2ud Com LCC41 London County Council ANNUAL REPORT OF THE COUNCIL, 1932 Vol. III (Part I) PUBLIC HEALTH (Report for the year 1932 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. 1933. No. 2985. Price 1s. London County Council ANNUAL REPORT OF THE COUNCIL, 1932 Vol. III (Part I) PUBLIC HEALTH (Report for the year 1932 of the County Medical Officer of Health) 1,000 (McC. 13536—76a) 17.8.33 CONTENTS Vital Statistics— Page Population 1 Infectious Diseases 5 Tuberculosis 12 Statistical Tables 14 Administration— Common and Seamen's Lodging Houses 18 Homeless Persons 18 Statistical Information 19 Sanitary Officers 21 Milk and Dairies Act 21 Venereal Diseases 23 Residential Treatment of Tuberculosis 26 Mental Deficiency Acts 39 Blind Persons Act 40 Midwives Acts and Children Act—Nursing Homes Registration Act— Adoption of Children Act 41 Examination of Staff 46 Laboratory Work 47 Chemical Branch 47 London County Council ANNUAL REPORT OF THE COUNCIL, 1932. VOL. III—(Part I) REPORT OF THE COUNTY MEDICAL OFFICER FOR THE YEAR 1932. 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. Population. The population enumerated in London by the census on the night of 26th April, 1931, was 4,397,003, including 10,500 non-civilians. In this census the place of usual residence was also recorded, so that two population figures are available, the enumerated population already stated, and the normal resident population, which was 4,419,877. The resident population was not ascertained in the census of 1921 but was estimated by the Registrar-General to have been about 4,524,000. The Registrar-General's estimates of the resident populations of the metropolitan boroughs in 1932 are shown in the table on page 14, and the rates given in this Annual Report are calculated upon these figures. The estimates of population since 1921 have been revised in the light of the census of 1931 and the death-rates for intercensal years have been adjusted accordingly. Movement of population. The net result of movement of population between the two censuses is shown by the difference between the census populations and the figure obtained by adding to the first census the intercensal births and deducting the intercensal deaths. In the following table gain (+) or loss (-) of population as the result of intercensal movements is shown for the county of London and each of the metropolitan boroughs. As the census is not always taken at the same time of year, the figures have been based upon the estimated population in the middle of each census year. The relative volume of population movement in the three intercensal periods 1901-1931 may be seen from the last five columns of the table. Comparison of the movement before and after the war period shows that the heavy pre-war loss of population of the more central areas has decreased, but that, in certain of the less [13536] (1) 2 central areas, such as Fulham and Camberwell, the outward movement has increased. Area. Population middle of 1901. Population increase 1901-31 (actual). Natural increase (Births less deaths) 1901-31. Intercensal movement of population. Gain( +)or Loss ( —) of population by migration— i.e., actual increase of population less natural increase. 1901-11. 1911-21.* 1921-31. Total 1901-31. Percent age. West. Paddington 144,200 + 2,101 + 24,067 - 15,414 - 2,456 - 4,096 - 21,966 -15.2 Kensington 176,821 + 7,241 + 18,376 - 14,789 + 1,082 + 2,572 - 11,135 - 6.3 Hammersmith 112,631 + 23,298 + 28,456 - 4,687 + 2,179 - 2,650 - 5,158 - 4.6 Fulham 138,448 + 13,462 + 47,296 - 9,225 - 8,135 - 16,474 - 33,834 -24.4 Chelsea 73,876 - 14,287 + 5,292 - 11,799 - 2,757 - 5,023 - 19,579 -26.5 Westminster, City of 182,567 - 53,889 + 3,460 - 29,602 - 14,897 - 12,850 - 57,349 -31.4 North. St. Marylebone 133,053 - 34,557 + 9,919 - 22,951 - 13,698 - 7,827 - 44,476 -33.4 Hampstead 82,300 + 8,323 + 8,561 - 2,538 379 + 2,679 - 238 - 0.3 St. Pancras 235,369 - 37,775 + 45,216 - 41,222 - 16,640 - 25,129 - 82,991 -35.3 Islington 335,441 - 11,842 + 79,277 - 46,465 - 13,758 - 30,896 - 91,119 -27.2 Stoke Newington 51,336 + 381 + 8,479 - 5,118 - 34 - 2,946 - 8,098 -15.8 Hackney 219,800 - 3,830 + 53,958 - 22,994 - 13,032 - 21,762 - 57,788 -26.3 Central. Holborn 59,231 - 22,341 + 946 - 12,047 - 4,796 - 6,444 - 23,287 - 39.3 Finsbury 101,266 - 30,979 + 21,424 - 24,643 - 16,070 - 11,690 - 52,403 - 61.7 City of London 26,657 - 16,109 - 2,401 - 6,552 - 4,419 - 2,737 - 13,708 - 51.4 East. Shoreditch 118,504 - 20,898 + 35,300 - 23,209 - 15,295 - 17,694 - 56,198 - 47.4 Bethnal Green 129,720 - 21,442 + 42,751 - 21,774 - 22,131 - 20,288 - 64,193 - 49.5 Stepney 298,985 - 73,514 + 95,958 - 71,100 - 52,442 - 45,930 - 169,472 - 56.7 Poplar 168,898 - 13,450 + 58,138 - 31,764 - 14,941 - 24,883 - 71,588 - 42.4 South. Southwark 206,306 - 33,481 + 53,889 - 40,538 - 20,643 - 26,189 - 87,370 - 42.3 Bermondsey 130,650 - 18,635 + 38,909 - 22,166 - 16,698 - 18,680 - 57,544 - 44.0 Lambeth 302,533 - 5,833 + 66,845 - 38,503 - 9,240 - 24,935 - 72,678 - 24.0 Battersea 169,403 - 9,481 + 45,950 - 25,108 - 10,732 - 19,591 - 55,431 - 32.7 Wandsworth 233,985 + 122,578 + 64,965 + 43,804 + 262 + 13,547 + 57,613 + 24.6 Camberwell 260,022 - 7,756 + 67,282 - 30,604 - 11,495 - 32,939 - 75,038 - 28.9 Deptford 110,632 - 3,265 + 33,120 - 16,660 - 5,968 - 13,757 - 36,385 - 32.9 Greenwich 96,217 + 4,422 + 26,089 - 12,263 - 1,816 - 7,588 - 21,667 - 22.5 Lewiaham 128,480 + 93,606 + 39,347 + 14,811 + 3,891 + 35,557 + 54,259 + 42.2 Woolwich 117,652 + 30,176 + 37,366 - 13,443 + 9,756 - 3,503 - 7,190 - 6.1 London County 4,544,983 - 127,776 + 1,058,235 - 558,563 - 275,302 - 352,146 -1,186,011 - 26.1 ,, N. of Thames 2,789,103 - 300,107 + 584,473 - 417,893 - 212,619 - 254,068 - 884,580 - 31.7 ,, S. of Thames 1,755,880 + 172,331 + 473,762 - 140,670 - 62,683 - 98,078 - 301,431 - 17.2 * Including London war losses, estimated at about 70,000, distributed among the metropolitan boroughs in proportion to pre-war population. Overcrowding. In the 1931 census volume for the county of London, statistics are giver bearing upon the question of overcrowding. The changes which have taken place in the tenemental occupation of the county as a whole are broadly indicated in the following table:— 1911. 1921. 1931. Number of private families 1,023,951 1,120,897 1,190,030 Number of private families per occupied dwelling 1.51 1.60 1.63 Average size of family 4.15 3.79 3.46 Average rooms per person in 1-9 roomed tenements 0.88 0.91 0.98 Average number of rooms per family in 1-9 roomed tenements 3.56 3.38 3.36 Percentage of total private family population living in tenements occupied by more than two persons per room 17.84 16.11 13.13 One to four- roomed tenements. The intercensal increase in the number of families in tenements of 1 to 4 rooms was 68,538, or 8 per cent., compared with an increase of 130,831, or 18 per cent., in the preceding intercensal period. The decrease in the number of persons living in tenements occupied by more than two per room between 1921 and 1931 amounted 3 to 142,146; during the same period the number of children under ten years of age fell by 151,176, and it is to the decrease in the child population that the decline in the proportion of the population living more than two per room is mostly due. The following table shows the changes which have taken place in the occupancy of 1 to 4 roomed tenements in London during the past four censuses:— Tenements of Percentage of total tenements. Percentage of total population living in one to four-roomed tenements occupied by more than two persons per room 1891. 1901. 1911. 1921. 1931. 1891. 1901. 1911. 1921. 1931. 1 room 9.2 14.7 13.5 13.2 12.2 5.10 3.26 2.58 2.31 2.29 2 rooms 16.4 19.8 19.2 21.1 21.5 7.84 6.54 6.14 5.50 4.97 3 rooms 15.8 17.8 21.4 23.5 25.1 4.57 4.14 4.93 4.66 3.34 4 rooms 14.1 13.7 16.1 18.0 18.4 2.19 2.07 2.40 2.29 1.41 1-4 rooms 55.5 66.0 70.2 75.8 77.2 19.70 16.01 16.05 14.76 12.01 The proportion of the private family population of the county and of each metropolitan borough living in tenements with more than two persons per room in 1911, 1921 and 1931 is shown in the following table, in which the boroughs are arranged in topographical order to facilitate comparison:— Metropolitan boroughs. Percentage of total private family population living in tenements occupied by more than two persons per room. 1911. 1921. 1931. West:— Paddington 16.2 15.4 12.3 Kensington 17.1 16.7 12.6 Hammersmith 14.2 13.8 10.2 Fulham 14.6 13.1 10.5 Chelsea. 14.9 13.7 10.2 Westminster, City of 12.9 10.1 7.1 North:— St. Marylebone 20.7 17.9 13.1 Hampstead 7.1 6.5 4.1 St. Pancras 25.5 22.4 17.6 Islington 20.0 19.4 16.0 Stoke Newington 8.8 8.1 6.6 Hackney 12.4 11.5 9.6 Central:— Holborn 25.6 19.8 17.1 Finsbury 39.8 34.0 29.4 City of London 12.3 6.6 5.6 East:— Shoreditch 36.6 32.0 29.1 Bethnal Green 33.2 27.8 23.6 Stepney 34.9 29.0 23.6 Poplar 20.6 21.2 20.1 South:— Southwark 25.8 23.5 21.6 Bermondsey 23.4 23.2 21.8 Lambeth 13.6 12.7 10.6 Battersea 13.3 12.4 11.9 Wandsworth 6.3 6.8 5.2 Camberwell 13.5 12.8 10.4 Deptford 12.2 12.8 11.0 Greenwich 12.1 13.8 11.1 Lewisham 3.9 4.7 4.1 Woolwich 6.3 7.8 5.7 London County 17.8 16.1 13.1 4 It will be seen that, between the census of 1911 and that of 1921, the proportion of the population in tenements living more than two per room had increased somewhat in Deptford, Greenwich, Lewisham, Poplar, Wandsworth and Woolwich, but in the intercensal period 1921 to 1931 there was no instance of increase in the percentage of such tenements. Marriages. The marriages registered in London during 1932 numbered approximately 39,268 or 18.0 per thousand of the population, the corrected rate for the preceding year being 18.8. Births. The births in London during 1932 numbered 62,233, compared with 65,684 in the preceding year. The birth-rate was 14.3 per thousand as against 15.0 in 1931. This is the lowest birth-rate recorded in London, the number of births being 8,743 less 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 14. The average annual number of births in London for the years 1930-31 was 67,565, compared with the average for 1920-22 of 105,053. In the series of short life-tables for London discussed in the medical officer's annual report for 1923 (pp. 10-14), it was shown that the births in London since 1841 had throughout sufficed to maintain a life-table population in excess of that of the decennial censuses. A short life-table for the years 1930-31 shows, however, that the births in these years fell short of maintaining the census population of 1931 by about a quarter of a million. The decline in the births after 1900 was for many years counterbalanced by the even more rapid decline in infantile mortality, but in more recent years the former factor has overshadowed the latter. On comparing the results for 1930-31 with those for 1920-22, it is found that the expectation of life at birth has increased by 4 • 5 years for both sexes, but most of this increased expectation is due to decrease in mortality in the early years of life—thus, at the age of 5 years the expectation is increased by 2.1 years, and at the age of 20 by only 1.4 years. A life-table for the decennium 1921-30 would not show so large an increase in expectation, as the death-rate in 1930-31 was somewhat below that of the decennial average. The decrease in the birth-rate has a direct bearing upon future housing and education requirements of the county, which tend to decline. In regard, however, to the treatment of the aged sick, the indications are for increased requirements owing to the ageing of the county population; for, after middle-age, the sickness rate increases rapidly, and in the intercensal period 1921-31 there was an increase of more than 100,000 in the number of persons over 35. The position is illustrated by the following figures for the last three census enumerations:— Age-Group. 1911. 1921. 1931. Number. Percentage. Number. Percentage. Number. Percentage. Under 5 467,414 10.3 376,055 8.4 297,151 6.8 5—14 835,619 18.5 809,212 18.0 650,279 14.8 15—34 1,630,487 36.1 1,518,906 33.9 1,571,946 35.7 35 and over 1,588,165 35.1 1,780,350 39.7 1,877,627 42.7 Census total 4,521,685 100.0 4,484,523 100.0 4,397,003 100.0 Deaths. The deaths in the total population of London during 1932 numbered 53,611, giving a death-rate of 12.3 per thousand, compared with 12.4 in 1931. 5 The distribution of deaths by ages in 1932 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 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 1932 4,143 1,084 960 641 453 847 1,195 2,291 2,897 5,429 8,793 24,878 53,611 It will be seen that the deaths in 1932 were less by 677 than in 1931. The epidemic prevalence of measles during the year caused 822 deaths, an increase of 707 from this cause over that of the preceding year, but this increase was set off by a decline in the mortality from most other causes of death. It is, however, noteworthy that there was an appreciable increase in the deaths from almost every infectious disease. A comparison of the number of suicides in the years 1920-22 with that in the years 1930-32 shows an increase at all periods of life. The number of deaths due to street accidents showed that the decline, noted last year, still continues, there being 683 deaths in the 52 weeks of this year compared with 731 deaths in the corresponding period of last year. Compared with the years 1920-22, the deaths from this cause in 1930-32 have increased by nearly 100 per cent. at all other ages than between 5 and 15 years. As the result of special provision for the safety of school children the increase at this age is only about 20 per cent. The death-rates from all causes and from certain specified causes in each metropolitan borough in 1932 and in London as a whole in 1932 and earlier years will be found in the tables on pages 14 and 16. Infant mortality. The deaths under one year of age per thousand births were 67 as compared with 65 in the preceding year. It will be seen from the following table that one of the principal causes of the slight increase on the figures for 1931 was the increased mortality from diarrhoea, associated with the heat wave during August:— Cause of death. 1911 to 1914. 1915 to 1918. 1919 to 1922. 1923 to 1926. 1927 to 1930. 1928. 1929. 1930. 1931. 1932. Measles 3.40 3.84 1.64 2.02 2.07 3.93 0.61 3.12 0.44 2.44 Whooping-cough 3.63 4.45 2.50 2.60 3.14 2.45 6.15 0.89 2.15 2.59 Influenza 0.27 1.10 0.81 0.38 0.48 0.23 0.96 0.26 0.46 0.39 Tuberculosis 3.40 3.20 1.52 1.26 0.89 0.95 0.77 0.79 0.70 0.96 Bronchitis 6.41 6.72 4.42 2.91 2.30 2.56 2.87 1.66 2.56 2.09 Pneumonia 12.28 14.96 12.60 11.51 12.10 13.03 14.15 9.85 13.90 10.25 Diarrhoea 24.28 16.10 12.16 9.36 8.87 9.52 9.93 9.07 8.94 11.78 Premature birth 18.16 17.42 17.00 14.74 14.17 14.22 14.81 13.71 15.24 14.51 Congenital defects 14.69 14.66 11.26 8.39 7.38 7.60 7.65 7.11 6.65 7.58 All causes 108 103 79 65 64 67 71 59 65 67 Infectious Diseases. The notifications, attack-rates and death-rates of the principal infectious diseases in London in 1932 and earlier years are shown in the tables on pages 14 to 17, and for the constituent metropolitan boroughs in 1932 in the table on page 14. Anthrax. During the year one case of anthrax was notified in each of the boroughs of Stepney, Lambeth and Shoreditch. The case in Stepney, a male aged 38, was admitted to the Council's St. George-in-the-East hospital on 15th May and died the 6 same day. The medical officer of health of Stepney reported that the source of infection was attributed to a shaving brush purchased in that borough. The stock (16 dozen) from which this brush was sold had been obtained in January, 1931, and the country of origin was not marked. The brushes were made of goat's hair. Some had been sold to shopkeepers and the remainder retailed to customers who could not be traced. Two dozen of the brushes, together with those used by the deceased and his brother, were examined bacteriologically by the Ministry of Health with the following result:—"brushes used by deceased; both the free hairs and the resin embedded stump gave moderate numbers of anthrax colonies, i.e., there is a strong presumption that the infection of the brush was primary and not secondary. The two dozen brushes were examined in four batches of six for economy. Each batch yielded abundant colonies of virulent anthrax bacilli, i.e., in each batch at least one brush was anthrax infected which is sufficient to condemn the lot." With a view to preventing the continued sale of anthrax-infected brushes, full particulars of this case were circulated to the medical officers of health of the metropolitan boroughs and contiguous areas. As a result of this circular a number of the brushes were recovered and destroyed. The case in Lambeth was that of a butcher (aged 23) employed at the central meat market, Smithfield. The medical officer of health of Lambeth reported that the patient developed a pustule on his hand on the morning of 21st September. In the evening there was a considerable degree of inflammation sufficient to arouse suspicion of anthrax. He was removed to King's College hospital where Sclavo's serum was administered. His condition rapidly improved under treatment. The condition was definitely due to a "malignant pustule," but efforts to isolate the bacillus anthracis from the pustule were unsuccessful. No source of infection could be traced in Lambeth, and although anthrax rarely occurs in pigs there was just the possibility that the patient had scratched his hand with the nose-ring of a pig carcase in the course of his employment. The Shoreditch patient was a male, aged 23, employed as a wool sorter. The borough medical officer of health reported that the man had handled English and American hair, and so was probably infected in the course of his employment. The patient was removed to St. Bartholomew's hospital, treated with Sclavo's serum and made a complete recovery. A bacteriological examination was made but no bacilli were detected in serum from the vesicle. Smallpox. The number of notifications of smallpox was 1,131 compared with 1,452 in 1931. The following table shows the incidence of the disease in the years 1931 and 1932 in the separate London boroughs:— Metropolitan Borough. Number of notifications. Metropolitan Borough. Number of notifications. West— 1932 1931 East— 1932 1931 Paddington 2 - Shoreditch 14 122 Kensington 1 2 Bethnal Green 25 145 Hammersmith - 49 Stepney 26 352 Fulham 2 - Poplar 177 101 Chelsea - - Westminster 4 2 North— St. Marylebone - 2 South— Hampstead 1 - Southwark 161 31 St. Pancras 5 4 Bermondsey 16 3 Islington 162 66 Lambeth 218 256 Stoke Newington 1 1 Battersea 16 3 Hackney 34 43 Wandsworth 12 5 Camberwell 66 116 Central—- Deptford 56 37 Holbom 1 3 Greenwich 17 9 Finsbury 105 89 Lewisham 2 7 City of London - 1 Woolwich 7 3 Total 1,131 1,452 7 During the year three deaths from smallpox occurred, particulars of which are as follows:— Borough. Age. Sex. Vaccinal condition. Date of death. Certified cause of death. Deptford 3 weeks F. Unvacc'd. 25.3.32 I (a) Pyaemia. (b) Smallpox. Camberwell 79 years F. Vace'd. in infancy 10.4.32 I (a) Cardiac failure. (b) Senility. (c) Variola. Bermondsey 56 years M. Vacc'd. in infancy 23.5.32 I (a) Myeloid epulis. (b) Pyelitis. II Smallpox discrete. During the year four ships on which cases of smallpox had occurred during their voyages from eastern ports arrived in the port of London. On two of these the patients had been landed at foreign ports whilst on another the patient died and was buried at sea. On the fourth ship, the patient had been unwell for some days and on the arrival of the ship at Bellamy's wharf he developed a rash and attended the Seamen's hospital, where he was detained as a suspected case of smallpox. He was admitted to the Council's receiving station at South wharf and was found to be suffering from the type of smallpox prevalent in the east. Passengers from three other ships on which smallpox had occurred arrived in London by overland routes. Particulars of all these cases, together with the names and addresses of the crews and passengers were circulated to the medical officers of health of the metropolitan boroughs and other areas, in order that all potential contacts might be kept under surveillance during the possible periods of incubation. No secondary cases were reported. As a result of representations made by the Lambeth Borough Council to the Society of Medical Officers of Health (Metropolitan Branch)the Metropolitan Boroughs' Standing Joint Committee and the Ministry of Health, some relaxation of administrative procedure for dealing with cases of the prevalent mild type of smallpox has been agreed to with special reference to the treatment of patients in their homes. The selection of cases for home treatment is always made by the borough medical officer of health who is in a position to determine the severity of the cases and to decide whether the home conditions are such that the cases can with safety be treated at home. During 1932 five cases of smallpox were treated in their homes. Chickenpox. In three metropolitan boroughs orders, made under the provisions of section 55 of the Public Health (London) Act, 1891, making chickenpox notifiable, expired and were not renewed. At the end of the year this disease was notifiable in Paddington, Chelsea, Hammersmith, Islington, City of London, Poplar, Deptford, and the Port of London. Cerebrospinal (spotted) fever. During the year 247 notifications of cerebrospinal fever were received, but in 13 of these the diagnosis was not confirmed. Of the 234 cases confirmed, 100 proved fatal. In addition 48 deaths were recorded by the Registrar-General of cases which had not been notified, thus making a total of 148 deaths. The disease reaches its highest prevalence during the winter and spring, the greatest number of cases being recorded during the first quarter of the year. The number of notifications for each quarter during the last two years are shown below :—• Year. 1st quarter. 2nd quarter. 3rd quarter. 4th quarter. 1931 65 55 31 24 1932 104 76 39 28 Reference to serum treatment for this disease will be included in Vol. IV (Part I) of the Annual Report. 8 Encephalitis lethargica. The notifications of acute encephalitis lethargica numbered 47. In 7 of these the diagnosis was not confirmed; of the 40 actual cases, 12 proved fatal. In addition 39 deaths were recorded by the Registrar-General of cases which had not been notified, and 8 which had been notified in previous years, making a total of 59 deaths for the year. Particulars of cases admitted to the post encephalitis lethargica unit at the Council's Northern hospital are given in Vol. IV (Part I) of this Report. Poliomyelitis and polioencephalitis. Notifications of poliomyelitis and polioencephalitis numbered 89 ; the diagnosis was not confirmed in seven of these. Of the 82 actual cases, 10 proved fatal. In addition, 9 deaths were recorded by the Registrar-General of cases which had not been notified, making a total of 19 deaths. Particulars of acute cases admitted to the Council's Western hospital and of cases admitted to the Council's Queen Mary's hospital for children, Carshalton, for treatment of crippling effects of the acute stage, are given in Vol. IV (Part I) of the Annual Report. The Ministry of Health in November issued a memorandum (166/Med.) on the pathology, diagnosis and treatment of poliomyelitis, in which reference was made to treatment by means of human convalescent serum. In view of a possible outbreak of the disease, a small conference of representatives of the Medical Research Council, the Lister Institute, the voluntary hospitals and the Council's medical staff met on several occasions to consider questions relating to the provision of serum. This conference has now (March 1933) made arrangements for the collection of blood from voluntary donors and the preparation of serum and its issue from special centres to hospitals and practitioners on certain conditions. A memorandum has been prepared with explanatory notes on the use of the serum and also a form to be filled up with a view to obtaining statistical information as to the results obtained. Food poisoning. Under the provisions of the London County Council (General Powers) Act, 1932, (section 7) medical practitioners are required to notify the borough medical officers of health of any persons who are suffering or are suspected to be suffering from food poisoning. In collaboration with the Metropolitan Boroughs' Standing Joint Committee arrangements were made for borough medical officers of health to forward to the Council particulars of all notified cases, in order that the information might be circulated to all the metropolitan boroughs. The Act became operative in July, 1932, and from that date until the end of the year, particulars of 466 cases were received. Three cases proved fatal. In two instances, however, verdicts of death from natural causes were returned. In the third case, the incriminated food was not ascertained, though illness was attributed to the Salmonella group. There appears to have been no widespread infection from any one source, except that 14 cases were reported amongst a wedding party in Bethnal Green, where the food suspected was chopped liver. The following statement shows the age and sex incidence of the notified cases:— Age. 0- 5- 15- 25- 35- 45- 55- 65- Total. Male 13 28 27 52 20 21 20 7 188 Female 15 27 65 59 37 34 23 10 270 In eight cases the age was not stated. The following statement shows the numbers of notifications in recent years, excluding duplicate notifications and military cases:— Year. 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 Cerebro-spinal fever 86 65 93 93 83 93 70 121 88 175 247 Encephalitis lethargiea 66 98 600 293 224 142 100 92 60 40 47 Poliomyelitis and polioencephalitis 40 111 116 55 95 86 54 66 37 56 89 9 In a considerable number of the cases notified the suspected food had been consumed by all members of the family and, as only one person had been affected, it appeared that the illness was not due to actual food poisoning but to indigestion or idiosyncracy. The attention of the Society of Medical Officers of Health (Metropolitan Branch) was drawn to this matter (in February, 1933) and it was suggested that it might be desirable to consider whether the circulation of particulars of all these cases was of any real value. After careful consideration, the Special Purposes Committee, to whom the question was referred, stated their opinion that the Act did not define food poisoning in such a way as to distinguish between the term in its strict medical acceptance and the examples of indigestion or idiosyncracy which had been quoted, that there was always the apprehension that what at first sight might appear trivial would eventually prove of urgent importance, and that the present procedure should be continued in the hope that, when the newness had worn off, general practitioners would limit their notifications to cases of true food poisoning. Dr. W. Stott, medical officer of health for the borough of Southwark, stated (February, 1933) that he had issued a circular to medical practitioners in the borough drawing attention to the advisability of adopting a definite line of action in the selection of cases for notification. Notification of alleged cases of food poisoning should of course provide a valuable field for investigation. Little is known of the distribution of food poisoning organisms in nature and research into food poisoning outbreaks should result in detecting the causative micro-organisms, elucidating their origin and ascertaining the circumstances bv which food becomes infected. Measles. The deaths from measles in 1932 numbered 822 compared with 115 in 1931. The disease became epidemic towards the end of 1931, and reached a maximum towards the end of April, 1932. The death-rate was 0.19 per thousand. The death-rates in London and England and Wales in recent years have been as follows:— Area. 1921. 1922. 1923. 1924. 1925. 1926. 1927. 1928. 1929. 1930. 1931. London 0. 05 0.34 0.08 0.29 0.07 0.20 0.04 0.30 0.05 0.23 0.03 England and Wales 0.06 0.15 0.14 0.12 0.14 0.09 0.09 0.11 0.09 0.11 0.08 Whoopingcough. There were 348 deaths from whooping-cough in London during 1932 compared with 307 in 1931. The death-rate was 0-08 per thousand. I he death-rates in London and England and Wales in recent years are shown in the following table:— Area. 1921. 1922. 1923. 1924. 1925. 1926. 1927. 1928. 1929. 1930. 1931. London 0.12 0.25 0.09 0.11 0.19 0.05 0.12 0.09 0.26 0.03 0.07 England and Wales 0.12 0.17 0.11 0.10 0.16 0.11 0.09 0.08 0.16 0.05 0.06 Scarlet fever. There were 14,119 notifications of scarlet fever in 1932 (52 weeks), the corresponding figure for 1931 being 12,025. The attack-rate was 3-3 per thousand as against 2-8 in 1931. The deaths numbered 85, giving a death-rate of 0-02 per thousand of the population at all ages and a case-mortality of 0-6 per cent. The seasonal incidence, as shown by the notifications (uncorrected for errors of diagnosis) received in successive four-weekly periods during the year, was as follows:— l- 5- 9- 13- 17- 21- 25- 29- 33- 37- 41- 45- 49-52 895 908 1,001 954 1,084 1,045 1,021 840 787 1,291 1,635 1,396 1,262 10 The notifications (uncorrected for errors in diagnosis), deaths and crude casemortality during 1932 were as follows :— Year 1932. (52 weeks.) Age-period. Total. 0- 1- 2- 3- 4- 5- 6- 7- 8- 9- 10- 15 + Notifications 122 584 950 1,139 1,342 1,612 1,419 1,117 869 763 2,302 1,900 14,119 Deaths 3 19 7 9 8 11 6 2 3 1 7 9 85 Crude case - mortality percentage 2.46 3.25 0.74 0.79 0.60 0.68 0.42 0.18 0.35 0.13 0.30 0.47 0.60 The death-rates in London and England and Wales in recent years are shown in the following table:— Area. 1921. 1922. 1923. 1924. 1925. 1926. 1927. 1928. 1929. 1930. 1931. London 0.06 0.07 0.03 0.03 0.02 0.02 0.01 0.02 0.02 0.03 0.02 England and Wales 0.03 0.04 0.03 0.02 0.03 0.02 0.01 0.01 0.02 0.02 0.01 Diphtheria. Notifications of diphtheria numbered 8,087 in 1932 (52 weeks), compared with 8,384 in 1931. This gives an attack-rate of 1.9 per thousand, which is the same as in the preceding year. There were 313 deaths, giving a death-rate of 0.07 per thousand living. The case-mortality was 3.9 per cent., compared with 3.1 per cent. in 1931. The seasonal incidence, as shown by the notifications (uncorrected for errors of diagnosis) received in successive four-weekly periods during the year was as follows:— l- 5- 9- 13- 17- 21- 25- 29- 33- 37- 41- 45- 49-52 611 648 517 465 588 604 559 524 539 779 807 777 669 The notifications (uncorrected for errors in diagnosis), deaths and crude casemortality during 1932 were as follows:— Year 1932. (52 weeks.) Age-period. Total. 0- 1- 2- 3- 4- 5- 6- 7- 8- 9- 10- 15 + Notifications 201 423 656 726 779 835 709 557 456 367 1,010 1,368 8,087 Deaths 18 37 33 41 41 45 25 19 10 8 25 11 313 Crude case - mortality percentage 8.96 8.75 5.03 5.65 5.26 5.39 3.53 3.41 2.19 2.18 2.48 0.80 3.87 The death-rates in London and England and Wales in recent years are shown in the following table:— Area. 1921. 1922. 1923. 1924. 1925. 1926. 1927. 1928. 1929. 1930. 1931 London 0.25 0.25 0.13 0.12 0.11 0.12 0.09 0.09 0.08 0.10 0.06 England and Wales 0.13 0.11 0.07 0.06 0.07 0.08 0.07 0.08 0.09 0.09 0.07 Diarrhoea and enteritis. Diarrhoea and enteritis caused 781 deaths among children under two years of age or 12.55 per thousand births. The corresponding rate in 1931 was 9.71. 11 Puerperal fever and pyrexia. There were 218 notifications of puerperal fever and 741 notifications of puerperal pyrexia in 1932 (52 weeks) compared with 291 and 828, respectively, in 1931 (52 weeks). The deaths from puerperal sepsis numbered 83 and from other accidents of childbirth 103, the deaths per thousand births being 1-33 and 1-66 respectively. These give a maternal mortality-rate of 2-99 and both separately and conjointly are the lowest rates hitherto recorded in London. The deaths from puerperal fever and other accidents of childbirth per thousand births in each metropolitan borough and in the county of London in the periods 1920 to 1927 and 1928 to 1932, together with the deaths in childbirth in 1932, are shown in the following table:— Metropolitan boroughs. Childbirth deaths per 1,000 births. Number of deaths in childbirth. 1920-27. 1928-32. 1932. Puerperal fever. Other causes. Total. Puer. peral fever. Other causes. Total. Puerperal fever. Other causes. Total. Western. Paddington 1.5 1.8 3.3 1.7 1.9 3.6 2 4 6 Kensington 1.9 1.7 3.6 2.4 1.8 4.2 4 5 9 Hammersmith 2.1 1.7 3.8 1.8 1.7 3.5 3 4 7 Fulham 1.9 1.6 3.5 2.4 1.6 4.0 2 5 7 Chelsea 1.9 2.9 4.8 2.1 2.1 4.2 - - - Westminster 1.5 2.9 4.4 3.2 3.2 6.4 2 4 6 Northern. St. Marylebone 2.1 2.6 4.7 2.2 2.5 4.7 2 2 4 Hampstead 1.8 1.6 3.4 1.6 2.6 4.2 1 1 2 St. Pancras 1.4 1.7 3.1 1.2 1.6 2.8 9 5 14 Islington 1.4 1.5 2.9 1.8 1.8 3.6 7 7 14 Stoke Newington 2.5 1.9 4.4 2.1 3.1 5.2 1 3 4 Hackney 1.8 1.5 3.3 1.4 2.1 3.5 3 8 11 Central. Holborn 2.9 0.6 3.5 2.0 1.0 3.0 2 - 2 Finsbury 0.9 1.4 2.3 2.3 1.1 3.4 - - City of London 2.0 1.0 3.0 5.2 - 5.2 - - - Eastern. Shoreditch 1.1 1.2 2.3 1.1 1.6 2.7 1 3 4 Bethnal Green 0.9 1.6 2.5 1.8 1.2 3.0 1 1 2 Stepney 1.0 1.4 2.4 1.0 1.4 2.4 3 6 9 Poplar 1.2 1.7 2.9 1.1 1.6 2.7 5 6 11 Southern. Southwark 1.3 1.4 2.7 1.8 1.4 3.2 4 7 11 Bermondsey 1.1 1.8 2.9 1.8 1.6 3.4 2 3 5 Lambeth 1.8 1.3 3.1 1.3 1.5 2.8 6 3 9 Battersea 0.9 1.9 2.8 1.2 2.0 3.2 2 2 4 Wandsworth 1.6 1.7 3.3 2.2 1.8 4.0 6 6 12 Camberwell 1.7 1.5 3.2 2.1 1.5 3.6 4 4 8 Deptford 1.6 1.7 3.3 1.9 1.2 3.1 2 3 5 Greenwich 1.0 1.4 2.4 1.6 1.8 3.4 1 3 4 Lewisham 1.1 1.9 3.0 2.0 1.5 3.5 4 6 10 Woolwich 1.2 1.6 2.8 2.3 2.2 4.5 4 2 6 London 1.5 1.6 3.1 1.8 1.7 3.5 83 103 186 The deaths in childbirth in 1932 are shown in the above table but not the deathrates, as, owing to the smallness of the figures, the rates for a single year may be misleading. The maternal mortality rates are, however, set out in the table on page 14. 12 Enteric fevers. There were 195 notifications of fevers of the enteric group in London in 1932 (52 weeks) compared with 186 in 1931. The deaths in the calendar year numbered 20 as against 24 in 1931. This is the lowest number of deaths recorded in London from this cause. The remarkable decrease in the mortality from enteric fever during the present century will be seen from the figures in the table on page 16. The seasonal incidence, as shown by the notifications (uncorrected for errors of diagnosis) received in successive four-weekly periods during the year was as follows :— l- 5- 9- 13- 17- 21- 25- 29- 33- 37- 41- 45- 49-52 6 9 8 9 5 21 24 15 26 24 21 15 12 The death-rates in London and England and Wales in recent years are shown in the following table:— Area. 1921. 1922. 1923. 1924. 1925. 1926. 1927. 1928. 1929. 1930. 1931. London 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 England and Wales 0.02 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 Influenza. The deaths from influenza during 1932 numbered 1,222, compared with 1,121 in 1931. A relatively small epidemic which began in December, 1931, continued throughout January, February and March, 1932, and during the 13 weeks ended 26th March 974 deaths from influenza were recorded. A more severe epidemic became prevalent towards the end of 1932, and during the first 12 weeks of 1933 caused 1,976 deaths. The mortality during this epidemic was undoubtedly very much increased by the severe wintry weather which occurred when the epidemic was at its height towards the end of January. The weekly deaths from influenza, pneumonia and bronchitis during the latter epidemic period are shown in the following table :— Disease. Week ended Total. January. February. March. 7 14 21 28 4 11 18 25 4 11 18 25 Influenza 93 242 338 370 368 261 130 74 42 21 21 16 1,976 Pneumonia 133 160 194 227 246 132 107 90 91 83 89 77 1,629 Bronchitis 74 124 162 149 181 116 69 53 49 36 40 27 1,080 Total 300 526 694 746 795 509 306 217 182 140 150 120 4,685 Acute primary and influenzal pneumonia notifications 282 461 483 519 530 388 190 126 141 135 112 99 3,466 Rheumatic fever. The deaths in London from rheumatic fever in 1932 numbered 110, of which 47 were among children under 15 years of age. The corresponding figures in 1931 were 158 and 66 respectively. Cancer. There were 7,019 deaths from cancer in 1932, as against 7,159 in 1931. The death-rate per thousand was 1-61. There was an increase of 29 in the deaths among males and a decrease of 169 among females compared with the previous year. Tuberculosis. Tuberculosis. The deaths from tuberculosis of the respiratory system in London during 1932 numbered 3,564, giving a death-rate of 0'82 per thousand living, the corresponding figures for 1931 being 3,907 and 0 90 respectively, and 3,826 and 0 87 for 1930. There were 522 deaths from other forms of tuberculosis in 1932 as against 552 in 1931, the death-rates being 0-12 and 0-13 respectively. 13 The annual death-rates from pulmonary and non-pulmonary tuberculosis in recent years are shown in the subjoined table:— Period. Pulmonary tuberculosis death-rates. Non-puhnonary 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 1932 1.08 0.59 0.82 0.14 0.11 0.12 The number of primary notifications in metropolitan boroughs during 1932 (52 weeks), after correction of figures within each metropolitan borough by the exclusion of cases notified as primary but subsequently found to have been previously notified, was 7,474, the corresponding figure for 1931 being 7.732. The following is an analysis of the notifications in London during 1932 (52 weeks ended 31st December, 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. 4 18 63 67 293 490 801 602 645 402 118 3,503 4,952 F. 6 22 38 75 392 561 717 388 192 136 69 2,596 3,707 Other forms of tuberculosis M. 17 117 152 88 92 62 74 43 26 27 12 710 851 F. 12 92 129 89 65 77 100 49 25 16 11 665 794 All forms of tuberculosis M. 21 135 215 155 385 552 875 645 671 429 130 4,213 5,803 F. 18 114 167 164 457 638 817 437 217 152 80 3,261 4,501 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 knowledgo otherwise than by formal notification. 0- 1- 5- 10- 15- 20- 25- 35- 45- 55- 65 + Total. Pulmonary tuberculosis. M. 4 9 11 3 27 68 110 120 110 56 38 556 F. 2 6 9 13 43 92 145 65 40 29 18 462 Other forms of tuberculosis M. 15 43 41 28 19 16 18 6 9 8 4 207 F. 13 29 29 24 26 14 31 8 10 6 13 203 All forms of tuberculosis M. 19 52 52 31 46 84 128 126 119 64 42 763 F. 15 35 38 37 69 106 176 73 50 35 31 665 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. Death returns from local registrars 196 84 transferable deaths from Registrar-General ... 151 78 Posthumous notifications 73 53 "Transfers" from other areas 570 173 Other sources 28 22 The returns received under the Public Health (Tuberculosis) Regulations, 1930, from the medical officers of health of the metropolitan boroughs show that there were 28,399 cases of pulmonary tuberculosis (16,145 males and 12,254 females) and 10,596 cases of other forms of tuberculosis (5,471 males and 5,125 females) on the registers of the metropolitan boroughs at the end of 1932. 14 Vital statistics for the metropolitan boroughs and the county of London in the year 1932. (Rates per 1,000 of civil population.) Metropolitan boroughs. Arranged in topographical order.) Estimated resident populntion 1932. Births. Deaths. Infant mortality (per 1,000 births). Measles Scarlet [ever. Diphtheria. Whooping cough. Typhoid fever. Diarrhoea and Enteritis, age 0-2 (per 1,000 births). Phthisis. Pneumonia. Bronchitis. Cancer. Maternal mortality (per 1,000 births). Notifications of Infectious disease. Scarlet fever. Diphtheria. Typhoid fever. Erysipelas. Cerebro ppina! fever. Acute pneumonia. If o efom Paddington 143,600 13.8 13.3 107 .18 - .09 .09 - 27.2 .75 1.04 .45 1.77 3.03 2.00 1.40 .03 .41 .06 1.73 Kensington 183,500 12.9 13.6 98 .25 .02 .16 .20 .01 26.2 .58 1.02 .44 1.61 3.81 2.78 2.43 .08 .44 .05 1.28 Hammersmith 133,700 14.5 12.8 66 .22 .03 .06 .04 .01 10.8 1.01 .85 .60 1.54 3.61 4.43 1.44 .03 .39 .06 1.34 Fulham 149,600 14.3 12.4 58 .17 .01 .07 .08 .01 10.3 .92 .82 .31 1.58 3.28 3.64 1.19 .07 .71 .07 1.62 Chelsea 59,430 11.9 12.9 52 .15 .02 .03 .10 - 16.9 .81 .82 .30 1.85 - 2.96 1.66 .12 .61 .02 2.03 Westminster, City of 126,400 9.3 12.5 67 .02 .02 .02 .02 - 8.5 .75 .90 .47 1.50 5.10 1.53 .60 .06 .39 .06 .41 Northern St. Marylebone 96,430 10.9 13.1 87 .19 - .01 .15 - 23.7 .69 .80 .35 1.86 3.80 2.00 .87 .07 .57 .02 .80 Hampstead 90,130 10.9 11.6 54 .03 .02 .04 - .01 8.2 .36 .58 .26 1.93 2.04 1.90 .76 .09 .28 .01 .77 St. Pancras 194,000 14.0 13.2 69 .14 .03 .05 .13 .01 20.6 .86 .95 .50 1.89 5.16 2.67 1.55 .04 .61 .07 1.28 Islington 319,100 16.0 12.7 68 .16 .02 .06 .09 - 12.1 .85 1.05 .52 1.71 2.74 3.09 1.89 .05 .52 .04 1.08 Stoke Newington 51,680 15.0 12.9 54 .14 .04 .08 - - 10.3 .95 .77 .54 1.68 5.16 2.65 1.50 .10 .54 .08 .37 Hackney 214,200 14.5 11.5 54 .23 .02 .05 .06 - 6.1 .71 .71 .42 1.53 3.53 3.11 1.58 .04 .58 .03 .83 Central. Holbom 36,440 9.6 14.2 72 .03 - .05 - - 31.5 .93 .91 .74 1.95 5.73 1.60 2.12 .11 .50 .03 .83 Finsbury 69,030 16.0 13.4 88 .42 .04 .10 .17 - 11.7 1.06 .96 .97 1.48 - 3.99 2.65 .04 .57 .07 1.40 City of London (a) 10,370 6.4 12.4 45 .10 - .10 .10 - - .68 .87 - 1.83 - 2.81 2.04 .19 .68 - .29 Eastren. Shoreditch 95,800 17.5 12.3 80 .63 .06 .07 .04 - 15.5 .92 1.00 .40 1.54 2.39 4.86 3.10 .05 .41 .13 .35 Bethnal Green 106,300 15.4 12.1 69 .40 .03 .16 .09 .01 15.3 .93 .87 .40 1.52 1.22 5.56 3.34 .05 .91 .06 1.48 Stepney 223,000 16.8 12.5 60 .30 .03 .10 .06 .00 12.0 .85 .94 .42 1.72 2.41 4.44 3.62 .05 .86 .15 1.64 Poplar 152,400 17.2 12.1 63 .20 .02 .10 .04 .02 5.7 .88 .93 .68 1.35 4.20 4.24 2.99 .03 .53 .08 2.48 Southern. South wark 168,900 16.2 13.1 72 .31 .02 .08 .12 - 12.5 1.01 1.00 .40 1.56 4.04 3.71 2.67 .01 .46 .05 1.11 Bermondsey 110,100 16.6 12.1 57 .25 .01 .09 .15 - 7.6 1.06 1.01 .32 1.64 2.73 4.07 2.40 .02 .45 .08 .93 Lambeth 292,300 14.8 12.5 56 .14 .01 .11 .08 .01 10.2 .85 1.01 .51 1.51 2.09 2.68 1.51 .05 .46 .04 1.31 Battersea 157,000 14.8 121 58 .15 .03 .06 .07 - 9.5 .90 .66 .46 1.71 1.72 3.82 2.29 .03 .59 .08 2.38 Wandsworth 353,300 11.8 11.6 63 .10 .01 .04 .06 .00 14.6 .69 .51 .50 1.54 2.88 2.22 1.02 .05 .38 .02 1.55 Camberwell 248,000 14.6 12.0 65 .12 .01 .06 .07 - 10.2 .86 .84 .56 1.60 2.22 3.62 1.89 .03 .39 .04 1.03 Deptford 105,100 15.9 12.3 65 .22 .04 .06 .09 .01 13.8 .88 .78 .50 1.74 3.00 5.19 2.28 .02 .71 .04 .96 Greenwinh 99,590 14.8 12.0 81 .22 .01 .07 .08 - 16.2 .77 .82 .44 1.58 2.71 4.29 2.36 .07 .68 .06 1.32 Lewisham 221,500 12.7 10.2 55 .08 .02 .06 .05 .00 7.1 .59 .58 .42 1.42 3.55 2.32 1.02 .01 .44 .06 1.38 Woolwich 146,900 14.0 11.1 60 .17 .02 .05 .05 .01 3.9 .95 .55 .46 1.43 2.92 3.64 1.51 .02 .30 .08 1.66 London, 1932 4,357,800 14.3 12.3 67 .19 .02 .07 .08 .00 12.5 .82 .84 .47 1.61 2.99 3.26 1.87 .04 .51 .06 1.31 London, 1931 (b) 4,417,207 14.9 12.3 65 .03 .02 .06 .07 .01 9.7 .88 1.01 .59 1.62 3.81 2.72 1.90 .04 .52 .04 1.56 (a) Including Inner and Middle Temple, (b) Figures etc., calculated on revised population estimate. 15 COUNTY OF LONDON.—Notifiable infectious diseases.—Notifications per 1,000 of population. Period Annual rates per 1,000 living. Anthrax Cerebro-spinal fever Continued fever Diphtheria Dysentery Encephalitis lethargica Enteric fever Erysipelas Malaria Ophthalmia neonatorum (per 1,000 births) Pneumonia Polioencephalitis Poliomyelitis Puerperal fever (per 1,000 births) Puerperal pyrexia (per 1,000 births) Scarlet fever Smallpox Typhus 1891-95 (a) (a) .00 2.4 (a) (a) .78 1.54 (a) (a) (a) (a) (a) 2.17 (a) 5.3 .26 .00 1896-1900 (a) (a) .00 2.9 (a) (a) .82 1.24 (a) (a) (a) (a) (a) 2.03 (a) 4.4 .02 .00 1901-05 (a) (a) .00 1.9 (a) (a) .52 1.08 (a) (a) (a) (a) (a) 2.10 (a) 3.6 .46 .00 1906-10 (a) (a) .00 1.6 (a) (a) .28 .97 (a) (a) (a) (a) (a) 2.27 (a) 4.2 .00 .00 1911-15 .00 .05 .00 1.8 (a) (a) .17 .98 (a) (a) (a) (a) (a) 3.11 (a) 3.6 .00 .00 1916-20 .00 .07 .00 2.3 (a) (a) .09 .60 (a) 8.95 (a) (a) .02 3.00 (a) 2.7 .00 .00 1921-25 .00 .02 .00 2.86 .00 .05 .08 .43 .03 9.05 1.24 .00 .01 3.59 (a) 3.69 .00 .00 1926-30 .00 .02 .00 2.81 .01 .03 .08 .47 .01 9.89 1.46 .00 .01 4.10 (a) 3.28 .33 .00 1921 .00 .02 .00 3.62 .01 .05 .07 .47 .05 10.81 .96 .00 .01 3.55 (a) 7.27 .00 .00 1922 .00 .02 .00 3.38 .01 .01 .06 .43 .03 9.17 1.56 .00 .01 3.28 (a) 3.81 .02 .00 1923 .00 .01 .00 2.26 .00 .02 .07 .40 .02 8.33 1.04 .00 .02 3.84 (a) 2.21 .00 - 1924 .00 02 .00 2.30 .00 .13 .09 .41 .02 8.36 1.47 .00 .02 3.43 (a) 2.50 .00 - 1925 .00 .02 .00 2.72 .00 .06 .09 .42 .01 8.58 1.18 .00 .01 3.83 (a) 2.66 .00 - 1926 .00 .02 .00 2.95 .00 .05 .07 .39 .01 8.97 1.22 .00 .02 4.24 (a) 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 1.15 .00 1931 (b) .00 .04 .00 1.90 .01 .01 .04 .52 .01 9.60 1.56 .00 .01 4.44 12.64 2.72 .33 - 1932 .00 .06 .00 1.86 .02 .01 .04 .51 .01 11.07 1.31 .00 .02 3.51 11.94 3.25 .26 - (a) Comparable figures are not available for this period. (b) Figures etc., calculated on revised population estimate. 16 COUNTY OF LONDON.—Principal vital statistics, 1891-1932. Period Annual rate per 1,000 living Mortality per 1,000 living Annual mortality per 1,000 births Births Marriages Deaths (all causes) Cerebro-spinal fever Diphtheria Enteric fever Scarlet fever Small-pox Whoopingcough 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 (a) 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 0.19 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 (b) 14.9 18.7 12.3 0.03 0.06 0.01 0.02 0.00 0.07 0.03 0.25 0.88 0.12 1.01 0.59 0.14 2.83 1.62 0.13 65 9.7 2.01 1.80 1932 14.3 18.0 12.3 0.03 0.07 0.00 0.02 0.00 0.08 0.19 0.28 0.82 0.12 0.84 0.47 0.14 2.91 1.61 0.13 67 12.5 1.33 1.66 (a) Comparable figures are not available for this period. (b) Figures etc., calculated on revised population estimate. 17 Infectious Diseases.—Notifications in the County of London during the 52 weeks ended 31st December, 1932. Metropolitan borough. Anthrax. Cerebrospinal fever. Continued fever. Diphtheria (including membranous croup). Dysentery. Encephalitis lethargica. Enteric fever. Erysipelas. Malaria. Ophthalmia neonatorum. Pneumonia. Polioencephalitis. Poliomyelitis. Puerperal fever. Puerperal pyrexia. Scarlet fever. Smallpox. Typhus. If extern— Paddington - 9 - 200 5 - 4 59 1 22 247 1 2 7 31 286 2 - Kensington - 10 - 444 27 2 15 81 3 16 233 - 2 9 31 508 1 - Hammersmith - 8 - 192 1 1 4 52 - 19 178 - 1 2 28 589 - - Fulham - 10 - 177 2 3 11 106 2 28 241 - - 11 38 541 2 - Chelsea - 1 - 98 - 1 7 36 1 6 120 - - 1 10 175 - - Westminster, City of - 7 - 76 2 2 7 49 1 12 51 - 1 9 7 192 4 - Northern— St. Marylebone - 2 - 83 2 - 7 55 1 8 77 - 1 5 26 192 - - Hampstead - 1 2 68 1 2 8 25 1 6 69 - - - 11 170 1 - St. Pancras - 13 - 299 4 1 7 117 2 74 247 1 3 29 47 516 5 - Islington - 13 1 601 15 2 15 165 2 94 342 1 4 35 59 982 162 - Stoke Newington - 4 - 77 1 - 5 28 - 12 19 1 1 2 10 136 1 - Hackney - 6 - 337 - 5 9 124 2 27 176 1 2 5 84 663 34 - Central— Holborn - 1 - 77 1 1 4 18 1 4 30 - 2 1 6 58 1 - Finsbury - 5 - 182 2 2 3 39 - 14 96 - - 1 10 274 105 - City of London - - - 21 - - 2 7 - - 3 - - - - 29 - - Eastern— Shoreditch 1 12 - 295 7 1 5 39 - 29 33 - 3 4 29 463 14 - Bethnal Green - 6 - 353 - - 5 96 1 19 156 - 3 2 15 588 25 - Stepney 1 33 - 802 - 2 11 191 1 33 363 2 10 9 30 985 26 - Poplar - 12 - 453 2 2 4 80 - 28 376 2 3 7 31 643 177 - Southern— Southwark - 8 - 448 2 1 2 77 1 26 186 - 5 7 24 623 161 - Bermondsey - 9 - 263 - 2 2 49 - 10 102 - 3 8 27 446 16 - Lambeth 1 13 - 439 2 1 14 133 6 60 381 - 2 17 33 779 218 - Battersea - 12 - 358 - 3 5 92 4 30 371 - 1 4 14 596 16 - Wandsworth - 8 - 360 - 3 18 133 2 34 546 1 7 16 30 781 12 - Camberwell - 9 - 467 - 2 7 96 5 24 253 - 7 7 21 893 66 - Deptford - 4 - 238 - 1 2 74 1 11 100 - 3 2 16 543 56 - Greenwich - 6 1 234 2 1 7 67 1 24 131 - 3 3 11 425 17 - Lewisham - 14 - 224 - 4 2 98 1 10 304 - 4 10 28 511 2 - Woolwich - 11 - 221 1 2 3 44 1 7 242 - 6 5 34 532 7 - Ages 0- - 40 - 201 4 1 1 57 - 687 297 1 6 - - 122 13 - „ 1- - 65 - 2,584 45 2 12 87 - - 983 7 41 - - 4,015 92 - „ 5- - 24 2 2,924 16 3 21 67 - - 568 1 13 - - 5,780 216 - „ 10- - 20 - 1,010 5 3 22 69 1 - 233 - 3 - - 2,302 214 - „ 15- - 25 - 425 1 3 29 116 - - 353 - 5 12 61 699 174 - „ 20- 1 22 - 372 2 4 36 121 - - 339 - 2 54 217 476 120 - „ 25- 1 26 2 378 3 7 32 260 17 - 592 1 6 119 359 471 100 - „ 35- 1 18 - 112 - 5 20 317 11 - 618 - - 32 99 174 63 - „ 45- - 5 - 52 1 10 11 406 6 - 633 - 2 1 5 57 74 - „ 55- - 1 - 20 - 5 6 391 4 - 510 - 1 - - 19 44 - „ 65- - - - 7 2 4 4 228 2 - 377 - - - - 4 19 _ „ 75+ - 1 - 2 - - 1 111 - - 170 - - - - - 2 - London, 1932 3 247 4 8,087 79 47 195 2,230 41 687 5,673 10 79 218 741 14,119 1,131 - London, 1931 2 175 3 8,384 58 40 186 2,294 32 629 6,880 5 51 291 828 12,025 1,452 - 18 Common and seamen s lodging houses Administration The supervision of the 150 common lodging houses licensed by the Council under the London County Council (General Powers) Act, 1902, entailed 5,208 day visits and 120 night visits by the inspectors. The supervision of the 20 seamen's lodging houses licensed under the Merchant Shipping Act, 1894, entailed 460 visits by day and 28 by night. Census of homeless persons A census of homeless persons in London was taken on the night of Friday, 12th February, 1932. 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 clear and cold. No persons were found sheltering under arches or on staircases. In the streets 73 men and 14 women were found, compared with 60 men and 18 women on the night of the census in 1931. In the common lodging houses 13,966 persons were accommodated compared with 14,970 in 1931. In the free shelters and labour homes not licensed, 1,208 men, 138 women and 20 children were accommodated compared with 1,057 men, 137 women and 17 children in 1931. The number of persons in casual wards and in the associated hostel on the night in question was 836 (805 men and 31 women). The following table shows briefly the results obtained in the several years during which the enumeration has been undertaken by the Council:— Persona. 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 1920 14,333 88 51 14,472 1905 23,381 1,139 2,181 26,701 1921 14,090 188 66 14,344 1907 22,450 1,137 2,404 25,991 1922 13,076 289 112 13,477 1909 21,864 1,188 2,388 25,440 1923 13,891 400 141 14,432 1910 21,156 1,107 2,747 25,010 1924 14,165 429 82 14,676 1911 21,204 1,091 1,785 24,080 1925 14,425 503 118 15,046 1912 21,499 1,033 1,203 23,735 1926 14,593 668 103 15,364 1913 20,526 546 649 21,721 1927 14,724 777 101 15,602 1914 20,173 335 540 21,048 1928 14,738 835 78 15,651 1915 17,305 179 178 17,662 1929 14,648 860 31 15,539 1916 15,254 123 44 15,421 1930 14,855 740 79 15,674 1917 13,679 89 28 13,796 1931 14,970 689 78 15,737 1918 12,522 82 9 12,613 1932 13,966 836 87 14,889 1919 12,336 50 8 12,394 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. 19 COUNTY OF LONDON.—Statistics of the administrative work carried out during the year 1932. Sanitary authority. Cowsheda. 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 - - - - - - 166 - 19 - 1 477 120 1,395 22 9 - 286 230 4 2 942 396 Battersea - - 2 152 3 2 21 14 6 2 3 187 248 3,703 1,950 225 18 280 570 172 299 175 526 Bermondsey - - - - 13 62 49 13 8 1 3 1,103 8fi 1,772 1,166 587 6 296 511 145 155 136 531 Bethnal Green 9 39 2 208 9 142 25 4 - 2 5 359 457 9 1,081 131 - 290 828 159 297 196 609 Camberwell 1 13 2 122 10 34 192 11 11 1 5 430 47 4,558 2,977 547 5 488 2,119 272 343 188 231 Chelsea - - 2 17 - - 15 5 10 - 2 164 11 661 263 281 - 73 78 30 37 70 66 Deptford - - 2 258 7 33 14 - - - 6 1,166 22 1,728 1,111 110 - 216 215 158 93 194 355 Finsbury - - 1 96 4 57 62 4 8 2 2 470 26 12 1,101 122 23 181 244 84 174 251 374 Fulham - - 2 35 - - 57 4 11 4 2 84 18 5 1,198 122 - 109 184 133 289 98 430 Greenwich 1 5 2 21 1 13 28 6 12 1 2 90 7 867 780 27 1 105 154 134 118 69 80 Hackney 3 25 11 522 19 54 1,275 18 39 3 4 408 108 1,445 2,124 822 3 506 381 221 381 199 251 Hammersmith - - 5 355 2 18 100 14 12 3 1 244 279 2,461 833 48 76 130 1,285 133 236 225 752 Hampstead - - - - - - 5 1 2 - - - 1 889 1,816 32 53 78 143 67 117 59 108 Holborn - - 1 2 - - 209 3 8 - 12 835 332 - 218 134 2 141 247 27 87 291 479 Islington - - 13 424 16 57 133 14 115 2 20 724 75 6,146 2,789 88 105 698 1,068 336 267 503 707 Kensington - - 2 135 - - 124 4 3 - 5 259 353 3,866 1,445 271 22 152 446 169 246 148 1,755 Lambeth 1 12 5 455 4 48 45 45 45 1 3 448 44 - 5,671 1,310 35 408 4,796 311 576 238 262 Lewisham 1 4 7 982 - - 214 19 - - - - 3 1,389 1,058 128 - 132 448 124 245 114 318 Paddington - - 2 254 1 54 155 - 9 - 3 234 25 3 no red. 91 54 122 413 144 150 129 174 Poplar 3 23 5 20 8 29 61 11 14 - 6 636 143 2,731 1,620 283 - 107 365 162 297 819 1,967 St. Marylebone - - 1 40 2 50 592 14 37 - 5 754 3,179 3,147 722 561 23 135 266 78 125 358 450 St. Pancras - - 4 110 2 46 405 2 50 - 2 78 1,284 5,998 1,013 172 114 366 754 241 254 291 682 Shoreditch 2 30 - - 1 5 371 1 3 - 4 284 5 - 1,082 35 12 293 966 120 189 222 355 Southwark - - 4 290 4 16 3 1 1 1 19 2,307 1,705 3,131 2,155 1,442 16 388 1,320 209 465 363 1,013 Stepney 19 135 - - 55 324 232 19 22 2 21 3,118 320 10 1,977 303 6 422 1,453 273 403 365 593 Stoke Newington - - 4 62 2 16 3 - - - - - - 1,855 308 117 11 96 51 45 29 34 63 Wandsworth 1 9 5 915 2 2 140 10 38 - - - 154 - 3,377 195 3 441 583 551 466 352 254 Westminster - - - - - - 629 11 35 2 6 1,793 451 556 754 27 9 193 388 43 45 1,247 1,835 Woolwich 4 112 5 20 1 4 49 1 12 - 9 312 12 2,173 1,032 303 - 85 300 180 286 167 251 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 150; lodgers, 16,487. Visits—day, 5,208; night, 120. Seamen's lodging houses, number licensed, 20; Bermondsey, 2; Poplar, 4; Stepney, 14; lodgers, 927. Visits—day, 460; night, 28. Prosecutions—Smoke nuisances.—Islington, 1, £5 5s. 0d. costs; and 1, £10 10s. Od. oosts. Water supply.—Bermondsey, 1; Hammersmith, 1; St. Pancras, 1; Stepney, 1. Ice cream premises.—Islington, 1. Milkshops.—Bethnal Green, 1; Islington, 4; St. Pancras, 2. Restaurants and eating A ouses.—Hammersmith, 1. 20 Sanitary authority. 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, 1930. Underground rooms. Overcrowding. Houses let in lodgings. No. of houses closed by owner. No. of houses for the working classes. Houses unfit for habitation. lepresentations. 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. In pursuance of orders. Voluntarily. By owners. By L.A.I City of London 2,053 482 89 51 31 5 63 147 -— 3 3 51 153 - - - - - - - - - 8 Battersea 27,930 25,051 6,446 1,053 3,149 1,038 44 2,642 453 3 - 4 39 39 65 337 - 92 184 177 510 1 - 7 7 7 Bermondsey 18,711 18,567 3,727 5,014 6,587 1,920 - 6,587 7 - 5 8 1,411 311 76 460 - 335 346 3 172 4 - 7 1 224 Bethnal Green 18,285 prac. all 7,409 933 6,030 3,353 - 5,217 - - 1 1 many [ 170 922 - 98 74 - - - - - -- - Camberwell 42,692 34,152 4,424 1,170 4,196 1,304 56 4,440 - - - 5 112 33 240 221 5 fits 324 fits 124 shps. 4 - - - - - 6 8 Chelsea 11,924 2,487 622 163 575 99 - 423 - - - - 20 19 460 34 - - - - - - - 5 6 10 Deptford 19,030 prac. all 1,591 1,678 2,623 687 10 2,990 - 11 3 - - 1 notkpt - - 4 - - - - - - - - Finsbury 10,503 prac. all 1,740 1,529 2,179 296 - 2,179 - 5 5 24 24 785 3,837 - 52 - - - - - - - - Fulham 26,501 prac. all 2,852 333 2,332 480 65 1,905 384 4 - 36 30 304 2,451 - 257 112 1 2 - - - - 2 Greenwich 18,073 prac. all 885 1,414 904 103 - 1,403 - 1 1 21 14 104 73 - 12 50 — - - - - - 9 Hackney 36,381 14,770 5,868 43 4,832 1,246 1 4,949 - 1 14 14 86 35 194 207 - fits 754 fits 160 6 82 - - 2 2 56 Hammersmith 20,100 13,600 7,266 180 3,940 1,655 - 4,986 - - 7 10 93 87 2,495 - - 40 32 6 7 - 1 3 - 14 Hampstead 14,935 approx. one half 333 1,663 1,039 497 44 661 - - 44 37 10 8 1,578 1,330 - - - 4 4 3 1 - - - Holborn 6,462 - 803 107 427 51 - 427 - - 8 8 2 2 474 861 - blcks.2 block 1 4 3 1 pt. - 3 3 3 - fits. 34 fits. 28 Islington 46,000 29,000 6,886 1,425 4,662 629 63 19,244 63 - 42 42 72 71 1,006 2,235 - 93 - - - - - - - - Kensington 35,296 9,857 3,095 1,236 2,205 421 148 2,158 118 2 52 52 60 58 3,132 8,097 - - 20 4 6 9 18 - - 3 Lambeth 48,873 - 12,506 251 3,901 2,084 254 5,656 280 - 6 4 - - notkpt - - 430 350 approx 11 11 7 - 2 4 - Lewisham 47,000 - 1,959 685 1,936 389 - 1,890 - - - - 17 13 14 59 - - - 1 1 - - - - - Paddington 17,000 10,000 1,474 - 1,184 336 93 1,215 129 - 3 3 8 7 1,406 5,363 - - - 2 2 2 - - - - Poplar 23,583 23,000 approx. 8,835 7,303 6,424 2,611 1 5,689 - 1 - - 55 34 162 1,164 - 134 50 - - - — — 30 10 St. Marylebone 17,200 8,587 about 2,009 834 1,257 63 - 1,320 - - -8 88 19 19 1,055 8,088 - fits. 44 fits. 63 - - - - - - - St. Pancras 25,670 18,000 4,181 1,235 3,335 1,314 22 3,182 13 - 12 8 13 11 2,992 4,889 - 318 186 6 14 - - - - 8 Shoreditch 14,115 13,708 5,360 1,410 4,493 670 - 4,493 - - 7 7 198 240 409 184 - 52 - - - - - - - 11 Southwark 27,417 14,694 6,733 1,407 3,979 3,070 1,100 3,370 162 - 31 16 43 43 355 710 9 198 93 31 31 20 5 11 3 - Stepney 37,900 31,810 11,915 798 13,822 4,979 - 11,960 - - 54 36 94 71 2,658 2,778 -- 57 28 - - - - - - - Stoke Newington 8,671 3,974 826 201 685 39 - 1,478 - - 4 4 5 100 46 - - - 6 60 - - - - 2 Wandsworth 75,243 49,327 7,662 1,589 3,982 304 - 10,724 19 - 13 5 116 144 269 706 - 184 50 1 6 - 1 1 25 Westminster 22,536 6,043 1,517 875 1,378 57 - 1,565 - - 151 65 25 194 412 1,728 33 248 141 - - - - - 1 38 Woolwich 31,154 26,480 3,260 2,554 3,133 785 - 3,905 - - 65 8 40 40 notkpt 448 - 646 128 I5 15 8 - 3 27 112 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: Battersea, 1; Bethnal Green, 3; Holborn, 1; Islington, 15; Kensington, 1; Paddington, 1; Poplar, 3; St. Pancras, 3; Stepney, 3. Overcrowding—Hammersmith 2; Kensington, 2. 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, 1932; 21 Sanitary Inspectors, 1932. Sanitary authority. 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* Bermondsey 111,542 12 — — — 10 — Bethnal Green 108,194 11 — — — 12 — Camberwell 251,294 12 — — 2* 3 2* Chelsea 59,031 4 — — 1 — 1 Deptford 106,891 8 — — 1 7 2 Finsbury 69,888 7 — 1 — 6 — Fulham 150,928 10 — 1 — 7 — Greenwich 100,924 5 — 1 — 7 — Hackney 215,333 19 — 1 — 16 — Hammersmith 135,523 9 — 1 — 4 — Hampstead 88,947 6 — 1 — 3 — Holborn 38,860 3 — — 1* 1 1* Islington 321,795 19 — 2 — 8 — Kensington 180,677 12 — — 7* — 7* Lambeth 296,147 16 — 2 — 4 — Lewishain 219,953 10 — 1 — 9 — Paddington 144,923 9 — 2 — 8 1 Poplar 155,089 14 — 1 — 9 — St. Marylebone 97,627 8 3 — 3 4 2 St. Pancras 198,133 14 — 1 5* 16 5* 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 15 — — — 9 — Westminster, City of 129,579 12 — 1 — 8 — Woolwich 146,881 11 — 1 2 8 2 Total County of London 4,397,003 330 3 19 24 196 25 * Act both as sanitary inspectors and health visitors. Examination of milk. Milk and Dairies (Consolidation) Act, 1915. 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, which came into operation on 1st September, 1925, and superseded as from 1st September, 1926, Part IV. of the London County Council (General Powers) Act, 1907. During 1932, 2,197 samples of milk were taken from consignments sent to London from 36 counties and were submitted for biological examination. Of these samples 1,808 were taken from churns at London railway termini, 314 from churns entering London by road, and 75 from road and rail tanks at depots of large wholesale distributors. In the case of 1,957 samples, the biological examination was completed, and of these 215, or 10.9 per cent., yielded tubercle bacilli, as against 10.2 per cent, in 1931. 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 114 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 239 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 23 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 theinspectors while engaged in milk sampling. Details relating to any contraventions of the Order are transmitted to the authorities concerned. 22 Institutions under the control of the Council. 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. 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 11 10 1 9 1 Mental hospitals 137 127 12 115 10 Public assistance 15 14 — 14 i Public health 17 16 3 13 i The percentage of samples found to be tubercle infected of the total number of completed examinations made is 9-6. Each of the herds at the eight institutions whence the sixteen tuberculous samples emanated, was inspected, and sixteen cows were found to be suffering from tuberculosis and subsequently slaughtered. Results op 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 12 120 3 3 1 Mental hospitals 64 3,840 39 348 10 56 Public assistance 8 71 — 6 — — Public health 8 237 5 65 3 7 The veterinary surgeons confer with the farm bailiffs when making the inspections and give 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 Part IV of the Milk and Dairies Order, 1926. The veterinary surgeons make a routine quarterly inspection of the cows at each cowshed. The results are shown below :— Number of visits to cowsheds 205 Number of cows examined 4,697 Number of bulls examined 20 Number of cows presenting unhealthy conditions 110 as follows— Giving tuberculous milk 4 (cows slaughtered voluntarily by owners) With chronic cough showing clinical signs of tuberculosis 3 (cows slaughtered voluntarily by owners) With atrophy of one or more quarters 63 With other defects 40 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 45 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. 23 Venereal Diseases. In his annua] 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 1932, were as follows:— General Hospitals.—St. Thomas's; Seamen's; Boyal Free (women); Guy's; West London; Boyal 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 (Children); Mothers' hospital (Salvation Army), Lower Claptonroad, E. ; Children's, Waddon. 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 26) and the Boyal Free hospital (women). The number of new patients attending the hospitals during the year 1932 was 27,952, of which 4,941 were suffering from syphilis, 11,222 from gonorrhoea, and 187 from soft chancre, while 11,602 were diagnosed as not suffering from these diseases. A summary of the work done by the hospitals for each of the areas in the joint scheme during the year 1932 is shown in the following table:— London. Middlesex. Essex. Surrey. Kent. Herts. Bucks. East Ham. West Ham. Croydon. Total. "Other places." Grand total. New Patients— Syphilis 3,410 440 169 160 100 50 16 47 87 12 4,491 450 4,941 Soft chancre 113 13 8 3 3 2 1 2 7 1 153 34 187 Gonorrhoea 7,906 1,032 542 367 178 90 40 95 209 29 10,494 728 11,222 Not venereal 8,234 1,099 559 527 206 121 50 98 189 77 11,160 442 11,602 Total 19,663 2,584 1,278 1,057 487 269 107 242 492 119 26,298 1,654 27,952 Total attendances 772,839 69,760 44,667 26660 12657 6,340 2,504 8,151 19640 2,835 966,053 17868 983,921 No.of in-patientdays 34,533 2,778 1,824 2,217 1,043 694 193 159 352 284 44,077 9,946 54,023 Salvarsan subs.doses 46,370 6,091 3,505 2,405 1,131 684 211 673 1,468 216 62,754 2,182 64,936 Pathological Examinations. For or at centres— Spirochaetes 2,514 104 135 86 27 31 8 21 48 11 2,985 103 3,088 Gonococci 75,493 6,464 5,906 4,442 1,885 1,118 372 776 1,744 487 98,687 2.371 101,058 Wassermann 30,956 3,075 2,024 1,785 717 502 189 400 749 237 40,634 1,332 41,966 Others 33,620 2,130 7,004 1,092 653 283 137 1,174 2,740 165 48,998 1,247 50,245 Total 142,583 11,773 15,069 7,405 3,282 1,934 706 2,371 5,281 900 191,304 5,053 196,357 For Practitioners—- Spirochaetes 130 — — 3 — — — — — — 133 — 133 Gonococci 5,787 197 446 472 55 72 14 3 16 995 8,057 76 8,133 Wassermann 17,420 908 866 874 45 121 156 46 11 365 20,812 575 21,387 Others 9,087 153 664 316 17 35 17 35 11 320 10,655 318 10,973 Total 32,424 1,258 1,976 1,665 117 228 187 84 38 1,680 39.657 969 40,626 24 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 1932 3,270 1,671 172 15 8,566 2,656 12,008 4,342 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 1932, and also as to the number of cases of congenita] syphilis. The returns received from the treatment centres showed that, as regards syphilis, in approximately 49 per cent, of the new patients the disease was in either a primary or secondary stage, and, in the case of gonorrhoea, in 84 per cent., the infection had taken place within a year. Cases of congenital syphilis not known to have received previous treatment, numbered 336. The age and sex distribution were as follows:— Under 1 year. 1 and under 5 years. 5 and under 15 years. 15 years and over. Total / M. F. M. F. M. F. M. F. M. F. 19 35 6 12 30 58 69 107 124 212 Attendances. Importance is attached to the necessity for securing the regular attendance of patients at the clinics, more especially in the case of gonorrhoea, and efforts to secure the requisite provision of facilities for intermediate treatment at times other than during the hours when the medical officer attends are meeting with considerable success. A number of patients still fail to complete the full course of treatment considered necessary before final discharge, due in no small measure to the false impression that a cure has been effected on the disappearance of outward signs of the disease. The need for improving conditions likely to cause patients to discontinue attendance at the clinics or to transfer them from one clinic to another continues to receive careful attention. In past years the ratio of attendances has been stated as so many attendances to each new case of V.D. admitted to the clinic? 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 1932 the total attendances of V.D. patients was 907,406, and the ratio of attendances of V.D. patients to new V.D. cases was 55, compared with 57 in 1931 and 46 in 1930. 25 Comparative figures for the sixteen years during which the scheme has been in force are shown in the following table:— Year. New cases. Total attendances (venereal and non-venereal) In-patients days. Venereal. Non-venereal Total. 1917 13,025 2,360 15,385 120,659 63,923 1918 13,679 2,693 16,372 169,485 66,095 1919 23,147 5,118 28,265 307,722 73,211 1920 24,454 6,592 31,046 464,033 81,612 1921 19,368 6,050 25,418 496,209 79,692 1922 17,763 5,950 23,713 529,003 112,564 1923 19,006 6,644 25,560 555,509 106,662 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 1932 16,350 11,602 27,952 983,921 54,023 Attention is also drawn to- the very large number of non-venereal patients who present themselves for examination. This appears to indicate quite clearly that the general public is appreciating more and more the efforts which have been, and are being, made to spread far and wide a knowledge of the serious nature and grave after-effects of the venereal diseases. Another point worthy of note is the total number of examinations made of Pathology pathological specimens. Comparative figures for the sixteen years are shown in the and bacteriology following table:— Pathological examinations. Year. 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 1932 196,357 40,626 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 within the county availing themselves of this service is now 510, compared with 108 at the end of 1917. the first vear of the operation cf the scheme. Venerea 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 1932, the number of patients dealt with at these institutions from the areas in the scheme was 240, the aggregate number of days in residence being 26,416. Comparative figures for 1931 were 250 and 26,898. 26 The hostels undertaking work in connection with the scheme for the year 1932, were as follows:— 20-22, 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); 3.5, 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 01 maintaining treatment and observation 0f girls ana 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 1932 only three girls availed themselves of these facilities. The total number of days in residence was 574. 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 tho 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 stafi, 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. The year 1932 showed a further increase, the new patients numbering 4,013 and attendances 228,433. Of the new patients during 1932, 68 per cent, of the male and 46 per cent, of the female venereal cases were infections of less than one year's duration. The number of pathological examinations made at the clinic for the year 1932 was 65,618, an increase of 13,901 on the previous year's total. Of the 65,618 examinations, 9,434 were made for private practitioners, for whose convenience arrangements are in force for results of certain tests to be communicated by telephone within three hours of the delivery of specimens. Facilities for the study of venereal diseases are available for medical students and post-graduates, demonstrations being held weekly. Residential Treatment of Tuberculosis. The Council's tuberculosis scheme, adopted in May, 1914, commenced to operate in the following June. The scheme provided that responsibility for the treatment of persons insured under the National Health Insurance Act, 1911, should be the function of the London Insurance Committee. Residential treatment by the Council was limited to non-insured adults and children other than those appropriate for reference to the poor-law guardians. By the end of the year 1914 the Council had in use 200 beds for adults (100 in voluntary institutions, and 100 in institutions provided by the late Metropolitan Asylums Board) and 381 beds for children (231 in voluntary institutions, and 150 in Metropolitan Asylums Board institutions). Owing to war conditions, however, the Council was unable then to develop its scheme fully and the accommodation was not equal to the demands, with the result that there was a long waiting period extending frequently to three months, especially in the case of surgical tuberculosis in children. Some relief so far as children were concerned was secured in 1917 by an arrangement with the Invalid Children's Aid Association, who undertook the provision of convalescent treatment for suitable cases with the assistance of a grant from the Council, thus releasing the Council's beds for more serious cases. In this way an average of about 260 children a year were dealt with, until in 1926 the 27 Council, in compliance with requirements of the Ministry of Health, made direct arrangements with voluntary institutions for these cases. On 1st May, 1921, by Act of Parliament of that year, sanatorium benefit under the National Health Insurance Acts ceased, and the responsibility for the provision of treatment for tuberculosis of ex-service patients and insured adults became the additional responsibility of the Council. The number of applications received for residential treatment during the year 1921 was 5,266 (4,234 adults and 1,032 children) and the number of patients under treatment in residential institutions on 31st December, 1921, was 2,051 (1,382 adults and 669 children). The operation of the Local Government Act, 1929, still further extended the obligations of the Council for providing residential accommodation for the treatment of tuberculosis, and hospitals and sanatoria provided both by former boards of guardians and the late Metropolitan Asylums Board were transferred to the Council. For a time admissions to the former were continued under the poor law, but later the Council "appropriated" the hospitals in accordance with the provisions of the Local Government Act, 1929, and patients were removed from the purview of the poor law. During the year 1932, the distinction was continued by classifying patients either as "tuberculosis scheme" or "municipal" patients, the latter term including patients in general hospitals and certain patients sent to voluntary sanatoria. 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. 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 following table shows the development of the provision for residential treatment in London since 1914, inclusive of cases dealt with by the London Insurance Committee between 1914 and May, 1921, and of those treated directly by the Council under its tuberculosis scheme:— Beds occupied at end of year. Year. Adults. Children. Total. 1914 722 90 812 1915 544 241 785 1916 481 320 801 1917 526 375 901 1918 816 376 1,192 1919 1,308 557 1,865 1920 1,636 704 2,340 1921 1,382 669 2,051 1922 1,370 655 2,025 1923 1,458 707 2,165 1924 1,612 746 2,358 1925 1,668 792 2,460 1926 1,841 880 2,721 1927 1,946 884 2,830 1928 1,920 855 2,775 1929 2,083 858 2,941 1930 2,017 890 2,907 1931 2,255 898 3,153 1932 2,368 811 3,179 28 During the past three years, special attention has been given to the question of diagnosis of pulmonary tuberculosis in children. The negative sputum cases of pulmonary tuberculosis (classified as A cases) have always been difficult to assess. In adults this problem has been of less difficulty as diagnosis has always been more precise, and the proportion of cases on which doubt as to the accuracy of diagnosis might be cast (i.e., those in which the bacilli have not been found) has been relatively small. Thus, in 1929, the proportion of adult pulmonary cases (classified as A cases) discharged from treatment was only 16.25 per cent. In children, however, the opposite state of affairs has been the case, the majority of children receiving treatment for pulmonary tuberculosis being negative sputum (i.e., class A) cases. In 1929 the proportion of child pulmonary cases (classified as A cases) discharged from treatment was 78.17 per cent. In the absence of definite diagnosis, there has been a tendency to label a delicate child "tuberculosis" in order, most easily, to obtain for it a period of residential treatment or convalescence. The enlargement of the powers of the Council by the Local Government Act, 1929, has enabled the Council to provide convalescence and observation for such children. No child is now treated under the Council's tuberculosis scheme for a prolonged period in a residential institution without substantial evidence as to the presence of tuberculous disease. All "doubtful" children are now subjected immediately to a critical period of investigation at High Wood hospital, and an increased number are quickly discharged as non-tuberculous. This insistence on stricter diagnosis has made it possible to reduce the number of beds for children in voluntary institutions. Further, since the autumn of 1931 no child has been placed in a fully equipped voluntary surgical institution unless there have been very exceptional circumstances to justify such a course. It is estimated that, in this way, a saving of approximately £5,000 per annum has been effected. The development of the Council's tuberculosis scheme over a period of approximately twenty years has been gradual and may now be regarded as comprehensive. As from 1st April, 1933, all residential treatment of tuberculosis will be provided under the Council's tuberculosis scheme. As regards adults, it is proposed to continue the use of the Council's general hospitals for emergency cases and for bedridden or mainly bedridden advanced chronic cases, and to some extent for "observation" purposes to assist in determining future treatment. It is also proposed to continue the existing arrangements for the immediate admission to the general hospitals of urgent and acute cases on direct application to the medical superintendents by patients, tuberculosis officers, district medical officers and private medical practitioners. Other cases will be dealt with under the general procedure laid down in the tuberculosis scheme, the applications being received, as a rule, through the tuberculosis officers. The Council's special hospitals and sanatoria have been classified so as to provide for the distribution generally of patients according to classes distinguished as "early," "moderately advanced "or" advanced" cases; the "early" cases going mainly to King George V sanatorium (men) and to Pinewood sanatorium (women); the "moderately advanced" cases and "advanced" cases with prospect of improvement to Colindale hospital (men), Grove Park hospital (men and women) and Northern hospital, Winchmore-hill (women). St. George's home, Chelsea, is used for "observation" purposes in determining the future treatment of women who have been notified as definitely tuberculous. These arrangements are modified according to need. St. Luke's hospital, Lowestoft, is used for surgical cases of both sexes, and 29 23 beds (11 men and 12 women) at Grove Park hospital are also reserved for "advanced" surgical cases. Beds for "observation" cases, both for diagnosis and for use in determining the disposal of patients to appropriate institutions, are provided at Brompton hospital, and, to a limited extent, at the City of London Chest hospital, Victoria park. Voluntary institutions are used to the extent necessary (a) to supplement the accommodation in the Council's own institutions (in which from time to time beds have to be withdrawn from use on account of cleaning and in emergencies), (b) to provide for special types of case such as those sent to village settlements, where there is industrial training, and to Burrow Hill colony, where there are educational facilities, together with training for youths in gardening and clerical work, and (c) for persons requiring institutions where there is a special religious atmosphere or special climatic or other advantages. In addition, ambulant chronic advanced cases which do not require active treatment for the disease but which, for various reasons, need to be under medical supervision, are sent to voluntary institutions which cater specially for this type of patient, and where suitable accommodation is available at a low rate of payment. As regards children, High Wood hospital is used both for the treatment of pulmonary and gland cases and for "diagnostic observation" purposes. Princess Mary's hospital, Margate, and Queen Mary's hospital, Carshalton, provide for surgical cases, and Millfield convalescent home, Rustington, is used for convalescents from all these institutions. Voluntary fully equipped surgical institutions for children are used only to a very limited extent except Heatherwood hospital, Ascot, in which the Council is under obligation, until it takes over the hospital in about 1937, to accept and maintain the use of 80 beds so soon as the authorities of the hospital are able to render that number of beds available for the sole use of the Council. Generally speaking, beds in voluntary institutions are taken only for convalescent children who have usually received treatment in fully equipped hospitals or sanatoria. This convalescence can be provided more suitably and more economically in convalescent homes than by retaining the children for completion of treatment in the Council's hospitals. The " homes " principally used are situated on the sea coast. The following table indicates the number of applications from adults for residential treatment under the tuberculosis scheme 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 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 1932 18 2,191 1,811 159 1,162 779 6,120 Of the 6,120 adult cases recommended during 1932 for residential treatment under the tuberculosis scheme, 67 were subsequently withdrawn, 5,419 were accepted and 634 were not accepted. The 5,419 cases were disposed of as follows:—(a) 1,634 were passed for admission to "observation" beds in order to determine "diagnosis" or "suitability for sanatorium treatment"; (b) 3,785 were passed for admission direct to sanatoria or hospitals. Of the foregoing accepted cases, 235 for various reasons failed to enter institutions. 30 The 634 cases not accepted under the scheme were generally cases of advanced disease. 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 number of cases not accepted in 1931 was 1,230, and the reduction is largely due to the fact that tuberculosis officers have made greater use of the Council's general hospitals, and recommended fewer advanced cases for treatment under the scheme. 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, 1,561 patients were discharged from "observation beds "and their classification was as follows (the corresponding figures for 1931 also being given):— 1932. 1931. *Pulmonary. Number Percentage. N u niber . Percentage. Group A 319 26.30 316 27.60 Group Bl 61 5.03 57 4.98 Group B2 584 48.14 565 49.34 Group B3 249 20.53 207 18.08 Total pulmonary cases 1,213 100.00 1,145 100.00 Surgical cases 4 26 Total diagnosed as tuberculous 1,217 1,171 In the remaining 344 cases the diagnosis of tuberculosis was not confirmed. Oi the 1,217 cases definitely diagnosed as tuberculous, 969 pulmonary cases were sent to sanatoria, 14 to institutions for advanced cases, 17 died in the "observation" hospitals, 3 cases were transferred to surgical institutions, and 214 were discharged home or were arranged for independently of the Council's tuberculosis scheme (including patients sent to voluntary institutions as " municipal" cases). The total number of admissions to institutions, exclusive of the Council's general hospitals, during 1932 was 5,289, compared with 5,192 in 1931. At the beginning of the year 2,255 patients were under treatment so that the total number of cases treated under the scheme in 1932 was 7,544, compared with 7,451 in 1931 The number of tuberculosis scheme cases under treatment on 31st December, 1932, was as follows (the corresponding figures for the previous year being shown in brackets):— Voluntary institutions London County Council in stitutions Ex-service pensioners for tuberculosis. Civilian adults. Total. ... 50(51) 676 (618) 726 (669) ... 10 (25) 1,327 (1,304) 1,337 (1,329) Total 60 (76) 2,003 (1,922) 2,063 (1,998) In addition there were 305 patients receiving treatment in sanatoria as " municipal " cases. 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. 31 The immediate results of the treatment of patients discharged on completion of treatment during 1932 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, 702 patients were discharged in 1930 with the disease "quiescent." Of these 320 or 45.6 per cent, were cases of pulmonary (Group A) tuberculosis and 77 or 11 per cent, were in Group Bl. The total number of Group A cases in 1930 was 681. and 320 of these or 47.0 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. Immediate results of treatment. Classification. A Bl B2 B 3 Surgical. Total. 1930. 1931. 1932. 1930. 1931. 1932. 1930. 193l\ 1932. 1930. 1931. 1932. 1930. 293i. 1932. 1930. 1931. 1932. Quiescent 320 356 338 77 100 111 200 162 214 — — — 105 93 165 702 711 828 45.6 50.1 40.8 11.0 14.1 13.4 28.5 22.7 25.9 — — — 14.9 13.1 19.9 100 100 100 47.0 46.9 50.0 46.4 49.3 53.9 9.1 7.4 8.9 — — — 25.7 22.9 34.8 15.7 15.3 17.6 Not quiesoent 348 397 326 89 108 95 1,959 1,988 2,131 687 834 740 288 300 292 3,351 3,622 3,584 10.4 11.0 9.1 2.7 2.8 2.7 58.4 54.9 59.5 19.9 23.0 20.6 8.6 8.3 8.1 100 100 100 51.1 52.2 48.2 53.6 50.7 46.1 89.5 90.8 89.1 64.1 75.7 78.7 70.4 73.9 61.6 74.7 77.7 76.5 Died in institution 13 7 1 30 39 46 373 267 200 16 13 17 432 326 275 3.0 2.1 4.4 — — — 7.0 12.0 16.7 86.3 81.9 72.7 3.7 4.0 6.2 100 100 100 1.9 0.9 1.8 — — — 1.4 1.8 2.0 35.9 24.3 21.3 3.9 3.2 3.6 9.6 7.0 5.9 Total 681 760 676 166 203 206 2,189 2,189 2,391 1,040 1,101 940 409 406 474 4.485 4,658 4,687 15.2 16.3 14.4 3.7 4.4 4.4 48.8 47.0 51.0 23.2 23.6 20.1 9.1 8.7 10.1 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 It is satisfactory to note from the figures relating especially to early pulmonary cases (A and Bl) that there is a continuous improvement in the immediate results of treatment as judged by the number of patients who are discharged as quiescent. Of recent years, it has been possible to provide longer periods of treatment for favourable cases and this, together with the more extensive use of modern methods such as collapse therapy and treatment by gold salts, has undoubtedly had its effect. This is shown more clearly in the following table :— Year Percentage of A cases discharged as quiescent. Number of cases discharged. Percentage of Bl cases discharged as quiescent. Number of cases discharged. Percentage of B2 cases discharged as quiescent. Number of cases discharged. 1927 27.5 657 28.8 253 2.2 2,270 1932 50.0 676 53.9 206 8.9 2,391 It is hoped that the improvement in these immediate results of treatment will be translated eventually into improved ultimate results. In any case, this immediate improvement is of considerable importance as it enables more patients to return to their families with greater safety and comfort and with better prospects of a resumption of work. With regard to children, the numbers recommended for treatment under the Council's tuberculosis scheme during each of the last five years were respectively 1,081 in 1928, 1,069 in 1929, 1,121 in 1930, 1,201 in 1931 and 1,120 in 1932. 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. 32 Of the 1,120 children (i.e„ patients under 16 years of age) referred to the Council in 1932, 1,059 were accepted for treatment, and 61 were not accepted or were withdrawn; 27 of the accepted cases for various reasons failed to enter institutions after acceptance. There were 898 children (including 24 cases admitted by late boards of guardians) under treatment at the beginning of the year, and 1,007 children were admitted during the year, making the total number of children treated in 1932 1 905 compared with 2,046 in 1931 The number of cases under treatment on 31st December, 1932, was 811, distributed as follows:— London County Council institutions 641 Voluntary institutions 170 The condition of the children under 15 years of age (on admission) who were discharged from residential institutions in 1932 is indicated in the following table, the figures in brackets being those for 1931:— Immediate results of treatment. Classification. Surgical. Total. A Bl. B2. B3. Quiescent 143 (102) 3(6) 6 (1) -(-) 387 (426) 539 (535) Not quiescent 42 (63) - (6) 15 (30) 12 (16) 76 (147) 145 (262) Died in institution 2 (2) -(-) 2 (3) 6 (8) 19 (19) 29 (32) Total 187 (167) 3(12) 23 (34) 18 (24) 482 (592) 713(829) Papworth and Preston Hall village settlements. The Councilsends a number of patients to Papworth village 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; 26 of the Council's former patients have been accepted as permanent employees of the industrial settlement at Papworth and 24 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 in respect of 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 100 patients at Papworth and 88 at Preston Hall were being treated under this arrangement. The corresponding figures for 1931 were 71 in each institution. 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 colonv. 33 Tuberculosis dispensary service. 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, and three more in January, March and May, 1932, respectively. The lads have been kept under special observation by the chief officer of the parks department, and his reports on all the boys have been uniformly excellent and have borne testimony, not only to the soundness of judgment in the selection of the boys for training, but to the efficiency of the training at the colony. In London the dispensary service, which is an integral part of the Council's tuberculosis scheme, is provided by the metropolitan borough councils. The Council makes a grant to these councils of approximately 25 per cent, of the net approved expenditure by the borough councils, after deducting the sum included in the general exchequer grant under the Local Government Act, 1929, in substitution for the former fixed grant paid by the exchequer as compensation for the cancellation of grants under the National Health Insurance Acts. There are now 23 municipal dispensaries (including two branch dispensaries) and 8 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 34 and 35. 34 35 Tuberculosis Dispensaries.—analysis of Returns, January-December, 1932. Metropolitan borough. On dispensary register, 1-1-32 Transferred during 1932 from other areas and cases returned after discharge. Examined for first time during 1932. (a) New cases excluding contacts. (6) Contacts (printed in italics) Total r number nclud- — ing contacts) under dispensary upervision during 1932. Removed from dispensary register during 1932. On dispensary register 31-12-33. Visit to home for dispensary purposes by No. of X-Key examina tions. Definitely tubercular. Diagnosis not com pleted. Pulmonary. Nonpulmonary. Diagnosis not completed. Nontuberculous. Total. (a) Re- covered, (b) Nontuber ular printed in italics.) (a) Transferred to other areas or lost sight of . (b) Died printed in italics). Defin- itely tuber- cular Diagnosis not completed. Total attendances. Tuber culosis officers Nurses or health Visitors No , of speci- of spu- tum ex- amined Adults. Children. Adults Children. Adults. Children. Adults Children. Adults Child. Batteraea 913 103 39 , 127 1 1 23 17 2 28 1 16 2 214 98 121 108 392 100 155 112 1,814 43 621 72 110 904 64 3,741 159 1,148 656 112 Bermondsey 941 34 15 138 15 8 7 18 2 8 2 15 1 285 229 153 340 456 246 170 349 2,211 53 1,047 66 116 913 16 4,241 1 ,299 1,335 1 ,387 526 Bethnal Green 733 11 14 89 4 3 12 1 18 1 6 3 3 2 211 125 134 125 318 133 158 128 1,495 8 601 86 67 728 5 4,522 133 5,010 613 203 Camber well 1,683 54 61 | 151 59 10 3 17 3 8 7 6 11 2 359 399 176 441 533 472 196 451 5,450 68 1,418 149 145 1,650 20 5,250 617 5,376 1 395 423 Chelsea 257 9 29 62 4 6 2 16 11 6 2 1 237 72 183 93 321 78 ; 201 95 990 11 592 35 31 312 9 2,795 68 !,680 309 384 Deptford 554 48 55 108 3 13 17 20 7 16 5 148 71 90 131 289 78 126 136 1,286 41 467 79 67 583 49 3,010 198 5.677 669 149 Finsbury 578 1 73 91 8 6 1 7 2 6 — 2 118 94 82 152 216 104 96 153 1,221 36 465 75 59 584 2 3,518 874 2,677 610 37 Fulham 903 10 59 159 2 4 13 27 2 7 2 274 137 243 145 453 139 276 147 1,987 23 816 183 98 858 9 3,583 291 5,405 658 130 Greenwich 699 13 54 6 2 1 12 5 — — 163 61 106 72 229 67 113 73 1,194 46 413 35 52 648 — 2,747 187 5,302 216 261 Hackney 1,274 15 65 196 12 10 24 1 18 18 6 4 342 219 213 217 580 238 245 217 2,634 38 1,003 138 111 1,331 13 7,195 310 5,119 1 157 296 Hammersmith 760 3 55 116 & 7 11 1 10 1 — 179 111 54 112 306 118 71 112 1,425 16 459 110 91 748 1 2.690 284 1,101 472 107 Hampstead 174 7 75 36 3 — 6 3 3 2 1 - 55 47 22 38 100 52 26 38 472 167 51 16 231 7 1,029 16 1,043 83 79 Holborn 223 1 13 31 2 2 1 2 1 1 2 3 11 20 2 32 46 23 5 36 347 18 65 20 20 219 1,172 43 1,180 149 36 Islington 1,455 27 72 223 31 16 7 35 21 5 10 2 1 1 249 203 87 212 517 236 125 225 2,657 60 758 313 163 1,349 14 7,607 321 6,168 866 353 Kensington 854 29 35 152 1 15 17 16 3 24 13 179 194 87 186 372 195 131 189 1,805 64 679 111 93 821 37 2,499 127 2,036 502 43 Lambeth 1,577 79 47 270 26 10 3 22 2 10 1 61 27 16 17 485 342 113 204 838 397 149 225 3,312 56 1,248 219 154 1,548 87 7,205 860 4,779 1,174 1,308 Lewisham 1,018 2 40 148 1 4 1 14 10 2 14 2 7 134 57 54 85 310 60 75 88 1,593 96 351 80 82 981 3 2,721 394 2,005 224 4 Paddington 1,096 21 28 126 7 2 1 17 29 9 2 7 1 363 143 367 140 508 150 405 151 2,359 68 1,014 136 75 1,056 10 9,546 556 5,580 406 202 Poplar 867 25 63 136 15 4 2 12 1 19 1 19 1 8 4 281 205 229 241 448 222 260 248 2,133 35 991 110 111 854 32 5,577 200 6,756 1,419 232 St. Marylebone 509 81 22 76 5 4 10 6 6 6 25 19 75 22 41 26 167 33 76 45 933 4 204 74 36 521 94 2,899 154 2,081 204 40 St. Pancras 744 65 69 181 3 5 32 15 30 2 8 130 38 58 63 373 43 86 63 1,443 24 308 202 95 751 63 3,121 81 4,330 523 101 Shoreditch 670 53 90 76 4 4 4 13 9 1 14 3 254 114 128 100 343 119 159 103 1,537 44 649 67 79 671 27 3,861 171 2,849 1,192 125 Southwark 693 37 46 176 12 5 24 26 4 7 1 7 o 111 117 43 179 318 130 81 185 1,490 65 469 146 106 697 17 3,324 188 3,551 551 52 Stepney 1,675 229 29 251 8 35 7 18 41 60 6 31 8 267 300 158 406 586 314 265 421 3,519 80 1.193 144 129 1,884 89 7,741 183 6,249 939 146 Stoke Newingtor 217 3 19 43 1 — 6 1 2 2 2 — 71 61 29 43 122 65 31 43 500 6 204 44 32 214 — 1,115 116 719 312 53 Wandsworth 1,397 37 90 296 2 8 1 21 21 95 11 17 7 397 136 250 215 809 149 296 223 3,001 89 1,035 164 192 1,391 130 5,455 191 5,572 1,664 125 Westminster 649 2 39 227 3 7 2 23 19 6 4 1 89 40 57 54 343 43 84 62 1,222 11 256 220 75 655 5 2,321 73 3,373 207 61 Woolwich 1,030 16 11 201 10 9 1 17 15 1 3 — 390 208 250 200 611 218 274 202 2,362 122 1,077 101 105 954 4,935 492 5,708 471 533 Total 24,143 1,015 1,253 3,940 250 190 40 446 15 412 46 447 94 203 74 6,071 3,863 3,530 4,360 10,904 4,222 4,335 4,520 50,392 1,215 18,570 3,230 2,510 24,056 811 115420 8,586 107809 19,02 6,119 36 The following is a summary, for purposes of comparison, of certain sections of the foregoing table:— Metropolitan borough Number of new cases examined per 100 deaths from tuberculosis in the borough Number of contacts examined per 100 deaths from tuberculosis in the borough Total attendances per case on register Tuberculosis officers' visits per case on register Nurses' visits per case on register Number of definitely tubercular persons on dispensary register per 100 inhabitants X-ray examinations Number of cases on register classified as T.B. plus. per 100 new cases and contacts per 100 new cases Battersea 333 129 3.8 .16 4.2 .56 14.7 20.4 403 Bermondsey 490 468 4.5 1.40 4.6 .81 43.0 84.0 345 Bethnal Green 433 237 6.1 .18 4.1 .67 27.2 42.6 266 Camberwell 293 372 3.1 .36 5.0 .65 25.6 58.0 815 Chelsea 929 314 8.7 .20 11.4 .53 56.1 75.1 129 Deptford 395 203 4.6 .31 5.8 .54 23.7 35.9 337 Find bury 367 302 6.0 1.49 4.5 .83 6.5 11.8 220 Fulham 458 180 4.0 .33 3.9 .57 12.8 17.8 290 Greenwich 384 157 4.0 .27 4.9 .66 54.1 76.3 234 Hackney 412 258 5.3 .23 2.3 .61 25.0 40.7 554 Hammersmith 241 147 3.6 .38 5.4 .55 16.0 28.3 297 Hampstead 315 225 4.3 .06 4.3 .25 36.5 62.7 104 Holborn 134 155 5.2 .19 5.2 .56 32.7 70.6 111 Islington 205 147 5.5 .23 4.5 .41 32.0 55.0 637 Kensington 400 302 2.9 .14 2.3 .45 4.8 8.5 288 Lambeth 351 221 4.4 .53 2.9 .53 81.3 132.5 765 Lewisham 267 102 2.7 .40 2.0 .44 .75 1.0 460 Paddington 748 246 8.9 .52 5.2 .72 16.6 22.1 245 Poplar 460 305 6.2 .22 7.6 .55 19.6 32.7 454 St. Marylebone 324 104 4.6 .25 3.3 .53 12.4 164 231 St. Pancras 240 55 3.7 .10 5.3 .37 17.8 22.0 392 Shoreditch 497 220 5.5 .24 4.0 .69 17.2 24.9 293 South wark 210 166 4.6 .26 4.9 .40 7.2 13.0 320 Stepney 383 331 3.9 .09 3.1 .83 9.2 17.0 878 Stoke Newington 294 207 5.2 .54 3.3 .41 20.3 34.6 109 Wandsworth 382 128 3.6 .12 3.6 .39 8.3 11.1 832 Westminster 388 95 3.5 .11 5.1 .50 11.4 14.2 225 Woolwich 574 272 5.1 .51 5.9 .65 40.8 60.2 331 Average 389 216 4.77 .37 4.5 .56 24. 05 39.0 377 Following up of discharged cases. Adults.—During the year investigations were made concerning the adult cases discharged from hospitals or sanatoria in 1926; the number investigated tvas 3,932, including 268 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 1925 cases:— Classification. Total. Percentage alive five years after discharge. Percentage dead. A 487 (533) 76.2 (75.4) 23.8 (24.6) B 1 216 (284) 62.5 (61.6) 37.5 (38.4) B 2 2,236 (1,908) 28.4 (30.9) 71.6 (69.1) B 3 725 (818) 4.0 (4.0) 96. 0(96.0) Surgical 268 (225) 78.7 (79.1) 21.3 (20.9) Particulars obtained in 1931 as to the fitness for work of the 1,381 surviving adult patients who were discharged from treatment in 1926 show that out of a total of 506 A and B1 cases, 70.4 per cent, were at work. The corresponding percentage for the A and B1 cases in the 1925 group was 70-7. The percentages at work in the other categories and also the corresponding figures for the 1925 group (shown in brackets) are as follows:—B2, 45.8 (50.2) per cent.; B3, 31.0 (27.3) per cent.; and surgical, 611 (72.5) per cent. Of the total number of 1,381 in all categories, 56.8 (61.1) per cent, were at work, 7.4 (7.8) per cent, were fit for work but were unemployed, 35.8 (31.1) per cent, were unable to work (including cases receiving further residential treatment). 37 Children.—The particulars obtained as to the after histories of children discharged in 1926 relate to 642, of which 193 are pulmonary and 449 nonpulmonary. The mortality records are as follows, the figures in brackets referring to last year's enquiry into the 1925 cases:— Classification. Total. Percentage alive five years after discharge. Percentage dead. A 140 (148) 91.6(93.2) 8-4 (6-8) B 1 5 (5) 20.0 (80.0) 80-0 (20-0) B 2 19 (35) 52.7 (37.1) 47.3 (62.9) B 3 26 (27) 3.9 (—) 96.1 (100.0) Surgical 449(367) 93.8 (89.6) 6.2 (10.4) 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 64 (74) 90.6 (86.5) 9.4(13.5) Spine 41 (44) 87.8(70.6) 12.2 (29.4) Other bones 89 (85) 95.5(94.1) 4.5 (5.9) Glands 212 (134) 94.9(94.8) 5.1 (5.2) Other parts 43 (30) 95.3 (80.0) 4.7 (20.0) Open-air Of the 140 surviving pulmonary cases 51 were at school and 63 at work, and of 421 surviving non-pulmonary cases, 207 were at school and 171 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 540 children suSering from pulmonary tuberculosis or from tuberculous glands with no open wounds, who do not require treatment in residential institutions. The work of these schools is dealt with in the school medical officer's report (Vol. Ill (Part II) p. 40). 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 the effectiveness of the tuberculosis scheme is considerably assisted by their cooperation. The scope of activity of the committees has widened since the inception of the scheme; and the work involves close co-operation with the various social agencies and public officials in the respective boroughs. 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 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 daring the year was 7,544 adults and 1,905 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. 38 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 are in all 14 such classes in operation in London, an addition of two classes since the previous year. 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. In each centre there is an organiser, usually honorary, whose duties embrace visiting absentees, arranging sales of handiwork, fostering the social side of the class and acting as treasurer. Over £200 was realised at the handicraft exhibition held in the hall of the Carpenters' Company, in September, 1932. This exhibition was organised by the Standing Conference of Tuberculosis Care Committees, and opened by the Lord Mayor of London. 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. One workshop is for men training to take their places in the leather trade, and one is a firewood factory for unskilled workers. Tuberculosis contact scheme. The tuberculosis contact scheme was put into operation on 1st April, 1925, and provides:— (а) for the removal of children from heavily infected and overcrowded homes occupied by a member of the family suffering from advanced tuberculosis. (б) for the boarding-out of children who cannot otherwise be satisfactorily provided for while their mothers are undergoing residential treatment for tuberculosis. With regard to (6), it is also found that the boarding-out of children is sometimes necessary in cases where the patient is a widower. The scheme is carried out through the Central Invalid Children's Aid Association, who secure suitable homes for the children, make all arrangements for their admission and discharge, and keep them under supervision during the time they are boardedout. The Association also arrange for the homes to be periodically inspected. There is no lower age limit and young infants are sometimes sent away under the scheme, although considerable difficulty has always been experienced in finding suitable homes for infants under twelve months of age. The elder children are mainly sent to capable foster-mothers in the country. If possible, foster-mothers are selected who have some experience of nursing. The very young infants are sent to babies' hostels in London as it is found that they are readily susceptible to illness and treatment is frequently necessary. Recommendations for the boarding-out of children are received by the medical officer of health of the Council in the first instance from the borough tuberculosis officers, together with a statement of the grounds upon which removal of the children is desired. Each case has to be approved by the medical officer of health of the Council. If accepted, the borough medical officer of health is requested to refer the 39 case to the Invalid Children's Aid Association. A form of medical certificate as to the fitness of each child is completed by the tuberculosis officer, and forwarded to the local branch of the Invalid Children's Aid Association. The medical officer of health of the Council sends a confirming note to the Central Invalid Children's Aid Association. All cases are reviewed periodically in order to determine whether or not children may return home, except of course, in those cases where the children are sent away in order to enable the parents to receive residential treatment. These latter cases are reviewed when the parents are discharged and may be retained for boarding out if the parents are still infective. The average stay varies from between three to six months, although it has been advisable for certain children to be kept away for more lengthy periods, in some cases from eighteen months to two years. The decision as to the discharge of the children is a function of the medical officer of health of the Council. The applications received during 1932 were 259, and 211 children were accepted, the remaining 48 being withdrawn or unsuitable. At the end of the year 93 children were being maintained under this scheme. The actual expenditure incurred, including travelling expenses of children and escorts and incidental expenses, such as medical attention, is periodically paid by the Council to the Invalid Children's Aid Association, and a grant of £300 a year is also paid to them to cover the cost of administration of the scheme. The accounts are audited from time to time by the comptroller of the Council. Provision is made for the current year in the Council's annual maintenance estimates for maintaining a daily average of 100 children, the total inclusive estimated expenditure being £4,280. The cost of placing the elder children varies from 12s. to 15s. per week per child and in the case of the young infants may be as high as 20s. per week. The general average cost is about 15s. per week. Parents are required to contribute according to their means towards the cost of maintenance of the children. The amounts are assessed and collected by the Invalid Children's Aid Association and are paid over to the Council. From the inception of the scheme until 1932, 1,856 children have been dealt with, as follows:— Year Number Tear Number 1925 428 1930 202 1926 260 1931 196 1927 169 1932 211 1928 219 1929 171 Total 1,856 Supply of surgical appliances. Reports have been received in many cases which indicate that the children gain in general health as a result of their removal to clean, healthy surroundings. This is particularly noticeable in the case of children removed from crowded homes. Arrangements were also made through the Invalid Children's Aid Association for providing children with surgical appliances after discharge from institutional treatment, and in G8 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. Cases dealt with by the Council. Mental Deficiency Ads, 1913-27. On 3rd December, 1932, there were being dealt with by the Council 8,981 cases. Of these 5,546 were in institutions, 146 under guardianship, 3,257 under supervision 40 and 32 in places of safety awaiting action. During the year 1,241 cases were examined with the following results:— Sex Case classification Feeble minded Imbecile Idiot Morally defective Not defective Total Children Adults Children Adults Children Adults Children Adults Children 1 Adults Children Adults Male Ordinary cases 31 49 92 3 5 1 — — 7 9 135 62 Special school leavers 239 — — — — — — — — 239 Public assistance cases 4 18 5 2 1 1 — 2 4 1? 25 Casual ward cases 12 — — — 66 78 General hospital cases 1 19 4 2 1 — — — — 10 21 Sections 8 & 9 of M.D. Acts 11 51 1 — — — — 3 — 1 12 55 Female Ordinary cases 24 84 96 6 9 __ 8 24 137 114 Special school leavers 205 — — — 205 Public assistance cases — 39 2 5 — 1 — — — 8 2 53 Casual ward cases — — 6 6 General hospital cases 3 15 8 6 4 — — — 2 9 17 30 Sections 8 & 9 of M.D. Acts — 24 — — — — — — — 4 — 28 Total 518 311 208 24 20 3 — 3 23 131 769 472 829 232 23 3 154 1,241 Casual wards. During the year, in addition to regular monthly visits to the casual wards, certifying officers under the Mental Deficiency Acts were called upon to see special cases on 21 occasions. The total number of cases inspected was 658. Of these 84 were examined in detail, and the number deemed to be mentally defective was 12. In a number of cases advice was given regarding special treatment, viz. :— 4 cases were offered facilities for the remedial treatment of stammering, and 1 case for lip-reading; arrangements were made for 2 cases to be seen by the Council's aurist; 3 cases were referred to observation wards ; while in 14 other cases various forms of training or treatment were recommended. Blind training, etc. Blind Persons Act, 1920. The work of revising the register of blind persons has been continued in accordance with the scheme approved by the Council in July, 1931. One of the provisions of this 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. In addition the certification of workshop employees has been carried out as in rirevious vears. The following table shows the number of cases considered and the recommendations made Description. Registration of the blind. Training of the blind. Total. M. F. M. F. (1) Applicants who were examined and were certified as blind 638 633 41 21 1,333 (2) Acceptance of certificates issued bv hospital and private doctors 286 282 — — 568 (3) Applicants who were examined and not certified as blind 89 91 11 6 197 (4) Found blind but unfit for training — — — 5* 5* (5) Previously certified as blind and found fit for training — 16 4 20 (6) Previously certified as blind and found unfit for training — — 1 — 1 Total 1,013 1,006 69 31 2,119 * Included in (1) above. In addition to the numbers in the above statement 33 applications for examination were withdrawn. 41 Midwives Acts, 1902 to 1926, Nursing Homes Registration Act, 1927, Children Act, 1908, and Adoption of Children Act, 1926. The Midwives Acts, 1902-1926, and the Rules of the Central Midwives Board Midwives. 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. (f) Payment of proportion of any annual deficit incurred by Central Midwives Board. Certified midwives to the number of 909 gave notice of intention to practise within the county during the year, compared with 934 in 1931. 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; 2,398 visits were paid this year compared with 2,471 in 1931. Infringements of the Rules of the Central Midwives Board to the number of 53 were reported during the year, compared with 64 in 1931. Of these 41 were slight, and a verbal caution was deemed to be sufficient; 11 cases of a more serious nature were dealt with by a written caution, and 1 midwife was interviewed and caution by the Committee Suspension of midwives. The Midwives Act, 1926, requires that, in the case ol midwives suspended rrom 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; 42 midwives were suspended from practice during the year in order to prevent the spread of infection, and in 21 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 3 enquiries were made into such cases, compared with 7 in 1931. In all 3 cases 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 324 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, 408 in 1930, and 363 in 1931. Of the cases reported this year 175 were male and 146 female, while in 3 cases the sex was not stated; 174 were reported as macerated, 148 not macerated, and in 2 the condition was not stated. Puerneral During the year 219 cases of puerperal fever were investigated, compared with 283 in 1931. Of these cases 35 proved fatal, compared with 59 in 1931, a case mortality of nearly 16.4 per cent., compared with 20.8 per cent, in 1931. In addition 42 Puerperal pyrexia. the Registrar-General recorded 26 deaths from puerperal sepsis,which were not certified as fever, compared with 41 the previous year. The distribution of notified cases, with the mode of delivery, was as follows, deaths being shown in brackets:— Medical practitioners 55(6); certified midwives 43(9); medical practitioners and certified midwives 17(3); hospitals and poor-law institutions 69(13); medical students 9(0); cases of miscarriage or abortion where no attendant was engaged 24 (4); medical students and certified midwives 2 (0).—Total, 219 (35). 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 on 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. The number of notifications of puerperal pyrexia investigated during 1932 was 783, compared with 871 in 1931. The cases were distributed as follows, the deaths being shown in brackets:—Medical practitioners 94(3); certified midwives 128(8); medical practitioners and certified midwives 7(0); hospitals and poor-law institutions 479(17); medical students 25(1); cases of miscarriage or abortion where no attendant was engaged 50(2)—Total 783(31). Three of the cases, with one death, 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 5,990 such notices were received, compared with 6,326 in 1931. The estimated number of confinements conducted by midwives in independent practice during the year was 26,105. This appears to indicate that medical aid was necessary in about 22.9 per cent, of the cases, compared with 22.4 per cent, during 1931. 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 718 and the amount paid to medical practitioners in respect of the cases was £733, compared with £699 in 1931 Inflammation of the eyes— Notices. During the year 1,155 notices were received from midwives indicating that medical aid had been summoned for inflammation of the eyes of infants, compared with 1,288 in 1931; 37 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 1,192 cases, 333 proved to be ophthalmia neonatorum, compared with 326 in 1931; 349 other cases that did not occur in midwives' practices were also notified, making a grand total of 682 cases during the year, the percentage occurring in the practice of midwives being 48.8 per cent., compared with 52.2 per cent, in 1931. All the 43 midwives' cases were investigated, and it was found that 325 were completely cured; in 3 cases injury to the eyes resulted (2 of these cases died subsequently), 4 other cases died, and 1 could not be traced owing to the removal of the parents. Thirty-six cases became in-patients at St. Margaret's hospital, compared with 51 during 1931. Pemphigus neonatorum. During the year 59 cases of pemphigus neonatorum occurred in the practice of midwives, compared with 99 during the previous year. 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 1932 numbered 770, compared with 700 in 1931. 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 fees to medical practitioners 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. Claims accepted during the year numbered 3,528, compared with 4,038 in 1931, the total amount involved being £4,077 17s., compared with £4,521 Is. in 1931. 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, 58 claims amounting to £65 19s. were refused during 1932. 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. 44 The number of nursing homes on the register on 1st January, 1932, was 258. During the year 1932, 13 homes were added, of which 5 had applied during 1931, and 31 were removed on cancellation of the registration, leaving 240 on the register on 31st December, 1932. All cancellations were made at the request of the persons registered and/or upon change of ownership. There were 25 applications for registration during the year, of which, at the end of the year, 7 had been withdrawn and 8 granted, 10 being still under consideration. 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 1932 the Council granted 114 exemptions from the provisions of the Nursing Homes Registration Act, 1927, in respect of premises not conducted for profit. These exemptions were for a period due to expire on 30th June, 1933, after which date the exemption may be renewed at the discretion of the Council from year to year. The homes have on the whole been satisfactorily conducted. The improvement noted in the report for 1931 in the cleanliness, general orderliness and in the staff of homes has continued. Owing, however, to financial stringency there has been a tendency to delay necessary re-decoration, and in several cases the attention of keepers has been directed to this matter with satisfactory results. A number of the older homes have closed or have changed ownership. In the latter event the new owners were required to fulfil all the requirements for a " new " home. Maternity and childwelfare work by voluntary associations- Under the Maternity and Child Welfare Contributions (London) schemes 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 54 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 the financial year 1932-33 was £31,263. 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 one mother and baby home was closed for financial reasons, and one baby home was closed on account of expiration of lease. The patients remaining at the time of the closing of these homes were transferred to other homes. An increase in the amount of the grant to one mother and baby home was sanctioned by the Minister of Health. The Council, at the request of the Minister of Health (Circular 1271) considered the question of the voluntary associations conducting maternity and child welfare services in London, which the Minister should be advised to include in a new scheme to be prepared by him under section 101 (6) of the Local Government Act, 1929, with effect for four years as from April, 1933, and the amount of annual contribution to be paid to each association. 45 In connection with this matter 51 voluntary associations, to which the Council is required to make payments under the existing schemes, and in addition two associations previously not "grant aided," were consulted as to the Council's proposals for the ensuing grant period. The Minister of Health was informed of the result of the Council's consideration of this matter Children Act, 1908, Part 1 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. Thirteen qualified nurses carry out the work of inspection and act as visitors under the Act. 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 of the reception of a child subject to Part I of the Children Act is a punishable offence. Proceedings were taken against seven foster-mothers during the year for this offence. In four cases fines were imposed, two cases were dismissed, 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 1932 there were 1,541 homes under inspection, compared with 1,797 at the end of 1931, the number of nurse-infants therein being 2,152, compared with 2,601 at the end of 1931. Approximately 27,768 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 1932 it was necessary so to remove 3 nurse-infants, compared with 4 in 1931. 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; 760 such reports were made during 1932. In 514 cases the premises were found to be satisfactory; in 84 homes sanitary defects were discovered, while overcrowding was found in 92 homes. Overcrowding and sanitary defects combined were found in 9 homes. In 61 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 358 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, 16 nurse-infants died, compared with 26 in 1931, 25 in 1930, and 27 in 1929. In 8 cases inquests were held, a verdict of death from "natural causes" was recorded in 7 cases, and in 1 case from "accidental causes." In none of these cases was blame attached to the foster-mother. 46 During the year the Children and Young Persons' Act, 1932, was enacted; the amendments of Part I of the Children Act, 1908 (Infant Life Protection) contained in the new Act will come into force on 1st January, 1933. The principal amendments are the raising of the age limit of a notifiable nurse-child to 9 years from 7 years, and the requirement for persons (except in emergency) to give notice of their intention to receive a nurse-child, instead of giving notice after reception of the child. It is anticipated that during the year 1933 the functions of the "local authority" under Part I of the Children Act, 1908, as amended, will be transferred from the Council to the metropolitan borough councils. Adoption of Children Act, 1926. The Adoption of Children Act, 1926, provides for the legal adoption of infants. A Court, upon the hearing of an application for an adoption order, may appoint some public body to act as guardian ad litem, with the duty of safeguarding the interests of the infant before the Court, and, where the body so appointed is the local authority, may authorise the authority to incur any necessary expenditure. The Council, at the request of the Home Secretary, has agreed to act as guardian ad litem of children who are the subject of applications for adoption orders in London. The Council's medical officer deals with those children who have been or are nurseinfants under the supervision of the public health department. During the year 1932 the total number of applications dealt with by this department was 59. The results of the hearings were as follows:—54 full adoption orders and 2 interim adoption orders were made; 3 applications were refused. Examination of Staff. During the year 9,009 examinations, including 482 home visits, were made of members of the staff, other than that under the direction of the Education Committee. These may be classified as follows:— Entrants 1,290 Sickness cases 7,185* Casualties, illness, etc., at County Hall 534 *912 of these were dealt with in the first instance by telephone and correspondence. As a result of the examinations, 378 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 47 55 102 Diseases of the bones and joints 19 17 36 Disability following trauma 1 1 2 Pulmonary tuberculosis 18 27 45 Other diseases of the lunge 25 10 35 Malignant disease 9 5 14 Renal disease 3 3 6 Functional nervous disorders 27 26 53 Organic nervous disorders 13 6 19 Senile decay 9 5 14 Post operative debility 4 5 9 Sight and hearing defects 7 1 8 Endocrine disorders 2 10 12 Miscellaneous 15 8 23 Total 199 179 378 * Including cases of varicose veins, abdominal disorders, tuberculosis of the kidney, spine and joints, papilloma'of the bladder, gastric ulcer, cnteroptosis, pyrexia, sinusitis, rhinitis, cystitis. 47 Fifty-four applicants for appointment to the permanent service failed to pass the medical examination for the following reasons:— Males. Females. Total. Defective hearing and ear diseases 4 3 7 Defective vision and eye diseases 13 1 14 Poor physique and deformities 6 7 13 Cardio-vascular disease 3 8 11 Kidney disease, albuminuria, &c. 2 4 6 Tuberculosis and lung disease — 2 2 Functional nervous disorders — 1 1 Total 28 26 54 Bacteriological work done in the laboratory at County Hall. The investigations carried out during the year 1931-32 are summarised below under the various headings. The work undertaken in this laboratory is chiefly associated with the control of infectious diseases in the Council's day and residential schools, and in addition a certain amount of bacteriological investigation is carried out on material such as water, milk, etc., submitted to the Council's chemist for analysis. Diphtheria Carrier investigation (see also Annual Report Vol. Ill, Pt. II, page 58).— 4,856 specimens were examined, of which 270 yielded positive morphological KLB; of 438 cultures submitted to animal test, 204 were virulent, 31 avirulent and 203 negative. Ringworm.—884 specimens of hair of the head were examined. Fungus was identified in 265 (206 small spore, 59 large spore). Hcemolytic streptococcus carriers.—(a) puerperal fever contacts—24 specimens were examined (4 positive, 20 negative). (b) presumed contacts of scarlet fever—10 specimens were examined (all negative). Vincent's angina.—Throat swabs from two reported cases failed to show spirilla or fusiform bacilli. Sputum examinations.—70 specimens were examined, tubercle bacilli being found in 28 cases. Urine (for presence of albumen).-—8 specimens were examined, 3 yielding positive results. Discharges (a) urethral or vaginal—11 specimens were examined, one showed gonococci and pus cells. (b) conjunctival—All were negative for gonococcus. B. xerosis was found in one and Morax-Axenfeld identified in another. Water (a) from Council's institutions, schools, etc.—Of the 187 specimens examined, 69 were abnormal and 118 normal. (b) from swimming baths—one of two specimens examined was abnormal. Work of the Chemical Branch. The work of the chemical 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 consists 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. A considerable number of samples have been examined in connection with the Petroleum Acts and the Fertilizers and Feeding Stuffs Act, 1926. An important part of the work of the branch consists of the consideration of, and giving advice on, matters involving scientific questions. 48 Examination of samples. The total number of samples examined in 1932 amounted to 9,480. The following table shows their classification:— Air (from tunnels) 255 Greases 30 Asphalt 15 Insecticides 7 Building materials 84 Meals 2 Cement 294 Metals— Disinfectant 14 Driers 12 Solder 18 40 Drags and medical stores 1,010 Various 22 Feeding stuffs 212 Milk, condensed 16 Fertilisers 66 Floor oils and polishes 36 „ for schools 459 Foods, Groceries— „ for hospitals and institutions 148 Bacon 52 „ farm 7 Baking powder 26 „ (cream) 9 Butter 4 „ foods 2 Cakes, biscuits, bread 64 Oils— Cereals 5 Cheese 55 Fuel 15 240 Cocoa 22 Lighting 34 Cocoanut, etc. 4 Lubricating 152 Coffee and chicory 6 Painting 21 Egg powder 21 Miscellaneous 18 Flavouring essences 21 Oilman's sundries 10 Fish 104 Paints, stains and varnishes 344 Flour 59 Petroleum 113 Jelly 2 Rainwater, etc. (atmospheric pollution) 108 Lard and dripping 6 Sewage 39 Margarine 113 Shampoo preparation 6 Meat extracts 23 Soap and soap powders 120 Miscellaneous foodstuffs 11 Sulphur determinations (air) 1,568 Mustard 8 Turpentine 11 Pepper and spice 6 Urine 1,367 Pickles 11 Water (softening treatment, County Hall) 355 Preserved meat 51 Sugar 82 Water, boiler 607 Syrup and treacle 33 „ river 406 Vinegar 37 „ drinking (from wells) 296 Yeast 32 858 „ drainage 3 „ and deposit (County Hall) 57 Gas— „ from bathing lakes 14 Dry cleaners 69 128 Wax (composition) 8 Flue 59 Miscellaneous 104 Milk samples. The total number of milk samples examined during the year in the central laboratory was 614. Of this number 459 were of milk supplied to children in the elementary schools, whilst 148 were from supplies to general, special and mental hospitals and public assistance institutions, under contracts which require a minimum of 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 some recent years, only slightly over 1 per cent. being deficient in fat, and approximately 1.5 per cent. containing added water, 2.6 per cent. of the total thus being below the chemical standard required. The corresponding figures for the past three years were 2.4, 7.1 and 12.0 per cent. in 1931, 1930 and 1929, respectively. Of the 9 samples reported as containing added water, 6 were found on analysis to give direct results showing the addition of water, notwithstanding the presence of the full amount of non-fatty solids required by the contract. The condition of the supplies in respect of extraneous matter, however, was again less satisfactory: for of the 614 samples examined, 56 (about 9 per cent.) were found to contain an excessive amount. In all these cases the results were communicated to the chief officer of supplies, who was thus enabled to take up the matter with the contractor. 49 In addition to the above, 238 samples of milk supplied to schools and general, special and mental hospitals and public assistance institutions, were examined bacteriologically at the Southern Group laboratory at the Park hospital, or at the bacteriological laboratory at the County Hall. The results obtained are shown in the tables set out below. The milk supplied to schools (other than open-air schools), mental hospitals and public assistance institutions is not purchased under any of the standards specified in the Milk (Special Designations) Order, 1923, and a standard was devised for what would be regarded as ordinary clean milk. The standard adopted was : bacterial content, not more than 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 general and special hospitals and open-air schools provide for the supply of pasteurised milk, which is required under the provisions of the Milk (Special Designations) Order, 1923, to conform to the following standard: the milk must not contain more than 100.000 organisms per c.c. As in the case of raw milk for school supplies, the requirement as to the absence of B. Coli in 1/1,000 c.c. was adopted. Raw Milk. School supplies. Conforming to standard 135 Not conforming to standard— B. Coli present in 1/1,000 c.c. 42 61 Bacterial count exceeding 300,000 per c.c., but conforming to B. Coli standard 9 Bacterial count exceeding 300,000 per c.c., together with excess of B. Coli 10 Samples examined 196 Mental hospitals and public assistance institutions— Conforming to standard 5 Not conforming to standard— B. Coli present in 1/1,000 c.c. 1 Samples examined 6 Pasteurised Milk. Hospital supplies—- Conforming to standard 17 Not conforming to standard— B. Coli present in 1/1,000 c.c. 4 14 Bacterial count exceeding 100,000 per c.c. but conforming to B. Coli standard 3 Bacterial count exceeding 100,000 per c.c., together with excess of B. Coli 7 Samples examined 31 Open-air schools— Conforming to standard 1 Not conforming to standard— B. Coli present in 1/1,000 c.c. 1 4 Bacterial count exceeding 100,000 per c.c. but conforming to B. Coli standard 1 Bacterial count exceeding 100,000 per c.c. together with excess of B. Coli 2 Samples examined 5 50 In all these cases of defective supplies the attention of the chief officer of supplies was called to the matter, and in the more serious cases the medical officer of health of the district was also informed. The arrangement which I was able to conclude for the co-operation of the medical officers of health in regard to the examinations of milk supplied to Council's institutions and schools in the county and in certain areas outside the county has been continued during the year with very satisfactory results. Under this arrangement it has been possible to reduce the number of samples examined at the central laboratory from 1,784 in 1931 to 614 in 1932. Some of the boroughs have been unable to undertake the bacteriological work, and it has not been possible to arrange a scheme of co-operation with the local medical officer of health in respect of certain of the out-county institutions. Under the scheme I have received reports on the chemical examinations of 1,197 samples of supplies to Council's institutions and schools, of which number 41 were deficient in butter-fat and 2 contained added water. In addition to the above, results have been received of the bacteriological examinations of 176 samples of pasteurised milk, of which 11 failed to comply with the requirements of the Milk (Special Designations) Order, 1923, and of 136 samples of raw milk, seven of which fell below the adopted standards. Drugs. Of the 1,010 samples of drugs and medical supplies examined during the year 97 (or 9.6 per cent.) were found to be either definitely unsatisfactory for use or below standard strength or quality. Satisfactory 913 Unsatisfactory or below standard— Deficient in active constituent 23 97 Tincture, etc., deficient in alcohol 12 Specific impurities found 16 Dirty 5 General deficiency 35 Misdescribed 7 Total 1,010 These figures show some improvement compared with the previous year, when 16.9 per cent. of the samples analysed were either unsatisfactory or below standard. Some rather unusual examples may be of interest. A sample described as acidum aceticum glaciale was found to contain 72 per cent. methyl salicylate; two samples of aspirin, phenacetin and caffeine citrate powders contained caffeine itself, instead of caffeine citrate. An artificial green dye was found in a sample of tinctura stramonii which was consequently rejected, as were two consignments of calamina præparata B.P.C. which consisted almost entirely of zinc oxide. In connection with the provisions of the Fertilisers and Feeding Stuffs Act, 1926, 278 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 within the purview of the City Corporation or Port Sanitary Authority. The results of the analyses were: Fertilisers and feeding stnfia. Samples of feeding stuffs. Complied with guarantee 87 Deficient 47 Constituents in excess of guarantee 60 Guarantee incorrect in form or no guarantee ... 18 Total 212 Samples of fertilisers. Complied with guarantee 21 Deficient 12 Constituents in excess of guarantee 21 Guarantee incorrect in form or no guarantee 12 Total 66 51 These figures are very similar to those of last year, though the number of feeding stuffs showing a deficiency on the guarantee is slightly less. One sample supplied as "ground phosphates" was found to consist of basic slag, which has a much lower phosphoric acid content. A "meat meal" was adversely reported on as containing an excessive amount of vegetable husks, seed, etc. A sample of Turkish middlings was found to contain an appreciable quantity of corncockle seed and condemned as being likely to be harmful if fed to poultry. There is still much evidence of a lack of appreciation of the meaning of the statutory statement, which frequently bears little relation to the composition of the material. This is usually rather better than the statement suggests. A careful watch has been kept during the year on the quality of the drinking water at those institutions of the Council which derive their supplies from private wells. Two hundred and ninety-six samples have been examined from thirty-seven institutions. As a result of the advice given on the basis of these analyses, permanent chlorinating plants have been installed during the year at four wells (London industrial colony, Sutton; Hanwell mental hospital; St. Pancras institution; and West Park mental hospital). In the case of the other three large institutions in which chlorinating plants had previously been installed, these have functioned satisfactorily during the year. An improvised chlorinating system was also fitted up at Hanwell residential school, the expense of a permanent plant not being considered justifiable in view of the pending closure of the school. Directions were also supplied to a tenant of the valuer's department as to chlorinating the supply from a well on his rural premises. Temporary chlorination of tanks was again carried out early in the year at Mitcham children's home, which was closed soon afterwards. In two other large institutions, as a result of the analyses of samples of water, recommendations were made for a thorough cleaning out of the storage tanks; after this treatment the quality of the water was satisfactory. In addition to the sampling and examination of fuels for the tramways and other departments, and the routine chemical examinations 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 the installation and operation of high-pressure plant having sufficient capacity to carry the bulk of the peak load of the station, coal economy and corrosion. The introduction of this plant, involving higher temperatures and pressures has necessitated a much more critical adjustment of furnace and boiler condition than heretofore. 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 7.8 per cent., the corresponding figure for the northern outfall being 8.75 per cent. The dry matter in individual cargoes varied from 1 to 16 per cent. at the southern outfall, the mode lying between 7 and 8 per cent. The corresponding figures for the northern outfall varied between 4 and 15 per cent., the mode being about 9 per cent. 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 has been investigated. This work is of increasing importance owing to the changing activities of riverside undertakings, which may conceivably alter the character of the water of the river which flows through the county, and also is the diluting medium for the council's effluent. The weather conditions during the summer were such as to make it unnecessary to treat the effluent from the Council's outfalls works. 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. Water supplyPrivate we Greenwich power station. Outfalls. River Thames. Sludge digestion. 52 The effects of varying temperatures of digestion, from 61°F. to 126°F., have been studied as well as other variations of treatment. A considerable yield of gas of high calorific value is obtained under very varying conditions. Chemical examination of the changes undergone by the sludge indicate that this gas is mainly a product of the breakdown of fat, largely from soaps, rather than cellulose. Experiments are proceeding. 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 extended its activities to include coke and has issued specifications covering the greater part of its scope; one on standard Definitions and Tests for Fire Resistance and Combustibility, which has issued a final report; and more recently one on Containers for Acids and Corrosive Liquids. The chemist is chairman of three panels of these committees. He is also a member of the Government Committee on Atmospheric Pollution. The systematic examination of the air in the vehicular tunnels at Blackwall and Rotherhithe, which was commenced in 1929, was continued throughout the year, attention again being concentrated on the morning rush hour period about 10 a.m. British engineering standards and other committees. Vehicular tunnels The following table giving the averages of all samples taken during the last three years shows clearly the great improvement produced in the atmospheric conditions in the tunnels by the new ventilating plants:— Year. Carbon-monoxide. Fog shade. No. of samples. Average CO content parts per 100,000. No. of results above limit.* No. of samples. Average fog shade. No. of results above limit.† Blackwall Tunnel— 1930 104 21.5 39 24 6.2 3 1931 104 9.2 2 26 4.0 10 1932 103 11.1 9 25 4.5 4 Rotherhithe tunnel— 1930 103 16.4 25 26 7.3 16 1931 103 19.6 41 26 7.8 21 1932 102 10.9 10 25 6.1 12 * Limit for carbon-monoxide: 20 parts per 100,000. † Limit for fog shade: 6 (i.e., 1.92 milligrammes black suspended matter per cubic metre of air). The figures for 1930 may be taken as representing the old conditions, for the new ventilating plant at Blackwall was completed in July, 1931, and the last instalment of that at Rotherhithe in February, 1932. Both have, therefore, been in operation practically throughout 1932. Since all samples were taken at about the worst normal conditions, it is evident that the atmosphere in the tunnels has in general been maintained in very satisfactory condition, notwithstanding the continual increase which is taking place in the amount of motor traffic passing through them. The question of the range of visibility is intimately connected with that of atmospheric pollution and observations from the fléche 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 1932 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 1932 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. The visibility in the quadrant N.E. continues to show the improvement on the average of the previous five years which was noted in 1931. Visibility. 53 Diagram showing the mean (in miles) of the greatest distance at which objects could bedistinguished at mid-day from the fleche at county hall. during 1932 and 1927-1931 Diagram showing the mean (in miles) of the greatest distance 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, 1932 and 1927-1931. INDEX Subject. Page Adoption of Children Act, 1926 46 Anthrax 5 Bacteriological Laboratory 47 Births 4 Blind Persons Act, 1920 40 British Engineering Standards Committee 52 Cancer12 Cerebro-Spinal Fever 7 Chemical Branch 47 Chickenpox 7 Children Act, 1908 45 Common Lodging Houses 18 Cowsheds 22 Deaths 4 Diarrhœa 10 Diphtheria 10 Drugs, Testing of 50 Encephalitis Lethargica 8 Enteric Fevers 12 Fertilisers and Feeding Stuffs Act, 1926 50 Food Poisoning 8 Homeless Persons 18 Housing Acts (Statistics) 20 Housing Acts (see Volume II of Report) Infant Mortality 5 Infectious Diseases 5 Influenza 12 Marriages 4 Maternal Mortality 43 Measles 9 Subject. Page. Medical Examination of Staff 46 Mental Deficiency 39 Midwives Acts 41 Milk and Dairies Act 21 Milk Sampling 48 Nursing Homes 43 Ophthalmia Neonatorum 42 Overcrowding 2 Polioencephalitis 8 Poliomyelitis 8 Population 1 Puerperal Fever 11, 41 Puerperal Pyrexia 11,42 Rheumatic Fever 12 Sanitary Officers 21 Scarlet Fever 9 Seamen's Lodging Houses 18 Sludge Digestion 51 Smallpox 6 Tuberculosis (Contact Scheme) 38 Tuberculosis (Notifications) 12 Tuberculosis (Residential Treatment) 26 Tuberculosis (Dispensary Service) 33 Vehicular Tunnels 52 Venereal Diseases 23 Visibility 52 Vital Statistics 1 Water Examination 51 Whooping-cough 9 PUBLICATIONS OF THE LONDON COUNTY COUNCIL. The undermentioned publications, issued by the Council, may be purchased through any bookseller or from the Council's Agents, P. S. KING & SON, LIMITED, 14, GREAT SMITH STREET, WESTMINSTER, S.W.I, from whom a complete list of the Publications of the Council may be obtained. Annual Report of the Council for 1931:— Vol. I. (Part I.) Powers and dutiesElections — Finance — Rating and Taxation—Public Protection—Traffic— Public Amenities—Domestic and Miscellaneous Services. 1s. 6d. No. 2982. Vol. I. (Part II.) Public Assistance. 1s. No. 2983. Vol. II. Public Health, General matters as to public health, Main Drainage and Housing. 1s. No. 2958. Vol. III. (Part I.) Public Health, Report of County Medical Officer of Health. Is. No. 2918. Vol. III. (Part II.) Public Health. Report of School Medical Officer. 1s. 6d. No. 2905. Vol. IV. (Part I.) General and Special Hospitals. 2s. 6d. No. 2935. Vol. IV. (Part II.) Hospital Finance. 1s No. 2951 Vol. IV. (Part III.) Medical Supplement 5s. No. 2937. Vol V. Education. 1s. No. 2927. Vol VI. Mental Hospitals. 14s. No. 2936. Vol VII. Abstract of Accounts and Index. 6d. (In preparation) report for 1932 :— Vol. III. (Part I.) No. 2985. Vol. III. (Part II.) No. 2977. Vol. V. (Ready shortly) 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. III, 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. 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. 1930-31. No. 2919. London Statistics. Statistics relating to London and the public services therein, with certain statistics of the adjacent districts. (Issued annually.) Vol. XXXV. 1931 -32. 15s. No. 2980. Statistical Abstract for London. Comparative statistics for 10 years relating to parishes, metropolitan boroughs, poorlaw 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. Vol. XXV. 1922-1932. (Ready shortly) Statistics of Metropolitan Boroughs.— Population, vital statistics, electors, finance and rates, &c., for each borough.— Prepared and published by the London County Council on behalf of the Metropolitan borough councils, and designed as a common appendix to their reports. 1d. 1930-31. No. 2868; 1931-32. No. 2923. Census, 1921. Report upon the statistics relating to Greater London contained in the various volumes of the Census of England and Wales. 1921. 1s. No. 2550. Municipal Map of London, 1931. In 28 sheets; scale 6 inches to a mile. 1s. 6d. a sheet; complete sets, with key sheet, 35s. Street Index, 5s. THE LONDON COUNTY COUNCIL GAZETTE. Issued weekly. Containing full particulars of appointments, contracts, etc. Price 2d. Annual subscription, payable in advance, 13s. post free. The Survey of London (a series 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-bv-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. 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LCC 41 London County Council ANNUAL REPORT OF THE COUNCIL, 1932 Vol. III (Part II) PUBLIC HEALTH (Report for the year 1932 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 far the sale of the Publications of the London County Council. 1933. No. 2977. Price 1s. 6d. London County Council ANNUAL REPORT OF THE COUNCIL, 1932 Vol. III (Part II) PUBLIC HEALTH (Report for the year 1932 of the School Medical Officer) 1000 (M.C. 13471—76a.) 6.6.33. CONTENTS. page The London School Medical Service 2 Staff 5 Results of Medical Inspection 6 Medical Inspection at Secondary and Trade Schools 13 Following-up 14 Schools and Homes transferred from Poor Law Authorities 18 Adoption of Children 20 Chronic Invalidity 20 Wage-earning Employment of School Children 21 Medical and Dental Treatment 21 Stammering Children 28 Personal Hygiene Scheme 29 Health Classes 30 Rheumatism Scheme 31 Special Inquiries 34 Feeding of School Children 36 Open-air Education 38 Convalescent Camp Schools 42 School Journeys 43 Nursery Schools 43 Child Guidance 45 Defective Children 48 Cases of Cerebro-macular Degeneration 52 Size of Families from which Mental Defectives come 52 Schools for the Blind 52 Schools for the Deaf 52 Residential and Industrial Schools 53 Examinations of Employees in the Education Service and Scholars 56 Infectious Disease in Schools 57 Statistical Tables.— I. Medical Inspections 67 II. Defects 67 III. Exceptional Children 68 IV. Treatment of Minor Ailments 71 V. Medical Inspection—Number of Children Examined 72 VI. Medical Treatment—Number of Cases Treated 72 Index 73 London County Council \NNUAL REPORT OF THE COUNCIL, 1932 VOL. III (Part II) REPORT OF THE SCHOOL MEDICAL OFFICER FOR THE YEAR 1932 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. During the year 1932 the work of the school medical service continued uninterruptedly. For many important criteria of the health and well-being of London school children the best figures attained since the inauguration of school medical inspection some twenty-five years ago were recorded ; for example, the percentages of children with serious dental decay, adenoids and enlarged tonsils, running ears, hardness of hearing, and lack of personal cleanliness were all the lowest ever recorded. Having regard to the difficult economic conditions under which so many families are living special attention has been paid to problems of nutrition. It is remarkable that the nutrition of the children has been so well maintained, the number recorded as subnormal having increased since 1931 by only one per thousand, and, except for 1930 and 1931, being the smallest yet found. When the 1932 figures for nutrition for all the children subjected to routine inspection at the statutory age groups are analysed, it is found that the nutritional condition of the eight- and twelve-year-old children is better than in the previous year, and the small increase in subnormal nutrition which is shown when the figures are aggregated is due entirely to the school entrants. This would appear to be associated with the recent epidemic of measles, a disease which notoriously leaves children in a debilitated condition. Important tests of the value of school medical work are the condition of the leavers and the percentage of the defects, found at any age, which are adequately treated. Speaking generally, the figures relating to these matters are quite satisfactory. The leavers are in better health than their predecessors of a few years ago, and, of the children in whom defects were discovered at routine inspections, 81.6 per cent. were undergoing treatment or were discharged before the end of the year as no longer requiring treatment. There is little of special moment to record in connection with the incidence of infectious diseases in schools. Diphtheria has been less prevalent in the last two than in other recent years, but scarlet fever increased from the low level which occurred in 1931. The usual biennial epidemic of measles occurred in the winter of 1931-32, and small-pox is still troublesome, though the tendency is definitely towards decline and the disease is still of a very mild type. The number of cases of scabies is increasing (see page 13). There has been a considerable extension during the year of the scheme for the immunisation against diphtheria of the children in the residential schools. The scheme for the control of rheumatism makes unabated progress. In this section of the work the most important development was the provision of a considerable number of additional beds for children suffering from this disease in consequence of the enlargement of Queen Mary's hospital for children, Carshalton. In an effort to reduce the length of this report and thereby to promote economy in the printing bill, not so many special reports as heretofore are included. Particular attention may, however, be directed to the following:—Report on the place of detention, where the number of children admitted is increasing considerably (page 53); the work of the special classes for myopes in central schools and reference to a forthcoming report on the development of myopia in children (page 35); enquiry into nutrition and the provision of meals (page 37); scheme for the adoption of children (page 20); the disinfection of sand-pits (page 45). In closing this introduction reference must be made to the retirement from the service of Mr. Macleod Yearsley, the Council's consulting aural surgeon. A brief summary of his pioneer work for the deaf child is given on page 52. (1) 2 The London school medical service. Medical Before dealing in detail with the work of the school medical service for the inspection. year 1932, it may be desirable to give a brief outline of the activities of that service. The Council is required to provide medical inspection for children attending elementary schools (a) at entrance to school, (b) at the age of 8 years, and (c) at the age of 12 years. The Council's own regulations provide for the examination of leavers in the term next before they are due to leave school; also that children must be certified medically fit before entrance to a central school. Children noted at inspections as suffering from defects are kept under observation by a system of re-inspections. The first usually takes place in the second term following the inspection, and if not discharged a further re-inspection is made. (About 40—50 re-inspections are made in one session). "Specials," i.e., ailing children and children to whom particular attention has been drawn by care committees, head teachers, attendance officers, tuberculosis officers, etc., are also seen by school doctors at medical inspections. The Council's regulations provide for the award of scholarships and free places at educational institutions being subject to the candidate's passing satisfactorily a medical examination. A similar condition also applies to permanent appointments for officers under the direction of the Education Committee (teachers, schoolkeepers, etc.). The medical examinations for such awards and appointments are usually held at the County Hall medical examination rooms. Officers under the direction of the Education Committee who are absent from duty on account of prolonged ill-health or in regard to whom the question of superannuation arises, are also referred to the school medical officer for medical examination and report. Cases in which children are found by school doctors to be suffering from defects which are causing injury to health are referred (if the care committee's efforts are unsuccessful) to the special officers of the school attendance service for "pressure" to be brought to bear on the parents. Should their services prove ineffective, cases are frequently brought before the school doctor in order to see whether a medical certificate can be supplied stating, in the terms of the Children Act, that the child is "suffering from neglect of treatment which is likely to cause unnecessary suffering and injury to health." Many of these cases are referred to the National Society for the Prevention of Cruelty to Children to take court action where necessary and desirable. In any such cases, where visual, aural or dental defect are involved and the N.S.P.C.C. propose taking court action, the children are specially examined by one of the Council's specialists. Children found in the course of medical inspections to be anaemic and debilitated are nominated by the school doctors for admission to the Council's residential openair schools at Bushy Park, Margate and St. Leonards. Groups of children are sent regularly to these schools for periods of from 4 to 6 weeks. The schools are recognised as "special" schools, and after nomination by the school doctor a final examination is necessary by one of the Council's certifying medical officers. Assessments (up to 15s. a week) towards the cost of food, etc., are made by care committees. Children taking part in school journeys are medically examined before departure, firstly, with a view to preventing the departure of any child showing signs of infectious disease, and, secondly, in order to exclude from the party, or to give appropriate advice to, any child who is suffering from serious trouble such as ear disease, heart disease, etc. Health classes are held for children in any one school who are suffering from deformities such as flat feet, slight curvature of the spine, etc. Appropriate exercises are advised under medical supervision, and the children are specially examined from time to time by the school medical staff. Under certain conditions children between the ages of 12 and 14 years are allowed to undertake employment outside school hours, but a medical certificate to the effect that the child is medically fit for such employment is necessary in all such cases. The school medical staff conduct these examinations, which are usually treated as "specials." 3 Children licensed to perform in public entertainments must be medically certified as fit and must be seen at regular intervals. Such examinations are usually held at County Hall. In special schools the age groups subjected to routine inspection are the same as in elementary schools, but children are liable to attend until the age of 16 years. It is the duty of the Council to provide education for blind and deaf children, and such children are medically examined with regard to their particular defect. It is also the Council's duty to ascertain what children in its area are (i) mentally defective, idiots or imbeciles, and (ii) epileptic or physically defective. Children admitted to schools for the mentally or physically defective are medically examined with special reference to the defect once in 9 months. Blind and deaf children are also medically examined at 9-monthly intervals. Children at myope and hard-of-hearing schools are also medically examined for their special defect from time to time. Such children generally leave school at 14 years of age. Open-air schools are recognised as schools for the physically defective, and the children are medically examined for admission, and from time to time when in attendance. In the Council's secondary schools the medical inspection of pupils is statutory on admission and at each subsequent year of their period of attendance, and the Council's regulations provide for detailed medical examinations at the ages of 12 and 15 years. These examinations also apply to Council scholars at nonmaintained schools. The Council also provides for medical inspection of fee-paying pupils at nonmaintained schools if the Governors apply for it. The grant to the Governors is adjusted according to the number of sessions given to the work by the Council's staff. Dental inspection is carried out at all elementary schools including some Dental central schools, the desired object being to see each child once a year. Such Inspections inspection is, however, not generally carried out in respect of children who are to be medically inspected in any particular year. Visits to schools by school doctors are frequently necessary in connection with infectious the occurrence of infectious diseases, notably scarlet fever, diphtheria and smallpox, diseases with a view to preventing a further spread of these diseases. When a child is found at a medical inspection to be suffering from any defect, Medical an advice card is issued to the parent. If the parent is present this is done at the treatmentinspection; otherwise the parent is interviewed at a later stage by the care committee worker and if he has not taken any action, and is desirous that the child shall be treated under the Council's arrangements, application is made by the care committee to the divisional treatment organiser for the child to attend one of the appropriate centres. The following is a statement as to the defects dealt with at the 90 treatment centres and the financial arrangements in 1932:— Defect for which treatment is provided. Cost to Council (including establishment charges). Paid to centre committees. Capitation. Charge to parents. Minor ailments (discharging ears, blepharitis, etc.) 7/6 1/- 1 /- after free fortnight. Ear, nose and throat, usually adenoids and/or enlarged tonsils. 16/11 2/15/- T. & A op. in-patient 2/- non-operative treatment. 5/- for in-patient operative treatment. †Vision 6/1 2/- None. Teeth V/- 2/- 1/- slight. 2/- ordinary. 3/- extensive. X-ray (ringworm) 25/1 v- 2/- †The examination of eyes for visual defect is regarded as "inspection" and not treatment. 4 The Council is bound to make a charge to the parents for medical treatment. These charges are either paid at the centre or collected by school attendance officers. Care committees are authorised by the Council to reduce or remit the charges in cases of hardship. The following grants are made to centre committees:— (a) Initial equipment—£75 for eye, ear, nose and throat centres ; £150 for X-ray; and £100 for dental work. (b) Initial adaptation of premises—£100. (c) Capitation—as set out above. (d) Additional maintenance grant towards running expenses—this is varied according to individual circumstances. (e) Use of premises when required for medical inspection purposes—£10. (f) Salaries of treatment staff (temporarily reduced 1932-3):— (i) Surgeons—£80 per annum in respect of each session a week. (ii) Anaesthetists—£75 per annum in respect of each session a week. (iii) Dentists—£60 per annum in respect of each session a week. (iv) Minor ailment doctors—£66 per annum in respect of each session a week. The Council has 8 centres for the remedial treatment of stammering children. There are at any one time about 200 children under this treatment. These cases are selected as a result of school medical examinations, and nominations are accepted from teachers. The children actually attend the centres for treatment on two occasions a week, each visit lasting for about 50 minutes. The remainder of their time they spend at their lessons at the ordinary schools. Arrangements are made for children suffering from ear discharge and other affections of the ear to be seen at 11 special ear centres by specialist aural surgeons. The nominations for such cases are received by the divisional treatment organisers from the minor ailment centres mainly, from school nurses, school doctors and school teachers, etc., and from the aural sessions at the school treatment centres and hospitals. At these special clinics ionisation treatment is given in suitable cases. The Council has made arrangements with various district nursing associations whereby their nurses attend to carry out the daily nursing treatment required in connection with minor ailments. Frequently such nurses attend the appropriate treatment centres between the morning and afternoon school sessions, between 4 and 6 o'clock in the evening, and on Saturday mornings. These nurses work under the direction of the medical officer in charge of the minor ailment department, and when necessary visit the homes of the children who are under treatment. The Council's school nurses generally visit the homes of children after operations for tonsils and adenoids under the Council's treatment centre arrangements, but on occasions arrangements are made for such visits to be paid by the district nurses. Under the Council's scheme for dealing with rheumatism in school children, arrangements have been made for children, discovered in the course of medical inspection to be suffering from rheumatism, to be dealt with either by attendance at one of 16 rheumatism supervisory centres, or in certain cases to be accommodated at Queen Mary's hospital, Carshalton, High Wood hospital or Downs hospital. With regard to the latter cases, on their discharge from these hospitals, they are automatically followed up and re-examined as " specials " by the school doctors, on an average three times a year up to their school leaving age, or until such time as their medical supervision is no longer considered necessary. Cleansing. The powers of the Council as regards the cleansing of verminous children are permissive. Every child is seen at least once a term by a school nurse. The Council's cleansing scheme provides for voluntary attendance, followed by compulsory cleansing (if necessary). Arrangements are made with 20 borough authorities for the use of their cleansing centres and with 10 treatment centre committees, the latter being reserved entirely for slight cases (heads). The payment made to the borough authorities is 5 2s. for each verminous child, and 1s. for each attendance in the case of scabies. The payments to the medical treatment centres are at the rate of 1s. 4d. or 1s. 6d. per case according to the size of the centre. In addition the Council has 10 centres of its own, usually situated in districts where no arrangements are possible with the appropriate boroughs. Staff. The public health department is organised in 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 late London poor-law guardians; and (iii) general public health administration including housing and the school medical service. A principal medical officer is in charge of each of the three branches, viz. (i) special hospitals, etc., Dr. J. A. H. Brincker; (ii) general hospitals and public assistance 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, 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); north-east (divisional medical officer, Dr. G. Chaikin); south-east (divisional medical officer, Dr. H. R. Kidner); southwest (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); nine part-time assistant aurists ; one part-time consulting dental surgeon (Mr. B. Samuel); 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 124 sessions a week; 9 medical officers (part-time) at open-air schools ; 269 surgeons and anaesthetists at treatment centres; and 97 dentists at treatment centres, of whom 67 are employed as inspecting dentists in the schools. 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 and approved schools. 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 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 to Ponton-road place of detention. The duties of the position of part-time consulting surgeon for aural disease, rendered vacant by the retirement of Mr. P. M. Yearsley, were taken over by Mr. A. G. Wells. 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, 80 school nursing sisters and 290 nurses. * Two vacancies—also one and a half medical officers are temporarily seconded for work under the Mental Deficiency Acts (equivalent substitutes authorised). 6 The results of medical inspection in 1932. The number of elementary school children examined in the three statutory age groups (entrants, children aged 8 and children aged 12) during the year 1932 was 180,905. In addition, 39,120 children were examined in detail in the term prior to that in which they were due to leave school, and 1,870 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 95,855; and 58,870 were examined in connection with outbreaks of infectious disease. The total inspections amounted to 376,620, which represents a considerable increase in every department on the numbers in the previous year, namely 336,444. To this must be added the children, 163,491 in number, who were re-inspected because of some previously noted defect. The school doctors thus see each year a very large proportion of the children attending school. Parents are invited to be present at all routine inspections, and attended in 68-5 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 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. The rebellion of elder boys against being tied to their mothers' apron strings is shown by the fact that the percentage of mothers present at the inspection of elder boys is only 33.2 per cent. Refusals. Refusals of parents to submit children for medical inspection are so few in number as to be almost negligible. During the year 1932, the parents of 113children (50 boys, 63 girls), compared with 76 in 1931, refused to allow them to be examined by one of the Council's assistant medical officers. Fifteen objections were subsequently withdrawn, and in 15 instances either medical record cards were endorsed by a private medical practitioner or medical certificates as to physical fitness were produced. The cases were distributed amongst the divisions as follows: N., 7 ; N.E., 12; N.W., 24; S.E., 31; S.W., 39. Requests for During the year 1932, other authorities asked for the medical record cards of cards 517 children who had removed to areas outside London. In 297 cases cards were obtained and forwarded, 108 could not be traced, 9 had not previously been examined and 35 concerned children who were not attending schools in the County of London. In the remaining 68 cases inquiries are still being made. The number of children subjected to routine inspection who were referred for treatment was 93,024, 42.5 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 17.5, compared with 18.9 in the previous year. The analysis of the results of medical inspection set out in the paragraphs 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. Nutrition. There has been much speculation and enquiry during the year as to the nutritional state of the school children, as it appeared to many that the large amount of unemployment and reduction in family incomes might have adversely affected them. Both general and special enquiries made during the year showed that no noticeable change has taken place in the condition of the children, and that in London there has certainly not been any perceptible decline in the children's nutrition. Special interest, of course, is attached to the figures of medical inspections, and it is necessary to study them with care. The children are classified by the school doctors as (1) excellent, (2) normal, (3) subnormal, (4) definitely ill-nourished. 7 The following table shows the numbers inspected in each group, and their classification according to nutrition:— Age Group. Number inspected. Classification. (1) (2) (3) (4) Entrants, boys 29,183 6,172 21,521 1,484 6 ,, girls 29,162 6,670 21,366 1,119 7 8-year group, boys 26,858 4,184 20,965 1,704 5 ,, ,, girls 26,274 5,148 19,807 1,316 3 12-year group, boys 34,909 6,780 26,383 1,743 3 ,, ,, girls 34,519 7,528 25,481 1,505 5 Total 180,905 36,482 135,523 8,871 29 It will be seen at once that the definitely ill-nourished children found are less than one in 6,000. Taking categories 3 and 4 together, the percentages of each sex found with subnormal nutrition in each of the code age groups, compared with similar percentages in previous years, are given in the following table:— Age Group. 1920. 1925. 1930. 1931. 1932. Entrant boys 6.4 5.7 4.4 4.4 5.1 girls 5.9 50 3.5 3.6 3.8 8-year-old boys 9.0 8.5 6.3 6.6 6.3 girls 7.8 7.2 51 5.0 5.0 12-year-old boys 6.3 6.5 51 5.2 5.0 girls 5.6 6.3 4.5 4.2 4.3 All above age groups 6.7 6.3 4.8 4.8 4.9 The combined figures reveal that in the year 1932 there were one in a thousand more children found during the code age group inspections to be subnormal than in 1931 and 1930. This slight deterioration is due to the larger proportion of the entrant infants (principally boys) who were found to be subnormal. In considering the condition of the new entrants it should be remarked that the infant population had just been subjected to the effects of a wide-spread epidemic of measles and these effects fell almost entirely upon the children of five years old and younger. The disparity between the figures for infant boys and for infant girls may be ascribed to the greater vulnerability to adverse influences of the males. This is shown in the fact that the number of boys is always greater than the number of girls born, yet fewer of the boy babies survive the perils of infancy, so that the female population is in the end considerably in excess of the male. The children in the 8-year and 12-year old groups, taking boys and girls together, were found, in 1932, in better condition than in 1931, for those found subnormal in these two age groups were actually one per thousand less in 1932 than in the previous year. These figures bear out the experience of the school medical service that, while at school, children under stress are promptly noticed and means taken to prevent ill-nourishment. The means available for coping with those subnormal in nutrition include school feeding, the provision of milk and cod liver oil on the advice of the school doctors, the transference to day open air school or residential camp school, or the arrangement of convalescence through voluntary bodies or in the Council's own institutions, etc. Much was done in the early spring in the way of arranging for convalescence for the infants who had suffered from measles, through a special arrangement with the Invalid Children's Aid Association. Apart from the exceptional incidence of subnormal conditions upon the entrant children it is found that the condition of the children generally not only has not deteriorated but has even slightly improved. Attention was called during the year to an investigation made by Dr. H. H. Bashford, of the Headquarters Medical Department of the Post Office. 8 A consecutive series of 200 boys of 16 years of age examined between the years 1929 and 1931 was compared with a similar consecutive series examined under the same conditions between 1905 and 1908. It was considered that they represented similar groups socially, coming mostly from working class districts. This being so, this investigation affords additional proof of the betterment in physique which has occurred during the past 25 years. The boys of to-day weighed 1 stone 2 pounds more and were 1£ inches taller than their predecessors, and considerable improvement was found in the girls. Boys. Girls. 1905—1908. 1929—1931. 1902—1905. 1927—1930. Height. Weight. Height. Weight. Height. Weight. Height. Weight. ft. in. St. lb. ft. in. St. lb. ft. in. St. lb. ft. in. St. lb. 5 5 8 3 5 6£ 9 5 5 2i 7 12 5 3£ 8 4 Cleanliness. The percentage of children found free even from traces of nits or pediculi in the hair was 95.8 and of those free from traces of body vermin, 99.9. 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. free in 1913 to 75 per cent. in 1923, 91.9 per cent. in 1930, and 93.5 per cent. in 1931. This figure has still further increased in 1932, when the new high level of 95.8 per cent. has been obtained. This result reflects very great credit upon the work of the school nurses, and even gives fresh hopes to those optimists among us who look forward to the total extinction in our time of the louse as a human parasite at any rate in London. It is already 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 only to be found in one in a thousand. This remarkable progress in freeing the children of the elementary schools from parasitic infestation has been accompanied by the raising of the general level of care, of tidiness and of happiness, and forms by no means the least of the benefits which the school medical service has brought to the schools, the teachers, and the population generally. Dental decay. The proportion of children found at medical inspection in a satisfactory dental condition was 67.4 per cent., compared with 64.4 per cent. in 1931, and 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 53.9 to 55.2. When, however, comparison is made between the proportions of children in the three age groups having serious dental decay, the percentage improvement in the 8-year and 12-year groups is most marked. Details are set out below:— Age Group. 1924. 1927. 1930. 1931. 1932. Sound. Serious decay.* 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 55-6 12-2 ,, girls 58.4 12.4 50.7 15.2 52.2 14.9 53.6 13.5 54.7 12.1 8-year-old boys 58.5 10.0 61.1 8.1 66.7 6.8 67.0 5.7 68.8 4.7 ,, girls 58.0 10.2 60.9 8.3 65.4 6.8 66.4 5.9 68.8 4.7 12-year-old boys 68.0 3.4 70.6 2.7 73.1 2.1 74.6 1.7 75.1 1.5 ,, girls 70.5 2.6 72.3 2.3 75.3 1.6 76.2 1.4 78.0 1.1 All above age groups 62.1 8.5 60.3 9.3 62.9 8.6 64.4 7.4 67.4 5.8 * Serious decay = four or more carious teeth requiring treatment. From this table it will be seen that, while among entrants there is only a slight improvement since 1924 in the proportion of serious dental decay, among the 8-year 9 and 12-year groups the proportion has fallen in 1932 to less 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. It is, however, gratifying to note that year by year there is a substantial improvement in the dental condition of the school children. This improvement is also shown in the results of the inspections carried out by the Council's dental inspectors which appear on page 26. In the statutory age groups 9,336 children were referred for treatment of enlarged tonsils or adenoid growths; this is 5.1 per cent. of the children examined, compared with 6.6 per cent. in 1931, 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 those age groups. The percentages requiring treatment for these conditions were:—entrant boys 9.4, girls 8.7; 8-year boys 4.3, girls 4.7; 12-year boys 2.2, girls 2.8. There has been in the past year a considerable drop in the percentage of children referred for treatment for enlarged tonsils and adenoid growths. This is a continuation and accentuation of a tendency which has been apparent for the last three or four years. The very high proportion of children referred for operation during late years is partly due to the overtaking of arrears which accumulated owing to the reluctance of parents to submit their children to operation under the out-patient procedure which was formerly their only choice. The policy of the Council, which was to substitute in-patient treatment for out-patient treatment in respect of these conditions, removed this reluctance. There is, however, also an alteration going on in the attitude of the medical profession with regard to performance of the operation as a precautionary or preventive measure. It is now thought by many that, provided that the tonsils are healthy, mere enlargement should not be regarded as a reason for operative treatment. Careful observation has shown that the removal of simply enlarged tonsils does not exercise that preventive influence on subsequent attacks of disease to the extent which was expected. Although the performance of the operation in cases where the tonsils and throat are unhealthy, or actual obstruction exists, is undoubtedly most necessary and, in the great majority of such cases, brilliantly successful, there is now developing a reluctance to submit cases for the operation which were formerly referred on purely preventive grounds, and a greater reliance is being placed in the latter group of cases on a waiting policy. A consideration of the figures for the two years suggests, however, that it is the former reason (viz. the overtaking of arrears), which is chiefly responsible for the drop in the number of cases referred for treatment. The figures given above relate to the cases referred for treatment only. Many more cases of tonsils and adenoids are recorded for observation than are referred for treatment, and it has never been the custom in the London school medical service to refer cases indiscriminately for operation. In 1931, 15.1 per cent. of the children examined were recorded as having enlarged tonsils and adenoid growths, and 6.6 per cent. of the total examined were referred for treatment. In 1932, 11.9 per cent, of those examined were recorded as having enlarged tonsils and adenoids, and 5.1 per cent. of the total examined were referred for treatment. The proportion referred for treatment of those found with enlarged tonsils and adenoids was the same in both years, viz., 43 per cent. A distinction should be drawn between the operation for enlarged tonsils and that for adenoid growths. The indications for treatment by operation in the two conditions vary fundamentally, and there is complete agreement by all authorities that where there is diminution of hearing capacity, or obstruction leading to mouth breathing, adenoid growths should be removed without delay. Of the 9,336 children b Enlarged tonsils and adenoid growths. 10 referred for treatment in 1932, no less than 6,587 were referred for enlarged tonsils only. It is clear therefore that, as conservative and waiting methods are likely to be adopted in still greater measure for those children who have enlarged tonsils but none of the stigmata of adenoid growths, there may in the immediate future occur a considerable diminution in the number of operations performed. With a view to securing uniformity of practice amongst the staff a memorandum on the indications for operation has been issued to the school medical staff, including both those engaged in medical inspection in schools and those carrying out operations at the treatment centres. Otorrhœa and hardness of hearing. Otorrhoea was noted in 1,493 children, or .8 per cent. of those examined, compared with 1 per cent. in 1931 and 1930. The highest proportion of these cases was found in the entrant group. In no year prior to 1930 was the percentage of children with "running ears" less than one; and the result this year in this respect is therefore the best yet obtained. 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 446 children, or only .2 per cent. of those examined. This compares favourably with 453 in 1930, 696 in 1929, and 868 in 1927, and again is the best result yet obtained. The apparent improvement in the number of cases of discharging ears found must, however, to some extent, be discounted owing to the larger number of 12-year old children inspected. Mention is made in another part of the report (page 25) of the use of the audiometer, which brings to light many minor degrees of hardness of hearing and cases of unilateral deafness. Defect of vision. Children in the 8- and 12-year age groups have their visual acuity tested by means of the Snellen cards, those whose defects have been corrected having their vision tested wearing their glasses. In the 8-year old group 41 per cent. boys and 43.2 per cent. girls, and in the 12-year old group 34.6 per cent. boys and 38.2 per cent. girls were unable to pass the normal vision test. These figures show a very considerable improvement on the results obtained in 1931, when 45.6 of 8-year old boys, 46.1 per cent. of 8-year old girls, 38.4 per cent. of 12-year old boys and 40.6 per cent. of 12-year old girls failed to pass the tests. The improvement year by year in the condition of the children in this and in all other respects is very gratifying and encouraging to the service. Defects of a more serious character (i.e., vision of 6-12 or worse in either eye) occurred in 15.1 per cent. boys and 15.8 per cent. girls in the 8-year old group, and in 17.1 boys and 18 per cent. 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 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. Heart and anaemia. Heart defect (functional or organic) was reported in 3,356 children or 1.9 per cent., compared with 1.8 per cent. in 1931, and 2 per cent. in 1930. As usual, older girls presented a percentage (2.4) in excess of older boys (1.8), and the slight set back is entirely due to the increased number of heart cases reported in elder girls. 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 this excessive incidence of rheumatism. Anaemia was found in 1,989 cases, or 1.1 per cent., the same as in 1931, 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. 11 Lung defects were noted in 3,776 children (2.1 per cent.). This is an improvement of .2 per cent. on last year. Lungs. The bulk of the cases are provided by the entrants (3.8 per cent.). These cases are largely bronchial catarrh, which is especially prevalent amongst entrant infants who present rickety manifestations, and the preponderance of incidence upon infant boys compared with girls holds as in rickets. Tuberculosis. There were 62 children in the three age-groups reported to have symptoms indicative of pulmonary tuberculosis, but only 12 of these were not already under treatment. In addition, 48 children had other forms of tuberculosis. The incidence of tuberculosis in any form found at routine inspections is .06 per thousand. The figures show a definite decline, although for many years the amount of tuberculosis amongst school children has been very small. Nervous diseases. Epilepsy was noted in 52 cases, compared with 65 in 1931, 60 in 1930 and 73 in 1929 ; chorea in 158 cases, compared with 170 in 1931, 186 in 1930 and 178 in 1929 ; paralysis in 63 children, compared with 81 in 1931, 76 in 1930 and 122 in 1929. Symptoms of rickets or the effects of early rickets were noted in 595 children. This is .32 per cent., compared with .4 per cent. in 1931 and 1930. Infant boys had an incidence of .9 per cent., and infant girls .4 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. Here again the apparent decline needs to be considered in relationship to the fact that the older groups examined were greater in numbers compared with the entrant infants than in the previous year. Rickets. Deformities. Spinal curvature accounted for 764 cases (.4 per cent.), the same proportion as last year. Of these, 319 (.9 per cent. of those examined) were among the 12-year old girls, while the 12-year old boys showed .5 per cent. Other deformities were present in 1,789 children (1 per cent.). This is an increase of .1 per cent. on 1931. 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, 47 .7; 8-year olds, 53 .1; 12-year olds, 52.1; and "leavers" (131/2) 55.5. These figures show that the percentage of children with obvious vaccination marks is less than last year, just as last year's percentages were less than those of the previous year. Thus the number of children protected from smallpox by vaccination grows less with each succeeding year. Vaccination. 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. The health of the leaving child. This year's "leaver" group was formed of the children born in the year 1918-19, and consequently the numbers are small, consisting of 19,649 boys and 19,471 girls only. In nutrition they were found to be better than the younger groups, only 3.8 per cent.of the boys and 3.2 per cent. girls being classed as poorly nourished, compared with 5 per cent. boys and 4.3 per cent. girls in the 12-year age groups. In personal cleanliness this group also shows an improvement on the 12-year olds, 98.5 per cent. boys and 95.5 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-year old group, for both boys and girls, the percentage with satisfactory mouths being 74.1 in the case of boys, and 74.8 in the case of girls, compared with 75.1 and 78 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. 12 Spinal curvature in the "leaver" girls was reported in 1.2 per cent. of the cases compared with .9 per cent. at age 12; on the other hand heart defect in the "leaver" girls was 1.8 per cent. compared with 2.4 per cent. in the 12-year old group. The falling off in the condition of the teeth of the "leaver" children is not a satisfactory feature of the school medical work. It is due to the fact that skilled inspection of the teeth by the inspecting dental surgeons does not extend as a rule to the children aged 12 and 13 years, but ceases at the age of eleven in most schools. This should be remedied by increased dental inspections so soon as the time is favourable. During 1932, of the total of 38,754 children who had been examined in this group, 16,352 were found to require medical or dental treatment; prima facie this showed the need for the inspection of this particular age group, but, in order to obtain further assurance on this point, an analysis was made of the medical cards, chosen at random, of 500 children who had been medically examined as "leavers." Analysis of inspection of 500 "leavers." This analysis showed that in these 500 cases, whilst 267 children were marked as free from any defect, there were 296 defects noted either for treatment or observation in the remainder, some of the children having two or even three defects. It is important to observe that of these 296 defects, 181 were noted as having arisen since the previous inspection at the age of 12 years. These 181 new defects were classified thus: defective teeth, 80; vision, 40; enlarged tonsils or adenoids, 13; skin disease, 12 ; ear disease and hearing, 7; heart and circulation, 7; deformities (spinal and flat foot), 9; others, 13. Attention was then drawn to the possibility that, inasmuch as these children leave school within a comparatively short period after their inspection, they might not receive the treatment indicated owing to the care committees not having sufficient time in which to follow up the cases adequately. It was urged that if discovery of a defect did not lead to immediate remedial treatment, the primary object of the inspection had not been achieved, and the cost incurred had been wasted. Whilst it cannot be admitted that the giving of advice to older children of this age and the warning of parents are not in themselves of considerable benefit, it was, in fact, ascertained that, at one typical medical treatment centre, about one-eighth of the medical cards in that centre, respecting children for whom appointments for treatment were requested, related to children in the " leaver " group, thus showing that a considerable amount of treatment is obtained as a result of the inspections of the "leavers"; in fact, it is found that certain parents who neglect earlier advice to obtain treatment, accept it when work is about to be commenced and an untreated defect will cause difficulty in certification by the certifying factory surgeon. Special examinations. 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 95,855, and this figure does not include another 58,870 who 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 to be suffering therefrom in the former generally exceed those in the latter. Thus 1,795 children with scabies were referred for treatment at special inspections, compared with 117 only at routine inspections. Heart trouble requiring treatment was detected in 352 children at special inspections, compared with 257 at routine inspections. So far as tuberculosis is concerned 76 children were referred for treatment from special inspections, but only 27 from routine inspections (including that of the extra "leaver" group). In regard to epileptics 79 first came to notice at special inspections, compared with 20 at routine inspections, and 197 children with chorea were referred for treatment at special inspections, compared with 78 at routine examinations. 13 Again 1,531 children suffering from malnutrition were brought forward at special inspections while the lesser number of 1,109 were found at routine inspections of the age groups. 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. One disturbing feature is the continued increase in the number of cases of scabies amongst the children. It will be noted above that 1,912 cases of this disease were brought before the school doctors in 1932, whereas in 1931 the number was 1,098. This continued increase in the number of cases of scabies, which was nearly doubled during the year, has been apparent for some years : possibly examinations of the skin associated with the prevalence of smallpox has brought these cases to light. Conclusions. In 1932 the general improvement which had taken place during the preceding years has strikingly continued, and new records have been achieved. Personal hygiene in particular has again made noteworthy advance; the nutritional state of the child while in attendance at school 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 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 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 work of the school medical service may therefore be regarded with satisfaction though not with complacency. The mountain of physical defect, which the young organisation faced at the beginning of the present century, has been attacked with success, and the physical condition of the school children is very greatly improved— even beyond expectation. There still, however, remains much to be done, and, although progress in children's care has been continued in spite of the adverse economic conditions and the children as a whole have not been allowed in any way to suffer, it is reasonable to suppose that, had it not been for the heavy additional burdens imposed by the war and the succeeding economic crisis, progress would have been more rapid, and the condition of the children at the present time would have been nearer that ideal state which it is the ambition and aim of the school medical service to achieve. It is greatly to be desired that it will not be found necessary to curtail in any essential feature this fundamental work, whose aim is to secure such a foundation of health for the industrial population on leaving school as will stand the nation in good stead in the long struggle ahead in the economic sphere. Medical inspection 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, in accordance with the instructions of the Board of Education, 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. The figures subsequently analysed are derived only from the schools where the medical inspections are carried out by the Council's own staff. No detailed reports of medical inspections are received from the schools at which the pupils are examined by the doctor appointed by the governors, but the record cards of all scholarship children examined are sent for the school medical officer's inspection at the end of each term. Including students in training colleges, 14,222 pupils were examined during the year, a decrease of 62 compared with the previous year, and in 3,979 cases records 14 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 seven cases the clothing was found to be poor and in two infestation with head vermin was noted. Dental condition. The percentage of children, aged 12, with sound teeth was: boys, 78.7; girls, 80.3; but at the age of 15 this percentage had fallen by 5.7 per cent. among boys and 4.7 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 1.5 and 1.1 in elementary schools at this age. Vision. At the age of 12, 72.1 per cent. or the boys and 71.8 per cent. or the girls were able to pass the vision test, compared with 65.4 and 61.8 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 17.3 per cent, of the boys and 15.6 per cent. of girls were wearing glasses at the age of 12, but at the age of 15 the percentages were 23.4 boys and 20.6 girls. In spite of the much greater percentage wearing glasses at the age of 15, the number of pupils with normal vision had fallen to 68. 6 per cent, among boys and 66.1 per cent. among 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. Nutrition. The nutritional figures in secondary schools give rise to some concern as 7.2 per cent. of boys and 12.2 per cent. of girls are returned as below normal. These are worse percentages than in elementary schools, and it is intended during the year to extend to secondary schools the investigations into nutrition to be held in elementary schools. Training colleges. Of the 1,171 students examined in training colleges, 3 were found to be suffering from extensive dental caries; 87.3 of the men and 83.5 of the women passed the vision test, but 28 per cent. of the men and 31.7 of the women were wearing glasses. Re- inspection. The re-inspection of l,749 secondary school pupils (involving 6,720 ailments) was carried out; 1,802 defects had been remedied, 860 had improved, and in 1,058 (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. At any rate the deterioration between the ages of 12 and 15, which the above figures show, requires earnest consideration. 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 1932, 162,163 children' were re-inspected. At the first re-inspection 105,226 cases of defects requiring treatment and 30,964 observation cases (some children having more than one defect) were reviewed. At the second re-inspection 56,937 treatment and 22,002 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 exactly the same as last year, being the highest percentage yet recorded. 15 First Re-inspections, 1932. (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 19,262 148 91 5,156 2,559 538 377 1,259 3,591 5,543 .8 .5 26.8 13.2 2.8 2.0 6.5 18.6 28.8 Minor ailments 6,256 164 25 1,509 443 433 229 1,624 805 1,024 2.6 .4 24.1 7.1 6.9 3.7 26.0 12.9 16.3 Nose and throat 16,925 59 11 6,103 319 1,016 105 1,462 2,018 5,832 .3 .1 36.1 1.9 6.0 .6 8.6 11.9 34.5 Teeth 51,553 1,472 346 20,640 750 1,608 149 3,594 834 22,160 2.8 .7 40.0 1.5 31 .3 70 1.6 43.0 Other ailments 11,230 224 139 351 551 1,373 1,160 2,492 3,267 1,673 2.0 1.2 3.1 4.9 12.3 10.3 22.2 29.1 14.9 Total 105,226 2,067 612 33,759 4,622 4,968 2,020 10,431 10,515 36,232 2.0 .6 32.1 4.4 4.7 1.9 9.9 10.0 34.4 Second Re-inspections, 1932. Refraction 12,876 80 47 2,354 1,527 297 233 1,077 3,296 3,965 .6 .4 18.3 11.9 2.3 1.8 8.3 25.6 30.8 Minor ailments 3,143 40 15 535 256 169 130 864 512 622 1.3 .5 17.0 8.1 5.4 4.1 27.5 16.3 19.8 Nose and throat 9,860 6 9 2,629 126 536 51 1,396 1,514 3,593 .0 .0 26.7 1.3 5.4 .5 14.2 15.4 36.5 Teeth 24,022 700 182 7,878 274 641 97 2,371 531 11,348 2.9 .8 32.8 11 2.7 .4 9.9 2.2 47.2 Other ailments 7,036 67 62 183 390 630 711 1,746 2,364 883 1.9 .9 2.6 5.5 8.9 101 24.8 33.6 12.6 Total 56,937 893 315 13,579 2,573 2,273 1,222 7,454 8,217 20,411 1.6 .6 23.8 4.6 3.9 2.1 13.1 14.4 35.9 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 326, of which 59 were forwarded to borough councils or other local authorities. Of the cases followed up at school, 18 were found on the first examination to have otorrhoea, 7 of these had cleared up on second examination. Aural disease and scarlet fever 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. In July there were 21 schools out of a total of 991 where the care committees were not functioning as regards medical following-up work, and in 14 others they were not independent of official help, i.e., organisers had to find other voluntary workers from time to time to carry on. Plans are on foot for filling most of the gaps, but probably others will arise. The figures given, therefore, are likely to be about average. Teachers are eligible to serve on care committees but they have not the right to vote. The voluntary workers are responsible for acquainting the school doctor with any particular difficulties with which the family has been contending, such as unemployment, lack of proper accommodation, illness, etc., any of which might help the school doctor in determining the action desirable in any particular case. Such Children's care committees. 16 action may not be confined to medical treatment under the Council's arrangements, but may require that use be made of other ameliorative channels which are not always under the Council's supervision. In this way the Council's school medical service is brought into touch with other social and medical organisations with undoubted advantages to the children and their parents. After a medical inspection the voluntary worker is expected to visit the homes of the children recommended for medical treatment (except where satisfactory arrangements can be made with the parents at the actual inspection) and, if the parents do not propose to make other arrangements, are unable to afford treatment from a private doctor, and are willing to allow the child to be dealt with under the Council's medical treatment scheme, application is made by the care committee secretary to one of the five divisional treatment offices for an appointment at one of the centres or hospitals. An analysis of the medical re-inspections in 1932 of children previously noted as defective and requiring treatment reveals that by the efforts of the doctors, nurses, care committees, teachers and parents, 81.6 per cent. of the children were treated (not necessarily all under the Council's arrangements) or were discharged as no longer needing treatment. There are 150 paid organisers, including all grades. These organisers are divided into two groups—(1) those engaged on "general" work, i.e., recruiting, training and organising voluntary care workers, and (2) those engaged on medical treatment centre work. The majority of the organisers possess a social science certificate or a university degree, or both, and some have in addition a health visitors certificate or nursing training. At medical inspections an organiser is very rarely present, though a voluntary worker is usually there in addition to a school nurse. A treatment organiser is present on the occasion of a dental inspection and then no school nurse is there. At about 95 per cent, of the medical inspections in elementary schools a voluntary worker is present. The treatment organisation is based on five divisions, corresponding to the five divisions of the school medical work. Each of the divisions is under the control of a divisional treatment organiser. The total paid staff allocated to the treatment side is 86 organisers. The actual units of the organising staff, treatment and "general," are, however, interchangeable between the "general" and the treatment sides. The annual cost of the treatment organisation for 1932 is estimated at £21,690, and, with the addition of clerical and typing work of £5,612 a year, a total of about £27,000 a year. This represents approximately a charge of about 1s. per head of the average school attendance. A treatment organiser attends the Council's medical treatment sessions at the centres and hospitals. She is expected to place before the doctor all relevant information as to the home conditions, etc., which is provided by the care committee secretary. She is required to advise the doctor as to the appropriate educational and ameliorative agencies available, not only under the Council's arrangements, but also through various social and philanthropic bodies, and she is required to convey to the school care committee any suggestions as to social and convalescent treatment made by the doctor ; and also, where necessary, she arranges for the case to be transferred to wherever the appropriate treatment can be obtained. The basis on which the number of the organising staff is allowed, by the Council, is 1 unit of staff for each 2,200 medical or 4,400 dental cases. In addition, sessions of organisers' time have been granted for special clinics, such as for rheumatism and ionisation (or special ear inspection) centres. With the developments of the treatment work, it has been possible to spread the time of the organisers over the centres, and to pool the clerical work involved at the divisional treatment offices. In this way it has been possible to effect economies by the substitution at various times of clerical officers for 14 organisers authorised by the Council and in the future this process will continue. 17 It has been considered whether a more mechanical method can replace that of the home visiting system in cases where the parents are willing to accept treatment as soon as the need of it is brought to their notice. Although in the early days of medical treatment much personal persuasion of parents was necessary, as the education of parents proceeds personal persuasion can be reduced, and a communication to them as to the need of treatment should suffice in many cases. At the medical inspections where the parents are present, the care committee worker makes all arrangements for treatment there and then, and even now in some schools instead of visiting the homes of those parents who are absent an advice card is sent to the parents informing them of the need for medical treatment and asking them whether a voucher is required for attendance at one of the centres. This card is intended to be returned to the head teacher, and it is only when the card is not returned to the school or a refusal is obtained that the care committee is asked to follow-up by home visiting. This follows closely upon the lines of the method employed at dental inspections where, in cases which the parent is not present, the cards asking for consent to treatment are written by the organiser at the time of the inspection and given to the head teacher to distribute and collect. In schools where the head teacher insists upon the return of the dental consent cards, the scheme works well, but in others little is achieved until the care committee begins to function. The advantage of this scheme is that the voluntary worker is relieved of part of her work of home visiting, though she may still be required to visit some of the homes to enquire on general questions, such as the provision of spectacles, convalescence, assessment, etc., but on the other hand some additional work is thrown on the teaching staff. It has been thought advisable to arrange for a trial of the scheme at about 30 schools where the care committees, head teachers and school doctors are all sympathetic to the proposal. No economy is necessarily expected under this arrangement, but greater efficiency may be effected. More time will be made available to the voluntary workers for the persuasion of indifferent and difficult parents by dispensing at the outset with home visiting in those cases where the parents have shown their willingness to act upon the advice of the school doctor. Unfortunately many parents display considerable dexterity in avoiding things for their own and their children's good. Where the good offices of the voluntary worker fail, such cases are handed on for special visiting to the "special officer," a member of the divisional officer's school attendance staff. If all this fails the school doctor issues a certificate in accordance with the provisions of section 12 of the Children Act, 1908, and the case is forwarded to the National Society for the Prevention of Cruelty to Children, which in appropriate circumstances undertakes prosecution. During 1932, 565 cases, involving 683 defects, were reported to the Society: these included 303 dental defects, 196 vision cases, 94 nose and throat affections and 21 cases of ear disease or deafness. These figures are appreciably smaller than in 1931. Cases referred to the N.S.P.C.C. The work of the care committee organisers who now attend many voluntary hospitals has continued to be of inestimable value in co-ordinating the remedial measures advised at the hospitals with the social activities of the school care committees. Co-ordination of hospital and social work. In the British Medical Journal for 21st January, 1933, a full reference was made to the influential American " White House Conference on Child Health and Protection." The ineffectiveness of general hospital work through its dissociation from social agencies was the main theme. Co-operation between hospitals and community social agencies is hampered, and there is failure by those responsible for the treatment of children in hospitals and dispensaries to appreciate the strategic opportunity for inculcating good habits based on sound principles. How to bring the hospitals and social agencies together in a practical working arrangement which will not cramp the free activities of either was the greatest problem, and difficult to 18 In London, on the other hand, the legal responsibility of the education authority for the medical treatment of all children of school age, the far-sighted policy which has brought about a great system of social care for the school children in which voluntary and official elements are closely combined, and which maintains cooperation with every kind of voluntary organisation in the field, allotting to each its appropriate share in the organisation, and the placing at the disposal of voluntary hospitals of the services of liaison officers in the persons of organisers of care committee work has completely solved the problem so far as concerns those hospitals (which are now many) who have desired to be associated in this way with the great work of children's care carried on through the medium of the schools. Guy's hospital. The following report on Guy s hospital indicates the extent and character of this work:— The Council has again secured the attendance of assistant organisers of care committee work in the aural, eye, orthopaedic and skin departments of Guy's Hospital. It has thus been possible to keep the school care committees supplied with up-to-date information in regard to children attending these departments. The almoner has been most helpful in obtaining information from other departments for school doctors, school care committees, and school attendance officers. Subjoined is the divisional treatment organiser's report on the work in the departments attended by an organiser:— "In the aural department 1,577 new cases were seen during the year; 745 were discharged cured, and the care committees reported that no further treatment was necessary in the case of an additional 81 children. In the out-patient department 138 operations for the removal of tonsils and adenoids were performed, and the children were taken home by the Council's ambulance after the operation. "In the eye department 1,362 new cases were seen. Of these, 890 were tested for glasses, which were prescribed for 777, while 113 were found not to require glasses. During the year 758 children obtained their glasses, but this includes some ordered in 1931. In addition, 8 children were referred to the Council's hospital, White Oak, Swanley, for treatment for chronic eye trouble. "In the orthopaedic department 200 new cases were seen, of whom 36 were discharged cured, and 92 were reported as having left school, left London or refused further attendance. There are 508 children attending periodically for supervision, many of whom are referred to the massage department for treatment. The organiser checks their attendances each week, and reports to the care committee if they do not attend regularly. "In the skin department 907 new cases were seen during the year, of which 17 were suffering from ringworm of the head and 104 from scabies. "There were 56 new cases in the diphtheria carrier clinic during the year, with a total of 233 attendances. "Arrangements were made for a great number of children attending the aural and skin departments, for whom daily treatment by a nurse was necessary, to have the treatment carried out at the school treatment centres. "The number of children referred to the school medical officer for special examination during the year with a view to admission to the schools specified is as follows: Schools for the physically defective, 20; open-air schools, 3; epileptic colony, 1; hard-of-hearing school, 1. In addition, 6 children were recommended for re-examination with a view to their transfer from schools for the physically defective to elementary schools." General. Schools and Homes transferred from former Poor Law Authorities. In the report for 1931 (Vol. Ill, Part II, p. 15), a description was given of the progress made in securing a more uniform system in the administration of the medical arrangements in the various schools and homes transferred to the Council's jurisdiction from the former poor-law authorities. The general arrangements have worked well, and further progress has been made especially in extending the scheme for immunisation against diphtheria (see p. 65), and the organisation of a visiting specialist service for refraction of the eyes. Dietary. The new provisional dietary described in detail in last year's report was introduced into the Council's residential schools in March, 1932. The effects of the dietary have been watched by Dr. Wilfrid Sheldon, who is mainly responsible for the following interim report:— All the children have been weighed and their heights measured both at the time of introduction of the diet (March, 1932) and again after six months (September, 1932). Conclusions are based partly on the figures for height and weight returned from the schools and also on the special reports of the superintendents and medical officers of the schools, who have commented on the general value of the diet, its palatability, practicability and effect on the children's health. They were also invited to make any suggestions as to suitable modifications. 19 It may be said at once that, from a close analysis of the measures of height and weight of roughly 1,000 children at these homes, the effect of the diet has been beneficial and, in fact, both the height and weight have increased in excess of the expected gain. This expected gain in height and weight was derived from the standard figures for the growth of elementary school children used in the department. The measurements of the children from whom the standard was prepared are, however, given at yearly intervals, and do not, therefore, offer a strictly accurate basis for comparison with the measurements of the children at the residential schools, since these latter measurements only cover a period of six months. This will be seen to be important when it is remembered that children do not gain in height and weight equally throughout the year, but tend to increase in height at one period and in weight at another. Furthermore, during the first six months of operating the new diet it was necessary for the superintendents of the homes (or those responsible for ordering the daily menus) to become accustomed to the various features of the new dietary tables. This, in some cases, took a little time, and any early errors or misunderstandings of the schedules may possibly have affected in either direction the heights and weights taken at so short an interval as six months. A more thorough estimation of the value of the new diet could be made over a period of a year instead of six months, and it has been arranged to have the heights and weights taken again in March of this year in order that a report on the whole of the first year's working of the diet may be made. The weights of the children, about 1,000 in all, at four representative schools have been analysed. The schools selected were Anerley, Hornchurch, Hammersmith and Stifford and Grays, three of which are large schools, while Hammersmith is smaller. The results show that, on the whole, the children have generally gained weight in slight excess of the expected gain. The measurements show that, at the beginning of the new dietary the children in the residential schools were already up to the expected weight of elementary school children, reflecting credit on the previous care of the children. A point which is not shown in the analysis is the fact that at Anerley school, of 391 children, 50 showed a slight loss in weight, although taken on the whole the children at that school showed an average increase. The superintendent of Anerley has reported that the new dietary worked very well indeed. He states that the children have enjoyed the greater variety, the better breakfasts, and the increase in the amount of food ; while the medical officer also reports that the diet is satisfactory. It is possible that a few of the weighings may have been incorrect, and it should be possible to establish whether this is so or not when the weighing is repeated in March of this year. It is also possible that the children in question were previously too fat to be really healthy. This is definitely stated to be the case in three girls who lost weight at Banstead school. The gain in weight at the other three schools has been wholly satisfactory and there are no figures in them for loss of weight comparable with those at Anerley. The heights of the children at the four schools already mentioned have also been analysed. During the visits of the medical officers to these homes it has often been the impression that the children, though robust and in good condition, were nevertheless somewhat stunted in height. The analysis now made confirms this impression, for it shows that at all ages from three to fourteen, at the beginning of the new diet, the average height of the children was below standard by an amount varying from one to three inches. During the six months of the new diet there has been a very satisfactory average increase in height. Children at the age of six have increased in height according to the expected normal increase, but at all other ages up to fourteen the increase in height has been greater than the expected increase, and children of three, five, eight and thirteen have reached the expected height for their ages. A review of the reports of the superintendents of the residential schools shows that they are all satisfied with the new diet and many of them are enthusiastic. They welcome the variety afforded by the schedule, especially the increase of fruit, and many of them remark that the variety is particularly appreciated at breakfast. Practically all the schools mention with regret that the dietary does not provide for the giving of an egg as such once a week, and consideration is being given to the possibility of providing for this, at all events during the summer. The medical officers echo the superintendents' reports in stating the diet has been beneficial, and they point out that the health of the children has been maintained at a satisfactory level. Sufficient information, has already emerged to show that the dietary is a suitable one and it has been recommended that, with the slight modifications suggested, it should be approved provisionally for another year. That nocturnal incontinence is one of the most troublesome complaints afflicting children in the residential schools was pointed out in last year's report. In the issue of "The Practitioner" for December, 1932, Dr. Langdon Brown, the Regius Professor of Physic in the University of Cambridge, drew attention to the suggestion of G. W. Bray that some cases of enuresis are due to allergy. Dr. Langdon Brown gave reasons for supposing that the drug ephedrine might be of special use in such cases. Following upon this, the medical officer of the Shirley schools reported that he had tried ephedrine hydrochloride upon children suffering from the complaint in that school with encouraging results. Enuresis. 20 Adoption of children. Under the Poor Law Act, 1930, the Council maintains about 8,500 London children ; in respect of about 3,000 of these the rights and powers of parents are, under section 52 (1), vested in the Council. The Adoption of Children Act, 1926, made it possible for a natural parent to divest himself absolutely of his rights and liabilities in respect of his child, and secured the adopter against any possible interference at any future time by the natural parent. Further it conferred upon the adopted child practical equality with legitimate children and substituted for the birth certificate an adoption certificate. Application for adoption must be made to a court, who may grant an adoption order which cannot be revoked, except by the granting of another order. The court may make the granting of an order conditional upon the observance of specified provisions. The Council, in July, 1932, decided to grant consent to the adoption, by private persons, of children maintained under the Poor Law Act, 1930; officers were approved to interview the prospective adopters, and to make such other enquiries as were considered necessary. No payments are either required from the adopters or made to the Council, and as a rule arrangements are made for the child chosen to stay on trial with the prospective adopters for a few months before legal adoption is agreed to by the Council. One of the conditions of the scheme is that the physical and mental condition of the children concerned shall be ascertained, as far as practicable, before consent is given to their being entrusted on probation to private persons. For such purposes the completion of a full medical questionnaire is required. This, in so far as the children in the residential schools and homes under the control of the Education Committee are concerned, is filled in by the medical officers of the appropriate school and home. Arrangements are made for carrying out a Wassermann test on the blood of each child for whom a definite application has been made by a prospective adopter. The arrangements for adoption are also applicable to the nurseries under the control of the Central Public Health and Public Assistance Committees. The number of children selected for adoption from the residential schools and homes under the control of the Education Committee since the inception of the scheme is (in March, 1933) 48, and several further applications have been received. 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 are analysed, and the result gives the only index available of the causes of chronic invalidity in childhood. The subjoined table shows the number of children reported to have been out of school for more than three months in November, 1932, and comparative figures for the four preceding years. 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 31 cases of epilepsy and 13 cases of encephalitis lethargica) show a satisfactory drop. Ringworm, formerly a chief cause of prolonged absence from school, accounts for only 5 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 130 cases, and ear disease for 46. 21 Cases out of School for three months, November, 1932, and the four preceding years. Cases. Percentage of total. 1928. 1929. 1930. 1931. 1932. 1928. 1929. 1930. 1931. 1932 Rheumatism, heart disease and chorea 681 680 678 546 550 30.95 30.77 32.82 33.67 31.87 Nervous disorders 199 148 99 93 65 9 05 6.70 4.80 5.74 3.76 Tuberculosis (all forms) 216 264 295 212 219 9.82 11.95 14.28 13.07 12.68 Anaemia and debility 141 105 129 52 77 6.40 4.75 6.24 3.21 4.46 Ringworm 17 22 22 9 5 0.77 0.99 1.06 0.55 0.29 Skin complaints (excluding ringworm) 56 58 49 38 45 2.55 2.62 2.37 2.34 2.61 Eye disease 62 84 72 70 63 2.82 3.80 3.49 4.31 3.65 Infectious diseases 106 85 73 34 90 4.82 3.85 3.53 2.10 5.22 Other defects 722 764 649 568 612 32.82 34.57 31.41 35.01 35.46 Total 2,200 2,210 2,066 1,622 1,726 100 100 100 100 100 Wage-earning employment of school children. During the year 1932, 3,079 applications (3,046 boys and 33 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 first numbers are in respect of boys, the figures for girls being given in brackets: delivery of milk, 267; delivery of newspapers, 1,775 (19); carrying or delivery of goods or parcels, 442 (2); in or in connection with a shop, 219 (4); in a coal yard, 4; industrial work at home, 1; house work away from home, 15 (4); as a messenger, 51 (3); not stated, 24. Certificates in respect of two or more occupations were granted to 139 boys. In 145 cases the certificates were granted subject to medical treatment being obtained, and in 86 additional cases other conditions were imposed. Certificates were refused on medical grounds to 38 boys. 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 65 boys and 1 girl were not proceeded with. School children employed in entertainments. The number of children examined under the regulations governing the employment of children in entertainments was 610 (108 boys, 502 girls). One child, a girl, was rejected on medical grounds—rheumatism. Eighty-seven children, 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 54, visual defect 16, throat condition 2, skin affection 6, personal hygiene 7, scoliosis 1, and heart condition 1, During the previous year only 281 children employed in entertainments were examined, so that the work in this respect more than doubled during 1932. The children are examined by the doctor on duty at the County Hall when they come to obtain their licences, the majority of the examinations taking place just before the pantomime season, i.e., towards the end of December. 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. There are 73 centres and 17 hospitals included in the Council's medical and dental treatment scheme. In addition to these 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. 22 The following table shows the provision made in 1932, and the number of ailments actually treated during the years, 1920, 1931 and 1932:— Ailment. Provision made in 1932. Ailments treated 1920. Ailments treated 1931. Ailments treated 1932. Defective vision 42,122 32,540 44,686 44,172 Ear, nose and throat 20,994 15,800 20,703 17,364 Ringworm 511 2,100 268 224 Minor ailments 78,209 44,440 101,391 100,275 Teeth 147,453 99,220 139,723 134,769 Total 289,289 194,100 306,771 296,804 It will be observed that during the year 7,515 ailments 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. Eye defects. The total number of eye cases dealt with during the year was 44,172, compared with 44,686 during the year 1931, a decrease of 514. From 1924 to 1931 the number of cases of defective vision dealt with in the eye department increased from 31,986 steadily at the rate of about 1,600 a year. The falling off in the numbers in 1932 is more apparent than real, and is accounted for by an alteration of the method of issuing voucher cards. Previously a new voucher card was issued, if necessary, at the end of six months and the case became a new case for which a new capitation fee was paid. In 1932, however, it was decided to make the "life" of a voucher one year. There was consequently a reduction of the number of vouchers issued and a saving in cost was effected. Ringworm. 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 224, compared with 268 during the year 1931, and 1,703 during the year 1921. Minor ailments. Nursing treatment of children suffering from minor ailments was given in 100,275 cases during the year, a decrease of 1,116 on the number dealt with during 1931. Ear, nose and throat. During the year 17,364 children were treated in the ear, nose and throat departments, a decrease of 3,339 compared with the number dealt with in the preceding 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 1932 the number of throat operations performed under the Council's scheme was 13,765 compared with 16,243 during the year 1931. 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 1923-32 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 1932 15,558 26.6 23 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. Two reasons are advanced for the falling off in the numbers during 1932. Firstly, it was decided that, on 1st April, 1932, the charge to the parents for operation should be increased from 2s. to 5s. This may have affected the readiness of parents to consent to operations, though this is unlikely as the care committees have power to remit the charge whenever the circumstances justify this. Secondly, the extension of in-patient arrangements made possible by the use of the general hospitals transferred to the Council from the guardians of the poor resulted in the overtaking of arrears during 1930 and 1931 so that the number of children suffering from enlarged tonsils and adenoid growths at recurrent medical inspections in schools has become much fewer. Thirdly, there is the tendency to adopt a waiting attitude in certain cases instead of recommending immediate operation. Continued use has been made of the Council's general hospitals during the summer months and facilities have been given at St. Charles', Mile End, St. John's and St. Leonard's hospitals. So closely knit are the operations for the two conditions that it has not hitherto proved possible to separate the figures into operations for (i) tonsils only, (ii) adenoids only, or (iii) tonsils and adenoids together. It will be seen from Table II in the appendix that nose and throat cases noted at the medical inspections as requiring treatment, are divided into the three categories referred to above. Of the total number of cases the percentage of cases referred for (i) enlarged or unhealthy tonsils only was 72 per cent., (ii) adenoids only 7 per cent., and (iii) tonsils and adenoids together 21 per cent. Assuming that these percentages were applicable to the cases aotually operated upon, the number of operations performed during the year, viz., 13,765, would be divided as follows: (i) tonsils only, 9,910; (ii) adenoids only, 964; and (iii) tonsils and adenoids together, 2,891. Endeavours are being made to secure more accurate information in the future. It is essential that all children should be taught the proper method of breathing through the nose, and this is especially necessary where children have been operated upon for enlarged tonsils and adenoids, for, in almost all cases of enlarged tonsils and adenoid growths, the child has acquired the habit of mouth breathing. Breathing exercises classes have therefore been formed at the various treatment centres, and are undertaken by one of the nurses under the supervision of the aural surgeon. With a view to uniformity instructions have been drawn up for the use of the nurses concerned and a leaflet on more simplified lines has been issued for the parents so that the exercises may be continued in the homes. Breathing exercises. The special aural staff consists of Mr. A. G. Wells and nine part-time assistant aurists who attend at eleven special aural clinics. Aural clinics. The following is the substance of the report submitted by Mr. Wells:— The figures returned by the five divisions for the year under review are set out in tables I and EL From the figures in table I it will be seen that the percentage of cases cured is 67.4, and that each case averaged five attendances. From table II it will be seen that the percentage of cases cured was 30; partially relieved 10; unrelieved 3.8; and that each case averaged four attendances. In addition 56 cases of nasal defects were also treated. Table III gives a detailed analysis of all the cases of otorrhoea treated and shows the number of "acute" ears, the cause of persistence of discharge in the "chronic" ears, the number cured, the number requiring operation, those lost sight of and the number still under treatment on 31st December, 1932. Statistics. 24 Table I—Otorrhœa cases. Division. Total no. of examinations made. New cases. Cases carried over from 1931. Old cases returned. Cases examined, but no treatment required. Cases cured. Lost sight of. Cases transferred elsewhere. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. N.E. 2,722 3,330 247 294 168 200 199 231 45 58 364 437 45 51 - - S.W. 3,670 4,894 350 400 152 180 254 298 65 128 443 561 50 63 20 23 S.E. 4,289 5,185 277 353 184 227 264 317 56 72 392 474 33 36 3 5 N. 3,841 4,822 375 520 145 173 213 259 82 134 401 505 76 92 1 2 N.W. 2,598 3,298 225 311 179 231 104 124 33 51 230 291 37 49 16 20 Total 17,120 21,529 1,474 1,878 828 1,011 1,034 1,229 281 443 1,830 2,268 241 291 40 50 Table II—Deaf cases. Division. Total no. of examinations made. New cases. Cases carried over from 1931. Old cases returned. Cases cured. Cases partially relieved. Cases unrelieved. Cases requiring no treatment. Lost sight of. Cases transferred elsewhere. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. N.E. 120 205 30 48 3 4 8 15 4 7 1 2 2 4 7 14 S.W. 164 321 23 44 8 14 9 16 14 25 1 2 3 6 — 2 4 S.E. 317 581 49 90 16 29 6 12 22 42 12 23 — 4 8 2 4 N. 198 390 27 51 12 24 4 8 14 22 4 7 3 5 3 6 3 5 3 6 N.W 235 397 21 38 32 56 3 5 5 8 — — — — 1 2 6 11 2 4 Total 1,034 1,894 150 271 68 123 25 45 63 112 21 39 7 13 10 20 20 38 5 10 Table III—Analysis of Otorrhcea Cases. Cause of suppuration. Total ears. Cured. Referred for mastoid operation. Lapsed. Still under treatment. Acute otitis media suppurativa 168 133 5 6 24 Chronic otitis media suppurativa due to (I) Tympanic Conditions (a) Tympanic sepsis (T.S.) simply 1,713 1,273 1 90 349 (b) T.S. + granulations 305 172 28 28 77 (c) T.S. + polypi 37 17 15 — 5 (d) T.S. + caries 19 3 2 — 14 (e) T.S. + other conditions 9 4 2 — 3 (II) Tympanic Conditions + (a) Unhealthy tonsils and adenoids 246 157 1 11 77 (b) Nose conditions 230 150 — 12 68 (c) Mouth conditions 2 2 — — — (III) Tympanic Conditions + (a) Attic disease 138 36 63 11 28 (b) Mastoid disease (no operation yet done) 148 4 131 5 8 (c) Mastoid disease (operation already done) 517 274 37 21 185 (IV) Tympanic Conditions + (a) External otitis 47 40 3 4 (6) Structure of meatus 1 — — — 1 External otitis 103 89 — 2 12 Total 3,683 2,354 285 189 855 25 Table III includes the cases of otorrhœa in children at the residential schools. It will be seen that by deducting the number of lapsed cases from the total number of ears treated, the percentage of cured cases arrived at is 67.4, compared with 65.6 last year. The residential school children, housed at Andover children's homes (if over 5 years old) and at Hornsey Rise children's homes (if under 5 years old) and treated at the after-care clinic, Kentish Town, show the following results:— Otorrhœa cases treated 178 „ „ cured 150 „ „ referred for mastoid operation 17 Still under treatment on 31st December, 1932 11 Residential schools. This shows that 84.2 per cent. of these cases were cured. Besides these otorrhoea cases, there were 29 other children who attended for treatment, but were found to have no otorrhoea at the time of examination. Some of them, however, required the removal of wax or operation for the removal of tonsils and adenoids, etc. During the summer the senior and junior girls of Stanhope-street school were tested by means of the audiometer, and the following are the details of the examination:— Test I.—418 children were examined, 293 satisfied the test, and 125 failed. Test II.—Of the 125 who failed test I, 9 were absent for test II; 71 satisfied this test, and 45 failed, i.e., 11 per cent, failed after test II. Of the 45 children who failed after test II, 8 were absent from the clinical examination and treatment, while 37 children were treated. Test III.—Of the 37 children who were treated, 5 were absent for this test, 16 satisfied the test, and 16 failed, i.e., 4 per cent, only of the whole number examined failed after treatment. At the clinical examination of those who failed after test II, all except three showed clinical evidence of defects which could be responsible for the loss of hearing. The clinical defects found in these children were:— Audiometer. Catarrhal changes in 21 ears. Tonsils and adenoids requiring operation in 6 children. Scars in tympanic membrane in 3 ears. Otorrhoea in 9 ears. Dry perforation in tympanic membrane in 4 ears. Defective nasal conditions in 11 children. Wax in 6 ears. Old mastoid operation in 1 ear. Treatment of these children was followed by improvement sufficiently good to enable 16 to pass test III (i.e., 50 per cent.). Five other children were improved in their hearing, but not sufficiently to enable them to pass test III. Of the 45 children who failed to pass both tests I and II, only 10 had any record of defective hearing on their medical record cards. No case suitable for a hard-of-hearing class was discovered as a result of this special testing. One case appeared in the first instance a possible transfer to a hard-of-hearing school. This child was operated on in the Downs hospital, for mastoid disease, and treated subsequently at the after-care clinic, Kentish Town, where the condition cleared up entirely. Her hearing in consequence was improved sufficiently to enable her to carry on with advantage at the elementary school. Mr. Formby is now devoting Thursday morning in each week to audiometer testing in schools. The following figures give the details of the work done at the after-care clinic, Kentish Town:— Number of attendances of ear, nose and throat cases 6,050 „ patients treated—584, representing 644 ears. Number of ionisation administrations 2,585 „ ultra-violet irradiations 225 „ dressings 3,224 Number of ear patients treated after mastoid operation 256 = 292 ears. other ear patients treated 328 = 352 ears. After-care clinic, Kentish Town. The following are particulars of new patients discharged from Downs hospital during 1932:— Patients. Ears. No treatment required 40 44 Treated at the Council's clinics—now well 2 2 Treated at Kentish Town—now well 107 122 Still under treatment, Kentish Town, on 31st December, 1932 49 55 Still under treatment at the Council's clinics on 31st December, 1932 17 20 Referred back for further operation 10 12 Lost sight of since 8 8 Total 233 263 26 The following are particulars of the cases referred from Downs hospital in 1931, and continuing treatment into 1932:— Patients. Ears. Referred back to Downs hospital for further operation 13 16 Treated at Kentish Town—now well 24 28 Lost sight of 5 7 Total 42 51 In addition to the above the following are particulars of cases which were operated on in Downs hospital and discharged in 1931, but went to the Council's clinics and continued their treatment into 1932:— Patients. Ears. Treated at the Council's clinics—now well 3 3 Still under treatment at the Council's clinics 12 14 Referred back to Downs hospital for further operation 4 6 Lost sight of 4 5 Total 23 28 Teeth. The work at the 68 dental treatment centres has continued during the year on normal lines. No additional centres have been established although there is pressing need for a centre for the large additional school population which has migrated to new housing estates in the Streatham area. If suitable accommodation can be found, steps will be taken to open a centre. The number of sessions devoted to inspection of the children in the schools by the 67 inspecting dental surgeons was 2,462. The number of children examined was 273,737 compared with 268,545 during the year 1931, an increase of 5,192. The number found to require treatment was 174,809, or 63.86 per cent. compared with 64.5 per cent. in 1931. This is the smallest percentage found in the history of the London school dental service. The returns from the treatment centres, including children from allocated schools dealt with at the Eastman clinic, show that during the year 134,769 children were dealt with. This represents a reduction of 4,954 cases as compared with the year 1931, when 139,723 cases were treated, but in addition 3,204 children from unallocated schools were treated at the Eastman clinic. The following table shows the growth of the Council's dental treatment scheme during the past 22 years:— Dental inspection and treatment. Year. Inspection. Treatment. Number inspected. Number found to require treatment. Percentage. Number of centres. Number of cases treated. 1911 No information available. - 3 5,720 1912 Do. - 7 9.799 1913 31,858 25,492 80.0 18 20,130 1914 56,491 46,290 81.9 25 32,439 1915 69,516 56,864 81.8 29 44,875 1916 81,794 66,624 81.5 31 49,844 1917 89,962 71,447 79.4 36 56,913 1918 106,586 83,068 77.9 43 68,445 1919 144,456 112,227 77.0 43 79,216 1920 154,347 115,619 75.0 47 89,456 1921 151,395 111,250 73.5 48 94,177 1922 192,730 137,487 72.5 48 84,848 1923 236,658 166,454 70.3 53 95,332 1924 256,542 178.802 69.7 54 99,045 1925 262,482 182,524 69.5 56 112,964 1926 237,022 163,422 68.9 57 113,932 1927 224,553 157,537 70.1 61 124,992 1928 226,279 156,001 68.9 63 129,255 1929 240,040 163,114 67.9 64 129,953 1930 251,251 165,616 65.9 65 138,280 1931 268,545 173,180 64.5 68 139,723 1932 273,737 174,809 63.9 68 134,769 27 The special arrangement under which the entire dental supervision of the children attending certain schools in the neighbourhood is dealt with by the authorities of the Eastman clinic has continued during the year. When the scheme was inaugurated in May, 1931, three schools, viz., Cromer-street, Manchester-street and Prospect-terrace were concerned in the arrangement. During 1932 the following schools have been added to the number: St. Alban's, St. Peter's Italian (Holborn), Blundell-street, Buckingham-street, Gilford-street, York-road (Islington, W.), St. Pancras (C.E.), Lancing-street, Thanet-street (St. Pancras, S.E.), Exmouthstreet, Netley-street, and Stanhope-street (St. Pancras, S.W.). It was originally the practice for a portable dental chair to be taken to each school, and for the mouths of the children to be charted in detail, under supervision of a qualified dental surgeon, by dental nurses or hygienists, who at the same time undertook prophylactic work where necessary. The latter arrangement, which is still in force, occupies a considerable amount of time, and, although a complete index of the condition of a child's mouth is very desirable, it is of little or no value if the child fails to attend the clinic for treatment. The unavoidable disturbance of the normal school routine by the prolonged attendance of the dentists and dental hygienists caused the authorities of the Eastman clinic to cease the practice of using the portable chair in the schools, and the question of limiting the charting to an indication on the record card as to whether the child's mouth is healthy or in need of treatment is under consideration. By this arrangement less time would be spent in the schools, but a more thorough examination of the mouth would be necessary when the child first attended the clinic for treatment. To secure the attendance of the children the authorities of the clinic have arranged for a conveyance to call at the various schools to collect such cases as are required to attend, and transport them to the clinic. The parents are notified in advance and are asked to be present at the clinic at the appropriate time to receive their children after treatment. During the year 1932 the total number of children from the schools concerned, who were dealt with at the clinic, was 3,323. In addition, 3,204 children from unallocated schools were treated. The work is undertaken by the authorities of the Eastman clinic without charge to the Council. A small number of scholarship and central school cases are, however, treated at the clinic at an inclusive charge to the Council of 7s. a case, this being the average cost per case at the centres throughout London. During 1932 the number of these cases treated was 7. Eastman clinic. The special dental centre at 22, Gainsborough-road, Hackney Wick, established in May, 1929, and financed by the Manor Charitable Trust, was closed at the end of March, 1932. It is intended that work on the lines of this special centre shall be continued through the Trust for the Berkshire-road school children if suitable accommodation at that school can be made available for the purpose. The Wick special centre. A special scheme of dental inspection and treatment was introduced in connection with the Prunella centre, 31, Cable-street, St. George-in-the-East, when it was opened in January, 1927. This experiment was instituted as a result of suggestions made by officers of the Board of Education in 1926. The main variations in the scheme from the ordinary routine followed generally at other dental centres were that a combined inspection and treatment record card was used; that sporadic and medical cases were treated separately from the scheme proper, but were brought into the scheme subsequently by being re-inspected by the dentist, these cases being recorded on a combined record card of a distinctive colour ; that a simple consent form was used, which covered all forms of dental treatment including treatment under a general anaesthetic; and that cases found at dental inspections to require gas treatment were given gas appointments in the first instance. As a result of the working of this experiment extending over six years, it became evident that the scheme was too elaborate, and involved a considerable amount of unnecessary labour on the part of the dental surgeon, head teachers and organisers, without commensurate results. It was therefore decided that, after the summer holidays, 1932, the work at the Prunella centre should be organised on the same lines as other centres in London, and the special scheme abandoned. One clear Speciarl dental scheme at Prunella centre. C 2 28 advantage, however, emerged from the scheme and this was the making of direct "gas" appointments at the dental inspections in the schools. By this method at least one visit to the centre prior to the gas appointment is saved, and this arrangement is being continued, and has, moreover, been applied in connection with other centres in London. In making direct appointments it is essential that the dental surgeon satisfies himself that no filling is also required, as it is the experience generally that any necessary fillings shall be undertaken before treatment under an anaesthetic is given. Remedial exercises. The Council s medical treatment scheme does not include general subsidies for the treatment of orthopaedic cases. These are dealt with through the special and general hospitals of the Council and at voluntary orthopaedic hospitals and orthopaedic departments of general voluntary hospitals. There is, however, one centre at Woolwich, organised by the Woolwich Invalid Children's Aid Association, which is assisted financially by the Council, owing to the distances to be travelled by the child patients when attending hospitals in central London. At this remedial clinic children suffering from paralysis, congenital deformities, rickets, poliomyelitis and other crippling defects are given massage, manipulation, electrical treatment and exercises. Mr. P. B. Roth, the visiting orthopaedic surgeon, attends the clinic regularly, and Dr. H. R. Kidner acts as medical officer. The clinic is very popular and the majority of the children are referred there by school doctors and the medical officers of the borough welfare centres. Charges to parents. For many years the standard charge made by the Council to parents in respect of medical and dental treatment of school children has been 2s., covering all necessary treatment for a period of 6 months. In the case of minor ailments free treatment has been given for the first fortnight after which 1s. is charged, and, where slight treatment only has been given in dental cases, the charge has been 1s. From 1st April, 1932, these charges were varied in certain instances. Firstly, the charge for operative treatment of enlarged tonsils and adenoids was increased from 2s. to 5s. All children operated on under the Council's scheme are retained in the various centres as in-patients. Although the cost to the Council has been considerably increased, viz., by 7s. 3d. a case, compared with the cost when children were treated as out-patients, the charge to the parents has remained the same. It was therefore considered equitable that the charge of 2s. should be increased to 5s. Parents appreciate the care and attention given to their children in the wards, and it was found that some were desirous of giving more than the amount charged, as a mark of their appreciation. Secondly, in those dental cases where extensive treatment is undertaken the charge was increased to 3s., the normal charge for ordinary cases remaining at 2s. The aim of the dental service is to secure that the children commence treatment in the early stages of dental decay, when teeth can be saved. Accordingly, with a view to encouraging early treatment, 1s. only has been charged when slight treatment only has been necessary. The average cost to the Council of dental cases is approximately 7s. Although there has been a slight falhng off in the number of cases treated, the total amount collected from parents has increased. So far as those parents who are unable to pay are concerned, it is made clear to them that the care committees will reduce the charge by 50 per cent., or remit it altogether. Salaries of officers. Following the general lines adopted throughout the Council s service, the various members of the staff of the school treatment centres and hospitals agreed to a voluntary reduction in their salaries amounting on an average to 5 per cent., and this was put into operation on 1st April, 1932, for a period of twelve months. The reductions in respect of service on one session a week were as follows:—eye, ear, nose and throat, and ringworm surgeons from £80 to £75 15s. a year, aural and dental anaesthetists from £75 to £71 5s. a year, minor ailments doctors from £66 to £62 18s. 6d. a year, and dental surgeons from £60 to £57 7s. 6d. a year. Stammering children. At the eight centres maintained for the treatment of stammerers a total of 371 children attended during the year; of these, 47 were discharged as cured and 36 as 29 provisionally cured, while 78, many of whom had greatly improved, left for various reasons. The 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 instructress on each half day. Dr. E. J. Boome reports as follows:— In former reports mention has been made of the use of relaxation as an essential part of the treatment of stammerers. The importance of this has been further demonstrated during the past year. Still further emphasis has been laid upon it, and the technique has been improved with beneficial results. Greater stress has been laid on the value of practising relaxation at home, and the card of instructions has been altered to meet this. The extent to which quite young children can bring about a state of mental and physical repose is surprising. This complete relaxation, however, depends entirely, in the earlier stages, upon the personality and experience of the instructress. Opportunity to acquire this experience is now given by the Council to selected candidates who wish to pursue the method. As a result of this training, several student-assistants have obtained posts with other local authorities. During the past year distinguished visitors from the provinces, the dominions and several foreign countries have been welcomed at the centres. Many of these visitors came with the object of gaining information with a view to instituting the same method in their own areas. An experimental meeting of parents was tried at three of the centres by Miss M. A. Richardson. The number of mothers sufficiently interested to come to the meeting was disappointing, but the keenness of those who did attend more than compensated for this. In each case the instructress gave a short address, which was followed by questions and the discussion of problems and difficulties. Several parents remained after the meeting for further advice. One of the chief difficulties of treatment still remaining is the lack of interest—if not direct opposition—shown by some of the parents, e.g., one mother did not attend the meeting because she " had to wash up," and another because she " forgot " ! The care committee has rendered valuable assistance in many of these cases, but there is no doubt that a child whose relatives at home do not co-operate makes slower progress. Personal hygiene scheme. The number of examinations made by school nurses at rota visits during 1932 was 1,992,748, and verminous conditions were found in 195,534 cases, or 9.8 per cent., compared with 10.6 per cent. of cases examined in 1931. 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. Per. centage. Verminous children referred to centres. Subsequently cleansed by parents. Verminous children cleansed at centres. Scabies and impetigo cases bathed at centres. 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 1932 1,992,748 195,534 9.8 116,139 23,896 92,243 5,125 Of the 195,534 cases in which verminous conditions were noted, 111,071 (56-8 per cent.) were found to have nits only. The figures shown in the second, third and fourth columns are obtained from the records made by the school nurses themselves as a result of their rota visits. At each rota visit all the children in the school are examined. Such rota visits are made at least once a term to each school, but to some schools, where, generally speaking, conditions are below the normal, additional rota visits are paid each term. It follows, therefore, that each child should have at least three inspections in a year, and it is probable that a certain number of verminous cases are tabulated more than once in the course of the year. This has proved a convenient method of determining the standard of cleanliness, and has been adopted for many years. The Board of Education have, however, expressed a desire for a return giving the 30 number of individual children found to be verminous in the course of the year as distinct from the record of instances of uncleanliness, and arrangements have accordingly been made for this individual figure to be obtained in connection with the records for 1933. A high standard is required before a child is classified as "clean." Even if only afflicted with a few nits, a child is classed as verminous, and the condition brought to the notice of the parents. The advice cards definitely set out the methods which can be adopted for remedying the condition; and the nursing staff at the cleansing centres can requisition from the supplies department a stock of special metal combs for sale to parents. There are now 10 Council centres, 20 borough council centres, and 10 centres organised by voluntary committees; but, as the last named are limited to head cleansings, these are not equipped with sterilisers or baths. A small sub-centre organised by a voluntary committee at Putney began operations in 1932. The following particulars for 1932 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 90,800 Number of children attending voluntarily at bathing centres after advice cards 45,972 Number of statutory notices served in accordance with section 87 of the Education Act, 1921 24,248 Number attending bathing centres after statutory notices— (а) voluntarily 4,793 (b) compulsorily 16,139 Number of cases in which police court proceedings were taken 279 As in the case of the rota inspections these returns have been obtained from terminal records, and here again it is probable that certain children are reported more than once during the year. The problem of the repeated attendance is a difficult one, having regard to the serious lack of facilities in many homes; on the other hand the constant repetition of voluntary facilities offered by the Council is liable to be abused, and a proposal is to be considered that, if a child once attends voluntarily at a centre as a result of the invitation set out on the advice card, the next notice, a statutory one, should not contain an offer of a voluntary attendance at a cleansing centre. Ambulances are provided for the conveyance of children from out-lying schools to the bathing centres. During 1932,11,923 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 30,405 in 1932, compared with 34,529 in 1931. Use of Borough Councils' washing baths. Health Classes. Health classes are authorised by the Education Committee and organised in schools where special facilities exist. A number of pupils not exceeding 25, selected by the school doctor, are taken daily for physical exercises, preferably in the open-air, by a teacher on the ordinary staff of the school who is especially experienced. They are intended to correct posture deformities of the spine and feet in an early stage, and by giving the children simple appropriate exercises more frequently than is possible generally, to prevent the development of more advanced conditions of flat-foot or spinal curvature. Formerly these classes were more numerous in the schools, and produced very satisfactory results. Unfortunately, for various reasons the number of health classes has decreased. In 1932 they numbered 74. 29 being in bovs' and 45 in girls' departments. 31 Two special reports on these classes have been received from the school doctors, Dr. E. M. Johnson reports as follows:— Priory-grove (boys') school A health class has been held at the Priory-grove (boys ) school for half an hour each morning in the playground, except in wet or foggy weather. The number of boys in the class is usually about 23 ; the total number for the year (including leavers) is 26. The boys vary in age from 9 to 13 years. The majority of the boys are suffering from slight degrees of scoliosis, kyphosis or flat-foot, the remainder from malnutrition or "poor physique." Of the 26 boys, 17 show definite improvement in chest expansion measurements, in 9 boys there is no improvement. The majority of the boys show improvement in colour and physique, and the cases of scoliosis and kyphosis have much benefited as a result of the daily exercises. Dr. G. Pollock reports as follows:— Mantua- street (girls') school. The health class at Mantua-street (girls') school was continued throughout the year in practically the same way as in the past few years. The class has had the benefit of the same teacher during all the time it has been held. Both teacher and girls take part in the class with enthusiasm. All the defects treated were of a comparatively minor nature, such as slight stoop, lordosis, elevation of one shoulder, slight lateral curvature, or faulty attitude when at schoolwork. Some of the children had no very obvious defect, but it was thought that the exercises would have a beneficial effect on them generally. All the children showed some definite improvement. On 1st March, 1932, 21 children were examined, but before the end of the year 5 children had left the school, so that only 16 had three examinations, the last of which was on 29th November, 1932. The head teacher continues to be much interested in the class, and there should be no difficulty in having another health class for 1933. Rheumatism scheme. The following statistics show the operation and growth of the rheumatism Statistics, scheme during 1932; corresponding figures for two previous years are also shown:— 1930. 1931. 1932 Number of nominations 639 943 1,234 „ „ children admitted to special hospitals 324 655 953 Cases seen by medical referee in voluntary hospitals 86 181 257 „ „ ,, „ in their homes 147 391 501 „ „ „ „ at supervisory centres 86 140 291 ,, „ ,, „ at County Hall 18 26 109 Reports made by care committees on home conditions 307 551 814 " Following-up " reports made by care committees 391 631 693 Cases seen at County Hall on return from hospital 210 222 597 Re-examinations by school doctors 505 645 1,188 Number of children attending supervisory centres for first time 1,387 1,792 2,001 Total number of attendances at supervisory centres 6,670 9,767 12,833 Number of cases reported to medical officers of health re dampness, etc., or to housing manager for better accommodation 67 115 152 The figures show very strikingly how in two years this work has doubled. Dr. Banks Raffle is mainly responsible for the following report on the work of the rheumatism section:— During the year 1932, 1,234 nominations for hospital treatment under the rheumatism scheme were received. The admissions to hospital, or for convalescent treatment, reached the unprecedented figure of 953. The total number of children attending the rheumatism supervisory centres was 4,538. The school doctors reported specially on 1,047 children who had received hospital treatment under the scheme, this number being in addition to the children who, after hospital treatment, had been passed to the rheumatism supervisory centres for followingup. The rheumatism register at the County Hall contained the names of more than 23,000 rheumatic children resident in the administrative county of London. These figures give some idea of the growth of a scheme which began in a small way in 1926. The increase in the number of nominations for hospital treatment, 1,234 in 1932, compared with 943 in 1931, is to be attributed to the knowledge of the nominating agencies that the scheme had increased accommodation at its disposal. The voluntary hospitals nominated 635 children, the rheumatism supervisory centres 275, and school doctors and child care committees 185. Other nominating agencies contributed a similar proportion of the total nominations to that in previous years, except that there was an increase in the number of recommendations by 32 private doctors and of direct applications from the parents of children. In addition to the 1,234 nominations received during 1932, there were 41 nominations remaining for consideration at the end of 1931, which made a total of 1,275 nominations to be dealt with by the section during the year. The distribution of these nominations throughout the year was in accordance with past experience. During the months from April to September, inclusive, 606 children (263 boys and 343 girls) were recommended, and during the remainder of the year 628 (243 boys and 385 girls). This confirms the opinion that rheumatism is by no means confined to the so-called "rheumatism months," and that the sex ratio of the disease is upset during the summer months by an increase in the number of boys affected. From the beginning of May the task of dealing with so large a number of children was lightened by the provision of more beds at Queen Mary's hospital, Carshalton, and of accommodation at the Downs hospital, Sutton, for children convalescent from rheumatic attacks and for cases of advanced heart disease, for both of which categories the public provision was quite inadequate. Hospital treatment or convalescence was provided for 953 children (861 first admissions and 92 re-admissions). Of these 428 were boys and 525 girls. The medical referees reported that 73 of the children nominated for admission to hospital were not suitable for hospital treatment or convalescence under the scheme. Parents refused treatment for their children in 70 cases; 38 children were admitted to other hospitals after being nominated to the section for treatment; one child died of diphtheria whilst awaiting consideration, and a girl received convalescent treatment through the general hospitals organisation as she was more suitable for a convalescent home for adults. Of the remaining 139 nominations, 69 had been reported suitable for treatment and were awaiting admission to hospital at the end of the year; there were 10 nominations received during the last week in December, the refereeing of which was undertaken in the beginning of 1933, and there were 60 children nominated early in the year who could not be considered for treatment owing to the shortage of beds before May and were left to voluntary agencies to deal with. In order to preserve statistical continuity with former reports the cases admitted to Queen Mary's hospital, Carshalton, and those admitted to High Wood hospital, Brentwood, are analysed separately. These children had not previously had hospital treatment under the scheme. During the year 534 (255 boys and 279 girls) were treated at Queen Mary's hospital, Carshalton. and 189 (53 boys and 136 girls) at High Wood hospital, Brentwood. The average age of these children on being accepted fpr treatment was about the same as that of those admitted last year—nine and a half years. The age of onset of the first symptoms of rheumatism was ascertained from the histories of 689 of these children. In 286 children (41 per cent.) the onset was in the 6-8 age period, which agrees with the findings of the investigation of 1.700 case histories recorded in the report for 1930. The variety of rheumatism from which these children were suffering was:— Boys. Girls. Total. Articular rheumatism 229 299 528 Chorea 79 116 195 308 415 723 There were 35 cases (15 boys and 20 girls) of acute articular rheumatism amongst these children and 13 cases (6 boys and 7 girls) of acute chorea. These children were admitted to hospital within a few hours of their being reported, through the valuable co-operation of the medical superintendents of Queen Mary's hospital, Carshalton, and High Wood hospital, Brentwood. This co-operation could not be more fully demonstrated than by the fact that during the past three years every child reported to be suffering from acute rheumatism or acute chorea and certified by a medical referee for treatment as an acute case, has been provided with immediate treatment in one of these hospitals. 33 The heart was reported to be affected in 392 children (154 boys and 238 girls) admitted to Queen Mary's hospital, Carshalton, or to High Wood hospital, Brentwood. Of the 528 cases of articular rheumatism, valvular disease of the heart was diagnosed in 184 (65 boys and 119 girls), carditis in 122 (58 boys and 64 girls), while 7 children (3 boys and 4 girls) were suffering from congenital heart disease. Amongst the 195 cases of chorea there were 47 children (18 boys and 29 girls) with valvular disease of the heart, and 32 (10 boys and 22 girls) with carditis. Several of the cases of carditis showed a rheumatic infection superimposed on a congenital heart lesion and evidence is being accumulated in support of the hypothesis that the congenitally deformed heart falls an easier victim to the rheumatic infection than does the normal heart. The Downs hospital, Sutton, admitted 138 children (64 boys and 74 girls) during 1932. As has already been stated these children would not have been considered suitable for treatment under the rheumatism scheme as originally organised. The ability to provide for these cases marks a distinct step forward in the attempt to deal with the problem of the rheumatic child in London. This is particularly true of the provision of supervised convalescence for children who are well on the way to recovery from a rheumatic attack, for convalescence of an ordinary character does not provide for the medical oversight which is essential in these cases. Of the children admitted to the Downs hospital, Sutton, 116 (62 boys and 54 girls) were or had been suffering from articular rheumatism, and 22 (10 boys and 12 girls) from chorea. Advanced heart disease was present in 31 (16 boys and 15 girls), and 107 (48 boys and 59 girls) were in a convalescent stage. There were re-admitted to hospital during 1932, 92 children (56 boys and 36 girls) who had been previously receiving hospital treatment under the rheumatism scheme. Acute articular rheumatism had developed in 4 (2 boys and 2 girls), acute chorea in 2 (1 boy and 1 girl), sub-acute rheumatism was present in 51 (18 boys and 33 girls) and sub-acute chorea in 35 (7 boys and 28 girls). Valvular disease of the heart was diagnosed in 27 (9 boys and 18 girls) of the children suffering from articular rheumatism, and in 8 (3 boys and 5 girls) of those suffering from chorea. The discharges from hospital during the year were 843 (380 boys and 463 girls). On admission to hospital 663 (296 boys and 367 girls) were suffering from articular rheumatism and 180 (84 boys and 96 girls) from chorea. On discharge 301 (112 boys and 189 girls) had valvular disease of the heart and there were 9 cases of congenital heart disease (2 boys and 7 girls). The average length of stay in hospital of these children was rather more than six months. Of the 843 children discharged from hospital during the year, 572 (253 boys and 319 girls) were reported as being fit for the ordinary curriculum of an elementary school, 137 (72 boys and 65 girls) were deemed suitable for an elementary school with restriction of games and drill, 97 (42 boys and 55 girls) were certified for schools for physically defective children, 30 (7 boys and 23 girls) were over school age, and in 7 cases (6 boys and 1 girl) the parents of the children had removed outside the county area whilst their children were receiving treatment in hospital. There were 11 deaths (4 boys and 7 girls) in hospital during the year. Of these children 2 had been admitted for treatment in 1930, 4 in 1931 and 5 in 1932. From 1st May, 1932, to the end of the year accommodation was provided for all children nominated and coming within the scope of the scheme. In all cases where this was possible the children nominated were examined within seven days of such nomination, and, except for a week or two at the end of the year when there was a little delay the admission of suitable cases to hospital followed promptly. Summary. In the report for 1931 it was stated that the pressure of work had fallen with particular severity on two of the centres which are responsible for the supervision of children suffering from rheumatism. The centre at the Queen's hospital for children had been over-worked during the whole of 1931, and to relieve this centre an additional rheumatism centre was opened in April, 1932, at the school treatment centre in Church-street, Stoke Newington. The monthly session held at Putney was found to be inadequate to the needs of the district and from April, 1932, sessions took place fortnightly. It was also found necessary to hold an extra weekly session Rheumatism supervisory centres. 34 at the Royal Waterloo hospital during part of the year and extra sessions have been provided at the Hammersmith centre to cope with the growing attendance at this centre. It must be remembered that the children attending rheumatism supervisory centres do so for a lengthy period; and, in a comparatively new scheme, the children who were attending the centres in former years are still attending, whilst each year many children recently attacked by rheumatism are added to the numbers on the roll of the centres. During the past year 4,538 children attended the sixteen centres now distributed through the administrative county; these children made 12,883 attendances and there were amongst them 2,001 children attending for the first time. The work of the individual centres is analysed in the subjoined table:— Name of rheumatism supervisory centre. Number of children attending during 1932. Number of new cases. Attendances of old cases. Total attendances. Average number per session. No. of children from the centre who received hospital treatment or convalescence under rheumatism scheme. Downham 297 105 473 578 13 27 " Elizabeth Bullock " 258 103 469 572 13.3 22 Eltham 138 109 242 351 9 18 Hammersmith 291 150 491 641 16 14 Hospital for sick children (Gt.Ormond-street) 488 191 1,959 2,150 7.1 15 King's College hospital 281 134 876 1,010 23 9 Lewisham 276 139 407 546 12.1 22 Princess Elizabeth of York hospital (Shadwell) 340 140 514 654 15.9 48 Putney 136 80 176 256 12.8 17 Queen's hospital for children 598 157 1,327 1,484 30 31 Royal Free hospital 286 146 1,051 1,197 26.6 21 Royal Waterloo hospital 577 224 1,780 2,004 24.7 15 St. George's hospital 178 105 286 391 9.3 2 St. Marylebone general dispensary 105 42 434 476 10 4 Stoke Newington 82 82 164 246 7.2 1 Woolwich 207 94 233 327 8 9 Total 4,538 2,001 10,882 12,883 — 275 Education of myopes. Special inquiries. Dr. E. M. McVail has written the following report upon the special classes for myopic children in central schools:— Two classes for myopes were opened in April, 1928, one at the Ensham central school and the other at the Hugh Myddelton central school. Both classes are mixed, and with occasional exceptions the maximum roll is in each case 22, allowing an average attendance of 20. It is now possible to report with some assurance on the results of these classes. At the Ensham central school the special classroom for myopes is within the central school premises on an upper floor, and is light, airy and furnished with special appliances for the short-sighted. Information as to the children's scholastic work has been taken largely from notes very kindly supplied by the head master. Boys and girls attend the ordinary central school classes, and are arranged in five groups according to the year in which they are working. Unlike the ordinary central school pupils, they return to their own classroom, where they have supervision by a special teacher, for periods of rest from close work, and for " home work " under sight-saving conditions. Certain children are allowed by the school oculist to read books with clear print for short and stated periods, the time varying in each case according to the condition of the eyes. Others with worse defect are, for a quarter of an hour twice a day, allowed to read notes made by the touch method with a " Bulletin " typewriter. "At least one text book has been copied in this 35 large type for the use of the short-sighted. Where the myopia is high and progressive, or where fundus changes are marked, the children are kept strictly to myopic regulations, and are read to by others. In teaching, various devices such as French gramophone records are used, and full advantage is taken of the metal and woodwork, laundry and cookery centres attached to the school. At these centres modification to suit the myopes is made in work such as drawing and measuring, the children's interests are diverted from book work, and much valuable training is given. Four myopes were successful at the London Chamber of Commerce examination during the year 1931-32, gaining distinctions in geography (3), English (2), arithmetic (2), and history (1), and passes in English (2), history (1) and French (1). These attainments bear witness to the fact that, in spite of the handicap of short sight, the myopes compare very favourably with the normal central school pupils. Examinations of this type are specially suitable for myopes, in that subjects can be taken singly or several at a time. By arrangement with the examining bodies, all public examinations of myopes both at secondary and central schools are taken under sight-saving conditions. The headmaster reports that in the school examinations of March, 1932, myopes were, in science, first in four classes and third in one; in mathematics, first in two classes and second in three; in art, first and second in one class; in English, first in one class, fourth in one and fifth in two; in history, first in two classes, second in two and fifth in one; in geography, first in two classes and second in one; and in French, first in two classes. In memory tests in particular the myopes are said to excel. Drawing is done on a large scale, and one boy has designed a poster which has been accepted for exhibition by the Royal Society of Arts at South Kensington. The above results speak for themselves. On leaving school the teachers give valuable advice and help to myopes in obtaining suitable occupations, and their special teacher, who, by her cheerfulness and efficiency, has had much influence with the children, has taken a particular interest in this matter. Three of those who took London Chamber of Commerce examinations have now left school. One hopes to become a commercial traveller; another studies pharmacy and is with a firm of chemists, and a third is training as a buyer in a sheet and blanket firm. Of the others who have left, one went to the stationery department of a large warehouse, one to train as a saleswoman in a gown shop, one to work as a florist, one to the piano department of a well-known firm, and one to do light work on a farm. Only one child took up clerical work, and it is believed that she has since obtained more suitable employment. Records of a total of 15 myopes who have been at the school for two years or more show that the mean average increase of the myopia has been 0-214 dioptre per eye per year. At the Hugh Myddelton central school there was until recently only the technical bias, commercial training having been introduced for the first time this year. No pupils have yet sat for the London Chamber of Commerce examinations. Instruction is, on the whole, similai to that at the Ensham central school. " Bulletin " typewriters, which are a great advantage in the higher education of myopes, have not yet been introduced. The myopes are also handicapped by the fact that their special classroom is in the school for the mentally defective, apart from the central school building, and is on the ground floor where lighting is not of the best. Their special teacher is, however, keen and enthusiastic, and by hard work has managed to overcome many difficulties, in which she is helped by the head master and staff. The results of the last yearly examinations show that at this school also the myopes, as a rule, do more than hold their own amongst the ordinary children. Out of 16 classes, myopes were first in two, second in one and third in three. When possible the parents of myopes leaving school are seen by the special teacher and advised as to suitable occupations. Of 15 who have left one is an outdoor assistant to a grocer, one (a girl, not myopic, but with nystagmus and defective vision) is training as a dancer, two work in stock rooms of a domestic bazaar and of a wholesale jeweller, one does domestic work at home, one is a general hand in a printing factory, one is with a firm of cabinet makers, one helps his father on a farm, one is in a silk merchant's warehouse, one is training in laundry supervision, and one is in a cricket-bat factory. So far as can be ascertained, only four have taken up unsuitable occupations, two being clerks, one a hairdresser, and one in his father's tailoring shop. The mean average increase in a total of 15 myopes who have been at the school for two years or more is 0 • 195 dioptre per eye per year. As a result of this investigation it has been decided that, if and when possible, there should be some extension of the higher education of myopes at central schools. If possible the special classroom will in all cases be within the building used by the ordinary children. Increase in myopia. Dr. J. H. Mcllroy has conducted an investigation into the incidence and progress of myopia in school children attending treatment centres between 1926 and 1933. During this period 284 children were repeatedly examined under cycloplegia ; and, of 137 boys, 77 per cent, were found to be hypermetropic and 23 per cent, myopic ; while of 147 girls, 73 per cent, were hypermetropic and 27 per cent, myopic ; 36 indicating a higher incidence of myopia in girls. The annual average rate of progress towards myopia in hypermetropics, and towards higher myopia in myopes was among boys .27 dioptres, and among girls .30 dioptres; showing a higher rate of progress towards myopia in girls than boys. Dr. Mcllroy's paper will be published in full in the Medical Supplement (Vol. IV, Part III) to this Report, illustrated by charts, which show how a certain number of children who commenced with hypermetropia ended with myopia, and the exact age at which this change took place. 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. 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. As the result of the additional stress thrown upon the scheme by unemployment, the number of cases in which the school doctors' opinion has been sought in connection with school feeding has very considerably increased. The following are the statistics of meals provided by the Education Committee to children in ordinary elementary schools :— Number of individual children (December, 1932). Meal. On payment. Free. lity accepted by Public Assistance Committee. Dinners 1,096 6,311 497 Milk 13,877 10,787 Cod-liver oil and malt . 3,286 1,948 — Over and above the official scheme detailed above, there are in the schools many clubs, on a voluntary basis, for the provision of milk. In a report made during 1931 it was stated that there were 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 were 152 clubs supplying 10,000 children not under the " bottle " scheme. It is now stated that there are about 100,000 children obtaining milk at school through voluntary milk clubs. Samples of meals, as served, are taken from time to time for examination in the central laboratory at County Hall. One sample has been taken during the year, and was found to be satisfactory. Milk samples. 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 459. Of this number 420 were found to be satisfactory, the remaining 39 being found to be unsatisfactory, by reason either of the presence of extraneous matter (31), deficiency of fat (6), or by the addition of water (2). The quality of supplies under these contracts as shown by chemical examination continues to improve, although the presence of extraneous matter in such a proportion of the consignment leaves room for greater precautions in the handling of the supplies. With the exception of open-air schools, milk supplied under contract for school children is not required to conform to any bacteriological standards such as are 37 required under the Milk (Special Designations) Order, 1923, it being subject only to the proviso that is shall be entirely "pure new milk . . . clean and perfectly sweet on delivery." With a view to securing a better control, however, the scheme referred to in my report of last year, 1931, has been carried into effect. In order to include bacteriological examinations, a standard has been devised of what would be regarded as ordinary clean milk. The standard adopted was:—Bacteriological content—not more than 300,000 per c.c.; B. coli not to be present in 1/1,000th c.c. If below these standards the chief officer of supplies was informed that the milk could not be regarded as satisfactory. The results of these examinations are tabulated below:— Raw Milk. Conforming to standard 135 Not conforming to standard— B. coli present in 1/1,000th c.c., but bacterial count below 300,000 42 Bacterial count exceeding 300,000 per c.c., but conforming to B. coli standard 9 Bacterial count exceeding 300,000 per c.c., together with excess of B. coli 10 61 Samples examined 196 Pasteurised Milk. Open-air school— Conforming to standard 1 Not conforming to standard— B. coli present in 1/1,000th c.c., but bacterial count below 100,000 1 Bacterial count exceeding 100,000 per c.c., but conforming to B. coli standard 1 Bacterial count exceeding 100,000 per c.c., together with excess of B. coli 2 4 Samples examined 5 In my report of last year I referred to the arrangement then being made for the co-operation of the medical officers of health of the metropolitan boroughs in the examination of milk supplied to the Council's schools in their respective boroughs. From results received under this arrangement it is found that 687 samples of supplies have been examined chemically and 135 bacteriologically during the year. Of the former number about 4.5 per cent. were found to be unsatisfactory whilst of the latter about 5 per cent. failed to conform to the standard as to 300,000 bacteria per c.c. or to the presence of B. coli in 1/1,000th c.c. In all these cases suitable action was taken by the medical officer of health of the borough concerned. It will be seen that the medical officers of health of the metropolitan boroughs have rendered valuable assistance in this work of safeguarding the quality of the milk supplies to necessitous and other school children. Provision of mealscomparative inquiry. In June, 1932, the education officer and school medical officer were instructed to select certain provided and non-provided schools from a list supplied by the comptroller of the Council for a detailed comparative enquiry as to the provision of meals therein. The medical enquiries arising out of this instruction were carried out by Mr. R. H. Simpson, M.D., M.R.C.P., an assistant medical officer. Dr. Simpson's report covered four lines of enquiry, as set out below:— (i) The examination of children who were having dinners. It was found that the necessitous children provided with free dinners were generally healthy and in a good state of nutrition. Only 5 children out of 174 examined were considered to be undernourished. The proportion of the children in the non-provided schools having free meals exceeded that in the provided schools by about 4 to 1. It was thought that divergence of opinion as to the standard of necessity could not account for the whole of this disproportion, although the adoption of a less critical attitude in certain non-provided schools contributed in no small measure to the disproportionate result. 38 There was, however, evidence that the children were on the whole poorer in the non-provided than in the provided schools. (ii) The consideration of children being given milk at schools. The number of children belonging to voluntary milk clubs was found to be about 6 per cent. greater in the provided than in the non-provided schools. The proportion recommended milk by the school doctors was the same in both groups. There was no evidence that the lower percentage of dinner cases in some schools was due to free milk being given in place of dinners. (iii) A review of unselected records of sub-normal children in the two groups of schools who were not on the free dinner list. The proportion of free cases of milk or cod liver oil meals amongst these children was nearly twice as great in the non-provided as in the provided schools. In both groups of schools about 80 per cent. of the sub-normal children had been treated fully according to the doctors' recommendation and an additional 10 per cent. in part. (iv) An examination in the two groups of schools of sample records of children recommended for treatment for defective vision. This was a "control" observation intended to test the care committee activities in the two groups of schools in a matter unconnected with the question of feeding. As the result it was found that rather better results were obtained in the provided than in the non-provided schools. Provision. IA/I/I C/U/ l/W / V . Provision for education in the open air includes nine day open-air schools (non-tuberculosis) with accommodation for 1,627 children, and six day open-air schools (tuberculosis) accommodating 618 children. There are also seven country and seaside convalescent camp schools, accommodating 518 children for periods varying from one to three months, through which 4,479 children pass annually; and 210 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, organised in the summer of 1931 in consequence of an offer from the Shaftesbury Society of their school at Loughton (Epping Forest) to be used as an open-air school for ailing mentally defective children. 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. The reports made on the experiment were favourable in all respects, and provision was made for the opening of the school again for two months in 1932. By the generosity of Mrs. Warren, chairman of managers of Bravington-road school for the mentally defective, the Council was enabled to conduct the school for a third month especially for the benefit of ailing mentally defective girls. Arrangements similar to those of last year were accordingly made with the Shaftesbury Society. The children were selected by the school medical officer, and 25 boys went to the school in May, 24 younger girls in June, and 25 older girls in August. Medical reports, letters of thanks from parents, and reports from head teachers of day schools from which the children were selected, all affirm that the experiment was an unqualified success again this year, the children being brighter and more responsive since their return. This experiment has shown beyond all doubt that ailing children sent to such a school are enabled by improved health and training to derive greater advantage thereafter from their education at the day schools for the mentally defective. The gross cost of the school under the very favourable terms offered by the Shaftesbury Society amounts to £120 for a period of four weeks. 39 The school was visited periodically by medical officers of the public health department. One of these officers, Dr. Boome, submitted the following report:— There were eight cases of kyphosis (bending of the spine) in the last party, who were materially improved by their stay here. Also in the party there were four cases of enuresis (bed wetting), which cleared up before the end of their stay. All the children, with the exception of one girl, gained weight there. This girl lost 4 lbs. at the end of the first fortnight, but subsequently attained her original weight. There is no doubt that this year, as in 1931, the experiment has justified itself. These children have gained not only improved health, but a different outlook. The results obtained have been of a very high standard, and will doubtless express themselves in the later lives of these children, increasing the possibility of their becoming self-supporting members of the community. The enthusiastic work of the teachers has been an essential factor in the successful working of the scheme which, in my opinion, has a real economic value. Dr. E. M. McVail reported as follows on the girls:— The children on the whole showed very marked benefit from their stay. Their pleasure in their surroundings and their response to the kindness and efficiency of their head mistress were very evident. Either cabbage or lettuce was given daily, and in addition to the ordinary meals each child had an apple. The mid-day meal inspected was plentiful and appetising. On warm days the children wore only knickers, vests and plimsolls. Underclothing was washed twice weekly and nightdresses fortnightly. Washing facilities consisted of two baths supplied with a geyser and eight wash basins. All children had a bath and had their hair washed once a week. Thorough ablution with hot water was carried out daily. Washing flannels, which it was difficult to keep for individual use, were scalded in a pail of boiling water twice a day. Each child had her own towel and tooth-brush. For each bed there were three blankets, as well as cotton sheets and a mackintosh. After the mid-day meal all children had 1½ hours' rest on canvas beds, if possible in the open air, but otherwise in the large school-room. A lean-to shed was used for games in wet weather. Most of the time was occupied with games, cricket, dancing lessons or manual work, not more than about an hour of reading or writing being done daily. Upen-air schools for non-tuberculous children. The nine day open-air schools tor non-tuberculous children maintained by the Council have continued to do their excellent work throughout the year. At Charlton-park school there have been some difficulties in regard to shelter from the weather at the most inclement times during the winter months. Fortunately, winters in England have of late been on the whole mild, but the occasional short lived blizzards produce much discomfort while they last. The difficulty is that of providing adequate shelter against these very exceptional conditions without altering the general open-air character of the buildings, upon which the benefit to the children and the raison d'etre of the school depend. In schools such as this designed to give full sanatorium treatment for debilitated children whose condition gives rise to the apprehension of future tuberculous disease, any form of heating is anathema. Where heating is provided, the schools quickly lose their open-air character—" you cannot heat the open-air." Much attention has been given to the problem at Charlton Park, and it is hoped that measures to be taken with a view to providing more shelter without unduly closing in the buildincs will overcome the difficulties. The following table gives the roll of the day open-air schools on 22nd December, 1932:— Boys. Girls. Total. Aspen House 84 65 149 Bow Road 115 75 190 Brent Knoll 94 56 150 Charlton Park 78 58 136 Downham 88 56 144 Holly Court 160 126 286 Stowey House 187 90 277 Upton House 88 63 151 Wood Lane 76 68 144 Total 970 657 1,627 The corresponding numbers at this time last year were 966 boys, 682 girls, total 1,648. 40 Annual reports are submitted for each school by the assistant medical officer in charge. The following report by Dr. C. N. Atlee on Holly Court open-air school is selected as an example:— The number of children on the roll of the Holly Court open-air school for this year was nearly 300; 142 were admitted, and 156 were discharged, the number of discharged noted as being "fit" amounting to 112. The remaining discharges were for such causes as removal from district, and in a few cases by wish of the parents, the long tram journey sometimes causing sickness amongst a particular type of nervous child. The health of the children has been excellent, only three cases of infectious diseases having occurred throughout the year. The average increase in weight was 3 kgm. for boys and 31 kgm. for girls. Sun bathing was carried on from June until October, some 100 selected cases being so treated. Personal hygiene was very good, the standard being high. A weekly inspection and a weekly bath were part of the standard routine of the school. Foot inspection of the whole school was carried out with a view to cleanliness and for detection of cases of weak arch. A Woulfi's bottle apparatus was also equipped for the purpose of giving breathing exercises to children suffering from poorly expanded chests and bronchial troubles. Meals were served in the open air under cover, and were varied each day, care being taken to include in the daily menu a proportion of fresh vitamin foods, such as salads, butter, milk, fresh fruit and vegetables. The following is a sample menu:—Breakfast: Porridge or fresh fruit, milk, bread and butter, marmalade, cocoa and milk; Dinner: Roast beef with two vegetables, milk pudding and fruit; Tea: Hot milk with tea, bread and butter, jam or cake. The members of the care committee have been good enough to send several cases from crowded areas and tuberculous families, who have derived great benefit from the air and feeding. Open-air schools for tuberculous children. In addition to the provision of treatment for tuberculous children in residential institutions, the Council continued the use of the open-air schools specifically for 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 540 children. The number on the roll on 31st December, 1932, was 567, and the average attendance for the year was 473.8. 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 1932, 162 children were admitted and 179 discharged. Of the latter, 38 were transferred as fit to attend elementary schools, 59 were fit for work, 50 were transferred to residential institutions for residential treatment for tuberculosis or admitted to hospitals for various reasons, 22 moved away, 3 were transferred to special schools, and 7 were discharged for other reasons. In 1925, vocational classes were opened at Springwell House and Stormont House open-air (tuberculosis) schools, 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 eardeniner. Instruction in carnentrv is also given at this school. The following school journeys were made during the year 1932 :— School. Period. Place visited. No. of children. From To Elizabethan open-air school 7th June 21st June Bognor Regis 15 21st „ 5th July Whitstable 15 Geere House 1st „ 15th June Sandon 24 Kensal House 17 th 1st July Tankerton 25 Nightingale House 5th 21st „ ,, 25 Stormont House 7th „ 21st June Bognor Regis 24 21st „ 5th July Whitstable 25 Springwell House 2nd Sept. 16th Sept. Broadstairs 51 204 41 The following is an extract from the report of the medical officer of the Stormont House open-air school:— All the children leaving school were placed in employment without any particular difficulty, and it is satisfactory to know that a child's chances of obtaining work are not prejudiced in any way by the fact of his attendance at a special school for tuberculous children. Open-air classes in parks and playgrounds. The number of open-air classes held in connection with the elementary schools in 1932 was 210. Of these 12 were of type A (children selected on medical grounds from a group of schools); 68 were of type B (children selected on medical grounds from the various classes of a single school); 38 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). Eight classes are permanent, that is to say they are outside the yearly programme and do not need re-authorisation each year. In addition, 50 of the 210 classes were continued throughout the winter, where the suitability of the sites had been approved by the school medical officer. Of the 210 classes, 74 were held in parks, gardens, playing-fields and other open sites, while 128 were held in school playgrounds (of which 24 were roof-playgrounds). 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 aænmic, 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, provided that the additional nourishment required is available, and that they are adequately clothed and shod, while the latter cannot stand such treatment and require warmth and coddling. The medical reports again illustrate these results. Fifty-five detailed reports were received from the school doctors on the open-air classes. While the great majority of the classes are highly successful and exercise a powerful effect upon the health of the children, a few do not give comparable results. At a non-provided school in Putney it has been recognised for many years that the care bestowed upon the children is of a particularly high standard. Of the results of the open-air class at this school, the school doctor reports:— This class is becoming increasingly popular with the parents. In fact, the benefits derived from it are so obvious that one finds the parents almost unanimous in their desire to get their children especially admitted to it. I am told by the parents and teachers that the children after admission sleep better, eat better and improve markedly in both mental and physical alertness. The success of this class is undoubtedly due to the devotion and unsparing care and keen observation of the head mistress and of the mistress in charge of the class, and to the fact that the care committee secretary is most successful in getting suggested treatments carried out. Another school doctor reports on two open-air classes rum by neighbouring non-provided schools, A and B. The report on the former is in the following terms:— This time there is a most noticeable improvement generally. Fifty per cent. appear mentally alert, but originally were all subnormal, with the exception of 5. The mistresses attribute the general and consistent improvement to the fact that they have a regular meal (i.e., at school) at mid-day, 12 to 12.30; then from 12.30 to 1.15 or longer they lie down and rest. They do not run about in the dinner hour and none goes home. They have a good quantity of milk or cocoa daily. Their dinners are "sensible" ones. At this class 75 per cent. improved in colour and 70 per cent. in nutrition. In contrast is the report on school B:— The children come from poor homes ; many are badly flea-bitten. General health appears fairly good. The nutrition is very poor, noticeably so. The children are all very pale and nearly all extremely thin. The lack of improvement is very disappointing. The children go home at mid-day, which is not the case in school A, and they do not sleep in the afternoon, which is the case there. The head teacher is going to make some new arrangements next year. The situation is not very good, and, if a better one could be found, it would be advisable, as an open-air class is badly needed here. At this class no child improved in colour and the great majority made no improvement in nutrition. D 42 At a Council school in Wandsworth the school doctor reports:— I am more than pleased with the results in the class this year. It has been magnificently run. There has been great improvement in the attendance at school of the delicate children. I notice most improvement in the children who suffer from chronic bronchitis and cervical adenitis. The mothers report that, in spite of the fact that these open-air class children sleep in the afternoon at school, they sleep better at night. Most of them have become so hardy that it is difficult to keep them covered with their blankets while lying out of doors. In this class, out of 23 children, all improved in colour and 22 in nutrition. At a Council school in Lambeth the school doctor reports:— Two girls giving a history of rheumatism without cardiac lesion are keeping well and remain free from rheumatism. One girl subject to chronic bronchitis has recently had a severe attack and has been recommended for convalescence. One very anaemic girl, whose home conditions are bad, has been sent to an open-air school. The majority of the girls, though still below standard physically, have shown definite improvement, and are found to be brighter and more alert in their work. In continuance of last year's practice, 8 out of the 25 girls slept out of doors in the garden of Lady Margaret settlement from the beginning of June until 12th September, with the exception of two weeks during the holidays, when all, except one girl, were sent away through the Country Holiday Fund. These girls all came from overcrowded homes. They enjoyed sleeping out very much, and their health benefited greatly. All the girls in the class are receiving milk daily in school. It is evident from the above report that all the necessary accessories to open-air life were carefully provided by teachers and care committee workers. Fifteen of the 25 girls improved in colour and 16 in nutrition. On the other hand, there have been two or three reports of a much less enthusiastic character on the open-air classes. Of an open-air class in Westminster the school doctor reports:—"I do not think any outstanding advantage can be claimed for this class as a whole"; and of a class in North Kensington it was reported that the school doctor considered the results the reverse of beneficial. Open-air classes act by stimulating the metabolism of the body and thus producing an increased and healthy appetite, which must be satisfied if good and not harm is to accrue. It is clear that it may be perilous to place debilitated children entirely in the open-air without enquiring whether the extra nourishment required as a consequence is forthcoming, and taking steps to provide it where lacking. Open-air classes, as the reports show, are capable of bestowing much benefit upon the children, but to do this they must be run "magnificently," as, it must be said, most of them are. Convalescent camp schools. The numbers of children passing through the residential convalescent camp schools during 1932 were : boys, 2,795 ; girls, 1,684 ; total, 4,479. The experimental camp school for mentally defective children at Loughton has already been described. Still another additional provision has been an arrangement bv which a certain number of Roman Catholic erirls are sent to St. Marv's. Dover. In detail the numbers were:— Provided schools :— Boys. Girls. King's Canadian school, Bushy 2,770 — George Rainey, St. Leonards — 621 Wanstead House, Margate — 535 Total 2,770 1,156 Non-Provided schools:— Fairfield House, Broadstairs - 209 Russell Cotes school, Bournemouth — 239 St. Mary's, Dover — 31 Loughton 25 49 Total 25 528 43 By the courtesy of the head master of the King's Canadian residential open-air Remedial school, Bushy Park, I have received the following report of the remedial work work. carried on for the benefit of the boys in residence:— During the year 2,770 boys were in residence for periods of either four or six weeks; of these 274 were granted an extension of either two or three weeks on the school doctor's recommendation. The average increase in weight among the children who stayed 4 weeks was 2.8 nounds: for the six weeks period the averaee train was 4.1 rounds. The school doctor selected 1,155 boys (41.6 per cent. of total entrants) for remedial exercises. These may be summarised as follows:— Flat-foot, and kindred disabilities 513 Defective breathing (including stammerers) 117 Scoliosis (mainly postural) 59 Kyphosis and round shoulders 57 Various and general 409 The system of treatment in small groups is used for the majority of cases, only those who would appear to benefit from individual work, including a few heart cases, being excepted. Flat-foot and kindred cases are taught a few corrective exercises, which are also printed on cards for home use. Country dancing and boxing footwork are used as correctives. A form on which particulars of selected cases are entered, together with a statement that home exercises have been taught, has been brought into use. This form is attached to the usual medical card thus assuring re-inspection at which progress may be noted and further treatment advised. This procedure applies to cases of flat-foot, of which a large number are still received. Other cases are treated for their disability, and supplied with cards of reminders but no home exercises. All are given a course of quickening and strengthening exercises and examined by the school doctor prior to departure. During the last term trial was made of the Council's scheme of treatment for stammerers, with marked success in 11 cases. The following figures relating to the general health of the boys are interesting:— Treatments given by school nurses for minor ailments 18,936 Cases of infectious illness 3 Other cases sent to hospital 2 Admitted to sick ward and nursed here during the year 19 On the dental side 1,151 boys received treatment—extractions, fillings, soalings and gum treatment. School journeys. During the year 1932, 332 school journeys were made (compared with 449 in 1931), and the children taking part were medically examined in all cases before departure. In all 10,753 children were examined (the corresponding figure for 1931 being 13,671); and of these 53 were rejected as unfit to take part in the journeys on various grounds, including the following (the figures in parenthesis refer to the year 1931):—otorrhœa, 4 (4); infectious disease or contacts, 2 (3); tonsillitis and kindred ailments, 11 (15); temperature, 3 (3); personal hygiene, 3 (3); skin diseases, 9 (13). Several children were provisionally rejected on grounds connected with personal hygiene but were subsequently passed after visiting a bathing centre. Nursery schools. Dr. E. M. McVail reports that, at the beginning of the year 1932, the total recognised nursery school accommodation in London was 1,064 places in 14 schools, 560 places being maintained and 504 aided. In 1932, this accommodation was raised from 1,064 to 1,104 by the opening of St. Christopher's (aided) nursery school in Bridgewater-street, St. Pancras. In February, 1932, after 18 months' experience of the working of the experimental schools at Columbia Market (Bethnal Green) and Old Church-road (Mile End) it was decided as a temporary measure to write down the recognised accommodation at each of these schools from 150 to 120 places, thus reducing the total recognised accommodation to 1,044. That the two experimental schools are filling a need in their neighbourhood is evidenced by the fact that at each school there has been a waiting list of 25 to 30. Preference for admission is given to children recommended by welfare centres and school doctors, home conditions receiving due consideration. Reports indicate that the children continue to derive great benefit from attendance. At the Rachel McMillan nursery school, premises in the rear of Wellingtonstreet were, in May, 1932, vacated and a new building for 50 children was opened on D 2 44 a site in Church-street and The Stowage. This building is of brick and has a south aspect. The playroom, airy and pleasant, measures 46 feet by 20 feet, allowing 18 square feet per child. Access to the playground, laid out with flower beds, is by five French windows. It is generally agreed that a very valuable feature of nursery schools is the summer holiday, which most superintendents contrive to arrange. In 1932 ten of the 15 schools sent all or many of the children to the country for periods ranging from two to six weeks. At two other schools efforts are being made to have such a holiday in 1933. The Eachel McMillan nursery school, from which in 1932 it was possible to send away only the most delicate children, was during the summer closed for only six school days. In September Dr. O'Connor reported as follows:— I was greatly impressed by the healthy, bright, alert appearance of the children who had been in attendance, compared with the pale, listless, tired-looking children who had been admitted at the beginning of the term. The absence of sores was remarkable. The re-opening of the school after the usual summer closure has always been marked by the number of children requiring treatment for septic sores and personal hygiene. The absence of diarrhoea has also to be noted. No cases occurred among the two-year olds in attendance. I understand some severe cases of sunburn have occurred among the children living in the district. No case has been reported among the children attending the school. The attendance at the beginning of this term has been better than usual and it is expected this will be maintained, as the mothers are so pleased with the condition of their children they do not consider they need the usual ''hopping" holiday. The average attendance during holidays was 217 out of 260. Twelve months ago a new diet was introduced into the "special" shelter reserved for the most delicate children. The main difference between the new and the ordinary diet is an increase in the amount of fruit and vegetables, an allowance of liver twice a week, cod liver oil and malt twice a day and barley sugar twice a day. It is interesting to note the way in which the children have responded to the change, as usually this type of child is rather suspicious of anything new introduced into the menu. Tripe is not popular, it is looked upon with disfavour and always referred to as the "soapy dinner." On the other hand liver with stew is eaten readily by all the children. The addition of a little grated cheese to a dish causes it to be eaten with great relish; there is never any of this left over. Fruit and barley sugar daily probably lessen the craving for sweets after school hours. Most of the children on admission to the special shelter suffer from some form of digestive disturbance. In many cases this is due to dietetic errors, constipation, rickets, etc. Tea, fish and chips, stewed eels and cooked foods are the usual diet of the pre-school child in this neighbourhood. Milk, cocoa, vegetable stews, minoe, etc., are all new foods to these children, and on admission they are sometimes a little difficult about food. One little girl, aged about 2 years, whom I knew at the school a few years ago, wanted nothing but tea. I enquired and found that prior to coming to the nursery school she had tea six times a day, beginning at 6 a.m. Miss Atkins, who is in charge of the shelter, informs me that it is remarkable how very few of the children suffer from any digestive or bowel trouble now. On the whole the children in the shelter look healthy, have a good colour and appear more " alive." The average attendance in this shelter is 83 per cent., and in a similar shelter (non-medical) 85 per cent. At Old Church-road nursery school, 37 children were taken away for three weeks during the summer holiday to Banstead. These were selected by the school doctor for delicacy or over-crowding at home, and were afterwards reported to have benefited markedly by the change. During the winter term their health and attendance were particularly good. The trouble taken in making such holiday arrangements is often very great, and shows unlimited devotion by the superintendents and their helpers. The question of disinfection of tooth brushes having arisen, the advice of Mr. Samuel, the Council's consulting dental surgeon, was obtained and the following circular was issued to nursery schools :— (1) Tooth brushes should be soaked weekly for 20 minutes in a solution of 1 in 100 carbolic acid, or, alternatively, in a solution of 1 in 2,500 thymol. After disinfection they should be thoroughly rinsed in clean water. 45 (2) Tooth brushes should be renewed when the bristles become loose or worn. The frequency of renewal will depend largely on the quality of the brushes and may vary from six months to a year. The Parks and Open Spaces Committee of the Council recently had under consideration the question of disinfection of sandpits, and a rule as to their regular disinfection by bleaching powder was made. Bacteriological examination by Dr. McCartney of the sand used at the three nursery schools belonging to the Council indicated that, although contamination was less in nursery schools than in parks, a similar method of disinfection was desirable, and circulars were sent to nursery schools on the lines laid down by the Parks and Open Spaces Committee. The amount of bleaching powder suggested by Dr. McCartney is 1 pound for 20 tons of sand. Advice given was that in nursery schools the surface of the pit should once a month be moistened thoroughly with a hose (or watering can) and then sprinkled with a solution of bleaching powder and water. The surface of the sand should be well turned over and further sprinkling done with the solution. Finally the sand should be well sprayed with water so that all the sand is wetted and the pit covered over for at least three hours. For pits in the Council's nursery schools measuring about 7½ feet square by 18 inches deep, about 2⅓ozs. of bleaching powder should be used in the sprinkling solution. This should first be made into a paste with a small quantity of water and then stirred into the water to be used for sprinkling. The sand in sand trays should be similarly treated once a month, but only a very small amount of bleaching powder is needed for the sprinkling solution. Investigation has been made of the mortality from measles between 1st August, 1931, and 31st July, 1932, in the 13 nursery schools in existence throughout that period:— Average number on roll of 13 schools 952 Total number of cases of measles 335 Number treated at home 238 Number treated in hospital 97 Number of deaths at home 0 Number of deaths in hospital 4 Of 335 cases of measles, 4, i.e. 1-19 per cent., were fatal. The ages of children at nursery schools are from 2 to 5 years, and the 4 deaths occurred amongst children of 2, of whom 3 had been at the nursery school for a month or less and whose health had, therefore, had little chance of improvement. The fourth, a particularly delicate child, had been at school for 5 months. No deaths from measles occurred in children over 2 years old. From December, 1929, to June, 1930, the latest period for which printed figures are available, the mortality from measles amongst 17,299 children of 2 to 5 years old in 24 metropolitan boroughs was 1.11 per cent. At nearly all nursery schools children are selected for admission because of delicacy or poverty, and the mortality of 1.19 per cent. is, in comparison with 1.11 per cent. for normal children of all social ranks, of favourable significance. In the 24 metropolitan boroughs, of 192 deaths from measles between 2 and 5, 98 occurred in children of 3 to 4 and 4 to 5. The fact that amongst nursery school children there were no deaths in these periods indicates increased stamina and power of resistance to infection gained from attendance at the schools. Child guidance London child guidance clinic. During the year 1932 the number of Council cases referred to the London child guidance clinic, Canonbury, was 173, of whom 107 were boys and 66 were girls. The ages of the children referred, the source of, and the reasons for reference, are set 46 out in the following statements, submitted by Dr. Wm. Moodie, the director of the clinic:— Ages of Children referred. Boys. Girls. Ages of Children referred. Boys. Girls. 5 years 4 1 12 years 16 12 6 ,, 9 6 13 ,, 8 6 7 ,, 12 2 14 ,, 8 7 8 „ 10 6 15 „ 1 — 9 ,, 18 10 16 ,, 1 — 10 7 5 No record 5 4 11,, 8 7 Total 107 66 Source of reference. Head teachers 42 Care committees 39 School doctors 27 Parents 19 School medical officer 10 Hospitals Children's courts 10 8 Invalid Children's Aid Association 2 Private doctor 1 Other sources 15 Total 173 Reasons for reference. Backwardness 37 Nervousness 24 Theft 23 Behaviour at home 16 Behaviour in school 15 Enuresis 12 Temper tantrums 11 Stammering and speech defects 8 Truancy 5 Sex troubles and masturbation 5 Night terrors 3 Delinquency 1 Wandering 1 Migraine 1 Lethargy 1 Suicidal tendency 1 No record 9 Total 173 N.B.—Children are often referred for more than one difficulty, but the major one only has been included in this table. Assignment of cases. Full service 32 per cent. Special service 43 „ „ Diagnostic and unassigned 25 „ „ 100 „ „ Results of treatment-—Full service cases. Adjusted 53 per cent. Partly adjusted 23 „ „ Unadjusted 17 „ „ Transferred to other clinics 3 „ „ Permanently placed 4,, ,, 100 „ „ N.B.—These percentages refer to all (including Council) cases dealt with at the clinic. N.B.-—The term "partly adjusted" indicates that, though seemingly normal, some latent instability persists, and may cause recurrence of difficulties at a later date. East London child guidance clinic. The work at the East London child guidance clinic, which is organised at the Jew's Free school, Whitechapel, by the Jewish Health Organisation of Great Britain, has continued during the year, under the direction of Dr. Emanuel Miller. With the approval of the Board of Education, the attendances of children at this clinic are, as at the other two child guidance clinics mentioned in this report, counted as equivalent to attendance at school. From the report submitted by Dr. Miller, it appears that, during 1932, the total number of cases referred to the clinic was 177 (129 boys and 48 girls), of which 150 were in attendance at Council schools. The age distribution was as follows: under 5 years of age, 5; between 5 and 14 years, 152; over 14 years, 20. 47 Source of reference. School doctors 49 Head teachers 23 Care committees 14 Hospitals and clinics 16 Parents 5 Private doctors 7 Children's courts 34 Various agencies 29 Total 177 Reasons for reference. Theft, pilfering 41 Nervousness, excitability, restlessness, depression 35 Backwardness 20 Enuresis 19 Beyond parental control 17 Unmanageable at school 12 Aggressive, spiteful, violent, destructive 12 Night terrors, sleep walking 12 Stammering and other speech difficulties 10 Temper tantrums 9 Unable to keep job 9 Unusual fears 4 Habit spasm and nervous movements 3 Truancy 3 Wandering 3 Solitary 3 Masturbation and sex difficulties 2 Hysterical suppression of speech 2 Food fads... ... 1 Special reading disability 1 Dislike of women 1 N.B.—One child may be referred for more than one reason. During the year there were 925 interviews of patients by psychiatrists, and 250 by psychologists. Social service workers paid 1,027 visits outside the clinic, and there were 40 case conferences. Interviews within the clinic, with parents, teachers, guardians, etc., concerning patients are not included in these figures. Disposal. Institution 2 Approved school 11 Foster home 5 Environmental adjustment only (change of school, convalescence, transfers) 16 Consultative advice given 14 Seen for Jewish orphanage 9 Results of treatment. Result. Carried over from 1931. New rases 1932. Total. Satisfactorily adjusted 8 55 63 Partially adjusted 8 9 17 Unadjusted or unsuitable 1 27 28 Still under treatment 21 62 83 The child guidance clinic organised at the Maudsley hospital, Denmark-hill, under the direction of Dr. Mapother, dealt with 382 new cases during the year 1932, of which 294 were children of school age. In addition, 268 cases which had previously attended were seen, making a total of 650 cases treated during the year ; of these 502 were children of school age (291 boys and 211 girls). The ages of the school children dealt with were as follows :— Maudsley hospital guidance clinic. Ages of children referred. Ages of children referred. 5 years 22 11 years ... 47 6 38 12 99 ••• "• ... 65 7 58 13 99 ••• ••• •** ... 41 8 69 14 99 ••• ••• ••• ... 32 9 72 10 58 Total ... ... 502 48 Source of reference. (New cases of school age.) Care committees 112 School authorities (other than care committees) 47 Spontaneous 45 Hospitals 32 Private doctors 24 Probation officers 7 Other sources 27 Total 294 Diagnosis. Nervousness 158 Behaviour problems 115 Enuresis 91 Organic or mental diseases 68 Backwardness 29 Certifiably defective 25 Delinquency 13 Intelligence quotient only 3 Total 502 The number of cases discharged during the year was 242, leaving 260 cases still in hand at the end of the year. The 242 cases discharged may be classified as follows: Improved 114 Partially adjusted 56 No improvement 47 Not suitable for treatment 25 Total 242 Admission examinations. Defective children. Examinations with a view to the admission of children to special schools, other than hospital schools, were made in 5,430 cases, a decrease of 254 from the number examined in the previous year. The following table shows the number of children nominated for examination and the recommendations made :— Defect. Number nominated. Suitable for admission to Returned to elementary school. Invalided as for the time unfit for any school. Notified under M.D. Acts. Boys. Girls. BUnd school. Myope class. Swanley. Boys- Girls. Boys. Girls. Boys. Girls Boys. Girls. Boys Girls. Boys. Girls. Ocular 037 808 16 9 84 103 94 113 424 560 19 23 _ _ Deaf school. Hard of hearing class. Aural 143 122 Boys. Girls. Boys. Girls. 63 62 5 3 - - 30 26 45 31 P.D. school. Day open-air school. Residential P.D. school. Physically defective 862 869 Boys. Girls. Boys. Girls. Boys. Girls. 564 564 22 12 54 32 185 204 37 57 — — M.D. school. Boys. Girls. 1 Mentally defective 1,102 723 434 282 591 344 43 50 *34 *47 Epileptic colony. Boys. Girls Epileptic 93 71 22 12 48 30 23 29 — — Total cases 2,837 2,593 1,365 1,184 1,311 1,200 127 162 34 47 5,430 2,549 2,511 289 81 *Of these 25 boys and 40 girls were imbeciles ; 4 boys and 1 girl were idiots; and 5 boys and 6 girls were feeble-minded. 49 The numbers of children actually attending special schools will be found in table III of the statistical tables at the end of this report. Children admitted to P.D. schools. The Following statement shows the nature ot the conditions tound among the children certified as suitable for admission to schools for the physically defective at the admission examinations during the year:— Morbid conditions Boys. Girls. Total.   Infantile paralysis 34 30 64 Cerebral paralysis 28 19 47 Various paralyses 11 15 26 Tuberculosis of bones and joints 85 70 155 Osteomyelitis 22 9 31 Rickets and resulting deformities 8 5 13 Congenital deformities 22 17 39 Traumata and amputations 32 10 42 Non-tuberculous arthritis and synovitis 9 2 11 Rheumatism and chorea 26 35 61 Various chest conditions—fibrosis, bronchitis, asthma 63 39 102 Kidney diseases 7 8 15 Heart diseases— Congenital 20 34 54 Acquired valvular 188 234 422 Non-valvular 44 60 104 Anaemia 1 1 2 Pseudo-hypertrophic muscular dystrophy 5 1 6 Various nervous conditions, ataxia, etc. 1 1 2 Other diseases—chiefly medical 12 6 18 Total 618 596 1,214 Children returned to elementary schools or invalided. The following statement gives an analysis of the 483 cases examined for admission to special schools for the physically defective, as a result of which the children were either returned to elementary schools or were invalided as unfit for any school:— Morbid conditions. Elementary school. Invalided. Infantile paralysis 24 4 Cerebral paralysis Various paralyses 2 5 12 3 Tuberculosis of bones and joints 17 5 Osteomyelitis 6 5 Rickets and resulting deformities 16 5 Congenital deformities 14 1 Traumata and amputations 14 2 Non-tuberculous arthritis and synovitis 4 — Rheumatism and chorea 75 11 Various chest conditions—fibrosis, bronchitis, asthma 30 5 Kidney diseases 5 Heart diseases—- Congenital 25 4 Acquired valvular 65 17 Non-valvular 54 6 Anaemia 21 2 Pseudo hypertrophic muscular dystrophy 3 1 Various nervous conditions, ataxia, etc 3 5 Other diseases—chiefly medical 6 6 Total 389 94 483 Rota visits to the schools. The special schools were visited at least once a quarter, and every child present was seen at least once during the year ; the total number of examinations made was 18,758, and in addition 537 special examinations were made of children already on the rolls of special schools in connection with applications for non-enforcement of 50 attendance and for similar reasons. 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. Open- air school. Epileptic colony. Physically defective - 15 - - 1 - 9 _ Mentally defective 1 - - 1 1 1 - 1 Sight saving _ 2 - 5 - - - - Blind _ _ 5 _ _ - - - Deaf — _ - — - 1 - - Hard of hearing - - - - 18 - - - After trial in a special school, 89 children were excluded (70 as imbecile, 16 as feeble-minded ineducable and 3 as feeble minded "detrimental") and 36 were invalided on medical grounds. There were also 596 cases returned, on improvement, to elementary schools, or, when over 14 years of age, deemed to be no longer certifiable and allowed to leave school. The details are as follow:— Acton taken. Special school classification. P.D. M.D. Blind. Deaf. Sight saving. Hard of hearing. Total. Returned, on improvement, to elementary schools 251 20 _ - 5 10 286 Over 14 years of age and allowed to leave as no longer certifiable 161 79 10 4 49 7 310 Total 412 99 10 4 54 17 596 Decertification of P.D. children. The following table classifies the 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. Infantile paralysis 17 12 Cerebral paralysis 2 1 Various paralyses 1 2 Tuberculosis of bones and joints 30 38 Osteomyelitis 3 12 Rickets and resulting deformities 1 18 Congenital deformities 7 24 Traumata and amputations 7 17 Non-tuberculous arthritis and synovitis 3 17 Rheumatism and chorea 18 25 Various chest conditions—fibrosis, bronchitis, asthma 1 5 Kidney diseases — 2 Heart diseases— Congenital 8 3 Acquired valvular ... ... ... ... ... ... 32 31 Non-valvular 25 37 Anaemia 1 2 Pseudo hypertrophic muscular dystrophy — — Various nervous conditions—ataxia, etc. 2 Other diseases-—chiefly medical 5 3 Total 161 251 412 51 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 1932 (the figures in brackets being those for the previous year):— (a) Feeble-minded— Boys. Girls. (1) Leavers 124 (205) 128 (228) (2) Detrimental 3 (8) 2 (4) (3) Special circumstances 2 (3) 2 (1) (4) Ineducables 12 (5) 15 (4) (b) Imbeciles 78 (93) 82 (76) (c) Idiots 3 (5) 4 (2) (d) Moral defectives 0 (0) 0 (0) 222 (319) 233 (315) Total 455 (634) Mental Deficiency Acts. Cases notified to the local authority. After-careers. The chief officer of the mental hospitals department lias furnished the following return for the year 1932 on after-care of children formerly attending special schools for the mentally defective, but whose names were not notified to the Mental Hospitals Committee as being cases in which the Education Committee were of opinion that further aid in the form of supervision, guardianship or institutional care under the Mental Deficiency Acts was necessary:— Classification. Male. Female. Total. Grand total under headings. (1) Number of children born in or subsequent to 1914 who have left special schools and who were on the books of the supervision section on 31st December, 1932 501 260 761 761 (2) Number who after trial have proved themselves to be incapable by reason of mental or physical defect of undertaking remunerative employment 5 4 9 9 (31 Number emnloved as under:— (a) Industrial or manual occupations (i.e., factory work, trade or any part of a trade) 260 164 424 (b) Agricultural or rural occupations 3 — 3 (c) Domestic occupations— M. F. Total 11 48 59 (1) Receiving remuneration 8 39 47 (2) Required for work at home 3 9 12 (d) Commercial, shop assistant, or selling behind a counter, office boys or girls 14 1 15 (e) Gone into Army, Navy or Merchant Service — — — (f) Blind alley or other precarious occupations (i.e., vanboys, newsboys, errand boys and girls, selling from a barrow) 119 6 125 (g) In work, but no details as to nature of employment 7 1 8 634 (4) Number judged to be employable but out of work 64 18 82 82 (5) Number whose careers have not been traced:— (a) Not visited and not seen at bureaux 15 7 22 (b) Visited but no information obtainable 3 11 14 36 (6) Cases dealt with in addition to above include those who have since :— (a) died 1 4 5 (b) attained the age of 18 years 304 193 497 (c) been dealt with under M.D. Act 19 19 38 (d) been lost sight of, or have left London 10 6 16 556 N.B.—In addition to the 761 after-care cases shown in the above return there were 554 boys and girls between 16 and 18 years of age who had left special schools and were under statutory supervision on 31st December, 1932. These also were on the books of the supervision section for placing in employment. 52 Cases of cerebro-macular degeneration. During the year two cases of cerebro-macular degeneration were noted. The cases were sisters aged 9 and nearly 15. Both girls walked and talked at a normal age and attended elementary schools; they suffered from epilepsy and they both showed signs of deterioration at the age of 8. On examination in October, 1932, the elder one was deemed to be an imbecile and the younger one feebleminded (ineducable). There seems to be no history of fits in either the father or mother who are both living and healthy; two elder brothers, however, died from this complaint in Darenth training colony, and they too, it is stated, began to deteriorate when 8 years old. The family consisted of eight children born at intervals between 1905 and 1923 and every alternate child was affected in this way. Institutional care was recommended in both cases. Size of families from which mental defectives come. Dr. F. C. Shrubsall, who gave evidence before the Departmental Committee on Sterilisation of Mental Defectives, quoted figures from previous Annual Reports, particularly that for 1912, and gave details of an investigation made into 1,934 families, one member of which came to notice as a feebleminded primary ament. No other member of the family was defective in 1,598 cases. One brother or sister was defective in 244 cases. Two brothers or sisters were defective in 60 cases. Three brothers or sisters were defective in 21 cases. Four brothers or sisters were defective in 8 cases. Five brothers or sisters were defective in 3 cases. The figures for these 1,934 families showed that 40 parents, 17 siblings, 3 grandparents and 9 collaterals had been dealt with as insane, and 14 parents had been dealt with as mentally deficient; in 19 families one member of the fraternity had gained scholarships, and in two families two members had gained scholarships. Schools for the blind. The children attending the two residential and three day schools for the blind were examined to determine whether or not they could be classified as blind within the meaning of the Blind Persons Act, 1920, as well as under the Education Acts. During the year 195 children were seen by Dr. E. M. McVail, who classified 182 as so blind as to be unable to do work for which eyesight is essential. Twelve were deemed not to be blind within the meaning of the Act and were transferred to sightsaving classes, and one youth over 16 who was undergoing treatment at hospital was also found not to be blind. It should be stated that the children in all the Council's schools for the blind are taught to read Braille, and to all intents and purposes the curriculum has been designed for children who are actually blind and not for those merely unable to read the ordinary school books. Schools for the deaf. During the year Mr. Macleod Yearsley, F.R.C.S., the consulting aural surgeon, retired on reaching the age limit. Mr. Yearsley joined the service in 1907, and was associated with the then medical officer (education) in all the earlier developments of the schools for the deaf. In particular the establishment of separate series of schools and classes for those who were only partially deaf was initiated by him. Prior to the establishment of such classes, the hard-of-hearing child was ill provided for from the educational standpoint. He either remained to drag out a rather colourless existence, not always even in the front row, in an ordinary class, or was transferred to a school for the deaf. Occasionally, if his responses to tests were very inferior, he was admitted to a school for the mentally defective. In that school he benefited to a limited extent by the individual attention he received ; in the school 53 for the deaf, while he did well educationally, he found himself in an atmosphere to which he was unused, because the attitude of mind and method of thought in the very deaf are totally different from those in the partially deaf, which are essentially those of the hearing. Mr. Yearsley reported in 1909 on the need for classes of an intermediate character presenting some elements both of instruction for the deaf and for the hearing. The pioneer class was opened at Ackmar-road school in September, 1910. The demands for accommodation made it necessary for the earlier classes to be held in schools for the deaf, although arrangements were made to keep the pupils in the "hard-of-hearing" classes separate from those on the deaf side. Later, the experiment having proved satisfactory, it was possible to provide separate schools. These classes for the partially deaf have been a great boon. Indeed some of their pupils, having returned to ordinary schools after acquiring a sufficiency of lip reading to reinforce such residual hearing powers as they possessed, won scholarships in competition with children of normal hearing. Mr. Yearsley has pointed out how the teachers, especially the heads of the schools, overcame the initial difficulties of the new venture. These classes, thanks to the teachers, the inspectorate and the surgeon, have supplied a very real want. This development of a new type of school attracted much attention in the United States, and Mr. Yearsley by invitation published in an American review a special account of the methods in use, in order that the knowledge which had been gained might be more widely spread on that continent. Following this, classes of a somewhat similar type have been introduced in certain American states. Mr. Yearsley's pioneer work in this relation has been recognised generally in European medical circles. During his period of office, Mr. Yearsley has reported, inter alia, on the questions of adenoids and suppurating ears, the results of the treatment of adenoids and enlarged tonsils, the use of telephonic aids in the education of the partially deaf, the electrophonoide method of treatment of deafness, and the prevention of deafness. In particular, Mr. Yearsley has urged that deaf children should receive special education from the earliest possible moment, notwithstanding that by law deafness is a lawful excuse for non-attendance up to the age of seven. He has been very successful in persuading parents of deaf or partially deaf children of the advantages of attending suitable schools and a large number of children have reaped the benefits of his efforts. Residential and industrial schools. There are seven residential special schools (viz., two for blind, two for deaf, one for mentally defective deaf and two for mentally defective children) providing accommodation for 355 residential and 216 day scholars. To each school a medical officer is allocated and provision has also been made for inspection and treatment by a dentist. Three industrial schools and a place of detention have accommodation for 352 and 105, respectively. Owing to the absence through illness of Dr. T. J. T. McHattie, the medical supervision of Ponton-road place of detention was taken over by Dr. E. B. Argles in September. From his detailed report the following summary has been extracted:— During the year 938 boys and 114 girls were admitted, an increase of 209 over the number for 1931. Thirteen children were admitted for brief periods as "lodgers" or "place of safety" cases. The daily average number in residence was 42 • 8, the highest figure being 54 in the month of June and the lowest 32.7 in January. Owing to the occurrence of infectious disease and quarantine restrictions the average length of stay was materially increased in December. Cases were sent from 57 courts, 833 cases from London courts and 219 from out-county Courts. courts. Special reports were asked for by courts in 223 cases, 51 per cent. of which related to the Islington and Toynbee Hall juvenile courts and 32 per cent. to out-county courts. 54 Charges. The following table shows the nature of the charges made :— Charges. Boys. Girls. Stealing 386 32 Breaking, entering and stealing 122 3 Breaking and entering 19 — Larceny 98 11 Felony 3 — Burglary 1 — House-breaking 2 — Stealing motor car 6 — Suspected person 31 — Embezzlement 10 — Receiving 4 — Being on enclosed premises 2 — Defrauding 3 — Unlawful possession 8 —• Trespassing 1 — Begging 2 — Non-attendance at school — 4 Beyond control 102 19 Breach of recognisances 32 3 Wandering 28 15 Obtaining by false pretences 3 1 Loitering for betting 1 — No means of support — 2 Arson 3 — Education Act cases 22 5 Killing and maiming 2 — Wilful damage 9 — Absconding 1 — Armed with offensive weapon 1 — Unlawful assault 2 1 Aggravated assault 1 — Unlawful threat 3 — Unlawful wounding 1 — Insulting behaviour 1 — Loitering with intent 1 — Parents' criminal habits 1 5 Obscene language 1 — Unfit guardian — 2 Soliciting males 1 — Indecent assault 13 — Gross indecency 1 — Indecent exposure 4 — Attempted carnal knowledge 1 — Living in circumstances of moral danger 2 6 Frequenting company of prostitutes — 1 Residing with prostitute 3 3 Apparently feeble-minded — 1 Total 938 114 The preponderance of delinquency fell within the 11-14 year age group. Stealing and allied offences contributed 68 per cent. of the cases of boys and only 40 per cent. of the girls. On the other hand a greater proportion of cases of wandering and being out of control occurred in the latter. Cycle and car stealing have been prevalent. It might be mentioned in passing that the youngest car thief was a boy just over ten years old, but with the height of a boy of eight. He started and drove a stolen light car for half a mile in a crowded district without damage to life or property. Quite an appreciable proportion of thefts seem to show premeditation. Among boys, as might perhaps be expected, charges in connection with breaches of recognisances were more prevalent in the age group 14-16 than in any other. An impression was gained that the majority were in work though perhaps not continuously. Youths of this age seem to have a certain amount of time on their hands and might have been more usefully occupied in attending evening school classes. 55 Physical defects. The physical state of the children as shown on the cards of those cases where the records are complete is revealed in the following table:— Defect. Boys. Per cent. Girls. Per cent. Fair nutrition 476 50.7 38 33.3 Poor nutrition 118 12.5 12 10.5 Malnutrition 7 .7 — — Fair physique 421 44.9 32 28.1 Poor physique 152 16.2 13 11.4 Very poor physique 2 .2 — — Heart 30 3.2 1 .9 Lungs 17 1.8 3 2.6 Vision— 6/9 or 6/12 in either eye 88 9.4 13 11.4 Above 6/12 in either eye 128 13.6 22 19.3 Diseases of eyes 26 2.7 — - Squint and ptosis 25 2.6 2 1.8 Teeth (three or more decayed) 89 9.5 10 8.7 Nose and throat 84 8.9 9 7.9 Ears 21 2.2 4 3.5 Deaf or hard-of-hearing 8 .9 1 .9 Rickets 62 6.6 2 1.8 Sores and impetigo 38 4.1 1 .9 Other skin diseases 42 4.4 9 7.9 Anaemia 34 3.6 10 8.7 Enlarged glands 8 .9 — - Deformities 63 6.7 2 1.8 Errors of development 30 3.2 — — Scars of operations 35 3.7 — — Hernia 8 .8 — — Affections of testis and cord 2 .2 — — Injuries to limbs 7 .7 — — Rheumatism 4 .4 1 .9 Chorea 1 .1 — — Epilepsy 6 .6 — — Tic and spasm 1 .1 — — Stammer 17 1.8 — — Speech defects 4 .4 — — Enuresis 21 2.2 — — Endocrin disturbances 5 .5 — — Albuminuria 2 .2 — — Syphilis 1 .1 1 .9 Stigmata of degeneration 1 .1 — — Colour blindness 3 .3 — — Various 11 1.2 2 1.8 The general physique and state of nutrition of the delinquents compares unfavourably with the figures for London as a whole. Dental disease and nasal obstruction were more apparent and evidence of past rickets was about thirty times higher than that for the ordinary elementary school population. On the other hand the frequency of disease of the heart and lungs was low. Taken as a whole, the London delinquent child is below the average of the county as a whole, but out-county delinquents were noted to have more defects than those living within the county. Retardation. The subjoined table is compiled from the records of 1,019 children whose complete records were available. It has been assumed that the educational ability and general intelligence reaches its maximum average at the age of 14. Retardation. Mental age. Calculation age. Reading age. Number. Percentage. Number. Percentage. Number. Percentage. Up to or over testing age 1 year retarded 2 years „ ,, 3 ,, ,, 4 „ ,, 5 „ ,, 6 ,, „ 301 232 239 127 67 33 20 29.5 22.8 23.5 12.5 6.6 3.2 1.9 143 167 187 190 169 87 76 14.0 16.4 18.3 18.6 16.6 8.5 7.5 356 200 154 120 69 45 75 34.9 19.6 15.1 11.8 6.8 4.4 7.4 56 Among those of better intelligence a higher percentage of children were up to age in reading than in calculation while at the other end of the scale the arithmetical ability was superior to the reading ability. Forty-four children were deemed certifiable as mentally deficient. Sickness. There were 554 cases of sickness or minor ailments during the year, of which 210 were cases of skin disease of a trivial nature. It was found necessary to send 33 cases to hospital. There were also 8 cases of illness among members of the established staff. A small outbreak of scarlet fever occurred during the months of October, November and December. The willing co-operation of the superintendent and staff has greatly facilitated the medical work and the keeping of records. Examination of employees in the education service and scholars. During the year 8,004 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 1933. Male Female Male Female Male Female Male Female Permanent service 406 397 388 390 7 3 11 4 Teaching awards 258 607 238 577 2 10 18 20 Scholarships— Myopes 5 7 5 7 — — Others 3,316 3,034 3,205 2,978 20 3 91 53 3,985 4,045 3,836 3,952 29 16 120 77 Total *8,030 7,788 †45 197 * Including 2 permanent service cases (male), 17 teaching awards (6 male, 11 female) and 7 scholarships (5 male, 2 female) referred from 1931. †The causes of rejection were mainly defects of vision, unsatisfactory general health and morbid conditions of the heart. In addition to the above, 160 examinations were made of scholars (54 male, 106 female) with a view to determining their fitness to continue to hold awards, and of these 14 (6 male, 8 female) were found to be unfit. Re-examinations were made of 1,973 entrants, scholars, etc., who were referred at the first examination for treatment for one or more remediable defects. Cases specially referred. There were also referred to the public health department, 3,581 special cases in which medical advice was required. This figure includes 2,945 teachers (589 men, 2,356 women) and 636 cases of employees (147 men, 489 women) including those in institutions transferred to the Council under the Local Government Act, 1929. In regard to recommendations governing sick leave to teachers, 1,920 or 70 per cent, of the teachers concerned were over 40 years of age; this shows an increase of 2 per cent, on that of the previous year. In connection with these cases 43 home visits were paid during the vear. Teachers of physical education. During the year 297 applicants for admission to the Council's courses of physical education were examined. Of these 18 were deemed to be either temporarily or permanently unfit to undergo the training on the following grounds:— Poor general condition 5 Myopia 1 Varicose veins 5 Adenoma 1 Hernia 2 Recent appendicectomy 1 Rheumatism 2 Recent injury 1 57 Infectious diseases in schools. ' The numbers of cases of infectious illness reported by head teachers as occurring among school children during 1932, compared with similar figures reported during the preceding five years, are shown below:— Year. Diphtheria Scarlet fever. Measles and German measles. Whooping cough. Chicken pox. Mump9. Scabies. Ophthalmia. 1927 5,097 6,498 8,119 8,387 17,358 13,876 820 492 1928 5,178 7,505 41,891 8,592 13,657 5,744 901 408 1929 5,081 7,462 19,313 12,076 12,346 14,010 932 644 1930 5,297 7,558 34,251 3,239 13,573 9,439 930 506 1931 3,202 5,626 3,811 9,019 13,598 5,685 1,068 889 1932 3,338 6,832 34,922 7,624 11,440 8,016 1,160 649 The number of cases of smallpox notified (and confirmed) among school children during the year was 419, compared with 604 in 1931. A special reference to the cases of ringworm found in the schools appears later in this section of the report. As has been explained in previous annual reports, head teachers are required to report particulars of all children absent from school or excluded on account of infectious illness or suspected infectious illness, or of infection in the homes, to the school medical officer, the borough medical officers and the divisional officers (school attendance). The information thus supplied forms the basis of any special preventive action taken in the school. The information is also of special value to the borough health services as it is only by this means that the existence of the bulk of nonnotifiable infectious diseases is brought to light. The necessity for obviating delay in transmitting these daily records is obvious, and, although the compilation of reliable information as to the reasons for absence is often a matter of difficulty, the work done by the teaching staff, with the co-operation of the attendance staff, in this connection is worthy of the highest praise. Every effort is made in the light of experience gained to reduce the loss of school attendance on account of infectious diseases, and reference has been made from time to time in previous annual reports to amendments, which have been made with this end in view, to the exclusion periods both of patients and contacts. After consulting the borough medical officers of health and the Board of Education, it was decided, in June, to alter the regulation regarding the exclusion from school of certain home contacts of measles, German measles, chickenpox and whooping cough. Under the Council's regulations, home contacts of these diseases attending senior departments of the schools are allowed to remain in attendance if they have already suffered from the disease concerned, and this regulation has been applied now to. children attending the. hinrliost class in infants' denartinenfcs. The following table gives information regarding the schools specially visitea 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 ,°.f visits. Number examined. N.E. 31 28 3,558 53 47 7,684 26 6,115 N. 13 12 1,040 41 39 5,213 24 5,374 N.W. 15 14 1,186 50 44 5,412 - S.W. 25 23 2,006 44 40 4,468 25 3,354 S.E. 32 30 2,919 47 42 4,706 23 4,835 Total 116 107 10,709 235 212 27,483 98 19,678 The children in six schools were also specially examined from time to time on account of outbreaks of ophthalmia (four schools) and trachoma (two schools). In addition to investigations by medical officers, valuable work was done by the school nursing staff in following up the medical officers' visits in connection with E 58 the occurrence of scarlet fever, diphtheria, smallpox, ophthalmia and trachoma, as well as in the special visitation of the schools where there were outbreaks of whoopingcough and chickenpox. Diphtheria. During the year 116 investigations into the occurrence of diphtheria were conducted in 98 different schools, twelve having been visited twice and three on three occasions. Including the children seen during these visits and a number of others individually inspected as possible carriers or as home or school contacts of diphtheria cases, a total of 3,058 were examined by throat and nose culture, and in 5, with a history of ear discharge, cultures were taken from the ears as well. Of the total, 137, or 4.5 per cent., including 3 with ear discharge, showed the presence of diphtheria bacilli. Virulence tests applied to the 137 positive cultures by animal inoculation at the Council's Southern group laboratory showed 124 (over 92 per cent.) to be virulent, and 13, including the 3 ear cultures, to be avirulent. In subsequent re-examination of 49 positive carriers, 24 still proved positive and 25 were then negative; 8 of the 24 cultures were tested for virulence, 6 being returned as virulent. It may be noted that in 62 of the 98 schools visited for special investigation a total of over 1,100 children were examined in affected classrooms, where, previous to the visits, a total of nearly 200 cases of diphtheria had been reported, or an average of over three cases per school, but not a single culture from the 1,108 swabbed yielded bacilli morphologically resembling diphtheria. These findings are of particular interest as there are still many people who look upon the day school as the most potent, if not the only, cause of spread of the infectious disease in the community. In 44 schools, including eight schools where previous investigation had failed to show any carriers, 889 children were examined in affected classrooms. In these schools a total of 180 cases of diphtheria had been reported up to the time of the first or second visits, or an average of over four cases per school. Of the 889 children examined, 77 showed the presence of bacilli morphologically resembling diphtheria. Tests showed 72 to be virulent. Therefore eight per cent, of those examined were carriers of virulent organisms, whilst the carrier rate per school was 1.5. Individual schools, however, varied considerably both in the number of cases reported and in the carriers found. Thus in one school, where 7 cases had occurred (3 in one classroom), out of 21 children examined, 6, or 28 per cent, of those examined, proved to be virulent carriers. In a second school, where 8 cases were reported in one classroom, 4 out of 19 children, or 21 per cent., were positive and virulent. In a third with a total of 8 cases (6 being in one classroom), there were 6 virulent carriers amongst 45 examined, or 13.3 per cent. In another school, with 5 cases reported (4 being from one classroom), out of 23 children examined, 3, or 13 per cent., proved positive carriers. In a fifth instance, 4 cases had occurred, and examination of 44 children yielded 3 virulent carriers, i.e., 7 per cent. In the remainder of the 44 schools, the discovery of one or two carriers resulted from each investigation. Thus in the five schools referred to above, among 152 children examined, there were 22, or 15 per cent., yielding virulent diphtheria bacilli, and in 39 schools, where 734 children were examined, 55 were found to be carriers of bacilli morphologically resembling diphtheria, 50, or 6.8 per cent., being virulent and 5 avirulent. Diphtheria "carrier" clinics. The arrangements made with three voluntary hospitals, viz.: London, St. Mary's and Guy's, for the treatment of diphtheria carriers at special out-patient clinics, were continued during 1932. Reports have been kindly furnished by the medical officers in charge of these clinics. In this connection it may be noted that the cases referred to the clinics through the school medical service are those in which virulence has been established as a result of animal inoculation. 59 The clinic at the London hospital is under the care of Mr. F. Muecke, who has reported as follows :— On arrival 20 cases were found to be positive and 35 negative. The following is an analysis of these cases:— Result. Positive. (12 operations.) Negative. (12 operations.) Total. Discharged 12 30 42 Ceased to attend 5 4 9 Current cases 3 1 4 Total 20 35 55 Dr. A. B. Porteous, who is in charge of the clinic at St. Mary's hospital, has submitted the following report:— During the year 1932, 19 cases were referred to the diphtheria carrier clinic of St. Mary's hospital. Their ages varied from 3 to 15 years, and they were sent in from the following sources Paddington, 9 ; Kensington, 5 ; St. Pancras, 3 ; St. Marylebone, 1 ; Hoi born, 1. Twelve of these cases came through the Council, six from medical officers of health, and one from the out-patient department of St. Mary's hospital. The methods of examination and treatment have been as reported last year. Vaccines have been made use of. In only one case was it necessary to operate on the throat. In one case the ear was suspect, but this proved negative to the virulence test. Of the 19 cases, eight failed to show suspicious organisms at their first and subsequent examinations at this hospital. This seems worthy of comment. 3 had organisms suspicious of K.L.B. in nose only. 4 „ „ „ „ in nose and throat only. 1 „ „ „ „ in throat only. Twelve virulence tests were done, and of these only two were positive. One of these was a nose carrier, which was treated with vaccine and cleared up in six weeks. The other had a membrane on the tonsil and was sent to a fever hospital. One cannot reach any certain conclusions in regard to such a small number of cases. I still think that vaccines—autogenous and stock—are useful. It is interesting to note that of the 11 cases carrying suspicious organisms, 2 cleared up in two and four weeks, respectively, 7 were proved to be non-virulent and 2 were virulent, 1 clearing up in four weeks and the other being sent to hospital. The final result is that with the exception of one child who ceased to attend here but went elsewhere, and one sent to hospital, all these cases were proved harmless. Professor John Eyre has furnished the following statement regarding the work carried out at the special clinic at Guy's hospital:— The clinic has continued its work during the year 1932 under the charge of Dr. L. W. Cann (bacteriological department), and Mr. R. J. Cann (throat department), the two medical officers originally appointed in 1926, who have throughout rendered conspicuously meritorious service in dealing with the carrier problem. The number of new cases was slightly less than that noted for the previous year—a diminution probably due to the elimination of " possible " cases by the application of the virulence test at some " pre-clinic " period. This suggestion derives some support from our figures, which show that the diphtheria bacillus was recovered from 62 per cent, of the cases in 1932, as compared with 39 per cent, only in 1931. In all, 61 new cases were examined ; these grouped according to the organisms isolated, were as follows:— K.L.B. (diphtheria bacilli) 38 Hoffmann bacilli only 13 No diphtheroids 10 Total 61 An investigation of virulence of K.L.B. present and isolated from the various cases showed the following results Virulent: In tonsil 9 In nose 7 In tonsil and nose 5 — 21 Non-virulent: In nose 13 Not tested 4 Total 38 60 Of the four cases carrying K.L.B., the virulence of which was not tested, two were cases of acute nasal diphtheria and were immediately dispatched to the fever hospital, and the third was a "contact" of one of these acute cases. The fourth case presented a foreign body in the nose. Of the 21 cases oarrying virulent K.L.B.:— One case, a small child, suffering from a congenital heart lesion, had atrophic rhinitis and failed to respond to nasal treatment. After seven months intermittent attendance the child was referred to a fever hospital. One case lapsed in attendance for two months owing to bronchitis, and on return to the clinic was found to be clear of the Klebs Lceffler bacillus infection. Nine cases became spontaneously clear in three weeks or less, i.e., before the period requisite to define them as true carriers, and were probably contact cases only. Four cases, long standing tonsillar carriers with no other focus of infection in the upper respiratory tract, were freed as the result of tonsillectomy. In each of these cases virulent organisms were recovered from the depths of the tonsils. The residue, six cases in all, had almost certainly contracted nasal diphtheria during the few weeks prior to the first attendance at the clinic, but had not been certified. Four of these cleared up in three weeks or less ; two cases ceased attendance, and it is probable that these were referred to fever hospitals. Thus, with the two cases of nasal diphtheria referred to isolation hospital on their first appearance at the clinic, there were eight cases of nasal diphtheria attending during the year. In addition, several other cases were suspected of having had nasal diphtheria. The medical officers on duty record it as their opinion that the child suffering from nasal diphtheria is a more potent source of danger to the community than either the case of acute faucial diphtheria, or any carrier, since this child is usually not sufficiently ill to be confined to the house, and exudes a bloodstained nasal discharge which is a most effective vehicle for the spread of infection. They therefore emphasise very forcibly the fact that eight cases of recognisable nasal diphtheria, i.e., cases with membrane in the nose and a bloodstained nasal discharge, were referred to the clinic during the year. Scarlet fever. It will be noted that there has been a small increase in the number of cases of scarlet fever reported from the schools during 1932 as compared with the previous year, but the figures are not so high as those for the preceding three years. As a result of special examinations in school by the Council's medical staff, cases of mild type were discovered and notified, and a number of children excluded from school on account of such findings as sore throat, etc. In ten schools children were kept under observation by the nursing staff for periods ranging from two to six weeks. Smallpox among school children. During the year, 1,131 cases of smallpox were notified (and confirmed) in London and of these 419 were among school children. The following statement shows the number of cases occurring among the children during the year, grouped in schoo' terms, for each division :— Division. Spring term. Summer term. Autumn term. Total. N.E 5 17 84 106 N. 24 55 16 95 N.W — — — — s.w 86 69 16 171 S.E. 25 22 — 47 Total 140 163 116 419 The cases were all of the prevalent mild type. Facilities for vaccination on the school premises by public vaccinators were granted whenever applications for vaccination were received from the parents, and, at the written request of the parents, about 500 children in 7 schools were vaccinated. The special arrangement whereby home contacts of smallpox are allowed to attend school if in a healthy condition, which has now been in force for some years, has been continued. These contacts are kept under daily supervision by the school nurses, whose services have also again been extensively used in connection with the daily surveillance of schools attended by children notified as cases of smallpox. 61 The following table summarises the reports submitted by the school nurses in connection with this work :— 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 borough medical officer of health. No. of hours devoted to work. N.E. 1,047 (65) 15 24 195 126 777 N. 1,751 (105) 7 19 907 69 947 N.W. 111 (6) — 1 7 1 27 S.W. 2,322 (115) 10 22 648 231 989 S.E. 585 (43) 1 5 103 73 276 Total 5,816 (334) 33 71 1,860 500 3,016 I would like once again to draw attention to the harmonious relationships between the officers of the school medical service, the school attendance staff and the borough health services in connection with the measures adopted to prevent the spread of smallpox in the schools. Experience of the prevailing type of mild smallpox has again shown the difficulties arising from the numbers of missed cases, and efforts have been directed, especially in areas where the disease persists, to ascertaining the reasons for absence from school at the earliest possible moment. As a result of intensive investigation and close co-ordination between the officers concerned, many previously undetected cases have been brought, to liffht. There has been a decrease in the number of cases of whooping-cough reported from the schools in 1932 as compared with 1931. The school nurses visited 45 schools where whooping-cough was prevalent for the purpose of keeping the children under observation and advising the head teachers as to exclusion or re-admission of children to school. Whoopingcough. The number of cases of chickenpox reported from the schools (11,440) is the lowest recorded since 1922. The school nurses visited 127 schools for the purpose of keeping the children under special supervision. Chickenpox. There was an increase in the number of cases of mumps m 1932 as compared with 1931. This number (8,016) is, however, below the average for the preceding ten vears (9.725). Mumps. A reference to the action taken in connection with the ascertainment and treatment of cases of scabies armears elsewhere in this renort. Scabies. (a) Acute ophthalmia outbreaks occurred in two separate areas during 1932, affecting 3 schools in North Lambeth and 1 in Hackney. The children in these schools were kept under supervision by the school medical and school nursing staffs, working in close co-operation with the borough health services. Special preventive measures were taken and, as a result, infection was restricted to the four schools. In this connection, attention was given particularly to the use of towels and handkerchiefs. Ophthalmia. (b) There were two outbreaks of trachoma among school children during 1932. This eye affection which was once so very prevalent in London, especially in poorlaw schools, is now almost stamped out. The first outbreak concerned a school in Walworth and occurred in February. One of the boys was found to be suffering from this disease and was removed to the Council's ophthalmia hospital (White Oak hospital). As a precautionary measure, all the other children in the school were medically examined, and, as a result, three non-active cases of trachoma were detected. Of these, two were also removed to White Oak hospital, but in the third case the parent preferred to take the child elsewhere for treatment. The children at the school were kept under daily supervision by the school nurse and a special arrangement was made for following up the school absentees by co-operation with the borough health services. No further cases occurred and in due course the special visitation of the school was discontinued. 62 The other outbreak occurred in a school in Limehouse, where one of the children was found in February to be suffering from the disease. As a result of this discovery the school was visited, and the medical examination of the other children resulted in the finding of seven further cases; three of these belonged to the same family as the original case. All the children except one were admitted to White Oak hospital. Necessary precautionary measures were taken at the school to prevent the spread of infection, and the children were kept under daily supervision through the school medical service. Close co-operation was maintained with the borough medical officer who arranged for the visitation of school absentees. The outbreak subsided in May. Measles. A preliminary survey ot the measles epidemic which commenced in .November, 1931, was made in the Annual Report for 1931. The epidemic ended in the elementary schools in July, 1932. A comprehensive report dealing with various aspects oi the epidemic, such as incidence, mortality, hospital treatment, scheme of control in the school, home nursing, etc., is being prepared and will be published in due course. Ringworm. The following table shows the number of cases of ringworm of the scalp among the children in the Council's schools dealt with during 1932 compared with the figures for preceding years :— Year. New cases. Cured cases. Cases outstanding at the end of the year. Percentage of cures effected by X-ray treatment. 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 1932 358 370 89 75 It will be seen that the number of new cases of ringworm continues to diminish and that at the end of 1932 there were only 89 known cases amongst school children in London. Not many years ago the existence of ringworm amongst the children in the Council's schools constituted a most troublesome problem. At the end of 1912 over 5,000 children were suffering from the disease; by 1922 the number had been reduced to 2,700. The number recorded this year (89) is the lowest on record. The virtual extinction of ringworm is a tribute to the excellence of the work carried out by the school nursing service in connection with the detection of cases and their following up. During the year, 879 specimens of hair stumps, sent by the school nurses, were examined for ringworm at the laboratory at the County Hall. Ringworm fungus was found in 240 of these (181 small snore and 59 laree snore). Favus. Post encephalitis lethargica. No case of favus was reported during the year. During the year 11 school children (8 male and 3 female) were admitted to the Council's post encephalitis lethargiea unit at the Northern hospital, and 14 (8 male and 6 female) were discharged. One child died, the certified cause of death being (a) status epilepticus, (b) polioencephalitis. At the end of 1932 there were still 35 boys and 13 girls under treatment in the unit. Play centres. Close co-operation has been maintained with the Play Centres Committee, who were notified with regard to all schools where infectious illness was prevalent. The Committee are continuing the scheme for the distribution of notices warning parents against sending children to the centres if they are unwell or are home contacts of infectious illness, as outlined in the annual report for last vear. School journeys. Particulars of the arrangements made for school journeys during 1932 are set out on page 43. 63 The special precautions to which reference was made in the last Annual Report were again adopted with a view to preventing the spread of infectious illness. Ihree cases of scarlet fever occurred in December at the Mayford industrial school, and at Ponton-road place of detention six cases were reported during October, November and December. Industrial schools and place of detention. The affected children were removed to the Council's hospitals and appropriate action was taken to prevent any spread of infection. The few sporadic cases of infectious illness that occurred in the schools during the year do not call for special comment. Ihe Education Committee, in June, authorised the immunisation of the children in the residential special schools on the same lines as at the residential (transferred) schools to which reference is made below. Residential special schools. ihree medical officers from the Council s hospital service who had had previous experience of active immunisation undertook the supervision of the work until the medical officers of the school had received the training necessary to enable them to assume the duties themselves. The material required was supplied from the Belmont laboratories as in the case of the residential schools and children's homes. The work of obtaining the necessarv parental consents was carried out bv the school attendance staff. Ihe following figures relating to the consents obtained may be of interest:— Number. Children resident in schools 337 (approximately) Consents obtained 220 (65 per cent.) Refusals 93 (28 per cent.) Still awaiting parental consent 24 (7 per cent.) The following summary gives some idea of the progress of the work up to the end of December, 1932 :— Number. Tested for susceptibility to diphtheria 212 Negative to test 149 (70 per cent.) Positive to test 63 (30 per cent.) Immunised against diphtheria 42 N.B.—In 21 cases the process of immunisation had not been completed on 31st December, 1932. The scheme adopted for the prevention of the spread of infectious diseases in the residential schools, children's homes and children's receiving homes transferred from the various authorities to the control of the Council on 1st April, 1930, was outlined in the last Annual Report. This scheme was put into operation in July, 1931, and, in May, 1932, the medical officers in charge of these schools were invited to attend a conference to discuss questions relating thereto, and it was decided that the advisability or otherwise of modifying the arrangements should be considered later when further experience had been obtained. Residential (transferred) schools, children's homes and children's receiving homes. A brief review of the incidence of infectious illnesses in the residential schools and children's homes during 1932 is set out below. It may here be stated that all cases of infectious illness (except impetigo and scabies) occurring in these institutions are removed to one or other of the Council's special hospitals. Diphtheria.—Cases of diphtheria were reported from some of the schools during the year. Arrangements were made for the swabbing of contacts where considered necessary, 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. Diphtheria investigations were undertaken in 15 schools during the year, and a total of 1,583 children and 39 adults were bacteriologically examined by throat and nose culture ; while in 13 of the children suffering from otorrhoea, cultures were taken also from the ears. Positive results were obtained from 95 children, or 6 per cent., including 10 ear cultures, and 1,488 or 94 per cent, proved negative ; while 3 adults showed organisms morphologically indistinguishable from diphtheria bacilli, and the other 36 were negative. Subsequent examination of 20 of the positives yielded 17 still positive. 64 Tests showed the 3 adults to be carriers of virulent bacilli. In 87 cultures obtained from children, 72 were virulent, and 15 avirulent. Of the 10 ear cultures, only 1 proved virulent. In 5 of the 15 schools investigated on account of diphtheria not one positive result was obtained among 163 children examined. In the other 10 schools, 1,420 children were examined, yielding 95 positive results (74 virulent) with a virulent carrier rate of over 7 per school, and an average of 5 per cent, among those examined. The proportion of carriers found varied considerably in different schools, from 14 positive out of 87 or 16 per cent., to 7 out of 200 or 3-5 per cent, of the children examined. All the cases in which diphtheria germs were found were removed to the Council's hospitals for treatment. Reference is made later in this report to the measures adopted for active immunisation against diphtheria in these residential schools and homes. The protection so far afforded by this means constitutes a barrier against the spread of diphtheria, and it has been possible in the case of some of the schools to effect some reduction in the routine swabbing of contacts. Scarlet Fever.—Outbreaks of scarlet fever occurred during the year at Ashford, Hanwell, Lamorbey, Leytonstone and Shirley, and several cases were reported over periods of some months from Banstead. Cases also occurred amongst the children at three of the receiving homes. The cases were of the mild type that has been prevalent in London in recent years, and the spread of infection in the schools was no doubt due to the difficulty experienced in diagnosing cases sufficiently early. In some of the schools the fact that outbreaks of tonsillitis appeared to be due to the same primary infection militated against an effective control, and it was decided to remove to one of the Council's hospitals all children found to be suffering from tonsillar infection. Some of these were subsequently diagnosed as cases of scarlet fever, thus demonstrating the difficulty in detecting all cases when the disease is prevalent. These and other precautionary measures were effective in arresting the spread of infection in all the schools by the end of the year. Mumps.—A number of cases of mumps occurred at Norwood in January, at Ashford in March, and at Lamorbey in the early spring. At Leytonstone there were two minor outbreaks. At Shirley a number of cases occurred during the latter part of the year, the youngest children being particularly affected. In each of the affected schools suitable measures were taken to prevent the spread of infection. Chickenpox.—In the first three months of the year a number of cases occurred at Hanwell, where it was alleged that spread was induced through the overcrowding of one of the blocks of the school buildings. The necessary steps were taken to secure a re-arrangement of the accommodation. Some cases occurred at Banstead in the spring and at Hutton during July. Cases were also reported from the Henniker House receiving home. Whooping-cough.—A number of children were involved in an outbreak of whooping-cough at Shirley during the latter part of the year, and minor outbreaks were also reported from Anerley, Cumberlow Lodge, and Leytonstone. Measles.—Several of the residential schools and children's homes were affected by the measles epidemic which occurred during the period November, 1931, to August, 1932, and groups of cases were reported from Andover (January), Ashford (May to July), Banstead (May to July), Hanwell (April), Hornchurch (March to May), Hutton (June to July and September to October), Lamorbey (May to August), Leytonstone (March to June), Norwood (January and August to December), Peckham (March to May), Shirley (March to June). Adult serum was supplied for use in several instances, and a reference to the results obtained will be made in the special report on the measles epidemic which is being prepared for publication. Ringworm.—Several cases of ringworm occurred at Andover, Hornsey Rise and Shirley during the year. A few cases were also reported from Cumberlow Lodge 65 Hanwell, Hutton, Leytonstone, and Stepney. During the year seven mercury vapour lamps with Woods glass screens were supplied to schools and homes where cases of ringworm occurred, and were found of great assistance in detecting cases in the earliest stages. In some instances, also, an assistant superintendent of school nurses visited the school or home to give advice. All cases of ringworm are removed to the Council's Goldie Leigh hospital for treatment. During the year 101 specimens of hair stumps were sent to the laboratory at the County Hall for microscopical examination. Ringworm fungus was found to be present in 43 cases (all small spored). Impetigo.—Some cases of impetigo were reported amongst the children at Banstead in October. All necessary precautions were taken at the school. Scabies.—Difficulty was experienced in effectively treating several cases of scabies amongst the children at Hanwell and ultimately (in February, 1933) they were removed to the Council's Goldie Leigh hospital for treatment. Ophthalmia.—Six cases of ophthalmia were reported amongst the children at Leytonstone in August. Molluscum contagiosum.—An unusual form of skin disease occurred at Ashford in February, and Dr. J. M. H. MacLeod, the consulting physician for skin diseases at Goldie Leigh hospital, visited the school. Dr. MacLeod diagnosed the disease as molluscum contagiosum, and, after following his advice as to treatment and measures to be taken for the prevention of spread of the disease, the cases cleared up and no further difficulty was experienced. The source of the infection could not be traced. As may be expected, the control of infectious diseases in these residential schools and children's homes of varying size, each with a population of susceptible material of all ages from 3 up to 16, presents many problems which can only be solved by experience. Prior to 1st April, 1930, these institutions were separate entities, each overcoming its difficulties in its own way. Since the Council assumed control an attempt has been made to view the position from the widest aspect, and, although it has been necessary to introduce procedures differing in many instances from those previously practised, a tribute is due to the medical, nursing and other staffs of these institutions for their co-operation, and for the manner in which they have carried out their duties. In the Annual Report for 1931 reference was made to the fact that the Education Committee had decided, not only to continue the arrangements made by the late authorities with regard to the active immunisation of the children at four schools and homes (training ship " Exmouth," Mitcham, Norwood and Shirley), but to provide facilities for the immunisation of children in any of the other residential schools and children's homes where the managing committee so desired. It was stated that immunisation measures had been sanctioned at the following schools and homes, viz.:—-Ashford, Banstead, Cumberlow Lodge, Hammersmith, Hanwell, Hutton, Lamorbey, Leytonstone, Ongar, Peckham, Stifford. In May, 1932, the scheme was extended to include the Hornchurch children's home. Active immunisation against diphtheria in the residential schools and children's homes. The public assistance department has co-operated with the education officer's department in obtaining the necessary parental consents, and to facilitate this side of the work a form was drawn up for signature by parents or guardians together with an explanatory leaflet. Some idea of the magnitude of the task involved may be realised when it is stated that it became necessary to deal with all the children in residence at the twelve schools and homes where active immunisation had been introduced for the first time, together with new admissions to these schools and homes, as well as to the four other institutions where the measure had been in operation under the late authorities. Altogether, there were nearly 5,000 children to be dealt with in this way. No alterations have been made in the arrangements outlined in the Annual Report for last year. 66 Nine medical officers of the Council's hospital staff, with previous experience of the process, were selected to commence the work and to train the medical officers of the schools in the necessary technique. The medical officer of one of the schools undertook the work from its inception. The arrangements have worked very smoothly, and the medical officers of the schools are taking full charge as they become conversant with the process. The Mitcham children's home, at which Dr. R. A. O'Brien, director of the Wellcome physiological research laboratories, assisted by Dr. H. J. Parish, had carried out the immunisation work for several years, closed on 31st March, 1932. The children were transferred to other schools and homes, and arrangements were made for the history as to Schick-testing and immunisation to be communicated to the schools and homes concerned. As stated in my report of last year, the Schick test toxin and prophylactic used in connection with the immunisation have been supplied from the Council's laboratories at Belmont, with the exception of that used at Norwood which has been obtained from the Wellcome research laboratories. The history as to testing and immunisation has been recorded on a special card by the medical officer in charge of the work, and arrangements have been made for the cards in respect of those children whose treatment had been completed to be sent to Dr. White, the director of the Belmont laboratories, to enable him to collate the results obtained. The following is a summary of the work completed during 1932 :— Number. Tested for susceptibility to diphtheria 2,574 Negative to test 1,767 Positive to test 807 (31 per cent.) Immunised aeainst diphtheria 622 N.B.—-In 185 cases immunisation was still in progress on 31st December, 1932. In the twelve schools and homes in which active immunisation was introduced during 1932, 25 cases of diphtheria occurred among the children since immunisation commenced ; in the case of two of these the parents had refused consent to immunisation against the disease ; in 20 of the cases parental consent to immunisation had not yet been obtained, while in two cases active immunisation had not been completed when the children contracted the disease. In the case of one child who developed diphtheria in December, 1932, there is no definite record of the child's having been actively immunised, but a reference has been traced from which it would appear that the child may possibly have been immunised in 1929. The cases of diphtheria referred to are those in which definite symptoms of the disease have been diagnosed at the Council's special hospitals. During the same period 27 children in the schools concerned were found to be harbouring germs associated with diphtheria. These children were removed to one or other of the Council's special hospitals, but they did not develop diphtheria. Active immunisation does not of course affect the " carrier " condition. In November, 1932, the Ministry of Health issued a memorandum on the " Production of Artificial Immunity against Diphtheria," in which it was pointed out that diphtheria causes considerable interference with school life and entails a heavy charge, and it was urged that attention should be drawn to the advantages to be obtained from immunisation and that where practicable, the necessary facilities for obtaining such protection should be offered to parents or guardians of children over one year of age. The special advantages of immunisation in residential schools or other establishments for children and adolescents were emphasised. It was pointed out, however, that immunisation is not a way of dealing with an individual attack of diphtheria, or with the "carrier" condition, and that, unlike the passive immunity produced by diphtheria antitoxin which is immediate but transient, active immunity requires some time for its full development, but endures for years and perhaps throughout life. The memorandum contained recommendations on the practice of active immunisation against diphtheria. 67 STATISTICAL TABLES. Table L Medical Inspection, 1932. (a) Routine Inspections. Group. Boye. Girls. Total. Entrants 29,183 29,162 58,345 Age 8 26,858 26,274 53,132 Age 12 34,909 34,519 69,428 Leavers 19,649 19,471 39,120 Total elementary schools 110,599 109,426 220,025 „ special schools 1,029 841 1,870 (b) Other Inspections. Special inspections 49,573 46,282 95,855 Infectious disease enquiries — — 58,870 Re-inspections — — 163,491 Table II. (a) Defects found at medical inspections in 1932. 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. Element. ary schools. Special schools. Malnutrition 1,109 7 902 3 1,531 379 Skin—Ringworm, head 1 — — — 20 3 „ „ body 42 — 4 — 28 6 Scabies 117 2 2 — 1,795 11 Impetigo 173 3 4 — 454 11 Other disease (non-tubercular) 1,001 4 130 — 749 86 Eve—Blepharitis 796 3 75 — 328 17 Conjunctivitis 174 3 9 — 293 84 Keratitis 3 — — — 13 1 Corneal opacities 16 — 6 — 26 12 Defective vision, excluding squint 16,810 168 6,879 86 3,853 499 Squint 1,278 4 379 — 539 53 Other conditions 198 1 46 1 285 57 Ear— Defective hearing 283 6 118 1 235 82 Otitis media 1,082 21 350 2 638 138 Other ear disease or defect ... 606 5 104 — 267 55 Nose and throat— Enlarged tonsils 7,284 33 7,064 13 1,959 418 Adenoids 699 2 417 — 353 43 Enlarged tonsils and adenoids 2,183 7 641 1 740 49 Other conditions 789 4 266 1 677 110 Enlarged cervical glands 337 1 1,041 2 242 270 Defective speech 119 1 165 — 131 49 Teeth—Dental disease or defect 63,437 408 1,155 5 4,633 76 Heart and circulation, heart disease— Organic 23 — 88 1 7 8 Functional 28 — 247 — 10 15 Not stated 206 2 2,467 19 335 734 Anaemia 843 3 587 2 498 187 Lungs—Bronchitis 993 2 923 6 253 86 Other non-tubercular 256 — 631 5 210 186 Tuberculosis— Pulmonary definite — — 7 — 4 6 „ suspected 15 — 48 2 29 125 Glands 9 1 16 — 18 15 Spine — — 1 — 2 4 Hip — — 4 — 6 1 Bones and joints — — 4 — 5 2 Skin 1 — 1 — 5 1 Other forms 2 — 4 — 7 10 68 STATISTICAL TABLES—Table II—continued. (a) Defects found at medical inspections in 1932. Elementary and special schools—continued. 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. Nervous—Epilepsy 20 — 22 1 79 28 Chorea 78 — 65 1 197 125 Paralysis 13 — 18 1 192 102 Other conditions 172 2 230 — Deformities— Rickets 72 — 29 — 27 17 Spinal curvature 614 5 230 3 89 20 Other 741 8 493 1 232 77 Other conditions 2,745 22 1,326 4 3,142 986 Mental defects — — — — 605 171 (b) Children found at routine medical inspection to require treatment (excluding uncleanliness and dental disease). Age group. Inspected. Found to require treatment. Percentage requiring treatment. Entrants 58,345 9,865 16.9 Age 8 53,132 9,840 18.5 Age 12 69,428 12,591 18.1 Leavers (age 13¼) 39,120 6,395 16.3 Total, elementary schools 220,025 38,691 17.6 „ special schools 1,870 *299 16.0 *Not including the 3peoial defects for which the children are in the special schools. Table III. (a) Exceptional children in London in 1932. Boys. Girls. Total. Blind (including partially blind). (1) Suitable for training in a school for the totally blind. At certified schools for the blind 105 92 197 At public elementary schools — — — At other institutions — 3 3† At no school or institution 1 1 2 (2) Suitable for training in a school for the partially blind. At certified schools for the blind or partially blind 365 482 847 At public elementary schools 8 11 19 At other institutions 5 12 17† At no school or institution — — — Deaf (including deaf and dumb and partially deaf). (1) Suitable for training in a school for the totally deaf or deaf and dumb. At certified schools for the deaf... 300 263 563 At public elementary schools — — — At other institutions 2 1 3† At no school or institution 1 1 2 (2) Suitable for training in a school for the partially deaf. At certified schools for the deaf or partially deaf 74 95 169 At public elementary schools 3 — 3 At other institutions 11 8 19† At no school or institution — — — Mentally defective. Feeble-minded At certified schools for mentally defective children 2,518 1,845 4,363 At public elementary schools 7 3 10* At other institutions 11 6 17† At no school or institution 3 3 6 69 Table III —continued. (a) Exceptional children in London in 1932—continued. j Boys. Girls. Total. Epileptics. Suffering from severe epilepsy At certified schools for epileptics 59 53 112 At certified residential open-air schools — — — At certified day open-air schools — — — At other institutions 4 11 15| At public elementary schools — — — At no school or institution 23 26 49‡ Suffering from epilepsy which is not severe. At public elementary schools 221 202 423 At other institutions 4 7 11† At no school or institution — — — 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 77 106 183 At certified residential open - air schools — — — At certified day open-air schools 1 — 1 At public elementary schools — — — At other institutions 2 5 7 At no school or institution — — — 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 33 2 35 At certified residential open-air schools — — — At oertified day open-air schools 93 97 190 At public elementary schools 76 81 157 At other institutions — 2 2 At no school or institution 5 8 13 Tuberculosis of the peripheral glands. At sanatoria or sanatorium schools approved by the Ministry of Health or the Board of Education 42 41 83 At certified residential open-air schools — — — At certified day open-air schools 166 117 283 At public elementary schools — — — At other institutions 3 2 5 At no school or institution — — — Abdominal tuberculosis At sanatoria or sanatorium schools approved by the Ministry of Health or the Board of Education 16 7 23 At certified residential open-air schools — — — At certified day open-air schools 49 23 72 At public elementary schools — — — At other institutions — 1 1 At no school or institution — — — 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 246 200 446 At public elementary schools 9 11 20 At certified day open-air schools 8 9 17 At other institutions 2 1 3 At no school or institution — — — Tuberculosis of other organs (skin, etc.). At sanatoria or hospital schools approved by the Ministry of of Health or the Board of Education 5 9 14 At public elementary schools 11 7 18 At certified day open-air schools 10 3 13 At other institutions 2 3 5 At no school or institution — — — 70 Table III—continued. (a) Exceptional children in London in 1932—continued. Boys. Girls. Total. Physically defective. 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 residential cripple schools - - - At certified day cripple schools 80 41 121 At certified residential open-air schools 357 257 614 At certified day open-air schools 970 657 1,627 At public elementary schools 3,204 3,089 6,293 At certified hospital schools 178 277 455 At other institutions 4 3 7t At no school or institution 42 24 66 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 167 95 252 At certified residential cripple schools 17 9 26 At certified day cripple schools 1,370 1,112 2,482 At certified residential open-air schools - - - At certified day open-air schools - - - At public elementary schools - - - At other institutions 9 7 16† At no school or institution 10 7 17 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 89 146 235 At certified residential cripple schools - - - At certified day cripple schools 464 877 1,341 At certified residential open-air schools 1 1 2 At certified day open-air schools - - - At public elementary schools - - - At other institutions 14 18 32† At no school or institution - - - *At the time of report were waiting admission to schools for the mentally defective, †Undergoing treatment in general hospitals, etc. ‡At the time of report were awaiting admission to certified schools. (6) Reiurn of children suffering from more than one defect, 1932. Defect. Type of School. Day M.D. Residential M.D. Day Blind Residential Blind Day Deaf Residential Deaf Epileptic colony Day P.D. Certified hospital Schls. At other institutions (Gen. hosp., etc.) At no Schl. Total Boys. Girls. Boys. Girls. Boys. Girls. Boys. Girls. Boys. Girls. Boys. Girls. Boys. Girls. Boys. Girls. Boys. Girls. Boys. Girls. Boys. 1 Girls. Boys. Girls.  M.D. and deaf 2 8 - - - - - - - - 3 2 - - - - - - - - - 1 5 11 M.D. and crippled 54 20 - - - - - - - - - - - - 16 15 7 9 3 - - 1 81 45 M.D. and heart 28 30 1 - - - - - - - - - - - - - - - - - - - 30 31 M.D. and epileptic 25 22 2 - - - - - - - - - 30 11 - - - - - - - - 57 33 Blind and crippled - - - - - - - - - - - - - - - - - - - - - - - 1 Blind and heart - - - - - - - - - - - - - - - - - - - - - - - 1 Blind and epileptic - - - - - 1 1 - - - - - - - - - - - - - 1 1 Deaf and crippled - - - - - - - - - 2 7 2 - - - - - - - - - - 7 4 Deaf and heart - - - - - - - - 1 1 - 1 - - - - - - - - - - 1 2 M.D. and T.B - -_ -— - - - - - - - - _ - - - - - 1 - - - - - 1 Epileptic and crippled - - - - - - - - - - - - 1 1 3 3 - - - - - 1 4 5 Epileptic and heart - - - - - - - - - - - - 1 - 1 1 - - - - - - 2 1 Epileptic, M.D. and crippled. - - - - - - - - - - - - - 3 - - - 1 - - 1 - 3 4 Crippled, M.D. and blind - - - - - - - - - - - - - - - - - - - - - - - 1 Blind and M.D. - - - - - - - - - - - - - - - - - 1 1 - - - 2 1 Crippled and T.B. - - - - - - - - - - - - - - - - - - - - - 2 - Heart and crippled - - - - - - - - - - - - - - 71 9 1 - - - - - 72 9 Heart, epileptic and crippled. - - - - - - - - - - - - - - - - - - - - - - 1 - Heart, crippled and M.D. 1 - - - - - - - - - - - - - - - - - - - - - 1 - 110 80 3 - 1 2 1 1 1 3 10 5 35 15 93 28 10 14 4 - 1 3 269 151 420 71 Table IV. Treatment table. Group I.—Minor ailments, excluding uncleanliness, for which see Group V. Disease or defect. Defects trea ted or under treatment. Under Council's scheme. Otherwise. Total. Skin-— Scabies 5,125 — 5,125 Impetigo Ring-worm, head 224* 234 458† body 100,275 2,492 102,767 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.) 105,624 2,726 108,350 *192 by X-ray. †326 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) 41,672 1,811 45,983 Other defect or disease of the eyes (excluding those in Group I) 2,500 (estimated) — Children for whom glasses were prescribed—under the Council's scheme, 29,548; otherwise 1,280 (estimated). Children who obtained or received glasses—under the Council's scheme, 26,200 = 88-6 per cent.; otherwise 1,063. 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. 13,765 1,793 15,558 3,599 19,157 Group IV.—Dental defects. Number of children who were :— (a) Inspected by the dentist—Age groups 5 years and under 13,272 6 „ 31,844 7 „ 36,531 8 „ 13,916 9 „ 39,811 10 „ 44,853 11 „ 39,697 12 „ 19,758 13 ,, 23,589 14 „ and over 10,466 273,737 (b) Found to require treatment 174,809 (c) Actually treated 134,769 72 Gboup IV.—Denial defects—continued. 2. Half days devoted to inspection 2,462 21,377 „ „ „ treatment 18,915 3. Attendances by children for treatment 234,928 4. Fillings—permanent teeth 107,325 138,857 „ temporary teeth 31,532 5. Extractions—permanent teeth 56,411 353,234 „ temporary teeth 296,823 6. Administration of general anaesthetics for extractions 71,689 7. Other operations—permanent teeth 33,701 „ „ 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 1,992,748 (c) Instances of uncleanliness 195,534 (d) Children cleansed under Council's arrangements 116,335 (e) Cases in which legal proceedings were taken under the Education Act, 1921 (section 87) 279 Table V. Medical inspection.—Number of children examined, 1922-1932. Year. Routine examinations. Special examinations. Re- inspections. Examinations at special enquiries into outbreaks of infectious disease. Ionisation centre attendances. Rheumatism supervisory centre attendances. 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 1932 221,895 95,855 163,491 58,870 18,154 12,833 Table VI. Medical treatment.—Number of cases treated under the Council's scheme and by other agencies, 1922-1932. Year, Minor ailments. Vision. Nose and throat. Dental. Under the Council's scheme. Otherwise. Under the Council's scheme. Otherwise. Under the Council's scheme. Otherwise. Under the Council's scheme. Otherwise.* 1922 71,478 2,989 32,752 1,871 8,720 1,805 84,848 5,858 1923 82,475 2,235 31,986 1,573 11,936 1,162 95,332 4,722 1924 83,751 1,931 32,747 1,189 12,980 1,193 99,045 4,285 1925 91,691 2,351 36,356 1,520 15,066 1,633 112,964 4,472 1926 92,683 1,961 37,985 1,687 15,168 1,615 113,932 4,321 1927 103,019 1,796 40,293 1,593 18,176 1,797 124,992 4,689 1928 101,254 1,772 40,984 1,837 20,162 2,336 129,255 4,758 1929 101,666 1,615 41,620 1,905 19,903 2,282 129,952 4,473 1930 105,118 1,435 43,579 1,961 19,760 1,904 138,280 5,849 1931 106,072 1,492 44,686 2,082 20,703 1,935 139,723 5,282 1932 100,275 2,726 44,172 1,811 17,364 1,793 134,769 5,195 *It is not possible to give complete figures, but those given are the result of following up of medical inspections. Other children receive dental treatment outside the Council's scheme as a result of dental inspection. 73 INDEX, PAGE Adoption of children 20 After careers 51 Anaemia 10 Care committee organisation 15 Cerebro-macular degeneration 52 Chickenpox 61, 64 Child guidance 45 Cleanliness 4,8 Convalescent camp schools 42 Deformities 11 Diphtheria 58, 63, 65 Ears 10,15, 22, 23, 52 Employees, Examination of 56 Employment of school children 21 Enuresis 19 Eyes 10,14, 22, £2 Favus 62 Health classes 30 Heart 10 Industrial and residential schools 53,63 Infectious diseases 3,57 Invalidity, Chronic 20 Lungs 11 Measles 62,64 Medical inspection 2,6 Medical treatment 3,21 Mental deficiency 51,52 Molluscum contagiosum 65 Mumps 61, 64 page Myopia 34 Nervous diseases 11 Nursery schools 43 Nutrition 6,14,18, 36 Open-air education 38 Ophthalmia 61, 65 Personal hygiene 29 Physical deficiency 49 Play centres 62 Post encephalitis lethargica 62 Remedial exercises 28 Residential and industrial schools 53,63 Rheumatism 31 Rickets 11 Ringworm 22,62,64 Sandpits, disinfection of 45 Scabies 13, 65 Scarlet fever 15, 60,64 School journeys 43,62 Secondry and trade schools 13 Smallpox 60 Staff 5 Stammering 28 Teeth 3,8,14, 26 Tonsils and adenoids 9 Transferred schools and homes 18,63 Tuberculosis 11,40 Vaccination 11 Whooping cough 61, 64 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 fob 1930 :— Vol. I. (Part I). Powers and duties— Elections — Finance — Rating and Taxation—Public Protection—Traffic— Publio 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 Offiocr of Health. Is. No. 2850. Vol. III. (Part II) Publio Health. Report of School Medical Officer. Is. 6d. No. 2851. Vol. IV. (Part 1).—General and Special Hospitals. 2s. (id. No. 2875. Vol. IV. (Part II).—Hospital Finance. Is. No. 2876. Vol. IV. (Part III).—Medical Supplement. 5s. 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