LCC 40 The Royal Sanitary Institute Library. London County Council ANNUAL REPORT OF THE COUNCIL, 1931 Vol. III (Part I) PUBLIC HEALTH (Report for the year 1931 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 Street, Victoria Street, Westminster, S.W.1, Agents for the sale of the Publications of the London County Council. 1932. No. 2918. Price 1s. London County Council ANNUAL REPORT OF THE COUNCIL, 1931 Vol. III (Part I) PUBLIC HEALTH (Report for the year 1931 of the County Medical Officer of Health) CONTENTS Vital Statistics— Page. Population—Marriages—Births—Deaths 1 Infectious Diseases 2 Statistical Tables 6 Tuberculosis 10 The Increased Mortality from Pulmonary Tuberculosis amongst Young Women 12 Administration— Common and Seamen's Lodging Houses 15 Homeless Persons 15 Disinfestation 15 Statistical Information 17 Sanitary Officers 19 Milk and Dairies Act 20 Venereal Diseases 21 Tuberculosis 25 Laboratory Work 34 Mental Deficiency Acts 35 Blind Persons Act 45 Midwives Acts and Children Act—Nursing Homes Registration Act— Adoption of Children Act 46 Examination of Staff 51 Chemical Branch 51 London County Council. ANNUAL REPORT OF THE COUNCIL, 1931. VOL. III—(Part I) REPORT OF THE COUNTY MEDICAL OFFICER FOR THE YEAR 1931. By Sir Frederick Menzies, K.B.E., M.D., F.R.C.P., 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 holidav when the census was taken. Population. The enumerated population of London is shown by the census taken on the night of 26th April, 1931, to have been 4,397,003, including 10,500 non-civilians. There was, therefore, an intercensal decrease of 87,520, including 1,600 non-civilians. During this period the births have exceeded the civilian deaths by over 237,000 so that the movement of population has resulted in a net loss in the ten years of about 325,000, excluding non-civilians. The estimated populations of the metropolitan boroughs in 1931, based upon the preliminary census results, are shown in the table on page 6, and the rates given in this Annual Report are calculated upon these figures. The marriages registered in London during 1931 numbered approximately 41,210, or 18.8 per thousand of the population, the corrected rate for the preceding year being 195. Marriages. The births in London during 1931 numbered 65,084 compared with 69,447 in the preceding year. The birth-rate was 15.0 per thousand, as against 15.8 in 1930. This is the lowest birth-rate recorded in London, the number of births being fewer by 5,292 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 6. Births. The deaths in the civil population of London during 1931 numbered 54,288 giving a death-rate of 12.4 per thousand, compared with 11.6 in 1930. Deaths. The distribution of deaths by ages in 1931 and recent preceding periods is shown in the following table:— Period. 0- 1 - 2- 5- 10- 15- 20- 25- 35- 45- 55- 65+ All ages. 1919-22 7.836 2,131 1,919 1,376 853 1,175 1,318 3,103 4,238 6,414 8,265 19,828 58,456 1923-26 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 1931 4,270 862 721 622 463 953 1,248 2,353 3,052 5,795 9,047 24,902 54,288 It will be seen that the deaths in 1931 exceeded those of 1930 by 3,296. The increase is almost entirely due to influenza and the increased deaths from respiratory and heart diseases commonly associated with a prevalence of influenza. For the first time for a number of years the deaths due to street accidents show a decided tendency to decrease, the total being 731 for the 52 weeks of the year compared with 822 for the 53 weeks of 1930; among children under 15 years of age the deaths decreased from 166 to 146. [12605] (1) 2 The death-rates from all causes and from certain specified causes in each metropolitan borough in 1931 and in London as a whole in 1931 and earlier years will be found in the tables on pages 6 and 8. The deaths under one year of age per thousand births were 65, this rate being somewhat higher than the exceptionally low rate of the preceding year. Infant mortality. It will be seen from the following table that one of the chief causes of the increase upon the figure for 1930 was the higher mortality from respiratory diseases. Cause of death. 1911 to 1914. 1915 to 1918. 1919 to 1922. 1923 to 1926. 1927 to 1930. 1927. 1928. 1929. 1930. 1931. Measles 3.40 3.84 1.64 2.02 2.07 0.63 3.93 0.61 3.12 0.44 Whooping-cough 3.63 4.45 2.50 2.60 3.14 3.08 2.45 6.15 0.89 2.15 Influenza 0.27 1.10 0.81 0.38 0.48 0.46 0.23 0.96 0.26 0.46 Tuberculosis 3.40 3.20 1.52 1.26 0.89 1.05 0.95 0.77 0.79 0.70 Bronchitis 6.41 6.72 4.42 2.91 2.30 2.12 2.56 2.87 1.66 2.56 Pneumonia 12.28 14.96 12.60 11.51 12.10 11.37 13.03 14.15 9.85 13.90 Diarrhoea 24.28 16.10 12.16 9.36 8.87 6.97 9.52 9.93 9.07 8.94 Premature birth 18.16 17.42 17.00 14.74 14.17 13.94 14.22 14.81 13.71 15.24 Congenital defects 14.69 14.66 11.26 8.39 7.38 7.17 7.60 7.65 7.11 6.65 All causes 108 103 79 65 64 59 67 71 59 65 Infectious Diseases. The notifications, attack-rates and death-rates for the principal infectious diseases in London in 1931 and earlier years are shown in the tables on pages 6 to 9, and the constituent metropolitan boroughs in 1931 in the table on page 6. Two cases of anthrax were notified during the year, in the boroughs of Camberwell and Paddington respectively. The first case, a male, aged 23, was engaged in the business of broom and brush maker, and was probably infected by bristles, used in the business, which were imported from Russia, China and Germany. The second was a female, aged 71, of no occupation. The source of infection was not traced. The patients were treated with anti-anthrax serum at King's College hospital and a nursing home respectivelv. and made food recoveries. Anthrax. Smallpox and Chickenpox. The mild type of smallpox, which has been prevalent in London since 1928, abated during the year, when there were 1,452 cases compared with 5,149 in the year 1930. The subjoined table shows the notified cases which occurred during the year. It will be observed that whilst the disease was most prevalent in the eastern districts. Lambeth and Camberwell in the south were centres of heavy infection. Metropolitan Borough. Number of notifications. West— 1931 1930 Metropolitan Borough. Number of notifications. East— 1931 1930 Paddington — 3 Kensington 2 4 Hammersmith 49 21 Fulham — 7 Chelsea — — Westminster 2 3 North— St. Marylebone 2 6 Hampstead — 3 St. Pancras 4 175 Islington 66 242 Stoke Newington 1 29 Hackney 43 493 Central— Holborn 3 14 Finsbury 89 193 City of London 1 11 Shoreditch 122 788 Bethnal Green 145 951 Stepney 352 958 Poplar 101 631 South— Southwark 31 104 Bermondsey 3 47 Lambeth 256 46 Battersea 3 9 Wandsworth 5 8 Camberwell 116 306 Deptford 37 48 Greenwich 9 28 Lewisham 7 11 Woolwich 3 10 Total 1,452 5,149 3 Three deaths occurred amongst smallpox patients, particulars of which are as follows:— Borough. Age. Sex. Vaccinal condition. Date of death. Certified cause of death. Stepney 7 days F. Unvacc'd. 1.4.31 I (a) Inanition. (b) Smallpox in utero. Lambeth 7 years F. Unvacc'd. 21.4.31 I (a) Encephalo-myelitis. (b) Smallpox. Stepney 63 years M. Vaccinated in infancy. 27.5.31 I (a) Cardiac vascular degeneration. (b) Chronic bronchitis. II Smallpox. The borough medical officers of health furnish daily, on a prescribed form, information regarding all cases of smallpox and their contacts. These reports are collated and circulated daily to medical officers of health of the metropolitan boroughs and of the home counties, and also to various county boroughs and other authorities concerned (Ministry of Health, Port of London Authority, Army, Royal Air Force, etc.). A rota of smallpox experts in the Council's service is maintained for purposes of consultation in doubtful cases. The services of these experts are available when required by any of the borough medical officers of health. Chickenpox was made notifiable in two additional metropolitan boroughs, whilst in several instances the orders making the disease notifiable expired and were not renewed. At the end of the year the disease was notifiable in Paddington, Chelsea, Hammersmith, Islington, Stoke Newington, City of London, Poplar, Stepney, Deptford, Greenwich and the Port of London. During the year 1931 (52 weeks), 175 cases of cerebrospinal fever were notified : in 16 the diagnosis was not confirmed. Of the 159 actual cases 97 (61 per cent.) proved fatal. In addition 44 deaths were recorded during the year by the RegistrarGeneral of cases which had not been notified. Cerebrospinal (spotted) fever. As will be seen from the subjoined tabular statement, there was a considerable increase in the number of cases reported during 1931, compared with recent years. The Ministry of Health in July published an interesting report (No. 65 in the series on Public Health and Medical Subjects), reviewing the incidence, distribution, methods of treatment, etc., of cerebrospinal fever. Special reference was made in this report to serum treatment and the Ministry asked medical officers having charge of patients to report the results obtained from the various types of sera. Arrangements have been made for the required information to be furnished by any of the Council's hospitals concerned. During the year, 40 cases of encephalitis lethargica were notified. The diagnosis, however, was not subsequently confirmed in 8. Of the actual 32 cases, 6 proved fatal. In addition 37 deaths were recorded by the Registrar-General of cases which had either not been notified or had been notified in previous years. Encephalitis lethargica (sleepy sickness) . Owing to the pressure on the accommodation at the post-encephalitis lethargica unit at the Northern hospital, 115 additional beds have been provided. There is now accommodation for 150 adults and 90 children. In addition there are 16 beds for emergency purposes. During the year there were 122 admissions to the adult wards (75 men and 47 women) and 28 discharges (18 men and 10 women), whilst one man and one woman died. Particulars of children treated in the post-encephalitis lethargica unit are given in the annual report of the school medical officer (Vol. III, Part II, p. 88). 4 Poliomyelitis and Polioencephalitis (infantile paralysis) During the year under review, 56 cases of poliomyelitis and polioencephalitis were notified. The diagnosis was not, however, confirmed in 5 cases. Of the 51 actual cases, 4 proved fatal. In addition 2 deaths were recorded by the RegistrarGeneral of cases which had not been notified, making a total of 6 deaths for the year. Eleven cases of poliomyelitis were admitted to the Western hospital, where special facilities are provided for the treatment of acute cases. Eight of these were later transferred to Queen Mary's hospital, Carshalton, where treatment is provided for paralysis following the acute stage of the disease, and 3 had been discharged before the end of the year. Admissions of cases of this disease to Queen Mary's hospital numbered 76 (46 male and 30 female) and 38 males and 29 females were discharged. There were 11 males and 37 females under treatment at the end of the year. Notifications, as shown below, were received in each registration year since 1921, excluding duplicate notifications and military cases:— Year. 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 Cerebrospinal fever 103 86 65 93 93 83 93 70 121 88 175 Encephalitis lethargica 233 66 98 600 293 224 142 100 92 60 40 Poliomyelitis and polioencephalitis 57 40 111 116 55 95 86 54 66 37 56 Measles. The deaths from measles in 1931 totalled 115, compared with 1,027 in 1930. The disease became epidemic towards the end of the year. The deaths in successive four-weekly periods in this epidemic compare with the figures for the three preceding epidemics as follows:— Years. October—December. January—June. Total. (36 weeks). 1931-32 7 16 44 59 69 152 240 157 92 836 1929-30 10 24 50 91 133 243 269 189 50 1,059 1927-28 6 41 83 163 200 362 322 188 73 1,438 1925-26 38 84 133 216 196 205 167 84 27 1,150 Whooping cough. It will be noted that the epidemic of 1931-32 was less severe than that of 1929-30. There were 307 deaths from whooping-cough in London during 1931, compared with 128 in 1930. The death-rate was 0-07 per thousand. Scarlet fever. There were 12,025 notifications of scarlet fever in 1931 (52 weeks), the corresponding figure for 1930 being 16,699 (53 weeks). The attack-rate was 2.8 per thousand as against 3.7 in 1930. The deaths numbered 71, giving a death-rate of 0.02 per thousand of population at all ages, and a case mortality of 0.6 per cent. Diphtheria. The notifications of diphtheria numbered 8,384 in 1931 (52 weeks), compared with 13,411 (53 weeks) in 1930. This gives an attack-rate of 1.9 per thousand, as against 3.0 in the preceding year. There were 262 deaths, giving a death-rate of 0.06 per thousand living. The case mortality was 31 per cent. compared with 3 3 in 1930. Diarrhœa and Enteritis. Diarrhœa and enteritis caused 638 deaths among children under two years of age, or 9.71 per thousand births. The corresponding rate in 1930 was 9.89. Puerperal fever and pyrexia. There were 291 notifications of puerperal fever and 828 of puerperal pyrexia in 1931 (52 weeks) compared with 293 and 740, respectively, in 1930 (53 weeks). The deaths from puerperal sepsis numbered 132, and from other accidents of childbirth 118 ; the deaths per 1,000 births being 2.01 and 1.80, respectively. The death-rates from puerperal fever and other accidents of childbirth per thousand births in each metropolitan borough, and in the county of London in the 5 periods 1920-1927, and 1928-1931, together with the deaths in childbirth in 1931 are shown in the following table:— Metropolitan Boroughs. Childbirth deaths per 1,000 births. Number of deaths in Childbirth. 1920-27. 1928-31. 1931. 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 1.9 3.8 4 6 10 Kensington 1.9 1.7 3.6 2.6 1.8 4.4 7 8 16 Hammersmith 2.1 1.7 3.8 1.8 1.6 3.4 2 2 4 Fulham 1.9 1.6 3.5 2.8 1.4 4.2 5 4 9 Chelsea 1.9 2.9 4.8 2.6 2.6 5.2 3 1 4 Westminster 1.5 2.9 4.4 3.6 3.2 6.8 4 1 5 Northern. St. Marylebone 2.1 2.6 4.7 2.3 2.7 5.0 1 2 3 Hampstead 1.8 1.6 3.4 1.8 3.0 4.8 1 1 2 St. Pancras 1.4 1.7 3.1 0.7 1.5 2.2 2 5 7 Islington 1.4 1.5 2.9 1.9 1.9 3.8 12 11 23 Stoke Newington 2.6 1.9 4.4 2.3 2.9 5.2 3 1 4 Hackney 1.8 1.5 3.3 1.5 2.0 3.5 4 7 11 Central. Holborn 2.9 0.6 3.5 1.2 1.2 2.4 — — — Finsbury 0.9 1.4 2.3 2.8 1.3 4.1 3 2 5 London, City of 2.0 1.0 3.0 6.3 — 6.3 — — Eastern. Shoreditch 1.1 1.2 2.3 1.2 1.5 2.7 — 3 3 Bethnal Green 0.9 1.6 2.5 2.0 1.4 3.4 4 6 10 Stepney 1.0 1.4 2.4 1.0 1.3 2.3 3 4 7 Poplar 1.2 1.7 2.9 0.9 1.5 2.4 3 4 7 Southern. Southwark 1.3 1.4 2.7 2.6 1.6 4.2 6 5 10 Bermondsey 1.1 1.8 2.9 2.0 1.6 3.6 8 3 11 Lambeth 1.8 1.3 3.1 1.3 1.6 2.9 6 9 15 Battersea 0.9 1.9 2.8 1.3 2.2 3.5 5 10 15 Wandsworth 1.6 1.7 3.3 2.4 1.9 4.3 15 2 17 Camberwell 1.7 1.5 3.2 2.4 1.6 4.0 7 6 13 Deptford 1.6 1.7 3.3 2.1 1.1 3.2 4 2 6 Greenwich 1.0 1.4 2.4 1.9 1.7 3.6 5 5 10 Lewisham 1.1 1.9 3.0 2.1 1.4 3.5 10 6 16 Woolwich 1.2 1.6 2.8 2.4 2.5 4.9 6 2 8 London 1.5 1.6 3.1 1.9 1.7 3.4 132 118 250 The deaths in childbirth in 1931 are shown in the above table, but not the maternal mortality, as 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 that during this period 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 1928-31. The rate shown for the City of London in 1928-31 is based upon too small a number of cases to be representative. There were 186 notifications of fevers of the enteric group in London in 1931 (52 weeks) compared with 291 in 1930 (53 weeks). Enteric fevers. The deaths in the calendar year numbered 24, as against 26 in 1930. This is the lowest number of deaths recorded in London from this cause. 6 Vital statistics for the several metropolitan boroughs and the County of London in the year 1931. (Rates per 1,000 of civil population.) Metropolitan boroughs. (Arranged in topographical order.) Estimated civil population 1931. Births. (a) Deaths. Infant mortality (per 1,000 births). Measles Scarlet fever. Diphtheria. Whooping cough. Typhoid fever. Diarrhoea and Enteritis, age 0-2 (per l,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 140,300 14.8 13.1 87 .11 — .06 .06 .01 12.5 .83 .93 .59 1.61 4.80 2.66 1.82 .06 .49 .03 2.42 Kensington 174,600 14.2 14.1 76 — .01 .04 .06 .01 14.1 .73 1.33 .78 1.91 6.04 2.38 1.47 .11 .36 .05 1.45 Hammersmith 135,100 15.3 12.2 68 — .01 .04 .05 — 9.2 .81 .98 .69 1.70 1.92 2.07 1.68 .01 .36 .07 1.04 Fulham 151,200 15.1 12.3 68 .01 .01 .06 .05 .01 6.6 .98 1.04 .47 1.51 3.94 2.18 1.49 .03 .56 .06 1 .79 Chelsea 57,220 12.8 14.1 42 .02 — .03 .05 — 5.4 .89 .82 .40 2.29 5.44 1 .61 1.23 .04 .37 2.24 Westminster, City of 115,600 10.1 13.6 74 — — .04 .04 .02 13.3 .91 1.15 .72 1.85 4.14 1.37 1.25 .09 .36 .05 .42 Northern. St. Marylebone 93,460 11.4 13.1 66 .02 .03 .04 .02 .03 12.2 .87 1.13 .44 2.02 2.81 2.70 1.51 .13 .57 .05 .85 Hampstead 87,740 11.2 11.7 61 — .01 .02 .02 — 8.1 .47 .68 .48 1.88 2.04 2.11 .85 .06 .41 .02 .94 St. Pancras 195,200 15.2 13.4 67 .01 .01 .10 .07 .01 10.1 .94 1.03 .73 1.85 2.36 2.23 1.71 .07 .49 .06 1.40 Islington 324,600 16.7 12.7 63 .02 .02 .05 .11 — 10.9 .87 1.15 .71 1.63 4.25 3.38 2.19 .05 .55 .03 1.50 Stoke Newington 51,380 15.2 12.7 54 — — .02 .02 — 10.3 1.05 .80 .58 1.93 5.13 2.03 1.13 .04 .59 .04 .80 Hackney 217,000 15.5 11.5 60 — .02 .07 .04 .00 11.9 .71 1.04 .42 1.58 3.27 2.30 1.86 .03 .46 .03 .86 Central. Holborn 34,470 10.2 14.3 74 .03 — — .12 .03 8.5 .93 1.10 .78 2.29 — 1.75 2.15 .12 .49 .15 1.11 Finsbury 70,120 17.1 14.0 66 .06 — .06 .10 .01 11.7 1.20 1 .27 .98 1.40 4.18 2.45 2.72 .04 .59 .06 1.74 London, City of (b) 9,710 6.4 14.6 81 — — .21 — — — .72 1.03 .62 1.96 — 1.76 1.55 — .62 1.55 Eastern. Shoreditch 98,260 17.1 12.5 75 .26 — .07 .11 .01 19.6 .90 1.40 .61 1.24 1.78 3.04 2.79 .06 .52 .05 .67 Bethnal Green 109,200 16.8 12.5 88 .05 .01 .06 .09 .01 27.2 1.09 1.46 .58 1.18 5.45 3.93 2.95 .03 .89 .06 1.69 Stepney 225,800 17.5 13.1 78 .11 .02 .08 .14 — 18.2 1.04 1.30 .51 1.51 1.77 5.59 2.94 .02 1.06 .03 1.99 Poplar 156,300 17.5 12.4 77 .06 .02 .07 .12 — 7.3 .97 1 .34 .78 1 .41 2.56 3.73 2.48 .03 .64 .05 3.86 Southern. Southwark 172,900 16.9 14.0 61 .02 .02 .05 .10 .01 5.5 1.20 1.18 .72 1.68 3.42 2.98 2.47 .03 .75 .07 2.38 Bermondsey 112,400 17.4 12.6 57 .02 .01 .05 .05 .01 6.1 1.05 1.37 .57 1.33 5.62 2.70 2.29 .01 .43 .08 1.45 Lambeth 295,900 15.3 12.7 60 .00 .02 .07 .09 .00 6.6 .86 .93 .57 1.78 3.32 2 04 1.56 .02 .52 .02 1.58 Battersea 159,800 15.5 12.1 57 .01 .04 .03 .03 .01 3.6 .89 .78 .54 1.77 6.06 3.13 2.21 .03 .46 .02 2.25 Wandsworth 353,200 12.3 11.4 62 .01 .01 .05 .05 — 5.8 .79 .59 .54 1.64 3.92 1.90 1.23 .02 .37 .02 1.59 Camberwell 252,100 14.7 11.9 56 .01 .02 .07 .04 .01 8.1 .96 1.01 .61 1.53 3.51 2.98 1.80 .02 .47 .06 .92 Deptford 107,200 16.3 12.0 53 .01 .06 .11 .10 — 5.2 .93 1.05 .51 1.62 3.44 3.91 2.44 .02 .53 .01 102 Greenwich 99,640 14.8 11.4 65 .02 .01 .11 .05 .01 9.4 .97 .92 .47 1.63 6.70 2.57 2.84 .12 .64 .01 1.35 Lewisham 220,800 141 10.2 50 .01 .02 .08 .05 .01 7.1 .67 .64 .48 1.49 5.14 2.97 1.69 .05 .32 .03 1.29 Woolwich 142,600 14.6 11.6 59 .01 .04 .04 .06 — 2.8 1.04 .88 .64 1.54 3.71 2.37 1 .91 .04 .57 .05 2.56 London, 1931 4,363,800 15.0 12 .4 65 .03 .02 .06 .07 .01 9.7 .90 1.02 .60 1.64 3.81 2.78 1.93 .04 .53 .04 1 58 London, 1930 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. 7 COUNTY OF LONDON.—Notifiable infectious diseases.—Notifications per 1,000 of population. Annual rates per 1,000 living. Period Anthrax Cerebro-spinal fever Continued fever Diphtheria Dysentery Encephalitis lethargica Enteric fever Erysipelas Malaria Ophthalmia neonatorum (per 1,000 births) Pneumonia 1 Polioencephalitis Poliomyelitis Puerperal fever (per 1,000 births) Puerperal pyrexia (per 1,000 births) Scarlet fever Smallpox s 1891-95 ... ... .00 2.4 ... ... .78 1.54 ... ... ... ... ... 2.17 ... 5.3 .26 .00 1896-1900 ... ... .00 2.9 ... ... .82 1.24 ... ... ... ... ... 2.03 ... 4.4 .02 .00 1901-05 ... ... .00 1.9 ... ... .52 1.08 ... ... ... ... ... 2.10 ... 3.6 .46 .00 1906-10 ... ... .00 1.6 ... ... .28 .97 ... ... ... ... ... 2.27 ... 4.2 .00 .00 1911-15 .00 .05 .00 1.8 ... ... .17 .98 ... ... ... ... ... 3.11 ... 3.6 .00 .00 1916-20 .00 .07 .00 2.3 ... .09 .60 ... 8.95 ... ... .02 3.00 ... 2.7 .00 .00 1921-25 .00 .02 .00 2.86 .00 05 .08 .43 03 9.05 1.24 .00 .01 3.59 ... 3.69 .00 .00 1926-30 .00 .02 .00 2.81 .01 .03 .08 .47 .01 9.89 1.46 .00 .01 4.10 ... 3.28 .33 .00 1921 .00 .02 .00 3.62 .01 .05 .07 .47 .05 10.81 .96 .00 .01 3.55 ... 7.27 .00 .00 1922 .00 .02 .00 3.38 .01 .01 .06 .43 .03 917 1.56 .00 .01 3.28 ... 3.81 .02 .00 1923 .00 .01 .00 2.26 .00 .02 .07 .40 .02 8.33 104 .00 .02 3.84 ... 2.21 .00 — 1924 .00 .02 .00 2.30 .00 .13 .09 .41 .02 8.36 1.47 .00 .02 3.43 ... 2.50 .00 — 1925 .00 .02 .00 2.72 .00 .06 .09 .42 .01 8.58 1.18 .00 .01 3.83 ... 2.66 .00 — 1926 .00 .02 .00 2.95 .00 .05 .07 .39 .01 8.97 1.22 .00 .02 4.24 ... 2.68 .00 — 1927 .00 .02 .00 2.69 .01 .03 .07 .43 .01 11.11 1.49 .00 .02 3.57 12.21 2.91 .00 — 1928 .00 .02 .00 2.74 .01 .02 .13 .48 .02 10.19 1.38 .00 .01 4.09 10.67 3.45 .07 .00 1929 .00 .03 .00 2.68 .01 .02 .08 .49 .01 10.42 1.98 .00 .01 4.46 10.84 3.60 .43 — 1930 .00 .02 .00 3.01 .01 .01 .07 .54 .01 8.74 1.24 .00 .01 4.15 10.48 3.74 115 .00 1931 .00 .04 .00 1.93 .01 .01 .04 .53 .01 9.60 1.58 .00 .01 4.44 12.64 2.76 .33 — 8 COUNTY OF LONDON.—Principal vital statistics, 1891-1931. Annual rate per 1,000 living Mortality per 1,000 living Annual mortality per 1,000 births Period Births Marriages Deaths (all causes) Cerebro-spinal fever Diphtheria Enteric fever Scarlet fever Smallpox Whooping cough Measles Influenza Tuberculosis Pneumonia (all forms) Bronchitis Other resp. dis. Heart disease Cancer Diabetes Infants 0—1 Diarrhoea and Enteritis 0—2 Puerperal fever Other acc. of ch. birth. Resp. Other 1891-95 30.8 17.3 19.8 (a) 0.53 0.13 0.24 0.02 0.52 0.59 0.41 1.83 0.80 1.45 2.45 0.48 (a) 0.80 0.07 156 23.8 2.15 2.22 1896.1900 29.7 18.4 18.5 (b) 0.45 0.14 0.14 0.00 0.47 0.57 0.27 1.75 0.69 1.32 1.80 0.35 (a) 0.92 0.07 162 41.3 1.70 1.74 1901.05 28.6 17.7 16.4 (a) 0.20 0.08 0.11 0.07 0.36 0.45 0.17 1.58 0.57 1.46 1.41 0.26 1.31 1.01 0.08 139 30.4 1.64 1.52 1906.10 26.5 17.4 14.9 (a) 0.14 0.04 0.10 0.00 0.29 0.42 0.22 1.39 0.48 1.49 1.22 0.22 1.26 1.11 0.10 114 23.8 1.46 1.47 1911.15 24.0 20.0 14.8 0.02 0.13 0.03 0.05 0.00 0.22 0.43 0.16 1.39 0.39 1.33 1.29 0.21 1.54 1.16 0.11 108 28.0 1.40 1.57 1916.20 20.0 20.1 15.1 0.04 0.17 0.02 0.03 0.00 0.20 0.28 1.01 1.43 0.34 1.38 1.30 0.19 1.70 1.28 0.09 92 15.4 1.64 1.72 1921.25 19.9 17.9 12.3 0.01 0.17 0.01 0.04 0.00 0.15 0.17 0.32 1.01 019 1.14 0.97 0.16 1.66 1.38 0.10 71 11.7 1.36 1.63 1926.30 16.2 18.6 12.3 0.02 0.10 0.01 0.02 0.00 0.11 0.16 0.30 0.90 0.14 1.00 0.72 0.16 2.29 1.52 0.12 64 10.2 1.66 1.69 1921 22.1 19.4 12.5 0.02 0.25 0.01 0.06 0.00 0.12 0.05 0.23 1.07 0.21 1.09 0.99 0.16 1.56 1.33 0.09 81 21.6 1.42 1.56 1922 20.9 18.3 13.5 0.01 0.25 0.01 0.07 0.00 0.25 0.34 0.57 1.08 0.21 1.45 1.13 0.17 1.70 1.33 0.11 75 7.1 1.36 1.48 1923 20.1 17.2 11.4 0.01 0.13 0.01 0.03 0.00 0.09 0.08 0.17 0.97 0.19 0.95 0.84 0.15 1.60 1.39 0.10 61 10.3 1.37 1.52 1924 18.6 17.2 12.2 0.01 0.12 0.01 0.03 0.00 0.11 0.29 0.37 0.98 0.18 1.16 0.98 0.15 1.69 1.42 0.10 69 8.7 1.24 1.84 1925 17.9 17.2 11.9 0.01 0.11 0.01 0.02 0.00 0.19 0.07 0.24 0.95 0.17 1.04 0.90 0.16 1.77 1.44 0.09 68 10.8 1.42 1.77 1926 17.1 17.2 11.6 0.02 0.12 0.01 0.02 0.00 0.05 0.20 0.18 0.88 0.15 0.94 0.79 0.16 1.79 1.46 0.10 64 12.0 1.61 1.74 1927 16.1 18.2 12.1 0.01 0.09 0.01 0.01 0.00 0.12 0.04 0.40 0.91 0.14 1.00 0.83 0.17 2.01 1.49 0.11 59 7.6 1.31 1.60 1928 16.2 18.9 12.1 0.01 0.09 0.01 0.02 0.00 0.09 0.30 0.13 0.89 0.14 0.93 0.59 0.16 2.22 1.52 0.12 67 10.3 1.59 2.00 1929 15.8 19.1 14.2 0.02 0.08 0.01 0.02 0.00 0.26 0.05 0.71 0.96 0.13 1.33 0.97 0.20 2.93 1.55 0.13 71 11.0 1.88 1.73 1930 15.8 19.5 11.6 0.02 0.10 0.01 0.03 0.00 0.03 0.23 0.08 0.87 0.12 0.78 0.44 0.12 2.51 1.57 0.12 59 9.9 1.93 1.40 1931 15.0 18.8 12.4 0.03 0.06 0.01 0.02 0.00 0.07 0.03 0.26 0.90 0.13 1.02 0.60 0.14 2.86 1.64 0.13 65 9.7 2.01 1.80 (a) Comparable figures are not available for this period. 9 Infectious Diseases.—Notifications in the County of London during the 52 weeks ended 2nd January, 1932. Metropolitan borough. Anthrax. Cerebrospinal fever. Continued fever. Diphtheria (including membranous croup). Dysentery. Encephalitis lethargica. Enteric fever. Erysipelas. Malaria. Ophthalmia neonatorum. Pneumonia. Polioencephalitis. Poliomyelitis. Puerporal fever. Puerperal pyrexia. Scarlet fever. Small-pox. Typhus. W estern— Paddington 1 4 3 254 2 — 9 68 — 18 339 1 2 10 31 372 — — Kensington 8 — 256 25 1 20 62 1 14 252 — — 8 62 415 2 — Hammersmith — 9 — 227 2 2 1 49 — 12 140 — — 5 31 279 49 — Fulham — 9 — 224 — 1 4 85 — 17 270 — 4 10 50 328 — — Chelsea — — — 70 — — 2 21 — 6 128 — 1 — 7 92 — — Westminster, City of — 6 — 144 1 1 10 42 i 7 48 — — 4 15 158 2 — Northern— St. Marylebone — 5 — 141 — — 12 53 — 11 79 — 1 11 22 252 2 — Hampstead — 2 — 74 5 2 5 36 1 5 82 — 3 3 15 185 — — St. Pancras — 12 — 332 2 2 13 96 1 45 272 — 1 24 38 434 4 _ Islington — 10 — 709 6 1 16 177 1 88 485 — 4 45 67 1,093 66 — Stoke Newington — 2 — 58 — — 2 30 — 7 41 — — 5 14 104 1 — Hackney — 7 — 403 1 2 7 99 1 28 187 — — 6 67 497 43 — Central— Holborn — 5 — 74 2 — 4 17 — 7 38 1 — 3 3 60 3 — Finsbury — 4 — 190 — — 3 41 1 22 122 — — 3 20 171 89 — London, City of — — — 15 — — — 6 — — 15 — — — — 17 1 — Eastern— Shoreditch — 5 — 273 3 3 6 51 — 32 66 — — 9 15 298 122 — Bethnal Green — 6 — 321 1 1 3 97 3 22 184 — 1 7 15 428 145 — Stepney — 6 — 662 1 3 5 239 4 23 449 — 4 8 36 1,259 352 — Poplar — 8 — 387 — 4 5 99 — 37 602 1 5 17 23 582 101 — Southern— Southwark — 12 — 426 1 — 5 130 1 20 411 — 2 12 36 514 31 — Bermondsey — 9 — 257 — 1 1 48 — 14 163 — 1 12 36 303 3 — Lambeth — 7 — 461 2 1 6 152 3 37 466 1 — 15 47 602 256 — Battersea — 3 — 352 1 3 5 74 2 38 358 — 6 7 24 499 3 — Wandsworth — 6 — 434 1 6 8 132 5 40 561 1 4 18 22 669 5 — Camberwell 1 15 — 453 1 2 5 118 4 29 231 — 1 8 30 750 116 — Deptford — 1 — 261 — — 2 57 — 22 109 — 1 5 16 418 37 — Greenwich — 1 — 282 1 1 12 64 1 5 134 — 2 6 15 255 9 — Lewisham — 6 _ 372 2 10 70 1 15 284 — 2 21 30 654 7 — Woolwich — 7 — 272 — 1 5 81 1 8 364 — 6 9 41 337 3 — Ages 0— — 35 — 239 3 — 2 97 629 559 1 2 — — 137 14 — „ 1— — 49 — 2,763 22 4 10 91 — — 1,404 1 29 — — 3,282 97 — „ 5— — 21 — 2,816 17 2 17 79 — — 633 1 9 — — 4,908 320 — „ 10— — 11 1 1,052 3 4 19 67 — 232 — 3 — — 1,905 292 — „ 15— — 16 — 476 1 4 22 100 — — 356 — 5 12 65 675 199 — „ 20— 1 6 — 389 2 1 30 123 1 — 369 1 2 73 250 469 144 — „ 25— — 15 2 397 1 2 42 216 15 — 637 1 1 148 381 440 133 — „ 35— — 8 — 163 5 8 23 281 8 — 777 — — 57 130 153 93 — „ 45— — 7 — 45 4 10 13 465 8 — 688 — — 1 2 45 83 — „ 55— — 6 — 27 — 2 5 423 — — 594 — — — — 10 55 — „ 65— 1 1 — 12 — 2 3 227 — — 408 — — — — — 20 — „ 75+ — — — 5 — 1 — 125 — — 223 — — — — 1 2 — London, 1931 2 175 3 —8,384 58 40 186 —2,294 32 629 6,880 5 51 291 828 12,025 1,452 — London, 1930 1 88 6 13,411 40 60 291 2,387 29 617 5,531 8 29 293 740 16,699 5,149 2 10 Influenza. The deaths from influenza during 1931 numbered 1,121, compared with 366 in 1930. The disease became epidemic in January, the deaths reaching a maximum in the week ended 14th February, when they numbered 116. The total deaths from influenza in the 13 weeks ended 4th April were 797. Influenza again became epidemic towards the end of the year and in the second week of 1932 there were 145 deaths. The age-distribution of deaths in both epidemics was almost identical, about 70 per cent, of the deaths occurring among persons of 55 years and over. Rheumatic fever The deaths in London from rheumatic fever in 1931 numbered 158, of which 66 were among children under 15 years of age. The corresponding figures in 1930 were 174 and 72 respectively. Cancer. There were 7,159 deaths from cancer in 1931 as against 6,908 in 1930, and 6,865 in 1929. The death-rate per thousand was 1.64. There was au increase of 81 in the male deaths and of 170 among the females. Ihe movement of the cancer mortality-rate in London at decennial intervals is shown in the following table. The approximate death-rates for the period 19291931 are based upon the census figures of 1931. Period. Age group. 25- 35- 45- 55- 65- 75-85 1860-52 Males 0.09 0.21 0.60 1.09 1.86 1.77 Females 0.21 0.86 1.68 2.44 2.98 2.77 1860-62 Males 0 09 0.28 0.73 1.45 2.23 1.85 Females 0.20 0.85 1.97 2.74 3.61 2.71 1870-72 Males 008 0.31 0.91 1.86 2.37 2.38 Females 0.23 1.02 2.04 3.42 3.34 3.54 1880-82 Males 010 0.39 1.20 2.55 3.81 3.51 Females 0.19 1.10 2.35 3.74 4.82 4.85 1890-92 Males 014 0.52 1.65 3.60 5.58 5.35 Females 0.23 108 2.57 4.31 5.92 6.81 1900-02 Males 0.11 0.45 1.72 4.34 7.47 8.26 Females 0.19 0.92 2.58 4.68 6.94 8.64 1910-12 Males 0.13 0.48 2 09 5.27 913 10.51 Females 0.17 0.89 2.34 4.62 6.98 9.37 1920-22 Males 0.12 0.50 2.01 5.70 10 05 12.49 Females 0.17 0.77 2.30 4.52 7.21 10.60 1929-31 Males 0.14 0.55 2 06 5.62 11.11 15.99 Females 0.17 0.76 2.18 4.14 7.69 12.30 In the annual report for 1927 the results of an analysis of the London cancer mortality from 1850 to 1922 were discussed (pages 16-24), and reasons were given for the conclusion that among persons over 35 years of age the movements of the mortality from 1850 onwards are, in the main, correlated with the year of birth and not with progressive changes in conditions of life, and that, assuming the same correlation to hold in the future, the female mortality at the younger ages will continue to decline, while that of males will continue to increase. This trend of the mortality-rates is, as will be seen from the above table, broadly maintained in the figures for 1929-31. The mortality from cancer among women between 35 and 65 years of age, who were born in the period 1865-1877, has decreased by 12 per cent. upon those of women born in 1835-1847; while the corresponding figures for males show an increase of 27 per cent. The relative values of the various factors concerned in the trend of the mortality from cancer cannot, however, be stated with any accuracy. Tuberculosis. Tuberculosis. The deaths from tuberculosis of the respiratory system in London during 1931 numbered 3,907, giving a death-rate of 0.90 per thousand living, the corresponding figures for 1930 being 3,826 and 0.87 respectively, and 4,230 and 0.96 for 1929. There were 552 deaths from other forms of tuberculosis in 1931 as against 526 in 1930, the death-rates being 0.13 and 0.12, respectively. 11 The annual deaths and death-rates from pulmonary tuberculosis in recent years are shown in the subjoined table:— Period. Pulmonary Tuberculosis Death-rates. Non-pulmonary Tuberculosis Death-rates. Males. Females. Total. Males. Females. Total. 1922-24 1.28 0.78 1.01 0.22 0.17 0.19 1925-27 1.19 0.67 0.91 0.18 0.14 0.15 1928 1.14 0.68 0.89 0.17 0.12 0.14 1929 1.24 0.72 0.96 0.15 0.11 0.13 1930 1.13 0.64 0.87 0.13 0.11 0.12 1931 1.14 0.68 0.90 0.15 0.11 0.13 The number of primary notifications in metropolitan boroughs during 1931 (53 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 7,732, the corresponding figure for 1930 being 8,051. The following is an analysis of the notifications in London during 1931 (53 weeks ended 2nd January, 1932):— Form of tuberculosis notified. Sex. Number of Formal Primary Notifications of new cases of tuberculosis. Total Notifica tions. 0- 1- 5- 10- 15- 20- 25- 35- 45- 55- 65 + Total all ages Pulmonary tuberculosis M 2 19 70 56 326 507 818 693 618 372 141 3,622 5,316 F 2 17 47 96 397 569 727 411 259 121 62 2,708 3,971 Other forms of tuberculosis M. 22 117 172 96 107 56 72 29 30 19 14 734 884 F. 12 98 137 77 78 90 89 38 23 14 12 668 798 All forms of tuberculosis M. 24 136 242 152 433 563 890 722 648 391 155 4,356 6,200 F. 14 115 184 173 475 659 816 449 282 135 74 3,376 4,769 In addition to the primary cases shown in the above table, 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 formal notification. 0- 1- 5- 10- 15- 20- 25- 35- 45- 55- 65 + Total. Pulmonary tuberculosis M. 2 6 3 7 21 50 123 102 84 70 38 506 F 4 6 7 10 29 70 135 66 37 23 27 414 Other forms of tuberculosis M. 10 31 28 19 24 22 20 8 12 10 4 188 F. 8 37 19 18 15 14 25 9 9 3 6 163 All forms of tuberculosis M. 12 37 31 26 45 72 143 110 96 80 42 694 F. 12 43 26 28 44 84 160 75 46 26 33 577 The sources of information as to the unnotified cases shown in the above table were as follows:— Source of information. Number of cases. Pulmonary. Non-pulmonary. from local registrars 259 106 Death returns transferable deaths from Registrar-General ... 147 77 Posthumous notifications 53 41 "Transfers " from other areas 429 121 Other sources 31 7 The returns received under the Public Health (Tuberculosis) Regulations, 1924, from the medical officers of health of the metropolitan boroughs show that there were 29,565 cases of pulmonary tuberculosis (16,795 males and 12,770 females) and 11,060 cases of other forms of tuberculosis (5,759 males and 5,301 females) on the registers of the metropolitan boroughs at the end of 1931. 12 The Increased Mortality from Pulmonary Tuberculosis amongst Young Women. The increased mortality from pulmonary tuberculosis amongst young women has been the subject of considerable discussion. In the annual report for 1926, it was shown that this increase, although greatly emphasised during the Great War, could be traced back in origin to somewhere between 1890 and 1900. The movement in the mortality during the past thirty years for both males and females is shown in the following table, which shows the deaths from pulmonary tuberculosis in London per 100,000 living:— Period 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- Males 1900-02 51 15 17 82 172 260 443 519 427 317 131 1911-13 37 15 17 72 148 208 320 360 364 263 150 1920-22 16 5 14 84 151 151 210 261 235 168 82 1929-31 14 6 6 66 119 130 163 226 209 137 74 Females. 1900-02 42 23 32 76 97 150 251 214 166 121 77 1911-13 32 15 35 81 96 117 159 153 127 113 66 1920-22 18 9 31 111 131 114 111 96 81 81 53 1929-31 14 6 19 100 125 98 81 66 54 43 31 Increase ( + )or decrease ( — ) per cent. of ratio in 1929-31 on 1911-13 rales:— Males -62 -60 -65 - 8 -20 -37 -49 -37 -43 -48 -51 Females -56 -60 -46 + 23 + 30 -16 -49 -57 -57 -62 -53 It will be noted that the female mortality from pulmonary tuberculosis at ages 10-15 is about double that of males throughout, although in both sexes the mortalityrate has markedly fallen. The increase in mortality in recent years among young women first becomes apparent after this age-group, but is practically confined to the age-period 15-25. At first sight the explanation which suggests itself of the remarkable increase in this age-period is that it is due to change of occupation from school and domestic work to commercial and industrial employment. In the annual report for 1926, it was shown that the statistics relating to the mortality from pulmonary tuberculosis bore out the view that the chief factor is nutrition. It was also shown that no consideration of the causes influencing mortality from phthisis could reach conclusive results if it did not take into account the concurrent death-rate from all other causes. The effect, however, of taking into account the general death-rate makes no difference to the conclusions to be drawn from the mortality-rates shown in the preceding table. There has not only been an actual increase in the mortality from pulmonary tuberculosis among women aged 15 to 25, but there has also been an increase relatively to all other causes of death at this age-period which is not shown at other ages. In the following table the deaths from pulmonary tuberculosis at ages 15 to 25 are stated as a percentage of the deaths at the same ages from all causes, in areas of differing degrees of urbanization:— Areas of England and Wales Males Females 1911-13 Per cent. 1920-22 Per cent. 1928-30 Per cent. 1911-13 Per cent. 1920-22 Per cent. 1928-30 Per cent. London 34.9 34.5 32.8 35.6 43.2 45.1 County boroughs 33.4 33.2 32.3 38.7 42.5 43.4 Urban districts 29.3 29.5 27.6 37.2 40.7 41.9 Rural districts 28.1 29.2 23.0 36.4 39.4 38.7 England and Wales 31. 1 31.4 29.0 37.4 41.5 42.3 13 There is, it will be seen, a very marked contrast in the rates for the two sexes, the male percentage showing some tendency to a decrease in all areas, but among females the relative increase in phthisis mortality is greatest in the most highly urbanised areas, the rural districts showing practically no change throughout. The suggestion is, of course, that in the rural areas the occupation of young women has not changed to the same extent as in the urbanised areas. On the other hand, when the London figures are considered, it is found that when a group of metropolitan boroughs representing the poorest population, or the population with the highest death-rate, is compared with the group of better class areas, or boroughs with low mortality-rate, the increase in pulmonary tuberculosis per cent, of all deaths among young women of 15 to 25 is much the same in both groups. Actually, it is somewhat higher in the better class group. The figures are as follows:— Group of boroughs 1901-10 1926-30 Increase ( +) or Decrease (—) Males Females Males Females Males Females 1. Hampatead, Lewisham, Wandsworth 36.9 33.7 34.3 47.2 -2.6 + 13.5 2. Bermondsey, Bethnal Green, Finsbury, Shoreditch, Stepney 34.9 32.8 35.9 43.9 + 1.0 +11.1 If change of employment from domestic work to commercial or industrial occupations or "industrialisation" were alone the cause of the increased mortality from phthisis, the change should be far more conspicuous in the better class areas ; for in these the occupation figures of the census years 1911 and 1921 show that, in the ten years intervening between them, the proportion of young women of this age engaged in domestic service decreased by nearly one-half, while in the poorer group of the population the number employed in domestic service is comparatively negligible in both censuses. I am indebted to the Registrar-General for figures relating to the mortality from all causes among single, married and widowed women in London during the years 1911 and 1921. Unfortunately, the deaths from pulmonary tuberculosis separately are not available; and, before discussing these figures, it is necessary to show that there has been no difference in the general trend of mortality at different age-periods among young women from all other causes than pulmonary tuberculosis. This will be seen from the following table:— Age period Deaths in 1911 Deaths in 1921 (on 1911 population) Increase ( +) or Decrease (—) Pulmonary tuberculosis All other causes Pulmonary tuberculosis All other causes Pulmonary tuberculosis All other causes No. Per cent. No. Per cent. 10- 71 348 64 338 - 7 - 9.9 - 10 - 2.9 15- 169 343 253 328 + 84 + 49.7 - 15 — 4.4 20- 240 404 315 369 + 75 + 31.2 - 35 - 8.7 25- 277 496 289 471 + 12 + 4.3 - 25 - 5.0 30- 275 580 238 512 - 37 — 13.5 - 68 —11.7 35- 288 790 196 599 - 92 —31.9 -191 -24.2 40-45 272 1,014 172 751 -100 -36.8 -263 -25.9 It is clear from these figures that any increase in the death-rate from all causes at the ages 15-25 must be almost entirely due to increase in the mortality from pulmonary tuberculosis. 14 The figures of mortality from all causes among unmarried and married women are as follows:— Age Deaths in 1911 Deaths in 1921 (on 1911 population) Increase (+ ) or Decrease (—) No. Per cent. Single Women 10 419 402 - 17 - 4.1 15 504 574 + 70 + 13.9 20 478 527 + 49 + 10.3 25 337 358 + 21 + 6.2 30 260 229 - 31 -11.9 35 237 195 - 42 —17.7 40-45 239 207 - 32 -13.4 Married Women 15 8 7 - 1 -12.5 20 162 157 - 5 - 3.1 25 424 390 - 34 - 8.0 30 566 494 - 72 -12.7 35 771 553 -218 -28.3 40-45 912 622 -290 -31.8 Thus, practically the whole of the increase in mortality from pulmonary tuberculosis has been among single women. An obvious explanation of this is that young women suffering from pulmonary tuberculosis do not marry. It may, however, reasonably be questioned whether this does, in fact, explain the great divergence in the figures, as there is at this age-period some proportion of cases of pulmonary tuberculosis which are unsuspected until within a comparatively short time before death. The possibility cannot be altogether excluded that the young women most adversely affected by present conditions are those who do not marry. It is possible also, bearing in mind the nutrition factor, that, were the mortalityrate available separately for young employed women living at home and those who are self-supporting, the latter class would be found to have the higher increase in mortality. The mortality-rates of single women have been calculated for each year of life for ages 10 to 25 in the period of 1911 to 1913 and 1921 to 1923 in England and Wales, the result being as follows:— [/### ]Age last birthday Annual average death rate per lf000 living at each age (England and Wales) Increase (+ ) or decrease (—) in rate Increase (+ ) or decrease (—) in rate per cent. 1911-1913 1921-1923 10 1.96 1.69 -.-27 - 14 11 1.87 1.54 - .33 -18 12 1.92 1.63 - .29 -15 13 2.08 1.86 - .22 -11 14 2.32 2.03 - .29 — 12 15 2.47 2.30 - .17 - 7 16 2.61 2.46 - .15 - 6 17 2.72 2.61 - .11 - 4 18 2.62 2.66 +. 04 + 2 19 2.80 2.83 + .03 + 1 20 2.77 3.00 + .23 + 8 21 2.99 2.91 - .08 - 3 22 2.86 3.13 + .27 + 9 23 2.84 3.04 + .20 + 7 24 3.04 3.18 + .14 + 5 25-30 ... 3.25 3.43 + .18 + 6 30-35 4.23 3.86 - .37 - 9 These figures show that among women the first sign of the increased mortality between 1911-13 and 1921-23 appears at the close of school life and becomes 15 established about the age of 18. The mortality-rates given previously clearly show that in the early years of adolescence the resistance to pulmonary tuberculosis is far lower among young women than young men and it would therefore be expected that when adverse economic conditions are added at this period of life the young women will be much more affected than young men. If this is the explanation of the facts, an improvement in economic conditions affecting young women wage-earners should be followed by a decline in the present excessive mortality from pulmonary tuberculosis among them. Administration. The supervision of the 151 common lodging houses licensed by the Council under the London County Council (General Powers) Act, 1902, entailed 5,674 day visits and 170 night visits by the inspectors. The supervision of the 22 seamen's lodging houses licensed under the Merchant Shipping Act, 1894, entailed 475 visits by day and 22 by night. Common and seamen's lodging houses. A census of homeless persons in London was taken on the night of Friday, loth February, 1931. 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 very cold with a north-east wind. No persons were found sheltering under arches or on staircases. In the streets 60 men and 18 women were found, compared with 47 men and 25 women on the night of the census in 1930. In the common lodging houses 14,970 persons were accommodated compared with 14,855 in 1930. In the free shelters and labour homes not licensed, 1,057 men, 137 women and 17 children were accommodated compared with 631 men, 117 women and 18 children in 1930. The number of persons in casual wards and in the associated hostel on the night in question was 689 (674 men and 15 women). In London Rowton Houses, 5,007 men were accommodated and there were 38 vacant beds. Census of homeless persons. The following table shows briefly the results obtained in the several years during which the enumeration has been undertaken by the Council:— 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 1931 14,970 689 78 15,737 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. A full account of the action taken under the various Housing Acts will be found Housing, in Volume II of the Annual Report of the Council, 1931. Disinfestation. At the institutions transferred to the Council by virtue of the Local Government Act, 1929, it was found that disinfesting was, in some cases, done by a contractor, and in others by the hospital staff. In order to obtain some idea of the extent of the work involved, thirty hospitals were visited, and it was found that 14 had contracts 16 with various firms for the eradication of pests. When the new contracts were under review, the tenders for all the hospitals where the work was done by contract varied from £219 to £819, and it was felt that not only was there an element of uncertainty as to the amount and value of the services rendered, but that it was work which could be done more effectively and economically by the Council's staff. The Public Health Committee eventually decided that arrangements for the disinfesting of the general hospitals and institutions allocated for use as hospitals should be carried out under the supervision of the inspectorate of the general public health branch of the public health department, the hospital or institutional staff continuing to discharge such duties as were requisite in connection with the repression of pests. In addition to the hospitals, visits have also been made, on complaint, to certain public assistance institutions as well as to schools. The most serious pest is the " cockroach " ; it is met with in practically all the kitchens and in many of the storerooms. The existence of conduits for hot water and steam pipes, the difficulty of getting under and around fittings and other structural factors make the total elimination of this insect, at present, practically an impossibility. In an attempt to secure vermin-proof buildings, minor works have, in some cases, been carried out, and where this has been done control has been rendered much easier. Other pests met with are rats, mice and, in a less degree, crickets, ants, flies, moths and, rarely, bugs. In the case of rats, ratlime and one or other of the red squill preparations have been found useful. Virus is not used. The usual procedure is for the inspector to visit, suggest remedies and explain what should be done. This is followed by further visits, sometimes in the day, but generally at night when further advice is given. Liquid sprays, insecticide powders, sticky baits, poisonous baits and traps all have their uses and are generally employed in combination. While there is some difference in the value of the various insecticides the predominating factor making for success is a personal one, depending on the intelligence and enthusiasm of the local officer detailed for the work. A very real difficulty arises from the fact that the work has mostly to be done at night after work in the kitchens has ceased, at a time when, unfortunately, only a small staff is working, and such officers as are on duty have their time already fully occupied. I am satisfied that the procedure above described, which has been substituted for the older practice of contracting with private firms, for disinfesting what are now the Council's institutions, is much more efficient and certainly has effected substantial economies in this important work. The inspectors engaged thereon, in addition to the qualifications which an inspector's training confers, have spared no pains to make themselves expert advisers in this work. They are in liason with the entomologists and other naturalists at the government museums, and the measures adopted are the best that can be suggested by scientific advisers, both within and without the Council's service. 17 COUNTY OF LONDON.—Statistics of the administrative work carried out during the year 1931. 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 — — — — — —- 102 2 16 — 1 477 116 1,029 All — — 278 215 4 2 901 530 Battersea — — 2 — 3 3 24 14 1 4 3 187 283 3,888 1,514 213 23 273 594 176 301 179 238 Bermondsey — — — — 13 47 15 5 3 — 3 1,103 53 641 1,085 599 5 290 641 137 200 144 629 Bethnal Green 11 46 2 208 9 107 22 — — 1 5 359 621 21 1,186 259 — 268 734 161 275 192 622 Camberwell 1 15 2 166 10 35 190 12 23 3 5 430 76 4,703 2,937 317 25 445 1,787 259 323 181 264 Chelsea — — 2 15 — — 21 2 6 — 2 164 26 656 204 257 2 73 105 25 31 70 61 Deptford — — 2 278 6 10 18 2 — — 6 1,166 5 1,933 950 80 — 216 256 136 120 194 258 Finsbury — — 1 102 4 44 62 4 19 3 2 470 15 2 608 145 12 161 248 74 181 214 290 Fulham — — 2 79 — — 206 1 7 — 2 84 14 4 1,176 87 — 153 101 131 290 98 170 Greenwich 1 4 3 34 3 12 61 4 20 1 2 90 11 1,020 750 39 2 106 141 129 144 62 60 Hackney 3 21 12 483 18 43 1,334 25 25 4 4 307 85 3,080 1,581 601 2 456 779 203 326 194 187 Hammersmith — — 7 326 3 35 77 25 11 1 1 280 197 2,631 733 43 75 117 1,075 127 256 148 636 Hampstead — — 1 7 — — 2 — 2 — — — 14 939 39 8 161 66 124 54 128 60 82 Holborn — — 1 5 — — 265 8 13 2 12 835 449 18 252 178 — 130 127 25 54 275 505 Islington — — 13 524 16 46 118 22 154 4 20 708 90 5,408 3,057 96 89 413 853 292 168 476 571 Kensington — — 3 207 1 51 281 2 1 — 5 259 341 3,943 1,521 367 77 151 446 140 180 141 1,277 Lambeth 1 12 6 477 4 48 55 55 55 — 3 448 — — 5,174 736 48 621 3,106 256 351 214 241 Lewisham 1 4 7 1,529 — — 205 12 6 2 — — 22 814 1,364 93 — 129 344 161 192 116 329 Paddington — — 2 201 1 53 197 2 13 — 3 234 24 9 no rcrd 73 138 118 397 127 165 123 151 Poplar 3 17 7 41 7 7 49 3 15 — 6 636 74 2,782 1,803 231 3 105 298 132 262 813 1,842 St. Marylebone — — 1 58 3 90 262 4 17 — 4 739 3,529 3,358 911 481 11 123 311 76 130 340 672 St. Pancras — — 4 173 2 25 540 7 69 6 2 78 1,214 6,294 1,014 148 120 338 657 233 232 289 615 Shoreditch 2 26 1 7 2 8 794 6 4 — 4 284 10 — 980 26 13 287 1,195 109 233 203 570 Southwark — — 4 105 4 16 6 4 1 1 20 2,353 1,693 2,955 2,173 604 15 361 1,787 176 528 376 1,504 Stepney 19 118 — — 54 198 232 29 17 4 22 3,375 326 32 2,466 278 6 413 1,588 270 333 361 470 Stoke Newington — — 4 55 1 13 1 — 2 — — — — 1,418 289 131 2 84 74 40 37 32 60 Wandsworth 1 12 5 799 2 7 72 3 36 — — — 165 26 4,565 620 1 345 686 512 11 326 241 Westminster — — — — — — 854 10 49 2 6 1,795 399 428 613 11 19 194 268 76 42 1,212 1,318 Woolwich 5 161 5 20 1 4 120 1 42 — 9 318 18 2,016 895 49 2 94 393 166 272 165 378 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 151; lodgers, 16,703. Visits—day, 5,674, night, 170. Seamen's lodging houses, number licensed, 22 ; Poplar, 3 ; Stepney, 19 ; lodgers, 861. Visits—day, 475 ; night, 22. Prosecutions—Smoke nuisances.—Camberwell, 1, £5 5s. Od. costs ; Islington, 1, £5 5s. 0d. costs. Water Supply.—Hammersmith, 3; Islington, 1. Ice cream premises.—Hammersmith, 3. Milkshops.—Islington, 9; City of London, 11; Battersea, 6; St. Pancras, 3; Stepney, 1. 18 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 Housing Act 1925/30. 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 1,431 505 151 120 147 35 67 264 — — — — — — 52 156 — — — — — — — — — — Battersea 27,852 24,973 6,503 2,909 3,376 1,137 16 2,505 314 — — 3 60 60 62 258 — 17 89 159 411 — — — — 9 Bermondsey 18,656 18,512 3,772 5,530 6,428 1,435 13 6,428 — — 13 — 1,775 300 63 357 — 95 286 6 6 4 2 61 Bethnal Green 18,156 prac. all 6,950 1,108 5,793 3,231 6,803 — — 1 — — — 170 808 — 38 89 — — — — — — — Camberwell 41,356 33,085 4,060 1,089 3,984 1,508 48 4,138 — — 1 — 103 36 240 187 1 fits 227 shps 12 fits 280 — — — — — 71 59 Chelsea 11,919 2,483 673 159 709 212 — 514 — — 1 1 40 40 426 30 — fits 132 — — — — — — 1 83 Deptford 18,200 prac. all 1,977 2,884 3,511 1,097 12 3,883 18 — 3 — — — — — — — — — — — — — — — Finsbury 10,889 prac. all 1,637 1,544 2,564 291 — 2,564 — — 4 4 7 7 789 3,862 — 91 53 — — — — — — 6 Fulham 24,580 prac. all 3,522 740 2,628 433 136 2,672 472 — 5 5 17 16 180 2,425 — — fits 369 1 7 — — — — — Greenwich 17,934 prac. all 917 12 1,111 — — 1,853 — — — — 15 7 100 101 — 296 50 — — — — — — 18 Hackney 35,570 14,016 6,478 253 4,933 1,264 4 5,105 — — 8 7 130 45 195 82 fits 95 fits 754 — — — — — — 70 Hammersmith 20,100 13,600 8,342 152 5,011 2,008 4,280 — — 10 7 69 98 2,495 — — 57 36 2 2 2 2 — — — Hampstead 13,356 approx. one—half 966 1,248 1,850 747 12 1,488 — — 36 36 24 24 1,675 1,989 — — tnmts 1 1 — — — 3 — Holborn 3,473 8,571 tnmts. 499 — 453 71 — 453 — — 20 20 6 6 484 776 — — 162 — — — 1 2 2 — Islington 46,000 28,700 7,613 1,661 4,621 523 54 18,114 54 — 33 33 59 59 992 986 — 145 — — — — — — — — Kensington 35,296 9,857 2,786 1,239 2,306 393 174 2,202 195 1 73 73 62 59 3,090 8,964 — — 7 57 7 1 2 — — Lambeth 46,742 — 8,857 347 3,646 230 155 5,034 150 — 4 4 — — — — — 469 350 3 103 — — — — — Lewisham 47,000 no recrd 2,242 960 1,620 446 — 1,620 — — 1 1 59 48 14 59 — — approx 1 1 1 1 — — — Paddington 17,000 10,000 1,536 — 1,272 390 211 1,177 190 6 6 15 11 1,406 6,013 — — — — — — — — — — Poplar 23,700 23,000 approx. 8,059 2,213 4,992 1,655 — 4,856 — — 1 1 59 22 148 1,076 — 15 111 4 109 — — 2 1 — St. Marylebone 19,764 8,543 about 1,859 1,012 1,260 51 — 1,311 — — 13 13 12 12 1,055 7,874 — 13 60 — — — — — — 80 St. Pancras 27,280 18,000 5,058 1,170 3,797 1,488 40 3,690 36 — 1 1 25 23 2,618 3,985 — 99 95 9 36 — — — 2 7 Shoreditch 14,016 13,690 8,365 — 5,586 859 — 5,586 — — many 4 168 192 410 885 — 78 52 18 18 2 — — 65 23 Southwark 26,382 14,496 7,122 3,711 7,011 3,389 264 7,319 225 — 1 1 27 27 355 343 — 95 200 10 373 1 — — — 114 Stepney 37,772 31,911 9,436 5,467 12,802 5,457 — 11,359 — — 15 17 97 58 2,540 1,874 — 54 approx 167 1 76 1 — — — — Stoke Newington 8,668 3,974 773 237 759 76 — 1,741 — — 2 2 100 39 — — — — — — — — — 7 Wandsworth 74,993 49,230 8,731 2,731 4,938 506 6 12,923 — — 55 11 112 1?7 267 631 — fits. 72 fits. 87 6 81 ? 1 18 19 Westminster 25,321 6,094 1,262 1,032 1,244 62 1,478 — — 59 46 12 40 393 1,683 2 224 225 2 38 3 — — — Woolwich 30,625 25,766 3,798 3,242 3,233 893 — 3,218 — — 1 1 70 42 ntkept 497 — 397 252 25 25 1 27 2 65 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 : Islington, 14 ; Kensington, 4 ; Paddington, 10 ; Poplar, 1 ; St. Pancras, 3 ; Stepney, 2 ; Stoke Newington, 1. Overcrowding—Bethnal Green, 3; Hammersmith 2; Hampstead, 2 ; Islington, 5 ; Kensington, 3 ; St. Pancras, 1; Underground Rooms—Islington 1. 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, 1931; 19 Sanitary Inspectors, 1931. District. Population (Census) 1931 Male. Female. Health Visitors. Whole time. Part time. Whole time. Part time. Whole time. Part time. City of London 10,999 25 — 1 — — — Battersea 159,552 11 — — 2* 8 2* (* Act both as Sanitary Inspectors and Health Visitors.) Bermondsey 111,542 12 — — — 10 — Bethnal Green 108,194 11 — — — 12 — Camberwell 251,294 12 — 2† — 3 2† (Including 1 Food & Drug Inspector & 1 Food Inspector.) († The two Female Sanitary Inspectors also act as part-time Health Visitors.) Chelsea 59,031 4 — 1 — 1 — (Excluding 3 Chelsea Health Society Visitors, subsidised by Council .) Deptford 106,891 8 — — 1 7 2 Finsbury 69,888 6 — 1 — 6 Fulham 150,928 10 — 1 — 7 — Greenwich 100,924 5 — 1 — 10 — (Including 3 T.B. Visitor.) Hackney 215,333 19 — 1 — 16 — (Including 2 T.B. Visitors) Hammersmith 135,523 11 — 1 — 4 — Hampstead 88,947 7 — 1 — 3 — Holborn 38,860 3 — — 1* 1 1* (.Acts both as Sanitary Inspector and Health Visitor.) Islington 321,795 19 — 2 — 8 — Kensington 180,677 11 — — 7* — 7* (Including 1 Food Inspector.) (* Act both as Sanitary Inspectors and Health Visitors.) Lambeth 296,147 15 — 2 — 6 (Including Visitors.) 2 T.B. Lewisham 219,953 10 — — — 9 — Paddington 144,923 9 — 2 — 8 1 Poplar 155,089 14 — 1 — 12 — (Including 2 Meat & Food Inspectors.) (Includes 3 T.B. visitors. Excludes 9 Vol. Assoc . Health Visitors) (plus 1 Sister Incharge o f Light Centre) St. Marylebone 97,627 8 3 — 3 4 4. St. Pancras 198,133 15 — 1 5* 17 5* (Including 2 Food Inspectors and 1 Factory and Workshop Inspector.) (Factory A Workshop Act.) (* Act both as Sanitary Inspectors and Health Visitors.) Shoreditch 97,042 13 — — — 6 — Southwark 171,695 13 — 1 — 9 — Stepney 225,238 19 — — — 11 — Stoke Newington 51,208 3 — — — 3 — Wandsworth 353,110 17 — — — 9 — Westminster, City of 129,579 12 — 1 — 8 — Woolwich 146,881 11 — 1 2 8 2 Total County of London 4,397,003 333 3 21 21 206 26 Total for 1921 4,484,523 335 3 22 20 200 25 20 Tuberculous milk. 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 30th June, 1932. Examination of 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. During 1931, 2,160 samples of milk were taken from consignments sent to London from 37 counties and were submitted for biological examination. Of these samples 1,990 were taken at London railway termini, and 170 from supplies entering London by road. In the case of 1,970 samples, the biological examination was completed, and of these 201, or 10.2 per cent., yielded tubercle bacilli, as against 9.1 per cent. in 1930. As from 1st July, 1931, the examination of the samples has been carried out in the Council's Southern group laboratory at the Park hospital, and 1,123 of the 2,160 samples were examined at the County Hall. From the copies of reports forwarded by the county medical officers of health for those counties from which tubercular samples were obtained, it would appear that 109 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 187 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 51 of these samples the deaths of the guinea pigs were attributed to infection conveyed in the milk. The facts relating to these cases also were referred to the various county medical officers of health concerned for them to take such action as might appear necessary. Conditions which contravene the provisions of the Milk and Dairies Order, 1926, are sometimes observed by the inspectors while engaged in milk sampling. Details relating to any contraventions of the Order are transmitted to the authorities concerned. The cows kept at institutions under the control of the Council have been inspected quarterly by the Council's veterinary surgeon. In addition, samples of the milk have been taken twice during the year from the supplies given by the herds at each of the institutions. Mental hospitals and transferred institutions. In respect of those institutions transferred to the Council by the Local Government Act, 1929, the cows have been inspected and samples of the milk taken on one occasion only, the scheme having only been applied to those institutions from 1st July, 1931. The results of the routine inspection and the biological examination of the samples taken from the milk of the herds are shown in the following tables:— Results of Milk Sampling. Department Number of samples taken Number of completed examinations Number found to be tubercle infected Number found to be negative Number of cases of acute intercurrent infection Education 10 10 2 8 Mental hospitals 100 88 5 83 12 Public assistance 2 2 1 1 — Public health 5 5 — 5 — The percentage of samples found to be tubercle infected of the total number of completed examinations made is 7.6. Each of the herds at the six institutions whence the eight tuberculous samples emanated, was inspected, and eight cows were found to be suffering from tuberculosis and subsequently slaughtered. 21 Results of Veterinary Inspection. Department Number of visits Number of examinations made Number of cows with tuberculosis Number of cows with other unhealthy conditions (apart from T.B.) Cows Bulls Young stock Education 6 76 2 2 Mental hospitals 45 3,521 30 241 5 26 Public assistance 2 24 — 1 — Public health 2 81 2 — — — 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 quarterly inspection of the cows at each cowshed. The results of his visits are shown below:— Number of visits to cowsheds 244 Number of cows examined 6,984 Number of bulls examined 2 Number of cows presenting unhealthy conditions as follows— 54 Giving tuberculous milk 1 (cow slaughtered voluntarily by owners) With atrophy of one or more quarters 21 With other defects 32 It is interesting to note that the number of licensed cowsheds in the county has diminished from 738 in 1889, the year of the Council's inception, to 48 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. 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 1931, 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. 22 Clinics with all-day medical and intermediate treatment have been provided at St. Thomas's hospital; St. Paul's hospital; Guy's hospital; West London hospital; the London County Council (Whitechapel) clinic (see page 24) and the Royal Free hospital (women). The number of new cases of venereal disease dealt with under the scheme during 1931 was 14,841, of which 4,530 were syphilis, 9,973 gonorrhoea, and 338 soft chancre. Comparing these figures with those of the previous year, it will be observed that the total number of new cases dealt with is 1,866 fewer than in 1930. Year. Syphilis. Gonorrhœa. Soft chancre. Non-venereal. Total. 1930 5,225 11,123 359 10,162 26,869 1931 4,530 9,973 338 11,106 25,947 Increase + or decrease — -695 -1,150 -21 +944 -922 The decrease in the number of new cases of venereal disease is partly accounted for by reason of the fact that, for the year 1931, the returns required from the treatment centres were designed to afford information as to the number of cases with new infections which come under treatment annually. In consequence, only those cases dealt with for the first time during the year which were not known to have received treatment previously for the same infection at any clinic, are included as new cases. To be comparable with previous years, the figures for 1931 would read as follows: Syphilis, 5,179; Gonorrhœa, 10,622; Soft chancre, 359, a net decrease of 547. 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 1931 3,009 1,521 326 12 7,713 2,260 11,048 3.793 With regard to the new cases of venereal disease, an attempt was made to ascertain whether the infection was recently acquired in patients attending the clinics for the first time during the year 1931, and also as to the number of cases of congenital syphilis. The returns received from the treatment centres showed that, as regards syphilis, in approximately 56 per cent. of the new patients the disease was in either a primary or secondary stage and, in the case of gonorrhoea, in 88 per cent., the infection had taken place within a year. Cases of congenital syphilis not known to have received previous treatment, numbered 543. The age and sex distribution were as follows:— Congenital Syphilis—New Patients. Under 1 year. 1 and under 5 years. 5 and under 15 years. 15 years and over. Totals M. F. M. F. M. F. M. F. M. F. 17 20 14 19 62 106 110 195 203 340 23 Attendances. Importance is attached to the necessity for securing the regular attendance of patients at the clinics, more especially in the case of gonorrhœa, 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. 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 1931 the total attendances of V.D. patients was 858,031, and the ratio of attendances of V.D. patients to new V.D. cases was 57, compared with 46 in 1930 and 44 in 1929, thus showing a considerable increase in attendances per case. Comparative figures for the fifteen years during which the scheme has been in force are shown in the following table:— Year. New cases. Total. Total attendances (venereal and non-venereal) 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 1931 14,841 11,106 25,947 930,348 56,541 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 and bacteriology. Another point worthy of note is the total number of examinations made of pathological specimens. Comparative figures for the fifteen years are shown in the following table:— Year. Pathological examinations. from treatment centres. From medical practitioners. 1917 13,988 3,649 1918 25,973 6,380 1919 51,554 10,464 1920 58,920 14,027 1921 66,134 18,472 1922 74,022 19,836 1923 69,784 24,403 1924 79,005 24,797 1925 106,064 26,346 1926 100,543 27,565 1927 107,512 27,046 1928 107,410 29,785 1929 114,840 32,605 1930 125,177 33,309 1931 161,092 35,498 24 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 494, 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, and where various interests and occupations could be provided. 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 1931, the number of patients dealt with at these institutions from the areas in the scheme was 250, the aggregate number of days in residence being 26,898. Comparative figures for 1930 were 272 and 30,362. The hostels undertaking work in connection with the scheme for the year 1931, 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 up to eleven 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 an 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 1931 only three girls availed themselves of these facilities. The total number of days in residence was 850. 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 taken over by 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 by a loyal and efficient staff, the clinic has been an unqualified success. During the first six months the clinic was in use, 1,527 new patients and 76,183 attendances were registered, whilst for the year 1931, the number of new patients was 3,545 and the attendances totalled 215,445. Of the new patients, 76.2 per cent. of the male and 66.6 per cent. of the female venereal cases were infections of less than one year's standing. The number of pathological examinations made at the clinic for the year 1931 was 51,717, of which 7,236 were made for medical practitioners, for whose convenience arrangements have been 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, and the weekly demonstrations have been well attended during the year. 25 The subjoined graph shows the weekly attendances of patients, both before and after 1st July, 1930, when the clinic was taken over by the Council. The Council's Tuberculosis Scheme. Residential treatment. Residential treatment for tuberculous persons (adults and children) ordinarily resident in the county of London is provided by the Council (a) under its tuberculosis scheme in its own special hospitals and sanatoria and in approved voluntary institutions and (b) as "municipal" patients in its own general hospitals and also in approved voluntary institutions. Broadly speaking, patients who are likely to improve materially from residential treatment and a proportion of more advanced cases with reasonable prospect of restoration to some degree of working capacity are dealt with under the tuberculosis scheme, and the remaining patients, those acutely ill and those with chronic disease, are treated as "municipal" cases. Of the latter, patients confined to bed or mainly bedridden are accommodated in general hospitals, and those able to be up for some eight hours a day without rise of temperature are sent to residential institutions in the country provided with grounds and facilities for occupation. The patients are distributed among suitable institutions having regard to their needs. Cases in institutions both under the Council's tuberculosis scheme and in the Council's general hospitals are reviewed from time to time 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 tuberculosis scheme. 26 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 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 1931 26 2,276 1,834 230 1,021 787 6,174 Of the 6,174 adult cases recommended during 1931 for residential treatment, under the tuberculosis scheme 72 were subsequently withdrawn, 4,872 were accepted and 1,230 were not accepted. The 4,872 cases were disposed of as follows:—(a) 1,654 were passed for admission to "observation" beds in order to determine "diagnosis" or "suitability for sanatorium treatment"; (b) 3,218 were passed for admission direct to sanatoria or hospitals. Of the foregoing accepted cases, 286 for various reasons failed to enter institutions. The 1,230 cases not accepted under the scheme were generally cases of advanced disease of the type formerly dealt with by boards of guardians. Many of these have been accommodated in the Council's general hospitals or, if ambulant, in voluntary institutions in the country as "municipal" patients. 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, 1,539 patients were discharged from "observation beds" and their classification was as follows (the corresponding figures for 1930 also being given):— *Pulmonary. 1931. 1930. Number. Percentage. Number. Percentage. Group A 316 27.60 292 35.39 Group Bl 57 4.98 28 3.39 Group B2 565 49.34 366 44.37 Group B3 207 18.08 139 16.85 Total pulmonary cases 1,145 100.00 825 100.00 Surgical cases 26 21 Total diagnosed as tuberculous 1,171 846 In the remaining 368 cases the diagnosis of tuberculosis was not confirmed. Of the 1,171 cases definitely diagnosed as tuberculous, 867 pulmonary cases were sent to sanatoria, 31 to institutions for advanced cases, 9 died in the "observation" hospitals, 4 cases were transferred to surgical institutions, and 260 were discharged home or arrangements made for them independently of the Council's tuberculosis scheme (including patients sent to voluntary institutions as "municipal" cases). The total number of admissions to institutions during 1931 was 5,192, compared with 4,907 in 1930. At the beginning of the year 2,259 patients were under treatment so that the total number of cases treated in 1931 was 7,451, compared with 6,990 in 1930. The number of tuberculosis scheme cases under treatment on 31st December, *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. 27 1931, was as follows (the corresponding figures for the previous year being shown in brackets):— Ex-service pensioners for tuberculosis. Civilian adults. Totals. Voluntary institutions 51 (50) 618 (626) 669 (676) London county council institutions 25 (22) 1,304 (1,319) 1,329 (1,341) Total 76 (72) 1,922 (1,945) 1,998 (2,017) In addition there were 257 patients receiving treatment in sanatoria as "municipal" cases. The immediate results of the treatment of patients discharged on completion of treatment during 1931 and the two preceding years, including those discharged from approved sanatoria as "municipal" cases, are indicated in the subjoined 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, 569 patients were discharged in 1929 with the disease "quiescent." Of these 278 or 48.9 per cent. were cases of pulmonary (Group A) tuberculosis and 108 or 19 per cent. were in Group B. The total number of Group A cases in 1929 was 685, and 278 of these or 40.6 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. Immediate results of treatment. A B1 B2 B3 Surgical. Totals. 1929. l930. 1931. 1929. 1930. 1931. 1929. 1930. 1931. 1929. 1930. 1931. 1929. 1930.. 1931. 1929. 1930. 1931. Quiescent 278 320 356 108 77 100 91 200 162 — — — 92 105 93 569 702 711 48.9 45.6 50.1 19.0 11.0 14.1 15.9 28.5 22.7 — — — 16.2 14.9 13.1 100 100 100 40.6 47.0 46.9 51.2 46.4 49.3 3.9 9.1 7.4 — — — 22.7 25.7 22.9 12.3 15 .7 15.3 Not Quiescent 400 348 397 103 89 103 2,239 1,959 1,988 541 667 834 290 288 300 3,579 3,351 3,622 11.2 10.4 11.0 2.9 2.7 2.8 62.6 58.4 54.9 15.1 19.9 28.0 8.2 8.6 8.3 100 100 100 58.4 51.1 52.2 48.8 53.6 50.7 95.5 89.5, 90.8 55.4 64.1 75.7 73.1 70.4 73.9 77.4 74.7 77.7 Died in institution 7 13 7 — — — 13 30 39 436 373 267 17 16 13 473 432 326 1.5 3.0 2.1 — — — 2.7 7.0 12.0 92.2 86.3 81.9 3.6 3.7 4.0 100 100 100 1.0 1.9 0.9 — — — .6 1.4 1.8 44.6 35.9 24.3 4.2 3.9 3.2 10.3 9.6 7.0 Totals 685 681 760 211 166 203 2,343 2,189 2,189 977 1040 1,101 405 409 406 4,621 4,485 4,059 14.8 15.2 16.3 4.6 3.7 4.4 50.7 48.8 47.0 21.1 23.2 23.6 8.8 9.1 8.7 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 With regard to children, the numbers recommended for treatment under the Council's tuberculosis scheme during each of the last five years were respectively 1,190 in 1927, 1,081 in 1928, 1,069 in 1929, 1,121 in 1930 and 1,201 in 1931. 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 1,201 children (i.e., patients under 16 years of age) referred to the Council in 1931, 1,115 were accepted for treatment, and 86 were not accepted or were withdrawn; 78 of the accepted cases for various reasons failed to enter institutions after acceptance. There were 949 children (including 59 cases admitted by late boards of guardians) under treatment at the beginning of the year, and 1,097 children were admitted during the year, making the total number of children treated in 1931 2,046, compared with 1,884 in 1930. The number of cases under treatment on 31st December, 1931, was 898, distributed as follows:— London County Council institutions 733 Voluntary institutions 165 28 The condition of the children under 15 years of age (on admission) who were discharged from residential institutions in 1931 is indicated in the following table, the figures in brackets being those for 1930:— Immediate results of treatment. Classification. Surgical. Totals. A. Bl. B2. B3. Quiescent 102 (123) 6(2) 1 (5) — (—) 426 (302) 535 (432) Not Quiescent 63 (80) 6 (4) 30 (25) 16 (7) 147 (205) 262 (321) Died in institution 2 (3) — (—) 3 (—) 8 (5) 19 (19) 32 (27) Total 167 (206) 12(6) 34 (30) 24 (12) 592 (526) 829 (780) Papworth and Preston Hall Village Settlements. The Council sends a number of patients to PapworthVillage Settlement, near Cambridge, and to the Preston Hall Colony, Aylesford, Kent, both under its tuberculosis scheme and as "municipal" cases. A careful selection is made with a view to the admission of patients most likely to be accepted later as suitable for settlement in the colony; 23 of the Council's former patients have been accepted as permanent employees of the industrial settlement at Papworth and 20 at Preston Hall. The serious problem is the patient who, after some 12 or 18 months' treatment and training, has small prospect of entering a settlement. As both colonies are industrial concerns it is necessary that only the most efficient should be accepted for employment. The Council has accordingly entered into arrangements with the authorities of the institutions for a reduction of the fee charged concerning those patients who, although unlikely to be fully self-supporting, are yet able to be of some commercial value. These cases are subject to periodical review at intervals of a few months. At the end of the year 71 patients at Papworth and 71 at Preston Hall were being treated under this arrangement. 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. A scheme has been adopted under which arrangements are 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. This scheme contemplates that five youths will be accepted for such employment during each financial year. Three youths commenced work in the parks department under the scheme in April, May and September, 1931, respectively. Very satisfactory reports have been made concerning their conduct, work and industry from the officers under whom they have been placed. The following excerpts are taken from the reports:— Case 1.—He is the type of young man which is too rare in the gardening ranks and should be encouraged. He is being given a varied experience in the work and should become a valuable asset Case 2.—He is willing, industrious and keen at his work. He adapts himself to all park work Case 3.—He adapts himself well to park and nursery work . . . keen and energetic, takes great interest in his work .... is likely in due course to become an efficient member of the gardening staff. Definite arrangements have been made for two other youths to commence work in the parks early in 1932 and additional youths have been provisionally selected at the colony for employment in the parks during the ensuing year. 29 Satisfactory results were also reported in respect of boys trained in clerical work. A considerable number of boys passed Pitman's shorthand examinations while others were successful in various examinations of the Society of Arts. Tuberculosis dispensary service. In London the dispensary service, which is an integral part of the Council's tuberculosis scheme, is provided by the metropolitan borough councils. The net cost, after deduction of an amount equal to the amount of Government grant paid prior to the introduction of the "block public health grant" under the Local Government Act, 1929, is divided, in roughly equal parts between the County Council and the borough councils. At the end of 1930 there were 23 municipal dispensaries (including one branch dispensary) and 10 dispensaries at voluntary hospitals or under voluntary management, some of which served more than one borough. One of these hospital dispensaries, the Royal Chest hospital, City-road (branch of Royal Northern hospital) then served the boroughs of Finsbury, Islington and Shoreditch. During 1931, however, the boroughs of Finsbury and Shoreditch terminated the arrangement and provided municipal dispensaries and borough tuberculosis officers, and the Royal Chest hospital dispensary has been retained to serve, jointly with a dispensary at the Royal Northern hospital, Holloway-road, the borough of Islington alone. During the year the St. Pancras Borough Council transferred its dispensary from Oakley-square to new premises in Camden-road, and the Westminster City Council transferred its dispensary from Monck-street to Ebury-bridge. In addition the Woolwich Borough Council opened a branch dispensary during the year at 197, Well-hall-road, Eltham. There are now 26 municipal dispensaries, including two branch dispensaries and 10 dispensaries at voluntary hospitals or under voluntary management, some of which serve more than one borough. 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 30 and 31. 30 Tuberculosis Dispensaries.—Analysis of Returns, January-December, 1931. Metropolitan Borough. on Dispensary Register, 1-1-31 Transferred during 1931 from other areas and cases returnee after discharge Examined for first time during 1931. (a) New cases excluding contacts. (b) Contacts (printed in italics). Total number (including contacts) under dispensary supervision during 1931. Removed from Dispensary Register during 1931. On Dispensary Register 31-12-30. Total attendances. Visits to home for dispensary purposes by No. of specimens of sputum examined. No. of X-Ray examina tions. Definitely T.B. Diagnosis not completed. Pulmonary. NonPulmonary. Diagnosis not completed. NonTuberculous. Total. (a) Recovered. (b) Non T.B. (printed in italics.) (a) Transferred to other areas or lost sight of (b) Died (printed in italics) Definitely T.b. Diagnosis not completed. Adults. Children. Adults. Child ren. Adults. Children. Adults. Children. Adults. Children. T.B. Officers. Nurses or Health Visitors. Battersea 915 56 32 133 8 10 17 47 37 208 109 398 171 1,781 15 76 913 103 3,917 204 4,175 769 129 — — — 1 3 2 69 134 72 137 557 117 Bermondsey *993 26 12 124 5 14 19 22 7 291 121 451 152 2,171 86 40 941 34 4,085 1,348 4,059 1,307 605 20 — — 1 3 2 184 327 207 330 954 116 Bethnal Green 691 10 18 93 4 8 29 14 4 262 125 377 162 1,508 — 42 733 11 4,653 146 3,094 610 187 3 — — — 1 2 103 141 107 143 636 86 Camberwell 2,196 30 54 177 2 21 11 122 16 343 164 663 193 3,694 466 171 1,683 54 5,230 725 9,234 1,157 456 56 2 3 4 23 12 151 307 233 325 1,138 182 Chelsea 241 9 19 56 3 6 8 8 1 239 228 309 240 939 3 47 257 9 2,999 53 3,859 305 297 3 — — — — — 65 53 68 53 592 31 Deptford 566 55 23 105 8 14 13 16 11 165 84 300 116 1,194 37 103 554 48 2,886 206 3,072 660 138 4 — — — 4 11 52 63 60 74 377 75 Finsbury 525 2 76 76 9 11 9 1 — 176 104 264 122 1,372 6 67 578 1 3,861 823 3,008 729 95 9 4 — 2 — — 147 221 156 227 652 68 Fulham 900 11 46 161 10 23 16 6 4 298 270 488 300 2,160 18 136 903 10 3,581 292 3,608 595 122 2 — — 1 — — 207 205 209 206 993 100 Greenwich 694 18 8 88 5 14 18 8 5 157 93 267 121 1,342 — 63 699 13 2,927 219 3,354 276 420 7 1 1 1 — — 103 121 111 123 489 78 Hackney 1,219 10 66 181 12 15 13 18 7 371 205 585 237 2,613 22 131 1,274 15 7,886 298 3,118 1,259 285 6 — — 1 1 2 229 257 236 260 1,065 106 Hammersmith 896 9 36 116 1 21 17 2 — 209 95 348 113 1,601 75 191 760 3 2,285 197 3,474 393 89 9 2 1 5 1 — 87 94 98 101 493 79 Hampstead *166 7 29 54 2 8 4 1 2 100 28 163 36 506 1 87 174 7 1,160 10 1,244 97 72 5 3 1 — — 4 44 48 50 55 223 14 Holborn 200 — 10 38 3 5 2 — — 14 8 57 13 321 6 20 223 1 901 39 1,189 148 18 3 — 1 — 1 — 15 21 20 21 58 13 Islington 1,471 13 61 262 18 27 35 8 8 252 75 549 136 2,752 29 280 1,455 27 8,154 321 5,855 1,056 345 42 7 1 7 3 8 219 235 265 257 784 177 Kensington 843 34 51 142 6 22 11 12 6 189 84 365 107 1,775 40 86 854 29 2,730 130 2,252 500 42 7 — — — 4 1 206 157 217 158 666 100 Lambeth 1,594 85 53 297 8 19 23 62 20 514 95 892 146 3,378 73 140 1,577 79 7,266 808 5,824 1,150 1,271 18 5 2 1 25 19 304 234 349 259 1,325 184 Lewisham *977 — 46 173 3 17 20 22 6 173 70 385 99 1,690 44 82 1,018 2 2,914 381 1,844 221 26 5 1 — 3 1 — 81 92 87 96 448 96 Paddington 1,136 12 30 119 3 13 40 8 10 448 332 588 385 2,384 41 153 1,096 21 9,152 495 5,384 468 156 9 — — 10 1 2 116 95 126 107 991 82 Poplar 776 45 71 117 8 26 23 9 11 247 190 399 232 1,730 5 58 867 25 5,364 229 7,051 1,640 94 24 3 1 2 2 6 52 117 79 128 647 128 St. Maryle- bone 461 89 27 83 5 6 9 8 21 88 30 185 65 946 — 60 509 81 2,822 118 1,987 242 39 4 1 — 1 — 11 45 57 49 70 268 28 St. Pancras 784 67 67 151 11 17 24 28 4 156 78 352 117 1,536 31 223 744 65 3,264 151 4,129 175 65 4 — — — 7 4 49 85 60 89 379 94 Shoreditch 666 3 28 87 10 8 16 14 21 299 169 408 216 1,634 43 39 670 53 4,531 156 2,545 960 81 12 3 3 1 11 7 133 143 159 154 756 73 Southwark 651 39 25 164 12 16 24 11 16 123 24 314 76 1,417 27 108 693 37 4,122 26 3,296 509 40 9 1 2 6 1 9 121 163 133 179 431 121 Stepney 1,652 124 64 227 25 20 33 115 37 244 139 606 234 3,369 76 143 1,675 229 6,543 134 5,609 1,028 84 6 7 — — 14 12 296 354 316 373 1,096 150 - Stoke Newington 250 5 15 43 1 5 5 7 — 85 22 140 28 569 8 75 217 3 1,217 101 769 351 42 1 — — — 1 — 75 54 77 54 236 30 Wandsworth 1,408 57 59 290 10 28 12 32 5 568 236 918 263 3,087 49 181 1,397 37 4,966 124 5,546 2,157 187 23 — — — — — 156 203 179 203 1,220 203 Westminster *648 9 19 214 11 21 18 7 1 57 20 299 50 1,110 4 219 649 2 2,314 148 3,469 192 42 4 6 1 2 — — 21 51 26 59 172 64 Woolwich 1,055 24 6 166 11 12 19 5 6 365 260 548 296 2,399 68 43 1,030 16 4,416 471 5,181 677 525 11 1 — 1 5 — 204 248 220 250 1,113 129 Total 24,574 849 1,051 3,937 214 427 488 613 266 6,641 3,458 11,618 4,426 50,978 1,273 3,064 24,143 1,015 116146 8,353 107129 19,631 5,945 306 47 17 50 112 114 3,534 4,280 3.969 4,491 18,759 2,724 31 *Figures amended since completion of return for 1930. 32 Following up of discharged cases. Adults.—During the year investigations were made concerning the adult cases discharged from hospitals or sanatoria in 1925; the number investigated was 3,768, including 225 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 1924 cases:— Classification. Total. Percentage alive five years after discharge. Percentage dead. A 533 (440) 75.4 (75.9) 24.6 (24.1) B 1 284 (255) 61.6(65.5) 38.4(34.5) B 2 1,908 (1,871) 30.9(32.3) 69.1 (67.7) B 3 818 (821) 4.0 (4.4) 96.0 (95.6) Surgical 225 (244) 79.1 (75.4) 20.9 (24.6) Particulars obtained in 1930 as to the fitness for work of the 1,378 surviving adult patients who were discharged from treatment in 1925 show that out of a total of 577 A and B1 cases, 70.7 per cent. were at work. The corresponding percentage for the A and B1 cases in the 1924 group was 65.4. The percentages at work in the other categories and also the corresponding figures for the 1924 group (shown in brackets) are as follows:—B2, 50.2 (46.4) per cent.; B3, 27.3 (26.9) per cent.; and surgical, 72.5 (65.6) per cent. Of the total number of 1,378 in all categories, 61.1 (55.6) per cent. were at work, 7.8 (7.8) per cent. were fit for work but were unemployed, 31.1 (36.6) 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 1925 relate to 582, of which 215 are pulmonary and 367 nonpulmonarv. I he mortality records are as follows, the figures in brackets referring to last year's enquiry into the 1924 cases:— Classification. Total. Percentage alive five years after discharge. Percentage dead. A 148 (113) 93.2 (92.9) 6.8 (7.1) B1 5 (3) 80.0 (100.0) 20.0 (—) B2 35 (22) 37.1(22.7) 62.9 (77.3) B3 27 (37) — (2.7) 100.0 (97.3) Surgical 367 (384) 89.6(88.8) 10.4 (11.2) The mortality rates of the non-pulmonary cases classified according to the location of the disease are as follows:— Location of Disease. Total. Percentage alive five years after discharge. Percentage dead. Hip 74 (69) 86.5 (81.2) 13.5 (18.8) Spine 44 (49) 70.6 (71.4) 29.4 (28.6) Other bones 85 (89) 94.1 (92.0) 5.9 (8.0) Glands 134 (149) 94.8 (95.3) 5.2 (4.7) Other parts 30 (28) 80.0 (92.9) 20.0 (7.1) Of the 155 surviving pulmonary cases 47 were at school and 83 at work, and of 329 surviving non-pulmonary cases, 124 were at school and 160 at work. In addition to the 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 (Vol. III (Part II) p. 54). Tuberculosis care work. The valuable work of the tuberculosis care committees in arranging assistance for tuberculous patients and their families cannot be summarised statistically, but 33 the effectiveness of the tuberculosis scheme is in no small measure due to their cooperation. 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. The tuberculosis care committees work in close association with the tuberculosis officers, and it is the practice for all tuberculous persons attending a tuberculosis dispensary, who appear to the tuberculosis officer to be likely to need assistance, to be referred to the tuberculosis care committee for the necessary advice and help. The presence of tuberculosis in a home creates problems which the tuberculosis care committee are constantly helping to solve, such as provision for the support of the family during the patient's absence, the care of children, the improvement of home conditions, employment, housing, health insurance, pensions, outfits, plans for the future, and other cognate matters. The value of the experience, knowledge, expert advice and, in some instances, financial help, placed at the disposal of the patients by the tuberculosis care committees is invaluable. The number of patients treated in residential institutions under the tuberculosis scheme during the year was 7,451 adults and 2,046 children. About one-third of these were assessed to pay contributions towards the cost. The enquiries are made by the care committees, who recommend the amounts of assessment to the Council and also collect the contributions. Handicraft classes. Among the activities of the tuberculosis care committees in several boroughs is included the organisation of the dispensary 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 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. In addition, classes for glove-making have been established independently of the Council in four boroughs in co-operation with the Central Fund for the Industrial Welfare of Tuberculous Persons. Employment. Assistance to patients in obtaining employment following residential treatment is a feature of the activities of the tuberculosis care committees. In view of the importance of the question of employment, 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. Two workshops for the employment of men ex-sanatorium patients have been established by the Central Fund for the Industrial Welfare of Tuberculous Persons. These are known as Spero Workshops. The first was opened in 1922 at Cross-street, Hatton Garden, Holborn, for the making of leather goods requiring skilled workers. The employees are selected from men who have received preliminary training during treatment for tuberculosis at King George V sanatorium, Godalming. The workshop provides for some 20 to 25 men. The second workshop is a firewood factory opened in 1929 and is for unskilled workers. This is at 74, Paradise-street, Rotherhithe, and provides for about 40 to 50 men. The Council places a large contract for firewood with this factory. The men are paid trade union rate of wages, and remunerative employment is thus found for a certain number of the Council's ex-sanatorium patients. The work is still experimental and the maintenance of the workshops is still dependent, to some extent, unon a subsidy from charitable funds. Boarding out of contacts, 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 34 make other arrangements, children have been provided for, in order to enable their mothers to accept residential treatment. The applications received during 1931 were 234, and 162 children were accepted, the remaining 72 being withdrawn or unsuitable. At the end of the year 72 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 56 cases apparatus was so supplied. The cost of these instruments is 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 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. The balance of the fund is, however, being applied as indicated above. Report on the Work of the Bacteriological Laboratory at County Hall. 'Carrier' Investigations. Diphtheria.—In the course of investigation into the occurrence of cases of diphtheria in the elementary schools and children's residential and receiving homes, a total of 3,407 swabbings from throat and nose and a few from the ear, were examined from 3,389 individuals, yielding 124 or 3.6 per cent. with morphological B.diphtheriœ, (K.L.B.) including 10 positive from ear discharges. In the elementary schools, inclusive of children, teachers, and members of the staff, 2,558 cultures were examined—from 2,455 children, yielding 79 or 3.2 per cent. positive K.L.B. (including 5 positive from ear discharges), and from 93 adults, only one of which proved positive. In residential and receiving homes, a total of 849 cultures from 839 individuals, yielded 44 or 5.2 per cent. positive K.L.B. (including 4 positive from ear discharges). Of the total of 124 cultures recognised morphologically as positive K.L.B., 114 were submitted for virulence tests by animal inoculation performed at the Southern Group laboratory, and yielded 78 virulent (67.8 per cent.) and 12 avirulent (12 per cent.), and in the remaining 24 (20 per cent.) the organisms were identified as diphtheroids or "K.L.B. not found." Of 6 K.L.B. cultures tested from ear discharges, 2 were virulent and 4 avirulent. Streptococcus.—Puerperal fever contacts.—29 examinations were made of 24 midwives for the presence of streptococcus hœmolyticus in throat culture. Four proved positive in primary culture and one on later re-examination—i.e., 17 per cent. Scarlet fever contacts.—Throat and nose cultures from 20 children in hospital proved negative for hæmolytic streptococcus. Meningococcus.—Two contacts of a case of cerebrospinal fever in a receiving home were examined with negative result. Ringworm Examinations. In 876 hair specimens, 284 or 33.5 per cent. proved positive, including 220 small spore fungus, 62 large spore, and 2 only favus. Cerebrospinal Fluid Examinations. 182 specimens of cerebrospinal fluid were examined from 159 patients at St. James', Fulham, Highgate and St. Pancras hospitals up to the end of October, 1931. 35 The cases were classified as follows under the heading of:— Meningitis. 1. Tuberculous 31 61 specimens from 52 cases. 2. Meningococcal 18 3. Influenzal 5 4. Pneumococcal 3 5. Undetermined (influenzal or meningococcal) 4 Otitis Media and Complications (14). Cerebral Lesions—Tumour abscess, encephalitis (10), Hæmorrhage, thrombosis, arteriosclerosis (28), Cerebral and spinal neurosyphilis (10). Lesions of the Spinal Cord (12), Abnormal Menial States (12), Meningismus (22), General Diseases (13). Miscellaneous Material. Sputum.—In 23 (or 41.8 per cent.) of 55 specimens of sputum examined, tubercle bacilli were found. Urine.—Six specimens were examined microscopically and chemically. Two showed the presence of albumin 0.04 and 0.025 per cent. respectively, with granular and cell casts. Blood.—Examinations were made of six individuals, either by complete count, differential leucocyte counts, or films for presence of malarial parasites (the latter in two cases examined proved negative). Slide preparations from vaginal, urethral or conjunctival secretions from ten persons, showed vaginal gonococci in one. Milk Examinations.—128 samples of milk supplied to 64 elementary schools, 24 hospitals and 20 residential institutions, were examined—quantitatively for total bacterial content per c.c. and qualitatively for presence of coliform organisms, after 48 hours incubation at 37°C. Fifty-four samples were passed as satisfactory and 74 were regarded as unsatisfactory—an analysis of the results is contained in the complete report on the examination of milk, undertaken in the Council's laboratories, and appearing on pages 52-53. Water Examinations.—Seventy-two samples of the water supplies, chiefly from deep wells, in 14 different institutions under the Council's control were examined quantitatively for total bacterial content per c.c. and qualitatively for presence of coliform organisms—in addition to the chemical analyses undertaken in the chemical laboratory. Materials prepared in the County Hall laboratory. For the bacteriological work conducted in the laboratory during the year, some 36,500 c.c. of fluid and solid media were prepared; in addition over 5,300 tubes of serum were made for use in the diphtheria investigations conducted in schools and institutions. Cases dealt with by the Council Mental Deficiency Acts, 1913-27. On 7th December, 1931, there were being dealt with by the Council 7,861 cases. Of these 4,679 were in institutions, 106 under guardianship, 3,030 under supervision and 46 in places of safety awaiting action. During the year 3,282 cases were examined in detail; the figure includes 708 cases examined at general hospitals (including Edmonton and Brentwood epileptic colonies). In addition 631 persons were scrutinised in casual wards, with a view to seeing if there were prima facie ground for further investigation. 36 The results of the examinations of the 3,282 cases were as under:— Sex. Case classification. Idiot. Imbecile. Feebleminded. Moral defective. Not defective. Enquiries. Total. Males Ordinary cases 8 119 481 1 28 — 637 Public assistance cases 3 30 69 — 93 6 201 General hospital cases 3 3 23 — 13 21 63 Epileptic colonies — 7 48 — 190 10 255 Ex-M.A. B. cases* 1 3 3 — 397 4 408 Females Ordinary cases 3 96 433 — 43 — 575 Public assistance cases 5 34 129 — 38 4 210 General hospital cases 2 7 26 — 17 6 58 Epileptic colonies — 12 92 — 225 3 332 Ex-M.A. B. cases* 2 20 7 — 499 15 543 Total 27 331 1,311 1 1,543 69 3,282 *These cases were almost all at the Tooting Bee hospital for elderly persons, the majority being over 60 years of age; many were mildly psychotic or demented, and in others, whose condition suggested a possibility that there had been mental defect in early years, it was impossible to prove this owing to their age and the lack of early record. Analysis of cases examined. In the sub-joined table Dr. Shrubsall has set out his findings in an analysis of a random sample of 10,000 cases that have been examined under the Mental Deficiency Acts, with a view to comparing clinical type with grade of defect. Type. Grade. Idiot. Imbecile. Feeble-minded Total. Primary amentia 135 1,910 5,079 7,124 Mongols 37 427 10 474 Cretins 4 86 26 116 Hydrocephals 15 58 22 95 Microcephals 29 69 21 119 Plegic 96 299 151 546 Plegic and epileptic 71 113 39 223 Epileptics 121 463 348 932 Miscellaneous 20 144 207 371 Total 528 3,569 5,903 10,000 From this it would appear that there is a higher proportion of cases of secondary amentia amongst idiots and imbeciles. Taking the cases as a whole the proportion of primary aments is lower than that usually anticipated, but in this connection it must be remembered that the lower grade cases are more likely to require some form of public assistance or control, and so are more readily brought to notice. The distribution found is intermediate between that which would be obtained from the study of the population of inmates of certified institutions and that of the general population as found by Dr. Lewis in such a survey as that conducted for the Wood Committee. As this table deals with cases considered under the terms of the Mental Deficiency Acts, it does not include a large number of children in special schools, none of whom would be idiots, and few of whom would eventually prove to be imbeciles. Thus the reduced proportion of the feeble-minded can be readily understood. Ascertainment of mental deficiency in casual wards. During the year under review various certifying officers have visited casual wards with a view to ascertaining whether any of the inmates were mentally deficient. 37 For this purpose three methods were employed, viz.:— (1) Such inmates as had been suggested by the superintendent of the casual ward, usually on the advice of the visiting medical officer, were examined in detail by a certifying officer under the Mental Deficiency Acts. (2) On some occasions a certifying officer was present at the monthly special examination of the inmates by the local visiting medical officer. Both officers then saw every case and any one suspected of mental abnormality was examined in detail. (3) On certain other occasions a certifying officer visited particular wards, and himself, having seen and passed every inmate scrutinized, set aside for further investigation any who showed signs of abnormality. As a result of the first method it was found that there were cases of mental deficiency, 4; psychosis, 1; instability or mild dementia not certifiable as mental deficiency or insanity, 5; cases in which special treatment was desirable, 3. Of the remainder the conditions found suggested that the persons concerned were of a rather poor type in intelligence and cultural level, but that they fell within the limits of normality. At the time of the special monthly visits or on the occasions when the certifying officer alone saw all the inmates, the total numbers seen were 631. More detailed examination of these showed cases of mental deficiency, 4; psychosis, 4; instability or mild dementia, 5; bad stammering, 6. In 41 instances the persons either fell within the limits of normality, or, in a few cases, the available history could not establish evidence of defect prior to the age of 18. The proportion of mental deficiency found was lower than had been anticipated by the certifying officers, but the superintendents of casual wards were of opinion that this was in accord with past experience, and that, as it was being ascertained and dealt with through other channels, mental deficiency was not commonly found in the London casual wards. In this connection it may be added the majority of the subnormal inmates found had drifted into the county from the outlying country districts. It is noteworthy that out of all the cases seen, only one had attended a London school for the mentally defective. Mental condition of epileptics at Brentwood colony. Dr. Duncan has made an analysis of the mental condition of 292 cases of epilepsy in patients over the age of 16, who have been in residence at Brentwood colony for periods varying from a few weeks to 18 years. The ages of the inmates ranged up to 86 years. On examination 194 were found not to be defective within the meaning of the Mental Deficiency Act; and 98 were certifiable as mentally defective. In spite of their disability, many of the patients had been engaged in various kinds of occupations before admission, but eventually had had to give them up, chiefly on account of the frequency of the fits. The following were the occupations followed:— Occupation Not amentia. Mentally defective. Total. Domestic service 75 13 88 Factory 26 14 40 Dressmaking 4 1 5 Tailoress 3 — 3 Shirtmaker 1 — 1 Hospital nurse 1 — 1 Waitress 1 — 1 Laundress 5 — 5 Saleswoman 5 — 5 Wardmaid 1 — 1 Typist 3 — 3 Messenger 1 — 1 Barmaid 3 — 3 Milliner 3 — 3 Machinist 1 — 1 Upholsterer at home 2 — 2 Needlework at home 3 2 5 Book-keeper 2 — 2 Living at home—no work outside 54 68 122 38 Of the 194 who were not defective it was found that 106, many of whom had been subject to epileptic seizures for years, were normal in every respect and doing good work in the institution; 44 presented certain mental peculiarities (e.g., irritability, moodiness and violent temper), while a few showed definite psychotic tendencies—2 of these have since been removed to mental hospitals. The remaining 44, as ascertained from their relatives, had shown no signs of mental defect in early life, but now showed symptoms of mental deterioration, varying from failing memory and loss of interest in their work to a complete incapacity for rational conversation and employment, even in the institution. It was not found that this condition of dementia was more common in cases where the fits had commenced at an early age or where the patients had suffered from frequent attacks of petit mal over a long period. Of the 98 who were certifiable as mentally defective, it was found that their mental ages varied from 4 to 10. Amongst these 49 showed gross signs of mental deterioration, 26 of mental instability, 2 were blind, 10 suffered from hemiplegia and 1 was paraplegic. The response to problems of a non-verbal type in 50 cases whose mental age was 9 or over was as follows:— Passed. Failed. Healy A 42 per cent. 58 per cent. Ball in field (inferior plan) 14 „ 86 ,, Ball in field (superior plan) — 100 ,, Five weights 8 „ 92 ,, All failed in Burt's tests of verbal reasoning. In rote tests the results were:— Passed. Failed. 20 to 1 (counting backwards) 98 per cent. 2 per cent. 5 digits repeated 90 ,, 10 „ 6 „ „ 50 „ 50 ,, 4 „ reversed 10 ,, 90 ,, Months with checks 84 ,, 16 ,, The relation between the mental age as shown by tests of the Binet pattern and the age of onset of the epilepsy is indicated in the following table:— Age of onset of epilepsy. Mental age at time of examination. 4 5 6 7 8 9 10 Total 0—1 1 4 7 1 9 3 — 25 1—5 1 1 1 3 5 4 — 15 5—10 — — 3 4 5 5 — 17 10—18 — 1 2 4 9 9 1 26 18—30 — — — — 5 4 — 9 30—40 — — — — 2 — — 2 40—50 — — — — 1 — — 1 50—60 — — — — — 1 — 1 Not known — 1 — — 1 — — 2 The relation between the mental age on tests and educational attainments as indicated by reading ability was as follows :— Reading age (Burt). Mental age at time of examination. 4 5 6 7 8 9 10 Total Unable to read — 4 1 1 1 — 7 Reading age 4 yrs. 1 1 4 — 4 2 — 12 ,, 5 ,, — — — 1 — — — 1 ,, 6 „ — 1 1 2 — 1 — 5 ,, 7 ,, — — 5 2 5 2 — 14 ,, 8 „ — 2 3 7 5 — 17 ,, 9 „ — 1 2 9 6 — 18 ,, 10 „ — — — 1 6 6 1 14 ,, 11 „ — — — — 5 2 — 7 „ 12 „ — — — — — 1 — 1 ,, 13 „ — — — — — 2 — 2 Totals 1 6 14 12 37 27 1 98 39 The following table shows the kind of work on which the patients were engaged at the time of examination:— Not Amentia. Menially Defective. Total. Domestic 97 57 154 Laundry 13 8 21 Needlework and handicraft 35 7 42 Simple needlework, e.g., sewing on buttons 13 3 16 Garden 3 1 4 Poultry farm 3 — 3 No definite work 20 22 42 Too old for work 10 — 10 Totals 194 98 292 Enquiry was made as to the age of onset of fits in all cases and this was found to vary considerably, as shown by the following table:— Age at onset of fits. Not amentia. Mentally defective. Total. 0—1 years 30 25 55 1— 5 „ 17 15 32 5—10 ,, 18 17 35 10—20 „ 81 29 110 20—30 ,, 24 6 30 30—40 ,, 10 2 12 40—50 ,, 7 1 8 50—60 „ 4 1 5 60—70 „ 1 — 1 Not known 2 2 4 Totals 194 98 292 In cases where the onset of fits was late in life the epileptic attacks may be no more than a symptom of various pathological states, e.g., lesions of vascular and inflammatory origin or advanced arterial pressure. The following are examples:— S.C. aet. 78.—Onset of fits at 39 years. She had to identify her husband at the mortuary and had a "stroke" (left hemiplegia). Subject to fits ever since. Attacks come in series on an average every three months. Mentally normal. H.W. aet. 66.—Developed fits at 50 years of age after an emotional shock. Widow— has had 14 children. Fits infrequent—seven in 1930. Mentally normal. B.E. aet. 86.—First fit at 68 years (no cause given). Widow with 9 children. Has a series of fits—very severe—on an average once a month. Mentally normal. I.B. aet. 82.—First fit at 47 years (no cause given). Was a hospital nurse. Widow. On the other hand, M.H. aet. 72, widow with five children, has had fits all her life. Mentally normal. E.H. aet. 75, also mentally normal, has had them since infancy. Delinquent defectives. The records of the cases seen at the remand prisons have been investigated by Dr. Duncan for Holloway and Dr. Williams for Wormwood Scrubs and Brixton. Women.—During 1930 and 1931, 31 women were examined. Two (one, psychoneurotic and one border line insanity) were not certifiable, and 29 were deemed to be mentally defective within the meaning of the Mental Deficiency Acts. The following were the types of cases found:— Imbecile with evidence of superimposed psychosis 1 Feeble-minded with evidence of superimposed psychosis 3 Feeble-minded—Facile type 11 ,, Unstable type 12 „ Post encephalitic 1 „ Epileptic 1 Total 29 40 Mental age as compared with chronological age. Chronological age. Mental age. 5 6 7 8 9 10 Total 16—20 1 2 8 2 13 20—30 — — 1 2 6 2 11 30-40 1 — 1 1 — — 3 40—50 — — 1 1 — — 2 Total 1 — 4 6 14 4 29 Two of these were married women, 17 had been born and educated in London and 12 had come from various parts of the country, 4 having been in London for less than a year. Their ages varied from 16 to 49. School reports were obtained whenever possible, and the following were the results in the 17 London cases:— Attended M.D. school till 16 years of age 4 Attended M.D. school, excluded as imbecile 1 Regarded as M.D., but not put forward for statutory examination as there was a backward class in the school 1 " Always very dull " 2 Standard 2 at 14 years of age 1 „ 3 at 14 „ 1 „ 4 at 14 „ 3 ,, 5 at 14 ,, ,, 1 Attended elementary school, but no report obtainable 3 Total 17 Although some were said to have attained to Standard 4 and 5, their educational attainments were definitely below that level. In the case of the country women (12) the schools were communicated with by letter and the following reports obtained:— Always thought M.D. 2 Always very dull 5 Very low standard 3 Very backward—conduct extremely unsatisfactory 1 No report obtainable 1 Total 12 None of these country cases had attended schools for the mentally defective. The reading ages of the 29 cases are set out in the following table:— No sounds (imbecile) 1 Not equal to Burt 4 1 Equal to Burt 4 1 ,, 5 3 ,, 6 2 ,, 7 4 ,, 8 10 ,, 9 2 ,, 10 3 ,, 11 2 Total 29 Whenever the relatives could be traced, in the London cases, they were visited and enquiries made into the home conditions. In the country cases such enquiries were made by correspondence and sometimes by interviewing parents at the police court. It was ascertained that:—6, had definitely bad homes; 3, parents separated, conditions unsatisfactory; 5, father unemployed; 1, parents both dead; 2, very poor but apparently respectable; 1, no home, married woman with husband "on the road " ; 7, apparently good homes; 4, not known. 41 The family history was enquired into but only in 6 cases could a definite history of abnormal mental heredity be obtained. There was a history of intemperance in one parent in 3 cases, and in one case the woman herself was illegitimate and her mother had led an immoral life. A great many of the women had done little or no work since leaving school. Others had kept their jobs only for a short time, being dismissed for inefficiency, dishonesty or troublesome behaviour, and other signs of mental instability. Others " ran away " when they got tired of work. This was one of the factors which led to their getting into trouble with the police. There was one exception to this. A woman, aged 29 years (mental age 8), who had attended a school for the mentally defective until she attained 16 years of age, had been employed for 12 years by one firm as a button-hole maker, until during the past year or two her mental condition showed deterioration. Of the 29 women concerned 7 were known to have been leading immoral lives at time of arrest; 14 had been engaged in irregular domestic employment; 5 had been engaged in factory work; 2 earned their living by begging; 1 lived at home. There were 5 who had suffered at some time from venereal disease, and in 3 other cases the disease was active; 7 of the unmarried women had children; 2 had had one stillbirth; 1 had had one illegitimate child (this child is an imbecile and is in an institution for the mentally defective); 2 had had two illegitimate children; 1 had had four illegitimate children (1 still-birth, 3 children born alive—one of these is in a "home" and 2 are adopted); 1 had had one illegitimate child and was again pregnant; and one girl was pregnant. The following were the offences with which they were charged:— Drunkenness 2 Wandering, begging, etc. 8 Larceny 13 Abandoning illegitimate child 1 Indecency 1 Soliciting 1 Insulting behaviour 3 Total 29 The disposal of the 29 cases was as follows:— Removed to public assistance institution (place of safety) and later removed to mental hospital 1 Removed to certified institution (under the Mental Deficiency Acts) (place of safety) 1 Removed to local hospital (place of safety) 3 Sent to certified institution under the Mental Deficiency Acts 23 *Put under guardianship of parent 1 Total 29 *It was stated that this girl had a blind mother and invalid sister, and she was allowed to go home in order to look after them. Men.—Of 50 male cases seen in 1930-31 at Wormwood Scrubs and Brixton prisons and deemed to be certifiable under the Mental Deficiency Acts, 48 were feebleminded, one was imbecile and one morally defective. The following table gives their mental ages and their reading attainments:— Mental age. Number. Reading age. Number. Under 4 — Under 4 5 4 years 1 4 years 7 6 „ — 5 „ 4 6 „ 1 6 „ 14 7 „ 7 7 „ 5 8 „ 10 8 „ 6 9 „ 15 9 „ 6 10 „ 11 10 „ 1 11 „ 5 11 „ 1 Total 50 12 „ — 13 „ — 14 „ 1 Total 50 42 It may be noted that in general the reading age is far below the mental age as shown by tests of the Binet pattern. The physical conditions of the defectives were very varied, some being quite sound whilst others had heart disease, paralysis, epilepsy and the sequelae of encephalitis lethargica. The schools at which they had been in attendance were:— (a) Schools for mentally defective 28 (b) Elementary schools 15 (c) Poor-law schools 3 (d) Schools for the deaf 2 (e) Industrial schools 2 Total 50 (a) Of the 28 who had attended special (M.D.) schools, the early history was:— Left school before the date of the Mental Deficiency Act, but may have received voluntary supervision 3 Placed under statutory supervision 4 Placed under voluntary after-care 13 Deemed no longer certifiable under the Education Act before attaining age of 16 3 Sent to industrial schools and then supervised by the managers 1 Petition prescribed under Mental Deficiency Act, but dismissed by judicial authority 1 Placed in institution under Poor Law Order, but escaped or removed by parent 2 Left London and lost sight of 1 Total 28 Of the cases which had left school before the passage of the Mental Deficiency Acts, one had been discharged as being unfit to benefit by further school attendance, having reached his mental limits. In the cases which had been placed under statutory supervision, institutional care had been recommended, but action had been deferred owing to the refusal of consent by the parent under such circumstances that it was not possible to show that this consent was unreasonably withheld. Of the cases placed under voluntary after-care, one had an excellent report for conduct in the day school and subsequently attended an evening school, gaining three certificates for first-aid and home nursing. In 1926, however, there was a conviction for criminal assault for which the defective was placed on probation, and the repetition of the offence in 1931 rendered institutional care inevitable. In connection with the number placed under voluntary after-care, it may be noted that the greater number left school before the amending Mental Deficiency Act, 1927, came into operation. This Act permitted notification of the names of cases with a view to statutory supervision, whereas under the provision of the principal Act it was only possible to notify the names of those cases for which the local education authority deemed institutional care or guardianship to be essential. (b) Of those who had attended elementary schools, two who had come from the provinces, and one who had been at school in Ireland, would have been recommended for admission to a special (M.D.) school had they been London children. One who had been at school in Scotland was too high a grade both mentally and educationally for admission to a special (M.D.) school, and it is probable that his moral instability was not very evident during his school career. Of the eleven who had attended elementary schools in London, three were congenital defectives but had been at school prior to the passage of the Education (Deaf and Epileptic Children) Act, 1899; one had been recommended for a special (M.D.) school but evaded attendance thereat by leaving London; five were border-line cases though their educational attainments were a little above the special school level; one, who, owing to his ability as a letter writer, had caused doubt in the mind of the magistrate, was permitted two periods of probation during which he demonstrated conclusively his complete irresponsibility 43 and need of detention under the provisions of the Act; one was hard-of-hearing, and, being the son of foreign parents, was additionally handicapped by bilingual demands. (c) The three who had been in poor-law schools were all high grade defectives reported to have been backward and troublesome at school. (d) Of the two detained in schools for the deaf, one was reported to be almost unteachable and to have bad home circumstances, yet the parents would not permit the child to be sent to a school suited to children who are both deaf and mentally subnormal; in the other case the deficiency was brought to notice by his great instability in the more varied environment of the working world. (e) Those who had been in industrial schools were of relatively high grade but of increasing irresponsibility after leaving school. With regard to the environmental conditions, the history showed the home circumstances were good in six cases, fair in four, unfavourable in thirty-seven, whilst in the remaining three cases adequate history was not available. In eighteen cases the parents were of doubtful character or poor mentality, three of the cases being known as having one parent notoriously alcoholic, whilst in two of the cases the mother had been in a mental hospital. In four cases both parents were dead, and in eleven cases one was dead and the other too busy to exercise suitable control. In two instances only were the defectives illegitimate. The major portion of the cases, viz., forty, were disposed of by way of an order for institutional care. Of the remaining cases; one whose offence was not punishable by imprisonment was discharged, but taken to a place of safety pending presentation of a petition; in one the charge was dismissed as being trivial; and seven high grade defectives who were in work or had fair prospects of employment and good homes, were placed on probation to see if they could "float." In another, the mother averted institutional care by making a successful appeal to the magistrate, but she herself has since reversed her attitude and has requested the local authority to send her son to a suitable home. The variety of institutions provided by the Council has proved of great benefit, in that it enables classification to be made in terms of grade, attainments, mental stability and criminal antecedents. In this connection it may be stated that one defective declared that, having had experience of many institutions and "having tried most of such places in England," he had found that "of them all the one at Farmfield was undoubtedly the best." Darenth training colony. In 1930 Dr. E. J. Boome and Dr. A. C. Williams, under the Mental Deficiency Acts, ascertained 1,452 cases at Darenth who had been sent there under section 24 or 25 of the Lunacy Acts or under the Feebleminded Persons Order, 1911. Of these 22 were deemed not defective, 25 others were still under consideration on 31st December, 1931, and 200 children were found to be feebleminded but educable. Of the remaining 1,205 they have analysed a random sample of 200, mostly adults. The range of mental age was found to vary very greatly from imbeciles at 3 to very high grade cases with a mental age of 12 years. The physical condition also differed widely, 151 being healthy and 49 having defects, viz.:— Epileptic 16 Paralytic 9 Blind and partially blind 4 Deaf and hard of hearing 11 Cardiac diseases 3 Respiratory diseases 1 Miscellaneous 5 Total 49 44 These 200 cases were separated into the following groups according to their education before coming to Darenth, and their average mental and reading ages were as given below:— Imbeciles 51 Mental age. Reading age. Barely 5 Under 4 Education at Darenth only 10 7.5 4.0 Special (M.D.) school 61 8.0 6.51 Elementary school 32 8.0 6.5 Poor-law school 38 8.5 7.0 Other cases 8 Records incomplete. Total 200 The term "imbecile" is applied in the main to those with a mental age of six or less, but, when persons with this mental age were much better in practical ability, behaviour, cleanliness, etc., they were not included in this group. On the other hand a few with mental ages up to seven years, and who were altogether inefficient and useless, were included in the imbecile group. Under the poor-law school group are included a few children who were at charitable homes, such as Dr. Barnardo's, Waifs and Strays, etc. The special (M.D.) school group does not include those children who were found ineducable at a special (M.D.) school after a few months trial; they are included in the imbecile group. "Education at Darenth only," means persons not imbecile, who had received all their education at Darenth, having in most cases been admitted at an early age. It will be seen that the children from the elementary and those from special (M.D.) schools were on the average almost exactly comparable in intelligence and reading, while the children from the former poor-law schools were often of higher grade and in fact were the cases among whom the most difficulty in certification occurred. It will be noted as regards the effects of education that in both the elementary and the special (M.D.) school classes the reading age is just about eighttenths of mental age, and the ratio is very nearly the same for those who have attended poor-law schools. In the imbeciles the results of education were practically negligible—illustrating the fact that formal education with this class is really hopeless. Sometimes the reading age was disproportionately below the mental age. This was usually found to be the result of some such factor as defective sight or hearing, although there was one anomalous case of a person who was both myopic and hard of hearing but yet had a reading age of 10, while his mental age was only 8. He had been educated at a special (M.D.) school. Reading ages were occasionally above mental ages. This feature suggests a psychotic or epileptic degeneration, for then the subject loses much of his or her intelligence, but does not forget the reading that he or she has been taught in school. This is in line with previous experience. The initial ascertainment was done by Dr. Boome and Dr. Williams at Darenth, but certification on petition was carried out by other approved doctors at the County Hall a year or more later. On the 200 cases the decision differed in one case only (a high grade lad with a mental age of 12). The estimates of mental age were in close general agreement. In only 23 out of 200 cases did the mental age, as found by the respective tests, differ by as much as 1 year. Where the differences were greatest they were due to such conditions as marked instability, epilepsy, psychotic degeneration, hardness of hearing, hydrocephaly, syphilitic paraplegia, etc. In the great majority of cases the mental age found at the later examination was the lower, since degeneration had taken place in the interval. Occupation centres for children unfit for special schools. The Council 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. A routine examination was made of those in attendance at the time of the visits of the school doctors, 137 children, 45 75 boys and 62 girls, being examined. Their ages ranged from 6 to 17, all but 6 being between 8 and 16. In the condition of their clothing, cleanliness, nutrition and teeth they compared favourably with children in the elementary schools, with the exception of four girls found with dirty heads. It was noted that 61 children were in need of medical or dental treatment, five having two ailments needing attention. These included 39 dental defects, 11 defects of vision or eye disease, three cases of discharging ears, three nose and throat defects, two cases of enuresis, and eight other defects. The attention of the parents was drawn to these defects, and, in cases where they were unable to make arrangements for treatment, they were offered facilities under the Council's scheme for the treatment of school children. At subsequent re-inspections 28 cases were found to have been treated and were discharged, three were still under treatment, and one had so improved that treatment was no longer necessary, while twenty (16 dental cases) were still in need of treatment. Reports from the treatment centres show that in addition seven children were treated for minor ailments under the scheme, and two children were cleansed at the cleansing stations. At over 90 per cent. of the routine examinations a parent was present. There is evidence from this and from the condition of the children that they are well cared for at home, and for the most part sent to the occupation centres well fed and in a clean and tidy condition. When necessary the employment of guides has been sanctioned to convey the children between their homes and the centres. Blind Persons Act, 1920. Blind training, etc. In accordance with suggestions made by the Ministry of Health, the Council, in July, 1931, revised its scheme for the welfare of blind persons in the county of London. One of the provisions of the revised scheme was that no person's name should be finally entered on the register until he had been examined and certified to be blind within the meaning of the Blind Persons Act, 1920, by a medical practitioner with special experience in ophthalmology. This entailed the overhaul of the whole register of blind persons, numbering about 6,700. During the year 1931 it was only possible to deal with persons in receipt of domiciliary assistance, but the work is being continued. In addition the certification of workshop employees has been carried out as in previous years. In all 2,223 persons (909 males, 1,314 females) were examined, and certificates were granted in 2,044 cases (834 males and 1,210 females). In addition, certificates issued by hospital or private doctors were accepted in 547 cases (222 males and 325 females). The applicants who satisfied the conditions as to blindness were divided into the following categories (the figures for 1930 being given in brackets):— Males. Females. For registration 1,005 (117) 1,503 (135) For training 45 (56) 26 (25) For homes for the blind 5 (1) 6 (2) For homeworkers 1 (2) — (4) Totals 1,056 (176) 1,535 (166) Of the 2,223 persons examined, 179 (75 males, 104 females) did not come within the definition of blindness laid down by the Ministry of Health and were not certified as blind. As regards the 71 applications for training, 5 (4 males and 1 female), while found to be blind, were unfit for training, and 17 persons (12 male, 5 female) who had previously been certified as blind were examined as to physical fitness and found to be unsuitable for training. In four cases applications for examination were withdrawn. 46 Midwives Acts, 1902 to 1926, Nursing Homes Registration Act, 1927, Children Act, 1908, and Adoption of Children Act, 1926. Midwives. 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. (The Council's scheme of training includes (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. (/) Payment of proportion of any annual deficit incurred by Central Midwives' Board. Certified midwives to the number of 934 gave notice of intention to practise within the county during the year, compared with 901 in 1930. Practising midwives, other than those who work entirely in hospitals approved by the Central Midwives Board 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 ; 2,471 visits were paid this year compared with 2,322 in 1930. Infringements of the Rules of the Central Midwives Board to the number of 64 were reported during the year, compared with 81 in 1930. Of these 48 were slight, and a verbal caution was deemed to be sufficient; 12 cases of a more serious nature were dealt with by a written caution, and 3 midwives were interviewed by the Committee and personally cautioned. One midwife was reported to the Central Midwives Board and received a caution. 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; 48 midwives were suspended from practice during the year in order to prevent the spread of infection, and in 22 cases compensation was authorised. 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 7 enquiries were made into such cases, compared with 9 in 1930. In 5 cases no further action was taken ; in 2 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 363 still-births reported to the Council 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, 413 in 1929, and 408 in 1930. Of the cases reported this year 190 were male and 168 female, while in 5 cases the sex was not stated; 202 were reported as macerated. 159 not macerated, and in 2 the condition was not stated. Puerperal fever. During the year 283 cases of puerperal fever were investigated, compared with 284 in 1930. Of these cases 59 proved fatal, compared with 62 in 1930, a case mortality of nearly 20.8 per cent., compared with 21.8 per cent, in 1930. In addition 47 the Registrar-General recorded 41 deaths from puerperal sepsis which were not certified as fever, compared with 29 the previous year. The distribution of notified cases, with the mode of delivery, was as follows, deaths being shown in brackets :— Medical practitioners 71 (17); certified midwives 59 (9); medical practitioners and certified midwives 3 (1); hospitals and poor-law institutions 103 (23); medical students 19 (2); cases of miscarriage or abortion where no attendant was engaged 27 (7); not ascertained 1 (0).—Total, 283 (59). 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. In addition 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 ; 871 notifications of puerperal pyrexia were investigated during 1931, compared with 760 in 1930. The cases were distributed as follows, the deaths being shown in brackets:—Medical practitioners 139 (10) ; certified midwives 159 (11) ; medical practitioners and certified midwives 8 (1); hospitals and poor-law institutions 485 (24); medical students 33 (0); cases of miscarriage or abortion where no attendant was engaged 45 (2) ; uncertified women 2 (1)—Total 871 (49). Nineteen of the cases, with 4 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 to the Council. In the year now under review 6,326 such notices were received, compared with 6,516 in 1930. The estimated number of confinements conducted by midwives in independent practice during the year was 28,228. This appears to indicate that medical aid was necessary in about 22.4 per cent, of the cases, compared with 22.5 per cent, during 1930. Ophthalmia neonatorum. In 1926, regulations came into force rendering it no longer necessary for a midwife to notify a case of ophthalmia neonatorum 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's representative of the fee paid to a medical practitioner summoned by a midwife in a case of ophthalmia neonatorum, and the Council decided that parents should not be asked to reimburse the Council for fees paid for such medical attendance on account of a baby's eye affection. The number of cases of eye affection during the year was 761 and the amount paid to medical practitioners in respect of the cases was £699 Is., compared with £716 in 1930. Inflammation of the eves— Notices. During the year 1,288 notices were received from midwives indicating that medical aid had been summoned for inflammation of theeyesof infants, compared with 1,346 in 1930 ; 36 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 1,324 cases, 326 proved to be ophthalmia neonatorum, compared with 321 in 1930 ; 298 other cases that did not occur in midwives' practices were also notified, making a grand total of 624 cases during the year, the percentage occurring in the practice of midwives being 52.2 per cent., compared with 52.3 per cent, in 1930. All the 48 midwives' cases were investigated, and it was found that 320 were completely cured, in 4 cases injury to the eyes resulted, 1 died, and 1 could not be traced owing to the removal of the parents. Fifty-one cases became in-patients at St. Margaret's hospital, compared with 38 during 1930. In addition, two eye cases, which were not notified as ophthalmia neonatorum, were admitted to this hospital. In one of these cases the sight of one eye was slightly impaired. Instruction of midwives. As in past years, courses of demonstrations and lectures at convenient centres were provided for the post graduate instruction of midwives practising in London, Middlesex, Ealing, Edmonton, Tottenham and Willesden, the cost being shared by the local supervising authorities in proportion to the numbers of their midwives attending. In April, 1930, 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, at suitable intervals, a course of two lectures by two of the Council's medical officers particularly associated with the supervision of midwives. This course of lectures is provided four times a year for the instruction of pupils before each examination of the Central Midwives Board for candidates for admission to the Midwives Roll. 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. 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. Pupils attending during the year 1931 numbered 700. Pemphigus neonatorum. During the year 99 cases of pemphigus neonatorum occurred m the practice ot midwives, compared with 79 during 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 and are exchanged with the metropolitan borough medical officers of health as described in the annual report for 1929, was continued during the year. Payment of medical fees. The Midwives Act, 1918, imposed upon the Council the duty of paying medical practitioners' fees when they are called in by midwives in cases of emergency. The patient is required to reimburse the Council according to her means. The Minister of Health has 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, 57 claims amounting to £55 2s. were refused during 1931. Claims submitted during the year numbered 4,038, compared with 4,049 in 1930, the total amount involved being £4,521 Is., compared with £4,601 14s. 6d. in 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 provided for the registration of maternity homes. The Annual Report for 1928 (Vol. Ill, pp. 53-54) indicates fully the powers of the Council under the Act. 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 a 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. The number of nursing homes on the register on 1st January, 1931, was 271. During the year 1931, 25 homes were added, of which 12 had applied during 1930, and 38 were removed on cancellation of the registration, leaving 258 on the register on 31st December, 1931. Cancellation was in one case effected under an Order, 49 on the grounds that the person registered was not a fit person and that the home was not fit to be used as a nursing home ; and in the others, at the request of the persons registered and/or upon change of ownership. There were 32 applications for registration during the year, of which, at the end of the year, 8 had been withdrawn and 13 granted. The general considerations taken into account by the Council in administering the Act are fully described in the Annual Report for 1930 (Vol. Ill (Part I), pp. 53-54). In 1931 the Council granted 119 exemptions, and refused one exemption, from the provisions of the Nursing Homes Registration Act, 1927, in respect of premises not oonducted for profit. These exemptions were for a period due to expire on 30th June, 1932, after which date the exemption may be renewed at the discretion of the Council from year to year. Despite considerable hardship in many cases owing to financial stringency, 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. It is anticipated that this improvement will be maintained, especially as the less satisfactory older homes will 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. Under the scheme made by the Minister of Health under section 101 (6) of the Local Government Act, 1929, and continuing in force from 1st April, 1930, to 31st March, 1933, subject to any alteration which may be made by the Minister of Health under section 131 (2) of that Act, the Council is responsible for the payment of grants to 57 maternity and child-welfare associations. Similar grants are payable by the various metropolitan borough councils to other 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. The amount payable by the Council in 1931 was £33,064 for the year 1931-2. 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. In the course of the year three mother and baby homes were closed, two for financial reasons and one on account of insufficient inmates. The patients remaining at the time of the closing of these homes were transferred to other homes. Two homes under the control of one association were amalgamated, and the mother and baby home service is now being carried out at new premises. An increase in the amount of the grant to one baby home was sanctioned by the Minister of Health. 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. Qualified nurses carry out the work of inspection and act as visitors under the Act. During the year one inspector retired, and the vacancy was not filled in view of the fact that the number of foster children under supervision had decreased from 2,921 in 1923 (when the staff was established at 14) to 2,548 in 1930. 50 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. 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. Proceedings were taken against nine foster-mothers during the year for this offence. In five cases fines were imposed, three cases were dismissed (two with payment of costs), and one case was bound over. Newspaper advertisements of (or for) foster-mothers are followed up and there is extensive and constant co-operation between the Council and 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. At the end of 1931 there were 1,797 homes under inspection, compared with 1,773 at the end of 1930, the number of nurse-infants therein being 2,601, an increase of 53 over the number at the end of 1930. Approximately 29,000 visits were made during the year. 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 1931 it was necessary so to remove 4 nurse-infants, compared with 6 in 1930. The homes where nurse-infants are kept are visited when first notified in order to ascertain whether the sanitary condition of the premises is satisfactory ; 687 such reports were made during 1931. In 399 cases the premises were found to be satisfactory ; in 102 homes sanitary defects were discovered, while overcrowding was found in 95 homes. Overcrowding and sanitary defects combined were found in 23 homes. In 68 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. In addition to the above, special inquiries were also made in 449 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 being reported 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 and abate overcrowding. 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. If the foster mother refuses to return the child, appropriate action is taken under section 5 of the Act. 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 is duly carried out. If doubt exists in the visitor's mind with regard to the progress of the nurseinfant, one of the Council's medical officers attends and examines the child. During the year, 26 nurse-infants died, compared with 25 in 1930, and 27 in 1929. In 7 cases inquests were held, the same number as in the previous year: a verdict of death from " natural causes " was recorded in 2 cases, and in 5 cases from " accidental causes." In none of these 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. 51 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 1931 the total number of applications dealt with by this department was 48. The result of the hearings were as follows :—43 full adoption orders and 4 interim adoption orders made ; 1 application adjourned sine die. Examination of Staff. On the resignation of Sir John Collie on 15th February, 1931, the work of examining members of the staff of the Council, other than that under the direction of the Education Committee, was transferred to the public health department. The following is an analysis of the 6,540 examinations made during the 10J months under review :— Entrants 1,057 Sickness cases 4,949* Casualties, illness, etc., at County Hall 534 * 266 of these were dealt with in the first instance by telephone and correspondence. As a result of the examinations, 348 officers were deemed to be permanently unfit to carry out their ordinary duties in the service of the Council on the following grounds:— Males. Females. Total. Cardio-vascular disease 62 48 110 Diseases of the bones and joints 19 19 38 Disability following trauma 2 1 3 Pulmonary tuberculosis 23 8 31 Other diseases of the lungs 19 4 23 Malignant disease 17 3 20 Renal disease 3 1 4 Functional nervous disorders 18 10 28 Organic nervous disorders 21 4 25 Senile decay 7 5 12 Post operative debility 9 9 18 Sight and hearing defects 14 3 17 Endocrine disorders 4 3 7 *Miscellaneous 7 5 12 Totals 225 123 348 * Including cases of hernia, debility, disease of the digestive system, glycosuria, non-malignant growth, diverticulitis of the gullet. During this period, 250 visits were paid to the homes of officers and employees, who had left London either for treatment or in order to reside with relatives ; these involved journeys as far as Newport and Weston-super-Mare in the west, and Norwich and Lowestoft in the east. 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. Central laboratory. The greater part of the work done at the central laboratory has consisted, as in previous years, of the examination of materials of all kinds bought by or used for the Council, and of water, air, materials which have failed in use, and other matters arising out of the Council's undertakings. Besides these a considerable number of samples have been examined in connection with the Petroleum Acts and the Fertilizers and Feeding Stuffs Act, 1926. 52 Examination of samples. The total number of samples examined in 1931 amounted to 10,497, compared with 8,024 during 1930, and the following table shows their classification :— Air (from tunnels) 258 Greases 18 Asphalt 31 Handwork materials 232 Building materials 117 Insecticides 4 Cement 459 Meals 7 Disinfectant 46 Medical supplies 19 Driers 7 Drugs and medical stores 880 Metals— Feeding stuffs 222 Solder 18 41 Fertilisers 60 Various 23 Floor oils and polishes 32 Milk, condensed 19 Foods, Groceries— „ for schools 1,693 Baking powder 29 ,, for hospitals 354 Butter 5 „ farm 9 Cakes, biscuits, broad 49 Motor spirit 6 Cereals 15 Cheese 32 Oils- Cocoa 37 Lighting 42 Cocoanut, etc. 10 Lubricating 232 294 Coffee and chicory 2 Painting 16 Custard powder 3 Miscellaneous 4 Egg powder 3 Oilman's sundries 14 Flavouring essences 20 Paints 264 Fish 54 Petroleum 110 Flour 38 Rainwater, etc. (atmospheric pollution) 108 Jam and Marmalade 6 Sewage 11 Jelly 21 Shampoo preparation 2 Lard and dripping 6 Soap 85 Margarine 72 Sulphur determinations (air) 554 Meat extracts 2 Tobacco 2 Miscellaneous foodstuffs 59 Turpentine 36 Mustard 13 Urine 1,180 Pepper and spice 14 Water (softening treatment, County Hall) 157 Pickles 9 Preserved meat 43 Water boiler 755 Sugar 62 „ river 314 Syrup and treacle 23 „ drinking (from wells) 207 Vinegar 21 „ ,, (from public supplies) 5 Yeast 19 „ drainage 5 — 667 ,, laundry 5 Gas— „ from bathing lakes 4 Dry cleaners 6 1,124 Wax 3 Flue 1,118 Miscellaneous 74 Milk samples. The total number of milk samples examined chemically during the year in the central laboratory was 1,784. Of this number 1,517 were of milk supplied to children in the elementary schools, whilst 267 were from supplies to general and special hospitals, under contracts which require 3.25 per cent, of fat and 8.5 per cent, of other solids, except during the months of March and April, when the fat must not be less than 3 per cent. The quality of the supplies, generally, has been more satisfactory than in past years, less than 2 per cent, being deficient in fat, and only about 0.5 per cent, containing added water, 2.4 per cent, of the total being not up to the chemical standard required as against 7.1 per cent, during 1930. A consideration of the condition of the supplies in respect of extraneous matter, however, shows a less marked improvement; for, of the 1,784 samples referred to, 144 (slightly over 8 per cent.) contained an excessive amount of extraneous matter. This figure is, however, less by nearly 3.5 per cent, than that obtained during 1930. In all these cases the results are communicated to the chief officer of supplies, who is thus enabled to take up the matter with the contractor. In addition to the above, 264 samples of milk supplied to schools and general and special hospitals were examined bacteriologically at the Southern Group laboratory at the Park hospital, and at the bacteriological laboratory at the County Hall. The results obtained are shown in the tables set out below. 53 The milk used for school supplies is not purchased under any of the standards specified in the Milk (Special Designations) Order, 1923, and a standard had to be devised for what would be regarded as ordinary clean milk. The standard adopted was : bacterial content, 300,000 per c.c., and B. Coli not to be present in 1/1,000 c.c. If below this standard, the chief officer of supplies was informed that the milk could not be regarded as satisfactory. The contracts for the supply of milk to hospitals, prior to 1st October, 1931, included raw milk, certified milk, grade A pasteurised milk, grade A (T.T.) and pasteurised milk. These contracts were revised as from 1st October, 1931, to provide for the supply of pasteurised milk only. Under the provisions of the Milk (Special Designations) Order, 1923, graded milks are required to conform to the following standards :— Certified milk and Grade A milk Not more than 30,000 organisms per c.c. and must pasteurised. not contain coliform bacillus in 1/10 c.c. Grade A (tuberculin tested) milk Must not contain more than 200,000 organisms per and grade A milk. c.c. and must not contain coliform bacillus in 1/100 c.c. Pasteurised milk The milk must not contain more than 100,000 organisms per c.c. For the purposes of supplies to hospitals the standard mentioned above as to school supplies was applied to deliveries of raw milk, and as regards the presence of B. Coli only in the case of pasteurised milk. School Supplies. Conforming to standard ... 123 Not conforming to standard- B. Coli present in 1/1,000 c.c 23 Bacterial count exceeding 300,000 per c.c., but conforming to B. Coli standard 1 Bacterial count exceeding 300,000 per c.c., together with excess of B. Coli 29 - 53 Samples examined 176 Hospital Supplies. Raw Milk. Conforming to standard . Not conforming to standard : ... 18 B. Coli present in 1/1,000 c.c. 6 Bacterial count exceeding 300,000 per c.c. but conforming to B. Coli standard 3 Bacterial count exceeding 300,000 per c.c. together with excess of B. Coli 7 - 16 Samples examined 34 Certified and Orade A Pasteurised Milk— Conforming to standard 1 Not conforming to standard- Bacterial count exceeding 30,000 per c.c. together with presence of B. Coli in 1/10 c.c 1 Samples examined 2 Orade A (T.T.) Milk— Conforming to standard 2 Not conforming to standard— Bacterial count exceeding 200,000 per c.c. together with presence of B. Coli in 1 /100 c.c 2 Samples examined 4 54 Pasteurised Milk— Conforming to standard ... 25 Not conforming to standard— B. Coli present in 1/1,000 c.c. 11 Bacterial count exceeding 100,000 per c.c.but conforming to B. Coli standard 6 Bacterial count exceeding 100,000 per c.c., together with presence of B. Coli in 1/1,000 6 23 Samples examined 48 During the past year arrangements have been made for the co-operation of the medical officers of health for the areas in which the Council's schools and institutions are situated. One result of this scheme has been that the Council has had the advantage of receiving the results of the examination of 99 samples of milk bacteriologically and 181 chemically. An analysis of these results shows that all the samples were chemically satisfactory. The bacterial examinations, however, showed that 30 out of 99 samples failed to comply with the conditions laid down in the Milk (Special Designations) Order, 1923. The co-operation of the local medical officers of health also has the special advantage that, in suitable cases, legal action can be taken by the local authorities under statutory powers conferred upon them under the various Orders issued by the Ministries of Health and Agriculture and under the Adulteration of Foods Act. Drugs. Of the 880 samples of drugs and medical stores examined during the year 82 (or 9-3 per cent.) were found to be definitely unsatisfactory for use and a further 67 (or 7-6 per cent.) somewhat below standard strength or quality. Satisfactory ... 731 Unsatisfactory or below standard— Deficient in active constituent 28 Tincture, etc., deficient in alcohol 7 Specific impurities found 42 Dirty 11 General deficiency 49 Misdescribed 12 - 149 Total 880 Urine. Samples submitted as zinc sulphate were found to consist entirely of magnesium sulphate. A sample labelled " calamine prseparata B.P.C." contained no zinc carbonate, but 25 per cent, of calcium carbonate. Two samples supplied as oleum menthce piperita B.P. were found to consist entirely of the Japanese oil from mentha arvensis, and as such were rejected, since the British Pharmacopaeia requires that this substance shall be derived from fresh-flowering mentha piperitce. Since the retirement of the Council's medical examiner in February, 1931, the medical examinations have been carried out by the Council's medical staff at County Hall. The urine analyses required have been done in the chemical laboratory. During the year 1,180 specimens have been examined for sugar and albumen, and in many cases for casts, blood cells, etc., in addition. Graphitic deterioration of iron water pipes. The cast-iron water pipes laid in the clay soil at a residential school had burst in many places when subjected to a higher pressure of water than usual. Investigation of sections of pipe showed that failure was attributable to erosion and partial removal of iron by the action of salts in the soil. A remarkable feature of this kind of deterioration is that, except where bursts have occurred, the pipes retain their form, the mixture of graphite and oxides, etc., of iron left occupying the same volume as the original metal, although being soft enough to be cut with a knife. Forceps. stainless steel forceps, for surgical use in the hospitals, were examined as the result of complaints that certain forceps did not retain their lustre on sterilising by boiling water. Advice was given as to the prevention of this and as to the preservation of their rust-resisting properties. 55 Explosive properties of anesthetics. In connection with an inter-departmental conference on the dangers of explosion in operating theatres, the explosive properties of some anaesthetics have been investigated. It has been found that mixtures of ethyl chloride and air are explosive, within fairly wide limits, an objectionable product of the explosion being hydrochloric acid. Mixtures of oxygen and ether, as delivered from apparatus used in operating theatres, are violently explosive, and the addition of chloroform cannot be relied on to inhibit explosion. The source of ignition in these experiments, which were undertaken in view of the extensive use of electrical appliances in operating theatres, was a spark from a Ruhmkorff coil. Fertilisers and feeding stuffs. In connection with the provisions of the fertilisers and reeding btuns Act, 1926, 282 samples have been examined during the year under the supervision of the chemist who is the agricultural analyst for those parts of the county which do not come under the purview of the City Corporation or, Port Sanitary Authority. The results of the analyses were : Samples of feeding stuffs. Complied with guarantee 101 Deficient 63 Constituents in excess of guarantee 42 Guarantee incorrect in form or no guarantee 16 Total 222 Samples of fertilisers. Complied with guarantee 17 Deficient 10 Constituents in excess of guarantee 16 Guarantee incorrect in form or no guarantee 17 Total 60 The figures are very similar throughout to those of last year, though the number of samples with no guarantee or one incorrect in form shows some increase, thus emphasising the need for continued supervision of the conditions of sale of these commodities. It is remarkable that the apparently very wide limits of variation from the guaranteed composition which are allowed under the Act should so often be exceeded in the direction of supplying a better article than that stipulated. Flue gases. Flue gases have also been examined from time to time at Abbey Mills pumping station and at Woolwich ferry in connection with the efficient burning of fuel for steam raising. Boiler waters. The regular examination of the water before and after softening has been undertaken at County Hall and the pumping stations, thus ensuring a suitably softened water and more efficient and economical working of the boilers. River Wandle. A sample of water taken by a brewery for cooling purposes was obtained for examination as to its suitability for return into the river Wandle. Investigation showed that the water was of the same general character as the water of the river and, moreover, that the effluent was not returned to the river, but flowed into the sewer. Swimming bath water. In consequence of complaints of the deposition of a green slime (algae) on the glazed tiles of the indoor swimming bath at the Hutton residential school, an addition (when the bath was filled) of 1 lb. of chloride of lime to 65,000 gallons of water was found to be effective. The waters of several open-air swimming baths have been examined as to their freedom from suspended matter (green growths, etc.) and advice given as to the desirability of treatment or emptying. Water supply —private wells. The transfer of many institutions to the Council under the Local Government Act, 1929, caused a large increase in the amount of work in the examination of the water supply from private wells. Daring the year such supplies at 37 institutions were examined, a total of 208 samples being analysed. In eight of these cases advice 56 was given as to measures which should be taken to improve the quality of the water. At one of these wells (Hollesley Bay labour colony) a chlorinating plant was installed, and at Mitcham children's home the well sump and tanks were twice treated with a strong dose of bleaching powder. 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 problems connected with coal economy and corrosion. 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 begun in 1888 and 1890 respectively. At the southern outfall the percentage of dry matter in the sludge was slightly below 6 per cent., the corresponding figure for the northern outfall being 8-1 per cent. River Thames. ihe dry matter in individual cargoes varied from 4 to 14 per cent, at the southern outfall, the mode lying between 8 and 9 per cent. The corresponding figures for the northern outfall varied between 3 and 16 per cent., the mode lying between 7 and 8 per cent., with a decided skew distribution in favour of drier sludges. 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 tideway have been investigated. The weather conditions during the summer were such as to obviate the necessity for treatment of the effluent from the Council's outfall works. Sludge digestion. Experiments are being conducted at Crossness on the anaerobic digestion of sludge. The plant is designed to allow of agitation and of digestion at varying temperatures. The gas evolved can be measured and its calorific value determined. This work has not progressed sufficiently for any useful discussion of the results obtained. Biochemical purification plant at northern outfall. The large plant designed to treat some five million gallons per day has been brought into partial use. Towards the end of July the re-aeration tanks were filled with crude sedimented effluent and air blowing started. Actual treatment was begun on 25th November. At the end of the year about two million gallons of this effluent were being successfully purified by the action of the humus (" activated sludge ") which had then been formed. This amount has since been increased, and it is anticipated that as the amount of humus available for treatment is increased, a much larger volume of crude effluent can be purified to the desired degree. The working of the plant, which is of entirely novel design, has so far presented no special difficulty, although naturally it has required constant skilled supervision. A point that will be of interest is the provision of settling tanks of two different types, enabling a comparison to be made between the results respectively obtained in them. British engineering standards and other committees. The chemist has served as a nominee of the Council on three committees of the British Standards Association; one on the Sampling and Analysis of Coal, which has during the year extended its activities to include coke; one on Standard Definitions and Tests for Fire Resistance and the combustibility ; and more recently one on Containers for Acids and Corrosive Liquids. The two first-named committees have issued tentative reports which have been circulated for comments to organisations concerned in the matters dealt with. The chemist is chairman of two panels of these committees. He is also a member of the Government Committee on Atmospheric Pollution. Vehicular tunnels. The regular examination of the air in the vehicular tunnels at Blackwall and Rotherhithe was continued throughout the year, attention being concentrated on the period about 10 a.m. when the worst atmospheric conditions have been proved to occur. The new blowing fans in No. 2 shaft at Blackwall came into operation at the end of July, thus completing the new ventilation scheme at this tunnel. The 104 samples examined there during the year gave an average carbon monoxide 57 content of 9.2 parts per 100,000 ; only two samples exceeding the recommended maximum of 20 parts per 100,000. The great improvement in the atmospheric conditions brought about by the installation of the new ventilation plant is clearly proved when these figures are compared with last year's average of 21.5 parts carbon monoxide per 100,000 and 39 samples above the limit figure. The installation of the new plant at Rotherhithe was begun, but the exhaust fans in No. 2 and No. 3 shafts only commenced work in November and December respectively, their period of operation thus being too short to affect appreciably the averages for the whole year. At Rotherhithe 103 samples were taken, giving an average carbon monoxide content of 19.6 parts per 100,000; 41 contained more than the limit figure of 20 parts per 100,000. These results are rather worse than those of last year, and show a great contrast with the improvement at Blackwall. " Suspended matter in air " determinations were also made regularly at each tunnel and the results showed general agreement with those of carbon monoxide. Atmospheric pollution. The investigation of atmospheric pollution in the county of London has been continued, both in connection with the general scheme of the Atmospheric Pollution Committee of the Department of Scientific and Industrial Research to which the Council has contributed for many years and of which the chemist is a member, and in special directions made desirable by the pending erection of large power stations in the county. Six standard deposit gauges are erected in open spaces in the county. The analysis of the water and deposit collected at these places, at the Meteorological Office, and at stations maintained by the Cities of London and Westminster, afford the authorities concerned a fair estimate of the total pollution deposited in the whole of the county. Results obtained at Kew Observatory give information as to a less polluted district within the metropolitan area, comparable with similar information obtained by local authorities for districts widely scattered over England and Wales. In addition, smaller deposit gauges of a special type, and exposed discs of copper, yield information concerning local pollution and its effect on metal-work in places where conditions demand special records. At these places also special work on the sulphur content of the air is being carried out by a process developed by the Government chemist. The information thus obtained, supplemented by records of soot in the air at County Hall and Battersea Park, and other data, will be of value in connection with the study of emanations from power stations and other industrial developments in the county. Visibility. The question of the range of visibility is intimately connected with that of atmospheric pollution and observations from the fleche at County Hall and from sludge ships in the Thames estuary furnish collateral information as to the variations of efficiency of London air as a medium for the transmission of light. Observations of horizontal visibility in all directions continued during 1931 showed that on the whole it was higher than the average of the five preceding years. The subjoined diagram shows the mean distance in all directions at which objects could be distinguished at mid-day in each month of 1931 and of the preceding quinquennium, and is self explanatory. The range of visibility was greatest in the quadrant S.E. to S.W. and markedly so in the summer months June, July and August, as is shown by the second diagram. During 1931 the visibility in the quadrant N.E. showed a great improvement on the average of the previous five years. 58 diagram showing the mean distance (in miles) in all directions at which objects could be distinguished at mid-day from the fleche at county hall, during 1931 and 1926-1930. diagram showing the mean distance (in miles} in the directions stated at which objects could be distinguished at mid-day from the fleche at county hall during the summer months and during the whole year, 1931 and 1926-1930. INDEX Subject. Page Adoption of Children Act, 1926 50 Anthrax 2 Atmospheric Pollution 57 Bacteriological Laboratory 34 Births 1 Blind Persons Act, 1920 45 British Engineering Standards Committee 56 Cancer 10 Cerebro-Spinal Fever 3 Chemical Branch 51 Chickenpox 2 Children Act, 1908 49 Common Lodging Houses 15 Cowsheds 21 Deaths 1 Delinquent Defectives 39 Diarrhoea 4 Diphtheria 4, 34 Disinfestation 15 Encephalitis Lethargica 3 Enteric Fevers 5 Fertilisers and Feeding Stuffs Act, 1926 55 Homeless Persons 15 Housing Acts (Statistics) 18 Housing Acts (seeVolume II of Report) Infant Mortality 2 Infectious Diseases 2 Influenza 10 Marriages 1 Maternal mortality 5, 48 Subject. Page Measles 4 Medical Examination of Staff 51 Mental Deficiency 35 Midwives Acts 46 Milk and Dairies Act 20 Milk Sampling35, 52 Nursing Homes 48 Occupation Centres 44 Ophthalmia Neonatorum 47 Polioencephalitis 4 Poliomyelitis 4 Population 1 Puerperal Fever 4, 46 Puerperal Pyrexia 4, 47 Rheumatic Fever 10 Sanitary Officers 19 Scarlet Fever 4 Seamen's Lodging Houses 15 Sewage Treatment 56 Smallpox 2 Swimming Baths 55 Tuberculosis (Notifications) 10 Tuberculosis (Scheme) 25 Tuberculosis (Dispensary Service) 29 Tuberculous Milk 20 Vehicular Tunnels 56 Venereal Diseases 21 Visibility 57 Vital Statistics 1,6, 7, 8, 9 Water Examination 35, 55 Whooping Cough 4 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 foe 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. Is. No. 2801. Vol. V. Abstract of Accounts—Memoranda on Housing accounts and statistics—Index. 6d. No. 2848. Report for 1930 (New series) :— Vol. I. (Part I). Powers and duties— Elections — Finance — Bating and Taxation—Public Protection—Traffic—Public Amenities—Domestic and Miscellaneous Services. Is. 6d. No. 2903. Vol. I. (Part II). Public Assistance. Is. No. 2904. Vol. II. Public Health, General matters as to public health, Main Drainage and Housing. Is. No. 2894. Vol. III. (Part I).—Public Health, Report of County Medical Officer of Health. Is. No. 2850. Vol. III. (Part II) Public Health. Report of School Medical Officer. Is. 6d. No. 2851. (Report for 1931. No. 2905) Vol. IV. (Part 1).—General and Special Hospitals. 2s. 6d. No. 2875. Vol. IV. (Part II.).-—Hospital Finance. Is. No. 2876. Vol. IV. (Part III).—Medical Supplement. 5s. No. 2877. Vol. V. Education. Is. No. 2874. Vol. VI. Mental Hospitals. Is. No. 2880. Vol. VII. (Abstract of Accounts and Index. (In preparation.) Archives of Neurology and Psychiatry from the Pathological Laboratory of the London County Mental Hospitals. Cloth:— Vol. I (out of print)-, Vol. II, 1903, No. 680, 17s. 6d. ; Vol. Ill, 1907, No. 715, 17s. 6d. ; Vol. IV, 1909, No. 152, 10s. 6d. ; Vol. V, 1911, No. 1459, 10s. 6d.; Vol. VI. 1914, No. 1677, 10s. 6d. ; Vol. VII, 1918.. No. 1922. 10s. 6d. (out of print); Vol. VIII, 1922 (out of print) ; Vol. IX, No. 2501. 1927, 15s. ; Vol. X, No. 2823, 1931, 15s. Accounts in Abstract. Accounts of the Income and Expenditure of the Council from 1st April to 31st March. Is. Issued annually. 1929-30. No. 2846. London Statistics. Statistics relating to London and the public services therein, with certain statistics of the adjacent districts. (Issued annually.) Vol. XXXV. 1930-31. 15s. No. 2911. Statistical Abstract for London. Comparative statistics for 10 years relating to parishes, metropolitan boroughs, poor law areas, electoral areas. Administrative County of London, Greater London, etc. -—Education, rateable value, lunacy, pauperism, fires, finance, population, rates, locomotion, etc. Vol. XXIV. 1920-1930. 2s. 6d. No. 2857. Statistics of Metropolitan Boroughs.— Prepared and published by the London County Council on behalf of the Metropolitan borough councils, and designed as a common appendix to their reports. Id. 1930-31. No. 2868; (1931-32 in preparation.) Census, 1921. Report upon the statistics relating to Greater London cdhtnned in the various volumes of the Ct'iisus of England and Walqs. 1921 Is. No. 2550. Municipal Map of Londo 1931 In 28 sheets ; scale 6 inches to a mile. Is. 6d. a sheet,; complete se$e, with Key sheet, 35s. Street Index, 5s. THE LONDON COUNTY COUNCIL GAZETTE. " Issued weekly. Containing full particulars of appointments, contraeffljuatt&i^rice 2d. Annual subscription, payable in advance, 13s. ])ost free. The Survey of London (a series of volumes dealing both historically and architecturally with a number of London parishes), fully illustrated, is published by B. T. Batsford, Ltd., 15, North Audley-street, W.l, as follows :— Bromley-by-Bow—Vol. I, 10s. 6d., No. 485 ; Chelsea—(Part I) Vol. II (out of print), (Part II), Vol. IV, 21s., No. 1584, (Part III), Vol. VII, 21s., No. 2065, (Part IV), Royal Hospital, Vol. XI, 42s., No. 2532 ; St. Giles-in-the-Fields—(Part I), Lincoln's Inn Fields, Vol. Ill, 21s., No. 1488, (Part II), Vol. V, 21s., No. 1663 ; Hammersmith—Vol. VI, 21s., No. 1778 ; Shoreditch—Vol.VIII, 42s., No. 2180 ; St. Helen, Bishopsgate—(Part I), Vol. IX, 42s., No. 2280 ; St. Margaret, Westminster—(Part I), Vol. X, 42s., No. 2432, (Part II), Whitehall, Vol. XIII, 52s. 6d., No. 2722, (Part III), Whitehall and Downing Street, Vol. XIV, 52s. 6d., No. 2866 ; Allhallows, Barking— (Part I), The Church, Vol. XII, 31s. 6d„ No. 2634. The University of London Press, Ltd., in association with Messrs. Hodder and Stoughton, have issued a series of illustrated booklets, prepared by the Council, dealing in a popular way with the principal services administered by the Council. The series includes :— The Londoner's Education. 9d. net. Continued Education in London. 6d. net. The Special Services of Education in London, Is. 6d. net, paper ; 2s. 6d. net, cloth. Housing. 6d. net. Parks and Open Spaces. Is. net. Fire Brigade. 6d. net. Public Health. 6d. net. LCC 40 MEDICAL LIBRARY (MINISTRY OF HEALTH.) London County Council ANNUAL REPORT OF THE COUNCIL, 1931 Vol. Ill (Part II) PUBLIC HEALTH. (Report for the year 1931 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.I, Agents for the sale of the Publications of the London County Council. 1932. No. 2905. Price Is. 6d. London County Council ANNUAL REPORT OF THE COUNCIL, 1931 Vol. Ill (Part II) PUBLIC HEALTH (Report for the year 1931 of the School Medical Officer.) CONTENTS. PAGE Staff 2 Results of Medical Inspection 3 Inspection in Higher Education Institutions 9 Following-up 11 Schools and Homes transferred from Poor Law Authorities 15 Institutional Care of Children under 3 years of age 19 Chronic Invalidity 20 Employment of School Children 21 Medical and Dental Treatment 21 Stammering Children 34 Pefsonal Hygiene Scheme 35 Physical Education and Teaching of Hygiene 36 Rheumatism Scheme 40 Feeding of School Children 51 Open-air Education 53 Convalescent Camp Schools 56 School Journeys 57 Nursery Schools 57 Child Guidance 59 Deaf Children 65 Schools for the Blind 66 Residential and Industrial Schools 67 Defective Children 74 Examinations of Employees in the Education Service and Scholars 77 Children suffering from Cardiac Disease 77 Infectious Disease in Schools 83 Statistical Tables.— I. Medical Inspections 96 II. Defects 97 III. Exceptional Children 98 IV. Treatment of Minor Ailments 100 V. Medical Inspection—Number of Children Examined 101 VI. Medical Treatment—Number of Cases Treated 102 VII. Medical Inspection in Secondary and Trade Schools 103 London County Council ANNUAL REPORT OF THE COUNCIL, 1931 VOL. III (Part II) REPORT OF THE SCHOOL MEDICAL OFFICER FOR THE YEAR 1931. By Sir Frederick Menzies, K.B.E., M.D., F.R.C.P., D.P.H., F.R.S.E., County Medical Officer of Health and School Medical Officer. Introduction. In presenting the following report on the work of the school medical service during 1931, there is nothing spectacular to which I desire to draw attention. The steady progress recorded in recent years has been maintained despite the urgent need for retrenchment in public expenditure which reached a climax in September. It is recognised that the work of the school medical service is of outstanding value and of fundamental importance to the health and consequently to the welfare of the rising generation; hence the calls for curtailment of expenditure were not so insistent as in other spheres of municipal activity. Nevertheless, in any large service it is essential at frequent intervals to survey every aspect of the work for the purpose of clearing away anything which is obsolete or redundant, and of ensuring that every penny is well spent. The opportunity was taken, in the latter portion of the year, of reviewing every detail of the work, and any economies which could be made without impairment of efficiency were effected. An indication of the development of the service is given by the following figures which compare 1931 with 1911 and 1921:— 1911. 1921. 1931. (1) Total number of children examined in age groups 184,862 217,333 218,999 (2) Percentage referred for treatment (excluding dental caries) 380 19.8 18.5 (3) Percentage of children referred for treatment of defects found satisfactory on re-inspection 42.5 78.2 81.6 (4) Total number treated under Council's scheme Provision for 26,000 218,332 306,724 (5) Number inspected by dentists — 151,395 268,545 (6) Number of hospitals and centres under the treatment scheme 6 70 105 (7) Percentage found ill-nourished at routine medical examinations 9.6 5.5 4.5 (8) Percentage found unclean at routine medical examinations 9.8 .9 .5 (9) Percentage with discharging ears at routine medical examinations 2.2 1.1 .7 (10) Number of ringworm cases found in the schools 6,214 3,473 420 A recent addition to the work of the school medical officer is responsibility for the health of the 7,000 children in the residential schools transferred to the Council by the Local Government Act, 1929. Arrangements have been made to sift, out the defective children and transfer them to special schools : this benefits not only the children transferred, but also the normal children in the residential schools where the defective children had hampered the work. A special scheme has also been introduced (page 92) for the better control of the spread of infectious disease which incidentally has enabled a certain amount of valuable accommodation in " quarantine " blocks to be made available for other purposes : steps are being taken to immunise the children in many of the schools against diphtheria (page 94) and for an improved dietary to be introduced (page 16). 1000 (m«0. 12433—761.) 5.7.32. (1) b 2 With regard to the general work amongst the school children of London, smallpox continued to be prevalent and caused much anxiety and work, though fortunately its incidence was less than in 1930 (page 86). The special care given to rheumatic children was intensified during the year and the number of children admitted through the scheme to the Council's special hospitals was doubled owing to the additional accommodation which was made available. Special attention is directed to the portion of the report, which deals with the work of the Wick dental clinic (page 28), to the sections on care committee work (page 12), nursery schools (page 57), child guidance (page 59), children suffering from cardiac disease (page 77), and the experiment which was tried of sending selected children from the schools for the mentally defective to a camp school at Loughton (page 53). Staff. The public health department is organised upon the basis of three branches, (i) special hospitals including control of the acute infectious diseases and of the ambulance service ; (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 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 is 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 school children, 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 included one principal assistant medical officer for aural work (Mr. A. G. Wells) ; eight part-time assistant aurists ; one part-time consulting dental surgeon (Dr. A. Livingston, resigned 31st October, 1931); one part-time 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 ; 10 assistant medical officers giving six sessions a week ; 46 assistant medical officers giving three sessions a week ; additional temporary medical assistance for 140 sessions a week ; 9 medical officers (part-time) at open-air schools ; 266 surgeons and anaesthetists at treatment centres ; and 93 dentists at treatment centres, of whom 66 are employed as inspecting dentists in the schools. The duties of Miss D. E. Bannon, matron-in-chief of the public health department, 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 at present five assistant superintendents, 84 school nursing sisters and 296 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 •Two vacancies—also two medical officers are temporarily seconded for work under the Mental Deficiency Acts (equivalent substitutes authorised). 3 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) and an assistant medical officer who is attached for half his time to Ponton-road place of detention. The results of medical inspection. The number of elementary school children examined in the three statutory age groups (entrants, children aged 8 and children aged 12) during the year 1931 was 180,245—11,997 more than in 1930. In addition, 38,754 children were examined in detail in the term prior to that in which they were due to leave school, and 1,601 children in special schools were examined on reaching their respective age groups. Children referred for examination by nurses, school teachers, care committee workers, divisional officers, etc., for special reasons numbered 90,248 ; and 25,596 were examined in connection with outbreaks of infectious disease. The total inspections amounted to 336,444. To this must be added the children, 169,029 in number, who were re-inspected because of some previously noted defect. The school doctors thus see each year a very large proportion, considerably more than one-half, of the children attending school. Parents are invited to be present at all routine inspections, and attended in 74-5 per cent, of the examinations in the three statutory age groups. At the inspection of entrants, the proportion was 89 per cent., and in the " leaver " group 40-1 per cent. The presence of the parents at inspections is very important, as it brings them into touch with the school doctor and care committee workers, whereby they are led to realise the importance of obtaining any necessary treatment without delay. Refusals of parents to submit children for medical inspection are so few in number as to be almost negligible. During the year 1931, the parents of 76 children (28 boys, 48 girls), compared with 112 in 1930, refused to allow them to be examined by one of the Council's assistant medical officers. Four objections were subsequently withdrawn, and in nine instances either medical record cards were completed by a private medical practitioner or medical certificates as to physical fitness were produced. The cases were distributed amongst the divisions as follows : N., 6 ; N.E., 14; N.W., 17; S.E., 22; S.W., 17. Refusals 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. During the year 1931, other authorities asked for the medical record cards of 697 children who had removed to areas outside London. In 413 cases cards were obtained and forwarded, 175 could not be traced, 39 had not previously been examined and 32 concerned children who were not attending schools in the County of London. In the remaining 38 cases inquiries are still being made. The number of children subjected to routine inspection who were referred for treatment was 78,902, 43-8 per cent, of the number examined. This figure includes cases noted by the school doctors for dental treatment, and, if these cases be excluded, the percentage is reduced to 18-9. These percentages remain practically constant from year to year, varying only as the proportions in the different age groups vary. 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 examination of the " leaver " group are dealt with separately. Requests foi medical cards. The proportion of poorly nourished children found at routine inspections was Nutrition 4 • 8 per cent. This is the same percentage as last year, which was noted as being the B 2 4 lowest ever recorded in London. The following table shows the percentage of children found ill-nourished in the age groups :— Age Group. 1920. 1925. 1930. 1931. Entrant boys 6.4 5.7 4.4 4.4 „ girls 5.9 5.0 3.5 3.6 8-year-old boys 9.0 8.5 6.3 6.6 „ girls 7.8 7.2 5.1 5.0 12-year-old boys 6.3 6.5 5.1 5.2 „ girls 5.6 6.3 4.5 4.2 All ages 6.7 6.3 4.8 4.8 It is very satisfactory to note that, in spite of the difficulties of the times, the excellent condition of the general health of the children in the schools is being maintained, and that there is not the least decline perceptible in London in nutritional well-being. Attention has been called in previous reports to the fact that there is an irreducible remnant of children who are ill-nourished. Amongst these is the group which was studied by Dr. Leipoldt before the war under the title " Asthenia congenitalis universalis," and in the last Annual Report by Dr. Maurice Young under the heading " Arachnodactyly." The children in this group respond neither to feeding nor to convalescent treatment, and throughout school life remain, whatever is done, thin, pale and nervous. Cleanliness. The percentage of children found free even from traces of nits or pediculi in the hair was 95-2 and of those free from traces of body vermin, 99-7. For some years past the condition of the hair of the 12-year old girls has been taken as the criterion of cleanliness, and it has been pointed out that there has been a gradual improvement from 67 -2 per cent, in 1913 to 75 per cent, in 1923, and 91 9 per cent, in 1930. In 1931 the record figure of 93-5 per cent, was reached, a substantial improvement on the figures recorded in the previous two years. It is comparatively rare for the school doctor to find a child actually infested with body vermin ; a condition which 3 to 4 per cent, of the elementary school children exhibited in the early days of medical inspection, but is now to be found in little more than one in a thousand. It might have been expected that the campaign against the grosser conditions of neglect of personal hygiene which formerly obtained in the schools would rapidly have borne fruit in the earlier years of the school medical service, but the improvement took place only slowly, and, although this progressive improvement is still taking place every year, it is more difficult to attain now that the chronically dirty children have to be dealt with if further success is to be achieved. The results are a great tribute to the work of the school nurses. It would be impossible to praise too highly the efforts of these devoted women who carry on their work unflinchingly in the face of much obloquy poured upon them day after day by some of the rougher elements in the population. It is needless to say that this great work could not have produced its effects without the enthusiastic co-operation of the teachers in the schools, the attendance officers, and the sanitary officers of the borough councils ; but in addition the revolution, for it is nothing else, could not have been brought about without the winning over to the ideal of cleanliness of the great mass of the parents and the general support of a more enlightened population. Dental decay. The proportion of children found at medical inspection in a satisfactory dental condition was 64.4 per cent., compared with 62.9 per cent, in 1930. This improvement is not only in the 8-and 12-year old groups, the percentage among entrants has also risen from 52.6 to 53.9. When, however, comparison is made between the proportions of children in the three age groups having serious dental decay, the 5 percentage improvement in the 8-year and 12-year groups is most marked. Details are set out below :— Age Group. 1924. 1927. 1930. 1931. Sound. Serious decay. * Sound. Serious decay.* Sound. Serious decay.* Sound. Serious decay. Entrants boys 59.0 12.5 51.7 15.3 53.0 14.7 54.2 13.2 ,, girls 58.4 12.4 50.7 1.5.2 52.2 14.9 53.6 13.5 8-year-old boys 58.5 10.0 61.1 8.1 66.7 6.8 67.0 5.7 „ girls 58.0 10.2 60.9 8.3 65.4 6.8 66.4 5.9 12-year-old boys 68.0 3.4 70.6 2.7 73.1 2.1 74.6 1.7 „ girls 70.5 2.6 72.3 2.3 75.3 1.6 76.2 1.4 Total 621 8.5 60.3 9.3 62.9 8.6 64.4 7.4 * Serious decay = four or more cariou teeth requiring treatment. From this table it will be seen that, while among entrants there is no improvement since 1924 in the proportion of serious dental decay, among the 8-year and 12-year groups the proportion has fallen in 1931 to little more than half of that recorded in 1924. These figures do not necessarily mean a lessened incidence in dental disease, but reflect the efforts of the school dentists and treatment centres to remedy the deplorable conditions which formerly prevailed, and to a lesser extent still prevail. As stated in previous reports, the heaviest burden the school medical service has to bear is undoubtedly the poor condition of the children's teeth, and this is one of the gravest problems that those whose business it is to study the national health have to consider. In the statutory age groups 11,923 children were referred for treatment of enlarged tonsils or adenoid growths ; this is 6 • 6 per cent, of the children examined, compared with 6 • 7 per cent, in 1930 and 7 in 1929. These nose and throat conditions are found chiefly among the entrant group, many of the children in the older groups having already been dealt with before their examination in that age group. Indeed, the rate of operations carried out under the Council's scheme during the past few years has been so high as to exceed one-third of the school population during school life. The percentages requiring treatment for these conditions were :—entrant boys 10-7, girls 10-1 ; 8-year boys 5-1, girls 5-7 ; 12-vear boys 2-7, girls 3-6. Enlarged tonsils and adenoid growths. Otorrhcea was noted in 1,717 children, or 1 per cent, of those examined, this percentage being the same as in 1930. Over half these cases were found in the entrant group. In no year prior to 1930 was the percentage of children with " running ears " less than one ; in 1927 the percentage was 1-3 and in 1913 it was over 2 per cent. The institution of special ear centres for specialist examination of children with discharging ears has produced a considerable improvement. Consequent upon the attention paid in the early stages to conditions which, if neglected, produce deafness, there has been a considerable reduction of the numbers suffering from this defect. Hardness of hearing was found in 444 children, or only • 2 per cent, of those examined. This compares favourably with 453 in 1930, 696 in 1929, and 868 in 1927. Otorrhcea and hardness of hearing. Children in the 8- and 12-year age groups have their visual acuity tested by means of the Snellen cards, those who wear glasses having their vision tested with their glasses. In the 8-year old group 45 • 6 per cent, boys and 46 • 1 per cent, girls, and in the 12-year old group 38-4 per cent, boys and 40-6 per cent, girls were unable to pass the normal vision test. These figures show an improvement of about 2 per cent, on the results obtained in 1930, the improvement being probably due to the breaking down of the prejudice against the wearing of glasses, especially with regard to girls. Defects of a more serious character (i.e., 6-12 or worse in either eye) occurred in 17 per cent, boys and 16-7 per cent, girls in the 8-year old group, and in 18-3 boys and 18-8 girls in the 12-year old group. This again shows steady improvement which has been going on for several years—in 1925 the 8-year old group showed 18-4 per cent, with serious defect, in 1927 the percentage was 18, and in 1929 and 1931 16-8 and 16-9 respectively ; the 12-year old group in 1925 showed a percentage of Defect of vision. 6 Heart and anaemia. Lungs. Tuberculosis. Nervous diseases. Rickets. Deformities. Vaccination. 20.6, in 1927 it was 20.9, in 1929 this percentage was 19.3, and in 1931 it was only 18.5. The improvement is most marked among the 12-year old girls, and there is little doubt that the importance of the early correction of visual defect is becoming more widely recognised among the parents. Teachers dealing with the younger children asked some time ago that consideration should be given to the nature of the Snellen's types used for testing, which presented several difficulties to the modern child in recognising, as distinct from seeing, the letters. At the beginning of the year therefore a new series of test types was introduced in which seriphs to the letters were abolished, and a plentiful use made of letters which have the same form in capital and small type, such as 0, C, X, S and V. Heart defect (functional or organic) was reported in 3,212 children or 1.8 per cent., compared with 2 per cent, in 1930. As usual, older girls presented a percentage (2.2) in excess of older boys (1.8), but the drop from the previous year was greater in the girls (from 2.8 to 2.2 per cent.) than in the boys (from 2 to 1.8). In studies of rheumatism in the metropolis it is found that girls suffer to a greater extent than boys in the proportion of about 3 to 2. It is reasonable to deduce that the figures for heart defect reflect not only this excessive incidence of rheumatism but suggest that the improvement shown may be due to the greater care exercised over rheumatic conditions during recent years, and the more extended provision of hospital beds for this condition. Anaemia was found in 1,918 cases, or 1.1 per cent., compared with 1.2 per cent, in 1930. This is less than half the proportion found in 1926 and corresponds with the general improvement in nutrition. Lung defects were noted in 4,160 children (2.3 per cent.). This is the same percentage as last year. The bulk of the cases are provided by the entrants (3.9 per cent.). These cases are largely bronchial catarrh, especially prevalent amongst entrant infants who present rickety manifestations, although the preponderance of incidence upon infant boys compared with girls does not hold to the same extent as in rickets. There were 66 children in the three age-groups reported to have symptoms indicative of pulmonary tuberculosis, but only 13 of these were not already under treatment. In addition, 64 children had other forms of tuberculosis non-active. The incidence of tuberculosis in any form found at routine inspections is about 1 child per thousand. Epilepsy was noted in 65 cases, compared with 60 in 1930 and 73 in 1929; chorea in 170 cases, compared with 186 in 1930 and 178 in 1929; paralysis in 81 children, compared with 76 in 1930 and 122 in 1929. Symptoms of rickets or the effects of early rickets were noted in 758 children. This is .4 per cent.—the same proportion as in 1930. Infant boys had an incidence of .9 per cent., and infant girls .5 per cent. The stigmata of early rickets tend to disappear as growth proceeds and amongst older children signs were recorded in the 8-year old group of boys in .3 per cent., and in girls .2 per cent., and in the 12-year old group of boys in .2 per cent, and in girls .1 per cent. Spinal curvature accounted for 665 cases (-4 per cent.). Of these, 225 (.8 per cent, of those examined) were among the 12-year old girls, while the 12-year old boys showed .4 per cent. Other deformities were present in 1,594 children (.9 per cent.). This is practically the same figure as in 1930. Records are made of the presence or absence of vaccination marks when children are stripped for medical examination, but no inquiries are made. The following are the results of the doctor's observation of the percentage of children having vaccinal scars: entrants, 48.9; 8-year olds, 55.2; 12-year olds, 54.9; and "leavers" (131) 57.5. These figures show that the percentage of children with obvious vaccination marks is slightly less than last year. In Poplar, Bethnal Green and Shoreditch, where the percentage of entrants noted as vaccinated was very low (22.5, 26.0 and 32.8 per cent. respectively), the "leaver" group showed the percentage vaccinated as 44.1, 40.7 and 49.0 respectively. As was suggested last year, it would seem that in some districts where infant vaccination is low the recent prevalence of smallpox has led to a considerable amount of primary vaccination at school ages. 7 The Council has undertaken the examination of a fourth age group, namely, children who are leaving school. This examination takes place in the term prior to that in which the children are due to leave school. The results of this examination are available at the school-leaving conference, and are of assistance in determining the choice of a suitable occupation. Coming at the end of the school career, the examination is useful in estimating the results of medical attention received since the children entered school. This year's "leaver" group was formed of the children born in the year 1917-18, and consequently the numbers are small, consisting of 19,276 boys and 19,478 girls only. In nutrition they were found to be better than the younger groups, only 3 • 6 per cent. of the boys and 2.9 per cent, girls being classed as poorly nourished, compared with 5.2 per cent. boys and 4.2 per cent, girls in the 12-year age groups. In personal cleanliness this group also shows an improvement on the 12-year olds, 98.1 per cent, boys and 95.4 per cent. girls having perfectly clean heads. On the other hand, the dental condition of this group was found to be slightly inferior to that of the 12-yearold group, for both boys and girls, the percentage with satisfactory mouths being 74 in the case of boys, and 74-8 in the case of girls, compared with 74.6 and 76.2 respectively in the 12-year old group. In other respects the "leaver" children showed an improvement in health over the 12-year old group, with the exception of spinal curvature which affected the girls, but not the boys, to a greater degree. An analysis of the results of medical inspection of children in the age groups does not tell the whole story with regard to the health of the children in the schools. The children are, day by day, under the intelligent observation of their teachers, the school care committees, and the school nurses, and any gross variation from health is unlikely to pass unnoticed. The number of children, not in the age groups for routine examinations, submitted to the school doctors as special cases was 90,248, and this figure does not include another 25,596 which came under inspection in the course of enquiries into outbreaks of infectious diseases. Although the number of children seen at special inspections was much less than one-half of the number seen in the routine age groups, yet in the case of many diseases the actual numbers found in the former generally exceed those in the latter. Thus 999 children with scabies were referred for treatment at special inspections, compared with 99 only at routine inspections. Heart trouble requiring treatment was detected in 267 children at special inspections, compared with 248 at routine inspections. So far as tuberculosis is concerned 98 children were referred for treatment from special inspections, but only 32 from routine inspections (including that of the "extra" leaver group). In regard to epileptics 96 first came to notice at special inspections, compared with 20 at routine inspections; and 240 children with chorea were referred for treatment at special inspections, compared with 82 at routine examinations. It is clear, therefore, that full advantage is being taken of the doctors' visits to the schools and that really ailing children are promptly brought under medical advice. In 1931 there were no striking changes in the physical state of the children, but the general improvement which has taken place during the preceding years has continued, and new records have been achieved. Personal hygiene in particular has made noteworthy advance; the nutritional state of the child population has been maintained. Nowhere is there any sign of falling off. Although minor conditions of departure from health remain common, yet the grosser manifestations of disease are becoming more and more rare. The special supervision of rheumatic conditions in the school child is reflected in the lessened incidence of cardiac disease. The progress during school life is towards healthier conditions, and the leaver child is the healthiest of all the groups, both in boys and girls, save for a slight failure to maintain the improvement in dental conditions, and the continued slight increase of spinal curvature in the older girls, who, at the end of elementary school life, are growing faster than the boys. The health of the leaving child. Special examinations. Conclusions. 8 At the request of the local branch of the Invalid Children's Aid Association an attempt is being made to see, as special cases, in Southwark, as many children as possible on their return to infants' departments after absence for measles. An analysis of the first hundred cases examined shows that the most constant sequela is enlargement of the glands of the neck (49 per cent.), next in order comes unhealthy condition of nose and throat (36 per cent.). Many of the children suffered from bronchitis or broncho-pneumonia during the attack, and in 20 per cent, there were signs of bronchial trouble still present on return to school. Anaemia was also recorded in 20 per cent, of the cases. Nine per cent, had some trouble with their eyes, such as blepharitis or conjunctivitis, and some of them suffered from squint. Ten per cent, were found to be undernourished, while 5 per cent, had otorrhcea, and 5 per cent, had skin affections such as eczema or herpes. Sixteen per cent, were recommended for convalescent treatment as the result of the medical examinations, and 45 per cent, for malt and oil or milk in school. It is evident that a routine examination of infants on return to school after measles would be a desirable practice. It is, however, hardly a practicable proposition, as the examination to be useful must be immediately after the return to school, and the vast numbers of children suffering simultaneously in London during epidemic periods makes the task an impossible one. The reorganisation of schools on the lines of the Hadow Report is progressing apace. The principal organiser of children's care work, in the section on " followingup " in this report, discusses the repercussion of this reorganisation upon the care committee system. The changes being made have brought new problems for solution in regard to medical inspection. During the actual period of change there is being experienced some difficulty in arranging beforehand for the visits of the medical officers, owing to the uncertainty of the amount of work to be performed in each portion of the reorganised group of schools. A desire has been expressed by the managers and care committees of reorganised groups that the same school doctor should visit all the schools in the group, so that members of each family attending the individual schools shall all be seen by the same officer. This conflicts with a desire sometimes expressed that older boys' schools should be inspected by a man, and older girls' schools by a woman doctor. In secondary, technical and elder children's special schools, where the majority of the pupils are above thirteen years of age, the latter desideratum is fairly rigidly observed, but in elementary schools adherence is given to the policy of the same doctor for the whole group. The reorganisation of schools has also given further point to a desire that in London the incidence of the age groups selected for medical examination should be altered. At present all school children are inspected (i) on entrance to school, (ii) on reaching the age of 8 years, (iii) on reaching the age of 12 years, (iv) in the term before that in which they are due to leave, i.e., on approaching 14 years of age. The two last examinations are rather crowded together and both fall within the period spent in the senior schools. It is at the age of eleven that children are selected to pass to senior schools, including scholarship holders to secondary schools, those winning places in central schools, and those drafted to senior schools within the reorganised groups. It would be more convenient if the third age group selected were at age eleven rather than age twelve. There would be some saving of special examinations of scholarship candidates, all children with defects would be detected, and opportunities given for treatment before their final school remove. The age for transference to special school is seven years. In their recent report the Board of Education's Special Committee on Defects of Vision suggest that it would be a great advantage if all children had their eyesight tested at seven years of age. It appears, therefore, that it would be a logical scheme to bring the ages of medical inspection into organic relationship with the educational system by arranging Sequelae of measles. Reorganisation of schools. 9 the inspections to coincide with the breaks in the child's school life so that the inspections should fall (i) on entrance to school, (ii) at the age of seven years (first remove), (iii) at the age of eleven years (second remove), and (iv) at school leaving. The Council has approached the Board of Education with a view to sanction being given to the above alterations in the age periods. Medical inspections at secondary and trade schools. In the maintained secondary schools medical inspection has been carried out by the school medical staff over a very long period of years. The pupils are inspected in detail on entrance, again at the age of 12, and at the age of 15; in the intervening years the records of all pupils are reviewed, but a detailed examination is only carried out when there is some special indication or request. During the year 1929 the nature of the medical services in the rate-aided secondary schools came under review by the Council. There was found to be a considerable variation in practice in the different schools. In eleven schools the medical inspection of scholarship holders was carried out by the Council's doctors while there was no medical inspection of fee-payers. In nine the medical inspection of scholarship holders was carried out by the Council's doctors, and of fee-payers by doctors appointed by the governors. In ten the medical inspection of both scholarship holders and fee-payers was carried out by the Council's doctors, and in 22 the medical inspection of both scholarship holders and fee-payers was carried out by doctors appointed by the governors. The Council considered it desirable that all pupils (fee-payers and scholars) should be medically inspected, and the governors of 11 schools, where no medical inspection of fee-payers was held, were informed that the Council would be prepared to undertake the work if the governors so desired. It was further considered undesirable that there should be two doctors attending the same school, one for the inspection of the Council's scholars and the other for fee-payers. The regulations governing medical inspection and treatment in the secondary and trade schools embodying the decision of the Council are as follows :— (a) Medical inspection and treatment shall be provided for all pupils at the Council's secondary schools and for pupils holding scholarships or free places awarded by the Council at secondary schools aided by the Council. On application being made by the governing body, medical inspection shall be provided by the Council for fee-paying pupils in aided secondary schools. In addition to the statutory medical examination on admission, pupils attending the Council's secondary schools shall be medically examined at 12 and 15 years of age, and further medical examination shall take place only in cases in which a special examination appears to be necessary. (b) In secondary schools at which fee-paying pupils have been inspected by the Council's medical officers or doctors appointed by the governors, arrangements shall be made when necessary for such pupils to receive medical treatment under the Council's scheme, provided that (i) the parents cannot afford to make private arrangements for the necessary treatment, and (ii) payment is made therefor. (c) Foundation scholars in aided secondary schools may receive medical treatment under the Council's scheme on the same terms as scholarship holders. (d) On application being made by the governing body, medical inspection shall be provided by the Council for pupils in attendance at non-aided secondary schools, provided that the cost thereof shall be refunded to the Council by the governing body. (e) Pupils attending trade and domestic schools aided by the Council, where no system of medical inspection is in force, shall be periodically examined by the school medical officer. (/) Arrangements shall be made for the medical inspection and treatment of pupils holding the Council's scholarships at trade schools. Secondary, etc., schools. 10 (g) Candidates for the teaching profession shall be medically examined on entry into a secondary school, on entry into a training college, and on leaving a training college. Further medical examination shall take place only if the parent of the intending teacher or head master, head mistress or principal has doubts as to the suitability, on grounds of health, of the candidate for the teaching profession, or if the result of the preceding medical examination indicates that the case is one which requires to be kept under review. Following upon the decisions of the Council in 1929, negotiations have been conducted, as a result of which medical inspection has now been introduced into all the aided secondary schools, and the difficult situation arising from the visitation of schools by two different doctors has been removed. The present position is shown in the following table :— Analysis of Medical Inspection at Trainino Colleges, Technical Institutes and Secondary Schools. Schools, etc. Type.* Pupils examined by Total. Council doctor. Governor's doctor. Training colleges A 6 — 6 B — — C — — Technical institutes (including trade and domestic schools.) A 22 — 51 B 5 24 C — — Secondary schools A 28 — 84 B 22 31 C 1 * A = Maintained. B = Aided. C = Non-aided, t In seven schools fee-payers only are examined by the governors' doctor, while scholarship holders attend for inspection at the County Hall. X In addition, children holding scholarships at 15 non-aided schools attend for examination at the County Hall. The figures subsequently analysed are derived only from the 84 schools in column 3 where the medical inspections are carried out by the Council's own staff. No detailed reports of medical inspections are received from the schools in column 4, but the record cards of all scholarship children examined are sent for the school medical officer's inspection at the end of each term. The arrangements for treatment are as follows : a notice drawing the attention of the parent to the need for treatment is sent by the principal, and, if the parents are unable to make the necessary arrangements, facilities are offered at the school treatment centres on the understanding that the full cost of treatment is borne by the parent in the case of fee-payers, but in the case of Council and foundation scholars, the charges are the same as for children in elementary schools. The following table shows the number of pupils examined by the Council's school medical staff :— Number of Pupils. Schools, etc. Secondary schools. Technical schools. Scholarship holders at schools not examined. Training colleges. Total. Maintained by Council 6,135 1,797 — 1,233 9,165 Aided by Council 3,776 652 | 396* — 4,428 Unaided schools 295 — 691 Total 10,206 2,449 396 1,233 14,284 * Examined at County Hall. 11 During the year 14,284 pupils were examined, an increase of 814 over the previous year, and in 4,096 cases records were reviewed, but detailed examinations were not deemed necessary. As might be expected, the children in the secondary schools show a general superiority in physical fitness over children in the elementary schools. In four cases the clothing was found to be poor and in one girl infestation with head vermin was noted. The percentage of children, aged 12, with sound teeth was: boys, 75.7; girls, 79.7; but at the age of 15 this percentage had fallen by 6 per cent, among boys and 4 per cent, among girls. Of cases of widespread dental decay where 4 or more teeth were affected, the percentage among boys and girls of 12 years old was 1.1 and .9 respectively, compared with 1.7 and 1.4 in elementary schools at this age. At the age of 12, 70.4 per cent. of the boys and 68.7 per cent, of the girls were able to pass the vision test, compared with 61.6 and 59.4 in elementary schools; but, whereas in elementary schools the vision of children leaving at 14 years of age is better than that of the children of 12, the reverse is the case in the secondary schools, suggesting that the more serious strain in reading has a detrimental effect upon the eyesight. In secondary schools 15.7 per cent. of the boys and 18.5 per cent. of girls were wearing glasses at the age of 12, but at age 15 the percentages were 17.1 boys and 19.8 girls. The children in secondary schools are, as far as scholarship cases are concerned, selected children, and no child is admitted who is deemed incapable by reason of illhealth of benefiting from the education provided. Cases of heart disease, defects of nose and throat, and ear disease are rarer than in elementary schools, where there is no selection beyond that of drafting to special schools. Yet in the secondary schools there are more cases of postural defects such as curvature of the spine, again showing the effect of more intensive study, and in these cases also the incidence is higher at the age of 15 than at the age of 12. Of the 1,233 students examined in training colleges, 5 were found to be suffering from extensive dental caries; 76.5 of the men and 77.4 of the women passed the vision test, but 30.9 per cent, of the men and 31.9 of the women were wearing glasses. The re-inspection of 3,225 pupils (involving 3,494 ailments) was carried out; 1,602 defects had been remedied, 877 had improved, and in 1,015 (mostly dental cases) there was no improvement. There is, perhaps, still too little attention paid in certain places of higher education to the pursuit of health, and it may be that sacrifice is made to striving for examination results at the expense of the cultivation of healthy bodies. Following-up. The returns of the school doctors who re-inspect children found at the routine inspections in elementary schools to be ailing and in need of treatment make it possible to compile a statistical record of following-up. During 1931, 169,029 children were re-inspected; 132,622 had been noted as having one or more ailments requiring treatment, and 36,407 were being kept under observation. At the first re-inspection 108,797 cases of defects requiring treatment and 23,333 observation cases were reviewed. At the second re-inspection 61,077 treatment and 13,074 observation cases not cleared up at a first re-inspection were again reviewed. By combining the results of both re-inspections it is found that 81.6 per cent. of the children re-inspected were treated or discharged as no longer requiring treatment. This result is .9 per cent. better than last year and is the highest percentage yet recorded. Dental condition. Vision. Training colleges. Re- inspection. 12 First Re-inspections, 1931. (Percentages are given in italic type.) Defect treated. Treated. Untreated. By private doctor. Under Council's scheme. At other hospitals. Cured naturally. Improved. For observation only. Still needing treatment. Cured. Not cured. Cured. Not cured. Cured. Not. cured. Refraction 19,839 167 76 5,173 2,804 591 396 1,264 3,734 5,634 0.8 0.4 26.1 14.1 3.0 2.0 6.4 18.8 28.4 Minor ailments 6,983 198 34 1,704 482 432 271 1,855 910 1,097 2.8 0.5 24.4 6.9 6.2 3.9 26.6 13.0 15.7 Nose and throat 16,955 56 16 5,963 298 1,052 102 1,484 1,885 6,099 0.3 0.1 35.2 1.8 6.2 0.6 8.7 11.1 36.0 Teeth 53,600 1,369 308 22,072 687 1,602 178 3,863 865 22,656 2.6 0.6 41.2 1.3 3.0 0.3 7.2 1.6 42.3 Other ailments 11,420 233 80 203 428 1,396 1,217 2,685 3,523 1,655 20 0.7 1.8 3.7 12.2 10.7 23.5 30.9 14.5 Total 108,797 2,023 514 35,115 4,699 5,073 2,164 11,151 10,917 37,141 1.9 0.5 32.3 4.3 4.7 20 10.2 100 341 Second Re.inspections, 1931. Refraction 13,530 86 68 2,471 1,501 372 326 1,194 3,246 4,266 0.6 0.5 18.3 11.1 2.7 2.4 8.8 24 0 31 .5 Minor ailments 3,437 48 16 582 347 181 160 925 501 677 1.4 0.5 16.9 10.1 5.3 4.7 26.9 14.6 19.7 Nose and throat 9,988 26 1 2,581 102 615 67 1,461 1,532 3,603 0.3 0.0 25.8 10 6.2 07 14.6 15.3 36.1 Teeth 27,010 728 176 8,803 349 822 99 2,798 587 12,648 2.7 0.7 32.6 1.3 30 0.4 10.3 2.2 46.8 Other ailments 7,112 74 54 135 326 635 720 1,749 2,481 938 10 0.8 1.9 4.6 8.9 101 24.6 34.9 13.2 Total 61,077 962 315 14,572 2,625 2,625 1,372 8,127 8,347 22,132 1.6 0.5 23.9 4.3 4.3 2.2 13.3 13.7 36.2 Cases referred to the N.S.P.C.C. Aural disease and scarlet fever. Children's care committees. Organisation and duties. 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 the necessary treatment. In certain cases the Society takes legal proceedings under section 12 of the Children Act. During 1931, 721 cases, involving 830 defects, were reported to the Society : these included 375 dental defects, 292 vision cases, 84 nose and throat affections and 30 cases of ear disease or deafness. Owing to the close connection between certain infectious diseases and ear trouble an arrangement is made by which notification is received of children who have suffered from ear discharge while in a fever hospital. The names of infants under school age are sent to the local medical officers of health for the necessary action, while children of school age are examined by the school doctors at intervals of six months, until at two consecutive examinations no symptoms of the disease are found. The number of cases reported was 269, of which 32 were forwarded to borough councils or other local authorities. Of the cases followed up at school, 15 were found on the first examination to have otorrhcea, 8 of these had cleared up on second examination, and 3 were still affected ; the other 4 had not yet had a second examination. Two cases which were free from discharge at the first examination were found to be affected at a second inspection. All the cases not cleared up are being kept under observation. The following.up of children found to be in need of treatment or special observation is carried out by the school care organisation. The activities of the care organisation have been described as follows in a recent report by Miss Helen Nussey, the principal organiser :— There are approximately 1,000 elementary schools in which some 630,000 children are educated. For each school the Council has organised a care committee, which is a self.governing 13 body appointing its own chairman and honorary secretary. Every borough has a local association of care committees, composed of persons appointed by the Council and of representatives of the care committees and teachers. They are entrusted with the general supervision under the Education Committee of the work of the children's care committees of their respective areas. A staff of 155 professionally-trained women co-ordinate the work of the volunteers and give guidance to new members. When the Council decided to give an opportunity for the co-operation of the private citizen in work for the community by delegating to children's care committees certain of its duties, the trail had been already blazed by voluntary workers who had banded together to work for the children in the poorest schools, and who had clearly demonstrated the need to consider every handicapped child, not only in the light of its personal and immediate needs, but in relation to its home environment and ultimate well-being. In establishing the care committees the Council hoped that, by using the spirit of service which was everywhere abroad, bare Acts of Parliament could be interpreted in terms of human fellowship and understanding, and further that parents would personally be made aware of the many opportunities the London education service offered for the well-being and development of their children. The actual responsibilities of the care committees include the duty of:— (a) Seeing that no school child in need of food is unprovided for, either at home or through the school, and discriminating between the necessitous and non-necessitous home. (b) That no child found by the school inspecting doctor to require medical treatment or advice fails to receive it. (c) That no child leaving school shall do so in ignorance of the possibilities the district has to offer in the way of suitable employment, further education and social recreation. Under the Provision of Meals Act, 1906 (now Education Act, 1921, sections 83 and 84) application for free meals is made to the head teacher who has the power to grant emergency meals should the physical condition of the child warrant them. The honorary secretary of the care committee is immediately notified in order that arrangements for a home visit may be made to ascertain the cause of the trouble as it presents itself to the parents. A definite statement of income is taken and a friendly talk about ways and means ensues. The circumstances of the families of children who are fed for more than six months are reported to the chronic and difficult cases committees of the local associations, whose duty it is to advise what further action should be taken. The Act was intended to deal with malnutrition, which may have many causes. The care committee system is an attempt to find out and deal with the causes, whether physical or economic, and in this attempt the workers co-operate with the school doctors and the teachers and consult with others interested in the family, as well as enlisting the assistance of suitable social agencies of the neighbourhood. Milk meals are given in school on payment of cost price, or free or for part payment, on the recommendation of the school doctor on medical grounds, and on the decision of the care committee on economic grounds. A very large number of children have milk on payment into milk clubs arranged by the teachers. The figures in July, 1931, for official milk, i.e., milk given on a doctor's advice, were :— Number of children receiving milk for payment ... ... 14,300 Number of children receiving milk free ... ... ... 8,190 Under the Administrative Provisions (Medical Treatment) Act, 1907, (now Education Act, 1921, section 80) a routine inspection of each child takes place four times in its school career (in addition to a dental inspection in the intermediate years up to the age of 12) ; as an entrant (medical information is passed on from the infant welfare centres), at 8 and at 12 years of age, and the term before leaving school, but children's care workers, teachers and attendance officers are encouraged to present to the school medical officer children who seem to need medical advice between the official age groups. A care committee worker is present with the doctor at each medical inspection and is thus enabled in most cases to make immediate arrangements for treatment. Opposition to medical inspection having now practically disappeared, the mothers usually attend the inspections well, especially where the younger children are concerned. (In 1931 the attendance of parents at infants' inspections was 89 per cent., and the attendance of parents at all inspections 74-5 per cent.) The absent mother is visited afterwards by the children's care worker and the doctor's report explained. For such ailments as defective viRion, enlarged tonsils, dental decay and various skin complaints, comprised in the term " minor ailments," the Council makes provision by supporting " medical treatment centres," managed by local committees, or, if within a voluntary hospital, by the hospital board. A children's care organiser makes appointments at these on the application of the care committee secretaries and keeps them in touch with the progress of the case. The Council is statutorily bound to make a charge for treatment, but in cases of necessity the cost may be reduced or remitted by a decision of the care committee. About 300,000 children receive treatment at the centres every year, but the percentage of those claiming inability to pay is comparatively small. Medical treatment for other ailmenta can be obtained at various hospitals and the Council itself makes provision for in-patient treatment for tuberculosis, rheumatism, external eye trouble and other serious diseases in children. In addition, about 100 London children are sent every Provision of meals. Medical treatment. 14 Children Act, 1908. Children's moral welfare work. Behaviour problems. Backward children. week to residential schools maintained by the Council for delicate children who have as yet no physical signs. In all these cases the children's care workers are doing what is necessary with the parents in regard to persuasion, payment and outfit. A great change is coming over public opinion in regard to medical, and even dental, treatment. In 1931, 81'6 per cent, of the children found through medical inspection to be ailing were finally treated or discharged as no longer requiring treatment, the best result ever attained. The same year the Council's consulting dental surgeon, in reporting that 138,000 new cases were admitted to dental centres under the Council's scheme, attributed this figure largely to " the excellent and continuous work of the care committees." The strong opposition to the wearing of spectacles is also breaking down, not least because of the activities of spectacles clubs, whereby the care committee worker collects the necessary pennies regularly each week. Often the spectacles club is run side by side with a boot club, which encourages thrift and foresight and incidentally helps to solve the problem of sound, inexpensive footwear. Dr. Eric Pritchard, Chairman of the Executive Committee of the National Baby Week Council, recently advised those who wished to see the change which had taken place in child life during the last thirty years to take a walk down Whitechapel or the Old Kent-road any day at about 4 o'clock when the children are hurrying home from school. " The physique, clothing and cleanliness of the children are at least a hundredfold better than they were thirty years ago and at least 50 per cent, better than they were eleven years ago." The Education Act, 1870, which Sir William Hamer has described as the greatest Public Health Act ever placed on the Statute Book, the school medical service subsequently instituted with its school doctors and nurses, and the untiring zeal of the care committee workers in following up the advice of the doctors, have all had their influence in this general improvement. The majority of parents are sincerely anxious to do the best they can for their children, but there is still a mass of ignorance and carelessness to contend with. Where friendly offices fail the neglect is handled officially either by a special officer of the Council or in more serious cases by the National Society for the Prevention of Cruelty to Children, to whom the Council leaves prosecution cases under section 12 of the Children Act, 1908, which deals with neglect to provide medical aid, etc. In contemplating the enormous elementary school population of London—well over half a million—it is remarkable how seldom the need arises to resort to the more drastic methods. A special group of officers has been appointed by the Council to deal with all charges under sections 58 and 59, which deal with children liable to be sent to industrial schools, etc. The care committee always has an opportunity of reporting on its previous dealings with the family involved, and this information may prove an important factor in the decision of the Court. Often, too, the care committee is made to realise through a charge having been brought that things are not well in a particular home, and, if the child has not been placed on probation, the committee renew their efforts to provide what is most needed—often recreative outlets for a healthy young person who is getting into trouble for lack of them. When the searchlight of the children's care organisation was turned on the darker places of child life, some very serious instances of moral offences against children were revealed, and in 1912 definite arrangements were made for handling these cases through the organising staff. A small committee of members and officers of the Council was formed to raise voluntary funds to enable them to do what was best for each child, unhampered by difficulties of finance when parental and local resources were insufficient. Gradually, however, voluntary societies were formed in each district to provide a trained worker—called the children's moral welfare worker—for this highly specialised work, which it was clear should be a first call on the time of anyone undertaking it. The work is carried out in close collaboration with the district organiser, who delegates her responsibility for the personal side of it to the worker, while remaining responsible to the Education Committee for all action taken. The essence of the system is to maintain close co-operation with the police with a view to supplementing their action on the social side whenever this is desirable. Among the many difficulties about which parents consult care committee workers and teachers are problems connected with the children's behaviour, which is sometimes of the abnormal or anti-social type causing anxiety and threatening serious consequences later on. Early consideration of such problems may help many children to adapt themselves who would otherwise swell the numbers of those charged in the juvenile and adult courts. Certain clinics for " child guidance" are now available. Here the child's behaviour and point of view can be studied in the light of a full examination of his physical, psychological and intellectual equipment, and of his home and school environment. In the framing of a " diagnosis and treatment " plan, the knowledge of the family background possessed by the care committee is of great value ; and, with the help of experts, care committee workers are gaining fuller understanding of the psychological needs of children and parents. This growing insight is helping them not only to share in bringing about the social readjustment suggested by the clinics, but, more valuable still, it is leading to preventive work when very early signs of children's difficulties begin to appear. Certain care committees have made special efforts to help backward children in the hope that early concentration on the problem may help the child to make a better adjustment in school and thus lessen the handicap when a start has to be made in the industrial world. Where, as so often happens, backwardness is due to causes that lie in the home environment or in the physical 15 condition ot tnr child, their help may be very valuable. The fact that teachers are ready to refer such children to the care committees implies close collaboration and a clear appreciation, on their part, of the social point of view. Children's care workers have a unique opportunity of seeing the evil effects of bad housing on the elementary school population. Physical deterioration of the children, due to overcrowding, insufficient sleep and nervous strain, cannot escape their observation, and the recognition that improved housing is fundamental for social progress has on occasion led care committee members to concentrate almost entirely on this aspect of their work. Many individual care committees bring flagrant cases of overcrowding and bad conditions to the notice of the housing authorities, and two local associations have a sub-committee with the same object in view. Many care workers are to be found as members of local voluntary housing committees, whose object it is to re-condition unsuitable habitations at small cost. One care committee member is known, after studying the problem in other areas, to have inaugurated one of these housing schemes which is reported to " bid fair to bring about a complete transformation in what has been for many years one of the dingiest, most insanitary and overcrowded spots in London." Recent reports of the Board of Education point to the fact that what it terms the " load of disability " in child life is lifting. Not the least important factor in this change is the higher standard of education and sense of responsibility on the part of parents. It is increasingly possible to leave the initiative to them when the physical well-being of their children is at stake, with the consequence that the care committee, less preoccupied by individual propaganda on behalf of health and hygiene, and less concerned with the making and keeping of appointments at hospitals and treatment centres, can turn attention to less obvious problems and to more general propaganda on cognate subjects. Health lectures to groups of parents and older children and encouragement of such an organisation as the Junior Red Cross, with its concomitants of observance of simple health laws and formation of a sense of social responsibility, have been found to stimulate the growth of sound principles to a remarkable extent. The reorganisation of the schools in accordance with the recommendation of the Hadow Report, i.e., the transfer of all children to senior schools at the age of II, is having a profound effect on children's care committee work, in that it involves a re-orientation of ideas. Hitherto care committee work has generally been very closely connected with the individual school to which all the members of one family went. The head teachers and the care committee workers consulted eacn other constantly and very often the families were intimately known to both. The care committees now have to consider how, with the children of one family attending Beveral different schools, they can retain the ideal of one visitor to each family and yet preserve the link between the school and the home. A possible line of development will be that, while in the junior schools the care committees will concentrate on the home visiting, in the senior direct contact with the children of an age to be co-operators in plans for themselves might prove to be the best method. The care committees have so far adapted themselves and grown with changing conditions, and it is hoped that they will once more prove their vitality, and, surviving the disrupting effect of reorganisation, will be able to join in the educational ideals expressed in the Hadow Report. Schools and Homes transferred from former Poor Law Authorities. Last year reference was made to the various schools and homes transferred to the Council's jurisdiction from the former poor-law authorities. During 1931 further steps have been taken to devise as far as possible a uniform system of administration of the medical arrangements, notably in connection with infectious diseases, by the organisation of a scheme of medical certification, daily supervision by a nurse and prompt removal from the institutions of cases of infectious illness, thus obviating the necessity for quarantine, and rendering redundant accommodation formerly reserved for probation and observation purposes. Also steps were initiated towards arranging for the immunisation against diphtheria of the children in those schools and homes where the managing committees had assented to the scheme. (Further reference to these matters are made on page 94 of this report.) The arrangements made continued during the year whereby cases of otorrhcea from these schools were temporarily lodged at the Andover children's homes, Islington, and the Hornsey Rise Home while attending the after-care clinic, Kentish Town, for ionisation treatment (>ee p. 24). Attention was given during the year to the system of dental hygiene at the homes. From the preliminary survey made of these institutions by Dr. Margaret Hogarth, it appeared that in practically all of the homes some system of dfntal inspection and treatment had been provided, but that in two of the institutions, viz., Cumberlow Lodge, South Norwood, and the Hornsey Rise children's home, Islington, no provision had been made for routine oversight by dental surgeons. Housing. Attempts at group education. Reorganisation of schools. Residential schools and homes. Ionisation. Dental treatment. 16 Dietaries. Accordingly, Dr. Alexander Livingston, the then consulting dental surgeon of the Council, was asked to prepare schemes for these two homes, both of which were for the accommodation of children under 5. In the case of Cumberlow Lodge (which is outside the county) a local dental surgeon was appointed to inspect all children at the Lodge at half-yearly intervals and to deal with any cases requiring treatment at his surgery. With regard to Hornsey Rise, advantage was taken of its proximity to the Holloway treatment centre, where the Council had made arrangements for the dental treatment of day school children from neighbouring schools, to arrange for one of the dental surgeons working at this centre to visit the home at six-monthly intervals and to treat at the Holloway centre all cases requiring attention. In the last annual report it was stated that a uniform dietary for these institutions was considered desirable as an early measure of reform. During 1931 all the dietaries in use were carefully examined, and the character and suitability of the meals noted. Perhaps the greatest difficulty to be met in feeding children in institutions in this country is that of ensuring a sufficient supply of water soluable anti-scorbutic vitamin C during the winter months. This vitamin is destroyed by cooking, and winter milk cannot be relied upon to provide it. It is found in fresh fruit and raw vegetables, especially swede j uice and in tinned tomatoes. At one important children's institution the difficulty had in the main been surmounted by giving raw salads during the winter. These consist of raw cabbage, beetroot, carrots, turnips and other produce of the garden passed through the mincing machine and served (all raw) mixed with sauce. Salads such as described are found to be most acceptable to all the boys, and they had also been successfully given to children of all ages and both sexes in the Leytonstone school. Undoubtedly, occasional meals with butter not only add to the interest of the meals and the taste of the food, but also give the necessary amount of vitamin D. Generally the supply of fresh fruit was inadequate. Some fresh fruit should be given to every child every day, especially the young ones. Also the calcium content of the food was often poor and, with so much carbohydrate given, calcium metabolism is interfered with. As a result of the investigation a new dietary was approved for use at the residential institutions under the control of the Education Committee. The diet is presented in the form of a table of foods for each separate meal of the day, but the choice of menu for any one day is left to the authority at each school, so that a very great field is left for variety in the selection of the daily menu and also in the methods of cooking and serving the food ; above all, it is pointed out that the regular recurrence of one particularly uninteresting item on the same day every week throughout the year should be avoided. As margarine, while useful as a source of heat, has ordinarily no vitamin value, butter is introduced into the dietary twice a week, both at breakfast and tea time. Deficiency in vitamin C is made up by the introduction of a daily fruit ration in addition to the provision of raw salads throughout the year. In view of the fact that apples are our best medicofuge and have the property of leaving the mouth in a clean and wholesome state, the fruit ration is prescribed in a form of a definite amount of apple to be taken every day as the last item of food. An addition of cheese at tea time twice a week has been introduced as a correction of the calcium deficiency in the dietaries generally. The caloric value of the dietary for children of 10-15 years is about 3,000 per 24 hours, an average of 35 calories per pound body weight. The protein, fat and carbohydrate value will be approximately 100 grms., 110 grms., and 425 grms. respectively. The new scale thus provides at a reasonable cost a well-balanced dietary, giving ample quantities of the proximate food principles, and meets the necessities in regard to vitamin content. Notwithstanding anything in the dietary table the children are to be fed according to appetite and the superintendents of the institutions have been requested to observe the heights and weights of the children, in order that the whole question 17 may be reviewed at the expiration of a period of six months from the date of the adoption of the new dietary scale, which is set out below :— Provisional Dietary Scale for Residential Homes and Schools. Breakfast. Amount. 11 a.m. Dinner. Amount. Tea. Amount. Supper. Age 3-9 yrs. 10-15yrs. 3—9 yrs. Age 3-9 yrs. 10-15 yrs. Age 3-9 yrs. 10-15yrs. Over 9 yrs. Porridge ½ oz. raw 1½ oz. raw Milk, jpt. Meat, beef, such as top side, 3 oz., or 4 oz. uncooked ; leg, 3½ oz., or 5 oz. uncooked ; ox cheek, aitch bone, brisket, 4 oz., or 6 oz. uncooked. * Four times a week. Bread (white, brown or currant) 5 oz. 6 oz. Children over 9 years who choose it to have supper consisting of a slice of bread (2 oz.) and margarine (£ oz.), 1 hour before bed-time. (Rolled oats or medium Scotch meal and milk twice a week) ½ pt. ½ pt. Margarine or dripping (5 days a Bread (white or brown) 3-6 oz. 4-8 oz. Mutton, such as leg, 3 oz., or 4 oz., uncooked; breast or neck, 4 oz., or 6 oz. uncooked. week) ½ oz. ½ oz. 2 oz. cooked. 3 oz. cooked. Butter (twice a week) ½ oz. ½ oz. See note + Margarine (80 per cent, animal fat) twice a week: dripping 2 days a week ½ oz. ½ oz. Liver, pork, bacon, rabbit. Corned beef (once a week) 2 oz. 3 oz. Fish (once a week) 4 oz. cooked. 6 oz. cooked. Jam or treacle or honey (once a week) 1 oz. ½ oz. Butter twice a week ½oz. |½oz. Soup (pea or lentil) or meat broth (allow ½ oz of meat uncooked). Once a week. 8 oz. ½ pt. Tomato cheese (twice a week)f ½ oz. ½ oz. Herring ($) or filleted haddock (2£ oz.) once a week 2½ oz. 2½ oz. Potato 4—5 oz. 4—8 oz. Apple ft 2½ oz. 2½ oz. Strict attention to be given to the cleansing of teeth immediately before bed-time. Fresh vegetables in season (greens, carrots, turnips or onions) or 4 oz. 5 times a week 4 oz. at least 3 times a week Cake once a week (bread ration reduced) 3 oz. 4 oz. Fried bacon or slice of cold bacon or rissole twice a week 1½ oz. 1½ oz. Dried peas and beans 2 oz. not more than twice a week. 2£ oz. not more than 3 times a week. Tea: ½th pt. of milk per child ½ pt. ½ pt. Marmalade and syrup twice a week ½ oz. ½ oz. *Boiled or milk pudding 5 times a week in winter ; twice a week in summer 4 oz. 5 oz. On other days, jam or treacle tart (hot) 4 oz. 5 oz. **Fresh salads to be given frequently in place of jam, tomato cheese, etc. Cocoa or coffee (j pt. milk per child) 5 times a week ½ pt. ½ pt. Or fruit pie 4 oz. 5 oz. Or stewed fruit (hot or cold) 3 oz. 4 oz. Or fruit salad of dried fruit 3 oz. 4 oz. With any of these, milk puddings can be served ; the choice of dish depending partly on the prevailing weather 2 oz. 3 oz. Fried potatoes 2 days a week 3 oz. uncooked. 4 oz. uncooked. Additional ingredients each week per child: f lb. of sugar, & pt. milk, 4 oz. flour, 2 oz. fat, J egg, Porridge may be withdrawn from the dietary during the summer months, at the discretion of 2 oz. dates or raisins, condiments as may be necessary. the superintendent, provided that the bread ration is then increased, and that the milk ration is not • Boiled pudding (suet, date, raisin, bread, etc.) made according to the formula of flour 2 oz., reduced, suet | oz., fruit | oz. Bread crumbs may be used in lieu of flour up to one-third of the quantity allowed. Bread is to be served at table in necessary quantities. f Tomato cheese—Cheese without rind to be passed through the mincer and mixed to a paste Potatoes—When potatoes are poor in quality, the ration may be supplemented with rice or dried with canned tomato pulp in proportion of 3 oz. cheese to 2 oz. tomato. This to be spread on bread peas. and margarine. Quantities—Unless otherwise stated, the quantities shown in the table are in an uncooked state. ft Every child to have 2\ oz. of raw apple every day served at the end of the last meal, whether Children under 5 years of age—Children aged three to five should have their food allowances tea or supper. * " adjusted in accordance with age, and the quantities in the table may safely be diminished. Pish at •* Salads—During winter months raw salads should be provided by passing through the mincer this age should be without bones ; coffee and raw salads (with the exception of lettuce leaves in season) O available garden produce : cabbage, beetroot, carrots, turnips, swedes, etc., and serving raw with should be omitted. The full milk and fruit allowances should, however, be strictly adhered to. salad dressing. This may be given at dinner instead of cooked vegetables with cold meat; or at Appetite—Notwithstanding anything in this dietary table, each child shall be fed according to breakfast or tea on days when extras are not available ; or in place of extras on other days. appetite. 18 Treatment in hospital. Enuresis (bed wetting). In the past the cost of feeding has varied considerably as between school and school, but the average weekly cost per child in all schools during the year 1930-31, before the new dietary scale was introduced, was about 4s. 3£d. In a booklet containing the dietary which has been prepared and issued to all the residential schools a series of menus and recipes, compiled from the dietary chart by the Council's superintendent of domestic economy, is included, giving examples of varying meals covering four weeks. It is anticipated that the cost of the new dietary will not exceed that of the old. Further progress was made in unifying the methods of dealing with those children where definite hospital treatment was indicated. Formerly, in some of the homes cases of infectious disease and grave illnesses were treated in a special hospital section within the curtilage of the home. In other instances, it had been usual to obtain accommodation for such cases at local hospitals, but, generally speaking, the principle has now been established that a school is not a proper place in which to nurse children suffering from acute illnesses, and that such cases must be transferred to one of the Council's special or general hospitals, except in the case of serious accidents or urgent cases occurring at the extra county schools, where the officers have been advised to telephone to any local hospital in the first instance. The problem of nocturnal enuresis is one that arises in connection with all residential institutions for children. It is also a matter of deep concern to many parents of children living under normal home conditions; so much so that, when, in 1926, special attention was given to the subject so far as it affected the Council's residential special and open-air schools, it was arranged that a leaflet of helpful suggestions should be drawn up and forwarded to the care committees of day schools in order that they could advise parents when necessary. The matter was also specifically discussed at a conference in June, 1930, at the County Hall of the medical officers of the transferred residential schools. On this occasion several members of the conference explained the methods they employed for dealing with the trouble at their schools. The general impression appeared to be that the psychological factor was of prime importance, that each particular method of treatment had cured a certain number of cases, but that there were a few " obstinate " cases on which existing methods make no impression. In 1931 Dr. W. H. P. Sheldon visited typical residential schools of the " barrack " and the " cottage home " type, and also the training ship " Exmouth," and submitted a detailed report resulting in the following recommendations :— (1) As part of the initial examination when a child is first admitted, examination of the urine for reaction, specific gravity and albumen should be carried out and recorded on the medical record card. In the case of the bed-wetters this examination should be repeated at intervals of three months until such time as the habit is overcome. (2) It would be an advantage if all the homes kept a daily register of enuresis. The register should be kept in a ledger and maintained by the master so that the rise or fall in incidence and the improvement of individual cases could be quickly seen. The following recommendations apply to persistent cases (when a child is temporarily out of health as from a cold or bilious attack, temporary bed-wetting is likely to occur; for these, routine measures are not needed):— (1) General health.—It is important to attend to the general health ; particularly with regard to such disturbances of health as may interfere with sleep. Infection of the nasopharynx, caries of the teeth, disordered appetite, impaired digestion or constipation may all play a part in maintaining the habit. (2) Bedding.—It is important that the children should be warm at night and their beds made so that they can be well tucked up and excluded from draughts. The mattresses should be firmly stuffed, unevenly filled palliasses and mattresses are unsuitable as likely to disturb the sleep, and it is better that the mattresses should be buttoned. The mattresses should be protected from soiling by being covered with a large mackintosh sheet which should be prevented from wrinkling by being ringed at intervals along the edge and tied with tapes to the sides or under the bed. The mackintosh should be covered by a thin blanket and this, in turn, covered by an undersheet. These children often need more bed covering than others, and, as a rule, should be provided with one extra blanket. (3) Chambers and lavatories.—For children under seven years of age chambers should be provided at the bedside and these should not be emptied by the children but by attendants. 19 Older children should use the lavatory. This should be lighted all night. The floor of the dormitories, of the corridor leading to the lavatory and of the lavatory is, in most homes, made of stone and, therefore, all children should have at night socks or slippers under their beds or else the floors should be covered with some warmer material such as cocoanut matting. (4) Fluid intake.—The fluid intake should be limited at teatime to one breakfast-cup of weak tea. As far as possible extra fluid should not be given after this. As, however, in most homes children have free access to the taps, this limitation of fluid would not always be practicable. (5) Rousing at night.-—At bedtime those in attendance should see that the bed-wetters always pass their water before getting into bed. If it is found that these children wet their beds before 10 o'clock it is a good plan to get them up in twenty to thirty minutes after first going to bed in order to pass their water again so as to be reasonably sure that their bladders are properly emptied. Persistent cases should again be roused at 10 o'clock. Regularity in doing this is important and the time of rousing should always be as near 10 o'clock as possible, otherwise it is impossible for the child to acquire a habit of waiting until 10 When roused at 10 the child should be thoroughly awakened so that he realises fully the purpose for which he is got up. As a rule the child should not be roused again during the night. For children below seven a regular night staff should be employed in order to attend to their needs at any hour. In order to facilitate the control of enuresis the affected children should be grouped together at night-time. In the barrack homes the cases should be grouped in that end of the dormitory which is nearest to the lavatory, or, when a few cases only occur, these should be drafted to a dormitory set aside for this condition. In the cottage homes the cases might well be grouped in one cottage under the control of the most suitable foster-mother. The routine measures outlined above should then be carried out. When a child has been dry for three weeks without failure, he should no longer be roused at 10, but should be expected to deal with his needs as the occasion demands. After another three weeks, without failure, in this group, he should be transferred back to a " dry bed " without a mackintosh sheet. One value of this grouping is that it indicates to the child that a dry bed is something to be striven after, and, while there should be no blame attaching to a child for going into the wet ward, he should receive definite praise for getting out of it. (6) Specific measures.■—In nervous children who seem anxious to rid themselves of the habit, but have no confidence in their power to do so, it is often helpful to increase their confidence in their powers during the day. This may be done by making them pass water every hour by the clock during the day. Between these occasions they are not allowed to go to the lavatory. After a week the interval is increased to every two hours and so on until it can be pointed out to the child that he is capable of holding his water without difficulty for as long as four or five hours at a stretch. He will then appreciate that there should be no difficulty in keeping a dry bed until 10 o'clock at night. For dull and backward children such a system is of little use. For them a desire for a dry bed is best encouraged by making it worth their while. They should be roused two or even three times during the night by the attendants so that they are not given a chance of wetting their beds. These children can sometimes be encouraged by incorporating competitive schemes into the routine management, as, for instance, by having a large calendar hanging over each bed. The child rings in colour each day on the calendar when he wakes with a dry bed. One complete month ringed in this way should be the child's object and, in addition to being changed to a dry bed, some suitable reward should mark the satisfactory completion of the competition. As a rule the cure of enuresis lies in the general management of the child by the attendants. The frequent giving of homilies to the children is undesirable, since the children either soon get to know what is coming to them and take no notice, or their incapacity to cure themselves is accentuated into a morbid dread of having a wet bed. Medical measures such as drugs, faradism, etc., play but a minor part, and it should be the aim of the attendants to stop bed-wetting by the children in their homes by their own efforts. Institutional care of children under 3 years of age. The administrative scheme for discharging the functions transferred to the Council by Part I of the Local Government Act, 1929, provides that the Council's Central Public Health Committee shall be charged with the duties relating to the institutional care of " separated "* children under three years of age. The Council, however, in December, 1930, decided that, subject to the necessary accommodation being available and to the selection being made by the medical officer of health, healthy separated children under this age should be admitted to transferred schools and children's homes under the management of the Education Committee. A survey of the whole " nursery " accommodation under the control of the Council was made by Dr. Hogarth, and, as a result, the principle of grading by age was adopted, and the older healthy children of 1^ to 3 years are transferred to the Education Committee's institutions, leaving the younger children in institutions * For definitions of " separated " and " non-separated " children, .tee Annual Report of the Council, 1930, Vol. IV (Part I)—44 Public Health—General and Special Hospitals " (p. 80). C2 20 controlled by the Central Public Health and Public Assistance Committees. Not all the institutions of the Education Committee were considered suitable for " nursery" accommodation, and, as it was estimated that there were about 280 such healthy infants, after some allowance had been made for children at voluntary institutions, etc., it was computed that there was a deficiency of about 65 places in the education nurseries. Structural alterations were accordingly authorised at the Shirley residential school and Leytonstone children's home to cover this deficiency. These two institutions, together with nurseries at Cumberlow Lodge, Hornchurch, and Hutton, will provide 235 cots for the reception of healthy separated children between the ages of ½ and 3 years. About 170 of these children have already been accommodated in the existing nurseries under the control of the Education Committee, and Dr. Hogarth comments on the remarkably rapid increase in their rate of growth and general development and on the obvious improvement in their appearance, and states that the removal of these older children has made possible more suitable arrangements for the younger group of children in the nurseries under the control of the other two committees concerned. Chronic invalidity. The school attendance department reports each month the names of children who have been absent from school for three months on account of illness. Each year the cases on the list for the month of November is analysed and the result gives an index of the causes of chronic invalidity. The following table shows the number of children reported to have been out of school for more than three months in November, 1931, and comparative figures for the three preceding years. There is a considerable drop in the total figures which is possibly due to the removal from the school rolls of the names of children who have been absent for long periods and are receiving institutional treatment, and in many cases, indeed, instruction at the hospital school. The number of children absent on account of rheumatism, chorea and heart disease still forms a very high proportion of the total and proves how largely this group of diseases is responsible for ill-health in childhood, especially among girls, who account for nearly twice as many cases as boys. Nervous disorders (including 41 cases of epilepsy) show a higher proportion than last year, though the actual number of cases is less. Ringworm, formerly a chief cause of prolonged absence from school, accounts for only 9 cases, compared with 129 in 1919. Since the introduction of X-ray treatment for ringworm, the average length of absence has steadily declined and consequent upon the shorter period of infectivity the danger of the spread of the disease has likewise diminished. Among other ailments, respiratory diseases, other than tuberculosis, accounted for 149 cases, and ear disease for 38. Cases out of School for three months, November, 1931, and the three preceding years. Cases. Percentage of total. 1928. 1929. 1930. 1931. 1928. 1929. 1930. 1931. Rheumatism, heart disease and chorea 681 680 678 546 30.95 30.77 32.82 33.67 Nervous disorders 199 148 99 93 9 05 6.70 4.80 5.74 Tuberculosis (all forms) 216 264 295 212 9.82 11.95 14.28 13.07 Anaemia and debility 141 105 129 52 6.40 4.75 6.24 3.21 Ringworm 17 22 22 9 0.77 0.99 1.06 0.55 Skin complaints (excluding ringworm) 56 58 49 38 2.55 2.62 2.37 2.34 Eye disease 62 84 72 70 2.82 3.80 3.49 4.31 Infectious diseases 106 85 73 34 4.82 3.85 3.53 2.10 Other defects 722 764 649 568 32.82 34.57 31.41 35.01 Total 2,200 2,210 2,066 1,622 100 100 100 100 21 Wage-earning employment of school children. During the year 1931, 3,368 applications (3,326 boys and 42 girls) were dealt with under the by-laws for medical certificates in connection with the employment of school children out of school hours. The nature of the work for which certificates were granted is shown below ; the numbers are in respect of boys, the figures for girls being given in brackets : delivery of milk, 222 (1); delivery of newspapers, 1,963 (16); carrying or delivery of goods or parcels, 513 (4); in or in connection with a shop, 303 (6); in a coal yard, 3 ; industrial work at home, 3 ; house work away from home, 17 (5); as a messenger, 70 (1); not stated, 57 (2). Certificates in respect of two or more occupations were granted to 48 boys and 1 girl. In 150 cases the certificates were granted subject to medical treatment being obtained, and in 164 additional cases other conditions were imposed. Certificates were refused on medical grounds to 43 boys and 4 girls. In regard to 6 boys, the provisional certificates were withdrawn on account of non-compliance with the conditions under which the certificate was issued, and the applications of 78 boys and 2 girls were not proceeded with. The number of children examined under the regulations governing the employment of children in entertainments was 281 (43 boys, 238 girls). One child, a girl, was rejected on medical grounds—rheumatism. Thirty-four children, all boys, were referred for treatment in the first instance and given certificates of fitness at a subsequent medical examination. The conditions requiring treatment were dental decay 25, visual defect 7, aural condition 1, skin affection 1. Medical treatment. The arrangements made by the Council for the medical and dental treatment of school children have proceeded upon similar lines to those of the past few years. In the scheme for the year, provision was made for expansion where necessary, and for the establishment of new centres in North Islington, North Kensington, Limehouse, Streatham, and at King's College hospital; of these, two centres, one at North Islington for the treatment of minor ailments, and the other at King's College hospital for eye (refraction) treatment, were opened ; but, owing to inability to obtain suitable premises, the other new centres could not be provided. At the end of the year 1931 there were 73 centres and 17 hospitals included in the Council's medical and dental treatment scheme. In addition the special centre for in-patient treatment of tonsils and adenoids at Woolwich, viz., the Cyril Henry centre, and the dental centre for the residential children at the King's Canadian camp school, Bushy Park, were continued during the year. The following table shows the provision made in 1931, and the number of children actually treated during the years, 1920, 1930 and 1931 :— Ailment. Provision made in 1931. Number treated 1920. Number treated 1930. Number treated 1931. Defective vision 41,600 32,540 43,579 44,686 Ear, nose and throat 20,500 15,800 19,760 20,703 Ringworm 664 2,100 358 268 Minor ailments 78,705 44,440 101,298 101,391 Teeth 147,152 99,220 138,280 139,723 Total 288,621 194,100 303,275 306,771 It will be observed that during the year some 18,000 children in excess of the number for which provision was made were actually treated. This was mainly on account of the large numbers of cases dealt with in the minor ailment departments. Such cases are mainly fortuitous, and it is quite impossible to make a close estimate of the needs of each of the 67 minor ailments centres in the various districts of London. School children employed in entertainments. 22 Eye defects Ringworm. Minor ailments. Ear, nose and throat. Ionisation. Divisional statistics, otorrhoea cases and deaf cases. The total number of eye cases dealt with during the year was 44,686, compared with 43,579 during the year 1930, an increase of 1,107. Approximately 42,000 were cases suffering from errors of refraction, and during the year spectacles were ordered in 30,151 cases ; in 27,939 of these spectacles were obtained, a percentage of 92-6. It is gratifying again to be able to report that, owing to the gradual elimination of the incidence of ringworm amongst the child population in London, it has been possible to reduce still further the provision for the X-ray treatment of such cases. During the year under review the total number of ringworm cases dealt with was 268, compared with 358 during the year 1930, and 1,703 during the year 1921. Nursing treatment of children suffering from minor ailments was given in 101,391 cases during the year, an increase of 93 on the number dealt with during 1930. During the year 20,703 children were treated in the ear, nose and throat departments, an increase of 943 over the number dealt with in the preceding year. There was a considerable congestion of cases awaiting treatment during the early part of the year, and it was necessary to augment the number of beds for the children needing operative treatment for enlarged tonsils and adenoids. This was accomplished by utilising certain of the Council's general hospitals during the summer months, when the normal reduction in the demand for accommodation rendered a number of beds available. This has been very advantageous, as it is recognised that tonsil and adenoid operations are better performed during the summer than the winter months. Towards the latter part of the year there has been a remarkable falling off in the number of cases found to require treatment, and, when it is remembered that during the past decade well over 100,000 school children in London have had operations for enlarged tonsils and adenoids, this experience is not surprising. During the year 1931 the number of throat operations performed was 16,243, compared with 16,215 during the year 1930. The numbers of cases of operations for the removal of tonsils or adenoid growths among school children, and the rate per 1,000 children on the school roll for the years 1923-31 are as follows :— Year. Number. Rate per 1,000. Year. Number. Rate per 1,000. 1923 7,656 11.3 1928 17,372 27.1 1924 8,051 11.8 1929 17,186 28.2 1925 12,179 18.0 1930 18,119 30.4 1926 13,165 20.2 1931 18,178 31.3 1927 14,843 22.8 The number for each year consists of those treated under the Council's scheme, with the addition of those reported at re-inspections to have been treated by various agencies outside the scheme. It will be seen that, of the present children leaving school, at least one in five has had an operation for tonsils and adenoids, but that, if the rate of operations during the past two years be maintained in the future, one in every three of the children entering school at the present time will have had this operation performed by the end of the elementary school life. This emphasises the importance of endeavouring to elucidate the cause of adenoid growths. Table II in the appendix shows the number of children treated in each year since 1910. The special work at the ear centres under the care of the Council's aurist, Mr. A. G. Wells, and his eight assistants, has continued during the year. One new centre at Somers Town was opened, making in all ten centres in various districts of London. The eight assistant aurists attend at the centre and give to the work twenty-four sessions per week between them. The following is the substance of the report submitted by Mr. Wells :— The following tables give the details of the work done in the special aural clinics for otorrhoea and deaf cases respectively ; and these tables show the statistics for the separate divisions of London :— 23 Otorrhcea Cases. Division. Total No. of examinations made. No. of ears examined and treated. No. of ears cured. No. of ears discharged not needing treatment. No. of ears in children lost sight of. No. of ears relapsed. No. of ears still under treatment. Children. Ears. S.W. 3,784 4,714 777 512 166 66 181 156 N. 3,387 4,714 701 423 166 76 130 161 N.E. 2,297 3,220 605 384 46 24 84 137 S.E. 4,480 5,319 771 430 55 42 70 247 N.W. 2,613 3,227 466 237 43 57 54 118 Totals 16,561 21,194 3,320 1,986 476* 265 519 819 * These are in addition to the " Number examined and treated," viz., 3,320, making altogether 3,796 seen. Deai- Cases. Division. Total No. of examinations made. No. of ears examined and treated. No. of ears cured. No. of ears No. of ears in children lost sight of. No. of ears relapsed. No. of ears still under treatment. Improved Unrelieved. Children. Ears. s.w. 106 212 22 2 8 4 4 - 4 N. 181 352 82 17 9 18 14 2 24 N.E. 65 110 29 6 5 2 6 - 10 S.E. 234 434 67 20 25 1 - - 21 N.W. 105 207 60 10 10 12 14 — 14 Totals 691 1,315 260 55 57 37 38 2 73 Classification of Otorrhcea Cases. Cause of suppuration. Total ears. Cured. Referred for mastoid operation. Children lost sight of. Still under treatment. Acute otitis media suppurativa 161 124 6 10 21 Chronic otitis media suppurativa due to (I) Tympanic Conditions (a) Tympanic sepsis (T.S.) 1,586 1,162 — 88 336 (b) Tympanic + granulations 355 178 36 38 103 (c) T.S. + polypi 68 25 22 4 17 (d) T.S. + caries 19 10 — 1 8 (e) T.S. + other conditions 14 8 — 3 3 (II) Tympanic Conditions + (a) Tonsils and adenoids 284 191 3 25 65 (b) Nose conditions 94 61 1 12 20 (c) Mouth conditions 3 2 — 1 — (Ill) Tympanic Conditions + (a) Attic disease 161 54 57 15 35 (b) Mastoid disease (no operation yet done) 147 3 124 7 13 (c) Mastoid disease (mastoid operation already done) 506 240 33 27 206 (IV) Tympanic Conditions + (a) External otitis 44 28 — 5 11 (b) Structure of meatus 2 1 — — 1 External otitis 75 63 — 6 6 Cause undetermined — — — — — Totals 3,519 2,150 282 242 845 24 Residential schools. Audiometer. The first table shows the following points :— (a) The total number of examinations made during this year, viz., 16,561 children, representing 21,194 ears, is greater than last year, when there were 14,844 children representing 17,232 ears. These numbers include only the examinations made at the ten special aural clinics. (b) The percentage of cases " cured " is 65. This figure is obtained by deducting the cases which were lost sight of, viz., 265, from the number examined and treated, viz., 3,320, and comparing this number with those cases which were " cured." (c) The average attendance per ear is approximately six. (d) The proportion of " relapsed cases " is 1 in 6. This proportion is still very high, though not so high as last year, when it was 1 in 5. In the Annual Report for 1930 were enumerated the main causes of these relapses, viz., (1) water entering the ear in some way, and (2) the neglect of ordinary nasal hygiene ; and some of their many complications were stated. It was also recommended that it should be made part of the school routine for teachers of all school classes to occupy five minutes at the beginning and end of both morning and afternoon sessions, in instructing children in the use of the handkerchief (or its substitute), and the correct method of blowing the nose ; also that part of this time should be employed in instructing the children in correct nasal breathing. Since this was written many reports have been received from the assistant aurists of the great incidence of nasal disease, chiefly catarrh and rhinitis, but also of sinus disease, among the children who attend the aural clinics for otorrhcea ; and it has been recognised that the root of the trouble in a large percentage of these cases arises in the nose. The average number of examinations per session throughout the year works out at about 16 children, representing 20 ears. The second table shows the number of cases treated for pure deafness unaccompanied by otorrhcea. Of these, 24-7 per cent, were relieved completely of their defect of hearing, 25-6 per cent, were partially relieved, 16-6 per cent, were unrelieved, and about a quarter of those treated were still under treatment at the end of the year. A large proportion of the deafness in children arises from the condition of the nose, and the suggestions already made on this subject have importance in regard to deafness. The third table gives a detailed analysis of all cases of otorrhoea requiring treatment, and it includes the cases of otorrhcea found in the residential schools and treated at the after-care clinic, Kentish Town. It shows the various conditions of the ear responsible for the otorrhoea ; the numbers suffering from each condition, the number of cases " cured " by ionisation or other method of treatment; the number requiring a mastoid operation ; those lost sight of and the number still under treatment at the end of the year. A striking figure again this year is the number of cases coming under treatment, that have had a mastoid operation, viz., 506, or about 1 in 7 of the cases seen. Some of these are healing mastoids fresh from operation for mastoid disease, but most of them are re-infections as a result of one or other of the causes stated above. It was found when the Council took over the Poor Law institutions that many cases of otorrhoea existed in the residential schools and that very little was being done for them. Arrangements have been made now for these children to be transferred to Andover Home, in the case of children over 5 years old, and to Hornsey Rise Home in the case of children under 5 years old, to enable them to attend at the after-care clinic, Kentish Town, for treatment as often as is considered desirable, and for their re-transfer to their own schools when they are well. During the past year Mr. Wells has treated from these schools 198 cases of otorrhoea, of which 165 were " cured " ; 9 needed a mastoid operation, and 24 were still under treatment at the end of the year. The percentage of " cured " cases will be seen to be 83 -3. In addition to these, 6 deaf cases attended, of which 4 were completely relieved and 2 partially relieved, 7 who needed operation for tonsils and adenoids, 4 needed removal of wax, 1 needed removal of a cherry stone, 1 had marked nasal catarrh, was diatolised and cured ; 22 cases required no treatment of any kind. Since the residential school cases have come under Mr. Wells' care, he has treated 279 cases of otorrhoea from these schools, of which 239 have been " cured," giving a percentage of 85 -6. An audiometer, which is an instrument for the detection and accurate measurement of defective hearing extending over a wide range, was obtained at the beginning of 1931. It provides, by means of a gramophone record, a voice which dictates figures, commencing loudly and gradually fading away to a very soft note over a measured range. It is capable of testing any number of persons up to forty at a time. Those being tested apply headphones to the ear, first on one ear and then on the other, and as the voice is heard calling out the figures, these are recorded on charts which contain suitable tables, with spaces in which to enter the numbers as they are called out. When the person being tested fails to hear the softening voice, he either enters a wrong number or fails to make an entry in the proper space ; and, by examining the chart, the number of units of defect of hearing is seen at a glance. 25 The great advantage of this apparatus, apart from the large number (up to 40) which can be tested at one sitting, is that the voice is constant at each degree of intensity of sound, and consequently all are tested under identical conditions as far as the voice is concerned. The conditions which are likely to vary are such as the surroundings, e.g., noisy traffic outside the examination room at one time and quiet at another, or the correct adjustment of the headphone to the ear; if there is mal-adjustment of the headphone at one time and not at another, the result is bound to vary ; so, too, the result will vary according to the amount of noise, etc., surrounding the examination room. Such variations as these can be eliminated with care and arrangement. During the year the children of Exmouth-street school were submitted to the test. The number of children tested was 420. At the first test the following result was obtained :— Class of Child. Passed. Failed. Senior Boys 126 36 Junior Mixed Boys 87 54 „ „ Girls 72 45 285 135 By "failing" is meant those who showed at least 9 units of defective hearing out of 100 in one or other ear. Later the 135 who failed in the first test were given a second test with the following result:— Class of Child. Passed. Failed. Absent. Senior Boys 20 16 — Junior Mixed Boys 41 12 1 „ „ Girls 39 5 1 100 33 2 Thus it will be seen that, on being re-tested, 100 of those who failed at the first test passed on the second occasion ; two were absent and missed the re-test; while 33 still failed. To follow this up to its logical conclusion, these 33 were then submitted to a physical examination to see if any cause for the hearing defect could be found. At the examination two of these children were absent. The remaining 31 children had 40 ears which showed hearing defect. Of these 40 ears, 38 ears showed conditions which could have been the cause of the hearing defect. Of the 31 children, 24 would be likely to benefit from treatment of their defective condition. Among the defects noted were :— Wax in 5 ears. Ear discharge " 8 „ Dry perforations " 3 „ Catarrhal changes " 17 „ Scar in drumhead " 3 „ Old mastoid operations " 3 „ Needing operation for tonsils and adenoids " 7 cases. An interesting point is that, of the 33 children who failed at both tests, only two had been noted on their medical record cards to be suffering from any defect of hearing. Dr. Crowden, of the London School of Hygiene, who is greatly interested in the subject, and who has carried out examinations in the Council's deaf schools and elsewhere, has been accumulating statistics, and is making an exhaustive analysis from the results he has obtained. It has been thought that when this report is issued it may contain indications suggesting certain lines on which to proceed in such a way as to secure the greatest profit, regard being had at the same time to the financial situation. A good year's work is again recorded at the after-care clinic, Kentish Town. It is here that After-care the residential school children are treated. Cases that have been operated on for mastoid disease clinic, at the Downs Hospital for Children form the bulk of the remainder of the work done here ; while Kentish there is also a sprinkling of miscellaneous cases from the schools, and members of the Council's Town, staff, e.g., nurses and other employees sent by the medical examiner for a specialist's opinion. Total attendance 5,564 Number of ionisations 2,175 Ultra-violet irradiations 255 Dressings to ears 2,661 26 Downs hospital : Mastoid operations. Patients. Ears. Number of cases treated after mastoid operation 288 334 „ „ non-operation cases treated 252 290 540 624 Details of the mastoid operation cases are as follows:— Number referred from Downs hospital in 1931 232 270 ,, „ „ ,, „ „ 1930, continuing treatment into 1931 56 64 288 334 The following are the particulars of the cases referred from Downs hospital in 1931 :— Patients. Ears. Discharged from Downs hospital "Ear dry" 36 37 Treated at aural clinics and cured 2 2 Still under treatment at aural clinics 23 28 Treated at after-care clinic and "cured" 107 126 Still under treatment at after-care clinic 38 46 Referred back to Downs hospital for further operation 22 26 Lapsed 4 5 232 270 The following are the particulars of the cases referred from Downs hospital in 1930 and continuing treatment into 1931 :— . Patients. Ears. Treated at after-care clinic and "cured" 31 36 Referred back to Downs hospital for further operation 18 19 Lapsed1 3 4 Still under treatment at after-care clinic 4 5 56 64 Patients. Ears Residential school children treated 165 Discharged cured 165 Referred for mastoid operation 9 Still under treatment 24 198 Miscellaneous cases : Treated and discharged cured 66 70 Still under treatment 21 22 87 92 252 290 It will thus be seen that of the 334 ears treated, after a mastoid operation during 1931,201 or 60.2 per cent. were "cured," 45 or 13.4 per cent. were failures and had to be re-admitted to the Downs hospital for a further operation, 51 or 15.3 per cent. were still under treatment at the after-care clinic at the end of the year, 28 or 8.3 per cent. were still under treatment at other Council clinics at the end of the year, and 9 or 2.7 per cent. were lost sight of. With a view of obtaining some information which might prove useful, Mr. Wells, from detailed information supplied by the medical superintendent, made an analysis of the mastoid operation cases from the Downs hospital which were followed up at the after-care clinic last year. Particulars of these were given in the last year's report, and by combining the figures for the two years, more reliable information is obtained by reason of greater numbers. 27 The Year 1930. Type of operation done. Number of cases. Total length of period of healing. Heath conservative type without flap 13 271 weeks Cortical with removal of incus and muscle graft — Cortical with muscle graft 6 69 „ Heath conservative type with flap 3 46 „ Epitympanic 2 41 „ Radical with muscle graft 18 252 „ Radical without flap 43 1,064 , Radical with flap 18 367 „ Radical with Woolf skin graft 1 26 „ Radical with skin pedicle 1 16 „ Total 105 2,152 weeks. The Year 1931. Type of operation done. Number of cases. length o/f period of healing. Heath conservative type without flap 2 71 weeks Cortical with removal of incus and muscle graft 1 5 „ Cortical with muscle graft 55 973 „ Radical with muscle graft 40 762 „ Radical without flap 27 781 „ Radical with flap 33 740 „ Radical with Woolf skin graft 1 14 „ Total 159 3,346 weeks. These tables show that, in 1930, 105 cases took 2,152 weeks to heal, which gives an average of 20.5 weeks per case; whereas in 1931, 159 cases took 3,346 weeks to heal, which gives an average of 21 weeks per case. Combined, the 264 cases took 5,498 weeks to heal, which gives an average of 20.8 weeks per case. The separate types of operation done, the number of cases of each, and the length of time 0 healing for both years combined are shown below:— Type of operation done. Number of cases. Number of weeks. Average Number of weeks per case. (a) Heath conservative type without flap 15 342 23 (b) Cortical with removal of incus and muscle graft I 5 5 (c) Cortical with muscle graft 61 1,042 17 (d) Heath conservative type with flap 3 46 15.5 (e) Epitympanic 2 41 205 (/) Radical with muscle graft 58 1,014 17.5 (g) Radical without flap 70 1,845 26.5 (h) Radical with flap 51 1,107 21.5 (i) Radical with Woolf skin graft 2 40 20 (k) Radical with skin pedicle 1 16 16 In the above table (o) to (e) inclusive are conservative types of operation, and (/) to (k) are radical types of operation. Of the conservative types of operation the numbers of (6), (d) and (e) are too small to give any reliable indication. Of the remaining types of operation it would appear that the cortical operation with muscle graft gives the best results as regards the period of healing, viz., 17 weeks per case on an average. Of the radical types of operation the number of (t) and (k) are too small to consider. Of the remaining types of operation it would appear that the radical operation with temporal muscle graft gives the best results, viz., 17J weeks per case on an average. This result of the combined years gives the same result as was arrived at from the figures of 1930. It should be understood that every case must be judged on its merits as regards type of operation done, and, while the above figures show that certain types of operation give the best results, it may not be possible always to perform this type of operation. But from practical 28 Teeth. The Wick special centre. experience it can be said that, in the vast majority of cases, it is possible to adopt one type of conservative operation in conservative cases, and one type of radical operation in radical cases. It will be seen by studying the above table that there is 6 weeks saving in time of healing by the cortical operation with muscle graft, as compared with the next best result in the conservative group; while in the radical group there is 4 weeks saving in time of healing by the radical operation with muscle graft as compared with the next best result. This is an indication that the two muscle graft operations might be done in preference to other types of operation in all cases except those which appeared to require particularly another type. A further advantage of the muscle graft operations is that the after treatment is not painful and does not distress the children at all. It is mainly just keeping the ear clean (the discharge, as a rule, not being profuse), and ionisation. The great point of importance is to know when to perform the conservative muscle graft operation and when the radical. Sometimes this is very easy to decide, at others it is most difficult. During 1931, out of 67 conservative muscle graft operations, 55 were successful, while 12 had to undergo a second operation because the conservative operation was not sufficient. With careful examination of the ear both before operation as well as on the operating table, and with greater experience, the number of unsuccessful cases should be reduced in number. These statistics, however, go to prove a case for the muscle graft operation, while providing a warning to use the utmost care in making a decision between the conservative and radical types. Occasion is here taken to express acknowledgment of the debt due to Dr. Price, the medical superintendent, for his assistance and co-operation in the scheme by which children found at the school treatment centres to require mastoid and other operations are admitted to the Downs hospital. During the year 1931 the work at the 68 dental centres included in the Council's scheme continued satisfactorily. Two new centres were opened, at the Bermondsey Medical Mission hospital and at Stoke Newington, while a special arrangement was made in addition with the Eastman clinic. The total number of sessions devoted to dental inspections in the schools, but not including the special arrangements in connection with the Eastman clinic and the Wick special centres, was 2,376 during the year, and these were carried out by the 66 inspecting dentists, of whom 12 were women. The number of children examined was 268,545, an increase of 17,294 compared with the year 1930; of these, 173,180 were found to require treatment, representing 64-5 per cent. The following table shows the steady improvement in the general condition of the mouths of the children in the schools, and represents the result of the work undertaken at the treatment centres and of the endless propaganda in the schools, both with the children and the parents. Year. Percentage requiring treatment. Year. Percentage requiring treatment. 1915 81.8 1924 69.6 1916 81.5 1925 69.8 1917 79.4 1926 69.0 1918 78.1 1927 70.0 1919 77.0 1928 68.9 1920 75.0 1929 67.9 1921 74.5 1930 65.9 1922 72.5 1931 64.5 1923 70.3 During the year 1931 the total number of children treated under the Council's scheme was 139,723, compared with 138,280 during the preceding year, an increase of 1,443. The aim of a school dental service is primarily one of prevention and conservation, and from table IV at the end of the report it will be observed that 132,237 fillings in temporary and permanent teeth were undertaken during the year. This is an increase of over 10,000 compared with the year 1930, whilst the number of extractions was reduced from 410,419 to 393,579. The special dental centre at the Wick, Hackney, which was organised and financed by the Manor Charitable Trust, has continued its intensive work during the year in connection with the Berkshire-road and Gainsborough-road schools. The dental oversight of the children attending these schools was transferred to the Trust, and 29 the arrangement has been in operation for about two years. The organisers of the scheme were very anxious to compare the results obtained by this specialised service with the results of the efforts of a normal centre in the same district. Permission was, therefore, given for an independent inspection to be undertaken by Mr. Pitts, D.S.O., M.R.C.S., L.D.S., consulting dental surgeon to the Hospital for Sick Children, Gt. Ormond-street, the Royal Dental hospital and the Middlesex hospital, of the children in the two schools attached to the Wick special centre and in two similar schools, Glyn-road and Sidney-road, attached to the Wick normal centre. The following is the report submitted by Mr. A. T. Pitts :— The inspections on which this report is based were carried out during the months from May to September, 1931, at the request of the Hon. Arthur Villiers, D.S.O., and by permission of the London County Council. The object of the inspection was to ascertain whether the condition of the teeth of those children who had attended the Wick dental clinic showed any appreciable difference from those children who had received dental treatment under the ordinary conditions which prevail in the various dental centres of the London County Council. The particular features which mark out the work at the Wick dental centre from that at other clinics is that as far as possible all children attending the Gainsborough-road and Berkshireroad schools had dental inspection and prophylactic treatment in the form of cleaning and polishing the teeth carried out by a specially trained dental hygienist attached to the clinic. In addition, each child is instructed in the proper use of a tooth-brush and the reasons for doing so. A follow-up system of letters and visits in the case of parents who refuse treatment is in force which has resulted in a very low percentage of refusals. A number of talks to children in the schools was also given, amounting to 166 in the period June, 1929, to March, 1930. The special features may be summed up as an intensive campaign against dental disease among a relatively stable school population by means of treatment, propaganda and prophylaxis carried out by a staff of dentists, dental hygienists, and home visitors. This scheme at the Wick dental clinic has now been in force for two years. It seemed possible, therefore, that the children who had attended this clinic might show some difference in their dental condition compared with those who had been inspected and treated in the ordinary way at clinics for which the Council was entirely responsible. The writer of this report was given an entirely free hand in regard to inspection and collection of data. This is emphasized to show that there was nothing "tendentious" in the inspection which was quite independent. The conclusions arrived at represent the views of the writer alone. It was decided to take a number of children of each age group from 6 to 14 inclusive, from those children at Gainsborough and Berkshire-road schools, who had attended the Wick dental clinic, and a similar number of children of the same age groups from Glyn-road and Sidney-road schools where the children had received treatment at a Council clinic. An attempt was made to select 50 of each group, and to inspect an equal number of boys and girls, but various difficulties arose, and it was found that in some groups the number exceeded 50 and in others fell short of that number, while the number of controls was 88 fewer than the children treated at the Wick clinic. The discrepancies in the various age groups were not great, and, though it has made the task of comparison more difficult, I am of opinion that the results of the inspection have not been invalidated thereby. The arrangements were made by the Council, through Dr. Livingston, the consulting dental surgeon to that body, who arranged that the heads of the schools should be notified and facilities for inspection provided. The selection of children for inspection at the Gainsborough and Berkshire-road schools was much aided by the services of Miss Bennett, organising secretary of the Wick special centre, who, being familiar with the schools and known to the teachers, was able to arrange that all children seen at these schools had been treated at the Wick clinic. It should be made clear, however, that there was no attempt to select favourable cases for inspection, but, since there were many children at these two schools who had never received treatment at the Wick clinic because they had come from other districts and had received treatment elsewhere, it was obviously necessary to see that the children inspected had in fact been to the Wick clinic. The only selection was to see that a roll was prepared of a definite number of children in each age group with an equal proportion of boys and girls so as to eliminate any waste of time at the periods of inspection. At the control schools preliminary work of this kind was unnecessary, as none of the children had attended the Wick clinic. Dr. Livingston accompanied me at each inspection, and also inspected the children, but his inspection was independent of mine. We used a similar form on which to record data but we did not compare results or make any effort to agree on our charting of the mouths. Thus the data on which this report is based were entirely obtained by me and have not even been seen by Dr. Livingston. The form used provides columns in which to record the condition of teeth, carious being graded into slight, saveable and unsaveable, both for temporary and permanent dentitions. The name and age group are given. There is a column for gums and general condition, articulation, normal, treated and sound, date of last treatment, and notes. As a rule no particular note was taken of the articulation, exoept that any obvious irregularity was briefly noted. The date of the last treatment was filled up later by Miss Bennett from the record cards at the Wick clinic. In the case of the controls this column was left blank as these data were not easily available and Method of inspection. 30 Gums and general condition. Articulation. Normal. Treated and sound. it did not seem worth while to go to the labour of procuring the treatment cards from the centres and identifying the control children inspected. A very careful charting of each child was made. New sharp probes of various kinds were used so as to ensure as far as possible that no cavities were overlooked. I purposely adopted a stringent test of each child both of the Wick clinic children and the controls. Every crevice, however small, in which a probe would stick was regarded as a cavity, in the same way one would adopt in charting up a private patient in one's own surgery. In assessing carious teeth as slight, saveable or unsaveable, I used the following tests : A cavity in which a probe would just stick or which went just below the enamel was regarded as slight. I included in this group teeth which had not completed eruption if the occlusal crevice would retain a sharp probe. Among them were many teeth in which the " cavities " represented developmental defects and in which a filling was a prophylactic treatment rather than a remedial treatment for caries. This is the standard which most dentists adopt in the treatment of children in private, and, though it may not always be practised in school dentistry, yet it represents the ideal, and for that reason I used this test in assessing whether a tooth should be regarded as carious or not. Slight caries, therefore, means caries actually present, or potential caries which would probably follow if the crevice were not obliterated by a filling. Proximal cavities unless very obviously in the earliest stage, were regarded as saveable because the forecasting of the eventual size of approximal cavities is much more difficult than in occlusal cavities ; as frequently they turn out to be larger than one would think I thought it advisable to put the majority of such cavities in the group of saveable. All teeth so extensively carious that the pulps were obviously dead, or in which treatment would lead to an exposed pulp, were regarded as unsaveable. There were a good many teeth in which the grading was difficult. Where there was any doubt, I placed the tooth in question among the unsaveable teeth. I took as my criterion the fact that in school dentistry the aim is to fill as permanently as possible as large a number of teeth as possible. Hazardous restorations which may have a limited life and require frequent inspections are out of place, and teeth which involve a prolonged treatment, except in special circumstances, are better extracted. I therefore adopted a somewhat drastic attitude in assessing carious teeth as unsaveable. I grouped the general condition of the mouth under the headings of good, moderate and poor. By "good" I mean that the general hygiene of the mouth was good : there was an absence of tartar, there was no inflammation of the gums ; the teeth looked bright and the gums firm and pink. The presence of a brown stain round the necks of the teeth was not regarded as a reason for excluding a mouth from this category. Rather the contrary in fact, for I noted that in many mouths which were conspicuously clean, a brown stain was often present. Pickerill has noted this fact and has even termed the brown stain the " health line." He infers that this stain is due to some factor which aids in the natural cleanliness of the mouth. It is not, however, an invariable concomitant of oral cleanliness, though in general my observations confirm those of Pickerill. The brown stain is a narrow zone of stippled pigment near to the gum margin but not impinging on it, so that there is a narrow area of normal enamel between the stain and the gum. Quite different from this is the green stain which adjoins the gums and instead of being sharply defined, is diffused. Where this stain is present the teeth look dull instead of bright, and the mouth is often dirty. The actual presence of caries might co-exist with a clean mouth, and similarly a mouth free from caries might, though not often, be classed as "poor" so far as the cleanliness of the gums was concerned. A purely localised inflammation due to a septic tooth did not necessarily prevent me from classing the gums as good if the general condition of the rest of the mouth was good. By "moderate" I meant that there was slight gingivitis, or the teeth looked dull though food debris might be absent. The main factor was the presence of gingivitis. By "poor" I mean those mouths which had marked gingivitis or looked uncared for. Tartar might be present and it was obvious that the mouth received no attention, though I did not take as my standard any conscious efforts at oral hygiene, for by this test few children could have been placed in the category of "good." Many of these children suffered from irregularities which were really the cause of the poor oral condition. Though the cause was beyond any efforts of the child to remedy, I still placed such children in the third category, just as I placed in the first category those children with clean mouths whether they used a tooth-brush or whether it was due to a natural immunity and any personal hygiene was quite absent. As already stated, the form I used was one in use in the Council's dental service, but as it did not seem to have any bearing on this inspection, I did not note in detail the state of the articulation, though in the column of " notes " some brief note of irregularities present was made. In this category were placed those children with a sound dentition in which no fillings had been done. Where temporary teeth were absent I made enquiries. If it seemed that they had been lost naturally, they were regarded as normal. If there was any evidence to suggest that they had been extracted because of caries, then the child was not classed as normal, but as "treated and sound." The number of normal children was very low, four in the children attending the Wick centre and 13 in the control group. In this category were placed all children whose mouths had been rendered sound by fillings or extractions. Even if a child had only one slight cavity, and, although this might have developed in a tooth which had erupted since the last treatment, the child was still excluded from this category. The only exception to this was in children of 12 and over. In these children a loose temporary tooth, even though carious, was not taken into account. Such a tooth had practically outlived its functional activity, and its natural loss was close at hand. It seemed reasonable, 31 therefore, to regard such mouths as treated and sound, if only such defects as these were present. Dr. Livingston concurred with me on this point. But if a temporary tooth was firm and useful, and seemed likely to have a considerable period of life before it, then the presence of caries in such a tooth even in a child of 11 or 12 excluded it from this category. Arrested caries in a tooth was considered as the equivalent of a filled tooth, and did not exclude a child from this group. This column was filled up, after the last inspections, by Miss Bennett from the record cards at the Wick clinic. But in the controls this could not be ascertained, at any rate without much difficulty. Prom the point of contrast, the date of last treatment has been ignored, though I have tried to make some use of it as bearing on the results of treatment at the Wick clinic. The object of the inspection was to see whether there was any difference between the children treated at the Wick clinic compared with a control group treated at the Council's clinics. I do not confine myself to the narrow point as to whether there was any difference which could be ascribed solely to the activities of the dental hygienist at the Wick clinic, but broadly in regard to the dental condition as a whole. The first method of testing the data used was to see whether the number of children "treated and sound" varied in the two groups. This means that both dentitions were sound. Now in the age group from 6 to 9 the temporary dentition is the more important from the point of view of function. From 9 to 11 the temporary teeth rapidly lessen in importance in proportion as they become shed and are replaced by the premolars. From 12 onwards the value of the temporary teeth in mastication is negligible. I have, therefore, dissected out from the figures those children with permanent teeth sound, though with caries in the temporary teeth, and have made two groupings of "treated and sound"; one with both dentitions sound, and the other with the permanent teeth only sound. The value of this second group is slight in the earlier ages, but to my mind important in the later age groups. Since the number of children in the age groups of the Wick centre and the control group is not always comparable I have reduced the figures to percentages. Treated and sound.—Both dentitions. Wick centre— Number examined 460 Number treated and sound 190 (41.3 per cent.) Controls— Number examined 372 Number treated and sound 97 (26 per cent.) Treated and sound.—Permanent dentition only. Wick centre— Number examined 460 Number treated and sound 234 (50 per cent.) Controls— Number examined 372 Number treated and sound 148 (39.7 per cent.) Comparison of percentages by age groups. Age. Treated and Sound Both Dentitions. Treated and Sound Permanent Dentition Only. Wick centre. Controls. Wick centre. Controls. Number ex* amined. Number treated and sound. Percentage. Number examined. Number treated and sound. Percentage. Number treated and sound. Percentage. Number treated and sound. Percentage 6 years 26 12 46.1 24 2 8.3 17 65 3 12 50 7 „ 25 13 52 24 1 4.1 18 72 6 25 8 „ 65 20 30.7 50 9 18 40 61 4 26 52 9 „ 57 17 29.8 50 13 26 30 56 6 23 46 10 „ 90 29 32.2 50 14 28 36 40 26 52 11 „ 87 21 24.1 50 20 40 33 37 9 25 50 12 „ 50 24 48 50 18 36 27 54 18 36 13 „ 45 20 44.4 50 14 28 23 51 16 32 14 „ 15 10 66.6 24 6 25 10 66 6 6 25 It will be seen that testing the two groups of children by the "treated and sound" standard, there is a decisive preponderance of such children in the Wick centre group which showed 41-3 per cent." treated and sound," as compared with 26 per cent, in the control group. The fact that the number of the children in the two groups is not the same is perhaps unfortunate, but I doubt whether it seriously affects the difference as expressed in percentages. When the age groups are contrasted, it will be noted that this preponderance between the two sets of children is not always the same. In some it is relatively slight while in the 11-year group there was actually a larger number of "treated and sound of both dentitions and of permanent dentition only, in Date of last treatment. The examination of the data. 32 the control group than in the Wick centre group. Yet, looking at the figures as a whole, it is difficult to resist the conclusion that the Wick children were in a better dental condition as a result of dental treatment than the control group. But the test of "treated and sound," though satisfactory up to a point, fails in that it discloses nothing of the condition of those children not in this category, that is, "treated but not sound." The children in this group range from those with perhaps one slight cavity in a permanent molar or even a developmental crevice, up to those with many carious teeth. It seemed to me that this group might provide some useful data expressed in terms of teeth requiring treatment. In order to arrive at a basis of comparison, I have expressed the carious teeth in terms of so many per child and have given the index figure of the temporary and permanent teeth separately. Taking the total number of teeth, which includes those with slight cavities, saveable teeth and unsaveable, all grouped together, it will be seen that the index figure of teeth carious per child is not very striking. In the case of the temporary teeth the number per child in the Wick centre is greater than in the control group, being 0.85 per child in the former against 0.50 per child in the controls. In the permanent dentition there is a more favourable figure for the Wick children, the index figure per child being 0.84 against 1.07 in the controls. But when the carious teeth are segregated into two groups, saveable and unsaveable, the figures are interesting. There is comparatively little difference between the Wick children and the controls as regards saveable teeth, but a very definitely smaller figure per child of unsaveable teeth in the permanent dentition, for while the Wick children have only 0-06 unsaveable permanent teeth per child, the controls have 0.33 per child. Can one justifiably deduce from these figures that the favourable ratio of dentitions treated and sound " in the Wick children is corroborated by the figures provided by an investigation of the amount and degree of caries present in the two sets of children ? Total temporary teeth carious— Wick centre 259 (0.85 per child) Control 318 (0.56 per child) Total temporary teeth carious but saveable— Wick centre 112 (0.24 per child) Control 90 (0.24 per child) Temporary teeth carious and unsaveable— Wick centre 147 (0.31 per child) Control 170 (0.45 per child) Total permanent teeth carious— Wick centre 386 (0.84 per child) Control 400 (1.07 per child) Total permanent teeth carious but saveable— Wick centre 358 (0.8 per child) Control 287 (0.77 per child) Total permanent teeth carious and unsaveable— Wick centre 28 (0.06 per child) Control 123 (0.33 per child) I am of opinion that these figures, though taken by themselves they might not justify any decisive pronouncement, yet, takenin conjunction with the "treated and sound" figures, strengthen the view that the Wick children have a better dental condition than the controls. It is too much to expect that any dental supervision and treatment, however thorough, will suffice to retain the temporary teeth in a sound condition throughout their functional lifetime. Treatment of these teeth is at best a patching up which needs to be done at short intervals and even then it is rarely that they will last out their normal span. The real test of school dentistry is the condition of the permanent dentition. It must take a considerable period for caries in a permanent tooth to attain a degree which makes it unsaveable. The very much smaller incidence of such teeth in the Wick group is significant for it shows that while the attendance at the Wick clinic may not have diminished greatly the liability to caries, yet the intensive and regular treatment has borne fruit in that the number of unsaveable teeth is greatly reduced. In 460 children there were only 28 unsaveable permanent teeth, while in the 372 control children the number of such teeth was 125. The last test applied to the children was the condition of the gums and mouth generally. Many conditions affect the cleanliness of the mouth, so that a clean mouth may not necessarily denote a high degree of personal hygiene, or a dirty mouth a neglect of hygiene measures. Irregularities of the teeth, caries leading to abscess formation or to disuse of that side in eating because of pain, are a common cause of a dirty mouth. Similarly, a clean mouth may be due to a high degree of vigorous mastication and a diet rich in coarse, fibrous foodstuffs needing efficient chewing. Since the main feature of the Wick clinic has been the service of a dental hygienist carrying out prophylactic cleaning as a routine part of the treatment, it might seem reasonable to interpret the condition of the gums in terms of the personal oral hygiene of the children concerned. 1 think one should be very cautious in drawing such conclusions. The figures of the two sets of children are not highly significant. There is, however, in all three groups a more favourable condition of the gums in the children treated in the Wick centre 33 than in the control groups. In order to make a comparison I have turned the figures into percentages. Condition of gums. Percentages. Wick centre. Control. Good 55 49 Moderate 38 35 Poor 7 16 Taken in conjunction with the other two tests they point in the same direction and are, therefore, of some significance. But I should be disinclined to press the significance too far. The fact that the treatment cards of the children attending the Wick centre are kept there, made it easy to examine the cards of all the children inspected. In the case of the control children these facilities were not available. It would have greatly increased the difficulties of the inspection to have procured these cards, and entailed much clerical work, and for that reason no attempt was made to correlate the inspection with the previous treatment of the control children. But some interesting data can be deduced from the treatment cards of the Wick children to which a brief reference may be made. A striking feature of the data is the much larger number of children "treated and sound," both of the temporary and permanent dentitions, and the permanent dentition only, in theWick children. Without having access to the treatment cards it might be argued that the frequency of treatments was the cause, and that a large proportion of children "treated and sound" had been treated too recently for any fresh trouble to have arisen. I therefore divided the "treated and sound" children into two groups: (a) those treated over one year, and (b) those treated one year or less. The following table gives the results :— Children Treated and sound.-—Both dentitions— One year or more 36 Less than one year 55 Treated and sound.—Permanent dentition only— One year or more 121 Less than one year 104 The figures speak for themselves and show that, whatever be the cause of the large number of "treated and sound" children, it cannot be that their attendance at the Wick clinic was so recent that fresh caries had not had time to occur. In an inspection of this kind, carried out throughout by the same person using the same methods, the clinical impressions gained in the course of the inspection, as apart from specific data tabulated at the time, are not without their value. It became apparent early in the course of the inspection of the Wick centre children, which was carried out before the examination of the controls, that the results of treatment were very good. At that time I did not know, of course, whether the dental condition of the controls would turn out to be better or worse, but it was quite certain that the Wick children set a high standard. One thing I noticed was the large amount of conservative work in the mouths of these children. The number of fillings which had been done was very large. Later on I was able to check this impression from the record cards, and noted the number of fillings in each child. The figures may be of interest. The number of fillings in temporary teeth was 464. The number of fillings in permanent teeth was 1,194. These figures are taken from the record cards, and represent in many cases treatment at periods of six months over nearly two years. In some cases the same tooth had been filled on more than one occasion. But these figures represent the actual number of fillings carried out as gleaned from the children's cards. I did not take any note of the number of fillings present in the control children, but I feel certain that the number was far less. It is possible, though I am not prepared to state it definitely, that this may serve to explain the slight difference between the number of carious teeth per child in the Wick and the control groups. Where stress is laid on conservative treatment and as large a number of teeth as possible are filled, it permits a greater amount of recurrent caries than when the treatment is of a more drastic character and a larger number of teeth are extracted. Another feature which deserves mention is that in many children the fissures in the permanent molars had been thoroughly opened up and filled on the lines advocated by Hyatt. It was a pleasure to see fillings so well done and lasting so well. I noted that in these cases recurrent caries was very slight. Conclusions based on a comparatively small number of children who had received the special treatment at the Wick centre for the short time of two years should be made cautiously. That the Wick children showed a better dental condition is indisputable. To what can this be ascribed ? Three possibilities present themselves :— (i) The prophylactic treatment of cleaning and polishing carried out by the dental hygienist. (ii) The efforts made to persuade parents who had refused treatment to recant by means of letters and visits as well as talks on dental hygiene, which may all serve to bring about what the Americans call " Toothmindedness." (iii) The character of the work done at the clinic. Data applicable to the Wick special centre children only. General impressions. Conclusions. D 34 Eastman clinic. With regard to the first I should doubt whether there was any evidence that the efforts to get the mouths clean by cleaning them, providing facilities at the clinic for the use of a toothbrush, etc., have had much effect. I questioned many children and found that on the whole the use of the tooth-brush was sporadic and often absent. Often I found, when I saw a mouth particularly clean, that the child denied the use of a brush at all. A denial may be accepted at face value, though a statement that a brush is used regularly must be accepted with a large grain of salt. At the same time it would not be fair to regard the efforts of the hygienist as useless. Perhaps their value is chiefly that it is part of the planned campaign which tends to push the parents and the children in the direction of taking an interest in the hygiene of the mouth. With regard to the second, all efforts directed to reducing the number of refusals, and to bring about regular attendance for treatment, must help in reducing the incidence of caries and improving the oral condition of the children for whom the Wick clinic was responsible. It may be noted here that no attempt was made to select children who had attended regularly for treatment. A child who had been inspected by the school dentist at the Wick clinic even though the parent only allowed the child to attend once, was included. There were quite a number of such children. With regard to the third possibility, I attach some importance to the fact that the treatment itself was throughout conceived and carried out on both prophylactic and remedial lines, e.g., the prophylactic filling of permanent molars, and the large number of fillings per child all testified to a very thorough conception of the role of the school dentist. There is no attempt, in saying this, to disparage the work carried out at other dental centres. The work present in the control children was distinctly good, and their condition on the whole, excellent, but, since the Wick clinic was started for a special purpose, it is natural that those connected with it should regard themselves as being participators in a pioneer movement and should be unconsciously keyed up to a high level of achievement in consequence. It is fair to conclude that the good dental condition of the children treated at the Wick clinic is an expression of the general quality of the work of all connected with the clinic, and is due, partly to the excellent quality of the remedial treatment, and partly to the prophylactic work and propaganda which has resulted in a high percentage of children accepting regular treatment and in consequence learning to take an interest in the oral hygiene. I should like in conclusion to say that I am deeply indebted to the assistance of Miss Bennett, whose help was of the utmost value and who spared no pains to make my task as easy as possible. At the request of the authorities of the Eastman clinic, Royal Free hospital, the Council agreed to allow the dental inspection and treatment of the children attending the Cromer-street, Manchester-street and Prospect-terrace schools to be undertaken by the clinic on the same lines as at the Wick special centre. A portable dental chair is taken to each school, where the mouths of the children are charted by dental nurses or hygienists, who also undertake prophylactic work at the same time. Appointments are made for the children to attend the clinic for treatment which is carried out by dental surgeons appointed by the clinic authorities. The scheme was put into operation in May, 1931, and, during the period up to the end of the year, 758 children received treatment, and on an average each child made seven attendances. In addition to this work the clinic authorities undertake the dental treatment of scholarship and central school children who may express the wish to attend the clinic. During the period from May to December, 37 such cases were dealt with. It is proposed, so far as can be done without injury to the existing school treatment centres, that further schools shall be allocated to the Eastman clinic, in the area served by it. Stammering children. At the eight centres maintained for the treatment of stammerers a total of 329 children attended during the year ; of these, 54 were discharged as cured and 16 as provisionally cured, while 57, many of whom had greatly improved, left for various reasons. Formerly the arrangements for attendance provided that a group of 12 children should attend a course twice weekly for periods of 1½ hours each, but it was felt that, with smaller groups and shorter attendances, greater concentration could be obtained from the children, more individual attention could be given to them, and freer movement in the classrooms could be obtained. The Education Committee accordingly sanctioned a re-arrangement of these conditions, and this re-arrangement came into operation at the beginning of the summer term. 35 The new arrangements are on the following lines (i) each child attends twice weekly for periods of 50 minutes each; (ii) each group of children is limited to 9; and (iii) 3 groups are dealt with by the same instructor on each half day. Dr. E. J. Boome and the assistants employed upon this work consider that this change has been justified, and they have asked that it should be continued. It is debatable whether whole-time treatment is better than the part-time system, but Dr. Boome considers that excellent results accrue where the children attend but twice weekly. The child's normal school routine is hardly interfered with, and he is not made to feel that he is different from his fellows. Moreover, where reorganisation of the nervous system is in progress it is found that greater advance is made in the intervals than during actual practice, and stimulation is far more effective if intermittent rather than constant. Travelling to and from these centres by tram or omnibus is considered by Dr. Boome sometimes to be a help in restoring self-confidence. Disappointment is frequently felt at the slow progress of many children, but on this point Dr. Boome states " In London we get a class in which there appears over a period to be no progress, but, after a while, the whole class seems to make a big effort and the final results well repay the time and trouble taken. I never give up hope with a stammerer, even if the parents do not co-operate. I have seen cases, after two or three years' disappointing progress, suddenly pick up and be completely cured. Of course, we get our social workers to obtain reports on the homes, and if necessary invite the parents to the centre in order to persuade them to help." Personal hygiene scheme. The number of examinations made by school nurses at rota visits during 1931 was 1,971,363, and verminous conditions were found in 210,113 cases, or 10.6 per cent., compared with 12.1 per cent, of cases examined in 1930. This marks a very definite improvement in personal hygiene, and corresponds with the findings of the doctors at medical inspections recorded earlier in this report. Particulars of the examinations and the results of the cleansing schemes during the past six years are given below :— Year. Examinations at rota visits. Verminous conditions noted at rota visits. Percentage. Verminous children referred to centres. Subsequently cleansed by parents. Verminous children cleansed at centres. Scabies and impetigo cases bathed at centres. 1926 1,840,106 288,721 15.6 120,171 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 1931 1,971,363 210,113 10.6 114,435 25,421 89,014 4,413 Of the 210,113 cases in which verminous conditions were noted, 120,580 (57.3 per cent.) were found to have nits only. The continued rise during the past six years in the number of cases of scabies treated at the cleansing centres is somewhat perplexing, and is only partially accounted for by increased examinations by the nurses in connection with smallpox. An additional factor is the reference of cases from general hospitals, where the Council's facilities are becoming more widely known. The bases of the Council's cleansing scheme are emphasis upon the parents' primary responsibility, followed by compulsion where necessary as provided by section 87 of the Education Act, 1921. In the earlier stages of the scheme parents are advised of the trouble, and invited to avail themselves of the facilities provided by the Council. It is only after a child has been seen by at least two different nurses that a statutory notice is issued to the parents. These notices are served through the attendance branch of the education officer's department, and are either handed to the parents in person or forwarded by means of registered letter. A higher standard is required before a child is classified as "clean." Even if only afflicted with "nits," a child is classed as verminous, and the condition brought to the notice of the parents. The later advice cards definitely set out the methods d 2 36 Use of Borough Councils' washing baths. Central schools. Elementary schools.— (1) Physical training. which can be adopted for remedying the condition; and, as enquiries had been frequently made as to whether the special metal combs used at the cleansing centres could be purchased by parents, arrangements were completed during 1931 whereby the nursing staff at the cleansing centres can requisition from the supplies department a stock of such combs for sale to parents. During 1931 new disinfecting and cleansing stations were opened by the Bermondsey and the Lewisham Borough Councils, and the Council entered into agreements for the use of these centres for children. The small centre at the "Chaucer" school was closed, and the children from all contributory schools were transferred from this centre to the new Bermondsey station. There are now 10 Council centres, 20 Borough Council centres, and 9 centres organised by voluntary committees; but, as the last named are limited to head cleansings, these are not equipped with sterilisers or baths. The following particulars for 1931 are in respect of the cleansing scheme operated from the Council's and Borough Councils' centres (as distinct from the "head" cleansing centres):— Number of advice cards issued to parents 87,410 Number of children attending voluntarily at bathing centres after advice cards 40,767 Number of statutory notices served in accordance with section 87 of the Education Act, 1921 25,228 Number attending bathing centres after statutory notices— (a) voluntarily 5,855 (6) compulsorily 15,367 Number of cases in which police court proceedings were taken 428 Ambulances are provided for the conveyance of children from out-lying schools to the bathing centres. During 1931, 12,056 children were thus conveyed, practically all compulsory cases. 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. The number of children attending for warm baths during school hours was 34,529 in 1931, compared with 35,089 in 1930. Physical Education and Teaching of Hygiene. The organisers of physical education (Mr. A. H. A. Gem and Miss Grant S. Clark) presented a report to the Education Committee for the two years ended July, 1931, from which the following notes have been taken. Boys.—It is very noticeable that the best work is carried out in those schools which have a measure of specialisation in force. Where the attempt is being made to divide the work amongst five or six teachers, it is generally found that the measure of success achieved has not been great, whereas in cases where it has proved possible to put the work into the hands of two or perhaps three suitable teachers, the results are promising. Oirls.—In the past two years, one training course reserved for teachers in central schools has been held. It is usual to have a certain amount of specialisation and this is more particularly the case as regards the upper classes. The more advanced type of work is becoming better understood by the teachers, and is therefore performed with greater skill by the pupils. The addition of a limited range of apparatus work has added greatly to the interest and effectiveness of the lessons. This is handled with much more confidence now, and in some instances reaches a high standard. Oeneral.—Generally speaking, the time devoted to this branch of education in the central schools is inadequate. Whilst realising that demands on the time-table are somewhat greater than is the case in the ordinary elementary school, it is considered that three half-hour lessons a week would not be an unreasonable allocation of time. The reorganisation of schools at present proceeding has inevitably created many difficulties from the physical training point of view. Prior to the commencement of the reorganisation practically every school had on its staff one or more teachers who had a working knowledge of the requirements of the 1919 syllabus, but with the redistribution of staff the position has materially altered, and much work lies ahead in this matter before the balance can be re-adjusted. The 1919 syllabus constituted a very real advance on that of 1909, but the teachers and children quickly adapted themselves to this step forward, and the work now taken in the teachers' classes is a definite advance on that contained in the 1919 syllabus. It is clear that if the senior children are to be adequately exercised, still more advanced work is now necessary. 37 Syllabus work.—(i) Boys.—Speaking in general terms, the instruction has definitely improved, and this is perhaps specially noticeable in the general activity section of the lesson which was referred to in the last report as being the weaker side of the work. There is now a better appreciation of the fact that the games played and the activities carried out must be suited to the age of the child performing them, and this section of the lesson is much more adequately planned than was formerly the case. (ii) Oirls.—The work seen in the last two years shows that the approved contemporary type of lesson has taken hold, and there are now very few schools in which it is not interpreted to a reasonable degree. Where the work is really well done the children are supple and agile and have developed that sense of control and poise (sometimes to a remarkable extent) which is the final test of good training. (iii) Infants.—With the active type of lesson which has been employed of recent years, there has developed a sturdiness and sure-footedness which must give these young children a delightful feeling of strength. As the number of teachers who have attended classes increases, so does the work throughout the schools gain in general effectiveness. A better use is now made of a progressive scheme which demands more of the children at the various stages where they are ready and eager to give more. However simple and informal the exercises are, they always have a certain "form" to which attention should be paid if they are to obtain the best results. This side of the training is sometimes lost sight of. It is unusual now to come upon a school where the value of outdoor activity is not realised. General organisation.—There is increasingly in evidence a readiness on the part of many of the head teachers to make fuller provision for the physical training of their children, and it is now a comparatively rare event to find a school content to devote the minimum times required by the Code to this side of education. Whilst many schools have daily lessons or their equivalent, there are still some in need of a more liberal allocation of time. In schools which have been fully inspected during the past two years the average number of periods given to all branches of physical education is four per week in the senior classes and four per week in junior classes. These times constitute a definite advance so far as the juniors are concerned, and although still falling somewhat short of the allocation desired, they nevertheless indicate that steady progress is being made in this direction. Health classes.—Various factors have combined to reduce the number of these classes recently. With the reorganisation of departments and the consequent change of staff, some schools have found it necessary to drop these classes temporarily. In other cases the classes have ceased owing to the fact that the school doctor has found that the children do not now require this special type of lesson. It is considered that contributory reasons for this satisfactory state of affaire are as follows : the increase in time given to physical training throughout the school and more especially in the junior classes, the more effective work done in the infant schools and the type of exercise (requiring increased mobility) employed. It is more common to find the lessons taken out of doors than was formerly the practice. A special course for teachers of health classes will be held in the summer term of 1932. Equipment and Accommodation.—The London child has very limited opportunities of playing on grass and thus the problem of taking part in certain types of jumping is a difficult one. An experiment is now being tried of providing sand pits in a few senior playgrounds for long and high jumping. There are some half-a-dozen schools whose playgrounds are to be remodelled, and it is in these schools that the experiment is to be undertaken. The provision of jumping pits should not only ensure a distinct improvement in the quality of the jumping, but also will make possible the introduction of many admirable group activities. The quality of the swimming instruction has improved during the past two years, and the problem is now far more frequently tackled on a class, rather than an individual basis. For some years there has been confusion owing to the multiplicity of swimming certificates issued; and, moreover, experience shows that during the school age there is not a sufficiently marked difference between the swimming of the boys and that of the girls to justify the acceptance of different standards. It has been decided that in future the Council shall issue one certificate only, that the certificate shall be a learner's certificate and that the distance required shall be 40 yards both for boys and for girls. Advanced certificates are issued in great variety by local associations and by the London Schools' Swimming Association. It will be recalled that attention was directed to the inadequate cleansing and lavatory facilities provided in many of the public baths and it was decided that representations should be made to the various borough councils with regard to this matter. It was considered that better results might be achieved if the representations were made in a semi-official manner, and a conference was therefore arranged with the London Schools' Swimming Association at which it was decided that the various affiliated local associations should raise the matter with their respective borough authorities. In the meantime the Council improved the facilities in its own baths, which are now well equipped in this direction. The admirable efforts of the London Schools' Swimming Association have met with only slight success, as only five additional footbaths, five additional shower baths and two additional lavatories have been provided. The majority of the authorities have not adopted a progressive policy in this matter and it is recommended that the Council, being the largest user of these baths, should, when financial circumstances permit, bring (2)Swimming 38 (3)0rganised games. (4) School sports. Games, athletics and swimming out of school hours. the matter officially to the notice of those concerned with a view to ending a state of affairs the undesirability of which should be obvious to all. It is disappointing to note that new baths are still being erected upon the old pattern with the dressing boxes in such a position as to necessitate entrance to them being made from the sides of the baths ; this planning makes it impossible to have the edges of the baths kept really clean. During the first years of the reorganisation of physical education the energies of the organising staff were of necessity directed towards the building up of physical training lessons, and having achieved some measure of success in this direction, it has been possible during the last two years to give more time to the problem of organised games. It was clear at the outset that too great reliance was placed in the games of football, cricket and netball and that these games were nearly always played on the full practice game principle. It was a rare occurrence to find the various phases of the games being taught (for instance, a game of cricket was always played instead of giving batting, bowling, catching and fielding practices), whilst other excellent team games such as rounders, stoolball and Rugby touch were seldom taught. The technical problem, therefore, which had to be faced was of a two-fold nature:— (1) To strengthen the traditional games by building up the various phases of those games ; (2) To introduce other types of team games. With this end in view a series of half-time courses have been held, devoted entirely to the teaching and organisation of games, swimming and athletics. Four such courses have been held for the men teachers and one for the women teachers, attended by 139 men and 36 women respectively. This wider point of view with regard to the playing of games will necessitate a different allocation of pitches in the parks, a wider range of markings and the provision of some additional equipment to be stored at the parks. The chief officer, parks department, has been extremely helpful not only in providing grounds on which courses could be held, but also in extending the existing facilities for organised games in those parks which have already been covered by games courses. Only the fringe of the problem has so far been touched, and much work lies ahead before the standard of efficiency of the organised games reaches that of the physical training lesson. In June of this year the first playing field provided with class-rooms was ready for use. The schools commenced to use the ground on 8th June, and the new venture has started with every prospect of success. Each school has been visited since the opening of the ground and special help has been given to each teacher. Four additional playing fields have been acquired and these will come into use in the near future, whilst it is hoped that ultimately a ring of such fields will be formed around London. It is of interest to be able to record that a steady increase has taken place during recent years in the number of schools holding their own sports meetings. During the past season over 470 closures have been granted for this purpose. In the majority of cases these events are well organised and form a valuable feature of the life of the schools. There is a noticeable improvement in the arrangement of many of the programmes and events more suitable to children of elementary school age are being included. Events of too strenuous a nature are gradually being eliminated, and the choice of the victor ludorum is happily disappearing. Such a system tends to deprive the meetings of much of their interest, as the indifferent performer has no chance, whilst the children competing for the supposed honour take part in more events than their physique can stand. It is a matter for regret that in a report of this nature the admirable work done outside school hours cannot be referred to in any great detail. It should be stressed again that these activities are in the main conducted by a limited number of teachers who, week after week, year after year, give up their own time to this valuable work. The basic work commences in the school, from there spreads to the district associations and reaches its culminating point in the all-London associations. The rapid development of school sports and swimming meetings is all to the good. Formerly the practice was for district associations to organise big meetings catering for large entries from the schools. Whilst such events were admirable illustrations of good organisation, they were apt to become somewhat impersonal and the tendency now is for schools to run their own events in which all the children can take part and for the selected children only to pass on to the district and London events. Brief details follow of the work of the various London associations. The London Schools' Athletic Association now has 25 district associations affiliated, of which 20 entered teams for the annual championship meeting. London was very successful in the English schools' championship, winning both the boys' and girls' events. The question of the physical strain imposed on children taking part in highly competitive athletics is one which causes concern to many; it is, therefore, of interest to note that, one of the rules of the London Schools' Athletic Association lays down that no boy or girl may compete in more than one event other than a relay race. This sensible rule indicates that the officers are alive to the possible dangers which might arise. The reorganisation of schools at present proceeding has had its effect on the work of the London Schools' Amateur Boxing Association. In the first place it has centralised boys over eleven years into relatively few schools in each district, thus severely limiting the potential centres of activity. In the past the failure of one school to participate could not check progress because only a small percentage of eligible boys were affected. Such a defection now would affect a large percentage of eligible boys and the Association is more than ever dependent on the goodwill 39 of the headmasters. It is hoped that all concerned will co-operate in furthering the work of the Association. In spite of the difficulties, successful competitions were held and 1,011 boys took part. The London Schools' Cricket Association has had a successful season and now has twentyfive affiliated district associations (within the county). The reorganisation of schools has, for the time being, had an adverse effect on the Cricket Conference training scheme. In 1929 the number attending was 860, but this fell to 600 in 1930. This year there has been a slight increase, and it is confidently anticipated that, when conditions become more settled, the number of boys taking advantage of the scheme will steadily increase. The London Schools' Football Association was formed in 1893 with only eight district associations in affiliation. It now caters for 49 associations and seven central school leagues. The total number of schools in greater London under the control of the Association is 1,079. Practically all elementary schools are dependent on the playing field facilities provided by the local authorities and in the London County Council area there are 350 pitches in use every Saturday morning. The scheme whereby the allocation of these pitches is dealt with by the London Schools' Football Association and the parks department works very satisfactorily. The Association conducts annually five competitions, all of which have been carried out with great success. It is of interest to record that the Islington team won the English schools' shield this year. The London Schools' Netball Association has had a successful season and now has 23 district associations affiliated, representing 289 London schools. The London Schools' Swimming Association has had a successful year and there are now 56 affiliated districts. During the year alterations have been made with regard to the certificates issued. There are now in existence 100 yards and 50 yards certificates for both boys and girls, known respectively as the first and second class certificates. The number of certificates gained is as follows :— First class. Second class. Total. Boys 6,696 8,778 15,474 Girls 12,264 9,012 21,276 Grand Total 36,750 As a natural corollary to the ability to swim, great stress is laid on life-saving, and the results achieved, whilst not quite numerically so great as last year, are nevertheless highly commendable. Advanced certificate. Elementary certificate. Total. Boys 1,116 1,537 2,653 Girls 2,005 2,447 4,452 Grand Total 7,105 Seven further names were added to the roll of honour for those saving, or attempting to save, life, bringing the total up to 430. It is of interest to quote the following extract from the annual report of the London Schools' Swimming Association, dealing with the problem of the provision and use of the lavatory and cleansing facilities:— "... a large number of the older establishments are sadly lacking in this respect (i.e., lavatory and cleansing facilities) and even where facilities such as footbaths do exist, the use of the same by bathers is often not insisted upon before they are allowed to enter the pool. "Much work remains to be done in the education of the authorities and of the general public in this direction, and teachers are urged to bring all their influence to bear on this matter and especially in the case of the children of to-day who will be the public of to-morrow." A growing volume of public opinion is noticeable with regard to this important question, and it is considered that pressure should be brought to bear on the authorities concerned to provide adequate facilities and to make the use of them compulsory for all. Hygiene is now generally taught, according to a syllabus, to older children in the schools. One of the most distressing features of the work of children's care is the widespread indifference on the part of the population to care of the teeth. The school dental service and the care organisation have always been alive to this, and much Teaching of hygiene. 40 has been done to educate the public, but the mass of inertia in this respect is still heavy. Any assistance that can be given in regard to this educational work is very welcome. The Dental Board of the United Kingdom, in April, 1931, drew the Council's attention to their portable dental exhibit, and their service of trained demonstrators. It was agreed by the Education Committee that, as an experiment, permission should be granted for demonstrations to be given to the older children in eight Islington schools. In every case the report of the head teacher on the results of the demonstration was favourable. The following report from one of the head teachers concerned is an example which is typical of the whole : I beg to report upon the dental demonstration given in my school on 21st January by a lecturer from the Dental Board of the United Kingdom. The demonstration in every way was highly successful; the lecturer had a splendid command of her subject, and the ability to get into touch with her audience quickly and to hold their attention ; the models she brought were admirably chosen to illustrate the process of dentition, and the progress of decay. Both lecturer and models stimulated the children to ask questions both of the lecturer and of their mistresses. The science mistresses on the stall were highly delighted with the demonstration and used one of the models to illustrate a point that had arisen in the course of the physiology lessons. As the school course includes hygiene and elementary physiology, the demonstration fits into the lessons and will be referred to again by the mistresses. I hope it will be possible to hear the Board's lecturer again next year when a new batch has entered the school. An immediate result of the demonstration was the application by several children for dental vouchers at the school treatment centre, a thing that rejoiced the heart of the care committee secretary. So, both on educational and social service grounds, I would advocate the repetition of the demonstration given here in other post-primary schools. As the results were so very successful, it has been decided to ask the Education Committee to extend the experiment to a further London district, and it is to be hoped that the exhibit and demonstrations will become a permanent part of the educational system. Statistics. Increased hospital accommodation. Rheumatism scheme. The following statistics show the operation of the rheumatism scheme during 1931; corresponding figures for the previous year are also shown :— 1931 1930 Number of nominations 943 639 „ „ children admitted to special hospitals 655 324 Cases seen by medical referee in voluntary hospitals 181 86 „ „ „ „ in their homes 391 147 „ „ „ „ at supervisory centres 140 86 „ „ „ „ at County Hall 26 18 Reports made by care committees on home conditions 551 307 " Following-up " reports made by care committees 631 391 Cases seen at County Hall on return from hospital 222 210 Re-examinations by school doctors 645 505 Number of children attending supervisory centres for first time 1,792 1,387 Total number of attendances at supervisory centres 9,767 6,670 Number of cases reported to medical officers of health re dampness, etc., or to housing manager for better accommodation 115 . 67 Dr. Banks Raffle is mainly responsible for the following report on the work of the rheumatism section :— During the year 1931 the work of the rheumatism scheme was extended by the provision of four additional rheumatism supervisory centres and by the provision of more beds at Queen Mary's Hospital for Children, Carshalton, and High Wood Hospital for Children, Brentwood, for the residential treatment of those children who required it. 41 This further hospital accommodation removed to some extent the difficulty of dealing with boys, which had been experienced from the beginning of the scheme, and rendered the average age of the children admitted to hospital rather lower than it had been in previous years. With regard to this latter point, the average age ol admission for residential treatment remained constant at ten years from the beginning of the rheumatism scheme, until the past year, since when it has fallen to 9 • 5, and this lowering of the average age was accentuated from July when further beds became available. The point is of some importance since the average age of onset of rheumatism in all cases dealt with under the scheme since 1926 is eight years, and the further from this age the child is before coming under treatment, the more likely are cardiac complications to ensue. During the year 943 children were nominated for residential treatment as shown below:— Nominated by Boys. Girls. Total. Voluntary Hospitals, In-patients 99 116 215 „ „ Out-patients 105 192 297 Private doctors 13 16 29 Rheumatism supervisory centres 60 99 159 School doctors 53 74 127 Parents 6 7 13 School care organisation 11 10 21 Invalid Children's Aid Association 26 36 62 Education officer's department 10 10 20 Total 383 560 943 The majority of the cases nominated by the school doctors were already under treatment either by a private doctor or at a hospital. These nominations were distributed as follows throughout the year :— January 74 July 82 February 65 August 48 March 63 September 87 April 54 October 106 May 67 November 130 June 78 December 89 The number of nominations, as was noted last year, does not fall off as would be expected in the summer months. The fall in the nominations in August is due to the school holidays, and to the closure of the rheumatism supervisory centres and of certain of the out-patient departments of voluntary hospitals. The number of children admitted to hospital during the year was 655 (boys 242, girls 413); viz., Queen Mary's Hospital for Children, 365 ; High Wood Hospital for Children, 278 ; and the Downs Hospital for Children, 12. This number (655) comprised 591 new cases, 8 cases admitted twice during the year, and 56 children who had had residential treatment under the scheme in previous years and were re-admitted for treatment during the year. Of the 591 new cases, 59 children (articular rheumatism 49, chorea 10,) were acutely ill, and were admitted to hospital within a few hours. In many cases, urgent admission was only made possible by the willing co-operation of the medical superintendents of Queen Mary's Hospital for Children and High Wood Hospital for Children, a co-operation which is gratefully acknowledged. The sex distribution of the forms of rheumatism amongst these children were Boys Girls Articular rheumatism 166 255 Chorea 60 110 Nomination of children for residential treatment. Children admitted to hospital. 42 Children discharged from hospital. The ages of the children treated for the first time were :— Disease or condition. Age in years. 3 4 6 6 7 8 9 10 11 12 13 14 15 Articular rheumatism— Boys 2 4 8 11 14 21 22 17 22 23 13 6 3 Girls 3 7 12 8 27 20 26 32 37 47 22 10 4 Chorea— Boys - 1 1 4 5 14 5 15 8 2 4 1 - Girls - 1 2 9 13 22 12 12 16 12 7 1 3 Totals 5 13 23 32 59 77 65 76 83 84 46 18 10 The condition of the heart in these children was :— Disease or condition. Normal. Heart affected. Valvular disease of heart. Articular rheumatism— Boys 57 109 54 Girls 87 168 72 Chorea— Boys 32 28 9 Girls 78 32 12 Totals 254 337 147 In 154 cases the children came from unsuitable homes, in 26 of which the houses were overcrowded, and in 128 the home was damp. During the year 56 children (16 boys and 40 girls) who had already been given residential treatment under the scheme were re-admitted to hospital. residential treatment under the scheme were re-admitted to hospital. The condition of these children on re-admission was :— Disease or condition. Boys. Girls. Rheumatic fever _ 1 Subacute rheumatism 2 10 Subacute rheumatism and heart disease 7 12 Chorea 4 10 Chorea and heart disease 3 7 Totals 16 40 Of the uncomplicated cases of subacute rheumatism, 8 had been in hospital in 1930, 2 in 1929, and 2 in 1928. Of the subacute cases with heart disease, 7 were treated under the scheme in 1930, 7 in 1929, 2 in 1928, 2 in 1927, and 1 in 1926. Of the choreic children whose hearts were not affected, 5 had been in hospital in 1930, 6 in 1929, 2 in 1928, and 1 in 1927. The choreic children with heart disease who had had residential treatment were grouped as follows: 5 in 1930, 3 in 1929, and 2 in 1927. Of the above children 4 had already been in hospital twice under the scheme. During the year 425 children were discharged from hospital (59 of whom were removed by their parents before the completion of their treatment) and 4 died in hospital. Of these 425 children, 280 (93 boys and 187 girls) were suffering from the articular form of rheumatism, and 145 (40 boys and 105 girls) from chorea. The heart was unaffected in 276 children, 89 were suffering from mitral regurgitation, 48 from mitral stenosis and regurgitation, and 12 had aortic and mitral disease. When discharged from hospital 13 children were over school age, and 15 were held to be unfit for school. Of those children who were sent to school 89 were certified for schools for the physically defective, 66 were recommended for elementary schools with restrictions as to games and drill, and 242 children were deemed fit for the ordinary curriculum of an elementary school. 43 In continuance of the following up of children who had received residential treatment under the scheme and who have since left school, care committee representatives have visited the homes of 101 children (33 boys and 68 girls). Their reports show that 37 of these children have had rheumatic symptoms since leaving school, and that 33 of them have remained under medical supervision. It is gratifying to learn that 91 of these children have been regularly employed, some of them, of course, in sedentary occupations. The reports of the school care committee visitors show, moreover, that the children are generally well housed : there being only three cases of overcrowding and two of dampness notified in the 101 visits. As a corollary to the report of last year on the age of onset of rheumatism in children, an investigation has been carried out during 1931 into the age at which the child's heart is particularly susceptible to rheumatic infection. The histories of 682 rheumatic children from the date of onset of rheumatism to the age of 14 years were reviewed and it appears from the figures obtained that the child who develops rheumatism before 9 years of age is much more likely to sustain a damaged heart than is one whose first rheumatic attack is delayed until after this age. Condition Age of onset of rheumatism 2 3 4 5 6 7 8 9 10 11 12 13 14 Heart affected at 14 – 1 8 10 23 26 28 21 20 25 28 14 19 Heart not affected at 14 2 4 8 15 21 28 21 25 45 67 89 57 77 Percentage hearts affected 0 20 50 40 52.5 48.1 57.1 45.6 30.8 27.2 23.9 19.7 19.8 The larger number of total cases in the later age periods is explained by the fact that the rheumatism scheme having begun in 1926, many of the younger cases in the scheme have not as yet attained the age of 14 years. One thousand attacks of rheumatism, distributed over a period of five years, were studied in relation to monthly variations in rainfall, air humidity, air and earth temperature, and hours of sunshine. An increase in incidence of rheumatism was usually found when the rainfall was below normal for the time of year : not so constantly an excessive rainfall spelt less rheumatism ; both these being contrary to popular opinion. Variations in air humidity appear to have little influence on the prevalence of rheumatism. A low air temperature with an average rainfall has also little influence, but a temperature above normal with an average or excessive rainfall seems to diminish the incidence. An increase in the hours of sunshine usually diminishes the amount of rheumatism, but the influence of the increased number of sunny hours does not combat the influence of a decrease in rainfall. Less sunshine usually means an increase in rheumatism. So far as it is justifiable to draw conclusions from the data available, a rainfall below the average for any season of the year appears to be the most potent factor in the production of an increase in rheumatic incidence, the combination most likely to give an increase in rheumatism being a rainfall below normal, a diminution of the amount of sunlight, and a low air temperature; that producing an opposite effect being a rainfall above normal, more than the average amount of sunshine, and a high air temperature. Three new rheumatism supervisory centres were opened during the year: Lewisham (April), St. George's Hospital (April) and Eltham (August). From April the Royal Free Hospital rheumatism supervisory centre was subsidised by the Council for the first time. There are now 15 rheumatism supervisory centres working under the scheme, and it is hoped to relieve the pressure on the Queen's Hospital Centre and on that at the Royal Waterloo Hospital by the provision during the coming year of a centre at Stoke Newington, and allowing an extra session to cope with the increase in work at the Royal Waterloo Hospital. It is also intended to have one session a fortnight at the Putney centre, instead of one session a month as at present. Followingup of discharged children. Age of onset in relation to heart disease. Rheumatism and climatic conditions. Rheumatism supervisory centres. 44 Rheumatism supervisory centres— St. George's hospital. East London hospital. Lowisham. During 1931, 3,816 children attended the centres, making 9,767 attendances, and of these children 1,792 attended for the first time. Recommendations were made by the medical officers in charge of the centres in regard to 2,913 children, and of these recommendations 39 related to the home conditions of the children and were referred either to the medical officer of health of the borough in which the child resided, or to the housing department of the Council. There were 346 recommendations for residential treatment; 159 for residential treatment at one of the special hospitals under the rheumatism scheme; and 187 for treatment at other hospitals. In this connection it should be noted that some of the subsidised centres attached to voluntary hospitals admit children direct to the wards of the parent hospital. There were 399 recommendations for convalescence and 1,244 for non-residential treatment. At the Council's centres such treatment is restricted to conditions which are lowering the resistance of the child to the rheumatic infection, e.g., dental sepsis, tonsillitis, etc., whilst at the subsidised centres at voluntary hospitals treatment for the rheumatic condition is also sometimes prescribed. There were 885 recommendations concerning school attendance; 331 of these were for exclusion from school for a period, 165 were for schools for physically defective children, and 389 for restrictions in elementary school activities. Analysis of the reports on the children visiting the centres for the first time during 1931 reveals that, of 1,792 children, 532 were diagnosed as non-rheumatic, 1,027 as articular rheumatism (400 boys and 627 girls), and 233 (97 boys and 136 girls) as suffering from chorea. In 148 boys suffering from articular rheumatism the heart was affected, whilst 213 girls suffering from the same form of the disease had cardiac disease. In the chorea cases the heart was affected in 18 boys and 31 girls. From April, 1931, complete returns have been made from the centres showing the agencies nominating children for attendance at the centres for the first time, and the information so received relates to 1,403 children. Of this number 138 children were nominated from County Hall as part of the procedure of following up Public Assistance cases discharged from Queen Mary's Hospital for Children, Carshalton, or from the Downs Hospital for Children, Sutton. In all, 936 children were recommended by school doctors, school care committees or head teachers, 177 were sent to the centres by hospitals, in 99 cases the parents themselves brought the children to the supervisory centres, 27 were nominated by private practitioners, 17 children were nominated bv the Invalid Children's Aid Association, and 9 came from various other agencies. Dr. Levick, commenting on the work of the St. George's Hospital rheumatism supervisory centre, which opened in April, 1931, points out that the first batch of children attending the centre were those who were suffering from established heart disease, and who were referred from other departments of the hospital. He emphasises the value of the convalescence, provided by St. George's Hospital at the Atkinson Morley home at Wimbledon, in increasing the resistance of those children whose hearts are as yet unaffected, against the rheumatic infection. The East London Hospital rheumatism supervisory centre is reported on by Dr. Gotch, the honorary physician in charge. Dr. Gotch classifies the children attending the centre during the year :— (1) Those with symptoms suggestive of rheumatic infection but without any confirmatory objective evidence (45 per cent.). (2) Those with symptoms and later (3 to 6 months) showing objective signs (35 per cent.). (3) Those with symptoms and definite objective physical signs at the first examination (20 per cent.). Dr. Baker reports a successful opening for the Lewisham rheumatism supervisory centre, which also came into being in April, 1931. One feature of the work at this centre is the comparatively large numbers of children nominated for attendance by their parents. Dr. Baker has adopted a system under which children suffering from true rheumatism, but with no signs of active disease, are inspected every three months, 45 whilst children in whom rheumatism is not definitely diagnosed attend every six months—unless earlier attendance becomes necessary. The Queen's Hospital rheumatism supervisory centre has had a strenuous year, as has already been noted. Dr. Winnicott reports that the average attendance per session was 33.6. He emphasises the value to the centre of the increased facilities for residential treatment provided at Queen Mary's Hospital for Children, Carshalton, and High Wood Hospital for Children, Brentwood, especially in the treatment of early or doubtful cases. Dr. Winnicott records his interesting experience at the centre that it is very unusual for carditis to develop in a child attending the centre, except in one already known at the first visit to be subject to rheumatic arthritis or chorea. He is of the opinion that further work at the rheumatism supervisory centres may reveal that what is at present suggested by the words "pre-rheumatic" and "prechoreic" is without basis on clinical fact. Dr. Preston has submitted a report on the Downham, "Elizabeth Bullock" and Putney rheumatism supervisory centres. This report is of so interesting a nature that it is printed in entirety. The report is as follows :— In Table I are shown the numbers of cases attending the three centres during the year and in Table II the total number of inspections and re-inspections actually carried out. Table I. Downham. •• Elizabeth Bullock. " Putney. Boys. Girls. Total. Boys. Girls. Total. Boys. Girls. Total. New cases seen (1931) 62 69 131 41 60 101 21 35 56 Old cases re-inspected 90 105 195 63 90 153 8 22 30 Total cases seen 152 174 326 104 150 254 29 57 86 Table II. Downham. "Elizabeth Bullock." Putney. Total number of inspections and re-inspections 574 542 198 Average attendance per session 11-4 12-3 14.2 At Downham there has been an increase on the numbers seen in the previous year, and a few extra sessions were necessary in order to deal with new cases. At this centre, 75 per oent. of appointments made for new cases and 73 per cent, for old cases were kept. At "Elizabeth Bullock" centre, the figures are practically identical with those of the previous year, 81 per cent, of appointments made for new cases and 67 per cent, for old cases were kept. The Putney centre (opened in May, 1930) has continued to justify its existence. Regular sessions are still held only once a month, but it has been necessary to hold three extra sessions during the year to avoid congestion. It may be that fortnightly sessions will be required in the near future. At this centre, 81 per cent. of appointments for new cases and 64 per cent, for old cases were kept. Table III shows the discharges, etc., from the three centres; the policy of keeping under continued observation those cases considered to be definitely rheumatic (even though free from active symptoms) has been continued; but as a result of continued observation, it has been found possible to discharge many of the doubtful cases still under observation in 1930. The smallness of the number of cases who repeatedly fail to keep appointments and thus "get out of touch," continues to be a gratifying feature. Queen's hospital. Downham, "Elizabeth Bullock" and Putney. 46 Table III. Downham, " Elizabeth Bullock ' Putney Rheumatism. Doubtful Rheumatism. NonRheumatism. Total. Rheumatism with Carditis. Non-cardiac Rheumatism. Doubtful Rheumatism. NonRheumatism. Total. Rheumatism with Carditis. Non-cardiac Rheumatism. Doubtful Rheumatism. NonRheumatism. Total. Discharged free from rheumatism 1 17 31 49 _ _ 18 15 33 _ _ 5 7 12 Transferred to other centres 13 6 19 _ _ _ _ _ _ _ _ _ _ Left school 3 4 2 9 7 9 4 3 23 1 - - 1 2 Left district or failed to attend 4 1 2 7 1 3 _ _ 4 _ 2 _ _ 2 Died 1 1 - 2 - — - 1+ 1 1 — - _ 1 Totals 22 29 35 86 8 12 22 19 61 2 2 5 8 17 * Died from Diphtheria. f Killed (motor accident). The subjoined table shows a classification of the cases seen:— Table IV. Classification. Downham. "Elizabeth Bullock." Putney. Boys. Girls. Total. Boys. Girls. Total. Boys. Girls. Total. Cases with a definite history of acute arthritis. C(i) with carditis 14 19 25 39 39 58 17 17 31 34 65 2 6 6 1 8 16 (ii) no carditis 5 14 19 17 14 31 4 4 8 Cases with a definite history of chorea. (i) with carditis 7 21 8 22 16 43 7 13 11 19 18 32 1 3 11 5 2 8 (ii) no carditis 14 14 28 6 8 14 2 4 6 Cases with a history of insidious illhealth regarded" as " True rheumatism.'' '(i) with carditis 13 26 12 32 25 58 7 21 7 34 14 65 8 12 4 14 12 26 (ii) no carditis 13 20 33 14 27 41 4 10 14 Cases with indefinite history, doubtfully rheumatic and no carditis 46 52 98 23 43 66 4 21 25 Cases definitely diagnosed as nonrheumatic 40 29 69 13 23 36 4 7 11 °Including 2 cases of congenital morbus cordis, + „ 1 case „ „ „ +,,2 cases ,, ,, ,, § ,, 1 case ,, ,, ,, || „ 1 case „ „ ,, 9 cases of acute arthritis also had chorea. The following table shows the arrangements which have been made for institutional treatment of the children in attendance:— Table V. Downham. "Elizabeth Bullock." Putney. Total. Carshalton or Brentwood 25 28 7 60 Downs 4 7 4 15 I.C.A.A. heart homes 2 2 2 6 I.C.A.A. ordinary convalescent homes- 15 15 6 36 Other convalescent homes 1 3 4 8 Residential open-air schools 7 4 3 14 Other institutions (hospitals, etc.) 9 6 2 17 Total 63 65 28 156 47 The increase in the number of cases admitted to Carshalton and Brentwood has been of great advantage ; it is gratifying to see the satisfactory general condition, even in serious heart cases, on their return from these institutions ; whilst, for the milder cases, a period of prolonged treatment is provided, which would be out of the question at a London hospital, but which is of immense value in giving such cases a good prospect of a permanent recovery. The help of the Invalid Children's Aid Association has again been most valuable, especially in the case of debilitated children without active rheumatism or carditis. Treatment at residential open-air schools is reserved for debilitated children considered entirely free from rheumatism or chorea. Table VI shows the arrangements which have been made with regard to school attendance. Whilst every effort is made to allow as many children as possible to continue at ordinary elementary schools, experience seems to suggest that children with definite cardiac trouble do better if they go to a school for the physically defective on their return from an institution. In addition there are a certain number of cases of quiescent rheumatism and chorea (especially chorea), who, although free from cardiac involvement, are continually having little set-backs and seem quite unable to attend school regularly. To tell their mothers to "keep them quiet at home" is often a mere waste of words ; they simply run the streets and then on their return to school are behind with their work, with the result that they worry and fret and develop an attack of chorea. If such children are sent to a P.D. school they are frequently able to attend regularly without relapsing, and continued courses of residential treatment are avoided. Moreover, in the case of children considered unfit for active games, etc. (although otherwise fit for elementary schools), instructions for the exclusion of such activities are frequently vitiated by the fact that such children have opportunities for taking strenuous exertions on the way home, etc. ; at P.D. schools closer observation is possible. Further, an invalid child is less likely to develop an " inferiority complex " when all his companions are in like case, than at a school where all the others are playing football whilst he is compelled to stand aside. Table VI. Downham. " Elizabeth Bullock." Putney. Cases of rheumatism and chorea with carditis. Cases of rheumatism and chorea without carditis. Doubtful rheumatism. Nonrheumatism. Cases of rheumatism and chorea with carditis. Cases of rheumatism and chorea without carditis. Doubtful rheumatism. Nonrheumatism. Cases of rheumatism and chorea with carditis. Cases of rheumatism and chorea without carditis. Doubtful rheumatism. rheumatism. Attending secondary and central schools 6 3 9 1 — — 2 — 1 — — — Attending elementary schools without restrictions — 38 65 49 — 50 55 30 — 5 18 10 Attending elementary schools with restrictions 35 16 10 9 24 22 6 2 15 17 7 I Attending P.D. schools 24(8) 8(1) — — 26 (14) 2(1) 1 1 4(1) – – – Attending open-air schools —— 2 4 4 – – 1 – – – – Attending M.D. schools —— – – – 2 1 – – – – – – Absent from schools practically throughout 10 2 1 – 5 2 1 — 2 3 — — The figures in brackets indicate the numbers of cases transferred to P.D. schools during the current year. As pointed out in the report for 1930, one of the most difficult problems at a rheumatism supervisory centre is the assessment of those children who complain of recurrent pains in the limbs without any history of acute arthritis or chorea. At the present time, there appears to be no definite means of saying which of these cases are "true rheumatics," (and potential cases of carditis) and one has to rely largely on one's clinical impressions. A review has been made of the notes of all the cases attending the centres, and certain data prepared for comparison between the various groups. For this purpose the cases have been sub-divided as follows:—(a) cases with a definite history of acute arthritis; (b) cases of insidious rheumatism with carditis; (e) cases of insidious rheumatism without carditis; (d) cases of doubtful insidious rheumatism. (The classification of a case under (c) or (d) is, of course, only based on clinical impressions and for some purposes they have been grouped together.) 48 Onset. Persistence of symptoms. Location of pains. Time of onset of pains. Meteorological conditions. From this analysis, the following facts emerge:— Onset of the (6) cases (50 cases); in 24 per cent, there is evidence to suggest that the disease followed an acute infectious illness (scarlatina heading the list). A similar onset is suggested in 8 per cent, of the insidious cases without carditis ((c) and (d) comprising 260 cases in all). The conclusion to be drawn from this would seem to be that particular attention must be directed to children who complain of pains which seem to have followed an acute illness, especially scarlatina. To judge the persistence of symptoms, 127 cases from Group (a); 40 from Group (o); 67 from Group (c); and 138 from Group (d) were kept under observation for six months or more (in some cases over three years). The progress was as follows :— Table VII. (a) Percentage. (b) Percentage. (e) Percentage. (d) Percentage. Entire freedom from symptoms 50 60 37 57 Occasional complaint of pains 28 17 33 27 Numerous complaints throughout 13 18 18 16 Definite relapse 9 5 12 — The striking facts which emerge from these figures are (i) that, on the whole, the most serious cases keep as free from symptoms as the presumably milder cases, and (ii) that a great many children continue to complain persistently of pains over a long period in spite of the fact that there are no objective signs to account for them. In fact, Table VII is to some extent misleading in that Group (d) naturally includes a number of very mild cases whose symptoms are of a transitory nature, and these swell the figures. If these were excluded and segregated to a class by themselves ("possibly non-rheumatic,") the proportion of persistent complainers among the "doubtful cases" would appear larger. Pains which persist in one joint over a long period, suggest that some disease other than rheumatism must be excluded (e.g., tuberculosis, coxa vara, flat-foot, trauma, etc.). Apart from this, pains in the joints themselves are more likely to be rheumatic than pains in the muscles, etc. Definite swelling of a joint (other gross diseases being excluded) must be taken as diagnostic of "true rheumatism" and a child who has had a swollen joint must undergo a course of serious treatment. Evidence on the matter of swollen joints, however, seems extraordinarily difficult to elicit from parents. With regard to pains distributed through the bones and muscles in general, the location was as follows in the various groups :— Table VIII. (a)* Percentage. (b) Percentage. (C) Percentage. (d) Percentage. Pains in both upper and lower limbs 50 52 56 30 Pains in lower limbs only 40 43 40 50 Pains in arms only 8 4 1 case 8 Pains " all over " 2 0 2 cases 8 * These observations apply to pains suffered during "quiescent" periods; the pains of acute rheumatic attacks are not described. Attempts to ascertain the time of day at which pains were most likely to occur in the different groups, have been disappointing. On the face of it, pains which occur during the night and keep the child awake would seem to be of some severity, but they appear to have come in the night as frequently among the cases who otherwise seem of a mild nature as in the more serious cases. Complaints of pains being worse in damp weather are less frequent than might be expected, but this may be partly due to lack of observation on the part of the mothers. In most cases, children are not seen sufficiently frequently to make careful observations on the relation of pains to weather; but the impression is certainly gathered that bouts of pain are more likely to occur as the result of sudden changes, than as the result of any particular type of weather. Incidentally, conditions which tend to make people sensitive to meteorological changes may make them subject to rheumatism; and, in this connection, it is tentatively suggested that a very thin-walled house (the interior of which will tend to be of changeable temperature) may be less suitable for a rheumatic child than an overcrowded unattractive residence in a tenement dwelling or old house, which, however, has thick well-built solid walls. At a rheumatism supervisory centre, one's efforts are very largely directed to the detection of early signs of carditis and it is in the hope of preventing serious cardiac damage that so many mild cases of suspected rheumatism are kept under continued observation. One cannot help being impressed with the large number of children who continue for many years to complain of 49 intermittent pains in the limba without showing any cardiac abnormality. On the other hand, the cases of insidious rheumatism "with organic carditis often complain very little of pain, whilst (as shown in Table VII) 50 per cent of children who have had rheumatic fever have not complained subsequently of pain. Yet that some of these "mild cases" really do suffer from quite severe pains cannot be denied, and one sometimes asks oneself whether one is doing these cases full justice in directing so much attention to their hearts ; is it possible that some of these children have a myo-fibrocitis of chronic nature ? Many of one's adult patients suffer from similar symptoms and one's efforts are principally directed to the relief of the pains by means of baths, massage and other forms of physio-therapy. In our present state of knowledge (or lack of it), it does not seem reasonable to say that any child, persistently suffering from pains in the limbs, is not rheumatic, unless one can provide some alternative explanation for the occurrence of the pains. The following disorders have been found among children sent to the clinics for supposed rheumatism. Flat feet and other minor orthopaedic defects; scoliosis and postural defects; coxa vara (one case); defective circulation from tight garters, etc.; arthritis of traumatic origin; calcium deficiency; an»mia and general debility; dyspepsia and acidosis; catarrhs; enlarged glands; habit spasms ; nervousness; abnormal psychology; congenital morbus cordis; healthy children with functional murmurs; erythema nodosum; purpura. During the year the rheumatism supervisory centre at the Hospital for Sick Children, Great Ormond-street, lost the services of Dr. Sheldon, who had been in charge since its inception. Dr. Moncrieff, in reporting on the work of the centre for 1931, pays just tribute to Dr. Sheldon's outstanding pioneer work. A little over half the number of the children attending the centre are on the rolls of Council schools, the remainder coming from extra-metropolitan areas. Dr. Moncrieff reports that the children attend regularly, and that the increase in parental interest is shown by the small number of patients discharged for non-attendance in 1931 compared with previous years. He emphasises the valuable work done by the Hospital's Heart Home at Lancing, to which 63 of the children attending the clinic were sent for convalescence during the year, and points out that the accommodation of the home has been increased by the addition of twenty beds. He also reports its recognition as a residential school by the Board of Education. Dr. Sophian, in his report on the Woolwich rheumatism supervisory centre, records that, of 119 children attending the centre during the year, 21 had definite rheumatic heart disease, suspicious heart changes were found in 40 children, and that 58 showed no clinical evidence of heart involvement. Dr. Sophian states" It has become apparent to me that greater resort must be made to convalescence . . . thereby exploiting to the full the usefulness of the supervisory centre." Dr. Gerald Slot, who is in charge of the Hammersmith and Royal Waterloo centres, has investigated the conditions under which the children attending these centres sleep. Of 455 children, 44 had a bed and room to themselves, 129 had a bed to themselves but shared a room, whilst 282 shared a bed with one or more others. Dr. Slot emphasises the point that in many of these cases it is impossible for the children to secure the necessauy amount of rest. On the preventive side he relies upon the Invalid Children's Aid Association and schools for physically defective children; and he is of opinion that, where special treatment at Queen Mary's Hospital, Carshalton, or High Wood Hospital, Brentwood, has been deemed necessary, consolidation of such treatment at a school for physically defective children is indicated. Dr. Slot states further that in his opinion if these children are sent to a school for physically defective children they will make satisfactory progress with their education, whilst, if they are allowed to remain at an ordinary school for a lengthy period, their activities being restricted, the effect on their characters is very disturbing. The effect of prescribing "no school" for several weeks or months has a like effect, and Dr. Slot states that these children are much better off at a school for physically defective children, where they have medical supervision and the attention of specially trained nurses, than when they are playing in the streets or acting as household drudges. At the Hammersmith centre an investigation has been made into the diets of the children. On the whole the diets appeared to be deficient in protein, and the parents were advised to make use of the cheaper protein foods, e.g., herrings, and rheumatic cases. Hospital for Sick Children. Woolwich. Hammersmith and Royal Waterloo hospital. E 50 King's College hospital. Eltham and Royal Free hospital. St. Marylebone general dispensary. to give their children a generous supply of vitamins in the form of fresh fruit, viz., orange juice, apples and other cheaper fruits in season. Dr. Slot sums up the measures of chief value in the prophylaxis of rheumatism at a rheumatism supervisory centre :— (1) Co-operation with parents is ensured. (2) The elimination of naso-pharyngeal and dental sepsis. (3) The building up of the constitution by adequate convalescence. (4) The administration of glucose in the form of barley sugar. (This simple measure has been found of great value in suitable cases.) (5) The realisation of a special rheumatic psychology. Dr. A. Gilpin's report on the King's College Hospital centre reveals that, out of a total of 273 children attending the centre, 253 were Council cases. During the year 137 children attended for the first time and of these 92 were considered to be suffering from rheumatic conditions. Of these 92 cases, 22 had rheumatic pains alone, with no cardiac involvement, no chorea or nodules. The remaining 70 cases were suffering from "further" rheumatic manifestations in the form of cardiac disease, chorea, etc. In the 45 non-rheumatic cases seen during the year the following diagnoses were made:— Debility and other minor ailments 18 Functional cardiac bruits 11 Tonsils and adenoids 8 Tic and habit spasms 4 Congenital heart disease 3 Enlarged mediastinal glands 1 Dr. Olive Rendel classifies the condition of the children seen by her at the Royal Free Hospital and Eltham centres :— Active rheumatism 23 Quiescent rheumatism 48 Doubtful rheumatism 38 Probably not rheumatic 20 Dr. Rendel diagnosed the non-rheumatic cases : Oral sepsis, 2; septic tonsils, 1; rickets, 1; congenital heart and septic tonsils, 1; habit spasms, 2; functional cardiac murmurs, 8; postural defect, 1; allergy (cyclical vomiting, asthma, urticaria), 3; and badly fitting boots, 1. Dr. Halls Dally has communicated a report on the St. Marylebone centre from which the following extracts have been made:— The preventive aspect is held to be the prime objective. Parents are encouraged to bring their children for examination whenever possible prior to the manifestation of rheumatic symptoms, and for treatment where the disease already exists. Pale and weakly children, often irritable, fretful and troublesome, possibly with nervous twitchings, and difficult to deal with, when coming of rheumatic stock, are brought for supervision before actual stigmata of rheumatic disease have become apparent. The disease frequently begins insidiously as a general falling-off in health, accompanied by pallor, " growing pains," and occasional sore throats. By timely advice to parents, as to pre- and post-natal management, combined with appropriate treatment to raise the resistance of the child against unfavourable influences in general, it is believed that weakly children of rheumatic stock may themselves be aided to work out their own immunity. A detailed analysis of 250 cases is appended. Rheumatic History previous to Attendance.—Pains in limbs, in 177 cases; Upper respiratory infections, in 78 cases; Acute rheumatic fever, in 28 cases; Chorea in 16 cases; Rheumatic cardiac affections, in 9 cases; Swelling of joints, in 15 cases; Erythema nodosum, in 2 cases; No symptoms in 15 cases. Symptoms on First Attendance.—Pains in limbs, in 121 cases; Tonsillitis, in 1 case; Swelling of joints, in 4 cases; Pallor and loss of weight, in 8 cases; Twitching, in 15 cases; Nervous instability, fatigue, anorexia, vasomotor disturbances, &c., in 69 cases; Dyspnoea, in 7 cases; No symptoms, in 46 cases. Nutrition.—Good, in 90 cases ; Fair, in 94 cases ; Poor, in 66 cases. Teeth.—Excellent, in 8 cases ; Good, in 94 cases ; Defective, in 148 cases. Eye Colour.—Grey, in 92 cases ; Brown, in 65 cases; Blue, in 41 cases; Hazel, in 29 cases; Not stated, in 23 cases. Arterial Pressure.— Variation Average 0- 5 70-120 94.6 52- 80 61 5-10 78-140 109 50- 90 68 10-15 92-150 121 50- 90 68 Cardiac Classification.— (а) Potential cardiac cases— History and complaints suggestive of rheumatism; no cardiac involvement, no disability for ordinary life 73 Rheumatic history, never cardiac involvement, now well 33 (b) Organic cardiac cases— Rheumatic history; cardiac involvement which has now disappeared 9 Rheumatic history; present signs of cardiac involvement, but no symptoms referable to heart 33 History suggestive of rheumatism; present signs of cardiac involvement, but no symptoms referable to heart 33 Rheumatic history; present signs and symptoms of cardiac involvement, but no disability for ordinary life 14 Rheumatic history; present signs and symptoms of cardiac involvement, and definite disability for ordinary life 11 (c) "Functional" cardiac cases— Transitory cardiac arrhythmias, effort syndrome, etc. 44 250 Clinical observations.—Hereditary and familial factors cannot be disregarded, for manifestations of rheumatic disease are found frequently to occur in several members of one family. The degree of aetiological significance to be attached to the several factors in environment is still uncertain. Influences in lowering general resistance appear to be due to overcrowding, insufficient sunlight, sitting about in damp clothes, and defects or deficiencies in diet, particularly of calcium, iodine and phosphorus. Calcium deficiency and acid retention seem to be favoured by milk poor in quantity and quality. Many children attending are found to be getting not more than a quarter of a pint of milk a day, and show rapid improvement after increase to a pint or more. Till now the tonsils have received more attention than the rest of the respiratory tract. Yet, independently or not of removal of the whole of the tonsillar tissue, rheumatism and its recrudescences have been observed in about 80 per cent, of cases to follow a closely precedent nasal or pharyngeal inflammation. Ample evidence is afforded by children at this centre of inherent instability and susceptibility. There is a lack of adaptation to changing meteorological conditions, and the potentially or actually rheumatic child is the delicate member of the family, with liability to frequent "colds" and malaise. Instability of the heat-regulating mechanism induces abnormal body temperatures, as well as functional cutaneous disabilities. On the psychical side these children are often "awkward" and difficult, with sympathetic instability, evidenced by aberrant vasomotor reactions, and central nervous lack of control, shown by spasmodic movements at times ending in Sydenham's chorea. Modern medicine is reverting to those broad philosophical principles of the ancient Greek physicians which dealt with diatheses rather than with diseases, and with types of constitution rather than with morbid entities. One of the most important of these, the "rheumatic" diathesis, for long has attracted the attention of physicians, until quite recent times when it became overlaid by the newer bacteriological concept of "infection."That infections can and do occur during the course of rheumatism in adults and children alike is undeniable, but the view that infection is responsible for the earliest manifestations, such as instability, "growing pains,"&c., denying any other causal possibility cannot, in my judgment be upheld. " Seeds do not grow on every soil," nor do micro-organisms grow and produce their effects in the body unless under conditions that favour their development. From this standpoint infection is not primary, "coming as a bolt from the blue,"but is always grafted upon an underlying metabolic state. Feeding of school children. Dinners are provided for necessitous children attending school, and follow menus which have been approved by the school medical officer. Each dinner provides at least 25 grammes of protein and 750 calories of heat value. E2 51 Hair Colour.—Red, in 13 cases; Dark, in 67 cases; Medium, in 138 cases; Fair, in 23 cases; Not stated, in 9 cases. 52 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 specially in need of it, irrespective of financial or social necessity, on the advice of the school doctors. These children are kept under continuous and careful observation and are weighed regularly by the school nurses. The following table gives the weekly average of children fed in the ordinary public elementary schools during 1931 (excluding special schools):— Dinners. Milk. Cod liver oil and malt. Free 3,508 8,158 1,546 Part or full payment 866 16,076 2,766 Over and above the "official" scheme detailed above, there is a very large number of "clubs" on a voluntary basis in the schools for the provision of milk. In a report made during the year it is stated that there are no less than 1,248 such "clubs" in the elementary and special schools conducted on the lines of the Milk Publicity Council's scheme, by which milk is provided for 78,000 children daily, each child having a separate bottle. Furthermore, there are 152 "clubs" supplying 10,000 children not under the " bottle "scheme. Samples of meals, as served, are taken from time to time for examination in the central laboratory at County Hall. Seven such samples have been taken during the year, six of which were found to be satisfactory; the remaining meal was somewhat deficient in protein content and calories, and attention was directed to this fact. During the year under review the quality of the milk supplied under the Council's contracts for necessitous children has been kept under control by systematic examination. The total number of samples chemically examined in the public health department during the year was 1,517. of this number nearly 90 per cent. were found to be satisfactory, the remaining 10 per cent. being found to be unsatisfactory, by reason either of the presence of extraneous matter (dirt), deficiency of fat, or by the addition of water. A comparison of these results with those of the previous year shows a marked improvement in the general quality of the supply; the number of samples indicating an addition of water or an abstraction of fat being only 33 (2.2 per cent. against 7.1 per cent. for 1930). It is regrettable, however, that this improvement in the quality of the supplies was less marked as regards the presence of extraneous matter, the results of examination showing 8.1 per cent.as unsatisfactory in 1931, against 11.5 per cent. in 1930. The presence of dirt in the milk supplied, which is largely due to careless handling between the cow and the school, is receiving special attention. All cases in which an excessive amount of extraneous matter is found are brought to the notice of the supplies department for appropriate action—regardless of the chemical composition of the milk. With very few exceptions milk supplied for necessitous children is not required by the contracts to conform to any bacterial standards, such as are required by the Milk (Special Designations) Order, 1923, made by the Minister of Health under Statute in respect of graded milk, it being subject only to the proviso that it shall be, inter alia, "Pure, new milk clean and perfectly sweet on delivery." With a view to securing better control, however, the scheme has been extended during the year so as to include bacteriological examinations, for which purpose arrangements were made for samples in duplicate to be collected on delivery at the schools, one sample being forwarded for bacteriological examination at the Southern group laboratory at the Park hospital, or, alternatively, to the bacteriological laboratory at County Hall; the other being submitted for chemical examination. In order to co-ordinate the work and to avoid overlapping in the examination of milk supplied to schools throughout the county, the co-operation of the medical 53 officers of health of the metropolitan borough councils has been sought, and arrangements made whereby a copy of the results of such examinations made by the borough analysts is forwarded to the school medical officer for information. A proportion of these reports includes particulars of bacteriological examinations. Copies are forwarded to the chief officer of supplies, who, in cases where the bacterial content is high, takes up the matter with the contractor. The number of samples examined in the Council's own laboratories is being reduced in consequence of the above-mentioned arrangements with the boroughs. A result of the sampling being done by the boroughs is that, on any breach of the Foodand Drugs (Adulteration) Act, 1928, legal proceedings can be taken against the contractor. Open-air education. Provision for education in the open air includes nine day open-air schools (non-tuberculosis) with accommodation for 1,648 children, and six day open-air schools (tuberculosis) 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 200 open-air classes in playgrounds and parks providing for upwards of 6,000 children. An interesting and successful addition to the open-air facilities in London was afforded by the experimental residential convalescent camp school, for children normally attending day schools for the mentally defective. In May, 1931, an offer was accepted from the Shaftesbury Society for their school at Loughton (Epping Forest) to be used exclusively for two parties (25 boys and 25 girls) from day schools for the mentally defective for one month each. In accordance with this arrangement, which was approved by the Board of Education, 25 boys went to the school in June, and 25 girls in September, together with two teachers from the day special schools in charge for each period. The charge for boarding made by the Society was 12s. 6d. a week per child and 25s. a week per teacher. Arrangements were made for the nomination, by the certifying medical officers, of any boys or girls in schools for the mentally defective who were noted as requiring a country holiday for health reasons. From these nominations a selection was made, parents were interviewed and assessed, and a final medical examination was made of the boys by Dr. Slowan and of the girls by Dr. Boome. The following report was submitted by Dr. Boome:— Boys.—Twenty-five boys were selected from various special schools. They were of varying ages, and of all grades of feeble-mindedness. From the experimental point of view the choice of the children was a very good one, showing what could be done with all types of the defect. I visited the school on three occasions and Dr. Slowan twice. A school nurse visited the school three times a week and attended to minor ailments. During our visits the school was inspected, meals seen, and special cases examined. All the boys were, on arrival and at intervals, weighed and measured and chest measurements were taken. We found that, in the event of sudden illness occurring, arrangements were made for a local general practitioner to be called in. The staff were very keen on making the experiment a success and any suggestions made by us were welcomed and put into operation. Considering that the two masters had not worked together before, their co-operation and wholeheartedness cannot be too highly commended. The gain made by the boys was really striking in physical benefit. All the boys, according to their headmasters' reports since the return to day school, have done well. One headmaster stated that he hoped in the near future that more of his boys might have this opportunity. From the medical point of view the experiment must be considered an unqualified success and proves that, under suitable conditions, mentally defective children cause practically no more difficulty than normal children in residential holiday schools or on school journeys. Girls.—Twenty-five girls were finally selected. They were of various ages, types and grades of feeble-mindedness. The choice, as in the case of the boys, was a good one, there being a fair average sample of mentally defective children—not a group selected as specially easy to handle. A few cases who were passed with some hesitation as an experiment did unexpectedly well. 54 Similar arrangements to those for the boys' party were made, for a school nurse to visit and for a local general practitioner to be called in if necessary, but, in fact, no visit by a general practitioner was required. One excellent feature differing from the boys' arrangements was the provision of hammock chairs for the rest hour, the chairs being put out in the open air when weather permitted. Progress in physical and mental condition was noted as the time went on. There was no homesickness at any time and a cheerful and happy atmosphere prevailed; the girls took a greater pride in themselves and in their personal appearance during their stay. Here again the staff's efforts resulted in the complete success of the experiment. General conclusions.—The success of this experiment was facilitated, in our opinion, by the special knowledge and skill of teachers and by the fact that the children themselves were of similar mental type. Probably if these children were sent to residential schools such as Bushy and Margate, the same result would not be obtained, owing to their sense of inferiority when with comrades of normal intelligence. The medical records show that, without exception, the children benefited very much physically by their stay, and letters of thanks from the parents endorse these records. Reports from children's care committees and head teachers of the day schools from which the children were selected affirm that they have been brighter and more responsive since their return. The following table gives the roll of the day open-air schools on 19th December 1931:— Boys. Girls. Totals. Aspen House 87 61 148 Bow Road 125 70 195 Brent Knoll 88 58 146 Charlton Park 89 55 144 Downham 81 65 146 Holly Court 164 146 310 Stowey House 179 101 280 Upton House 78 55 133 Wood Lane 75 71 146 Totals 966 682 1,648 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 suitable children notified under the tuberculosis regulations, 1930, as suffering from tuberculosis of the lungs or glands. 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 550 children. The number on the roll on 31st December, 1931, was 570, and the average attendance for the year ending 31st March, 1931, was 456.9. Admission to these 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. During the year 1931, 154 children were admitted and 189 discharged. Of the latter, 29 were transferred as fit to attend elementary schools, 68 were fit for work, 63 were transferred to residential institutions for residential treatment for tuberculosis or admitted to hospitals for various reasons, 16 moved away, 7 were transferred to special schools, and 6 were discharged for other reasons. In 1925, vocational classes were opened at Springwell House and Stormont House open air schools (T), 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 classes at Stormont House are in needlework and gardening. Instruction in carpentry is also given at this school. Open-air schools for tuberculous children. 55 The following school journeys were made during the year 1931:— School. Period. Hostel. No. of Children. From To Geere House 29th May 12th June St. Edith's Holiday Home, Leigh-on-Sea 23 Springwell House 4th Sept 18th Sept. Grays Retreat, Dovercourt 67 Stormont House 4th Sept 18th Sept. do. do. 47 Nightingale House 7th May 21st May 11, St. George's Terrace, Heme Bay 38 Do. 21st Sept. 5th Oct. do. do. 29 The following is an extract from the report of the medical officer of the Stormont House open air school:— Attention is drawn to the happier mental outlook of the backward child on his transfer from an ordinary elementary school. I have no doubt that this is due to the fact that in an ordinary elementary school the child, through enforced absence due to sickness, is often at the bottom of his class, although probably older than his class-mates, and so develops a sense of inferiority, while at an open-air school he associates with children in the same backward state, and, therefore, attracts less attention to himself, and probably less criticism. In place of an intense dislike of school and the desire to absent himself on the slightest pretext, he gradually regains confidence, and will attend as regularly as his health will allow. The number of open-air classes held in connection with the elementary schools in 1931 was 200. Of these 14 were of type A (children selected on medical grounds from a group of schools); 66 were of type B (children selected on medical grounds from the various classes of a single school); 36 were of type C (consisting of a single class from one school, educated continuously at one open-air station); and 84 of type D (consisting in a rotation of classes from one school occupying one open-air station). Six classes are permanent, that is to say they are outside the yearly programme and do not need re-authorisation each year. In addition, 43 of the 200 classes were continued throughout the winter, where the suitability of the sites had been ascertained by the school medical officer. Of the 200 classes, 67 were held in parks, gardens, playing-fields and other open sites, while 133 were held in school playgrounds (of which 23 were roof-play grounds). Children in classes of the types A and B are kept under special observation by the school doctors. Long experience has shown that in London there are two types of children who are weakly and anaemic, and require special care. They may be termed for shortness the bronchitic type and the rheumatic type. The former thrive only on open-air treatment of the sanatorium type, and for these the more exposure they get the better they are, while the latter cannot stand such treatment and require warmth and coddling. The medical reports again illustrate these results. The increases in weight given refer to the period from May to October. St. Barnabas (Boys) open-air class. (Dr. Dan vers-Atkinson.) Average increase in weight 2.1 kilos. One child showed cardiac enlargement and had rheumatic pains in the legs, and was discharged from the class. "Colds" have been infrequent. One boy, who had frequent bronchitic attacks, has been exempt from them during period of attendance. Cervical glands have subsided in one boy admitted for them. St. James' Park open-air class. (Dr. Dan vers-Atkinson.) Average increase in weight 31 kilos. Five children out of 11 with cervical adenitis (including one tuberculous) show improvement. Subjects of frequent chest colds show cure or definite improvement. Rhyl-street open-air class. (Dr. Richenda Gillett.) Very few coughs and colds. Open-air classes in parks and playgrounds. 56 Lollard-street (Girls) open-air class. (Dr. Adam.) Average increase in weight 1.8 kilos. General all-round improvement. Winstanley-road open-air class. (Dr. Pollock.) Average increase in weight 1.7 kilos. Only one child appeared to suffer from bronchitis, and that cleared up before the last inspection. Walnut Tree-walk (Boys) open-air class. (Dr. Adam.) Average increase in weight 1.2 kilos. One boy who lost weight has a rheumatic history and is undergoing hospital treatment. In others general all round improvement. Nightingale-square (R.C.) open-air class. (Dr. S. H. Griffiths.) Average increase in weight 2.2 kilos. There were no rheumatic children in the class. Children with enlarged cervical glands did well. Putney C.E. open-air class. (Dr. H. McQuaid.) Average increase in weight 1 kilo. I was amazed to find that in spite of the bad weather this class has shown excellent results : 26 out of the 28 children look really well. Those with bronchitis are all much better. The enlarged cervical glands subsided in those children with chronic cervical adenitis. West-hill (Infants) school open-air class. (Dr. R. S. Johnson.) Average increase in weight 0.78 kilos. A case of recurrent pyelitis lost all symptoms and gained 1.1 kilos. Two cases of bronchitis now show no signs in chest; in two cases enlarged cervical glands subsided. Burdett-Coutts (Infants) open-air class. (Dr. Danvers-Atkinson.) One child showed symptoms of rheumatism and was discharged from the class. At the Lollard-street (girls) open-air class an interesting "unofficial" arrangement was made for the girls to sleep out in the garden of the Lady Margaret Hall Settlement. This is described in the following letter from the care committee member who organised the experiment:— We could hardly have found a less propitious summer for the experiment, and during the greater part of the time the children had to sleep in our hut, with the doors wide open, instead of in the garden. They came however with unfailing regularity, loved coming, slept like tops, and gave wonderfully little trouble. When the middle of August came and we were all going away for our holidays, I had to tell the children that they must stop coming, and I shall not forget the wails of the two eldest in particular, who had to go home to sleep, one on a broken sofa, the other to be one of three in a bed. I think that in each of these oases there were 5 or 6 people in one small room. The experiment was not a very long one—6 or 7 weeks—and the season was bad, but it certainly did seem to do the children good, and the mothers were enthusiastic about it. The school doctor at Lollard-street school expressed much interest in the experiment and knew which children were coming here. I quite hope that we may be able to do this again next summer, possibly on a larger scale. Convalescent camp schools. The numbers of children passing through the residential convalescent camp schools during 1931 were: boys, 2,807; girls, 1,510; total, 4,317. The experimental camp school for mentally defective children at Loughton has already been described. Still another additional provision has been an arrangement by which a certain number of Roman Catholic girls are sent to St. Mary's, Dover. In detail the numbers were:— Provided schools:— Boys. Girls. King's Canadian School, Bushy 2,718 — Barham House, St. Leonards 64 493 Wanstead House, Margate — 531 Totals 2,782 1,024 Non-Provided schools:— Fairfield House, Broadstairs — 168 Russell Cotes School, Bournemouth — 237 St. Mary's, Dover — 56 Loughton 25 25 Totals 25 486 57 The following details are given of the remedial work carried out at the King's Canadian residential open-air school. The number of admissions was 2,718, of whom 46.6 per cent, received necessary remedial treatment at the remedial centre under physical training experts. There was an average increase in weight of 2.96 lbs. during the period that the children remained at the school. In all 302 boys received treatment for physical defects: 116 for kyphosis, 37 for lordosis, 83 for postural scoliosis, 61 mouth breathers, and 3 bow legs. Treatment was given to 612 boys, in small groups, for faulty carriage, shallow breathing, flat chests, etc. There were, in addition, 341 cases of flat foot that showed most promise of cure. These were thoroughly taught a few simple corrective exercises, supplied with printed cards of the same, and given advice as to footwear. The number of cases of flat foot shows no sign of abatement, and the above number does not represent the whole of the trouble, as many cases have passed the stage at which the limited treatment available would be effective. Particulars of treatment by doctor, school nurses, and dentist are as follows: minor ailments—14,080 treatments given; infectious illness—5 cases were sent to the appropriate hospital and 25 cases of sickness were treated in the sick ward; dental—extractions 878, fillings 1,104, gum treatment 871 treatments of 189 boys, Scalings 535. School journeys. During the year 1931, 449 school journeys were made (compared with 503 in 1930), and the children taking part were medically examined in 448 cases before departure. In all 13,671 children were examined (the corresponding figure for 1930 being 16,415) ; and of these 53 (97 in 1930) were rejected as unfit to take part in the journeys on various grounds, including the following (the figures in parenthesis refer to the year 1930):—otorrhoea, 4 (10); infectious disease or contacts, 3 (8); tonsillitis and kindred ailments, 15 (12); temperature, 3 (7); personal hygiene, 3 (3); skin diseases, 13 (9). Several children were provisionally rejected on grounds connected with personal hygiene but were subsequently passed. The precautions taken to prevent the spread of infectious illness are shown on page 90. Nursery schools. At the beginning of the year 1931, the total recognised nursery school accommodation in London was 1,004 in 13 schools, 400 places being maintained and 604 aided. In October, 1931, this accommodation was raised from 1,004 to 1,064 by the opening of the North Kensington nursery school in Kensal-road, W.10. This is a pleasant and well-designed building with two open-air classrooms, the space in which gives 19 square feet for each of the 60 children. Until April, 1931, when the school suffered an irreparable loss in the death of Miss Margaret McMillan, to whose devoted work the success of this school, and indeed that of the whole nursery school movement, is due, the Rachel McMillan nursery school in Deptford consisted of an aided portion (160) and a maintained portion (100). Thereafter the aided portion was taken over by the Council. The total accommodation remained unchanged, but the effect was that the recognised roll of schools for which the Council is solely responsible (560 in three schools) now exceeds that of the aided schools (504 in 11 schools). Proposals at the end of the year included a school for 40 on the top (fourth storey) of a block of flats in Bridgewater-street, St. Pancras, and another for about 50 children in Claverton-street, Westminster. Special observation has been made of the Council's two experimental nursery schools in Columbia Market, Bethnal Green, and Old Church-road, Mile End. Great improvement in the physical and mental condition of the children at both schools has been noted. Meals consist of a light lunch of milk, bread or rusks and butter, or porridge and milk at about 9 o'clock, a good and varied two-course dinner, followed by a piece of raw apple at or shortly before midday, and a meal of milk, home-made cake or King's Canadian residential open-air school. 58 bread, butter and jam at 3.30 p.m. In season, sandwiches of lettuces or grated carrots are given at the last meal. Nearly a pint of milk a day is consumed by each child, and in each school about a third of the children are, on medical advice, given cod liver oil and malt. This dietary, fresh air, free exercise and sleep in a restful atmosphere very quickly have their effect. Change in the condition of the skin has been particularly remarked. Described in many new admissions as being like a "nutmeg grater" (a condition associated with vitamin deficiency) the skin gradually becomes smooth and soft. A decrease in minor ailments at the Columbia Market nursery school is shown in the following table, submitted by the school nurse:— Ears. Blepharitis. Impetigo. Boils. Children being treated December, 1930 6 8 17 3 Children being treated December, 1931 3 1 1 - Physical training has contributed largely to the improvements noted. More than a third of the children attending Old Church-road come from homes of a single room, and at Columbia Market also many homes are very poor. The free exercise, impossible at home, which is obtained at the nursery school, is a potent factor in promoting healthy growth and in the prevention and cure of rickets. The apparatus provided, together with musical games and rhythmic exercises, are very suitable for little children. At both schools the doctor visits fortnightly and examines each child at least once a term. A nurse attends every morning for supervision of cleanliness, treatment of minor ailments and inspection for infectious disease. All children are seen on admission by the school nurse and within a fortnight by the school doctor, and only a very few have been excluded. At Old Church-road the school doctor is also medical officer to certain of the Stepney Borough Council infant welfare centres, and many children are sent by her from the centres to the nursery school. At both schools there is full co-operation between the local medical officers of health and the Council's staff. As indicated in the reports of both school doctors, treatment is being promptly carried out, and this cannot fail to have influence in the prevention of serious physical defects. The following report has been submitted by the school doctor (Dr. Turover) on the Columbia Market nursery school:— The school has very well justified its existence since its opening in August, 1930. The children are cleaner and better cared for by their mothers. They are all a better colour and poor circulations have improved. There has been a marked diminution in the incidence of coughs and colds during the last term, although during their first term at school there were a number of cases of bronchitis, especially in children with enlarged tonsils who were not used to being out of doors in all weathers. This has greatly fallen off now. A considerable proportion of the cases of enlarged tonsils and adenoids marked for observation have cleared up after a term or so in the school and those requiring treatment were promptly attended to. "Sores" are disappearing—although there are still a few cases of urticaria—with superadded infection—but, of course, many other factors are involved here. The social atmosphere of the school has a most important influence on the children. Those of them who were mismanaged at home, were asocial, and would not talk or mix with the other children, have mostly got over their difficulties. What impresses one most is to see them all happily occupied in games or individual play. The "jungle gym" and the sand pit are usually the centres of great attraction and the various running games, etc., keep the children warm in cold weather and provide the necessary amount of exercise. Judging by the steady increase in weight and height measurements and the general state of nutrition, the nourishment provided seems to be adequate. Very rarely is there any difficulty in the taking of food, and the children have got used to drinking more milk than they did at first. The children are, of course, carefully sorted out before admission. Up to now I have only had to reject epileptic children. One would, of course, not admit any rheumatic children, but the question of rheumatism rarely arises between the ages of two and five. The parents have, on the whole, responded very well as regards treatment for dental caries, enlarged tonsils and orthopaedic conditions. We have the advantage here of getting early treatment of these conditions, thus preventing deafness, otorrhoea, bronchial affections, maldevelopment of jaws and palate, and in securing good mental development in consequence. 59 There have been, comparatively speaking, few absences due to infectious disease. In that respect the daily attendance of a nurse is very helpful, as doubtful cases are immediately sent away for treatment before the infection has had a chance to spread, this chance also being minimised by the open-air life of the children. It would be interesting, a few years hence, to watch for the incidence of neurotic manifestations, delinquency and mental defectiveness in these children. I feel that the two or three years spent by the child at the nursery, under intelligent guidance and satisfactory physical conditions should prove of great value in the mental health of the child. In regard to the Old Church-road nursery school, Stepney, the following report has been submitted by the school doctor (Dr. Cotter):— Previous to the opening of the nursery school, Stepney, the provision of a suitable place for the "toddlers" attending the welfare centres in the neighbourhood was a trying problem for the medical officers and health visitors of the centres. The nursery school has been a most valuable remedy, for here the child from the overcrowded, poor home has the space, fresh air and sunshine, sleep, good food and companionship so essential for his proper development. The children admitted to the school in August, 1930, show a distinct improvement, both physically and mentally. The medical examination has revealed:— (1) frequent unsuitability of clothing ; (2) faulty nutrition leading to anæmia and rickets, enlarged tonsils and adenoids, dental caries and numerous other defects. (These defects were in much higher proportion amongst the older children.) (3) psychological difficulties, mainly due to cramped home conditions, and in a few cases the problem of dealing with the solitary child. (The progress of these children in the nursery school has been remarkable.) The nourishment provided and the general arrangements for the care and supervision of the children have been very satisfactory and beneficial. The equipment for play and occupation is excellent. The "jungle gym," swing and slide with steps, and the run-about toys provide splendid exercise and the healthy delight in pushing and pulling that is characteristic of a child between two and five years is apparent. All this apparatus, under the supervision of the teachers, assists the development of control of body and limbs. Up to the end of the summer term, no child has been considered physically unsuitable for admission to the school. A few children came for examination suffering from impetigo and pediculosis. They were excluded till treatment was completed and then re-examined. The parents are most willing to obtain treatment for their children when it is considered necessary. There has been very little infectious illness in the school. One case of smallpox did occur. I do feel the constant medical supervision helped to check the spread of infection. I wish to express my deep appreciation of the splendid work of the headmistress, the school nurse and the care committee representative in connection with the school medical inspections. I find, as a result of the co-operation between the parents, the teachers and the nurse, the standard of cleanliness and clothing, not alone of the children in the nursery school, but of the other children in the home, is raised. One feels the school tends to raise the hygienic standards existing in the home. Child guidance. The general principles upon which the Council has proceeded in regard to the reference of children to child guidance clinics was set out in the Annual Report for 1930. The work was continued throughout the year. Use has been made of the special departments for dealing with maladjusted children at Guy's Hospital, University College Hospital, Hospital for Sick Children, Gt. Ormond-street, and the London Hospital. With the first-named hospital, the co-operation has been greatly extended during the year. Information has been obtained not only through the care committees but by direct correspondence between the psychiatrists and the Council's medical officers. The arrangements for the treatment of children at the London child guidance clinic, Tudor Lodge, Canonbury, N.l, were described in the Annual Report for 1930. These have been continued during the year, and as the result of experience it has been found possible to simplify the work both professionally and administratively. The following information in regard to the clinic and its activities has been supplied by the medical director of the clinic, Dr. W. Moodie. The clinic is situated in a private house which has been specially fitted up to suit the needs of the work. The rooms are plainly furnished and care has been taken to avoid any similarity to a hospital. The aim of the clinic is to give advice concerning London child guidance clinic. 60 children who do not seem to derive full benefit from the ordinary school curriculum, or to respond to ordinary methods of discipline. Children of any age and young persons up to the age of 21 years are accepted for treatment subject to the consent, and a reasonable probability of co-operation on the part of the parents. All children are seen by appointment. There is, therefore, no waste of time and no waiting. The staff of the clinic consists of two doctors, two educational advisers (with teaching experience), six social workers, a part-time speech training specialist, a secretary, and clerical assistants. Children are usually seen between the hours of 10 a.m. and 5 p.m., but the clinic remains open until 9 p.m. on one evening a week for the convenience of young persons who are at work. The parents of a child are in the first instance always seen by a doctor, who, after having talked matters over with them, interviews the child, usually in their presence. He then advises as to the lines treatment will take. In simple cases advice is given at once. Except for the presence of the parent, all examinations are strictly private, no visitors of any kind being admitted, and no form of demonstration at any time being carried out on the patients, even for teaching purposes. A medical examination is carried out in almost every case; and older children are examined by a doctor of the same sex. If deemed necessary, a further examination is made by the psychologist, with a view to discovering the development of the child's intelligence, and his educational possibilities. Information concerning the child's behaviour is obtained by the social worker, who visits the school and the home. She can also, on her visits, convey the doctor's advice to the parents, and so obviate the necessity for his visiting the clinic so frequently as would otherwise be necessary. No physical treatment is given. If such is deemed necessary, the child is referred to the school medical officer, or to a suitable hospital or clinic for the purpose of obtaining it. Sometimes a period of convalescence or of residence in a school is advised, and arrangements are made for this through the Council. Where an educational difficulty is present, the psychologists are often able to point out the cause, and to suggest modifications of the school curriculum. Special individual tuition to children who suffer from some specific difficulty in learning is also given, but only with the assent of the teacher. As a general rule, teachers have co-operated wholeheartedly and have frequently expressed satisfaction at the results achieved. In many cases children have been helped over school difficulties which were the underlying cause of their behaviour disturbances. A speech-training class is held twice a week for the treatment of stammer and other speech defects, and the results obtained have been very promising. In many instances the disorder of speech was accompanied by other nervous symptoms, and since treatment for these can be given in the other departments of the clinic, satisfactory results have been obtained in cases which have not derived benefit from speech training alone. There is an excellent play hut in the garden of the clinic. Play groups are arranged where shy children, or children who have no facilities at home, may play together. This affords great pleasure to the children, gives them opportunity for self-expression, and enables general observation to be made of that type of behaviour. Those of school age come on Saturday mornings, and the younger ones on week-days. A part of the garden is left in a rough state and when the weather is suitable, is used as a playground. The play room and the play group have proved exceedingly popular, and increasing advantage is being taken of them. Children can be taught the use of play material, and their social adjustment can be improved. There is also a small library from which suitable books are lent to the children. A larger proportion of the problems arise in the home life of the child, and not in the school. Adjustment is easier for the child in the school than it is in the home ; conditions in school being well calculated to suit even unusual children, whereas in the post-war period of stress, many homes are not so. Parents as a general rule have shown themselves to be much interested in the work of the clinic, and have co-operated willingly. Care is always taken to give 61 advice to them in a commonsense way, so that they can understand the reasons for its being given. They are then always willing to act upon it. It has been necessary in an extremely small proportion of cases to place the children away from home, but this has been done only with the consent of the parents, and when circumstances rendered it absolutely necessary. The principle of the clinic is so to work that the child shall, if possible, remain at home during treatment. Circumstances, however, sometimes preclude this. A considerable number of patients have been sent for a short period of convalescence to improve their physical health, or to tide over times of stress in the home. Valuable assistance has been obtained from school care committees and other social organisations. Teachers and care committee workers have in many cases followed the course of treatment with close interest, assisting by supplying useful information and adopting suggestions made. During the year 1931 the number of Council cases referred to the clinic was 108, of whom 63 were boys and 45 were girls. The ages of the children referred, the source of reference, and the reasons for reference are set out in the following statements:— Ages of Children referred— 5 years 6 6 „ 6 7 12 8 17 9 12 10 11 Ages of Children referred— 11 years 12 12 „ 11 13 „ 12 14 „ 7 15 „ 1 16 „ 1 Total ]08 Source of reference. *Head teachers 28 School doctors 28 *Care committees 18 Parents 13 Children's courts 8 Hospitals 6 I.C.A.A 1 Other sources 6 Total 108 Reasons for reference. Backwardness 20 Theft 16 Behaviour in school 16 Behaviour at home 15 Nervousness 12 Stammer and speech defects 7 Truancy 5 Spitefulness 3 Word blindness 3 Enuresis 2 Unstable 2 Masturbation and sex troubles 2 Thumb sucking 2 Wandering 1 Begging for money 1 Not known 1 Total 108 *In many of these cases, reference was as a result of consultations between head teachers and care committees. N.B.—Children are sometimes referred for more than one reason, but the major reason only has been included in the table. 62 In a statement dealing with the work of the clinic during the period from April to December, 1931, the medical director of the clinic mentioned that 297 cases were accepted for treatment, of whom 134 attended Council schools of different categories. This shows that a certain number of children have been referred to the clinic otherwise than through the school organisation. The reasons for which children were referred were seldom simple, because simple behaviour difficulties yield to ordinary management. So far as treatment is concerned, it is understood that in about 10 per cent, of the cases the service was merely advisory. In 45 per cent, some simple form of treatment was carried out ; and in the remaining 45 per cent, the full resources of the clinic, medical, psychological and social, were brought to bear upon the cases. The number of children requiring direct mental treatment was extremely small. As to the duration of treatment, the cases fall into two groups. Those in which some slight or partial service was given were, on an average, under treatment for a period of about five months. Those in which more intricate and difficult treatment was carried out required in most cases about 18 months' observation. The results of the treatment are on the whole encouraging. In the field of child guidance it is usually a comparatively simple matter to dispel any particular symptom, and in many cases this has been done at one interview. The disappearance of the symptom, however, seldom indicates that the problem is satisfactorily solved, since the underlying cause is still present, and will almost inevitably give rise to future difficulties. A "satisfactory" result is recorded, therefore, only if the symptoms complained of disappear, and, in addition, other signs of behaviour or personality difficulty have been adjusted. The result is considered "fair" if the symptoms for which the child was referred disappear, but where it is felt that some fundamental difficulty still remains. In the majority of cases, where the result is regarded as "poor," the reason was due to lack of co-operation on the part of the parents. A survey of all the cases referred to the clinic shows that a "satisfactory "result was obtained in about 60 per cent., a "fair "result in 21 per cent., and a "poor" result in 19 per cent. From a follow-up survey of cases completed since the opening of the clinic, it appears that the number of relapses is very small. The Board of Education, in May, 1931, agreed to recognise the attendance of school children at the guidance clinic at Maudsley Hospital, Denmark-hill, as attendance at school under the provisions of the Education Act, 1921. The following report on the work of the clinic during the year has been received through the medical superintendent, Dr. Mapother. During the year 339 new cases were seen. By far the greater number of these were referred from the schools, either by the school medical officer, or through the care committees. The remainder come from other hospitals, private practitioners, various agencies for the care of children or attend spontaneously. The total number of attendances during the year, including both new and old cases, and also those attending by special appointment, was 2,135. The following statements show the source of reference, the reasons for reference, and the results of the year's working:— Source of reference of new patients. Other hospitals 30 Private doctors 65 Spontaneous 38 School authorities 174 Other sour 32 Total 339 Maudsley Hospital guidance clinic. 63 Reasons for reference. 1. Organic— (а) Chorea 7 (b) Congenital syphilis 3 (c) Post encephalitic syndrome 3 (d) Epilepsy (inc. petit mal)10 (e) Congenital G.P.I. 5 (f) Sense deprivation 3 (g) Anterior poliomyelitis 1 (h) Amentia after meningitis 1 (») Hydrocephalus 1 (j) Cerebral diplegia 1 — 35 2. Behaviour problems 89 3. Delinquency 6 4. Nervousness 135 5. Backwardness 31 6. Certifiably defective 19 7. Major psychoses— (а) State of excitement 2 (b) State of depression 1 (c) Schizophrenia 6 — 9 Laboratory tests only required 12 Nothing found requiring investigation or treatment 3 Total 339 There were 92 patients on the books on 1st January, 1931; therefore, together with the 339 referred to above, the total number treated during the year was 431. Of these 219 were still on the books on 31st December, 1931. Progress of those on the books. Satisfactory 157 Unsatisfactory 14 Good contact established 37 Attendance lapsed 11 Total 219 During the year 212 patients wen discharged. Condition on discharge. Improved 128 Not improved 42 Not treated, investigated only 35 For psychological tests only 7 Total 212 During the year, 53 oases were admitted to the wards. The clinic is held twice weekly, on Monday and Friday mornings. During the session arrangements are made for the children to form a play group, and a voluntary helper supervises this and provides reports on the child's behaviour with others, and on the use made of play material. It is hoped to develop this side of the work more fully. In addition to clinic mornings, a large number of cases are seen by appointment by two psychiatrists, who make a physical examination of each child, and the psychologist sees every case by appointment. Weekly conferences are held, and these are regularly attended by teachers, care committee workers, and others who may be able to contribute towards a better understanding of each case. The work has been greatly facilitated by the cheap fares now available, since recognition as a school clinic has been obtained. The department is served by two medical officers, a man and a woman, a part-time psychologist, a whole-time almoner, and both paid and voluntary clerical assistance. The East London child guidance clinic, which is organised by the Jewish Health Organisation of Great Britain, has been open since November, 1927, and occupies a suite of 7 rooms at the Jews' Free School, Whitechapel. The procedure is for school reports and a brief account of the social conditions of the family to be collected, and for the psychiatrist to see the child and whenever possible the parents or guardians. The work is not confined to Jewish children. East London child guidance clinic. 64 A preliminary conference is then held, at which a decision is made as to whether a full or partial service is likely to be necessary. When full service is given, the facts are discussed at a case conference attended by teachers and others interested. Observation in the playroom has been found of increasing value, and notes are made of the child's play activities and behaviour. A rhythm class has been started for children thought likely to benefit by this type of activity. Coaching is given in small classes to those of average intelligence who have specific educational disabilities. A number of cases in which it was found that the children were of low intelligence have been seen because they presented behaviour problems, but when the cause of the difficulty was deemed to be solely lack of intelligence, the case has not been further proceeded with, and the child has been referred to the school medical officer. When necessary, recommendations are made for special school instruction or for action under the Mental Deficiency Acts. The following tables show the number of cases which have been dealt with from the opening of the centre in November, 1927, to 31st December, 1931. This, it may be noted, is a four-year period, and the majority of the cases have been seen in more recent years. The total number of cases referred is 393 (males 235, female 158). Ages of children referred. Under 5 years 8 5 to 14 years 338 Over 14 years 44 Age unknown 3 Total 393 Source of reference. School doctors 124 Head teachers 42 Care committee 53 Hospitals and clinics 59 Parents 18 Private doctors 22 Probation officers and children's courts 32 Other agencies 43 Total 393 N.B.—In some cases reference was due to more than one agency. Reasons for reference. Backwardness 69 Nervousness 80 Enuresis 34 Behaviour in school 36 Temper tantrums 29 Behaviour at home 53 Stammer and speech defects 41 Unusual fears 19 Spitefulness, etc 28 Theft 37 Masturbation and sex difficulties 22 Night terrors, sleep walking 21 Habit spasm, nervous movements 16 Truancy 8 Wandering 9 Fits 3 Retarded in one subject 3 Faecal incontinence 3 Inability to keep job 4 Refusal to work 2 Solitary 1 Attempted suicide 1 Hysteria 1 Homicidal tendencies 1 Migraine 1 Inability to see (functional) 1 N.B.—One child may be referred for more than one reason. 65 Taking the work of the various child guidance clinics in London as a whole, they have formed a very useful addition to the available therapeutic armamentarium. The chief officer of the mental hospitals department has furnished the following After-careers, return for the year 1931 on after-care of children formerly attending special schools for the mentally defective:— Male. Female. Total. Grand total under headings. (1) Number of children born in or subsequent to 1913 who have left special schools and who were on the books of the supervision section on 31st December, 1931 616 347 963 963 (2) Number who after trial have proved themselves to be incapable by reason of mental or physical defect of undertaking remunerative employment 12 4 16 16 (3) Number employed as under:— (a) Industrial or manual occupations (i.e., factory work, trade or any part of a trade) . 336 208 544 - (6) Agricultural or rural occupation 4 — 4 — (c) Domestic occupation-— (1) Receiving remuneration M. F. Total 16 80 96 - 15 54 69 (2) Required for work at home 1 26 27 (d) Commercial, shop assistant, or selling behind a counter, office boys or girls 17 4 21 - (e) Gone into Army, Navy or Merchant Service — — — — (/) Blind alley or other precarious occupations (i.e., vanboys, newsboys, errand boys and girls, selling from a barrow) 145 3 148 813 (4) Number judged to be employable but out of work 60 30 90 90 (5) Number whose careers have not been traced:— (a) Not visited and not seen at bureaux 12 12 24 (6) Visited but no information obtainable 14 6 20 44 (6) Cases dealt with in addition to above include those who have since:— (a) died 1 1 — (b) attained the age of 18 years 338 198 536 — (c) been dealt with under M.D. Act 15 8 23 — (d) been lost sight of, or have left London 16 4 20 — (e) been dealt with by Pu blicAssistanceCommittee 1 — 1 581 N.B.—In addition to the 963 after-care cases shown in the above return there were 585 boys and girls between 16 and 18 years of age who had left special schools and were under statutory supervision on 31st December, 1931. These also were on the books of the supervision section for placing in employment. Deaf Children. During the year, Mr. Yearsley, the Council's consulting aural surgeon, has seen 351 children, the decisions regarding whom are set out on page 74. The cause of deafness in the partially deaf, deaf and defective, and deaf seen for the first time during the year was found in 31 cases to be congenital, and in 100 cases acquired, while in 4 cases the cause was uncertain. The congenital cases were classified as:— Boys. Girls. Total. True hereditary deafness 2 2 4 Sporadic deaf birth 11 14 25 Aphasia 0 2 2 Totals 13 18 31 66 The acquired cases were classified as:— Cause of deafness. Boys. Girls. Total. Diseases of the nervous system 3 2 5 Infectious fevers 13 15 28 Other infectious diseases 5 0 5 Primary ear disease 25 31 56 Injury 2 4 6 Totals 48 52 100 No cases of deafness due to notified cerebro-spinal meningitis occurred this year. This cause of deafness was almost unknown in this country before the War, although well recognised in the United States of America, but numerous cases have occurred since 1915. Only two cases of deafness were ascribed to congenital syphilis. The percentage of acquired deafness due to this cause since 1919 is shewn in the following table:— Year. Total acquired cases. Acquired cases due to congenital syphilis. Percentage. 1919 119 11 9.2 1920 135 12 8.8 1921 106 9 8.4 1922 95 7 7.3 1923 128 6 4.6 1924 85 9 10.5 1925 119 5 4.1 1926 162 7 4.3 1927 103 3 2.9 1928 67 1 1.4 1929 88 4 4.5 1930 118 7 5.9 1931 100 2 2.0 Totals 1,425 83 5.8 The high figure for 1924 is due rather to the small number of cases owing to other causes than to any marked increase in the number of syphilis cases. Schools for the. Blind. Classification has been made of all children who were in the Council's schools for the blind in the spring of 1931. The total number was 218. Of these, 213 were school children of 16 years old and under, the remaining five being girls of 16 to 18 under training at Elm Court (blind) school. Defect. Number. Percentage. Congenital defects— 85 38.99 Albinism 13 Nystagmus 13 Microphthalmia 11 Buphthalmia 7 Aniridia 5 Cataract 22 Congenital anophthalmos 1 Congenital dislocation of lenses 3 Congenital coloboma 6 Other congenital defects Ophthalmia neonatorum 4 46 * 21.10 Interstitial keratitis 13) 56 25.69 Choroido-retinitis 15 I Other choroiditis 9 Optic atrophy 19 Superficial keratitis 12 5.50 Macular disease 1 0.46 High myopia 5 2.29 Traumatism 3 1.38 Irido-cyclitis 7 3.21 Eyes excised (glioma) 1 0.46 Eyes excised (cause unknown) 2 0.92 Total 218 100.00 *Including two doubtful cases. 67 These figures may be compared with the analysis of 1,855 blind children of school age given by Mr. Bishop Harman in the report of 1922 of the Departmental Committee on the Causes and Prevention of Blindness. Grouping cases of interstitial keratitis, optic atrophy and choroiditis, conditions which may be associated with venereal disease, Mr. Harman's percentage is 40.32 compared with 25.69 in 1931, a notable decrease. The percentage of cases of ophthalmia neonatorum remains practically unchanged, namely, 19.75 in the cases examined prior to 1922, and 21.10 including two doubtful cases in 1931. Excluding a girl of 18 in the group of five undergoing training at Elm Court, the following is an analysis of the 45 cases of ophthalmia neonatorum in schools for the blind with reference to their year of birth :— Year of birth. Number of children. 1915 6 1916 5 1917 5 1918 4 1919 6 1920 5 1921 6* 1922 3 1923 2 1924 1 1925 2* Total 45 *Including one doubtful case. It would appear that, although the percentage of cases of ophthalmia neonatorum amongst blind children has not decreased, the actual number of cases of blindness from the disease is lessening. The decrease in numbers, however, is partly due to change in the definition of blindness introduced in the Blind Persons Act, 1920. In March, 1931, the total number of children in the Council's elementary schools was 610,101. Of these, 570,283 were in ordinary schools, 13,044 in special schools, and 26,774 in central schools. Calculated from the figure 610,101, and including the two doubtful cases, blindness from ophthalmia neonatorum was 7.37 per 100,000 children. This figure is higher than it should be, as it includes blind children up to 16 years old, whereas most elementary school children leave at 14, but it is given as a basis for future comparison. As regards congenital defects, the percentage has increased from 24.04 in Mr. Harman's group to 38.99 in 1931. This increase is, of course, relative, and is due mainly to the great fall in the incidence of interstitial keratitis and allied conditions. It is emphasised that most of the figures given relate to percentages. The actual numbers in the Council's schools for the blind have fallen from 316 in 1922 to 218 in the spring of 1931. This fall is due partly to change in the definition of blindness and partly to improved methods of treatment. Residential and Industrial Schools. There are seven 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. There are three industrial schools (two for boys, one for girls) with a total accommodation for 357. To each institution is allocated a medical officer and a dentist. The medical supervision of the Ponton-road place of detention has been under the charge of Dr. T. J. T. McHattie, one of the Council's full-time medical officers. His report is as follows :— The number of admissions to Ponton-road place of detention during 1931 was 866, of which 744 were boys and 112 girls. In addition, 19 boys returned from hospital or were brought back Industrial schools. Ponton-road place of detention. Residential schools. f 2 68 after absconding, bringing the total to 875. The new admissions exceeded those of 1930 by 71. The average monthly admissions were 71.3. Exclusive of staff, the average daily numbers in the home during the year were as follows :— January 35.6 February 42.3 March 38.7 April 36.5 May 35.7 June 36.0 July 40.0 August 30.7 September 29 .8 October 31.5 November 35.1 December 35.1 The length of stay in the home varies greatly and ranges from one night up to three months or more. The usual period of remand is from seven to fourteen days. The courts dealing with these cases were as follows :— Islington Juvenile Court 137 cases Toynbee Hall „ „ 148 „ Lindsay Hall „ „ 73 „ Carton Hall ,, ,, 32 ,, Battersea „ „ 38 „ Lambeth „ „ 82 „ Deptford „ „ 58 „ Woolwich „ „ 33 „ Guildhall „ „ 24 „ Various Petty Sessions 140 „ Various adult courts 71 „ Place of safety cases and lodgers (no court) 20 „ Total 856 cases As was the case last year just over one-third of all the charges were dealt with at the Islington and Toynbee Hall Juvenile. Courts. The subjoined table A shows the distribution of the charges according to age in regard to 839 children, of whom full reports were available, and of whom 727 were boys and 112 girls. The ages have been divided into five arbitrary groups, the first and last of which include children above and below school age respectively. Very nearly half (46.7 per cent.) of all boys charged with offences, and exactly half the girls, fall within the group of children above school age. The table shows well how great is the preponderance of stealing and its associated offences over all other charges. Simple larceny alone constitutes about 50 per cent, of all charges, and, omitting those at the end of the table, such as "living in circumstances" and the like, in which the child is the victim of parental neglect, the proportion becomes much higher. This is true for both boys and girls. Stealing begins early in life and becomes increasingly prevalent in both sexes as the years go on. The youngest thief in the series was a precocious youth of 6 years and 10 months, who had a mental age of 8 and a reading age of 10. He was admitted in February on a charge of being a "suspected person," and again in March for larceny. One boy stole at 7 years, but it is not until the 11.13 year group is reached that the numbers become serious. To this group belong 37.6 per cent, of the cases of stealing, and to the older group 51.8 per cent., while only 10 per cent, are found in children between 8.10 years old. The prevalence of petty theft among juvenile delinquents is readily explained without reference to physical defects or psychological reactions. Its accomplishment is easy, the opportunities for it are unbounded, the risk of detection is comparatively slight and, to the adventurous spirit, worth running, and no great skill or ingenuity is required to ensure success. There are few Artful Dodgers,"but many petty thieves; the former require training and experience, but anyone can " pinch "an apple from a stall, or pocket a necklace or a penknife from stores where goods are displayed temptingly on trays in the front of the shop. This experience agrees with that reported last year, and seems to show that premeditation plays a small part in juvenile theft, and that, in the great majority of cases, the root cause lies close to the surface and is to be found in the natural acquisitive instinct, unhampered by training, rather than in any deeper psychological reaction. The charge that ranks next to stealing in point of numbers is that of "being beyond parental control."The children coming under this head are, perhaps, more than any others, the victims of circumstances. Faulty heredity and even more faulty environment play the leading part in causation. The bulk of these children are habitual truants, many are hopeless liars and thieves. Few of them show any outstanding signs of either functional, nervous or physical defects. The average truant is a healthy young animal, who is simply following his normal instincts because he has never been taught by his parents to do otherwise. The influence of his teachers is nullified by his irregular attendance at school. Discipline in the home is either non-existent or takes the form of cuflings and hidings, to escape which the child covers his fault by lying. A vicious circle Charges. Stealing. Beyond control. 69 is formed, until sooner or later the parent, exasperated by the failure which his own laziness or ineptitude has brought about, takes the child to the police and charges him as being beyond control. The home conditions in these cases are almost always bad. Drink and other parental vices, over-crowding, loss of one or other parent by death or desertion, and the troubles so often associated with step-parents or foster-parents are among the commonest causes alleged. The effect of removal of these children into the remand home, where life is regulated by good feeding, regular sleep and exercise, and well directed discipline, is one of the most striking features of the work in connection with Ponton-road. In hardly a single instance has there been any real trouble with children or young persons after admission, and the most refractory of them settle down in a few days and behave in a normal and rational manner. As in stealing, so in loss of control, the cause is on the surface. Much that has been said of loss of control applies to the charge of wandering. Bad home conditions, incompatibility of temper between the child and his parents, and often ill-treatment, are among the usual causes. In addition, there is, in these cases, the craving for adventure, the desire for change and a definite wanderlust, which cannot be considered as pathological entities. In all 75 boys and 8 girls were admitted to Ponton-road more than once. Of the boys, 70 were admitted twice, 4 three times and 1 on no less than six occasions. No girl came in more than twice. Of the 75 boys, 35 were admitted for a repetition of the same offence. Table B shows the number of physical defects found in 765 children; 659 boys and 106 girls. While these figures show a somewhat lower percentage of defects among these children than those of 1930, they are still, on the whole, above the London average. This is more marked in the children above school age and in the boys than in the girls. The group of functional neuroses includes stammer, 12 cases; obvious signs of nervousness, such as facial spasm, blinking, tremor and the like, 16 cases; somnambulism, 4 cases; and enuresis and occasional bed-wetting, 59 cases. Of these last, only about 50 per cent, were probably cases of true enuresis. Of the 55 older boys reported for enuresis, four were mentally defective and 29 were dull or very dull. Nearly all had some associated physical or nervous disorder and seven were boys of markedly pool physique. Among the defects were included stammering (1), somnambulism (1), chorea (1) disordered action of the heart (1), undescended testicle (1) and orchitis following a kick (1). Ir three there were signs of rickets in early life, four had enlarged tonsils, and two had valvulai disease of the heart. One boy had signs of Frohlich's syndrome (adiposity due to unbalancec secretions of the endocrine glands) and one was suspected of masturbation. Whether the relation between these defects and the enuresis was one of cause and effect is not clear. A more likely factor is perhaps the disturbances associated with puberty. The impression is given that the majority of these cases are not pathological at all, but are the result of uncorrected bad habits and laziness, and, further, that bed-wetting is part and parcel of the delinquency and not a cause of it. All boys known to be bed-wetters are placed in special beds and are called at intervals during the night. In no case is a boy punished, and every encouragement is given to enable the boys to overcome the habit. The percentage of stammerers was 1.5 (11 boys and 1 girl). This figure is not much above the average for London children generally. There were five cases of only slight occasional stammer, and in no case were there any special features which could lead one to associate the condition with the offence with which the child was charged. Two cases only occurred during the year, one of scarlet fever and one of diphtheria. Both cases were sent to hospital at once, all contacts isolated and, in the case of diphtheria, swabbed. There was no spread of the disease. Three other boys were sent to hospital with suspected diphtheria during the year, but all proved to be negative. In addition to the defects in the table, 377 children were treated for minor injuries and ailments, septic sores and the like. Swabs were taken from 37 children for suspected diphtheria with negative results. In considering the mental condition of the children, the educational attainments and the general intelligence, as ascertained by Professor Burt's revision of the Binet Simon tests, have been taken separately. Each child, with the exception of the "place of safety" cases, who were admitted for one night only, was given a full mental test and the results recorded. Whenever possible, a few days were allowed to elapse after admission before the test was given, as it was found easier to secure co-operation and to gain the confidence of the child when he had settled down and become accustomed to the home. Owing to the short period of remand and to lack of time, however, this was not always possible. Table C is compiled from an examination of 674 children whose records are complete. It shows the marked disparity that exists between the actual intelligence of the delinquent and his educational attainments. The age level of the latter is obtained by taking the mean of the reading and arithmetic ages, and is almost invariably far below the mental age. This is true for both boys and girls and at all ages, but it is more marked in the older children. In many of these, a process of deterioration was apparent, and it was evident that they were beginning to forget what they had learned at school, especially in arithmetic, the level of which was almost always below that of reading. Wandering. Multiple charges. Physical defects. Functional nervous disorders. Enuresis. Stammering. Infectious Fevers. Mental conditions. 70 It will be seen that of the boys only 10 per cent, and of the girls 8 per cent, were up to their age or above it for reading and arithmetic, whereas 23.5 per cent, of boys and 25 per cent, of girls attained that level for general intelligence. Taking boys and girls together, 90 per cent, showed more or less retardation on education tests, while 76.4 per cent, were of more or less blunted intelligence. Again, 64.8 per cent, and 45.1 per cent, fell below a mental ratio of 85 on educational and mental tests respectively. Some attempt has been made to gain an insight into the correlation of particular offences to mental retardation, and, as a result of an analysis of the records of the boys over school age, it is found that for cases of stealing and its associated offences the average number of years retarded is 2.9, while in the case of charges involving sex offences the average retardation is 5 years. The numbers charged with the latter offence are too small to be of any real value. Of 742 children admitted during the year and of whom there are full records, 38, or 5.1 per cent., were defective mentally. Of these, 30 were boys and 8 girls. In addition to these, five youths and five young women of 16 years of age were received for one night only as "place of safety" cases pending the presentation of petitions on transfer to institutions under the Mental Deficiency Act. During the year 136 special reports on the physical and mental condition of the children were submitted to the magistrates. It is noteworthy that a very marked improvement takes place, not only in the physical condition, but in the general bearing and behaviour of the children who have been for any length of time in the place of detention. This improvement is due, no doubt, in large measure to improved cultural conditions, including regular habits, clean linen and adequate sleep and good feeding. The superintendent of the place of detention has rendered valuable assistance in keeping the records of the cases and facilitating examinations, etc. Mental defectives. Magistrates' reports. 71 TABLE A. Showing the Number of Charges at Different Ages among 839 Children at Ponton-road Place of Detention during 1931. BOYS. Nature of Charges. Stealing. Breaking, entering and stealing. Breaking and entering. Larceny and arson Burglary. Shopbreaking. Sacrilege. Embezzlement. Forgery. Demanding money by menaces. False pretences. Travelling without ticket. Suspected person. Trespassing. Begging. Street trading unlawfully. Playing pitch and toss. Using insulting words in public. Wilful damage. Arson. Assault. Causing bodily harm. Attempted suicide. Sex offences. Absconding from industrial school. Wandering. Breach of recognisances. Beyond control. Living in circumstances of moral danger. Parents of drunken habits. Education Act. Place of safety cases. Total. Ages— 14—15 179 29 4 1 1 5 - 5 1 1 1 _ 29 1 5 1 1 1 2 _ 5 1 - 6 - 15 15 3 1 _ 1 6 321 11—13 144 26 6 - - 5 1 1 _ _ _ 1 10 4 1 - - - - - - - - 4 2 8 14 45 - - 17 _ 290 8—10 38 3 2 - - - - - - - - - - - - - - - - 1 1 - - - - 4 3 32 2 1 11 _ 98 5— 7 2 - - - - - - - - - - - 1 - - - - - - - - - - - - 2 - 5 - - 4 _ 14 Under 5 - - - - - - - - - - - - - - - - - - - - - - - - - 2 - - 2 - - - 4 Total 363 58 12 1 1 10 1 6 1 1 1 1 40 5 6 1 1 1 2 1 6 1 - 10 3 31 32 85 6 1 33 6 727 GIRLS. Ages— 14—15 33 - - - - - - - - - - - 1 - - - - - - - - - 2 - - 10 2 1 2 — — 5 56 11—13 10 - - - - - - - - - - - - - - - - - - - - - - - - 2 2 9 5 1 4 — 33 8—10 3 - - - - - - - - - - - - - - - - - - - - - - - - 3 _ 2 3 1 3 _ 15 5— 7 - - - - - - - - - - - - - - - - - - - - - - - - - 3 - 1 - 1 1 _ 6 Under 5 - - - - - - - - - - - - - - - - - - - - - - - - - 1 - - - 1 - - 2 Total 46 - - - - - - - - - - - 1 - - - - - - - - - 2 - - 19 4 13 10 4 8 5 112 72 TABLE B. Showing the Physical Defects found among 659 Boys and 106 Girls at Ponton-road Place of Detention during 1931. Defects. Poor nutrition. Poor physique. Teeth, 3 or more decayed. Defective vision, 6—12 or more. Diseases of eyes. Squint and ptosis. Deafness. Diseases of ears. Throat and nose. Enlarged cervical glands. Heart. Lungs. Skin diseases. Rickets. Chorea. Rheumatism. Epilepsy. Congenital syphilis. Albuminuria. Anramia. Endocrine disorders. Hernia. Affections of testis and cord. Injuries to limbs. Scars of old operations. Developmental errors. Deformities. Stigmata of degeneration. Facial spasms and other nervous signs. Stammer. Somnambulism. Enuresis. Age 8— 14-15 34 34 32 74 5 6 5 11 21 4 12 12 26 9 _ 2 1 1 _ 4 2 1 9 8 14 3 14 1 8 5 3 34 11-13 25 33 25 44 3 8 6 15 19 1 8 9 7 5 2 1 _ 2 1 _ 4 _ _ 3 3 10 6 2 4 5 1 22 8-10 13 13 4 11 2 7 1 2 15 3 1 5 4 3 - - - - - 1 1 _ _ 4 2 9 1 2 4 2 _ 3 5- 7 2 1 6 - - 2 - 2 1 1 - - 1 2 - - - - - 1 - - - - - 1 - - - - - - Totals 7.4 81 67 129 10 23 12 30 56 9 21 26 38 19 2 3 1 3 1 6 7 1 9 15 19 23 21 5 16 12 4 59 Percentage. 9.7 10.6 8.8 16.9 1.3 3.0 1.6 3.9 7.2 1.2 2.7 3.4 4.9 2.5 0.3 0.4 0.16 0.4 0.16 0.8 0.9 0.16 1.2 2.0 2.5 3.0 2.7 0.6 2.1 1.6 0.5 7.7 73 TABLE C. Showing the Results of Mental Tests among 674 children at Ponton-road Place of Detention during 1931. BOYS. Age groups. Total. Total per cent. 14-15 Per cent. 11-13 Per cent. 8-10 Per cent. 5-7 Per cent. Educational attainments. Mental ratio 95 or over 11 4.4 34 13.9 12 14.3 3 37.5 60 100 „ „ 85 to 95 61 24.5 62 25.4 25 29.8 1 12.5 149 25.5 „ „ 55 to 85 147 59.0 132 54.1 43 51.2 2 25.0 324 55.5 „ „ below 55 30 12.1 16 6.6 4 4.7 2 25.0 52 9.0 Total 249 — 244 — 84 — 8 — 585 — General intelligence. Mental ratio 95 or over 27 10.8 68 27.9 37 44.0 5 62.5 137 23.5 „ „ 85 to 95 75 30.2 84 34.4 26 31.0 - - 185 32.0 „ „ 55 to 85 134 53.8 91 37.3 20 23.8 3 37.5 248 42.0 „ „ below 55 13 5.2 1 0.4 1 1.2 — — 15 2.5 Total 249 — 244 — 84 — 8 — 585 — GIRLS. Age groups. Total. Total per cent. 14-15 Per cent. 11-13 Per cent. 8-10 Per cent. 5-7 Per cent. Educational attainments. Mental ratio 95 or over 1 24 4 25 0 2 28-6 7 8-0 ,, ,, 85 to 95 2 4.9 10 40 0 4 250 5 71-4 21 23 0 ,, ,, 55 to 85 33 80.5 12.2 14 56 0 8 50-0 55 62 0 „ „ below 55 5 12-2 1 40 — — 6 70 Total 41 — 25 — 16 — 7 — 89 — General intelligence. Mental ratio 95 or over 5 12.2 4 16.0 8 50.0 5 71.4 22 25.0 „ „ 85 to 95 5 12.2 13 52.0 6 37.5 2 28.6 26 29.0 „ „ 55 to 85 30 73.2 8 32.0 2 12.5 — — 40 45.0 „ „ below 55 1 2.4 — — — — — — 1 1.0 Total 41 — 25 — 16 — 7 — 89 — 74 Defective children. Admission Examinations with a view to the admission of children to special schools were examination made5,684 cases, a decrease of 331 from the number examined in the previous year, and 19,293 others were re-examined during the year either at school or at County Hall. The following table shows the number of children nominated for examination and the recommendations made:— Defect. Number nominated. Suitable for admission to Returned to elementary school. Invalided as for the time unfit for any school. Notified under M.D. Acts. Boys- Girls. Blind school. Myope class. Swanley. Boys- Girls. Boys. Girls. Boys. Girls. Boys. Girls. Boys Girls. Boys. Girls. Ocular 668 757 10 9 88 141 97 86 451 485 22 36 — — Deaf school. Hard of hearing class. Boys. Girls. Boys. Girls. Aural 156 167 42 34 35 49 76 82 3 2 — — P.D. school. Open-air school. Physically defective Boys. Girls. Boys. Girls. 859 817 644 622 25 15 136 138 54 42 — — M.D. school. Boys. Girls. Mentally defective 1,167 881 496 397 551 385 57 50 *63 *49 Epileptic colony. Boys. Girls Epileptic 104 108 28 23 41 52 35 33 — — Total cases 2,954 2,730 1,465 1,376 1,255 1,142 171 163 63 49 5,684 2,841 2,397 334 112 *Of these 52 boys and 44 girls were imbeciles; 3 boys were idiots; and 8 boys and 5 girls were feeble-minded. Children The following statement shows the nature of the conditions found among the admitted to children certified as suitable for admission to schools for the physically defective at P.D. schools, the admission examinations during the year:— Morbid conditions Boys. Girls. Total. Infantile paralysis 46 29 75 Cerebral paralysis 13 14 27 Various paralyses 34 8 42 Tuberculosis of bones and joints 122 93 215 Osteomyelitis 16 12 28 Rickets and resulting deformities 7 8 15 Congenital deformities 21 27 48 Traumata and amputations 20 7 27 Non-tuberculous arthritis 13 10 23 Rheumatism, chorea, etc 29 63 92 Heart disease— Congenital 23 22 45 Acquired valvular 170 230 400 Non-valvular 52 67 119* Various chest conditions 53 17 70 Other diseases, chiefly medical 25 15 40 Totals 644 622 1,266 * In some of these cases evidence of valvular disease was somewhat uncertain but there has been transient evidence of valvular incompetence. 75 The following statement gives an analysis of the 370 cases examined for admission to special schools for the physically defective, in which the children were either returned to elementary schools or were invalided as unfit for any school:— Children returned to elementary schools or invalided. Morbid conditions. Elementary school. Invalided. Tuberculosis, actual or suspected; tuberculosis of bones, joints, etc. 19 4 Congenital deformities 10 14 Rickets and deformities from this cause 13 3 Fragilitas ossium — — Osteomyelitis 7 2 Various traumata 7 — Heart disease— Congenital 24 7 Valvular 66 29 Non-valvular 24 4 Anaemia 9 2 Rheumatism and chorea 47 5 Kidney diseases 5 3 Skin conditions — — Various chest conditions 10 6 Infantile paralysis 7 1 Cerebral paralysis — 8 Various paralyses 2 1 Epilepsy 1 — Pseudo-hypertrophic muscular dystrophy 4 3 Miscellaneous, nervous conditions, ataxia, etc. 12 1 Non-tuberculous arthritis and synovitis 4 2 Various 3 1 Total 274 96 370 Compared with the figures for the previous year, there has been need for fewer children submitted for admission to schools for the physically defective to be invalided from school attendance. The numbers for 1929 and 1930 were 168 and 113 respectively. The number who proved capable of continuing their education hi an elementary school was 274, compared with 306 during 1930. The special schools were visited at least once a quarter, and every child present Rota visits to was seen at least once during the year; the total number of examinations made was the schools. 18,681, and in addition 612 special examinations were made of children already on the rolls of special schools in connection with applications for non-enforcement of attendance and for similar reasons. As a result of the rota visits and the re-examinations the following re-classifications took place:— Transferred from schools for Re-classified for transfer to— P.D. school. M.D. school. Sight saving school. Blind school. Deaf school. Hard of hearing school. | White Oak, Swanley Open- air school. Epileptic colony. Physically defective _ 13 1 1 2 1 _ 12 1 Mentally defective 5 _ 1 _ 3 1 4 — 6 Sight saving 3 - - 6 - - 3 _ _ Blind - - 9 _ - - - _ Deaf - - - _ - 1 1 - - Hard of hearing - - - - 22 - - - - The number of children excluded was 74 (62 as imbecile, four as feeble-minded ineducable, and eight as feeble-minded detrimental) and 32 were invalided on medical grounds. 76 There were also 544 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 187 26 - 3 9 18 243 Over 14 years excluded as no longer certifiable 159 73 4 2 51 12 301 Decertification 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 schools for physically defective children 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 76 67 Rheumatism 8 14 Tuberculosis 20 26 Infantile paralysis 11 8 Rickets and deformities from this cause 1 18 Various traumata 5 12 Congenital deformities 6 8 Non-tuberculous arthritis and synovitis including pseudo-coxalgia 5 10 Chorea 4 11 Anæmia _ _ Osteomyelitis 10 2 Various paralyses 4 2 Fibrosis, bronchitis, asthma, etc. 3 2 Nephritis _ 2 Miscellaneous, nervous conditions, ataxia, etc. 4 7 Totals 157 189 Age groups of children in day special schools. The following table shows the age groups of children in day special schools on 31st March, 1931:- Type of school. 2—3 3—4 4—5 5—6 6—7 7—8 8—9 9—10 10—11 11—12 12—13 13—14 14—15 15—16 16* Totals. Mentally defective _ _ _ 1 15 131 374 508 635 716 531 477 589 581 142 4,700 Physically defective _ _ 5 55 139 217 352 443 531 483 421 449 380 306 71 3,852 Blind _ _ _ 6 6 15 13 17 32 20 18 5 _ _ _ 132 Partially blind _ _ _ 4 32 61 95 107 165 154 139 133 45 1 _ 936 Deaf and partially deaf _ 2 14 17 39 38 49 46 73 98 52 54 7 _ _ 480 Open-air (T.) _ _ _ 6 12 33 54 76 91 92 73 72 34 7 1 551 Open-air (0.) _ _ _ _ _ 10 92 242 356 292 251 240 74 3 _ 1,560 * Norwood (Girls) 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 Act, 1913, as amended by the Mental Deficiency Act, 1927, during the year 1931 (the figures in brackets being those for the previous year):— (a) Feeble_minded— Boys. Girls. (1) Leavers 205 (179) 228 (210) (2) Detrimental 8 (16) 4 (12) (3) Special circumstances ... 3 (0) 1 (0) (4) Ineducable 5 (20) 4 (17) (6) Imbecile 93 (209) 76 (166) (c) Idiots 5 (34) 2 (24) (d) Moral defectives 0 (0) 0 (0) 319 (458) 315 (429) Total 634 (887) 77 As was pointed out in last year's report, the large number of idiots, imbeciles and feeble-minded ineducable children ascertained in the year 1930 was due to the fact that, during that year, certain children, who had been for some years under the care of the guardians in institutions under the Metropolitan Asylums Board Order, 1911, had to be re-examined and notified through the education authority in order to bring them within the scope of the Mental Deficiency Act. These represent the accumulation during a period of years of cases which, prior to the coming into force of the Local Government Act, 1929, had been withdrawn from the purview of the local education authority. Examination of employees in the education service and scholars. During the year 8,534 entrants to the permanent education service, and candidates for teaching awards and for scholarships, presented themselves for examination. The following table indicates the numbers submitted for each grade and the results of the examinations:— Status. Number examined. Number fit. Number rejected. Number who withdrew after being referred for remediable defects or were not due for reexamination until 1932. Male Female Male Female Male Female Male Female Permanent service 486 586 472 578 10 4 4 4 Teaching awards 291 804 276 768 2 11 13 25 Scholarships— Myopes 11 17 11 17 — — — — Others 3,248 3,191 3,160 3,147 15 3 73 41 4,036 4,598 3,919 4,510 27 18 90 70 Total *8,634 8,429 45 160 * Including 18 permanent service cases (9 male, 9 female), 72 teaching awards (19 male, 53 female) and 10 Scholarships (5 male, 5 female) referred from 1930. The causes of rejection were mainly defects of vision, unsatisfactory general health and morbid conditions of the heart. In addition to the above, 155 scholars (58 males, 97 females) were examined with a view to determining their fitness to continue to hold awards. The total number of examinations was 10,531, an increase of 9-5 per cent, on the previous year. Some of the candidates were referred for one or more remediable defects. There were also referred to the public health department, 3,768 special cases in which medical advice was required. This figure includes 3,208 teachers (653 men, 2,555 women) and 560 cases of employees (166 men, 394 women) including those in institutions transferred to the Council under the Local Government Act, 1929. In connection with recommendations governing sick leave to teachers, 2,055 or 68 per cent, of the teachers concerned were over 40 years of age ; this number shows an increase of 2 per cent, on that of the previous year. In all 40 home visits were paid during the year in connection with these cases. During the year all applicants for admission to the Council's courses of physical education were examined, the number being 302. Of these 19 were deemed to be either temporarily or permanently unfit to undergo the training. Children suffering from Cardiac Disease. Dr. Slot has reported on the school aspects of cardiac children with particular reference to those in special schools for the physically defective. The schools visited in the course of inquiries were to be found in widely separated districts, as far apart as Camberwell, Peckham, Greenwich, Islington and Chelsea, and consequently covered children of varied social standing. Schools in different districts dealt with children from a different class of home, and of a different standard of mentality and tradition. In the majority Cases specially referred. Teachers of physical education. 78 of cases, however, the children did not seem to be drawn from the very poorest classes of labourers, but from that of artisans or small tradespeople. Living conditions may be overcrowded, but the homes are not usually actually in very bad repair or definitely damp. There is usually, too, so far as can be judged, not so much an actual lack of food, as lack of the right kind of food— bad feeding rather than actual starvation. The district in which, perhaps, these statements are most exemplified is Hammersmith. Here the children attending the rheumatism supervisory centre are drawn from the families of small tradespeople earning £2 to £3 weekly. There is only one slum area, by the river, in this district, and the children coming from this are not to be found among those suffering from rheumatism. In many schools, too, it has been found, in a most marked fashion, that the children suffering from rheumatism are notably of a different and much better type than the others. It has been suggested that this may be partly because children of this better type are more " fussed over " by their mothers, that, as there is sufficient money to clothe the children fairly well, they are given too many clothes, and that it is particularly in this class of family that the house is over-heated and badly-ventilated. The poorest classes, of course, live in a very much colder atmosphere, and the upper ones are much better educated in health conditions. Certainly it does not appear that cold and damp are, as once thought, the great predisposing causes of rheumatism. Many headmistresses and school nurses suggest that these are lack of sleep, bad feeding, and psychological excitement; and it would appear that rheumatism is a social disease, physical disability being caused by poor living conditions in general. Damp, however, it would seem, must be regarded not as the major cause, but merely as a " symptom " demonstrating the unsatisfactory housing accommodation in general. Home conditions vary enormously with different districts, and even with different children in the same school. Living-rooms, bedrooms and beds are usually overcrowded, and there are very few amongst the children who sleep alone. Conditions vary, however, from that of the most appalling slums, in which one may find three boys of 21, 19 and 18, and three girls of 15, 13 and 10 years sleeping in two double beds in one tiny room, to that of good middle class, where two sisters may be occupying twin beds in a large well-furnished and well-ventilated room. Insufficiency of sleep is, however, to be found in practically every case ; none of the children seem to go to bed early enough, or to obtain sufficient sleep even after having gone to bed. Very few children go before 9 or 10 o'clock. In cases where many people are sharing a room, or where the child's room may also be the living-room or kitchen, it is, of course, impossible to go to sleep even after going to bed. It is useless to ask or expect the other members of the family—who may be all adult—to keep quiet after the child has gone to bed, or to avoid its being wakened when they also retire. The result is that, in many cases, where sleeping accommodation is very limited, children do not go to bed until everyone in the house is also retiring. It is found that there is a great deal of deception about this question. Both children and parents persistently deny that the child goes to bed too late, and this is a point over which school and home authorities are constantly at loggerheads. Although children are made to rest in school, it is found that parents continually complain that it is impossible to make them do so at home, and that they are always dashing about. It is a constant source of worry to the school authorities that their work and care in school seems to be nullified out of school hours. Setting aside the parents who deliberately use the child to run errands, wash the floor, or mind the baby—of whom there are unfortunately far too manyparents seem to be able to exercise very little control over their children. Although, in some cases this is, perhaps, the result of a lack of interest, in others it appears to be more the lack of any systematic training or discipline. Examples serve to emphasise this extraordinary difference between home and school treatment. One boy with a very bad heart, who was always carefully brought from home, and sent back, by ambulance, was usually back outside the school, chasing up and down the street on roller skates within ten minutes ; another boy was carefully set down outside the front gate, over which he used to vault clear before rushing up the stairs ; while numerous boys, who have bicycles, tear round and round the streets near their homes as soon as they are released from school. Many school authorities have suggested that the school discipline, although undoubtedly advantageous from a purely medical point of view, perhaps defeats its own purpose by being too rigorous, and suppressing too far the energy of the children. It is felt that if they were allowed to be a little more energetic in school, and were not forced to rest so much, there would be less likelihood of their " working off" their energy in this really insane fashion as soon as they return home. One finds, perhaps, here a feeling that has been strongly emphasised by one headmistress, in dealing with the psychology of the child, an indication that some doctors are possibly too prone to consider the child simply as a heart case, and not as a human being. The lack of parental discipline amongst children, to which some reference has already been made above, is a point that is stressed by many of tho school authorities. Children seem, in a very large number of cases to do precisely as they please, to stay out late, and only to go to bed when they wish to do so. The children are not trained as babies to go to bed at any regular hour, to have their meals at regular times, or to evacuate the bowels regularly. The poorer mothers seem to have no idea of teaching their children either physical or moral discipline, and it is therefore almost impossible to train these children into really good habits when they reach school at the age of five years old or so. It is felt by many that a very strong effort must be made to induce mothers to train their babies from the very first, but it is extremely 79 difficult to induce them to do so, as they seem to have no idea of the importance of such training. Many a mother, too, with a very young baby, likes to have it always near her, in the living-room or kitchen, however late it may be, because of some obscure idea that the child " might have a fit." This reason, absurd as it seems, is often alleged as an argument against the child being put to bed at the proper time. Lack of discipline at home, indeed, seems to be one of the most important factors causing physical defectiveness amongst these children. Boots and clothing are usually quite good. The children, as has already been said, do not come from the very poorest classes, and they are, if anything, more often over than under-clad. It is very rarely that children are sent to school with poor clothes or bad boots. The parents know that a school nurse supervises all these details, and they take a pride in seeing that their child is as well dressed and clean as all the others. Like others, of course, the children vary in their standard of neatness. Some are untidy, just as some children always are, but in general the standard of boots, clothing and cleanliness is high, and better than that at an ordinary elementary school. There is always an efficient care committee, attached to each school, that supervises the well-being of the child. Feeding at home is usually not so much insufficient in quantity, as failing in the right constituents and proportions. It has been suggested that parents simply do not know anything about dietetics, and that they do not realise that the way they are feeding their children is at all inadequate. They usually do their best and are convinced that they are feeding the child well. Here again there is a great necessity for the education of parents if anything is to be done to help the child. It is found that after several months at one of the special schools where a good midday dinner is provided, the general condition of the children improves, and that they are never at their best after a long holiday spent at home. Where the food at home is plentiful, the children usually receive far too much starch, white bread and sweets, and not nearly enough fruit and vegetables. Meals are very often cold—in many cases the school dinner being the only hot, freshly cooked meal the child receives—and consist of tinned food, sausages, and ready cooked food from a " delicatessen" shop, etc.,among those children who are better off, and bread and jam, bread and margarine, and fish and chips among the others. At one school the children were asked to give an account of their usual food at breakfast, tea and supper. An analysis of the replies of the 32 children questioned will be found below. These children were between nine and thirteen years of age. Breakjast— Hot, cooked meal, i.e., Bacon and egg, boiled egg, fried bread, sausages, etc. 19 Tea 23 Cold meal, i.e., Coffee 2 A cereal food 5 Cocoa 5 Bread and butter 4 Nothing 2 Nothing to eat 2 No definite reply 2 Tea— All had a meal, usually consisting of bread and jam, or bread and butter, and occasionally cake or toast. Thirty had tea to drink, one coffee, and one nothing. Supper— Hot meal, i.e., Soup, fried egg, bloater, etc. 2 Coffee 2 Cold meal, usually— Cocoa 4 Bread and butter with occasionally a piece of cold sausage, etc. 13 Milk 3 Oxo 1 Fish and chips 10 Nothing 22 Nothing to eat 7 Feeding in school has to be, to a certain extent, a compromise between a really scientifically balanced menu and the meals received by the children at home. It is unanimously agreed that the children most definitely dislike eating anything that they have not had at home, and often, indeed, refuse to do so. The force of example of the other children, however, usually soon persuades them to do so, and they will soon try such things as vegetables which they have often never touched or seen at home. They usually seem to enjoy the school dinners very much and to have very hearty appetites. In some cases, however, "heart" children cannot eat too much of distending foods, such as potatoes, soups and bread puddings at a time, and have to be helped sparingly to such things. The meals provided are generally hot, freshly cooked and nourishing. Fish is usually served once a week, while plenty of potatoes, vegetables, fresh fruit and dried fruit salads are given. Roast or boiled meat, stews and hot-pots are among the staple dishes, while suet puddings are frequently given. An attempt is always made to balance the dietary carefully by giving fruit with a first course containing much starch, such as stewed meat, dumplings and potatoes, or a suet pudding after fish, etc. The children's individual tastes seem to vary just as those of normal children do, in each school. It is interesting to note, however, that a great discrepancy is to be found in the generalisations made about each school. In one, for instance, it was declared that the children universally detested fish, greens and milk puddings, while the nurse at another school actually enumerated 80 these items as amongst those most appreciated. I suggest that differences of this kind may, perhaps, be attributed to the difference in cooking at the various schools. It is generally agreed, however, that the children seem to prefer uncooked fruit and salads to stewed fruit and vegetables such as cabbage, and at most schools as much of the former as possible is given. Work in school usually begins about 9 o'clock, after the arrival of the " first-round " children, and continues until 11 o'clock, when there is a short break. In some schools, especially those for younger children, half-a-pint of milk is served to each child at this time. Lessons then continue until 12 o'clock, when the school dinner is served. After this is over the children play in the playgrounds, or rest if they are under medical orders to do so. In the schools for younger children, i.e., those with children about seven years old, all are made to lie down and rest after the meal, but in the others it is only those with specific medical instructions that have to do so. School begins again at 1.30 o'clock and continues until 3.30 o'clock. The subjects studied are the ordinary ones such as reading, writing, arithmetic, history, geography, singing, etc., but more time is devoted to handwork than at an ordinary school. Boys are taught wood-working—if fit—and boot and watch-making ; and girls learn fine sewing, dressmaking, embroidery, etc. A certain proportion, who are very anxious to do so, do some clerical work, and are forwarded, if possible, to commercial schools when they leave. The older children devote half their school hours to this vocational training, and a very large proportion of them are successfully placed in positions where they are at least partially self-supporting when they leave school. As a general rule these children have very little exercise. The very bad cases, of course, have to rest during the play-hour, and the other children have to be continually checked from running about too hard, or fighting, which many of them are very apt to want to do, in the playground. Mild games of ball are generally allowed, provided that the children do not run too much, but there is little systematic exercise. The difficulty, in arranging this, is in large part due to the divergent views of the physicians and surgeons under whom the children are placed for treatment. In one school carefully selected and supervised cases are allowed to do simple, carefully graduated, and severely rationed exercises to slow music, and it is found that these are greatly appreciated. At another school the milder cases are allowed to participate in eurhythmies, and to beat time to music, but no beating above the shoulder is allowed. The amusements of the children are also limited. At school, in the playtime, those that are made to rest often read comic newspapers, or play snakes and ladders, ludo, etc. It is usually found impossible to make the children sleep during their rest hour, and it is very difficult as a general rule, to keep them quiet at all. Outside school, the children generally play in the streets most of the time. In cases when they can afford to do so, they usually go to the cinema far too often. Amongst children who are fairly well-off it is common to find them going two, three, or even four times a week. It is found that where they can, to some extent, choose their amusements these children nearly all prefer those of an exciting type to those of a milder character. The intelligence of these children is generally just as good as that of the physically normal child, some mistresses going so far as to assert that it is often quicker. Their schooling, however, is usually very much interrupted by illness and absence, and they are generally reckoned to be two years behind the average child of their age in their school work. The children are usually extremely energetic in a peculiar way, in that they always want to dash about and are very excitable and emotional. They are easily upset by trifles, and need firm control. They usually lack concentration and are slap-dash in their work. Generally speaking they rarely have the patience to complete anything that needs applied energy over a long period, but they are definitely not lazy. With systematic training, however, concentration can usually be achieved, and the physically defective child will work just as well, and with just as good results, as the ordinary one. An important point that has been stressed by authorities at the special schools is the very bad effect that is produced upon such children by allowing them to remain in an ordinary school after they have been certified as physically defective. Such children are often put at the back of the class, and the teacher is given instructions that they are not to be pressed or worried in any way. The effect upon the character is naturally disastrous. The child becomes imbued with the idea that it is different from its fellows, and that there is no necessity for it to work ; it loses the habit of doing, as well as the inclination to do, anything. In the case of the conscientious child who, while perhaps feeling weak, tired or ill, makes the endeavour to keep up with strong and healthy companions, a sense of failure of effort, "getting behind" and consequent inferiority, is likely to be produced,which may develop into a permanent mental outlook of apprehension and a lack of self-confidence. As a result, when these children are finally transferred to a school for the physically defective, it is found almost impossible to do anything with them, and a long and difficult period of intensive training in mental discipline is necessary. There is a very marked difference between children who are immediately transferred toa P.D. school when found to be physically defective, and those that are left for some time in an elementary one ; and it is very desirable that all children should immediately be so transferred. It is felt that the mental deterioration which results from their being left in an ordinary school—especially from the point of view of encouraging the children to think themselves "different"—has necessarily an extremely deleterious effect upon them generally ; and that they would sooner improve physically as well as mentally, were they placed in an atmosphere suitable to their condition. 81 Inquiries made with regard to the physically defective child in the ordinary elementary school proved that the teachers in these schools would also be glad to see the children removed, as it is difficult to cope with a child who is outside the normal discipline of the form. From an inspection of the books of one child, who had been in the same form both before and after having had rheumatic fever, which had left her with a slightly affected heart, it was noticeable that her writing had much deteriorated, and that her work was generally much less neat. The mistress in charge, however, said that her intelligence seemed quite unaffected. This mistress thought that in general the physically defective children were definitely not so good at work requiring concentration and applied thought, such as mathematics, as at subjects which had an emotional appeal—a statement which corroborates those already made. She found that these children were more readily influenced through colour or music than by any mere process of reasoning—and this to a more marked degree than the ordinary child. This is, perhaps, in some ways a disadvantage, as the children are apt to become over-excited when any appeal is made to their emotions. At one school reference was made to another side of the question. It was stated that physically defective children—boys in particular—need especially careful supervision at the adolescent stage, from the point of view of morality. Being more thrown in upon themselves than the normal child, and being unable to "work-off" their energy in games and hard exercise, they were more likely to be affected by the changes associated with puberty and to adopt an unhealthy sexual viewpoint. Prom this angle, physically defective children need more careful watching than the ordinary child. The attitude of the. children towards the ambulance and towards other children provides another useful indication of their mentality. It is found that here a sharp differentiation must be made between little children or those whose have been physically defective from an early age, and those who have only been found to be so at the age of ten or twelve. Small children are always very pleased to ride in the ambulance. They like the ride and feel pleased and important to be signalled out for such an honour. Those who have been more or less physically defective from an early age merely accept the ambulance as part of their general routine, and simply think it a useful aid to them in getting to and from school with the minimum amount of discomfort. Amongst older children who have only just had to use it, however, there is a fierce resentment at the fact that they have to be "helped," and are no longer so strong or so capable as their former school-fellows. Their pride sometimes suffers badly through this. There is to be found amongst most "heart" cases a feeling of thankfulness that their defect does not "show" and that they cannot be distinguished from ordinary children. This is, of course, intensified by their association with cripples in schools for the physically defective. In general, however, the children do not appear to make any differentiation between themselves and normal children. They mix with them quite happily in the streets, and do not appear to regard themselves as "different." There appears to be very little feeling of inferiority among the children who look normal—although this may not be so with the crippled children. In school, their attitude is just that of normal children. Like them, they are either "good or bad mixers" socially, and, in general, conclusions can be drawn. Usually they are helpful and sympathetic towards one another. It is most unusual for one child to taunt another, or to comment in any way upon a disability. If any such instance should, rarely, occur, public opinion meets it with marked blame and repugnance. It is found that children, when first entering the school, are generally less sympathetic towards the others than those that have been there for some little time. Some of these children are rather spoilt, and given special privileges at home, and each of them is occasionally rather apt to regard himself as being the only person whose defect is worthy of sympathy and special treatment. It is of incalculable value for such children to be placed in an atmosphere where they become merely "one of a crowd," and have to realise that they are not of special importance. Unwise home treatment is, indeed, one of the greatest difficulties that have to be contended with in school. The "over-possessive" mother, who wraps her child round with care and special injunctions, giving it the feeling that it is different from everyone else, and encouraging valetudinarianism, is far too common ; and there is a feeling that the child with even a "cruel," or at least indifferent mother, has a better chance of achieving a healthy mental attitude than the child with an overfond one with regard to its defect. The reasons for which the children are absent provide another point that is of interest. In many cases they are absent to attend hospital, or by the doctor's orders. As regards this latter reason it is felt that there are a number of medical men who know very little about the schools, and often, without enquiring what kind of school the child attends, prescribe absence in cases where the child would be infinitely better looked after at school than at home. In most cases, where the child is at home, it is either, as has already been said, working at various domestic tasks, or else playing in the streets, obtaining no rest, having inadequate diet, and receiving insufficient medical supervision. Some children, of course, and more mothers, trade upon the child's physical infirmity in order to keep it awav from school. It is rarer, however, for the child to do so than for the mother, and in the latter case, it is found that the child is kept away upon some trifling excuse, which is, G 82 more difficult to disprove than in tho case of the normal child, in order to mind the baby, look after the house, run errands, etc. Apart from these two, unfortunately not uncommon, causes of absence, children are often away for real or unreal minor complaints. In the latter case these are usually diagnosed by the over-possessive mother referred to above, and in this case the child is often kept at home when it would be far better off at school. It has been suggested that parents, too, no less than medical men, do not realise the care and attention that are given to these children in school, and that much might be done to educate public opinion in this direction. Otherwise the children may be away for coughs, colds, attacks of influenza, and other usual ailments of children. They appear to be particularly affected by foggy weather, and also by slight digestive trouble. Bowel troubles are also a cause of absence in certain cases. It is found that in general neither the parents nor the children pay nearly enough attention to this vitally important detail, and that many of the children suffer from partial constipation. This is a detail which has to be continually supervised at school, and with regard to which education of the public is also greatly to be desired. Here again the lack of physical discipline of any kind is one of the greatest disadvantages of these children. It is usually found either that the parents have not the slightest idea of taking the trouble to train their child into regular habits, or that they have still less idea that it could possibly be of any importance to do so. Here again, education of the parent rather than supervision of the child is the goal to which one should look. The care committees represent the co-operation of the private citizen in the care of the community. There are between five and six thousand voluntary workers in London, who are assisted by a small band of paid trained workers, who co-ordinate the work of the others, and assist new-comers to understand what they have to do. The actual duties of the care committees are as follows :—- (i) To see that no child in need of food is unprovided for, either at home, or through the school, and to discriminate between the necessitous and the non-necessitous home. (ii) To see that no child found by the school doctor to require medical advice or treatment fails to receive it. (iii) To see that no child leaving school shall do so in ignorance of the possibilities the district holds for suitable employment, further education, and social recreation. The machinery of care committee organisation is similar in the case of the P.D. school to that in the ordinary elementary school, with the exception that a representative of the Invalid Children's Aid Association is always a member of the committee. This is of incalculable aid to the committee, since it is through this organisation that convalescence is arranged for those children whose parents would otherwise be unable to afford it, and that instruments, etc., prescribed for children are paid for by parents on the instalment system. (i) In cases where the children are receiving meals at a school for the physically defective— this is, of course, every child—parents are expected to pay the full cost of the meal, usually 4d. for school dinner. Should they claim that they are unable to do so, the case is referred to the care committee, who investigate the circumstances of the family, and suggest how much the parents shall pay, or if, in special circumstances, the meal shall be given free. A similar procedure is pursued in the case of extra milk, cod-liver oil and malt, etc., which may also be given at school in certain circumstances. This matter of payment is essentially one that has to be arranged with the parent, and through the care committee. Should there be any bad neglect of the child, which the committee is unable to rectify, the matter is passed on by them to a special officer of the Council, or, in extreme cases, to the National Society for the Prevention of Cruelty to Children. (ii) At the school medical examination, a member of the care committee is present, and afterwards visits parents who were unable to be there, to explain to them what the doctor said ; making them understand what treatment is neceasary, and why ; and further seeing that it is carried out. Arrangements for treatment at a hospital, or at one of the Council's treatment centres are made by the care committee workers, and convalescence, etc.,is arranged,as has been said, by the representative of the I.C.A.A. on the committee. While children are away under treatment, or convalescing, attempts are made by the care committee workers to improve home conditions, and to educate parents. It is found that the education of parents is one of the most valuable and necessary parts of the work of the committee, and that, very often through attention to the needs of one child, amelioration may be effected in the living conditions and life of a whole family. In the case of families receiving out-relief, etc., the committee also works with the Public Assistance Committee. (iii) Physically defective children, after leaving school, are watched over by the After-Care Association for Blind, Deaf and Crippled Children. (The " heart" children also come within this association's province.) Forms in regard to the child are filled in by the teacher and the care committee worker, and are sent to the Association, which tries to place children in situations where they will be happy, and where the work will be within their power. They also make suggestions regarding evening schools, clubs, etc., to each child, with reference to its individual needs. A grant is received from the Ministry of Labour to help in the work of placing children in appropriate situations. There is a representative from each school on the Association, and the visiting of pupils from each school is always done by the appropriate representative. Reports are obtained on the children for some two years after leaving. 83 Work still remains to be done, however, in following up for a longer period all the children who leave, in order to find out how many are able to do work that is of real value. Records of after history have been obtained from the heads of two schools, in one case of a group of 43 children, and in the other of a group of 12 boys. Of the 43 children in the first group, four had died ; six had had new attacks of rheumatic fever, leaving them unfit for work ; one child suffering from congenital heart trouble, who had previously been doing well at tailoring, had been seriously ill, and will be unfit for work in the future; one was definitely unsatisfactory with regard to work; and three had removed from the district, no details being obtainable. Of the 28 children remaining, 16 were girls, and 12 boys. Of the girls, two had had further relapses, but were again working; one, although well, was out of work; and three (one suffering from congenital heart trouble) were considered very delicate but were working. Two were married, and there was one child, which was quite healthy, in each case. The employments followed were dressmaking (seven girls), office work, lampshade making, envelope folding, embroidery, making cellophane cases for tooth-brushes, etc. The average income, based on eleven cases where the wages were known, was 22s. 4d. a week. Of the boys two had had further relapses, but were again working; and a third was very ill in hospital with pneumonia at the time that the report was given and was not expected to live. One was married. The trades followed were fitter's mate (motor engineer), electrician's mate, librarian, bootmaking, apprenticed to a surveyor, office work (2) and tailoring (4). The average income, based on eight cases where the wages were known, was 22s. a week. Of the 12 boys mentioned in the second series, three had had further relapses, but were again in work, and one had died. Two had won scholarships to the City of London College, where they had done very well, and they had afterwards taken up office work; 6 had been placed in situations by the After-Care Association, one by the school, and the others had found work for themselves. The trades followed were: light handicrafts (3), clerical work (3), tailoring (3), bootmaking, printing and woodwork. The wages earned were not mentioned except in one case (bootmaking and leatherwork), when it was £2 10s. a week. Infectious diseases in schools. The numbers of cases of infectious illness reported by the teachers as occurring amongst school children during 1931, 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. 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 1931 3,202 5,626 3,811 9,019 13,598 5,685 1,068 889 434 The number of cases of smallpox notified amongst school children during the year was 604, compared with 1,774 in 1930. Particulars of all children excluded or absent from school on account of infectious illness, and suspected infectious illness, or of infection in the homes, 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. If it appears from the information supplied that infection is spreading or is likely to spread amongst the children in the schools, arrangements are made for the special examination of the children by members of the school medical or school nursing staff. In certain cases the daily surveillance of the children for a definite period is undertaken by the school nursing staff. A handbook is issued, for the information and guidance of the teaching and other staffs concerned, on the general subject of the control of infectious diseases in the schools. It contains notes on the commoner infectious diseases and advice relating to the precautions to be taken in the schools to prevent the spread of infection, together with the regulations to be observed with regard to the exclusion and re-admission of the children concerned. G 2 84 The following table gives information regarding the schools specially visited by the school medical staff during the year:— Division. Diphtheria. Scarlet fever. Smallpox. Number of visits. Number of depts. visited. Number of children examined. Number of visits. Number of depts. visited. Number of children examined. Number ol visits. Number examined. N.E 25 23 2,518 45 43 5,616 50 9,382 N. 19 18 1,505 30 27 2,617 14 2,275 N.W. 13 11 991 24 22 2,618 1 437 S.W. 11 8 947 21 19 1,918 47 7,940 S.E. 28 25 2,547 39 35 4,319 12 1,364 Total 96 85 8,508 159 146 17,088 124 21,398 The children in four schools were specially examined by the school medical staff from time to time in connection with the occurrence of cases of ophthalmia. It will be noted that some diminution is recorded in the number of cases of diphtheria reported from the schools during 1931, compared with the last few years. Swabs were taken in 2,465 instances from children in the course of the special medical examinations, and submitted for bacteriological examination in the laboratory at the County Hall. Of these, 83 showed the presence of micro-organisms indistinguishable morphologically from B. diphtheria. These 83 positive results related to 79 children, of whom 25 were notified and removed to hospital. Tests for virulence were applied to some of the cultures; 51 being returned as virulent and 11 as avirulent diphtheria bacilli. The children from whom a virulent results were returned were allowed to resume attendance at school. Where virulent results were obtained and the children were not notified as cases of diphtheria, the parents were invited to take the children for treatment at one of the special diphtheria " carrier " clinics. The arrangements made 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 1931. The borough medical officers of health have, in certain cases, taken advantage of the facilities offered by these clinics for the treatment of persistent "carriers." The following reports, which the medical officers in charge of the "carrier" clinics have very kindly furnished, are of special interest. The clinic at the London hospital is under the care of Mr. F. Muecke, who reports as follows:— Children who, although at school, are suspected of being able to infect others with diphtheria, are sent to the special department of the London hospital for investigation and cure. When the ordinary out-patients are finished, the carriers are brought into the clinic, and their upper air passages thoroughly investigated as follows:— Tonsils.—The appearance, size and setting are noted, those deeply set or buried always being treated with suspicion. The tonsil is squeezed by pressure over the anterior pillar, and the amount and character of the expressed matter, if any, observed. The presence or absence of muco-purulent matter in the naso-pharynx, and the condition of the teeth complete the first part. Nose.—The nose is then examined, and the amount of air-passage, crusts, or mucopurulent discharge recorded, the healthy condition or otherwise of the middle meatus and midturbinate being a guide to the sinuses, as transillumination is not satisfactory in children. Ears.—Lastly, the ears are inspected, and the presence of any external or middle ear discharge noticed. The suspect is then sent to the bacteriological department, and a swab taken of the nose and throat. The result is communicated to the surgeon at the next week's sitting. Should this and a second swab be negative the patient is discharged, unless treatment in the ordinary way (as tonsillectomy) is advisable. A positive swab always indicates removal of tonsils and adenoids, unless this has already been done, in which case a careful search for remains or nasal trouble should be made. The nasal condition is usually of an atrophic character, and it is still disputed whether such a case is a genuine carrier and whether a true diphtheria bacillus is to be found. The treatment of this distressing condition is practically hopeless. Of the numerous remedies put forward the Diphtheria. Diphtheria "carrier" clinics. Clinic at the London hospital. 85 daily saline douche, combined with monthly packs on three consecutive nights, has been found to be the best. Iodoform gauze is used, the object of the pack being to clear away the scabs. After treatment the patient is again inspected, and sent to the bacteriological department, and ultimately discharged when two negative reports are obtained. Should the case still be positive the inoculation department is then called in to help. The following is a summary of the cases treated during the year ended December, 1931:— On arrival:— Positive cases 19 Negative cases 17 Total 36 Positive casts treated, as follows (16 operations):— Discharged 12 Current cases 5 Ceased to attend 2 Total 19 Negative cases treated as follows (9 operations):—— Discharged 11 Current case 1 Ceased to attend 5 Total 17 Total— Discharged 23 Current cases 6 Ceased to attend 7 Total 36 Dr. A. B. Porteous who has charge of the diphtheria "carrier" clinic at St. Mary's hospital, Paddington, reports as follows:— 17 cases (including one adult) were referred to the clinic during 1931. In all cases nose and throat were swabbed and examined in the routine way. One case was reported to be carrying K.L.B. in the ear, but this proved to be avirulent. Of these cases, on first examination, eight were negative in both nose arid throat ; five had (?) K.L.B. in nose only; three had (?) K.L.B. in both nose and throat; one had (?) K.L.B. in throat only. Several of these cases cleared up almost at once on local treatment before virulence tests were done. Virulence tests were done in six cases (subcutaneous method), and three proved to be virulent. In two cases, carrying suspicious organisms in both nose and throat, it is interesting to note that the nose organism in both was virulent, but that that isolated from the throat gave a negative virulence test. Treatment.—Local douches of 5 per cent, salt solution, of Pulv. Chlor. Co. one drachm to the half-pint of water have been used to clear up nasal soreness, etc., Pulv. Chlor. Co. is as follows:— Sodii Bicarb one drm. Boracis „ „ Sodii Chlor. „ „ Sacchari two drms. Vaccines.—Autogenous vaccines were used in the proved virulent cases and stock vaccines were used as a routine until the former were available or proved to be unnecessary. The dose of vaccine has been weekly starting at five million and this year no dose has been given higher than 15 million K.L.B. There is a tendency for local necrosis to occur at the site of inoculation with strong diphtheria vaccines. Cases have been few, but I believe that theee vaccines are of very definite use in clearing up carriers. Close co-operation is necessary with the nose and throat specialist to clcar away spurs, etc., which harbour sepsis in the nose, or to eradicate persistently infected tonsils. Three cases of chronic rhinorrhoea were found in the throat department of the hospital to be really carriers and were referred to this department for treatment. One case was interesting in that it carried virulent bacilli in the nose for three months. The nose was treated by the throat department but still the infection persisted. This child was then treated by the local medical officer of health in the anti-diphtheria clinic with toxoid-antitoxin mixture, the usual three injections. (Schick test was not done unfortunately.) The nose was found to be clear a fortnight later, and has remained so. The great importance of nasal infection over tonsillar infection is again illustrated in this year's results. Clinic at St. Mary's hospital. 86 Clinic at Guy's hospital. An attempt has been made to see if differentiation of types of K.L.B. could be made out in these carriers, as recorded in the Journal of Pathology and Bacteriology (September, 1931) by Anderson, Happold, McLeod and Thomson. The special tellurite medium described by them has been tried. It may be said that so far we have been unable to separate definite strains, the young colonies are usually smooth and look like the "mitis" form. The sugar reactions have corresponded with this; form starch and glycogen have never been fermented. The older colonies, however, have grown in radiated forms not unlike those described as gravis." Hemolysis was slight. This tellurite medium, or that of Allison and Ayling has proved extremely useful in isolating K.L.B. in dirty cultures and the proportion of virulent K.L.B. has, since the use of these special media, gone up in relation to the non-virulent varieties. I believe that this increase is due to the improvement in technique, so that where a slight infection of K.L.B. is present, we are now able to isolate them more consistently. Professor John Eyre has submitted the following statement on the work carried out at the clinic at Guy's hospital:— During the past year (1931) 70 new cases attended the diphtheria carrier clinic and, upon investigation, fell into the following groups:— Organisms isolated— Klebs Loeffler bacilli 27 Hoffmanni bacilli only 34 No diphtheroids 9 Total 70 Investigation of virulence o) cases with K.L.B— Virulent (including 3 cases of nasal diphtheria) 17 Non-virulent 8 Not tested 2 It is satisfactory to note that by 31st December all these carriers had been discharged as free from Klebs Loeffler bacilli. The appropriate oto-naso-laryngological measures obviously indicated by the existence of some definite pathological state, e.g., atrophic rhinitis, otitis media, etc., have been instituted in such of the carriers of non-virulent B. diphtheria: as needed them and have proved effective. Treatment has been continued in those cases carrying virulent K.L.B. upon lines similar to those in force last year. (а) It is of interest to note that four cases, in which no abnormality could be found in the nose or tonsils, became spontaneously free from K.L.B. in about 7-14 days. (б) Tonsillectomy was performed with success in six cases. (c) In five cases the "carrier" state was terminated by treatment with local applications only. (d) In the two remaining cases vaccine treatment with a stock B. difhtherice vaccine was combined with local applications with satisfactory results. Since the inauguration of the clinic in 1926 some 75 carriers of virulent K.L.B. have been treated during four consecutive weeks by the injection of a "stock" polyvalent K.L.B. vaccine. A critical study of the results noted sheds no light upon the value of this method of treatment. There is no evidence of its success that is not open to criticism and it has been decided in future to discontinue this form of treatment at the clinic. This opinion, of course, in no way conflicts with the claims put forward to support the administration of autogenous vaccines made from the organisms secondarily infecting and, therefore, presumably responsible for the maintenance of lesions in the nose and naso-pharynx. Such vaccines may assist in removing the nidus of infection, and with it a "home" for the diphtheria bacillus. In the detailed report upon the clinic published in 1929, the opinion was expressed that Schick testing and immunisation held the eventual solution to the problem of diphtheria in the Council's schools. A few cases of mild type were notified as a result of the examinations in school by members of the Council's staff, and a number of children were excluded from school on account of sore throat, etc. The children in five of the affected schools were kept under special observation by the nursing staff for periods ranging from two to six weeks. Among the 1,452 cases of smallpox notified in London during 1931, there were 604 school children. During the previous year, 1,774 school cases were recorded. Scarlet fever. Smallpox amongst school children. 87 The 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 term. Total. N.E. 111 115 30 256 N. 25 52 36 113 N.W. 32 — — 32 S.W. 18 21 113 152 S.E. 20 27 4 51 Total 206 215 183 604 The cases were all of the prevalent mild type. No vaccinated child developed the disease. One death occurred amongst the school children, the cause of death being reported as (a) encephalomyelitis, (b) smallpox. Records of the presence or absence of vaccination marks observed in the course of routine medical inspection are set out on page 6. Facilities for vaccination on the school premises by public vaccinators were granted whenever applications for vaccination were received from the parents, and about 1,000 children were vaccinated with the written consent of the parents. It is found that, however mild the disease, the majority of persons attacked fall ill three or more days before developing the characteristic rash. Children naturally absent themselves from school as a result of this premonitory illness, and the operation of the machinery which exists for notifying such absences through the school organisation, results in immediate attention being drawn to the existence of such cases. These factors are of special importance, for upon them is based the practice of allowing healthy contacts to remain in attendance at school. If, however, there was any evidence of the possibility of spread of infection in the schools, arrangements were made for the special examination of the children 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 124, compared with 228 during 1930. The services of the school nursing staff are 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 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. Reference was made in my report of last year to the fact that after consultation with the Ministry of Health and the borough medical officers of health, it had been decided that the home contacts of cases of smallpox should be allowed to return to school subject to their remaining in a normal state of health, and to their being kept under daily surveillance in school by the school medical and school nursing staffs. The employment of additional nursing staff was sanctioned to cope generally with the work entailed by the supervision of schools in connection with smallpox, and seven extra nurses commenced work in November, 1930. A summary is given below of the reports of the school nurses on the visits made to schools during the year in connection with the supervision of children in schools 88 where cases of smallpox occurred, and the daily supervision in school of home contacts of smallpox. Division. No. of visits to schools. (No. of schools concerned in brackets.) No. of cases of smallpox found as a result of examination by school nurse. No. of children excluded by school nurse with suspicious symptoms. No. of home contacts supervised in school. No. of absentees (home contacts) reported to medical officer of health. No. of hours devoted to work. N.E. 3,450 (184) 58 173 813 392 3,514 N. ] ,010 (52) 11 65 483 51 705 N.W. 142 (6) 2 6 49 65 213 S.W. 1,325 (66) 32 33 454 178 1,255 S.E. 685 (46) — 36 238 106 445 Total 6,612 (354) 103 313 2,037 792 6,132 Close co-operation has been maintained between the borough medical officers of health and their stalls and the school medical and school nursing services in connection with precautions taken to prevent the spread of smallpox in the schools. The nursing stafi have carried out their supervisory duties in a highly satisfactory manner, not only in connection with the general scheme of control in the schools, but also with the special examination in school of the home contacts; and in this connection it has been demonstrated that with adequate safeguards children who are home contacts of the prevalent mild type of smallpox may, with perfect safety, be allowed to remain in attendance at school. The school nursing staff have now acquired considerable experience of these supervisory duties, and, except for the necessity of providing additional skilled-nursing assistance, there appears to be no valid reason against relaxing the school quarantine regulations in respect of other diseases, and thus securing a further reduction in the enormous loss of school attendance caused through the exclusion of home contacts of infectious diseases. During the year under review, 20 children (15 boys, 5 girls) were admitted to the post encephalitis lethargica unit at the Northern hospital, Winchmore Hill. Seven boys and two girls were discharged, and one boy died. The fatal case was considered not to have suffered from encephalitis lethargica, but most probably from Schilder's periaxial encephalitis. The patient died after a series of convulsions. At the end of the year there were 35 boys and 17 girls under treatment. It will be observed from the tabular statement above that the number of cases of whooping cough reported from the schools (9,019) was higher than the figure recorded for 1930 (3,239), which, however, was exceptionally low. The school nurses visited 27 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. The school nurses visited 133 schools where chickenpox was prevalent, for the purpose of keeping the children under special supervision. The decrease in the number of cases of mumps compared with the previous two years will be noted. The children in 79 schools were kept under observation by the nursing staff. There has been an increase in the number of cases of ophthalmia reported from the schools. Much of this is due to an outbreak of the disease which occurred in a group of schools in Battersea in the late summer, and persisted throughout the autumn and winter terms. Special precautions were taken to prevent the disease spreading. The five schools affected were visited daily by the school nurses, and the children kept under special observation. Visits were also made by assistant medical officers where necessary. Measures were taken at the schools to prevent the spread of infection, including the cessation of attendance at the swimming baths, precautions in connection with the use of towels, restrictions as regards the use of books, etc. The closest co-operation was maintained throughout with the borough medical officer and his staff. The outbreak in this district had subsided by the end of the vear. Post encephalitis lethargica. Whooping cough. Chickenpox. Mumps. Ophthalmia. 89 The school nurses also kept under supervision, for varying periods, the children in schools where the prevalence of the diseases specified below made such a course desirable:— Impetigo 2 schools Influenza 2 „ Measles 7 " The visits for measles took place before the measles scheme of control described later was applied. The following table shows the number of cases of scalp ringworm amongst the Ringworm children in the Council's schools dealt with during 1931 compared with the figures for other years:— Year. Fresh cases. Cured cases. Cases outstanding at the end of the year. Percentage of cures affected by X-ray treatment. 1921 3,473 3,765 999 61 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 1931 419 420 107 62 It will be seen that the number of fresh cases of ringworm is still diminishing, and that at the end of 1931 there were only 107 outstanding cases. It will be observed, however, that the percentage of cures effected by X-ray treatment, after remaining consistently at over 70 for some years, shows a decline. It is difficult to state the reason for this, but, from enquiries that have been made, it would appear that the drop is due to a variety of causes. In some districts a prejudice against the use of X-ray treatment is reported. Parents are stated to have preferred to take their children to their own doctors and to receive lotion or ointment treatment. It is also reported that some hospitals to which the children are taken do not provide treatment by means of X-rays. It is gratifying to know that the number of cases at the end of the year was one-ninth of the number existing ten years ago. During the year, 876 specimens of hair stumps were sent by the school nurses to the laboratory at the County Hall for microscopical examination. Ringworm fungus was found to be present in 282 of these (220 small spore and 62 large spore). Favus was found to be present in two specimens. Both the affected children were subsequently cured. Precautions are taken to prevent the spread of infectious disease through the attendance of children at the evening play centres, which are usually held on school premises. The head teachers of the schools are required to notify the superintendents of the evening play centres of children who are absent or excluded from school on account of infection, in order that steps may be taken to secure that such children are excluded from the play centres. In addition parents are warned in the notices of exclusion issued from the schools that children who are excluded from school on account of infectious illness, or suspected infectious illness, should not attend these centres. The whole of the arrangements were carefully reviewed during the year, in consultation with the Play Centres Committee, in order that every possible step might be taken to ensure that infectious disease was not spread through the medium of the centres. The Play Centres Committee, who were very anxious to co-operate, agreed to print notices and distribute them twice yearly to the parents or guardians of all the children attending the centres, drawing attention to the importance of ensuring that children do not attend the centres if they are unwell or are absent from school owing to infection in the home. The superintendents of the play centres were also specially asked by the Play Centres Committee to exercise every care to ensure that no child is admitted to a play centre who is excluded from school on account of infectious illness. Favus. Play centres. 90 During the period from April to October 449 parties of school children, with 20 to 40 children in each party, left London under the aegis of the School Journey Association. Special precautions are taken to prevent the spread of infectious illness amongst the children in these school journey parties, and, in country districts, through the agency of these parties. The children proceeding with each party are medically examined by one of the assistant medical officers prior to departure, and, if it is not possible for this examination to take place on the day preceding the date of departure, arrangements are made for a school nurse to re-examine the children on the day prior to leaving London. Children excluded from school on account of infection in the home are not allowed to proceed on school journeys, and all possible precautions are taken to ensure that children suffering from an infectious illness or from symptoms suggestive of the onset of infectious illness are not allowed to accompany the parties. Swabs are taken for bacteriological examination if considered necessary. Special precautionary measures are also taken where school journey parties are proceeding from schools in districts where smallpox exists. The children are kept under careful observation by the teachers in charge whilst on holiday, and any child presenting suspicious symptoms is at once isolated and medical advice sought. By arrangement with the borough medical officers of health, information is furnished regarding the occurrence of cases of infectious illness in the homes of the children during their absence on school journeys. Particulars of such cases are then transmitted to the teachers in charge of the parties in order that the children may be kept under special supervision. One case of chickenpox occurred at an industrial school, and one case of diphtheria and another of scarlet fever at the place of detention. Appropriate action was taken to prevent the spread of infection. In consequence of the occurrence of several cases of ringworm among the children at Rayner's (deaf) school, Penn, Bucks, in the early part of the year, arrangements were made for the children at the school to be seen by one of the assistant superintendents of school nurses. As a result three more cases of ringworm were detected. All the infected children were removed to the Council's Goldie Leigh hospital. The necessary precautionary measures were taken at the school. Two cases of scarlet fever occurred at Anerley (deaf) school in April. The patients were removed to hospital, and all necessary steps taken at the school to prevent the spread of infection. A case of ophthalmia was reported among the boys aI Acre Lane (M.D.) school. The report on the measles epidemic of 1929-30, the preparation of which was delayed owing to pressure of work, was issued in July, 1931. This report contained a general review of the incidence, age distribution, and mortality during the epidemic and special references to such matters as hospital treatment, home nursing, serum treatment, and methods of control. In view of the recurrence of measles in epidemic form at the present time, it may be of interest to refer briefly to the conclusions to be drawn from past experience:— Measles epidemics occur in London every two years, commencing in the autumn and lasting for six or seven months. The only means of preventing a measles epidemic is by the use of serum; but, owing to practical difficulties, this preventive can, at the present time, only be applied in very restricted communities (hospitals, residential schools, etc.). The incidence is greatest in the age groups 1-5 and the deaths highest in the age groups 1-3. Practically all measles deaths result from complications (bronchopneumonia especially), which are to a very large extent avoidable if patients obtain adequate medical and nursing care. Children are not sent to hospital until complications have arisen. The younger the child the greater the risk of serious illness from complications. School journeys. Industrial schools ar place of detention. Residentia special schools. Measles. 91 The following measures were suggested for mitigating the effects of measles epidemics:— Efforts should be made to postpone an attack until after the third-fifth years of age. Adequate medical, nursing and hygienic care being the most important means for preventing the onset of complications, arrangements should be made for these facilities to be available where required either in the form of (a) hospital treatment or (6) the provision of nursing facilities. The discovery of cases of measles in their earliest stages in order that provision of treatment may be considered before complications arise. The maintenance of a supply of measles serum in a form convenient for use either in hospitals or in the homes. The instruction of the public in the serious consequences that may arise from measles attacks and in the measures to be taken to mitigate the effects of the disease. The preparation of the plans by the public health authorities for meeting emergencies in anticipation of measles epidemics. The following statement shows the numbers of school cases reported weekly by the head teachers, up to Christmas, during recent epidemics:— Weeks. 1919. 1921. 1923. 1925. 1927. 1929. 1931. October. 1st week 100 94 249 265 89 62 72 2nd week 128 103 301 315 129 104 73 3rd week 173 175 307 275 161 145 97 4th week 179 213 389 479 217 152 142 5th week — — — 435 259 118 80 November. 1st week 237 195 440 803 211 273 149 2nd week 293 269 644 592 260 254 139 3rd week 273 307 678 872 379 353 146 4th week 540 403 731 1,035 569 394 217 5th week 551 — 732 — — — — December. 1st week 438 359 915 1,251 684 455 235 2nd week 530 431 1,058 1,421 775 511 234 3rd week 324 316 924 1,528 856 473 270 4th week (part) ... — 237 — 777 663 — 98 The average number of school cases reported weekly during the first three weeks of March, 1932, was 1,950. As will be seen from this statement the present epidemic was unusually slow in developing in the schools. Preparations for dealing with the epidemic were commenced in June. The "scheme of control" which is applied in the schools during measles epidemics has been fully explained in previous reports. It may be again stated that the sole object of this scheme is to bring to the notice of the borough medical officers of health cases of measles in their earliest stages in order that consideration may be given to the question of providing home nursing facilities or arranging for admission to hospital. The observations of each of the borough medical officers of health on the working of this scheme had been obtained shortly after the end of the last epidemic and in collaboration with Dr. F. L. Keith, hon. secretary of the Metropolitan Borough Medical Officers' Group, a summary of these was prepared for consideration by the members of the Group. As a result of subsequent discussions on suggestions made by some of the borough medical officers it was finally decided that modifications should be introduced into the scheme to meet the difficulties arising from the same cases being reported from different sources (e.g., school nurse, school attendance officer, head teacher) and further, that the health visitors on the staff of the borough 92 medical officers of health should not be required to visit the homes of children absent from school for unknown causes. Arising out of a recommendation of the medical officer of health of the City of Westminster, it was also decided that a paragraph should be inserted in the measles warning notice, which is issued by the borough councils and distributed to the parents through the agency of the schools, to the eSect that " if children are absent from school for more than two days, parents are specially asked to send a note to the head teacher stating the reason for such absence." The Council, in November, 1931, had under consideration a report of the Central Public Health Committee on the hospital treatment of measles in London, and in connection therewith the Committee drew attention to the importance of the assistance which the public and particularly parents can give towards coping with measles epidemics. The Committee emphasised the serious nature of the disease and referred to the efforts that should be made to postpone its contraction, and to the necessity for adequate medical, nursing and hygienic care. This report was communicated to the press and received a considerable amount of publicity. A certain amount of measles serum from adults has been obtained as the result of an appeal to the staffs of the Council's hospitals for donors of blood. This serum is being used in the children's wards of the hospitals to prevent attacks of measles in very young children who have been exposed to infection, or to ameliorate the severity of an attack in the older ones. At the time of the preparation of this report (March) the use of this serum had been extended to the residential schools and children's homes for the same purpose. The scheme of control referred to above had been put into operation and applied to 166 schools before the Christmas holidays. At the end of the year, the Council authorised the employment of additional nursing staff to cope with the heavy demands on the time of the school nurses in connection with the application of the scheme in the affected schools. An analysis of the results of the special medical examination of certain children attending schools in Southwark is given on page 8. In my last annual report a brief reference was made to the formulation of a comprehensive scheme in connection with the control of infectious diseases in the residential schools and children's homes transferred to the Council under the Local Government Act, 1929. A review of the situation had revealed that the quarantine systems adopted in many of these institutions were often ineffective and wasteful, both in relation to accommodation and the employment of staff. Apart from these considerations it was found that the organisation adopted by the Council for the steady flow of children from the receiving homes to the schools, and from one school to another was being seriously interfered with. The main factors to be taken into consideration in preparing the scheme were :—(1) the provision of adequate protection against the introduction and spread of infection ; and (2) the minimum of disturbance (a) of the machinery devised by the public assistance and education departments for dealing with admissions, transfers, etc.; (b) of the regime of the schools and homes. After consultation with the education officer and chief officer of public assistance, the scheme which was approved by the Committees concerned was printed in booklet form, and became operative in July. The fact that the administration of the hospitals of the late Metropolitan Asylums Board has also been transferred to the Council has simplified the problem considerably, as it has been possible to provide for the immediate removal from the schools and homes of cases of infectious illness including diseases of the skin and eyes. The quarantine of schools and homes on the occurrence of infectious disease, i.e., the cessation of discharges and admissions and the general segregation of all contacts, has been abandoned in favour of a scheme of special supervision by means of which children are segregated as soon as the onset of illness appears, pending examination by the medical officer. The scheme provides that on receipt of the order for admission to a receiving home, the relieving officer is required to make enquiries at the home of the child Residential schools and children's homes. 93 and to enter on the admission form whether or not the child is known to have been exposed to any infectious illness during the preceding three weeks, stating the date of last contact. In the case of transfer from a Council's institution to a receiving home, similar information is given on a prescribed form. Children newly admitted to the receiving home are kept apart from the other children pending medical examination. If passed as fit, the new-comers take their places in the ordinary life of the home and are kept under daily supervision morning and night by the matron or a responsible deputy, who has had some experience of the recognition of infection in children. Due regard is paid to those children who are stated to have been in contact with infectious illness, and diphtheria contacts are kept apart pending bacteriological examination. Any child showing signs of illness or any abnormal condition of the skin, eyes, ears, throat or nose, is at once isolated and seen by the medical officer. All cases of infectious illness (except scabies and impetigo) arising in any of the schools or homes, are admitted without delay to one or other of the Council's hospitals. Prior to transfer from the receiving home to a residential school or children's home, the child is medically examined and a certificate of freedom from infection or exposure to infectious illness accompanies it to the school or home. On entering a residential school or children's home the child is kept under supervision as described above and provided it remains in normal health takes its place in the ordinary regime of the institution. If a case of infectious disease occurs in a children's receiving home, residential school, or children's home, the contacts are examined night and morning for a period appropriate to the disease by a nurse who has been instructed in the signs and symptoms of the commoner infectious illness. Any child found to be ailing is isolated at once, pending medical examination. Healthy contacts take their ordinary place in the life of the school or home. Contacts of diphtheria are kept apart pending the result of bacteriological examination. Special procedure is laid down for occasional leave, and, unless there is any special emergency, parents or guardians are required to give one week's notice when applying for leave for their children in order that the relieving officer may make enquiries as to the home conditions. Parents are required to state whether children, on returning from leave, have been in contact with infectious illness. Unless special emergency exists, relatives or friends are not allowed to visit the schools or homes if infectious illness has occurred in their homes during the preceding three weeks, and they are required to sign a declaration before their visit is allowed. The successful working of the scheme depends entirely on the conscientious fulfilment of the instructions laid down for the various staffs. The relieving officers and the medical officers and other staff of the receiving homes, residential schools and children's homes have co-operated loyally, and the smooth working of the new arrangements is attributable solely to the excellence of their work. As may be expected, special circumstances arise occasionally, and these are referred to officers in the public health department. The following is a brief review of the cases of infectious illnesses which were reported from the residential schools and children's homes, during 1931:— Diphtheria.—A few groups of cases of diphtheria were reported. Arrangements were made for the immediate swabbing of the contacts and the facilities afforded by the Council's laboratory at the County Hall were placed at the disposal of the medical officers of the institutions. The number of swabs submitted for bacteriological examination was 849. Of these, 46 cultures (including two re-examinations) showed the presence of micro-organisms morphologically indistinguishable from B.diphtheria; 37 of the cases (35 children and 2 staff) were officially notified and removed to infectious hospitals. Tests for virulence were applied to 29 of the cultures; 26 of these were reported to be virulent and three avirulent. The avirulent carriers were allowed to resume the normal regime of the institution. 94 Scarlet fever.—With the exception of a minor outbreak at one school (Hutton) very few cases of scarlet fever have been reported. Measles.—A few sporadic cases of measles have been reported. There was, however, no evidence by the end of the year to indicate that the epidemic had yet invaded any of the residential schools or children's homes. Whooping cough.—Minor outbreaks occurred at four of the institutions, Ashford, Hanwell, Norwood and Shirley. A sharp outbreak is to be recorded at Hutton, mainly during October. Chickenpox.—Minor outbreaks of the disease occurred at Peckham during the spring, and at Anerley in the autumn. At the last named the spread of infection had been arrested by the end of the year. Outbreaks at Ashford and Leytonstone were confined to the periods August to October and October to November. Cases occurred at Hanwell during November and December and there was evidence of continued spread of infection in January. Mumps.—With the exception of three schools (Anerley, Norwood and Leytonr stone) only a few sporadic cases of mumps were reported. At Anerley, the infection persisted during October and November. At Norwood, an outbreak commenced at the end of November and had not abated by the end of the year. Scabies.—An outbreak of scabies occurred at Hanwell. Arrangements were made for Dr. J. M. H. MacLeod, the consulting physician for skin diseases at Goldie Leigh hospital, to visit the school for the purpose of medically examining the children where necessary and advising as to treatment. Ophthalmia and Conjunctivitis.—A number of cases of conjunctivitis occurred at one school (Banstead); they were all among children from one cottage. The necessary precautionary measures were taken at the school to prevent the spread of the disease. Ringworm.—Some of the institutions reported the occurrence of cases of scalp ringworm during the year. Infected children were sent to the Council's Goldie Leigh hospital for treatment. Specimens of hair stumps taken from doubtful cases have been microscopically examined from time to time in the laboratory at the County Hall. A portable Wood's screen lamp has been of great assistance in detecting the slightly infected cases. Impetigo.—Twelve cases of impetigo were reported. Ten of these were from among the boys on the training ship " Exmouth." The medical officer of the ship stated that this was largely seasonal, and that the necessary steps had been taken to prevent the spread of infection. The late controlling authorities had introduced active immunisation against diphtheria at the Norwood and Mitcham children's homes, the Shirley residential school and on board the training ship " Exmouth." At Norwood and Mitcham, the work was carried out by Dr. R. A. O'Brien, director of the Wellcome Physiological Research Laboratories, assisted by Dr. H. J. Parish, and at Shirley by Dr. Holden, the medical officer of health of the county borough of Croydon. On the training ship " Exmouth," Dr. W. H. Kelleher, an assistant medical officer of the late Metropolitan Asylums Board, was responsible for the work in this connection. The Schick test toxin and diphtheria prophylactic were, in each case, obtained from the Wellcome laboratories. The immunisation of the children has been uniformly successful in preventing the spread of diphtheria in these institutions and in this connection the following notes are of interest. Mitcham.—A number of cases of diphtheria occurred annually before immunisation was commenced ten years ago. Since that time only two cases of diphtheria have been recorded (one of which developed the disease immediately after admission and the other before the immunising process had been completed) in spite of the fact that several severe epidemics occurred in the district. Norwood.—In 1922 there were 40 cases of diphtheria in this home, but immunisation was introduced in April of that year. Very few sporadic cases of diphtheria have occurred since and none of the children who have been subjected to immunisation have contracted the disease. Active immunisation against diphtheria. 95 Shirley.—Epidemics of diphtheria had occurred over a period of three years prior to 1929. In May of that year it was decided to immunise the children and since that time the school has been entirely free from the disease. Training Ship "Exmouth."—There were 57 cases of diphtheria amongst the boys during the years 1921-23. Active immunisation was begun in 1924, and since then 18 of the unprotected boys have contracted the disease. No case has occurred amongst boys who have received the full course of immunisation. It was decided to continue the existing arrangements at these four institutions pending consideration of the action to be taken at the remaining schools and homes transferred to the Council under the Local Government Act, 1929. Here it may be stated that cases of diphtheria occurred amongst the children at the Leytonstone children's home at the end of 1930, and the managing committee of that home subsequently applied for the introduction of immunisation. In July a report upon the subject was submitted to the Education Committee, in which it was pointed out that the process of immunising children against diphtheria is being increasingly adopted throughout this country and abroad, and that its efficacy in preventing the spread of diphtheria especially in children's residential institutions is generally recognised. It was stated that the schools and homes transferred to the Council are constantly receiving fresh batches of children, and that diphtheria may readily be introduced into these institutions. Having regard to these circumstances it was decided that the existing arrangements for the active immunisation against diphtheria should be continued in the four institutions referred to above, that no child should be immunised without the written consent of the parent or guardian or of the authority acting in loco parentis being obtained, that the introduction of immunisation should be approved for the Leytonstone children's home, and that any further applications by managing committees of the residential schools and children's homes should receive consideration. Schick test toxin and diphtheria prophylactic are prepared in the Council's laboratories at Belmont for use in the Council's fever hospitals, and it was decided that all requirements for these materials should be met from that source except in the case of the Norwood and Mitcham schools, where Dr. O'Brien and Dr. Parish obtain their supplies from the Wellcome laboratories. Consideration was given to the arrangements to be made for expert medical assistance to be available for carrying out the work in any of the schools and homes where the immunisation of the children was to be newly introduced. Certain members of the medical staff in the Council's hospital service have had previous experience of this work, and it was decided that they should supervise the work until the medical officers of the schools had received the requisite training. These decisions were communicated to the managing committees of the residential schools and children's homes, and as a result the committees of 10 of the schools and homes (Ashford, Banstead, Cumberlow Lodge, Hammersmith, Hanwell, Hutton, Lamorbey, Ongar, Peckham and Stifford) reported in favour of the introduction of immunisation. The sanction of the Council has now (March) been obtained and arrangements are being made for the work to be commenced at these institutions in the near future. The prophylactic prepared at the Belmont laboratories is a formolinised toxin (formol toxoid) similar to the preparation used elsewhere under the name of anatoxin, and Dr. R. G. White, the director of the laboratories, is keeping in close touch with the medical officers engaged on the work with a view to collating the results obtained from the use of this product. 9G Dr. R. A. O'Brien has submitted the following report on the immunisation work that has been carried out during the year at Norwood and Mitcham children's homes :— Mitcham residential school.—-82 new entrants were Schick tested in 1931. Of these 42 (or 51 per cent.) were Schick negative and 40 positive. 32 Schick positive reactors who had received immunising injections were Schick negative when re-tested in 1931, and an additional six children Schick positive and immunised in 1931 were negative on re-test in 1932. The discrepancy between the number of children found to be Schick positive on the first Schick test and the number Schick negative after immunisation is explained by the fact that some of the children were discharged from the school before the date of the re-test. Norwood children's home.—Three members of the staff who were Schick positive in 1930 and immunised were Schick negative after immunisation in 1931. No new-comers on the staff were presented for Schick test in 1931. 141 children were Schick tested, of whom 74 (or 52 per cent.) were negative and 67 positive. 48 Schick positive reactors who had received immunising injections were negative after immunisation. Of the remaining Schick positive reactors, seven who had been given their course of immunising injections towards the end of 1931, were negative on re-test in January, 1932. A few positive reactors had left the home and were not therefore available for re-Schick test after immunisation. In regard to the training ship "Exmouth," Dr. W. H. Kelleher, assistant medical officer in the special hospitals service, has submitted the following report:— During 1931, 80 new admissions were Schick tested with the following results:— Positive (susceptible) 36 (45 per cent.). Negative 44 Of the susceptibles 30 have received a full course of diphtheria prophylactic. Of the remaining six, four have not yet received the full course and two left the ship before immunisation was completed. Of the 30 who have received a full course, 20 are immune as shown by a negative re-test; the remaining 10 are not yet due for the re-test. In addition, immunisation was completed in the case of four boys who by the end of 1930 were not fully immune. Four carriers of virulent diphtheria bacilli were removed from the ship for isolation during the year. There were no cases of diphtheria. Formol toxoid, prepared at the Belmont laboratories, has been used since October, 1931, but the time has been too short to allow of an opinion as to its value as an immunising agent. At Shirley residential school the work was suspended temporarily, but has now been resumed. STATISTICAL TABLES. Table I. Medical Inspection, 1931. (a) Routine Inspections. Boys. Girls. Total. Entrants 34,250 34,033 68,283 Age 8 29,287 28,908 58,195 Age 12 27,251 26,516 53,767 Leavers 19,276 19,478 38,754 Total elementary schools 110,064 108,935 218,999 ,, special schools 869 732 1,601 (6) Other Inspections. Special inspections 45,241 45,007 90,248 Infectious disease enquiries — — 25,596 Re-inspections — — 169,029 97 Table 11. (a) Dejects found at medical inspections in 1931. Elementary and special schools. Disease or defect. • Routine inspections—Defects. Special inspections— Defects. Requiring treatment. Requiring observation. Requiring treatment. Requiring observation. Elementary schools. Special schools. Elementary schools. Special schools. Malnutrition 979 4 882 1 622 216 Skin— Ringworm, head 4 — — — 16 4 „ „ body 32 — 1 — 23 19 Scabies 99 1 2 — 999 14 Impetigo 226 — 3 — 414 10 Other disease (Non-T.B.) 939 8 92 1 628 48 Eye— Blepharitis 854 5 87 — 311 13 Conjunctivitis 216 3 14 — 242 12 Keratitis 7 1 — — 12 4 Corneal opacities 8 — 8 — 24 12 Defective vision, excluding squint 16,422 122 6,620 70 4,467 436 Squint 1,360 7 408 — 551 30 Other conditions 177 2 39 1 146 13 Ear— Defective hearing 285 7 123 1 246 71 Otitis media 1,197 19 432 1 683 118 Other ear disease or defect 640 9 102 1 207 24 Nose and throat— Enlarged tonsils 8,977 29 8,338 25 2,433 483 Adenoids 896 1 513 2 621 70 Enlarged tonsils and adenoids 3,010 9 785 3 816 47 Other conditions 811 4 284 1 379 42 Enlarged cervical glands 330 4 1,165 4 202 203 Defective speech 126 1 162 1 124 57 Teeth—Dental disease or defect 65,400 403 1,357 3 4,882 84 Heart and circulation, heart disease— Organic 23 — 99 1 12 3 Functional 31 — 219 1 5 6 Not stated 194 — 2,474 13 250 662 Aneemia 742 1 660 1 389 159 Lungs —Bronchitis 1,143 9 1,126 3 304 102 Other non-tubercular 248 1 558 — 167 186 Tuberculosis— Pulmonary definite 2 — 11 — 11 4 „ suspected 14 — 46 — 41 139 Glands 10 — 12 — 13 5 Spine 1 — 2 — 3 2 Hip 1 — 4 — 5 6 Bones and joints — — 3 — 3 — Skin — — 4 — 1 — Other forms 4 1 8 — 21 15 Nervo us—Epilepsy 20 1 33 — 96 35 Chorea 82 — 81 — 240 96 Paralysis 22 — 20 2 225 82 Other conditions 162 — 219 Deformities— Rickets 64 — 32 — 21 13 Spinal curvature 549 7 222 2 159 49 Other 567 5 447 2 205 32 Other conditions 2,819 12 1,268 2 3,715 1,110 Mental defects — — — — 448 363 98 (6) Children found at routine medical inspection to require treatment (excluding uncleanliness and denial disease). Age group. Inspected. Found to require treatment. Percentage requiring treatment. Entrants 68,283 12,220 17.9 Age 8 58,195 11,756 20.2 Age 12 53,767 10,094 18.8 Leavers (age 13¾) 38,754 6,594 17.0 Total, elementary schools 218,999 40,664 18.6 „ special schools 1,601 *250 15.6 * Not including special defects for which the children are in the special schools. Table III. (a) Exceptional children in London in 1931. 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 110 106 216 Attending public elementary schools — At other institutions 3 2 5 At no school or institution 2 1 3 (2) Suitable for training in a school or class for the partially blind. Attending certified schools or classes for the partially blind 378 479 857 Attending public elementary schools 6 6 12 At other institutions — — — At no school or institution 2 3 5 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 278 236 514 Attending public elementary schools — — At other institutions 22 23 45 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 71 96 167 Attending public elementary schools 4 1 6 At other institutions — — — At no school or institution — — — Mentally defective. Feeble-minded (cases not notifiable to the local control authorities.) Attending certified schools for mentally defective children 2,640 1,942 4,582 Attending public elementary schools* 5 4 9 At other institutions 145 70 215 At no school or institution 60 43 103 Epileptics. Suffering from severe epilepsy Attending certified schools for epileptics 95 63 158 In institutions other than certified — _ special schools Attending public elementary schoolst — — — At no school or institution 41 40 81 Suffering from epilepsy which is not severe. Attending public elementary schools 210 200 410 At no school or institution — — — 99 Table III—continued. Exceptional children in London in 1931—continued. Boys. Girls. Total. Pulmonary tuberculosis. Active pulmonary tuberculosis (including pleura and intrathoracic glands). At sanatoria or sanatorium schools approved by the Ministry of Health or the Board of Education 137 146 283 At certified day open-air schools 135 105 240 At other institutions — At no school or institution 13 15 28 Quiescent or arrested pulmonary tuberculosis (including pleura and intrathoracic glands). At sanatoria or sanatorium schools approved by the Ministry of Health or the Board of Educa tion — — — At certified residential open-air schools — — — At certified day open-air schoolsj 201 129 330 At public elementary schools 83 81 164 At other institutions — — — At no school or institution 5 6 11 Non-pulmonaru tuberculosis. Tuberculosis of bones and joints (not including deformities due to old tuberculosis). At sanatoria or hospital schools approved by the Ministry of Health or the Board of Education 347 277 624 At public elementary schools** 28 16 44 At other institutions — — — At no school or institution — — — Physically defective. At certified residential cripple schools — — — Delicate children, i.e., all children (except those included in other groups) whose general health renders it desirable that they should be specially selected for admission to an open-air school. At certified day cripple schools 8 4 12 At certified residential open-air schools 299 229 528 At certified day open-air schools 966 682 1,648 At public elementary schools 2,464 1,966 4,430 At other institutions§ 362 313 675 At no school or institution 175 243 418 Crippled children (other than those with active tuberculous disease) who are suffering from a degree of crippling sufficiently severe to interfere materially with a child's normal mode of life. At certified hospital schools 32 20 52 At certified residential cripple schools 15 6 21 At certified day cripple schools 1,254 1,008 2,262 At certified residential open-air schools — — — At certified day open-air schools — — — At public elementary schools — — — At other institutions§ 221 216 437 At no school or institution 31 30 61 Children with heart disease, i.e., children whose defect is so severe as to necessitate the provision of educational facilities other than those of the public elementary school. At certified hospital schools 1 1 2 At certified residential cripple schools — — — At certified day cripple schools 684 900 1,584 At certified residential open-air schools — — — At certified day open-air schools — — — At public elementary schools — — — At other institutions 246 379 625 At no school or institution¶ 63 93 156 * At the time of report were waiting admission to schools for the mentally defective. Chiefly institutions formerly under the Metropolitan Asylums Board, where special instruction is provided. †Institutions formerly under the Metropolitan Asylums Board. ‡These were all receiving treatment but in many instances opinions may vary as to whether the conditions are active or quiescent. **The disease is not active and children might be regarded as suffering from the past effects rather than present tuberculosis. It is uncertain whether these cases should be classed here or under crippled children. § At special hospitals approved by the Ministry of Health. Education is provided at the institutions which have since been recognised as special schools. H At the time of report were awaiting admission to schools for the physically defective. H 2 100 (6) Return of children suffering from more than one defect, 1931. Defect. School. Day M.D. Residential M.D. Day Blind. Residential Blind. Day Deaf. Residential Deaf. Epileptic Colony. Total. Boys. Girls. Boys. Girls. Boys. Girls. Boys. ' Girls. Boys. Girls. Boys. Girls. Boys. Girls. Boys. Girls. M.D. and deaf 1 _ _ _ _ _ _ _ _ _ 8 3 _ _ 9 3 M.D. and crippled 47 31 _ _ _ _ _ _ _ _ 1 _ _ _ 48 31 M.D. and heart 34 42 _ _ _ _ _ _ _ _ _ _ _ _ 34 42 M.D. and epileptic 22 27 _ _ _ _ _ _ _ _ _ _ 21 8 43 35 Blind and deaf _ _ _ _ _ _ _ _ _ _ 1 _ _ _ 1 _ Blind and crippled _ _ _ _ _ 2 _ _ _ _ _ _ _ _ 2 Blind and heart _ _ _ _ 1 2 _ _ _ _ _ _ _ _ 1 2 Blind and epileptic _ _ _ _ 1 1 _ _ _ _ _ _ _ _ 1 1 Deaf and crippled _ _ _ _ _ _ _ _ 1 2 1 _ _ _ 2 2 Deaf and heart _ _ _ _ _ _ _ _ 2 1 _ 1 _ _ 2 2 Deaf and epileptic _ _ _ _ _ _ _ _ _ 1 _ _ _ _ _ 1 Deaf, M.D. and crippled _ _ _ _ _ _ _ _ _ _ 3 _ _ _ 3 _ Epileptic and crippled _ _ _ _ _ _ _ _ _ _ _ _ 1 3 1 3 Epileptic and heart _ _ _ _ _ _ _ _ _ _ _ _ 2 _ 2 _ Epileptic, M.D. and crippled _ _ _ _ _ _ _ _ _ _ _ _ 4 1 4 1 Epileptic, M.D. and heart _ _ _ _ _ _ _ _ _ _ _ _ _ 1 _ 1 104 100 _ _ 2 5 _ _ 3 4 14 4 28 13 151 126 277 Table IV. Treatment table. Group I.—Minor ailments, excluding uncleanliness, for which see Group V. Disease or defect. Defects treated or under treatment. Under Council's scheme. Otherwise. Total. Skin— Scabies 4,413 — 4,413 Impetigo Ring-worm, head 268* 152 420† " body 101,391 1,340 102,731 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) Miscellaneous (minor injuries, bruises, sores, chilblains, etc.) 106,072 1,492 107,564 * 212 by X-ray. f 262 by X-ray. Group II.—Defective vision and squint (excluding eye defects treated as minor ailments, for which see Group I). Disease or defect. Defects dealt with. Under Council's scheme. Otherwise. Total. Errors of refraction (including squint, but excluding operations for squint) 41,986 2,082 46,768 Other defect or disease of the eyes (excluding those in Group I) 2,700 (estimated) – Children for whom glasses were prescribed—-under the Council's scheme, 30,151; otherwise 1,490 (estimated). Children who obtained or received glasses—under the Council's scheme, 27,939=92-6 per cent.; otherwise 1,216. 101 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. 16,243 1,935 18,178 4,460 22,638 Group IV.—Dental defects. 1. Number of children who were :— (a) Inspected by the dentist—Age groups 5 years and under 12,625 6 „ 33,678 7 „ 37,166 8 „ 12,824 9 „ 40,024 10 „ 45,982 11 „ 48,472 12 „ 12,114 13 „ 14,925 14 „ and over 10,735 268,545 (b) Found to require treatment 173,180 (c) Actually treated 139,723 2. Half days devoted to inspection 2,376 21,450 „ „ ,, treatment 19,074 3. Attendances by children for treatment 237,346 4. Fillings—permanent teeth 103,891 132,237 ,, temporary teeth 28,346 5. Extractions—permanent teeth 55,074 393,579 „ temporary teeth 338,505 6. Administration of general anaesthetics for extractions 78,125 7. Other operations—permanent teeth 29,289 ,, ,, temporary teeth Group V.—Uncleanliness and verminous conditions. (a) Average number of visits per school made by school nurse during the year 6 (b) Examinations of children in the schools by school nurses 1,971,363 (c) Instances of uncleanliness 210,113 (d) Children cleansed under Council's arrangements 109,166 (e) Cases in which legal proceedings were taken under the Education Act, 1921 (section 87) 428 Table V. Medical inspection.—Number of children examined, 1921-1931. Year. Routine examinations. Special examinations. Reinspections. Examinations at special enquiries into outbreaks of infectious disease. Ionisation centre attendances. Rheumatism supervisory centre attendances. 1921 296,807 73,572 180,699 — 3,387 — 1922 242,145 67,471 164,046 — 3,754 — 1923 198,722 106,806 146,260 — 3,357 — 1924 194,371 63,918 154,502 3,642 — 1925 240,365 76,357 159,388 — 7,996 — 1926 248,820 81,575 191,182 87,009 11,065 — 1927 256,123 82,394 193,260 95,147 12,091 — 1928 268,592 88,832 187,480 50,439 14,921 1,409 1929 248,036 91,012 185,989 39,711 14,588 5,125 1930 218,458 86,162 186,615 44,609 15,423 6,670 1931 220,600 90,248 169,029 25,596 17,252 9,767 102 Table VI. Medical treatment.—Number of cases treated under the Council's scheme and by other agencies, 1921-1931. Year. Minor ailments. Vision. Nose and throat. Dental. Under t he Council's scheme. Otherwise. Under the Council's scheme. Otherwise. Under the Council's scheme. Otherwise. Under the Council's scheme. Otherwise. 1921 ... 75,849 3,716 32,663 1,935 15,543 2,319 94,177 1922 ... 71,478 2,989 32,752 1,871 8,720 1,805 84,848 — 1923 ... 82,475 2,235 31,986 1,573 11,936 1,162 95,332 — 1924 ... 83,751 1,931 32,747 1,189 12,980 1,193 99,045 — 1925 ... 91,691 2,351 36,356 1,520 15,066 1,633 112,964 — 1926 ... 92,683 1,961 37,985 1,687 15,168 1,615 113,932 1927 ... 103,019 1,796 40,293 1,593 18,176 1,797 124,992 — 1928 ... 101,254 1,772 40,984 1,837 20,162 2,336 129,255 — 1929 ... 101,666 1,615 41,620 1,905 19,903 2,282 129,952 — 1930 ... 105,118 1,435 43,579 1,961 19,760 1,904 138,280 — 1931 ... 106,072 1,492 44,686 2,082 20,703 1,935 139,723 — 103 Table VII. Medical Inspection in Secondary and Trade Schools. Summary of Results of Examination. Age Group. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)(12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) No. of children examined in detail. Nutrition. Clothing. Skin and Hair. Teeth. Nose and throat defects. Enlarged glands. External eye disease. Vision. N umber of children wearing glasses. Ear disease. Hearing defective. Speech defects. Heart and Circulation. Anaemia. | Lung defects. Nervous system. Digestive system. Spine. Flat-foot. Other deformities. Defects of U.G. system. Other defects. Excellent. Normal. Below normal. Bad (i.e., \ Malnutrition) Good. Fair. Poor. Olean. Dirty. Pediculi present. Sound. Less than 4 decayed. 4 or more decayed. G/6 in both eyes. 6/9 in either eye. 6/12 or worse in either eye. l.C.C. scholars. Feepayers. Boys. — Age 12 1484 — 206 1196 82 — 1469 15 — 1481 3 — 1124 344 16 55 19 29 1045 207 232 232 8 4 15 33 20 9 6 1 12 31 30 10 33 — — 13.9 80.6 5.5 — 99.0 1.0 — 99.8 0.2 — 75.7 23.2 1.1 3.7 1.3 2.0 70.4 13.9 15.7 15.7 0.5 0.3 1.0 2.2 1.3 0.6 0.4 0.1 0.8 2.1 2.0 0.7 2.2 Age 15 1706 — 328 1281 95 2 1652 53 1 1686 20 — 1181 498 27 50 21 17 1156 264 286 292 8 12 13 44 11 9 14 3 55 50 48 25 72 — — 19.2 75.1 5.6 0.1 96.8 3.1 0.1 98.8 1.2 — 69.2 29.2 1.6 2.9 1.2 1.0 67.7 15.5 16.8 17.1 0.5 0.7 0.8 2.6 0.6 0.5 0.8 0.2 3.2 2.9 2.8 1.5 4.2 Other ages and specials 3792 — 633 2837 142 2 3469 72 1 3537 31 — 2547 839 89 135 63 32 2462 471 610 671 32 16 27 54 66 11 31 4 53 49 60 48 147 — — 17.5 78.5 4.0 — 98.0 2.0 0.0 99.1 0.9 — 73.3 24.1 2.6 3.6 1.7 0.8 69.5 13.3 17.2 18.9 0.8 0.4 0.7 1.4 1.7 0.3 0.8 0.1 1.4 1.3 1.6 1.3 3.9 Total 6982 1167 5314 319 4 6590 140 2 6704 54 — 4852 1681 132 240 103 78 4663 942 1128 1195 48 32 55 131 97 29 51 8 120 130 138 83 252 (Number reviewed 1996) — — 17.2 78.1 4.7 — 97.9 2.1 — 99.2 0.8 — 72.8 25.2 2.0 3.4 1.5 1.1 69.3 14.0 16.7 17.7 0.7 0.5 0.8 1.9 1.4 0.4 0.7 0.1 1.7 1.9 2.0 1.2 3.6 Girls. Age 12 1206 — 352 686 165 3 1192 14 — 1197 8 1 961 234 11 125 18 21 828 177 201 223 9 3 2 42 29 7 14 4 143 2 125 6 36 — — 99.2 56.9 13.9 — 98.8 1.2 — 99.2 0.7 0.1 79.7 19.4 0.9 10.4 1.5 1.7 68.7 14.7 16.6 18.5 0.7 0.2 0.2 3.5 2.4 0.6 1.2 0.3 11.9 0.2 10.4 0.5 3.0 Age 15 1952 — 859 947 146 — 1918 33 1 1913 39 — 1474 452 26 133 5 25 1310 312 330 387 8 17 7 52 45 4 15 10 308 204 92 49 80 Other ages and specials — 44.0 48.5 7.5 — 98.3 1.7 — 98.0 2.0 — 75.5 23.2 1.3 6.8 0.3 1.3 67.1 16.0 16.9 19.8 0.4 0.9 0.4 2.7 2.1 0.2 0.8 0.5 15.8 10.4 4.7 2.5 4.1 2911 — 972 1168 372 4 2429 50 1 2437 43 — 1791 654 58 266 34 69 1558 526 408 498 16 21 14 126 76 9 14 17 449 459 258 78 125 — — 38.7 46.4 14.9 — 98.0 2.0 0.0 98.3 1.7 — 71.6 26.1 2.3 9.1 1.2 2.4 62.5 21.1 16.4 20.0 0.5 0.7 0.5 4.3 2.6 0.3 0.5 0.6 15.4 15.8 8.9 2.7 4.3 Total 6069 — 2183 2801 683 7 5539 97 2 5547 90 1 4226 1340 95 524 57 115 3696 1015 939 1108 33 41 23 220 150 20 43 31 900 665 475 133 241 (Number reviewed 2069) — — 38.5 49.4 12.1 — 98.3 1.7 0.0 98.4 1.6 0.0 74.6 23.7 1.7 8.6 0.9 1.9 65.4 18.0 16.6 19.6 0.5 0.7 0.4 3.6 2.5 0.3 0.7 0.5 14.8 11.0 7.8 2.2 4.0 Training colleges. Men 149 — 26 113 9 1 149 — — 149 — — 135 13 1 9 3 — 114 23 12 46 — —. — 1 3 1 — — 3 — 1 — — — — 17.4 75.9 6.7 — 100.0 — — 100.0 — — 90.6 8.7 0.7 6.0 2.0 — 76.1 7.5.4 8.1 30.9 — — — 0.7 2.0 0.7 — — 2.0 — 0.7 — — Women 1084 — 444 509 104 27 1083 1 — 1081 3 — 910 170 4 88 11 16 839 156 89 346 — — 2 61 37 5 2 6 216 126 69 21 34 (Number reviewed 31) — — 41.0 46.9 12.1 — 99.9 0.1 — 99.7 0.3 — 83.9 15.7 0.4 81 1.0 1.5 77.4 14.4 8.2 31.9 — — 0.2 5.6 3.4 0.5 0.2 0.6 19.8 11.6 6.4 1.9 3.1 (Total number reviewed 4096) 14284 — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 104 INDEX, page After careers 65 Anaemia 6 Cardiac children 77 Care committee organisation 12 Chickenpox 88 Child guidance 59 Cleanliness 4,35 Convalescent camp schools 50 Deformities 6 Diphtheria 84, 93, 94 Ears 5,12, 22, 65 Employees, Examination of 77 Employment of school children 21 Encephalitis lethargica 88 Enuresis 18,69 Eyes 5,11,22,66,88 Favus 89 Heart 6,43,77 Hygiene, Teaching of 39 Industrial and residential schools 67,90 Infectious diseases 69,83,92 Invalidity, Chronic 20 Ionisation 15,22 Lungs 6 Measles 8,90 Medical inspection 3 Medical treatment 13,21 page Mental deficiency 69,76 Mumps 88 Nervous diseases 6 Nursery schools 57 Nutrition 3,13,16,51 Open.air education 53 Ophthalmia 88 Organised games 38 Personal hygiene 35 Physical deficiency 74 Physical education 36 Play centres 89 Residential and industrial schools 67,90 Rheumatism 40,78 Rickets 6 Ringworm 22,89 Scarlet fever 12,86 School journeys 57,90 Smallpox 86 Staff 2 Stammering 34,69 Swimming 37 Teeth 4,11,15,28 Tonsils and adenoids 5 Transferred schools and homes 15, 24, 92 Tuberculosis 6,54 Vaccination 6,87 Whooping cough 88 PUBLICATIONS OF THE LONDON COUNTY COUNCIL. 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