324 cases admitted during the year to Queen Mary's Hospital or High Wood Hospital, 18 had previously received hospital treatment under the scheme (six boys and 12 girls). Their condition on re-admission was:— Rheumatic fever with heart disease 2 Sub-acute rheumatism 3 „ „ with heart disease 3 Chorea 5 „ with heart disease 5 18 Relapsed cases. One girl with rheumatic carditis and one girl with chorea had been twice previously in hospital under the scheme. How far rheumatism affects the young person after leaving school is being investigated by the school care committees, as stated earlier in the report. Fifty-one questionnaires were sent out concerning children treated at Carshalton or Brentwood in 1926, 1927 and 1929, the children treated in these years being chosen so that the work of tracing those treated in the early days of the scheme should be begun, and a start also made with following-up, immediately on their leaving school, rheumatic children treated in hospital more recently. Of these 51 children, 2 had left London. After-care "following- up." The returns for the others (22 boys and 27 girls) are shown in the table below:— Left school 1 year or less. Left school more than 1 year. Left school more than 2 years. No. who had further attacks of rheumatism or chorea. No. who had received hospital in-patient treatment since leaving school. No. who were under medical supervision. No. who were able to keep employment selected on leaving school. No. who had to leave employment because of rheumatic handicap. No. who were incapable of regular work. (a) (6) (C) (d) (e) (f) (g) (h) (i) 19 14 16 18 9 13 36 8 5 The nature of the employment in which the 36 children (shown in column (g)) had been engaged since leaving school, was as follows:— Girls—Clerical work 4 Boxmaking 1 Packing 2 Boys.—Parcel and message delivery 6 Domestic service 1 Tailoring 1 Work on railway 1 Needlework 3 Sweetmaking 1 Factory work 1 Plumbing 1 Packing 2 Sign writing 1 Waiting 2 Work in retail trades 4 Bootmaking 1 Carpentry 2 Printing 1 Hairdressing 1 The above is an indication of the information which is being obtained in this new extension of the scheme's work. With a larger number of returns it will be possible to form some idea of the extent to which the rheumatic child is handicapped after leaving school, and as to how far the parents make use of other facilities for treating rheumatism when their children have passed out of the care of the school medical service. The number of children on the rheumatism register had attained the figure of 16,911 at the end of 1930. Of these 16,326 (6,421 boys and 9,905 girls) are under the age of 16 and come within the scope of the rheumatism scheme. The distribution of Distribution of children on rheumatism register throughout metropolitan boroughs. d 34 Registered Rheumatic Children. these registered rheumatic children throughout the metropolitan boroughs is shown in the table given below:— Boroughs. Child population (0-16) 1921 Census. Under 14, i.e., born in 1917 or since. 14 to 16, i.e., born in 1916, 1915, 1914. Over 16, i.e., born in 1913 or before. Total. Rate per 1,000 children. Boys. Girls. Boys. Girls. Boys. Girls. Boys. Girls. Boy . Girls. Boys. Girls. Battersea 26,684 26,785 146 181 46 84 4 11 196 276 7.3 10.3 Bermondsey 21,796 21,805 182 266 38 117 3 18 223 401 10.2 18.4 Bethnal Green 21,747 21,706 213 249 66 136 14 30 293 415 13.5 19.1 Camberwell 43,655 43,140 176 275 53 118 8 17 237 410 5.4 9.6 Chelsea 6,959 7,561 58 83 20 31 2 7 80 121 11.5 16.0 City of London 1,300 1,272 10 14 2 1 2 — 14 15 108 11.8 City of Westminster 11,974 12,568 85 108 6 35 — 1 91 144 7.6 11.6 Deptford 18,379 18,512 100 161 41 75 5 11 146 247 7.9 13.3 Finsbury 13,402 13,312 97 122 20 46 3 10 120 178 90 13.4 Fulham 24,140 24,019 152 210 40 90 — 14 192 314 8.0 13.1 Greenwich 17,334 16,370 141 230 44 78 9 19 194 327 11.2 20.0 Hackney 33,650 34,198 215 305 59 121 2 26 276 452 8.2 13.2 Hammersmith 18,320 18,563 159 229 51 80 1 6 211 315 11.5 17.0 Hampstead 8,702 9,392 17 21 6 13 1 2 24 36 2.8 3.8 Holborn 4,341 4,188 24 39 4 14 2 1 30 54 6.9 12.9 Islington 50,558 49,949 369 559 120 221 17 20 506 800 100 16.0 Kensington 19,956 21,219 120 179 24 91 6 10 150 280 7.5 13.2 Lambeth 44,979 44,500 409 487 109 185 17 25 535 697 11.9 15.7 Lewisham 25,059 24,655 275 371 64 95 8 14 347 480 13.8 19.5 Paddington 16,992 17,659 150 221 47 67 5 10 202 298 11.9 16.9 Poplar 30,107 29,787 295 373 63 185 6 28 364 586 12.1 19.7 Shoreditch 19,333 19,472 132 162 35 89 4 8 171 259 8.8 13.3 South wark 31,626 31,631 276 423 81 175 15 30 372 628 11 .8 19.9 St. Marylebone 10,723 11,771 49 70 9 17 3 2 61 89 5.7 7.6 St. Pancras 30,437 30,180 266 299 54 136 7 21 327 456 10.7 15.1 Stepney 46,272 45,486 379 598 126 299 16 35 521 932 11.3 20.3 Stoke Newington 6,892 6,996 28 55 9 15 — 2 37 72 5.4 10.3 Wandsworth 45,853 46,918 310 420 84 138 6 11 400 569 8.7 121 Woolwich 22,248 21,590 209 303 59 140 10 19 278 462 12.5 21.4 673,418 675,204 5,042 7,013 1,380 2,892 176 408 6,598 10,313 9.8 15.3 Note.—Although the Council's rheumatism scheme was established to provide for the treatment and supervision of children under the age of 16 years, a beginning has been made in 1930 with the " following-up " of children over that age who have received treatment in the Council's special hospitals. 35 Since the beginning of the rheumatism scheme at the end of 1926, 2,426 children have been nominated for hospital treatment and 1,008 children have received treatment at Queen Mary's Hospital, Carshalton, or at High Wood Hospital, Brentwood. This part of the work has required 255 visits to hospitals where the children were in-patients when referred to the Council, and 845 home visits for the purpose of ascertaining whether these cases were suitable for treatment under the scheme. With the admission of the children into hospital under the Council's scheme came the necessity for obtaining information concerning the home conditions in which they were living previous to the onset of rheumatism. This has called for 1,082 home visits by the representatives of the school care committees, and in looking through the files for the past four years one cannot but be impressed by the admirable way in which the reports on their visits have been rendered. Based on these reports, 147 communications have been made to the medical officers of health of the boroughs concerned drawing attention to unsatisfactory home conditions and in 66 cases support has been given to the application of the parents for special consideration under the Council's housing scheme ; 591 children have been examined at County Hall on their discharge from Queen Mary's Hospital or from High Wood Hospital and recommendations made as to the type of school for which they were suited and how far they could follow the full curriculum of the school. With the return of the children to their homes the assistance of the school care committees was once more necessary and 1,078 home visits were made and reports sent in, detailing the surroundings to which the children had returned, and whether they were receiving adequate medical supervision on returning to home life. The work in this respect has taken a step forward this year in that the school care committees are now supervising rheumatic children after they have left school. Review of scheme since its commencement. The medical supervision of the children on their return to school has been undertaken by the assistant medical officers at the schools themselves or by the specialist medical officers at rheumatism supervisory centres ; 355 of the children were referred back to the voluntary hospital which recommended them, but these cases are still supervised in school. The assistant medical officers furnished 1,272 reports on the physical condition of the children, recommending transference to another type of school should this be necessary, and stating if attendance at a supervisory centre or the out-patient department of a voluntary hospital is needed, or whether further treatment in hospital is more suited to their case. In reviewing the history of the scheme it is apparent that an increased number each year of the children is being sent for supervision at the rheumatism supervisory centres, rather than reliance being placed solely upon their being followed up in the schools. With the increase in the number of these centres it may be found possible to arrange for the majority of the children who have had hospital treatment under the scheme to attend at the centres for expert supervision. The Invalid Children's Aid Association has worked side by side with the rheumatism section in providing hospital accommodation for children needing this form of treatment. During the period under review the names of 1,214 children have been referred to the Association and 1,215 reports have been supplied stating whether treatment has been arranged for the children, or whether further treatment should be given under the scheme, and furnishing other valuable information concerning the family and the home circumstances. An analysis of 1,028 attacks of all forms of rheumatism shows that these attacks were more evenly distributed throughout the year than has been shown in other investigations. The first three months of the year and the last quarter are usually accepted as the peak period for rheumatism, and while this is true of a curve plotted to illustrate the above analysis a study of the figures for each month reveals that only 59 per cent, of the rheumatic attacks occurred in these two quarters of the year. In this series of 367 attacks of rheumatic fever only 58 per cent, were noted in the first and last three months of the year, and while the incidence of sub-acute rheumatism was heaviest in March and December, the general level was well maintained throughout the year. Chorea among boys falls in incidence from May D 1 Seasonal incidence. 36 to October but this lowering of incidence does not appear among girls. While an examination of these figures may not be of much scientific value they are of considerable interest in administration. Pressure on the beds at the disposal of the scheme has always been heavy even during what are regarded as the non-rheumatic months of the year. Comparative incidence of rheumatism in the sexes. The figures for the hospital admissions during the period in which the rheumatism scheme has been in operation do not provide any information of value on the comparative incidence of rheumatism in the sexes, for more beds have always been available for girls than for boys. The same criticism applies to the numbers of boys and girls in the nominations received, for, because of the known shortage of boys' beds, the agencies have hesitated to nominate boys. Some idea of the comparative incidence may be obtained from the reports of the rheumatism supervisory centres ; of 1,213 children definitely diagnosed to be rheumatic there were 482 boys and 731 girls. A like proportion appears in the figures on the rheumatism register for 16,911 children, there being 6,598 boys and 10,313 girls. The ratio of three rheumatic girls to two rheumatic boys is also shown for a number of years in the figures for children out of school for lengthy periods. The importance of bearing this proportion in mind in allotting future accommodation is readily seen when it is remembered that in the past one of the great administrative difficulties has been that a much smaller proportion of boys' beds has been provided than was necessary for the satisfactory working of the scheme. Age of onset. During the year an examination has been made of the statistics which have been accumulating since the inception of the rheumatism scheme for the purpose of obtaining some idea of the age at which first attacks of rheumatism (including chorea) make their appearance. The result shows that rheumatism reveals itself as a disease which usually begins during the early school life of the child. Examining the history of 1,700 rheumatic children it is found that 685 (40 per cent.) first attacks occurred in the 6-8 age period, and 498 (29 per cent.) in the 7-8-year-old period. A curve plotted to demonstrate the incidence of first attacks at the different ages shows a sharp rise from the age of five to a maximum at eight and then a fall to a level below that at age six and this level is maintained until the age of thirteen, whence the incidence falls below the level for the four-year-old. In 500 first attacks of rheumatic fever the chief incidence was within the same three years, 6-8 ; 200 (40 per cent.) of the attacks arise in this period with a maximum at six years of age, while in 386 cases of chorea 172 (44 per cent.) of first attacks fell within the 6-8 period with a maximum at seven. A family history of rheumatism is more frequently met with in children whose initial attack of rheumatism occurred before eight years of age, but faulty home environment was recorded more often in children whose rheumatism began after this age. Heredity may influence the age at which rheumatism makes its appearance. The incidence of the various manifestations of rheumatism in 1,287 children treated in hospital was:— Rheumatic fever. Sub-acute rheumatism. Chorea. 149 (67 boys, 82 girls) 784 (275 boys, 509 girls) 354 (102 boys, 252 girls) 11.6 per cent. 60.9 per cent. 27.5 per cent. Rheumatism and heart disease. Two sets of statistics are available which throw some light on the proportion of rheumatic children in whom the heart is attacked. The first of these is obtained from the discharge reports of 1,325 children treated at Carshalton or Brentwood: 728 (55 per cent.) of these children had heart disease of whom 346 (26 per cent, of the total number) had established valvular disease. These children were suffering from rheumatism of a severe nature. The returns from the rheumatism supervisory centres, on the other hand, supply a second set of figures relating to children who are affected by the milder manifestations of the disease in addition to others who have been more severely attacked. Of 1,529 children diagnosed as definitely rheumatic, the heart was affected in 630 (41 per cent.) and valvular disease of the heart was present in 209 (14 per cent.). 37 38 The incidence of the varieties of valvular disease was reported:— No. of cases of Valvular disease M itral regurgitation. Mitral stenosis or Mitral stenosis and regurgitation. Aortic disease. Mitral and Aortic disease. 555 236 42.5 per cent. 255 46 per cent. 22 4 per cent. 42 7.5 per cent. Rheumatic nodules. Including this year's figures, there are 39 cases which exhibited rheumatic nodules as recorded in the statistics of children who have been treated in hospital under the scheme. It is not possible to give an incidence figure for the appearance of nodules for in the discharge reports of many of the children who have been treated the presence or absence of nodules is not stated. The variety of rheumatic infection which these 39 children manifested at the time of the appearance of the nodules was:— Rheumatic fever 2 boys and 5 girls = 7 Sub-acute rheumatism 10 boys and 17 girls = 27 Chorea 5 girls ... ... = 5 Total 39 The majority of these children were either suffering from their first attack of rheumatism or rheumatism had first made its appearance a short time before the attack for which they came under the scheme. In many of the children the nodules appeared in more than one part of the body but the most frequent sites in the series were the extensor tendons of the wrists and the dorsum of the hands 7 cases ; elbows 5 cases ; occiput 3 cases. The condition of the heart in these children was : normal 11, suspected myocarditis 8, rheumatic myocarditis 3, valvular disease of the heart 17 (mitral regurgitation 6, mitral stenosis 3, mitral regurgitation and stenosis 7, mitral and aortic disease 1). Two of these children died while in hospital and three are still under treatment having been admitted during the past year. On discharge from hospital 14 of the children were judged to be fit for attendance at an elementary school with full curriculum, 10 were allowed to attend an elementary school but drill and games were forbidden, 8 were sent to schools for physically defective children, and 2 were thought to be unfit for attendance at any school. The history of 10 of these children has been followed over a period of two years. Three of them remained in schools for physically defective children their hearts being badly damaged and two of them having had further attacks of severe rheumatism ; 5 children had been able to continue attendance at an elementary school with limitation of games and drill and two had been able to follow the full curriculum of ordinary school life. Importance of sub-acute rheumatism. Sub-acute rheumatism in its various manifestations is of particular concern to an organisation devised as a preventive force. The child with acute articular rheumatism or chorea as a rule receives medical attention either at its home or in hospital, but the sub-acute case frequently drifts on for years without receiving any active assistance. In these sub-acute cases one of three things may happen. The child may continue to suffer the discomfort and handicap of its pains without complications, or the debilitation of the continued rheumatism may reach a point at which the invading disease is enabled to flare up in an acute attack either articular or nervous, or when the child is medically examined by reason of the onset of other symptoms of disease it will be found that heart disease has insidiously established itself. In 1,700 first attacks of all forms of rheumatism the onset was indicated by sub-acute articular rheumatism in 813 cases (48 per cent.). Out of 180 hospital cases of sub-acute rheumatism with rheumatic heart disease, 75 of the children had never had any other form of the disease. Protean character of rheumatism When a large number of cases is reviewed rheumatism is vividly seen as a protean disease. A child may have a series of attacks of acute articular rheumatism extending over some years, and when an acute phase once more makes its appearance it may take the form of chorea. Similarly, a child with a long history of chorea will develop an attack of acute articular rheumatism. It is the sub-acute variety which shows itself the most ready to pass into another species of the disease. Histories were obtained in 500 cases of rheumatism showing that an acute phase followed an intermittent 39 sub-acute rheumatism of four, five and seven years' duration, while some of the choreic cases had had attacks of sub-acute rheumatism for as long as seven years. Nor is the story of the sub-acute form of the disease told when its tendency to pass into an acute stage or to initiate cardiac disease has been noted. As Dr. Sheldon has recently emphasised, many children who have every symptom of sub-acute rheumatism when examined in their homes or in the out-patient department of a hospital exhibit no sign of it while resident in a hospital or convalescent home. It would be easy to be satisfied with the conclusion that these children have never had sub-acute rheumatism and that their admission to hospital was due to a mistake in diagnosis. Unfortunately the subsequent history of these children does not confirm this view for, at a later date, the symptoms of rheumatism reappear. A girl is at present under consideration for hospital treatment who has twice before spent some months in hospital. On neither occasion had she any symptom of active rheumatism while in hospital. The most cheering aspect of the question is the changed attitude of the parents towards mild attacks of rheumatism. At lectures to parents, and at interviews in their homes they show themselves keenly appreciative of the cardiac menace of rheumatism. This is to be attributed to the increased interest which the assistant medical officers working in the schools are taking in the disease, to the patient, painstaking pioneer work of the rheumatism supervisory centres, and to the influence in the homes of the school care committee visitors. Even with the increased number of beds available this year it has been impossible to meet the demands of parents for treatment for their children. Parental attitude. The children, who are examined on their return from treatment at Carshalton or Brentwood, are bronzed and well, and all symptoms of rheumatism have disappeared. The reports from the assistant medical officers on the special examinations of these children in school, over a year or two, show that the majority of them do not need further residential treatment, although many of the children have mild attacks of rheumatism which can be treated at home under medical advice. The question naturally arises how far the prolonged course of treatment adopted at Carshalton or Brentwood compares in its results with the shorter residential treatment provided by other hospitals, or that given at the out-patient departments. There were no data to answer this question until Dr. Warner recently threw some light on the matter. After pointing out that the cases sent to Queen Mary's Hospital, Carshalton, were initially more severe than those treated by other methods, he states that the relapses in the first three years are only half the number met with in cases which have not had prolonged institutional treatment. There appears no reason why such commendation should not equally apply to the work at High Wood Hospital, Brentwood. Results of prolonged hospital treatment. Since the inauguration of the scheme 128 children treated in hospital have relapsed sufficiently to need further hospital treatment. Of these 28 had been removed from hospitals by their parents before the completion of their treatment. The remainder were:— Rheumatism 37 Rheumatism with heart disease 31 Chorea 28 Chorea and heart disease 4 100 Relapses. There are so many factors which may have an influence in bringing about the recrudescence of the various manifestations of the rheumatic infection that an enquiry as to the causes of relapse ends in the " might " and the " may." It has been thought, for example, that the length of time which a child remains in hospital influences the chances of a recurrence. The average stay of the above children in hospital was 29 weeks, which is a lengthy stay for cases many of which had already had treatment in some other hospital before being sent to Queen Mary's or High Wood. Moreover the stay of these children compares favourably with that of the children who have not relapsed sufficiently to need once again hospital treatment. 40 Factors influencing the recurrence of rheumatism. Of other factors environment and heredity seem to play that indefinite part which is met with in studying the causes of rheumatism. In these relapsed children a family history of rheumatism was met with in 27 (40 per cent.) of 67 cases in which the information was available. In 609 cases in which the family history was known and in which no relapse occurred rheumatic inheritance was shown in 212 (34 per cent.). In 100 of these relapsed children the home conditions were investigated. Taking as unsuitable environment, dampness, or four or more persons per room, or three persons or more in the child's bedroom, or a combination of these, 62 (62 per cent.) of the children were unsuitably housed. This figure may be compared with 426 children out of 748 cases, or 57 per cent, investigated, whose home surroundings were not good and who have not relapsed. Unfortunately no information was available on the family income per head, or details as to the feeding of the children, perhaps the most important point of all. Handicap of the rheumatic child. In the table given below is set out the type of school which was thought to be the most suitable for 1,082 children who were returning to every-day life after a stay in hospital. The heart condition in 810 of these children was found to be normal, and in 272 there was evidence that the heart was affected. It should be noted that "no swimming" is not classed as a restriction since practically all these rheumatic children are forbidden to swim for a time after their return from hospital. Disease on admission to hospital. HEART NORMAL (810). HEART AFFECTED (272). Disposal on discharge. Disposal on discharge. Elementary, school, no restrictions Elementary school, no drill or games. School for physically defective. Invalid. Elementary school, no restrictions. Elementary school, nc drill or games. School for physically defective. Invalid. Rheumatic fever 77 26 12 0 5 5 13 0 Sub-acute rheumatism 281 115 39 5 22 48 132 7 Chorea 172 56 17 10 5 10 24 1 Total 530 197 68 15 32 63 169 8 Per cent. 65-4 24-3 8-4 1-9 11-8 23-2 621 2-9 The decisions recorded in this table are revised according to the needs of the children as decided by the assistant medical officers at their special periodic examinations of the children in school, and by the doctors in charge of the various rheumatism supervisory centres, but the figures shown indicate to some extent the handicap of the rheumatic child during its school life. Detailed reports of rheumatism supervisory centres. The physicians in charge of the Council's rheumatism supervisory centres have in many cases supplied detailed reports of the year's work. The rapidity with which the centres have grown in number and the readiness with which the parents of rheumatic children seek advice upon them are testimony to the need and value oi this type of institution. Rheumatism now takes the first place amongst diseases which produce chronic invalidity in our children and the work of the supervisory centres is an attempt to limit so far as possible the crippling which results from this most serious complaint. Woolwich supervisory centre. Dr. John Sophian, at the Woolwich supervisory centre, has noted that the incidence of rheumatic pains falls more heavily in the Eltham area than in the other districts served by the centre, and he suggests that among the factors to account for this, are the clay sub-soil, and the large proportion of newly built houses. He refers especially to the high percentage of attendance and to the willingness of the parents to follow the advice given. The help given by the Invalid Children's Aid Association is gratefully acknowledged. King's College Hospital. Dr. J. H. Easton reports that the rheumatism supervisory centre at Kings College Hospital opened on April 2nd, 1930. Especial care has been taken in enquiries into the conditions governing the environment of each of the 186 patients who have attended, and where possible adequate steps have been taken to improve these. East London Children's Hospital. Dr. W. F. Gaisford reports that the supervisory centre at the East London Hospital started in January, 1930. Special care has been taken to impress upon the 41 parents the necessity for providing adequate footwear. The parents' co-operation has been excellent and the attendance of written-for old patients is usually about 85 per cent. Dr. Gaisford remarks that 81 per cent, of the children attending were blondes, a percentage which is definitely beyond the bounds of coincidence. Dr. Wilfrid Sheldon points out that the number of children attending the supervisory centre at Great Ormond Street Hospital during 1930 was 940. The centre serves not only London but Greater London as well. A little more than one-half the children attend from the London area proper. Regular attendance has been satisfactory. Two hundred and fourteen children were convalesced during the year. Dr. Sheldon groups the children with heart disease into four classes. Those whose heart disease is acutely active are admitted to the wards of the hospital; those whose heart condition is early and mild are sent to one of the various special heart homes in the country (such as Lancing, West Wickham, Carshalton or Brentwood) ; those whose hearts have passed to such a condition that the main therapeutic requirement is prolonged rest and institutional treatment are drafted to Dr. Sheldon's ward at the Cheyne Hospital; finally those cases where the disease is no longer active and the heart, though injured, has its action fully compensated are recommended for admission to schools for the physically defective. Thirty-one children during the year were thus recommended, and of these 30 have already been admitted to special schools. Great Ormond Street Hospital. Dr. Gerald Slot reports that this centre opened in May, 1930, and from May to December 108 new cases attended. He finds the parents on the whole very willing to take advice, but the greatest difficulty in early cases is to get them to realise the importance of rest and longer sleep at night. Hammersmith supervisory centre. Dr. T. W. Preston, who has had charge of the centres at Downham, Wandsworth and Putney, has supplied a combined detailed report upon the work of the three centres. The report, which follows, gives an admirable idea of the work which the supervisory centres are accomplishing. Downham, Wandsworth and Putney supervisory centres. In Table I are shown the number of cases attending the three centres during the year and in Table II the total number of inspections actually carried out. Table I. Downham. Elizabeth Bullock. Putney. Boys. Girls. Total. Boys. Girls. Total. Boys. Girls. Total. New cases seen during 1930 61 63 124 46 63 109 15 21 36 Old cases re-inspected during 1930 61 88 149 59 86 145 6 9 15 Total cases seen 122 151 273 105 149 254 21 30 51 Table II. Downham. Elizabeth Bullock. Putney. Total number of inspections and re-inspections 538 608 89 Average attendance per session 12.2 13.8 10 The number of new cases seen at Downham and Wandsworth (Elizabeth Bullock centre) is smaller than in 1929, but as a large proportion of the cases has to be kept under continued observation, the total number of inspections and re-inspections is greater. The discharges are set out in Table III. Comment on the small number of cases discharged is made elsewhere. Table III. Downham. Elizabeth Bullock. Putney Left school 14 18 1 Discharged as free from rheumatism 15 32 - Transferred to other centres 3 1* - Total 32 51 1 * In addition. 15 were transferred to Putney centre; these constitute the 15 re-inspection cases included in the Putney figures. 42 The Putney centre was started in May, 1930, and at present only monthly sessions are held. From the number of cases attending, the opening of the centre would appear to be justified, but at present there seems no need for more frequent sessions. On the whole parents have shown themselves anxious to avail themselves of the opportunity of having their children examined at the centres, as shown by the fact that at Elizabeth Bullock and Putney 77 per cent, of the invitations issued to new patients have been accepted. Of those cases who were asked to keep under the general supervision of the centre, only 13 have failed to do so at Downham, 22 at Wandsworth and one at Putney. The large majority of the new cases has been referred by the school medical service; only a small number has been referred by private practitioners. Table 4 shows the arrangements which have been made for institutional treatment for the children attending. Downham Elizabeth Bullock. Putney. Total. Carshalton and Brentwood 18 23 4 45 I.C.A.A. Heart homes 3 5 — 8 I.C.A. A. Ordinary convalescent homes 12 9 3 24 Other convalescent homes — 2 2 4 Residential open-air schools 6 7 1 14 Other institutions (hospitals, etc.) 10 9 1 20 Total 49 55 11 115 The increased number of available beds at Carshalton and Brentwood has proved a tremendous boon and the gratifying results obtained from sending the children to these institutions leads to the hope that still further accommodation will be provided in the future. The help of the Invalid Children's Aid Association has again proved invaluable, especially in the case of debilitated children without active rheumatism or carditis. Table 5 shows the arrangements which have been made for the children with regard to school attendance. Classification. (a) Downham Centre. (b) Elizabeth Bullock Centre. (c) Putney Centre. Cases with carditis. Cases of chorea & rheumatism, but no carditis. Doubtful rheumatics. Non- rheumatics Cases with carditis. Cases of chorea & rheumatism, but no carditis. Doubtful rheumatics. Non-rheumatics Cases with carditis. Cases of chorea & rheumatism, but no carditis. Doubtful rheumatics. Non-rheumatics Attending secondary and central schools 7 2 6 - - - 2 3 - - - - Attending elementary schools without restrictions - 14 72 40 - 27 64 54 - 4 16 8 Attending elementary schools with restrictions 41 24 8 2 29 20 8 - 7 4 4 - Attending physically defective schools 16 (6*) - - 1 13 (7*) 2(1*) - - 4(2*) - - - Attending open-air schools — 3 3 3 - - — 1 - — — - Attending mentally defective schools - - - - 2 - 1 1 - - - - Left school and now at work 2 1 6 - 1 3 2 2 1 - - - Absent from school practically throughout 7 6 9 — 14 4 1 — 2 — 1 - Totals 73 (6) 50 104 46 59(7) 56(1) 78 61 14 (2) 8 21 8 * Transferred to P.D. schools during the current year. 43 Table 6 shows a classification of the cases seen. Classification. Downham. Elizabeth Bullock. Putney. Boys. Girls. Total. Boys. Girls. Total. Boys. Girls. Total. A. Cases with a definite history of acute arthritis— (i) with carditis 16 22 20 37 36 59 15 28 17 42 32 70 1 3 5 7 6 10 (ii) no carditis 6 17 23 13 25 38 2 2 4 B. Cases with a definite history of chorea— (i) with carditis 5 14 6 24 11 38 2 11 8 17 10 28 1 2 1 4 2 6 (ii) no carditis 9 18 27 9 9 18 1 3 4 C. Cases with a history of insidious ill-health and showing definite carditis 13 13 26 9 8 17 2 4 6 D. Cases with indefinite histories and showing no cardiac involvement 44 60 104 27 51 78 8 13 21 E. Cases definitely diagnosed as non-rheumatic 26 20 46 30 31 61 6 2 8 It will be observed that about 37 per cent, have a definite history of acute arthritis or chorea (A and B) ; 8 per cent, have definite carditis but give no history of acute illness (C) ; 20 per cent, are considered to be definitely not rheumatic (E); whilst 35 per cent, give a history of symptoms related to rehumatism but having no sign of cardiac involvement (D); probably many of these cases are not rheumatic ; 11 cases gave a definite history of acute arthritis and chorea. Of these 8 had carditis. Increasing experience has shown that many of the definitely rheumatic cases, even those with carditis, are capable of leading active lives with progressively decreasing restrictions, but it is felt that a child known to be definitely rheumatic is never free from a risk of further manifestations and therefore it is the present practice at the three centres under discussion never to discharge these cases until they leave school. If the children are well, the mothers are told that no treatment is necessary but that it would be desirable for the children to be seen in 6 or 12 months to make sure that they are still well. The most difficult cases are those which come under Classes C and D. Under Class C are 49 children thought by their mothers to be healthy but found at some routine examination to have serious carditis. When did these children develop carditis ? At these three centres the mothers of all children reputed to be suffering from " insidious carditis " have been subjected to a searching examination and it is surprising to find that a certain number of mothers who, on first enquiry, avow that their children have never been ill will subsequently let slip some remark about "... when he was in-hospital " ; and on enquiring why he had been taken to hospital, " Why, when he had St. Vitus Dance, of course! " In this way quite a number of cases which were originally classified under " C " have been subsequently found to belong to " A " or " B." Of the 49 cases finally left in Group C, there was some evidence in 14 that the carditis may have been the result of some acute illness, and in 6 others the mothers seemed so casual or unintelligent that it was felt that little significance could be attached to the negative history. In submitting these figures it is not intended to suggest that carditis of insidious onset does not occur, but it is suggested that a grave valvulitis should not be assumed to have developed insidiously merely because the mother says the child has never had rheumatic fever. In an attempt to prevent these tragic cases from developing, a large number of children having symptoms of a rheumatic nature are referred to the centres ; these cases constitute about 35 per cent, of those seen (Table 6) (Group D). How many of these cases are potentially Group C ? In the present state of our knowledge there seems to be no reliable method of diagnosing the muscular pains of true rheumatism 44 from those vague pains which are so frequent in debilitated children. A certain number can be eliminated by a positive diagnosis of some other condition which would adequately account for the symptoms ; the rest can only be kept under observation and final judgment reserved. At the present time the majority of these cases are being kept on the roll for periodic re-examination, including those thought to be not rheumatic, for the following reasons (1) The cases at present classified as " D " must be either rheumatic or non-rheumatic ; actually a definite opinion is formed (but not expressed) at the first examination but obviously the opinion can be of no value until the lapse of time has proved the correctness or otherwise of the opinion. It is hoped that after a sufficient interval some useful purpose may be served by a comparison of these two groups. (2) The treatment and management of a child suffering from true rheumatism is entirely different from that of a child suffering from the vague pains of flabby muscles, deficient calcium, etc. The former requires rest and the restriction of strenuous exercises which will tax the heart ; for the latter, exercises and games are to be encouraged. When in doubt it is a temptation to " play for safety " and to restrict exercises, but if the child's heart is normal (and a heart must be either normal or abnormal) one is doing it serious disservice by the adoption of a policy which may make it a flabby hypochondriac for the rest of its life. At these centres it is the practice to encourage exercises for those children considered to be non-rheumatic ; it is realised, however, that in a certain number of them the view may be mistaken and therefore it is considered that there is an obligation to keep them under observation so that the mistake may be recognised at the earliest possible opportunity. It may be added that present impressions are that an error is more often made on the side of over-caution than the reverse. (3) Although these cases may not be rheumatic many of them are unwell, and if a mother brings a child up for certain symptoms it seems hardly fair to discharge it without suggesting something to help. It is encouraging to note that some of these cases show definite improvement in health as the result of simple suggestions as to diet, general hygiene, etc., and it is to be hoped that some of them will grow up to believe that a bottle of medicine is not essential for the maintainance of good health. With regard to diet one certainly gains the impression that many of these children improve as the result of milk and cod-liver oil in school ; in those cases in which glucose has been recommended the results have been less dramatically successful than some modern teaching would lead one to hope. Table 7 shows the condition of the tonsils in the various groups. The Table would be of greater value if distinction was made between complete and incomplete tonsillectomies but it was found that insufficient material existed for making this sub-division. One's impressions certainly are, however, that whilst a completely tonsillectomised rheumatic child is better off than his non-tonsillectomised brother, he will be better off with his tonsils intact (even though they be unhealthy) than with tags remaining after an incomplete operation. Cases with carditis. Definite rheumatics without carditis. Doubtful rheumatics. Nonrheumatics. 146 114 203 115 Per cent. Per cent. Per cent. Per cent. Tonsillectomy before onset of symptoms 26 25 27 45 Tonsillectomy after onset of symptons 26 28 24 Tonsils, large or unhealthy or both 16 18 14 21 Tonsils not apparently unhealthy 24 27 27 28 No note 8 2 8 6 45 Table 8 shows a classification of the various cases considered to be suffering from organic carditis. In addition there were 11 cases of congenital morbus cordis ; one of these had chorea, 10 were non-rheumatic. Classification. • Acute rheumatism cases. Chorea cases. Insidious cases. Total. Myocarditis only 16 5 15 36 Mitral incompetence 31 7 26 64 Pure mitral stenosis 4 4 2 10 Combined mitral disease* 20 6 6 32 Combined mitral and aortic disease 1 — 1 Aortic disease 1 — - 1 Combined mitral dis. and adherent pericardium 1 1 2 Total 74 23 49 146 * One case was associated with congenital dextrocardia. Table 9 shows the occurrence of murmurs considered to be "functional." Total cases. Total with functional murmurs. Per cent.[1###] A. Rheumatic fever cases* 65 17 26 B. Chorea cases* 49 11 22 D. Cases of " insidious rheumatism "* 203 81 40 E. Non-rheumatic 115 23 20 Total 432 132 30 * The cases having organic carditis are excluded from these totals. When a patient gives a history of rheumatism it is a temptation to ascribe any systolic murmur to " myocarditis " ; on the other hand when a loud systolic murmur is unexpectedly found in an apparently healthy person there is a temptation to dismiss it as "functional" without too much attention to its quality. The figures shown in the table demonstrate that some attempt has been made to assess these murmurs on their merits and without attention to the history. It is now generally agreed that a systolic murmur may be of no significance but the large number of systolic murmurs considered to be functional in this report may almost lead to a suspicion that at these centres almost too little importance is attached to a murmur. This comment may be made : during the course of the year a certain number of cases has been diagnosed as suffering from carditis and subsequent events have rather suggested that one's view may have been mistaken, but of the numerous cases considered to have functional murmurs, in not one of them have subsequent events led one to retract the diagnosis. Table 10 supports the established view that sinus arrhythmia is essentially a physiological event. The opinion further is submitted that, when this irregularity appears in a heart which is diseased, it is some evidence that it is recovering. Total cases. Number showing S.A. Percentage. Cases with carditis 146 32 22 Cases of definite rheumatism without carditis 114 37 32 Doubtful rheumatics (without carditis) 203 62 30 Non-rheumatics 115 31 27 Special Inquiries and Reports. I. This investigation consisted of the examination of the children of families living in basements and the comparison of the data thus obtained with those obtained from the examination of controls. The list of basement children was compiled by the Council's inspectors as the result of inquiry among families occupying basements in the boroughs of Kensington, Paddington, Westminster, Islington, Finsbury, Poplar, Stepney and Southwark. Inquiry into the condition of children living in basements. (Dr. A. Banks Raffle.) 46 The basement children were examined in their schools in company with a double set of controls. That is, two children not living in basements were compared with each basement dweller. These control children were selected by the head teacher for similarity in age and social circumstances, and they were of the same sex as the basement child. The identity of the basement dweller was not known to the examining doctor until the examination in the department was completed : 254 basement children were examined during the investigation and 508 controls. The inquiry was divided into three parts : medical history, physical examination, and school history. The latter included an assessment of the child's progress at school and the regularity of its attendance. The medical history was obtained from the medical inspection cards,, supplemented, on occasion, by information obtained from the head teacher, or, in the case of the older children, by the child itself. This part of the investigation did not supply data of much value. Basement dwellers do not seem to be more prone to infectious disease than other children living in the same neighbourhood. One exception must be made to this statement: the diphtheria incidence amongst children living'in basements was twice (5.1 per cent.) that amongst the controls (2.5 per cent.). Of other conditions bronchitis and pneumonia were 14.6 per cent, as compared with 12.4 per cent. in the controls, rheumatism 1.1 per cent., as compared with 0.2 per cent., whilst a history of affections of the throat and nose was rather more common (6.1 per cent.) amongst the controls than amongst the basement dwellers (5.5 per cent.). The physical examination, was directed rather to certain specific points, e.g., debility, defective sight, rheumatism, rickets, than to a complete examination. The majority of the children were weighed and measured and it will be seen that at most ages the basement child compared unfavourably with its controls. This was more marked in the case of the older children. The medical examination showed that basement dwellers were not far behind non-basement dwellers in cleanliness, but that they were not so well nourished; 35.7 per cent. of the basement children being definitely under-nourished compared with 19.1 per cent. of the controls. Pallor of the skin or mucous membranes, indicative of anaemia, was present in 44.1 per cent. of the children living in basements and in 38.8 per cent. of the controls. Defective vision (less than 6/9 either eye) was practically the same for the two classes of children—basement 24.4 per cent., controls 24.8 per cent. Throat and nose affections were found in 7.4 per cent. of the basement dwellers and in 3.3 per cent. of the controls. Symptoms of rheumatism were found in 2.2 per cent. of the children living in basements and in 0.8 per cent. of the nonbasement children. In this connection it should be noted that an analysis of the figures for the children suffering from rheumatism and admitted to Queen Mary'sHospital, Carshalton, or to High Wood Hospital, Brentwood, show that out of 600 cases 70 (11.7 per cent.) children lived in houses having basements, and of these 41 (6.8 per cent.) actually lived in the basement. Rickets was evenly distributed between the two classes—7.1 per cent. basement, 7.3 per cent, controls. The educational inquiry revealed that there were fewer children living in basements who were making normal progress at school than amongst the children selected as their controls. The head teachers returned 43.6 per cent. of basement children and 24.8 per cent. of the controls as definitely backward; 11.8 per cent, of the basement dwellers and 5.9 per cent. of the controls were irregular in their attendance at school. The more important findings of the investigations are set out in the following tables. In the tables the children have not been divided into sexes or into half-yearly periods since the system of controls, of the same sex and within a month or two of the basement child in age, seemed to render this unnecessary. The statistical findings of the inquiry although showing clearly the disadvantage which basement dwelling children suffer do not reflect fully the impression which the examining doctor received throughout its progress. In some areas, e.g., Southwark, it was possible to pick out four or five of the basement children from their controls. 47 whilst it was quite impossible to do so in Paddington. This is no doubt due to a difference in the type of basements in the two boroughs. Although the numbers are not very large, yet the children were examined with great care and the investigation shows that the basement child appears to be deficient in vitality. This is revealed in its physical measurements, its physical condition, and in its progress at school. It seems significant also that whilst basement children are not unduly affected by rickets, a disease of the first year or two of life, they fall a readier prey to rheumatism which attacks children after the rickets period. Figures demonstrating the incidence of phthisis amongst basement dwellers would be of great interest for this disease follows rheumatism in age incidence amongst children.. The effect of basement dwelling is more likely to be cumulative than having its maximum effect in infancy. Analysis of the data at various stages of the investigation showed the ratio of defects between the basement dwellers and their controls to be fairly constant. For this reason it appears as though little further information would be obtained by conducting an inquiry on a wider basis. In the following tables figures shown in italic type are percentages:— Basement. Controls. Defective nutrition 35.7 19.1 Pallor 441 38.8 Affections of throat and nose 7.4 3.3 Rheumatism 2.2 .8 History of diphtheria 5.1 2.5 Subnormal school progress 43.6 24.8 Irregular school attendance 11.8 5.9 Number examined 254 508 Cleanliness— Good 1 88 (34.6) 194 (38.2) Fair 2 141 (55.5) 270 (53.1) Bad 3 25 (9.8) 44 (8.3) Nutrition— Good 1 37(24.6) 95 (18.9) Fair 2 126 (49.6) 316(62.2) Bad 3 91 (35.7) 97 (19.1) Pallor 112 (44.1) 197 (38.8) Affections of throat and nose 19 (7.4) 17 (3.3) Vision—less than 6/9 either eye 49 (24.4) 78 (24.8) Rheumatism 6( 2.2) 4 (.8) Rickets 18 (7.1) 37 (7.3} Medical History. Diphtheria 13 (5.1) 14 (2.5) Affections of throat and nose 14 (5.5) 32 (6.1) Pneumonia or bronchitis 37 (14.6) 64 (12.4) Rheumatism 3 (1.1) 1 (.2) School Data. Progress above normal 43 (16.9) 109 (21.) „ normal 100 (39.3) 273 (53.7) „ below normal 111(43.6) 126 (24.8) Irregular attendance 30 {11.8) 30 (5.9) Age. Basement. . Controls. Number. Average height (cms.). Number. Average height (cms.). 4 7 102.2 14 102.2 5 14 109.0 28 106.1 6 15 110.4 30 111.7 7 29 115.7 58 117.0 8 23 121.8 46 121.9 9 27 125.2 54 125.3 10 41 131.7 82 132.4 11 23 133.7 46 135.4 12 24 140.3 48 141.3 13 17 146.2 34 152.5 48 Age. Basement. Controls. Number. Average weight (kgs.) Number. Average weight (kgs.) 4 11 16.6 22 16.5 5 15 15.5 30 17.7 6 15 18.7 30 19.5 7 29 21.2 58 21.2 8 25 23.6 50 24.1 9 36 25.8 72 25.5 10 41 27.9 82 28.7 11 27 29.4 54 52.1 12 28 32.3 56 34.7 13 20 37.4 40 29.0 Ophthalmia in children's residential institutions. The school medical officer. II. The investigation of ophthalmia in children's residential institutions.—The transference of the Poor Law schools to the Council's education system on 1st April, 1930, has been the means of focussing attention upon certain conditions which are apt to be endemic in children's institutions. Amongst these an important place is occupied by endemic ophthalmia. It became necessary to devote a considerable amount of time to this at the Anerley residential schools when there was found to be a considerable amount of ophthalmia complicated by the presence of a few children who were considered to have trachoma. An identical condition also complicated by the presence of trachoma was found to exist in one of the large philanthropic orphanages in the county, the managers of which gladly welcomed the assistance of the school medical service in investigating the condition and taking measures for its eradication. Mr. Bishop Harman in opening a discussion in the section of ophthalmology at the annual meeting of the British Medical Association, Winnipeg, 1930, gave the following account of trachoma in London:— " In former days the chief breeding places of trachoma in London were the Poor Law schools. The children of destitute families were drafted into huge barrack schools. These schools were ravaged from time to time by epidemics of ophthalmia, which was always endemic. Stephenson, in an historical note, showed that the evil of these schools was known as early as 1848. In 1858 Bowman made recommendations regarding them. Ten years later similar recommendations were made by George Critchett. Nettleship in 1874 inspected all these schools, and of one he stated that ' not 15 per cent, of the eyes could be described as healthy.' A report in 1888 by Litteljohn, the medical officer of one of the schools, in which he said ' Children have contracted the disease in the school • • • to an appalling extent,' attracted the attention of Parliament. An isolation school for ophthalmia was provided under the care of Sydney Stephenson. From later London reports I find that the separate attempts of the local London Poor Law authorities were amalgamated by the Metropolitan Asylums Board. Two ophthalmia schools were established in the country north and south of London in 1903 and 1904 in charge of Treacher Collins. At the time of the foundation of these isolation schools the average number of children housed in the Poor Law schools was 10,800. The accommodation of the isolation schools was 720. In the first year 625 children were admitted, of whom 292, or 46 7 per cent., were suffering from trachoma. The segregation of affected children was so efficacious that in 1918 there were only 186 entries, and one of the isolation schools was closed. In 1921 there was a risk that the other would be closed too for lack of cases. It was therefore determined to admit children also from the elementary schools. Even with this far wider field from which to gather patients the demand upon the resources of the school at Swanley has been below the accommodation. In January, 1930, only 253 of the 364 beds were occupied. Thirty-nine were pauper children gathered from the Poor Law schools with a roll of 6,375 children ; 12 were cases from outside London ; and 152 were elementary school children. Of the total cases, 67 were trachomatous, or 26'5 per cent. " A most effective agency in the control of trachoma is the School Medical Service. For the past twenty-five years I have been intimately connected with this work in the County of London. My duties as ophthalmic consultant include work at a consultation centre at the County Hall, to which are referred children whose sight presents special difficulties in education or medical treatment. " By Act of Parliament the education authority is responsible for the medical inspection and treatment of the school children. The schools are visited regularly and all the children examined in specified groups. Those requiring treatment are referred to their home doctors or to school clinics maintained by the authority. Parallel with this arrangement there is the School Attendance Department, which has the duty of investigating the reasons for the absences of children from school. Absences of more than a specified period are reported to the head office for special investigation. This dual organisation within and without the schools ensures a very complete supervision of health of the children. 49 "The efficiency of the organisation was well demonstrated a few years ago. Early in 1924 an unusual number of absences from school on account of ' external eye disease ' was reported by the attendance officers in the Thames-side districts of Poplar and Stepney. A batch of the affected children was brought to the consultation centre at the head office. I found them to be suffering from early and acute trachoma. Thereon all absentees and the other children of their families, and also the children of the schools they had attended, were medically inspected. A definite epidemic of trachoma was discovered among the children of a few schools in the poorest quarter close to the docks. Ordinarily cases of trachoma average a score a year for the whole school population of London. In this year, 1924, the numbers seen were : January, none; February, none ; March, 17 ; April, 34 ; May, 51 ; June, 36 ; July, 51 ; August, 2 ; September, 4 ; October, 4; November, 10; December 6; making a total of 215 cases. The affected children were transferred for treatment to the Swanley Ophthalmia School, now under the direction of Stephen Mayou, with the most satisfactory results. The epidemic was confined to the original area of its outbreak, and ceased at the end of the year. I have heard some hard sayings about the school attendance officer. It has been asserted he is as hard-hearted as the pedagogue of a familiar Pauline argument; but his strictness is an invaluable safeguard to the children, as was demonstrated in this outbreak. Imagine what might have happened in densely populated London if there had been no inquisitorial attendance officer." The bulk of the investigation into the ophthalmia at the orphanage and the residential school to which reference has been made was carried out by Dr. J. Hamilton Mcllroy, who has made the following report:— As the result of the discovery of several cases of trachoma, Mr. Bishop Harman suggested an inspection of all children in these two institutions, for the purpose of detecting all cases of true or suspected trachoma. Drs. McVail and Mcllroy visited the orphanage on 25th October, 1929. The medical officer and the school nurse were present and offered every facility for the inspection. Dr. J. Hamilton Mcllroy s report. The Orphanage. All the children in attendance, boys 210, girls 150, were inspected and a list was made of those suffering from any form of conjunctival disease. This list comprised 53 boys and 40 girls. Of these, 6 boys and 12 girls showed signs of granular conjunctivitis suggestive of trachoma and were referred to Mr. Bishop Harman at the County Hall. Only one boy and one girl were considered by Mr. Bishop Harman to have trachoma, and were sent to the White Oak Hospital, Swanley. The boy remained at Swanley until June, 1930. On his return he suffered a relapse and attended the Belgrave Children's Hospital. He was re-admitted to school in December cured, but to prevent relapse was given daily treatment. The girl, who was sent to Swanley remained there until 18th February, 1930, when she returned to school. She relapsed, however, and Mr. Bishop Harman again sent her to Swanley. She was re-admitted to school in July, 1930, cured. She was kept under observation until 14th November without relapse. Of the other cases on the list none was excluded from school, but all were asked to attend at the County Hall at periodic intervals to see Mr. Bishop Harman and were advised rigorous daily treatment. They all improved very much and were gradually released from attendance. Their condition at the date of the last inspection (4th December, 1930), was as follows:— 3 boys, 1 girl still on treatment (once daily). 2 boys, 6 girls to be kept under observation. 2 girls discharged cured. 1 boy, 3 girls had left school. The list of cases (40 boys, 53 girls) showing conjunctival disease was given to the school authorities. The school nurse retained a copy for her own use and treatment as indicated for each child was carried out: six re-inspections (mainly by Dr. Mcllroy) at frequent intervals were made of the children on this list. At the date of the last visit (4th December, 1930) the list comprised in all 76 cases (41 boys and 35 girls), but 60 of these (31 boys and 29 girls) were under observation only. Of the 16 under treatment only one case (girl) was of sufficient severity to require treatment twice daily, i.e., the institution had become almost clear of active eye trouble. During the course of the last three inspections a re-inspection of the whole school took place. A few cases discovered amongst these re-inspections, together with some cases occurring amongst new admissions account for the increased numbers towards the end of the period of enquiry. 50 Method of Inspection.—Inspection took place in the doctor's or teacher's room as was convenient. A table with a basin of weak disinfectant and a plentiful supply of towels were provided. The oculist sat at the table in a position for good daylight; inspection and the children entered in single file, each child being seated opposite the oculist during examination. The eyelids were everted sufficiently to obtain a satisfactory view. The school nurse made notes on each case as directed. Advice was given regarding individual treatment and it is to be noted that these suggestions were accepted and carefully carried out in every case. Conditions found on Examination.—Except for the two Swanley cases in which there were definite signs of trachomatous infection, the majority of the cases were of the so-called " follicular " type of conjunctivitis. In some the condition was typically follicular, the lower lids alone being affected. In some the conjunctiva of the lower lid and also of the fornix and bulb were studded with vesicular-like enlargements which often had a brownish or blood-stained tinge. It was noticed that these enlargements became more engorged and obvious the longer the lid was kept everted, thereby suggesting a vaso-motor irritability. Other cases, and it was in these the question of infectivity became more urgent, exhibited varying degrees of granulation from a mere roughness apparent in the lower lids and at the extremities of the upper lids to a more widespread granulation which suggested the possibility of trachoma, latent or otherwise. It is difficult from the administrative point of view to make hard and fast rules concerning these cases of conjunctivitis. Definite cases of trachoma and of acute conjunctival diseases present no difficulty as in these cases exclusion from school or isolation is imperative. But in a large number of borderline cases in which there is a certain degree of granulation in the conjunctiva without pronounced symptoms (corneal affection, photophobia, etc.), would complete or partial isolation be justified ? Are these children to be cut off from swimming for example ? A child with a lid condition that is faintly suggestive of contagious disease must not be allowed to run the risk of spreading the contagion to others. Most lid conditions are chronic and until they have cleared up the child may have to be cut off from much of its normal daily activities and amusements. This to a child without any declared " disability " seems inexplicable and may lead to untoward results mental and physical. On the other hand, if it be decided to legislate merely for those on whom definite suspicion can rest there is a risk that the condition may be spread. In practice it has been assumed that all the cases in the list are potentially infective and require local treatment. No case which required treatment was allowed to take up swimming until specially permitted. That a course of inspection and treatment is of benefit in these cases can be seen from the results obtained. The specific causation of conjunctival disease in an institution such as the one inspected cannot be explained from the facts available and the idea of a bacteriological examination had to be abandoned on account of practical difficulties. That some external irritant (dust) or internal excitant (diet, e.g.) acts as a common factor is not unlikely. Anerley Residential School. As in the case of the orphanage above reported, the inquiry at this residential school was carried out in close co-operation with the medical officer in charge and treatment was assiduously applied by the school nurse although much extra work on her part was involved. The numbers on the roll at the time of the first inspection (28th May, 1930) were 564, of whom 531 were actually in attendance. Thirty-one children were absent at Broadstairs, but were inspected on their return to Anerley. The first inspection of children in attendance extended over three visits, viz., 28th May, 4th and 5th June. A list of 190 children (88 boys, 102 girls) affected with any form of conjunctival disease was drawn up. Of these, in the case of 7 boys and 3 girls trachoma was suspected and the children were referred to the County Hall where Mr. Bishop Harman recommended them for admission to Swanley. Four of them, 3 boys and 1 girl, were seen again on 19th September on their return. They were advised 51 to continue treatment once daily in order to maintain a cure. Only two others (1 boy and 1 girl) had returned at the time of the last inspection (5th December). No fresh cases of trachoma, suspected or definite, were encountered during the course of the inspections. Of the others, 76 boys were not trachomatous but were suffering from various forms of conjunctivitis (follicular, granular, catarrhal) sufficiently marked to require treatment—the more severe, twice or thrice daily and the less severe once daily. The remainder (6 boys), were only slightly affected and were noted " for observation " only. Treatment at school was advised in the case of 91 girls once or twice daily as indicated. Eight girls were marked " for observation." An analysis of the figures is given in the Table. It was considered advisable to classify the various forms of conjunctivitis as far as possible although the distinction between the " follicular " and " granular " type was sometimes difficult to make. The lid conditions were very much the same type as those met with at the orphanage. In both institutions it was of interest to note that there was a tendency for the left eye to be affected more than the right, and in some cases—particularly those progressing towards recovery—the left was the only one affected. The figures for this " solitary " eye affection are as follows :—(Note.—It was only during the progress of the inspection that this feature was appreciated and full note of the difference between the two eyes was not made in the earlier inspections. For this reason the figures are probably under-estimated.) " Solitary " eye affection as noted. Anerley Residential School—At time of first inspection— (28th May, 4th and 5th June):— R.E. chiefly or alone affected, 2 cases out of 190, i.e., 1 per cent. L.E. „ „ 14 cases out of 190, i.e., 7.3 per cent. At time of final inspection—(5th December):— R.E. chiefly or alone affected, nil. L.E. „ „ 3 cases out of 84, i.e., 3.5 per cent. Orphanage—At time of first inspection at which note was made {viz., 20th February) :— R.E. chiefly or alone affected, nil. L.E. „ „ 8 out of 83 cases, i.e., 9.6 per cent. At lime of final inspection (4th December):— R.E. chiefly or alone affected, nil. L.E. ,, „ 14 out of 87 cases, i.e., 16 per cent. The tendency for emphasis in the left eye may be of some value in differentiating the diagnosis of contagious and non-contagious forms of conjunctival disease. In the contagious forms in which infection is often conveyed to the right eye by a righthanded person, as in most cases of true trachoma, the right eye alone is affected or is in advance of the left. On 25th June at Dr. Mcllroy's request, Dr. Soper examined all the throats of the affected children in order to find out if any correlation between the eye condition and state of the tonsils existed. Dr. Soper's report showed that 35 out of the 81 boys on the list (i.e., 43 per cent.), and 36 out of the 102 girls on the list (i.e., 35 per cent.), showed enlargement of one or both tonsils in varying degrees. A particularly careful system of ensuring clean towels is in use in this school. Immediately after use each towel is placed in a receptacle and taken to the laundry and no towel (face or bath) is used a second time without washing. This precautionary measure should minimise the risk of contagion to a very great extent. The further precaution was sugested that instead of a common piece of soap the use of a form of liquid soap would further minimise the chances of contagion and steps were taken to have the suggestion carried out. With regard to washing and bathing arrangements every child has fresh water. Foot and shower baths are used for boys and girls over 9½ years of age—the younger children have tubs. The water of the swimming bath is changed and the bath thoroughly cleansed once a week. E l 52 Impaired hearing in elementary school children. Dr. Mabel Russell. III.—Hearing Tests.—Continuous attention has been paid at school medical inspection to the question of hearing tests when reliance must be placed upon such a test as that of the forced whisper. As an example of the work done in this way the following report has been submitted by Dr. Mabel Russell, who has paid special attention to the hearing of the children in three of the elementary schools under her charge. It is generally agreed that with the age group examinations and special cases referred by teachers or parents few, if any, children with any gross degree of deafness miss detection during their school life. On the other hand, minor degrees of impaired hearing (from a preventive point of view, the most important) can more easily be missed, and it was with a view to ascertaining to what extent this was true that enquiry was made, limited to three of the Council's schools in Chelsea. As a class test the children were asked to write down two words which were given with the ordinary spoken voice, care being taken not to raise the voice in the slightest. For the first word the examiner faced the class, but with the lips hidden, and for the second word went to the back of the class (i.e., behind the children) thus, children in front and back rows had an equal chance of hearing ; in some of the larger classes it was found necessary to divide the class into two sections for the purpose of carrying out the test. Any child who failed to write down both words correctly was examined later in more detail to ascertain whether there was any physical cause for deafness or a past history of otorrhcea or other aural ailment. The forced whisper test was then applied. The children examined varied in age from 8 to 14 years. Total number examined ... ... ... ... ... ... ... ... 434 „ „ failing in class test ... ... 129 „ „ with slight impairment of hearing (after forced whisper test applied) 18 „ „ definitely deaf ... 2 Of the 2 definitely deaf—one well known to the school doctor has been under treatment for some long time without improvement, and has now been passed for the hard of hearing class. The second child has only been in London some 11 months, but in the re-distribution of the children from one school to another had missed being brought up for a special examination. She also has been now passed for the hard of hearing class. Of the 129 children who failed in the class test—45 gave a history of otorrhcea or the removal of tonsils. Age incidence. Number examined. Number failed. Hearing slightly impaired. Number with history of otorrhoea or tonsils removed. 8-10 years 176 38 2 17 10-14 „ 258 91 16 28 Many of the failures to pass the class test were found to be due to inattention, mental dullness or difficulties in spelling the words given. Arising out of the enquiry the most impressive fact is that so many of the children who failed in the class tests had a history of ear or throat trouble and although, in a room in which there was more or less freedom from noise, some of them responded quite well to individual tests, there was evidently some slight impairment of hearing which might progress to a more serious degree of deafness later. It is difficult to secure treatment for these very slight impairments of hearing, mainly for the following reasons :— (a) Parents do not notice anything wrong, or do not realise the need for treatment at this stage. (b) The general hospitals and some children's hospitals are so over-crowded in their out-patients' departments that the physician or surgeon has no time to make a detailed examination of a child who apparently hears ordinary speech quite well, a first impression probably confirmed by the parents' own conviction that there is nothing wrong. 53 These, however, appear to be just those cases which should be kept under treatment or observation by otologists, to prevent, if possible, progressive impairment of hearing and deafness in later life. It seems necessary that strong pressure should be brought to bear upon parents to obtain early and prolonged treatment for all cases of otorrhœa, and that cases not responding to treatment at the Council's treatment centres should be referred to otologists without undue delay. Arising out of the enquiry, the conclusion has been formed that the ordinary forced whisper test for defective hearing is very unscientific, for it is impossible to ensure with any degree of accuracy that the conditions are the same for each child tested. The voice tires, the tone changes and errors of all kinds are apt to creep in. Moreover, in a school building it is impossible to eliminate external noise, and this adds to the difficulty of any hearing test. The use of the audiometer in hearing tests. The Audiometer.—In view of the unsatisfactory nature of the tests of hearing in general use, special attention has been given to a scientific instrument for testing hearing latterly introduced in America, termed the "Audiometer." The instrument has been studied and brought to further perfection and standardised for English use by Dr. Crowden at the University of London School of Hygiene and Tropical Medicine. Dr. Crowden's work has been followed step by step by one of the Council's officers. The following is quoted from a report recently made by Dr. Crowden upon an investigation carried out in the elementary schools of the Borough of Hornsey, where 1,500 children were tested:— "The 4-a audiometer is essentially a gramophone fitted with a magnetic pick-up which enables the sound to be transmitted to a number of single headphones instead of through the ordinary horn. These telephone receivers are made up in sets of eight, and it is possible to join five of these sets together and so transmit the sound to 40 headphones at once without diminishing the intensity of the sound heard at any one of them. As many as 40 children can therefore be tested at the same time. The use of headphones rules out at once one of the objections to the whisper test—namely, the reflection of sound from the walls of the examination room. "The record is standardized and the same record is used for each child or group of children, so the other main objection—namely, the variability in the strength of the whisper—is also ruled out. In this connection it should be stated that each record may be played 90 to 100 times, after which it becomes worn in places and must be discarded. Another advantage worthy of note is that with the gramophone audiometer test there is no possibility of the child reading the lips or expression of the examiner." As the result of a report upon the subject the Education Committee gave authority for the purchase of an audiometer and with assistance kindly given by Dr. Crowden, experimental tests are now being carried out in the London schools. Arachnodactyly or "Spider limbs. " Dr. Maurice L. Young. IV.—Arachnodaclyly.—Dr. Maurice L. Young has investigated in the school children brought before him at medical inspections a not uncommon condition which has been termed "arachnodactyly," a name taken from one of the most striking characters shown by the children affected. Dr. Young's paper will be published in full in the clinical reports, but a brief account of the condition as described by him is included here on account of its interest to school medical inspectors. Dr. Young describes three grades of the condition as found by him:— "In the first the child appears as tall, thin, long-limbed and lanky, he tends to speak in a slow calculating type of voice, yet is alert and of normal mentality; the face is long and thin, the mouth small and narrow, the lower jaw is somewhat pointed and projects as does the nose; the supra-orbital ridges are prominent; the ears always large, especially the lobes, and their cartilage is often deficient; the whole skull may show some degree of dolichocephaly; the features tend to be old for the age, this latter point being especially characteristic; the entire musculature shows some degree, however slight, of flaccidity, ill development and loss of tone, and in addition, it may be possible to demonstrate a laxity of the ligaments. "In more pronounced cases there are noticed a high vaulted palate, winging of the scapulae, deformities of the bony thorax, flaccidity of the musculature, and some increase in length of hands and feet. "In a still further grade is found 'arachnodactyly'—a peculiar condition of the hands and feet in which the metacarpal bones and phalanges are abnormally long, giving a ' spidery' appearance to the organs, pronounced muscular flaccidity with consequent skeletal deformities and congenital deformities, especially of the eye, such as dislocation of the lens, small pupils, nystagmus or persistent pupillary membrane." In the annual report of the school medical officer for 1913 an account was given by Dr. Leipoldt of a condition termed by him "asthenia congenita universalis." 54 The children afflicted with this condition were described by him as "thin, with slight figure, marked slenderness of the limbs, long slender hands and feet, narrow oval face with proportionately greater development of the cranium than facial bones, smooth transparent dry skin with well marked surface veins, long eye lashes, well grown downy hair on arms and back, markedly pale complexion, long shallow narrow thorax, a sharp epigastric angle, a short and stiffened first costal cartilage (Freund's sign), marked flattening of the angulus ludovici (Rothschild's sign), and a floating tenth rib or costa decima fluctuans (Stiller's sign)." Dr. Leipoldt concentrated his attention especially on the last sign, viz., the floating tenth rib. He found that children with this sign were congenitally weaker than normal children, resist infection less, and are more prone to nervous diseases and diseases of nutrition. In Dr. Leipoldt's investigation Stiller's sign was present in 13.6 per cent. of 500 unselected London school children examined by him. There is no doubt that Dr. Leipoldt's description of asthenia congenita universalis is very close to Dr. Young's description of arachnodactyly and that they describe a single type. The type is one vaguely recognised by all who have had experience of school medical inspection, as has been described variously as "congenitally debilitated," "the nervous type," "the pretuberculous type," etc. Children so described, often exceptionally intelligent, are constantly brought forward on account of frequent absences from school, tendency to suffer from manifold ailments, particularly night terrors or chorea, and inability to withstand school pressure. It is these children that furnish the irreducible remnant of the malnourished and, as Dr. Young points out, they are the children who frequently disappoint when sent away for convalescence by returning in statu quo ante. Feeding of school children. Supervision of dietaries. Dinners are provided for necessitous children attending the schools and follow menus which have been approved by the school medical officer. Occasionally samples of the actual meals given to the children are taken in order to ensure that each child receives sufficient quantities of nitrogenous and calorific elements. Ten such samples were analysed in the public health department, all being satisfactory in food value. While children are placed upon the school dinner list by care committees as soon as there is social need, and before malnutrition has time to develop, additional nourishment in the shape of milk or cod liver oil is given to the children who are especially in need of it—irrespective of financial or social necessity—on the advice of the school doctors during medical inspection. These children are kept under careful and continuous observation and are weighed regularly by the school nurses. Excluding special schools, the numbers of "milk meals" or "oil meals "given in 1930 in the elementary schools upon the doctor's advice were:— Milk meals—To necessitous children 1,363,455 To non-necessitous children 3,396,549 Total 4,760,004 Oil meals—To necessitous children 279,444 To non-necessitous children 496,748 Total 776,192 In the case of the non-necessitous the cost was recovered from the parents, no charge, however, being made for service. The results of milk or oil given in this discriminating way have proved to be astonishingly good. Over and above the official scheme detailed above, there is a very large number of " milk clubs " in the schools taking advantage of the arrangements made by the National Milk Publicity Council for the supply upon a paying basis of milk to the scholars in bottles containing ½ pint. The general effect is no doubt excellent, but it is not possible to assess the benefit obtained from arrangements which are voluntary 55 or haphazard. Dr. C. E. Thornton endeavoured to do this but he was unable to show any difference in a school where a voluntary milk club existed from one where there was no such provision. The milk in the official scheme is supplied under contract and the quality is kept under control by frequent sampling. The total number of milk meals examined in the public health department during the year was 1,690. Of these 7.1 per cent. were found to be under the standard prescribed in the specification and these were brought to the notice of the supplies department and the purveyors; 194 samples contained an excessive amount of extraneous matter, in most cases of a nature indicating careless handling. Further measures for ensuring the cleanliness of the milk supply to the schools are under consideration. Open-air Education. Provision for education in the open air includes nine day open-air schools (nontuberculous) with accommodation for 1,460 children and six day open-air schools (tuberculous) accommodating 515 children. There are also five country and seaside convalescent camp schools accommodating 484 children for periods varying from one to three months, through which 4,600 children pass annually, and 199 open-air classes in playgrounds and parks providing for upwards of 6,000 children. Day openair schools for non tuberculous children. The following table gives the actual number of children who attended the day open-air schools (non-tuberculous) at some period during the year:— Boys. Girls. Wood-lane 80 68 Aspen House 115 89 Downham 64 58 Holly-court 237 197 Charlton-park 107 66 Upton House 134 100 Bow-road 156 92 Stowey House 290 153 Brent Knoll 124 70 1,307 893 Total 2,200 Open-air school, Downham. Dr. K. Butterfield. The provision was extended by the opening of a new day open-air school on the Council's housing estate at Downham. I am obliged for the following detailed account of this school to Miss Kathleen Butterfield, the school doctor:— "A new open-air school on the L.C.C. housing estate at Downham, Kent, was inaugurated on May 26th, 1930. "The school has a sunny open position on the slope of a hill. It is situated in a quiet by-road, the school buildings being more or less in line with the neighbouring houses and comprising four separate classroom shelters, a combined hall and dining-rootn shelter adjoining, one end of which is a brick building containing a closed bathroom, heated cloakroom, storeroom for blankets and kitchen; and at the other end a separate building containing teachers' rooms and a medical room. The children's lavatories are in a separate shelter well away from the other buildings. An asphalt playground (3,200 square feet in area) lies between the four classrooms and the dining hall. On the other side of the classrooms is a meadow extending back to a thicket. Adjoining the buildings are flower beds cultivated by the children. Unfortunately, the meadow is unfit for use all through the winter, since it becomes waterlogged, and the ground, owing to the clay subsoil, is heavy for the children to work during their gardening lessons. "The daily routine of the school is as follows:— 9.0—9.20 a.m.—Breakfast. 9.30—12.0 noon—Lessons. 12.15—1.0 p.m.—Dinner (12.40—1.20 p.m. in summer). 1.15—2.30 p.m.—Rest time. (1.35—3.15 p.m. in summer.) "The children lie down in flat canvas hammocks. After this they have breathing exercises. 2.50—4.0 p.m.—Lessons (gardening, handwork, music, literature, etc.). (3.15—5.5 p.m. in summer.) 4.0 p.m.—Tea. (5.15 p.m. in summer.) 4.30 p.m.—Go home. (5.45 p.m. in summer.) "Voluntary baths are available except when forbidden on account of otorrhoea chronic bronchitis, etc. 56 "The school is built to accommodate 130 children. On the opening day 48 children were admitted; the number on the roll at present being 110. The regularity of attendance is very good, having regard to the fact that these are delicate children, and that this winter has been a particularly foggy and damp one. The average attendance is 90 per cent. "On the whole, the children show definite improvement in general health, and are noticeably bright and happy. Of the 110 children in the school 50 are girls and 60 boys. Eight children have been transferred to Downham from other open-air schools, and many others were formerly in open air classes in the elementary schools at Downham. Twenty-two boys and 11 girls have extra milk, ½ pint daily in the middle of the morning, and eight boys and four girls have cod liver oil and malt, two teaspoonfuls daily, in school. "The children may be classified as suffering from: malnutrition, 46; anaemia, 40; enlarged cervical glands, 43; chronic bronchitis, 22; tuberculosis, 15; general debility, 15; unhealthy tonsils or adenoids or both, 14; chronic blepharitis, 6; chronic otorrhœa, 5; old rickets, 5; children with recent chorea, 4; fibrosis of lungs, 3; chronic nasal catarrh, 2; asthma, 2; tendency to corneal ulcers, 2; rheumatism, 1. One child had undergone an operation for empyema and six children had a family history of tuberculosis. "1. Malnutrition.—As regards nutrition, all the children have gained in weight whilst attending the school, the average increase for the boys being 1.7 kgs. and for the girls 2.3 kgs. All the children have increased in height, the average increase for the boys being 2.4 cms. and for the girls 2.5 cms. Other evidence of improved nutrition, e.g., elasticity of skin, firmness of muscles, is shown by 19 boys and 18 girls. "2. Anaemia.—17 boys and 14 girls show improvement in this respect. "3. Enlarged cervical glands.—Of seven children who have at some time been under treatment for tubercular glands, five are improved. One boy had to be referred to the Tuberculosis Officer on account of enlarged axillary glands and is now in Highwood Hospital. In twentythree cases the children have unhealthy tonsils or adenoids or have been operated on for tonsils and adenoids, and ten show improvement. Of four children subject to bronchial catarrh, three have improved. One child who attends hospital with chronic otorrhœa following an operation for mastoid abscess, and one who has chronic blepharitis, show no change. "4. Chronic Bronchitis.—Of these cases, eleven show all round improvement, two show improvement of general health, the chest condition remaining unchanged, three improved during the summer months, but had recurrences of bronchial catarrh and became anaemic during the winter, and in four cases the condition remains as before. "5. Tuberculosis.—Of three children who have had treatment for tubercular cervical glands, two have improved in general health, the glands remaining quiescent. Of three children who have been under treatment for abdominal tuberculosis, none has local symptoms now, two show general improvement, one child is still anaemic. Of three cases of old abdominal tuberculosis and enlarged bronchial glands, one is improved, one is anaemic although gaining in weight, and one is now off the roll of the school. Of three children who have formerly had treatment for tubercular chests, two are making good progress, one keeps thin and anaemic. One boy with enlarged cervical glands developed enlarged axillary glands and is now at Highwood. "6. General Debility.—Seven of these children show improvement. "7. Unhealthy Tonsils or Adenoids.—Four children have had an operation, and all are improved. In five cases an operation has been recommended. Three children remain unchanged. "8. Chronic Blepharitis.—In two cases the condition has improved, the other four remaining unchanged. "9. Chronic Otorrhoea.—-Two children have had ionisation and are cured of otorrhœa, one showing considerable improvement in general health. The others remain unchanged. "10. Old Rickets.—Three cases show general improvement in health. "11. Choreic Children.—Four children have formerly had chorea and now are keeping well. One had another mild attack of chorea during this winter. He is thin and anæmic and his heart is not affected. One child still shows slight involuntary movements. He is of poor nutrition and his heart has an apical systolic murmur. He does no drill, or games or school bathing. "12. Fibrosis of Lungs.—The general condition of these children is better. "13. Chronic Nasal Catarrh.—The local condition is unchanged. "14. Asthma.—One child has had no attack for some time and is making good progress. "The other was a moderately severe case of asthma and chronic bronchitis with eczema. I admitted him with some reluctance, on the recommendation of the hospital physician who was treating him, the child's mother also being anxious for him to attend the school. He had an attack of pneumonia in June, but since then has improved very much as regards general health and attends school fairly regularly. "15. Corneal Ulcers.—There has been no recurrence of ulcers, but one child still has chronic blepharitis and conjunctivitis. "16. Rheumatism.—One child with a history of an attack of acute rheumatism is doing well. "17. Empyema.—This child remains thin and pale. The chest expansion is fair on the affected side." 57 Detailed reports from the school doctors were received from all the other day open-air schools. From their reports the following accounts of the activities of the schools have been extracted:— Wood Lane open-air school. Dr. R. C. Norman. This open-air school, built expressly for its purpose, and not adapted, was opened on June 17th, 1929. The buildings, which comprise administrative offices, a dining and rest hall, and four open-air classrooms, with the surrounding land, cover 1} acres. The school lies exposed to every wind that blows, and is surrounded by large open spaces, playing-fields of other schools and tennis courts. "The accommodation is for 130 children, the roll 148, the number of boys and girls being practically equal. The average attendance is 118. In addition to the ordinary school hours of the elementary schools the children are expected to attend on Saturday mornings, and about 80 per cent. of the average attendance do attend. Three meals are provided during the school period each day, breakfast at 9 a.m., dinner 12 noon, tea from 5-5.30 p.m., somewhat earlier during the dark days. "A typical breakfast consists of porridge with milk and sugar, bread and marmalade or bread and butter, cocoa made with milk. A typical dinner would be meat (boiled salt beef, stew, roast beef or boiled mutton), vegetables, pudding (jam, suet, milk or fruit salad). For tea brown and white bread and butter, bread and jam, cake three times a week, milk and tea. On those days when fruit salad is not served, each child has some fruit, either an orange, banana or apple. The children give no trouble in taking their food, which is good in quality, properly cooked and nicely served. After dinner each child has 1¼ hours' rest on a Ceta bed 1½ hours in summer). The blankets used are numbered and each scholar only uses the one appropriated. "The plot of ground belonging to the school was a wilderness 18 months ago; to-day it literally blossoms as the rose, producing flowers and vegetables in abundance, the flower garden supporting two hives of bees from which 30 lbs. of honey were obtained last year. Three-quarters of a ton of potatoes were produced, which were sold to the kitchen for £5, and a plentiful supply of green and root vegetables also went into the same market. These funds have helped to instal wireless and a loud speaker, the broadcast educational lessons being received, and by connecting up suitable gramophone records, this music is used in the dancing lessons. Every child, boy and girl alike, does some work in the garden, that done by the girls being voluntary, but all show keenness. "About two dozen boys and girls have swimming lessons. There is scarcely one child in the school with a 'cold' and the head teacher informs me that some parents have told him that this is the first winter their children have been able to attend school without any break through illness. In the summer each scholar has a weekly hot bath, but in winter those children are exempted whose parents object. A little sun-bathing was done last summer, the boys dressed in shorts and girls in swimming costumes. This was liked by the children, and it is hoped to increase the numbers considerably during this coming summer, and devise a suitable form and colour of garment, enquiries concerning which are now being made. "Each child in the two senior classes has a plot of ground which is cultivated and planted according to fancy. "Teeth-cleaning drill is practised every day, but all do not possess brushes, meanwhile the, forefinger is used as a substitute. "Every day the minor ailments are attended to by the sister-in-charge on the school premises. "The whole tone of the school is excellent, due to a most capable, enthusiastic and pleasant. mannered head teacher, a quiet, thorough, painstaking sister and the earnest teaching staff. It is always a pleasure to visit the school, for one is sure of seeing real business proceeding and of receiving everv necessarv assistance." Stowey House School Dr. W. Slowan. This has been another satisfactory year at Stowey House School, 28 per cent. of the first year children and 38 per cent. of the second year having been found fit for discharge. In all, 107 children left at Easter fit either to return to their ordinary school or to leave altogether at the age of 14. As was said in last year's report the sun-bathing during the summer months has a great deal to do with the good results obtained. Started in the first week in May it continues till the second week in October. Each year sun-bathing is growing in popularity and it is now not an uncommon thing for children to show a desire to indulge in it more fully or more frequently than might be considered advisable by inexperienced critics. In view of the great importance of sun-bathing, it is to be regretted that it is apparently so difficult to ensure having the school filled at Easter so that all children could receive the maximum benefit. There is accommodation for 260 children but for the last five years the number on the roll at the beginning of the summer term has varied from as low as 252 to 283 and the school has not been full until June or later. A great improvement has lately been effected in the garden by the paving of the main pathway. There still remain to be considered other means of ameliorating the inclement conditions to which children at open-air schools are exposed in winter, 58 such as protection by means of screens from the cold winds, and floor heating of the classrooms to counteract the bad effects of sitting with cold and damp feet, but possibly those ideas are too Utopian for the present time. Holly Court open-air school. Dr. C. N. Atlee. During the year ending December, 1930, 186 children left this school and 141 were admitted. The causes of leaving were as follows: certified fit 126; parent's request 22; miscellaneous reasons 24; sent to convalescent homes 14. The chief reason for children leaving at parents' request is that the latter fear the long tram journey to the school, entailing sometimes transfers at dangerous places, such as the Nag's Head. Another drawback is the considerable walk from the tram to the school (15 minutes) up a steep hill. Other causes of leaving included mainly removals to new estates. The type of children admitted last year was generally of a poorer type than heretofore, especially from a mental point of view. In spite of the distance the average attendance was good, viz., 230 out of a roll of 247. The majority of the children admitted suffers from general debility due to poor feeding, bad hygiene, overcrowding and poor home conditions. In addition there are cases of anaemia, enlarged glands, tuberculous glands, bronchitis, asthma, old tuberculous peritonitis, fibroid lung, chorea and rheumatism rickets and children suffering from "nervous troubles." Generally during the year the weather was wet—a distinct handicap considering the muddy state of the paths and the often inadequate boot gear. In spite of this the children were out of doors for teaching, eating and resting; and only on about six occasions, during exceptionally severe weather conditions, was it found necessary to have them indoors. The shelters are well protected and sides are apparently not needed. The menus are extremely varied, well thought out and thoroughly adequate; fruit is given eveTy day, and a liberal portion of sugar provided. The children are given very liberal helpings, discipline is wonderfully maintained at meal times, and music is supplied by a gramophone. Only six cases of infectious disease were noted during the year, no epidemics of any kind, and in addition it was observed that there was a remarkable freedom from colds, catarrh and chilblains. Physical exercise is provided for by 20 minutes' "jerks" in the open-air every day—including deep breathing—and by gardening, woodwork and other outdoor activities. In every instance there has been noticed a great improvement in the mental condition, alertness and animal spirits of the children and a satisfactory increase in the height, weight and facial colour. Holly Court is a difficult school to administer, but praise is due to the excellent work carried out by the sister-in-charge, particularly in the matter of attending to minor ailments and the splendid discipline kept at meal times. The cases which do best in the open-air schools are those suffering from general debility alone. Chorea and rheumatism should, as a rule, be kept out. It would considerably facilitate matters at Holly Court if more suitable means could be provided for conveying children to the school. Far more children should be given the privilege of attending open-air schools. There are hundreds of children residing in the crowded and often insanitary areas of Hoxton, Somers Town, Finsbury, Islington, etc., of the debilitated type who would benefit enormously by such a change. The following cases are samples of improvement:— 1. Boy admitted September, 1928, with asthmatic attacks, lungs full of rales and rhonchi. Poor condition. Discharged May, 1930. Lungs clear, no further asthmatic attack, gained 8 kgs. 2. Boy admitted September, 1927, with chronic bronchitis and attacks of asthma. Lungs full of catarrhal signs. Discharged October, 1928. Gained 10 kgs. Lungs clear. No further attacks of asthma. 3. Girl admitted September, 1929, with enlarged glands of the neck and debility. Discharged September, 1930. Gained 5 kgs. Glands normal. Great improvement in general health. 59 4. Boy admitted September, 1929, with old tuberculous glands of the neck and enlarged glands, poor general condition. Discharged September, 1930. Gained 5 kgs. Perfectly fit with no obvious glands remaining. Brent Knoll open-air school. Dr. E. J. Roberts. Brent Knoll open-air school is very much what a model open-air school should be and this is clearly reflected in the progress in health and happiness of the children. One certainly gets the impression when a poor school is visited subsequent to a visit to Brent Knoll that the children should be exchanged, but this impression is only a compliment to the efficiency of the open-air school. General. All the reports are enthusiastic as regards the benefits derived from open-air education by the debilitated children who are chosen to attend them. In one or two instances the questions of protection from driving wind and the supply of artificial warmth in the winter are raised, but it cannot be said that any sort of case has been made out for the latter. The experience of those longest versed in the administration of the schools is that provided adequate means of drying clothes and changing boots are present, the supply of general artificial heating is not necessary and if adopted would at once alter the character of the schools and detract from their value for the purpose for which thev exist. Open-air schools for tuberculous children. In addition to the provision of treatment for tuberculous children in residential institutions the Council continued the use of the open-air schools, specifically for children notified under the Tuberculosis Regulations, 1912 (now merged in the Consolidated Tuberculosis Regulations, 1930), as suffering from tuberculosis of the lungs or of glands with no discharging sinuses. The six schools—Elizabethan (Fulham), Geere House (Stepney), Kensal House (Paddington), Springwell House (Battersea), Stormont House (Hackney), and Nightingale House (Bermondsey), have together accommodation for 565 children. The number on the roll on the 31st December, 1930, was 566, and the average attendance for the year ending 31st March, 1930, was 458.7. Admission to the schools is granted on a certificate of the medical officer of the Council, and children returning home after a period of residential treatment in sanatoria are given preference. In the course of the year, 215 children were admitted and 228 discharged. Of the latter, 45 were transferred as fit to attend elementary schools, 95 were fit for work, 52 were transferred to residential institutions for residential treatment for tuberculosis or admitted to hospitals for various reasons, 17 moved away, 10 were transferred to special schools and 9 were discharged for other reasons. In 1925, vocational classes were started at Springwell House and Stormont House open-air school, with the object of training children in subjects likely to be of use to them in obtaining employment. Two classes are held at Springwell House, one for boys and girls in commercial training which includes shorthand, typing and general office routine, and the other for girls in needlework. The vocational class at Stormont House is in needlework instruction and also in gardening. Instruction in carpentry is also given at this school. The following school journeys were made during the year 1930:— School. Period. Hostel. Number of children. From To Geere House 23rd May 6th June Dymchurch 20 Elizabethan open-air school 8th July 22nd July Seasalter 11 Springwell House open-air school (1) 17th June 1st July Arthur Home, Bognor. 20 Do. (2) 8th July 22nd July Seasalter 40 Stormont House (1) 17th June 1st July Arthur Home, Bognor. 21 Do. (2) 8th July 22nd July Seasalter 21 60 Below is printed an extract from the report of the medical officer of the Stormont House open-air school:— "Two school journeys were undertaken during the year, one of twenty-one boys to Whitstable, and the other for the same number of girls to Bognor. It is fortunate that the headmistress was able personally to take charge of both parties—a fact which certainly added to the success. A holiday in some form or another is essential to many of the children, and I consider that school journeys meet a need which would not otherwise be catered for. All the children did well and thoroughly enjoyed their stay by the sea." Open-air classes in parks and playgrounds. The number of open-air classes in connection with the elementary schools actually held during the year was 195, an increase of 17 over the number for 1929. Of these 15 were of type A (children selected for medical reasons from a group of schools), 61 were of type B (children selected for medical reasons from the various classes of a single school), 35 were of type C (consisting in a single class from one school educated continuously at one open-air station), and 84 of type D (consisting of a rotation of classes from one school occupying one open-air station). Of the 195 classes, 118 were held in school playgrounds while 77 were stationed in parks and other open spaces at a distance from their parent school. Forty-eight of the classes are being carried on through the winter. There are, in addition, over and above the 195 "programme" classes, four permanently established classes which do not enter into the annual programme figures. The children in these classes are kept under special observation by the school doctors, they are weighed and measured regularly and are given additional nourishment when required. Detailed reports have been received in the case of 80 classes. The general benefit accruing to the children is most marked, especially in those classes where the children are selected on medical grounds as especially likely to obtain advantage from open-air conditions. Although the equipment is of the slightest and the classes were originally projected for the summer months only, yet in many cases they have been continued throughout the winter months as well. The conditions under which the classes are held vary greatly, and the degree of improvement in health consequently also varies. In some neighbourhoods the poor nature of the accommodation possible militates against the best results, but, nevertheless, considerable improvement in health is noticed in the children. Dr. Edith Robinson comparing two type B classes under her medical supervision, one of which was held on the roof of the Forster School and one in Poole's Park, came rather surprisingly to the conclusion that the children in the roof playground benefited more than those in the park. The reasons she gives include the better arrangement for mid-day feeding at the Forster School, the possibility of withdrawal into shelter in bad weather and less distraction. St. Mary's, Putney, openair class. Other reports which may be quoted are those of the St. Mary's school, Felshamroad, Putney, of which Dr. McQuaid says:— "This class has been a remarkable success. There were several extremely poorly nourished children, and it is no exaggeration to say that they are unrecognisable they have improved so much. The mothers of nearly all the children came to the last inspection to express their appreciation of the improvement." White Lion Street openair class, 1930. Of the White Lion-street school open-air class, Dr. McKeown reports:— "During the year 1930 the general improvement in the physical and mental condition of the children attending the open-air class has been well maintained. The number of children on the roll at present is 28, and during the year the average number in attendance has been 30. The attendance has been good and there has been no case of serious illness amongst the children. On analysing the causes for absence it has been found that in a large proportion of the cases the absence was due to illness amongst the family at home so that the child was kept at home to help; or else the absence was due to some minor ailment or indisposition not lasting longer than three days. There has been no case of infectious illness during the year and no case of developing rheumatism. The class has not been obliged to be in the indoor classroom on account of the weather since February, 1929. "At the present time in this open-air class the children on admission show five principal defects—anaemia (present in 80 per cent. of the cases), very poor muscular tone due to imperfect nutrition and surroundings, defective posture as a result of the poor muscular tone, languid aspect, poor air entry into the lungs. The first improvement to be noted in nearly every case is the comparatively rapid lessening of the anaemia, with this there is an increase in appetite and a brightening of the general aspect of the child. In those cases where the defective posture is slight the recovery of muscular tone remedies it in a month or two. In the cure of some cases 61 of bad posture especially if there is slight scoliosis the child improves rapidly if she has in addition special exercises at Britannia Row—two girls are at present having these special exercises. "One girl in the class who had a very intractable eczema started to clear up after several months' attendance at the class, and though the eczema still does recur it is not nearly so severe. In nearly all the cases they are, of course, below standard—this is often on account of lengthy absences before admission to the class, but even the most backward show some improvement; after six months there is an increased interest in the school work and a greater power of attention." Convalescent Camp Schools. The numbers of children in 1930 passing through the convalescent camp schools were as follows:— Boys. Girls. King's Canadian school, Bushy 2,779 — Wanstead House, Margate — 521 Barham House, St. Leonard's 64 567 The Russell Cotes School of Recovery, Parkestone, Bournemouth — 207 Fairfield House, Broadstairs — 208 Totals 2,843 1,503 The stay of the children (who are selected by the school doctors during medical inspection) at the above schools varies from one to three months. A considerable amount of special remedial work is carried out at the King's Canadian school, a fully equipped dental clinic is constantly at work there and especial attention is given to minor postural deformities so common in debilitated lads. Mr. W. H. Devonshire, the Director, has submitted the following report:— "Report on remedial work at the King's Canadian School for the year ending December 31st, 1930.—Individual treatment was given to 242 boys, and treatment in small groups according to their disability to 977 boys, making a total for the year of 1,219 cases. "We have attempted, with, I think, a large measure of success, to deal with the problem of the ever-growing number of cases of flat feet visiting the school: 476 cases in the earlier stages, before any marked changes had occurred in the formation of the joints, were selected for treatment and visible improvement has been noted. "The scheme includes the teaching of a few simple exercises until the boy knows them by heart. He is then given a card on which the exercises are printed and encouraged to practise them daily. Finally, his parents are advised to have his boots wedged on the inside and to see that the boy continues his exercises on his return home. "This has naturally taken many boys from some of the other sections of our work—a summary of which appears below. All cases are selected by our school medical officer and re-examined on the conclusion of their stay. School roll during year 2,821 Boys to whom remedial exercises were given 1,219—43.2 per cent. "Summary of 'remedial exercise' cases:— Flat foot 476 Round back and flat chest 271 Bad carriage, etc. 176 Lateral curvatures (chiefly postural) 126 Lordosis (10 per cent. leaning backwards) 116 Torticollis (early cases) 2 Shallow breathing (marked cases) 48 Special massage (post fractures) 3 Height increase 1 Total 1,219 Children who have been away under the convalescent camp scheme are kept under observation by the children's care committee concerned; in many cases a special report is supplied at the end of six months after return. Many of the reports testify to the excellent care taken of the children and the benefit which they derive. 62 School Journeys, 1930. During the year 1930, 503 (513) school journeys were made. The figures in brackets are those for 1929. The children taking part in them were medically examined in 501 cases before departure. In all 16,415 (16,267) children were examined; of these 97 (110) were rejected as unfit to take part in the journeys on various grounds, as follows:—Suffering from otorrhoea 10 (9); suffering from infectious disease or contacts 8 (14); tonsillitis and kindred ailments 12 (15); "increased temperature" 8 (7); personal hygiene 3 (5); skin diseases 9 (23). Four children were prevented from going on account of the effects of recent vaccination. Several children were provisionally rejected for defective personal hygiene, but were subsequently passed fit. Nursery Schools. During the year 1930 two new experimental schools, each for 150 children, were established by the Council at Columbia Market, Bethnal Green, and at Old Church-road, Stepney. Recognition was given to two new voluntary schools, the St. Leonard's Nursery school on the Foundling Hospital site (accommodation 60) and the North Islington school, 110, Tollington-park, N.4 (accommodation 40). The new Jellicoe school, rebuilt on the old site at 6a, Rochford-street, N.W., has accommodation for 54 instead of 45 children as in the temporary premises. Proposals now under consideration are the erection of two schools on the tops of blocks of flats in the St. Marylebone and St. Pancras districts. The total recognised nursery school accommodation in London at the end of 1930 was 1,004 in 13 schools. Columbia Market and Old Church Road.—These schools, situate in poor and crowded districts, have each four open-air classrooms with good verandahs, two of the rooms being for 50 and two for 25 children. Originally the rooms were, excepting for a movable wooden balustrade, entirely open on one side; but whilst the older children who entered the schools when first opened at the beginning of the autumn term became gradually acclimatised to open-air conditions before the onset of winter, it was feared that the youngest and the late comers might suffer from cold, and means of protection from frost and fog in the form of adjustable canvas curtains were decided upon. On Columbia Market school Dr. Turover reports as follows:— "The Columbia Market nursery school (roll 78).—This school, for children between the ages of 2-5, was opened in August, 1930. The bulk of the admissions were unselected children, very few of them coming on the recommendations of hospital doctors or from other schools. "The majority of the children came from overcrowded homes, showing signs of rickets and faulty nutrition and malnutrition; some looked neglected and dirty. "It was with difficulty that I recognised the same children at subsequent visits. "They looked cleaner in every way, had a better colour, the eyes of those who were admitted with blepharitis had cleared up and spots and sores had disappeared. "They seemed contented and happy at their play, all of them occupied and much interested in the apparatus supplied. "Enuresis, I am told, is disappearing, the mothers say that bed wetting is now a rare occurrence, since the children have begun to be trained in regular habits. "It was difficult at first to get the children to take the good, plain food provided (which is served to them in a most attractive manner) as opposed to the food they were used to (pickles, relishes, fish and chips, etc.), but they are quickly acquiring the taste for it now and seem to tolerate the week end fare less, as evidenced by the Monday indisposition. "I am informed by the head teacher that the children's social sense is developing, and those children who were reported by the mothers as being nervous, or shy, or unfriendly are becoming much less so with the change of environment and encouragement on the part of the teachers. "Nearly all the children show an increase in weight and height. "There is no doubt that the advantages offered at the school, such as regular meals, rest and recreation, are having a most beneficial effect on the Bethnal Green toddler." Dr. Cotter's report on Old Church-road school is as follows:— "The site of the nursery school, Old Church-road, is well chosen, in the midst of rows of ugly, poorly ventilated, overcrowded houses teeming with children. 63 "The numbers on the roll have steadily increased since the school opened in August reaching 89 before the end of the term. The attendance on the whole is very satisfactory. Except for one case of smallpox, there has been no infectious illness amongst the children. Even for the short time the children have been under my observation, I can see distinct progress mentally and physically. Two cases of rickets show marked improvement. The parents are very willing to carry out any treatment suggested at the medical inspections. "One realises the nursery school provides much more than good food and treatment of physical defects. It fosters all round healthy development by providing a favourable environment, training in hygienic habits, and by encouraging free activity." Child Guidance. During the last two years increasing attention has been devoted to certain types of children who either fail to comport themselves normally or who do not make the educational progress that might reasonably be expected. The causes of failure sometimes depend on innate factors such as limited intelligence, physical defects, lack of emotional control or absence of interest and so of any incentive to profit by education. The needs of children with clearly defined defects have long been realised and special provision made in the form of schools for the blind or deaf, since extended for the help of those who have serious but far from complete loss of vision or hearing, for cripples and sufferers from heart disease, for the debilitated and for the mentally defective. As time went on it became clear that other groups needed help either because of some innate or acquired personal mental trait or lack or because of some stresses in their environment which the children were unable to meet unaided. To help such children it is necessary to study the individual, his surroundings, his family and his acquaintances, since the difficulties which give rise to behaviour problems result not so much from the struggle of the individual against more or less immutable physical obstructions as from the much more variable matter of the interaction and clash of personalities. For this purpose there is needed a physical study of the child as complete as can be made with perhaps rather more stress on neurological features than would be placed in a routine school examination of an apparently normal child. The principal points for investigation are the measure of the child's intelligence, attainments and reactions to educational material, such as can only be carried out by an educational psychologist or a medical practitioner who has devoted special study to this branch. Further should be recorded the emotional trends, instincts and desires of the child by a medical officer with psychiatric experience among children, and, above all, a careful study of the whole social situation should be made by a trained worker. When these data are collected it is often possible to do much to relieve existing difficulties or to prevent the onset of further problems either in the child under consideration, or which is of as much or more importance, in other members of the family. To secure such a result the co-operation, it may be said the understanding co-operation, of the family is required; where the parents are frankly hostile or refuse any assistance it is impracticable to do much to relieve the home situation and if the behaviour of the subject is such as to require and permit drastic action some steps must be taken to place the child for a time under more favourable auspices. When, however, the parents are really interested, or merely perplexed but well disposed and sometimes even when they are indifferent but not actively hostile they may be materially helped in the appropriate supervision and guidance of a distracted child. The child may be led to more personally gratifying intellectual and emotional expression, more acceptable recreational satisfaction and so to greater stability, which in turn facilitates scholastic progress and social adaptation. Several hospital departments and clinics are now at work in this field and afford greater or less opportunity of investigation in the different sections of the work which may be regarded as generally speaking requisite to a complete study. As the emphasis laid on the different lines of investigation, physical, psychological and social from different sources varies in intensity, it may be possible later to appraise their respective values. At the moment it seems probable that each has its place. For instance, to relieve the problems of one child individual attention and 64 even psychotherapy may be needed; for another, an indication of the need for a special line of instruction; for yet another, adjustment of home circumstances and explanations to perplexed parents of the special needs of the child; while in a few but often the more involved cases it may prove that one or both parents require psychiatric care. For this reason it will probably prove advisable for child guidance clinics or departments to be attached or closely affiliated to centres in which the minor mental disturbances or disabilities of adults are investigated or treated. This branch of remedial or preventive medicine is in its infancy but is likely to expand with the development, under the Mental Treatment Act, of out-patient departments and observational wards, as distinct from the old idea of the asylum. It seems probable too that ultimately arrangements will be required for the temporary care of a certain number of children away from their homes so as to afford both children and parents the benefits of a much needed change and rest from continuous family associations, such a change as has been for years available to those of adequate means in the public boarding schools for boys and girls. Another branch of the work which is likely to develop is the question of special provision for coaching children who have failed to receive adequate grounding in the fundamentals of one or more of the three elements (reading, writing and arithmetic), and who, by reason of age or special attainments in other subjects, have been promoted beyond their level but would suffer by being returned to a much lower class. It may require considerable research and an expenditure of time which could not be given by the school teacher, even if possessed of adequate psychological qualifications and experience, before an appropriate line of approach is discovered and proved to be effective. Work of this kind is being carried out increasingly by the psychologists attached to the various hospitals with child guidance departments and by the child guidance clinics. Departments dealing with maladjusted children with full provision for psychological and social investigation are now in action at Guy's Hospital, University College Hospital, Great Ormond Street Hospital, and the Maudsley Hospital, Denmark Hill. To a lesser extent, work is commencing elsewhere. The school medical service is in liaison with these departments by the agency of the care committee organisation and the almoner's departments of the hospitals, reports are exchanged and action taken as regards any feature of the school work which can advantageously be modified. The relationship has become closer during the last year and is likely further to be extended as experience is gained. A voluntary clinic has been established at "The Quest," Clarendon-road, in the Kensington area, under the direction of Dr. Lowenfeld, in which a small number of maladjusted children are studied, chiefly whilst they are occupied in a kind of playroom-occupation centre during two afternoons in each week. Though the methods of expression or emotional trends form the central feature of the work of this centre any child who requires it is given a full physical or psychological examination and a social worker loaned from the Child Guidance Council, ascertains the home situation and arranges any necessary explanations or adjustments. The children's room contains material for tests of intelligence, the expression of phantasy, constructional work and social or individual games. The types with which work is done comprise: (a) Children who need emotional release, who need to be encouraged in selfexpression since their repressions have often resulted in educational backwardness. (b) Children whose interest has become diffused and who need a framework within which such interests can be concentrated. This condition is, it is pointed out in a report of the centre, sometimes found in association with epilepsy and allied disorders. Though this centre is less closely linked with the medical work in the schools than those of the other centres, reports are received from time to time and the social worker keeps in contact with the children's care organisation in all that concerns those patients who attend London elementary schools. During the year ended September, 1930, some 98 cases had applied for treatment and 54 had been accepted of which 20 are stated to have been referred directly or indirectly through the school care committees. The clinic is close to the county boundary and many of 65 the patients come from extra-metropolitan areas or from other than elementary schools. The chief problems according to the initial statements were " nervousness," "enuresis," "unmanageable behaviour," and "untruthfulness." Sixteen of the fifty-four are described as having been cured or very greatly improved. An important niche in the remedial facilities of East London is filled by the undenominational child guidance clinic conducted by the Jewish Health Organisation of Great Britain. This has now been established for over two years and is temporarily housed at the Jews Free school, Bell-lane, E.1. The staff consists of two psychiatrists and a psychologist giving part-time service, two psychiatric social workers and voluntary assistants. It is open on two afternoons a week from 2-4 p.m. and two evenings from 5.30-7.30 p.m. It works in the closest co-operation with the school service from which directly or indirectly some 70 per cent. of the patients were referred. It is recognised as a school clinic and attendances are duly recorded. The investigations are very thorough and a case conference at which all angles of the problems are considered by the medical officers, psychologist and social workers and to which interested parties are invited is held for each child. The predominant type of problem has been either unexplained backwardness, nervousness, enuresis, misbehaviour shown in a general lack of control and in a smaller number of instances more personal difficulties such as habit spasms, night terrors, sex troubles and the like. The average level of intelligence of the children attending has shown a mental ratio of 99.4 per cent. or about the average of the general population, but few have been so seriously retarded as to be on or below the borderlines of mental deficiency. The average number of attendances per patient has been 8. Some of the cases have been dealt with in co-operation with other agencies. The psychiatrists in their report indicate that the average age of the children was between eleven and twelve years and point out that the problems of adolescence are most frequently found well before the age of puberty, during the period of the emergence of self-consciousness and of the struggle to accept social values in behaviour. Many cases pass relatively unnoticed until the problem reaches a sufficient degree of intensity to force itself upon the parents or teachers or both. With the increase in general interest and knowledge in such matters it is probable that, in increasing measure, problems will be brought to light at an earlier date, when they can as a rule be more readily resolved. In this task a series of lectures and conferences arranged by the authorities of the centre for the voluntary workers, teachers and others in the area has played an important and most useful part. The psychologist to the centre draws attention to the frequency with which the problem proved to be one of backwardness due not so much to lack of innate intelligence as to interference by some neurosis. He finds that a problem baulks a neurotic child either because of his excessive interest in its details to the consequent detriment of the main issue or because of his extreme perfunctoriness with details. Idiosyncrasies in intellectual adjustment have seemed to be traceable to fluctuations of interest, attention and effort, rather than to lack of endowment. Special defects and abilities have been rarely found. Dr. Miller and Dr. Burke point out that "Backwardness" is not always due to an absolute retardation but to emotional causes which produce not only disorder of social behaviour, but lack of attention, fear in facing scholastic tasks, the fear of humiliation, and that functional paralysis of the will which gives the appearance of stupidity to many of otherwise normal intelligence. The officers of this clinic have found more help from the study of the child and of environmental factors than from the mental history of other members of the family. Some of the most promising results have been obtained from children who have highly coloured mental family histories while a feeble constitution in the child itself as observed in its physical and mental make up, is much more likely to give early indications for a poor prognosis. The social workers here, as elsewhere, draw attention to the advantage and often the necessity for certain children to spend part of their holidays or even longer periods away from home. Arrangements for F 66 securing suitable holiday homes or families in which children can be boarded out is clearly becoming an essential feature of preventive and ameliorative social hygiene. The largest of the clinics is the London child guidance clinic established at Tudor Lodge, Canonbury-place, under the auspices of the Child Guidance Council, but financed by, and owing its existence to, the Commonwealth Fund of America, a fund established in 1918 by Mrs. Stephen V. Harkness, "for the welfare of mankind." One of the early enterprises of this fund was the study of maladjusted and delinquent children and the provision of courses of training for qualified social workers desirous of entering this field of activity. Since 1924 the activities of this fund have been referred to in the annual reports as a result of a visit of one of the senior medical officers to America in that year when he saw the work of the Children's Courts in various parts of Canada and the United States. Somewhat later, Mrs. St. Loe Strachey interested the trustees in the possibility of extending this branch of their work to Great Britain. After visits from the officers of the fund a Child Guidance Council was established and the fund financed various persons in the Council's service and otherwise to make visits and report on the work of child guidance in the United States. Following on this, the Child Guidance Council received an offer for financing the establishment of a clinic and for its maintenance for a period of years. The London County Council on 22nd May, 1928, decided to accept the offer of the Child Guidance Council for the establishment of a child guidance clinic in London as an experiment for three years, subject to the conditions (i) that no charge shall be made to the Council for three years for the attendance of school children at the clinic ; (ii) that the Council shall receive a report on each child referred to the clinic and at the end of each year a full report on the work of the clinic generally; (iii) that visits to the clinic by the Council's medical staff shall be allowed at any time; and (iv) that the arrangements are without prejudice to any decisions the Council may reach after the lapse of the three years' experimental period. The clinic has been fully equipped and staffed by psychiatrists, psychologists and social workers and acts in the closest connection with the school medical service. Each case is considered for acceptance by the medical director who decides whether to offer complete or partial service, i.e., whether a full investigation in all fields is required, or if an adjustment might be attempted in the first place based on a psychological or social service investigation. The activities of the clinic are based upon team work and each full case is considered at the case conference from the physical, mental and social angles, a scheme of treatment drawn up and carried through either by the social worker or in co-operation with any agency which may have referred the child. Full social work is a marked feature of this clinic which is more amply staffed than others owing to its present freedom from financial anxiety with its consequent restrictions. Attendances of school children are specially recorded as a result of the recognition of the clinic which enables investigations to be carried on without the loss of the school attendance mark. The psychologists have given special attention to problems of educational disability, and the investigation of aptitudes and the devising of special modes of approach forms a prominent feature in the treatment of the group of cases which can be called more especially scholastic problems. Owing to the recency of its inception reports are not as yet available on a full year's working, for the clinic year is intended to be coincident with the calendar year, the few earlier months being regarded as a period of preparation. The clinic at Canonbury commenced to receive cases from the schools in the autumn, 1929. In the first instance it was decided that the area from which cases should be drawn should be limited to the districts of St. Pancras and Islington. Subsequently, as the activities of the clinic became more widely known, cases from other districts have been referred for treatment. Up to the summer holidays, 1930, a total of 156 Council cases had been referred to the clinic. Of these, 82 were boys and 74 girls. The ages of the children referred, the source of reference and the reasons for 67 reference are set out in the following statements:— Ages of children referred. Ages of children referred. 4 years 3 13 years 13 5 „ 4 14 „ 28 6 „ 9 15 „ 5 7 „ 13 16 „ 1 8 „ 13 17 „ 1 9 „ 20 Others (? age) 5 11 17 156 11 „ 18 12 „ 6 Source of reference. *Head teachers 59 School doctors 29 *Care committees 21 Parents 15 Children's courts 5 Hospitals 4 Private doctors 2 Invalid Children's Aid Association 2 Other sources 19 156 * In many of these cases reference was as a result of consultations between head teachers and care committees. Reasons for reference. Nervousness 35 Masturbation and sex troubles 2 Theft 25 Sleeplessness 2 Stammer and speech defects 17 Inferiority 1 Backwardness 16 Night terrors 1 Spitefulness 12 Morbid religious mania 1 Enuresis 11 Dizziness 1 Behaviour in school 10 Not known 3 „ at home 9 Total 156 Truancy 8 Wandering 2 [Note.—One child may be referred for more than one reason, but the major reason only has been included in the table.] Reports on the individual treatment of some 84 of the cases have been received and in a great number of cases progress reports have been obtained from the school care committees and head teachers. In the majority of cases improvement had been noted, and seven cases had been satisfactorily dealt with and discharged; 12 cases were, however, discharged owing to refusal of parents to co-operate or to unsuitability for treatment at the clinic, etc. In addition to the actual clinical work the officers of the clinics have by lectures, demonstrations and case conferences done much to attract local attention to the value of mental hygiene and to the importance of dealing with children's problems at the earliest moment before any deviations of behaviour have received an unfortunate reinforcement by the influence of habit. Interest has been aroused in educational and social circles so that a considerable development of the activities may be anticipated in the coming year. Admission examinations. Defective Children. The total number of examinations conducted under the Education Act during the year was 24,560. 6,015 examinations with a view to admission to special schools were conducted, f 1 68 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. Unfit for any school. Notified under M.D. Acts. Ocular B. G. Blind school Myope class ley B. G. B. G. B. G. B. G. B. G. B. G 692 820 13 10 89 144 117 129 440 510 33 27 — — Aural 184 171 Deaf school Hard of hearing class 105 84 3 6 — — B. G. B. G. 37 38 39 43 P.D. 851 849 P.D. school Open-air school 149 157 50 63 — — B. G. B. G. 623 618 29 11 M.D. 1,253 957 M.D. school 561 406 52 43 64* 46* B. G. 576 462 Epileptic 111 127 Epileptic colony 49 46 29 46 B. G. 33 35 Total cases 3,091 2,924 1,556 1,490 1,304 1,203 167 185 64 46 6,015 3,046 2,507 352 110 an increase of 540 over the previous year. * Of these, 55 boys and 37 girls were imbeciles; 3 boys and 2 girls were idiots; and 6 boys and 7 girls were feeble-minded. Local Government Act. 1929. Survey of transferred schools. Included in the foregoing table are the numbers dealt with as a result of a preliminary survey of the Poor Law schools which came within the purview of the Education Authority owing to the Local Government Act, 1929. The details are as follows:— Defect. Number nominated. Suitable for admission to Returned to elementary school. Unfit for any school. Notified under M.D. Acts. Ocular B. G. Blind school Myope class Swan- ley B. G. B. G. B. G. B. G. B. G. B. G. 62 70 — — 2 5 36 48 19 16 5 1 — — Aural 25 19 Deaf school Hard of hearing class 20 13 — — — — B. G. B. G. 2 2 3 4 P.D. 16 17 P.D. school Open-air school 8 7 — — — — B. G. B. G. 7 10 1 — M.D. 141 107 M.D. school 76 63 — — 2* — B. G. 63 44 Epileptic 1 Epileptic colony — — — — — — B. G. 1 — 245 213 115 113 123 99 5 1 2 — 458 228 222 6 2 * Of these one was imbecile and the other feeble-minded. 69 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 schools for the physically defective at the admission examinations during the year. The distribution of morbidity is much the same as in recent years. Morbid conditions. Boys. Girls. Total. Infantile paralysis 52 36 88 Cerebral „ 16 22 38 Various paralyses 29 13 42 Tuberculosis of bones and joints 94 67 161 Osteomyelitis 18 6 24 Rickets and resulting deformities 19 13 32 Congenital deformities 26 26 52 Traumata and amputations 37 15 52 Non-tuberculous arthritis 3 7 10 Rheumatism, chorea, etc. 23 61 84 Heart disease:— congenital 34 30 64 acquired valvular 187 239 426 non-valvular 24 53 77 Various chest conditions 27 10 37 Other diseases chiefly medical 34 20 54 Total 623 618 1,241 Children returned to elementary schools or invalided. The following statement gives an analysis of the 419 cases examined for admission to special (P.D.) schools in which the children were either returned to elementary schools or invalided, i.e., unfit for any school:— Morbid conditions. Elementary school. Invalided Morbid conditions. Elementary school. Invalided. Tuberculosis, actual or suspected, of bones, joints, etc. 26 5 Various chest conditions:— Bronchiectasis, empyema, etc. 17 4 Congenital deformities 22 3 Rickets and deformities from this cause 7 2 Infantile paralysis 24 6 Cerebral paralysis 1 20 Fragilitas ossium 0 1 Various paralyses 7 4 Osteomyelitis 12 4 Epilepsy 3 5 Various traumata 10 2 Pseudo - hypertrophic muscular dystrophy 2 4 Heart, congenital 9 3 Heart, valvular 34 22 Miscellaneous, nervous conditions, ataxia, etc. 28 11 Heart, non-valvular 28 4 Anaemia 19 1 Rheumatism & chorea 57 9 Totals 306 113 Kidney disease 0 1 Skin conditions 0 2 Compared with the figures for the previous year rather fewer children have needed to be invalided from school attendance and a few more have proved capable of continuing their education in an elementary school. Rota visits to the schools. The special schools were visited at least once a quarter and every child present was seen at least once during the year, the total examinations amounting to 17,953; in addition, 592 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. 70 As a result of the visits and re-examinations the following re-classifications took place:— Transferred from schools or classes for Re-classified as: P.D. M.D. Sight saving. Blind. Deaf. Hard of hearing. White Oak Swanley. Open-air school. Epileptic colony. P.D. — 20 1 1 1 — 3 2 1 M.D 3 — — — 1 — 1 — 5 Sight saving 1 3 — 8 — — 1 — — Blind — — 7 — — — — — — Deaf — — — — — 4 — — 1 Hard of hearing — 2 — — 11 — — — — 76 children were excluded (53 as imbecile, 11 as feeble-minded ineducable, and 12 as feeble-minded detrimental) and 41 were invalided on medical grounds. There were also 540 cases returned, on improvement, to elementary schools or when over 14 years of age, excluded as no longer certifiable, the details are as follow:— Special school classification. P.D. M.D. Blind. Deaf. Sight saving. Hard of hearing. Total. Returned on improvement to elementary schools 180 19 0 2 10 19 230 Over 14 years of age, excluded as no longer certifiable 158 97 2 2 46 5 310 Be-certification of P.D. children. The following table shows the number of children who improved to such an extent that they were able to return from the special (P.D.) schools to the ordinary elementary schools or were "no longer certifiable" as defective between the ages of 14 and 16 years:— Defect. Cases passed no longer certifiable. Cases passed fit to return to elementary schools. Heart 68 57 Rheumatism 5 15 Tuberculosis 25 21 Infantile paralysis 23 10 Rickets and deformities from this cause 2 10 Various traumata 9 14 Congenital deformities 3 17 Non-tuberculous arthritis, and synovitis, including pseudocoxalgia 4 9 Chorea 6 13 Anaemia 1 2 Osteomyelitis 6 3 Various paralyses 2 3 Miscellaneous, nervous conditions, ataxia, etc. 4 6 Total 158 180 Mental Deficiency Acts. Cases notified to the local authority. The following table shows the number of cases notified by the Education Authority under Section 2 (2) of the Mental Deficiency Acts 1913-1927, during the year 1930. The figures in brackets are those for the previous year:— Boys. Girls. (а) Feeble-minded— (1) Leavers 179 (89) 210 (81) (2) Detrimental 16 (7) 12 (6) (3) Special circumstances 0 (1) 0 (1) (4) Ineducable 20 (0) 17 (1) (b) Imbecile 209 (81) 166 (58) (c) Idiots 34 (3) 24 (11) (d) Moral defectives 0 (0) 0 (0) 458 (181) 429 (158) Total 887 (339). 71 The figures this year are complicated by the fact that certain children who had been kept in institutions formerly under the charge of the Metropolitan Asylums Board under the provisions of the Metropolitan Asylums Board (mentally defective persons) Order, 1911, had to be notified through the Education Committee as a necessary preliminary to action under the Mental Deficiency Acts. It is therefore necessary to correct the foregoing figures by separating the numbers for the ordinary work from those for the "comb out" in the institutions concerned:— Ordinary school work. Ex M.A.B. institutions. Feeble-minded— detrimental 20 8 ineducable 16 21 Imbecile 143 232 Idiot 27 31 Totals 206 292 Cases in the institutions, of course, supply no leavers as these were not technically "schools." No doubt in past years some of the cases now called feeble-minded (ineducable) might have been deemed to be high-grade imbeciles. The difference in assignment to either of the two categories of any individual case on the border-line is affected considerably by the personal equation factor on the part of the certifying officers. It must always be a moot point whether a distinction can be made between one who cannot, quite, be taught to manage himself or his affairs and one who is very clearly in need of supervision and control for his own protection. Statement of the Number of Children notified during the year ended December 31st, 1930, by the Local Education Authority to the Local Mental Deficiency Authority. Analysis of 887 children notified:— Diagnosis. Boys. Girls. 1. (i) Children incapable of receiving benefit or further benefit from instruction in a special school: (a) Idiots 34 24 (b) Imbeciles 208 167 (c) Others 20 17 (ii) Children unable to be instructed in a special school without detriment to the interests of other children: (a) Moral defectives — — (6) Others 16 12 2. Feeble-minded children notified on leaving a special school on or before attaining the age of 16 179 210 3. Feeble-minded children notified under Article 3, i.e., "special circumstances" cases — — 4. Children who in addition to being mentally defective were blind or deaf 1 deaf* 2 blind† Totals 457 430 *—This case is included in 1 (i) (6) above. †—These cases are included in 1 (i) (c) and 1 (ii) (6) above. With a view to seeing if the passage into law of the Mental Deficiency Act, 1913, which stressed more prominently the social aspects of mental deficiency, had influenced the proportions admitted to the special schools Dr. Shrubsall has analysed all the records from the year 1902 to the present time. The Mental Deficiency Act introduced definitions of the terms idiocy and imbecility which were not mentioned in the Education Act of 1899 save by the terms that the children admitted to special schools were not to be imbecile. During this period 40,208 children out of the total numbers seen at admission examinations have been deemed to be mentally defective and of these 3,953 or roughly 9.8 per cent. were deemed to be ineducable in special schools on the grounds of idiocy or imbecility. Dividing the period into two sections 72 before and after the passage of the Mental Deficiency Act, it appears that in the first period from 1902-1913, out of 17,030 children deemed to be mentally defective, 1,480 or, roughly, 8.7 per cent. were deemed ineducable at the admission examination. In the second period, 1914-1930, out of 23,178 children deemed to be mentally defective, 2,473 or 10.67 per cent. were considered at the admission examination to be unfitted for special schools because they were either idiot or imbecile. This seems to indicate that the clearer definition of the terms on the social side had exerted some effect. Since 1914 the records kept for the purpose of the Mental Deficiency Act are available and they show that beside the children who were never admitted to special schools, 992 others had, after a period of trial at a special school, to be deemed imbecile. The corrected figures therefore give the following results:— Per cent. Mentally defective, possibly feeble-minded 19,713 85.05 Imbecile 3,193 13.78 Idiot 272 1.17 These figures compare with the proportions, feeble-minded 80.3 per cent., imbecile 16.0 per cent., idiot 3.6 per cent., found in urban areas by Dr. E. O. Lewis, the investigator for the Mental Deficiency Committee of the Board of Education and Board of Control In view of the fact that during this period the institutions then under the Metropolitan Asylums Board were taking a number of the lower grade defectives who thus did not always come to the notice of the education authority the figures suggest that there is no marked variation between the standard of the Mental Deficiency Committee's investigation and that used in London. Numbers admitted to M.D. Schools. From time to time attention has been called to the diminution in recent years of the numbers of children passed for admission to the special (M.D.) schools, these numbers in the post-war period having fallen from a maximum in 1919 to a minimum in 1928. The proportion of M.D. admissions to the number of children on the total roll of the elementary schools, was as follows:— Year. Roll elementary schools. Number of certifications M.D. schools. Percentage. 1918 719,277 1,386 .19 1919 709,381 1,604 .22 1920 727,495 1,399 .19 1921 724,834 1,385 .19 1922 718,793 1,172 .16 1923 700,559 1,034 .15 1924 698,589 1,129 .16 1925 680,190 917 .13 1926 677,171 827 .12 1927 665,125 853 .13 1928 652,919 732 .11 1929 639,014 802 .13 1930 623,728 1,038 .16 On this basis the fall in numbers does not parallel the changes in the roll, although the general diminution in the number of children due to the falling birth-rate and the transfer of families from crowded areas to the new housing estates, outside the county, must be an important factor. A large part of the change is undoubtedly due to the changes in the numbers of children at risk in any particular period. The mean chronological age of the children, at the time of admission, is on the average about 8½ years. The usual ages of admission lie between 6½ and 9½ years. It may be noted that the fall in the percentage of certification to roll begins at a time when the children born in 1915 attain the lower age and that the most marked part of the drop covers the period in which the children at risk, i.e., those on the roll between 6½ and 9½, were at their minimum owing to the low birth-rate during the war period. In the latter years of the period it is complicated by the increase of migration outward from the county of London. The rise in the last two years is probably 73 associated with the higher birth-rate for the years 1920 and 1921. As, however, the birth-rate has again fallen a further diminution in numbers may be anticipated. In order to test whether the change was in any way due to the number nominated or passed for admission to special (M.D.) schools, relative particulars for the last five years have been tabulated, from which it appears that there have been slight variations in the numbers nominated for examination, but no great variations in the proportions returned to elementary schools. The table is subjoined:— Year. Nominated. Certified M.D. school. Invalided. Notified under M.D. Acts. Feebleminded. Imbecile. Idiot. 1926 2,116 827 87 5 68 14 1927 2,178 853 122 7 101 11 1928 2,083 732 151 3 121 17 1929 1,953 802 120 6 100 14 1930 2,210 1,038 95 36 143 27 The increase in 1930 is largely due to cases being brought to notice in the poor law schools transferred to the Council under the provisions of the Local Government Act, 1929. It might also be questioned whether a material change has taken place in the standards of certification. With a view to elucidating this point, the data of the mental ages of the children have been classified in three yearly periods, the data for four of these being now available. From this it would appear that there has been no material change:— Chronological age in years. Mean Mental age in years. 1918-19-20. 1921-22-23. 1924-25-26. 1927-28-29. 7 4.9 4.8 4.6 4.6 8 5.7 5.7 5.6 5.6 9 6.3 6.5 6.4 6.3 10 6.8 7.0 7.0 6.9 11 7.1 7.4 7.4 7.5 12 7.7* 7.5 7.6 7.8 13 8.2* 7.8 7.7 8.0 14 8.4* 8.1 8.2 8.0 * Including re-examination cases. Further details of the last triennium are as follows, the table dealing only with children admitted to the special schools and excluding the re-examination of those already in attendance:— Mental Defectives 1927-28-29. Chronological age. Mental Age. Total. Mean Mental age. Annual gain. 3. 4. 5. 6. 7. 8. 9. 10. 7 65 212 240 84 3 - - - 604 4.6 - 8 9 76 218 396 80 2 - - 781 5.6 1.0 9 2 12 52 188 190 12 1 - 457 6.3 0.7 10 1 2 10 41 116 46 1 - 217 6.9 0.5 11 1 - - 11 42 62 4 - 120 7.5 0.6 12 - - 1 4 24 49 15 - 93 7.8 0.3 13 - - 1 1 15 15 17 2 51 8.0 0.2 14 - - 1 2 2 6 5 2 18 8.0 Nil 15 - - - 1 3 8 5 1 18 8.1 0.1 Total 78 302 523 728 475 200 48 5 2,359 5.9 - Mean chronological age 7.3 7.3 8.0 8.4 9.6 11.3 12.7 13.8 8.6 - - 74 The following table relative to children attending special (M.D.) schools shows their distribution according to the metropolitan boroughs in which they reside:— Borough. Boys. Girls. Borough. Boys. Girls. West— East— Paddington 66 44 Shoreditch 102 105 Kensington 78 73 Bethnal Green 116 92 Hammersmith 102 72 Stepney 160 133 Fulham 95 52 Poplar 161 137 Chelsea 27 12 South— Westminster, City of 25 21 South wark 156 122 North— Bermondsey 120 68 St. Marylebone 32 36 Lambeth 126 87 Hampstead 20 11 Battersea 148 106 St. Pancras 152 104 Wandsworth 156 86 Islington 244 186 Camberwell 130 101 Stoke Newington 24 14 Deptford 80 47 Hackney 94 80 Greenwich 64 56 Central— Lewisham 92 60 Holborn 10 8 Woolwich 86 72 Finsbury 84 57 Total 2,754 2,042 City of London 4 - An analysis has also been made of the types of the majority of the children dealt with during the year under the provisions of the Mental Deficiency Acts, in some cases directly after the original examination and in others after a period in a special school. Most of those deemed feeble-minded had remained under education in special schools until the age of 16, when their names had been notified with a view to statutory supervision, guardianship or institutional care. As a contrast the second half of the table shows the number found in institutions transferred under the Local Government Act, where inquiries had been completed before the end of the year. Juvenile Cases. Clinical type of defect. Routine cases. Cases in institutions transferred under the Local Government Act. Idiot. Imbecile. Feebleminded. Total. Idiot. Imbecile. Feebleminded. Total. Simple primary amentia 8 92 527 627 1 112 200 313 Mongolism 2 39 1 42 1 18 — 19 Cretinism — 4 3 7 — 3 — 3 Hydrocephaly — 1 1 2 2 7 1 10 Microcephaly 4 4 2 10 2 5 — 7 Post-encephalitis — 3 5 8 1 4 — 5 Plegia 5 21 19 45 8 36 10 54 Plegia and epilepsy — 5 4 9 9 18 1 28 Epilepsy 3 12 14 29 18 59 16 93 Traumata — 3 — 3 — 1 — 1 Miscellaneous 1 5 5 11 1 3 2 6 Total 23 189 581 793 43 266 230 539 Of the cases passed for admission to special (M.D.) schools, the type of defect found was as follows:— Clinical type of defect. Boys. Girls. Total. Simple primary amentia 562 445 1,007 Mongolism 3 2 5 Cretinism — 1 1 Hydrocephaly 1 1 2 Microcephaly 2 — 2 Post-encephalitis 3* 2 5 Plegia — 3 3 Epilepsy 5 7 12 Paresis — 1 1 Total 576 462 1,038 * One of these is probably neuro-syphilitic. 75 After careers of children formerly attending special schools. Return for year 31st December, 1930, 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 Acts, 1913-27. Male. Female. Total. 1. Number of children born in or subsequent to 1912 who have left special (mentally defective) schools, and who have been on the books of the association as "after-care" cases 790 431 1,221 2. Number of these who— (a) Have since died 1 — 1 (b) Are known to be incapable by reason of mental or physical defect of undertaking employment 22 11 33 (c) Have been subsequently dealt with under the M.D. Acts 30 11 41 3. Number employed in— (a) Industrial or manual occupations (i.e., factory work and trade or part of trade) 481 270 751 (b) Agricultural or rural occupations 6 — 6 (c) Domestic occupations (i.e., servants sleeping in or out, lift boys and those "helping at home") 22 105 127* (d) Commercial (i.e., shop assistants or selling behind a counter), professional (or Army and Navy), clerical (office boys and girls) 39 3 42 (e) Blind alley or other precarious occupations (i.e., van boys, newsboys, errand boys or girls selling from a barrow) 123 2 125 4. Judged to be employable but out of work 49 20 69 5. Number whose careers have not been traced or have left the neighbourhood 17 9 26 Total analysed under headings 2, 3, 4 and 5 790 431 1,221 * Of these 127 young people, 85 were receiving remuneration and 42 were required for work at home. Deaf Children. During the year, Mr. Yearsley, the Council's consulting aural surgeon, has seen 355 cases as against 368 for the previous year. The decisions in regard to them are set out on page 68. Analysing the causes of deafness in the case of 152 children seen for the first time relative to their being hard of hearing, deaf, and deaf with some other deficiency, 31 were found to be congenital, 117 due to acquired causes ; whilst in 4 the cause of deafness was doubtful. The ratio of the congenital to acquired causes was 15.3 to 84.7. The congenital cases were classified as:— Boys. Girls. Total. True hereditary deaf birth 5 4 9 Sporadic deaf birth 8 12 20 Aphasia — 2 2 13 18 31 The acquired cases were classified as:— Boys. Girls. Totals. Per cent. Disease of the nervous system 3 2 5 4 Infectious fevers 25 23 48 41 Other infective diseases 5 6 11 9 Primary ear disease 23 29 52 45 Injury 1 — 1 1 57 60 117 100 In last year's report, Mr. Yearsley pointed out that for the first time in eleven years no cases of deafness following epidemic cerebro-spinal meningitis had occurred in the records. This year four cases were noted, one case of the disease having occurred in each of the years 1924, 1927, 1928 and 1930. Seven cases were ascribed to congenital syphilis, a higher number than that noted last year; in each of these cases the deafness was complicated by present or past interstitial keratitis. In 76 connection with primary ear disease, past tonsillar disease and adenoids appear to have been a preponderating factor both as regards suppurative and catarrhal middle ear affection. Mastoid operations had been performed in 31 cases in which the deafness followed suppurative middle ear disease. Residential schools. Residential and Industrial Schools. There are 7 residential special schools (2 for blind, 2 for deaf, 1 for mentally defective deaf, 1 for mentally defective boys, and 1 for mentally defective girls) with a total accommodation for 355 residential and 216 day scholars. To each school is allocated a medical officer and provision has been made for dental inspection and treatment. Industrial schools. There are three industrial schools ( 2 for boys, 1 for girls ) with a total accommodation for 357. To each institution is allocated a medical officer and a dentist. Ponton-road place of detention. Dr. Verner Wiley's report. During the year, 785 children were admitted to Ponton-road place of detention. The medical supervision continued under the charge of Dr. Verner Wiley, one of the Council's full-time medical officers. His report is as follows:— Admissions.—The number of admissions recorded in the admission book for the year is 803 (696 boys and 107 girls). Subtracting re-admissions from hospitals returned absconders, etc., the number is 785 (685 boys and 100 girls). Courts.—The Courts dealing with these children and the numbers dealt with at each Court are as follow:— Cases. Cases. Toynbee Hall Juvenile Court 154 Petty Sessions, various 40 Islington Juvenile Court 118 Woolwich Juvenile Court 35 Lindsey Hall Juvenile Court 94 Battersea Juvenile Court 33 Various Middlesex Juvenile Courts 79 Guildhall Juvenile Court 9 Deptford Juvenile Court 67 "Place of Safety" cases and "Lodgers" (no Court) 11 Various Adult Courts 55 Lambeth Juvenile Court 50 785 Caxton Hall Juvenile Court 40 More than one-third of the cases came from the Juvenile Courts at Toynbee Hall and Islington. The large number coming from the various Middlesex Courts is also noteworthy. The following table shows the charges and months of admission:— Jan. Feb. Mar. Apr. May June. July. Aug. Sept. Oct. Nov. Dec. Total. 1. Larceny 29 27 29 29 28 22 25 21 19 30 17 25 301 2. Breaking, entering and stealing 4 — 6 1 8 6 7 12 17 13 5 4 83 3. Breaking and entering — 1 -— 9 3 3 3 1 2 — — — 22 4. Being in unlawful possession 1 1 — 6 3 — — — 2 — 3 — 16 5. Embezzlement 3 — 1 — 1 1 1 — 3 2 2 — 14 6. Found on enclosed premises — 1 1 3 — 1 — — — 3 — — 9 7. Stealing and receiving — 1 — — — — — — — 3 1 — 5 8. Larceny with forgery — — — — — — — — — — — 1 1 9. Stealing by a trick — — — — — — — — — 1 — — 1 10. Burglary — — 1 — — — — — — — — — 1 11. Burglary and arson — — — — — — — — — — 1 — 1 12. Robbery with threats — — 1 — — — — — — — — — 1 13. Obtaining money by false pretences — — — — — — — — — — 1 — 1 14. Defrauding the railway 1 — — — — — — — — 1 — — 2 15. Suspected persons 2 — 1 3 1 - 1 1 2 1 1 13 16. Loitering with intent, etc. — — 1 — — — — — — — — — 1 17. Beyond parental control 8 14 11 6 6 5 6 7 7 16 7 2 95 18. Wandering 3 3 5 11 10 2 5 3 8 9 5 2 66 19. Breach of recognisances 4 2 5 4 3 3 5 3 2 7 7 6 51 77  Jan. Feb. Mar. Apr. May. June July. Aug. Sept. Oct. Nov. Dec. Total. 20. Education Act cases 4 5 7 1 1 4 4 1 1 4 4 4 40 21. Wilful damage — — 2 — 2 — 5 — 1 — — — 10 22. Living in circumstances of moral danger — 4 — — — 2 — — 1 2 — 2 11 23. Sex offences — — — 3 2 2 1 1 — 1 1 1 12 24. Assault — 1 1 2 2 — — — — — — — 6 25. Parents, criminal 1 — 3 — — — — — — — — 1 5 26. Begging — — 1 — — 2 — — — — — — 3 27. Vagrancy — — — — — — — — 1 — — — 1 28. Trespass — 1 — — — — — — — — — — 1 29. Escaping from industrial school — — — — — — — — — 1 — — 1 30. "Place of Safety" and "Lodgers" — 1 1 1 — 2 1 — — — 2 3 11 Total 60 62 76 77 72 56 63 50 65 95 57 52 785 The admissions month by month remained fairly constant in total numbers. The falling off in August (50 admissions) and December (52 admissions) may be attributed to lessened activity of the courts during holiday time and the natural reluctance to place children on remand at Christmas time. Physical examination.—A complete physical examination was made in all but a few cases, who were admitted late at night and had gone to Court early next morning before examination could be carried out. As a result of the physical and psychological examinations— 728 were found fit to attend ordinary certified schools, 23 were fit only for special schools by reason of mental defect, 26 feeble-minded and 2 imbeciles were found fit only for institutional care, 6 (all heart cases) were found unfit by reason of physical defect. Complete records of the examination are available in 724 cases. Tables A and B show respectively physical defect in detail and a comparison of the physical defect of the delinquent group with the London age group children. Commentary on the physical condition.—(a) Nutrition and physique—The Ponton-road group shows a very marked inferiority in respect of nutritional state and physical make-up when compared with the average London children as met with in the age group examinations. No less than 22.2 per cent. of the Ponton-road children were estimated to be poorly nourished and 17.9 per cent. to be of poor physique. Compare the 4.5 per cent. of London age group children found to be poorly nourished. (b) Cleanliness of head and body and condition of the skin.—The condition of the skin and hair as regards cleanliness and that of the skin as regards presence or absence of disease, blemishes, etc., are good indications of the social environment of the subject. The contrast between the Ponton-road group and the London age groups is striking in these respects:— Percentages of children examined. Verminous heads. Verminous bodies. Skin disease. Ponton-road 22.1 5.0 16.2 London age groups 6.1 2.6 0.8 Table B sets out in detail the comparison between the physical condition of the delinquent children and the average London age group children. The very decided inferiority of the former is shown under every heading. (c) Functional nervous disease.—Under this heading are included all those children usually described by the term "nervous." Any undue nervous irritability, such as blepharospasm, hippus, exaggerated tendon reflexes, marked lack of muscular co-ordination, etc., was noted and included; 7.5 per cent. showed this "nervousness," and it is noteworthy that they were for the most part children of somewhat higher 78 social grade than the average delinquent, more intelligent and very frequently the charge against them was that they were "beyond parental control." In the upper grades of society an equal number of children would probably contain a higher percentage of this type of child. The condition can hardly be considered pathological. (d) Enuresis was noted in 42 (5.8 per cent.), and it is to be noted that more than 80 per cent. of these were over 12 years of age, indicating a fixed habit and one difficult to cure. It is probable that the presence of a considerable number of defectives amongst the older children is responsible for the high figure. (e) Stammer was noted in 3 per cent. of cases (22 children). Here again the majority of them were over 12 years old. All of them showed other signs of nervous instability. The London age group children figure for this defect is 0.2 per cent. (f) Congenital syphilis.—A very careful look-out was kept for the stigmata indicative of congenital syphilis in view of the opinion held by some workers in this country and in America that congenital syphilis is often found in delinquents and a possible causative factor. Only 7 children (0.9 per cent.) showed undoubted stigmata of this disease. (g) Rickets.—Compare the 5.9 per cent. of delinquent children showing skeletal signs of having had rickets in infancy with the London age group figure of 0.4 per cent. There is evidence, making a general comparison between the two groups, that the delinquent child is of poorer stock (note the much higher incidence of poor physique amongst them). His early nurture is faulty as evidenced by the high percentage of rickets. The high percentage of physical defect he shows is probably to a large degree to be attributed to ignorance of the parents and neglect on their part to remedy the child's defect when pointed out to them. The relation between the indifferent physical condition and the delinquency is, in all probability, an indirect one only. For instance, there seems to be little connection between, say, the theft of food and poor nutrition. In only one case did a child give, as a reason for his theft, that he was hungry. Stealing of food in fact, if we except sweets, is by no means common —food, that is, to be consumed forthwith. When stolen it is usually negotiable—in the form of tins of fruit, bottles of sauce, packets of peas, etc. Two cases, however, may be quoted where there appears to be a direct connection between the physical defect and the delinquency. One, a boy of 11, had three severe convulsions, subsequently diagnosed as due to generalised arterio-scelerosis, a very rare disease at that age. Subsequent to, but not prior to the onset of the symptomatic fits he began to show abnormality of conduct, violence of temper, swearing and pilfering, etc. It is reasonable to suppose—on analogy with similar conduct disorder in adults suffering from this disease—that this boy's change of character was directly due to cerebral arterial degeneration. The other case was that of a boy with a high degree of myopia. This boy's quarrelsomeness, general waywardness and wandering habits seemed to be attributable to his backwardness at school, itself due to his eye defect and not to lack of intelligence, which made him somewhat of an Ishmael and forced him, against his will, to associate with younger boys whom he despised. Over a period of two months, during which time his conduct was under observation, and during which he associated with boys of his own age, he gave no trouble whatever, and appeared to be a normal likeable boy. In general, however, it may be said that the very indifferent physical make-up of the delinquent has little direct bearing on the delinquency, but sheds a flood of light on the environment in which he fives. In addition to the routine physical examination, 153 cases of minor illness, accident dressings, etc., were attended to during the year. Mental and educational attainments.—An estimation of the mental and educational (reading and arithmetic) levels was made in 695 cases, the primary object being to ascertain fitness or otherwise to benefit by training in certified schools. Fifty-one (7.5 per cent.) were found to be mentally defective, as follows:— Mentally defective—fit for special schools only—23 cases. Feeble-minded (M.D. Act)—fit only for institutional care—26 cases. Imbecile—2 cases. 79 Table " A." Table showing in Detail, Physical Defect of 724 Children at Ponton-Road Place of Detention in 1930. Year of Birth. 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 Boys (628) 95 123 101 77 66 57 47 32 15 7 3 3 - 1 1 724 Girls (96) 19 16 12 8 8 6 7 5 3 3 2 3 2 1 1 Average height in cms. 160.3 155.9 148.5 142.8 138.5 134.8 130.8 126.0 122.2 117.4 109.6 103.8 102.7 93.0 86 .5 Per cent. „ weight in kgs. 49.7 45.1 38.7 34.7 32.2 30.2 27.7 25.2 23.5 221 18.2 17.0 16.8 14.2 12.1 Nutrition Good 26 36 14 9 16 12 6 3 2 1 1 _ _ - - 17.4 Fair 2 59 82 71 55 40 41 34 22 13 6 3 5 2 2 2 60.4 Bad 3 29 21 28 21 18 10 14 12 3 3 1 1 - - - 22.2 Physique Good 1 39 45 26 14 21 17 5 7 2 2 1 1 - - - 24.8 Fair 2 55 71 68 55 38 34 40 22 12 6 2 5 2 2 2 57.3 Bad 3 20 23 19 16 15 12 9 8 4 2 2 - - - - 17.9 Cleanliness of head Good 1 96 113 89 70 55 41 46 25 15 6 2 2 1 2 77.9 Fair 2 14 17 19 13 12 13 4 6 2 4 1 2 1 1 15.0 Bad 3 4 9 5 2 7 9 4 6 1 - 2 2 - - 1 7.1 Cleanliness of body Good 1 110 137 108 80 70 58 52 33 16 8 4 6 2 2 1 94.15 Fair 2 3 1 5 5 4 3 1 4 - 2 _ - - - 1 4.0 Bad 3 1 1 - - - 2 1 - 2 - 1 - - - - 1.05 Diseases of skin Scabies 3 2 - - - 1 - 2 - - - - - - - 16.2 Impetigo - 7 3 2 2 2 5 3 2 _ - - - Other 18 18 12 6 4 8 - 9 4 3 - - - - 1 Vision 6/6 71 95 79 55 59 40 32 23 15 - 5 6 2 2 2 60.4 6/9 8 11 9 9 2 4 9 7 1 - - - - - - 8.2 6/12 + 35 33 25 21 13 19 13 7 2 - - - - - - 31.4 Eye diseases 3 4 3 2 1 3 3 4 1 - - - - - - 3.3 Teeth 1 54 88 66 51 38 42 23 16 9 - 3 3 2 2 2 56.6 2 52 48 45 28 28 20 23 19 8 - 1 1 _ - _ 37.6 3 8 3 2 6 8 1 8 2 1 - 1 2 - - - 5.8 Ears Otorrhœa 2 3 2 3 2 2 _ _ 1 _ - - - - - 2.0 Deafness 1 2 1 4 1 2 1 1 - _ — __ _ _ _ 1.8 Other diseases 3 2 3 - - - 1 - 1 - - - - - - 1.3 Nose and throat Tonsils enlgd. 4 8 9 3 8 2 4 4 1 - 1 2 - - - 6.3 Adenoids 1 1 - 3 — 3 _ _ _ - - _ _ - - 1.1 Tons, and ads. - 1 - - - 1 1 2 1 - - 1 - - - 0.9 Heart Organic dis. 3 1 1 - 1 2 - - - - - - - - - 1.1 Functional dis. 2 2 2 3 1 _ _ 2 _ _ - - _ _ 1.6 Anaemia - 2 1 - 2 - - 1 - - - - - - - 0.8 Disease of lungs 5 2 5 3 3 2 1 3 - - 1 - - - - 3.4 Digestive disturbances— Hernia, etc. 1 - - - 1 - - - 1 - - 1 - _ _ 0.5 Nervous system Epilepsy 1 1 1 - - - - - - - - - - - - 0.4 Chorea — — — — — — — — — _ — - _ - - - Paralysis - 1 - - 1 — _ — _ _ _ _ - _ 0.2 Functional dis. 5 8 11 10 7 3 6 1 3 - 1 - - - - 7.5 Enuresis 6 5 6 7 3 6 3 1 3 1 1 - _ - - 5.8 Congenital syphilis - 2 1 1 1 - - 2 - - - - - - - 0.9 Speech Defect of articulation - - 1 1 - 1 - 1 - 1 1 - - - - 0.8 Stammer - 5 4 1 6 1 1 2 1 1 - - - - - 3.0 Genito- urinary Diseases 4 1 _ _ _ _ _ 1 _ - - - - - - 0.6 Abnormality 3 4 3 7 4 4 3 2 - - - - - - - 4.0 Rickets 8 7 8 3 5 4 4 1 1 - - - - - 1 5.9 Deformities 7 7 3 4 - 1 2 - - - - - - - - 3.4 Endocrine disturbances 2 7 6 3 - - - - - - - - - - - 2.4 Left handedness 5 13 9 6 4 4 3 2 - - - 1 - - - 6.4 80 Table B. Table Showing Percentage Defects in Age-Group Delinquents and Comparison with Defects Found in Age-Group London School Children, for 1930. 8-year-old group. 12-year-old group. "Leavers" Whole group. P.of D. Total. London  P.ofD. London P.of D. London P.of D. London Nutrition Good 1 11.1 17.1 19.2 18.5 10.6 24.2 17.4 20.5 Fair 2 72.3 77.2 65.0 76.7 64.7 72.5 60.4 75.0 Bad 3 16.6 5.7 15.8 4.8 24.7 3.3 22.2 4.5 Physique Good 1 13.3 No re- cord 26.1 No re cord 16.4 No record 24.8 No record Fair 2 60.1 54.9 64.8 57.3 Bad 3 26.6 190 18.8 17.9 Cleanliness of Head Good 1 83.4 94.4 65.1 94.4 82.5 96.1 77.9 94.9 Fair 2 11.1 5.1 20.6 5.1 15.2 3.5 15.0 4.5 Bad 3 5.5 0.75 14.3 0.5 2.3 0.4 7.1 0.6 Cleanliness of Body Good 1 88.9 97.1 82.3 97.4 94.2 97.8 95.0 97.4 Fair 2 0.0 2.8 4.6 2.5 5.8 2.1 4.0 2.5 Bad 3 11.1 0.15 3.1 0.1 0.0 0.1 10 0.1 Skin Scabies 0.0 0.8 1.5 0.7 0.0 0.6 1.0 0.8 Impetigo Other diseases 0.0 22.2 30 15.3 2.3 6.9 3.5 11.7 Teeth 1 50.1 66.1 51.9 74.4 60.1 73.3 56.6 65.2 2 44.4 27.1 46.6 23.8 32.9 24.9 37.6 27.7 3 5.5 6.8 1.5 1.8 7.0 1.8 5.8 7.1 Vision 6/6 88.9 52.3 63.6 57.4 64.8 61.3 68.6 56.6 6/9 0.0 30.3 6.3 23.1 10.5 19.7 8.2 24.9 6/12 + 11.1 17.4 30.1 19.5 24.7 19.0 23.2 18.5 Ears Otorrhœa 0.8 3.1 0.8 3.5 0.5 2.0 0.9 Deafness 5.5 0.3 3.1 0.3 4.7 0.3 1.8 0.3 Nose and throat Other diseases - 0.3 0.6 0.0 0.3 1.3 0.4 Tonsils enlarged 5.5 10.1 3.1 7.1 3.5 5.0 6.3 10.1 Adenoids 0.0 0.7 4.7 0.3 3.5 0.1 1.1 0.7 Tonsils & adenoids 5.5 1.5 0.75 0.8 — 0.3 0.9 1.8 Heart Organic diseases 2.1 31 2.4 0.0 3.5 1.9 1.1 2.0 Functional diseases 0.0 1.6 Anaemia — 1.1 0.0 1.3 0.0 0.9 0.8 1.1 Lungs — 1.7 3.1 1.0 3.5 0.5 3.4 1.2 Digestive disturbances 5.5 - - - - - 0.5 — Nervous system Epilepsy - 0.0 0.0 0.4 0.0 Chorea - — 0.0 0.1 0.0 0.1 Paralysis - 0.1 — 0.0 - 0.0 0.2 0.0 Functional diseases 16.6 0.5 4.7 0.4 11.7 0.3 7.5 0.3 Enuresis 16.6 — 9.4 — 8.2 — 5.8 — Speech Defect of articulation - 0.2 1.6 0.2 1.1 0.2 0.8 0.2 Stammer 5.5 1.6 1.1 3.0 Genitourinary Diseases — - - - - - 0.6 Abnormality 5.5 — 6.3 — 8.2 — 4.0 — Bickets 5.5 0.3 6.3 0.2 3.5 0.2 5.9 0.4 Deformity — 1.1 1.5 1.9 4.7 1.9 3.4 1.4 Congenital syphilis — — — — 11 — 0.9 — Endocrine disturbance — — — — 3.5 — 2.4 — Left.handedness — — — — — — 6.4 — 81 The percentage 7.5 compares with 8 found to be certifiably defective in last year's Ponton-road series of 401 cases, and with Professor Burt's estimate of 8. Of the 51 certifiable cases, 34 were known to be defective prior to admission to Ponton-road ; 17 hitherto unsuspected defectives were discovered as the result of examination there. Tables C, D, E, F and G give summaries of the result of the examinations. For educational levels, Professor Burt's standardized reading and calculation tests were used ; the Stanford revision of Binet's scale and Healy's form boards were used to estimate mental ages. In addition, a careful Porteus Maze test was made in 668 cases. The Porteus Maze test was selected as a test of intelligence as expressed in the form of practical ability as distinct from intelligence, which requires for its expression the use of verbal imagery. It is a valuable test in that it is accurately standardized, is independent of scholastic attainments and is a useful indicator in forming an estimate of the co-ordination between hand and eye, and thus to some degree of the level of attainment and the potential level of the subject in practical work. In addition, it brings to light the presence or absence of certain emotional qualities, such as impulsiveness, caution, foresight, patience, etc. Table C.—695 cases were examined as regards mental age with the following results:— Percentages.  Testing up to or above their chronological age 26.2 One year retarded 20.8 Two years retarded 18.4 Three years retarded 17.2 Four years retarded 9.4 Five years retarded 4.0 Six or more years retarded 4.0 Although 51 certifiable defectives are included in the 695 cases examined, it is evident that serious mental retardation is present in the majority. Eliminating the 26.2 per cent. who test up to their chronological ages, and taking out also the 7.5 per cent. known defectives, there remain about 65 per cent. of the whole group who are backward—many of them not far above the borderline of mental defect. Table D.—695 cases, as before, were examined as regards their educational, reading and calculation attainments. In making this table the mean of the reading and arithmetic ages, estimated on Prof. Burt's scale, is taken to indicate the general educational level. Thus a child who reads up to the 11-year level and whose level for calculation is 7, is given an educational age of 9. In actual fact, the levels for arithmetic are invariably much lower than those for reading in this series. The table shows the very great educational backwardness that exists in whole group. Thus :— Percentages.  Testing up to or above chronological age 10.5 One year retarded 14.5 Two years retarded 16.8 Three years retarded 18.8 Four years retarded 14.8 Five years retarded 13.1 Six or more years retarded 11.5 As above, discounting the 10.5 per cent. testing up to their normal level and the 7.5 per cent. known defectives, there remain 72 per cent. showing educational backwardness—extreme backwardness in many cases. It is clear from scrutiny of Tables C and D that this educational backwardness is not altogether due to lack of intelligence, but that there is here, also, a considerable failure in achievement, that is to say, a large percentage fail educationally to reach even their mental ages, that is, they fail to do as well as they are capable of doing. Table E.—Shows the results in 668 cases examined by the Porteus Maze test. The backwardness brought out by this practical test is even more striking than that shown in Tables C and D. Only 8.8 per cent. test up to their chronological ages. Eliminating these and the 7.5 per cent. known defectives, there remains the enormous figure of 83 per cent. showing backwardness in a test requiring practical ability, and G 82 muscular co-ordination, rather than prowess in the three R's. Careful observations made while using this test show a decided and clear cut difference between the response a defective makes and the response of a more trainable subject. The defective fails frequently to understand the general principle of the test and even the initial instructions, and makes stupid blunders again and again. He repeats his error and does not improve on re-trial. The non-defective fails by reason of poor muscular co-ordination between hand and eye, impulsiveness and lack of foresight. Frequently he improves on re-trial. The impression remains that of those examined by this test the great majority failed through lack of training in those qualities which go to make practical ability. Table F.—Compares mental, educational and Porteus levels. The failure of achievement is clearly shown. Table G.—In this table all the children of 14 years and over (excluding the defective) are considered. The number is 260. All these have left school. It was realized that the mental age of 14 is above the average to be expected in the social class from which the delinquent usually comes; consequently, the arbitrary mental age of 12 was taken as being the average mental age attainable by the subjects under review. Even so, only 55.4 per cent. of the 260 examined could reach a mental age of 12; only 28.8 per cent. reached this level in educational subjects and only 14 per cent. in practical ability. The social failure of these boys and girls as employable units is not to be wondered at. They were none of them certifiably defective and all capable of and in need of further long periods of training to enable them to compete in life with a reasonable prospect of success. Analysis of the delinquency.—Theft, actual, intended or probable, is at the base of over 70 per cent. of the charges made. Cases labelled "being in unlawful possession," " embezzlement," etc., merely express slight differences in the legal aspect; morally and in their psychological aspect these charges may be considered as theft. In the table of charges, numbers 1-13 relate to delinquencies of this nature (456 children). Again, of the 95 children charged with " being beyond parental control," theft was alleged in 33 of them. In the case of 51 children charged with "breach of recognisances," the original charge was theft in 38 cases. This gives a percentage of 72.2 of the cases in which stealing in one form or another was alleged. table "c" shows numbers who have mental ages above, up to, or below their chronological ages—the latter shown in years of retardation. (695 cases) Chronological age in years. Testing above chronological age. Testing up to chronological age. One year retarded. 2 years retarded. 3 years retarded. 4 years retarded. 5 years retarded. 6 years retarded. 7 years retarded. 8 years retarded. 9 years retarded.  4 2 — — — 5 1 2 3 — — — — — C 2 3 1 - - - - - - - - 7 6 4 2 — — — — 8 3 9 9 3 2 — — — — — 9 6 16 15 10 1 — — — — — — 10 6 17 25 6 3 i — — — — — 11 8 10 20 17 9 i 5 — — — — 12 9 14 10 23 8 3 4 — 2 — — 13 6 9 17 17 40 14 3 3 — — 1 14 — 14 11 14 22 18 3 4 3 2 15 — 39 30 36 34 29 13 6 6 — — Totals 43 139 145 128 119 66 28 13 11 2 1 Per cent. 26.2 20.8 18.4 17.2 9.4 4.0 1.9 1.6 0.35 0.15 83 Table "D" shows numbers who have educational levels above, up to, or below their chronological ages—-the latter shown in years of retardation (695 cases). Chronological age in years. Testing above chronological age. Testing up to chronological age. One year retarded. 2 years retarded. 3 years retarded 4 years retarded. 5 years retarded. 6 years retarded. 7 years retarded. 8 years retarded. 9 years retarded.  4 — 2 — - — 5 — 1 5 — — — - — — — — 6 — 1 3 2 - - - - - — - 7 — — 5 5 2 — — — — - — 8 1 3 7 7 2 i — — — - — 9 — 8 10 11 9 9 i — — - 10 1 7 15 17 9 5 4 - 11 1 9 10 17 10 11 8 4 __ - 12 4 2 9 8 18 12 13 1 6 - 13 2 10 7 10 25 21 14 13 5 2 1 14 4 8 10 16 17 15 7 7 4 2 1 15 — 9 20 24 35 30 34 16 11 10 4 Totals 13 60 101 117 132 104 81 41 26 14 6 Per cent. 10.5 14.5 16.8 18.8 14.8 13.1 5.5 3.5 2.0 0.5 Table " E " shows numbers whose practical ability as estimated by Porteus Maze test is above, up to, or below their chronological ages—the latter expressed as years of retardation (668 cases). Chronological age in years. Testing above chronological age. Testing up to chronological age. One year retarded. 2 years retarded 3 years retarded. 4 years retarded. 5 years retarded. 6 years retarded. 7 years retarded. 8 years retarded. 9 years retarded.  4 1 - - - - - - - - - 5 - - - - - - - - - - - 6 3 1 — 1 - - - - - - - 7 1 4 2 2 - - - - - - - 8 5 7 6 4 1 - - - - - - 9 3 6 18 17 3 1 - - - - - 10 2 10 15 16 12 2 - - — — - 11 2 5 7 19 19 11 4 1 1 — — 12 1 5 3 13 21 9 13 3 2 2 — 13 — 1 3 15 37 20 18 11 2 — 1 14 — — 2 5 14 20 19 16 7 3 1 15 — 2 7 19 38 49 42 18 7 4 1 Totals 17 42 63 111 146 113 96 49 19 9 3 Per cent. ... V 8.8 9.5 16.6 21.8 16.9 14.4 7.4 2.8 1.4 0.4 Table " F " compares the percentages of ch1ldren whose mental, educat1onal and Porteus levels are above, and up to, or below their chronological ages. Totals examined—695 mental levels; 695 educational levels; 668 Porteus levels. Up to or above chronological age) 1 year retarded. 2 years retarded. 3 years retarded. 4 years retarded. 5 years retarded. 6 years retarded. 7 years retarded. 8 years retarded. 9 years retarded.  Mental levels 26.2 20.8 18.4 17.2 9.4 4.0 1.9 1.6 0.35 0.15 Educational levels 10.5 14.5 16.8 18.8 14.8 131 5.5 3.5 20 0.5 Porteus levels 8.8 9.5 16.6 21.8 16.9 14.4 7.4 2.8 1.4 0.4 gi 84 Table "G."—Number examined, 260. Actual age= 14+. In this table certified defectives have been eliminated and the limit of chronological age has been lowered to 12 years, i.e., an artificial chronological age has been fixed at 12 years for all the 260. Testing up to or above artificial chronological age (12 year). 1 year retarded. 2 years retarded. 3 years retarded. 4 years retarded. 5 years retarded. C years retarded. 7 years retarded. 8 years retarded. 9 years retarded.  Mental levels 55.4 21.5 18.1 4.6 0.4 - - - - - Educational levels 28.8 19.6 18.0 18.5 8.5 5.4 1.2 — — — Porteus levels 140 20.8 27.6 22.0 10.8 4.0 0.8 - — Theft amongst girls.—24 cases are on record and of these 19 were over school age. Their occupations were : 10 domestic servants, 5 out of work, 2 factory hands, 1 shop assistant, 1 clerk and 5 school children. The age incidence is noteworthy, 17 of them being over 15 years old. The articles stolen were : money (10 cases), wearing apparel and jewellery (13 cases). The remaining case was that of a 9-year-old girl who stole an Easter egg. The mentality of these girls is also noteworthy: 1 was feeble-minded, 8 were on the borderline of defect (no doubt, some of these will come to certification later), 4 were definitely backward, 9 of average intellect and 2 intelligent. They were for the most part not Londoners. The sequence of events would appear to be that these backward, and possibly unemployable, girls leave their homes in the provinces for these reasons, seeking employment. There is a market for them in domestic service (just as backward boys tend to become perpetual errand boys) in London where they readily fall into mischief through lack of intelligence, lack of guidance and abundant temptation acting upon individuals with little moral training. It is an interesting fact that in every case these thefts were single-handed (compare with the boys below). Amongst the boy thieves there is a much wider range of age, the average age being slightly less than 13 years. In 269 instances the article stolen was ascertained: money, 76 cases; bicycles, 34 cases ; articles of food, 26 ; thefts from motors, 18; raids on small shops, 16; gas meters, 9; automatic machines, 9 ; watches, 9 ; raids on pavilions, sheds and closed schools, 9 ; lead and old metal, 11 ; cigarettes, 8; raids on Messrs. Woolworths, 6; torches, pistols, penknives and fountain pens, 6; growing trees, 4; showcases, 3; and empty bottles, 3. Lastly, in one case each, the article stolen was a motor-car, a motor-bicycle, a pony, two love birds in a cage and 35 pigeons. The article stolen often gives the only clue necessary to discover the whole reason for the theft. Every boy ardently desires to possess a torch and a fountain pen. Lead and empty bottles, growing trees, etc., are easily turned into cash for sweets or "the pictures" and receivers are many. Bicycle thefts are surprisingly common, the usual practice being to take the machine to pieces, reassemble it with various parts of other machines, re-paint it and sell it. There are easily available markets for such property and one suspects parental connivance, if not actual help in some of these cases. The culpability of these children is not in the province of the medical investigator, but one may be permitted to compare the following cases, all labelled " theft," as showing the range and degree of seriousness: (1) 3 boys, making up the equipment for their camp, climbed a garden fence and stole a kettle; (2) paper boy stole a bottle of milk from a doorstep and took it home to his mother; (3) boy, alone, in position of trust, stole £140 in a series of thefts lasting over a year. In 128 cases, the theft was single-handed; in 70 cases two boys were concerned, in 35 cases three boys, in 12 cases four boys, and in 12 cases five or more boys. In this respect compare the thefts by the 24 girls—all single-handed. In the case of gang theft amongst boys, there is ample evidence that premeditation is not the 85 rule. They frequently stumble into crime as in the case of five boys playing " Follow my leader." The leader in this case pulled at the lock of a show case containing watches. The followers each had a pull and the case opened! Theft followed— almost naturally. Again, consider the case of a gang of boys charged with stealing 1 cwt. of sugar from a lorry. Premeditation, here, is unlikely. It is more reasonable to suppose a preliminary investigation as to the contents of the sack and perhaps attempt to try its weight by one or two of the gang, the others being, as it were, stampeded into the commission of a crime. Lack of premeditation is apparent, also, in very many single-handed thefts such as that of the paper boy who steals the bottle of milk from the doorstep (3 such cases) and the messenger boy who thieves from the hall of the house he is visiting (many such cases). In these cases the pit of opportunity suddenly reveals itself and the weak one falls in. Considered psychologically, the reaction involved in the overwhelming majority of these theft cases is a very simple one—almost comparable to a reflex act in its simplicity. The desire to acquire and possess is instinctive and natural. When the barrier put up by training—religious, social, moral generally— is negligible or nil, the instinct to steal is unhampered, and if practised becomes a habit. In less than 2 per cent. of these cases did there appear to be a deeper psychological reaction calling for investigation. In the remainder, training— social and moral—over a sufficiently long period should eradicate the fault. Embezzlement.—13 cases occurred in the series and although in essence they were cases of theft, they had certain interesting features which merit short treatment under a separate heading. All these were messenger boys and all but one (14½) were over 15 years of age. All were physically very fit. Their mental ages varied as 11 (4), 12 (6) and 13 (3) —all well above the level of mental defect. The sums of money involved varied from a few shillings up to £16. All these boys showed lack of foresight in varying degrees in their response to the Porteus test. Their lack of wisdom and judgment was clearly shown in the foolish belief, held by all, that they could escape detection, and in their surprise at being caught. Their lack of moral training was shown in the ease with which sudden temptation bore down and carried away what little " nous " they possessed. Every one of these boys needed further education and moral training and was capable of benefiting by it. A word must be said, too, as to the lack of wisdom shown by an employer who will expose a lad to the temptation of stealing what is to him a fortune. Beyond parental control.—Of the children charged under this heading 85 were boys and 10 girls. Records are available in 85 cases. The ages ranged from 6—15, the average age for boys being 10½ years and for girls 11½. Truancy was alleged in 36 of them, stealing in 33, staying out late in 25, and other charges (bad temper and habits, swearing, etc.) in 29. Enquiries into the home situation of these children elicited the following facts which, in themselves, explain at once many of the cases and point the way to the cause:— In 32 cases the father was dead or had deserted the family. That is to say, in fully one-third of them the control necessary for family cohesion was wanting. In 13 cases the mother was dead or had deserted. In 16 cases the mother was at work all day. In 16 cases there were step-parents or unmarried partners. Parents were of different nationality in 3 cases, in 2 cases they were insane and in 2 cases parents had committed suicide. In 35 of the families there were five or more children. Many of these children were verminous, ill-nourished and otherwise neglected on admission to the Place of Detention. In only two of them was any complaint made during their period of remand that they were not easily controlled by the most gentle discipline. As regards their mental levels, 9 were defectives, 33 were noted as backward, 27 as average and 16 as above average: 23 were noted as being nervous and unstable. 86 General conclusions.—(1) The very inferior physical condition of the delinquent must be stressed again. This inferiority is to some degree inherent but much of it is acquired and capable of being remedied. (2) The mental backwardness of the whole group places them for the most part in the sub-cultural class of society. They are only capable of limited development. (3) The educational backwardness is striking and often extreme. This is not altogether due to lack of intelligence. There is a failure of achievement. They are capable of attaining a higher level than they do attain, especially in practical work. (4) Psychologically the delinquency is, in the overwhelming majority of cases, a simple problem of moral turpitude, involving a simple mental reaction. In only 2 per cent. of the cases under review did it appear to be of deeper significance and call for more than a single investigation. (5) The home and school situations contain the key to the solution of the majority of child delinquent cases. There is a valuable field here for the social workers of child guidance clinics. (6) Psychotherapy has only a very limited field in child delinquency. Special Reports.—In the course of the year 169 special reports were submitted to the magistrates. In compiling the report, I am greatly in the debt of Mr. M. J. T. Jones, the superintendent of the Place of Detention, for his help in keeping many of the records. Examination of Employees in the Education Service and Scholarship Candidates. During the year 7,955 entrants to the permanent Education service and candidates for the award of scholarships presented themselves for examination. examination. The following table indicates the number submitted for each grade and the results of the examinations :— Status. Number examined. Number fit. Number rejected. No. who withdrew after being referred for remediable defects or were not due for re-examination until 1931.  M. F. M. F. M. F M. F. Permanent service 482 587 464 574 16 6 11 10 Teaching awards 227 734 225 705 3 8 21 54 Scholarships 3,026 2,899 2,943 2,848 40 16 49 38 3,735 4 220 3,632 4,127 59 30 81 102 Total 7.955 7,759 89 183 These figures include 12 permanent service (M. 9 F. 3), 55 teaching awards (M. 22 F. 33), and 9 scholarship (M. 6, F. 3), cases referred from 1929. The causes of rejection were mainly defects of vision, unsatisfactory general health and morbid condition of the heart. The total number of examinations was 9,619. Some of the candidates were referred for more than one remediable defect. A new departure was made by the experiment of examining at their own schools certain candidates for the award of intermediate county scholarships. Examinations for this purpose were held on 87 occasions when 1,003 candidates were seen, of which only 18 had to be referred to County Hall for a second medical opinion ; 776 were passed as medically fit; one was rejected and 209 were found to require treatment for remediable defects such as defective vision or teeth, etc. Cases specially referred. There are also referred to the public health department, special cases in which medical advice is required. Particulars in regard to these are set out in the Annual Report for 1925. The number of examinations made was 3,477. The major part were teachers of whom 530 were men and 2,468 women. Of those examined in connection with sick leave, 1,850 or 66 per cent. of the teachers were over 40 years 87 of age, this percentage being the same as that of the previous year. Owing to the operation of the Local Government Act, 1929, a considerable number of employees at the former poor law schools was examined. Physical education of teachers. During the year all applicants for admission to the Council s course of physical education were medically examined. The number was 430, of whom 33 were deemed to be physically unfit to undergo the training. Accidents and sudden illnesses at County Hall. The arrangements made in 1922 whereby medical aid could be given in the event of cases of accident or sudden illness at the County Hall were continued during 1930 and aid was rendered and advice given in 527 cases. Generally, the cases were of a minor character, but of 48 cases of injury 1 was serious, and of 103 cases of illness 5 were serious ; 376 cases attended for the treatment of minor ailments. In addition, during June and July 12 persons employed at the County Hall who had been in contact with cases of smallpox were inspected on 90 occasions as a precautionary measure. Infectious Diseases in School. Introduction. The practice of controlling infectious illness by means of close supervision of the children in the schools referred to in previous annual reports has been further extended during the period under review, especially in relation to smallpox and with the employment of additional school nursing assistance, it has been possible to introduce departures from previous practice in regard to the attendance at school of the contacts of this disease. It is a matter for consideration whether the enormous loss of school attendance caused through the exclusion from school of home contacts of infectious disease could not be further eliminated if adequate skilled supervision were introduced to safeguard other children in the school population. Problems connected with the control of infectious illness in the residential schools and children's homes, the administration of which devolved upon the Council under the Local Government Act, 1929, are being submitted to most careful consideration. The different poor law authorities responsible had, prior to April, 1930, adopted various measures for the prevention of the introduction and spread of infection in the 32 institutions involved. Steps have been taken to co-ordinate and regularise the procedure and a comprehensive scheme has been formulated. The generalised systems of quarantine adopted in some of the institutions involving the segregation of healthy children will be discontinued and the basis of preventive action will rest on a carefully organised system of surveillance having as its objective the segregation only of the unhealthy children. Since these residential children's homes were transferred to the care of the Council advice has been given on various problems that have arisen and the facilities afforded by the Council's laboratory at the County Hall have been placed at the disposal of the medical staff The numbers of cases of infectious illness reported by the teachers as occurring amongst school children during 1930, compared with similar figures reported during the preceding five years, are shown below:— Year. Diphtheria. Scarlet fever Measles and German measles. Whooping cough. Chickenpox. Mumps. Scabies. Ophthalmia. Ringworm.  1925 6,033 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 1928 5,178 7,505 41,891 8,592 13,657 5,744 901 408 707 1929 5,081 7,462 19,313 12,076 12,346 14,010 932 644 610 1930 5,297 7,558 34,251 3,239 13,573 9,439 930 506 503 The number of cases of smallpox notified amongst school children was 1,774. as compared with 726 in 1929. 88 Diphtheria and Scarlet fever. Particulars of all children excluded or absent from school on account of infectious illness, and suspected infectious illness are circulated on a prescribed form by the head teachers to the school medical officer, divisional officers (school attendance), and borough medical officers of health, and if it appears from the information supplied that infection of diphtheria or scarlet fever is spreading or likely to spread amongst the children in the schools, arrangements are made for the special examination of the children by the school medical staff and in certain cases for the school nursing staff to undertake the daily surveillance of the children for a definite period. At the same time the teaching staff is warned of the necessity for maintaining a strict supervision over the children to detect suspects for special examination by the medical or nursing staff, or to exclude children who show signs of the onset of illness. The parents are informed of the reason for exclusion and are advised to keep the affected children under observation and to seek medical advice if necessarv. The following table gives information regarding the schools visited by the school medical staff during the year:— Division. No. of visits. Diphtheria. No. of schools visited. No. of children examined. No. of visits. Scarlet fever. No. of schools visited. No. of children examined.  N.E 46 27 5,053 43 32 6,306 N 35 25 3,279 29 23 2,939 N.W 43 35 3,184 23 19 1,668 S.E 42 30 4,472 57 34 6,659 s.w 48 36 6,395 39 26 4,654 Totals 214 153 22,383 191 134 22,226 Scarlet fever. There was little difference in the numbers of cases of scarlet fever reported from the schools during 1930 as compared with the last three or four years. The school medical staff paid 191 visits to schools where it appeared that infection was likely to spread and 22,226 children were directly supervised or specially medically examined in this connection. A few cases of mild type were notified as a result of these examinations and a number of children were excluded from school on account of sore throat, etc. The children in six of the affected schools were kept under special observation by the nursing staff for periods ranging from two to six weeks. Diphtheria. It will be noted that only slight variations have occurred in the number of cases of diphtheria recorded in recent years ; 153 of the schools affected during 1930 were visited on 214 occasions by the school medical staff; 6,688 swabs were taken from children and submitted for bacteriological examination in the Council's laboratory at the County Hall. These cultures were taken (a) at the schools, (b) in the course of routine medical inspections, (c) from children residing in the children's receiving homes, residential schools and children's homes. Of these, 823 cultures showed the presence of micro-organisms indistinguishable morphologically from B. diphtheria}. These 823 positive results related to 595 children, of whom 230 were notified and removed to hospital. Tests for virulence were applied to some of the cultures ; 19 were returned as virulent and 11 as avirulent diphtheria bacilli. The children from whom avirulent results were returned, were allowed to resume attendance at school. Diphtheria "carrier " clinics. The arrangements entered into with three voluntary hospitals, viz., London, St. Mary's, and Guy's, for the establishment of special clinics for the treatment of diphtheria " carriers," were continued during 1930. As stated in previous annual reports these are the only units specialising in this subject and some of the borough medical officers of health have taken advantage of the facilities offered by these clinics for the treatment of persistent " carriers " under, or over, school age. During the year 27 school cases attended at the London Hospital unit; 14 of these were found to be negative on re-swabbing. Operations for tonsillectomy were performed in 5 of these 14 cases. Of the 13 confirmed positive cases 6 were discharged 89 after treatment, 6 left school or refused further treatment and 1 case was still under treatment at the end of the year. The operation for tonsillectomy was performed in five of the positive cases ; six (nasal cases) received vaccine treatment. The clinic at St. Mary's Hospital dealt with 22 cases. Five of these were discharged after negative virulence tests were obtained. Stock vaccine was used in six cases. The period of treatment averaged 5 weeks, and with the exception of two children, who ceased to attend the clinic, all the cases were discharged by the end of the year. Dr. John Eyre, who is in charge of the clinic at Guy's Hospital, has submitted the following summary of the work done during 1930 :— " The routine work of the clinic during this, its fourth year, has been continued as originally planned with very few and then only trivial modifications. " The results of our examination of the new cases seen during the year are summarised as follows :— Total number of new cases 79 Organism isolated :— ("Virulent 21) K.L.B. Non-virulent 5 30 Not tested 4 B. Hoffmanni 28 Nil (no diphtheroids detected) 21 "The nose continues to be recorded as by far the commonest site of persistent residence both for the Klebs Loeffler Bacillus and the Bacillus Hoffmanni. "Compared with previous years we note that although the total numbers are smaller there is a greatly increased percentage of virulent over non-virulent amongst the strains of diphtheria bacilli isolated from these carriers. "Once more we must emphasise the insufficiency of one routine swab as a means of detection of carriers. It still frequently happens that cases, in which the first smears made from 24-hour inspissated serum slopes after no matter how careful a search fail to disclose any K.L.B., show a few colonies of that organism when plated upon a selective medium. (In this connection it may be noted that the selective medium described by Allison and Aylings has been tried out during the year, but the results obtained have not been such as would warrant its substitution for the Douglas's differential medium—which latter continues to be the medium we employ for the isolation of B. diphtheriae.) "Those cases showing a paucity of K.L.B., although probably of little present danger to others, may upon the development of some intercurrent catarrh proceed to expel much larger numbers of diphtheria bacilli and thus immediately become dangerous to those in their immediate neighbourhood. "This point is brought forward, not to encourage an elaborate but possible remedy by repeated swabbings,but to emphasize one of the reasons for our continued pessimism that this procedure can ever become more than an inefficient partial means of controlling diphtheria in the London County Council schools. "Treatment has in the main been purely local and upon general lines. Nine cases, however, were treated by vaccine therapy with good effect. For the persistent carriers with negative nasal swabbings tonsillectomy is still practised and during 1930 was carried out upon four cases; these cases have never yet failed to clear rapidly. "From the individual case records we may quote one which illustrates a not infrequent, but often unsuspected, factor in the 'carrier' condition. "E.V. female cet. 7.— In September, 1929, an elder sister was taken away with diphtheria. The patient (E.V.) was subsequently swabbed and the nose was found to contain K.L.B.—virulence test positive. "As repeated swabs were positive the patient was admitted to the local hospital where various gargles and other forms of local treatment were used. On one occasion even the throat was ' scraped.' At the end of twelve months the child was still a carrier and was sent to this clinic. In the course of the routine examination a 90 foreign body was found in the nose and removed. This body was so incrusted that its nature could not be determined, but as the ulceration healed so the swabs became negative." Diphtheria prevention in London, 1930. A special report on diphtheria prevention by means of the Schick test and active immunisation has been prepared for inclusion in the Scientific and Medical Supplement to the Annual Report of the Council for the year under review. Smallpox amongst school children. Among the 5,149 cases of smallpox notified in London during 1930, there were 1,774 school children. During the previous year, 726 cases occurred amongst school children. school children. lhe following statement shows the number of cases occurring amongst the children during the year, grouped in school terms, for each division :— Division. Spring term. Summer term. Autumn and Winter term. Total.  N. 290 143 44 477 N.E 522 413 189 1,124 S.W 22 6 9 37 N.W 2 1 9 12 S.E 42 48 34 124 Totals 878 611 285 1,774 The cases were all of the prevalent mild type. In one case it was reported that a vaccinated school child developed smallpox. With this exception no vaccinated child developed the disease. Two deaths occurred amongst the school children the causes of death being reported in the first case as (a) encephalomyelitis, (b) smallpox ; and in the second case as (a) pyaemia, cause unknown, (b) smallpox discrete modified. Facilities for vaccination on the school premises by public vaccinators were granted whenever applications for vaccination were received from the parents. Comparatively few applications were, however, received and only about 300 children were vaccinated with the written consent of the parents. In the majority of cases children suffering from smallpox had not attended school in an infectious condition. If, however, there was any evidence of the possibility of spread of infection, arrangements were made for the special examination of the children in the school to be conducted by one of the assistant medical officers and for the children attending the school to be kept under daily observation by the school nursing staff. The number of special visits paid to the schools by the assistant medical officers in this connection during the year was 228, of which 177 were in the north-east division. The services of the school nursing staff are being extensively used in connection with the surveillance of children in schools attended by children notified as cases of smallpox. The necessity for supervision is determined by reference to the relative dates of the onset of illness and of the last attendance at school. The affected schools are visited daily by the nurses for a period of 19 days from the date of attendance of the last case in the school. During the spring term 32 cases of smallpox were notified as a result of the school nurses' reports. These were all in the Poplar, Stepney and Bethnal Green areas. During the summer term 135 schools were at one time or another under the special supervision of the school nursing staff and 67 cases of smallpox were notified as a result of their reports. During 1930 efforts were made to deal with the problem of home contacts of school age. Under the Council's regulations the children concerned were excluded from school for a period of 16 days and the task of supervision in the homes was becoming a matter of some difficulty, especially in the areas in which smallpox was most prevalent. Apart from this consideration an enormous amount of school attendance was being lost. 91 After consultation with the Ministry of Health and the medical officers of health of the boroughs concerned, it was decided that the home contacts of cases of smallpox should be allowed to return to school provided that arrangements could be made for their daily examination in school by the school medical or school nursing staffs of the Council. By this means the disease could be detected in its early stages and reports furnished to the borough medical officers, whilst contacts who absented themselves from school could be brought to the notice of the borough medical officers. The borough medical officers were thus informed at once of all contacts who might possibly be developing the disease. Owing to the amount of time involved in this work healthy contacts were only allowed to return to those schools which were being kept under daily supervision on account of the occurrence of cases of smallpox. This " limited " form of the scheme was applied as required during the summer term in all boroughs (except Finsbury). During the autumn and winter terms, however, the scheme was extended to include all contacts in any of the schools (except children living in the borough of Finsbury) and the Council decided to employ additional nursing staff to carry out the work. Seven extra nurses commenced work in November. The following is a statement of the work done by the school nurses during the autumn and winter terms in connection with the supervision of the schools :— Division. No. of cases of smallpox found as a result of examination by school nurse. No. of children excluded by school nurse. No. of home contacts supervised in school. No. of absentees (home contacts) reported to medical officer of health. No. of visits to school. (No. of schools concerned in brackets). No. of hours devoted to work.  N.E. 26 155 670 320 2,235 (88) 2,539 N.W. 1 5 78 72 127 (8) 137 S.E. Nil 24 63 33 263 (21) 276 S.W. Nil 2 32 20 149 (10) 79 N. 2 6 110 20 353 (20) 161 Totals 29 192 953 465 3,127 (147) 3,192 Lhe number of hours devoted to the work is equivalent to the services of seven full-time nurses. The borough medical officers of health and their staffs have worked in close and harmonious co-operation with the school medical and school nursing services and the arrangements made for the supervision of large numbers of children in school and for the "following up "of those excluded by the school nurses and of the absentee home contacts have been attended with conspicuous success. The manner in which the school nurses have carried out their share of this important work is worthy of mention. Had it not been for their careful supervision and perceptiveness, many cases would have passed unnoticed. The excellent results obtained both in the prevention of infection and loss of school attendance by these new activities of the school nursing service have clearly demonstrated the advantages of a system of close supervision as compared with exclusion from school. It has, in fact, been shown that the only practical difficulty in extending the principle of supervision of contacts in school to most other infectious ailments lies in the large increase in the nursing staff which would thereby be entailed. Encephalitis lethargica. During the year under review, 21 children were admitted to the special unit at the Northern Hospital, Winchmore Hill, established by the late Metropolitan Asylums Board for dealing with children between the ages of 3 and 16 years suffering from the sequelae of encephalitis lethargica. 19 children were discharged during the year and one died. Detailed reports on this subject were included in the annual reports for 1925 and 1926. Reports on encephalitis lethargica, by Dr. G. A. Borthwick, medical superintendent of the Northern Hospital and Dr. F. L. Golla, director of pathology in the mental hospitals department, has already been published as a separate document, No. 2811, price 6d., and may be obtained from the Council's publishers. 92 Whooping cough. The number of cases of whooping cough reported from the schools (3,239) was the lowest figure recorded for many years. The school nurses visited eight schools where outbreaks occurred for the purpose of keeping the children under observation and advising the head teachers as to exclusion or re-admission of children to school. Chickenpox. The number of cases of chickenpox reported during recent years is given in the preceding tabular statement. The number reported (13,573) approximates to the numbers recorded during each of the preceding seven years except 1925 and 1927. The figure is, however, considerably above the average for the four years 1919-22, viz., 8,530. In all 77 schools affected with chickenpox were kept under special supervision by the school nursing staff for varying periods. Mumps. A large decrease in the number of cases of mumps as compared with 1929 will be noted in the foregoing statement. The school nurses visited 65 schools where mumps was prevalent. Ophthalmia. The term ophthalmia is used in a general sense by the teachers to indicate any affections of the eyes and it must not be assumed that a definite diagnosis was made in each of the cases reported. Special attention is directed to each case reported with a view to arrangements beine made for DroDer treatment. Ringworm The number of cases of ringworm of the scalp amongst the children in the Council's schools is still decreasing and at the end of 1930 there were only 110 outstanding cases. The results achieved in virtually eliminating this troublesome affection from the schools are attributable to the care exercised by the school nursing staff in detecting the cases in their earliest stages, to the work done in connection with " following up," and to X-ray treatment. Favus. The lollowing table shows the numbers of cases of scalp ringworm dealt with during recent years :— Year. Fresh cases. Cured cases. Gases outstanding at the end of the year. ntage of cures effected by X-ray treatment. 1919 3,447 3,103 1,259 57 1920 3,983 3,856 1,332 56 1921 3,473 3,765 999 61 1922 2,766 2,918 818 65 1923 2,322 2,395 705 69 1924 1,724 1,924 482 70 1925 1,518 1,611 373 71 1926 1,029 1,141 228 76 1927 896 868 249 76 1928 684 745 170 76 1929 590 603 146 76 1930 513 536 110 75 During the year, 930 specimens of hair stumps were sent by the school nurses to the Council's laboratory for microscopical examination. Ringworm fungus was found to be present in 300 of these (238 small spore and 54 large spore); favus was found to be present in 8 specimens. Four fresh cases of favus were found during the year. Three of these were cured. Table I. Medical Inspection. 1930. (a) Routine inspections. (6) Other inspections. Boys. Girls. Total. Boys. Girls. Total.  Entrants 32,455 32,177 64,632 *Special Age 8 30,805 30,263 61,068 inspections (1) 17,932 18,871 36,803 Age 12 21,455 21,093 42,548 „ (2) 25,708 23,651 49,359 Leavers 24,388 24,217 48,605 Re-inspections - - 186,615 Total — Elementary schools 109,103 107,750 216,853 Special schools 896 709 1,605 *(1) Special cases where individual notes are made. (2) Cases seen en masse where individual notes are not made unless noted for treatment or observation, e.g., camp school nominations, school journey children. etc. (Infectious disease contacts are not included in this figure.) 93 Table II. (a) Defects found at medical inspections in 1930. Elementary and special schools. Disease or defect. Routine inspections—Defects. Special inspections. —Defects. Requiring treatment. Requiring observation. Requiring treat - Requiring ES. s.s. E.S. s. S. ment. vation.  Malnutrition 888 6 802 2 429 179 Skin—Ring-worm, head — - — — 21 7 body 38 1 1 — 18 1 Scabies 84 2 — — 445 329 Impetigo 238 3 2 458 200 Other disease (non-T.B.) 880 12 90 819 105 Eye—Blepharitis 838 3 72 333 24 Conjunctivitis 219 3 12 — 249 17 Keratitis 3 — 1 — 18 1 Corneal opacities 11 — 8 — 35 15 Defective vision, excluding squint 17,211 150 5,759 54 4,133 499 Squint 1,292 12 337 — 671 55 Other conditions 204 4 57 — 237 35 Ear—Defective hearing 260 12 157 1 249 121 Otitis media 1,298 24 392 6 792 163 Other ear disease or defect 562 5 108 1 308 68 Nose and throat—Enlarged tonsils 8,999 26 7,834 9 2,807 576 Adenoids 898 6 517 — 439 85 Enlarged tonsils and adenoids 2,714 9 903 — 921 65 Other conditions 811 4 253 1 473 193 Enlarged cervical glands 405 — 1,316 3 256 257 Defective speech 110 - 182 2 148 72 Teeth—Dental disease or defect 66,194 401 962 10 5,478 90 Heart and circulation— Heart disease—Organic 33 - 111 6 3 Functional 28 — 284 — 2 3 Not stated 226 1 2,939 20 464 885 Anaemia 829 2 646 3 732 291 Lungs—Bronchitis 944 2 1,121 2 323 159 Other non-tubercular 255 3 628 - 208 262 Tuberculosis—Pulmonary definite 2 — 2 - 5 2 „ suspected 10 — 51 - 28 125 Glands 7 — 4 — 28 13 Spine — — - - 3 3 Hip 2 — 1 - 2 5 Bones ana joints 4 — 5 - 6 3 Skin 5 — 1 - 7 1 Other forms 5 — 5 - 15 17 Nervous—Epilepsy 21 2 27 - 127 86 Chorea 84 121 - 246 156 Paralysis 15 1 29 1 192 147 Other conditions 169 3 222 - — — Deformities—Rickets 46 — 35 - 52 25 Spinal curvature 695 10 224 2 196 47 Other 583 4 312 — 217 57 Other conditions 2,833 16 1,387 2 3,900 including 687 mental defects 1,256 including 235 mental defects (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 64,632 10,856 16.8 Age 8 61,068 12,543 20.5 Age 12 42,548 8,808 20.7 Leavers (age 13}) 48,605 8,486 17.5 Total elementary schools 216,853 40,693 18.8 Special schools 1,605 296* 18.4 *Not including special defects for which the children are in special schools. 94 Table III. Exceptional children in London in 1930. Boys. Girls. Total.  Blind (including partially blind). (1) Suitable for training in a school or class for the totally blind. Attending certified schools or classes for the blind 107 123 230 Attending public elementary schools - - - At other institutions 8 4 12 At no school or institution 4 1 5 (2) Suitable for training in a school Attending certified schools or or class for the partially blind. classes for the partially blind 429 469 898 Attending public elementary schools 7 7 14 At other institutions — — — At no school or institution 4 4 8 Deaf (including deaf and dumb and partially deaf). (1) Suitable for training in a school class for the totally deaf or deaf and dumb. Attending certified schools or classes for the deaf 268 233 501 Attending public elementary schools 1 _ I At other institutions 28 23 51 At no school or institution 2 5 7 (2) Suitable for training in a school or class for the partially deaf. Attending certified schools or classes for the partially deaf 80 92 172 Attending public elementary schools 1 1 2 At other institutions 1 — 1 At no school or institution 1 — 1 Menially defective. Feeble-minded (cases not notifiable to the local control authorities.) Attending certified schools for mentally defective children 2,747 1,974 4,721 Attending public elementary schools 1 2 3 At other institutions 135 68 203 At no school or institution 66 37 103 Epileptics. Suffering from severe epilepsy Attending certified schools for epileptics 92 70 162 In institutions other than certified special schools 5 3 8 A ttending public elementary schools 4 4 At no school or institution 43 60 103 Suffering from epilepsy which is not severe. Attending public elementary schools:— (Note.—-This includes children under observation on account of a suspicion of possible epilepsy.) Ordinary 227 211 438 Special 47 36 83 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 87 157 244 At certified day open-air schools 131 103 234 At other institutions 1 1 2 At no school or institution 36 33 69 95 Table III.—-continued. Boys. Girls. Total.  Non-infectious but active pulmonary and glandular tuberculosis. At sanatoria or sanatorium schools approved by the Ministry of Health or the Board of Education 167 133 300 At certified residential open-air schools - - - At certified day open-air schools 196 155 351 *At public elementary schools 40 29 69 At other institutions 1 2 3 At no school or institution - Delicate children (e.g., pre- or latent tuberculosis, malnutrition, debility, anaemia, etc.). At certified residential open-air schools 216 (a) 205 (a) 421 (a) At certified day open-air schools 941 (b) 645 (6) 1586(6 At public elementary schools 3,379 2,862 6,241 At other institutions 55 65 120 At no school or institution 81 68 149 Active non-pulmonary tuberculosis (Note.—Cases of more or less quiescent tuberculosis attend the special day cripple schools.) At sanatoria or hospital schools approved by the Ministry of Health or the Board of Education 639 438 1.077 *At public elementary schools 17 11 28 At other institutions — At no school or institution 24 16 40 Crippled children (other than those with active' tuberculosis), e.g., children suffering from paralysis, etc., and including those with severe heart disease. At certified hospital schools 7 2 9 At certified residential cripple schools 23 18 41 ‡At certified day cripple schools 1,988 1,991 3,979 At public elementary schools 666 760 1,426 At other institutions 250 280 530 At no school or institution 200 309 509 (а) As on 25th Nov., 1930, i.e., latest date on which a full attendance was made owing to approach of Christmas holidays. (b) As on 19th Dec., 1930, i.e., last day of attendance and before Christmas holidays. *Discovered at medical inspections and referred for treatment. † Awaiting admission to colony. ‡ These figures include children suffering from non-pulmonary tuberculosis more or less quiescent, or from the after-effects of such disease. Table IV. Treatment Table. Group I.—Minor Ailments, excluding uncleanliness, for which see Qroup V. Disease or defect. Defects treated oi under treatment. Under Council's scheme. Otherwise. Total.  Skin—Ring-worm, head 358* 178 536f ,, body — — — Scabies 1,985 3,462 3,462 — — Impetigo 1,477 !• Other skin disease Eye disease (external and other, but excluding cases falling in Group II) Ear disease cases in which operative treatment (e.g., mastoid operations, etc.), is given are excluded 101,298 1,257 106,017 Miscellaneous (minor injuries, bruises, sores, chilblains, etc.) 105,118 1,435 106,553 * 304 by X-ray. † 403 by X-ray. 96 Group II.—Defective Vision and Squint (excluding eye defects treated as minor ailments, Group I). Disease or defect. Defects dealt with. Under Councils scheme. Otherwise. Total.  Errors of refraction (including squint but excluding operations for squint) 41,079 1,961 45,540 Other defect or disease of the eyes (excluding those in Group I) 2,500 (estimated) — Children tor whom glasses were prescribed under Council s scheme, 30,087. Children who obtained or received glasses under Council's scheme, 27,505=91 -4per cent. Group III.—Treatment of Defects of the Throat and Nose. Number of defects. Received operative treatment. Total Received other forms of treatment. Total number treated.  Under Council's scheme. Private practitioner or hospital 16,215 1,904* 18,119 3,545 21,664 *95 by private practitioners, 1,809 at hospitals. Group IV.—Dental Defects. (1) Number of children who were— (a) Inspected by the dentist—Age groups 5 years and under 10,655 6 years 31,677 7 years 37,187 8 years 12,241 9 years 41,089 10 years 52,544 11 years 37,684 12 years 8,225 13 years 12,199 14 years and over 7,750 251,251 (b) Found to require treatment 165,616 = 65.91 per cent. (c) Actually treated 138,280 (including (d) ) (d) Re-treated as a result of periodical examination 40,209 (2) Half-days devoted to—inspection 2,241 treatment 18,315 20,556 (3) Attendances by children for treatment 236,611 (4) Fillings—permanent teeth 92,821 temporary teeth 29,299 122,120 (5) Extractions—permanent teeth 55,499 temporary teeth 354,920 410,419 (6) Administration of general anaesthetics for extractions 75,709 (7) Other operations—permanent teeth temporary teeth Group V.—Cleanliness. (а) Average number of visits per school made by school nurse during the year 6 (b) Examinations of children in the schools by school nurses 1,862,374 (c) Instances of uncleanliness 225,323 (d) Children cleansed under Council's arrangements 108,023 (e) Cases in which legal proceedings were taken under the Education Act, 1921 (Section 87) 366 INDEX. Subject. Page Adenoids and Tonsils, Inspection ... 5 Arachnodactyly 53 Aural Diseases, Treatment 16 Basement Dwellers, Examination of child 47 Brent Knoll, Open Air School 59 Child Guidance 63 Chronic Invalidity 14 Cleanliness, Inspection 4 Convalescent Camp Schools 61 Deaf Children 5 Defective Children 67 Dental Work, Inspection 5 Dental Work, Treatment 20 Dental Hygienists 22 Dietaries 54 Downham Open Air School 55 Downs Hospital 19 Employment of Children 15 Ear, Nose and Throat, Inspection 5 Ear, Nose and Throat, Treatment 16 Entrants, Condition of 7 Examination of Employees 86 Following-up 11 Hearing Tests 52 Heart Inspection 6 Higher Institutions (Education) Inspections 10 Holly Court Open Air School 58 Hygiene, Personal 29 Infectious Diseases 87 Subject. Page Inquiries: Special by School Doctors 45 Introduction 1 Leavers, Health of 9 Medical Inspection, Results of 3 Medical Treatment 16 Mental Defectives 72 Nursery Schools 62 Open Air Education 55 Ophthalmia in Residential Institutions 48 Otorrhcea 17 Personal Hygiene 29 Ponton Road Place of Detention 76 Re-inspections 11 Residential Schools 76 Rheumatism 30 Scholarship Candidates, Examination of 86 School Buildings 2 School Journeys 62 Staff 2 Stammering Children 27 Stowey House Open Air School 57 Tables: I. to IV. (Inspection and Treatment) 92-96 Teeth Treatment 20 Transferred Schools and Homes 12 Tuberculosis:— Inspection 6 Open Air Schools 59 Vision, Inspection 6 Vision, Treatment 16 Wood Lane Open Air School 57 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 of the Council for 1929 :— Vol. I. Powers and duties—Elections—• Finance—Rating and Taxation—Public Protection—Traffic—Public Amenities -—Domestic and Miscellaneous Services. 2s. 6d. No. 2827. Vol. II. Mental Hospitals. Is. No. 2737. Vol. III. Public Health, Main Drainage and Housing. 2s. 6d. No. 2731. Vol. IV. Education. 1s. No. 2801. Vol. V. Abstract of Accounts—Memoranda on Housing accounts and statistics—Index. 6d. No. 2848. Report for 1930:— Vol. III. Public Health (Part I). Report of County Medical Officer of Health. 1s. (Issued shortly.) Vol. III. Public Health (Part II). Report of School Medical Officer. 1s. 6d. No. 2851. Accounts in Abstract. Accounts of the Income and Expenditure of the Council from 1st April to 31st March. 1s. Issued annually. 1929 30. No. 2846. London Statistics. 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