REFERENCE COPY Not to be taken from the Library . LCC 43 London County Council ANNUAL REPORT OF THE COUNCIL, 1934 Vol. III (Part I) PUBLIC HEALTH (Report for the year 1934 of the County Medical Officer of Health) 850. (mcC. 11093—6) 14.9.35 CONTENTS Page Introduction 5 Vital Statistics— Population 11 Infectious Diseases 16 Tuberculosis 26 Statistical Tables 29 Administration— Slum Clearance 33 Milk and Dairies Act 35 Venereal Diseases 36 Treatment of Tuberculosis 40 Mental Deficiency Acts 55 Blind Persons Act 56 Midwives Acts—Nursing Homes Registration Act--Maternity and Child Welfare Contribution Schemes 56 Examination of Staff 60 Bacteriological Laboratory Work 61 Chemical Branch 61 Statistical Information 70 Sanitary Officers 72 London County Council ANNUAL REPORT OF THE COUNCIL, 1934 VOL. III—(Part I) REPORT OF THE COUNTY MEDICAL OFFICER FOR THE YEAR 1934 By Sir Frederick Menzies, K.B.E., M.D., LL.D., F.R.C.P., F.R.S.E., County Medical Officer of Health and School Medical Officer. Introduction. This report deals with the year 1934, and is produced in the midst of the celebrations of His Majesty's Jubilee. It is fitting, therefore, to give a short account of the development during the last 25 years of some of the more important of the public health services administered by the Council. It is of interest to discuss the trend of vital statistics during that period, the action taken towards the abolition of slums, and the inception and growth of such schemes as those for the prevention and treatment of venereal disease and tuberculosis, the action taken under the Mental Deficiency and Blind Persons Acts, the gradual improvement in the standard of work of midwives, and the development in the work of the chemical and bacteriological laboratories. The trend of public health statistics during the past 25 years, of which the main features are shown on the diagram on page 13, is of interest as reflecting the changes in the social and economic conditions of the London community, the effects of the World War of 1914-18, and the various improvements in public health administration during the period. Vital Statistics. The changes can roughly be measured by the following table:— Rates per 1,000. 1910. 1934. Percentage increase+ decrease- Birth-rate 25.5 13.4 -47.5 Marriage-rate 17.3 20.5 +18.5 Death-rate 13.7 12.2 -10.9 Infant mortality 103.0 67.0 -35.0 Tuberculosis death-rate 1.63 0.87 -46.6 Pulmonary tuberculosis 1.24 0.76 -38.7 Other „ 0.39 0.11 -71.8 Enteric fever death-rate 0.043 0.003 -93.0 It will be seen that the birth-rate has decreased by 47.5 per cent. The rate of decrease was accelerated during the War, a minimum rate of 16.0 being attained in 1918, but after the armistice it rapidly increased to a maximum of 26.4 in 1920, since when there has been a steady drop. The marriage-rate has increased over the period by 18.5 per cent. Already increasing before the War there was a marked rise in the first year of hostilities, the maximum of 25.9 being attained in 1915. Thereafter a slump occurred as the manhood of the nation took its place in the fighting line, the minimum of 17.5 being reached in 1917. After demobilisation, a rapid rise took place, the peak, 22.1, being attained in 1919. This was followed by a corresponding drop in the early post-war years. After 1926 the improvement in the economic situation caused (5) 6 another increase to a maximum of 19.5 in 1930, but another decrease followed when the situation worsened. There has been a steady rise during the last two years. The death-rate has on the whole steadily declined and the decrease amounts in all to 10.9 per cent., although there was a tendency to increase prior to the outbreak of the War. The influenza epidemics are reflected in the peaks of 1918, 1922 and 1929; the peak in 1915 was mainly due to respiratory disease. Infantile mortality has steadily declined by 35 per cent. during the past 25 years, in spite of peaks in the years 1911, 1915, 1918 and 1929. The work of health visitors, infant welfare centres, hospitalisation of young children suffering from infectious diseases, the lessening of the fly nuisance as a result of the replacement of horses by motor cars, and the more efficient control of milk supplies are among the causes of this gratifying result. There has been a steady decrease in mortality from tuberculosis, once known as the "great white plague." This decrease has been coincident with the development of a national scheme for combating the disease and with the general rise in the standard of living of the working classes. The death-rate from enteric fever has been practically eliminated as a result of improved sanitation and food supply control during the period in question. Housing. The past 25 years have seen a great movement to deal with insanitary housing, a movement gradually gathering momentum, although interrupted from time to time by the War and by periods of legal and financial difficulty, until, in the year 1934, it is possible to say that within two or three years practically all the larger insanitary areas in London capable of being dealt with under Section I of the Housing Act of 1930 will have been represented by the medical officer of health. During these years there has been a series of Acts of Parliament adding to or amending the powers contained in the Housing of the Working Classes Act of 1890. Under these Acts it has been possible for local authorities to clear insanitary areas and to provide rehousing for the displaced persons. It is not my province to enlarge upon the great schemes which have been undertaken for the provision of new houses for the working classes—that is fully dealt with in Vol. II of the Annual Report and other publications of the Council—but it is of interest to mention that at 31st March, 1935, 68,629 houses and flats had been provided by the Council, of which 60,090 had been erected since 1st April, 1910. The total accommodation houses nearly 307,000 persons at a capital cost, including the cost of the clearance of unhealthy areas, of some £44,000,000. In connection with the work of slum clearance it has been the duty of the medical officer's housing section to survey the whole of London to discover insanitary areas, to consult with the borough medical officers of health, and to represent to the Council those areas suitable for clearance. Prior to the Great War eight large areas had been represented to the Council and "declared," and work thereon had either been completed or was in progress. These areas involved the displacement of some 21,000 persons. Between 1919 and 1927 twenty areas were represented and "declared," involving the displacement of some 22,000 persons. From 1927 to 1930 there was an absence of representations, due mainly to legal difficulties in the working of the Acts, but in 1930 representations were resumed, and, from then up to and including 1933, 30 areas were represented involving the displacement of nearly 13,000 persons. During 1934 the pace has been much accelerated, and no less than 59 clearance areas occupied by over 20,000 persons have been represented. Inevitably this increase of work has necessitated an increase of staff, and, whereas in the early years of the period under review the part-time services of one medical officer and 2 to 4 sanitary inspectors was sufficient, there are at present (1935) engaged on this work 6 whole-time medical officers and 18 whole-time inspectors. Venereal diseases. The Public Health (Venereal Diseases) Regulations, 1916, made by the Local Government Board required that the councils of counties and county boroughs, 7 including the Common Council of the City of London, should make arrangements for the treatment at and in hospitals or institutions of persons suffering from venereal disease. These regulations were the outcome of the first report of the Royal Commission on Venereal Disease (March, 1916), which found that the effects of venereal disease upon the individual and upon the race were grave and far-reaching, involving a heavy loss to the community in actual and potential population as well as in money. The Commission recommended that arrangements should be made for providing free for the whole community adequate laboratory facilities for diagnosis, combined with the provision of adequate and skilled free treatment for all persons affected. In compliance with the regulations the London County Council, in co-operation with the councils of the counties and county boroughs immediately adjoining the county of London, prepared a scheme, which came into force on 1st January, 1917, to give effect to the recommendations. The scheme in brief comprised agreements with some 22 of the large voluntary hospitals in London to undertake the work of diagnosis and treatment in return for an annual grant in aid. The same year (1917) saw the passing of the Venereal Disease Act which made it an offence, where the facilities in question were in operation, for any person other than a duly qualified medical practitioner to treat, prescribe or give advice for the treatment of venereal disease. Since the inauguration of the scheme there has been a great development in the direction of larger clinics open all day, and at the present time the scheme includes six such clinics, one of which, the Whitechapel clinic, is administered and staffed entirely by the Council's officers. There are, in addition, six clinics providing all-day intermediate treatment. This tendency has led to the closing of some of the smaller and less effective clinics, and has undoubtedly tended to the greater efficiency of the scheme as a whole. During the first year of the operation of the scheme, the number of new cases of venereal disease dealt with was 13,025, whilst the number of cases not diagnosed as such totalled 2,360. The number of attendances made by these patients was 120,659. For the year 1920, when demobilisation had taken effect, the number of infected new cases dealt with increased to 24,454, and non-venereal to 6,592. Since that year the number of new cases of venereal disease attending the clinics in any one year has steadily declined, whilst the number of persons presenting themselves for diagnosis and found to be not suffering from venereal disease has practically doubled. The figures for 1934 show 16,064 new cases of venereal disease and 12,059 non-venereal. In 1920, the peak year for new cases, attendances of all patients totalled 464,033, whilst for 1934, with a considerably smaller number of new cases, the number of attendances recorded was 1,142,287. The large increase in attendances coupled with the increasing number of persons presenting themselves for examination is indicative of the growing use made of the clinics, and should do much to assist in checking the spread of infection. Anti-tuberculosis work in London commenced by voluntary effort during the later years of the reign of King Edward VII, although the work has been mainly developed during the present reign. From 1909 onwards a voluntary organisation known as the Central Fund for the Prevention of Tuberculosis established voluntary dispensaries in various parts of London. They associated with the provision of definite treatment an educational campaign combined with social welfare work for the benefit of sufferers and their families. About the same time two other independent voluntary dispensaries were provided, one in St. Pancras and the other in Poplar. The passing of the National Health Insurance Act in 1911, and the report in the following year of the Inter-departmental Committee on Tuberculosis (known as the Astor Committee), which investigated the whole problem and laid down general lines of working which are Tuberculosis. 8 still the model, gave the necessary stimulus and direction to public provision for dealing with the problem. Some of the Metropolitan Borough Councils made grants to the Central Fund, which by 1913 had instituted 11 dispensaries in London. The Council's tuberculosis scheme was adopted in May, 1914, and has not since been varied in its main principles. It was designed, in the first instance, to supplement existing effort, and, where possible, to incorporate within its activities all existing organisations. The scheme provided for the establishment of a dispensary service by each of the 28 Metropolitan Borough Councils and the Corporation of the City of London for the population of their particular areas, grants being made to the Metropolitan Borough Councils by the Council, and for arrangements for residential treatment to be made by the Council, in the first instance by utilising voluntary institutions, supplemented by accommodation to be provided by the late Metropolitan Asylums Board. The late boards of guardians were left to provide under the Poor Law in the infirmaries for the chronic advanced cases. Originally, special privileges were accorded to insured persons under the National Health Insurance Acts, and special arrangements were made for their treatment by the London Insurance Committee. These privileges were withdrawn by legislation as from May, 1921, and the Council became responsible for providing treatment for tuberculosis for all classes of the community, no difference being made between insured and uninsured persons. All the Central Fund dispensaries and the two voluntary dispensaries referred to above were incorporated within the Council's scheme, and in 1913 there was a total of 19 dispensaries. By 1918 there were 33. The voluntary Central Fund dispensaries, except one, were transferred to the Metropolitan Borough Councils in 1921, and at the present time there are 35 dispensaries, including 3 branch dispensaries, of which 9 are at voluntary hospitals. From 1915 onwards there has been in association with each tuberculosis dispensary a tuberculosis care committee or other similar organisation, whose function is to look after the social welfare of the patients. The passing of the Local Government Act, 1929, which constituted the Council as the hospital authority for London, changed materially the status and functions of the Council as the bed-providing authority under the tuberculosis scheme. The Council still, however, continues to use voluntary institutions, both to supplement its own provision and to provide for various special kinds of cases, such as those who need treatment under special environmental conditions or in a particular social or religious atmosphere. Among the voluntary institutions used for the Council's patients may be mentioned Papworth and Preston Hall colonies. Patients, if suitable, are accepted by the authorities as settlers in the residential villages associated with these colonies. At Burrow Hill colony boys from the age of 14 to 19 are given treatment combined with training in gardening or clerical work. A number of the boys trained in gardening are absorbed each year in the Council's parks department. In the first instance it was the practice to assess patients to pay contributions towards the cost of treatment, having regard to their financial position; but, since July, 1934, treatment has been provided free of charge, although voluntary contributions are accepted from patients who are in a position to make payment and wish to do so. The growth of the arrangements for residential treatment may be seen from the table set out on page 42. The large increase shown in the figures for the years from 1931 onwards is due to the transfer of functions from the poor-law authorities to the Council. Since 1933, admissions to beds in the tuberculosis wards of the Council's general hospitals have been made through the tuberculosis scheme. The Council has developed its preventive work in two additional directions (a) the provision of open-air schools and (b) the arrangements for boarding-out of child contacts. As regards the first of these, a voluntary school was established in 1909 at Kensal House, Paddington, under the auspices of the Central Fund for the Prevention of Tuberculosis. This was transferred to the Council in 1917. The 9 next step was encouragement in the establishment of open-air classes in association with tuberculosis dispensaries, and five such schools were established. From 1918 onwards in place of the dispensary schools the Council established day open-air schools to which children suffering from pulmonary tuberculosis or from tuberculous glands with no open wounds who do not require residential treatment are admitted. In 1933 it was decided to extend the use of these schools so as to include children who are suspected to be suffering from, or who are living in surroundings rendering them particularly liable to, the disease. There are now six such schools with accommodation between them for 515 children. The boarding-out scheme was commenced in 1925 to provide for the removal of children from heavily infected and over-crowded homes occupied by a member of the family suffering from advanced tuberculosis, and children who cannot otherwise be satisfactorily provided for while their mother, or in special circumstances the father, is undergoing residential treatment for tuberculosis. The children are boarded-out mainly in homes in the country by the Invalid Children's Aid Association, who make the necessary arrangements at the cost of the Council and supervise the foster-parents. The number of children so dealt with in 1934 was 246. The Mental Deficiency Act, 1913, had as its object the making of better provision for the protection and control of mentally defective persons who could not satisfactorily be dealt with under the existing powers. It made the Council the local authority for the purposes of the Act, and laid upon it the duty of providing the necessary care and control of (a) defectives who were neglected, and (b) defective children who were ineducable or who, on leaving a special school, were notified by the Education Committee as being in need of further care, supervision and control. It also made the ascertainment of all defective children a statutory duty, and, in conjunction with the Education Act of 1914, made the provision of special schools for the mentally defective a statutory duty instead of a permissive power. The primary duty of ascertainment rests with the Council as a mental deficiency authority for all ages below 7 and above 16, and as an education authority between these ages. The Mental Deficiency Act, 1927, was an amending Act which had as its main object changes in the definition of defectives to enable certain forms of mental deficiency due to disease or injury to be dealt with. Since 1914, when the Mental Deficiency Act came into force, the number of those persons below 7 or over 16 years of age examined and ascertained has increased; but the Council, having from the beginning carried into effect the permissive powers as regards special education, there was no sudden change in 1914, and the numbers of those of school age found defective have diminished pari passu with the population at risk. Mental Deficiency Acts. The Blind Persons Act, 1920, made it the duty of the Council to make arrangements to the satisfaction of the Minister of Health for promoting the welfare of blind persons ordinarily resident in the county. A scheme had to be submitted to the Minister of Health, and, as part of the machinery for carrying out the scheme, a proper system of registration of blind persons was necessary. In the early years after the passing of the Act, the persons examined by the Council's medical officer were applicants for vocational training and were few in number. In 1931, the Council, on the suggestion of the Minister of Health, decided that no person should be registered until he had been examined and certified by a medical officer with special ophthalmological qualifications, that the cases of persons already on the register should be reviewed, and that, if necessary, they should be examined. This entailed the overhaul of the whole register of blind persons numbering some 6,700. This work has been carried out since 1931, together with the examination of new applicants. Blind Persons Act, 1920. One of the most notable improvements during the past 25 years has been seen in the general standard of the work of mid wives, and without doubt the steady Midwives. 10 educational work carried on by the Council's medical inspectors of midwives and by means of post-graduate lectures and demonstrations has had much to do with this improvement. As an example of this it may be noted that, whereas 7 midwives were reported to the Committee for infringements of the rules in 1910, only 1 was so reported in 1934. Particularly is this improvement notable in the much greater use made of the services of doctors for cases of difficulty. In 1910 medical aid was summoned for 10 per cent. of cases, whereas in 1934 the percentage was 26.5. The number of inspectors of midwives has been increased from 2 in 1910 to 4 in 1934, while the number of midwives notifying their intention to practise increased from 470 to 898. A very notable fact in this connection is that the number of bona fide midwives in practice in London, that is, those unqualified by examination, has fallen from 91 in 1910 to 6 in 1934. Owing to the great stress laid upon the danger of blindness from inflammation of the eyes in the newly-born baby, the Council now provides free medical attention for all such cases where a doctor is called in by a midwife. As a result 955 cases were brought to notice in 1934, compared with 165 in 1910; and, whereas damage to the eyes ensued in 11 cases in 1910, no case of a damaged eye occurred in 1934. 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, also Part IV (Lving-in-Homes) of the London County Council (General Powers) Act, 1921. Nursing homes. There is no reliable information as to the number of nursing homes in London in 1927, that is before the Act came into operation, but 203 maternity homes were on the register and subject to inspection. The total number of applications for registration as nursing homes approved by the Council since the Act came into operation is 440. The total number on the register on 31st December, 1934, was 211, showing that the total number of registrations which have been cancelled, including voluntary withdrawals, since the Act came into operation is 229. In October, 1913, the Council's chemical staff was transferred to the public health department. The work of this staff, which includes a general analytical oversight of materials supplied to the Council or used in its undertakings and much advisory and experimental work for other departments of the service, has in most directions largely increased since 1913, and has, since the Council took over the hospitals and institutions under the Local Government Act, 1929, been added to in several important directions. Chemical and bacteriological laboratories at County Hall. A scheme for the control of medical supplies has involved the examination annually of large numbers of drugs and medicines, and in addition an analytical control is kept over the private water supplies of many of the institutions taken over. Advice has been given on many matters connected with engineering and other problems at the hospitals and institutions. A prolonged investigation of the condition of the river Thames and its relation to effluent discharged from the Council's outfalls, and researches on biological treatment of the effluent enabled the chief engineer and the medical officer to advise, in 1926, the construction of successive units of plant for the treatment of effluent as then discharged "until such time as the continued improvement of the river gave no ground for anxiety." The first unit of this scheme has successfully treated about 10 million gallons of effluent a day since August, 1932, and 5 further units are now under construction. The investigation of atmospheric pollution, both as part of the general scheme of the Research Committee of the Department of Scientific and Industrial Research and in connection with special cases of pollution of air in the county, and the control and purification of the water of swimming baths in open spaces in the county are matters of direct public health interest which have occupied the attention of the chemical staff. During the period the number of samples examined chemically at the central laboratory has increased from 7,613 a year to 9,873 a year, and the character of the examinations required has, generally speaking, greatly increased in complexity. 11 With regard to bacteriological work, in 1910 about 1,000 throat swabs were examined for diphtheria, and some 3,000 hair specimens were examined for ringworm. It was not, however, until 1912 that a laboratory equipped for the pathological examination of material in connection with the school medical service was provided. On the transfer of this laboratory to the County Hall in 1922, adequate accommodation and additional equipment were provided not only to cope with the growth of the school medical service, but also to deal with the bacteriological examination of milk, water, etc., in collaboration with the chemical laboratory. The numbers of examinations completed in the laboratory in 1934 were: swabs for diphtheria, 5,883; other pathological material, 65; hair specimens for ringworm, 634; samples of water and milk, 448. The work carried out in the laboratories provided at the hospitals is described in Vol. IV, Part I, of this report. Vital Statistics. 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 Registrar-General estimates the resident population of the county in the middle of 1934 to have been 4,230,200. The corresponding estimates for metropolitan boroughs are shown in the table on page 29, and the rates given in this annual report are calculated upon these figures. Population. The marriages registered in London during 1934 numbered approximately 43,267 or 20.5 per thousand of the population, the corrected rate for the preceding year being 19.0. The births in London during 1934 numbered 56,853, compared with 56,743 in the preceding year. The birth-rate was 13.4 per thousand as against 13.2 in 1933. The deaths in the total population of London during 1934 numbered 51,717, giving a death-rate of 12.2 per thousand, compared with 12.5 in 1933. Marriages. Births. Deaths. The distribution of deaths by ages in 1934 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 Annual average. 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 1931-34 3,906 915 841 669 477 809 1,182 2,320 2,891 5,554 8,968 24,756 53,288 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 1933 3,377 680 728 698 518 728 1,193 2,168 3,008 5,832 9,110 25,196 53,536 1934 3,832 1,036 957 715 475 707 1,094 2,167 2,606 5,160 8,921 24,047 51,717 The absence of any pronounced prevalence of influenza during 1934 was the chief cause of the decrease in deaths upon the number in the previous year. A slight decrease occurred in the deaths from street accidents, which numbered 752, compared with 763 in 1933. The changes in the death-rate from all causes since 1910 are broadly shown in the following figures relating to the years 1911-1913 and 1930-1932. These years are taken as a basis of comparison on account of their proximity to the census years 1911 and 1931, as errors arising from change in the age and sex constitution of the population are thus reduced to a minimum. The age groups selected represent, broadly, the periods of infancy, school age, the principal working ages and old age. Decrease in mortality in London. 12 London.—Contrast of death-rates per 1,000 living at selected age periods in the years 1911-1913 and 1930-1932. Age period. Males. Females. 1911-1913. 1930-1932. Decrease per cent. 1911-1913. 1930-1932. Decrease per cent. 0-5 years 43.0 22.9 47 36.3 18.4 49 5-15 2.7 1.9 32 2.6 1.6 36 15-25 3.1 2.8 12 2.5 2.4 4 25-65 13.3 10.6 20 9.2 6.9 25 65 years and over 89.6 83.5 7 76.5 63.0 18 All ages 15.9 13.3 16 13.1 11.0 16 The figures bear the impress, in varying degrees, of many administrative measures initiated or further developed during the period to which they refer, such as, in infancy, the infant and child welfare work, the hospitalisation of infantile whoopingcough and measles cases, milk and dairy farm inspection and the post-war control and organisation of the milk supply generally; at school ages, the expansion of the school medical service, provision of treatment centres, open-air schools, etc.; at higher ages, national health insurance and co-ordinated provision for the treatment of tuberculosis; and for the aged, old-age pensions, with the resulting diminution of institutional life among this class. The small reduction in mortality at ages 15-25, especially among women, shows that the young adults of to-day are not participating in the general improvement to the extent which has taken place in the other age-groups. The position of London in respect of child mortality is worthy of further discussion. The following figures show the reduction which has taken place in mortality among children at various ages under fifteen during the present century:— London.—Death-rates per 1,000 living among children tinder 15 years of age Age. Period. 1900-1902. 1910-1912. 1920-1922. 1930-1932. 0-1 years 179.3 126.1 87.6 67.4 1-2 „ 56.0 43.0 23.7 17.5 2-5 „ 14.8 10.3 10.6 5.0 5-10 „ 4.2 3.3 3.4 2.1 10-15 „ 2.4 2.0 2.0 1.4 For the purpose of comparison similar figures for England and Wales are shown in the following table, from which it will be seen that the mortality rates for London at the beginning of the century were, at all the ages shown, in excess of those for England and Wales, but that except at the age 1-2 a great deal of the leeway had been made up in 1930-1932:— Age. London. England and Wales. London, England and Wales = 100. 19001902. 19301932. Decrease per cent. 19001902. 19301932. Decrease per cent. 19001902. 19301932. 0-1 years 179.3 67.4 62.4 170.9 66.9 60.9 105 101 1-2 „ 56.0 17.5 68.7 47.5 14.6 69.3 118 120 2-5 „ 14.8 5.0 66.2 12.9 4.7 63.6 115 106 5-10 „ 4.2 2.1 50.9 4.1 2.2 47.4 103 96 10-15 „ 2.4 1.4 40.3 2.3 1.5 37.2 101 96 The reduction of the death-rate among children of school age from about 2 per cent. above that of England and Wales in 1900-1902 to about 4 per cent. below it in 1930-1932 is especially noteworthy. 13 14 A discussion on the relative mortality of children in England and Wales and in London during the period 1841-1920 will be found in the Annual Report of the Council for 1923, (Vol. III, pp. 95-97), where, also, comparison is made of the mortality from various diseases in the two areas at school ages. It was shown that the rates for London among children under 15 years of age were up to that time generally in excess of those for England and Wales. The death-rates from all causes and from certain specified causes in each metropolitan borough in 1934 and in London as a whole in 1934 and earlier years will be found in the tables on pages 29 and 31. The deaths under one year of age per thousand births were 67 as compared with 60 in the preceding year. Infant mortality The lowest infant mortality recorded in London was that in 1930, and a comparison of the 1934 figure therewith shows that the excess in the latter year is chiefly due to increased mortality from pneumonia and diarrhoea, as will be seen from the following table:— Cause of death. 1911 to 1914 1915 to 1918. 1919 to 1922. 1923 to 1926 1927 to 1930. 1931 to 1934. 1930. 1931. 1932. 1933. 1934. Measles 3.40 3.84 1.64 2.02 2.07 1.44 3.12 0.44 2.44 0.28 2.60 Whooping-cough 3.63 4.45 2.50 2.60 3.14 2.27 0.89 2.15 2.59 2.45 1.88 Influenza 0.27 1.10 0.81 0.38 0.48 0.40 0.26 0.46 0.39 0.46 0.30 Tuberculosis 3.40 3.20 1.52 1.26 0.89 0.77 0.79 0.70 0.96 0.83 0.60 Bronchitis 6.41 6.72 4.42 2.91 2.30 2.16 1.66 2.56 2.09 1.50 2.48 Pneumonia 12.28 14.96 12.60 11.51 12.10 11.45 9.85 13.90 10.25 8.27 13.40 Diarrhoea 24.28 16.10 12.16 9.36 8.87 10.86 9.07 8.94 11.78 10.70 12.01 Premature birth 18 16 17.42 17.00 14.74 14.17 14.91 13.71 15.24 14.51 15.23 14.65 Congenital defects 14.69 14.66 11.26 8.39 7.38 7.22 7.11 6.65 7.58 6.84 7.81 Other causes 21.48 20.55 15.09 11.83 12.60 13.52 12.54 13.96 14.41 130.44 11.27 All causes 108 103 79 65 64 65 59 65 67 60 67 The quarterly infant mortality-rate for the years 1930 and 1934 compare as follows: Year. Quarter. 1st. 2nd. 3rd. 4 th. 1930 78 55 44 60 1934 94 61 48 65 The winter of 1933-4 was less favourable to infant life, and this accounts for the increase in the mortality from pneumonia referred to above. The increase in the third quarter reflects the effects of the warm summer of 1934 and the consequent increase in infant diarrhoea. The death-rates from various causes shown above are stated in the following table as a proportion of the deaths from all causes in each of six successive fouryearly periods:— Cause of death. 1911 to 1914. 1915 to 1918. 1919 to 1922. 1923 to 1926. 1927 to 1930. 1931 to 1934. Measles 3.1 3.7 2.1 3.1 3.2 2.2 Whooping-cough 3.4 4.3 3.2 4.0 4.9 3.5 Influenza 0.3 1.1 1.0 0.6 0.8 0.6 Tuberculosis 3.1 3.1 1.9 1.9 1.4 1.2 Bronchitis 6.0 6.5 5.6 4.5 3.6 3.3 Pneumonia 11.3 14.5 15.9 17.7 18.9 17.6 Diarrhœa 22.5 15.6 15.4 14.4 13.9 16.7 Premature birth 16.8 16.9 21.5 22.7 22.1 23.0 Congenital defects 13.6 14.3 14.3 12.9 11.5 11.1 Other causes 19.9 20.0 19.1 18.2 19.7 20.8 All causes 100.0 100.0 100.0 100.0 100.0 100.0 15 There is, it will be observed, a marked decrease upon the initial percentage in the case of tuberculosis and bronchitis, and a noteworthy increase in the percentage of pneumonia deaths. With regard to premature births and congenital defects, the borderline of distinction is not sufficiently definite for any reliable deduction to be made from the relative changes in the percentage of deaths from these causes; and possibly, in the case of pneumonia, the increase may partly or wholly represent an increased preference for pneumonia over bronchitis on the certificate of the final cause of death. The remarkable decrease in infant mortality during the past twenty years is common, in much the same degree,to areas of differing social condition or environment in London. For the purpose of illustrating the variation of the rates according to the class of locality, tables were given in the annual reports of the medical officer for the years 1908 to 1910, which showed the mortality rates for certain groups of metropolitan boroughs. The test of social condition or environment used in the reports referred to was the percentage of persons living more than two per room, and on this basis the metropolitan boroughs were classed into five groups. Group I represented the boroughs with best environment or social condition and comprised those with less than 7.5 per cent, of the population living more than two per room, while at the other extreme group V contained all boroughs in which the proportion so living was 27.5 per cent, or more. Similar tables have been prepared for the period 1930-1932 for purposes of comparison. There have, of course, been changes in the status of some of the boroughs in the intervening twenty years, but it will be seen that notwithstanding these changes the graduation of the rates for the five groups in the period 1930-1932 is very similar to that for the years 1908-1910, and it is, therefore, reasonable to assume that the mode of grouping adopted affords a satisfactory basis of comparison. The rates of mortality which are shown in the following tables relate to deaths for three age periods in the first year of life, namely, (1) under one week, (2) under one month, and (3) under one year, per 1,000 births. It will be noted that the decrease in the mortality for 1930-1932 upon that of 1908-1910 is much greater for the whole of the first year than for the earlier periods of life shown :— Group. Deaths per 1,000 births. During first week. During first month. During first year. 1908-10. 1930-32. 1908-10. 1930-32. 1908-10. 1930-32. Decrease per cent. I 20 19 32 27 83 55 34 II 22 18 36 22 106 59 44 III 21 18 36 25 108 68 37 IV 23 17 37 25 112 70 38 V 22 17 36 24 127 72 43 Total 22 18 35 25 108 64 41 In the last column of the table the percentage decrease of the infant mortalityrates in each group for the first year of life is given, and, allowing for the fact that considerable changes in density of population have occurred in some of the boroughs, these percentage figures may be taken to indicate a practically constant rate of decline among the different classes of population concerned. The first point of particular interest in the figures is the fact that at the earliest period of life the mortality-rates are apparently not affected by the differing environmental conditions, and show less improvement relatively in the course of the twenty years, there being only a decrease of 18 per cent, in the mortality during the period. There is some slight indication in the figures for 1930-1932 that the infants born to mothers in the more densely populated or poorer boroughs have a better survival rate in the first week of life than those born in the better class areas. The second point is the remarkable fact that the infant mortality in the first year of life at the present time in the poorest group, comprising Bethnal Green, Finsbury, 16 Shoreditch and Stepney, is below that of the best group twenty years ago, which comprised the boroughs of Hampstead, Lewisham, Stoke Newington, Wandsworth and Woolwich. The same rate of decrease cannot go on indefinitely, and it is probable that we are now approaching a more stable rate. This would appear from consideration of the figures shown in the table on page 14, from which it will be seen that the rate of decrease of mortality differs widely in different conditions and that such causes of death as congenital debility and immaturity have not shown anything like the decrease shown in, for instance, tuberculosis. Infectious Diseases. The notifications, attack-rates and death-rates of the principal infectious diseases in London in 1934 and earlier years are shown in the tables on pages 29 to 32, and for the constituent metropolitan boroughs in 1934 in the table on page 29. Anthrax. Three cases of anthrax were notified during the year, one each in the boroughs of Camberwell, Deptford and Bermondsey. The patient in Camberwell, a male aged 26 years, worked for a firm of skin merchants in the metropolitan borough of Southwark, and the borough medical officer of health was of opinion that he was infected in the course of his employment. The patient died three days after his admission to Guy's hospital. The source of infection of the case in Deptford, a male aged 30 years, was attributed to goat skins which he had handled in the course of his employment as a barge hand. The site of the disease was the angle of the left lower jaw. The patient was admitted to St. Olave's hospital, and made a satisfactory recovery. The patient in Bermondsey was a male, aged 22, who was employed as a waterside labourer and had recently handled American hides and New Zealand wool. The source of infection was, however, not established. The site of the disease was the right forearm. The patient was admitted to Guy's hospital, and made a complete recovery. Smallpox. The number of persons notified as suffering from smallpox was 144 (compared with 531 in 1933), and of these, 4 were discharged as not suffering from smallpox The last confirmed case was notified and admitted to hospital on 20th June. Only one case was notified after that date, and this proved to be not smallpox. No cases have been notified during 1935 up to the present (August), and London has, therefore, been free from the disease for the past fourteen months. The following table shows the incidence of the disease in the years 1933 and 1934 in the separate London boroughs:— Metropolitan Borough. Number of notifications. Metropolitan Borough. Number of notifications. West— 1933 1934 East— 1933 1934 Paddington 1 — Shoreditch 29 2 Kensington — — Bethnal Green 11 1 Hammersmith — — Stepney 23 9 Fulham — — Poplar 141 2 Chelsea — — Westminster 1 — North— St. Marylebone — — South— Hampstead 1 — Southwark 63 22 St. Pancras — — Bermondsey. 21 7 Islington 11 70 Lambeth 127 1 Stoke Newington — — Battersea 4 1 Hackney 13 1 Wandsworth 1 — Camberwell 55 18 Central— Deptford — 1 Holborn 1 — Greenwich — — Finsbury 5 6 Lewisham 21 3 City of London — — Woolwich 2 — Total 531 144 17 During the year one death from smallpox occurred, particulars of which are as follows:— Borough. Age. Sex. Vaccinal condition. Date of death. Certified cause of death. Southwark 16 M. Unvaccinated 18.2.34 I (a) Encephalomyelitis. (b) Smallpox. The following table shows the numbers of persons notified as suffering from smallpox within the administrative county of London since the year 1928, when the mild or western type of the disease first invaded London:— Year. Number of notifications. Year. Number of notifications. 1928 296 1932 1,131 1929 1,908 1933 531 1930 5,149 1934 144 (no confirmed case after 20th June). 1931 1,452 A short history of the epidemic appears in vol. IV (part I) of this report. Information regarding the action taken by the school medical service in collaboration with the borough health services in connection with the control of smallpox in the Council's schools appears in vol. Ill (part II) of this report. During the year one ship on which smallpox had occurred during the voyage arrived in the Port of London from Brisbane. When the ship arrived at Port Said one of the pantry boys was landed, and was later diagnosed as suffering from smallpox. The vessel called at Marseilles. The lists of London addresses given by passengers who landed in order to proceed overland was received from the Ministry of Health and circulated to the medical officers of health of the metropolitan boroughs. On arrival of the vessel in the Port of London all precautionary measures were taken by the port medical officer, including the notification to the medical officers of health concerned of the names and addresses of passengers and crew. No secondary cases were reported. Passengers from two other ships on which smallpox had occurred arrived in London. Their names and addresses were forwarded to the medical officers of health concerned. In the City of London and the borough of Poplar, orders, made under the provisions of section 55 of the Public Health (London) Act, 1891, making chickenpox notifiable, were extended for a period of one year. At the end of the year this disease was notifiable in Paddington, Hammersmith, Chelsea, Islington, City of London, Poplar, Deptford and the Port of London. Chickenpox. During the year 137 notifications of cerebrospinal fever were received, bat in 13 of these the diagnosis was not confirmed. Of the 124 cases confirmed, 62 proved fatal. In addition, 15 deaths were recorded by the Registrar-General of cases which had not been notified, and one of a case which was notified in 1933, thus making a total of 78 deaths. Cerebrospinal (spotted) fever. I he notifications ot acute encephalitis lethargica numbered 29. In 5 of these the diagnosis was not confirmed ; of the 24 actual cases, 6 proved fatal. In addition 27 deaths were recorded by the Registrar-General of cases which had not been notified, and 3 which had been notified in previous years, making a total of 36 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. Cases which had not been notified during the acute stage are still being brought to light by applications which are made for hospital treatment of patients suffering from the after effects of encephalitis lethargica. All cases of post-encephalitis lethargica, not under treatment at the Northern hospital, are " followed " up for medical reports over a number of years ; during the year 85 cases were " followed up " through the co-operation of the borough medical Encephalitis lethargica. 18 officers of health and 4 through the co-operation of the school care committees. In addition, the school medical service from time to time reports on the condition of school children suffering from the after effects of encephalitis lethargica ; at the end of the year there were 36 children under such supervision in the schools. A review of 191 cases of post-encephalitis lethargica was made to endeavour to obtain some information as to the interval elapsing between the acute attack of encephalitis lethargica and the first appearance of the sequelae. The forms of application for admission to the special unit at the Northern hospital contain two questions: (1) " When did the attack of epidemic encephalitis occur ?" and (2) "When did the sequelae of the attack make their appearance ?" The information contained in the following statement was obtained from the answers given to these questions:— Age groups 0-5 6-10 11-15 16-20 21-30 31-40 41-50 Over 50 Number of cases under review 18 27 35 46 34 I 21 8 2 Number of cases where sequelae followed directly on acute attack 14 13 17 25 19 12 4 2 Number of cases where sequelae followed under a year from onset of attack 1242513 - Number of cases where sequela' followed the acute attack after an interval of 1 year 2 1 2 6 4 4 1 2 years 1 3 2 5 2 1 - 3 ,, 4 3 4 1 - - - 4 ,, - - 2 1 - 2 5 1 - 1 6 3 1 7 „ - - 3 - 1 8 - - - 2 1 9 „ - - - 1 10 - - - - - 1 11-13 - 1 - - - - - - It will be noted that in about 45 per cent, of the cases the sequelae were stated not to have appeared until the lapse of variable periods up to 10-13 years after the acute attack. Poliomyelitis and polioencephalitis. Notifications of poliomyelitis and polioencephalitis numbered 74; the diagnosis was not confirmed in 9 of these. Of the 65 actual cases, 4 proved fatal. In addition, 8 deaths were recorded by the Registrar-General of cases which had not been notified, and 1 of a case which was notified in 1933, making a total of 13 deaths. Particulars of acute cases admitted to the Council's Western hospital and of cases admitted when convalescent 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 this report. Serum treatment of acute anterior poliomyelitis In my last annual report, I referred to the scheme whereby the public health department of the Council have co-operated with the Ministry of Health, the Medical Research Council, and the Lister Institute, in arranging to maintain a stock of poliomyelitis immune serum with a view to its use in the treatment of infantile paralysis. The serum is obtained voluntarily from donors who have recently suffered from an undoubted attack of the disease and all batches of serum are tested for their protective properties at the Lister Institute before issue. Since the inception of the scheme in 1932, there has been a steady demand for the serum; it has only been possible to maintain an uninterrupted supply by restricting its employment to acute cases in the pre-paralytic stage of the disease, or in which the paralysis tends to spread, and by securing the co-operation of practitioners in returning unused serum as expeditiously as possible. 19 During the year under review serum was collected at intervals from patients convalescent from acute poliomyelitis at the Wingfield-Morris Orthopaedic hospital, Oxford, and at the Royal National Orthopaedic hospital, London, from which supplies were also obtained in the two previous years. In addition, Drs. L. P. Garrod and G. Murray Levick made considerable additions to the serum pool with blood taken from patients at St. Bartholomew's hospital, London, and the Heritage hospital for cripples, Chailey, respectively. The arrangement whereby the main supply of serum was deposited at the Western hospital, with subsidiary stocks at certain of the London voluntary hospitals, was found to work satisfactorily in practice, as serum is readily available to practitioners at any hour of the day or night. During 1934, there were 29 applications for serum in amounts varying from 25 c.c. to 200 c.c., making a total issue of 2,500 c.c. for the year. In 14 instances the full dose issued was administered chiefly by the combined intravenous and intrathecal routes; on 4 occasions only one-half the requisitioned dose was given, while 11 cartons were returned unopened, either because the diagnosis was revised in the interval, or more commonly, because the disease was recognised at a stage when but little benefit was likely to follow administration of the serum. It must be admitted that, as long as acute poliomyelitis remains a sporadic and relatively infrequent disease, serious practical obstacles will attend attempts at its control by means of immune serum, with corresponding difficulty in assessing the therapeutic efficacy of the serum. Only by timely administration of the serum to a considerable number of suitable cases, and by collation and analysis of detailed and accurate records of the clinical results following its use, will it be possible to arrive at a trustworthy estimate of its worth. The following statement shows the numbers of notifications in recent years o the diseases specified, excluding duplicate notifications and military cases:— Year. 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 Cerebro-spinal fever 93 93 83 93 70 121 88 175 247 216 137 Encephalitis lethargica 600 293 224 142 100 92 60 40 47 22 29 Poliomyelitis and polioencephalitis 116 55 95 86 54 66 37 56 89 66 74 The following table shows the age incidence of actual cases of smallpox and the three kindred diseases, cerebro-spinal fever, poliomyelitis (including polioencephalitis) and encephalitis lethargica. Age periods. Under 3. 3-5. 5-10. 10-20. 20-30. 30-40. 40-50. 50-60. Over 60. Total. Smallpox 2 8 22 52 26 9 7 6 8 140 Poliomyelitis and polioencephalitis 15 17 16 14 2 1 65 Cerebro-spinal fever 47 11 8 21 23 8 3 2 1 124 Encephalitis lethargica 2 — 1 6 5 5 3 1 1 24 In 1934 (52 weeks) particulars of 332 cases of food poisoning notified to the borough medical officers of health under the provisions of the London County Council (General Powers) Act, 1932, were received, compared with 419 for the year 1933. Three of the notified cases died. In some instances more than one member of a family was affected by illness, but the majority were isolated cases and were probably due to idiosyncrasies of the patients. Particulars are set out below of the only groups of cases that call for special comment. On 6th February, 22 inmates of the Bromley House institution developed symptoms of gastro-enteritis and 6 of the patients were removed to hospital where they remained for periods varying between 2 and 7 days. There were approximately 530 nmates in the institution at the time, and 14 members of the staff had meals in the building. An investigation was carried out by the medical officer of health of Poplar Food poisoning. 20 and one of the Council's pathologists. The examination of pathological material showed that no pus was present, and there was no evidence of any organisms of the salmonella or dysentery groups. No particular article of diet was implicated and no particular group of inmates was involved. Attention was directed to the possibility that infection might have been due to "carriers" of pathogenic organisms, but after detailed investigation no evidence was found to support this theory. On the other hand, there was no evidence for or against the possibility of the outbreak being due to toxins of these organisms. There was no evidence of metallic poisoning. On 20th February a woman and three of her family and a child living in the same house were admitted to St. Andrew's hospital, suffering from food poisoning. The medical officer of health of Poplar reported that the mother had stated that she had bought a tin of tongue from an itinerant vendor in a street market. Examination of pathological material and of the incriminated food was carried out in the Council's laboratories. No significant findings were made; enterococci and staphylococci aurei were, however, found in a portion of the tongue and it is possible that these organisms were the cause of the illness. No evidence of metallic poisoning could be traced. The borough medical officer of health was unable to trace any tins of tongue of the same brand in shops in the area. He ascertained, however, that one of the patients was employed at a wharf in Stepney largely connected with the canned goods trade and certain inferences led to the conclusion that the suspected tin was not purchased in the street market. Inquiries at the wharf showed that there was in store part of a parcel of 53 cases of tinned ox tongue of Russian origin of a similar type which had been landed from various shipments, the landings taking place from November, 1932, onwards. This parcel was transferred from one firm to another and the latter asked for the tins to be re.examined; as a result of the re.examination, on 23rd February, a number of the tins was found to be unsound. It is possible that the suspected tin had been obtained from this source prior to 23rd February. The bacteriological examination in the Council's laboratory of the contents of eight tins (four sound and four slack) showed the presence of organisms in two tins only (one sound and one slack). In the case of the sound tin, the organisms were non.pathogenic. In the slack tin, organisms were found resembling those isolated from the tongue which was suspected to have caused the illness of the five patients. There was no evidence of the presence of any metallic poisons. As a result of the bacteriological findings, the medical officer of health of Stepney had all the slack tins destroyed. An outbreak of illness in which 22 persons were affected occurred in June in the boroughs of Lewisham (18), Deptford (2) and Camberwell (2). The suspected cause of illness was boiled silverside of beef, prepared at a factory. The medical officer of health of Camberwell stated that the hygienic conditions under which the food was prepared were in every respect satisfactory; that the meat in question was probably not thoroughly cooled prior to being placed in the refrigerator, and that putrefaction may have taken place owing to the rapid cooling of the exterior and the consequent sealing of heat inside the joint. In July, 21 persons were affected by an outbreak of illness amongst a staff of persons employed in the service, etc., of food in the borough of St. Marylebone. The patients were taken ill after eating various foods left over from a dinner party on ihe previous evening. Examinations of food stuffs and specimens from the patients were made in the Council's laboratories. Bacteriological examination failed to reveal any pathogenic bacteria; the chemical examination showed a mere trace of lead in the vomits, but this, no doubt, was derived from sardines which contained 14 and 12 parts per million of lead in opened and unopened tins respectively, this amount being of the order of that frequently found in tinned sardines. The following statement shows the age and sex incidence in all cases notified during the year:— Age. 0. 5. 15. 25. 35. 46. 55. 65. Total. Male 6 20 32 32 15 20 15 5 145 Female 4 16 39 48 30 14 12 14 177 la 10 eases (3 male, 7 female) the ages were not stated. 21 The causes of illness in the 332 notified cases were stated to be as follows:— Fish 80 Fruit 9 Tinned fish and paste 31 Tinned fruit 3 Meat 112 Miscellaneous 85 Tinned meat 12 The deaths from measles in 1934 numbered 855 compared with 101 in 1933. Measles. The death-rate was .20 per thousand. The death-rates in London and England and Wales in recent years have been as follows:— Area. 1923. 1924. 1925. 1926. 1927. 1928. 1929. 1930. 1931. 1932. 1933. London 0.08 0.29 0.07 0.20 0.04 0.30 0. 05 0.23 0.03 0.19 0. 02 England and Wales 0.14 0.12 0.14 0. 09 0.09 0.11 0.09 0.11 0.08 0.08 0 .05 The course of the epidemic in 1933-34 in comparison with others of recent years is shown by the deaths in successive four-weekly periods:— Years. October to December. January to mid-June. Total (30 weeks). 1933-34 3 9 34 62 106 242 233 127 60 876 1931-32 7 16 44 59 69 152 240 157 92 836 1929-30 10 24 50 91 133 243 269 189 50 1,059 There were 293 deaths from whooping-cough in London during 1934 compared with 329 in 1933. The death-rate was .07 per thousand. Whooping. cough. The death-rates in London and England and Wales in recent years are shown in the following table:— Area. 1923. 1924. 1925. 1926. 1927. 1928. 1929. 1930. 1931. 1932. 1933. London 0 .09 0.11 0.19 0. 05 0.12 0.09 0.26 0. 03 0.07 0.08 0.07 England and Wales 0.11 0.10 0.16 0.11 0.09 0.08 0.16 0.05 0.06 0.07 0.06 There were 18,238 notifications of scarlet fever in 1934 (52 weeks), the corresponding figure for 1933 being 21,911. The attack-rate was 4.3 per thousand as against 5.1 in 1933. The deaths numbered 68, giving a death-rate of .02 per thousand of the population at all ages and a case-mortality of . 4 per cent. Scarlet fever. The seasonal incidence, as shown by the notifications (uncorrected lor 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 1,765 1,412 1,422 1,353 1,453 1,337 1,312 1,302 973 1,423 1,650 1,560 1,276 The notifications (uncorrected for errors in diagnosis), deaths and crude case mortality during 1934 were as follows:— Year 1934. Age.period. Total. 0- 1- 2- 3- 4- 5- 6- 7- 8- 9- 10- 15- Notifications (52 weeks) 115 629 1,172 1,51 1 1,741 1,994 1.636, 1,284 1,063 907 3,229 2,957 18,238 Deaths (365 days) 1 8 5 7 7 8 2 3 . 3 13 11 68 Crude case-mortality percentage 0.87 1.27 0.43 0.46 0.40 0.40 0.12 0.23 . 0.33 0.40 0.37 0.37 22 The death-rates in London and England and Wales in recent years are shown in the following table:— Area. 1923. 1924. 1925. 1926. 1927. 1928. 1929. 1930. 1931. 1932. 1933. London 0.03 0 .03 0.02 0.02 0.01 0.02 0.02 0.03 0.02 0.02 0.02 England and Wales 0.03 0. 02 0 .03 0.02 0.01 0.01 0.02 0.02 0.01 0.01 0.02 Diphtheria. Notifications of diphtheria numbered 11,782 in 1934 (52 weeks), compared with 9,557 in 1933. This gives an attack.rate of 2.8 per thousand as against 2.2 in the preceding year. There were 481 deaths, giving a death.rate of .11 per thousand living. The case.mortality was 3.9 per cent., compared with 3.8 per cent. in 1933. 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- 49-52 924 828 771 750 890 830 839 813 697 914 1,191 1,110 1,225 The notifications (uncorrected for errors in diagnosis), deaths and crude casemortality during 1934 were as follows:— Year 1934. Age-period. Total. 0- 1- 2- 3- 4- 5- 6- 7- 8- 9- 10- 15 + Notifications (52 weeks) 208 560 848 1,105 1,215 1,357 1,172 839 692 515 1,571 1,700 11,782 Deaths (365 days) 13 47 44 62 66 58 55 41 21 18 35 21 481 Crude case.mortality percentage 6.25 8.39 5.19 5.61 5.43 4.27 4.69 4.89 3.03 3.50 2.23 1.24 4.08 The death.rates in London and England and Wales in recent years are shown in the following table:— Area. 1923. 1924. 1925. 1926. 1927. 1928. 1929. 1930. 1931. 1932. 1933. London 0.13 0.12 0.11 0.12 0.09 0.09 0.08 0.10 0.06 0.07 0.08 England and Wales 0.07 0.06 0.07 0.08 0.07 0.08 0.09 0.09 0.07 0.06 0.07 Diarrhœa and enteritis. Diarrhœa and enteritis caused 728 deaths among children under two years of age or 12.80 per thousand births. The corresponding rate in 1933 was 11.74. Puerperal fever and pyrexia. Maternal mortality. There were 254 notifications of puerperal fever and 758 notifications of puerperal pyrexia in 1934 (52 weeks) compared with 255 and 838, respectively, in 1933 (52 weeks). The deaths from puerperal fever numbered 76 and from other puerperal causes 83, the deaths per 1,000 live.births being 1.34 and 1.46 respectively, giving a total maternal mortality rate of 2.80 compared with 3.66 in 1933. The deaths from puerperal fever and other puerperal causes per thousand births in each metropolitan borough and in the county of London in the periods 1920 23 to 1927 and 1928 to 1934, together with the deaths in childbirth in 1934, are shown in the following table:— Metropolitan boroughs arranged in topographical order. Childbirth deaths per 1,000 births. Number of deaths in childbirth. 1920-27. 1928-34. 1934. Puerperal fever. Other causes. Total. Puerperal fever. Other causes. Total. Puerperal fever. Other causes. Total. Western. Paddington 1.5 1.8 3.3 1.9 2.0 3.9 6 3 9 Kensington 1.9 1.7 3.6 2.1 1.7 3.8 2 1 3 Hammersmith 2.1 1.7 3.8 2.0 1.8 3.8 4 5 9 Fulham 1.9 1.6 3.5 2.3 1.7 4.0 3 3 6 Chelsea 1.9 2.9 4.8 1.6 2.2 3.8 3 3 Westminster 1.5 2.9 4.4 2.7 3.0 5.7 2 2 4 Northern. St. Marylebone 2.1 2.6 4.7 2.5 2.7 5.2 3 1 4 Hampstead 1.8 1.6 3.4 1.5 2.2 3.7 2 2 4 St. Panoras 1.4 1.7 3.1 1.3 1.8 3.1 3 7 10 Islington 1.4 1.5 2.9 1.7 1.8 3.5 4 7 11 Stoke Newington 2.5 1.9 4.4 1.5 3.6 5.1 _ 1 1 Hackney 1.8 1.5 3.3 1.4 1.8 3.2 3 2 5 Central. Holborn 2.9 0.6 3.5 2.3 1.5 3.8 1 - 1 Finsbury 0.9 1.4 2.3 1.8 1.1 2.9 . . . City of London 2.0 1.0 3.0 5.7 — 5.7 . . . Eastern. Shoreditch 1.1 1.2 2.3 1.2 1.5 2.7 1 1 Bethnal Green 0.9 1.6 2.5 1.6 1.1 2.7 1 2 3 Stepney 1.0 1.4 2.4 1.0 1.7 2.7 5 10 15 Poplar 1.2 1.7 2.9 1.3 1.4 2.7 5 3 8 Southern. South wark 1.3 1.4 2.7 1.6 1.3 2.9 3 3 6 Bermondsey 1.1 1.8 2.9 1.7 1.6 3.3 3 1 4 Lambeth 1.8 1.3 3.1 1.3 1.3 2.6 6 4 10 Battersea 0.9 1.9 2.8 1.3 1.7 3.0 3 4 7 Wandsworth 1.6 1.7 3.3 2.1 2.0 4.1 5 6 11 Camberwell 1.7 1.5 3.2 2.0 1.6 3.6 5 3 8 Deptford 1.6 1.7 3.3 2.1 1.4 3.5 2 3 5 Greenwich 1.0 1.4 2.4 1.6 2.0 3.6 1 3 4 Lewisham 1.1 1.9 3.0 1.7 1.4 3.1 2 2 4 Woolwich 1.2 1.6 2.8 2.0 2.0 4.0 2 1 3 London 1.44 1.64 3.08 1 .70 1.72 3 42 76 83 159 The deaths in childbirth in 1934 are shown in the above table but not the death. rates, as, owing to the smallness of the figures, the rates for a single year may be misleading. The maternal mortality rates for each metropolitan borough in 1934 are set out in the table on page 29, and for London as a whole annually since 1922 on page 31. It will be seen that the average annual deaths from childbirth per 1,000 live births for the seven years 1928.34 is higher than for the eight years 1920.27. The increase in the puerperal fever death.rate is .26 or 18 per cent., and in other causes .08 or 5 per cent. 24 Comparison of maternal mortality in London with that of England and Wales. Owing to the small figures upon which the London rates are calculated, it is necessary to take London rates for a period of years in order to obtain a reliable basis of comparison of maternal mortality in London with that of England and Wales. In the following table, rates are shown for the last two decennial periods:— Period. England and Wales. London. Sepsis. Other causes. Total. Sepsis. Other causes. Total. 1911.20 1.45 2.61 4.06 1.54 1.64 3.18 1921.30 1.57 2.52 4 09 1.51 1.66 3.17 The table shows that the principal cause of the slight increase of maternal mortality in England and Wales is the increase of deaths from puerperal sepsis. The epidemiological factor to be taken into account in regard to this feature was discussed in last year's report, and in regard to this an interesting discussion of the seasonal variations of incidence in deaths from diseases of streptococcal origin will be found in the annual report of the Registrar.General for 1932 (text, page 99). A far more striking contrast, however, between the rates of England and Wales and those of London is in regard to the maternal deaths from other causes than sepsis, for while the sepsis mortality does not differ much in the two areas, the deaths from other causes in England and Wales are 59 per cent. in excess of the London figure in 1911.20 and 52 per cent. in excess for 1921.30. In the following table similar figures are given for different parts of England and Wales:— England and Wales.—Deaths in childbirth due to sepsis and other causes in different areas, 1931.33 Area. Deaths per 1,000 live births. Percentage of live births in institutions, 1932. Sepsis. Other causes. Total. Northern 1.87 2.97 4.84 23.1 Midland 1.65 2.27 3.92 18.6 Eastern 1.37 2.34 3.71 12.2 South.western 1.37 2.61 3.98 17.4 Wales 1.95 3.97 5.92 8.2 London 1.68 1.81 3.49 51.5 England and Wales 1.70 2.58 4.28 24.0 It will be noted that the sepsis death.rate of Wales is above that in any other area, while London compares favourably with the average as represented by England and Wales as a whole. In London, where surgical skill is so much more readily available in emergency, a greater proportion of complicated cases are referred to hospitals ; and, with this higher proportion of emergency aid, a reduction of deaths from accidents of childbirth would be expected. The figures, therefore, show the deficiency of emergency aid in other areas, for the death.rate from accidents of childbirth, other than sepsis, in London is much the lowest of those shown in the table. In contrasting the mortality from sepsis with that from other causes, the duration of the disease or condition causing death has to be considered. Deaths from sepsis are infrequent within five days of labour, but the majority of deaths from other causes occur within this time. The figures for deaths in which the information is available for the years 1933 and 1934 in the Council's general hospitals are shown in the following table:— The Council's general hospitals.—Deaths among maternity cases. 1933 and 1934. Interval between delivery and death. Cause of death. Sepsis. Other causes. 1933. 1934. 1933. 1934. Under 5 days 1 0 33 24 5.10 days 4 5 7 3 10.20 days 5 3 7 6 20 days and over 6 6 8 2 25 A case which may be saved by skilful emergency aid may subsequently succumb to sepsis; on the other hand, in the absence of such emergency aid, death may occur earlier and before septic conditions could develop. There is therefore some tendency, though it may be small, for skilled emergency aid to increase relatively the deaths due to sepsis, since in all cases of maternal deaths in which the word sepsis is mentioned on the death certificate the death is assigned to that condition, equally whether sepsis was an inevitable terminal condition or the sole cause of death. On the other hand in years in which the epidemiological factor which governs the incidence of sepsis is relatively high, some of the cases which without the supervention of sepsis would have been assigned to other accidents of childbirth, such as those in which death occurs more than five days after delivery, would be transferred to the heading of sepsis. It is, therefore, necessary to bear in mind the probability that there is some interchange between the heading of sepsis and other causes of death respectively. The figures relating to deaths from abortion, of which the majority are due to sepsis, are given for single and married women, separately, for England and Wales as a whole since 1927 in the text volumes of the annual reports of the Registrar. General. In the following table the percentage of septic abortions to total deaths from sepsis among single and married women respectively are added:— Abortion. England and Wales.—Deaths from septic abortion. Year. Single women. Married women. Total deaths from sepsis. Deaths from septic abortion. Total deaths from sepsis. Deaths from septic abortion. No. Per cent. No. Per cent. 1928 72 20 28 1,099 198 18 1929 77 27 35 1,072 205 19 1930 79 26 33 1,152 271 24 1931 76 34 45 960 189 20 1932 76 38 50 908 219 24 The increase in the proportion of septic abortions, especially among single women, is independent of the movement of the total sepsis rate, which indeed was lower in 1931 and 1932 than in 1929 and 1930. The maternal mortality.rate has, as the figures show, been increasingly loaded by deaths attributed to septic abortion ; but it remains to be seen whether the increased proportion of septic abortions is an increase resulting, as would be supposed, from increased interference, or whether it is merely a "statistical" increase resulting from closer inquiries into the causes of deaths associated with pregnancy. In any case, however, the effect is to mask to some extent the results of the increased provision for ante.natal care during the period to which the figures relate as will be seen below. The influence of economic conditions upon the birth.rate and maternal mortality. rate has been referred to in previous reports, notably in that for 1928, page 25. In addition to the increase in septic abortions referred to above, the Registrar.General's returns show that with a decreasing birth.rate, the deaths from criminal abortion are increasing. In view of these tendencies it becomes of special importance to collect any evidence available of interference among the cases which come into the hospitals for post.abortive treatment, for sooner or later it will be recognised that the problem of abortion can no longer be left to settle itself. In order to assess fairly the value of the improved and extended ante.natal service, it is necessary to consider more particularly the cases which are likely to profit most, i.e., those cases in which pregnancy has been carried to labour. The following table contrasts the maternal mortality.rates of married women in England and Wales, excluding abortion, with the maternal mortality.rates as commonly calculated. Effect of improved ante-natal care. 26 England and Wales.—Maternal mortality, including and excluding abortion. Married women. Deaths excluding abortion per 1,000 registered legitimate births. All women. Deaths per 1,000 total births registered. Sepsis. Other. Total. Sepsis. Other. Total. 1928 1 .37 2.39 3.76 1.72 2.53 4.25 1929 1.36 2.28 3.64 1.73 2.43 4.16 1930 1.37 2.22 3.59 1.84 2.38 4.22 1931 1.22 2.15 3.37 1.60 2.35 3.95 1932 1.13 2.28 3.41 1.55 2.49 4.04 Figures for later years have not yet been published, but the above rates show that between 1928 and 1932 the maternal mortality.rate among married women whose pregnancy terminated in still.birth or live.birth decreased from 3.76 to 3.41, or by .35, while the corresponding decrease in the maternal mortality.rate as usually calculated was .21; the trend of the two sets of figures in the five years gives a decrease of 10.4 per cent. and 5.9 per cent., respectively. Enteric fevers. There were 109 notifications of levers of the enteric group in London in 1934 (52 weeks) compared with 164 in 1933. The deaths in the calendar year numbered 15 as against 25 in 1933. The remarkable decrease in the mortality from enteric fever during the present century will be seen from the figures in the table on page 31. 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 1- 5- 9- 13- 17- 21- 25- 29- 33- 37- 41- 45- 49-62 1 4 6 5 10 4 6 14 15 16 8 8 12 Influenza. The deaths from influenza during 1934 numbered 543, compared with 2,234 in 1933. Rheumatic fever. The deaths in London from rheumatic fever in 1934 numbered 145, of which 71 were among children under 15 years of age. The corresponding figures in 1933 were. 151 and 78 respectively. Cancer. There were 7,276 deaths from cancer in 1934, as against 7,093 in 1933. The death.rate per thousand was 1.72. There was an increase of 12 in the deaths among males and of 171 among females compared with the previous year. Tuberculosis. Tuberculosis. The deaths from pulmonary tuberculosis in London during 1934 numbered 3,227, giving a death.rate of .76 per thousand living. This is the lowest death.rate from pulmonary tuberculosis ever recorded in London, the corresponding figures for 1933 being 3,530 and .82 respectively, and 3,564 and .82 for 1932. There were 455 deaths from other forms of tuberculosis in 1934 as against 466 in 1933 and 522 in 1932. the death.rates being .11, .11 and .12, respectively. 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.pulmonary tuberculosis death.rates. Males. Females. Total. Males. Females. Total. 1922.24 1.28 0.78 1.01 0.22 0.17 0.19 1925.27 1.19 0.67 0.91 0.18 0.14 0.15 1928 1.14 0.68 0.89 0.17 0.12 0.14 1929 1.24 0.72 0.96 0.15 0.11 0.13 1930 1.13 0.64 0.87 0.13 0.1l 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 1933 1.10 0.58 0.82 0.12 0.10 0.11 1934 1.02 0.54 0.76 0.13 0.09 0.11 27 The number of primary notifications in metropolitan boroughs during the year 1934, 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 7,087, the corresponding figure for 1933 being 7,139. The following is an analysis of the notifications in London during the year 1934. 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+ Pulmonary tuberculosis Other forms of tuberculosis All forms of tuberculosis M. 3 38 60 90 271 493 751 584 597 375 159 3,421 4,580 F. 2 28 57 101 364 574 709 296 212 115 50 2,508 3,394 M. 7 95 129 90 68 66 83 31 18 23 12 622 737 F. 5 71 99 56 60 62 91 38 28 17 9 536 635 M. i 10 133 189 180 339 559 834 615 615 398 171 4,043 5,317 F. 7 99 156 157 424 636 800 334 240 132 59 3,044 4,029 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 until after death:— Form of tuberculosis notified. Sex. New eases of tuberculosis coming to knowledge otherwise than by formal notification. 0- 1- 5- 10- 15- 20- 25- 35- 45- 55- 65+ Total Pulmonary tuberculosis. M. 5 5 14 8 21 74 151 121 109 79 40 627 F. 1 3 5 12 35 81 115 61 36 28 18 395 Other forms of tuberculosis M. 7 38 29 35 15 18 16 10 3 7 7 185 F. 5 32 28 17 21 24 32 12 8 6 3 188 All forms of tuberculosis M. 12 43 43 43 36 92 167 131 112 86 47 812 F. 6 35 33 29 56 105 147 73 44 34 21 583 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 165 83 131 54 Posthumous notifications 51 36 "Transfers" from other areas 629 193 Other sources 46 7 The returns received under the Public Health (Tuberculosis) Regulations, 1930, from the medical officers of health of the metropolitan boroughs show that there were 27,095 cases of pulmonary tuberculosis (15,512 males and 11,583 females) and 9,862 cases of other forms of tuberculosis (5,088 males and 4,774 females) on the registers of the metropolitan boroughs at the end of 1934. The following table has been prepared from quarterly returns supplied by the medical officers of health of the metropolitan boroughs as to the number of cases added to and removed from the notification registers in each borough during the registration year, and the numbers remaining on the registers at the beginning and 28 end of the period. As these figures relate to the registration year, the totals are not the same as those shown in the preceding tables. Metropolitan boroughs in topographical order. Cases on notification register at beginning of 1934. Cases added to register during registration year. Brought to knowledge by Cases removed from register during the registration year. Cases on notification register at end of 1934. Notification. Otherwise. Cured, removed, etc. Deaths. Total. Per 1,000 of population. Western. Paddington 1,351 269 50 353 117 1,200 8.6 Kensington 910 229 72 116 126 969 5.4 Hammersmith 1,056 215 86 151 136 1,070 8.3 Fulham 1,694 290 27 171 99 1,741 12.0 Chelsea 383 105 35 105 48 370 6.4 Westminster, City of 1,313 266 39 120 98 1,400 11.3 Northern. St. Marylebone 876 157 37 94 80 896 9.7 Hampstead. 420 94 52 70 61 435 4.8 St. Pancras 1,629 277 85 308 193 1,490 7.9 Islington 3,304 534 122 619 346 2,995 9.7 Stoke Newington 332 77 40 80 52 317 6.3 Hackney 1,832 304 122 192 200 1,866 8.8 Central. Holborn 323 74 18 45 38 332 9.2 Finsbury 828 164 9 67 76 858 13.2 City of London 66 22 8 19 9 68 6.8 Eastern. Shoreditoh 1,638 158 36 131 105 1,596 17.6 Bethnal Green 1,330 155 33 115 94 1,309 12.8 Stepney 2,424 434 26 160 220 2,504 11.6 Poplar 1,190 254 47 169 157 1,165 8.0 Southern. Southwark 1,671 358 . 181 161 1,687 10.5 Bermondsey 1,008 173 27 100 106 1,002 9.5 Lambeth 2,518 514 77 345 235 2,529 8.9 Battersea 1,086 240 69 236 147 1,012 7.2 Wandsworth 2,204 485 117 428 290 2,088 6.0 Camberwell 2,135 341 119 220 245 2,130 8.9 Deptford 821 181 33 192 104 739 7.3 Greenwich 717 136 32 119 89 677 70 Lewisham 1,413 347 . 157 140 1,463 6.6 Woolwich 1,035 262 48 146 151 1,048 7.2 London 37.507 7,115 1,466 5,209 3,923 36,956 8.7 29 Vital statistics for the metropolitan boroughs and the County of London in the year 1934. (Rates per 1,000 of population.) Metropolitan boroughs arranged in topographical order. Estimated resident population 1934. Births. Deaths. Infant mortality (per 1,000 births). Measles Scarlet fever. Diphtheria. Whooping rough. Typhoid fever. Diarrhœa and enteritis, age 0.2 (per 1,000 births) Pulmonary tuberculosis. Pneumonia. Bronchitis. Cancer. Maternal mortality (per 1,000 births). Notifications of infectious disease. Scarlet fever. Diphtheria. Typhoid fever. Erysipelas. Cerebro spinal fever. Acute pneumonia. Western. Paddington 139,790 13.7 12.5 95 .16 — .09 .08 .01 22.9 .61 .84 .39 1.59 4.69 3.4 1.75 .06 .47 .02 1.36 Kensington 179,080 12.3 13.3 93 .31 .02 .08 .15 — 24.1 .58 .98 .30 1.90 1.37 3.23 2.14 .04 .45 .02 1.00 Hammersmith 129,170 13.8 12.9 77 .27 .03 .19 .15 — 12.3 .89 .78 .54 1.82 5.05 4.68 4.25 — .60 .05 1.21 Fulham 145,400 13.7 12.6 59 .21 .01 .21 .05 .01 8.5 .77 .87 .35 1.91 3.01 4.74 3.25 .03 .81 .03 1.26 Chelsea 58,160 10.8 13.4 65 .14 .17 .07 — 11.1 .57 .86 .33 1.79 4.76 3.26 2.36 .05 .66 .02 1.78 Westminster, city of 124,050 9.4 11.9 66 .10 .02 .07 .08 — 13.7 .69 .66 .41 1.87 3.42 2.77 1.24 .04 .46 .02 .39 Northern. St. Marylebone 92,320 9.0 12.7 61 .12 — .02 .05 .01 180 .67 .80 .36 1.95 4.80 2.29 1.13 .04 .62 .01 .76 Haropstead 90,000 10.4 11.3 53 .10 .01 .09 .03 .02 7.4 .59 .64 .31 1.62 4.26 2.28 1.46 .01 .35 .02 1.07 St. Pancras 187,540 13.2 12.9 65 .16 .01 .10 .05 12.6 .84 1.13 .45 1.79 4.05 3.76 2.45 .03 .82 .02 1.88 Islington 308,170 15.1 12.2 63 .12 .01 .10 .06 .00 9.0 .82 1.07 .61 1.90 2.36 3.54 2.66 .02 .63 04 .86 Stoke Newington 50,620 13.7 11.6 61 .08 .02 .12 .02 — 7.2 .73 .61 .55 1.66 1.44 3.07 1.66 .02 .63 .04 .48 Hackney 211,120 14.3 11.8 56 .13 .02 .13 .03 — 10.3 .74 .90 .40 1.70 1.66 4.63 2.88 .01 .57 .02 1.03 Central. Holborn 36,000 8.6 12.2 71 .11 .14 .06 .03 12.9 .75 .78 .53 1.44 3.24 2.12 2.14 .11 .31 .03 1.03 Finsbury 64,970 15.1 13.4 54 .25 .03 .20 .08 — 13.3 .86 1.06 .52 1.95 — 6.30 3.89 — .96 .11 1.0 City of London (a) 10,060 6.0 10.4 133 — — — — — 33.3 .89 1.19 .20 1.49 — 3.99 1.69 — .80 .10 .40 Eastern. Shoreditch 90,630 16.1 13.1 84 .32 .02 .14 .13 21.3 .93 1.34 .74 1.48 0.69 4.53 4.01 - .65 .03 .66 Bethnal Green 102,060 14.3 11.8 73 .33 .01 .10 .08 .01 21.9 .73 .99 .43 1.77 2.05 4.35 3.63 .03 .79 .03 1.51 Stepney 214,990 15.4 12.4 85 .41 .02 .10 .09 .00 20.0 .87 1.09 .37 1.49 4.54 3.99 3.51 .02 .76 .06 1.46 Poplar 146,370 15.5 12.3 62 .31 .03 .15 .08 — 7.9 .77 .98 .67 1.70 3.53 4.27 5.01 .02 .57 .05 3.67 Southern. Southwark 159,930 15.0 13.5 77 .41 .03 .13 .08 — 16.3 .89 1.22 .44 1.68 2.51 4.69 3.76 — .61 .08 1.13 Bermondsey 105,060 14.8 12.5 64 .36 .02 .11 .09 .01 14.8 .88 1.07 .69 1.60 2.57 5.70 3.55 .02 .70 .02 1.15 Lambeth 283,900 14.2 12.7 63 .24 .01 .16 .05 .00 9.4 .82 .96 .46 1.78 2.48 4.75 2.79 .01 .59 .04 1.18 Battersea 150,870 14.3 12.5 61 .21 . .13 .05 — 12.5 .72 .66 .71 1.59 3.25 4.47 4.07 .02 .52 .01 2.27 Wandsworth 345,250 110 11.2 58 .10 .02 .06 .03 .01 9.5 .68 .59 .44 1.73 2.90 4.46 1.74 .06 .44 .03 1.40 Camberwell 238,360 13.2 12.3 68 .13 .02 .08 .04 11.1 .85 .87 .50 1.68 2.54 3.77 2.11 .00 .59 .03 .87 Deptford 101,380 15.8 13.1 68 .42 .01 .19 .18 16.3 .91 .83 .59 1.86 3.13 5.21 2.91 .01 .55 .03 1.36 Greenwich 97,250 13.7 12.2 87 .16 .03 .05 .06 .01 22.4 .75 .96 .63 1.63 2.99 6.43 4.34 .02 .71 .02 1.58 Lewisham 222,180 12.2 100 43 .09 .02 .12 .06 .00 3.3 .58 .68 .35 1.56 1.47 5.75 2.17 .03 .65 .02 1.34 Woolwich 145,520 13.7 11 .3 63 .07 .02 .08 .09 4.5 .82 .87 .40 1.53 1.50 6.56 2.87 .06 .84 .02 1.82 London, 1934 4,230,200 13.4 12.2 67 .20 .02 .11 .07 .00 12.8 .76 .90 .47 1.72 2.80 4.32 2.79 .03 .61 .03 1.32 London, 1933 4,298,600 13.2 12.5 60 .02 .02 .08 .08 .01 11.7 .82 .83 .47 1.65 3.67 5.11 2.23 .04 .65 .05 1.47 (a) Including New and Middle Temple. 30 County of London.—Notifiable infectious diseases.—Notifications per 1,000 of population. Period Annual ratea per 1,000 living. Anthrax Cerebrospinal 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) (o) 2.03 (a) 4.4 .02 .00 1901-05 (a) (") .00 1.9 (°) () .52 1.08 (a) («) (a) (a) (a) 2.10 (a) 3.6 .46 .00 1906-10 (a) (a) .00 1.6 (a) (") .28 .97 (a) (a) (a) (a) (a) 2.27 (a) 4.2 .00 .00 1911-15 .00 .05 .00 1.8 (a) (o) .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 .01 409 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 10.4 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 .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 1933 00 .05 .00 223 .01 .01 04 .65 .00 9.31 1.47 .00 .01 4.51 14.81 5.11 .12 1934 .00 .03 .00 2.79 .01 .01 .03 .61 .01 8.24 1.32 .00 .02 4.48 13.37 4.32 .03 — (a) Comparable figures are not available for this period. 31 County of London.—Principal vital statistics, 1891-1934. Period Annual rate per 1,000 living Mortality per 1,000 living Annual mortality per 1,000 births Births Marriages Deaths (all causes) Cerebrospinal fever Diphtheria Enteric fever Scarlet fever Smallpox Whooping. cough Measles Influenza Tuberculosis Pneumonia (all forms) Bronchitis Other resp. diseases Heart disease Cancer Diabetes Infants 0—1 Diarrhoea and enteritis 0—2 Puerperal fever Other acc. of ch. birth Pulmonary Non.pulmonary 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 Ml 0.10 114 23.8 1.46 1.47 1911-15 240 200 14.8 0.02 0.13 0.03 0.05 000 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 1916-20 200 20.1 151 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 / l.7tt 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 1923 201 17.2 11.4 0.01 0.13 0.01 0.03 000 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 12.2 001 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 0.00 019 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 171 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 161 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 18.9 121 0.01 009 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 1.59 200 1929 15.8 191 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 0.00 003 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 14.9 18.7 12.3 0.03 0.06 0.01 0.02 000 0.07 0.03 0.25 0.88 0.12 1.01 0.59 0.14 2.83 1.62 0.13 65 9.7 201 1.80 1932 14.3 180 12.3 003 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 1933 13.2 18.9 12.5 0.03 0.08 0.01 0.02 0.00 0.08 0.02 0.52 0.82 0.11 0.83 0.47 0.15 3.06 1.65 0.14 60 11.7 1.69 1.97 1934 13.4 20.5 12.2 0.02 0.11 0.00 0.02 000 0.07 0.20 0.13 0.76 0.11 0.90 0.47 0.14 3.01 1.72 0.14 67 12.8 I 34 1.46 (a) Comparable figures are not available for this period. 32 Infectious Diseases.—Notifications in the County of London during the 52 weeks ended 31st December, 1934. Metropolitan boroughs in topographical order. Anthrax. Cerebrospinal fever. Continued fever. Diphtheria (including membranous croup). Dysentery. Encephalitis lethargica. Enteric fever. Erysipelas. Malaria. Ophthalmia neonatorum. Pneumonia. Polio encephalitis. Poliomyelitis. Puerporal fever. Puerperal pvrexia. Scarlet fever. Smallpox. Typhus Western— Paddington - 3 1 244 1 - 9 66 1 19 189 - 6 12 35 438 - - Kensington - 4 383 5 2 8 80 2 10 179 1 1 5 20 577 - - Hammersmith ... - 6 548 - 1 - 77 - 11 156 - 1 3 22 603 - - Fulham — 5 _ 471 1 2 4 117 - 15 182 1 2 4 39 688 - - Chelsea — 1 — 137 - - 3 38 1 1 103 1 _ 3 9 189 - - Westminster, City of - 3 1 153 3 - 5 57 1 4 48 - 3 5 13 343 - - Northern— St. Marylebone — 1 — 104 2 - 4 57 1 9 70 — _ 3 11 211 — - Hampstead - 2 - 131 2 1 1 31 1 7 96 — 3 5 21 205 — - St. Pancras — 4 - 458 8 1 6 154 9 33 352 - 2 14 27 703 — - Islington — 11 — 816 5 2 6 193 - 61 263 — 4 52 66 1,089 70 - Stoke Newington - 2 — 84 - - 1 32 - 3 24 - 1 3 17 155 — - Hackney - 5 - 607 1 2 3 119 2 21 216 - 4 21 80 975 1 - Central— Holborn - 1 - 77 2 - 4 11 1 2 37 - 3 2 112 - - Finsbury - 7 - 252 - - - 62 - 20 71 - 2 20 408 6 - City of London - 1 - 17 - - - 8 - - 4 - 1 - 40 - - Eastern— Shorediteh - 3 - 362 5 - - 59 - 18 60 - 3 6 22 409 2 - Bethnal Green - 3 - 369 1 1 3 80 2 12 154 - 3 1 12 443 1 - Stepney - 13 - 753 1 4 5 164 - 13 313 1 3 5 38 856 9 - Poplar - 7 - 731 16 - 3 83 1 21 536 - 4 11 35 623 2 - Southern— South wark 12 - 600 2 - 98 1 14 181 1 6 19 748 22 - Bermondsey 1 2 - 372 2 2 73 - 6 121 2 13 597 7 - Lambeth 10 - 790 2 2 166 - 34 333 2 16 76 1,346 1 - Battersea . 1 1 612 - 2 3 78 2 23 341 — 5 11 20 673 1 - Wandsworth - 11 1 599 4 3 19 151 2 36 481 2 3 16 13 1,534 - - Camberwell 1 6 - 501 1 - 1 141 1 19 206 3 16 38 896 18 - Deptford 1 3 - 294 - 1 1 56 - 22 138 — 3 6 15 527 1 - Greenwich - 2 - 421 - - 2 69 1 10 153 1 2 5 9 624 — - Lewisham - 5 - 480 - 1 6 144 1 16 298 — 4 12 33 1,274 1 3 - Woolwich . 3 . 416 - - 8 122 - 7 264 1 2 6 33 952 - - Ages 0- 24 - 208 6 49 467 380 2 4 - - 115 1 - „ 1- 36 - 3,728 20 2 6 77 2 - 1,168 31 - - 5,053 10 - „ 5- - 15 - 4,575 8 2 12 80 - - 498 4 17 - - 6,884 22 - „ 10- 13 - 1,571 2 2 6 90 - - 253 1 7 - - 3,229 27 - „ 15- 11 1 531 2 4 10 109 2 - 260 1 4 13 37 968 27 - „ 20- 1 13 - 465 3 4 15 136 3 307 63 233 737 17 - „ 25- 2 15 - 448 5 4 20 275 10 571 - 2 138 384 787 14 - „ 35- 3 - 157 9 5 16 390 9 - 573 - 1 39 102 319 9 - „ 45- - 5 1 60 1 3 15 518 3 - 562 - _ 1 2 105 6 - ,, 55- - 1 2 30 1 2 6 482 1 - 470 - - - - 33 6 - ,,65- - 1 - 8 1 1 3 259 - - 345 - - - - 6 4 - „ 75 + - - - 1 - - - 121 - - 182 - - - - 2 1 - London, 1934 3 137 4 11,782 58 29 109 2,586 30 467 5,569 8 66 254 758 18,238 144 London, 1933 3 216 5 9,557 31 22 164 2,766 21 527 6,299 6 60 255 838 21,911 531 - 33 Administration. Slum Clearance. Although public attention has been so focussed upon the slum problem that few are prepared to deny that it is a question of the first magnitude in our national life, there is, nevertheless, equal certainty that few, apart from those actually engaged upon the task, appreciate the variety of processes involved in the transference of a family from a slum dwelling to satisfactory housing conditions by action under section 1 of the Housing Act, 1930. There is first the work of survey of insanitary areas and their relation to surrounding property and consideration of how best to provide a site suitable for rehousing purposes ; then the laying out of the site to the best advantage and the planning of the new buildings to be erected thereon ; the erection of the buildings and finally the transference of men, women and children in a manner best calculated to meet their requirements as regards reasonable access to their work and the other amenities which are of great importance to the individual. These are separate parts of the task and, except for the survey, follow the initial step of " representation " of the insanitary area. Added to these, are the steps to be taken to prepare the necessary evidence for the local enquiry held by the Ministry of Health and attendance at the enquiry for the giving of the evidence and cross. examination thereon. The housing section of the public health department is mainly concerned with the first stage of " representation " and the preparation of evidence which, for clearance areas, begins as periodic inspections of working class property throughout the county, and ultimately resolves itself into a map of the particular insanitary area showing exactly the properties which, for the reasons set out in section 1 of the Housing Act, 1930, are unfit for human habitation or dangerous or injurious to health. The map is accompanied by a representation stating, inter alia, that the most satisfactory method of dealing with conditions in the area is the demolition of all the buildings included therein. As a climax to this first stage of a clearance scheme, the representation map may well appear to be a small thing. Certainly it is by no means indicative of the arduous work of detailed inspection, often on several occasions, of house after house. The tenant or occupier does not welcome disturbance, and is in a position to create obstacles and delay unless approached with some tact and good humour. Improvement area procedure in London is somewhat different as the bulk of the work falls on the metropolitan borough councils. The action taken as regards this type of area has, up to the present, been exploratory and largely experimental. For the past year, except in one instance of an improvement area which is mentioned later in the statistical statement, attention has been concentrated on clearance work. During the year the number of medical officers wholly engaged upon housing fieldwork has been gradually increased from one to five, and provision has been arranged for the making of two further appointments as required during 1035. Eight extra sanitary inspectors have been appointed, bringing the total inspectorial staff engaged on slum clearance to fifteen, and the clerical staff has also been suitably augmented. It may be desirable at this point to refer statistically to the year's work, it being understood, so far as clearance is concerned, that the figures relate only to representations submitted to the Housing and Public Health Committee in respect of property conforming to the provisions, as regards unfitness for human habitation, of section I of the Housing Act, 1930. If an area is sufficiently large in itself, or if it adjoins available land, it may offer possibilities as regards a site for rehousing purposes. In such case, the resolution of the Council usually provides for the purchase of additional land in order to provide a convenient rehousing scheme. Such augmentations are not referred to in the following statement:— Clearance. Number of areas represented under section 1 of the Housing Act, 1930 60 Number of houses included therein 3,540 This brings the total number of representations under the 1930 Housing Act up to 87, including 6,003 houses. 34 Improvement. Number of areas represented under section 7 of the Housing Act, 1930 1 Number of houses included therein 126 The total number of improvement areas declared under the Housing Act, 1930, is 3 containing 595 houses. In connection with the work of representation several difficulties present themselves to the medical officer who is charged with the duty of deciding whether a particular house should be condemned. The medical officer interpreting section 1 cannot take into consideration any question of hardship or cost to the owner. There is in the 1930 Act a workable definition of unfitness as regards sanitary defects, but many difficulties arise on the question of the state of disrepair. It is not unusual to find one or more rooms used as a shop, workshop, or store in premises originally constructed as a dwelling house, or again a house may be closed or in various stages of ruin. If the portion of the house used as a dwelling is sufficiently bad, or if the house or the converted part could be occupied again as a dwelling, the premises as a whole are included in the representation map. It sometimes happens, however, that when an order is confirmed, premises of this nature are found to be excluded by the Ministry of Health from the clearance area. It has been stated by the Minister of Health that in revising the proposed orders of local authorities the number of houses excluded by him amounted to about 12 per cent. This is the figure for the whole country. During the past year in respect of orders made by the Council the corresponding figure is rather less than 1½. per cent., and may be taken as indicative of the care with which the representations are made. A reference was made in last year's report to the need for collaboration between the metropolitan borough councils and the County Council, who are all equally authorities in London under the 1930 Act, except in as so far as the boroughs are required under Section 16 to notify to the Council their proposals in respect of any clearance area and ascertain whether the Council itself intends to deal therewith. It is clear therefore that, unless the borough authority and the Council have reached some measure of agreement as to what each shall regard as its contribution to the task, much energy may be dissipated in the preparation of dual schemes. A natural division of labour which suggests itself is that the Council, with its greater resources and broader organisation, should assume responsibility for the more costly and more complicated schemes and should undertake the clearance and redevelopment of the larger groups of slum areas which rightly fall as a burden on the whole of London's ratepayers. Accordingly a programme of three years' work was drawn up and approved. It embraces those larger areas which seem to offer a possibility of rehousing schemes, and the work is divided into sections to be undertaken approximately each half year. It was understood, however, that it might be found difficult or even undesirable to deal with the programmed areas strictly in chronological order, and that rearrangement to meet circumstances as they arise might be necessary. The object was to set a pace which could be followed and to accomplish the task within a time which could be envisaged. Apart from the larger areas in the programme, attention has to be directed also to a mass of insanitary housing in little cul.de.sac courts, alleys, and mews which could be made the subject of clearance orders but which, whilst increasing the rehousing requirements are, on account of their size and relative positions, incapable of contributing to the area available for rehousing sites. The first step towards co.operation between the boroughs and the Council was to agree upon the identity and location of the well.defined and scheduled small areas. This was done between the medical officers, and conferences were then held between representatives of the borough councils and the Chairman of the Council's Housing and Public Health Committee. The lists of areas prepared for these conferences were arranged in groups:—(a) larger areas on the Council's programme, (b) areas which had been notified as among borough council proposals, and (c) "unadopted" areas. The object of the discussions was to provide the borough representatives 35 with some idea as to the Council's proposals concerning the areas in group (a), to affirm the borough council's intentions in group (b), and, more especially, to arrive at some working agreement in respect of the areas in group (c) which had not hitherto been definitely brought into schemes of either the borough or the County Council, although the latter, at any rate, had taken some account of them in the mass in preparing its programme. These conferences between the responsible members of the respective authorities have clarified the position very considerably. In most cases the procedure to be adopted for groups (a) and (b) in the lists has been confirmed. In some instances it was found that the borough was anxious to undertake a larger programme than was expected and some of the areas in the Council's programme have been handed over for borough action. It was, however, not found easy to dispose of group (c) in a clear.cut fashion, because of the inherent difficulties in the matter of rehousing. By taking advantage of the Council's standard agreement to provide the necessary accommodation in consideration of a flat rate contribution, the boroughs have been enabled to proceed in the knowledge that their main stumbling block would be removed, provided, of course, that their requirements are co.ordinated with the Council's output of new dwellings. The mass of " unadopted " areas is receiving further careful consideration with a view to the possibility in a few cases of some scheme of grouping and redevelopment on the lines of the Housing Bill which was presented to Parliament in December. In the main that Bill deals with the problem of overcrowding. It also includes, however, several important amendments of existing Housing Acts. Milk and Dairies (Consolidation) Act, 1915. For several years it has been the practice for the Council to take samples of liquid milk arriving from the provinces for biological examination to ascertain the extent to which the milk supply on its arrival in London is infected with tuberculosis. In the event of a positive result, the medical officer of the county of origin is notified, when arrangements are made by him for the farm from which the milk originated to be visited and the herd examined. Examination of milk. The result of such sampling during 1934, as compared with work done in 1933, is as follows:— Quarter. 1933. 1934. Completed examinations. No. tuberculous. Percentage. Completed examinations. No. tuberculous. Percentage. 1st 556 46 8.3 234 26 Ill 2nd 662 32 4.5 231 25 10.8 3rd 555 73 13.2 302 29 9.6 4th 159 15 9.4 504 45 8.9 Total 1,932 164 8.4 1,271 125 9.8 N.B.—These figures refer to samples taken from churns only. The milk subject to sampling in 1934 was received from 25 counties. As a result of consequential investigations 69 cows were dealt with under the Tuberculosis Order, 1925; in some additional cases it was reported that the owners had taken action before the medical officer of the county concerned made his inspection. In addition to the samples given in the above table, 37 were taken in 1934 from tanks, of which 30 or 81 per cent. were tuberculous. It was decided that it served no useful purpose to continue to sample milk brought into London in tanks on account of the practical impossibility of tracing the farm of origin. Representations regarding this matter were made to the government departments concerned and evidence was given to the Committee of the Economic Advisory Council on Cattle Diseases. 36 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 surgeons, and samples of the milk have been taken at least twice during the year. The results of sampling and of veterinary inspection were as follows:— Department. Approximate stock at 31st December, 1934. Visits by veterinary surgeon. Samples taken Samples found to be tuberculous. Cows with tuberculosis. Cows with unhealthy conditions not tuberculous. Cows. Bulls. Education 9 - - 8 8 - - 1 Mental hospitals 847 19 44 54 212 14 11 131 Public assistance 13 - 3 8 13 - - - Public health 49 3 31 8 15 1 1 5 Total 918 22 78 78 248 *15 12 137 * Or 6 per cent. At the visits of the veterinary surgeons cows are sampled in groups and when a specimen proves positive and it is impossible to discover the diseased cow by clinical methods, individual samples are taken under the instructions of the veterinary surgeons, who confer with the farm bailiffs and give such advice as may be necessary for the treatment of suspected milk and the general maintenance of the herds. Licensed cowsheds. The cows in the London licensed sheds are inspected under the provisions of Part IV of the Milk and Dairies Order, 1926. The veterinary surgeons inspected each shed at least four times during the year, making 174 visits in all. During these inspections 3,516 cows were examined of which 229 were found to be unhealthy, seven suffering from tuberculosis of the udder or giving tuberculous milk, six in a state of tuberculous emaciation, 92 atrophied in one or more quarters and 124 with some other defect. The animals found to be tuberculous were slaughtered, either voluntarily by the owners or by the Council under the provisions of the Tuberculosis Order, 1925. The number of licensed cowsheds in the county has diminished from 738 in 1889, the year of the Council's inception, to 42 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 still containing open fields, while in Stepney and Bethnal Green the sheds are necessary for the supply of milk to Jewish residents in accordance with the requirements of their religion. Venereal Diseases. In his annual report for the year 1916, Sir William Hamer, at that time county medical officer of health, gave particulars of a scheme for the provision of the necessary facilities for the diagnosis and treatment of venereal disease which had been formulated as a result of conferences between representatives of the counties of London, Buckingham, Essex, Hertford, Kent, Middlesex and Surrey, and of the county boroughs of Croydon, East Ham and West Ham. The Local Government Board, in due course, signified its approval of the scheme, which came into operation on 1st January, 1917, and is known as the London and Home Counties Scheme. Hospitals. 1 he general and special hospitals undertaking in-patient or out-patient treatment and other work under the scheme at the end of 1934, were as follows:— General Hospitals.—St. Thomas's; Seamen's; Royal Free (women); Guy's; West London; Royal Northern; 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 Clapton- road, E.; Children's Medical Home, 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; 37 the London County Council (Whitechapel) clinic (see page 39) and the Royal Free hospital (women). In addition the following hospitals provide facilities for all-day intermediate treatment: Miller General hospital; Royal Northern hospital; St. John's hospital (Lewisham); St. Mary's hospital; Seamen's hospital; University College hospital. The number of new patients attending the hospitals during the year 1934 was 28,123, of whom 4,179 were suffering from syphilis, 11,720 from gonorrhoea, and 165 from soft chancre, while 12,059 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 1934 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 2,800 316 162 158 95 39 23 41 81 7 3,722 457 4,179 Soft chancre 91 4 10 5 2 2 — 1 8 — 123 42 165 Gonorrhoea 8,250 1,033 558 344 203 124 61 90 255 28 10,946 774 11,720 Not venereal 8,476 1,248 533 520 277 123 65 98 185 68 11,593 466 12,059 Total 19,617 2,601 1,263 1,027 577 288 149 230 529 103 26,384 1,739 28,123 Total attendances 879,167 88,899 64,162 25374 11182 8,353 4,215 12674 29883 2,222 1126131 16156 1142287 No.of in.patientdays 31,874 3,210 2,056 2,142 2,159 235 481 871 734 399 44,161 9,928 54,089 Salvarsan subs.doses 42,132 6,170 3,488 2,493 1,130 852 481 822 1,224 89 58,881 3,167 62,048 Patholoqical Examinations. For or at centres— Spirochaetes 1,979 103 74 55 21 14 15 4 16 3 2,284 146 2,430 Gonococci 105,316 10,514 10,096 4 963 1,984 1,131 999 1,945 4,157 571 141,676 2,485 144,161 Wassermann 41,468 3,849 2,151 2,088 990 66S> 365 410 761 286 53,030 1,731 54,761 Others 37,871 3,878 8,053 1,547 608 321 153 1,956 3,166 108 57,661 2,103 59,764 Total 186,634 18,344 20,374 8,653 3,603 2,128 1,532 4,315 8,100 968 254,651 6,465 261,116 For Practitioners— Spirochaetes 23 1 4 2 - - - - - — 30 — 30 Gonococci 6,126 259 913 509 199 52 47 31 18 1,032 9,186 94 9,280 Wassermann 15,795 1,036 1,179 1,176 185 55 131 41 18 721 20,337 470 20,807 Others 5,525 178 747 235 39 20 10 32 13 124 6,923 246 7,169 Total 27,469 1,474 2,843 1,922 423 127 188 104 49 1,877 36,476 810 37,286 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. Gonorrhœa. 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 1933 3,072 1,638 185 10 8,791 3,313 12,048 4,961 1934 2,673 1,506 159 6 8,689 3,031 11,521 4,543 38 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 1934, and also as to the number of cases of congenital syphilis. The returns received from the treatment centres showed that, as regards syphilis, in approximately 44 per cent, of the new patients the disease was in either a primary or secondary stage, and, in the case of gonorrhoea, in 81 per cent., the infection had taken place within a year. Cases of congenital syphilis not known to have received previous treatment, numbered 279. 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. 23 31 8 5 35 26 48 103 114 165 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 continues to receive careful attention. Where necessary, patients are transferred from one clinic to another, which they can attend more conveniently. In past years the ratio of attendances has been stated as so many attendances to each new case of Y.D. admitted to the clinics during the year. By this means an estimate, comparable year by year, is obtained of the efficiency of the work as measured by the continued attendance. For the year 1934 the total attendances of Y.D. patients was 1,060,773, and the ratio of attendances of Y.D. patients to new Y.D. cases was 66, compared with 59 in 1933. Comparative figures for the eighteen 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 1933 17,009 11,705 28,714 1,097,214 52,581 1934 16,064 12,059 28,123 1,142,287 54,089 The increasing number of non.venereal patients who present themselves for examination indicates that the general public is appreciating more and more the 39 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. The increased attendances show that patients are willing to take advantage of the improved facilities for intermediate treatment now available. Another point worthy of note is the total number of examinations made of pathological specimens. Comparative figures for the eighteen years are shown in the following table:— Pathology and bacteriology. Year. From treatment centres. From medical practitioners. Year. From treatment centres. From medical practitioners. 1917 13,988 3,649 1926 100,543 27,565 1918 25,973 6,380 1927 107,512 27,046 1919 51,554 10,464 1928 107,410 29,785 1920 58,920 14,027 1929 114,840 32,605 1921 66,134 18,472 1930 125,177 33,309 1922 74,022 19,836 1931 161,092 35,498 1923 69,784 24,403 1932 196,357 40,626 1924 79,005 24,797 1933 219,852 39,649 1925 106,064 26,346 1934 261,116 37,286 The increased number of specimens examined from the treatment centres is due partly to the increasing use of other tests for syphilis in addition to the Wasser. mann test (e.g., Kahn) and to the use of the complement fixation test for gonorrhoea. 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 526, compared with 108 at the end of 1917, the first year of the operation of the scheme. 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 1934, the number of patients dealt with at these institutions from the areas in the scheme was 269, the aggregate number of days in residence being 28,582. Comparative figures for 1933 were 230 and 25,891. Venereal disease; hostel accommodation. The hostels undertaking work in connection with the scheme for the year 1934, were as follows:— 20.22, Highbury.quadrant, N. (Royal Free Hostels Committee); 148, Lambeth. road, S.E. (St. Thomas's hospital); 80, Stockwell.park.road, S.W. (Southwark Diocesan Association for Preventive and Rescue Work); 35, Parkhurst.road, N. (West London Mission); 62, Regent's.paik.road, N.W. (Royal Free Hostels Committee); Salvation Army Hostels, 122.124 and 126.128, Lower Clapton.road, E. The desirability ot maintaining treatment and observation of girls and women for whom residence in hostels has been provided during the acute stages of venereal disease, engaged the attention of the Public Health Committee of the Council during the year 1928. As a result, arrangements were made with the authorities of certain rescue homes providing vocational training in domestic and other work, to receive up to eleven young women and girls who, although requiring continued treatment and observation, had been certified by the medical officer of a clinic as fit to reside in an institution without danger to other residents. These arrangements were completed in the autumn of 1928, but have not been utilised to the extent anticipated despite several circulars to V.D. clinics and hostels. During the year 1934 only one girl availed herself of these facilities. The total number of days in residence was 178. Rescue homes. 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. every week.day, The London County Counoil (Whitechapel) clinic. 40 and provision for intermediate treatment is available also on Sundays and Bank Holidays. The premises are rented from the London hospital, but the staff is appointed and the clinic maintained entirely by the Council. Under the directorship of Dr. T. Anwyl Davies, assisted by a loyal and efficient staff, the clinic has been an unqualified success. During the first six months the clinic was in use, 1,527 new patients and 76.183 attendances were registered, whilst for the year 1934, the number of new patients was 3,885 and the attendances totalled 322,904. Of the new patients during 1934, 64 per cent. of the male and 52 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 1934 was 88,317, an increase of 5,990 on the previous year's total. Of the 88,317 examinations, 7,563 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 midwives, medical students and post.graduates, demonstrations being held weekly. Review. Treatment of Tuberculosis. In previous Annual Reports from 1930 onwards, reference has been made to changes in the administrative methods for dealing with the treatment of the tuberculous resulting from the operation of the Local Government Act, 1929. As the year now under review is the fifth year since the Act began to operate on 1st April, 1930, it may be well to review briefly the developments which have taken place. Under the original tuberculosis scheme, it may be said that, broadly speaking, the Council directed its efforts towards providing appropriate residential treatment for persons likely to be restored to full working capacity, together with the provision of recuperative periods of treatment for moderately advanced cases with reasonable prospect of partial restoration to working capacity. Treatment for advanced and chronic cases was then regarded as the function of boards of guardians. This position was not rigidly maintained and a considerable proportion of patients sent into certain of the special tuberculosis hospitals of the Metropolitan Asylums Board under the tuberculosis scheme, as then administered, were advanced cases. There were a large number of deaths in these hospitals and they, therefore, tended to become unpopular and self.discharges were frequent. During the first year for which the Council became responsible for the administration of the transferred poor.law hospitals and Metropolitan Asylums Board institutions, the existing practice was largely continued pending experience of the type of case formerly dealt with by boards of guardians. In course of time, after the poor.law hospitals, which had become organised as general hospitals, had been " appropriated " under the provisions of the Local Government Act, 1929, tuberculous patients in general hospitals were removed from the purview of the Poor Law and were dealt with as " municipal" patients in the same way as other patients in these hospitals. The Council also continued the practice, in operation under boards of guardians, of placing in institutions in the country a number of chronic ambulant cases. In the past the detachment of these cases from the organisation operating the Council's tuberculosis scheme was a great hindrance in securing consent for admission to transferred general hospitals of patients who were no longer suitable for institutions used under the tuberculosis scheme, but who still required hospital treatment. Among other reasons, the dual visitation for assessment purposes by two separate organisations caused a considerable amount of irritation. The result was congestion of hospital cases in sanatoria, and some measure of blocking of the beds for patients more suitable for the treatment available therein. The decision of the Council to deal with all cases of tuberculosis as from 1st April, 1933, under the tuberculosis scheme afforded facilities for dealing with the matter in all its aspects as a single problem, so that patients could be transferred between the various institutions, according to their clinical classification, with the knowledge that their treatment was a continuous service. Assessments were entirely abolished in July, 1934. 41 Further factors in removing former obstacles to the effective use of the general hospitals as an integral part of the arrangements for dealing with tuberculosis in London are (a) the appointment of tuberculosis officers as honorary consultants on the staff of the general hospitals, with provision for regular visits to the hospitals, and (b) the close relationship which has been established between the medical superintendents of general hospitals and the central staff at County Hall responsible for the appropriate distribution of patients. Immediate admission can be secured to the general hospital nearest to the patient's home by direct arrangement between the tuberculosis officer or the patient's medical attendant and the medical superintendent, or if there is no vacant bed, to another general hospital. Some patients prefer to be sent to a hospital other than that serving their home address on account of some prejudice or other, such as that a relative died in the hospital, or that they prefer another district because of the "change of air" or some other reason. Wishes of patients in this matter are met as far as possible. Patients are continually leaving the general hospitals to go to sanatoria. Those .entering the general hospitals are consequently relieved of the sense of hopelessness which formerly prevailed among patients offered treatment in these hospitals. Seriously ill patients in increasing numbers now consent to enter the general hospitals. The greater readiness of patients to accept transfer from sanatoria to the general hospitals is seen in the following figures giving the cases transferred from sanatoria to the general hospitals during the years 1928.34:— Year. Number. Year. Number. 1928 117 1932 515 1929 155 1933 598 *1930 302 1934 649 1931 444 * The general hospitals were transferred to the Council on 1st April, 1930. Improvements have been effected in the general hospitals and among the advantages arising from their use for tuberculosis scheme patients, are the following:— (i) Patients developing complications (tuberculous or non.tuberculous) which cannot be treated effectively in tuberculosis hospitals or sanatoria can be transferred to a suitable general hospital, and return to a special tuberculosis hospital or sanatorium when the complication has been treated. (ii) The value of the direct transfer of advanced bedridden cases to general hospitals in London is reflected in the greater popularity of such institutions as Colindale hospital, Hendon, and Grove Park hospital, Lee, where there has been a considerable reduction in the number of deaths and self.discharges. (iii) Pregnant tuberculous women are now admitted into Grove Park hospital, Lee, where they can receive sanatorium treatment up to the time of confinement, and, at the same time, attend the ante.natal clinic at Lewisham hospital (which is situated close to Grove Park) and to which they are admitted for the actual confinement, afterwards returning for completion of treatment for tuberculosis to Grove Park hospital or other suitable tuberculosis hospital or sanatorium. (iv) Units for thoracic surgery have been established at two general hospitals (St. Andrew's, Poplar, and St. James', Wandsworth). There is also a panel of consulting thoracic surgeons and other consultants in connexion with both the general and the special tuberculosis hospitals and sanatoria, several of the latter now having operating theatres for the surgical treatment of pulmonary tuberculosis. (v) Beds in the general hospitals are occasionally used for observation purposes to determine the most suitable disposal of patients for treatment. (vi) A number of auxiliary services for patients having domiciliary treatment in association with the tuberculosis dispensary service, such as the provision of artificial pneumothorax refills, X.ray examinations and dental treatment, in respect of which some dispensaries found difficulty in securing the necessary 42 facilities within reasonable distance of the patient's home, are now provided at the Council's general hospitals. The inclusion of the general hospitals within the orbit of the tuberculosis scheme now completes the cycle enabling all forms of residential treatment for tuberculosis to be provided by inter.change of patients according to needs among a number of institutions equipped between them for all services. There is provision for a continual flow of patients between the various types of hospitals and sanatoria included within the Council's tuberculosis scheme. Bedridden and seriously ill patients can be treated in suitable institutions within reasonable access of their homes with advantage to the relatives in the saving of time and expense involved in visitation. Knowledge both of the benefits of nearness to home and hope of possible re.transfer to a sanatorium if they recover sufficiently are valuable assets in securing the effective use of these hospitals. It is worthy of note that among the voluntary institutions with which the Council has been able to establish working arrangements are Papworth village settlement, Cambridge, Preston Hall colony, Aylesford, Kent, and Burrow Hill colony, Frimley. The two former, in addition to giving special consideration to the absorption of suitable cases into the colony, regulate their charges to the Council having regard to the extent to which services of the patients are of financial value to the industries carried on by them. At Burrow Hill colony, special training in clerical and gardening work is given to youths between 14 and 19 years of age, and the Council takes five youths a year who have satisfactorily completed the gardening course into employment in its parks. The Council's scheme, therefore, embraces various types of residential institutions widely distributed, all of which are combined within a single service. It includes in its range facilities for treatment for every type of case and enables uniformity of classification of cases for statistical purposes to be made. The inclusion within the scheme of a number of voluntary institutions which specially cater for particular types of patients, including those desiring various social amenities, religious atmosphere or special climatic conditions, has proved to be of considerable value in the London tuberculosis service. The development of the provision for residential treatment in London since 1914 is shown below:— Beds occupied at. end of year. Year. Adults. Children. Total. Year. Adults, Children. Total. 1914 722 90 812 1924 1,612 746 2,358 1915 544 241 785 1925 1,668 792 2,460 1916 481 320 801 1926 1,841 880 2,721 1917 526 375 901 1927 1,946 884 2,830 1918 816 376 1,192 1928 1,920 855 2,775 1919 1,308 557 1,865 1929 2,083 858 2,941 1920 1,636 704 2,340 1930 2,017 890 2,907 1921 1,382 669 2,051 19311 2,255 898 3,153 1922 1,370 655 2,025 1932f 2,368 811 3,179 1923 1,458 707 2,165 1933f 3,216 787 4,003 1934 3,574 781 4,355 N.B.—The above figures include cases dealt with by the Insurance Committee from 1914 to 1921. †The figures for 1931 and 1932 include patients sent to sanatoria as "municipal" patients independently of the tuberculosis scheme, and those for years from 1933 onwards include these patients and also tuberculous patients treated in the Council's general hospitals, who on and after 1st April, 1933, are all regarded as tuberculosis scheme patients. 43 The numbers of applications for residential treatment during each of the last five years were as follows:— Year. Application for first period of treatment. Application for further treatment. Total applications. Ex. service. Civilian adults. Children. Ex. service. Civilian adults. Children. Male. Female. Male. Female. 1930 19 2,331 1,814 914 204 943 667 207 7,099 1931 26 2,276 1,834 941 230 1,021 787 260 7,375 1932 18 2,191 1,811 905 159 1,162 779 215 7,240 1933 2 2,793 2,121 753 155 1,707 1,113 214 8,858 1934 6 2,808 2,118 821 131 1,773 1,172 229 9,058 N.B.—As from 1933 "municipal" cases formerly treated in general hospitals are included in these figures. Applicants recommended for treatment during 1934 were disposed of as follows:— Adults. Children. (a) Admitted to "observation" beds to determine diagnosis or suitability for sanatorium treatment 1,545 181 (b) Passed for admission direct to sanatoria or hospitals 6,331 825 (c) Cases not accepted for residential treatment 72 22 (d) Cases withdrawn after application but before decision was reached 60 22 Total 8,008 1,050 N.B.—The treatment offered was refused in the cases of 191 adults and 24 children. For the purpose of the following tables patients of 15 years of age on admission are, except where otherwise stated, regarded as adults, owing to the " age " division required for the purposes of the Ministry of Health, although treatment was arranged in institutions for children. The extent of residential treatment and observation is shown below:— Classification. In institutions on 1st January, 1934. Admitted during the year. Discharged during the year. Died in institutions. In institutions on 31st December, 1934. Number of doubtfully tuberculous cases admitted for observation. Adult males 48 256 238 12 54 Adult females 54 244 238 5 55 Children 7 188 187 1 7 Total 109 688 663 18 116 Number of patients suffering from pulmonary tuberculosis. Adult males 1,671 4,311 2,992 1,120 1,870 Adult females 1,107 2,816 2,196 573 1,154 Children 220 273 185 26 282 Total 2,998 7,400 5,373 1,719 3,306 Number of patients suffering from non. pulmonary tuberculosis. Adult males 180 356 244 64 228 Adult females 181 346 282 32 213 Children 535 412 419 36 492 Total 896 1,114 945 132 933 Grand total 4,003 9,202 6,981 1,869 4,355 44 The distribution of patients in institutions on 31st December, 1934, is shown below, the figures for 1933 being given in brackets:— Hospital and institution. Ex-service men. Civilian adults. Children under 16 years. Total. London County Council special hospitals 7 (6) 1,375(1,330) 650 (605) 2,032(1,941) London County Council general hospitals 8(9) 1,122 ( 947) 50 (44) 1,180 (1,000) Voluntary institutions 27 (45) 1,035 ( 879) 81 (138) 1,143(1,062) Total 42 (60) 3,532(3,156) 781 (787) 4,355 (4,003) The following table shows the results of observation of doubtfully tuberculous cases discharged from observation hospitals:— Diagnosis on discharge from observation. For pulmonary tuberculosis. For non-pulmonary tuberculosis. Total. Stay under 4 weeks. Stay over 4 weeks. Stay under 4 weeks. Stay over 4 weeks. Male. Female. Children. Male. Female. Children. Male. Female. Children. Male. Female. Children. Male. Female. Children. Tuberculous 39 44 5 30 40 27 1 1 9 70 85 41 Non-tuberculous 108 75 14 55 71 59 2 3 8 15 9 66 180 158 147 Doubtful — — — — — . — — — — — — — — — — Total 147 119 19 85 Ill 86 2 3 8 16 10 75 250 243 188 The immediate results of the treatment of patients discharged on completion of treatment during 1934 and the two preceding years, are indicated in the subjoined tables. The percentages given in the second line of figures under each classification group represent the percentage of the total number of cases falling within each classification group. For example, in 1934 there were 721 "A," 240 "B1" 2,859 "B2" and 1,814 "B3" cases discharged during the year. Of these numbers, 286 or 39.7 per cent. group "A," 105 or 43.8 per cent, group "B1" 191 or 6.7 per cent. group "B2" and 3 or .2 per cent. group "B3" cases were discharged as quiescent, totalling 585 quiescent cases, or 10.4 per cent. of the total number (5,634) of pulmonary cases discharged during 1934. Immediate results of treatment. Adults. Classification. Quiescent. Not quiescent. Died in institution. Totals. Years. Years. Years. Years. 1932. 1933. 1934. 1932. 1933. 1934. 1932. 1933. 1934. 1932. 1933. 1934. A Number 338 306 286 326 323 395 12 6 40 676 634 721 Percentage 50.0 48.3 39.7 48.2 50.9 54.8 1 .8 0.8 5.5 100 100 100 B1. Number 111 89 105 95 108 133 - 1 2 206 198 240 Percentage 53 9 44.9 43.8 46 1 54.5 55.4 - 0.6 0.8 100 100 100 B2. Number 214 192 191 2,131 2,445 2,558 46 53 110 2,391 2,690 2,859 Percentage 8.9 71 6.7 89.1 90.9 89.5 20 20 3.8 100 100 100 B3. Number - - 3 740 666 787 200 183 1,024 940 849 1,814 Percentage — — 0.2 78.7 78.2 43 .4 21.3 21.8 56.4 100 100 100 Total Pulmonary 663 587 585 3,292 3,542 3,873 258 242 1,176 4,213 4,371 5,634 Percentage 15.7 13.4 10.4 78.2 811 68.7 61 5.5 20'9 100 100 100 Surgical 165 189 219 292 254 239 17 18 60 474 461 518 Percentage 34.8 41.0 42.3 61.6 55 1 461 3.6 3.9 11.6 100 100 100 Grand Total 828 776 804 3,584 3,796 4.112 275 260 1,236 4,687 4,832 6,152 Percentage 17.7 161 131 76.4 78.6 66*8 5.9 5 3 201 100 100 100 45 Children. Classification. Quiescent. Not quiescent. Died in institution. Totals. Years. Years. Years. Years. 1932. 1933. 1934. 1932. 1933. 1934. 1932. 1933. 1934. 1932. 1933. 1934. A. Number 143 106 114 42 40 38 2 3 187 146 155 Percentage 76.5 72.6 73.6 22 5 27.4 24.5 1.0 — 1.9 100 100 100 Bl. Number 3 6 5 2 2 3 8 7 Percentage 100 75.0 71.4 — 25.0 28.6 — — — 100 100 100 B2. Number 6 8 15 18 13 2 5 1 23 31 14 Percentage 26.1 25.8 — 65.2 58.1 92.9 8.7 16.1 7.1 100 100 100 B3. Number — — — 12 24 2 6 8 18 18 32 20 Percentage — — — 66.7 75.0 10.0 33.3 25.0 90.0 100 100 100 Total Pulmonary 152 120 119 69 84 55 10 13 22 231 217 196 Percentage 65.8 55.3 60.7 29.9 38.7 28.1 4.3 6. 0 11.2 100 100 100 Surgical 387 360 359 76 67 44 19 15 16 482 442 419 Percentage 80.3 81.4 85.7 15.7 15.2 10.5 4.0 3.4 3.8 100 100 100 Grand Total 539 480 478 145 151 99 29 28 38 713 659 615 Percentage 75.6 72.8 77.7 20.3 22.9 16.1 41 4.3 6.2 100 100 100 N.B.—1,402 patients were discharged during the year 1934 from sanatoria or hospitals or died in these institutions after less than 28 days treatment and are not included in the above table. As regards Papworth village settlement, Cambridge, and Preston Hall colony, Aylesford, Kent, careful selection is made in order to ensure that only those patients are admitted to these institutions who are potential settlers in the associated industrial villages ; 28 former patients have been accepted as permanent settlers at Papworth and 35 at Preston Hall. In addition there are a certain number of settlers for whom, owing to their permanent disability, a weekly part maintenance fee of from 10s. to 20s. is paid. For the purposes of this report, such settlers are regarded as patients undergoing residential treatment. Papworth and Preston Hall village settlements. The average numbers of London patients at Papworth and Preston Hall, re. spectively, during the past eight years are shown below :— 1927. 1928. 1929. 1930. 1931. 1932. 1933. 1934. Papworth 13 9 16 33 61 90 109 118 Preston Hall 18 13 13 10 53 84 89 113 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 or 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 Ministry of Agriculture and the Board of Education. The Council maintains an average of about 40 beds. A scheme is in operation under which arrangements are made for special training in gardening of selected youths with a view to their subsequent employment in the Council's parks department as " improvers " after two years training at the colony. This scheme contemplates that up to five youths will be accepted for such employment during each financial year. Four youths commenced work in the parks department under the scheme in 1931, and three more in 1932. During the year 1933 three additional youths commenced work in the Council's parks and six in 1934. Burrow Hill colony. 46 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 to the efficiency of the training at the colony. Only one appointment had to be terminated on account of the relapse of the patient. Following-up of discharged cases. Adults.-During the year investigations were made concerning the adult cases discharged from hospitals or sanatoria in 1928 ; the number investigated was 4,140, including 261 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 1927 cases:— Classification. Total. Percentage alive five years after discharge. Percentage dead. A 579 (505) 75.1 (73.5) 24.9 (26.5) B 1 187 (206) 65.7 (67.9) 34.3 (32.1) B 2 2,149(1,982) 34.6 (33.8) 65.4 (66.2) B 3 964 (972) 4.7 ( 6.1) 95.3 (93.9) Surgical 261 (246) 75.8 (73.9) 24.2 (26.1) Particulars obtained in 1933 as to the fitness for work of the 1,548 surviving adult patients who were discharged from treatment in 1928 show that out of a total of 558 A and B1 cases, 74.2 per cent, were at work. The corresponding percentage for the A and B1 cases in the 1927 group was 72.4. The percentages at work in the other categories and also the corresponding figures for the 1927 group (shown in brackets) are as follows :—B2, 54.3 (48.2) per cent. ; B3, 34.8 (21.7) per cent.; and surgical, 67.2 (72.5) per cent. Of the total number of 1,548 in all categories, 62.5 (58.9) per cent, were at work, 6.7 (6.2) per cent, were fit for work but were unemployed, 30.8 (34.9) per cent, were unable to work (including cases receiving further residential treatment). Children.—The particulars obtained as to the after histories of children discharged under 16 years of age in 1928 relate to 681, of whom 206 are pulmonary and 475 non-pulmonary. The mortality records are as follows, the figures in brackets referring to last year's enquiry into the 1927 cases :— Classification. Total. Percentage alive five years after discharge. Percentage dead. A 147 (143) 87.8 (91.6) 12.2 (8.4) B 1 1 (2) 100.0 (50.0) — (50.0) B 2 30 (18) 36.7 (33.3) 63.3 (66.7) B 3 28 (25) .- (-) 100 0 (100 0) Surgical 475 (521) 94.1 (94.4) 5.9 (5.6) 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 70 ( 69) 91.5 (85.5) 8.5 (14.5) Spine 41( 58) 92.7 (84.5) 7.3 (15.5) Other bones 108 ( 98) 95.4 (95.9) 4.6 ( 4.1) Glands 233 (271) 95.3 (97.8) 4.7 (2.2) Other parts 23 ( 25) 87.0 (100.0) 13.0 ( - ) Tuberculosis dispensary service. Of the 138 surviving pulmonary cases 48 were at school and 72 at work, and of 447 surviving non-pulmonary cases, 178 were at school and 176 at work. The tuberculosis dispensary service in London, while forming an integral part of the Council's tuberculosis scheme, is provided by the Metropolitan Borough Councils under conditions laid down by the Council. 47 An annual grant, based on actual expenditure approved by the Council for the year, was formerly made by the Council to the Metropolitan Borough Councils, subject to the dispensary service being carried out to the satisfaction of the Council. The grant, as nearly as possible, represented 25 per cent, of the actual net approved expenditure after deduction of the sum paid by the exchequer to the Metropolitan Borough Councils in compensation for loss of income arising from the withdrawal of " sanatorium benefit " for persons insured under the National Health Insurance Acts. The question of these grants was reviewed during 1933, and the Council, as from 1st April, 1933, substituted, for annual percentage grants based on actual expenditure, a system of fixed block grants in the form of annual payments of fixed amounts operating for periods of three years, based on examination of audited statements of actual expenditure during the triennium immediately preceding the commencement of each block grant period, together with a further statement of the amount of the probable expenditure by the Metropolitan Borough Councils during the ensuing grant period, and reasons for variations from previous expenditure. This arrangement does not include the City of London, which maintains its own dispensary at St. Bartholomew's hospital. There are now 34 dispensaries in all, including 3 branch dispensaries. Of these, 26 are ad hoc municipal dispensaries, and 8 (including 1 branch dispensary) are at voluntary hospitals or under voluntary management. This excludes the City of London dispensary at St. Bartholomew's hospital. In some cases a borough has two dispensaries, while in other cases a hospital dispensary serves 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 48 and 49. 48 ZD Tuberculosis Dispensaries.—Analysis of Returns, January-December, 1934. Metropolitan Borough. on dispensary rppister. 1—1—34. Transferred during 1934 from other areas and cases returned after discharge. Examined for first time during 1934. (a) New cases excluding contacts. (6) Contacts (printed in italics). Total number (including contacts) under dispensary supervision during 1934. Removed from dispensary register during 1934. On dispensary register 31-12-34. Visits to home for dispensary purposes by No. of specimens of sputum examined No.of X ray tions Definitely tubercular. Dlagnosis not confirmed. Pulmonary. Nonnulmonarv. Diagnosi not confirmed Nontuberculous. Total. (a) Recovered. (b) Non tubercular (printed in italics.) (a) Transferred to other areas or lost sight of (b) Died (printed In italics). Definitely tubercular Diagnosis not completed. Total attend ances. Adults Children. Adults Children. Adults Children. Adults. Children. Adults. Children. Tuberculosis officers Nurses or health visitors Battersea 883 82 34 147 5 8 9 42 23 162 102 359 139 1,706 62 102 828 105 3,577 290 4,200 536 123 6 4 88 111 94 115 514 95 933 Bermondsev 894 21 20 99 9 6 9 12 5 225 95 342 118 1,940 38 69 859 19 3,842 986 4,901 804 707 10 2 1 2 204 326 215 330 872 83 878 Bethnal Green 744 15 22 95 4 11 6 15 3 205 105 326 118 1,442 1 100 744 12 3,602 135 2,647 450 29c 2 2 4 4 83 122 89 128 524 61 756 Camberwell 1,666 30 64 143 5 15 13 9 1 337 95 504 114 3,074 10 148 1,663 17 6,087 424 9,009 1,718 577 45 4 5 1 4 3 297 337 351 345 1,096 140 1,680 Chelsea 325 3 35 60 3 7 7 1 — 232 109 300 119 952 23 76 313 2 2,387 59 3,375 283 508 1 4 3 2 1 58 101 61 109 503 35 315 Deptford 565 31 56 75 9 26 7 13 7 145 70 259 93 1,175 22 122 530 |33 2,800 242 3,898 675 184 2 3 7 5 67 87 76 95 388 SO 563 Finsbury 536 3 15 64 9 4 12 3 2 86 52 157 75 988 9 49 545 8 2,353 271 2,348 294 3e 6 18 1 2 55 120 62 140 327 50 553 Fulham 809 62 167 15 9 14 3 5 235 242 414 276 1,810 27 158 795 8 4,920 435 3,018 868 158 2 1 1 112 133 114 135 731 91 803 Greenwich 669 14 32 75 8 7 6 7 10 168 145 257 169 1,348 100 102 558 19 2,987 115 2,787 213 387 5 1 1 1 2 89 108 97 110 510 59 577 Hackney 1,317 16 84 176 17 11 13 16 7 372 171 575 208 2,626 34 203 1292 18 6,028 264 3,271 1,126 485 10 5 1 2 4 196 208 209 217 948 131 1,310 Hammersmith 713 2 76 128 4 15 6 1 160 40 303 51 1,541 30 93 758 1 3,103 371 4,147 501 141 21 3 1 5 192 174 214 182 568 91 759 Hampstead 226 7 23 47 2 6 3 2 2 75 22 130 29 486 27 166 203 1 1,140 20 1,033 82 9c 7 1 1 2 32 28 41 30 57 26 210 Holborn 238 2 | 6 37 1 2 2 1 12 6 51 9 350 18 25 232 - 930 70 1,207 126 39 8 7 21 14 29 15 55 20 232 Islington 1,287 8 77 280 12 39 21 - - 323 109 642 142 2,641 37 268 1,272 7 8,039 403 6,318 889 498 25 9 4 3 198 246 227 258 880 177 1,279 Kensington 742 27 55 141 2 18 21 15 14 171 69 345 106 1,662 5 101 785 29 1,968 134 1,926 405 73 O 1 186 200 187 200 653 89 814 Lambeth 1,605 95 59 278 8 22 20 57 9 343 62 700 99 3,229 38 265 1,489 88 7,279 913 5,001 1,108 1,393 30 8 2 1 47 15 320 248 399 272 1,188 161 1,577 Lewisham 965 2 73 139 5 18 7 21 2 138 41 316 55 1,639 84 87 947 3 2,847 356 3,638 277 91 1 2 87 138 89 139 426 92 950 Paddington 1,075 21 31 120 8 24 34 4 12 307 339 455 393 2,261 36 264 956 16 7,517 492 5,284 390 213 5 13 142 126 147 139 918 71 972 Poplar 864 20 25 136 12 16 17 7 2 277 184 436 215 2,144 64 70 850 12 6,373 370 7,030 840 298 13 2 2 4 2 1 283 281 298 286 1,042 106 862 St. Maryle- 516 14 18 106 4 7 4 4 6 64 30 181 44 873 5 114 476 37 2,616 113 2,175 184 40 bone 3 2 ll 10 32 42 46 54 177 64 513 St. Pancras ... 719 46 78 199 12 16 16 22 1 133 38 370 67 1,582 26 207 704 42 3,364 80 4,469 557 121 6 4 136 156 142 160 474 129 746 * Shoreditoh ... *685 27 46 90 9 10 13 7 4 232 161 339 187 1,587 18 85 673 19 4,298 184 2,891 953 198 2 3 1 3 5 144 145 149 154 707 85 692 South wark 603 24 57 183 6 16 17 26 13 73 15 298 51 1,377 19 150 641 46 3,130 346 3,430 550 103 15 2 1 7 167 152 183 161 410 111 687 Stepney 1,776 135 76 255 20 19 26 43 36 222 101 539 183 3,289 58 149 1,814 138 6,738 193 6,026 726 222 3 2 15 11 227 322 245 335 958 172 1,952 Stoke 211 4 30 54 2 3 2 5 1 80 24 142 29 542 6 35 235 7 1,321 94 1,608 351 66 Newington 1 1 78 46 SO 46 229 30 242 Wandsworth 1,347 47 111 261 10 25 13 36 — 361 210 683 233 2,776 87 144 1,371 38 4,706 775 3,772 1,467 182 5 1 1 162 186 168 187 966 170 1,409 Westminster 657 2 28 244 3 19 23 1 — 61 34 325 60 1,181 15 170 688 3 2,615 67 3,526 193 78 2 5 8 2 - 41 51 45 64 242 63 691 Woolwich 892 5 7 228 14 26 26 1 - 277 162 532 202 2,115 52 68 968 1 4,833 457 4,654 538 411 15 6 1 1 226 228 242 235 914 112 969 Total 23,529 703 1,300 4.027 218 405 367 372 166 5,476 2,833 10,280 3,584 48,336 951 3,590 23,189 735 111400 8,660 107589 17,104 7,714 239 85 13 42 124 78 3,923 4,436 4,299 4,641 17,277 2,594 23,924 * Figure amended by Borough Council since completion of return in 1933. 50 The following is a summary, for purposes of comparison, of certain sections of the foregoing table:— Metropolitan borough Deaths from tuberculosis. Number of examinations per 100 deaths from tuberculosis in borough. Total attendances per case on register Tuberculosis officers' visits per case on register Total consultations per case on register Nurses' visits per case on register Number of definitely tubercular persons on dispensary register per lou deaths from tuber culosis in borough. X-ray examinations Actual Per 1,000 inhabitants New cases. Contacts per 100 new cases and contacts per 100 new cases Adults Children Battersea 132 .87 377 71 87 3.8 .31 .34 4.5 627 17.4 24.7 Bermondsey 105 1.00 438 204 314 4.4 112 .41 5.6 818 70.3 153.7 Bethnal Green 81 .80 548 109 158 4.8 .17 .32 3.5 918 43.9 65.3 Camberwell 231 .97 287 151 149 3.6 .25 .37 5.4 719 43.9 93.4 Chelsea 43 .74 974 141 253 7.6 .19 .32 10.7 727 86.4 121.5 Deptford 102 1.01 345 74 93 5.0 .43 .18 6.9 519 35.2 52.3 Finsbury 63 .97 368 98 222 4.3 .49 .38 4.2 865 8.3 15.5 Fuiham 133 .91 518 85 101 6.1 .54 1.17 3.8 597 16.9 23.0 Greenwich 85 .87 501 114 129 5.2 .19 .48 4.8 656 61.1 90.8 Hackney 180 .85 435 116 120 4.6 .20 .65 2.5 717 40.1 61..9 Hammersmith 124 .96 285 172 146 4.1 .49 1.00 5.5 611 18.8 39.8 Hampstead 59 .66 269 69 50 5.4 .09 .51 4.9 344 39.1 56.6 Holborn 32 .89 187 90 46 4.0 .30 .55 5.2 725 37.5 65.0 Islington 281 .91 279 80 91 6.3 .32 .45 4.9 452 39.2 63.5 Kensington 118 .66 382 158 169 2.4 .16 .45 2.4 665 8.7 16.2 Lambeth 267 .94 299 149 101 4.6 .58 1.31 3.2 557 94.8 174.3 Lewisham 142 .64 261 62 97 3.0 .37 .47 3.8 666 J 5.2 24.5 Paddington 97 .70 874 151 143 7.7 .51 .29 5.4 985 18.8 25.1 Poplar 133 .91 489 224 215 7.4 .43 .39 8.2 639 24.1 45.8 St. Marylebone 68 .73 330 67 79 5.1 .22 .23 3.2 700 12..3 17.8 St. Pancras 173 .92 252 82 92 4.5 .11 .28 6.0 406 16.4 27.7 Shoreditch 94 1.04 559 158 163 6.2 .27 .22 4..2 715 23.9 37.6 Southwark 160 1 00 218 114 100 4.6 .50 .37 5.0 400 14.9 29.5 Stepney 208 .97 347 117 161 3.5 .10 .16 3.1 872 17.1 30.7 Stoke Newington 42 .83 407 190 109 5.5 .39 1.64 6.6 559 22.2 38.6 Wandsworth 274 .80 334 61 68 3.3 .55 1.28 2.7 500 14.3 19.9 Westminster 98 .79 392 45 65 3.8 .10 .60 5.1 702 15.8 20.3 Woolwich 146 1.00 502 165 160 5.0 .47 1 .27 4.8 663 33.9 56.0 Average 3,671 .87 377 117 126 4.7 .36 .59 4.5 631 33.8 55.6 Tuberculosis contact scheme. The tuberculosis contact scheme was put into operation on 1st April, 1925, and provides :— (a) for the removal of children from heavily infected and overcrowded homes occupied by a member of the family suffering from advanced tuberculosis. (b) 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 Invalid Children's Aid Association, who secure suitable homes, make all arrangements for the admission and discharge of children referred to them by the county medical officer of health, and keep them under supervision during the time they are boarded out. The Association also arrange for the homes to be periodically inspected. The scheme continued to operate satisfactorily during 1934 with the co-operation of the Association. There were 175 applications during 1934, concerning 297 children, of whom 246 were accepted, the remaining 51 being withdrawn or regarded as unsuitable. At the end of the year 140 children were being maintained under this scheme. The total number of children dealt with (246) is an increase over that for the previous year (209). The number still being cared for at the end of the year (140) is 33 in excess of the previous year's figure. 51 The subjoined report on tuberculosis " contacts" has been submitted bj Dr. F. J. Bentley, divisional medical officer. Report by Dr. F. J. Bentley on " contact " investigation Towards the end of 1932 it was thought it might be of interest to ascertain the proportion of cases of tuberculosis in which there had been known intimate association with a previous case of the disease. The metropolitan borough medical officers of health and the tuberculosis officers agreed that such an investigation should be undertaken, and promised their help. It was arranged that careful enquiry should be made in each new case to be recommended for residential treatment as to details of contact with previous cases of the disease. It was considered advisable generally to ascertain contact only within the intimate family circle, and so avoid the investigation becoming too diffuse. It was proposed, therefore, to concentrate on the following two categories, which it was thought would yield the most accurate data : (1) where a previously affected member of the immediate family was alive and suffering from either pulmonary or nonpulmonary tuberculosis ; and (2) where a death had occurred from pulmonary tuberculosis in the immediate family within the preceding five years. It was thought that in the first category there would be no difficulty in ascertaining whether the tuberculous relative was suffering from pulmonary or non-pulmonary disease, and, if the former, whether class T.B. plus or minus. In the second category it was not proposed to sub-divide into positive and negative. It was realised that association with the disease not falling within either of the above two categories might also be known; such as, for instance, a definitely known death from non-pulmonary tuberculosis within the preceding five years, or a death in the family from either pulmonary or non-pulmonary disease more remote than five years, or a more distant relative or even a lodger living with the family suffering from tuberculosis who might have been in close association with the patient. Whilst it was considered difficult to evaluate such association, tuberculosis officers considering any such of importance were invited to make a note accordingly. Contact otherwise outside the family circle was not to be specially enquired into, as here again it was considered advisable not to make the field too wide. Only primary applications for treatment arising directly from tuberculosis dispensaries have been included. Information is now available on the first 2,555 cases investigated. Of these, it was noted that in 1,793 cases there was " no known contact " with a previous case of the disease, leaving 762 cases or approximately 30 per cent, who exhibited contact of some sort. Details of only 159 surgical cases are as yet to hand, as the period of treatment in such cases is usually long and the classification is only completed on discharge from residential treatment. These are therefore excluded. In addition to these, it is proposed to exclude also from further consideration in the present report 260 female and 232 male pulmonary cases in which tubercle bacilli had never been demonstrated. There are thus left 1,904 T.B. plus cases, of which 1,157 were males and 747 were females. Tables I and II show the details of the findings in males and females, respectively. Where the relationship of the previous case occurring in the family has not been either that of parent, husband or wife, child, or brother or sister, they have been grouped together under the term " other contact." This term, therefore, includes any other intimate contact as mentioned previously and noted as important by a tuberculosis officer. " Other contacts " have not been sub-divided as to their clinical classifications. The frequency with which contact with a previous case is noted, is seen to diminish with increasing age ; thus, in class T.B. plus cases, whilst 15 per cent, of all males show previous important contact with the disease in the intimate family circle, the percentage ranges from 22 per cent, in the 16-20 year group down to 10 per cent, in those over 40 years of age. As age advances a similar diminution in the importance of contact with a previous case is seen in females. There is a difference, however, in that the scale in females is generally at a higher level, as approximately a quarter of all female T.B. plus cases investigated had been in intimate contact with a previous case of the disease in the family, the percentage showing contact ranging from 36 per cent, in the 0-15 year group down to 20 per cent, in those over 40 years of age. It is interesting to speculate on the reasons underlying the greater incidence of contact in females than in males. One explanation that would appear to be reasonable is that females are naturally more exposed to infection in the family by reason of their domestic and nursing duties. Another factor that must have a bearing is that of kissing. As regards the relationship of what may be called the " infecting " case, it is seen that in males 58 per cent, were brothers or sisters as against 47 per cent, amongst females, whilst parents were the " infecting " cases in 17 per cent, of males, as against 30 per cent, in females. The inverted commas are used because the facts given herewith are not by themselves considered conclusive of direct infection. Family predisposition, for instance, may be important in some cases. A tuberculous parent, then, would seem to be a greater danger to a daughter than to a son, and here again the reason may be the special position of women in the household in regard to nursing and domestic matters and the like. It will be seen that 12 per cent, of males and 13 per cent, of females who showed contact with a previous case in the family were marital contacts. A previous case of tuberculosis in a child, when dealing with a " new " case in an adult, immediately raises the suspicion that the primary case was in reality the adult; and it is probable that the 18 instances in " new " female cases and the 23 instances in males, where a child in the 52 family was previously known to be suffering from the disease, were mostly examples of this nature. Considering now the type of disease in the original case, it will be seen that nearly threequarters of the infecting ' cases are either living cases of pulmonary tuberculosis with positive sputum or cases which have succumbed to pulmonary tuberculosis within the immediately preceding five years. It is known that over 90 per cent, of pulmonary tuberculosis deaths five years after residential treatment are T.B. plus cases. It might almost be said, therefore, that where previous contact with the disease is found, in almost three-quarters of such instances the primary case was a positive sputum sufferer in the family either alive or only recently dead. It may be of interest to note finally that, where there is previous tuberculosis in the family, in 28 per cent, of instances there were two or more " original " cases of the disease ; or, in other words, there was more than one contact in over one-quarter of the cases in which important contact was noted. The following conclusions may be drawn from this investigation:— (1) Contact with a previously diagnosed case of tuberculosis in the family is of sufficiently common occurrence in the history of new patients to stimulate examination of contacts in the attempt to find early cases. (2) Thus in the age groups 16 to 30, 22 per cent, of new male positive sputum cases and 27 per cent, of similar female cases arise from families in which there has been a recent previously known case in parent, husband or wife, brother or sister, or child. (3) Approximately three-quarters of such previously known cases are themselves sufferers with positive sputum disease. (4) Every effort therefore should be made to examine and supervise, over a considerable period of time, contacts, especially young adult contacts, of living positive sputum cases or of those recently dead from the disease. TABLE I. Males. Class T.B. plus. Relationship. Previously known case, Age group of new cases. Total. Clinical classification. 0-15. 16-20. 21-25. 26-30. 31-40. Over 40. No. Percent age. Parent. Pulm. tub. class T.B. + living — 3 8 1 — — 12 — Pulm. tub. class T.B. — living — — — 1 — — 1 — Pulm. tub. (condition of sputum Known) living — — 1 1 — — 2 — Non-pulm. tub. living — — — — 1 1 2 — Non-pulm. tub., dead within last 5 years — 1 1 — — 2 — Pulm. tub., dead within last 5 years — 3 6 1 1 — 11 — Total — 7 15 5 2 1 30 17.2 Wife. Pulm. tub. class T.B. +, living — — — 1 1 9 11 — Pulm. tub. class T.B. —, living — — 1 — — 1 2 — Pulm. tub., dead within last 5 years — — — 1 3 4 8 — Total — — 1 2 4 14 21 12.1 Child. Pulm. tub. class T.B. +, living — — — — 1 6 7 — Pulm. tub. class T.B. —, living — — — — 1 2 3 — Pulm. tub. (condition of sputum unknown), living — — — — 1 5 6 — Non-pulm. tub., living — — — — 2 — 2 — Non-pulm. tub., dead within last 5 years — — 1 — 2 — 3 — Pulm. tub., dead within last 5 years — — — 1 — I 2 — Total — — 1 1 7 14 23 13.2 Brother or sister. Pulm. tub. class T.B. +, living — 5 20 7 7 5 44 — Pulm. tub. class T.B. —, living — 1 1 4 1 — 7 — Pulm. tub. (condition of sputum unknown), living — — — 2 2 2 6 — Non-pulm. tub., living — 2 1 2 1 1 7 — Non-pulm. tub., dead within last 5 vears — 3 1 1 — — 5 — Pulm. tub., dead within last 5 years — 3 11 3 5 9 31 — Total — 14 34 19 16 17 100 57.5 53 Previously known case. Age group of new cases. Total. Relationship. Clinical classification. 0-15. 16-20. 21-25. 26-30. 31-40. Over 40. No. Percent age. Total relatives as above. Pulm. tub. class T.B. +, living 8 28 9 9 20 74 42.5 Pulm. tub. class T.B. —, living 1 2 5 2 3 13 7.5 Pulm. tub. (condition of sputum unknown), living — — 1 3 3 7 14 8.0 Non.pulm. tub., living — 2 1 2 4 2 11 6.3 Non.pulm. tub., dead within last 5 years — 4 2 2 2 — 10 5.7 Pulm. tub., dead within last 5 years — 6 17 6 9 14 52 300 Total — 21 51 27 29 46 174 1000 Other contacts 3 6 15 13 25 46 108 — No known contact 2 67 145 114 201 346 875 — Total number investigated 5 94 211 154 255 438 1,157 — Percentage showing important contact — 22.3 24.2 17.5 11.4 10.5 — 150 Percentage showing any contact 60 28.7 310 26.5 21.8 20.6 — 24.4 TABLE II. Females. Class T.B. plus. Parent. Pulm. tub. class T.B. .+, living 3 4 6 2 1 .1 16 — Pulm. tub. class T.B. —, living — 1 3 — — . 4 — Pulm. tub. (condition of sputum unknown), living — — — — — 1 I — Non-pulm. tub., living — 1 1 — — — 2 — Pulm. tub., dead within last 5 years 1 14 10 1 4 2 32 — Total 4 20 20 3 5 3 55 30.2 Husband. Pulm. tub. class T.B. + , living — — 1 6 2 3 12 — Pulm. tub. Class T.B. —, living — — — — — 1 1 — Non-pulm. tub., dead within last 5 vears — — — — 1 — 1 — Pulm. tub., dead within last 5 years — — 1 5 2 2 10 — Total — - 2 11 5 6 24 13.2 Child. Pulm. tub. class T.B. living — — 1 — 3 3 7 — Pulm. tub. class T.B. —, living — — — — — 3 3 — Non-pulm. tub., living — — 1 2 1 — 4 — Pulm. tub., dead within last 5 years — 1 •— 1 1 1 4 — Total — 1 2 3 5 7 18 9.9 Brother or sister. Pulm. tub. class T.B. -f, living 1 6 8 8 5 1 29 — Pulm. tub. class T.B-, living — 4 4 3 — 2 13 — 1 Pulm. tub. (condition of sputum unknown), living — — 3 1 4 9 — Non-pulm. tub., living — 3 2 3 — — 8 — Non-pulm. tub., dead within last 5 vears — — 2 — — — 2 — Pulm. tub., dead within last 5 years — 6 5 9 4 — 24 — Total 1 19 24 24 13 4 85 46.7 Total relatives as above. Pulm. tub. class T.B. +, living 4 10 16 16 11 7 64 35.2 Pulm. tub. class T.B. —, living — 5 7 3 — 6 21 11.5 10 5.5 Pulm. tub (condition of sputum unknown), living — — 3 1 4 2 Non-pulm. tub., living — 4 4 5 1 — 14 7.7 Non-pulm. tub., dead within last 5 vears — — 2 — 1 — 3 1.6 Pulm. tub., dead within last 5 years 1 21 16 16 11 5 70 38.5 Total 5 40 48 41 28 20 182 100.0 Other contacts 1 13 12 15 24 19 84 — No known contact 8 79 127 103 101 63 481 — Total number investigated 14 132 187 159 153 102 747 — Percentage showing important contact 35.7 30.3 25.7 25.8 18.3 19.6 — 24.4 Percentage showing any contact 42.8 40.2 32.1 35.2 34.0 38.2 — 34.3 54 Supply ot surgical appliaucea. Arrangements were also made through the Invalid Children's Aid Association for assisting in providing children with surgical appliances after discharge from institutional treatment; such assistance was given in 70 cases. The Council's contribution 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 have been paid into the County Fund and, even so, since July, 1934, only voluntary contributions have been received. The balance of the fund is, however, being applied as indicated above. Open-air schools. In addition to the arrangements for residential treatment of tuberculous children, the Council has established six open-air day schools with accommodation for 515 children (allowing for a nominal roll of 618) suffering 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. III, Part II, p. 51). Tuberculosis care committee work. In each metropolitan borough there is a tuberculosis care committee or other organisation appointed or provided by the Metropolitan Borough Council for various welfare purposes, working in association with the tuberculosis dispensaries. The decision of the Council of 10th July, 1934, to grant free residential treatment for all cases of tuberculosis treated under the Council's scheme has caused considerable change in the work of the care committees. They no longer have to assess the weekly amounts that patients or their families should pay towards the cost of treatment. Voluntary contributions are, however, accepted from persons who feel they would like to make a payment and can afford to do so. The care committees are still required to make some assessments, but only towards the cost of dentures and spectacles supplied by the Council to patients undergoing treatment. The work of the committees has not been appreciably reduced because their principal concern has always been, and still is, with those cases that are necessitous and require help in some form. Previously, assessed cases only amounted to 28 per cent, of the total number of patients sent to residential institutions under the scheme. There has been increased activity amongst certain care committees in the raising of funds from voluntary sources. Several committees have successfully availed themselves of the scheme organised by the National Association for the Prevention of Tuberculosis for raising money by the sale of Christmas seals. Handicraft classes. The work of the handicraft classes has been carried on and excellent work has been done. On 24th and 25th October an exhibition and sale of the work of 13 classes was held at the Carpenter's Hall. The exhibition was opened on the first day by the Lord Mayor, and on the second day by the Chairman of the Council. Great variety and a high standard of craft work were displayed and the sales amounted to £195. In several boroughs exhibitions and sales by individual boroughs were also held during the autumn with good results. The only new activity that has been developed by the care committees since the last report has been the starting of cookery classes in two boroughs (Deptford and Woolwich). These are held at the dispensaries chiefly for the wives and mothers of patients to teach them how to do inexpensive invalid cookery and how to obtain the highest nutritive value from the cheapest foods. The classes appear to be popular and the care committees concerned are greatly encouraged by finding that the cookery taught is really being carried out in some of the homes of tuberculous patients. The two classes that have been started are likely, to be permanent except during the summer 55 Mental Deficiency Acts, 1913-27. On 31st December, 1934, there were being dealt with by the Council 9,945 cases. Of these 6,355 were in institutions, 214 under guardianship, 3,359 under supervision and 17 in places of safety awaiting action. Cases dealt with by the Council. During the year 1,003 cases were examined with the following results :— Sex Source of notification. Feeble minded Imbecile Idiot Morallydefective Not defective Total Children Adults Children Adults Children Adults Children Adults Children Adults Children Adults Mental hospitals department, etc. 34 31 82 6 8 3 — — 4 8 128 48 Special school leavers 227 — — — — — — — — — 227 — Male Public assistance 3 16 1 8 2 — — — 1 10 7 34 Casual wards — 9 — — — — — — — 32 — 34 General hospitals 5 5 3 1 1 — — — 2 3 11 9 Sections 8 & 9 of M.D. Acts 15 48 1 — — — — — — 3 16 51 Mental hospitals department, etc. 27 50 55 5 8 1 — — 3 6 93 62 Special school leavers 108 — — — — — — — 2 — 170 — Female Public assistance 3 25 1 8 — — — — 1 9 5 42 Casual wards — — — — — — — — — — — — General hospitals 5 16 3 2 — 1 — — 5 4 13 23 Sections 8 & 9 of M.D. Acts 5 17 — 2 — — — — — 6 5 25 492 210 146 32 19 5 — — 18 81 675 328 Total 702 178 24 — 99 1,003 During the year, nine visits were paid to casual wards. The total number of cases inspected was 132. Of these 34 were examined in detail, and the number deemed to be feeble-minded was 2. Casual wards. During the year 1934 assistant medical officers visited occupation centres on 19 sessions and in the course of these visits made complete examinations of 72 children between the ages of 8 and 16 years. During the same period school nurses visited centres on 74 other occasions for the purpose of carrying out personal hygiene examinations. Medical inspection of children at occupation centres. The following defects which required treatment or observation were reported : teeth, 28 ; nose and throat, 3 ; eye disease, including squint, 10 ; ear disease, 1 ; other defects, 14. The parents have been given facilities for obtaining treatment for these defects under the Council's scheme for the treatment of school children. Twenty-two cases previously noted for treatment have been re-inspected during the year and it is reported that seven children have received satisfactory treatment; three cases were reported to have cleared up naturally ; two cases were referred for observation; and the remaining 10 cases have received no treatment. The parents of two-thirds of the children inspected were present at the time of the medical examinations. There appears to have been no undue amount of disease or defect among the children examined, and in clothing, footgear, nutrition, cleanliness of skin and head they were again up to the standard of elementary school children. 56 Blind persons. Blind Persons Act, 1920. The following table contains particulars of applicants for registration or training under the provisions of the Blind Persons Act, 1920 :— Description. Registration of the blind. Training of the blind. Total. M. F. M. F (1) Applicants who were examined and were certified as blind 429 507 25 6 967 (2) Acceptance of certificates issued by hospital and private doctors... 43 44 — — 87 (3) Acceptance of certificates issued by hospital and private doctors stating applicants were not certifiable as blind 2 — — — 2 (4) Applicants who were examined and not certified as blind 128 164 13 8 313 (5) Found blind but unfit for training — — — 2* 2* (6) Previously certified as blind and found fit for training — — 10 6 16 (7) Previously certified as blind and found unfit for training — — 2 — 2 Total 602 715 50 22 1,389 * Included in (1) above. New form of certificate. On 5th October, 1933, the Ministry of Health issued a circular (No. 1353) recommending the adoption throughout England and Wales of a new form of certificate for use in connection with the registration and certification of blind persons under the provisions of the Blind Persons Act, 1920. The Ministry also requested that a copy of each certificate of blindness should be sent for research purposes to the Committee for the Prevention of Blindness. The new form of certificate has been in use since 1st January, 1934, and copies of certificates relating to blind persons are now sent periodically to the Prevention of Blindness Committee. Midwives Acts, 1902 to 1926, Nursing Homes Registration Act, 1927, and Maternity and Child Welfare Contribution Schemes. Midwives The Midwives Acts, 1902-1926, and the Rules of the Central Midwives Board regulating the practice of midwives provide for :— (a) Prevention of the practice of midwifery by unauthorised persons. (b) Training of midwives. (The Council's scheme of training includes, apart from the full training provided in certain of the hospitals, (i) lectures to pupil midwives throughout London on the Rules of the Board, etc., and on venereal diseases to certain of them ; (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 the annual deficit incurred by Central Midwives Board. The eleventh edition of the rules in section E (regulating, supervising, and restricting within due limits, the practice of midwives) of the Rules of the Central Midwives Board came into force on 1st October, 1934. The Board's memorandum on the new edition states that in preparing a fresh edition of section E, the Board had regard, not only to the inclusion of necessary 57 new matter and the deletion of matter which no longer required special mention, but also to the rearrangement of the order of the rules, and to redrafting them. In the Board's opinion, this step had become necessary owing to the fact that past additions to and subtractions from the original framing of the rules had resulted in loss of symmetry and clarity. The memorandum, which explains the alterations in the rules, and a copy of the new edition of section E, were sent by the Council in August, 1934, to each midwife on the list of midwives practising in the County, and the Council called attention to the responsibility of every midwife to make herself acquainted with the new rules. Certified midwives to the number of 904 gave notice of intention to practise within the county during the year, compared with 854 in 1933. 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 ; 2,421 visits were paid this year compared with 2,623 in 1933. Infringements of the Rules of the Central Midwives Board to the number of 42 were reported during the year, compared with 51 in 1933. Of these 37 were slight, and a verbal caution was deemed to be sufficient; 4 cases of a more serious nature were dealt with by a written caution, and one midwife was interviewed and cautioned bv the Committee. The Midwives Act, 1926, requires that, in the case of midwives suspended from practice in order to prevent the spread of infection, the local supervising authority must compensate such midwife for loss of practice by the payment of such amount as is reasonable in the circumstances of the case, provided that the midwife was not herself in default; 18 midwives were suspended from practice during the year in order to prevent the spread of infection, and 12 claimed compensation which was authorised. Suspension of midwives. 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 6 enquiries were made into such cases, compared with 7 in 1933. In 3 cases a caution was administered; in 3 cases no further action was considered necessary. Uncertified persons. During the year there were 274 still-births reported to the Council by midwives in their practice, compared with 594 in 1924, 510 in 1925, 513 in 1926, 486 in 1927, 473 in 1928, 413 in 1929, 408 in 1930, 363 in 1931, 324 in 1932 and 316 in 1933. Of the cases reported this year 145 were male, 128 female and in one case the sex was not stated ; 158 were reported as macerated, and 116 not macerated. Still-births. During the year 257 cases ot puerperal tever were investigated, compared with 259 in 1933. Of these cases 33 proved fatal, compared with 41 in 1933, a case mortality of 12.8 per cent., compared with 15.8 per cent, in 1933. The distribution of notified cases, with the mode of delivery, was as follows, deaths being shown in brackets :—Medical practitioners 62 (7); certified midwives 66 (8); hospitals and certified midwives 2 (1); hospitals and poor-law institutions 79 (13); medical students 10 (0) ; cases of miscarriage or abortion where no attendant was eneased 38 (4)—Total 257 (33). Puerperal fever. 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." Puerperal Pyrexia. 53 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 1934 was 746, compared with 851 in 1933. The cases were distributed as follows, the deaths being shown in brackets:—Medical practitioners 81 (7); certified midwives 94 (5); hospitals and certified midwives 3 (1); hospitals and poor-law institutions 516 (15); medical students 13 (0); cases of miscarriage or abortion where no attendant was engaged 39 (2)—Total 746 (30). Fifty-eight of the cases, with 7 deaths, were subsequently notified as puerperal fever, and are therefore shown in both tables. Medical aid. The Rules of the Central Midwives Board indicate the emergencies for which a midwife must advise in writing that medical aid be obtained, and for which such help must be secured. A notice in the approved form is sent to the doctor, and to the Council. In the year now under review 5,362 such notices were received, compared with 5,405 in 1933. The estimated number of confinements conducted by midwives in independent practice during the year was 20,180. This appears to indicate that medical aid was necessary in about 26.6 per cent, of the cases, compared with 25-8 per cent, during 1933. 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 claims for attending cases of eye affection during the year was 583 and the amount paid to medical practitioners in respect of the cases was £525 compared with £624 in 1933. Inflammation of the eyes— Notices. During the year 955 notices were received from midwives indicating that medical aid had been summoned for inflammation of the eyes of infants, compared with 1,052 in 1933 ; 23 other cases arose in which either medical aid was not called in by the midwife or she failed to notify the Council that she had done so. Of these 978 cases, 230 proved to be ophthalmia neonatorum, compared with 270 in 1933 ; 242 other cases that did not occur in midwives' practices were also notified, making a grand total of 472 cases during the year, the percentage occurring in the practice of midwives being 48.7 per cent., compared with 50.9 per cent, in 1933. All the midwives' cases were investigated, and it was found that 228 were completely cured ; 2 cases could not be traced owing to the removal of the parents. Forty-six cases became in-natients at St. Margaret's hospital, compared with 36 during 1933. Pemphigus neonatorum During the year 24 cases of pemphigus neonatorum occurred in the practice of midwives, compared with 37 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. 59 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, which are held at the County Hall. 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 numbered 755, compared with 701 in 1933. 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. Maternal mortality. 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. Payment of medical fees. Claims accepted during the year numbered 3,119, compared with 3,172 in 1933, the total amount involved being £3,625, compared with £3,729 in 1933. 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, 42 claims amounting to £52 5s. 6d. were refused during 1934. 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. III, pp. 53-54) indicates fully the powers of the Council under the Act. Registration of nursing homes. A nursing home is defined as " any premises used or intended to be used for the reception of, and the providing of nursing for, persons suffering from any sickness, injury or infirmity and includes a maternity home." The definition of a maternity home is " any premises used or intended to be used for the reception of pregnant women or of women immediately after childbirth." Consequently such premises require registration as a maternity home even though the women go to some other place for the actual confinement. The number of nursing homes on the register on 1st January, 1934, was 224. During the year 1934, 11 homes were added, of which 4 had applied during 1933, and 1 in 1932, while 24 were removed on cancellation of the registration, leaving 211 on the register on 31st December, 1934. With one exception cancellations were made at the request of the persons registered and/or upon change of ownership. During the year the keeper of a nursing home was prosecuted for infringements of the Council's by-laws in respect of the keeping of registers and receipt books. The defendant gave an undertaking to observe the by-laws and the summons was adjourned sine die on payment of £5 5s. costs to the Council. There were 18 applications for registration during the year, of which, at the end of the year, 2 had been withdrawn and 6 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. III, Part I, pp. 53-54). In 1934 the Council granted 112 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, 1935, 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. Improvement in the cleanliness, general orderliness and in the staff of homes has continued. Some of the older homes have closed or have changed ownership. Upon change of ownership the new owners were required to fulfil the requirements for a " new " home. 60 The first Maternity and Child Welfare Contributions (London) Scheme which was made by the Minister of Health under section 101 (6) of the Local Government Act, 1929, continued in force from 1st April, 1930, to 31st March, 1933, subject to alterations made by the Minister of Health under section 131 (2) of that Act, and fixed the amounts of the grants to be paid by the Council to the maternity and childwelfare associations named in the first schedule to the scheme. 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 block grants payable by the Ministry of Health to the Councils concerned. The Maternity and Child Welfare Contributions (London) Schemes, 1930 and 1932, made by the Minister, covered the grant period which expired on 31st March, 1933, The Maternity and Child Welfare Contributions (London) Schemes, 1933 and 1934, for the four years from 1st April, 1933 to 31st March, 1937, provide for payment by the Council of grants in each of the financial years 1933-34, 1934-35, 1935-36, 1936-37, to fifty voluntary associations. The current schemes provide for payment by the Council of grants amounting to £31,227 in the year 1934-35. The grants are 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 tims by the Council's officers. This work is performed by the medical staff engaged 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. During the year 1934 (i) two homes under the control of one association were amalgamated, and the mother and baby home service is now being conducted at new premises ; and (ii) one mother and baby home service was transferred from London to premises at Brighton. Increases in the amount of grants to one mother and baby home and to one baby home were sanctioned by the Minister of Health. Examination of Staff. During the year 9,271 examinations, including 308 home visits, were made of members of the staff. These may be classified as follows :— Entrants 1,587 Sickness cases 6,959* Casualties, illness, etc., at County Hall 725 * 1,587 of these were dealt with in the first instance by telephone and correspondence. Fifty-six applicants for appointment to the permanent service failed to the medical examination for the following reasons :—- Males. Females. Total. Defective hearing and ear diseases 2 4 6 Defective vision and eye diseases 12 8 20 Poor physique and deformities 5 5 10 Cardio-vascular disease 4 1 5 Varicose veins 1 2 3 Rheumatism — 1 1 Kidney disease, albuminuria, &c. 3 1 4 Tuberculosis and lung diseases 2 — 2 Functional nervous disorders — 2 2 †Miscellaneous — 3 3 Total 29 27 56 | Two cases of thyroid tumour and one of recurring tonsillitis. 61 As a result of the examinations of the staff, 452 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 57 66 123 Diseases of the bones and joints 29 36 65 Disability following trauma 4 1 5 Pulmonary tuberculosis 27 28 55 Diseases of the lungs other than pulmonary tuberculosis 18 13 31 Malignant disease 7 4 11 Gastro-intestinal disorders 5 2 7 Renal disease 4 2 6 Functional nervous disorders 21 28 49 Organic nervous disorders 12 6 18 Senile decay 8 15 23 Post-operative disability 2 4 6 Sight and hearing defects 9 16 25 Endocrine disorders 1 4 5 Varicose veins and ulceration 2 8 10 'Miscellaneous 2 11 13 Total 208 244 452 * One case each of goitre, abnormal infectivity, diabetes, actinomycosis, hernia and leukaemia; two cases each of continued pyrexia and general debility, and three cases of dermatitis. Work done in the bacteriological laboratory at County Hall. The investigations carried out during the year 1934 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 also to the Council's chemist for analysis. Diphtheria carrier investigation (see also Annual Report Vol. III, Pt. II, p. 40).— 5,883 specimens were examined, of which 372 yielded positive morphological K.L.B.; of 670 cultures submitted to animal test, 296 were virulent, 46 avirulent and 328 negative. Ringworm and favus.—634 specimens of hair of the head were examined. Ringworm fungus was identified in 206 (142 small spore, 64 large spore), including one case showing also large spore ringworm of body. Favus was identified in two specimens. Hcemolytic streptococcus carriers.—(a) puerperal fever contacts—25 specimens were examined (10 positive, 15 negative). (6) presumed contacts of scarlet fever—6 specimens were examined (1 positive and 5 negative). Sputum examinations.—46 specimens were examined, tubercle bacilli being found in 24. Urine.—4 specimens were examined, 3 from one case yielding tubercle bacilli. Discharges.—Urethral or vaginal.—15 specimens were examined, none proved positive for gonococci, but 5 were reported doubtful. Water (a) from Council's institutions, schools, etc.—375 samples were examined, 63 being not satisfactory in all respects and 312 normal. (b) from swimming baths—33 samples were examined from 5 baths. Milk.—40 samples were examined, 29 being reported unsatisfactory. Work of the chemical branch. The work of the chemical branch is carried out at three laboratories, viz., the central laboratory at County Hall, and the laboratories at the northern and southern outfall works. The work done at the central laboratory consists mainly of the chemical examination of materials of all kinds bought by the Council, for use in its numerous institutions or for its other activities. The greater portion of these are materials supplied Central laboratory. 62 under contract to the Council's specifications, where chemical analysis is essential to ensure that the quality of the goods delivered is equal to that specified. In addition, analysis is made of samples of air, foods, etc., 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 Act, 1928, 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 in connection with the various branches of the Council's work. Examination of samples. The total number of samples examined in 1934 amounted to 9,873. The following table shows their classification :— Air (from tunnels) 299 Asphalt 45 Building materials 101 Calculi 22 Coal, coke and ash 43 Cement 254 Chemicals 18 Disinfectants 19 Driers 31 Drugs and medical stores 864 Dust (atmospheric pollution) 60 Enamelware 236 Fertilisers and feeding stuffs 255 Floor oils and polishes 37 Food (suspected poisoning) 40 Foods— Bacon 49 Baking and egg substitute powders54 Beef extraots 100 Cakes, biscuits, bread 90 Cereals 13 Cheese 54 Cocoa 14 Dripping 10 Flavouring essences 24 Fish 131 Fish, tinned 15 Flour 72 Jam 10 Margarine 111 Miscellaneous foodstuffs 70 Mustard 9 Pickles 19 Preserved meats 84 Sugar 101 Syrup and treacle 32 Vinegar 37 Yeast 34 — 1,133 Gas-—Dry cleaners 61 Greases 13 Hospital equipment 38 Ink 20 Insecticides 25 Lamps, Gas detector 53 Meals 42 Metals— Solder 13 28 Various 15 Milk, condensed 10 „ schools and institutions 249 „ (cream) tinned 2 Oils- Fuel 8 Lighting 27 Lubricating 127 Painting 28 Miscellaneous 17 Oilman's sundries 19 Paints, stains 622 Petroleum (Petroleum Act, 1928) 80 Rainwater, etc. (atmospheric pollution) 108 Rubber 22 Sewage 56 Soap and soap powders 84 Sulphur determinations (air) 1,706 Turpentine and turpentine substitute 31 Urine 1,453 Varnish 30 Water, boiler 697 „ river 412 „ drinking (from wells) 200 „ and deposit (in leakage) 16 „ various 6 „ open-air baths 32 Miscellaneous 94 Of 652 paints, colours and varnishes examined, 542 were found to be satisfactory, 50 were of satisfactory composition but unsuitable for the particular work for which they were required and 60 were unsatisfactory. Observations are being made to ascertain the effects of the London atmosphere on paints of varying compositions, and also to what extent this is dependent on the medium used. The following table shows the classification and the results of the analyses of oils :— Satisfactory. Unsatisfactory. Fuel 8 — Lighting 27 - Lubricating 106 21 Painting 27 1 Miscellaneous 17 — 63 Various materials and apparatus for special purposes sent to the laboratory for examination during the year included :— (1) Gas alarm lamps of an approved design, which register a warning when there is a dangerous amount of combustible gas present in the atmosphere, were examined from time to time to ensure that they were correctly adjusted and sensitive to a lower limit of gas, before being issued for use in sewers, etc. (2) Wood, composite boards, etc., used as building material, were tested for fire resistance in accordance with the British standard specifications and for thermal conductivity. (3) Fire extinguishers, of the carbon-tetrachloride and other chlor-derivative type, were examined with a view to ascertaining to what extent the gases produced on discharge are poisonous. The sulphuric acid-soda type were examined to ascertain to what extent the spray given on discharge was acid and likely to be harmful to users or materials. (4) Fumigation of furniture, bedding, etc., with hydrocyanic acid. Tests were carried out to ascertain to what extent the poisonous gas can be removed by exposure to the air. (5) Electric batteries (dry).—Tests were carried out on a series of these batteries of different makes, to ascertain their relative durability under similar conditions of discharge. (6) Enamelware.—Towards the end of 1933 at the request of the chief officer of supplies the question was considered of formulating a specification for the properties of the glaze on enamelware for use in the Council's institutions. In view of cases of antimony poisoning which had been recorded as having occurred in various places, caused by the use of enamelware vessels for storing acid foods or drinks, the matter was primarily examined from the point of view of guarding against the risk of poisoning, but it became apparent that the test which was evolved had a very definite bearing on the quality of the enamel and its durability when in use. After due consideration it was decided to use hot .5 per cent, citric acid solution as being similar to a typical acid fruit preparation. Sample vessels (pie dishes, jugs, mugs, etc.), of reputable makers were examined to obtain precise data and on the basis of these tests, a specification was formulated which contained, inter alia, the following clauses:— All enamelware shall be guaranteed by the manufacturers to be free from antimony, lead, arsenic and any other injurious substance. Enamelware vessels will be considered to be sufficiently resistant to acid if when filled as full as is convenient with a boiling .5 per cent, solution of citric acid in water and allowed to stand for 24 hours without being heated or artificially coolea, the amount of ash yielded on ignition of the residue obtained when a definite proportion of the solution is evaporated does not exceed 1 milligramme per square centimetre of surface exposed to the action of the acid, and if on repetition of the treatment with a fresh similar volume of the boiling acid solution not more than a further .5 milligramme per square centimetre is obtained. This year 236 samples of enamelware have been examined on this basis and of these 58 (or 25 per cent.) have been rejected, 15 for containing antimony and 43 for failing to comply with the acid resistance test. It is worthy of remark that the large majority of the rejections were in the early part of the year and that latterly the quality of the samples submitted has greatly improved. Since this subject has been under investigation two other aspects of the importance of the acid resisting properties of enamels have become apparent—the solution of boron and fluorine compounds. The question as to whether small quantities of boron are deleterious to health has given rise to considerable discussion but the general consensus of opinion is that this is the case, and the use of boron compounds as preservatives for food has been totally prohibited in this country. Analysis has shown that from one to two-thirds of the acid extracts of the enamels examined has been boric acid. It has recently been stated that fluorine, either in food or in the body is a mere contamination, and for some years it has been recognised that excess of fluorides in the 64 diet of animals will produce changes in metabolism which manifest themselves in various parts of the organism, usually the bones, the pathological condition being known as " fluorosis." In some recent cases the cause of mottled teeth in children has been traced to the use of drinking water containing small amounts of fluorine. Many enamels contain a considerable proportion of fluoride and an acid extract which was examined showed an appreciable amount of this to have been dissolved. Since increased amounts of both boron compounds and fluorides weaken the resistance of enamels to acids there is further justification for the adoption of the acid resistance test. (7) Food poisoning.—Five outbreaks of suspected food poisoning were investigated during the year, and 40 samples were examined in connection with these, including urine, faeces, vomits, water, tinned tongue, chocolate, fruit jellies, sardines, butter, margarine and herrings in tomato sauce. In no case was there evidence of the presence of any poisonous material in significant quantity. Traces of metallic constituents were found in certain cases, for example lead in the vomits was in one instance probably derived from a meal of tinned sardines, which commodity sometimes contains up to 40 parts or more of lead per million. In this particular case the sardines which were eaten contained only 14 parts per million. (8) Tinned fish.—Fifteen samples were examined with respect to their lead content. The question originally arose in connection with tinned sardines, some recently published research work having shown that the lead content of these varied greatly, and that some, prepared by a certain process, contained an undesirably large amount. In the case of sardines the quantity of lead varied in the 9 samples examined from 9 to 40 parts per million, and in the 6 samples of other tinned fish from 0 to 3 parts per million. (9) Bread—Sale of Food (Weights and Measures) Act, 1926.—At the request of the chief oflicer, public control department, 5 samples were examined in connection with contemplated legal proceedings under the provisions of this Act. The vendors had sold the bread in question under the description of " fancy bread," but in each case analysis revealed no evidence that the sample was other than good quality ordinary bread. (10) Calculi.—During the year 22 specimens of renal, vesical and ureteric calculi from patients in one of the Council's hospitals were examined. The composition varied greatly in different cases and there appeared to be no definite classification. The main constituents were calcium oxalate and calcium phosphate though in certain instances magnesium ammonium phosphate predominated. Smaller quantities of uric acid, calcium carbonate and organic matter were also found in some cases. Milk samples. The total number of milk samples examined during the year in the laboratory at County Hall was 249. Of this number 136 were of milk supplied to children in the elementary and residential schools, whilst 105 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 percent, and 8 were from farms attached to institutions, etc. The quality of the supplies generally, has been less satisfactory than in recent years, 7 samples (2.9 per cent.) being deficient in fat. The condition of the supplies in respect of extraneous matter was again less satisfactory, for of the 241 contract samples examined 35 (over 14 per cent.) were found to contain an excessive amount. In addition to the above, 36 samples of milk supplied to schools and mental hospitals were examined bacteriologically 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) and mental hospitals is not purchased under any of the standards specified in the Milk (Special Designations) Order, 1923, and a standard was adopted for what would be regarded as ordinary clean milk. The standard 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. 65 The results of bacteriological examinations were as follows:— Raw milk. School supplies. Conforming to standard 5 Not conforming to standard— B. coli present in 1/1,000 c.c. 5 Bacterial count exceeding 300,000 per c.c., but conforming to B. coli standard 3 Bacterial count exceeding 300,000 per c.c., together with excess of B. coli 21 29 Samples examined 34 Mental hospitals— Not conforming to standard— B. coli present in 1/1,000 c.c. 2 Samples examined 2 Since 1st October, 1934, the milk supplied to necessitous children at schools has been obtained through the Milk Marketing Board's scheme and not through the Council's contracts, but head teachers were advised to obtain pasteurised milk only under this scheme. The Council's medical officer of health approves the source of supply and quality after consultation with the medical officers of health of the Borough Councils concerned, who take the necessary samples for examination. In all the cases of unsatisfactory supplies by contractors 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 made 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 scheme reports have been received on the chemical examination of 535 samples from hospitals and 447 from schools, of which 14 were deficient in fat (10 from hospitals and 4 from schools). In addition to the above, results have been received of the bacteriological examination of 200 samples of pasteurised milk supplied to hospitals of which 17 failed to comply with the standard laid down in the Milk (Special Designation) Order, 1923, and of 255 samples of milk supplied to schools, 34 failed to comply with the adopted standard or, in the case of pasteurised milk, with the standard for that grade. Of the 864 samples of drugs and medical supplies examined during the year, Drugs. 80 (or 9-3 per cent.) were found to be either definitely unsatisfactory for use or below standard strength or quality. Satisfactory 784 Unsatisfactory or below standard- Deficient in active constituent 29 Tincture, etc., deficient in alcohol 7 Specific impurities found 16 Dirty or badly made 8 General deficiency 14 Misdescribed 6 80 Total 864 The percentage of samples reported upon adversely during the previous year was 7.6, and the results for 1934, therefore, show an appreciable increase, thus emphasising the need for regular examination in order that supplies of drugs shall be kept strictly up to the required standard. Samples of two consignments of creosote capsules were rejected as having a content of one minim instead of two minims, and two samples of quinine hydrochloride tablets were found to be one 66 grain instead of two grains. In another case an emulsion of cod-liver oil and hypophosphites contained an artifical dye which should not have been present. Several calamine samples were rejected as containing large quantities of calcium and magnesium carbonates. Fertilisers and feeding stuffs. in connection with the provisions of the Fertilisers and Feeding Stuns Act, 1926, 255 samples have been examined during the year under the supervision of the chemist, who is the official 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 : Samples of feeding stuffs. Complied with guarantee 102 Deficient 26 Constituents in excess of guarantee 36 Guarantee incorrect in form or no guarantee 12 Contained deleterious substances 22 Total 198 Samples of fertilisers. Complied with guarantee 22 Deficient 4 Constituents in excess of guarantee 25 Guarantee incorrect in form or no guarantee 6 Total 57 Included in the number of samples of feeding stuffs containing deleterious substances were 17 taken from different bags of one consignment of linseed cake, composite samples of which had previously been found to contain castor seed. Examination proved this harmful constituent to be present in all the bags of cake, though the distribution, as was to be expected, was shown to be very uneven, fully justifying the contention that in any case in which even an extremely small amount of castor seed is found, the whole batch should be considered unfit for use as a feeding stuff. A sample of ground nut cake was reported against as containing an excessive amount of sand and silicious matter, which consisted largely of coarse sharp particles some of which were identified as being glass. The need for continued inspection and examination under the powers of the Act is clearly exemplified by the results of the past year. Drinking water supply. A regular chemical and bacteriological examination has been made ot the drinking water at those institutions of the Council which derive their supplies from private wells, and water from other sources has been tested when required. During the year 200 samples have been examined chemically and 387 bacteriologically from 38 institutions, in 10 of which chlorinating plants are in operation. In six cases a thorough cleaning of the tanks was recommended and after this treatment the quality of the water again became satisfactory. Outfalls. The long continued dry weather led to a strong septic sewage, which it was difficult to treat satisfactorily by sedimentation, being received at the outfalls. Although chemical treatment was begun earlier in the year than usual and continued for a longer period, the inadequacy of sedimentation alone to produce an effluent suitable for discharge into a river of greatly reduced flow was apparent. At the northern outfall about 10 million gallons daily were treated in the activated sludge plant with continued success, and the construction of five similar units will improve greatly the character of the total effluent discharged from this outfall. Much experimental work has been done in the hope of reaching more satisfactory additional chemical treatment in periods of very low river flow than has hitherto been used and found sufficient in ordinary summers. The dry matter in individual cargoes of sludge sent to sea from the northern outfall varied from 4 per cent, to 17 per cent., the average being 8.4 per cent., rather less than last year. At the southern outfall the average dry matter was 7.1 per cent., with variations from 3 per cent, to 13 per cent. In both cases the dry matter in the greater number of cargoes did not diverge greatly from the average. 67 The experiments on anaerobic digestion of sludge initiated at Crossness have been continued and a larger plant is to be constructed at Barking. In the report for 1933, the summer of that year was described as phenomenally River Thames. dry and not followed by winter rains. The cumulative effect of two dry summers was shown in the river early in 1934, when the naturally low flow of the river was further reduced by the demands of the Metropolitan Water Board. Chemical examination showed that the transitional state of sewage treatment in Middlesex affected the upper tidal reaches under these unusual conditions, and throughout the summer and well into the winter the river was in an unsatisfactory condition throughout the tideway as well as in regions where the summer condition is unfavourably affected by the effluent from the Council's outfalls. It is worthy of record that proportions of sea water approaching 7 per cent, were found at high water as high up the river as Kew. When the large new works being erected by the county councils of London and Middlesex are in operation a great improvement throughout the tidewav mav be expected. During the summer ot 1934 the number ot swimmers in out door baths and lakes controlled by the parks department was very great. At some of the baths fitted with plants for filtration and chlorination, it was only by continuous purification that the water was kept in satisfactory condition, but in one very large bath it was found necessary also to chlorinate the water in the bath at night in order to bring it to a satisfactory condition after a period when the number of bathers had been excessive. In very large baths it appears that, apart from the difficulty of avoiding streaming from inlet to outlet and consequent patches of water which are only slowly changed, the time of travel of water along the bath may, when the number of bathers is great, be sufficient for all the free chlorine to be expended unless the initial concentration is of an order which might cause irritation of the eyes and other delicate surfaces of the body. It is believed that this difficulty can be overcome by the use of ammonia in addition to chlorine. This chloramine treatment is being adopted at the large bath referred to above. Swimming baths and lakes. Three lakes, one relatively large, were used to so great an extent that, although the water was chlorinated in as efficient a manner as was possible, it was found necessary to close them to bathers on account of the unsatisfactory state of the water both as regards bacterial content and turbidity. One was, later in the year, allowed to be used to a limited extent by early morning bathers. These lakes will in the near future be replaced for bathing purposes by baths equipped with filtration and chlorination plants. The experience of the past summer has strengthened the conviction that shallow stagnant baths or lakes cannot be kept in satisfactory condition in summers when the weather induces large numbers to use them. Even with a limited use by clean bathers it is very difficult to keep artificial pools, where a proper balance of aquatic flora and fauna cannot be maintained, in a proper condition. The systematic investigations commenced in 1928 as to the condition of the air in Blackwall and Rotherhithe tunnels were continued during 1934, and in addition to examinations made during the rush period on Monday mornings, the carbon monoxide content of the tunnel air was determined on several occasions in 1933 and 1934 during the evening rush period and on other mornings than Monday. Vehicular tunnels. The visibility in all directions from the fleche of County Hall was above the average of previous years in all months of 1934 with the exception of November. In this month a week of exceptional fog depressed the average, and, besides, both maximum and minimum on any one day were low. The maximum for December was as high as that for March. Observations east of the Nore were not available for the winter months. The accompanying graphs (figs. 2 and 3) present the summarised results of all observations. In order to make them more generally useful, the international telegraphic code numbers and the meteorological office indication letters are shown on the scale of ordinates on both graphs as well as the distance in miles. Visibility. Also for each month the distance and direction of the furthest visible object or objects are shown as well as the average in all directions for all week-days. It 68 will be seen that on isolated occasions in the winter months visibility is fairly good whilst occasional mists in summer greatly reduce visibility. This was marked in June, when several misty days reduced the general visibility below that of either July, August or September. Fig. 2.—Diagrams showing the mean (in miles, international code numbers and the Meteorological Office indication letters) 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 months of 1934. Fig 3.—Diagram showing the mean (in miles, international code numbers and the Meteorological Office indication letters) of the greatest distance, also the maximum and minimum distances, at which objects could be distinguished at mid-day from the fleche at County Hall during 1934 and 1929-33 ; and observations taken from the sludge vessel at places east of the Nore light during 1934. 69 It will be noted from fig. 3 that both average and maximum visibility was usually highest in the quadrant south to west in those months which were not marked by a generally low visibility in all directions. It is noteworthy that, whereas the mode for the months January, February, November and December, 1934 was 4 in the international code (M.O. indication letter H) at County Hall, it was 6 (H) at Kew observatory, showing the decrease of visibility in London due to the influence of urban conditions. 70 County of London.—Statistics of the administrative work carried out by the Metropolitan Borough Councils during the year 1934. Cowsheds. Slaughterhouses. Offensive trades. Smoke nuisances. Common lodging houses. Cleansing of persons and rooms. Water supply. Milkshops. Ice cream premises. Restaurants and eating houses. Sanitary authority. No. licensed. No. of inspections. No. licensed. No. of inspections. No. authorised. No. of inspections. Observations. Intimations. Complaints. Notices. Houses licensed. No. of inspections. 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 — — — — — 340 24 1 4 107 1,154 251 22 291 121 16 16 974 981 Rattersea — — 2 122 3 5 61 8 10 2 3 92 209 3,989 2,490 308 21 314 196 212 99 128 249 Bermondsey — — — — 14 89 69 7 8 3 3 65 118 3,404 1,920 1,163 36 298 552 122 493 138 343 Bethnal Green 8 47 11 164 1 16 41 2 — 1 4 47 307 14 1,017 432 300 758 172 343 218 846 Camberwell 1 15 2 88 10 35 60 8 10 1 5 187 40 4,924 2,600 984 18 501 1,659 335 371 203 270 Chelsea — — 1 20 — — 30 — 10 — 2 24 31 540 390 412 70 130 30 41 70 68 Deptford — — 2 202 7 30 18 — — — 6 93 47 2,111 1,090 190 — 234 395 165 114 65 456 Finsbury — — 1 75 3 76 56 3 10 2 2 106 37 3 1,377 688 233 174 333 138 254 271 428 Fulham — — 2 142 — — 134 1 15 — 2 62 18 — 1,486 135 — 112 696 183 199 114 341 Greenwich 3 3 3 246 2 2 22 — 20 — 2 9 16 961 1,183 158 22 177 251 135 178 71 111 Hackney 3 36 10 632 16 81 1,814 17 46 8 3 36 130 2090 2,819 760 26 217 475 301 440 192 316 Hammersmith — — 4 301 — — 176 9 14 2 1 27 183 1,923 1,336 19 59 161 1,127 155 220 191 700 Hampstead — — — — — — 3 1 3 — — — 37 785 2,287 60 27 84 196 59 22 56 51 Holborn — — — — — — 156 6 16 1 6 54 158 4 313 155 6 144 125 42 95 298 453 Islington — — 8 504 12 142 83 12 30 2 20 396 41 6,087 1,924 276 200 401 628 448 199 537 693 Kensington — — 2 86 — — 159 2 12 — 5 165 652 4,085 1,733 662 47 149 512 200 142 163 1,437 Lambeth — — 3 137 3 50 74 74 74 — 3 172 272 — 5,644 2 031 — 518 1,821 408 1,566 177 520 Lewisham 1 4 6 510 — — 50 12 21 — — — 6 1,023 2,114 153 — 138 252 176 184 125 120 Paddington — — 2 250 1 50 47 — 11 — 3 59 43 7 244 54 129 333 178 161 130 83 Poplar 3 36 5 73 5 100 51 5 24 — 5 142 145 2,592 2,135 243 2 112 376 211 329 828 1,498 St. Marylebone — — 1 12 2 37 336 5 11 — 3 139 2,787 2,661 763 692 22 197 245 86 120 365 420 St. Pancras — — 2 152 2 45 396 3 42 1 1 32 2,156 6,008 1,245 228 109 387 799 296 252 292 763 Shoreditch 2 19 — — 1 6 24 5 4 — . 4 41 6 3 974 74 56 307 1,263 172 369 260 696 South wark — — 4 382 4 18 157 4 23 — 19 173 2,079 5,061 1,721 1,627 99 398 1,710 272 323 . 423 1,278 Stepney 19 134 — — 53 357 329 50 50 6 17 383 214 6 1.963 768 13 341 1,329 311 522 355 753 Stoke Newington — — 3 22 2 8 8 2 13 1 — — — 2,550 315 194 6 101 262 52 83 34 121 Wandsworth 1 15 5 796 — — 250 26 66 4 — — 280 — 3,431 121 46 240 721 566 599 444 561 Westminster — — — — — — 875 5 58 — 5 187 480 517 1.058 133 6 212 404 75 87 1,319 1,217 Woolwich 8 86 4 27 1 4 26 4 11 — 9 152 7 2,326 1,574 1,371 — 77 254 195 217 180 203 Note.—In the columns above a dash signifies a nil return. Prosecutions.—Common lodging houses—Chelsea, 2. Seamen's lodging houses—Poplar, 1. Ice cream premises—Poplar, 1 ; Stepney, 1 ; Islington, 1. Offensive trades—Stepney, 1. Water supply—Hammersmith, 3 ; Islington, 1. 71 Borough. No. of houses. No. of houses inspected. No. of notices served. No. of houses repaired or nuisances remedied under P.H. Act. No. of houses repaired under Housing Act, 1925/30. Underground rooms. Overcrowding. Houses let in lodgings. No. of houses closed by owner. No. of houses for the working classes. Houses unfit for habitation. In borough. Occupied by the working classes. Representations. Closing orders. Demolition orders. 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. City of London 2,101 492 176 179 19 2 53 125 - - 2 1 4 3 46 131 - - - - - - - - - 3 Battersea 28,146 25,257 8,001 725 2,990 1,292 19 2,285 230 - 654 — 20 20 66 757 — 29 5 131 253 — — 5 5 22 Bermondsey 19,022 18,878 4,353 2,583 4,818 1,977 - 4,818 — — 9 7 2,419 201 1,578 5,737 — 464 339 6 294 1 — 21 17 281 Bethnal Green 18,285 *18,000 7,473 856 5,151 2,286 - 5,535 — — — — 28 — 287 864 — 85 27 1 13 1 — — 11 13 Camberwell 43,123 34,500 4,856 965 4,920 1,476 10 4,328 1 — 1 3 102 51 239 245 8 338 392 6 36 2 — 3 — 66 Chelsea 12 413 5,550 833 173 468 72 — 373 — — 1 1 20 20 569 40 - — - — — — — — — 66 Deptford 19,400 17,460 2,301 1,532 2,656 632 4 2,965 - - 5 4 - - 666 - - 152 - 13 189 - - 9 13 - Finsbury 10,503 10,000 1,793 880 2.413 365 37 2,413 - - 67 63 13 12 821 3,477 31 73 118 - - — - — — 68 Fulham 26,729 26,729 3,943 551 3,092 716 278 2,829 190 — 19 5 37 23 555 4,657 - — — 4 33 — — — — - Greenwich 19,291 14,468 2,480 — 1,249 175 8 1,688 79 — 6 6 81 70 104 150 2 319 120 1 86 5 — — — 19 Hackney 37,197 15,523 5,985 1,894 4,528 1,320 60 4,452 53 — 38 17 80 34 508 1,293 — 688 315 8 127 4 1 — - 43 Hammersmith 22,691 17,500 7,643 180 3,519 1,355 - 3,401 — — 1 1 56 49 1,773 44 - 112 — 2 8 — 4 1 4 29 Hampstead 15,908 *9,500 948 78 912 170 256 614 — — 4 1 22 13 1,554 1,169 - — — 10 40 21 — — — 5 Holborn 6,462 - 600 70 396 56 2 396 - - 5 5 3 3 462 778 - 10 - 18 20 2 — 3 — - Islington 46,000 30,000 7,514 1,669 4,785 548 84 21,430 84 — 109 109 61 61 988 1,001 — 109 - 11 78 — — 9 5 1 Kensington 29,299 14,000 2,986 1,612 2,428 494 86 2,428 116 1 20 20 21 21 3,155 10,560 - 332 44 7 607 917 3 4 - — Lambeth 48,873 *36,000 11,958 315 4,306 146 9 4,784 163 - 27 16 - - - - - 617 600 9 26 7 — 1 10 12 Lewisham 49,000 - 2,724 554 1,447 458 — 1,198 — — 1 — 22 11 26 75 - - — 6 38 — — 3 2 — Paddington 20,826 10,000 1,735 - 2,114 327 135 1,467 119 — 145 131 48 45 1,416 4,479 - - — 165 199 149 — 7 - — Poplar 23,583 23,000 6,986 2,966 5,299 2,039 2 4,997 — 2 9 6 37 25 242 1,528 - 117 98 5 21 2 — 1 110 St. Marylebone 18,020 8,620 2,383 698 1,413 42 - 1,413 — - 73 73 28 28 1,055 7,290 — 147 250 - — — — — — — St. Pancras 25,670 18,000 4,540 570 3,397 1,344 11 2,918 50 - 79 58 22 15 4,072 2,747 — 298 153 5 12 — — — — 13 Shoreditch 14,077 13,559 7,670 1,325 4,785 668 - 4,785 — — 10 9 125 195 418 744 — 150 100 2 39 — — — — 17 Southwark 27,168 20,000 1,187 3,745 3,173 1,047 492 3,249 555 — 41 14 37 37 1,551 1,551 3 106 106 — — 29 1 22 19 — Stepney 37,757 31,708 4,935 698 12,807 4,728 13 11,164 2 - 698 86 74 62 2,770 2,327 — 128 101 17 68 2 — 4 4 — Stoke Newington 8,713 4,074 776 248 634 18 — 1,767 — - 6 6 4 2 In- c'mplete 84 — 100 - 1 52 52 — — — 4 Wandsworth 76,463 50,008 8,515 1,060 3,593 379 - 3,392 — - 18 9 88 293 343 644 — 417 - 12 129 2 — 6 18 95 Westminster City of 22,536 5,983 1,721 3,909 1,603 49 - 1,861 — - 29 18 51 94 Est.4,000 8,943 — 110 151 26 44 23 — 1 24 29 Woolwich 33,583 28,883 5,101 772 2,642 444 2 2,344 — - 5 3 30 18 No register 702 - 360 278 30 45 8 — 5 23 — *Approximately. 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: Bethnal Green, 9; Hampstead, 1; Islington, 1; Kensington, 10; Paddington, 4; Poplar, 2; St. Pancras, 2; Stepney, 4. Overcrowding.—Camberwell, 1; Greenwich, 1; Kensington, 3; Paddington, 1; St. Pancras, 1; Shoreditch, 1. 72 Sanitary Inspectors, 1934. 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 - 1 - Battersea 159,552 10 — — 2 8 2 Bermondsey 111,542 13 — — — 10 — Bethnal Green 108,194 11 — — — 12 - Camberwell 251,294 12 — 1 — 13 2 Chelsea 59,031 4 — — 1* - 1* Deptford 106,891 8 — — — 8 1 Finsbury 69,888 7 — 1 — 6 — Fulham 150,928 11 — 1 — 8 - Greenwich 100,924 6 — 1 — 10 - Hackney 215,333 20 — — — 18 — Hammersmith 135,523 9 — 1 - 4 - Hampstead 88,947 7 — — i 5 1 Holborn 38,860 3 — — i 1 1 Islington 321,795 20 4 2 — 8 — Kensington 180,677 14 — — 8* — 8* Lambeth 296,147 16 — 2 — 6 — Lewisham 219,953 10 — 1 — 11 — Paddington 144,923 12 — 2 — 9 1 Poplar 155,089 15 — 1 — 9 — St. Marylebone 97,627 8 3 1 3 4 2 St. Pancras 198,133 14 — 1 5* 14 5* Shoreditch 97,042 10 — — — 10 4 Southwark 171,695 14 — 1 — 9 — Stepney 225,238 20 — 1 - 10 — Stoke Newington 51,208 3 — — - 3 1 Wandsworth 353,110 15 — — — 10 — Westminster, City of 129,579 17 — 1 — 8 — Woolwich 146,881 11 — 1 2 9 2 Total County of London 4.397.003 345 7 20 23 224 31 *Act both as sanitary inspectors and health visitors. 73 INDEX Subject. Page Abortion 25 Anthrax 16 Bacteriological Laboratory 10, 61 Births 11 Blind Persons Act 9, 56 Cancer 26 Cerebrospinal Fever 17 Chemical Branch 10,61 Chickenpox 17 Cowsheds 36 Deaths 11 Diarrhœa 22 Diphtheria 22 Drugs, Testing of 65 Encephalitis Lethargica 17 Enteric Fevers 26 Fertilisers and Feeding Stuffs 66 Food Poisoning 19 Housing Acts (Statistics) 71 Housing Acts 6,33 Infant Mortality 14 Infectious Diseases 16 Influenza 26 Marriages 11 Maternal Mortality 22 Maternity and Child Welfare 60 Measles 21 Medical Examination of Staff 60 Mental Deficiency 9, 55 Subject. Page Midwives Acts 9, 56 Milk and Dairies Act 35 Milk Sampling 64 Nursing Homes 10, 59 Occupation centres 55 Ophthalmia Neonatorum 58 Polioencephalitis 18 Poliomyelitis 18 Population 11 Puerperal Fever 22, 57 Puerperal Pyrexia 22, 57 Rheumatic Fever 26 Sanitary Officers 72 Scarlet Fever 21 Slum Clearance 33 Smallpox 16 Swimming Baths 67 Tuberculosis (Care Committee Work) 54 Tuberculosis (Contact Scheme) 50 Tuberculosis (Notifications) 26 Tuberculosis (Residential Treatment) 7, 40 Tuberculosis (Dispensary Service) 7,46 Vehicular Tunnels 67 Venereal Diseases 6, 36 Visibility 67 Vital Statistics 5, 11 Water Examination 66 Whooping-cough 21 London County Council ANNUAL REPORT OF THE COUNCIL, 1934 Vol. III (Part II) PUBLIC HEALTH (Report for the year 1934 of the School Medical Officer) CONTENTS page Staff 6 Co-ordination 7 School Hygiene 7 Results of Medical Inspection 9 Following-up 18 Medical and Dental Treatment 20 Stammering Children 32 Left-handedness in Children 32 Rheumatism Scheme 33 Personal Hygiene Scheme 37 Chronic Invalidity 38 Infectious Diseases in Schools 39 Open-air Education 49 School Journeys 53 Physical Education 53 Provision of Meals 54 Co-operation of Voluntary Bodies 61 Defective Children 62 Ponton Road Remand Home 71 Child Guidance 73 Nursery Schools 77 Medical Inspection and Treatment—Day Continuation Schools, Evening Institutes and Junior Instruction Centres 78 Medical Inspection at Secondary and Trade Schools 80 The Teaching of Hygiene 81 Special Inquiries and Reports 82 Wage-earning Employment of School Children 86 Examinations of Employees in the Education Service and Scholars 87 Statistical Tables.— I. Medical Inspections 91 II. Defects 92 III. Exceptional Children 94 IV. Treatment of Minor Ailments 95 V. Medical Inspection—Number of Children Examined 96 VI. Medical Treatment—Number of Cases Treated 96 VII. Medical Inspection of Students in Higher Education Institutions 97 Index 99 900 (m.c. 11089-6) 27-6-35. London County Council ANNUAL REPORT OF THE COUNCIL, 1934 VOL. III (Part II) REPORT OF THE SCHOOL MEDICAL OFFICER FOR THE YEAR 1934. By Sir Frederick Menzies, K.B.E., M.D., LL.D., F.R.C.P., F.R.S.E., County Medical Officer of Health and School Medical Officer. Introduction. The progress of the school medical service and the improvement in the condition of the school children of London during His Majesty's reign. In recording the work of the school medical service each year it is inevitable that comparison should be made with the past. As this report will appear during the Jubilee celebrations it is appropriate that a brief record should be made of the changes and improvements which have taken place in the health of the school children during His Majesty's reign. His Majesty has abundantly shown his concern and affection for the nation's children and in particular for the school children of London. One of the most unforgettable events in connection with the Coronation festivities was the fete on 30th June, 1911, at the Crystal Palace, where their Majesties entertained one hundred thousand children from the elementary schools of London. The children of those children are now in the schools. It is fitting to note that the organisation and growth of care for the children's health in the London schools are exactly contemporaneous with the reign. Preparatory work had been done throughout the previous reign, but it was not until the year of His Majesty's accession that the school medical service of London took shape, and the gradual growth began of facilities for attending to the children's health which, step by step, has produced such an improvement as the early pioneers of the work did not dream could be attained in their lifetime. It was not until His Majesty had ascended the throne that the first school treatment centre in London was opened in Hampstead in 1910. Tn 1911 provision existed (excluding dental treatment) for the treatment of 27,647 children. In 1934 there were 74 treatment centres and provision was made (again excepting dental treatment) for 167,910 children. In 1900 the School Board for London by special resolution put on record their grave concern that 96 per cent. of scholarship children were found with advanced dental decay. At that time nothing could be done about it, as there was no provision for dental treatment and no power to provide it. In 1910 the first dental centre was opened. Now, there is provision for the treatment of 150,000 children annually, and only 4 per cent. of the scholarship candidates are found with advanced dental decay. The growth in the provision for dental treatment is shown in the diagram (fig. 1) on page 23. In 1910 there were 68 school nurses. In 1920 these had increased to 285 in number and in 1934 to 380. The effect of the nurses' patient and unremitting work is shown in the improvement in the appearance and cleanliness of the children. In 1912, 39.5 per cent. of the children in the schools were infected by parasites, in 1920 this percentage was reduced to 13.8 and in 1934 to 4.5. Ringworm of the scalp, formerly one of the greatest scourges of school children, is now rarely found. In 1911 there were 6,214 new cases of this disease, in 1920 there were 3,983, but in 1934 only 265. In 1912 the proportion of children with subnormal nutrition in London was 12.8 per cent. By 1934 it had been reduced to 4.6 per cent.; but these figures do not tell the whole story of improvement, for the children now returned as subnormal (5) 6 in nutrition are practically all slight cases, whereas formerly a large proportion were severe. It may help the reader to visualise the improvement which has taken place in this respect more accurately when it is pointed out that in the winter of 1909-10 the school doctor in a single school in Bethnal Green counted 91 children very seriously ill-nourished; this number is more than three times as great as those found illnourished to the same degree in 1934 by all the school doctors in all the schools of London. A diagram (fig. 2) on page 26 shows the gradual reduction of the number of children with discharging ears. The early reports of the school medical inspectors showed that visual defect was serious, that its incidence was much heavier upon girls than upon boys and that it advanced very rapidly in girls during school life. With improvement in school hygiene, the vision of the children, particularly the girls, has greatly improved and the girls no longer suffer from worse vision than the boys. The percentage excess of defective vision in 12 year old girls over 12 year old boys was, in several years, as follows:— Percentage excess of defective vision Year. in girls. 1913 17.6 1918 11.0 1922 9.3 1927 5.3 1931 2.7 1933 0.0 1934 0.0 His Majesty's reign is distinguished from all those that went before by consideration for the health of the children. The above figures and facts serve merely to illustrate the great advance which has already been made. The school children, many of whom were formerly unhappy, ill-nourished, defective, unclean and prematurely old, have been replaced by a generation which approaches more nearly to the ideal of a population healthy, wholesome and full of the joy of living. The Shakespearean description is at last out of date : the schoolboy of to-day no longer whines, nor creeps like snail unwillingly to school. 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 and dental 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. R. H. Simpson); north (divisional medical officer, Dr. Margaret C. Hogarth) ; north-east (divisional medical officer, Dr. G. Chaikin); south-east (divisional medical officer, Dr. H. R. Kidner); south-west (divisional medical officer, Dr. E. J. Boome). The remaining staff in 7 this branch of the school medical work includes 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. Barbara Tchaykovsky); one divisional medical officer for ophthalmic work, nursery schools, etc. (Dr. Elizabeth M. McVail); *21 whole-time assistant medical officers; 6 assistant medical officers giving six sessions a week; 53 assistant medical officers giving three sessions a week; additional temporary medical assistance for 123 sessions a week; 9 medical officers (part-time) at open-air schools; 68 parttime inspecting dental surgeons. There are 262 part-time doctors, surgeons and anaesthetists, and 99 part-time dental surgeons engaged at the hospitals and school treatment centres under the Council's scheme. These appointments are made by the authorities of the hospitals and treatment centres. 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 Home Office 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. J. M. Bickerton); two divisional medical officers (Drs. A. C. Williams and Jessie G. Duncan) and an assistant medical officer who is attached part time to Pontonroad remand home. The duties of consulting surgeon for aural disease in this section are rendered by Mr. A. G. Wells. The duties of Miss D. E. Bannon, matron-in-chief in the public health department, include the superintendence of the school nursing staff in addition to the supervision and organisation of the nursing and certain other staff at hospitals and institutions. The school nursing service comprises at present five assistant superintendents, 71 nursing sisters and 304 nurses. The loss during the year through retirement of Dr. A. W. Sikes, for many years divisional medical officer in the north-west division, and of Mr. Bishop Harman, consultant ophthalmological surgeon, is recorded with much regret. Particulars of Mr. Bishop Harman's work in connection with the formation of sight-saving classes will be found on page 69. Co-ordination. Arrangements for co-ordinating the work with that of the local sanitary authorities and with the hospital authorities of London were set out in detail in last year's report. The provision of milk to school children under the scheme of the Milk Marketing Board, which commenced on 1st October, 1934, necessitated further conference and combined action with the medical officers of health of the metropolitan borough authorities, who are jointly with the school medical officer responsible for the supervision of the quality of the supplies of milk and for the approval of the vendors (see p. 58). School hygiene. Very great improvements are taking place in the structural character of the school buildings, and many new amenities are being introduced with the object of rendering school conditions healthier and of keeping pace with advancing knowledge of hygiene. The provision of medical inspection rooms is being rapidly carried out in schools, both provided and non-provided, in which hitherto there have been no special facilities. The decision to introduce running hot water in children's lavatories, as well as in medical inspection rooms and teacher's rooms, is an important advance. Since 1925 the improvement of schools has been carried out in accordance with 3-year programmes. Two such programmes were carried through successfully, but the third programme, for the years 1930-33, was checked by the financial crisis of August, 1931. During 1934 a resumption of the three-year programme procedure was decided upon by the Council. *Two vacancies—also one medical officer temporarily seconded for work under the Mental Deficiency Acts and two for work under the Housing Acts (equivalent substitutes authorised). 8 On 30th October, 1934, the Council approved a new "standard planning" for elementary schools, in which great improvements are made in regard to hygiene. This standard will be used not only for new schools to be built but also in connection with the reconstruction and remodelling of those which are out of date. In addition to ten remodellings of schools included in the developments for 1934-35, the new programme includes, during 1935-38, the rebuilding or modernisation of 30 additional schools, 22 of which were built before 1880. Further, a new feature has been included in the programme, viz., for the reconditioning of premises and for pushing forward the provision of the conveniences and amenities included in the new standard planning by a systematic overhaul of schools in which rebuilding or remodelling is not necessary. It is the aim to make some approach in all schools to the level of the schools built on the new standard planning by providing medical inspection rooms, hot water systems for lavatories, provision for drying clothes in cloakrooms, indoor sanitary conveniences for babies, improved natural lighting, etc. The Council's scheme for the reduction of accommodation of classrooms to a maximum of 40 for older pupils and 48 for infants is almost complete, 99.6 per cent. of classrooms in provided schools and 94.5 per cent. of those in non-provided schools being now on this basis. While many of the advances in the standard planning are designed to improve educational facilities, some of these have important hygienic bearings and other advances are purely for hygienic reasons. The increased floor space to be provided in every type of department will give much healthier conditions and will diminish the risk of spread of contagious and infectious diseases. Under the new planning the floor space per child of classrooms in all departments will be increased by 8 or 9 per cent. Floor space in rooms for "under fives " will be increased by 25 per cent. A separate waiting room will be provided in connection with all medical inspection rooms; some wash-basins will be provided near the water closets, thus giving opportunity for hygienic habits. In suitable cases a physical training room will be provided of 1,800 square feet floor space, and this will be provided with separate changing rooms and shower baths for girls and boys; improvements will be made in the layout of playgrounds, increased area of playgrounds will be provided for infants (20 square feet per child instead of 16), and a separate playground of 800 square feet or more near the babies' room. Drinking water points will be provided on each floor. Increased space will be given in cloak rooms, giving 10 inch spacing of pegs in two rows, while a much needed improvement is introduced in the provision of drying facilities. The programme provides also for advances in equipment. It is proposed to supply a large number of tables and chairs in lieu of fixed dual desks. The table tops at present supplied measure 3 feet 5 inches by 1 foot 4 inches but it is hoped that, with the introduction of the new standard planning, it will be possible to supply larger tables. The heights of tables and chairs at present authorised for children aged 5 years and upwards are in 5 ranges as follows:— Table 1. Size No. Height of top of table from floor. Height of chair seat from floor. Suitable for children aged (approximately). 1 29 inches 17½ inches 12 years and upwards 2 27½ „ 16 10-12 years 3 24½ „ 14 8-10 „ 3a 22 „ 13 7-8 „ 4 20 „ 12 „ 5-7 „ There are in addition smaller tables and chairs provided for babies' classes. 9 The results of medical inspection in 1934. The year showed great activity in medical inspection. The change in the statutory age groups to be examined foreshadowed in the last report took effect in January, Age groups. In order to secure a better distribution over school life of the incidence of routine medical inspections, and to bring them into organic relation with the great periods of educational change under the Hadow reorganisation scheme, the examination at age 8 was altered to examination at age 7, and that at age 12 to examination at age 11. The routine groups to be examined thus became (i) on entrance, (ii) at age 7 (corresponding to the transference from infants' to junior departments), (iii) at age 11 (corresponding to the transference from junior to senior departments), and (iv) before leaving at approximately age 13½. As the sudden alteration from age 8 to age 7 would leave a group of children unexamined between entrance and age 11, in which case this group would have suffered unduly, it was decided that a "preliminary survey" should be made of the whole of the 8-year-old group during which vision testing, examination of the teeth and noting of any obvious defects would be carried out, while those children, who during the survey were considered to need detailed examination, were to be submitted to a complete examination in the usual way, after invitation to the parents to attend. Only after the completion of the 8-year-old group in this manner was the detailed examination of the new 7-year-old group to be begun. It was considered that the change over from age 8 to age 7 would take about five years. Much greater progress with the change over was effected than was anticipated, thanks to the energy which all concerned put into the work; and, instead of only a fifth of the seven-year-old group coming under examination as was anticipated, well over a third were completed; and this in spite of the fact that an abnormally large leaver group was due for examination and completed during the year. At this rate the change over should be completed within 3 years instead of the 5 years originally contemplated. In view of the special character of the examination of the 8-year-old-group, the results of their inspection will be separately treated in the following analysis of the results. In accordance with the precedent of previous years, the results of inspection of the leaver group will also be separately analysed. The number of elementary school children examined in the three statutory age groups (entrants, children aged 7 and children aged 11) during the year 1934 was 138,549. These were made up of 58,638 entrants, 26,359 children aged 7, and 53,552 children aged 11. The children aged 8 coming under preliminary survey by the school doctors was 47,001, of whom 3,739 were referred for detailed examination. In addition, 63,633 children were examined in detail in the term prior to that in which they were due to leave school, and 1,593 children in special schools were examined on reaching their respective age groups. The leaver group was by far the largest age group of children inspected during recent years, being 7,000 more than in 1933, itself a heavy year. In addition to routine groups, children referred by nurses, school teachers, care committee workers, divisional officers, etc., for examination for special reasons numbered 91,880; and 44,197 were examined in connection with outbreaks of infectious disease. The total inspections amounted to 386,858, which represents an increase on the numbers in the previous year, namely 377,167. To this must be added the children, 146,620 in number, who were re-inspected because of some previously noted defect. As inspections of all kinds and re-inspections totalled no less than 533,478 it is clear that, although some duplicate inspections are included, very few indeed of 10 the children in school escaped coming under the eye of the doctor in some way or another during the course of the year. Parents are invited to be present at all routine inspections, and attended in 77.6 per cent. of the examinations in the three statutory age groups compared with 74.1 per cent. in 1933 and 68.5 per cent. in 1932. At the inspection of entrants, the proportion was 91 per cent., and in the "leaver" group 42 per cent. It is most satisfactory to be able to note each year a very distinct advance in the interest of the parents in the inspections. The presence of the parent has a very considerable effect, and relieves very greatly the task of following-up, as it eliminates the necessity for home visiting and correspondence. Refusals. Refusals of parents to submit children for medical inspection are so few in number as to be almost negligible. During the year 1934, the parents of 65 children (31 boys, 34 girls), compared with 89 in 1933, refused to allow them to be examined by one of the Council's assistant medical officers. Nine objections were subsequently withdrawn, and in 10 instances either medical record cards were completed by a private medical practitioner or medical certificates as to physical fitness were produced. The cases were distributed amongst the divisions as follows: N., 4; N.E., 9; N.W., 17; S.E., 11; S.W., 24. Thus not only do parents attend the inspections in greater numbers each year, but refusals to allow inspection dwindle each year. The number of children subjected to routine inspection in the three statutory age groups who were referred for treatment was 58,521, 42.3 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 15.5, compared with 16.7 in the previous year, and 17.5 in 1932. This quite considerable drop shows the healthy conditions which prevailed in 1934. Each age group has its own peculiar constitution, by which liability to different ills varies from age to age. The change in age groups inspected makes less certain the comparisons hitherto possible from year to year over the whole length of time, now twenty-four years, during which inspections have been carried out in the three groups—entrants, children aged 8 and children aged 12. The smaller number of children in the 7-year group submitted to inspection also makes less valid the combined figures for all the age groups, as they are underweighted in respect to this age group, which normally is specially productive of certain tvDes of defect. The state of nutrition of the children. Unremitting attention has been given to the state of nutrition of the children in school. Acute anxiety lest the children should suffer has been the key note of the past three years. In the words of The Lancet, "the fear of underfeeding its children is haunting the conscience of the nation." By precept and instruction the question has been kept continually before the school doctors. It is therefore satisfactory to note that there has been no decline in the nutritional state of the children attending elementary schools in London. The Board of Education syllabus provides for every child to be marked during routine inspection as "1," "2," "3" or "4"; 1 being exceedingly good nutrition, 2 normal, 3 subnormal, and 4 definite pathological malnutrition. Complete surveys by the school doctors exist for about a quarter of a million children examined each year since 1912. In that year the number returned in classes 3 and 4 taken together formed 12.8 per cent. of the total examined. This proportion was gradually reduced until in 1930 the proportion was 4.8 per cent., and in 1931 this proportion remained unchanged. In 1932 there was a very slight setback to 4.9 per cent., the result mainly of an increase in ill-nourishment in the entrants who had just been through a very severe epidemic of measles. In 1933 the proportion of poorly nourished children was 4.7 per cent and in 1934 the proportion is 4.6 per cent., which is the lowest figure ever attained in London. 11 The figures in detail for each sex in each statutory age group are given in the following table:— Table 2. Nutrition subnormal—Percentage of children examined. Age group. 1920. 1925. 1926. 1927. 1928. 1929. 1930. 1931. 1932. 1933. 1934 Entrant boys 6.4 5.7 5.7 5.0 5.0 4.6 4.4 4.4 5.1 4.4 4.4 „ girls 5.9 5.0 4.8 4.0 4.1 4.0 3.5 3.6 3.8 3.8 3.8 Eight-year-old boys 9.0 8.5 8.2 7.3 6.7 6.7 6.3 6.6 6.3 6.4 *7.1 girls 7.8 7.2 6.6 6.1 5.2 5.2 5.1 5.0 5.0 5.0 *4.6 Twelve-year old boys 6.3 6.5 6.7 5.4 5.3 6.0 5.1 5.2 5.0 4.8 †5.0 „ girls 5.6 6.3 6.3 4.8 4.4 4.9 4.5 4.2 4.3 4.2 †4.1 All above age groups 6.7 6.3 6.2 5.3 5.1 5.2 4.8 4.8 4.9 4.7 4.6 *7 year-old children. †11-year-old children. The number of children found in category 4, i.e., definitely malnourished, was again insignificant, viz., 21 out of 138,549 examined. What is most to be remarked about the above figures is the steadiness maintained age by age in each of the six groups, and sex by sex, during the five years 1930 to 1934. Too much attention must not be paid to minute variations of a decimal point in the totals, as a preponderance of numbers of one particular age group in which subnutrition is relatively high would affect the total without reflecting any change in the nutritional state of the children. The 7-year-old children inspected in 1934 formed a small group, and subnutrition at this age amongst boys is constantly more apparent than in the other groups; the total result of 4.6 per cent. is thereby affected and the small diminution in the amount of subnutrition found is therefore not a real one. Dr. Alison Glover has pointed out that there seem to be "crises" of nutritional state at certain ages. It will be noticed that this is shown constantly in the London figures for the boys of the 8-year-old group, and it is more marked than usual in the 7-year-old boys examined during the past year. The seventh and eighth years appears to be critical ages for boys from this point of view. At all the age periods boys show a greater amount of subnutrition than girls, but this is intensified at the ages seven and eight. This is manifest not only in the figures but also is apparent when the children are surveyed en masse in the schools. A special report by Dr. Neustatter, which was the result of attention being drawn to the poor appearance of the junior boys in a Bermondsey school, bears this out. It seems that the superior sex is more sedate, serene and sedentary than their brothers at this age, while the latter engage in a feverish activity which overtaxes their immature strength and takes toll of their nutritional state. The boys lose their infantile chubbiness and overdo it. Taken as a whole the figures for nutrition are reassuring, and give no cause for anxiety with regard to the condition of the school children of London; on the other hand it is disquieting to find amongst its entrant infants an increase in the number of those with rickets, which up to this year had shown a steady decline. The percentage of children found free from even traces of nits or pediculi in the hair was 96.5 compared with 96.2 in the previous year. This is the best result ever obtained. 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 was still further improved in 1932, when the high level of 95.8 per cent. was obtained. Cleanliness. 12 Unfortunately the percentage in this group, which has always been chosen as the index group, fell back one unit in 1933 to 94.8, a disappointing result when the condition of the other groups was better in this respect than ever before. The reason why the 12-year-old girls were chosen as an index is that they have always given the worst result of all the groups, for mothers expect the older girls to look after their personal cleanliness themselves. In the year 1934 the percentage of 11-year-old girls entirely free from vermin is 94.8, being exactly the same as that of the 12-year-old girls in the previous year. It must be remembered that the parents are warned of the medical inspections upon which these figures are based, and the children appear spick and span for the occasion. The figures given in these results are therefore better than would be the case at surprise inspections, such as those carried out by the nurses in their rota visits to the schools. It is now very 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. Only 65 children were found in the age groups to be affected by body vermin in 1934, or less than one in 2,300. The remarkable progress since the inauguration of the school medical service 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. Clothing and footwear. When the children are undressed by the nurse preparatory to the medical inspection, she enters on the medical record card a note of the condition of the clothing and footwear. At a time of stress it is likely in most instances that the first sign of struggle will be a deterioration in clothing rather than in nutrition. In the following table the figures for 1934 are compared with those for 1921:— Table 3 Age group. 1921. 1934. Good. Fair. Bad. Good. Fair. Bad. Entrant boys 62.3 35.9 1.8 52.7 46.7 0.6 girls 62.7 35.8 1.5 54.7 44.7 0.6 Eight-year-old boys 58.6 38.5 2.9 *53.0 *46.1 *0.9 ,, girls 58.9 39.1 2.0 *54.9 *44.4 *0.7 Twelve-year-old boys 54.4 41.9 3.7 †53.7 †45.6 †0.7 „ girls 57.6 40.7 1.7 †55.3 †44.3 †0.4 *7-year-old children. †11-year-old children. It is found that while bad clothing and footwear are distinctly less frequent than formerly there has been a transfer from the "good" column to the "fair" column of from one to eight per cent. The indications from this survey are that while indigence and neglect have been alleviated things are "tighter" amongst those above the poverty line, and that clothing has suffered to some extent in order to provide sufficient food. Dental decay. Following upon the smaller numbers of children reported as treated for dental defect in 1933, the proportion of children found during 1934 in a satisfactory dental condition has declined, being 65.7 compared with 67.4 per cent. in 1933 and 1932 respectively, but is still better than that for former years, e.g., 64.4 per cent. in 1931, and 62.9 per cent. in 1930. 13 Details are set out below:— Table 4. Age group. 1924. 1927. 1930. 1933. 1934. 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 56.1 11.6 54.3 11.3 „ girls 58.4 12.4 50.7 15.2 52.2 14.9 55.3 11.7 54.3 11.4 8-year-old boys 58.5 10.0 61.1 8.1 66.7 6.8 70.7 4.5 *68.7 *5.0 „ girls 58.0 10.2 60.9 8.3 65.4 6.8 69.9 4.4 *67.6 *5.5 12-year-old boys 68.0 3.4 70.6 2.7 73.1 2.1 75.8 1.3 †75.9 †1.5 „ girls 70.5 2.6 72.3 2.3 75.3 1.6 77.0 1.1 †77.9 †1.2 All above age groups 62.1 8.5 60.3 9.3 62.9 8.6 67.4 5.8 65.7 6.3 *7-year-old children. †11-year-old children. N.B.—Serious decay means four or more carious teeth requiring treatment. It will be seen that the condition of the teeth of the 11-year-old children examined in 1934 does not differ very appreciably from that of the 12-year-old children examined in 1933, and that the 7-year-old children of 1934 are distinctly worse than the 8-year-old group of 1933, while the entrants of 1934 have smaller percentages with sound teeth than those of 1933. The halt in progress and, worse, the definite regression in the condition of the teeth is the one great blot which the returns show in 1934. It will be noted, however, that it is the younger children who are chiefly concerned, and that the older children who have longer been under the influence of school conditions and have had the benefit of school dentistry do not reveal the same falling away. The revelation last year of the setback in the numbers of children attending for treatment at the dental centres acted as a whip to those engaged in propaganda work and following-up, and the treatment results given on a later page show an improvement during 1934, which cannot fail to produce better results in the condition of the teeth as found at routine inspections. Each year children other than entrant infants have their visual acuity tested by means of the Snellen cards, those whose defects have been corrected having their vision tested wearing their glasses. The entrants of course cannot be tested as they do not know their letters. It was one of the reasons for ante-dating the inspection of the second group, that school children generally would have their first vision test a year earlier—at seven instead of eight. It is interesting therefore to compare the results of the 7-year test with those of the 8-year-old children inspected last year. In the 7-year-old boys inspected during 1934, 40.1 per cent. failed to reach normal vision, while in 1933, 39.7 of the 8-year-old boys failed; amongst the 7-year-old girls in 1934, 40.5 per cent. failed compared with 40.4 per cent. of the 8-year-old girls in 1933. The close approximation between these results is remarkable. It was feared that possibly a worse result might have been attained amongst the 7-year-old children owing to greater unfamiliarity with the letters, and that some allowance would have to be made for this. It appears now, however, that the 7-year-old test of vision is quite reliable. The earlier correction of defects resulting from the change should make an appreciable difference later. Amongst the 11-year-old group in 1934, 33.9 per cent. of the boys and 35.4 per cent. of the girls failed to pass the normal vision test, while in 1933 in the 12-year-old group 35.9 per cent. boys and 37.5 per cent. girls were unable to do so. There has been in recent years a considerable improvement in the numbers of children reaching normal vision, and a tendency for the visual acuity of the girls, which was formerly far worse, to approximate more closely to that of the boys. B Vision. 14 Defects of a more serious character (i.e., vision of 6-12 or worse in either eye) occurred in 12.9 per cent. of 7-year-old boys and 12.4 per cent. of 7-year-old girls, and in 16.1 per cent. of both 11-year-old boys and girls in 1934. In 1933 more serious defects occurred in 14.7 per cent. boys and 14.4 per cent. girls in the 8-year-old group and 17.7 per cent. boys and 17.4 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 defects, 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 18.5. The improvement is most marked among the older girls, and there is little doubt that the importance of the early correction of visual defect is becoming more widely recognised among the parents. The lower proportion of 7-year-old boys and girls with serious defects suggests that a saving in deterioration of vision will result through the earlier examination now carried out. The exact equality in 1934 of the sexes at eleven years in regard to more serious defects is a noteworthy feature. Hitherto all examinations of the older children in the schools have shown a preponderance of vision defects in girls over boys. The figures this year suggest that the relative increase in girls takes place after eleven years of age. The decrease in the preponderance of visual defects amongst the older girls is a testimony to the efficacy of the measures taken by the education authority to ensure better lighting in the classrooms and to prohibit sewing by artificial light. Enlarged tonsils and adenoid growths. In the statutory age groups 6,297 children were referred for some form of treatment of enlarged tonsils or adenoid growths; this is 4.5 per cent. of the children examined, compared with 4.1 per cent. in 1933, 6.6 per cent. in 1931, 6.7 per cent. in 1930, and 7 per cent. 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 in the individual age groups in 1934 were: entrant boys 7.8, girls 7.0; 7-year-old boys 4.0, girls 4.3; 11-year boys 1.3, girls 1.8. There has been a continued fall in recent years in the percentage of children referred for treatment for enlarged tonsils and adenoid growths, the increase in 1934 being due to the alteration in the age of the children examined. The older the children the fewer there are that suffer from ear, nose and throat defects. The proportion of those recorded as having enlarged tonsils and adenoid growths who were referred for treatment was 38 per cent., the same proportion as in 1933, compared with 43 per cent. in 1932. Of the 6,297 children referred for treatment for these defects, 4,252 were referred for enlarged tonsils only, 507 for adenoids growths only, and 1,538 for both enlarged tonsils and adenoid growths. Otorrhœa and hardness of hearing. Otorrhœa was noted in 1,187 children, or .9 per cent. of those examined, compared with .8 per cent. in 1933 and in 1932, and 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; in 1927 the percentage was 1.3, and in 1913 it was over 2 per cent. The increase by one in a thousand shown in 1934 is also due to the alteration in the age groups examined, as this defect is most prevalent amongst entrant infants and diminishes during school life year by year. Hardness of hearing was found in 221 children, or only .2 per cent. of those examined. This compares favourably with 383 in 1933, 453 in 1930, and 868 in 1927, and again equals the best result yet obtained. 15 Mention is made in another part of this report (page 29) of the use of the audiometer, which brings to light many minor degrees of hardness of hearing and cases of unilateral deafness, which, while not interfering with education, are sometimes the indication for active preventive treatment. Heart defect (functional or organic) was reported in 2,570 children or 1.9 per cent., the same percentage as in 1933 and 1932, compared with 1.8 per cent, in 1931, and 2 per cent. in 1930. As usual, older girls presented a percentage (2.2) in excess of older boys (1.7). Heart and anæmia. 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 in the female sex. Anaemia was found in 1,336 cases, or 1.0 per cent., compared with .9 per cent. in 1933, an improvement upon the years 1931 and 1932, when the percentage was 1.1 and upon 1930, with 1.2 per cent. Lung defects were noted in 3,013 children (2.2 per cent.), compared with 2.0 per cent. last year. The increase of .2 per cent. is due to the preponderence of entrant infants in the numbers examined this year in consequence of the small numbers of 7-year-old children examined, and is not a true increase. There is always amongst the entrant infants a certain amount of bronchitis found to be associated with errors in feeding. The 7-year-old children were in fact better than the 8-year-old children in 1933. Lung defects. The bulk of the cases are provided by the entrants (3.9 per cent. boys and 3.4 per cent. girls). These cases are largely bronchial catarrh, which is especially prevalent amongst entrant infants who present rickety manifestations, and the preponderance of incidence upon infant bovs compared with girls holds as in rickets. There were 60 children in the three age groups reported to have symptoms indicative of pulmonary tuberculosis, but only 6 of these were not already under treatment. In addition, 24 children had other forms of tuberculosis. The incidence of tuberculosis in any form found at routine inspections is .6 per thousand. For many years the amount of tuberculosis amongst school children has been very small. Tuberculosis, Epilepsy was noted in 36 cases, compared with 61 in 1933, 52 in 1932, 65 in 1931, 60 in 1930 and 73 in 1929; chorea in 95 cases, compared with 132 in 1933, 158 in 1932, 170 in 1931, 186 in 1930 and 178 in 1929; paralysis in 55 children, compared with 56 in 1933, 63 in 1932, 81 in 1931, 76 in 1930 and 122 in 1929. Nervous diseases. Symptoms of rickets or the effects of early rickets were noted in 683 children. This is .5 per cent., compared with .3 per cent. in 1932, and .4 per cent. in 1931 and 1930. Infant boys had an incidence of 1.0 per cent., compared with .7 per cent. in 1933, .9 per cent. in 1932, and infant girls .5 per cent., compared with .3 per cent. in 1933, ana .4 per cent. in 1932. The stigmata of early rickets tend to disappear as growth proceeds. It appears therefore that there has been an increase in rickets, which is a nutritional disease, amongst children below school age. Rickets. Spinal curvature accounted for 527 cases (-4 per cent.), the same proportion as last year. Of these 222 (-8 per cent, of those examined) were among the 11-yearold girls, while the 11-year-old boys showed -5 per cent. Other deformities, mainly flat foot were present in 1,449 children (1-0 per cent.). This is an increase of • 1 per cent, on 1933. Deformities. For the reason mentioned earlier it was decided that the 8-year-old group should, during 1934, be dealt with by means of a " preliminary survey " in which the school doctors would rapidly see all the children individually without undressing them, would note the obvious defects and refer for detailed examination in the presence of their parents any children who appeared during the preliminary survey to need this procedure. There were 47,001 children in the group (23,234 boys and 23,767 girls). Of these 3,739 (1,781 boys and 1,958 girls) or 7-95 per cent, were referred for detailed examination. The 8-year group. 16 Naturally those referred for detailed examination produced a higher proportion of defects than a normal age group, as they were specially selected cases. For instance, of the specially referred boys 12.4 per cent. were found to have enlarged tonsils and adenoid growths, whereas in the whole 8-year group in 1933,8.4 per cent. of boys were so found. Of the referred children (boys and girls) 4 per cent. had heart disease, compared with 1.8 per cent. in the 8-year group in 1933. But if the children found defective are related to the whole group from which they were derived, it will be seen that this method is not to be compared in efficiency with the normal complete medical examination usually carried out. Of the whole group, enlarged tonsils and adenoid growths were recorded in 3.8 per cent. of the boys compared with 8.4 per cent. of the 8-year boys in 1933, while heart disease in the whole group (boys and girls) was found in .5 per cent. compared with 1.8 per cent. in the 8-year group in 1933. It is clear therefore that, as similar figures are reported for every ailment charted, large numbers of defects were not discovered, particularly those which are slight and in their early stages, when it is so important to discover them, for the service is primarily a preventive one. It is well to put this apparent failure to discover the whole of the defects in this group on record. In times of national stress and difficulty it is often proposed that medical examinations should be curtailed or carried out in some more cursory way such as this. It is even sometimes suggested that it would be sufficient for the teachers to bring before the medical officer such children as they note to be ailing. The experience with the shortened method of inspection which has been employed in the past year confirms previous experiences of the same kind, and proves that it is impossible, if proper service is to be given and justice done to the children, to substitute superficial inspection for the detailed examination of every individual child. One of the most important reasons for not missing out the children born in 1926 was the fact that they would have had no investigation of their visual acuity until reaching the age of eleven. All the children were tested in the usual way and referred for treatment if defective. For this purpose the preliminary examination was quite effective, as 8.5 per cent. of the children in the group were referred for refraction. As the figure for the detailed examination of the 8-year-old group in 1933 was 8.3 per cent., it is clear that in 1934 no 8-year-old child failed to receive the usual attention in regard to visual acuitv. Special examinations. The number of children, not in the age groups for routine examinations, submitted to the school doctors as special cases was 91,880, an increase of 6,520 over that for the previous year, and this figure does not include another 44,917 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 the number seen in the routine age groups, yet in the case of many diseases the actual numbers found to be suffering thereform in the former generally exceed those in the latter. Thus 1,865 children with scabies were referred for treatment at special inspections, compared with 91 only at routine inspections. Heart trouble requiring treatment was detected in 282 children at special inspections, compared with 271 at routine inspections. In regard to epileptics 82 first came to notice at special inspections, compared with 39 at routine inspections, and 297 children with chorea were seen at special inspections, compared with 101 at routine examinations. This is evidence that considerable advantage is being taken of the doctors' visits to the schools to present to them promptly really ailing children. The health of the leaving child. The Council has undertaken the examination of a fourth age group, namely, children who are leaving school. This examination takes place in the term prior to that in which the children are due to leave school. The results of this examination are available at the school-leaving conference, and are of assistance in determining the choice of a suitable occupation. Coming at the end of the school career, the examination is useful in estimating the results of medical attention received since the children entered school. This year's "leaver" group was formed of the children born in the year 1920-21 and consequently the numbers are again, in consequence of the high birth-rate at 17 that time, larger than in the previous year. They comprised 31,801 boys and 31,832 girls. In nutrition they were found to be better than the younger groups, only 35 per cent. of the boys and 3 per cent. girls being classed as subnormal. They compared with 3.7 per cent. boys, and 2.7 per cent. girls in the previous year. In personal cleanliness this group also shows an improvement on the 12-year-old group, 98.7 per cent. boys and 96.6 per cent. girls having perfectly clean heads. The dental condition of this group was found to be slightly inferior to that of the 12-yearold group, for both boys and girls, the percentage with satisfactory mouths being 75.1 in the case of boys, and 75.8 in the case of girls, compared with 75.9 and 77.9 respectively in the 11-year-old group. In other respects the "leaver" children showed an improvement in health over the 11-year-old group. Spinal curvature in the "leaver" girls was reported in .8 per cent. of the cases, identical with the percentage at age 11; on the other hand, heart defect in the " leaver" girl was 2.1 per cent., compared with 2.2 in the 11-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 in all cases to the children aged 12 and 13 years, but ceases at the age of eleven in many schools. This should be remedied by the increased dental inspections which are to be carried out under the 3-year programme shortly commencing. The reorganisation of the tops of schools has also caused some difficulty in the way of following up the older children. 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 doctors' observation of the percentage of children having vaccinal scars: entrants, 45.9; 7-year-olds, 50.4; 11-year-olds, 55.1; and "leavers" (13½), 52; compared with, in 1933, entrants, 46.6; 8-year-olds, 49.3; 12-year-olds, 50.7; and "leavers" (13½) 55.1. 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. Vaccination. In 1934 a condition was noted chiefly in the north-eastern division which was apparently epidemic amongst the children in some schools. It had never previously come under the notice of the school medical service of London. It consisted in painful warts on the soles of the feet. Plantar warts. Dr. Chaikin, the divisional medical officer, followed up the cases and has written the account which follows:— It was reported from a school in this division that there were several children suffering from warts of a painful nature, on the feet, and that one of these children and others were under the care of the local foot hospital. Four children were found at this school, two of whom were attending the foot hospital, one, the London hospital, and one not under treatment. Twelve others were, also, on the books of the hospital, but only five could be traced to Council schools. All were examined by Dr. G. W. Bamber, who diagnosed the condition as plantar warts. The Council's consultant dermatologist was consulted and X-ray treatment was recommended^ The local foot hospital authorities were agreeable to this, and arrangements were made for treatment at the London hospital of those whose parents were willing, subject to the form of treatment being decided by the physician of the slun department of that hospital. It was ascertained that each child at the school, who went to swim, had a separate towel. The children affected discontinued attendance at the swimming lesson. The view of the Council's consultant dermatologist on the subject was as follows: " All three common varieties of warts, namely, juvenile flat-warts, ordinary warts, and plantar warts, are contagious and auto-inoculable, but not every individual is susceptible to them. Since the classical experiments of Wile and Kinger, in 1921, it has been generally accepted that all warts are due to a filter-passing virus. Whether or not the viruses of plantar warts and ordinary warts of the hand are identical, has yet to be decided. Plantar warts occur at all ages, and in epidemic form, in schools. It seems to me most probable that the virus is locally inoculated in walking on an infected cork or wooden grid in the bathroom. •' With regard to prevention, it is important that children should not run about wards or bathrooms with bare feet, and after the bath it is better that they should stand on a concrete floor than on a wooden grid or cork mat. The ideal is for each child to have its own towel to stand on. If there are cases in an institution, it would be well for the feet of the children using the same bathroom to be sponged with methylated spirit after the bath. It is advisable, also, to have the shoes swabbed out occasionally with a 1 in 40 lysol solution. 18 "At Goldie Leigh hospital all cases of plantar warts are treated by X-rays, a pastille dose and a half is given, the skin around the warts being completely screened. If that is not sufficient, a second dose is given after the lapse of a month. Other effective treatments are the actual cautery and surgical removal after freezing with carbon dioxide. If the warts are very superficial they can sometimes be got rid of by the continuous application of 30 per cent. salicylic plaster. At Goldie Leigh hospital there are generally a few cases, but there has never been any serious epidemic. " It is a curious fact, connected with all warts, that certain drugs, such as green iodide of mercury, and large doses of magnesium sulphate, may cause them to disappear. The explanation of this is a problem which must be left to the biochemist, in the same way as the explanation why warts not infrequently disappear, apparently spontaneously." The medical officer of the borough in which the school was situated from which the cases were reported was informed with regard to the question of swimming baths, and he wrote to the school medical officer that the floors of the dressing boxes of the baths are all tiled and are flushed after each occupation, and no grids or mats of any kind are used in the baths. The bath surrounds, which are tiled and sloping about one inch in three feet, are frequently flushed and the drains are treated with izal. Periodically the bath surrounds are, also, treated with chloros. The foot bath accommodation is ample and carbolic soap is provided for use by bathers and all towels issued to bathers are boiled. All the cases in the above-mentioned outbreak cleared up after treatment. The probable average duration was 8 months, and the duration of treatment before cure months. A further recent case has arisen in the same school, and a number of scattered cases have been reported from other schools including one secondary school. It is remarkable that all the cases reported have been girls, and that all were regular visitors to public swimming baths. 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 1934, 138,654 children were re-inspected, a decrease of 23,496 on the number for 1933. At the first re-inspection 89,869 cases of defects requiring treatment (some children having more than one defect) were reviewed. At the second re-inspection 48,785 cases not cleared up at a first re-inspection were again reviewed. By combining the results of both reinspections it is found that 75.1 per cent. of the children re-inspected were treated or discharged as no longer requiring treatment. This figure is not in gross so good as that of the previous years. In 1933 the figure was 82.2 per cent. It is the dental cases, however, which during the past year contributed more than one half of the cases to be followed-up, that cause the most difficulty and give the worst results. If these be eliminated the cases of defect satisfactorily dealt with at the time of the second re-inspection reached the proportion of 84.8 per cent. Table 5 First Re-inspections, 1934. (Percentages are given in italic type.) Defect treated. No. of Cases. Treated. Untreated. By private doctor. Under Council's scheme. At other hospitals. Discharg'd Improved. For observation only. Still needing treatment. Discharg'd Not discharg'd Discharg'd Not discharg'd Discharg'd Not discharg'd Refraction 17,334 148 81 4,443 2,043 523 359 1,491 3,482 4,764 .8 .5 25.6 11.8 3.0 2.1 8.6 20.1 27.5 Minor ailments 5,599 118 21 1,067 295 322 129 1,568 929 1,150 2.1 .4 19.0 5.3 5.8 2.3 28.0 16.6 20.5 Nose and throat 10,880 34 11 3,260 152 574 92 1,516 1,774 3,467 .3 .1 30.0 1.4 5.3 .8 13.9 16.3 31.9 Teeth 46,575 1,287 303 17,830 805 1,595 130 3,567 1,030 20,028 2.8 .6 38.3 1.7 3.4 .3 7.7 2.2 43.0 Other ailments 9,481 177 68 597 586 771 648 2,171 3,070 1,393 1.9 .7 6.3 6.2 8.1 6.8 22.9 32.4 14.7 Total 89,869 1,764 484 27,197 3,881 3,785 1,358 10,313 10,285 30,802 2.0 .5 30.3 4.3 4.2 1.5 11.5 11.4 34.3 19 Second Re-inspections, 1934. Refraction 11,697 46 22 2,220 1,263 275 199 1,224 2,857 3,591 .4 .2 19.0 10.8 2.4 1.7 10.4 24.4 30.7 Minor ailments 2,797 46 19 376 214 129 96 774 661 482 1.6 .7 13.4 7.7 4.6 3.4 27.7 23.7 17.2 Nose and throat 6,282 11 7 1,269 93 336 51 1,212 1,168 2,135 .2 .1 20.2 1.5 5.3 .8 19.3 18.6 34.0 Teeth 21,266 621 156 6,468 348 642 71 2,403 630 9,927 2.9 .7 30.4 1.7 3.0 .3 11.3 3.0 46.7 Other ailments 6,743 110 36 496 494 421 384 1,566 2,090 1,146 1.6 .5 7.4 7.3 6.2 5.7 23.3 31. 0 17.0 Total 48,785 834 240 10,829 2,412 1,803 801 7,179 7,406 17,281 1.7 .5 22.2 4.9 3.7 1.6 14.7 15.2 35.5 The following-up of children found to be in need of treatment or special observation is carried out by the school care organisation, consisting of upwards of 5,000 voluntary workers aided and supervised by a staff of paid organisers. 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 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 was formerly expected to visit the home of every child recommended for medical treatment (except where satisfactory arrangements had been made with the parents at the actual inspection) but in 1933 a method of written communication was introduced as an experiment and this was so successful that it is now the rule in an increasing number of schools. Only when no response is obtained or refusal is given does the social worker visit. Children's care committees. During 1934, 538 cases, involving 647 defects, were reported to the National Society for the Prevention of Cruelty to children: these included 351 dental defects, 162 vision cases, 48 nose and throat affections and 12 cases of ear disease or deafness. Cases referred to the N.S.P.C.C. The influence of the acute infectious fevers on the production of aural disease is shown by the high proportion of children who are deaf and partially deaf, in whom the trouble can be traced originally to an attack of measles or scarlet fever. One of the most important means therefore of preventing deafness and hardness of hearing is the after-care of children when they are discharged from the fever hospitals. Aural disease and the acute infections. An arrangement has been made whereby 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 850, of which 419 were forwarded to Borough Councils or other local authorities. Of the cases followed up at school, 16 were found on the first examination to have otorrhcea, and of the cases seen at second examinations the condition persisted in six. All the cases not cleared up are being kept under observation. In view of the importance of this procedure, efforts were made to secure fuller notification of cases. That these were successful is shown by the fact that the number of notifications from the isolation hospitals was more than double that of the previous year, but the large increase was chiefly in children below school age who were therefore not under the school care organisation. 20 It is reported that there is an increasing tendency on the part of employers to reject applicants with discharging ears. Medical and dental treatment. The arrangements for medical and dental treatment of children attending public elementary schools and scholars and pupils at secondary, trade and continuation schools, have proceeded very satisfactorily and the attendances of patients are once again on the up grade. No new centres were established during the year, the number where special arrangements for treatment obtain remains at 74 centres and 17 hospitals, together with the special in-patient centre at the Cyril Henry centre, Woolwich, and the dental centre for the children resident at the King's Canadian camp school, Bushy Park. During the previous year, 1933, there was a drop of 9,500 in the total number of children dealt with at the various centres compared with the year 1932, but in 1934, 6,858 more children received treatment than in 1933. The following table sets out the provision made and the actual numbers treated during 1934:— Table 6. Ailment Provision made in 1934. Numbers treated 1934. Numbers treated 1933. Eye 43,102 40,284 40,434 Ear, nose and throat 17,667 12,622 14,145 Ringworm 424 195 178 Minor ailments 79,777 114,809 110,600 Teeth 150,150 138,140 133,835 Total 291,120 306,050 299,192 Eye defects. The number of cases treated in the eye departments of the centres and hospitals during the year was 40,284 of which it is estimated that 2,000 were cases in which definite diseases of the eye were treated, the remainder being cases requiring correction for errors of refraction. It will be seen that this number is slightly less than that for 1933. During the year the number of cases in which spectacles were prescribed was 29,599, and spectacles were obtained in 27,497 cases, a similar percentage (92.9) to the year 1933. Ear, nose and throat. Once again there has been a reduction in the number of ear, nose and throat cases attending the centres and hospitals. During the year 12,622 cases were seen and 8,860 operations performed, compared with 14,145 and 10,008, respectively, during the year 1933. An analysis of the cases shows that in 7,686 the operation was for both tonsils and adenoids, in 700 cases for enlarged tonsils only, and in 443 cases for adenoid growth only. The remaining 31 cases were mainly operations for nasal defects in which cauterisation was required. Reference was made last year to the introduction of passive immunisation against scarlet fever and diphtheria at the Cyril Henry centre where the work is carried out directly by the Council. Particulars are given in the section of the report upon infectious diseases (p. 43). Ringworm. The incidence of ringworm of the scalp among the 500,000 children in the London schools is now comparatively rare. During the year only 195 cases were dealt with at the centres and hospitals of which 118 were treated by X-rays. Minor ailments. The number of minor ailments cases dealt with during the year was 114,809, including 13,087 cases seeu by nurses only. This compares with 110,600 and 11,876, respectively, during the year 1933. The total number of attendances made by the children at the various centres was 1,400,908. Dental treatment. No additions have been made during the year to the 69 dental centres in London. This number does not include the experimental centre at the Berkshireroad school, which is organised and maintained by the Manor Charitable Trust specially for the children attending the school. Dental inspections have been held 21 in the schools contributory to the various centres and during the year 2,492 inspection sessions have been held by the 68 inspecting dental surgeons. As a general rule children in the age groups examined by the school doctors, viz., entrants, children aged 7 and 11 and leavers, are not inspected by the dentist; but, in connection with certain of the centres, where the inspection of the schools on the rotas is completed in less than one year, it is the practice for the dentists to inspect children of all ages. It is intended that the scheme shall be extended so that by the conclusion of the next three years, children of all ages in all the schools in London will be inspected by the dentists at least once a year. The number of children inspected by the school dentists during 1934 was 273,672, compared with 275,213 during 1933. The number found to require treatment was 176,509 or 64.5 per cent. Table IV, group IV, at the end of this report shows the number of children of the various ages inspected, as well as the details of the treatment given at the hospitals and centres included in the scheme. The total number of children treated was 138,140 compared with 133,835 during the year 1933, an increase of 4,300. Included in the total is the number of children (3,710) from the schools allocated to the Eastman clinic who were treated at the clinic and 22 scholarship cases, as well as 488 cases dealt with at Berkshire-road school. The 1933 figures were compiled on a similar basis. In addition to the above there were 7,023 children from unallocated schools treated at the Eastman clinic. The number of sessions including general anaesthetic sessions held during the year was 18,211, compared with 18,713 during the previous year. It will be seen that, although some 500 sessions less were held, there were 4,300 more cases dealt with during the year. This is accounted for by the reduction in the number of sessions devoted to general anaesthetics, and it may be noted that there were 66,424 administrations of general anæsthectics, compared with 69,683 during 1933. This reduction has been effected by the more general use of local anaesthetics, especially in the treatment of the older children. Of recent years a considerable change of outlook towards the use of local anaesthetics in dental therapy has taken place throughout the dental profession. Efforts have been and are being made to use local anaesthetics more generally in the school treatment centres in suitable cases, and most of the dental surgeons have now adopted the practice with very good results. Moreover, the extraction of one or two teeth on the spot under a local anaesthetic saves another visit to the centre for gas treatment; and, apart from this economy of time, the child is not subjected to the nervous anticipation of further treatment, and the work is completed. During the year 31,945 local anaesthetics were given. The aim of the school dental service is conservative in character, and as a general principle every saveable tooth should be preserved. It is indicative of the progress of the dental scheme in London that year by year the number of saveable teeth is increasing, whilst the number of unsaveable teeth is decreasing. This is shown in the following table by the steady increase in the number of fillings undertaken, save for the slight setback in 1933, and the decrease in the number of extractions. Table 7. [## #]Year. No. of cases. No. of fillings. No. of extractions. 1928 129,255 116,818 406,748 1929 129,952 115,904 395,838 1930 138,280 122,120 410,419 1931 139,723 132, 237 393,579 1932 134,769 138,857 352,234 1933 133,835 134,678 332,146 1934 138,140 139,513 321,961 A problem that is ever present is that of the "casual" case—that is the child whose parents do not take advantage of the facilities offered at the school inspections, and who is only brought forward by the parent when acute toothache is the cause. Casual cases. 22 Such cases account mainly for the large number of permanent teeth extracted at the centres, since earlier attention would probably have saved these teeth from the forceps. In London this problem is further complicated by the fact that at many voluntary hospitals a dental department is maintained, and the parent who declines, for his child, the advice offered by the school dentist can without great difficulty obtain the emergency treatment which later on becomes necessary. There is also the factor that the charge made by voluntary hospitals to dental out-patients is less than that charged to the parent under the Council's scheme. Whilst the aim of the dental surgeons employed at the Council's treatment centres is to preserve particularly the permanent teeth during the child's school life, yet there are still a great number of parents who do not appreciate the value of conservative dentistry and consider extraction the only method which need be carried out. Orthodontics. No special facilities have hitherto been provided by the Council for dealing with orthodontic cases. Any requiring such treatment that have been discovered, either at the inspections in the schools or at the treatment centres, have been referred to the dental hospitals or the Eastman clinic for treatment. The Council has always felt that the cost of equipment and staff for a special dental workshop for the purpose of the school medical service alone was not justified. The position has altered since the transfer to the Council of the general hospitals under the provisions of the Local Government Act, 1929. The Council now maintains a special dental workshop primarily for its general hospitals where dentures and dental appliances are made by dental mechanics. As an experiment, for 6 months, 3 special orthodontic centres have been established at the Deptford, Hammersmith and Prunella (St. George-inthe-East) centres. The children are seen at a special session devoted entirely to orthodontic work, impressions are taken and the casts are sent to the Council's dental workshop at St. James' hospital, Balham, where the necessary appliances are made. These are forwarded by post to the centres, and the children attend periodically for observation and adjustment of the appliances. The estimated average cost to the Council of the appliances is 12s., and, during the experimental period, it has been decided that a uniform charge of 12s. shall be made to the parents for the whole course of orthodontic treatment including the appliance. This is in addition to the ordinary dental charge. In necessitous cases the school care committees are empowered to reduce the charge or to remit it altogether. The accompanying diagram (fig. 1) shows the growth in numbers of children annually treated for dental decay from the time that dental treatment of school children commenced in the first year of the King's reign. The two periods during which progress was arrested, viz., in 1922 and in 1932-33, were associated with unemployment and increased charges to the parents. Charges to parents. Under Section 81 of the Education Act, 1921, the Council is bound to make a charge not exceeding the cost for any medical or dental treatment given under its school medical arrangements. The charges prescribed for such treatment to children attending elementary schools, special schools and nursery schools, and for foundation scholars in aided secondary schools are substantially lower than the full cost. Parents, who, while not able to pay the fees of a private practitioner, are able and willing to pay the full cost of the medical or dental treatment of their children, are enabled to do so. The Council on 6th February, 1934, decided that, as an experiment for one year from 1st April, 1934, arrangements should be made for medical inspection and treatment of students attending the day continuation schools and three junior evening institutes. Fee paying pupils at secondary schools may under certain conditions avail themselves of the Council's school medical and dental treatment arrangements. The charges for these cases are the full cost as determined year by year. Machinery is however, in existence whereby reductions or remissions can be obtained where the circumstances justify such a course. 23 The calculated full cost during 1934 for each class of ailment treated was:— Enlarged tonsils and adenoids, 18s.; Minor ailments, 7s. 5d.; Dental treatment, 7s.; X-ray treatment for ringworm, 26s. 4d. For many years the prescribed charge made by the Council to parents of children in elementary schools in respect of medical and dental treatment of school children was 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. The charge for operative treatment of enlarged tonsils and adenoids was increased from 2s. to 5s. in April, 1932. All children operated on under the Council's scheme are retained in the various centres as in-patients. 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. In those dental cases where extensive treatment is undertaken, including the administration of an anaesthetic, 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. So far as those parents who are unable to pay are concerned, it is made clear to 24 them that the care committees will reduce the charge by 50 per cent., or remit it altogether. The "slight-treatment" cases in the dental departments, in which the charge of 1s. is made, numbered, in 1934,15,297, an increase on the figures for 1933, when they amounted to 13,393. No charge is made for refraction of the eyes in the case of defective vision. This is looked upon as an extension of medical inspection rather than as treatment. The cost of spectacles however in the case of children attending elementary schools (but not special schools where the Council bears the cost) falls upon the parents, assisted where necessary from voluntary funds. London Central Spectacles Committee. The care of the children in this respect is supervised by the voluntary London Central Spectacles Committee, who, in 1932, pointed out that the figure for that year showed a drop in the number of spectacles obtained ; this was disappointing, but understandable in view of the hard times. The percentage, 88.6, of the spectacles ordered, was the lowest since 1926, and it was hoped that the lost ground would be regained in the succeeding year. The falling off in 1932 led to redoubled efforts on the part of the care committees in 1933, and the hope that the lost ground would be regained was amply fulfilled, as in the latter year the percentage of children obtaining spectacles who needed them was 92.9, the highest ever yet achieved ; this percentage was repeated in 1934. In their 13th annual report the London Central Spectacles Committee state :— This recovery of lost ground pays tribute to the sustained efforts of all concerned through a period of very real difficulty. It must also be remembered that this percentage, excellent though it is, may not represent the full total. The figure given is arrived at from information available from all sources, but it is known that, in a certain number of cases, the fact that the spectacles have actually been obtained is not reported, and the percentage would be higher still if complete information had been received. The work of following up the cases and the collection and repayment of loans falls upon the care committees, and only those who have had experience can realise the weight of the burden they have to shoulder. The arrangement for co-operation with the Public Assistance Committees is now running more smoothly, and there is less delay in obtaining spectacles for children whose parents are in receipt of out-relief. Many reports from the districts record increased demands upon their funds, but side by side with these are encouraging accounts of repayment by parents. It is not possible to give the exact figure of the sum collected in each area, owing to the different forms in which the reports are sent in, but the following are the figures available:— Amount collected, £401 18s. 1d. Repayments by parents, £329 1s. 8d. These figures must not be taken as representing the full amounts, as several reports give no details of their financial position, and in certain districts funds for spectacles are combined with boots and clothing funds, so the actual sum devoted to spectacles can be only roughly estimated. Otorrhœa. When medical inspection of school children commenced in London in 1906, it was found that large numbers of children in the schools suffered from otorrhoea. Most of these cases were in a very offensive condition and the smell in the classrooms was often disgusting. The education authority had no power to provide treatment and the children attended out-patients' departments at hospitals in a haphazard fashion; in the intervals of attending the hospitals, the cases were left to the mothers, who were quite incapable of keeping the ears in a wholesome condition. It was clear that the hospitals' out-patients' departments were quite inadequate to deal with this work. By the Education (Administrative Provisions) Act, of 1907, local education authorities were given the power of providing treatment. The Education Committee were very impressed with the need of supplementing hospital out-patient treatment by some more appropriate scheme, and about 1909 the experiment was made of employing the district nurses to visit the homes of children who were found in school to have otorrhoea. It was found, however, that, although the ears were kept in a more hygienic condition, the cost per case was considerable, and there was the objection that the nurses' work was not under medical direction. About 1913, minor ailment departments were introduced at school treatment centres. At these the district nurses worked under medical direction; there was 25 no time lost in visiting homes (often to find that the children were out) and it was possible to give skilled nursing assistance to every child once, or even twice, every weekday. This led to a great improvement in the conditions and the old trouble of offensive ears in the classroom was got rid of. Gradually minor ailment departments increased in number, until there are now 70 covering the whole of London. The doctors in charge of minor ailments were, however, not specialists in otology, and, though a much larger number of discharging ears were cured than formerly, the departments still tended to be clogged up by cases which remained uncured. In order to ascertain whether something could not be done to reduce the chronicity of these cases, it was arranged for Dr. Wells, who was then a school doctor in the south-west division, to give up one session a week to carry on an " ear inspection clinic," and to this were referred cases from the surrounding minor ailment departments for special investigation and advice. Through his connection with the Metropolitan Asylums Board, Dr. Wells was able to secure in-patient treatment for those children who could not hope to be cured of otorrhoea except by mastoid operation or other in-patient treatment. The special inspection clinic proved to have great possibilities, and the system' was gradually extended to other areas. Dr. Eichholz of the Board of Education, who always took much interest in the development of aural work from the point of view of prevention of deafness, pointed out about 1920 the possibilities of zinc-ionisation treatment which Dr. Friel had advocated. The Education Committee in 1920, in sanctioning the extension of the inspection clinics, approved the introduction into them of the zinc-ionisation method of treatment. Dr. Friel himself was employed in the service, and the number of clinics grew. At each of them an aural surgeon of experience was appointed. By this time Dr. Wells had received a special appointment which allowed him to give his whole time to the development of the work. He also held an appointment with the Metropolitan Asylums Board, and himself carried out the operations at the Cleveland Street infirmary. In the first instance cases from the minor ailments departments which did not clear up after three months treatment were brought to the special ear clinics for investigation. Those suitable for ionisation were subjected to it; those needing operations were sent to Cleveland Street. It was found desirable, however, to obtain advice at the special clinics at an earlier stage in many cases; and in 1925 the school medical officer addressed a memorandum to the honorary secretaries of the treatment centres on this point, asking that all cases which did not clear up within a month should be referred for specialist examination. There was still, however, a tendency on the part of the minor ailment departments to retain cases unduly, and the principle was adopted of working through all ear cases on the lists of the minor ailment centres in turn. This is the practice which still obtains. All through the development of the scheme the importance of ready and prompt transference of children needing it to in-patient treatment has been borne in mind ; and the Council's school medical service has worked in close co-operation with the Metropolitan Asylums Board's and latterly the Council's special hospitals. In the early years, before this liaison had been established, the work was very greatly hampered through the long waits for hospital beds which made any preventive scheme very difficult indeed. With the provision at Cleveland Street this difficulty disappeared. When the Downs hospital was made available for this work—largely to meet the demands of the school medical service—Cleveland Street was closed. Children returning from the Downs hospital are kept under observation. This was done at Leighton Road after-care clinic by Mr. Wells, but the geographical position of the clinic was unsatisfactory, and some two years ago the work was moved to a more central position at St. George's dispensary, Blackfriars Road. As 26 the children are attending elementary schools and properly are being supervised by the responsible authority, the Education Committee, the work was transferred from the special hospitals division to the school medical service. The success of the work can be deduced from the accompanying diagram (fig. 2) giving the reduction in incidence of otorrhoea found at routine inspections from 1911 to 1934. Aural clinics. .Statistics. Dr. A. G. Wells reports on the special aural work as follows:— The following tables give the figures for the otorrhoea and the deaf cases treated at the special aural clinics, and returned by the divisional treatment organisers for the year:— Table 8.—Ear, nose and throat, excluding partly deaf cases. Division. Total no. of examinations made. New cases. Cases carried over from 1933. Old cases returned. Cases examined, but no treatment required. Cases cured. Lost sight of. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. S.E. 4,123 4,857 388 475 176 202 278 320 36 56 501 608 61 78 N.W. 2,235 2,832 203 259 127 154 144 166 57 72 235 290 34 42 N.E. 2,808 3,343 215 271 114 132 183 207 38 48 294 339 23 30 N. 3,490 5,454 318 418 144 173 266 334 82 138 374 470 81 97 S.VV. 3,741 4,769 434 612 147 223 226 244 112 223 460 554 35 42 Total 16,397 21,255 1,558 2,035 708 884 1,097 1,271 325 537 1,864 2,261 234 289 From these figures it will be seen that each child averaged approximately five attendances. Table 9.—Deaf cases. Division. Total no. of examinations made. New cases. Cases carried over from 1933. Old cases returned. Cases cured. Cases partially relieved. Cases unrelieved. Cases requiring no treatment. Lost sight of. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. S.E. 211 377 30 56 6 12 8 13 18 35 1 2 6 12 1 2 N.W 299 560 29 53 8 16 9 14 8 15 4 8 2 4 2 4 3 5 N.E. 108 203 28 52 2 4 1 2 8 15 5 10 — — 1 2 1 1 N. 236 433 23 42 19 38 7 13 10 20 2 3 1 2 1 2 5 10 S.VV. 80 152 18 34 8 15 1 2 5 10 1 2 — — — — 3 6 Total 934 1,725 128 237 43 85 26 44 49 95 13 25 3 6 10 20 13 24 27 From these figures it will be seen that the percentage of " cases cured " was 26.6, 1.6 per cent. " partially relieved," 7 per cent. " unrelieved," 7 per cent were lost sight of, the remainder being still under treatment at the end of the year ; and that each child averaged approximately 4J attendances. In addition to the above, 384 cases were treated for defects of the nose, ear and throat. The following table gives a detailed analysis of all the cases of otorrhoea treated, and shows the number of acute ears, the cause of the persistence of discharge in chronic ears, the number cured, the number requiring operation, those lost sight of, and the number still under treatment on 31st December, 1934. This table includes the otorrhoea cases of the children from residential schools. T able 10—Analysts of Otorrhœa cases. Cause of suppuration. Total ears. Cured. Referred for mastoid operation. Lapsed. under treatment. Acute otitis media suppurativa 255 213 5 10 27 Chronic otitis media suppurativa due to (I) Tympanic Conditions (a) Tympanic sepsis (T.S.) 1,698 1,248 — 76 374 (6) T.S. + granulations 234 130 21 17 66 (c) T.S. + polypi 46 22 7 4 13 (d) T.S. + caries 18 1 3 3 11 (e) T.S. + other conditions 9 3 — 2 4 (II) Tympanic Conditions + (a) Tonsils and adenoids 192 136 — 19 37 (b) Nose conditions 270 206 — 16 48 (c) Mouth conditions — — — — (III) Tympanic Conditions + (a) Attic disease 76 20 27 6 23 (b) Mastoid disease (no operation yet done) 166 4 151 4 7 (c) Mastoid disease (operation already done) 586 298 43 49 196 (IV) Tympanic Conditions + (a) External otitis 49 40 — 1 8 (b) Stricture of meatus 2 2 — — — External otitis 100 85 — 6 9 Cause undetermined — — — — — Total 3,701 2,408 257 213 823 From these figures it will be seen that the percentage of " cases cured " is approximately 69. The residential school otorrhoea and other cases continued to be transferred to Norwood children's home to attend for treatment at the after-care clinic at St. George's dispensary, 86, Blackfriars road, as required. The following are the details of these cases:— Total number of ears treated 164 „ „ „ cured 128 „ „ „ referred for mastoid operation 12 „ „ „ lost sight of 4 Still under treatment on 31st December, 1934 20 These figures show that 78 per cent, of the cases were " cured." 28 In addition to these cases of otorrhoea, there were a number who attended and were found to be free from ear discharge. The following are the detail :— Children requiring no treatment 21 „ „ operation for tonsils and adenoids 3 „ „ „ „ adenoids 1 „ „ removal of wax 1 „ „ treatment for deafness 2 „ „ ,, „ defects of nose 2 „ „ ,, „ dry perforation healing 2 „ lapsed 1 After-care clinic. The work done at the after-care clinic mainly consisted of the after-treatment of mastoid operation cases, and the treatment of the residential school children suffering from defects of ear, nose and throat. The details of the work done at the clinic are as follows:— Total attendances during the year 7,600 Number of ionisation treatments 2,517 „ ,, ultra-violet radiations 218 „ ,, dressings 4,814 Patients. Ears. Total number of patients seen 506 583 Number requiring no treatment 51 51 „ diastolisation only 6 — „ referred to Downs hospital 20 24 „ treated and discharged cured 326 385 „ continuing treatment at end of year 90 109 „ treated—later lapsed 13 14 Total 506 583 Patients. Ears. Discharged from Downs hospital in 1934 230 250 Continuing treatment from 1933 54 60 Total 284 310 Detailed analysis— Patients. Ears. Discharged from Downs hospital—no further treatment required 27 27 Treated (at clinic) and discharged cured 147 164 Referred back to Downs hospital for further operation 13 14 Lapsed after treatment 10 11 Still under treatment at end of year 60 67 Transferred to other L.C.C. clinics —now well 3 3 „ „ „ „ still under treatment 18 18 „ „ „ „ since lapsed 6 6 Total 284 310 Cases not requiring operations (excluding residential school)— Patients. Ears. Treated and discharged cured 78 92 Continuing treatment at end of year 22 30 Total 100 122 29 In the last annual report the value was stressed of the gramophone audiometer for the detection of hearing defects in elementary school children, and an extension of its use was recommended. The Council considered the matter and approved a scheme put forward which comprised the full-time services of one nurse to do the actual testing and perform other duties connected with the work ; and the services of an otologist for two sessions a week, to deal with the clinical examination of " failed " children, and the treatment where possible, of those cases in need of treatment, for the purpose of relieving the hearing defect. With this " unit" it is hoped that about 30,000 children may be dealt with each year. A second unit will be formed in April, 1935, and a third in April, 1936. When all three units are in full working order it is computed that about 90,000 children will be tested during each year. Audiometer. Certain difficulties existed in the efficient working of this scheme, but an effort is being made to surmount them. The first difficulty arises after test II, when it becomes necessary to make a clinical examination of the " failed " children. Hitherto this examination has been conducted at one of the special aural clinics, and a notice was sent to parents requesting their attendance with their children for the clinical examination. It was found that a not inconsiderable proportion of such children failed to attend, which considerably reduced the value of the work done. This difficulty has been overcome by arranging for the examination to take place in the schools. The parents are invited to be present with their children and the care committee worker of the school is also asked to be present. Should the otologist, at this examination, find any defect to exist which seemed to account for the loss of hearing, and to be of the opinion that some form of treatment would be likely to relieve the condition, the position is, there and then, explained to the parent, whose acquiescence in the treatment is asked for. The care committee worker then follows the case up, and when treatment is completed, notifies the nurse, who then arranges for test III, to see if the treatment obtained has produced the desired result. For the purpose of conducting test III the nurse asks the head teacher of the school of any child concerned, to arrange for the child to attend at the school in which the nurse happens to be carrying out the audiometric testing, which as a rule can be arranged at a school in the neighbourhood. Hitherto, not only did many children fail to attend the clinical examination at the special aural clinic, but of those who did attend many failed to obtain the treatment recommended, the result being that the number available for test III was only a small proportion of those who failed in test II. With the new plan, it is found that a considerably higher percentage of children are obtaining treatment and the real object of the work, viz., the detection and alleviation of defects of hearing in their earlier stages, thus preventing in many cases the onset of permanent loss of hearing, is being attained to a material extent. There is, of course, a percentage of parents who, unaware of any hearing defect in their child, are not willing to have the treatment recommended, but doubtless as the object of this work is more understood and appreciated by parents, this number will grow less. There are a number of pitfalls in the testing which are revealed by experience, such as extraneous noises, inattention of the children, imperfect application of the telephone to the ear, which tend to vitiate the results obtained, but a careful watch is being kept for these, and means of eliminating them sought for. It is not proposed to deal in great detail with this now, but the matter will be fully discussed in the report next year, when more experience will be available. The new scheme was only started on 5th November, 1934, consequently the numbers for that year are not large. Only children in the senior departments are being tested at present, but as many as forty children can be tested at a time. Special tests have been devised by the Research Committee working at the London School of Hygiene and Tropical Medicine, for the testing of children of the infant departments. These consist of a series of pictures of familiar objects in sliding frames, e.g. cow, ball, which are spoken by the voice from the gramophone record and on hearing the names of these objects the child presses on the appropriate frame and eliminates the picture from view. When the child no longer does this correctly, the point has been reached where his hearing fails. As in the records for testing the older children, the record is graded in decibels. Only a few children can be tested at a time by this method. It is in use in Tottenham and works quite successfully. Whatever objections may be advanced against the gramophone audiometer, none can be regarded as serious, and indeed most that have been put forward are quite remediable by careful attention to conditions of testing. In any case it is without equal as a method of sorting out C 30 children with hearing defect expeditiously, and it is especially useful in detecting unilateral defects of the less severe grade which would in all probability be overlooked without its aid. The results of the examination of 4,061 children are here recorded in graph form. Fig. 3 indicates the percentage of passes and failures of boys, girls and all children in three separate groups. Fig. 4 shows the same thing in " ears " instead of children. Fig. 5 shows the hearing acuity for all ears by groups. These are divided into four groups :—(1) —3 to +6, which represents all the passes, (2) a separate group of the +9, this group being what may be described as the " border-line failure group," (3) 12 to 18, and (4) 21 to 30. 31 Fig. 6 is a differential analysis of the better ear of the failed children, before and after treatment. It is a guide to the educational impairment existing, but modification of education for individual children depends on whether deafness persists after treatment. Fig. 7 is a differential analysis of all ears before and after treatment. The results of the tests show that 91 per cent. of the children had normal hearing, or less than 9 decibels loss of hearing, and 9 per cent. had 9 or more decibels loss. In terms of ears 93.9 per cent. have normal hearing or less than 9 decibels loss, 2.2 per cent. had 9, and the remainder had more than 9 decibels loss. The clinical defects found amongst the children with 9 or more decibels loss on the second test, who presented themselves at the clinical examination were as follows:— Catarrhal condition of middle ear, 75; wax, 53 ; otorrhoea, 35 ; tonsils and adenoids, 17 ; dry perforation of tympanic membrane, 10 ; nothing found, 7 ; scars in tympanic membrane, 6 ; rhinitis, 5 ; adenoids, 3 ; old mastoid operation, 2 ; debility, 1 ; deflected septum, 1 ; foreign matter, 1 ; nasal catarrh, 1 ; sclerosis middle ear, 1. In the latter part of the year, an audiometric examination with the Pure Tone (2B) audiometer of all the deaf and partially deaf children, was commenced. It was found impossible CI 32 to complete this work by the end of the year, and those remaining will be dealt with in the early part of 1935. All children are being tested by both air conduction and bone conduction and audiograms made. A certain number are also being tested with calibrated tuning forks and the 4A gramophone audiometer to compare the results of the three methods. From the examinations already made, some very interesting and important facts are being revealed, but this will form the subject of a report when all the children have been tested. Stammering children. At the eight centres maintained for the treatment of stammerers a total of 373 children attended during the year ; of these, 91 were discharged as cured, while 66, 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 states that he is more than ever convinced that stammering is curable, in spite of the length of time taken in certain cases, and he reiterates the importance of never giving up a case. He has reported as follows:— It has frequently been found advisable when a child has been attending a centre for a long time to discharge him temporarily so soon as he shows sufficient signs of improvement to warrant this. The confidence engendered will often result in a further advance after which another short term at the centre may complete the cure. This system of temporary discharge from a centre is now being applied to those cases that are still lacking in self-confidence although they have practically ceased to stammer. If the child realises that he can return to the centre at a moment's notice, he feels a sense of security which increases his confidence. An instance occurred recently in which a boy A., who had really ceased to stammer, was obviously alarmed at the thought of leaving the centre. It was found that another boy at A's school, who was due to leave school shortly was badly in need of treatment but there was no vacancy at the centre. A was asked to give up his place to his school fellow for one term, but was told that the vacancy would be kept for him. By the end of the term A had realised that he was " self supporting " and required no further help. Later reports confirmed the completeness of A's cure. A further advance has been made in the study and practice of relaxation and its effects on conditions other than stammering are proving to be more far reaching with the growth of experience. Enuresis, for instance, appears to yield to treatment by relaxation with remarkable rapidity. In fact it very seldom persists in these stammerers beyond the first month of attendance at a centre. It is more than ever apparent, however, that complete relaxation can only be taught by those who themselves have mastered the art, and who understand the psychological and physiological processes involved. As there continues to be a large number of applicants wishing to avail themselves of the facilities offered by the Council for experience in the treatment of stammerers, it is now being realized that attendance alone at a centre—although essential to the student—is not sufficient training. This has been particularly demonstrated by the more mature and experienced students who complained of the lack of systematised training. An experimental course of one year was therefore initiated to supply this need and a beginning was made in September, 1934, with six students. This course is in no way intended to be a full training for the beginner. It is essentially a supplementary course for those with orevious experience in dealing with children. The right personality and suitability generally for this type of work were taken into consideration when approving candidates. In order that these students may get the greatest possible advantage from their year's course, it is considered advisable to transfer them from one centre to another at stated intervals. Visits have been made to the centres by individuals from all parts of the world interested in the treatment of stammering. Left-handedness in children. The existence of a number of children who appear to be naturally left-handed and the effects upon them of attempts to correct what appears to be a disadvantage in a world consisting mainly of right-handed persons have always been of great interest to school hygienists. The question has become rather prominent during the last three or four years owing to the struggle for work which has resulted from wide-spread unemployment. There has, in consequence, been a general demand on the part of the teachers in London for guidance on the subject. Mr. G. E. Wear of the Ministry of Labour 33 addressed, at the Council's request, a special enquiry to juvenile advisory committees on the question and a summary of the results follows:— General Post Office.—In the case of candidates for appointment as telephonist or girl probationers, no applications are considered from those who cannot write easily and legibly with the right hand. Clerical.—Left-handedness was reported generally to be a bar by employers engaging staff where handwriting is essential; left-handed juveniles are stated to be poor and slow. From one area it is reported that employers will not consider left-handed juveniles where bookkeeping and ledger work is involved. It is also understood that the banks definitely will not engage left-handed persons. Engineering.—It was reported generally to be a definite bar where juveniles are required to operate machines and to work in a " team." Needle Trades.—It was reported generally a bar. It would appear to be chiefly due to the fact that left-handed and right-handed girls cannot work together. It is reported from one area that the largest employer of machinists states that his best workers are left-handed, but the difficulty is in the training ; the girls take much longer to learn and require more patience in teaching. Other trades where left-handedness is reported to be a bar are cabinet-making, piano-making, sports goods, bookbinding and hairdressing. The consultative committee of head mistresses of girls' schools drew attention to advice which had in certain cases been given to head teachers regarding the method which it was considered desirable to adopt in dealing with left-handedness in children, and asked that similar information should be conveyed to all head teachers. The request was referred to the chief inspector, who appointed a committee of inspectors to inquire into the matter and to ascertain whether, and if so in what degree, left-handedness is a handicap in industry and commerce. The question was also discussed with the medical officer, on whose advice the letters referred to by the consultative committee were written. It appeared desirable that head teachers should have some guidance in the treatment of left-handed children, and it was suggested by the chief inspector that a circular should be issued in the following terms :— There are exceptional children who appear to be naturally left-handed. There are also many children who have acquired left-handedness, though in many of these cases the exact cause may be obscure. But whether left-handedness in any particular case is innate or acquired, the tendency to use the left hand is often firmly fixed before school age. The conventions in writing are, however, arranged to suit right-handed people, and anyone who writes with the left hand will work under a definite, if slight, handicap all his life. There is evidence also that left-handedness is a handicap in certain commercial and industrial occupations. It would, therefore, appear to be desirable that some attempt should be made, particularly in the early stages of teaching writing, to encourage all children to use the right hand. Many lefthanded children have learnt to write with the right hand without any apparent disadvantage. It will be appreciated that in cases in which the left-handedness is either natural or well established, there may be some danger in exercising any pressure in this matter. The medical officer points out that school hygienists are agreed that there certainly should be no attempt to make children right-handed by means of punishment or ridicule. He states further that pressure is likely to result in producing a harmful degree of emotional disturbance. This has been found in some cases to result in nervous symptoms, including stammering. It will be recognised, therefore, that in any attempts to encourage children to be right-handed, it is very necessary to proceed with great caution, and to desist if any signs of abnormal emotional disturbance are shown. The Council agreed that the head teachers should be advised in the above terms, but directed that stress should be laid upon the words printed in italics. Rheumatism scheme. Dr. A. B. Raffle was seconded during the course of the year to the housing section and his place in charge of the rheumatism scheme was taken by Dr. C. E. Thornton. A slight decrease in the number of children nominated for institutional treatment under the scheme is recorded, 1,571 being nominated this year, as against 1,845 in 1933. The decrease is entirely confined to the group of mild or latent cases dealt with by supervisory centres, out-patient departments and school doctors. The nominations received from the in-patient departments of the voluntary hospitals show a nearly 50 per cent. increase over those of the previous year (348 compared 34 with 244); and, as these are the more severe and acute cases, it is clear that no notable decrease in the incidence of rheumatism or chorea can be visualised at present. During the first half of the year it became increasingly evident that, if the growth of an abnormally long waiting list were to be avoided, with a consequent delay in admitting cases, a more rigorous sifting of the nominations would have to prevail. In the very mild or doubtful cases, therefore, local supervision at a supervisory centre or out-patient department was advised, and numbers of slightly more definite cases were dealt with by means of supervised convalescence. For this purpose greater use was made of the Lower Southern hospital at Dartford. As a result of these measures it has again become possible to admit the majority of cases within ten days of nomination, and the more urgent cases immediately. The system of having the children who are nominated for treatment under the scheme examined by " referees " specially selected for this work is clearly of the utmost value in preventing undue congestion of the rheumatism units with unsuitable cases. Of the 1,571 nominations for institutional treatment received, the voluntary hospitals were responsible for more than half (804), the majority of the rest being sent in by school doctors (320) and supervisory centres (313). A certain number of parents refuse to accept treatment when they understand that it involves the child being away from home for six months or more. As many of the children do not appear very obviously ill, this attitude on the part of the parents is perhaps understandable, but even so the total number of refusals during the year was relatively small, being 111 only. The figures showing the conditions present in the children admitted to the rheumatism units and convalescent homes (table 12) show the usual preponderance of girls as sufferers from rheumatic infections (662 girls ; 434 boys). The percentage of those cases in which the heart had become implicated is almost exactly the same in the two sexes (boys 38, girls 37), indicating that, although girls are obviously more susceptible to the rheumatic infection than boys, there is no sensible difference in the severity of the type of attack experienced. That evidence is present of the heart being affected in nearly 40 per cent. of the cases admitted is certainly disquieting, but happily in many cases the degree of involvement is slight; and, what is still more gratifying, an analysis of 1,094 unselected cases discharged during 1934 revealed the fact that, of the 600 who showed signs of cardiac involvement on admission, 149 (i.e. nearly 25 per cent.) had no signs of cardiac disease on discharge. Even allowing for the possibilities of observational variations, these figures afford striking evidence of the value of prolonged rest in cases of rheumatic carditis. Furthermore, of the 490 cases without cardiac complication on admission, only ten developed signs of cardiac involvement whilst in hospital, and seven of these were of a very mild or even doubtful type. The case of those who insist that the prevention of cardiac crippling depends on the early and prolonged treatment of juvenile rheumatism becomes even stronger as information about this obscure disease accumulates. Herein lies the value of the present rheumatism scheme. Rheumatism cannot be prevented until more has been discovered of its aetiology, but there is good hope that its devastating effects on the heart can be minimised or avoided altogether by early and prolonged rest. Unfortunately many of the cases have well-established heart disease before they come under treatment, and in table 13, showing the recommendations made with regard to education in the 1,226 cases discharged from Carshalton, High Wood and the Downs hospitals in 1934, it will be seen that 198 (i.e., 16 per cent.) were found fit to attend a school for the physically defective only, and 28 were unfit for any form of education. Of the 128 who were over school age on discharge, a proportion also were only fit for the very lightest work on account of cardiac disease. In considering the incidence of rheumatism and chorea separately it is difficult to come to any definite conclusions. The diseases are closely related, and, in a large majority of mild cases of chorea, careful enquiry elicits the presence of 35 rheumatic symptoms ; conversely many cases of subacute rheumatism not labelled chorea exhibit a nervous instability verging on this condition. The analysis referred to previously of 1,094 cases discharged during 1934 did, however, show that permanent damage to the heart is relatively rare in cases of chorea in which there is no history of symptoms suggestive of rheumatism in the ordinarily accepted sense of the word. Of the 637 girls, 143 (i.e., 22.5 per cent.) were cases of " pure " chorea, and of these only 13 showed signs of permanent cardiac damage. Of the 457 boys, 77 were cases of " pure " chorea (i.e., 17 per cent.) and only seven of them developed permanent cardiac lesions. It is noteworthy that the percentage of cases developing definite cardiac disease was almost exactly the same (9 per cent.), in the two sexes. A similar fact has been noted when dealing with its relative incidence as a complication in boys and girls in the case of rheumatic infections generally (boys 38 per cent.; girls 37 per cent.). The statistics relating to the work of the supervisory centres are shown in tables 11 and 14. An increase is shown both in the number of cases attending the centres for the first time in 1934, and in the total number of attendances throughout the year. A new centre at the Bermondsey Medical Mission was opened in the early part of the year, and three new centres, one in Camden Town (in connection with the Hampstead General hospital), and also one in Poplar and one in Deptford are to be opened in 1935. At certain of the centres not connected with hospitals, the doctors expressed a desire for facilities to be provided to enable them to obtain an orthopaedist's opinion on certain types of case. Arrangements have been made whereby these cases may be referred to the orthopaedic consultants attached to the Council's general hospitals. In addition to the 5,466 children under supervision at the supervisory centres, 1,803 are kept under supervision by the school doctors, who furnish a report on each case at regular intervals to the divisional medical officer. Immediate action can thus be taken to obtain further treatment should necessity arise. Ancillary to the work of actually treating and supervising children suffering from rheumatism, a constant endeavour continues to be made to deal as far as possible with unsatisfactory environmental conditions at home. In this connection the care committee visitors perform an invaluable service in reporting on the home conditions of the children. In 1934 following these reports (nearly a thousand in number), 159 cases of unsatisfactory housing conditions were referred to the borough medical officers of health. In a large proportion of these cases reports were subsequently received intimating that the defects complained of (chiefly dampness) had been satisfactorily dealt with. Table 11. Particulars. 1932 1933 1934 Total number of nominations 1,234 1,845) 1,571 Nominations received from voluntary hospitals 635 1,017 804 „ „ „ rheumatism supervisory centres 275 352 313 „ „ ,, school doctors 185 293 320 „ „ „ other sources 139 183 134 Number of children admitted to special hospitals 953 1,447 1,096 Cases seen by medical referee in voluntary hospitals 257 244 348 ,, „ ,, „ „ in their homes 501 720 561 „ „ „ „ „ at rheumatism supervisory centres 291 394 329 „ „ „ „ „ at County Hall 109 357 248 „ „ at County Hall on discharge 597 817 867 Number of cases under supervision by school doctors 1,188 1,481 1,803 Reports made by care committees on home conditions 814 1,147 995 Number of rheumatism supervisory centres 16 16 17 Number of sessions at rheumatism supervisory centres 686 999 1,051 Number of children attending rheumatism supervisory centres for first time 2,001 1,973 2,187 Total number of attendances at supervisory centres 12,883 14,880 15,340 Number of cases reported to medical officers of health re dampness, etc., or to valuer for better accommodation 152 230 159 36 Table 12.—Admissions to special hospitals and convalescent homes during 1934. Hospital or home. Boys. Girls. Rheuma. tism and/or chorea with no apparent cardiac involvement Rheumatism or chorea with cardiac disease Rheumatism and/or chorea with no apparent cardiac involvement Rheumatism or chorea with cardiac disease. Total Queen Mary's hospital, Carshalton High Wood hospital 167 21 115 14 195 73 141 58 618 166 Downs hospital 60 34 97 45 236 Lower Southern hospital 15 3 32 2 52 Holy Cross convent 5 — 19 — 24 Total 268 166 416 246 1,096 Table 13.—Recommendations on discharge as to future education. Hospital. P.D. school. Elementary school. Totally unfit. Over school age Removals from L.C.C. area. Total. Queen Marv's, Carshalton 127 540 5 92 17 781 High Wood 24 110 20 18 16 188 Downs 47 183 3 18 6 257 Total 198 833 28 128 39 1,226 Table 14.—Rheumatism supervisory centres. Name of rheumatism supervisory centre. Number of children attending during 1934. Number of new cases. Attendances of old cases. Total attendances. Average number per session. Number of children from the centre who received hospital treatment or convalescence under the rheumatism scheme. Bermondsey Medical Mission 191 166 189 355 11.8 18 Downham 340 131 499 630 14.3 20 "Elizabeth Bullock" 270 103 450 553 13.2 15 Eltham 226 88 381 469 11.4 12 Hammersmith 322 122 587 709 17.3 10 Hospital for Sick Children (Great Ormond-street) 368 138 1,824 1,962 6.5 7 King's College hospital 417 166 862 1,028 19.8 16 Lewisham 393 155 482 637 13.6 18 Princess Elizabeth of York hospital (Shadwell) 419 176 703 879 17.9 25 Putney 189 82 266 348 15.1 11 Queen's hospital 570 158 1,342 1,500 19.2 28 Royal Free hospital 261 170 1,561 1,731 38.5 35 Royal Waterloo hospital 754 232 2,430 2,662 31 .0 9 St. George's hospital 203 81 303 384 9.1 1 St. Maiylebone dispensary 88 38 429 467 11.1 2 Stoke Newington 173 67 537 604 13.7 7 Woolwich 282 114 308 422 9.8 7 Total 1934 5,466 2,187 13,153 15,340 14.6 241 1933 figures 5,093 1,973 12,907 14,880 14.9 297 37 Personal hygiene scheme. For the purpose of assisting at medical inspections, each school nurse is allocated to a group of schools. Each school in the group is also visited by the school nurse on a rota, in order that she can carry out the inspection of the personal hygiene of the children. At each rota visit all the children in the school are so inspected ; each school is visited at least once a term, the schools where conditions are below normal receiving two or more such rota visits each term. Thus every child is seen at least three times a year. In 1934, 1,720,469 examinations of children were made at these rota visits. In 148,960 cases the child was noted as verminous, i.e., in 8.6 per cent. of the examinations, compared with a percentage of 9.0 on the similar figures for 1933 and 9.8 for 1932. From the records made on this basis a consistent improvement has been shown in the condition of the children's personal hygiene year by year; but, in accordance with the desire of the Board of Education, arrangements were made, by means of a small index card, to determine the number of individual children found unclean during the year, thus eliminating the possibility of counting separately the second or third record of uncleanliness in respect of any one child. The number of individual children so recorded was 83,207 (about 13 per cent. of the children on the school rolls compared with 15 per cent. in 1933), a figure which represents all those children who were noted infested with live vermin or their ova. About 54 per cent. of the cases in which verminous conditions were recorded at the rota visits are stated to be infested with nits only. The bases of the Council's cleansing scheme are emphasis upon the parents' primary responsibility, followed by compulsion, where necessary, as provided by section 87 of the Education Act, 1921. In the earlier stages of the procedure parents are advised of the trouble, and invited to avail themselves of the facilities provided by the Council. It is only after a child has been seen by at least two different nurses that a statutory notice is issued to the parents. These notices are served through the attendance branch of the education officer's department, and are either handed to the parents in person or forwarded by means of a registered letter. There are 10 Council centres, 20 borough council centres, and 9 centres organised by voluntary committees; but, as the last named are limited to head cleansings, these are not equipped with sterilisers or baths. The following particulars for 1934 are in respect of the cleansing scheme operated from the Council's and Borough Councils' centres (as distinct from the " head " cleansing centres):— 1934 1933 Number of advice cards issued to parents 80,260 85,808 Number of children attending voluntarily at bathing centres after advice cards 40,079 42,833 Number of statutory notices served in accordance with section 87 of the Education Act, 1921 22,302 23,954 Number attending bathing centres after statutory notices— (а) voluntarily 4,749 4,970 (6) compulsorily 14,016 15,916 Number of cases in which police court proceedings were taken 465 304 At the head cleansing centres 23,171 cases attended during the year compared with 25,051 in 1933. The figures in the above tabular statement are obtained from records kept on a terminal basis at each of the centres, and, as is the case with the rota inspection figures, a child may be recorded more than once in the same year. The individual record cards at the centres show that in 1934 a total of 73,903 children attended the bathing and head cleansing centres. Not all these children were, however, referred under various stages of cleansing schemes, but a certain number attended voluntarily before their departure for the residential schools, country holidays, etc., or at the request of parents, teachers and others. 38 Children taken for compulsory cleansing are either accompanied to the centre by the school nurse or, in the case of outlying schools, are taken by ambulances. In 1934, 11,531 children were conveyed in the ambulances. Children suffering from scabies and impetigo are treated at the bathing centres. The total of such cases was 5,545 for the year, a slight increase on the number for the previous year (5,311). 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 31,742 compared with 32,610 in 1933. Scabies. The continued high incidence of scabies which shows no sign of abatement gives cause for concern. The difficulties in dealing with this scourge are great. While school children can be, and are, inspected, the disease which is very contagious affects older and younger members of the family who cannot be inspected ; and, although they are offered facilities for treatment by the local sanitary authority, there is no means other than persuasion of ascertaining their condition or of bringing pressure upon them to take advantage of the facilities. The school children, who have been treated, return to homes where other members of the family are untreated and reinfection is frequent. The co-operation of the sanitary departments of the Borough Councils in respect of simultaneous disinfection of homes is gratefully acknowledged. Chronic invalidity. The school attendance department reports each month the names of children who have been absent from school for three months or more 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 returns were formerly dealt with at the head office, but in 1934, it was found more convenient for them to be received at the local divisional medical offices, where action could be more quickly taken in appropriate cases. The reduction in the numbers shown in the subjoined table is due to the fact that the majority of the children who are ill for long periods are dealt with at the Council's special children's hospitals. In 1933 these were recognised by the Board of Education as hospital schools. The children who are at these hospitals are therefore no longer accounted " out of school," and no longer appear as in former years in the returns. The subjoined table shows the number of children reported to have been out of school for more than three months in November, 1934, 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 17 cases of epilepsy and 5 of encephalitis lethargica) accounted for 59 children. 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 56 cases, and ear disease for 26. On account of the greater incidence of the rheumatic diseases upon girls (191 as against 129 in boys), the total invalidity amongst girls is greater than that amongst boys (468 to 420). There were 22 boy cripples and 17 girl cripples. 39 Table 15.—Census of chronic invalids, November, 1934, and the four preceding years. Ailment. Cases. Percentage of total. 1930. 1931. 1932. 1933. 1934. 1930. 1931. 1932. 1933. 1934. Rheumatism, heart disease and chorea 678 546 550 608 320 32.82 33.67 31.87 33.40 36.00 Nervous disorders 99 93 65 95 59 4.80 5.74 3.76 5.20 6.64 Tuberculosis (all forms) 295 212 219 209 79 14.28 13.07 12.68 11.50 8.90 Anaemia and debility 129 52 77 75 40 6.24 3.21 4.46 4.10 4.53 Ringworm 22 9 5 4 5 1.06 0.55 0.29 0.22 0.56 Skin complaints (excluding ringworm) 49 38 45 51 25 2.37 2.34 2.61 2.80 2.82 Eye disease 72 70 63 76 8 3.49 4.31 3.65 4.10 0.91 Infectious diseases 73 34 90 70 45 3.53 2.10 5.22 3.80 5.07 Other defects 649 568 612 632 307 31.41 35.01 35.46 34.88 34.57 Total 2,066 1,622 1,726 1,820 888 100 100 100 100 100 Infectious diseases in schools. The numbers of cases of infectious illness reported by head teachers as occurring Day among school children during 1934, compared with similar figures reported during the preceding six years, are shown below:— Table 16. Year. Diphtheria. Scarlet fever. Measles and German measles. Whooping cough. Chicken pox. Mumps. Scabies. Ophthalmia. 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 1933 4,446 11,357 14,130 8,373 10,863 9,591 1,091 427 1934 5,439 8,850 37.701 5,029 10,283 6,354 1,131 554 The number of cases of smallpox notified (and confirmed) among school children during the year was 46, compared with 419 in 1932 and 170 in 1933. Special investigations into the occurrence of the infectious diseases specified in the following table were carried out by the school medical staff during the year:— Table 17. 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 of visits. Number of children examined. N.E. 30 26 2,994 27 25 3,522 N. 22 18 1,369 37 33 4,819 2 340 N.W. 38 30 3,458 28 22 3,133 — — S.W. 59 43 5,258 73 56 9,918 1 80 S.E. 32 26 2,311 69 55 6,995 — — Total 181 143 15,390 234 191 28,387 3 420 The children in four schools were also specially examined from time to time on account of outbreaks of ophthalmia. In addition to investigations by medical officers, valuable work was done by the school nursing staff in following up in the schools the medical officers' visits in connection with the occurrence of scarlet fever, diphtheria, smallpox and ophthalmia, as well as in the special visitation of the schools where there were outbreaks of whooping-cough and chickenpox, mumps, measles, German measles and scabies. 40 Diphtheria. Diphtheria appeared in epidemic form in parts of London during the autumn, and this is reflected in the increase in the number of cases reported from the schools —2,727 cases during the first seven months of the year, and 2,712 during the four months of the autumn and winter terms. During the year 4,985 children attending elementary schools were examined by swabbing of the throat and nose (and of the ear in a small number) for the presence of diphtheria bacilli. Of these 4,728 proved negative and 257 yielded positive results, i.e., 5.1 per cent. of those swabbed. Re-examination of positive or doubtful cases was made in 54 cases and diphtheria bacilli were found to be still present in 34 of these. The results of biological virulence tests applied to the 257 diphtheria cultures showed 225, or 87.5 per cent., to be virulent and 32 avirulent (i.e., of all the children swabbed 4.5 per cent. were virulent carriers). Among 38 school teachers who were home or class contacts of diphtheria, two only yielded diphtheria bacilli, one proving avirulent in 3 successive swabbings and the other virulent in the primary swab but avirulent in two subsequent reswabs. School investiga- tions. There were 181 special visits by assistant medical officers to 143 school departments for the investigation of the occurrence of diphtheria in the various classrooms. The children in 20 schools were kept under special supervision for various periods by the school nurses. In the course of the visits of the assistant medical officers a total of 15,390 children were examined and 3,390 swabbed. At the time of the visits 127 children were excluded on account of suspicious conditions of the throat and nose. In 110 of those swabbed, or 3.1 per cent., diphtheria bacilli were obtained, 105 of the cultures proving virulent and only 5 avirulent. Of the remaining children other than those examined in the course of special investigations, one group included 1,361 children who were swabbed as selected cases by doctors or school nurses in schools or at treatment centres owing to some suspicious defect of throat, nose or ear. In this group of 1,361, diphtheria bacilli were obtained in 142 (or 10.4 per cent.), 116 (or 8.5 per cent.) proving virulent and 26 avirulent. The other group consisted of 234 children who were swabbed preparatory to their being sent to convalescent homes as a safeguard to exclude chance diphtheria carriers being admitted to the homes. In 5 of the 234 swabbed, diphtheria bacilli were found, four proving virulent and one avirulent. The three groups of school children may be summarised as follows:— Table 18. Group. Numbers swabbed Diphtheria bacilli present in Virulent Avirulent Virulent diphtheria carrier rate. School investigations 3,390 110 105 5 per cent. 31 Selected children 1,361 142 116 26 8.5 Convalescent home entrants 234 5 4 1 1.7 Total 4,985 257 *225 32 4.5 *87.5 per cent. of those in whom diphtheria bacilli were present. In the five respective divisions the subjoined table presents a comparison of the results of school investigations including the apparent diphtheria carrier rate, as well as the diphtheria incidence and case mortality in the total boroughs included in each division. The figures for diphtheria incidence are provisional and subject to correction in the various boroughs concerned. 41 Table 19. Division. Population. No. of visits to Schools. No of depts. visited. No. of children examined. No. of children swabbed. Diphtheria bacilli present in No. virulent Carrier rate per cent. Diphtheria rates (all ages.) Total notifications Case rate. Total deaths. Mortality rate. Case mortality rate. per 1,000 per 100,000 Per cent. N.E. 765,000 30 26 2,994 543 22 21 3.9 2,570 3.36 85 11.1 3.3 N. 814,700 22 18 1,369 386 16 16 4.1 2,142 2.63 89 10.9 4.2 N.W. 900,000 38 30 3,458 686 25 24 3.5 2,075 231 102 11.3 4.9 S.W. 980,500 59 43 5,258 1,162 28 26 2.2 2,605 2.66 107 10.9 4.1 S.E. 937,500 32 26 2,311 613 19 18 2.9 2,487 2.65 90 9.6 3.6 Total 4,397,700 181 143 15,390 3,390 110 105 31 11,879 2.70 473 10.76 3.98 In all, 5,439 cases of diphtheria were reported from schools, representing an attack rate of 10.3 per 1,000 of the 527,283 children on school rolls. 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 1934. Diphtheria " carrier " clinics. Reports have been 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 biological tests, and that efforts have been made, more especially during the last three months of the year, to limit the cases referred for treatment to those who might be regarded as persistent " carriers." The clinic at the London hospital is under the care of Mr. Francis Muecke, who has submitted the following summary of cases for 1934:— On arrival 38 cases were found to be positive and 42 negative. The following is an analysis of these cases:— Table 20. Result. Positive on arrival. (26 operations.) Negative on arrival. (1 operation.) Total. Discharged cured 37 41 78 Ceased to attend 1 1 2 Total 38 42 80 Dr. L. W. Cann has furnished the following statement regarding the work carried out at the special clinic at Guy's hospital:— During the year there were 95 new cases, while 13 cases were carried over from 1933 and are included in the following summary. Six cases still attending are not included. K.L.B. present. Virulent—tonsils 10, tonsils and nose 4, nose 24, total 38 (including 4 cases notified as nasal diphtheria). Non-virulent—tonsils, 3, nose 8, total 11. Not tested—nose 1, total 1. Total cases with morphological K.L.B., 50 ; Hofmann only found, 18 (two virulence tests). Other diphtheroids found, 5 (three virulence tests). No diphtheroid organisms, 29. There has been no alteration in the standards used or treatment employed. It is again obvious that the majority of cases sent to the clinic are not persistent carriers. Many have already lost their K.L.B., by the time they reach the clinic and the majority of the remainder become clear after a few attendances. It would be unwise to attribute this to any treatment. The 10 cases carrying virulent K.L.B., in the tonsils only, cleared rapidly except for two. In both of these latter tonsillectomy was done about one month after the last swab taken at the clinic. In one case subsequent superficial and deep cultures from each tonsil were negative for K.L.B. It would have been well to have swabbed the child again after admission to the ward, before tonsillectomy. 42 The second case gave negative cultures from one tonsil, a fair number of K.L.B. in the other, whilst the adenoids gave an almost pure heavy growth of K.L.B. This although striking is the only occasion upon which the adenoids from a carrier have been cultured. One case was a persistent carrier for six weeks at the end of which time a brother was removed to hospital with diphtheria. As home conditions made it impossible to keep the child isolated he was notified and sent to the carrier unit at the North-Eastern hospital. The only case not recorded in the above list was the best case since the clinic commenced. He was not placed in the above list as he was a dental surgeon who had recently qualified at Guy's and was not really eligible for the clinic. On his first attendance at the end of February, he was greatly worried as his wife and two patients had recently contracted diphtheria—both the latter with an interval of four days after the extraction of teeth. On his next attendance a few days later he brought the more convincing evidence that two further cases, whose teeth he had extracted a day or two before his first visit here, had developed diphtheria. In each case the interval was again four days. After enquiry he said there had been no other case of diphtheria in the neighbourhood except for one man, another of his patients, who contracted diphtheria about three weeks after extraction of teeth. He had a cleft palate with a history of infected nasal infection and chronic catarrh. Three sets of swabs from right tonsil, left tonsil, right nostril and left nostril showed K.L.B. only in the left nostril and not in large numbers. A virulence test was positive. It was thought likely that the left antrum was the chief focus. With intensive local treatment including the use of Dimol snuff three negative sets of swabs were obtained by the end of the month. As nothing has been heard from him since discharge, it is presumed that no further infection has occurred. It is of interest that (i) the case gives almost conclusive evidence of repeated infection within a few days ; (ii) 5 out of the 6 cases had only one contact with the carrier so that the interval could be accurately assessed. In 4 out of the 5 the interval and presumptive incubation period was four days. These 4 cases were all children, the 5th being an old man. Generalised Schick-testing and immunisation are awaited to end this clinic. Dr. A. B. Porteous, who is in charge of the clinic at St. Mary's hospital, has submitted the following report:— During the year, 36 cases were referred to St. Mary's hospital diphtheria carrier clinic, compared with 22 in the previous year. Of these, 2 were adults and the remainder were children in ages ranging from 14 months to 14 years. 17 cases were consistently negative. 6 „ gave suspicious organisms in throat only. 9 „ „ „ „ „ nose only. 2 „ „ „ „ „ both nose and throat. 1 „ „ „ ,, ,, ear only. 1 „ „ „ „ „ nose, throat and ear. Virulence tests were carried out in 10 cases, and 5 were positive. Vaccines were used in 7 cases, and 3 were referred to the throat department for tonsillectomy and other treatment. The case which was under treatment longest during the year lasted 13 weeks. Two cases were returned patients who had previously been discharged as negative from fever hospitals. Active immunisation against diphtheria. Facilities for Schick-testing and immunisation against diphtheria were provided in three more metropolitan boroughs during the year, making a total of 18 boroughs in which this work is now carried out at the infant welfare or special centres, or by special arrangement with medical practitioners. The Council has assisted in propaganda in connection with this work by authorising the use of the school organisation for the distribution of leaflets issued by the Borough Councils. A reference to the Schick-testing and active immunisation against diphtheria of children in the Council's residential schools and homes appears at the end of this section of the report. Scarlet fever. Although the incidence of scarlet fever did not reach epidemic proportions, the number of cases reported from the schools was high throughout the year ; and 234 special visits were paid to 191 school departments by assistant medical officers. In 24 schools the children were kept under observation by the school nursing staff for various periods. In the course of the special investigations 28,387 children were examined, and 405 excluded from school owing to suspicious conditions of the throat, nose or ears, or skin—but only 8 cases were notified as suffering from scarlet fever at the time of visit. 43 The distribution among the five divisions was as follows :— Table 21. Division. Visits paid. Numbers examined. Numbers excluded. Cases of scarlet fever and deaths, all ages. Cases. Deaths. No. Per, 1,000 No. Per 100,000 N.E. 27 3,522 33 3,102 4.1 13 1.7 N. 37 4,819 95 2,942 3.6 11 1.4 N.W. 28 3,133 48 3,037 3.4 10 1.1 S.W. 73 9,918 107 4,306 4.4 13 1.3 S.E. 69 6,995 122 4,885 5.2 19 2.0 Total 234 28,387 405 18,272 4.15 66 1.5 In all 8,850 cases were reported in the schools, representing an attack rate of 16.8 per 1,000 of children on school rolls, or 18.8 per 1,000 of those in attendance. The figures with regard to the incidence and case mortality are provisional and subject to correction in the various boroughs concerned. Reference was made in the last annual report to the practice which had been adopted at the Cyril Henry treatment centre of immunising children against scarlet fever and diphtheria before tonsil and adenoid operations, with a view to the prevention of the occurrence of those diseases after the operations had been performed. The practice was continued during 1934 subject to parental consent being obtained in each case. The following report on the results obtained has been received from Dr. H. R. Kidner, divisional medical officer:— Scarlet fever. Cyril Henry treatment centre. Pre-operation immunisation against post-operation scarlet fever and diphtheria has been continued throughout the year 1934. No case of either disease was reported as following the operation in any child who received the injection, but two children, who were not injected because they had suffered from previous attacks of diphtheria, were certified as suffering from scarlet fever and removed to fever hospitals two days and five days, respectively, after the operation. One other child was admitted to the South-Eastern fever hospital seven days after operation, notified as suffering from diphtheria, but it was proved on bacteriological tests to be streptococcal tonsillitis. Statistics for the year are as follows— 1,523 children attended for operation. 216 „ were deferred for operation on that day as unfit. 938 „ were injected with the combined serum. 276 „ were not injected because they had had previous attacks of scarlet fever or diphtheria. 93 parents refused consent. Two children had a serum rash during the two days stay in the centre, and 87 were reported by the nurses visiting the homes subsequently as suffering from a " reaction," usually an urticarial rash; the parents are all warned that this may happen and in no case was the child reported as being seriously affected. The operating surgeons are satisfied that the inoculation is of value. One reports definitely fewer cases of pyrexia, to which he was called after the operation, in the proportion of roughly 6 to 1, and he has adopted the procedure in his private practice. The sister-in-charge reports fewer post-operative complications such as haemorrhage and sepsis. During the year, 144 cases of smallpox were notified (and confirmed), and of these 46 were among school children. All these cases occurred during the period January to June. The few cases notified after June proved not to be smallpox. The following statement shows the number of cases occurring among school children grouped in school terms, for each division:— Smallpox among school children. Table 22. Division. Spring term. Summer term. Autumn and winter term. Total. N.E. - - - - N. 25 5 - 30 N.W. - - - - S.W. 2 - — 2 S.E. 10 4 — 14 Total 37 9 — 46 44 The cases were all of the mild type and without exception occurred amongst unvaccinated children. 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, 70 children in one school 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, was continued. These contacts were kept under daily supervision by the school nurses, whose services have again been used in connection with the daily surveillance of schools attended by children notified as cases of smallpox. The following table summarises the reports submitted by the school nurses in connection with this work:— Table 23. 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. 16 (9) - - 4 5 5 N. 535 (27) 7 29 87 34 344 N.W. — - - - — - S.W. 109 (6) - - 13 4 34 S.E. 160 (11) - - 28 39 74 Total 820 (53) 7 29 132 82 457 Experience of the type of mild smallpox again showed the difficulties arising from the numbers of missed cases, and efforts were directed to ascertaining at the earliest possible moment the reasons for absence from school. As a result of intensive investigation and close co-ordination between the officers of the school medical and nursing service, the school attendance staff and the borough health services, a few previously undetected cases were brought to light. Measles. The biennial epidemic of measles, which began in London in the autumn of 1933, continued until July, 1934. During the period of the epidemic (9 months) 38,949 cases were reported from the schools, compared with the 35,705 reported during the epidemic (9 months) of 1931-32. A special report dealing with various aspects of the epidemic, such as incidence, mortality, treatment, administrative measures, use of serum, is being prepared for publication. Whoopingcough, chicken pox, mumps. The following are the numbers of schools kept under daily supervision for varying periods by the school nursing staff on account of the diseases mentioned: whooping-cough, 38; chickenpox, 134; mumps, 111. In the course of their visits to these schools, the school nurses inspected the children and advised the head teachers as to exclusion or re-admission to school. Scabies. A reference to the action taken in connection with the ascertainment and treatment of cases of scabies appears elsewhere in this report. The children at two schools were kept under special observation for a time by school nurses on account of the occurrence of several cases of the disease amongst the children. Ophthalmia. Minor outbreaks of ophthalmia occurred during the year at four schools. The children in the affected schools were kept under supervision by the school medical and school nursing staffs, working in close co-operation with the borough health services. Measures were taken to obviate the spread of infection through the use of school towels. 45 The following table shows the number of cases of ringworm of the scalp among Ringworm, the children in the Council's schools dealt with during 1934 compared with the figures for preceding years:— Table 24. 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 1933 336 334 86 68 1934 265 281 65 73 During the year, 603 specimens of hair from school children, were examined for ringworm at the laboratory at the County Hall. Ringworm fungus was found in 195 of these (132 small spore and 63 large spore). Two cases of favus were discovered after microscopical examination. 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 have continued 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. Favus. Play centres. The special arrangements were continued for the medical examination of children before departure for school journeys. Particulars of the general arrangements made for school journeys during 1934 are set out on Page 53. School journeys. There was a minor outbreak of chickenpox at Mile Oak school in the spring. No other cases of infectious illness occurred in the approved schools. Nine cases of diphtheria occurred during the year at the Ponton-road remand home. As a result of swabbing, 2 virulent carriers were found. References to the progress of active immunisation against scarlet fever at the Mayford school and of active immunisation against diphtheria at Mile Oak school appear later in this section of the report. Approved schools and remand home. A few sporadic cases of diphtheria, scarlet fever and chickenpox occurred in the three residential open-air schools. The few cases of infectious diseases that occurred amongst the children in the residential special schools do not call for special comment. Reference to the scheme of active immunisation against diphtheria in these schools appears later in this section of the report. Residential open-air schools. Residential special schools. As stated in the last annual report, children to be admitted to a receiving home who are known to have been in contact with infectious disease are sent in the first instance to a "contact" block at Earlsfield House receiving home. Contacts of infectious diseases at the three receiving homes have also been admitted to this block. With regard to the latter group, the restricted accommodation of the contact block necessitated a careful selection of contacts being made. These arrangements have worked satisfactorily and will be continued. Residential schools, children's homes and children's receiving homes. During the year, loo children were admitted to the contact block at Earlsfield House under these arrangements ; of these 30 developed the disease to which they had been stated to have been exposed and 8 developed other diseases. A brief review of the incidence of infectious illnesses in the residential schools, children's homes and children's receiving homes during 1934 is set out below. The cases of infectious illness (except scabies and impetigo) were removed to one or other of the Council's hospitals. All practicable steps were taken in close cooperation with the officers of the schools and homes with a view to preventing the spread of infection. D 46 Diphtheria.—During the year 75 children were transferred to the fever hospitals as cases of clinical or bacteriological diphtheria. Of these 20 proved to be purely bacteriological, 28 were diagnosed as suffering from clinical or faucial diphtheria, and 14 as nasal diphtheria. In the remaining 13, the diagnosis of diphtheria was not confirmed. In connection with these cases 572 children were swabbed in 16 of the schools, diphtheria bacilli being found in culture from the throat or nose in 53, and, of these, 50 proved to be virulent and only three avirulent. The virulent cases were removed to hospital. Re-examination of 18 children showed diphtheria bacilli to be present in 14. In addition, 28 adults employed in the schools and homes were swabbed, all proving negative except one, in whom virulent diphtheria bacilli were found. The results of examinations in 1934 of children in the residential schools and homes may be compared with those of the two previous years, as follows:— Table 25. Year Number of children swabbed. Diphtheria bacilli found. 1934 572 *53 1933 791 56 1932 1,622 98 *50 virulent; 3 avirulent. Scarlet fever.—Cases of scarlet fever of mild type occurred in several of the schools and homes. A minor outbreak occurred at one of the receiving homes, but its spread was speedily arrested. Measles—The effects of the measles epidemic were felt in most of these establishments during the first half of the year. German measles—An outbreak of German measles occurred in one school, and there were groups of cases at three others. Whooping-cough—A few cases of whooping-cough were reported from some of the schools. Chickenpox—Outbreaks of chickenpox occurred in four of the schools, and more or less isolated cases were reported from some of the other establishments. Mumps.—There was a series of cases of mumps in each of two schools, and some isolated cases elsewhere. Scabies—Cases of scabies were reported from six of these establishments. Impetigo—There were cases of impetigo in six of the schools. Ophthalmia and conjunctivitis—A group of cases of ophthalmia and conjunctivitis occurred in one school. Ringworm—A few cases of scalp ringworm occurred in these establishments. As stated in the last annual report, a Wood's glass analytical lamp has been provided at each of the schools and homes where electric current is available, and all new entrants are "lamped " as a routine. Specimens of hair stumps taken from suspected cases were microscopically examined from time to time in the laboratory at the County Hall. Out of 24 specimens examined, ringworm fungus was found to be present in 5 (4 small spore and one large spore). As stated in the last annual report an outbreak of body ringworm occurred amongst the boys on the training ship "Exmouth," during the winter months of 1933-34, which necessitated the evacuation of the ship (on 29th January) and the temporary transfer of the boys to the Hanwell residential school which was then empty. The first cases occurred at the end of September, 1933, but such preventive measures as the daily inspection of the boys, the immediate removal to the shore infirmary of suspected cases and the disinfection of clothing, bedding, etc., appeared to have little effect on the spread of infection, and it was decided that all the cases should be immediately removed to Goldie Leigh or Queen Mary's hospital and that one of the Council's dermatologists (Dr. J. M. H. MacLeod), who is also visiting 47 consultant to Goldie Leigh hospital, should visit the ship from time to time for the purpose of examining the boys and advising as to preventive measures to be taken. On Dr. MacLeod's recommendation the heads of all the boys on the ship were examined from time to time, specimens from suspected cases being microscoped. Additional medical staff was provided to assist Dr. Vickerman Smith, the medical officer of the ship, with the daily examinations. A certain amount of washing of clothing, etc., had been carried out on board the ship. This was, however, discontinued; all laundrywork being sent, after disinfection, to one of the Council's hospital laundries. Special care was taken to prevent the promiscuous wearing of caps and clothing. Dr. MacLeod kept the cases (which were treated by X-rays) under observation at both the hospitals named above, and on his recommendation the boys who had suffered from the disease were kept in quarantine for a period of three weeks after they had been stated to be cured. Dr. MacLeod reported that the disease was in the form of small red patches, some of which were dotted over with yellow heads which were distributed on the skin, in most cases on covered parts of the body, and that, though the lesions had all the appearance of being due to a ringworm fungus, it was impossible from their appearance to decide the exact fungus, and that on cultivation for a week the fungus was found to be the trichophyton crateriforme (Sabouraud), one of the ringworm fungi of the endothrix group which grows on the human skin and scalp and is not of animal origin. He further stated that endothrix ringworm had been until recently a rare variety of ringworm in this country, forming only four per cent, of the total cases, and that it is more difficult to exterminate than the ordinary microscopic type for the following reasons:—(i) it is more difficult to diagnose on the scalp, as it commences in minute patches so small as to be difficult to find, and the broken hairs do not form stumps but break off so short as to resemble blackheads ; (ii) the infected hairs do not fluoresce with Wood's glass light; (iii) it is impossible to diagnose it with certainty without a microscopical examination and possibly a culture; (iv) it differs from microsporon ringworm in not dying out on the scalp at the age of puberty. Dr. MacLeod recommended that, as ringworm spores in the dry state remain viable for at least six months, the ship should be evacuated. Before entering the Hanwell school, every possible precaution was taken to ensure that all the boys and their gear, etc., were free from any suspicion of infection, but one boy was slightly infected with the same type of ringworm three weeks after arrival at Hanwell. The necessary cleansing and disinfection of the ship was completed during February and March, and the boys returned in batches during the week ending 7th April. No case of the endothrix type of ringworm occurred amongst the boys after that date. In all, 122 boys were reported as suffering from body ringworm during the outbreak. The arrangements for the Schick-testing and active immunisation against diphtheria of the children in the residential schools have been described in previous annual reports. Active immunisation against diphtheria in the residential schools, etc. The progress of the work during 1934 is shown in the following table:— Residential schools and children's homes. Residential special schools. Number tested for susceptibility to diphtheria 1,850 169 Number of susceptibles found 760 48 Number of susceptibles whose course of immunisation had not been completed during 1933 116 10 Number who completed the full immunising course and gave Schick negative reactions on re-test 611 48 Number who left the schools before course of injections had been completed 81 1 Number outstanding on 31st December, 1934, who had received one or more injections and whose course of immunisation was to be completed in 1935 184 9 D I 48 The numbers of children residing in these schools and homes on 31st December, who had not been Schick-tested, were as follows:— Residential schools and children's homes. Residential special schools. New admissions 194 23 Parental consent refused 155 34 Not tested for other reasons 81 6 Total 430 63 The medical officers of the schools state generally that there has been little or no local or general reaction to the formol toxoid, that the process of immunisation has not interfered with the ordinary routine of the children in their home and school life and that the percentage of parental refusals is comparatively small. They further state that there is often delay in receiving consents, due apparently to lack of interest on the part of the parents. The following report made by Dr. A. W. Soper, the medical officer of Anerley residential school, is of interest, as it shows the results obtained in one of the largest of the Council's residential schools and children's homes:— Active immunisation was commenced at this school early in 1934 :— Number of children Schick-tested 459 „ „ positive 147 „ „ negative 312 „ who left before completion of immunisation 16 „ of parental consents refused 28 „ of children completely immunised (re-Schick negative) 131 Eleven children were admitted to the infirmary with slight pyrexia, the longest time in the infirmary being three days. One child developed diphtheria on the 3rd day after the Schick test. The introduction of the scheme of active immunisation against diphtheria at Mile Oak approved school, with accommodation for 150 boys, was authorised by the Education Committee on 25th April, 1934, after the consent of the Home Office had been obtained. The work, which was begun in August, was undertaken for the first few weeks by Dr. L. J. M. Laurent of the Western hospital, and was taken over by Dr. F. H. Allfrey, the medical officer of the school, in October. During the year, 167 boys were Schick-tested and of these, 43 gave positive reactions, 121 were negative and 3 left before the result of the test was read. The course of three injections was completed, followed by negative re-tests in the cases of 34 boys, 3 left the school before immunisation had been completed, and there remained 6 for completion of the immunising process in 1935. Twelve boys had not been Schick-tested at the end of 1934. Active immunisation against scarlet fever. Active immunisation against scarlet fever of the children at the Shirley residential school was commenced on 1st February, 1934. Dr. C. M. Jones, the medical officer of the school, took over the work in April from Dr. L. J. M. Laurent of the Western hospital. Active immunisation against scarlet fever has been continued at Mayford approved school by Dr. L. G. Higgins, the medical officer of the school. The progress of the work at these two schools during 1934 is shown in the following table:— Shirley residential school. Mayford approved school. Number tested for susceptibility for scarlet fever 469 45 Number of susceptibles found 66 15 Number who completed the full immunising course and gave negative reactions on re-test 52 7 Number who left the schools before immunising course had been completed 3 Number outstanding on 31st December, 1934, who had received one or more injections and whose course of immunisation was to be completed in 1935. 11 8 49 Oven-air education. Provision for education in the open air includes nine day open-air schools (non-tuberculosis) with accommodation for 1,460 children, and six day open-air schools (tuberculosis) accommodating 515 children. There are also seven country and seaside convalescent camp schools, accommodating 520 children for periods varying from one to three months, through which 4,432 children pass annually; and 220 open-air classes in playgrounds and parks providing for upwards of 6,000 children. Provision. The nine day open-air schools for non-tuberculous children maintained by the Council have continued their excellent work. The following table gives the roll of these schools on 19th December, 1934:— Open-air schools for non-tuberculous children. Boys. Girls. Total. Aspen House 89 58 147 Bow Road 109 82 191 Brent Knoll 84 48 132 Charlton Park 86 59 145 Downham 94 51 145 Holly Court 179 115 294 Stowey House 156 116 272 Upton House 86 60 146 Wood Lane 85 58 143 Total 968 647 1,615* *Note—The roll of an open-air school may be 20 per cent, above the nominal accommodation. Interesting reports are invariably received from the school doctors regularly visiting the day open-air schools (Type 0). Two such reports on the work of the year are set out below. Dr. T. Legge has reported as follows upon Holly Court open-air school:— Holly Court open-air school. Number on roll, January, 1934 241* Number admitted during the year 136 Children removed from roll during 1934— Fit for elementary school ana over age 67 Removals from district 10 Transferred back to elementary school at parents' request 11 For periods at convalescent hospitals 17 Miscellaneous 9 114 * Note—Admissions exceeded discharges during the year by about 50. As a site for an open-air school in London, Holly Court cannot be beaten. It lies on a southern slope of the "northern heights," on the borders of Parliament Hill Fields, Kenwood and Hampstead Heath. This unsurpassed situation gives great scope for many delightful rambles for nature study and for open-air geography. Physical activities have been largely incorporated into the lessons. A considerable proportion of the work consists in gardening, woodwork, building construction, nature rambles, dancing, singing and games. The new Board of Education syllabus of physical training has been adopted with slight modifications, the more strenuous exercises being omitted. For these physical activities the classes are organised into boy's and girl's sections separately, whereas for the ordinary school work the classes are " mixed." The summer of 1934 being particularly sunny, progressive sun bathing was much indulged in during the warmer months on the school lawn ; the special sun bathing costumes being designed and made at the school. A marked feature of the school is the small number of children who contracted infectious diseases, there being only three cases of notifiable disease during the year. About 12 to 20 is the average number of minor ailments treated daily by the sister at the school. Steps are now being taken to improve the facilities for drying wet clothes at the school; and the voluntary boot club continues to function in a satisfactory manner. Much thought has been given by the head master and staff, to the question of the children's diet. It has been possible to improve and vary the menus considerably. Particularly have the amo.ints of milk, fresh fruit, vegetables and salads been increased. That bane of institutional feeding, the stereotyped weekly menu, with the same dishes re-appearing on the same days of the week invariably and ad nauseam, has been done away with. Here the children never know beforehand what the piece-de-resistance and " afters " for mid-day dinner are going to be. This 50 fact undoubtedly increases the appetite and gusto for food; indeed, the astonishingly large helpings that the older children will put away, should be seen to be believed. Of the many benefits this open-air school regime confers on these young developing souls, the sum total of which is of incalculable value to them, it seems to me that the most important single physical factor—the sine qua non—is the wholesome and adequate feeding which these hungry youngsters get. Upton House open? air school. Dr. J. L. Newman has reported as follows upon Upton House open-air school:— The number of children on the roll of the school has stood fairly consistently throughout the year 1934 at about 130. Room could actually be found for some 20 more, but it is fortunate that the maximum number has not been maintained, since with a margin to spare, there is no risk of urgent cases being kept waiting. The defects from which the 130 are suffering are made up as follows— Infections (styes, boils, otorrhœa) 4 Adenitis, cervical 7 Lung diseases— Asthma 3 Recurrent coughs, simple 15 ,, „ with signs of bronchitis 16 „ „ with signs of more gross lung damage 10 Mediastinal adenitis 2 — 46 Skeletal defects— Postural 7 Old tuberculous 1 — 8 Nervous disorders— Organic 1 Functional 11 — 12 Tuberculosis contacts 20 Miscellaneous (anaemia, debility, delicate) 33 Total 130 The 66 children who make up the first four and a half groups in this classification are all suffering from some defect which is either interfering with their school work and attendance, or may be expected to do so if curative measures are not undertaken. All have done well, and even of the ten who show signs of fibrosis of the lung with or without bronchiectasis, none has given any evidence of that progressive deterioration, and sometimes rapid decline, which is only too often seen in the out-patient departments of our hospitals. The group of tuberculosis contacts consists of those who have recently been in an unsatisfactory state of health, or who are living under bad home conditions from which it is desirable to remove them as far as possible. None of them has shown any signs of active tuberculosis. There remains the large group of children, 44 in number, who are suffering from functional nervous disorders or have been labelled anaemic, debilitated or delicate. These are fundamentally healthy children, who may be considered under two headings. First there are those whose home conditions are so prejudicial as to interfere with their education, and, of these, the following are typical cases:— P.Q. was nervous, tearful and could not concentrate. No physical abnormality. Father, suffering from " war neurasthenia," worries her and assaults her mother. X.Y. was "always ailing" and often away from school. No physical abnormality. She is one of 15 living in a basement flat. Under the second heading comes a large group of children who are pale, thin or dark under the eyes, and, although they show no evidence of disease, they are a source of anxiety to parents, teachers and sometimes even to nurses and physicians. They are easily, often too easily, labelled anaemic, debilitated and delicate; and, from their being often spoken of in this way, the confidence of all concerned in their physical welfare is undermined, and the foundations of a neurosis are laid. For such children as these, a course at an open-air school is of great value, since a period of close physical supervision combined with a graph showing a satisfactory gain in weight is much the best way of demonstrating a real freedom from disease, and at the same time, it does occasionally allow the diagnosis of debility to be amended to one of organic disease. Moreover, there is always the educative value of life at such a school as this, for even in these days of intensive health propaganda, the beneficial and not unpleasant effects of currents of fresh air, no less than the other items in the regime, have often to be experienced to be believed. Of the 35 children returned to elementary schools during the year, 32 were of this latter kind, and the other discharges were made up as follows:—at age of 14, 33: at parents request, 3; left district, 4; while 17 were transferred to other special schools, convalescent homes, etc. 51 In addition to the provision of treatment for tuberculous children in residential institutions, the Council continued the use of the open-air schools (type T) specifically for children with quiescent tuberculosis and for those suspected to be suffering from tuberculosis or living in conditions rendering them particularly liable to the disease. The tuberculosis officers of the areas in which the schools are situated serve as medical officers of the schools and pay weekly visits to them. Open-air schools for tuberculous children The six schools—Elizabethan (Fulham), Geere House (Stepney), Kensal House (Paddington), Springwell House (Battersea), Stormont House (Hackney), and Nightingale House (Bermondsey) have a total nominal roll of 618. The number on the roll on 31st December, 1934, was 572, and the average attendance for the year was 494.4. 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 1934, 216 children were admitted and 214 discharged. Of the latter, 50 were transferred as fit to attend elementary schools, 112 were fit for work, 3 were transferred to institutions for residential treatment for tuberculosis or admitted to hospitals for various reasons, 25 moved away, 15 were transferred to special schools, and 9 were discharged for other reasons (e.g., the distance was found to be too great for the children). Efforts were made to secure that, during 1934, every child in attendance at these schools should have a holiday out of London either by means of private arrangements or through the education school journey organisation. The following school journeys were made during the year, through the ordinary school journey organisation:— Table 26. School. Period. Place visited. No. of children. From To Elizabethan open-air school 1.6.34 14.6.34 Whitstable 21 „ „ „ 2.7.34 15.7.34 „ 24 Geere House 15.6.34 29.6.34 Chelmsford 25 Kensal House 15.6.34 29.6.34 Whitstable 25 31.8.34 13.9.34 „ 25 Nightingale House (Boys) 22.6.34 5.7.34 Littlehampton 45 „ „ (Girls) 10.7.34 24.7.34 „ 35 „ „ (Mixed) 3.9.34 16.9.34 „ 40 Stormont House 16.5.34 28.5.34 Broadstairs 70 Springwell House 31.8.34 13.9.34 Isle of Wight 80 In addition, provision was made for a further 56 children in accommodation specially set aside for the purpose at Princess Mary's hospital for children, Cliftonville, Margate. They went in two parties for a fortnight each, from 8th September to 6th October. The accommodation thus utilised was designated for the period, " The Holiday School." Only a very small residue of children failed to receive a holiday for various reasons, such as removal from district, private arrangements for holiday failing to materialise, etc. The numbers of children passing through the residential convalescent camp schools during 1934 were : boys, 2,860; girls, 1,572 ; total, 4,432. Convalescent camp schools. The experimental camp school for mentally defective children at Loughton has already been described (Annual Report for 1932, Vol. III, Part II, p. 38). In detail the numbers were:— Provided schools:— Boys. Girls. King's Canadian school, Bushy Park 2,835 — George Rainey, St. Leonards — 574 Wanstead House. Margate — 533 Total 2,835 1,107 52 Non-provided schools:— Boys Girls Fairfield House, Broadstairs — 173 Russell Cotes school, Bournemouth — 239 St. Vincent's, Hastings — 28 Loughton 25 25 Total 25 465 The actual number of children away at these schools at one time in November, 1934, was: Bushy Park, 270; Margate, 64; St. Leonards, 64; Bournemouth, 30; Broadstairs, 36; Hastings, 4. Total, 468 children, of whom 198 were girls and 270 boys. The head master of the King's Canadian residential open-air school has submitted the following account of the physical activities:— In addition to the physical training taken in the ordinary class-work, 1,579 boys, out of a total of 2,835 admitted to the school, received further exercises. Of these, 521 boys received special corrective exercises. With regard to general training, difficulties arise owing to the great differences of age of boys in the same class. This difficulty has been overcome, however, and new progressive courses for four and six weeks have been made to suit the younger boys, while giving ample scope to the senior boys. Special remedial work does not present this difficulty, as each child is given individual attention. Cases for treatment are chosen by the school doctor and include boys having a tendency towards kyphosis, lordosis, scoliosis, torticollis and flat feet. Serious cases of flat feet are followed up after leaving the school. Such cases have totalled 30. Special cards of corrective exercises are issued to flat feet cases for use in the home, while cards giving general instructions with regard to carriage, posture and breathing are issued to the remainder. In this way an effort is made to further and complete the work done in the school. A pleasing feature of the work is the interest and enthusiasm shown by the parents of the children, and this assists the work considerably. As in 1933, the physical standard of boys from Paddington, Peckham and Deptford is considerably below that of the remaining districts visiting the school. Below is a summary of cases treated at the school:— Total on roll 2,835 Total taken for general remedial exercises 1,579 Total taken for special remedial exercises 521 The numbers of special cases treated were: kyphosis, 180; lordosis, 74; scoliosis, 48; torticollis, 2 ; flat feet, 179; mouth breathing, 37; knock knee, 1. The average increase in weight (four weeks) was 2.5 lb. Of the 2,835 boys admitted in 1934, it was possible to grant extensions to 179 for health reasons. During the year 22 boys suffering from infectious diseases were transferred to appropriate hospitals while 3 others were admitted to hospital for other serious illness. During the year 18 were nursed in the sick ward at the school. The number of separate treatments for minor ailments given by the school nurses was 19,332. It has been found possible to continue at the school the treatment of 30 stammerers. Particulars of dental treatment carried out during the year are as follows:— Total number of bovs treated 1,624 Extractions (a) undergas 243 (6) local anaesthetic 143 Fillings 1,077 Scalings 636 Gum treatment—number of boys 182 Fairfield House, Broadstairs. The children on their return from the camp schools are kept under observation by the school care committees. An analysis of notes made by them in regard to a number of children who went to Broadstairs shows that, in 90 per cent, of the cases, not only were the children remarkably improved on return from their stay, but that this improvement in health was maintained for many months, and indeed as long as observation has been kept up, extending in some instances into after-school life. The children at Broadstairs are examined at the beginning and end of their stay for the haemoglobin content of the blood. An examination of a number of the records on the return of the children shows that there was an average increase of 8.7 per cent, in haemoglobin. Open-air classes in parks and playgrounds. The number of open-air classes held in connection with the elementary schools in 1934 was 220, an increase of 11 compared with 1933. Of these 12 were of type A (children selected on medical grounds from a group of schools); 85 were of type B (children selected on medical grounds from the various classes of a single school) ; 53 34 were of type C (consisting of a single class from one school, educated continuously at one open-air station) ; and 89 of type D (consisting in a rotation of classes from one school occupying one open-air station). Nine classes are permanent, that is to say they are outside the yearly programme and do not need re-authorisation each year. In addition, 62 classes were continued throughout the winter, where the suitability of the sites had been approved by the school medical officer. About one-third of the classes were held in parks, gardens, playing-fields and other open sites, while the others were held in school 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 anaemic, and require special care. They may be termed for shortness the bronchitic type and the rheumatic type. The former thrive only on open-air treatment of the sanatorium type, and for these the more exposure they get the better they are, 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. Forty-six 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 beneficial effect upon the health of the children, a few do not give such satisfactory results. Dr. A. B. Francklyn has made a careful study of the heights and weights of the children in two open-air classes—those at Barlby-road and Essendine-road schools, and has compared the rate of growth of the children with that of poorly nourished children retained in the ordinary school, who were given milk in school on the doctor's advice. This report is printed under " special enquiries " on page 85. Barby-road and Essendine-road open-air classes. School journeys. In 1934, 407 school journeys were made (compared with 358 in 1933), and the children taking part were medically examined in all cases before departure. In all 13,569 children were examined (the corresponding figure for 1933 being 12,185); and of these 72 were excluded as unfit to take part in the journeys on various grounds, including the following (the figures in parenthesis refer to the year 1933):—otorrhœa, 7 (10); infectious disease or contacts, 4 (2); tonsillitis and kindred ailments, 12 (9); temperature, 11 (11); personal hygiene, 2 (0); skin diseases, 14 (14). Several children were provisionally rejected on grounds connected with personal hygiene but were subsequently passed after visiting a bathing centre. Separate figures are given on page 51 respecting the school journeys from open-air schools for tuberculous children. Physical education. Complete particulars of the arrangements for physical education in the London elementary schools were given in the last annual report. The organisers report biennially. In January, 1934, a circular was issued to all schools drawing attention to the Board of Education's syllabus of physical instruction for schools, 1933, and explaining its use. Mention has been made (page 8, of the advanced provision for physical education now being included in plans of new and remodelled schools. Formerly the standard rules for playgrounds merely gave the area of the playground, viz.: 30 square feet for older children and 16 square feet for infants. This took no account of the shape of the playground, and it was found that, although the requisite area was provided, the shape of the playground was often such as to render much of the space useless. The new standard planning adopted by the Council in 1934 takes into account the lay-out of the playground as well as its area. The new standard is: shape to permit 54 of 1 pitch 160 by 110 feet, or 2 pitches each 110 feet by 60 feet; 2 concrete cricket wickets for net practice for boys; a jumping pit; a garden plot of about 100 square yards; 20 square feet per head to be provided for infants, with separate playground of 800 square feet or more near the babies' room. Provision of meals. Dinners are provided for necessitous children attending school, and follow menus which have been approved by the school medical officer. Samples of meals provided are taken from time to time and submitted for analysis by the Council's chemist. Forty-two samples (representing 21 two-course meals) were examined during the year, the required standard being that each complete meal should contain 25 grammes protein and have a heat value of 750 calories. It is the function of the school care committee to place upon the feeding list every necessitous case requiring additional nourishment in order to profit by the education provided. It is considered reprehensible to wait until ill-nourishment due to lack of food has occurred to the extent that it requires the intervention of the school doctor. The head teacher of the school is empowered immediately to place any necessitous child provisionally upon the dinner list, without waiting either for the care committee's consideration of the case, or for the school doctor's visit. The arguments which led the Council to adopt economic rather than medical grounds for feeding necessitous school children were as follows:— (a) If no action is taken until the child shows signs of malnutrition, the child must already have gone through a stage of suffering unalleviated, in which he or she was unable to take full advantage of the education provided and unnecessary suffering is inflicted, which the Education Committee refused to contemplate. A wise education authority will prevent malnutrition, not wait until it is established. (b) The sudden cessation of food supply to a vigorous, well-nourished child immediately produces suffering, and prevents that child taking full advantage of the education provided even within a few hours, although a doctor could find nothing wrong. The child is hungry and obviously cannot pay attention to its lessons, and the more vigorous and healthy the child is the greater his suffering. It would be cruel to deny such a child food, yet no doctor could find anything more than any lay person, i.e., a medical examination is unnecessary. It is well known that ill-nourished children do not suffer to the same extent. By a merciful dispensation of providence after the pangs of the first week or so the body sinks into a dull tolerance of the condition and the children cease to feel hunger; and, although malnutrition will after some time become apparent on medical examination, the failure of the children to take full advantage of the education provided is less obvious than it is when the condition is acute and the children's vigour still present. While children are placed upon the school dinner list as soon as there is social need, and before malnutrition has had 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 by the care committees and the school doctors and are weighed regularly by the school nurses. The practice of giving milk under the powers of the Education (Provision of Meals) Act, 1906, to children found at medical inspection to be debilitated began in London in 1909. In the winter of 1909-10, Dr. Hawkes a part-time school doctor working in Bethnal Green called attention to the children of one school (Wolverley-street). Most of them belonged to large families dwelling in small 55 houses, in almost chronic destitution, the mothers often being the bread-winners and the fathers out of work. At the medical inspection a list was recommended to the school care committee as suitable for extra meals of milk and cod-liver oil. Of 91 children who had been assessed as " nutrition 4," i.e., definite malnutrition, who had been placed on milk, only 9 were so assessed at the end of the year. Thus commenced a practice which proved of great importance. It rapidly spread from school to school in London and became a recognised part of the Council's measures for combating ill-nourishment in school children. Later the example of London was followed by many of the provincial authorities. Under the Milk Act, 1934, the scheme of the Milk Marketing Board was introduced for the supply of milk at reduced prices to all children attending school in October, 1934. Particulars of the scheme so far as it affects London are given later in this section. The number of official milk meals supplied in elementary schools by the Council in 1933-34 was nearly 4¾ millions, of which rather more than 2½ millions were paid for out of the rates. The price now charged to parents in a position to pay for the official milk meals is that fixed under the Milk Marketing Board Scheme, viz. id. for one-third pint bottle. The numbers of individual children receiving each type of meal were as follows:— Table 27. Meal. May, 1934 (21 school days). November, 1934 (22 school days). December, 1934 (14 school days). For payment. Free. For payment. Free. For payment. Free. Dinners 1,249 6,934 1,604 5,892 1,495 5,725 Milk 12,696 14,513 11,768 14,997 11,235 15,691 Cod-liver oil and malt 3,272 2,136 3,028 2,234 3,014 2,190 The monthly averages of individual children fed for the calendar year, 1934, were: for payment, 16,214 ; free 20,686. The numbers of individual children fed in December, 1933, were:— Table 28. Meal. On payment. Free. Dinners 1,284 7,190 Milk 12,641 12,775 Cod-liver oil and malt 3,816 2,094 There was thus a decrease of 14.3 per cent, in children on dinners, an increase of 5.9 per cent, in those on milk and a decrease of 11.9 per cent, in those on oil and malt in December, 1934, compared with the number in December, 1933. The children who are given milk in school on the advice of the school doctor are kept under very close observation. They are all children whose nutritional state gives, or has given, some cause for anxiety. Notes on the improvement of such children are given in Dr. Francklyn's report on page 85. In the north-eastern division, Dr. Chaikin has given very close attention to the following up of the children on "official" milk, and he has supplied a very detailed statistical report on the results of the re-inspections of the children during 1934, from which the following summary is compiled. Records of 5,849 current cases were available for analysis, comprising 2,977 boys and 2,872 girls. Dr. Chaikin's report on children on milk. 56 The length of time the children had been on milk and the ages (years of birth) of the children are given in the following tables:— Table 29. Year of birth. Meals commenced in the following years and under observation since: 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 Boys (milk being continued) 1919 — 1 — 1 2 1 - - - - 1 1920 9 4 12 7 — 3 4 4 2 2 - 1921 41 110 27 25 18 31 17 14 5 5 1 1922 35 46 26 18 46 31 27 23 6 - - 1923 44 60 28 68 25 25 23 4 - - - 1924 31 79 107 60 47 41 16 4 - - - 1925 56 173 69 68 50 33 3 1 - - - 1926 101 99 82 66 23 9 - - - - - 1927 105 134 78 31 10 - - - - - - 1928 100 116 58 10 - - - - - - - 1929 91 68 25 1 - - - - - - - 1930 28 17 - - - - - - - - - 1931 5 - - - - - - - - - - Total 646 907 512 355 221 174 90 50 13 7 2 Girls (milk being continued). 1919 1 2 1 5 - - - - - - - 1920 9 12 19 9 6 6 6 3 2 2 - 1921 51 95 41 34 15 30 17 5 9 3 - 1922 53 57 41 34 46 20 20 16 2 2 - 1923 62 51 30 69 29 17 20 5 2 - - 1924 46 60 98 45 38 51 12 5 - - - 1925 61 159 61 55 40 17 5 - - - - 1926 110 75 82 58 19 3 - - - - - 1927 85 117 79 34 8 1 - - - - - 1928 93 106 46 11 - - - - - - - 1929 90 65 15 1 - - - - - - - 1930 37 21 - - - - - - - - - 1931 4 - - - - - - - - - - Total 702 820 513 355 201 145 80 34 15 7 - A number of children, at the inspections in the last term of 1934, were found no longer to require official meals, which they had been receiving. There were 232 girls and 203 boys. The following table shows the distribution according to the year of birth, the state of nutrition, and the number in each year:— Table 30.—Children discharged from official milk scheme. Year of birth. Number. State of Nutrition. 1 Excellent. 2 Normal. 3 Slightly sub-normal. 4 Malnourished. Boys. 1919 6 2 4 - - 1920 7 - 7 - - 1921 15 2 13 - - 1922 15 4 10 1 - 1923 34 6 27 1 - 1924 38 7 31 - - 1925 29 5 24 - - 1926 23 4 18 1 - 1927 15 3 12 - - 1928 17 2 14 1 - 1930 4 — 4 — - Total 203 35 164 *4 — Percentage — 17.2 80.8 2.0 — In these cases it was found that milk did not suit the children and convalescence or reference to hospital for treatment was advised. 57 Year of birth. Number. State of Nutrition. 1 Excellent. 2 Normal. 3 Slightly sub-normal. 4 Malnourished. Girls. 1920 6 1 5 — — 1921 28 8 20 — — 1922 25 7 18 — — 1923 30 3 27 — — 1924 31 9 22 — — 1925 45 8 35 2 — 1926 31 8 23 — — 1927 17 3 14 — — 1928 12 2 9 1 — 1929 7 3 4 — — Total 232 52 177 *3 — Percentage — 22.4 76.3 1.3 — *In these cases it was found that milk did not suit the children and convalescence or reference to hospital for treatment was advised. The range of years of commencement of the above "official" meals was from 1927 to 1934. The subjoined table shows the comparative state of nutrition of 6,284 boys and girls in the current and discharged groups, the percentages being given in italics:— Table 31. Group. State of nutrition. Border-line cases. Total. 1 2 3 4 1/2 2/3 3/4 Discharged boys 35 164 4 - - - - 203 17.2 80.8 2.0 - - - - - Current boys 75 1,688 984 18 5 207 - 2,977 2.5 56.7 33.1 0.6 0.2 6.9 - - Discharged girls 52 177 3 - - - - 232 22.4 76.3 1.3 - - - - - Current girls 67 1,668 883 19 4 230 1 2,872 2.33 58.08 30.74 0.65 0.14 8.01 0.04 — Total 229 3,697 1,874 37 9 437 1 6,284 Percentage 3.66 58.83 29.82 0.59 0.14 6.95 0.01 — It will be noted that a small percentage of children with " excellent" nutrition continued to receive milk. These were children whose parents were unable to pay for milk in school, and who were formerly of poor nutrition. The school doctors noted the progress of the children, and their remarks have been collected into three groups or classes which are:— Group A.—Those with the best progress. Group B.—Those with fair, " average " or slight progress. Group C.—Unsatisfactory. Particulars in regard to children who continue to receive milk are set out below:— Table 32. Sex. A. Definite improvement. B. Slight improvement. C. Stationary or unsatisfactory. Number Per cent. Number Per cent. Number Per cent. Boys 1,656 60.1 877 31.9 219 8.0 Girls 1,674 62.5 834 31.2 168 6.3 58 The following are the corresponding figures for children to whom milk is no longer given :— Table 33. Sex. A. Definite improvement. B. Slight improvement. C. Stationary or unsatisfactory. Number Per cent. Number Per cent. Number Per cent. Boys 182 90.5 14 7.0 5 2.5 Girls 220 96.1 9 3.9 — — The heights and weights of the children placed on milk were ascertained by a random sampling of the records of 100 boys and 100 girls born in 1925 (aged 9), and in the following tables are compared with the average heights and weights of London children at the same age:— Table 34. Sex. Height. Weight. Milk children London averages. Milk children. London averages. cms. c.ms. kilos. kilos. Boys 125.8 125.2 25.8 25.5 Girls 128.1 124.7 23.6 25.0 The increase in physical measurements over a period of one year is shown in the following table:— Table 35. Sex. Increase in height. Increase in weight. Milk children. London averages. Milk children. London averages. cms. cms. kilos. kilos. Boys 4.66 4.7 2.59 2.0 Girls 5.30 4.5 2.05 2.1 Disparity in numbers of free meals. It is curious that the boys did better than normal children in increase in weight, while the girls did better than normal children in increase in height. In 1932 the comptroller of the Council commented on the disparity between the number of dinners provided, free of charge, for children of certain neighbouring schools. A detailed inquiry was subsequently carried out by the education officer and the school medical officer jointly. After considering the result, the Special Services Sub-Committee decided that similar investigations should be made in other parts of London. Such an inquiry was conducted during 1934 by Dr. R. H. Simpson, who had carried out similar previous investigations, and was concerned with three provided schools suggested by the Shoreditch local association: The Laysterne, Crondallstreet and St. John's-road. Scheme of Milk Marketing Board. In July the proposals became known, which the Government had in view, under the Milk Bill, 1934, to make provision for the supply of milk to schools at prices below the regional prices fixed for other customers by the Milk Marketing Board. The Bill became law, and the scheme was put into force on 1st October, 1934. The scope of the scheme is as follows: milk is supplied in one-third pint bottles with straws, at a charge to the consumer of ½d. a bottle, to all full-time schools or courses for children recognised by the Board of Education for grant. The scheme applies only to milk supplied in one-third pint bottles drunk directly by the children in schools, and not to that used for cooking or instructional purposes. The vendors and the quality of the milk supplied must be approved by the local medical officers of health in consultation with the school medical officer. During September a conference was held between the Council's medical officers and the medical officers of health of the Borough Councils, and as a result it was decided that only pasteurised milk should be approved for the purpose of the scheme in London. There had been for a number of years voluntary milk clubs at very many schools, run mainly under the auspices of a scheme of the National Milk Publicity Council, and before the new scheme came into operation there were more than 100,000 children in London day schools who were supplied through these clubs each school 59 day with one-third pint bottles of milk costing 1d. each. It appeared, therefore, that the best way of working the new scheme would be by expanding the voluntary organisation. The Council, under the "feeding" clauses of the Education Act, was also supplying milk ordered to debilitated children by the school doctors. This milk had hitherto been supplied in bulk and the standard amount supplied was a half-pint daily. Over 20,000 children were receiving milk in this way and in a great proportion of the cases it was free. It was decided that the standard amount of milk to be given as milk meals ordered by the school doctors under the official scheme should be two-thirds of a pint, given in the one-third pint bottles twice daily. In spite of the difficulties of organising such an immense scheme in the short space of time available between the end of the summer vacation and the commencement of the scheme, the new procedure was brought into being on 1st October. This would have been impossible but for the enthusiasm and voluntary efforts of the teaching staff. So successful were they that it was reported that, during the week ended 12th October, 1934, there were no fewer than 364,157 children having milk in school through the voluntary clubs, an increase of 256 per cent. In November there were also 26,765 debilitated children receiving "official" milk on the recommendation of school doctors. Some curiosity was displayed as to the reasons why some 27 per cent. of the children in the schools were not taking the milk provided at reduced charges in school. A questionnaire was issued by the education officer to the head teachers, and replies were received showing the reasons why 85,447 children were not taking the milk. The reasons and the percentage of the total number giving each reason were as follows : Poverty of the parents, 25; distaste for milk, 33; parents consider that children have enough nourishment at home, 24; "milk spoils the appetite for midday meal," 4; indifference of parents or children, or money spent on sweets, etc., 4; children object to cold milk, 2; children consider themselves too old, 1.5; parents object on principle, 2.5; children have cod-liver oil or dinner, and this considered sufficient, 1.5; milk causes sickness or is against doctor's orders, .5. In assigning the reason for children not having milk to the poverty of the parents, the head teachers felt that in many cases the real cause was often apathy or indifference. The school care committees were advised that when the only reason, known or supposed, for a child not having milk was poverty, the earliest opportunity should be taken of consulting the school doctor as to whether or not the child should have official milk meals. This has led to an increase of 23 per cent, in the number of milk meals given free of cost to children in school. The inauguration of a scheme of this magnitude was bound to have its difficulties There was doubt in some quarters as to whether the injunction that all milk to be supplied should be "pasteurised" meant that the milk should be sold as pasteurised milk and labelled as such. Steps have been taken to make it quite clear to all that this is indeed the intention. One of the criticisms frequently made has been that the milk should be heated. The school medical officer has consistently held that this is unnecessary. When the cool milk is imbibed slowly through straws no discomfort is felt subsequently. The irregular heating of milk would tend to destroy its peculiar properties, which make it so valuable to children and which constitute the chief reason for giving milk in school. Teachers are advised that the milk must not be subjected to heat treatment, but that the chill should be taken off the milk by allowing it to stand, in cold weather, near the radiators. Many ingenious wirework devices have been evolved for draping the bottles upon the radiators for this purpose. The effect of milk on school children has been demonstrated several times on a large scale. It stimulates growth in a remarkable way. This special effect is confined to raw or pasteurised milk, and is lost on cooking. Cooked milk is merely a fattening food. Raw or pasteurised milk provides a stimulus to growth, and does not appear to produce obesity. Formerly it was thought that the forces of growth in height were purely congenital, and could not be affected in a positive direction by any means within our 60 disposal, although a negative result in the way of stunting could be produced byimproper feeding, as is the case when children suffer from rickets. It now appears, however, that by taking milk the child can add, if not a cubit, at any rate, some inches to his stature. Whether this means that the forces of growth are stimulated to increased activity for a time, but that growth will end at an earlier period, or whether it means that the children will be really taller as adults is not known. The stimulus to growth in height rather than to the production of fatness is seen in records relating to Dr. Chaikin's debilitated girls mentioned above. Dr. C. E. Thornton has made two sets of observations upon normal children having milk in school, compared with controls not having milk. In the first series, the children were all in the same school, the Oliver Goldsmith; the number of milk cases was 53, and the number of controls of the same age was 91. The period under observation was six months. The average gain in weight was—milk cases, .69 kilograms; controls, .94 kilograms ; the average gain in height was—milk cases, 2.26 centimetres ; controls, 2.17 centimetres. A second series was watched over 11 months in two schools, one Athelney-street in which the milk cases were, and the other Elfrida-street, in which were the controls. The schools were of similar character. The results were: average gain in weight— 93 milk cases, 2.64 kilograms; 90 controls, 2.91 kilograms; average gain in height— milk cases, 6.9 centimetres ; controls, 4.2 centimetres. These results were all in relatively small groups; but, if they are proved to be general, they should go far to remove the fears of the not inconsiderable number of children, principally girls, who refuse milk, not because they really dislike it, but through the abhorrence of the idea that they may become fat. Nutrition centres. The Committee of the Jewish Health Organisation established, towards the end of the year a voluntary dietetic service at the East London child guidance clinic. The part-time services of a qualified dietitian with hospital training and experience in lecturing on the subject is utilised. The work of the dietitian consists in explaining to the parent, on the basis of the doctor's findings, where the child's food habits are wrong, in pointing out the importance of different kinds of food and how they should be used to avoid errors of diet, and in giving practical assistance in the construction or choice of dietaries. In cases of malnutrition resulting from ignorance on the part of the parents or from the economic condition of the family, the endeavour of the dietitian is to instruct the parents as to which foods, within the means of the family, make a dietary best suited to the growth and development of the child. It is hoped that it may also be possible to give information and make suggestions in the course of these interviews as to food values and methods of cookery which will be of practical use, not only in the feeding of the child, but also to the dietary of the whole family. It was anticipated that the dietitian would be able to handle a greater number of cases than the East London clinic could supply, and the Jewish Health Organisation was desirous that children in the Council's elementary schools should also be allowed to attend the clinic for the dietitian's service only, and suggested that such children should be referred to the clinic by the Council's school medical officer and school doctors. During the initial period no charge is being made for the attendance of these school children, but the number of such children is limited and determined from time to time by experience as to the demand for and capacity of the service. It has been considered advisable at first, so far as children sent direct by school doctors are concerned, to limit the service to the north-eastern division and to extend the area by degrees. For the time being, the dietitian's sessions are held after school hours. The Education Committee considered that an experiment on the lines suggested would be welcome, and arranged that parents of children in suitable instances should be recommended to avail themselves of this service. In the programme for the year 1935-36 the Council has determined to establish five experimental nutrition centres, one in each division. These are to be worked in conjunction with a scheme for the regular weighing and measuring of the children in school twice a year by the school nurses. This is proposed in order that a watch shall be kept upon the rate of growth of each individual child with a view to bringing 61 under medical examination at an early stage every child who does not show normal progress in physique. As the result of recent nutrition surveys in the schools it was found that certain children, found to be undernourished after extremely careful examination by an experienced physician, were sent to voluntary general hospitals by the school care committees. They were found at the hospitals to have no disease and were sent away with nothing done. The parents were dissatisfied, as well as the school care committees, and the suggestion was made that the school service referred to hospital very trivial conditions " which wasted the time of the hospital physicians." On the other hand, a strong public opinion has grown up, which holds that the local education authorities should be doing more for the ill-nourished child, especially in the very earliest stages of malnutrition. It was therefore decided, in a tentative and experimental way, to include in the programme of the school medical service for the year 1935-36 additional provision for special investigation of such children referred from the ordinary school medical inspections at special inspection centres and, as the children concerned are those who show failure to reach the normal condition of nutritional state for reasons not immediately apparent, the arrangements proposed were termed "nutrition centres." As, during the experimental period, they should be immediately under the observation of the divisional medical officer, a centre has been chosen in each division as near as possible to the divisional medical offices. The divisional medical officers have each nominated from the staff engaged in their divisions an assistant medical officer (part-time) with special experience in paediatrics. To each centre an experienced nurse will be allotted and a specially selected organiser with experience in social economics. At each centre it is proposed during the first year to hold one session per week. The function of the centres has been set out above. It is intended to carry out a more extended enquiry into the causes of the failure to reach a satisfactory nutritional state in certain children than can be carried out in the press of the ordinary school medical inspection. Careful investigation will be made of the family budgets and dietaries, and advice on the latter given to the parents. Simple observations such as urine testing and haemoglobin estimation will be carried out at the centres, but in special cases, if more extended bio-chemical investigations are needed, these can be made in conjunction with the Council's laboratories. The centres will, during the experimental period, work under the immediate observation of the divisional medical officers, who will report and compare notes at the regular conferences which are held at the County Hall with the senior medical officer in charge of the school medical service. The organiser at the centre will be in close and continuous touch with the school care committees, who, by personal visitation, will keep in touch with the children both at home and school and will report to the organiser for the doctor's information. In any case where a period of observation in hospital is desired, this will be arranged at the Council's special hospitals for children, e.g., Queen Mary's, Carshalton, or High Wood. The selection of children will be carried out by the divisional medical officer from nominations by the school doctors. The primary cases to be included are those at present under observation by the school doctors for nutritional defect who at the periodical re-inspections and weighings at school have not shown improvement. Co-operation of voluntary bodies. The general care of the children in the London elementary schools is carried on by a social service, consisting of voluntary workers organised into school care committees, which are assisted and directed by paid organisers. This system prevents the work of medical inspection and treatment and the wider work of general physical E Social care organisation. 62 care of the child becoming stereotyped and bureaucratised, a fault which might otherwise be difficult to avoid. Friendliness and co-operation with the parents are the key notes of this social service. The teachers whenever possible give much assistance, and in many cases it is entirely owing to their help and devotion that the care committee work in the schools is possible. The services of the National Society for the Prevention of Cruelty to Children are freely given in the supervision of unsatisfactory families. The Invalid Children's Aid Association gives unstinted help in the care of the crippled children and in convalescing children recovering from acute disease. Co-operation with voluntary hospitals. London is abundantly rich in voluntary hospitals which provide extensive services for the poor. It has been the aim of the school medical service to work harmoniously in co-operation with these. While some of them are definitely included in the authority's scheme for medical treatment, others are only linked with the service by voluntary arrangements. At a number of hospitals a liaison officer or officers, consisting of a member or members of the Council's care committee organising staff, attends regularly and keeps the hospitals in touch with the social services of the schools. The presence of the organiser at the hospital ensures following-up for all the children under the scheme, and influences the proper care and following-up of children attending the hospitals not under the scheme, too, for "non-Council" ailments, as the organiser is appealed to on behalf of these also. The association of the organisers with voluntary hospitals makes a great difference in the results of hospital treatment, and generally speaking the condition of children attending hospitals where the Council's organisers attend is satisfactory, whereas the condition of children attending hospitals outside the scheme where no organiser attends is as regards following-up often quite unsatisfactory. The scope of the work in those hospitals in which the Council maintains an organiser or organisers is shown in the following report dealing with Guy's hospital:— Guy's hospital. There are three assistant organisers working in Guy s hospital, in the aural, eye, orthopaedic and skin departments, and the diphtheria carrier clinic. These organisers form a link between the hospital physicians and surgeons and the school care committees. The care committees are supplied with up-to-date information about children attending these departments and they furnish reports for the information of the hospital doctors. In departments where there is no organiser, the almoner obtains reports for the care committees and divisional officers. In the aural department 1,308 new children were seen during the year; 619 were discharged cured, 16 left school and 22 were reported well by the care committees. During the year 1,061 new children attended the eye department; 979 were tested for glasses, and of this number 743 had glasses prescribed and 81 were found not to require glasses. In regard to the other 155, no change in glasses was necessary. During the year, 724 pairs of glasses were obtained but some of these were prescribed in 1933. In the orthopaedic department 165 new children were seen, of whom 5 were found not to require treatment ; 28 children were discharged cured, 76 left school, 4 left London and 6 were referred to other departments for treatment. A number of children were referred to the massage department for treatment, and the organiser checks their attendances once a fortnight and reports to the care committees if they do not attend as directed. Twelve children had minor operations performed in the out-patient department, and there are 573 children attending periodically for supervision. During the year 609 new children attended the skin department, which is a slight decrease on last year's numbers. Of these, 15 were suffering from ringworm of the head and 87 from scabies. The ringworm cases were referred to the light department of the hospital for X-ray treatment, and the majority of the scabies cases to the school bathing centres. There were 95 new cases in the diphtheria carrier clinic during the year, with a total of 375 attendances. The majority of children attending in the aural, eye and skin departments were treated at home, but in some cases arrangements were made for them to have daily treatment at the school treatment centres. The numbers of children referred to the school medical officer for special examination were as follows:—Schools for the physically defective, 11; partially sighted class, 4; hard-of-hearing school, 3; White Oak hospital, Swanley, 5; while 8 children were recommended for re-examination with a view to their transfer from schools for the physically defective to elementary schools. Defective children. Examinations with a view to the admission of children to special schools, other than hospital schools, were made in 4,598 cases. The following table shows the number of children nominated for examination and the recommendations made:— 63 Table 36. Defect. Number nominated. Suitable for admission to Returned to elementary school. Invalided as for the time unfit for any school. Notified under M.D. Acta. Boys. Girls. Blind school. Partially sighted. Swanley. Boys. Girls. Boys. Girls. Boys. Girls. Boys. Girls. Boys Girls. Boys. Girls. Ocular 507 638 1 4 63 82 87 71 338 472 18 9 — — Deaf school. Hard of hearing class. Aural 123 106 Boys. Girls. Boys. Girls. 78 69 - 1 - - 26 21 19 15 P.D. school. Day open-air school. Residential P.D. school Physically defective 817 719 Boys. Girls. Boys. Girls. Boys. Girls. 166 141 42 48 - - 522 482 26 15 61 33 M.D. school. Mentally defective 896 660 Boys. Girls. 508 330 46 35 *40 *32 302 263 Epileptic colony. Epileptic 60 72 Boys. Girls. 27 33 19 25 14 14 Total cases 2,403 2,195 1,121 1,000 1,117 1,045 125 118 40 32 4,598 2,121 2,162 243 72 ♦ Of these 30 boys and 25 girls were imbeciles ; 7 boys and 4 girls were idiots ; and 3 boys and 3 girls were feeble-minded. The numbers of children actually attending special schools will be found in table III of the statistical tables at the end of this report. The following statement shows the nature of the conditions found among the children certified as suitable for admission to schools for the physically defective at the admission examinations during the year:— Table 37. Morbid conditions. Boys. Girls. Total. Infantile paralysis 29 29 58 Cerebral paralysis 11 17 28 Various paralyses 15 13 28 Tuberculosis of bones and joints 73 65 138 Osteomyelitis 31 11 42 Rickets and resulting deformities 3 2 5 Congenital deformities 18 11 29 Scoliosis 1 9 10 Traumata and amputations 22 6 28 Non-tuberculous arthritis and synovitis 22 6 28 Rheumatism and chorea 18 37 55 Various chest conditions—fibrosis, bronchitis, asthma 80 38 118 Heart diseases- Congenital 26 15 41 Acquired valvular 194 217 411 Non-valvular 18 23 41 Anæmia 3 5 8 Pseudo-hypertrophic muscular dystrophy 10 1 11 Various nervous conditions, ataxia, etc. 1 3 4 Other diseases—chiefly medical 8 7 15 Total 583 515 1,098 E I 64 Children returned to elementary schools or invalided. The following statement gives an analysis of the 397 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 for the time unfit for any school:— Table 38. Morbid conditions. Elementary school. Invalided. Infantile paralysis 8 4 Cerebral paralysis 5 5 Various paralyses 9 8 Tuberculosis of bones and joints 16 4 Osteomyelitis 7 1 Rickets and resulting deformities 5 — Congenital deformities 6 1 Scoliosis 4 1 Traumata and amputations 18 6 Non-tuberculous arthritis and synovitis 4 - Rheumatism and chorea 47 6 Various chest conditions—fibrosis, bronchitis, asthma 31 8 Heart diseases— Congenital 14 6 Acquired valvular 75 19 Non-valvular 19 7 Anæmia 16 1 Pseudo-hypertrophic muscular dystrophy 1 2 Various nervous conditions, ataxia, etc. 3 1 Other diseases—chiefly medical 19 10 Total 307 90 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 16,159, and in addition 601 special examinations were made of children already on the rolls of special schools in connection with applications for non-enforcement of attendance and for similar reasons. As a result of the rota examinations the following re-classifications took place:— Table 39. Transferred from schools for Re-classified for transfer to— P.D. school. M.D. School. Partially sighted school. Blind school. Deaf school. Partially deaf school. Open- air school. Epileptic colony. Physically defective - 13 - - - 1 6 4 Mentally defective — - 2 - - 1 - - Partially sighted 1 2 - 1 - - - 1 Blind - - 14 - - - - - Deaf — - 1 - — 4 — - Partially deaf - - - - 8 - - - After trial in a special school, 78 children were excluded (39 as imbecile, 16 as feeble-minded ineducable, 4 as "special circumstances" and 5 as feeble minded "detrimental") and 18 were invalided on medical grounds. 65 There were also 653 cases returned, on improvement, to elementary schools, or, when over 14 years of age, deemed to be no longer certifiable. The details are as follow:— Table 40. Action taken. Special school classification. P.D. M.D. Blind. Partially sighted. Deaf. Partially deaf. Total. Returned, on improvement, to elementary schools Over 14 years of age and excluded as no longer 210 13 - 15 3 8 249 certifiable 229 65 2 106 2 - 404 Total 439 78 2 121 5 8 653 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:— Decertification of physically defective children. Table 41. Morbid conditions. Cases deemed no longer certifiable. Cases deemed fit to return to elementary schools. Infantile paralysis 17 7 Cerebral paralysis 1 — Various paralyses 3 1 Tuberculosis of bones and joints 26 19 Osteomyelitis 7 8 Rickets and resulting deformities — 6 Congenital deformities 10 12 Scoliosis 1 - Traumata and amputations 4 8 Non-tuberculous arthritis and synovitis 6 14 Rheumatism and chorea 22 26 Various chest conditions—fibrosis, bronchitis, asthma Heart diseases— 2 2 Congenital 3 7 Acquired valvular 97 67 Non-valvular 26 24 Anæmia — 2 Various nervous conditions—ataxia, etc. - 1 Other diseases—chiefly medical 4 6 Total 229 210 Table 36 (p. 63) indicating the number of children examined to determine whether some form of special education might be desirable appeared to indicate some difference in sex distribution in the case of those diagnosed as mentally defective or epileptic and of those suspected of being physically defective. To inquire further into this point Dr. Shrubsall and Dr. Williams have taken the records of the children Sex distribution in defective children. 66 examined between the years 1926 and 1933, inclusive, and the proportion of the sexes nominated, those found suitable for a special school and those for the time being unsuited for school attendance are shown in the following table :— Table 42. Type of defect. Percentage of sexes in those Nominated for examination. Passed for a special school. Invalided. Deemed ineducable. M. F. M. F. M. F. M. F. Physically defective 50.2 49.8 50.2 49.8 50.1 49.9 - - Epileptic 52.1 47.9 58.0 42.0 45.7 54.3 — — Mentally defective 58.3 41.7 56.7 43.3 — — 54.4 45.6 These figures seemed to indicate an excess of boys over girls in the epileptic and mentally defective classes. The proportion of the sexes attending the ordinary elementary schools at the beginning of 1933 was male, 50.6; female, 49.4. As the figures for the physically defective are very similar it is evident that there is no clear sex selection in this field where also the proportions of the sexes among those found defective and those nominated are reasonably constant. A little over 69 per cent, of those put forward as physically defective are found suited for special school education, and just over 8 per cent, of either sex found temporarily unfit for school attendance. That about 78 per cent, of the nominees are found unfit for the ordinary school shows that the nominations are soundly based. In the case of the epileptics the distribution is more irregular; more boys than girls are nominated and more boys are accepted for special school education, but more girls are invalided for a period. If the two groups are added it is found that there is no material sex difference in suitability of selection, 65.1 per cent, in the case of boys and 65.8 per cent, in the case of girls, of those nominated being found to evince such manifestation of epilepsy as to render them unfit for education in ordinary schools, though the proportions among those accepted show a slight preponderance of males. This question of sex distribution in epilepsy is one on which there is some difference of opinion, most English text books stating that there is a slight preponderance of females and most American text books that there is a preponderance of males. This is a question on which the accommodation available, and even the number of persons actually admitted to schools, throws little light. Special school accommodation for epileptics is entirely of a residential character, and children are only sent subject to the consent of their parents. This is an important feature, for the dissatisfied parent of a child placed therein against his will could upset the equanimity of other parents on visiting days, and this in turn would react adversely on the children, for placid and equable conditions play an important part in the treatment of epilepsy. It is true that attendance could be enforced by law if it could be shown that the refusal of the parental consent was unreasonable, but, as this refusal is not to be held unreasonable if withheld in a bona fide belief that it is for the child's benefit, and as it is not difficult for any parent to get a medical certificate that a child would be better at home lest he should fret if removed, it is in effect useless, save in most exceptional cases, to attempt such action. The preceding tables indicate clearly that while there is little difference in the sex incidence of epilepsy of such a degree as to interfere with ordinary schooling there is a much greater willingness on the part of parents to allow boys to be sent to boarding schools. This may be partly due to special affection for the girls, but is more probably connected with the greater difficulties in early life which arise from the unstable behaviour of epileptic boys. In the case of the mentally defective the proportion of boys is greater in all the categories but is greatest in the numbers nominated and smallest in those deemed 67 to be ineducable. Although the number of girls nominated is smaller the proportion of those nominated who are deemed to need special education is slightly greater : 42.7 per cent, girls compared with 40 per cent. boys. This may depend on several factors, probably the most important is instability of behaviour. In early years the mentally defective boy is likely to be a somewhat greater nuisance in the school and to the community than is the mentally defective girl, and it has always been found that active or aggressive aberrant behaviour attracts attention, while mere placid failure to make progress tends to be overlooked or to be for a considerable time accepted as backwardness or shyness. It may be, too, that the woman teacher exercises patience under the adversity of endeavouring to teach the seriously retarded for a longer period than her male colleague. When it comes to a later phase there is some evidence that the woman teacher seeks the protection afforded by the Mental Deficiency Acts for her seriously retarded girls more readily than the man who is hopeful for the temporary employability of the boys in unskilled work unless they show aggressive anti-social traits. The proportion of the sexes among the mentally defective who are in some way being cared for by the Council under the Mental Deficiency Acts, viz., 50.3 per cent, males and 49.7 per cent, females, is so similar to the proportion of the sexes in the elementary schools as a whole, viz., 50.6 per cent, boys to 49.4 per cent, girls, as to show there is no real sex difference, but the proportion for whom the stricter form of community control, institutional care or guardianship is required, 52 per cent, males to 48 per cent, females, shows the slight difference which may be accounted for by anti-social behaviour. The prevalance of instability in the children sent to schools for the mentally defective is noteworthy. Of course, naughtiness and lack of discipline are common in those of normal intelligence ; but, when with marked intellectual retardation there co-exists irresponsible and irrational behaviour, there is the more reason for special care. In the school medical officer's report for 1922, in referring to the later history of defectives, it was noted that social and industrial failure were much more marked when both features were present, e.g., a lad of extreme stupidity but of stolid type might keep a simple job, while one of the same intellectual capacity but irresponsible or slightly lacking self-control would be dismissed from every post after a few weeks. That temperamental instability plays an important part even in the earlier years is shown by further inquiries made by Dr. A. C. Williams into the differences between children nominated for examination and as a result either passed into special schools for the mentally defective or returned for a further trial in the ordinary elementary school. Special schools have been functioning in London since the middle of the eighteennineties, and this educational provision has been accompanied by an increasing degree of medical and social supervision. In the earlier years, the greater number of children found in the schools to need treatment were of necessity referred to voluntary hospitals and in this connection the help given by the voluntary workers of the Invalid Children's Aid Association proved invaluable in the matter of the persuasion of parents, arrangements for regular attendance at hospital and for the interchange of information between the medical officer visiting the school and the physicians or surgeons of the hospitals concerned. With the establishment of care committees, after the coming into force of the Education (Administrative Provisions) Act, the extent of the social services which could be rendered materially increased, while the introduction of medical inspection into the elementary schools secured the attendance at special schools of a number of children who might not all have been ascertained under the previous system. Gradually arrangements were made for supplementing the efforts of the voluntary hospitals, largely through the use of the facilities of the Metropolitan Asylums Board. Cases of ophthalmia were dealt with at the White Oak hospital and later this provision was rendered available for cases of interstitial keratitis and other affections of the eye Treatment and following up of children with incapacitating defects. 68 which required prolonged treatment but which did not entirely prevent education so far as this could be carried out on the hospital premises. At a later date, certain ear cases were received at the Downs hospital. Admission to these hospitals was not exclusively or even chiefly through the school organisation, since the Metropolitan Asylums Board naturally received cases direct from the institutions of the poor-law guardians. In a similar manner largely but not exclusively, through the intermediation of the Board, arrangements were completed for dealing with cases of tuberculosis both pulmonary and surgical, and later for sufferers from osteomyelitis, polioencephalitis and encephalitis lethargica. Such cases were often admitted from hospitals ; but, so far as they were passed through the school organisation, the children were seen by the consultant medical officers in the public health department of the Council and arrangements made for their re-examination so soon as notification of their discharge from hospital had been received, to determine the most suitable provision for their further education. As a result of the consolidation of services brought about by the Local Government Act, 1929, the Council now controls a wide range of hospitals and institutions, so that the procedure for following up and interchange of records has been simplified. Large numbers of children still naturally attend voluntary hospitals for treatment; but, when residential care for long periods is required, these hospitals usually apply to the Council for the transfer of the children, and in all cases the facilities available are kept before the notice of the professional and social service staffs. Cases may be admitted to the Council's special hospitals direct from either voluntary or the Council's general hospitals, but more cases than formerly are now seen by the Council's consultant officers attached to the school service, thus ensuring a somewhat more continuous record of observation should the children subsequently attend a day special school. It has been possible to arrange that from certain of the special hospitals the children shall come to the County Hall on their discharge, and at the same time be seen and have the necessary notes made on the special school record card if they are proposed for such form of subsequent education. In any case, a recommendation is made by the head of the special hospital as to the type of schooling suggested, and in some cases a certifying officer pays regular visits to the hospital to determine the most desirable schooling, just before the discharge of the patient, and notes the findings on the special school card. On discharge those children who have been admitted to special hospitals from voluntary hospitals are referred for after-care or supervision to their hospital of origin. Those who have been at the Princess Mary's or the Heatherwood hospital are seen at after-care clinics which are held by the superintendents of those hospitals at the County Hall. On these occasions minor repairs or adjustments to appliances can be carried out, or the necessary data noted by the mechanic if more is required. If necessary, children return to the hospital for further treatment or adjustment of appliances. In the case of the Queen Mary's hospital, Carshalton, children whose appliances need repair or readjustment return perhaps only for the day, perhaps for a few days, according to the amount of attention required. In these after-care clinics there is a close liaison with the school service ; and, where the clinic is held at the County Hall, the surgeon can consult at once with a certifying officer if he has any suggestions to make as to the modification of the educational provision. It is now quite usual for orthopaedic cases to commence their treatment in the special hospitals before attaining school age, and to attend day special schools for the first time on their discharge. In older days a child was often in attendance at a day special school for some time before admission to a hospital, or was attending school with a limb or back immobilised for long periods, visiting a hospital out-patient department from time to time for supervision by the surgeon in charge of his case. Such instances are now very rare, those children who need prolonged immobilisation are got away to special hospitals where they obtain the advantages of country air and surroundings with education, even though they be for a long 69 time bedridden. The provision directly provided by the Council for children is as follows :— Hospital. Type of case. Accommodation. Queen Mary's, Carshalton. Surgical tuberculosis. Orthopaedic cases. Heart disease. Congenital malformations. General. 1,284 Princess Mary's, Surgical tuberculosis. Orthopaedic cases 221 Margate. Convalescence 50 Heatherwood, Ascot Surgical tuberculosis. 126 The Downs, Sutton Ear diseases. Rheumatism and heart disease. General. Convalescence. 360 High Wood, Brentwood Rheumatism 206 Tuberculosis 220 Northern (part of), Winchmore Hill Encephalitis 84 . White Oak, Swanley Eye diseases 364 Goldie Leigh, Abbey Wood. Skin diseases. Convalescence 248 St. Anne's, Heme Bay General for cases needing seaside treatment and convalescence.127 Millfield, Littlehampton Seaside convalescence 98 Southern Dartford. (Lower), Convalescence 250 Besides these, the Council contracts with various homes and hospitals for cases which may need country or seaside residence and supervision, but not in most cases active surgical treatment. Cases of chronic bronchitis and the like may be sent to residential open-air schools, such as the Sun Trap, Hayling Island, or St. Catherine's, Ventnor. Epileptic children of special school age, if of adequate mentality, are sent to the schools at the Lingfield, Chalfont, or Much Hadham colonies, admission being preceded by reports from the Council's certifying officers. During the year Mr. N. Bishop Harman, F.R.C.S., the consulting ophthalmic surgeon, retired on reaching the age limit. Mr. Harman joined the service in 1903, and was associated with the then medical officer (education) in the earlier development of the schools for the blind and the partially sighted. His reports on the causes of blindness and seriously defective vision were for a long time the most authoritative statistical data available. His influence was largely responsible for keeping up official and public interest on the question of the prevention of blindness, which was shown by the making notifiable of ophthalmia neonatorum and by the establishment and setting up of committees on the question of the prevention of blindness. The blind and partially sighted. In the report of the Departmental Committee of the Ministry of Health, 1926, Mr. Harman was responsible for many of the data, and, in co-operation with others, for the classifications adopted. He showed that over one-third of cases of blindness had their incidence during the school years, and that certain of the conditions were capable of being alleviated by improved methods of notification and treatment. Recent statistics have shown the considerable fall which has taken place in blindness originating at, or before, the school age, as the result of the improved treatment of venereal disease including ophthalmia neonatorum and the closer supervision resulting from the inspection of a considerable number of infants in welfare centres and almost the entire school population during the school age. Mr. Harman is, however, best known for his work in connection with the classes for the partially sighted. In an historical retrospect in the report of the Committee of Enquiry into Problems Relating to Partially Sighted Children, which has recently been issued, it was pointed out that the initiation and development of the system of special education for partially sighted children in London was due in no small measure to the enterprise and foresight of Mr. Harman. His suggestions and the procedure adopted in London were discussed at international conferences and the procedure adopted by the Council gave a lead, not only to public authorities in England, but to the whole western world. In particular Mr. Harman's ideas have been taken up with enthusiasm in America where many " sight-saving classes " 70 exist and where suitable material, in the form of maps, diagrams and clear type text-books, has been published. A form of desk which he suggested for the prevention or limitation of stooping, was adopted in London schools, and, with minor modifications, elsewhere. In addition to this, Mr. Harman's work in the selection and subsequent oversight of suitable candidates for the residential ophthalmic school at Swanley, instituted by the Metropolitan Asylums Board and later taken over by the Council under the Local Government Act, 1929, has been most useful in the control and care of cases of ophthalmia and other contagious eye conditions, such as interstitial keratitis. Deaf children. During the year Mr. Wells examined 229 children with defective hearing, the decisions regarding whom are set out on page 63. The cause of deafness in the partially deaf, deaf and defective, and deaf, seen for the first time during the year, was found in 31 cases to be congenital, and in 177 cases acquired, while in 21 the cause was uncertain. The congenital cases were classified as follows:— Cause of deafness. True hereditary deafness 6 Sporadic deaf birth 17 Aphasia 8 Total 31 The acquired cases were classified as :— Cause of deafness. Disease of the nervous system 9 Infective conditions 10 Other infectious disease 4 Nasal obstruction 43 Ear disease 106 Injury 5 Total177 Mr. Wells also visited the schools for the deaf and partially deaf and examined all the children. As a result, 8 children in schools for the partially deaf and 3 children in schools for the deaf were returned to elementary schools as having improved. Two children in schools for the deaf were found to have improved, and being over 14 years of age were allowed to leave. The reclassification table on page 65 gives particulars of the re-allocation of children already in attendance at special schools. Mental Deficiency Acts. Cases notified to the local authority. The following table shows the number of cases notified by the education authority under section 2 (2) of the Mental Deficiency Act, 1913, as amended by the Mental Deficiency Act, 1927, during the year 1934 (the figures in brackets being those for the previous year):— (a) Feeble-minded— Boys. Girls. (1) Leavers 148 (169) 143 (186) (2) Detrimental 2 (3) 3 (3) (3) Special circumstances 2 (-) 2 (1) (4) Ineducable 8 (17) 11 (11) (b) Imbeciks 55 (72) 43 (67) (c) Idiots 7 (5) 4 (3) 222 (266) 206 (271) Total 428 (537) After-careers. The chief officer of the mental hospitals department has furnished the following return for the year 1934 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 71 further aid in the form of supervision, guardianship or institutional care under the Mental Deficiency Acts was necessary:— Table 43. Classification. Male. Female. Total. Grand total under headings. (1) Number of children born in or subsequent to 1916 who have left special schools and who were on the books of the supervision section on 31st December, 1934 366 221 587 587 (2) Number who after trial have proved themselves to be incapable by reason of mental or physical defect of undertaking remunerative employment 2 2 4 4 (3) Number employed as under :— (a) Industrial or manual occupations (i.e., factory work, trade or any part of a trade) 233 163 396 (6) Agricultural or rural occupations — — — (c) Domestic occupations— M. F. Total (1) Receiving remuneration 6 16 22 (2) Required for work at home 1 18 19 7 34 41 (d) Commercial, shop assistant, or selling behind a counter, office boys or girls 4 1 5 (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) 74 1 75 517 (4) Number judged to be employable but out of work 29 9 38 38 (5) Number whose careers have not been traced:— (a) Not visited and not seen at bureaux 5 — 5 (b) Visited but no information obtainable 12 11 23 28 (6) Cases dealt with in addition to above including those who have since :— (a) died 1 1 2 (b) attained the age of 18 years 203 71 274 (c) been dealt with under M.D. Act 20 17 37 (d) been lost sight of, or have left London 8 9 17 330 X.B.—In addition to the 587 after-care cases shown in the above return there were 453 boys and girls between 16 and 18 years of age who had left special schools and were under statutory supervision on 31st December, 1934. These also were on the books of the supervision section for placing in employment. Ponton-road remand home. The medical supervision of Ponton-road remand home has been carried out by Dr. C. N. Atlee. During the year 1934, 2,057 children and young people were admitted to the remand home, of whom 1,801 were boys, and 256 were girls. Amongst this number, out-county cases totalled 636. The number sent to hospital was 85, and 609 were found to be verminous and were cleansed. Special psychological and medical reports were called for in 269 instances by the magistrates and duly complied with ; 82 children were persistent bedwetters. The number admitted and dealt with, shows an increase over last year of 729, of whom 145 were out-county. The reasons for admission are tabulated and have been abbreviated, stealing and allied offences accounting for the majority, as usual. There is an increase in the number noted under "needing care and protection," this being a useful measure for removing children from conditions likely to bring them into trouble and securing for them some means of supervision. "Suspected persons," and "breaking and entering with intent," appear to be common charges. The remainder do not seem to call for any special comment. Taken as a whole, the young people and children admitted, with a few exceptions, were representative of the usual type of normal elementary school child, such as one finds in the course of routine school work, with 72 normal temperament and mentality. The usual causes of delinquency were traceable in almost every case. They are lack of proper discipline, with inadequate parental control and general slackness, defective home and environment, bad companions, etc. The general health and physique were found to be fairly normal, in fact, the majority were well fed and in good health generally; even some young people who had "hitch hiked" to London from Wales and the North, in the hope of finding work here, showed no signs of food deprivation. The detention in the remand home seems to do the children good in more ways than one, the regular life and discipline exerting a very beneficial effect. The diet would appear to be adequate and well thought out. With regard to physical defects, no child was found to be suffering actually from the effects of insufficient food. The 178 cases who are noted as showing subnormal nutrition were mainly representative of the large class who are naturally and normally thin, probably from temperamental causes due to detective pancreatic secretion or other gland dysplasias. Weak feet, often associated with hammer toes, valgus and crooked toes, appeared to be common. The number of cases of undescended testicle may have been underestimated, this condition, which is very common, usually corrects itself by the age of puberty, but, tends to leave some permanent weakness, and possibly accounts for the large numbers of men who have definite inguinal hernia in later life. Strangely enough, there were five cases of partial hypospadias. The subject's attention was purposely not called to this defect which is occasionally found in a minor degree during school inspection. There was no active rheumatism, but all the fifteen heart cases were the result of a previous attack of the articular fever. The proportion of cases of mental defect was about the same as in previous years, 47 cases were feeble-minded or border-line. Many others were seriously retarded educationally. Several mentally defective children were found to have marked superadded psychotic tendencies of the nature of schizophrenia. Some very useful and correct summings up, unfortunately too few, of the character and disposition of certain of the children were sent in by their head masters. In order to arrive at a fair estimate of a child's make up, together with his general behaviour and reactions, it is necessary to observe him over some period, and there is every opportunity for this to be done at the remand home, given time, by the medical officer working in liaison with the superintendent and his officers. Table 44. Ponton-road remand, home—Reasons for admission. Offences. Boys. Girls. Offences. Boys. Girls. Stealing and allied offences 1,021 74 Wilful damage ... 19 — Breaking and entering 282 4 Needing care and protection ... 82 102 Burglary 2 — Attempted suicide — 1 Suspected persons 71 1 Insulting words 2 1 Defrauding 10 — Loitering and trespassing 16 1 Begging 12 I Sex offences 20 — Beyond control 119 35 Army or Navy deserters 3 — Breach of recognisance 39 7 Absconding from approved school 10 2 Wandering 22 6 Drunk and disorderly 1 — Assault 5 — Total 1,782 247 Assault with firearms 1 — Inflicting grevious bodily harm 7 — Miscellaneous 28 Arson 1 I Grand total 2,057 Education Act offences 37 11 Table 45. Ponton-road remand home—Physical defects. Defect. Boys. Girls. Defect. Boys. Girls. Subnormal nutrition 171 7 Non-tuberculous lung catarrh 58 6 Subnormal physique 224 12 Epilepsy 3 — Vision— Defective speech 40 5 6/9 or 6/12 39 1 Enuresis 80 2 6/12 or less 215 40 Congenital syphilis 4 1 Eye disease 19 3 Gonorrhœa 2 — Squint and ptosis 55 12 Vaginal discharge — 5 Colour vision defect 18 1 Varicocele 30 — Teeth (three or more decayed) 116 19 Imperfectly descended testicles 120 — Nose and throat 139 11 Partial hypospadias 5 — Ear disease 43 2 Abnormal feet, weak arches, etc. 130 15 Defective hearing 27 — Spinal deviations 45 9 Valvular heart disease 12 2 Congenital abnormalities 30 6 Congenital heart malformation 3 — Hare lip and cleft palate 1 — Skin disease 67 5 Spina bifida occulta 1 — Enlarged glands 90 10 Infantile paralysis 2 — Hernia 4 1 Osteomyelitis 1 — Tuberculous spine 2 — 73 During the year 665 children were seen who were reported sick, and, of these, 85 were sent to hospital. Most of the accidents were of a minor nature and were treated on the premises; several, however, of the nature of doubtful fractures, were sent to hospital for confirmation by X-rays and subsequent treatment. One case of diphtheria occurred of the serious "bull necked" variety, with a fatal issue after removal to hospital. The remaining cases of diphtheria were clinically certifiable, but not necessarily positive to bacteriological tests subsequently on further examination in the isolation hospitals. Sickness and casualties. With regard to the infectious diseases, it was not possible to trace any source of infection from the premises or from contacts there. In all these cases, systematic daily inspection of all the contacts was made, and swabs taken where necessary. Very little active venereal disease was found, most of the cases of vaginal discharge being due to a simple leucorrhœa, not uncommon in girls about the age of puberty. Table 46. Ponton-road remand home—Cases treated for sickness and casualties. Diphtheria 8 Tonsillitis 114 Scarlet fever 1 Glands enlarged 5 Chickenpox 1 Accidents 116 Otorrhcea 28 Epilepsy 3 Eye diseases 10 Post rheumatic valvular heart disease 2 Gastric diseases 11 Swabs taken 66 Ringworm 1 Incomplete abortion 1 Skin diseases 110 Vaginal discharge 10 Scabies 6 Gonorrhoea 2 Stomatitis 2 Colds with pyrexia 78 Tuberculosis of bone 1 Bronchial catarrh 85 Total 665 Influenza 4 The very able and kind co-operation of the superintendent, Mr. M. S. T. Jones, and his assistants in the work, and his skilled advice on many difficult matters is greatly appreciated by the medical officers who have worked at the remand home. Child guidance. The problem of the maladjusted or "difficult" child has for many years caused considerable anxiety to teachers, care committees and school doctors. The varying aspects of the case concern both the educational and medical authorities alike, and with the establishment of special child guidance clinics some attempt has been made to tackle the problem on a scientific basis. Speaking generally, the incidence of neuroses in children is mainly due to either some inherent disability or some undesirable environmental influence. Different methods of approach have been attempted by various schools of thought but the difficulty has always been to discover the hidden factor responsible for the peculiar mental outlook of the child under observation. The most satisfactory results appear to be obtained through the team work of the psychiatrist, the psychologist and the social worker, who, after careful observation of the child's reactions especially during periods of play when the child exhibits self-expression without hindrance, are able to suggest a mode of treatment best suited to the individual child and the peculiar problem. The assistance of the school authorities, medical staff and care committee workers is necessary to the child guidance authority in aiding the course of treatment recommended, and there is no doubt that work of very great importance is being carried out. The Council gives every facility available by way of intercommunication between child guidance clinics and the various branches of the school educational and medical services. Moreover, with the consent of the Board of Education five different child guidance clinics in London have been recognised under section 80 of the Education Act, 1921, in order that the attendances of school children at the clinics may be regarded as equivalent to attendance at school for registration purposes. The clinics referred to are (1) Maudsley hospital clinic, Denmark-hill, S.E.5; (2) London child guidance clinic, 1, Canonbury-place, N.l; (3) East London clinic, Jews' Free school, Whitechapel, E.l; (4) the Institute of Medical Psychology (Tavistock clinic), Mallet-place, W.C.I, and (5) the West End hospital for Nervous Diseases, 73, Welbeck-street, W.l. The subjoined information with regard to the work of the clinics has been submitted by the authorities of the clinics concerned. The work at this clinic has proceeded on the usual lines during the year. Cooperation with head teachers and school care committees has been very helpful, and useful information and recommendations have been exchanged between them and Maudsley hospital guidance clinic. 74 the clinic. The number of school children referred to the clinic during the year was 345, of which number 194 were boys and 151 girls. The majority of cases were referred by school care committees and hospital authorities, while a number of cases were sent by private doctors, education authorities and relatives of patients. The age distribution was: 5 to 8 years, 109; 9 to 11 years, 122; 12 to 14 years, 100; over 14 years, 14. Dr. Wm. Moodie, medical director of the clinic, reports that, during the year 1934, the number of school children dealt with at the clinic was 191. Of these, 125 were boys and 66 girls. The age distribution was: under 5 years, 7; 5 to 8 years, 66; 9 to 11 years, 69; 12 to 14 years, 46; and over 14 years, 3. London child guidance clinic. A comparison of the intelligence quotients of the cases referred to the clinic shows that a larger proportion of children of high or average intelligence were referred compared with previous years. This is probably accounted for by the increased use which is being made of the clinic by head teachers for advice as to the treatment of backward children where the backwardness is not due to defects of intelligence. The work of the clinic generally has continued on the lines of (1) full service of intensive treatment, (2) special service with less intensive treatment and (3) diagnostic or advice service only. Each case, however, is given individual consideration, and treatment is designed to suit the particular needs of the case. Close co-operation has been maintained with both the school medical and educational services, and special tribute is paid to the work undertaken in this connection by the Council's district care organisers. The clinic does not restrict its activities to clinical work. It is also interested in the dissemination of knowledge of the aims and methods of child guidance. Monthly case discussions are held which are attended by teachers, care committees and social workers, and members of various professional groups. In addition discussions are arranged for special groups, and lectures outside the clinic are given by members of the clinic staff. The following tables show the sources of reference of the cases, and the reasons for reference:— Source of reference. Reasons for reference. Head teachers 34 Backwardness 31 District organisers 87 Nervousness 30 Parents, relatives and friends 23 Stealing and lying 30 Hospitals 13 Lying 2 Invalid Children's Aid Association 6 Enuresis 24 Private doctors 3 Unmanageable 19 Probation officer 5 Temper outbursts 9 Charity organisations 3 Speech difficulties 6 Barbican Mission to Jews 3 Truanting and wandering 4 Parent's employer 1 Sex difficulties 4 Bermondsey Medical Mission 3 Night terrors and fears 1 Welfare centres 2 Lack of concentration 4 Magistrate 1 Screaming fits 1 Orphanages 1 Depression 1 Fulham child guidance clinic 1 Vocation guidance and psychological tests 4 Scout master 1 St. Margaret's day nursery 1 Sleeping difficulties 2 Children's house, Bow 1 Sleep walking 2 St. Pancras dispensary 1 Word blindness 1 Juvenile employment exchange 1 Admission to Northampton home 2 - Fears about school 2 Total 191 Advice re placement 2 - Advice re management 1 Begging 1 Refusal to attend school 1 Quarrelsome 1 Heart attacks 1 Asthma 1 Incontinence 1 Constipation 1 Restlessness 1 Puts everything in his mouth 1 Total 191 75 The results of treatment were as follows :— Cases cloved. Adjusted or completed 76 Partially adjusted 5 Unadjusted 4 Placed 1 Cases still under treatment. Full service 57 Special service 42 Diagnostic service 4 Unallocated 2 Total 191 Dr. Emanuel Miller, director of the East London clinic, which was established in 1927 by the Jewish Health Organisation of Great Britain, reports that during 1934, there has been a very large increase in the number of cases referred to the clinic through the school services, especially in regard to educational backwardness and reading disabilities. East London clinic. He also mentions that play-room work has been further developed on systematic lines with the help of research students from the Institute of Education. During 1934, there were 178 new cases referred to the clinic from the schools and these, together with cases in hand at the beginning of the year, total 269 school children dealt with during the year. Of these, 177 were boys and 92 girls. The age distribution was: under 5 years, 7; 5 to 8 years, 61; 8 to 11 years, 91; 11 to 14 years, 92; and over 14 years, 18. The following tables show the sources of reference of the cases during 1934, and the reasons for reference :— Source of reference. Reasons for reference. School doctors 109 Theft, pilfering 28 Head teachers ... ... 18 Nervousness, excitability 66 School care committees ... 25 Backwardness 36 Hospitals and clinics 31 Enuresis 16 Parents and friends 26 Beyond control 23 General practitioners 9 Unmanageable at school 12 Probation officer and children's courts 29 Aggressive, spiteful 15 Other agencies 22 Night terrors, sleep walking 11 Stammer 10 Total ... 269 Other speech defects 10 Temper tantrums 4 Lack of appetite 1 Headaches 1 Habit spasm 8 Truancy 9 Wandering 5 Solitariness 2 Masturbation, sex difficulties 2 Reading disability 1 Inability to keep job 4 Depression 3 Faecal incontinence 2 Total 269 An analysis of the results of treatment shows:— Discharged, cases. Satisfactorily adjusted 78 Partially adjusted 28 Unsuitable or unadjusted 43* Advice only 14 Still under treatment. Progress satisfactory 32 No change 11 Too early to report 18 Failed to attend 16 Awaiting appointments at end of year 29 Total 269 *Including 19 cases which were found to be border line or mentally defective. 76 The Institute of Medical Psychology. Although the Institute of Medical Psychology (Tavistock clinic) has been dealing with maladjusted children for some considerable time, it was not until 1934 that the clinic sought and obtained recognition by the Board of Education, under section 80 of the Education Act, 1921, in order that the attendances of children might be regarded as equivalent to attendances at school. The clinic authorities pointed out that their work previously had been hampered by the lack of co-operation with the school organisation. This has now been adjusted and head teachers and care committee workers from the schools are giving ready assistance by attendance at clinic conferences, consultations with clinic workers, and co-operation in carrying out recommendations as to treatment, as well as supplying information in the initial stages. The number of school children dealt with at the clinic during 1934, was 82, of which number 47 were boys and 35 girls. The age distribution was : from 4 to 7 years, 19 ; 7 to 10 years, 26 ; 10 to 14 years, 32 ; and over 14 years, 5. source of reference. Care committees 16 Head teachers 14 Hospitals 12 Parents and friends 12 Medical practitioners 7 Religious institutions 6 Medical officer of health 5 Children's special worker 3 Infant welfare centres 2 Probation officers 2 Education authorities 1 Other clinics 1 Publicity 1 Total 82 Reasons for reference. Neurosis 28 Behaviour difficulties 14 Stealing 12 Enuresis 12 Speech difficulties 5 Educational 4 Backwardness 4 Sex difficulties 3 Total 82 Results obtained. Adjusted 9 Partially adjusted 9 Unadjusted 5 Unsuitable or unco-operative parents 11 Transferred to hospital 4 Placements 5 Still under treatment 33 Advice only 6 Total 82 West End Hospital for Nervous Diseases. The authorities of the West End Hospital for Nervous Diseases in 1932 organised a child guidance unit at the hospital, and the object of the unit was stated to be the diagnosis and treatment of emotional and behaviour disorders of children and young adolescents, cases of "nervous" children, the mentally retarded, the juvenile delinquent and the sufferer from the sequelae of encephalitis lethargica, referred by practitioners, school authorities, magistrates, etc. The children are first examined in the ordinary out-patient department of the hospital before being transferred to the guidance unit. The work is under the direction of Dr. Emanuel Miller, and the methods adopted conform very closely to those used at the Canonbury and East London child guidance clinics. Close co-operation has been established with care committees and head teachers in the district, and contact has been both effective and cordial. During 1934, with the consent of the Board of Education, the unit was recognised under section 80 of the Education Act, 1921, in order that the attendances made by children at the clinic might be recognised for school records. The work has continued during the year and a special organised play-room has been established in connection with the unit for the observation of children under treatment. A psychologist is also engaged to deal with special cases of backwardness in reading and arithmetic. 77 The number of children referred to the clinic during the year was 104, which, together with 64 cases in hand at the beginning of the year makes a total of 168 cases. The age distribution of the 104 new cases was: from 5 to 8 years, 46; 9 to 11 years, 34; 12 to 14 years, 21; over 14 years, 3. The following is an analysis of the cases dealt with:— Source of reference. From out-patient clinics of West End hospital 50 School care committees 22 Other hospitals 14 Juvenile courts 9 Other child guidance clinics 3 Private practitioners 2 Head teachers 2 Child guidance council 1 Marylebone Health Society 1 Total 104 Reasons for reference. Tics and jerky movements 14 Stealing 13 Backwardness 10 Unmanageable 10 Anxieties 10 Restlessness 7 Stammer and speech defects 6 Hysterical illnesses 4 Intelligence tests only 4 Advice re school 3 Sex difficulties 3 Night terrors 3 Solitariness 3 Enuresis 3 Enuresis and faecal incontinence 2 Faecal incontinence 1 Spitefulness 2 Screaming 2 Temper 2 Masturbation 1 Truanting 1 Total 104 Results obtained. Cases closed— Adjusted 41 Partially adjusted 10 Unadjusted or parents unco-operative 14 Transferred to other clinics 4 Unsuitable for treatment 5 Consultation only 21 Cases still under treatment 73 Total 168 Nursery schools. Much attention was given in 1934 to questions concerning nursery schools and their possible development. A summary is given below of the action taken by the Council in recent years and of the various ways in which the general question has recently been brought to notice. Voluntary nursery schools have been aided by maintenance grants from the Council since 1919. There are now twelve such schools in London recognised by the Council for grant. In 1921, the Council provided 100 nursery school places on the Stowage site, (Greenwich), where Miss Margaret McMillan had already established a voluntary nursery school which was aided by grant from the Council. Since Miss McMillan's death in 1931, the whole of the nursery school on the site has been maintained by the Council. For ten years the Council's school and the voluntary school had been organised together as one school under one superintendent. In 1930, two experimental detached nursery schools were opened: Columbiamarket and Old Church-road. Reports on the working of these schools were considered, and it was decided that, while in essentials the schools were fulfilling their purpose, further experience was necessary before any final conclusions could be reached on certain points of staffing and reorganisation, and also on the question raised by the consultative committee of head mistresses of infants' schools that nursery classes should be provided rather than detached nursery schools. F 78 In the same year, the Council had considered a circular from the Board of Education and the Ministry of Health on "children under school age." This circular urged local education authorities, in framing their programmes of educational development, to consider the provision of nursery schools and nursery classes. The Council decided, however, to make no departure from its previous policy until the extent of the commitments which might fall upon it as the result of the projected legislation for the raising of the school-leaving age was known. The Special Services Sub-Committee in November, 1933, received a deputation from the consultative committee of head mistresses of infants' schools, urging the provision, within infants' departments, of what they described as nursery wings. The deputation submitted the view that this method of providing for very young children was preferable to establishing detached nursery schools. A report, issued in December, 1933, of the Board of Education's Consultative Committee, under the chairmanship of Sir W. H. Hadow, entitled "Infant and Nursery Schools," dealt fully with the various questions affecting the mental and physical development of children up to the age of seven. Many of its recommendations were in accordance generally with the Council's policy with regard to young children in its schools. With regard to nursery classes and nursery schools, local education authorities were recommended to survey the needs of their areas and to provide facilities, in consultation with the Board of Education, for the nurture and training in schools of children under five, whether in nursery schools or nursery classes. The report advised that where children under five are admitted to infants' schools, nursery classes should be the normal type of provision. The representative managers have recommended the provision of nursery schools, particularly in areas which have been scheduled for slum clearance and in, or adjacent to, the Council's housing estates; and the Special Services Sub-Committee in April, 1934, received a deputation from the Nursery School Association of Great Britain, urging the reservation on housing estates of sites for nursery schools and better provision, on nursery school lines, for children in infants departments. Dr. E. M. McVail (divisional medical officer), Miss E. Stevenson (senior woman inspector) and Miss G. Sanson (inspector of infants' methods) were asked to report comprehensively upon the whole question. As a result of the consideration of their report, the Council has agreed to the principle of nursery school development in London, and provision for this has been made in the three-year programme 1935-38. Dr. E. M. McVail reports that accommodation in nursery schools has, during the year 1934, remained unchanged, viz., 1,044 places in 15 schools. Of this accommodation, 500 places in 3 schools are maintained, and 544 places in 12 schools are aided. Eight schools, including the 3 maintained, have a Council doctor, whilst 7 aided schools make their own arrangements. Children in all schools are seen at least once a year and in many once a term, special cases being examined more frequently. All except one aided school now have a Council nurse, who visits daily for treatment of minor ailments, advises as to suspected infectious disease and inspects for cleanliness. The number of visits paid by the medical officers was 210, and 3,079 examinations were made of the children. The Council's treatment centres are available for the treatment of nursery school children, and at most schools the parents co-operate well by having medical recommendations carried out. Children with rickets as a rule improve markedly with the nursery school regime—fresh air, exercise, milk, cod-liver oil and suitable food—and hospital treatment is only exceptionally necessary. Out of 1,585 children examined, 162 were noted to have rickets to a greater or less degree. Medical inspection and treatment—Day continuation schools, evening institutes and junior instruction centres. Day continuation schools and evening institutes. With a view to closing up to some extent the gap in physical care between school leaving and the commencement of provision of medical benefit under the national health insurance scheme the Council decided that, as an experiment for one year, arrangements should be made as from 1st April, 1934, for the medical 79 inspection and treatment of students attending the Council's day continuation schools and those attending three junior evening institutes, provided that the students were not more than sixteen years old at the time of the inspection and agreed to undergo such inspection or treatment. The Board of Education approved this proposal on the understanding that their approval was limited to the scheme then put forward, and that they would not necessarily be in a position to approve any extension of the proposal in future years. The results of medical inspections from 1st April, 1934, to 28th February, 1935, are set out below. The figures relate to all the 11 day continuation schools and to Shillington-street, the " Stewart Headlam," and Gopsall-street evening institutes:— Table 47. Sex. No. examined. Nutritional state. Condition of clothing and footwear Cleanliness skin and hair. Teeth. Vision. No. wearing glasses. Various other defects found. No. advised to have treatment. Excellent. Normal. Subnormal. Bad. Good. Fair. Bad. Clean. Dirty. Pediculi present. Sound. Less than 4 decayed. More than 4 decayed. Normal. Slightly subnormal. Treatment required. Day continuation schools. (Estimated number of students eligible—4,000.) Boys 400 149 239 12 — 362 37 1 397 - 3 286 111 3 304 47 49 69 94 114 Girls 357 149 192 15 1 348 9 — 345 11 1 261 87 9 260 46 51 57 104 92 3 selected evening institutes (estimated number of students eligible—900). Boys ... 162 32 111 19 — 133 29 — 161 1 - 126 33 3 *79 31 24 13 63 27 Girls ... 108 38 66 1 3 87 21 — 98 8 2 66 32 10 *57 25 13 7 104 81 *The vision of 28 boys and 13 girls has not yet been tested. The medical inspections at the evening institutes are limited to the winter season (September to April). Twenty-six students at day continuation school have been re-inspected for defects previously noted; 12 defects had been satisfactorily treated and 4 were under treatment at the time of the re-inspection. Forty students from the day continuation schools applied for and received treatment for defects at the day school treatment centres. Some hesitation is apparent on the part of many of the students in accepting inspection. A number are at work with employers who provide medical care for illness and accident, but there is no periodical overhaul (except possibly on entry) with a view to discovering incipient defects. It will probably be some time before the advantages are appreciated fully by the students. The Ministry of Labour in a circular (A.C.6) issued in November, 1934, emphasized the desirability of securing the services of a school medical officer for the oversight of the juveniles at the junior instruction centres for unemployed boys and girls, especially those in regard to whom the superintendent desired advice, and drew attention to the fact that a local authority for higher education could at these courses arrange to provide, as medical treatment, milk at cheap rates for those juveniles who were medically certified to be under-nourished. Junior instruction centres. The medical inspection of the juveniles began on Monday, 31st December, 1934. The medical officers were advised to interview all juveniles, to recommend milk for those obviously requiring it and to carry out a detailed medical inspection where it appeared desirable, provided the juvenile was willing. F I 80 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 information at the end of each term. Including students in training colleges, 14,345 pupils were examined during the year, an increase of 716 compared with the previous year. Amongst these the number of routine age group examinations was 8,151 and of special examinations 6,224. Further details of the distribution of these students in the various institutions are given in the Appendix (table VII). In addition to the above, the records of 4,128 pupils not in the age groups 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, but in one case the clothing was found to be poor and in one infestation with head vermin was noted. Dental condition. The percentage of children, aged 12, with sound teeth was: boys, 82.5; girls, 78.8; but at the age of 15 this percentage had decreased by .4 per cent. among boys and increased by .6 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 1.7 and 1.3, respectively, compared with 1.4 and 1.0 in elementary schools at this age. Vision. At the age of 12, 71.1 per cent. of the boys and 68.5 per cent. of the girls were able to pass the vision test, compared with 69.2 and 65.8 in elementary schools; but, whereas in elementary schools the vision of children leaving 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 16.6 per cent. of the boys and 19.6 per cent. of girls were wearing glasses at the age of 12, but at the age of 15 the percentages were 18.7 boys and 22.9 girls. In spite of the much greater percentage wearing glasses at the age of 15, the number of pupils passing the vision test remained approximately the same, viz., 70.2 per cent. among boys and 67.5 per cent. among girls. Care of eyesight in secondary schools. Nutrition. In September, 1926, sight-saving education for myopic pupils was begun at Clapton and Peckham (now Honor Oak) county secondary schools for girls and at the Raine's foundation school for boys and still continues. The nutritional state of the pupils in the secondary schools, as returned by the school doctors, reverses the sex incidence of subnutrition found in elementary schools. In the elementary schools, girls at each age are better nourished than boys, but in the secondary schools, while only 4.8 per cent. of the boys are reported as subnormal, amongst girls, 6 per cent. are so returned. On the much smaller figures supplied from the routine inspections in secondary schools, there is more room for the personal equations of the examiners to obtrude themselves, still the figures suggest that the prevailing sentiment in favour of " slimming " affects the question. It is stated that many girls refuse milk in school giving the reason that it will make them " fat." Defects. The pupils 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 81 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. The re-inspection of 3,106 pupils in higher education institutions was carried out 1,698 defects had been satisfactorily treated, 168 were under treatment, 832 hac had treatment but needed further treatment, and in 887 cases, no treatment had beer obtained. Re- inspection. The following-up of defects discovered at secondary schools is left to the head masters and mistresses. When the parent is not present, a letter recommending treatment is sent, generally in the name of the head master or mistress. The parents normally respond readily. Scholarship children attending secondary and trade schools are given the same facilities for medical treatment under the Council's arrangements as children in elementary schools. For fee-paying pupils at secondary schools who have been inspected by the Council's medical officers or doctors appointed by the governors, arrangements are made when necessary for medical treatment to be received under the Council's scheme provided that (i) the parents cannot afford to make private arrangements and (ii) payment is made therefor. Of the 878 students examined in training colleges, none was found to be suffering from extensive dental caries; 82.1 per cent. of the men and 77.7 of the women passed the vision test, but 38.8 per cent. of the men and 26.0 of the women were wearing glasses. Training colleges. The teaching of hygiene. The school medical staff is not directly identified with the work of teaching hygiene. In all elementary schools, however, formal teaching of hygiene takes a place in the syllabus. A considerable amount of informal help is given by the doctors and nurses. Applications for addresses by the medical staff to parents and children are numerous and are always met. No additional staff, however, has been allowed for this, and if applications were to increase to a great extent it would be impossible to accede to the requests with the present staff. The work of the school nursing service is very largely devoted to the practical inculcation of good habits of personal hygiene. As eighty per cent. of parents attend the medical inspection of their children at some stage during school life, the school doctors exercise a potent influence through their individual advice, and though the effect of this is incalculable it is probable that there is no greater influence for health at work in the population generally. At dental inspection a little homily is generally given by the dental inspector to the parents as a group on the importance of dental care. The scheme organised by the education officer for dental demonstrations in the schools by officers of the dental board is now a permanent feature of hygiene teaching in the London schools, and reports are received which show that these demonstrations awake great interest and are of much value. In many of the boroughs the medical officer of health takes great interest in the work of education in health. "Health week" is commonly associated with a mass attack, in which the school children are provided for by special addresses and demonstrations. The treatment centres are capable of becoming in truth health centres, and parents visiting them learn much in regard to the general care of their children. The Downham treatment centre proclaims itself as a health centre, and sets an example in this respect by organising public lectures including cinematograph displays. Red Cross "links" have been established in many schools particularly in the south-western division. These are intimately associated with the work of the school nurses, and give great assistance in creating enthusiasm and a "public opinion " amongst the school children in regard to cleanliness and hygienic living. 82 There is a demand for health instruction on the part of the population over school age. In the evening schools there are some 250 classes in infant care, health, home nursing and first aid with over 3,000 pupils. These classes are conducted by selected medical practitioners. There are also 46 courses of lectures provided by the Education Committee for mothers attending infant welfare centres, with an average attendance of 20 at each lecture. Advanced lectures are also given to teachers in the evenings, and the assistant medical officers who carry out medical inspection of the students in training colleges assist there with the teaching of hygiene which is a compulsory subject. Special inquiries and reports. Certain special inquiries and reports have been included in their appropriate sections. Reference has been made to Dr. R. H. Simpson's enquiry into the provision of school dinners (p. 58); Dr. G. Chaikin's enquiry into the effect of milk meals (p. 55); Dr. E. McVail's joint report with the education inspectors on nursery schools and classes (p. 78); Dr. A. G. Wells' report on the special aural work (p. 26); and Dr. C. E. Thornton's report on the rheumatism scheme (p. 33). Mr. Lambrinudi's report on kyphosis. Mr. L. Lambrinudi, one of the Council's orthopædists, has conducted a research into the incidence and causation of kyphosis in children in London schools. The schools visited were those in Southwark in close proximity to Guy's hospital. The results were published in the British Medical Journal of 3rd November, 1934. Mr. Lambrinudi found that it was common for children in school to possess short hamstring muscles, that this was more often unilateral than bilateral, and that in the former there was invariably rotation of the lumbar vertebras towards the shortened side. His conclusions may be quoted in his own words:— I doubt if any but a few cases of adolescent kyphosis are the effect of congenital causes. The key to the problem lies in those mysterious fissures in the cartilage plate (of the spinal vertebræ, which I believe arise from flexion injuries. During the rough and tumble of play any child might sustain a flexion injury sufficient to produce these fissures, but I believe that the back of a child whose hamstring muscles are short is more susceptible to traumata of this nature, particularly if his general musculature is poor on account of previous debility or overgrowth. I would go even further, and say that not only do short hamstring muscles predispose to flexion injuries, but that they also give rise to rotation of the vertebrae and ultimately to scoliosis. If I have succeeded in convincing you that shortening of the hamstring muscles is an important factor, then we ought to agree that children with that condition should be watched with the utmost care and intelligence at school, and that toe-touching exercises in gymnastic classes should be condemned as a routine practice. Dr. Neustatter's report on physique of junior boys in a Bermondsey school. A member of the Education Committee noted that the junior boys in one Bermondsey school, at which she distributed the prizes, appeared to her to lack stamina to an exceptional degree which she had not noticed in other schools she had visited. Dr. Thomas visited the school and agreed with this opinion. The conditions referred to anaemia and posture rather than to malnutrition. The school is one that has no playing field within a distance which is within reach of younger boys. It has been stated in an earlier section of this report (p. 11), that junior boys are at a critical age, and that many types of defect reach their maximum amongst them. Dr. Neustatter, who is the school doctor at the school in question, was asked to pay special attention to the physique of the boys and he has submitted the following report:— There were four workers—two care committee workers, one nurse and the doctor. The investigation was carried out in a large room. The doctor sat in the middle with one of the care committee on his left. The nurse weighed and measured the children, and called out the weights to the second care committee worker, who sat beside her. She also made a note of the address of the child and its age. A class of about thirty was brought up, removed their shoes, but not their clothes, and were weighed and measured. The children were lined up in such a way that each child approached the doctor from the front, walking towards him for a distance of about five yards. Thus was considered a matter of some importance, as it allowed the doctor to get a good view of the "tout-ensemble" of the child's bearing, expression, comparative size, etc. 83 The child stood on the doctor's right was inspected, and the remaining points in the form filled in. At the same time, if necessary, the child was referred to the care committee worker on his left, if milk or convalescence was indicated, for her to take the necessary particulars. Milk cards were filled in by the care committee worker and signed in a bunch at the end. Cases for convalescent treatment were referred as specials for the next medical inspection. In this fashion it was possible to see 240 children in just over two sessions (excluding an hour to an hour and a half preparing the scheme at the first session), equalling approximately 3½ hours of actual inspection. In addition to this the headmaster and the care committee had picked out a selection of particularly unhealthy looking children preparatory to the investigation, who were inspected by the doctor before the routine examination was made. The following defects were noted:— Faces: (i) Pallor—particularly the rather greyish pallor that these children sometimes suffer from. (Care was taken not to confuse the pallor of ansemia with that of the blond or red-haired fair-skinned child); (ii) A flabby, pasty skin, especially bagginess under the eyes; (iii) Expression—note was taken of the two extremes, the dull listless expression on the one hand, and the rather hectic look on the other; (iv) Prematurely old and tired faces. General physique: This was judged by the growth, by the state of the musculature, by flabbiness, excessive thinness, and/or, stunted growth. Posture was also taken into account. These descriptions are not very precise, but it is not possible to do more than record a general impression, which is based on observation of the above points. For recording purposes some kind of classification was needed. The children were therefore placed in the following four categories:— (i) Exceptionally good physique—These cases were boys who were well grown, very well developed muscularly, had good colour, healthy skins, and an alert bearing. In popular language they were " A 1." (ii) Average physique—-This comprised children, who, while not as exceptionally well developed as the others, nevertheless were bright and healthy, and had no obvious defects. They were quite satisfactory. (iii) Poor physique—These boys fell short of (ii) in so far as they had one or more of the defects enumerated above, which made them unsatisfactory. (iv) Bad physique—These were of such undoubtedly poor physique, that they would unhesitatingly be recommended for an open-air residential schoool such as Bushy, at a routine or special inspection. A record of height and weights was also made, in case some kind of objective record was needed. Little importance is attached to these findings, which are, however, included for completeness. Table 48. Classification. Age. Total. 7 years. 8 years. 9 years. 10 years 11 years Above average weight 10 41 41 39 10 141 Below ,, „ 2 13 15 16 9 55 Above average height 9 39 40 46 15 149 Below „ ,, 3 16 16 17 10 62 Exceptionally good physique 1 1 5 7 0 14 Average physique 5 36 31 33 13 118 Total 6 37 36 40 13 132 Poor physique 6 14 18 14 8 60 Bad „ 0 5 3 5 3 16 Total 6 19 21 19 11 76 Total number of cases showing dental caries, 33; anæmia, 46. N.B. Originally it was only intended to weigh and not to measure. Measuring was commenced on the second session. Therefore, owing to a certain number of absentees, the figures for weights and heights do not exactly correspond. Having classified the physique of the children as shown, an attempt was made to investigate the underlying factors and to see if anything emerged. A street analysis was made but except in one instance, there was no evidence of markedly uneven distribution of the various groups. 84 A detailed inquiry into the factors tabulated below was made by the care committee. They paid a visit to each of the homes of the 60 cases recorded, which were selected as a " random " sample, and filled in a questionnaire, in each case, and from these, the following table is compounded:— Table 49. Number of cases. Factors investigated. Average number of individuals in family. Average earnings. Average number of individuals in bedroom. Average number of individuals in 1 bed. Average hours of sleep. Standard of ventilation. Number of cases of damp houses. Where child plays. Average hours out of doors daily. Estimate of feeding. 40 (36 of poor and 4 of bad physique). 6 £2 6 4.3 2.5 11 29 good 3 fair 8 poor. 8 34 in yard 6 in parks. 3½ 30 good 7 fair 3 poor. 20 (all of exceptionally good physique). 5-5 £2 10 3 2 11 17 good 3 fair 2 17 in street 3 in garden 3½ 17 good 3 fair. Here again the table shows no significant difference between the two groups, though it shows the number of large families and general overcrowding. The largest family comprised 11 members, in 16 cases over 4 individuals shared a bedroom, the maximum being 8. In this case, 6 were in a bed! In 6 cases, 3 shared a bed. In the family of 11, the physique of the child was bad. The records of the other cases show no outstanding cause for bad physique. It will be seen that the inquiry includes an estimate of the type of feeding; as this was made by the care committee, it is very difficult to convey the standard, as the estimate is an expression of opinion by their individual members. An example of the type of feeding described as good was as follows: breakfast—2 pieces of toast, egg, or cereal, or bacon; dinner—meat dish, vegetable, potatoes; tea—bread and butter ; sunper—broth or meat. An example of "poor" is: bread and butter for tea, supper and breakfast (while the parent was out of work Quaker Oats or rice for dinner could not be afforded); meat puddings and vegetable for dinner. Obviously the opinion must be formed on the spot. The care committee, in summarising their results, say: "In most cases the children seemed to be getting enough to eat; there were three cases where the physical condition might have been due to under nourishment, and 6 where the children were finicky about food; on the other hand, a few cases were exceptionally well fed, porridge, meat, vegetables and fruit, forming a large part of the diet." They express the opinion that housing overcrowding seems to be the real difficulty. They conclude by saying that, in their opinion, in all the cases of the children of exceptionally good physique, although other circumstances are the same, "the mother is an extraordinarily capable and efficient manageress." As these families average 5½ in size, and the income averages £2 10s., such a statement is a testimony to a high degree of skill on the part of the mother. Although none of the findings shows a direct ætiological relationship to the case of poor and bad physique, probably the overcrowding and lack of suitable facilities for outdoor recreation (51 out of 60 of the children played in the street), play an important part in bringing about the condition of unsatisfactory physique; the more so as pallor was so often an outstanding feature. If these conditions could be altered, it seems a reasonable assumption that a number of the children now classed as " poor," would fall into the "average" class. The writer, moreover, would like to put forward two other theories as to the unsatisfactory condition of these boys. (i) A tentative suggestion that there is a psychological factor present, indirectly due to the overcrowding. Under the conditions in which these children live they are perpetually surrounded by others, they have no privacy; and, as is at times revealed by children, they are aware of and worried by the difficulties with which most of their parents have to contend. This, in conjunction with the noise, might be responsible for the strained expression and prematurely old faces of so many of these children. (ii) A more definite suggestion, often confirmed by findings at routine inspections, that these children frequently get insufficient sleep. These points might repay investigation. Finally, there is the question of diet. The care committee report reveals little actual shortage of food, though the quality of the food does not come up to a very high standard. At a time when the question of nutrition is to the fore, it is as well that other factors, such as those cited above especially fresh air and sunshine, should not be lost sight of. It must be emphasised that this enquiry was not into the question of malnutrition, but into the condition of physique, which as Dr. Robert Hutchinson has aptly pointed out, is quite a different matter. Dr. Neustatter's estimation of the nutritional state 85 of the boys examined shows that they do not differ materially in this school from the standard usually found in this respect. At a meeting of the Royal Society of Medicine in February, 1935, Dr. Robert Hutchinson remarked that there is still a great deal of confusion from failure to distinguish between physique and nutrition. Dr. A. B. Francklyn has made a short study of gains in height and weight at the Essendine-road and Barlby-road open-air classes, and has compared them with those of certain debilitated children receiving milk in school. The object of this analysis is to determine, if possible, the actual improvement in the children's health by objective means. The first point that emerges on comparing the results obtained at Barlby-road open-air class, with those of Essendine-road open-air class is the superiority of results obtained at Essendine-road during the period for April to October, 1934 (see figs. 8 and 9). Dr. Francklyn's report on open-air classes. fig. 8. graph comparing gains in weight in the three groups, april to october, 1934. fig. 9. graph comparing gains in height in the three groups, april to october, 1934. The average gains in weight andheight, respectively, were 1.24 kilos., and 2.27 cms., at Barlby-road, compared with 1.49 kilos. and 4.1 cms. at Essendine-road. The superior gain in weight is almost negligible, but the gain in height is markedly above that of Barlby-road, and is significant. If the results of these two classes are compared with the results obtained from children on "official milk," it will be seen that the two open-air classes show a superiority in both height and weight for the summer session. The children on "official milk" only show an average gain of 0.9 kilo. in weight, and 1.9 cm. in height for the period from May to October. But on examining their records over longer periods the picture is found to be reversed. The children on milk gain steadily throughout the year at an almost uniform pace. Winter gains and summer gains are almost of a constant nature. Take for instance, this record for the past twelve months:— Table 50.—Gain in height and weight of children on "official milk." Period. Gain in Weight. Height. October to January 0.9 kilos. 1.8 cms. January to May 0.8 „ 2.0 „ May to October 0.9 „ 1.99 „ The fluctuations are slight and almost insignificant. If the average gains at Barlby-road open-air class are considered over the same period, marked fluctuations in weight and rate of growth are disclosed :— Table 51.—Gain in height and weight of children at Barlby-road open-air class. Period. Gain in Weight. Height. October to January 0.38 kilos 1.23 cms. January to May 0.3 „ 1.87 ,. May to October 1.2 „ 1.94 „ 86 The total yearly gains are all in favour of the children on "official milk"; they have an average greater increase in weight of 0.78 kilo. and of 0.75 cm. in height. Unfortunately there are no records of weight and height for the Essendine-road open-air class in the winter, as the children concerned return to in-door conditions. The results of the Essendine-road open-air class appear satisfactory. The improvements in height and weight compare favourably with the other two groups; and both parents and teachers give corroborative evidence of improvement in health. It is to be noticed that the gain is most marked during the holiday period and that there appears to be a correlation between the degree of nutrition and the rate of improvement. Debilitated children appear to put on weight at a faster rate than healthy children, given good conditions. On analysis of results of the Barlby-road open-air class, the average increase in weight over the summer is less than that obtained at Essendine-road open-air class by 0.25 kilo., and there is also a slower rate of growth; the average gains being 1.83 cm. behind those of Essendineroad. If Essendine-road open-air class is taken as the measure, the results at Barlby-road are not up to standard. They were so, however, for the period April to October, 1933. fig. 10. graph comparing mean gains in weight and height, barlby road open-air school and group of selected milk cases, january, 1933, to october, 1934. Again the improvement in 1934 is not as satisfactory as that of 1933. There is a smaller average gain in both height and weight for 1934, and these results are appreciably below those observed in a very similar group of children on "official milk" (see fig. 10), though their homes are very much the same as those of the Barlby-road open-air class. It seems likely that, in the case of the Barlby-road class, "food energy" is being spent on keeping up bodily heat in the winter months out of doors. The very excellent figures obtained in the "official milk " group are worthy of note. Wage-earning employment of school children. In the year 1934, 3,304 applications (3,274 boys and 30 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 : 87 delivery of milk, 250; delivery of newspapers, 1,746 (14); carrying or delivery of goods or parcels, 541 (5); in or in connection with a shop, 295 (5); in a coal yard, 12; industrial work at home, 1; house work away from home, 16 (1); as a messenger, 43 (2); miscellaneous, 10 (1). In 234 cases the certificates were granted subject to medical treatment being obtained, and in 44 additional cases other conditions were imposed. Certificates on medical or other grounds were refused to 85 boys and 1 girl for the following reasons: rheumatism, 1; dental condition, 1; defective vision, 3; heart condition, 5; scoliosis, 3; poor general condition, 9; flat-foot, 3; bronchitis, 1; non-medical reasons such as " withdrawn," illegal hours, under or over age, etc., 60. The number of licences granted to permit children to take part in entertainments during 1934 was higher than in any year since the Council first took over the duty of granting licences in 1920. This year there was an unprecedented demand for children to appear in pantomimes, and this was one of the causes of the increase. There were also more troupes of children appearing in cinemas and music halls throughout the year. The Council's decision that a child shall not take part in more than two performances a day has had its full effect in 1934, with the result that more children are being employed to act as substitutes so that the troupe may be able to perform three times a day in cinemas. Employment of children in entertainments. The number of medical examinations of children under the regulations governing the employment of children in entertainments was 723 (74 boys, 649 girls). Four children, girls, were rejected on medical grounds—one enlarged glands, one hernia, one chest trouble, and one heart disease. One hundred and twenty-six 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 77, visual defect 19, throat condition 3, skin affection 12, personal hygiene 8, anaemia 2, ear affection 3, and flat-feet 2. Examination of employees in the education service and scholars. In the year 7,266 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:— Table 52. Status. Number examined. Number fit. Number rejected. Number who withdrew after being referred for remediable defects or were not due for reexamination until 1935. Male Female Male Female Male Female Male Female Permanent service 275 438 260 428 4 3 11 7 Teaching awards 145 383 143 372 1 3 1 8 Scholarships 3,059 2,991 2,917 2,890 21 5 121 96 Total 3,479 3,812 3,320 3,690 26 11 133 111 *7,291 7,010 †37 244 * Including 6 permanent service cases (4 male, 2 female), 11 teaching awards (3 male, 8 female) and 8 scholarships (1 male, 7 female) referred from 1933. † The causes of rejection were mainly defec ts of vision, unsatisfactory general health and morbid conditions of the heart. 88 In addition to the above, 148 examinations were made of scholars (49 male, 99 female) with a view to determining their fitness to continue to hold awards, and of these 8 (2 male, 6 female) were found to be unfit. Re-examinations totalling 1,792, were made of entrants, scholars, etc., who were referred at the first examination for treatment for one or more remediable defects. The total number of examinations was 9,231. Cases specially referred. There were also referred to the public health department 3,513 special cases in which medical advice was required. This figure includes 3,079 teachers (599 men, 2,480 women) and 434 schoolkeepers, cleaners, etc. (107 men, 327 women). In regard to recommendations governing sick leave to teachers, 2,015 or 71 per cent, of the teachers concerned were over 40 years of age; this shows a decrease of 1 per cent. on that of the previous year. In connection with these cases, 18 home visits were paid during the year. Health of teachers. The records for the years 1930 to 1934 (inclusive), of the deaths and premature retirements on account of ill-health, occurring among the teaching staff in elementary,excluding special, schools, have been specially examined by Dr. J. G. Duncan and Dr. A. C. Williams. Deaths of teachers. The causes of death and age at death are set out below:— Table 53. Disease Age Total 20-29 30-39 40-49 50-54 55-59 60— M F M F M F M F M F M F M F Respiratory system— Tuberculous 3 2 1 1 4 2 1 2 2 — — — 11 7 Non-tuberculous 2 - 1 2 6 5 5 4 1 4 2 1 17 16 Influenza — — — — — 3 — — — — — — — 3 Organic nervous disease — 2 1 3 2 1 — 4 4 3 1 4 8 17 Gastro-intestinal disease — — — 3 5 3 3 — 2 3 3 3 13 12 Circulatory diseases — 1 2 1 5 11 4 4 5 6 2 5 18 28 Septicaemia — — — — — 5 — 2 — — — — — 7 Cancer, etc. — — — 1 2 8 4 15 3 9 - 2 9 35 Accidents 2 2 2 1 4 4 — 4 2 - — 13 8 Kidney — — 1 1 1 1 1 1 3 1 2 — 8 4 Operations (site unknown) — 1 — 1 1 3 2 1 — 2 — — 3 8 *Miscellaneous — 1 — 2 2 1 1 1 2 1 — — 5 6 Cause unknown — — — 2 3 6 4 3 3 3 4 — 14 14 Total 7 7 8 19 32 53 29 37 29 34 14 15 119 165 Deaths at all ages—Yearly average 23.8 33.0 *One case each of anaemia, debility, scarlet fever, streptococcal infection, diphtheria and lymphatic leukaemia, two cases of diabetes and three of death following childbirth. In 19 cases the teachers died from operations for known conditions and these have been entered under the appropriate heading. 89 The causes of retirement of teachers who have left the service on medical Breakdowns, grounds are set out below :— Table 54. Disease Age Total 20-29 30-39 40-49 50-54 55-59 60 + M F M F M F M F M F M F M F Respiratory diseases—- Tuberculous — — — 3 3 3 — 1 — — — — 3 7 Non-tuberculous — — 1 1 1 1 3 6 4 11 — — 9 19 Nervous Diseases— Organic — — — 1 — 4 1 2 2 2 — 1 3 10 Functional — — 3 5 2 18 5 25 9 45 2 1 21 94 Psychosis — — — 1 1 7 2 2 — — — — 3 10 Arthritis — — — 1 — 5 — 10 2 20 — 3 2 39 Gastro-intestinal disease — — — — 1 5 2 3 4 7 — 1 7 16 Kidney diseases - - - - - 2 — 2 1 1 — — 1 5 Circulatory — — — 1 1 15 1 17 2 41 — — 4 74 Cancer — — — — 2 6 — 5 — 6 — — 2 17 Deafness — — — 1 1 3 — 8 2 7 — 1 3 20 Defects of vision — — — — 1 — — 3 — 6 — — 1 9 Diseases of larynx — — — — 1 — — — — 2 — — 1 2 Exophthalmic goitre — — — — — 2 — — — 3 — — — 5 General debility — — — 1 — — — 1 1 6 — 1 1 9 Miscellaneous — — — 4 1 1 3 — — 5 — — 4 10 Total — — 4 19 15 72 17 85 27 162 2 8 65 346 Yearly average 13 69.2 *One case of eczema, two of septicaemia, three of anaemia and four each of diabetes and uterine disorder. Comparing the incidence of "breakdowns" in the present series with that shewn in the table issued in the Annual Report for 1929 (vol. III, p. 143), the following interesting facts emerge:— (a) The total number of "breakdown" cases in each period is very nearly the same, i.e., 1930-1934, 411; 1925-1929, 417. (b) The cases of pulmonary tuberculosis are now considerably lower. (c) There is a considerable rise in the prevalence of rheumatic conditions during the period under review, and this was particularly obvious in the later months of 1934. (d) Ten teachers were obliged to leave the service on account of defective vision. In two cases the disabling condition was blindness from the effects of rapidly increasing myopia. There were also two similar cases of teachers at a secondary and a special school respectively, records of which are not included in the table. All these teachers had been passed into the service prior to the commencement of the present century. That the number of these cases is no higher is probably due to the fact that candidates suffering from severe myopia are rejected at the entrance examination, the standards used for which are in conformity with the advice of the Council of British Ophthalmologists. (e) The total number of teachers invalided out of the service on account of nervous and mental disorders did not differ greatly in the two quinquennia, but there is a greater tendency for the mild or functional type to preponderate over the graver organic disease. It is very difficult, from the records, to distinguish exactly between the classes; it is particularly common for a psychosis to be described in the early stage as a nervous breakdown. In both sexes the largest number of cases occurred in those who were suffering from definite physical disease, often of a depressing nature, e.g., thyroid disturbance, colitis, deafness, neuritis and rheumatic conditions and worry following operations. About one quarter of the total cases invalided out of the service were of the neurotic type. In seven of the men nervous trouble had first been 90 noted during War service, and most authorities state that War neurosis occurred almost exclusively in the constitutionally highly strung. It was noted, especially among the women, that home worries were an important factor, many of them having to bear heavy domestic responsibilities, often including the nursing of elderly parents and other sick relatives. (f) As shown below, the age group at which "breakdowns" took place was later in the second series:— Table 55. Years Age. 20—29 30—39 40—49 50—54 55—60— 1925—29 3 34 99 122 159 1930—34 0 23 87 102 199 This difference is also shewn in the age-distribution of the deaths :— Table 56. Years Age. 20—29 30—39 40—49 50—54 55—60— 1925—29 30 37 86 67 80 1930—34 14 27 85 66 92 Deaths from respiratory (tuberculous and non-tuberculous) disease were both somewhat fewer than in the earlier series. The influence of the 1929 influenza epidemic is to be noted, for in that year there were 3,118 deaths from the disease among the general population of London. (g) So far as influenza itself is concerned, there were only three deaths in the period under review, as compared with twenty-four during 1925-1929. (h) Accidents were twenty-one as against twenty-two in the former analysis. Thus, it will be seen that there has not been the rise that would be anticipated from the general increase in street fatalities. Duration of service. The annual average number of elementary, excluding special, school teachers on the staff for the years under review was 5,649 men and 12,038 women, making a total of 17,687. The average number of elementary, excluding special, school teachers leaving the service on all grounds annually, was 925. The average number of those lost by disease, was 139 (56.8 deaths and 82.2 breakdowns), and those who left on account of other causes, 786, i.e., taking up other appointments, voluntary retirements at age 60-65, marriage, domestic circumstances, giving up teaching, going abroad, compulsory retirement, and miscellaneous reasons. It has been ascertained that in only a very few of these cases has ill-health been even a contributory factor. Thus it may be said that about 15 per cent. of the annual wastage is due to death or disease. It will be seen that the loss to the service through "breakdown" in the younger teachers was nil, and only slight (23 cases) in those up to 40 years of age. In this latter group also, the deaths were few and many of them were due to such causes as accidents, pneumonia and encephalitis lethargica, from none of which the young and healthy are immune. In 1929, it was noted that while women broke down more frequently than men, the deaths among men were relatively much more numerous. The figures for the present quinquennium illustrate these facts even more strongly, the yearly average shewing:— Males Females Deaths 1 in 237 1 in 365 Breakdowns 1 in 435 1 in 174 so that a woman is more than twice as likely to be obliged to retire on health grounds as a man (2.5:1), but is less likely to die in the service (1:1.5). In general, the findings support the suggestion put forward in 1929, that many men have family obligations and so struggle on when their health would indicate retirement. 91 Tuberculosis is the only disease that definitely kills more men than women, i.e., 11:7 in the period ended 1934, and 17:8 in the earlier period. The proportion of the sexes of the teaching staff under review is of the order 1:2. This indicates that tuberculosis is a more prominent cause of death in men, but the numbers are small and the differences may not be of great significance. The chief affections that are relatively, as well as absolutely, higher as causes of breakdown in women are arthritis, disease of the circulatory system and deafness. The numbers of "breakdowns" in schoolkeepers, 1930 to 1934, inclusive, are in themselves small, but they illustrate the tendency generally observed for the breakdown to be concentrated on arthritis and circulatory diseases in those of 60 years of age and over, or approaching that age. Particulars are set out below:— Breakdowns in schoolkeepers. Table 57 Disease. Age. 20-29 30-39 40-49 50-54 55-59 60 + Total. Respiratory diseases— Tuberculous — — — — 2 1 3 Non-tuberculous — 1 — — 2 3 Nervous diseases— Organic — — 2 — — 2 Functional — — — 1 1 2 Psychosis — — 1 — — — 1 Gastro-intestinal — — — — — 1 1 Arthritis — — — 1 2 5 8 Circulatory diseases— Cancer, eto. - — 1 1 - - 2 Heart - — — 1 2 7 10 Arterio-sclerosis - — — — 2 8 10 Varicose veins - — 1 1 2 3 7 Deafness - — 1 — — 1 Vision - — — 2 — — 2 Hernia - — 1 — — — 1 Genito-urinary - — — — 1 1 2 Total - — 5 9 12 29 55 During the year 360 applicants for admission to the Council's course of physical education were examined. Of these 28 were deemed to be either temporarily or permanently unfit to undergo the training on the following grounds: poor general condition, 8; varicose veins, 11; recent injury, 1; renal calculus, 2; post-operative disability, 2; hernia, 1; heart disease, 1; recurring dislocation of the shoulder, 1; fistula, 1. Teachers of physical education. STATISTICAL TABLES. Table I.—Medical Inspection, 1934. (a) Routine Inspections. Group. Boye. Girls. Total. Entrants 29,576 29,062 58,638 Age 7 13,353 13,006 26,359 Age 8 (preliminary survey only) 21,453 21,809 43,262 Age 8 (detailed examination) 1,781 1,958 3,739 Age 11 26,951 26,601 53,552 Leavers 31,801 31,832 63,633 Total elementary schools 124,915 124,268 249,183 „ special schools 888 710 1,598 (6) Other Inspections. Special inspections 46,056 45,824 91,880 Infectious disease enquiries — — 44,197 Re-inspections — - 146,620 92 Table II. (a) (1) Defects found at medical inspections of all children except those aged 8 years. Elementary and special schools. Disease or defect. Routine inspections— Defects. Special inspections— Defects. Requiring treatment. Requiring observation. Requiring treatment. Requiring observation. Elementary schools. Special schools. Elementary schools. Special schools. Malnutrition 1,278 8 824 4 775 305 Skin—Ringworm, head 1 — — — 12 6 „ „ body 23 1 — — 19 1 Scabies 91 — — — 1,865 7 Impetigo 123 — 1 — 346 7 Other disease (non-tubercular) 877 4 85 1 733 80 Eye— Blepharitis 725 5 60 1 226 14 Conjunctivitis 170 — 15 — 239 17 Keratitis — — — — 6 — Corneal opacities 3 — 4 — 14 — Defective vision, excluding squint 13,428 93 5,183 67 3,208 350 Squint 1,089 2 406 1 410 40 Other conditions 182 2 48 — 188 25 Ear— Defective hearing 156 3 93 1 149 38 Otitis media 971 10 307 3 473 99 Other ear disease or defect 389 4 119 1 193 62 Nose and throat— Chronic tonsillitis 4,904 12 5,902 10 1,142 341 Adenoids 557 1 278 1 202 16 Chronic tonsillitis and adenoids 1,636 2 613 — 454 36 Other conditions 684 3 220 — 493 100 Enlarged cervical glands 295 1 1,044 1 213 185 Defeotive speech 87 — 167 — 109 60 Teeth—Dental disease or defect 58,757 330 1,384 4 4,160 102 Heart and circulation, heart disease— Organic 34 1 69 — 2 2 Functional 26 — 173 — 14 12 Not stated 211 2 2,339 17 266 733 Anaemia 587 1 482 1 362 160 Lungs—Bronchitis 817 — 863 5 144 68 Other non-tubercular 233 1 528 — 125 163 Tuberculosis— Pulmonary definite 3 — 8 — 1 — „ suspected 10 — 57 — 8 29 Glands 5 — 6 — 6 3 Spine 1 — 1 — 1 2 Hip — — 1 — 1 1 Bones and joints — — 2 — 1 2 Skin 1 — 1 — — — Other forms 1 — 2 — 1 1 Nervous—Epilepsy 22 — 17 1 46 36 Chorea 57 2 44 — 183 114 Other conditions 207 3 232 1 137 80 Deformities— Rickets 83 — 54 — 14 21 Spinal curvature 497 6 211 4 59 21 Other 728 5 522 1 206 70 Other conditions 2,646 15 1,232 3 3,451 1,244 Total 92,595 517 23,597 128 20,657 4,653 93 (a) (2). Defects found at medical inspections of children aged 8 years. Elementary and special schools. Disease or defect. Routine inspections— Requiring treatment. Requiring observation. Elementary schools. Special schools. Elementary schools. Special schools. Malnutrition 174 — 55 — Skin—Ringworm, head — — — — „ body 1 — — — Scabies 9 — — — Impetigo 43 1 — — Other disease (non-tubercular) 93 1 4 — Eye— Blepharitis 142 1 8 — Conjunctivitis 39 — 1 — Keratitis — — — — Corneal opacities — — — — Defective vision, excluding squint 3,992 10 881 5 Squint 170 1 32 — Other conditions 21 — 1 — Ear— Defective hearing 36 — 11 — Otitis media 167 1 22 — Other ear disease or defect 68 — 11 — Nose and throat— Chronic tonsillitis 1,009 5 421 — Adenoids 92 — 17 — Chronic tonsillitis and adenoids 250 1 20 — Other conditions 80 — 17 — Enlarged cervical glands 114 1 115 — Defective speech 28 — 8 1 Teeth—Dental disease or defect 11,395 41 145 1 Heart and circulation, heart disease— Organic — — 3 — Functional 1 — 5 — Not stated 34 3 152 — Anæmia 125 — 29 — Lungs—Bronchitis 32 — 34 — Other non-tubercular 29 — 41 — Tuberculosis— Pulmonary definite — — — — ,, suspected 2 — 4 — Glands 3 — — — Spine — — — — Hip — — — — Bones and joints 1 — — — Skin — — — — Other forms — 1 3 — Nervous—Epilepsy 4 — 2 — Chorea 17 1 10 — Other conditions 24 — 17 — Deformities— Rickets 1 — — — Spinal curvature 20 — 6 — Other 40 2 26 1 Other conditions 357 5 148 — Total 18,613 75 2,249 8 G 94 (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 58,638 8,445 14.4 Age 7 26,359 4,295 16.3 Age 8 (preliminary examination only) 43,262 5,893 13.6 Age 8 (in detail) 3,739 929 24.8 Age 11 53,552 8,800 16.4 Leavers—age 13¾ 63,633 9,701 15.2 Total, elementary schools 249,183 38,063 15.3 „ special schools 1,598 199 12.5 Table III. (a) Exceptional children in London in 1934. Classification. At certified special schools. At public elementary schools. At other institutions* At no school or institution Total. Day Residential Blind children — 125 — 7 3† 135 Partially sighted children 720 — 17 17 — 754 Deaf children 283 241 — 7 6‡ 537 Partially deaf children 150 — 2 26 — 178 Mentally defective children— Feeble-minded children 3,604 261 5§ 9 7 3,886 Epileptic children— Children suffering from severe epilepsy — 122 — 34 13¶ 169 Physically defective children— Tuberculous children— Pulmonary 124 291 — 24 — 439 Non-pulmonary 344 455 — 13 — 812 Delicate children 1,964 515 6,159|| 9 — 8,647 Crippled children 1,758 351†† — 11 — 2,120 Children with heart disease 1,821 221 — 34 — 2,076 * Undergoing treatment in general hospitals, etc. †At time of report were awaiting admission to schools for the blind. ‡Under enforceable age. § At time of report were awaiting admission to M.D. schools. ¶Awaiting admission to certified schools. ††lncludes 25 children at Northern hospital (post encephalitis lethargica). ||Of these 53 children were suitable for admission to open-air schools (O) but their parents refused to allow their transfer to such schools. The remainder could not be certified as incapable by reason of physical defect of receiving proper benefit from the instruction in the ordinary public elementary schools, but they might have benefited from a period of open-air treatment. (b) Return of children suffering from more than one defect, 1934. Defect. Type of School. At other institutions (Gen. hosp., etc.) At no schl. Total Day M.D. Residential M.D. Residential blind Day deaf Residential deaf Epileptic colony Day P.D. Certified hospital 6chls. M.D. and deaf 7 - - 1 8 - - 1 - - 17 M.D. and crippled 46 3 - - - - 2 16 2 - 69 M.D. and heart 38 - - - - - 1 - - - 39 M.D. and epileptic 26 - - - - 28 - - - - 54 M.D. and T.B - - - - - - - 2 1 - 3 M.D., cripple and heart 1 - - - - - - - - - 1 M.D., crippled and deaf - - - - 7 - - - - - 7 Blind and epileptic - - 1 - - - - - - - 1 Blind and M.D. - - - - - - - 1 - - 1 Deaf and crippled - - - - 1 - - 1 - - 2 Deaf and heart - - - - 1 - - - - - 1 Epileptic and crippled - - - - - 1 3 2 - - 6 Epileptic and heart - - - - - 6 1 - - - 7 Epileptic and deaf - - - - - 1 - - - - 1 Heart and crippled - - - - - - 26 - - - 26 Heart and T.B. - - - - - - - - - - 1 118 3 1 1 17 36 33 23 4 - 236 95 Table IV. Treatment table. (a) Group I.—Minor ailments, excluding uncleanliness, for which see group V. Disease or defect. Defects treated or under treatment. Under Council's scheme. Otherwise. Total. Skin— Scabies 3,409 — 5,545 Impetigo 2,136 Ringworm, head 195* 151 346† „ body 114,809 880 115,689 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.) 120,549 1,031 121,580 * 118 by X-ray. †249 by X-ray. (b) 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) 38,284 1,653 41,937 Other defect or disease of the eyes (excluding those in group I) 2,000 (estimated) * Children for whom glasses were prescribed—under the Council's scheme, 29,599; otherwise 1,277 (estimated). Children who obtained or received glasses—under the Council's scheme, 27,497 = 92.9 per cent.; otherwise 992. *Included in Group I minor ailments. (c) Group III.—Treatment of defects of the throat and nose. Number of defects. Defect. Received operative treatment. Total. Received other forms of treatment. Total number treated. Under Council's scheme. Private practitioner or hospital. Tonsils 700 581 1,281 3,762 13,738 Adenoids 443 64 507 Tonsils and adenoids 7,686 241 7,927 Other 31 230 261 Total 8,860 1,116 9,976 (d) Group IV.—Dental defects. 1. Number of children who were:— (a) Inspected by the dentist—Age groups 5 years and under 17,958 273,672 6 „ 30,243 7 „ 28,323 8 „ 20,549 9 „ 38,223 10 „ 38,980 11 „ 18,519 12 „ 33,747 13 „ 31,584 14 „ and over 15,546 H 96 (d) Group IV.—Dental defects—continued. (b) Found to require treatment 176,509 (c) Actually treated 138,140 2. Half days devoted to inspection 2,4921 20,703 „ ,, „ treatment 18,211 3. Attendances by children for treatment 232,327 4. Fillings—permanent teeth 116,4921 139,513 „ temporary teeth 23,021] 5. Extractions—permanent teeth 57,6041 321,961 „ temporary teeth 264,357 6. Administration of general anæsthetics for extractions 66,424 7. Other operations—permanent teeth 23,776 „ „ temporary teeth (e) Group V.—Uncleanliness and verminous conditions. (a) Average number of visits per school made by school nurse during the year 1934 6 (b) Examinations of children in the schools by school nurses 1,720,469 (c) Number of verminous children noted 83,207 (d) Children cleansed under Council's arrangements 73,903 (e) Cases in which legal proceedings were taken under the Education Act, 1921 (section 87) 465 Table V. Medical inspection.—Number of children examined, 1924—1934. Year. Routine examinations. Special examinations. Reinspections. Examinations at special enquiries into outbreaks of infectious disease. Special ear inspection centre attendances. Rheumatism supervisory centre attendances. 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 1933 218,654 85,360 165,048 71,600 18,023 14,880 1934 250,781 91,880 146,620 44,197 17,331 15,340 Table VI. Medical treatment.—Number of cases treated under the Council's scheme and by other agencies, 1924-1934. 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.* 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 105,624 2,726 44,172 1,811 17,364 1,793 134,769 5,195 1933 116,089 1,322 40,434 1.827 14,145 1,312 133,835 4,806 1934 §120,549 880 40,284 1,653 12,622 1,116 138,140 4,805 *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. †Includes skin and head ringworm cases. § Includes 13,087 "nurses' cases." 97 Table VII. Medical inspection of students in higher education institutions, 1934. Classification. Council secondary schools. Other secondary schools. Council and other junior tech. schools. Training colleges. Total. Boys. Girls. Boys. Girls. Boys. Girls. Male. Female Male. Female Number of institutions 12 16 14 10 16 14 1 4 43 44 I. Routine detailed examination at— (1) age 12 760 973 1,030 482 293 71 — — 2,083 1,496 (2) age 15 714 829 1,191 450 620 738 — — 2,525 2,017 II. Examination (not necessarily detailed) at other ages (i.e., specials) 1,189 1,599 868 592 503 595 67 811 2,627 3,597 III. Reviewals 739 1,594 862 434 274 210 — 15 1,875 2,253 IV. Re-inspections 429 1,036 795 355 163 310 — 18 1,387 1,719 99 INDEX page After-care clinic 28 After careers 70 Anæmia 15 Approved schools 45 Blind children 69 Chickenpox 44, 46 Child guidance 73 Children's care committees 19,61 Cleanliness 11 Clothing and footgear 12 Convalescent camp schools 51 Co-operation with voluntary bodies 61 Co-ordination 7 Day continuation schools 78 Deaf children 70 Defective ohildren 62 Deformities 15 Diphtheria 40, 46,47 Ears 14, 19,20,26 Employees, Examination of 87 Employment of school children 86 Evening institutes 78 Eyes 13,20,80 Favus 45 Heart 15 Hygiene, Personal 37 Hygiene, School 7 Hygiene, Teaching of 81 Infectious diseases 39 Invalidity, Chronic 38 Junior instruction centres79 Kyphosis 82 Left-handedness 32 Lungs 15 Measles 44, 46 Medical inspection 9, 18, 78, 80 page Medical treatment 20, 78 Mental deficiency 70 Milk scheme 58 Mumps 44, 46 Nervous diseases 15 Nursery schools 77 Nutrition 10, 54, 60, 80 Open-air education 49 Ophthalmia 44,46 Orthodentics 22 Otorrhoea 14, 24 Personal hygiene 37 Physical deficiency 65 Physical education 53 Physique of junior boys 82 Plantar warts 17 Play centres 45 Remand home 71 Residential schools 45 Rheumatism 33 Rickets 15 Ringworm 20, 45, 46 Scabies 38, 44, 46 Scarlet fever 42, 46, 48 School hygiene 7 School journeys 45,61, 53 Secondary and trade schools 80 Smallpox 43 Spectacles 24 Staff 6 Stammering 32 Teeth 12, 20, 80 Tonsils and adenoids 14 Tuberculosis 15, 51 Vaccination 17 Whooping-cough 44, 46 London County Council ANNUAL REPORT OF THE COUNCIL, 1934 Vol. IV (Part I) PUBLIC HEALTH (Report on the Hospitals and General Medical Services under the control of the Hospitals and Medical Services Committee) 800—(M.C. 112536)—26.10.35 CONTENTS page Introduction 5 Grouping of hospitals and institutions 9 Classification of patients and inmates 10 General Hospitals— Admissions 14 Ceremonial openings of new blocks 14 Special units at hospitals 15 Maternity 15 Mental observation wards 17 Epileptics 18 Venereal disease 18 Treatment of enlarged tonsils and adenoids 19 Artificial pneumothorax refills 19 Oxygen therapeutic service19 X-ray and radium treatment 20 Electro-medical apparatus 20 Electro-cardiographs 20 Out-patients 21 Dental services 21 Dietaries 21 Hours of rising, retiring and meals of inmates 23 Boarded-out cases 23 District medical work 24 Casual wards 30 Adoption of Children Act, 1926 32 Institutional care of healthy children under three years of age 32 Medical education 33 British Postgraduate Medical School 34 Medical research 34 Legacy 34 Window cleaning 35 List of hospitals 36 Statistical tables (see p. 3) 13, 45 Special Hospitals— Infectious hospitals—Fever hospitals 73 „ „ Smallpox hospitals 101 „ „ Medical instruction104 „ „ Hospital for ophthalmia neonatorum and vulvovaginitis 104 „ „ Hospital for venereal diseases 104 Hospitals for tuberculosis 105 Children's hospitals 112 List of hospitals 115 Statistical tables (see pp. 3 and 4) 73,119 (2) Matters affecting both General and Special Hospitals— page Planning and development 149 Pathological laboratory services 155 Supply and repair of artificial limbs 175 Donations 176 Funerals of persons of Moslem faith 176 Information for the press 176 Departmental committees 176 Hospital Staff 179 London Ambulance Service 185 STATISTICAL TABLES GENERAL HOSPITALS. I Admissions, discharges and deaths 45 II Accommodation 49 III Pulmonary tuberculosis 51 IV Mental wards 52 V Out-patient treatment 53 VI Classification of patients by diseases 54 VII Tuberculosis—classification by site 60 VIII Malignant neoplasms 61 IX Operations 62 X Massage or physio-therapeutic departments 68 XI X-ray work 69 XII Dental work 70 XIII „ „ —Analysis of out-patients 72 SPECIAL HOSPITALS. Infectious Diseases— I Admissions, discharges, transfers and deaths 119 II Discharges and deaths quarterly 124 III Mistaken diagnosis 125 IV Smallpox—admissions, discharges and deaths 126 V „ —borough distribution 126 VI „ —condition as to vaccination 127 VII „ —deaths during 1934 127 VIII „ —mistaken diagnosis 128 IX Post-encephalitis lethargica 128 Tuberculosis— X Admissions, discharges and deaths 129 XI Pulmonary tuberculosis—duration of treatment 130 XII „ „ —immediate results of treatment 130 XIII „ „ —capacity for work on discharge 132 XIV Non-pulmonary tuberculosis—age and sex of patients—summary 133 XV „ „ —surgical operations under anaesthetics 134 XVI „ „ —causes of death 136 (3) Sick Children— page XVII Admissions, discharges and deaths 137 XVIII Queen Mary's hospital, Carshalton—non-tuberculous orthopædic cases 138 XIX „ „ —various diseases 139 XX „ „ & Princess Mary's hospital —surgical operations 140 XXI „ „ —causes of death 143 XXII Downs hospital—diseases of the ear 143 XXIII „ „ & Princess Mary's hospital—various diseases 144 XXIV „ „ —surgical operations 146 XXV „ „ & High Wood—causes of death 146 XXVI St. Anne's home—treatment of debility 147 XXVII Goldie Leigh hospital—various diseases 147 XXVIII White Oak hospital—diseases of the eye 148 XXIX High Wood hospital—non-tuberculous cases 148 PATHOLOGICAL SERVICES. I Record of examinations—Group laboratoiy at Archway hospital 162 II „ „ „ „ Lambeth hospital 163 III „ „ „ „ Lewisham hospital 164 IV „ „ „ „ Mile End hospital 165 V „ „ „ „ St. Mary Abbots hospital 166 VI Specimens dealt with at central histological laboratory 167 VII Record of examinations—Southern group laboratory 168 VIII Products prepared at Southern group laboratory 170 IX Record of examinations—Northern group laboratory 171 X Belmont laboratories—supply of antitoxin, etc. 172 XI Pathological examinations carried out in hospital laboratories 173 LONDON AMBULANCE SERVICE. Accident Section— I Number of calls dealt with 190 II Hourly record of calls 191 III Calls on each day of the week 191 IV Monthly summary of calls 191 V Summary of calls by boroughs 192 VI Analysis of cases 192 VII Number of cases taken to hospitals 193 VIII Number of cases taken to hospitals and removed within 24 hours 193 IX Average time to reach case and hospital 194 X Mileage run by ambulances 194 General Section— XII Number of miles run and persons conveyed, 1930-34 195 XIII Particulars of persons conveyed, 1933 and 1934 195 XIV Mileage run by ambulances 196 (4) London County Council. ANNUAL REPORT OF THE COUNCIL, 1934. VOL. IV (PART I)—PUBLIC HEALTH (General and Special Hospitals). REPORT ON THE HOSPITALS AND GENERAL MEDICAL SERVICES UNDER THE CONTROL OF THE HOSPITALS AND MEDICAL SERVICES COMMITTEE. By Sir Frederick Menzies, K.B.E., M.D., LL.D., F.R.C.P., F.R.S.E., County Medical Officer of Health and School Medical Officer. Introduction. The progress of the hospital service during His Majesty's reign. During the first twenty years of His Majesty's reign the public hospitals of London were administered by the poor-law authorities, but, as the Local Government Act, 1929, transferred the functions of these authorities to the Council, by whom the hospitals have been administered since 1st April, 1930, it is appropriate that a reference should be made in this report, which will appear in the Jubilee year, to the improvements effected and the extension of the facilities provided in the hospitals since His Majesty ascended the throne. The passing of the Poor Law Act of 1867 enabled separate accommodation, to be provided for the sick poor in workhouse infirmaries. Since that year there lias been a gradual development of the accommodation provided for the sick poor, and an increasing tendency to make such provision on hospital lines. In the early years of the present century gradual progress was made in improving the poor-law infirmaries. The improvements were, of course, more marked in certain hospitals than in others, and this was particularly evident in London, where no fewer than 25 boards of guardians were responsible for the administration of the hospitals, and considerable diversity was inevitable. The Local Government Act of 1929, however, by placing the poor-law infirmaries under the control of the County Council, furnished an opportunity in London of unifying the hospital service and bringing the different establishments up to a uniform standard of efficiency. The Act also made possible the final stage in the evolution of the modern municipal hospital from the old poor-law infirmary by conferring upon local government authorities power to acquire or "appropriate" hospitals for the reception of the sick, unfettered by the Poor Law. The Council quickly took advantage of the opportunity, and on 1st April, 1931, "appropriated" most of the general hospitals which had been transferred to its control a year earlier. The remainder have since been appropriated. These hospitals are now administered under the Public Health Acts as municipal hospitals, and the proportion of patients admitted under a relieving officer's order, formerly the great majority, is steadily decreasing, until in 1934 it was less than 18 per cent, of the total number of admissions. The magnitude of the task confronting the Council on 1st April, 1930, may be illustrated by the fact that on that date it assumed responsibility for no fewer than 76 general and special hospitals and institutions containing more than 42,000 beds and a staff of nearly 20,000. Buildings which were out of date, or on other grounds unsuitable or inadequate for their purpose, required to be adapted or demolished and rebuilt; existing equipment needed to be overhauled or replaced, and much new apparatus was required ; the staff, of many grades and working on differing conditions of service, had to be assimilated into one service. During the period which has elapsed since 1st April, 1930, considerable progress has been made in dealing with these problems. New hospital blocks have been built and reconditioning works carried out, and a continuing programme of structural alterations is gradually bringing the hospitals up to a high standard of modern efficiency. Improved facilities have also been provided to enable advantage (5) 6 to be taken of the latest advances in medical and surgical science, while out-of-date equipment is being replaced where necessary by up-to-date appliances. Striking progress has been made in maternity and ante-natal work. There were 723 maternity beds in the Council's hospitals in 1934. and, of the 56,853 births in the whole of London in that year, no fewer than 12,738 took place in the Council's hospitals. Further developments have been the organisation of a scheme of consultant and specialist services covering every branch of medicine and surgery, and of a pathological service providing all the necessary facilities in this important branch of medical work. Finally, there has been considerable extension of the facilities for medical and nursing instruction, the most notable development in medical education being the establishment at Hammersmith hospital of the British postgraduate medical school. The opening of the school will undoubtedly mark one of the most important steps in medical progress. The foregoing brief account of the progress of the hospital service during His Majesty's reign may be illustrated by the following table of statistics. The first two columns of figures relate to only twenty-two of the twenty-nine general hospitals transferred to the Council in 1930, as statistics for the year 1910 were not available from all the hospitals. The last column, however, gives statistics for all the general hospitals now under the Council's control:— Particulars relating to 22 general hospitals. All general hospitals. 1910. 1934. 1934. Number of beds 12,899 14,051 19.037 (excluding 658 maternity cots). Number of admissions 63,393 127,141 155,915. Number of patients admitted with 51,110 (80 per 23,509(18-5per 27,843 (17-8 per cent, relieving officers' orders. cent, of total cent of total of total admissions). admissions). admissions). Number of medical staff, excluding 73 (1 to 176 beds) 182 (1 to 77 beds) 238 (1 to 79 beds), consultants. Number of nursing staff 1,620(1 to 8 beds) 4,315 (1 to 6,076 (1 to 3 beds). 3.25 beds). Number of operations 4,764 28,537 33,689. Number of births in hospital 953 10,909 (excluding 12,636 (excluding 512 449 still-births). still-birth3). Extent of X-ray work (number of Practically none. 110,595 130,830. films taken). Number of out-patients ... ... Very few (no ante- 90,526 (including 109,368 (including natal patients). 11,273 ante-natal 13,065 ante-natal patients). patients). The special hospitals of the Council were the hospitals of the late Metropolitan Asylums Board and were taken over by the Council under the provisions of the Local Government Act, 1929. In 1910 there were 13 hospitals for infectious diseases other than smallpox. This latter disease was dealt with in what are now known as the River hospitals, situated at Dartford, and during the whole of the last twenty-five years the greater part of the accommodation provided in the River hospitals, when not required for smallpox, has been used or available for other infectious diseases. One of the infectious diseases hospitals was in 1912 converted into a mental hospital. It is interesting to note that measles and whooping-cough were first admitted to the infectious diseases hospitals in December, 1910. In addition to the infectious diseases hospitals, the late Board had a number of special hospitals and schools for various classes of poor-law children. There were in 1910 two residential schools for children suffering from contagious diseases of the eyes (one at Brentwood, Essex, and one at Swanley, Kent), one residential 7 school at Sutton, Surrey, for children suffering from ringworm and other contagious diseases of the skin, and three seaside homes. At all of these education was given. One of the two ophthalmia schools—the one at Brentwood—was found in 1918 to be in excess of requirements owing to the steady decline which had occurred in the number of cases requiring treatment, and it has therefore since been used for other purposes (children suffering from tuberculosis and from rheumatism). For the same reason the ringworm school at Sutton was also found to provide more accommodation than was needed, and was put to other uses. Since 1914 ringworm cases have been accommodated at Goldie Leigh hospital at Abbey Wood, which was taken over from the Woolwich guardians for the purpose. Queen Mary's hospital for children, Carshaiton, Surrey, also formed one of the special hospitals for children belonging to the late Board. This hospital was originally erected as a convalescent fever hospital, but as, in the meantime, the resources it had been necessary for the Board to provide for smallpox had enabled other accommodation to be liberated for convalescent fever cases, it was never used for this purpose. Shortly before 1910 it was opened under the name of the Children's Infirmary as a hospital for children requiring various kinds of medical or surgical treatment. In 1911 Her Majesty the Queen graciously consented to the hospital being styled, " Queen Mary's hospital for children." In 1930 the accommodation was 900 beds, and extensions were in course of erection which have since increased the accommodation to 1,284 beds. This hospital now contains the largest physically defective school of the Council, with a staff of about 35 teachers. The Council has appropriated all the special hospitals for public health purposes, and has thereby removed them from the category of poor-law establishments. The organised treatment of tuberculosis on an extensive scale is a development which has taken place entirely during the period under review. With the passing of the National Health Insurance Act in 1911, the establishment of sanatoria for the treatment of tuberculosis was begun by the late Board. Certain of the then existing establishments of the Board, or portions of them, were used for the purpose, and, as the scheme for the treatment of the disease developed, other hospitals were acquired or erected. One of the new hospitals erected, which was completed in 1919, was at Margate, and included within its curtilage one of the three seaside homes above referred to. His Majesty the King was graciously pleased to command that the new hospital should be styled, " Princess Mary's hospital for children, Margate." The Council is now able to accommodate in its own special hospitals and sanatoria about 2,300 tuberculous patients. There were other special diseases for which the late Board had provided accommodation, such as venereal diseases in girls and in parturient women, and ophthalmia neonatorum. All these services have been taken over, continued and developed by the Council. The number of admissions to the special hospitals for 1910 and 1934 are as follows :— 1910. 1931. Fever and smallpox hospitals 15,248 53,577 Children's hospitals and homes 5,170 7,519 Tuberculosis hospitals None 4,516 Others None 847 20,418 66,459 There is one other special branch of work to which attention must be called, and that is the work of the laboratories. Two central research and pathological laboratories were established by the late Board for the special hospitals, and at these laboratories highly specialised work was carried out, including the preparation and supply of media and other material required for use in the various hospitals of the Board. Since the transfer of the services to the Council in 1930, the work has greatly increased, and the Council has provided five additional group laboratories and a histological laboratory so as to meet the needs not only of the special hospitals, but also of the general hospitals. 8 At Sutton, Surrey, an establishment—the Belmont laboratories—had been provided by the Board for the production of diphtheria antitoxin and certain other material used in the diagnosis and treatment of infectious disease. The work of this establishment has considerably developed, and arrangements are being made for the provision of increased accommodation. General. Hospital services. The hospital service of the public health department of the London County Council comprises the hospitals and institutions (to be used as hospitals), except the mental hospitals, together with certain ancillary services, forming part of the functions transferred to the Council on 1st April, 1930, under the provisions of the Local Government Act, 1929. Historical surveys of these services prior to 1st April, 1930, will be found in the Annual Report of the Council for 1930 (Vol. IV, Part I). Divisions of work. The hospital branch is divided into two main divisions, one dealing with general hospitals (principal medical officer, Dr. W. Brander), and the other with special hospitals (principal medical officer, Dr. J. A. H. Brincker). The matron-in-chief (Miss D. E. Bannon) deals with questions relating to nursing and female domestic staff in both types of hospital. General hospitals division. The work or the general hospitals division embraces the management of 29 acute hospitals (including 1 children's hospital), 11 hospitals and institutions for chronic sick patients, 2 convalescent hospitals and 2 colonies for sane epileptics, i.e., 44 hospitals and institutions, containing a total bed accommodation of 27,043. This figure includes a number of beds at present occupied by healthy aged and infirm inmates in the 11 institutions. This work, moreover, includes a number of ancillary services such as medical instruction and training of nurses and midwives in connection with these hospitals, the provision and management of district medical and nursing services and dispensaries, and of medical and nursing services for public assistance institutions, institutional maternity work and arrangements for the institutional care of healthy children under three years of age separated from their parents. A list of the general hospitals and institutions, together with particulars of the chief hospital officers, bed accommodation, and other details of interest will be found on pages 36 to 44 of this report. Special hospitals division. The special hospitals division deals with the management of 31 hospitals (containing 13,567 beds) of which 16 are for infectious diseases, including 1 for ophthalmia neonatorum and young children suffering from congenital syphilis and vulvo-vaginitis, and 1 for women and girls suffering from venereal diseases, together with units for post-encephalitis lethargica and the radium treatment of cancer of the uterus; 6 are for tuberculosis in adults and 4 (with parts of two others) are for tuberculosis in children: one of the four also includes a unit for rheumatism in children; 5 are children's hospitals, including 2 for those requiring prolonged treatment, in the country, 1 for children suffering from ringworm and other skin diseases, 1 for children suffering from ophthalmia and interstitial keratitis, and 1 children's seaside convalescent home; together with a receiving station for smallpox patients. The variation in the number of beds at the special hospitals compared with that for 1933 is due to an increase of accommodation at Queen Mary's hospital for children, and the taking over of Heatherwood hospital on 1st October, 1934. Provision is made in the infectious hospitals for the instruction of medical students and of candidates for the diploma in public health, and in the infectious, tuberculosis and children's services for the training of nurses. Provision is also made, in separate establishments, for pathological and bacteriological work, the manufacture of antitoxins, and for research work. A list of the special hospitals and institutions, together with particulars of the chief hospital officers, acreage of sites, bed accommodation, etc., will be found on pages 115 to 118 of this report. Arrangement of report. Whilst it is only to be expected in a hospital organisation of the extent, both as to numbers and as to kinds of hospitals, administered by the department, that many important matters must arise which affect both the general and the special (e.g., fever, tuberculosis, and children's) hospitals—matters indeed of common interest 9 to all hospitals—nevertheless each branch of the administration produces its own peculiar problems. The section concerning general hospitals deals with the admission of patients to hospital, the various groups of patients dealt with, and the arrangements made for the patients both medically and generally. This section also includes reference to certain ancillary services and matters outside the administration of the hospitals. The special hospitals section is sub-divided according to the character of the hospitals concerned. Another section deals with matters affecting both general and special hospitals. Details of the expenditure incurred on the hospital services will be found in the Annual Report of the Council, Vol. IV, Part II (Hospital Finance), which is published separately. Hospital finance. Grouping of hospitals and institutions—Recovery of expenses. The Council on 13th November, 1934, decided that, for the purposes of the enactments specified in section 58 of the London County Council (General Powers) Act, 1934, the undermentioned groups of institutions under the management of the Hospitals and Medical Services Committee should be deemed, as regards each group, to be one institution. The principal effect of grouping establishments for the purposes of the section quoted above will be that uniform rates of maintenance will be fixed from time to time for each group of hospitals or institutions of a comparable nature instead of varying rates, as hitherto, according to the particular hospital or institution in which a patient is treated or maintained. Except in the case of recovery from local authorities, the actual sum assessed, if any, will, of course, depend upon ability to pay. Group I (Hospitals for acute sick)— Archway. St. Charles'. Bethnal Green. St. George-in-the-East. Dulwich. St. Giles'. Fulham. St. James'. Hackney. St. Leonard's. Hammersmith. St. Luke's, Chelsea. Iiighgate. St. Mary Abbots. Lambeth. St. Mary, Islington. Lewisham. St. Nicholas'. Mile End. St. Olave's. New End. St. Pancras. Paddington. St. Peter's. St. Alfege's. St. Stephen's. St. Andrew's. Group II (Institutions allocated for use as hospitals and hospitals for chronic sick)— City of London. St. Alfege's. Constance Road. St. John's. Fulham. St. Leonard's. Hackney. St. Mary Abbots. Hammersmith. St. Pancras. Holborn and Finsbury. South Grove. Lambeth. Group III (Hospitals for convalescents)— Queen Mary's, Sidcup. St. Benedict's. Group IV (Colonies for epileptics)— Brentwood. Edmonton. Group V (Children's hospitals)— The Downs. Princess Mary's. Goldie Leigh. Queen Mary's, Carshalton. Heatherwood. White Oak. High Wood. 10 Group VI (Children's hospiials)— Millfield. St. Anne's home. Norwood. Group VII (Sanatoria, etc.)— Colindale. Pinewood. Grove Park. St. George's home. King George V. St. Luke's, Lowestoft. Group VIII (Hospitals for infectious diseases)— Brook. River hospitals—Joyce Green Eastern. and Orchard (when used for Grove. fever cases). North-Eastern. South-Eastern. Northern. Southern. North-Western. South-Western. Park. Western. It will be seen that the Council's general hospitals are divisible into two groups, I and III, according to use. So far as the institutions in group II are concerned, it may be necessary, as a result of the adoption by the Council of proposals for the re-classification of patients and inmates in public health and public assistance institutions (see below), to vary the grouping indicated above. With regard to the infectious diseases hospitals, there is no duty of recovery of the cost of maintenance of London cases. Flat rate charges were already in operation in regard to non-London cases admitted to the fever and smallpox hospitals. The River hospitals consist of Long Reach, Joyce Green and Orchard hospitals. They are primarily intended for smallpox cases, but when not required for smallpox patients, Joyce Green and Orchard hospitals are used for fever cases, and they have accordingly been placed in group VIII in this respect. No grouping for smallpox is contemplated. The classes of infectious disease admitted to St. Margaret's hospital and Sheffield Street hospital are not altogether comparable, and the charges for non-London cases at these two hospitals will continue to be separately calculated. As regards the tuberculosis hospitals, all tuberculosis cases are now dealt with under the Council's tuberculosis scheme, and the Council decided on 10th July, 1934, not to ask for any contributions towards the cost of the residential treatment of tuberculosis. For the purpose, however, of charging for non-London cases, all the tuberculosis hospitals and sanatoria have been grouped as one institution. Classification of patients and inmates of public health and public assistance institutions. General. In November, 1934, the Council considered a joint report of the Hospitals and Medical Services Committee and the Public Assistance Committee with regard to the question of the classification of patients and inmates in public health and public assistance institutions. The institutions concerned were 12 institutions and the one " non-appropriated " hospital (St. John's) under the control of the Hospitals and Medical Services Committee. and 15 institutions under the control of the Public Assistance Committee. Redistribution of cases between Hospitals and Medical Services and Public Assistance Committees. Generally the institutions in question were of the type referred to in the report of the Royal Commission on the Poor Laws and Relief of Distress, 1909, as the "general mixed workhouses." The Royal Commission emphasised the necessity of classification by institutions. They said "it is partly the great size to which some of these institutions have grown which makes it impossible to deal with all classes of inmate in a suitable way, but the difficulty mainly arises out of the attempt to deal in one institution with people requiring such very different treatment as the infirm and able-bodied, the old and the young, the feeble-minded, epileptic, insane and those of bad character. The difficulty can only be met by setting apart special institutions for special cases as was intended by the Royal Commission of 1832, so that it may be possible to deal humanely with the aged without thereby attracting 11 the young, and so that the able-bodied loafer may be kept under strict discipline, and not allowed to lose the power to work." The Royal Commission report then went on to state: "it is mainly with a view to facilitating this specialisation of treatment that we have recommended the enlargement of areas" (viz., transfer of guardians' duties to county and county borough councils). There had, therefore, been general condemnation of the general mixed workhouses both from the point of view of administration and of the grant of suitable remedial assistance for the poor, and one of the objects of the Local Government Act, 1929, was to enable county and county borough councils so to classify their various establishments as to provide the best possible service for the patients and inmates in the most economical form. So far as London was concerned, the changes brought about by this Act were of such magnitude that, during the first four years, the new authority had been very largely occupied with current matters of administration, and, apart from this fact, it was undesirable that the question of classification should be attempted until some measure of the problem which had to be dealt with could be taken. Experience had shown, however, that the time had arrived for the Council to consider the matter. Questions of staffing, of new works, of alterations and reconditioning had come up for attention, consideration of which had had to be deferred pending re-classification, and these matters gave point to the necessity for determining the future functions of the premises concerned. Further, while inmates were housed in two sets of institutions under the control of different committees, it was difficult to ensure equality of treatment. Although the rules made by the two committees were generally framed on similar lines, the presence of comparatively small numbers of persons differing in their requirements from the majority of cases in an institution made the application of the rules a matter of difficulty. There was also the point that under the prevailing conditions it was impracticable for the Public Assistance Committee properly to keep under review the cases of those persons who were receiving institutional relief in public health establishments, and to this extent there was a risk of lack of uniformity in the administration of relief in the county. The development of public assistance policy depended upon the settlement of this problem, and it was evident that, until it was decided how the various classes of inmate should be dealt with and what should be the future purpose of a particular institution, or block of buildings, little or no real progress would be made. The position was that the institutions allocated to the Public Assistance Committee contained at the date of transfer a number of public health cases and vice versa, and that a preliminary survey had been carried out with a view to the classification of inmates while still under the respective boards of guardians. Persons who had been classified as infirm in one union fell into the category of chronic sick in another; in some cases all persons who could attend the dining hall for meals were designated able-bodied, while in others this category included only those who were fit for work. It was necessary, therefore, to determine a uniform basis upon which to work, and the Council decided that every patient or inmate in the undermentioned establishments under the management of the Hospitals and Medical Services Committee and the Public Assistance Committee should be individually placed in one of the following classes:— A. Able-bodied. Persons physically capable of work. B. Healthy. Healthy persons who, though not considered capable of continuous daily work, are able to look after themselves and to attend dining hall, this class to include healthy aged, healthy deformed, healthy cripples, healthy feeble-minded, expectant and nursing mothers. 12 C. Infirm. Persons who are normally able to get up and who, although not able to attend dining hall, could use a nearby dayroom, this class to include persons who require a certain amount of assistance from staff in dressing, toilet, or in moving from room to room, and also certain persons who in bad or cold weather may require to spend a few days in bed. D. Chronic sick. Persons suffering from any specific disease necessitating their confinement wholly or practically wholly to bed, this class to include persons who require daily and continuous treatment from the medical officer, and also extremely aged persons who, though suffering from no specific disease, are confined to bed on account of extreme weakness. E. Menial cases. F. Maternity cases. G. Children 3 years and over— (1) healthy. (2) sick. H. Infants (i.e., children under 3 years) — (1) healthy. (2) sick. The public health establishments comprise the following institutions City of London, Constance Road, Fulham, Hackney, Hammersmith, Holborn and Finsbury, St. Mary Abbots hospital (institution), St. Alfege's, St. Leonard's, St. Pancras, South Grove, Lambeth hospital (institution portion), St. John's hospital (chronic sick). The public assistance establishments are—Institutions:—Bromley House, Poplar, Waterloo House, Islington, St. Marylebone, Chelsea, Westminster, Swaffield Road, Camberwell, Christchurch, Newington, Ladywell, Woolwich; Homes for aged poor—Lambeth home, Langley House. The Council also decided that inmates in classes A, B, C, G (1) (pending transfer to schools under the management of the Education Committee), and H (1) (except infants separated from their parents) should be placed under the control of the Public Assistance Committee, and patients in classes D, E, F, G (2), H (1) (infants separated from their parents), and H (2) should be placed under the control of the Hospitals and Medical Services Committee. It was recognised that it would be necessary, even in public assistance institutions, to have sick wards in which it would be possible to deal with sickness of short duration, and thus reduce the number of transfers between the two classes of institutions for slight causes. Such sick wards would deal only with short and slight illnesses, and should not be of such a nature that it would be necessary to allocate to them special nursing staff. All that was needed was accommodation so situated in the institution that an inmate who had to go to bed for a day or so could be cared for by the attendants without inconvenience. On the basis of the foregoing criteria a classification was made in February, 1934, of the patients and inmates in both public health and public assistance institutions, as a result of which the following decisions were reached :— (i) the transfer of South Grove institution to the control of the Public Assistance Committee as from 1st January, 1935 ; (ii) the diversion of admissions as from 1st December, 1934, to ensure that public assistance cases are admitted to public assistance institutions and public health cases to public health establishments, provided that they remain accessible to their friends and relations ; and (iii) if opportunity occurred, the exchange of inmates between institutions, e.g., the sick inmates in a ward in a public assistance institution to be transferred to a public health establishment, and the resulting vacant accommodation occupied by a number of infirm inmates from public health establishments. 13 South Grove institution was selected for transfer as it was a detached institution not associated with any general hospital, and did not contain any large mental or special unit properly belonging to the hospitals and medical service. Moreover, the buildings would be difficult to adapt for use entirely by chronic sick cases. Transfer of South Grove institution. trior to 1st December, 1934, the practice in allocating cases admitted on relieving officer's orders was, with a few exceptions, the same as existed under the late boards of guardians, i.e., applicants were given orders for the institution which formerly belonged to the parish or union in which they resided, without reference to the question whether it was the appropriate institution under a scheme of classification. This practice was discontinued when the basis of reclassification was settled and put into operation; and, since 1st December, 1934, admissions by relieving officers' orders of chronic sick cases have been to public health establishments and of able-bodied, healthy and infirm cases to public assistance institutions. The diversion of admissions. The Council was informed that, in framing proposals for the diversion of admissions, every step would be taken to provide that inmates should be accommodated in establishments as accessible to their homes as was practicable. The existing arrangements for transfer from hospitals to other establishments of ablebodied, healthy or infirm cases would be continued but chronic sick patients transferred from a hospital would be sent to a public health institution. The operation of this system will effect a gradual adjustment in the appropriate allocation of cases between the institutions of the two services. As beds are freed in an institution opportunity arises for the re-distribution of cases within that institution, so that the buildings can be used for the class of inmate for which they are most suitable. A further effect is to make apparent the works of adaptation which will be required in both sets of institutions in order that necessary schemes for improvement of accommodation can be prepared. The advantage ot such exchanges will be that the statt concerned, together with furniture and equipment, can also be exchanged between institutions of the two services. Nursing staff engaged on the care of the sick in public assistance institutions can gradually be transferred to public health establishments, and the staff of attendants in public health establishments to public assistance institutions. The necessity for transfers of staff depend, however, upon the incidence of admissions. An examination of returns of admissions over a period showed that infirm, healthy and able-bodied cases diverted from public health to public assistance institutions numbered at least twice as many as the chronic sick cases diverted from public assistance to public health establishments. It is impossible to forecast the net result of the changes so far as staff are concerned, as such considerations as the varying standards of staffing requirements for different classes of inmate have to be taken into account. The proposals for the diversion of admissions do not, however, involve any immediate expenditure on works of alteration or adaptation. Exchange of inmates and financial considerations. General Hospitals. Statistical tables. For full statistical information with regard to the patients in the general hospitals and institutions, tables I to XIII on pages 45 to 72, should be consulted. Condensed statistics of the sick patients in the general hospitals and public health and public assistance institutions since 1st January, 1931, are as follow:— Patients. Year ended 31st December, 1931. Year ended 31st December, 1932. Year ended 31st December, 1933. Year ended 31st December, 1934. On books at commencement of period 21,712 22,229 21,736 21,630 Admitted 156,904 160,848 161,366 166,955 Births (excluding still-births) 9,696 10,974 11,414 12,738 Discharged 145,375 151,625 151,335 159,837 Died 20,708 20,690 21,551 20,932 Remaining on 31st December 22,229 21,736 21,630 20,554 B 14 Admissions. The subjoined chart shows the number of patients treated in the general hospitals of the Council week by week during the year 1934, compared with the previous year. It will be seen that no considerable variation has occurred during the past year. Ceremonial openings of new blocks. St. Giles' hospital. The new reception block at St. Giles' hospital, comprising out-patient and ante-natal accommodation and casualty and receiving rooms, etc., was opened by Lord Snell on 27th April. Lewisham hospital. The Right Honourable Lord Dawson of Penn, P.C., G.C.V.O., M.D., LL.D., President of the Royal College of Physicians, opened on 9th October the new ward block at Lewisham hospital. Lord Dawson subsequently expressed his commendation of the design and work of the hospital. 15 Special units in hospitals. In certain of the general hospitals there are special units for branches of medical and surgical work which are of such a specialised nature that it is not convenient or economical to establish a unit for them at every hospital. Special units have also been established from time to time for research in the treatment of certain diseases. The reasons for the establishment of such special units were summarised in the Annual Report for 1932 (Volume IV, Part I, p. 37). The arrangements for the following special branches of medicine and surgery have been continued during the year and very valuable work has been performed:— (i) plastic surgery ; (ii) radium therapy ; (iii) chronic rheumatoid diseases ; (iv) thoracic surgery; (v) thyroid diseases; (vi) diabetes; (vii) pernicious anaemia ; (viii) congenital syphilis (children under 7 years of age). The special arrangements made for the treatment of lobar pneumonia by antipneumococcal serum at St. Olave's and St. Andrew's hospitals, which were mentioned in last year's report, were continued until 31st May, 1934, as also were similar arrangements at Hammersmith hospital. The radium centre for the treatment of carcinoma of the uterus was transferred on 3rd March, 1934, from the North-Western hospital to Lambeth hospital and the plastic surgery unit from Hammersmith hospital to St. James's hospital on 1st July, 1934. A unit for dealing with surgical cases within the general category of congenital malformations in children was opened at Highgate hospital on 1st February, 1934, and subsequently transferred on 1st July, 1934, to Queen Mary's hospital for children, Carshalton. Detailed reports on the following will be published in the medical supplement to this report (Volume IV., Part III) :—(i) plastic surgery; (ii) radium therapy; (iii) treatment of carcinoma of the uterus by radium; (iv) thoracic surgery; (v) thyroid disease ; (vi) diabetes; (vii) pernicious anaemia. Maternity. The number of births in the Council's hospitals continues to increase at a rate which has made it no easy task to provide the necessary accommodation. The figures are as follows * Numbers of women confined in general hospitals and institutions. 1929. 1930. 1931. 1932. 1933 1934. 8,641 9,688 10,038 11,239 11,668 13,050 Births in general hospitals and institutions. Live. still Total. 1931 9,696 495 10,191 1932 10,974 451 11,425 1933 11,414 503 11,917 1934 12,738 515 13,253 * These figures exclude deaths during: the ante-natal period. The total number of maternity beds at the end of 1934 was 723, an increase of 49 on the number available in 1933. Sixteen of the beds still remain in a public assistance institution, but it is hoped that it may be possible to move this unit to a hospital in the vicinity within a short period. During the year a large new maternity block was opened at Lewisham hospital. This is the first maternity unit for the design of which the Council has been entirely responsible, and the results have been found in practice to be eminently satisfactory. A total of 64 beds has been provided with receiving rooms, five labour rooms, babies' nurseries, a specially heated room for premature babies, balconies, and ample single room accommodation for emergency or abnormal cases. The new maternity unit at Hammersmith hospital was completed by the end of the year. The present accommodation is 33 beds, but it is contemplated that an extension will be added when a new block is built. The accommodation consists of two large labour rooms for " booked " cases, clinical laboratory, babies' bathrooms. 16 room for premature babies, labour room for "suspect" cases, balconies and accommodation for staff. Arrangements have been made to keep the "booked" cases, which have received ante-natal care entirely separate from the potentially infectious cases. The unit is staffed by the obstetrical teaching staff of the British Postgraduate Medical School under Professor James Young. Ante-natal clinics. The number of patients seen at the Council's ante-natal clinics has increased as follows :— Year. New cases. Total attendances. 1932 9,448 48,618 1933 12,126 57,884 1934 13,065 73,142 Not only has the number of attendances increased, but the percentage of women confined in the Council's hospitals who have had ante-natal care over an adequate period has also risen. (The figures for 1933 are shown in brackets.) L.C.C. clinics 11,436 (9,685) 87 (83) per cent. L.C.C. in-patient only Private doctor or other sources Nil 1,630 (1,999) 13(17) „ Not stated * Total 13,066 (11,684) * These figures include 11 (16) women who died during the ante-natal period. The figure for 1934 also includes 4 cases where the 3rd stage only was conducted in a Council's hospital, and 1 case where death from toxaemia of pregnancy occurred before the 28th week. The average number of attendances of those attending the Council's hospital clinics may be considered to be very satisfactory, but it does not adequately represent the amount of work done. A number of the women who make one or two attendances only at Council's clinics are under regular supervision from their midwife or doctor or at a borough clinic, and have been referred to the hospital for consultation purposes only. A system is now in full working order whereby cases which "lapse" from the Council's clinics are visited by the borough health visitors and urged to return, but these instances are very few. The staffing of the clinics has been strengthened and efforts have been made to reduce the period of waiting and the number of patients seen at each session. The blood pressure is taken in every case, and in many hospitals at every attendance. A Wassermann test is made on each new patient. The demand for dental treatment, which was formerly reluctantly accepted, has now risen rapidly and is putting heavy pressure on the dental services of the hospitals. Careful attention is paid to the nutrition of the mothers. Milk and other forms of extra nourishment can be obtained from the borough authorities under the maternity and child welfare scheme or from the relieving officer as the circumstances of the case indicate. At St. Mary Abbots hospital special research is being undertaken into the effect of nutrition in toxæmic patients. New premises for ante-natal clinics were opened during the year at Dulwich, St. Giles' and Paddington hospitals, and a ward was adapted for temporary use as a clinic at St. Stephen's hospital. Post-natal clinics. The number of new cases at post-natal clinics has again greatly increased, and the hospitals report that these clinics are doing most valuable work in detecting pathological conditions left after confinements. There were 4,078 new patients, who made a total of 6,013 attendances during the year. Maternal deaths. The strenuous efforts made by all concerned to reduce the maternal mortality rate have had a gratifying result. The figures for the year 1934 show a substantial improvement on the records for previous years. As has been pointed out in previous reports, the special conditions prevailing in the Council's hospitals make comparison with the general mortality rate of the country an extremely difficult matter. The main cause of discrepancy is the very large number of abortions admitted to the hospitals, but the admission to the wards of numerous cases of general disease coincident with pregnancy (e.g., influenzal pneumonia or heart disease) also tends to over-weight the mortality rate. An arbitrary 17 but simple method has had to be adopted of presenting the figures for patients dying from abortion separately from those concerning women who die after the twentyeighth week of pregnancy. The total numbers were as follows :— 1933. 1934. Classification. No. Rate per 1,000. No. Rate per 1,000. A Deaths of women confined in general hospitals and institutions after the 28th week 84 7.2 66 5.1 (а) Death due to pregnancy or confinement 57 4.9 47* 3.6 (1) Ante-natal care in L.C.C. clinic 31 3.2 24 2.1 (2) Ante-natal care, other sources or nil 26 13.1 23 14.1 (b) Death associated with pregnancy or confinement 27 2.3 19 1.5 (1) Ante-natal care in L.C.C. clinic 6 0.6 7 0.6 (2) Ante-natal care, other sources or nil 21 10.5 12 7.4 B Confined before admission (after 28th week) 21 — 17 — C Abortions (cases treated in hospital)— 3,008 (1933) 3,417 (1934) 50 — 50 — D Ectopic gestation (cases treated)—151 (1933) 109 (1934) 8 — 9 — *Includes 1 death from nephritis at 24th week. A summary of the figures shows clearly the advantage which accrues from regular ante-natal care. Allowing for the fact that "emergency" cases are necessarily a selected group, often sent into hospital because they presented some abnormality, the difference is striking. Total Total Rate per Deaths due Bate Deaths Rate Ante-natal care. cases. deaths. 1,000. to pregnancy per associated with per or con1,000. pregnancy or 1,000. finement. confinement. I. L.C.C. clinic 11,436 31 2.7 24 2.1 7 0.6 II. Other sources or nil 1,630 35 21.5 23 14.1 12 7.4 Total 13.066 66 5.1 47 3.6 19 1.5 A detailed study of the maternal deaths in 1934 will be published in the medical supplement to the annual report (Vol. IV, Part III). Mental observation wards. The scheme for the reorganisation of the mental wards into larger units has progressed during the year, the most notable event being the opening of the reconditioned block at Constance Road institution. This unit contains 35 male and 35 female beds, with ample accommodation for the classification of acute cases and a pleasant day-room and dormitory for convalescent or non-certified cases on the upper floor. There are special baths for the hydro-therapeutic treatment of excited patients which is intended to obviate the necessity for use of the padded room. The medical superintendent of the Maudsley hospital visits the unit twice weekly as consultant, and the services of a trained psychiatric social worker are available. Every effort is being made to ensure that patients admitted to the observation wards are dealt with under the Mental Treatment Act rather than the Lunacy Acts, if that is possible. Certain administrative difficulties are found to interfere seriously with the extensive application of both the "voluntary" and "temporary" clauses, and the matter is being further explored in co-operation with the mental hospitals and public assistance departments. 18 Epileptics. Brentwood colony. The number of beds at Brentwood colony remains at 437, and there are usually about 50 vacancies, mainly in the children's block. The 60 beds for children under 16 are rarely more than one-third occupied. The practice has been continued of excluding patients who show definite mental deterioration, and of providing a steadily increasing standard of training for those admitted. As well as the usual domestic activities, an increasing number of interesting and varied occupations are provided in the workrooms, about 110 women being thus employed. The show of work at the County Hall in June and at the "open day" in September gave the patients for the first time a much appreciated opportunity of displaying their work, including rugs, toys, lacework, weaving and needlework. It was felt that insufficient use had been made of the large grounds for the employment of patients, and a gardening instructress with considerable experience in the training of institution inmates was therefore appointed on the retirement of the gardener. A scheme for the training of certain of the more capable women as her assistants has already been begun and gives every prospect of success. It is hoped ultimately to have about 50 of the younger women regularly employed on the land. This type of work is greatly enjoyed by the patients themselves, and has proved of definite benefit to their health. Edmonton colony. The number of beds at Edmonton colony is 328, which approximates closely to the demand for admission, and enables a few special cases to be accepted from outcounty authorities. The number of active and employable men in the colony now definitely exceeds the existing provision in the workshops and on the farm. The carpenter's and boot-repairing shops are producing an increasingly high standard of work and more places are needed for patients able and willing to be trained. The equipment and maintenance of the colony is being gradually improved, and the removal of the laundry, which is contemplated, will permit a re-organisation of the dayroom accommodation which is now inadequate. A complete survey of the epileptics in both the colonies has now been made by the consultant neurologist and some valuable and interesting information has been obtained. Venereal disease. There has been no change during the year in the accommodation for adult venereal patients in the Council's general hospitals, the accommodation remaining at 108 beds for males and 96 for females, in addition to the 82 female beds provided in Sheffield Street hospital (see p. 104). During the current year 641 female and 800 male patients were admitted to the wards. The number of V.D. maternity cases has increased, probably owing to the greater care in diagnosis at the ante-natal clinics attached to the Council's hospitals. Each of the three female wards now has a side ward for 6 to 8 cots for the babies of mothers under treatment. Statistics of the work done in the wards are difficult to supply, as the usual test of efficiency in a V.D. scheme, i.e., the number of patients who remain under treatment until cured, is in no way applicable to the conditions prevailing in the Council's V.D. wards. The admission and discharge of these patients is determined by social circumstances as well as by their clinical condition. A man or woman who has a home to go to may ask to be discharged to attend an out-patient clinic while still in an infective condition, while a patient of the vagrant or common lodging house class may wish to be retained during the whole period of infectivity, and it is in the interests of the community that he should so remain. Owing to the obligations of secrecy in dealing with this disease no complete "follow up" of discharged patients is possible, but a good liaison is maintained with the out-patient clinics conducted at voluntary hospitals under the Council's scheme, and patients on discharge are given full information about facilities for continuing treatment. 19 Certain patients in special circumstances attend as out-patients at the Council's hospitals, but the number is kept as low as possible. It is a common experience in the management of wards for V.D. patients that grave disciplinary problems often arise, a fact which is in no way surprising when a number of able-bodied young persons are congregated in a limited space without adequate employment. There is little scope for ordinary domestic work under hospital conditions, and many of the women patients have no knowledge of handicrafts, no money to buy material, and no incentive to start. As the treatment in many cases extends over several months and occasionally for a year or more, bad habits of idleness are naturally formed under such conditions, and the mental stagnation does nothing towards that strengthening of character which should be looked upon as a necessary part of treatment. Occupation classes. Prolonged efforts to find voluntary workers who would undertake the responsibility of running classes in V.D. wards proved fruitless, and in April, 1934, the education officer, who was already conducting similar work in voluntary V.D. hostels, was asked to supply trained instructresses from the evening institutes. A weekly class in needlework was arranged at the Bethnal Green unit, and two similar classes per week at Lambeth and St. Stephen's hospitals. A short cultural class in English was also organised in each ward. As most of the women, including those whom it was most desired to keep busy, were penniless, it was found necessary to provide material free for those who could not afford even the cost price and to allow the women to keep the finished article. From the start the experiment has been a gratifying success. The industry of the girls is as remarkable as their former idleness. They are eager to learn and have produced admirable garments for themselves and their babies. The class in English directs its attention to suitable light literature and current affairs, and gives a wider range to the patients' thoughts and conversation. There is unanimous testimony that the discipline of the wards has greatly improved, and that the women, with the exception of a small intractable minority, co-operate well in these efforts made to help them. Treatment of enlarged tonsils and adenoids. During 1934, as in former years, it was found necessary to supplement the existing arrangements for the treatment of enlarged tonsils and adenoids in connection with the school medical service, by arranging for some of this work to be undertaken at the following general hospitals for the periods stated :— Mile End hospital 1st January to 31st December, 1934. St. Charles' hospital 1st May to 31st July, 1934. Artificial pneumothorax refills. It has been the practice at certain of the general hospitals to administer artificial pneumothorax refills, at the request of the tuberculosis officers of the Metropolitan Borough Councils, to patients suffering from tuberculosis, who have been under the care of the tuberculosis officers at the local dispensaries. Similar arrangements were in existence between certain of the Borough Councils and voluntary hospitals, and in such cases a charge of 10s. 6d. was usually made for each attendance. The Council decided to make a similar charge, except in cases where the refill was administered by the tuberculosis officer, in which case it was decided that a fee of 5s. only, to cover establishment charges, should be made. Facilities for the administration of artificial pneumothorax refills and also the necessary X-ray screening, are available at 24 of the general hospitals and the Borough Councils were invited to take advantage of these facilities as from 1st July, 1934. Oxygen therapeutic service. Dr. E. P. Poulton, who is one of the physicians to Guy's hospital, and also a member of the Council's staff of consulting physicians, has devoted a considerable amount of time for upwards of ten years to research with a view to ascertaining 20 the best method of administering oxygen to patients. For practical purposes there are two ways of administering oxygen, viz.:—(1) by nasal catheter, and (2) by means of an oxygen tent. The latter method is widely used in America, but its use in this country is only just beginning. It is claimed that, in certain cases, the tent method is more effective than that of the nasal catheter, and that this has been proved both experimentally and clinically. It is also claimed that lives have been saved by the tent method that would most certainly have been lost otherwise. As a result of his research, Dr. Poulton has devised a form of oxygen tent which has proved of great use in dealing with the following classes of cases : (i) heart failure, especially in elderly subjects, when associated with bronchitis; (ii) pneumonia; (iii) asthma (especially when the oxygen is combined with 5 to 7 per cent. of carbon dioxide; (iv) coronary thrombosis; (v) whooping-cough; (vi) any form of breathlessness, except that due to diabetes or uraemia; (vii) coal gas and veronal poisoning ; and (viii) coma (except coma due to diabetes). The value of the research conducted by Dr. Poulton has been recognised by the Medical Research Council, who have made an annual grant towards the cost of the investigations. This grant has been utilised by Dr. Poulton in remunerating a fully qualified physical therapeutist, who is employed in explaining the principles and details of working the tent to the medical man and nurse in charge of the case, and in demonstrating the methods of gas analysis. Dr. Poulton has generously placed his own oxygen tent and also the services of the physical therapeutist at the disposal of the Council without any charge except for transport and oxygen. The tent has been used at several of the Council's hospitals with good results. In order to encourage the work now being carried out by Dr. Poulton, and to prevent the termination of the present investigations, which are not yet completed, the Council agreed to make a special grant towards the expenses involved, and to purchase two of the latest pattern oxygen tents to be situated at Lewisham and Hammersmith hospitals. The tents at these hospitals will be available for use also at the Council's other hospitals. X-ray and radium treatment. During the year the unit at the North-Western hospital for the treatment of cancer of the uterus by means of radium was transferred to Lambeth hospital, where it could be in close association with the deep X-ray therapy plant. The honorary medical director (Sir Comyns Berkeley) is still in charge of the unit in its new home. The deep X-ray therapy department at Lambeth hospital was also extended by the addition of two 400 K.V. cannons, which, with the ancillary apparatus, cost approximately £5,000. These were the first cannons to reach an output of 400,000 volts to be installed in the Council's hospitals, but subsequently two others of a similar type were supplied to the British Postgraduate Medical School. The apparatus was supplied by the contractor on the understanding that if, at the end of an agreed period, the output did not reach 400,000, volts., the apparatus would be removed and that no expense would be incurred by the Council. The two cannons in question have proved satisfactory. Electro-medical apparatus. A comprehensive survey of the existing electro-medical apparatus in the massage departments of the general hospitals was carried out by the chief engineer. As a result of this survey, standard types of apparatus were approved, and the massage department of each hospital will be equipped or re-equipped, where necessary, at a total cost of approximately £8,300. Electro-cardiographs. In order to assist in the diagnosis of patients suffering from heart trouble and to secure their efficient treatment, the Council on 3rd July, 1934, authorised the supply of four mobile electro-cardiographs in addition to those already available in three of the acute general hospitals. 21 One cardiograph has now been allocated to each of the seven groups into which the Council's genera) hospitals are divided for the purpose of the consultant and specialist scheme. Patients requiring an electro-cardiogram are taken, where possible, for this purpose to the appropriate hospital in the group. Out-patients. As in previous years, authority has been granted for the treatment of certain patients by insulin or pituitrin at the out-patient departments of voluntary hospitals. The total number of 62 persons provided for during the year is the same as in 1933. Treatment by insulin and pituitrin. Arrangements for the treatment at the British Red Cross Society's clinic for rheumatism, the Institute of Ray Therapy and the St. John's clinic for patients suffering from rheumatic diseases were continued, and 39 patients, whose treatment could not be carried out at the Council's general hospitals, received treatment at these clinics during the year. Six patients accommodated at the City of London institution have been under treatment for lupus at the London hospital. Eleven adult patients suffering from trachoma were accommodated at the Holborn and Finsbury institution, and sent as out-patients to the Royal London Ophthalmic hospital for treatment. Clinics for special treatment. Dental services. After consultation with the British Dental Association, the Council fixed the scales of salaries and conditions of service for part-time and full-time dental surgeons appointed to the general hospitals, and, as opportunity has arisen, payments to dentists appointed to the hospitals have been assimilated to these scales. Additional dental sessions have been provided at a number of hospitals where they were required to enable the dentist to cope with immediate needs in the dental treatment of patients. In the meantime, opportunity has been taken to discuss with the medical superintendents the question of the types of cases in which dental treatment should be provided, with a view to establishing a more uniform standard throughout the hospital service. There can be little doubt that there is a growing realisation of the advantage of dental treatment in the medical care of patients ; and, as a result, it is contemplated that further developments in the dental services will take place in ensuing years. A table is given on pages 70-71 showing the work carried out by dentists in general hospitals during the year 1934. This has been prepared from such information as was available, but must be accepted with reserve as a uniform record system has only just come into use. The central dental laboratory has been removed from Hammersmith hospital to more convenient premises at St. James's hospital. The arrangements for the manufacture of dentures continue to be entirely satisfactory, and proposals are under consideration for an extension of the existing facilities. In addition to the manufacture and repair of dentures for a number of general hospitals, the laboratory also undertakes the manufacture of appliances required for the plastic surgery unit, and in connection with orthodontic treatment of school children carried out by the school medical service. Dietaries. The dieting of sick persons in hospitals and institutions is a medical question, and the duty of prescribing standardised scales therefor devolves upon the medical officer of health, subject to the right of the hospital medical staff to order such extras as are considered necessary, and to prescribe special diets in individual cases. The want of uniformity in the dietaries in force at the hospitals transferred to the Council in April, 1930, indicated the need for a measure of standardisation. As stated in preceding annual reports, uniform dietaries have been introduced provisionally, with modifications in detail, within the past two years. 22 Broadly speaking, hospital patients are dieted according to whether they are capable of partaking of an ordinary diet or a medium or light diet. The dietaries which have now been approved are shown below :— Meal. Ordinary diet. Diet no. 1. Medium diet. Diet no. 2. Light diet. Diet no. 3. Breakfast Tea, bread, butter, with extras such as egg, bacon, sausage, etc., porridge, jam or marmalade. Tea, bread, butter Tea, bread, butter. Lunch Milk or cocoa Milk Milk. Dinner Meat, bread, two vegetables, pudding. Fish (4 days) or chicken, rabbit or tripe (remaining day) bread, vegetable, milk pudding. Mutton broth or beef tea, bread, milk pudding. Tea Tea, bread, butter, jam or marmalade or cake. As for ordinary diet no. 1. As for ordinary diet no. 1. Supper Soup or beef tea and bread; or milk or cocoa and bread and butter or cheese; or bun or rock cake; or biscuits. As for ordinary diet no. 1 (no cheese). As for ordinary diet no. 1 (no cheese). An average daily allowance of 1½ pints of milk is provided per patient throughout the hospital. The children's dietaries are substantially the same as for adults, except in the matter of quantities. Suggested scales of dietary for children under three years of age have also been prescribed as a guide to medical officers. These dietaries were set out in the annual report for 1931, and have remained unaltered. The needs of chronic sick and mental patients, which include a number of aged and infirm inmates, practically bed-ridden, are not normally as great as those of the patients in the appropriated general hospitals. The standard dietary scales for this class of patient are not, therefore, quite so full and varied as those for the "acute sick," which include many young and convalescent persons who require "feeding up." The medical officer may at all times supplement the dietary of a chronic sick or mental patient by medical extras at his discretion. The dietary scales for chronic sick and mental patients in non-appropriated institutions are as follow :— Meal. Diet no. 1. Diet no. 2. Diet no. 3. Breakfast Tea or cocoa ; bread, butter, jam, marmalade or syrup; or porridge with sugar and milk; or on one day a week brawn, corned beef or sausage. Tea or cocoa; bread; butter, jam, marmalade or syrup. As for diet no. 2. Lunch Cocoa Milk Milk. Dinner* Meat, bread, two vegetables ; pudding. Fish, bread, potatoes; milk pudding. Mutton broth or beef tea, bread; milk pudding. Tea ... Tea, bread, butter, jam or marmalade or syrup or cake. As for diet no. 1 As for diet no. 1. Supper ... Soup and bread ; or tea, coffee or cocoa, with bun or rock cake, or biscuits or bread and butter or bread and cheese. As for diet no. 1 As for diet no. 1. * A cup of tea may be issued after dinner. 23 The dietaries of inmates, other than the sick, of institutions are prescribed by the Council on the advice of the medical officer of health, under Article 35 of the Public Assistance Order ; and, as the application of institutional dietaries is mainly the concern of the chief officer of public assistance, reference to the subject in this report is limited to a general statement. Provisional standardised dietaries have been in operation during the past twelve to eighteen months in public health and public assistance institutions. They were reviewed in 1934, and, with certain modifications, were finally adopted by the Council and introduced in all public health and public assistance institutions on 1st January, 1935. In framing these dietaries, due regard was paid to the recommendations of the Ministry of Health's Advisory Committee on Nutrition as regards the daily food requirements of able bodied persons. Judging from reports which have been received, it is apparent that the new dietaries have been welcomed by the inmates and have, on the whole, conduced to a greater measure of contentment in the institutions. Hours of rising, retiring and meals of inmates. In view of the variations which existed in the times of rising, retiring and of meals of inmates at the several public health institutions consideration has been given to the introduction of a uniform time table. It has accordingly been decided that the hours of rising and of going to bed and the hours of meals of inmates, other than inmates of sick wards, mental wards and nurseries, in institutions under the management of the Hospitals and Medical Services Committee shall be as follows, provided that aged and infirm inmates shall be allowed to go to bed in the evening before the prescribed times :— Rising 7 a.m. Breakfast 7.45 a.m. Dinner Noon. Tea 5 p.m. Supper At such times as the institution committee may prescribe. Retiring 9 p.m. Subject to any directions given by the medical officer of the institution, the time table prescribed is also applied to the sick wards and mental wards at institutions under the management of the Committee, provided that the institution committees shall be empowered to make such minor modifications in the time table as may be found advisable, and that it shall be referred to the institution committees to fix the hours of the lunch and supper meals in sick wards and mental wards. Boarded-out cases. Certain selected cases requiring convalescent treatment were sent to homes at the seaside maintained by voluntary agencies. The arrangements for the valescence of mothers with their infants were continued at St. Mary's home, Dover. During the year the average number of beds occupied at voluntary convalescent homes was 13. Convalescence. During the year, 18 patients suffering from rheumatic diseases were sent for spa treatment to St. John's brine bath hospital, Droitwich, and the Royal mineral water hospital, Bath. Spa treatment. Patients requiring convalescence for the treatment of neurasthenia and other nervous diseases referred from the psychiatric clinics established at St. Charles' hospital, St. Mary, Islington, hospital, Mile End hospital, and the Maudsley hospital, and, also, on the recommendation of other consultants, were sent to the Lady Chichester hospital and homes of the Mental After-Care Association with satisfactory results. During the year 17 patients were sent to the Lady Chichester hospital and 97 to mental after-care homes. Neurasthenia. At the end of 1933, 19 patients, who might be regarded as incurable, remained in homes managed by voluntary agencies. During 1934, a few patients were sent Incurables. 24 for special reasons to voluntary homes, and a certain number of patients chargeable to the Council in those homes died or were discharged. The number remaining at the end of the year was 17. Epileptics. There were 36 female and 38 male patients accommodated in voluntary epileptic homes and colonies, and in each case there were special reasons against their transfer to the Council's institutions. District medical work. During 1934 no important alterations have been made in the organisation of the district medical service, having regard to the fact that this service is to be completely reviewed in 1935. Considerable attention has, however, been given to the accommodation and equipment of the medical relief stations, with a view to increasing their suitability for use for the purposes of medical examination and treatment. A detailed survey was undertaken with a view to bringing the premises, where necessary, to a reasonably good state of repair ; to remedying any defects in heating and lighting, and to ensuring an adequate supply of hot water and medical equipment. Additional furniture has been provided where required, and structural alterations which were urgently necessary have been carried out. Certain re-arrangements have been made in the accommodation for district medical work during the year. Upon the opening of the new out-patient block at St. Giles' hospital, the medical relief station at Havil-street was closed, and the district medical officers, who formerly attended that station, are now accommodated at the hospital. In view of the unsatisfactory accommodation at the Blackwallroad medical relief station arrangements were made for the district medical work to be transferred to accommodation at St. Alfege's hospital. It was also found desirable, for administrative reasons, to close the medical relief station at Bartholomew-close and to arrange for the district medical officer to see patients at his private surgery. Upon the closure of Bartholomew-close medical relief station, arrangements were made for medicines to be supplied by local chemists. A further extension of the chemist system was necessitated by the closure of the dispensary at the Albertroad medical relief station. There are now 48 medical relief stations of which 32 are equipped with dispensaries, whilst in the case of the remaining 16 stations patients obtain necessary medicines from local chemists. There are 19 district medical officers who see their patients at their private surgeries, medicines being obtained from local chemists. Medical relief stations. Arrangements have been made under which at the first issue of medicines to outdoor medical relief patients, bottles are supplied as a matter of routine. Medicine bottles. During the year consideration has been given to the question of providing the services of a nurse at the medical relief stations. At the time of the review there were 12 medical relief stations at which the services of a nurse were available each day, 9 being attended by nurses from an adjacent hospital and 3 by nurses under other arrangements. At 36 stations no nurse attended, but arrangements of one kind or another obtained for giving some assistance to the district medical officer. Experience had shown that the services of a nurse at a medical relief station were very valuable, and that they raised the standard of attendance upon the patients. A nurse can relieve the doctor of routine services and give him time to make more thorough examinations ; she can also undertake work on behalf of the patients too trivial to justify the patient's being sent to hospital. It is, however, not practicable to employ a nurse at every medical relief station, owing, in some cases, to lack of accommodation for her and her work. At other stations the small number of patients does not justify the employment of a nurse. It was decided that the provision of nursing services should be extended gradually to include certain stations where the conditions are suitable and the nurse's services could be used to advantage. Arrangements were made with local district nursing associations for the services of a nurse to be provided daily at 4 medical Nurses at medical relief stations. 25 relief stations, viz. : Barnes-street, E.14, Harley college, Bow-road, E.3, Cathnorroad, W.12, and Renfrew-road, S.E.ll. These arrangements came into operation on 1st January, 1935. Similar arrangements are contemplated at other medical relief stations in the near future. It is a criticism frequently heard of the district medical service that it is out of touch with the specialised services now available for other classes of patients. Every effort has been made to remove this reproach from the district medical service of London. By a simple procedure the district medical officer can obtain, at the nearest Council's hospital, an expert opinion and report on any patient. The full resources of the Council's general hospitals as regards X-ray work, pathological examination, massage, electrotherapy, and convalescent treatment are freely available for any of those patients who require them. These facilities are being increasingly utilised. Specialist services. The following table shows the volume of work done as indicated by the number of consultations and domiciliary visits made by (a) part-time medical officers engaged in private practice and (b) medical officers on the staff of hospitals. Returns of work during 1934. District Medical Work—Return for twelve months, 1st January—31st December, 1934 Number of domiciliary visits. Nature of appointment. Quarter ended Total for 12 months ended 31st December, 1934. 31st March, 1934. 30th June, 1934. 30th September, 1934. 31st December, 1934. Part-time practitioners Medical officers on staff of hospitals 20,513 6,118 14,021 4,382 10,409 2,771 14,735 3,935 59,678 17,206 Total 26,631 18,403 13,180 18,670 76,884 Number of attendances at medical relief stations. Nature of appointment. Quarter ended. Total for 12 months ended 31st December, 1934. 31st March, 1934. 30th June, 1934. 30th September, 1934. 31st December, 1934. Part-time practitioners Medical officers on staff of hospitals 46,204 25,170 41,717 23,686 37,141 21,642 42,352 25,606 167,414 96,104 Total 71,374 65,403 58,783 67,958 263,518 Summary. Nature of appointment. Number of domiciliary visits. Number of attendances at medical relief stations. Number of persons. Part-time practitioners Medical officers on staff of hospitals 59,678 17,206 167,414 96,104 51,200 29,152 Total 76,884 263.518 80,352 No comparable figures are available for the calendar year 1933, as a very considerable reorganisation of districts came into operation on 1st April, 1933, and it was therefore impossible to obtain statistics for the first quarter of that year. Comparable figures are, however, available for the years ended 31st March. The number of domiciliary visits during the calendar year 1934 was 76,884, compared with 71,086 for the twelve months, 1st April, 1933, to 31st March, 1934. 26 The number of attendances at medical relief stations has increased from 262,643 in the twelve months, 1st April, 1933 to 31st March, 1934, to 263,518 in the year ended 31st December, 1934. Included in the persons (80,352) seen by district medical officers during the year are 20,914 who were seen only for the purpose of supplying reports. Arrangements have been made for the district medical officers records to be checked by visiting clerks who will also prepare the necessary statistics with regard to district medical work. These arrangements came into force on 1st January, 1935. Medical records and statistics. Statistics are furnished by all district nursing associations for the purposes of calculating the quotas to be paid to them from the Council's grant. These statistics, however, are limited to the number of cases nursed and the number of visits paid by the nurses, and give little indication of the nature of the work undertaken. District nursing scheme. It appeared desirable, in view of the magnitude and importance of the service, that more detailed information should be available in regard to the cases nursed. Through the courtesy of the associations concerned it has been possible to obtain detailed information from the following six nursing associations, which between them account for more than a quarter of the cases dealt with under the Council's scheme, and from their position give a representative idea of the work in London as a whole :— East London (South) District Nursing Association. Metropolitan (St. Pancras) „ „ Metropolitan (Bloomsbury) „ „ North London „ „ South London „ „ Woolwich and Plumstead „ „ With the exception of the North London and the South London Associations all are affiliated to the Queen's Institute of District Nursing. The number of cases dealt with under the scheme throughout London has increased from 2,942 in 1933, to 3,134 in 1934, while the number of visits has risen from 143,932 to 172,913. The average number of visits per person nursed has increased from 49 to 55. There is little doubt that the main reason for the rather considerable increase in the number of visits is to be found in the growing demands made on the nurses' time in connection with the administration of insulin to diabetic patients. The six nursing associations have furnished particulars as to the total number of general nursing cases dealt with, and the following table shows a comparison of the total figures with the figures relating to the Council's cases. Comparison between all general nursing cases and L.C.C. cases (male and female) and diabetes and non-diabetes in six selected districts. Nature of casea. Sex. Cases. Visits. Average visits per case. All general nursing cases (including L.C.C. cases) 13,116 310,197 23.6 L.C.C. cases Male 225 9,117 40.5 Female 610 44,296 72.6 Total 835 53,413 63.9 L.C.C. cases (excluding diabetes) Male 210 5,213 24.8 Female 515 19,393 37.6 Total 725 24,606 33.9 L.C.C. cases (diabetes cases) Male 15 3,904 260.2 Female 95 24,903 262.1 Total 110 28,807 261.8 27 The average number of visits to all general nursing cases is 23.6 as compared with 63.9 for the Council's cases. The latter figure is, however, reduced to 33.9 if diabetic cases are excluded. It should also be borne in mind that among the Council's cases the proportion of chronic cases is no doubt higher than among patients nursed outside the Council's arrangements, their chronicity being in most cases the ultimate factor bringing them under the care of the Council. The considerably higher proportion of females requiring nursing attention has been commented upon in previous years. There is no doubt that, apart from the fact that the incidence of sickness is higher in females than in males, women elect to remain at home when ill rather than be removed to hospitals, even when the illness is serious. Also the district nurse is very often only called in to male patients when the attention required is beyond the resources of the female members of the family. In the case of diabetics the average number of visits is about the same for each sex. At the same time the investigation brings out the well-known selective incidence of the disease—six females being affected to one male. The following table shows the number of patients and visits in the six selected districts classified as far as possible under "acute" and "chronic " conditions :— Classification of L.C.C. cases, acute or chronic, in six selected districts. Nursing association. Acute. Chronic. Unclassified. Total. Cases Visits. Average no. of visits. Cases. Visits. Average no. of visits. Cases Visits. Average no. of visits. Cases. No. of visits. Average no. of visits. East London (South) 50 1,450 29.0 106 21,995 207.5 5 100 200 161 23,545 146.2 Metropolitan (St. Pancras) 25 756 30.2 24 2,535 105.6 4 458 114.5 53 3,749 70.7 Metropolitan (Bedford-place) 53 954 180 61 5,964 97.7 2 34 17.0 116 6,952 59.9 North London 58 736 12.6 69 5,287 76.6 11 461 41.9 138 6,484 46.9 South London 114 2,209 19.3 79 3,106 39.3 8 296 37.0 201 5,611 27.9 Woolwich and Plumstead 93 1,089 18.1 67 5,351 79.8 6 32 5.3 166 7,072 42.6 Total for selected districts 393 7,794 19.8 406 44,238 108.9 36 1,381 38.3 835 53,413 63.9 Total L.C.C. cases for whole or London 3,134 172,913 55.1 It will be observed that the average number of visits (63.9) is higher than that for the whole of London (55.1). This is accounted for, in part, by the fact that the incidence of diabetes is proportionately high amongst the Jewish population served by the East London Nursing Association. From the above table it is apparent that acute cases seldom last more than three weeks, some possibly requiring more than one visit a day in the beginning. Chronic cases on the other hand averaged 108.9 visits each. These chronic cases, most of whom are in receipt of permanent relief, require prolonged nursing treatment, and, although no nurse may continue to attend a case except under medical instructions, it was felt that there should be a definite limit to the period during which a nurse should continue visiting without the attendance of a doctor. District medical officers have accordingly been informed that they should visit personally, as frequently as the circumstances of the case require and in every case not less frequently than once a month, every patient whom they have placed under the care of a district nurse. 28 More detailed information as to the conditions dealt with is given in the following table :— Classification according to diseases in six selected districts. Disease. Cases. Visits. Average no. of visits. Circulatory and lymphatic system 97 2,746 28 Respiratory system 87 2,833 33 Digestive, abdomen, etc. 95 1,812 19 Pelvic organs 44 1,114 25 Nervous system 43 2,439 57 Skin and underlying tissues 151 6,430 43 Bones and joints 61 3,268 53 Nose, ear and throat 47 898 19 Eye 17 651 38 Senility and debility 41 1,758 43 Diabetes 110 28,807 262 Infectious diseases 20 266 13 Unclassified 22 391 18 Total 835 53,413 63.9 The average number of visits paid to diabetic patients was no less than 262. Out of a total of 53,413 visits, more than half (28,807) were paid to diabetics. Of the 110 diabetics, 71 were "new" cases commencing during 1934, while 39, more than one-third, were " old " cases where treatment was continued from 1933. The proportion of " old " cases among the non-diabetics was less than one-seventh. It would seem that the diabetics are accumulating, and that next year a further increase in the amount of work in the treatment of this condition may be anticipated. A large proportion of the cases classified under "nervous system" are cases of paralysis which accounts for the high average of visits. Included under " bones and joints " are chronic cases of rheumatoid arthritis which raise the average considerably. Also under " skin and underlying tissues " are included cases of bed sores requiring dressing, which, except for this condition, would have been shown under " senility and debility." The following table shows the sources of reference of cases to district nursing associations :— Source of reference to district nursing association in six selected districts. District Nursing Association. Medical supt. of L.C.C. hospital or district medical officer. Persons in receipt of relief. Total. Voluntary hospital. Private or panel doctor. Other sources. East London 157 2 2 161 Metropolitan (St. Pancras) 32 15 3 3 53 Metropolitan (Bedford-place) 45 21 45 5 116 North London 91 22 23 2 138 South London 150 22 22 7 201 Woolwich and Plumstead 133 15 16 2 166 Total 608 95 111 21 835 Many of the 111 patients under private or panel doctors were short cases. It appears probable that these are patients on relief only for a short time, probably owing to illness, their private doctors continuing to treat them without fee. The remainder are persons in receipt of relief but still receiving treatment from a National Health Insurance doctor. The 21 cases shown under "other sources" include patients under the care of voluntary dispensaries, infant welfare centres, etc. 29 Attention has been drawn from time to time to cases leaving the Council's hospitals, still requiring nursing treatment and reported to the local nursing associations, either by the patients' friends or by voluntary charitable agencies or found by the district nurses themselves on their daily rounds. These cases were frequently patients who had taken their own discharge contrary to the advice of the medical superintendent. The whole question of district nursing was discussed with a deputation from the Metropolitan Federation of District Nursing Associations following representations which had been made by that body. It was decided that, in order to secure continuity of nursing treatment, patients, who are discharged from the Council's hospitals or who take their discharge against medical advice and who still require nursing treatment, should be referred to the local district nursing organisations so that they could arrange for a nurse to visit. Medical superintendents were also asked to communicate with the patients' private doctor or the district medical officer previously in charge of the case, stating that nursing services appeared to be necessary, and informing him that as a matter of urgency the local nursing association had been informed. In the case of a patient not previously under a district medical officer, who appeared to be financially unable to obtain the services of a private doctor, the relieving officer is informed in addition to the nursing association in order to ensure medical attention. Where, however, the patient continues to receive medical treatment in the out-patient department of the hospital (this does not include patients attending the medical out-relief station), any nursing treatment required is given at the hospital and not by the district nurse. In this way divided medical responsibility is obviated. During the past year there has been a pronounced increase in the number of diabetic patients receiving treatment under the Council's scheme. This increase is attributable to two causes : (a) the more widespread use of insulin in the treatment of the disease with a resulting increase in demands for nursing service in its administration ; and (b) the increasing advantage taken of the fact that patients unable to pay the full cost of insulin treatment can obtain such treatment by way of medical relief by applying to the relieving officer. Such patients immediately come within the category of patients entitled to home nursing services under the Council's scheme. This has had the effect of transferring to the Council's medical care a considerable number of patients from voluntary hospitals, notwithstanding the fact that the Council is prepared, in suitable cases, to defray the cost of insulin supplied at voluntary hospitals to necessitous persons. From the chronic nature of the disease, it is inevitable that the yearly increase in the number of cases will be maintained until a saturation point is reached when new cases will be balanced by a proportionate number of cases falling out. The majority of cases are referred to the district nurses by the Council's medical officers. In the east of London where, from the nature of the population, the largest numbers are concentrated, patients attend the medical out-relief stations. In St. George-in-the-East hospital and in the medical out-relief station in Vallanceroad adjoining St. Peter's hospital, special clinics are held weekly for patients suffering from this disease. The clinic at Vallance-road is a particularly good example of a diabetic clinic. Patients are carefully instructed in the importance of suitable diet, and a diet table is issued to each patient based on sugar calculation, which is done at frequent intervals. The educational part of the work is by no means the least important, and the district nurses' services are requisitioned to administer insulin, and to instruct patients how to give it themselves. In St. George-in-the-East particular attention is paid to instruction of patients by district nurses in the administration of insulin. In this connection, it is considered that still further use might be made of the services of these nurses in educating patients in regard to the effect of diet upon the disease. The remarkably large incidence of diabetes in East London demonstrated in the table below undoubtedly presents a problem to be tackled, especially in view of the increasing numbers. c 30 Numbers of diabetes cases and visits paid in six selected districts. District Nursing Association. Number of cases. Number of visits. Average number of visits per patient. East London (South) 72 20,146 280 Metropolitan (St. Pancras) 3 771 257 Metropolitan (Bedford-place) 12 2,979 248 North London 8 2,153 269 South London 8 568 71 Woolwich and Plumstead 7 2,190 313 Total 110 28,807 262 It will be seen that in five out of the six areas the number of visits per case for the year bears a more or less common relation. The low average of visits in south London is due to the fact that this association endeavours to teach every patient how to administer insulin himself, or, if this is impossible, a member of the patient's household is shown how to do it. It is gathered that in east London there is a marked unwillingness among the majority of the patients coming under the Council's scheme to administer insulin to themselves, although when it is calculated that each patient has to be visited at least once a day, and sometimes twice and three times daily (certain cases were shown in the returns to have had 600 and 700 visits in the year), it is apparent that a certain number do arrange for the administration of insulin themselves. Casual wards. Section 12 (1) of the Public Assistance (Casual Poor) Order, 1931, as amended by instrument, provides :—"If any casual appears to require medical attention the master shall, as soon as practicable, obtain the attendance of the medical officer, and make arrangements for the transfer of the casual to an appropriate ward or establishment unless the medical officer is of opinion that he can properly be treated in the casual ward. The master shall also bring to the notice of the medical officer any casual who appears to be suffering from mental illness." Most of the casual wards have accommodation for between sixty and eighty casuals, and in practice, in order to fulfil the requirements, the medical officer of each ward usually visits at least every morning. Section 12 (4) of the Order provides :—"The medical officer shall on one day at least in every month medically examine every casual in the casual ward at the time of his visit." In accordance with this requirement, arrangements have been made under which a medical examination is held simultaneously once a month at each of the casual wards, at which every inmate present is seen by the ward medical officer. By arrangement with the county medical officer of Middlesex, the monthly examination in the Middlesex casual wards is now held on the same day as the examinations in the London wards. Monthly examinations were also held at the Hostel during the earlier part of the year, but these were discontinued following a review of the arrangements for the examination and treatment of the casual and homeless poor. The great majority of the inmates of the casual wards are habitual casuals, and there is reason to believe that very few escape for long the monthly examination. Casuals found to be in need of medical treatment are transferred to the appropriate hospital or institution. It is considered that the existing arrangements for the ascertainment and treatment of illness amongst casuals are reasonably adequate, subject to certain minor administrative reforms which have since been effected, and are discussed in a later paragraph. 31 The position as regards the Hostel is somewhat different. The majority of the inmates are not of the " habitual casual " type, and it was felt that any steps which would assist in preventing them from drifting into that mode of life would be of considerable value. The period of stay at the Hostel is on an average twelve days, but on occasions it extends to as long as four weeks. It was accordingly decided that arrangements should be made for the systematic medical examination of all persons admitted to the Hostel. This arrangement was put into operation in October, 1934, and rendered unnecessary the continuance of the monthly examinations. It was also considered desirable to systematise the procedure for the treatment of sick casuals. The cases requiring action fall into three categories :— (1) Inmates suffering from various minor ailments, such as slightly sore feet, which are likely to be cured during the time the man is detained in the casual ward. It was felt that these should be treated in the ward itself. (2) Inmates suffering from (a) minor ailments which cannot be healed within the period of detention, but which do not call for admission to hospital, and (b) defective teeth, need for surgical apparatus, or some defect apart from illness, such as defective vision. It was arranged that these inmates should be offered admission to the appropriate institution, and that, if out-patient hospital treatment were necessary, the master and medical officer of the institution would make the necessary arrangements for the inmate to be sent to the appropriate hospital. (3) Inmates suffering from definite illness or requiring operative treatment. These patients were to be offered admission to the appropriate general hospital. Experience has shown that, for the purpose of the temporary treatment of acute emergencies and of trivial ailments, it is essential for the medical officer to have at his disposal a small supply of drugs, stock mixtures and dressings. Suitable arrangements were made accordingly. A survey of the casual wards revealed the fact that in a number of cases the accommodation at the disposal of the medical officer for the examination of patients was inadequate or unsuitable, and that certain necessary equipment was lacking. These matters have all received attention. The arrangements for treatment in the case of inmates of the Hostel are similar in the main to those in force at the casual wards. There is, however, a need for better facilities for treatment on the premises for simple minor ailments, owing to the fact that the sojourn of inmates at the Hostel is considerably longer than at the casual wards. Accordingly, arrangements are being made for the provision of an adequately equipped consulting room at which the services of a district nurse will be available when required. The number of casuals examined at the twelve monthly inspections in 1934, including inspections at the Hostel up to September, ranged from 349 at the December examination to 549 at the February examination. The total number of casuals who slept in the wards on the nights preceding the twelve examinations was 7,494. A certain number of casuals inevitably escape examination, as they take their discharge at an early hour in the morning. The number actually examined was 5,408 (73 per cent.). This total includes a considerable number of re-examinations of persons seen at previous examinations. As in 1933, the most prevalent defects were found to be skin complaints, hernia, heart disease, varicose veins, defective teeth and bronchitis. Of the casuals examined 66.5 per cent. were noted as having good nutrition, while the majority of the remainder were noted as having fair nutrition. The reports of the medical officers also revealed a high standard of personal cleanliness among the casuals. Attention was drawn to the fact that the washing rooms of the casual wards, which are excellently equipped, contained no fixed foot baths with hot and cold water, such as are installed in all the common lodging houses. It had been found that foot baths to which the patients have access are an important feature in keeping the feet in good condition, and are highly appreciated by the inmates. A 32 certain number of admissions to hospitals and institutions from the casual wards are due to sore feet. It was decided that in the first instance a foot bath should be installed in the ablution rooms at Hackney and Southwark casual wards. The report of the Departmental Committee on the Relief of the Casual Poor emphasised the importance of ensuring that the attention of the proper officer of the authority is drawn to any casual who appears to be a feeble-minded person liable to be dealt with under the Mental Deficiency Acts. Accordingly it was thought desirable to supplement the monthly examination carried out by the casual ward medical officer by a special investigation conducted by medical officers of the public health department delegated for this purpose. One of the casual wards (including the Hostel) was visited each month in rotation, and suitable action was taken in any case coming under the Mental Deficiency Acts. In addition, medical officers of the casual wards from time to time reported any case in which they suspected that inmates were mentally defective, and arrangements were made for a medical officer in the public health department to proceed at once to the casual ward and examine the inmate. The experience of two years showed that very few cases of mental defect were to be found in the casual wards, and in these circumstances it was felt that no useful purpose would be served by continuing the routine visits to the casual wards for mental examinations. The medical officers and superintendents of the wards are now well informed as to the facilities which are available for ascertaining and dealing with persons under the Mental Deficiency Acts, and they have been carefully instructed in the indications of mental deficiency. It was therefore decided to rely upon arrangements for special visits for the examination of individual casuals whom medical officers suspect to be mentally defective. In the cases of persons of unsound mind the normal procedure is followed, i.e., the medical officer of the ward gives notice in writing to a relieving officer, who takes any necessary steps to effect the removal of the patient. In borderline cases of psychosis, where a further report on the mental condition appears desirable, but where there are insufficient grounds for an Order under the Lunacy Act, inmates are offered admission to the nearest hospital at which there is a mental consultant in attendance. During the year the visiting medical officer from the public health department examined in detail 25 inmates following a cursory inspection of all the casuals in the wards. Only one was found to be defective, and the inmate was conveyed to a place of safety. Three inmates were referred by ward medical officers for special examination. One was found to be defective and was conveyed to a place of safety. Adoption of Children Act, 1926. During 1934 medical examinations were completed in respect of 44 children for whose adoption applications had been made by private persons. In five of these cases the children were found to be unsuitable, the remainder being certified as medically fit. The majority of these children were maintained in residential schools under the management of the Education Committee. A full adoption order was made in respect of one child who was selected from children in a public health nursery. Institutional care of healthy children under three years of age. The accommodation provided for healthy children under three years of age has been reduced by the closure of the nursery at Hammersmith institution. The nursery at Hackney institution has also been emptied in anticipation of the demolition of the cottages to form the site for the new nurses' home. These cottages had been adapted for use as a nursery but were so unsatisfactory for the purpose that their use could be regarded only as a temporary expedient. The decrease in available cots 33 resulting from these closures was, in part, offset by an increase in accommodation provided by the enlargement of the nursery at Woolwich institution. The accommodation remaining at the end of the year was 304 cots in public health establishments and 255 in public assistance institutions, a total of 559, compared with 589 at the end of 1933. The available accommodation provides a margin against the temporary closure of nurseries for quarantine as the result of outbreaks of infectious disease, and against the heavy demands on accommodation which recur annually about August. The highest and lowest numbers accommodated at any one time are shown in the following table which discloses a considerable decrease from the previous years :— Winter, 1934. Summer, 1934. Highest. Lowest. Highest. Lowest. Public health and public assistance nurseries 462 382 480 376 These comparatively low figures are possibly due in part to the greater incidence of infectious disease, particularly of measles and whooping-cough, resulting in 401 transfers being made to infectious hospitals, whereas in 1933 the number of children contracting these diseases was unusually low. The number of children who were admitted to the nurseries for the first time in 1934 was 1,580, a somewhat lower figure than the corresponding one for 1933. The children maintained in the Council's nurseries are classified as (a) separated from their parents, (6) non-separated from their parents. Definitions of these categories were set out in the annual report for 1930, where it was also explained that, under the Council's administrative scheme, children in category (a) are placed in the care of the Hospitals and Medical Services Committee, and those in category (b) under the care of the Public Assistance Committee. It has hitherto been the practice to make no differentiation between these cases so far as their accommodation in public assistance and public health nurseries is concerned, but the grouping of separated children in public health nurseries and non-separated children in public assistance nurseries will no doubt gradually ensue as a result of the reclassification. of inmates between the public assistance and public health departments which is now in progress. A survey conducted in 1934 showed that there were on an average 135 children regarded as "separated" and 299 presumed to be "non-separated" in the nurseries at any one time. The figures cannot, however, be regarded as conclusive and a further investigation is being undertaken as to the relative number in each category for which accommodation is required. In addition to the children maintained in public assistance and public health nurseries, there are a number over the age of 18 months who have been removed to nurseries in residential schools under the Education Committee's control, and in Roman Catholic schools. The total number so transferred in 1934 was 171, the highest number maintained at the residential schools at any one time being 186. During the year progress has been made with structural alterations at various nurseries, and, where necessary, with the provision of additional equipment and the replacement of cots by those of newer type. Medical education. The arrangements instituted in 1933 for the training of undergraduates in the Council's general hospitals have been reviewed and found to be generally very satisfactory. Advantage was taken of all the facilities offered to the medical schools, with the exception of one medical school where clinical facilities already available were considered to be adequate. The affiliations have been continued, and are set out in the subjoined table. There are also included in the table details of the affiliations of general hospitals with certain medical schools for the purpose of the instruction of undergraduates in obstetrics. These arrangements provide for two students at a time to be resident at each of the Council's hospitals concerned during the period of training. In addition to the arrangements commenced in 1933 provision has now been made for the instruction of students from St. Bartholomew's, Middlesex and King's College hospital medical schools, the students from the last-mentioned alternating in residence at Lewisham hospital with undergraduates from St. George's hospital medical school. 34 As in previous years, alterations have been made from time to time as has been desirable, in the arrangements for post-graduate instruction in the general hospitals. Undergraduate Instruction. Medical school. Council's hospital. Medical school. Council's hospital. Charing Cross hospital St. Charles'. St. Bartholomew's hospital Hackney. Guy's hospital St. Alfege's. Bethnal Green. St. Olave's. St. George's hospital St. Mary Abbots. Lewisham. St. Mary's hospital Paddington. King's College hospital St. Giles'. St. Thomas's hospital Lambeth. Dulwich. University College hospital St. Mary, Islington. Middlesex hospital Archway. Westminster hospital St. Stephen's. Royal Free hospital St. Mary, Islington. Highgate. St. Pancras. Obstetric Instruction. Medical school. Council's hospital. Medical school. Council's hospital. London hospital Mile End. St. George's hospital Lewisham. Middlesex hospital St. Mary Abbots. King's College hospital Lewisham. St. Bartholomew's hospital St. Giles'. St. Thomas's hospital St. James'. St. Andrew's. British Postgraduate Medical School. During the year the work of building and equipping the premises to be occupied by the British Postgraduate Medical School, to which reference was made in the annual report for the year 1933 (Vol. IV, Part I, p. 66), was proceeded with. Considerable progress was made, and it was anticipated that the school would be opened during May, 1935. Medical research. In addition to the arrangements mentioned in previous annual reports, facilities have been granted in a number of instances to enable research to be carried out at the general hospitals in the treatment of various diseases. Arrangements were made for Mr. Laurence F. O'Shaughnessy, F.R.C.S., to collect data from patients in seven general hospitals in South London to assist in his researches into cases of surgical shock. Permission was also granted to Dr. R. R. Armstrong, M.D., F.R.C.P., to carry out research work in the treatment of mastitis or breast abscess in the lying-in wards of St. Giles' hospital. Dr. Armstrong had previously conducted research on this problem at St. Bartholomew's hospital and on the treatment of pneumonia at the Council's hospitals. Facilities were granted at St. Charles' hospital to Dr. N. F. Maclagan, of the Courtauld Institute of Biochemistry, the Middlesex hospital medical school, for pursuing a scheme of research which he has been carrying out with the aid of a grant from the Medical Research Council. The work consisted of collecting a large series of test meals in cases of ulcer and cancer of the stomach by the use of histamine. At the request of the Therapeutic Trials Committee of the Medical Research Council, permission has been granted for tests of the use of a male hormone known as Hombreol in early cases of prostatic enlargement with urinary symptoms. The work was undertaken under the supervision of the medical superintendent of St. Mary Abbots hospital. Trials have also been authorised of the use of suprarenal cortical extracts in the treatment of patients suffering from Addison's disease in the general hospitals, the work being undertaken by Dr. S. Levy Simpson, M.D., B.Ch. Legacy. By the will of Mr. James Foster, who died on 20th June, 1934, a sum of £200 (less duty) was bequeathed to Fulham hospital on the understanding that it would be applied for the particular benefit of the women patients of the hospital. The sum of £180 was received, and this was invested in the purchase of 3 per cent. London County Consolidated Stock and the income derived from this investment will be applied by the Fulham hospital committee in accordance with the wishes of the testator. 35 Window cleaning in hospitals. The contract for the cleaning of windows in general hospitals and institutions situated in the London area originally provided for twelve cleanings a year. In view of representations received, the Council decided in July, 1934, that, in a number of hospitals situated in the east end of London, the number of cleanings should be increased from twelve to seventeen a year, and that these should be carried out once a month during the months from April to October, inclusive, and twice a month during the remaining months of the year. 36 List of General Hospitals and Institutions under the Control of the Hospitals and Medical Services Committee Hospital or Institution and situation. Date of opening. Medical Superintendent, other Medical Staff (excluding consultants) Matron and Steward. Normal accommodation 1.4.1934. Special Units. General statistics. Admissions. Births. Surgical tions. Outpatients' attendances. Archway hospital, Archwayroad, Highgate, N.19. 1879 Medical Superintendent: C. D. S. Agassiz, M.C., M.D., M.R.C.P., D.P.H. Other Medical Staff: 5. Matron : Miss E. R. Wain. Steward : A. M. Jennings. 568 Group laboratory, histological department. 3,529 1 355 127 Bethnal Green hospital, Cambridge-road, E.2. About 1900 Medical Superintendent: W. P. Greenwood, M.D., M.R.C.P., F.R.C.S. (Eng.) Other Medical Staff: 8. Matron: Miss E. Dodd, R.R.C. (to 30.4.34), Miss M. R. Dreyer (from 1.5.34). Steward : J. E. W. Lambley. 650 V.D. ward (females), maternity ward, antenatal clinic, out-patients' department. 5,152 305 1,197 11,206 ‡ Brentwood colony, Brentwood, Essex. (Sane epileptics.) About 1854 Superintendent: Miss J. N. Richards. Visiting Medical Officer : J. D. Fiddes, M.C., F.R.C.S. (Edin.), M.A. B.Sc., M.B., Ch.B. 437 - 96 - - - City of London institution, 2a, Bow-road, E.3. 1849 Master : H. C. Stuttle. Medical Officer : E. T. Pinhey, O.B.E., M.B., Ch.M. Other Medical Staff: 2. Matron : Mrs. A. Ewins. 623 Mental observation ward,* ward for skin diseases †888 - - - Constance-road institution, East Dulwich, S.E.22. 1892 Medical Officer and Master (Acting) : 0. W. Roberts, M.D., M.S., F.R.C.S. (Eng.). Other Medical Staff: 2. Matron (Acting): Miss R. E. Wallace, R.R.C. (to 18.10.34). 817 Mental observation ward,* nursery for healthy children. †696 - - - * Mental consultant available. †Sick inmates only. ‡ Subsequently renamed St. Faith's hospital. 37 List of General Hospitals and Institutions under the Control of the Hospitals and Medical Services Committee—continued. Hospital or Institution and situation. Date of opening. Medical Superintendent, other Medical Staff (excluding consultants) Matron and Steward. Normal accommodation 1.4.1934. General statistics. Special Units. Admissions. Births. Surgical operations. Outpatients' attendances. Dulwich hospital, East Dulwich-grove, S.E.22. 1886 Medical Superintendent: O. W. Roberts, M.D., M.S., F.R.C.S. (Eng.). Other Medical Staff: 7. Matron : Miss R. E. Wallace, R.R.C. (to 18.10.34). Acting Matron: Miss L. M. Smith (from 19.10.34). Steward : H. A. Lewington. 733 Maternity ward, ante-natal clinic. 6,388 550 1,678 1,637 ‡Edmonton colony, Silverstreet, N. 18. (Sane epileptics.) 1916 Superintendent : C. Izzard. Visiting Medical Officer : B. E. Moss, M.B., B.S., M.R.C.S., L.R.C.P. Matron : Mrs. C. Izzard. 328 - 124 - - - Fulham hospital, St. Dunstan's-road, Hammersmith, W.6. 1884 Medical Superintendent: C. T. Parsons, O.B.E., M.D. (to 31.1.34). C. D.Covle, M.B., B.Ch., B.A.O. (from 1.2.34). Other Medical Staff: 6. Matron : Miss M. G. Allbutt. Steward : F. A. Croft. 562 Mental observation ward,* maternity ward, antenatal clinic, nursery for healthy children. 4,708 374 773 3,158 Fulham institution, FulhamPalace-road, W.6. 1849 Master : E. R. Adlington. Medical Officer : C. T. Parsons, O.B.E., M.D. (to 31.1.34). C. D. Coyle, M.B., B.Ch., B.A.O. (from 1.2.34). Matron : Mrs. E. R. Adlington. 475 - †72 - - - Hackney hospital, Highstreet, Homerton, E.9. 1874 Medical Superintendent: J. I. P. Wilson, M.D., F.R.C.S. (Edin.), D.P.H. Other Medical Staff : 8. Matron : Miss F. M. Punter. Steward: F. Wood (to 31.10.34). E. A. R. Williams (from 1.11.34). 774 Maternity wards, antenatal clinic, out-patients' department, electrocardiograph. 7,477 820 2,103 82,828 * Mental consultant available. † Sick inmates only. ‡ Subsequently renamed St. David's hospital. 38 List of General Hospitals and Institutions under the Control of the Hospitals and Medical Services Committee—continued. Hospital or Institution and situation. Date of opening. Medical Superintendent, other Medical Staff (excluding consultants) Matron and Steward. Normal accommodation 1.4.1934. Special Units. General statistics. Admissions. Births. Surgical operations. Outpatients' attendances. Hackney institution, 2, Sydney-road, Homerton, E.9. About 1850 Acting Master : N. Turner. Medical Officer : J. I. P. Wilson, M.D., F.R.C.S. (Edin.), D.P.H. Matron: Mrs. H. J. Elkington. 1,116 Nursery for healthy children (closed 18.12.34). t362 — — — Hammersmith hospital, Ducane-road, Shepherd's Bush, W.12. 1905 Medical Superintendent: Sir Thomas Carey Evans, M.C., M.D., F.R.C.S. (Eng.), L.R.C.P. Other Medical Staff: 4. Matron : Miss E. Northover, R.R.C. Steward: E. W. H. Sargent. 366 Maternity ward, ante-natal clinic, out-patients' department, plastic surgery unit (transferred to St. James' hospital, Aug., 1934), electro-cardiograph. 2,882 138 1,150 9,574 Hammersmith institution, Ducane-road, Shepherd's Bush, W.12. 1905 Medical Officer and Master (Acting): Sir Thomas Carey Evans, M.C., M.D.,F.R.C.S. (Eng.), L.R.C.P. Matron : Miss E. Northover, R.R.C. 522 Nursery for healthy children (closed 8.5.34). 131 - - - Highgate hospital, Dartmouth Park-hill, N.19. Holborn and Finsbury institution, Shepherdess Walk, N.l. 1868 1873 Medical Superintendent: C. Thackray, M.D. Other Medical Staff: 5. Matron : Miss R. Jones, R.R.C. Steward : W. H. Lees. Medical Officer and Master (Acting) R. Thane Taylor, M.R.C.S., L.R.C.P. Other Medical Staff: 1. Matron : Miss I. Russell. Accounting Officer: J. W. Parslow. 557 978 - Mental observation ward (closed 1.5.34), nursery for healthy children. 3,324 f765 1 - 724 - 1,459 - Lambeth hospital, Brookstreet, S.E.11. 1878 Medical Superintendent: P. J. Watkin, M.C., M.R.C.S., L.R.C.P. Other Medical Staff: 12. Matron : Miss N. B. Woodman. Steward : T. W. Wallis. 1,310 Mental observation ward, V.D. wards, maternity wards, ante-natal clinic, group laboratory, radium and deep X-ray therapy, out-patients' department. 8,117 645 1,633 9,618 † Sick inmates only. 39 List of General Hospitals and Institutions under the Control of the Hospitals and Medical Services Committee—continued. Hospital or Institution and situation. Date of opening. Medical Superintendent, other Medical Staff (excluding consultants) Matron and Steward. Normal accommodation 1.4.1934. Special Units. General statistics. Admissions. Births. Surgical operations. Outpatients' attendances. Lewisham hospital, Lewisham, S.E.13. 1817 Medical Superintendent: H. Nockolds, D.S.O., M.B., B.S., M.R.C.S., L.R.C.P. Other Medical Staff: 7. Matron: Miss I. B. Clunas. Steward: W. Milton. 634† Maternity wards, ante-natal clinic, group laboratory, out-patients' department. 6,248 951 1,933 28,102 Mile End hospital, Bancroftroad, Mile End, E.l. 1881 Medical Superintendent: Alan Randle, M.C., M.D. Other Medical Staff: 8. Matron: Miss F. C. Griggs, C.S.M.M.G., S.R.N. Steward: E. A. R. Williams (to 31.10.34). A. G. Stapleton (from 1.11.34). 540 Psychiatric out-patient clinic, maternity wards, ante-natal clinic, nursery for healthy children, treatment of school children for tonsils and adenoids, aural clinic, electrocardiograph, group laboratory. 5,680 624 1,133 15,054 New End hospital, Hampstead, N.W.3. About 1800 Medical Superintendent: R. H. Swindells, M. B. ,Ch. B., F.R. C. S. (Edin.). Other Medical Staff: 3. Matron: Miss E. Fisher. Steward: A. E. Liddell. 260 Maternity wards, ante-natal clinic, Graves' disease unit. 2,124 315 503 4,763 Norwood hospital for children, Norwood, S.E.27. 1880 Superintendent: S. A. Morris. Other Medical Staff: 1 Medical Officer: E. Smallwood, M.D. (to 30.4.34). Renee Ritchie, M.B., Ch.B. (from 1.5.34). Matron: Miss F. Knight. 222 Nursery for healthy children. 1,381 - 89 - Paddington hospital,Harrowroad, W.9. 1886 Medical Superintendent: W. G. Bendle, M.B., B.S., F.R.C.S. (Edin.). Other Medical Staff: 7. Matron: Miss G. E. Copeman. Steward: L. T. C. Rouse. 603 Maternity ward, ante-natal clinic, out-patients' department. 4,699 483 757 11,267 † Increased to 778 from 1.11.34. 40 List of General Hospitals and Institutions under the Control of the Hospitals and Medical Services Committee—continued. Hospital or Institution and situation. Date of opening. Medical Superintendent, other Medical Staff (excluding consultants) Matron and Steward. Normal accommodation 1.4.1934. Special Units. General statistics. Admissions. Births. Surgical operations. Outpatients attendances. Queen Mary's hospital, Sidcup, Kent. 1930 Medical Superintendent: Clifford Ellingworth, M.B., B.S. Other Medical Staff: 3. Matron: Miss I. M. Jeffery. Steward: G. Handford. 500 — 3,661 — 7 — St. Alfege's hospital, 48, Vanbrugh-hill, Greenwich, S.E.10. 1874 Medical Superintendent: W. D. Wiggins, M.R.C.S., L.R.C.P., D.P.H. Other Medical Staff: 8. Matron: Miss S. Millward. Steward: J. Anderson. 645 1 Mental observation ward,* maternity wards, antenatal clinic, out-patients' department, electro-cardiograph. 6,673 612 2,057 24,976 St. Alfege's institution, Woolwich-road, S.E.10. About 1830 Medical Officer and Master (Acting): W. D. Wiggins, M.R.C.S., L.R.C.P., D.P.H. Matron (Acting): Miss S. Millward. 846 Nursery for healthy children, mental observation ward. †904 — — — St. Andrew's hospital, Bow, E.3. 1871 Medical Superintendent: J. R. M. Whigham, M.C., M.S., F.R.C.S.(Eng.). Other Medical Staff: 8. Matron: Miss E. A. Woodhouse. Steward: E. H. Whitworth. 620 Maternity wards, anteand post-natal clinics, out-patients' department, thoracic surgery unit. 7,037 660 1,751 53,204 St. Benedict's hospital, Church-lane, S.W.17. ‡1931 Medical Superintendent: W. Pratt, L.M.S.S.A. Other Medical Staff: 2. Matron: Miss H. Harper. Steward: T. W. Thomas (to 1.7.34). S. B. Delaporte (from 2.7.34). 320 — 1,929 — — — St. Charles' hospital, St. Charles'-square, Ladbrokegrove, W.10. 1881 Medical Superintendent: Basil Hood, M.R.C.S., L.R.C.P. Other Medical Staff: 5. Matron: Miss E. Cockayne. Steward: H. G. Commings. 752 Psychiatric out-patient clinic, V.D. ward (males), ante-natal clinic (emergency septic and V.D. maternity cases), treatment of school children for tonsils and adenoids. 5,615 9 955 4,916 * Mental consultant available. † Sick inmates only. ‡ Buildings erected 1888. 41 List of General Hospitals and Institutions under the Control of the Hospitals and Medical Services Committee—continued. Hospital or Institution and situation. Date of opening. Medical Superintendent, other Medical Staff (excluding consultants) Matron and Steward. Normal accommodation 1.4.1934. Special Units. General statistics. Admissions. Births. Surgical operations. Outpatients* attendances. St. George-in-the-East hospital, Raine-street, Wapping, E.1. About 1844 Medical Superintendent: A. C. Gairdner, M.A., B.M., B.Ch., F.R.C.S. (to 31.10.34). J. G. Leebody, M.B., Ch.B., F.R.C.S. (from 1.11.34). Other Medical Staff: 6. Matron: Miss A. Stuart-Gray, R.R.C. Steward: J. A. G. Chinn. 410 Maternity wards, antenatal clinic, out-patients' department. 4,002 270 716 39,868 St. Giles' hospital, Brunswick-square, S.E.5. 1875 Medical Superintendent: H. O. West, M.D., M.R.C.P., D.P.H. Other Medical Staff: 11. Matron: Miss M. E. Jones, A.R.R.C. Steward: E. E. Pinner. 810 Maternity wards, ante-natal clinic, out-patients' department, electro-cardiograph. 8,478 945 1,690 9,421 St. James' hospital, Ouseleyroad, Balham, S.W.12. 1909 Medical Superintendent: W. L. Maccormac, M.B., Ch.B., F.R.C.S. (Edin.). Other Medical Staff: 11. Matron: Miss C. E. Todd. Steward: W. O. Ward. 902 Maternity ward, ante-natal clinic, out-patient department, thoracic surgery unit, plastic surgery unit (transferred from Hammersmith hospital, Aug., 1934). 11,916 1,099 2,935 14,826 St. John's hospital, St. John's-hill, S.W.11. Part 1870. Part date unknown. Medical Superintendent: E. F. W. Nixey, M.B., Ch.B. Other Medical Staff: 3 (1 part-time). Matron: Miss E. M. Thompson. Steward: S. P. Delaporte (to 1.7.34). T. W. Thomas (from 2.7.34). 637 Mental observation ward,* psychiatric after-care clinic, unit for treatment of congenital syphilis in children. 1,223 1 35 1,238 * Mental consultant available 42 List of General Hospitals and Institutions under the Control of the Hospitals and Medical Services Committee—continued. Hospital or Institution and situation. Date of opening. Medical Superintendent, other Medical Staff (excluding consultants) Matron and Steward. Normal accommodation 1.4.1934. Special Units. General statistics. Admissions. Births. Surgical operations. Outpatients' attendances. St. Leonard's hospital, Hoxton-street, N.1. 1872 Medical Superintendent: T. J. Kelleher, M.B., B.Ch., B.A.O. Other Medical Staff: 7. Matron: Miss M. Pilkington. Steward: F. C. Yates (to 15.7.34). S. W. Garratt (from 16.7.34). 574 Maternity wards, ante-natal clinic. 4,348 452 910 8,338 St. Leonard's institution, Reeve's-place, Hoxton, N.1. About 1863 Medical Officer and Master (Acting): T. J. Kelleher, M.B., B.Ch., B.A.O. Matron (Acting): Miss M. Pilkington. 174 - (There are no sick in mates in this institution.) St. Luke's hospital, Sydneystreet, Chelsea, S.W.3. 1874 Medical Superintendent: E. T. Holland, M.R.C.S., L.R.C.P. Other Medical Staff: 5. Matron: Miss S. Smith-Bevan, R.R.C. Steward: R. J. Hughes. 391 - 2,884 2 610 2,057 St. Mary Abbots hospital, 28-30, Marloes-road, Kensington, W.8. 1871 Medical Superintendent: J. Carver, B.Sc., M.B., B.Ch., F.R.C.S. (Eng.), L.R.C.P. Other Medical Staff: 9. Matron: Miss M. M. Ingman. Steward: J. T. Bacon. 555 Mental observation ward, maternity wards, antenatal clinic, group laboratory, electro-cardiograph. 5,207 853 1,254 6,228 St. Mary Abbots institution, Marloes-road, Kensington, W.8. About 1846 Medical Officer and Master (Acting): J. Carver, B.Sc., M.B., B.Ch., F.R.C.S. (Eng.), L.R.C.P. Matron: Miss M. M. Ingman. 605 Nursery for healthy children. †260 - - - † Sick inmates only. 43 List of General Hospitals and Institutions under the Control of the Hospitals and Medical Services Committee—continued. Hospital or Institution and situation. Date of opening. Medical Superintendent, other Medical Staff (excluding consultants) Matron and Steward. Normal accommodation 1.4.1934. Special Units. General statistics. Admissions. Births. Surgical operations. Outpatients' attendances. St. Mary, Islington, hospital, Highgate-hill, N.19. 1900 Medical Superintendent: W. R. M. Turtle, M.B., B.S., M.R.C.S., L.R.C.P., D.P.H. Other Medical Staff: 8. Matron: Miss M. N. Travers. Steward: H. Malyon. 858 Psychiatric out-patient clinic, training school for masseuses, maternity ward, ante-natal clinic, pernicious anaemia unit, urological diseases unit, electro-cardiograph. 7,550 504 974 3,921 St. Nicholas' hospital, Plumstead, S.E. 18. 1872 Medical Superintendent: F. J. Power, L.R.C.P.I., L.R.C.S.I., L.M. Other Medical Staff: 4. Matron: Miss K. M. Wilkinson Steward: A. G. Staplehurst. 334 Mental observation ward, maternity wards, antenatal clinic, out-patients' department. 3,532 354 1,277 40,205 St. Olave's hospital, Lowerroad, Rotherhithe, S.E.16. Part 1840 Part 1876 Medical Superintendent: R. K. Ford, M.D., M.M.S.A. Other Medical Staff: 9. Matron: Miss A. Blakesley. Steward: A. C. Harris. 683 Mental observation ward, maternity wards, antenatal clinic, out-patients' department. 6,928 539 2,611 42,043 St. Pancras hospital, Pancrasroad, N.W.1. 1886 Medical Superintendent: W. Feldman, M.D., M.R.C.P. Other Medical Staff: 5. Matron: Miss E. F. Davey. Steward: W. R. Chaplin. 380 Maternity ward, ante-natal clinic. 4,340 530 508 6,074 St. Pancras institution, 4, King's-road, N.W.1. About 1805 Master: W. R. Chaplin. Medical Officer: W. Feldman, M.D., M.R.C.P. Matron: Miss V. R. Spencer-Jones, R.R.C. 1,172 Mental observation ward,* nursery for healthy children. †292 - - - * Mental consultant available. † Sick inmates only. 44 List of General Hospitals and Institutions under the Control of the Hospital and Medical Services Committee—continued. Hospital or Institution and situation. Date of opening. Medical Superintendent, other Medical Staff (excluding consultants) Matron and Steward. Normal accommodation 1.4.1934. Special Units. General statistics. Admissions. Births. Surgical operations. Outpatients' attendances. St. Peter's hospital, 74, Vallance-road, E.1. 1842 Medical Superintendent: C. D. Coyle, M.B., B.Ch., B.A.O. (to 31.1.34). W. J. Gill, M.D., F.R.C.S. (from 1.2.34). Other Medical Staff: 5. Matron: Miss D. M. Jarvis. Steward: S. W. Garratt (to 15.7.34). F. C. Yates (from 16.7.34). 404 Psychiatric after-care clinic, V.D.ward (males), maternity ward, ante-natal clinic, out-patients' department. 3,186 146 502 13,531 St. Stephen's hospital, 369, Fulham-road, S.W.10. 1878 Medical Superintendent: D. S. Sandiland, M.R.C.S., L.R.C.P. Other Medical Staff: 6. Matron: Miss E. J. Booth. Steward: H. S. B. Booth. 718 V.D. ward, maternity ward, ante-natal clinic, rheumatic clinic. 5,477 453 869 3,724 South Grove institution, Mile End-road, E.3. 1872 Master: S. A. Cranwell. Medical Officer (Acting): Alan Randle, M.C., M.D. Other Medical Staff: 1 (part-time) Matron: Miss A. E. Brown. 678 - †456 - - - † Sick inmates only. 45 GENERAL HOSPITALS. Table I (a)—Admissions, discharges and deaths, 1934* (including infants in maternity wards). Hospitals. Hospital. Normal accommodation. In hospital on 31st December 1933. Admissions during the year. Births during the year. Discharges during the year. Deaths during the year. In hospital on 31st December 1934. Maternity cots. Other. Archway - 568 406 3,529 1 3,006 561 369 Bethnal Green 18 650 552 5,152 305 4,920 559 530 Dulwich 16 733 634 6,388 550 5,852 969 751 Fulham 12 562 495 4,708 374 4,396 686 495 Hackney 38 774 711 7,477 820 7,250 1,055 703 Hammersmith 12 366 342 2,882 138 2,875 334 153 Highgate — 557 462 3,324 1 2,914 467 406 Lambeth 32 1,310 1,284 8,117 645 7,982 990 1,074 Lewisham 48 634 606 6,248 951 6,397 788 620 Mile End 42 540 389 5,680 624 5,763 511 419 New End 19 260 230 2,124 315 2,223 239 207 Norwood children's — 222 138 1,381 — 1,304 69 146 Paddington 20 603 522 4,699 483 4,639 551 514 Q. Mary's, Sidcup — 500 369 3,661 — 3,598 58 374 St. Alfege's 35 645 518 6,673 612 6,390 884 529 St. Andrew's 36 620 510 7,037 660 6,976 750 481 St. Benedict's — 320 287 1,929 — 1,920 26 270 St. Charles' — 752 564 5,615 9 4,871 770 547 St. George-in-the-E. 25 410 332 4,002 270 3,965 331 308 St. Giles' 52 810 722 8,478 945 8,310 1,076 759 St. James' 51 902 897 11,916 1,099 11,531 1,496 885 St. John's — 637 552 1,223 1 892 334 550 St. Leonard's 23 574 518 4,348 452 4,271 564 483 St. Luke's, Chelsea — 391 313 2,884 2 2,490 398 311 St. Mary Abbots 48 555 443 5,207 853 5,512 594 397 St. Mary, Islington 20 858 800 7,550 504 6,946 1,094 814 St. Nicholas' 19 334 322 3,532 354 3,330 546 332 St. Olave's 28 683 550 6,928 539 6,622 754 641 St. Pancras 25 380 264 4,340 530 4,364 513 257 St. Peter's 13 404 331 3,186 146 3,055 310 298 St. Stephen's 26 718 612 5,477 453 5,308 654 580 Brentwood colony - 437 359 96 - 108 4 343 Edmonton colony — 328 299 124 — 103 6 314 Total 658 19,037 16,333 155,915 12,636 150,083 18,941 15,860 * Warded sick staft are included with patients throughout in the statistics of general hospitals and institutions. 46 General Hospitals—continued. Table I (b)—Admissions, discharges and deaths, 1934. Children under 16 Years of age. Hospital. In hospital on 31st December, 1933. Admissions during the year. Births during the year. Discharges during the year. Deaths during the year. In hospital on 31st December, 1934. Archway 84 938 1 890 36 97 Bethnal Green 99 1,706 305 1,867 69 174 Dulwich 90 783 550 1,240 63 120 Fulham 113 1,007 374 1,302 67 125 Hackney 151 1,377 820 2,131 120 97 Hammersmith 69 646 138 794 36 23 Highgate 110 1,210 1 1,137 50 134 Lambeth 133 1,137 645 1,670 99 146 Lewisham 74 1,304 951 2,121 91 117 Mile End 115 2,104 624 2,555 135 153 New End 40 313 315 608 35 25 Norwood children's 138 1,370 — 1,294 68 146 Paddington 76 1,213 483 1,563 132 77 Queen Mary's, Sidcup — 39 — 39 — — St. Alfege's 116 1,594 612 2,039 140 143 St. Andrew's 116 2,037 660 2,593 106 114 St. Benedict's — 32 — 32 — — St. Charles' 86 1,364 9 1,248 115 96 St. George-in-the-East 95 1,499 270 1,699 68 97 St. Giles' 154 1,772 945 2,535 143 193 St. James' 154 2,516 1,099 3,362 204 203 St. John's 9 44 1 33 4 17 St. Leonard's 109 1,226 452 1,583 81 123 St. Luke's, Chelsea 74 704 2 672 36 72 St. Mary Abbots 74 660 853 1,412 110 65 St. Mary, Islington 194 1,823 504 2,136 109 276 St. Nicholas' 65 825 354 1,092 71 81 St. Olave's 111 1,606 539 1,986 95 175 St. Pancras 12 212 530 698 30 26 St. Peter's 22 92 146 236 10 14 St. Stephen's 45 668 453 1,032 51 83 Brentwood colony 21 16 - 17 - 20 Edmonton colony — 1 — 1 — — Total 2,749 33,838 12,636 43,617 2,374 3,232 47 General Hospitals—continued. Table I (c)—Institutions—Admissions, discharges and deaths—Sick inmates only 1934. (including infants in maternity cots). Institution. Normal accommodation. In institution on 31st December 1933. Births during the year. Admissions during the year. Discharges during the year. Deaths during the year. In institution on 31st December 1934. Maternity cots. Other. Public Health Institutions— City of London — 431 459 — 888 819 148 380 Constance-road — 675 618 — 696 512 191 611 Fulham — 76 76 — 72 68 4 76 Hackney — 464 461 — 362 291 95 437 Hammersmith — 112 112 — 131 135 52 56 Holborn and Finsbury — 487 395 — 765 602 132 426 St. Alfege's — 488 459 — 904 806 132 425 St. Mary Abbots — 256 253 — 260 226 104 183 St. Pancras — 478 448 — 292 518 99 123 South Grove — 279 270 — 456 356 114 256 Total — 3,746 3,551 — 4,826 4,333 1,071 2,973 Public Assistance Institutions — Chelsea — 130 140 — 412 477 26 49 Islington — 488 450 — 1,392 1,117 221 504 Ladywell — 308 293 — 361 284 76 294 Newington — 242 211 — 1,098 810 299 200 Poplar — 256 232 — 548 402 131 247 St. Marylebone 15 179 195 102 1,231 1,277 55 196 Waterloo House — 263 208 — 635 525 105 213 Westminster — 25 17 — 537 529 7 18 Total 15 1,891 1,746 102 6,214 5,421 920 1,721 Grand Total 15 5,637 5,297 102 11,040 9,754 1,991 4,694 Notes.—(a) The following have no accommodation for the sick: Public Health Institutions—St. Leonard's. Public Assistance Institutions—Bromley House, Camberwell, Christchurch, Lambeth Home for Aged Poor, Swaffield-road and Woolwich. (b) Owing to changes in the classification of accommodation for sick inmates made during the year, the above figures, particularly those for St. Pancras and St. Marylebone, are approximate. 48 General Hospitals—continued. Table I (d)—Discharges and deaths classified according to mode of admission, 1934. Hospital. Medical superintendent. Relieving officer's order. Lunacy order. Transferred from Births. (a) Staff cases. Other. (b) Total. Direct. (c) From medica practitioner. From voluntary hospital L.C.C. hospital L.C.C residential school L.C.C institu tion. Archway 1549 473 27 1139 - 106 2 199 1 71 - 3567 Bethnal Green 3055 1455 249 111 - 68 37 60 305 139 - 5479 Dulwich 1184 2189 275 2219 - 91 15 114 550 169 15 6821 Fulham 1020 2324 259 375 260 114 6 213 375 124 12 5082 Hackney 2982 3189 211 689 - 78 25 119 812 198 2 8305 Hammersmith 539 1870 174 49 - 96 9 66 146 81 179 3209 Highgate 348 1351 683 691 - 112 - 105 1 90 - 3381 Lambeth 3176 825 896 1652 278 829 19 396 658 189 54 8972 Lewisham 2115 3348 55 425 - 72 36 23 943 168 - 7185 Mile End 2197 2033 90 856 - 225 29 68 629 130 17 6274 New End 589 903 71 391 - 72 2 24 320 65 25 2462 Norwood children's 23 22 157 520 - 325 314 7 - - 5 1373 Paddington 1714 1489 820 293 - 53 15 277 482 41 6 5190 Queen Mary's, Sidcup 2 - 20 222 - 3322 - 36 - 52 2 3656 St. Alfege's 1950 3158 289 694 131 96 14 171 618 144 9 7274 St. Andrew's 4089 264 8 2293 - 112 140 48 673 92 7 7726 St. Benedict's 2 - 13 218 - 1607 - 66 - 39 1 1946 St. Charles' 861 2616 507 1032 - 230 20 245 9 115 6 5641 St. George-in-the-East 2710 1019 170 34 - 38 2 10 273 40 - 4296 St. Giles' 1889 3025 607 2148 - 129 143 357 960 116 12 9386 St. James' 2463 2572 849 4884 - 207 134 628 1100 184 6 13027 St. John's 35 - - 393 80 626 2 42 1 45 2 1226 St. Leonard's 1332 2113 20 690 - 25 52 14 464 119 6 4835 St. Luke's, Chelsea 934 1054 172 227 - 119 69 259 2 47 5 2888 St. Mary Abbots 660 2861 221 961 102 166 10 227 861 37 - 6106 St. Mary, Islington 1257 1748 1050 2957 - 125 22 274 515 89 3 8040 St. Nicholas' 1066 1940 43 47 9 60 4 280 348 79 - 3876 St. Olave's 2415 2905 596 444 24 71 51 165 529 114 62 7376 St. Pancras 1403 1382 841 283 - 36 - 344 517 71 - 4877 St. Peter's 1316 1260 31 390 — 51 1 116 151 47 2 3365 St. Stephen's 2145 782 1201 493 — 218 25 544 447 107 — 5962 Brentwood colony 8 1 4 45 1 27 - 6 20 112 Edmonton colony 3 — — 19 — 44 — 35 - — 8 109 Total 47031 50170 10606 27843 884 9568 1199 5559 12690 3008 466 169024 (a) Discharges and deaths during the year of children born in hospital. For the total births during the year, see table I (a). (b) The principal modes of admission included under this heading are (i) admissions under contract (e.g., Hammersmith), mostly maternity cases received under agreement with the borough council ; (ii) admission on recommendation of the tuberculosis officer (e.g., St. Olave's); (iii) admissions under Section 28 of the London County Council (General Powers) Act, 1928, and (iv) admissions under Justices' Order. (c) Emergency admissions, admission from the Council's school clinics, etc., by the medical tendent but not including any admission by the medical superintendent on the certificate of a general practitioner, whether emergency or not. 49 General Hospitals—continued. Table II (a)—Accommodation, 1934. (Including cots in maternity wards and infants in maternity cots.) Hospital. Average accommodation. Beds occupied. Average duration of stay in days. Maximum. Minimum. Average. Number. Per cent. Archway 568 518 240 351 61.8 37.0 Bethnal Green 666 636 388 490 73.6 34.0 Duhwich 749 782 579 686 91.6 38.8 Fulham 574 531 396 466 81.2 40.3 Hackney 798 792 594 682 85.5 30.2 Hammersmith 378 374 143 264 69.8 32.8 Highgate 556 558 342 445 80.0 50.0 Lambeth 1,342 1,380 1,033 1,179 87.9 39.3 Lewisham 716 718 562 638 89.1 33.6 Mile End 583 504 309 410 70.3 24.6 New End 279 267 182 226 81.0 35.8 Norwood children's 221 191 126 154 69.7 32.8 Paddington 623 553 439 503 80.7 32.7 Queen Mary's, Sidcup 500 531 361 471 94.2 47.2 St. Alfege's 680 667 461 558 82.1 27.4 St. Andrew's 656 585 371 492 75.0 22.4 St. Benedict's 320 316 270 301 94.1 59.1 St. Charles' 752 629 415 531 70.6 34.2 St. George-in-the-East 435 367 263 313 72.0 26.9 St. Giles' 862 816 633 722 83.8 28.7 St. James' 953 992 794 891 93.5 25.4 St. John's 637 614 494 554 87.0 179.7 St. Leonard's 595 590 403 474 79.7 39.4 St. Luke's, Chelsea 391 368 226 298 76.2 35.5 St. Mary Abbots 606 491 325 409 67.5 25.9 St. Mary, Islington 878 920 635 777 88.5 35.0 St. Nicholas' 353 351 267 320 90.7 29.3 St. Olave's 711 701 539 623 87.6 29.4 St. Pancras 406 342 224 282 69.5 21.8 St. Peter's 427 342 194 268 62.8 29.7 St. Stephen's 744 710 503 605 81.3 35.3 Brentwood colony 437 367 303 362 82.8 887.0 Edmonton colony 328 327 288 309 94.2 313.0 Total 19,724 18,830 13,302 16,054 81.4 34.1* * Excluding the two colonies and St. John's hospital, the average is 32.3 days. 50 General Hospitals—continued. Table II (b)—Institutions.—Accommodation.—Sick inmates, 1934. (Including cots in maternity wards and infants in maternity cots.) Institution. Average accommodation. Beds occupied. Average duration of stay in days. Maximum. Minimum. Average. Public Health Institutions— City of London 446 461 380 445 218 Constance-road 681 633 560 605 313 Fulham 76 76 74 76 290 Hackney 464 462 415 436 436 Hammersmith 112 112 51 73 371 Holborn and Finsbury 484 435 374 396 142 St. Alfege's 488 470 422 445 145 St. Mary Abbots 273 264 181 235 515 St. Pancras 356 143 89 121 54 South Grove 280 275 226 263 218 Total 3,660 3,331 2,772 3,095 229 Public Assistance Institutions — Chelsea 139 145 46 126 266 Islington 487 508 450 490 163 Ladywell 308 304 287 297 254 Newington 238 223 190 205 65 Poplar 253 269 233 251 149 St. Marylebone 155 220 178 193 32 Waterloo House 255 219 181 201 126 Westminster 25 20 4 13 9 Total 1,860 1,908 1,569 1,776 114 Grand Total 5,520 5,239 4,341 4,871 167 Note.—Owing to changes in the classification of accommodation for sick inmates made during the year, the above figures, particularly those for St. Pancras and St. Marylebone, are approximate. 51 General Hospitals—continued. Table III—Tuberculosis wards—Pulmonary tuberculosis cases only, 1934. Hospital. Accommodation in wards for pulmonary tuberculosis. In hospital on 31st December, 1933. Admissions. Discharges. Deaths. In hospital on 31st December, 1934. Archway 96 87 313 198 130 72 Bethnal Green 43 29 155 101 53 30 Dulwich 60 53 229 140 82 60 Fulham 22 20 94 52 40 22 Hackney 52 51 188 120 74 45 Hammersmith 30(a) 27 86 81 32 - Highgate 54 50 146 97 59 40 Lambeth 38 28 163 106 51 34 Lewistham 52 41 182 114 67 42 Mile End 30 27 150 107 44 26 Paddington 30 25 110 73 39 23 St. Alfeee's 24 36 138 103 51 20 St. Andrew's 40 25 166 97 65 29 St. Charles' 56(b) 47 308 188 95 72 St. George-in-the-East 21 10 118 80 33 15 St. Giles' 84 65 270 181 94 60 St. James' 66 58 284 172 114 56 St. Leonard's 23 20 111 68 43 20 St. Luke's, Chelsea 60 31 155 99 49 38 St. Mary Abbots 24 20 65 42 27 16 St. Nicholas' 51 24 161 95 65 25 St. Olave's 61 53 174 127 55 45 St. Peter's 12 16 57 41 22 10 St. Stephen's 56 45 201 143 62 41 Total 1,085 888 4,024 2,625 1,446 841 (а) Closed, August, 1934. (b) Increased to 84, August, 1934. 52 General Hospitals—continued. Table IV (a)—Mental wards in hospitals, 1934. Hospital. Accommodation in mental and observation wards on 31st December, 1933. In hospital on 31st December, 1933. Admissions. Discharges. Deaths. In hospital on 31st December, 1934. Accommodation in mental and observation wards on 31st December, 1934. Fulham 19 20 350 337 15 18 19 Lambeth 31 16 408 386 8 30 31 St. Alfege's 15 9 157 157 9 -* 15 St. John's 56 21 642 555 93 15 56 St. Mary Abbots 11 10 148 148 2 8 11 St. Nicholas' 9 5 71 49 26 1 9 St. Olave's 6 2 94 86 3 7 12 Total 147 83 1,870 1,718 156 79 153 * Ward closed for alterations. Table IV (5)—Mental wards in institutions, 1934. Institution. Accommodation in mental and observation wards on 31st December, 1933. In institution on 31st December, 1933. Admissions. Discharges. Deaths. In institution on 31st December, 1934. Accommodation in mental and observation wards on 31st December, 1934. Public Health Institutions— City of London 60 36 590 573 17 36 60 Constance-road 20 14 190 162 3 39 78 Holborn & Finsbury 27 7 61 65 3 - -* St. Alfege's 39 17 671 593 65 30 39 St. Pancras 52 21 469 439 32 19 51 Total 198 95 1,981 1,832 120 124 228 Public Assistance Institutions — Islington 28 25 369 363 13 18 28 Newington 10 7 147 152 2 — —† St. Marylebone 28 16 339 325 9 21 28 Waterloo House 47 24 472 442 30 24 48 Westminster 25 17 534 530 3 18 25 Total 138 89 1,861 1,812 57 81 129 Grand Total 336 184 3,842 3,644 177 205 357 * Ward closed 1st May, 1934. † Ward closed 22nd October, 1934. 53 General Hospitals—continued. Table V—Out-Palients.—Summary of statistics relating to out-patient treatment for the year ended, 31st December, 1934. Hospital. Out-patients. Ante-natal clinics. Total number of persons seen. Number of these who had previously received inpatient treatment Total number of attendances. Number of women seen. Total number of attendances. Archway 56 3 127 - - Bethnal Green 5,284 670 11,206 309 1,398 Dulwich 733 162 1,637 619 4,061 Fulham approx 1,000 * 3,158 404 2,819 Hackney 12,675 750 82,828 898 5,434 Hammersmith 1,691 681 9,574 111 416 Highgate 198 85 1,459 — — Lambeth 2,016 241 9,618 591 2,903 Lewisham 5,652 1,076 28,102 1,073 5,263 Mile End 6,046† 2,497 15,054† 639 4,551 New End 1,027 148 4,763 371 1,240 Paddington 2,422 392 11,267 405 2,413 St. Alfege's 3,978 608 24,976 648 3,820 St. Andrew's 8,392 1,010 53,204 708 2,825 St. Charles' 2,094† 373 4,916† — — St. George-in-the-East 11,778 1,260 39,868 313 1,457 St. Giles' 4,218 453 9,421 926 5,843 St. James' 2,555 1,168 14,826 1,193 6,532 St. John's 372 1 1,238 — — St. Leonard's 1,229 439 8,338 412 2,305 St. Luke's, Chelsea 1,897 160 2,057 38 332 St. Mary Abbots 1,524 357 6,228 859 3,823 St. Mary, Islington l,024† 240 3,921† 470 1,939 St. Nicholas' 5,251 727 40,205 462 3,321 St. Olave's 5,042 756 42,043 476 3,923 St. Pancras 976 689 6,074 467 3,335 St. Peter's 5,460 300 13,531 203 1,055 St. Stephen's 1,713 213 3,724 470 2,134 Total 96,303 15.459* 453,363 13,065 73,142 * Records incomplete at Fulham hospital, † Including psychiatric out-patient clinic statistics, viz: — Hospital. No. of No. of persons seen. No. of attendances. St. Charles' 387 833 St. Mary, Islington 472 1,451 Mile End 450 1,838 Total 1,309 4,122 54 General Hospitals—continued. Table VI (a)—Discharges and deaths classified according to principal disease or condition treated, 1934. Hospitals. (The diseases are set out as nearly as practicable in the order in which they appear in the International List of Causes of Death, 4th revision.) Principal disease or condition treated. Archway. Bethnal Green. Dulwich. Fulham. Hackney. Hammersmith. Highgate. Lambeth. Lewisham. Mile End. New End. Norwood children's. Paddington. Queen Mary's, Sidcup. St. Alfege's. St. Andrew's. St. Benedict's. St. Charles'. St. George-inthe-East. St. Giles'. St. James'. St. John's. St. Leonard's. St. Luke's, Chelsea. St. Mary Abbots. St. Mary, Islington. St. Nicholas'. St. Olave's. St. Pancras. St. Peter's. St. Stephen's. Brentwood colony. Edmonton colony. Total Infectious, etc., diseases— Measles 16 27 6 14 16 5 20 7 7 58 9 29 27 2 19 45 - 32 148 11 54 - 8 14 14 17 3 8 3 2 13 - - 634 Whooping- cough 10 3 - 9 3 3 6 1 1 22 4 12 14 - 8 6 - 12 18 5 19 - 2 27 5 2 3 11 — 7 — - 213 Influenza, Infl. pneumonia 64 63 80 30 49 26 26 136 24 24 6 6 32 64 43 24 14 44 9 64 132 6 35 29 72 58 33 64 79 59 135 2 - 1532 Erysipelas 44 42 53 56 100 6 79 45 64 52 16 2 25 18 54 40 14 63 20 65 97 - 38 8 50 105 34 62 12 25 82 — — 1371 Other epidemic, etc., diseases 52 78 19 57 49 14 49 34 27 105 16 62 41 16 37 86 8 69 146 72 145 3 41 84 50 65 11 39 10 19 38 — — 1542 Tuberculosis— Pulmonary 361 160 233 107 212 127 166 166 198 171 20 7 129 8 164 231 4 302 129 313 317 3 116 167 89 69 168 211 32 100 220 - - 4700 Other forms 32 12 26 25 52 29 17 40 42 17 9 5 20 19 38 41 14 23 17 67 64 1 10 15 32 26 33 30 11 15 25 - — 807 Syphilis 12 36 17 23 9 5 5 137 11 10 4 1 12 10 17 7 7 38 9 11 17 20 18 8 13 30 13 18 13 44 78 — — 653 Gonococcal infection, soft chancre 6 46 10 12 8 2 3 175 3 6 7 — 18 2 4 7 — 150 7 10 22 — 6 7 2 24 2 8 9 141 177 — — 874 Septicaemia, pyaemia 29 39 38 37 40 24 15 63 41 26 16 15 46 14 53 40 6 43 55 62 45 1 20 23 21 43 29 133 16 41 96 — — 1170 Neoplasms— Carcinoma 120 126 257 148 229 97 106 923 174 126 61 — 110 86 221 192 33 143 71 279 389 13 97 84 137 309 102 171 109 91 120 — — 5124 Sarcoma 3 9 4 3 6 1 8 27 7 10 2 1 3 2 4 11 2 5 3 5 10 1 — 7 4 8 2 7 1 3 2 — — 161 Other or not defined malignant disease 1 — 3 4 2 3 1 46 6 3 2 — 2 2 5 1 — 9 1 6 2 1 1 2 3 5 4 3 2 1 3 — — 124 Non-malignant tumours, etc. Rheumatism, etc. 22 31 64 33 69 36 26 105 79 37 31 4 33 21 53 70 40 43 18 72 100 — 34 36 56 34 34 72 29 21 31 1 — 1335 Rheumatic fever acute rheumatism 80 130 110 71 165 48 38 82 117 94 23 46 30 112 69 175 66 73 70 146 161 1 50 41 47 136 33 128 37 32 41 — — 2452 Chronic or undefined rheumatism, gout 59 63 99 45 101 59 38 85 40 33 29 4 48 87 79 70 102 89 41 168 159 18 43 46 69 100 38 126 105 53 109 — — 2205 Fibrositis, lumbago 16 22 17 17 35 6 20 39 20 41 4 — 14 13 29 32 4 24 12 20 26 — 18 12 10 23 6 32 8 28 19 — — 566 Rickets 7 3 — 11 — — 2 1 2 1 1 2 10 — 10 — — — 1 3 3 — — 2 4 6 — 5 1 — — — — 75 Diabetes 29 26 45 29 57 16 10 29 44 24 10 — 16 19 34 51 24 31 36 34 44 8 16 10 19 38 18 34 24 81 27 — — 883 55 Table VI (a)—continued. Principal disease or condition treated. Archway. Bethnal Green. Dulwich. Fulham. Hackney. Hammersmith. Highgate. Lambeth Lewisham. Mile End. New End. Norwood children's. Padding ton. Queen Mary's, Sidcup. St. Alfege's. St. Andrew's. St. Benedict's. St. Charles'. St. George-inthe-East. St. Giles'. St. James'. St. John's. St. Leonard's. St. Luke's, Chelsea. St. Mary Abbots. St. Mary, Islington. St. Nicholas'. St. Olave's. St. Pancras. St. Peter's. St. Stephen's. Brentwood colony. Edmonton colony. Total. Diseases of glands 4 7 10 13 3 7 3 14 7 8 57 — 11 7 6 7 22 5 9 8 24 4 3 4 6 18 3 5 4 3 8 — — 290 Anaemia 10 4 9 16 6 5 8 11 18 4 4 — 2 14 14 11 29 19 22 15 27 4 5 8 3 45 11 8 24 9 9 — — 374 Other blood diseases 2 — 4 1 2 1 2 2 1 — 5 6 4 0 2 2 5 1 ~~ 1 1 3 4 4 5 3 3 — 76 Alcoholism, etc. 4 3 10 36 5 7 5 30 14 3 4 — 30 16 5 1 25 14 6 25 19 4 2 29 14 5 18 29 11 28 — 402 Nervous System, etc. Meningitis 2 — 2 1 10 1 — 4 2 2 — 2 — 4 — 2 2 3 3 — 1 1 2 6 1 4 2 1 2 — — 60 Tabes dorsalis 11 9 19 7 12 4 5 15 7 2 3 — 9 16 16 5 4 11 2 11 17 6 15 7 5 10 2 13 13 15 8 — — 279 Cerebral haemorrhage,embol ism,thrombosis 52 41 136 47 54 19 42 94 62 17 17 24 23 83 63 29 57 25 101 143 29 35 37 54 132 47 76 78 41 90 1748 Paralysis from ac. poliomyelitis 1 2 1 2 1 — — — 3 2 2 — — — 2 — — — — — 17 General paralysis of the insane 4 1 5 11 3 2 7 1 1 1 1 1 7 6 6 2 5 13 24 5 3 10 2 8 3 5 4 141 Paralysis agitans 6 4 12 2 5 4 4 3 5 — 2 — 1 2 13 1 6 4 4 2 18 2 3 2 6 7 2 4 3 5 3 — 135 Other paralyses 4 5 1 7 7 3 6 7 4 6 2 5 8 9 6 5 14 3 4 11 1 1 3 2 9 6 2 4 1 2 — — 162 Other insanity 29 7 17 216 16 11 14 287 12 22 14 — 22 3 147 19 8 69 10 27 85 337 12 17 121 54 27 78 72 9 18 — — 1780 Epilepsy 11 19 29 22 31 9 14 31 22 15 14 2 46 2 31 39 1 28 19 42 74 22 30 21 39 15 12 27 38 28 60 103 106 1002 Idiocy, imbecility 2 2 2 20 5 1 2 7 2 4 5 3 — 5 1 9 2 4 6 25 — — 3 10 1 7 1 2 2 — — 134 Disseminated sclerosis 6 1 8 6 7 1 9 6 5 4 — 6 16 8 12 5 2 9 8 2 1 4 8 4 5 6 7 3 11 — 178 Neuritis, neuralgia, sciatica 6 10 24 18 11 7 15 17 11 10 — 14 15 14 11 8 16 14 29 35 1 6 11 15 17 7 14 4 8 12 — — 389 Dis. of the eye 27 24 27 32 32 11 21 49 14 25 4 10 20 12 39 23 5 47 17 45 67 2 15 14 30 35 28 73 17 23 27 1 806 Dis. of the ear 52 91 93 55 147 65 104 117 120 124 46 44 82 30 93 115 12 89 74 147 214 1 48 41 47 120 57 111 17 13 46 — — 2415 Other diseases of nervous system 90 122 86 75 141 71 49 127 98 107 41 42 73 74 157 168 72 140 68 111 204 49 63 91 123 209 73 126 155 75 111 3191 Total diseases of the nervous system 303 336 461 508 487 219 269 772 372 342 158 108 304 206 619 472 164 497 244 540 891 503 232 254 458 638 270 551 414 229 396 104 106 12427 Circulatory System Valvular heart disease 43 69 70 58 90 21 24 67 48 33 15 8 20 89 53 89 69 37 15 108 124 24 27 42 22 64 45 79 45 26 51 — — 1565 Myocardial disease 120 173 146 132 151 41 112 145 83 171 43 4 81 104 166 319 117 126 65 278 440 360 141 124 150 234 84 92 105 97 236 — — 4640 Other heart disease 34 62 42 24 56 55 19 85 60 33 11 19 10 43 43 53 36 124 59 70 45 4 27 35 33 128 25 70 35 67 37 — — 1444 Aneurysm — 6 1 4 4 3 2 — 3 9 1 8 1 2 3 7 12 1 3 — 2 4 4 6 7 2 3 — — 102 Arteriosclerosis 28 24 33 166 304 26 18 190 98 28 43 69 34 65 52 29 53 12 75 98 13 49 30 76 74 23 25 58 31 42 — — 1866 56 Tablk VI (a)—continued. General Hospitals—continued. Principal disease or condition treated. Archway. Bethnal Green. Dulwich. Fulham. Hackney. Hammersmith. Highgate. Lambeth. Lewisham. Mile End. New End. Norwood children's. Paddington. Queen Mary's, Sidcup. St. Alfege's. St. Andrew's. St. Benedict's. St. Charles'. St. George-inthe-East. St. Giles'. St. James'. St. John's. St. Leonard's. St. Luke's. Chelsea. St. Mary Abbots. St. Mary, Islington. St. Nicholas'. St. Olave's. St. Pancras. St. Peter's. St. Stephen's. Brentwood colony. Edmonton colony. Total. Hypertension 25 13 31 11 49 17 15 17 9 23 9 - 12 16 37 10 19 38 17 15 31 1 26 6 18 33 3 29 7 35 18 - - 590 Gangrene 1 8 8 2 4 7 4 11 9 5 - - 4 5 11 5 1 8 1 4 6 — 4 5 4 11 4 10 3 5 5 - - 155 Disease of the veins (nonpuerperal) 55 43 83 66 67 37 29 06 50 32 23 - 52 54 57 67 24 79 37 117 80 - 35 34 61 75 40 81 41 47 61 - - 1623 Other diseases of circulatory system 19 50 37 40 51 24 35 56 49 63 14 28 40 8 71 81 5 38 44 70 66 1 29 24 26 53 35 65 8 12 28 - - 1170 Total, diseases of circulatory system 325 434 452 499 778 229 256 671 410 391 160 59 291 362 504 684 301 505 253 744 902 404 341 300 392 676 263 457 30E 322 481 - - 13155 Respiratory System— Coryza, rhinitis, catarrh 9 5 11 16 15 8 9 38 12 10 10 6 55 3 9 10 3 10 41 14 73 — 7 8 6 10 4 3 1 7 - — 422 Bronchitis, 269 275 161 132 254 95 292 167 108 238 42 133 203 40 213 332 28 244 203 255 261 — 241 120 158 365 83 122 89 52 200 — — 5375 „ chronic 206 249 227 153 174 71 187 302 89 134 52 3 195 446 215 269 142 182 105 273 310 13 177 97 147 318 96 285 143 192 272 — 1 5725 ,, not stated 2 i 4 1 1 — — 1 1 — 2 3 — 4 — 1 6 — — — — — — — 2 — 1 — 3 - — — 33 Lobar pneumonia 94 98 152 51 171 73 102 104 125 84 9 10 49 319 90 113 36 109 79 96 5 — 76 39 30 208 5 7 152 53 44 42 1 2671 Bronchopneumonia 80 136 92 77 113 52 85 159 169 176 14 92 30 76 203 141 20 188 48 309 135 2 168 56 75 327 71 181 50 29 89 1 3444 Pneu. other or not stated 2 3 17 1 3 3b 2 1 31 14 - 19 9 6 13 13 2 5 1 273 1 6 13 18 Pleurisy and 25 40 53 26 46 39 35 60 58 29 13 6 29 162 40 60 49 54 20 84 93 — 22 24 23 52 26 39 18 28 52 — — 1305 Asthma and hay fever 17 18 25 20 33 33 12 46 30 22 8 2 24 87 35 33 44 34 17 36 45 2 32 21 27 64 8 36 27 48 9 — 1 896 Other diseases of respiratory system 57 44 44 33 79 31 42 68 24 67 18 4 36 83 41 94 18 57 34 56 73 2 43 27 23 71 17 55 29 49 36 - - 1355 Total, diseases of respiratory system 761 869 771 525 887 406 800 946 617 792 180 258 643 1225 856 1065 354 886 552 1124 1268 20 772 410 502 1435 367 875 424 450 731 1 3 21775 Tonsils,enlarged etc. 108 258 219 163 303 117 140 191 142 288 101 119 126 46 204 192 31 161 243 285 535 19 158 156 218 232 46 259 94 99 181 3 — 5437 Tonsils enl. with adenoids — 4 3 13 55 6 2 10 90 14 12 10 3 — 111 199 — 73 — 44 6 4 1 26 7 2 114 11 820 Adenoids - 4 2 1 — 1 2 5 4 6 3 2 2 — 7 2 — 6 1 5 1 — 1 — 1 — 2 — — — 1 — — 59 Ulcer, stomach and duodenum 30 74 127 57 152 46 45 113 109 50 35 — 45 306 91 68 41 68 36 149 211 — 31 35 56 96 43 117 43 44 81 - - 2399 Chronic dyspepsia 11 8 21 21 8 « 3 19 9 5 12 5 3 13 29 13 11 17 16 16 73 - 6 12 2 2 2 15 2 10 16 - - 386 57 Table VI (a)—continued. Principal disease or condition treated. Archway. Bethnal Green. Dulwich. Fulham. Hackney. Hammersmith. Highgate. Lambeth. Lewisham. Mile End. New End. Norwood children's. Paddington. Queen Mary's, Sidcup. St. Alfege's. St. Andrew's. St. Benedict's. St. Charles'. St. George-inthe-East. St. Giles'. St. James'. St. John's. St. Leonard's. St. Luke's,Chelsea. St. Mary Abbots. St. Mary, Islington. St. Nicholas'. St. Olave's. St. Pancras. St. Peter's. St. Stephen's. Brentwood colony. Elmonton colony. Total. Diarrhoea and enteritis 67 91 52 74 133 35 105 72 46 125 17 77 98 9 102 112 4 102 82 99 180 — 117 55 92 152 40 88 51 27 45 — — 2349 Appendicitis 22 72 213 109 213 108 60 94 313 91 62 3 141 167 157 136 57 118 55 197 366 1 37 52 122 140 113 160 23 26 110 — — 3538 Hernia 20 47 72 59 72 54 30 85 91 52 18 1 29 94 85 65 25 44 34 107 123 2 32 23 38 69 46 83 29 27 36 — — 1592 Intestinal obstruction,acute 2 1 6 3 4 5 5 1 6 10 1 — 5 4 6 3 1 4 - 8 11 - 4 3 4 5 4 5 1 1 3 — — 116 do. chronic or not stated 4 7 13 3 20 9 2 9 6 9 6 — 10 15 12 6 12 9 1 10 25 - 4 2 6 18 8 24 8 10 — — 272 Stasis, constipation 12 58 63 28 76 19 19 58 68 43 15 9 79 2 55 58 1 77 34 73 149 2 46 29 68 84 21 53 35 26 18 — — 1378 Cirrhosis of liver 2 3 4 8 6 3 6 3 5 1 — — 2 6 2 6 — 5 — 5 15 2 2 — 4 3 4 8 4 1 6 — — 116 Biliary calculi 3 14 14 5 18 6 2 17 13 14 4 — 2 9 16 9 5 5 4 10 24 1 5 3 13 13 8 13 8 8 5 — — 271 Other diseases of digestive system 96 215 200 158 213 122 110 217 183 205 71 42 179 98 204 224 54 170 142 324 321 5 115 74 135 234 100 258 121 87 115 — — 4792 Total, diseases of digestive system 377 856 1009 702 1273 537 531 894 1085 913 357 268 724 769 1081 1093 242 859 648 1332 2040 36 559 470 766 1050 551 1094 415 364 627 3 — 23525 Oenito - Urinary System— Acute nephritis 6 8 24 14 17 10 12 12 15 7 6 3 7 12 6 20 5 14 13 28 28 1 5 2 4 17 13 23 4 4 10 — — 350 Chronic nephritis 27 17 30 45 18 16 13 31 27 99 12 — 25 21 25 28 15 14 19 36 90 30 15 9 10 53 14 99 10 8 19 — — 875 Nephritis, not stated 1 — — — _ — — — 1 — — — — — — 1 — 2 — 2 1 — 1 — — — — 1 — — — 10 Other diseases of kidney 23 27 23 56 30 22 38 66 35 20 4 25 15 43 53 31 48 39 57 106 7 23 15 31 84 29 62 38 18 37 — — 1164 Diseases of bladder 13 10 29 12 21 6 7 19 26 16 5 3 9 7 9 25 9 18 17 17 36 8 7 6 35 22 16 29 10 10 16 — — 473 Urinary calculi 4 17 27 5 23 14 6 8 9 13 6 — 8 20 25 9 6 7 16 25 24 — 2 5 17 13 11 8 9 8 — — 360 Diseases of prostate (nonmalignant) 14 39 53 18 51 16 16 14 10 8 4 — 22 45 29 38 — 21 8 52 64 1 28 15 46 30 21 23 18 29 14 — — 747 Stricture of urethra 5 7 5 5 4 3 3 3 4 1 2 — 2 4 16 6 — 18 1 21 24 — 3 6 5 12 2 9 9 12 8 — — 200 Other diseases of urinary organs 1 6 4 — 4 2 7 8 7 1 2 — 7 4 5 4 — 16 3 5 5 — 4 2 2 10 1 13 4 6 10 — — 143 Mon-puerp. and non-venereal diseases of genital organs 26 117 101 101 159 88 57 132 90 81 49 10 105 8 293 128 48 118 50 144 196 3 57 54 124 129 75 92 100 41 74 — — 2850 Total, diseases of genito-urinary system 120 248 332 223 353 185 143 265 255 261 106 20 210 136 451 312 114 276 166 387 574 50 145 114 274 372 184 362 201 137 196 — — 7172 Pregnancy, parturition. Skin, bones, etc. 87 511 940 584 1273 299 98 1062 1316 942 443 758 911 948 54 166 450 1476 1757 10 654 91 1242 1003 516 844 848 279 708 — — 20270 Boil, carbuncle 34 50 47 22 57 15 29 61 39 49 13 3 26 27 60 52 10 53 31 55 94 1 23 22 33 50 10 77 26 28 34| — — 1131 58 Table VI (o)—continued. General Hospitals—continued. Principal disease or condition treated. Archway. Bethnal Green. Dulwich. Fulham. Hackney. Hammersmith. Highgate. Lambeth. Lewisham. Mile End. New End. Norwood children's. Paddington. Queen Mary's, Sidcup. St. Alfege's. St. Andrew's. St. Benedict's. St. Charles'. St. George-inthe-East. St. Giles'. St. James'. St. John's. St. Leonard's. St. Luke's, Chelsea. St. Mary Abbots. St. Mary, Islington. St. Nicholas'. St. Olave's. St. Pancras. St. Peter's. St. Stephen's. Brentwood colony. Edmonton colony Total. Abscess 24 48 36 29 56 14 19 50 60 61 7 21 32 9 85 67 6 52 47 88 121 — 45 21 27 52 31 89 30 15 25 — — 1277 Ulcer, bedsore 10 17 15 6 25 9 28 17 10 3 4 2 20 9 34 10 3 32 10 22 75 1 24 8 13 28 7 30 25 16 31 — — 544 Eczema 19 12 26 14 14 3 3 11 11 28 7 16 21 4 13 29 2 31 16 44 4 — 21 9 6 21 7 22 10 13 24 — — 461 Scabies 41 46 14 13 14 1 15 85 7 34 3 25 70 2 49 16 — 57 19 26 48 — 34 29 31 40 47 20 15 36 50 — — 887 Other diseases of skin and cellular tissue 195 191 120 122 122 69 157 299 113 201 43 117 170 40 180 281 33 228 117 230 348 2 136 81 92 235 94 193 105 109 139 — — 4562 Dis. of bones, joints and muscles 29 48 71 58 84 56 34 133 80 56 35 10 54 64 102 89 37 64 60 89 120 4 47 20 65 87 76 111 27 51 48 — — 1909 Neo-Natal diseases, etc. Congen. malformations (ages under 1 year) (a)- 1 3 3 4 1 — 1 8 4 2 — 4 — 3 2 — — 2 5 3 — 2 — 2 4 1 — — — 1 — — 56 (b) 4 1 1 3 2 4 8 4 10 5 1 1 6 — 11 1 — 3 — 5 10 — 1 2 3 4 3 2 1 — 2 — — 97 Congen. debility sclerema icterus (ages under 1 year) (a)- 1 9 3 11 1 — 3 — 1 2 — 1 — — — — — 1 5 3 — 1 — 1 9 1 7 1 — 2 — — 63 (b) 6 3 13 10 8 6 9 8 11 9 2 5 14 — 24 2 — 16 7 21 12 2 4 2 4 27 3 8 7 — 1 — — 244 Prem. birth (ages under 3 months) (a) 1 7 22 13 14 2 1 36 13 11 6 — 17 —- 11 9 — 2 4 26 26 — 14 2 32 14 7 11 28 3 11 — — 343 (b) 1 — 1 2 5 1 — 2 2 1 1 — 4 — 2 — — 3 — 4 3 — 2 1 3 3 2 2 6 — — — — 51 Injury at birth (ages under 3 months) (a)- — — 2 — — — 2 2 2 — — — — 1 1 — — 1 3 2 — — — 1 — 1 1 2 1 1 — — 23 (b) 1 — 1 — — — — — — — — — 1 — — 1 — — 1 — — — — — — — — — — — — — — 7 Other diseases peculiar to early infancy (a)- — 5 3 1 1 — 6 1 7 1 — 2 — 13 4 — — — 3 9 — — — 19 — 2 26 1 1 1 — — 107 (b) 2 5 — 3 2 3 1 2 1 2 1 — 2 — 9 2 — 4 — 10 5 — 2 — 13 1 — 1 3 — — — — 74 Other— Senile decay 9 16 173 7 19 12 11 6 72 14 3 — 8 2 83 7 13 36 20 27 172 — 48 24 50 33 59 22 116 3 55 — — 1120 Senile dementia 5 2 15 41 4 1 6 44 1 2 3 — 3 — 33 — 4 16 6 4 64 73 — 1 16 6 28 22 42 3 11 — — 456 Violence 148 467 497 425 658 333 253 607 705 280 228 35 541 201 566 482 84 421 405 614 1167 10 550 271 397 398 383 745 621 333 534 — — 13359 Other or ill-defined diseases 44 54 96 29 83 54 38 118 47 46 32 19 68 78 92 45 110 107 64 37 78 3 57 95 71 90 20 66 85 28 112 1 — 1967 No disease— (i) Born in hospital 288 505 327 755 139 — 590 915 600 302 ' 438 416 652 ~~— 8 261 905 1040 1 451 — 793 470 332 464 473 140 424 — — 11689 (ii) Other 38 36 72 99 98 81 20 80 74 341 27 210 80 6 82 244 23 75 53 110 305 2 104 24 63 116 22 77 79 22 47 — — 2710 Grand Total 3567 6479 6821 5082 8305 3209 3381 8972 7185 6274 2462 1373 5190 (c) 3656 7274 7726 (c) 1946 5641 4296 9386 13027 1226 4835 2888 6106 8040 3876 7376 4877 3365 5962 112 109 169024 (a) Born in hospital. (b) Born outside hospital. (c) Convalescent cases. 59 General Hospitals—continued. Institutions. Table VI (6)—Discharges and deaths classified according to principal disease or condition treated, 1934. Institution. Acute infectious disease Influenza. Tuberculosis. Malignant disease Rheumatism (6). Venereal disease Child-birth. Mental disease Senile decay and senile dementia Violence. Other diseases classed as:— Other diseases. W) Total. Pulmon ary. Nonpul monary. Puerperal fever. Other. (e). Nervous Respiratory. Circulatory. Digestive. Genitourinary. Skin Public Health Institutions (a). City of London 2 2 10 16 5 5 3 10 385 61 10 78 52 102 8 16 61 141 967 Constance Road 5 2 6 4 16 6 5 — 4 130 135 11 80 71 158 10 12 10 38 703 Fulham — — — — 1 3 — — — 2 2 3 15 14 22 2 1 2 6 72 Hackney 2 10 2 — 16 3 5 — 26 12 21 6 35 56 101 26 7 16 42 386 Hammersmith — 4 — 7 6 — — — 1 49 4 19 24 33 5 10 9 16 187 Holborn and Finsbury 16 7 4 2 14 11 3 — — 46 16 21 122 82 189 54 13 55 79 734 St. Alfege's 2 — — — 10 11 — — 19 387 215 6 98 56 67 7 7 11 42 938 St. Mary Abbots 3 2 1 1 8 7 2 — 28 4 64 5 27 23 108 10 3 34 330 St. Pancras — 2 1 4 1 — — 1 326 113 13 47 20 41 2 4 1 41 617 South Grove — 3 — 1 17 11 2 — — 1 29 11 49 63 142 40 40 23 38 470 Total 30 30 25 25 98 64 20 — 88 1,294 705 90 570 461 963 164 113 188 476 5,404 Public Assistance Institutions (a). Chelsea 38 6 2 1 3 6 2 — 54 9 56 6 44 33 43 38 13 82 67 503 Islington 6 36 6 — 18 8 9 — 24 316 21 21 162 187 143 42 26 59 254 1,338 Ladywell 3 — 2 — 8 7 — — — 3 52 7 28 68 63 25 8 17 69 360 Newington 2 10 6 2 7 22 1 — 1 125 22 24 78 259 255 88 53 68 86 1,109 Poplar 9 33 2 2 11 9 — — 1 8 32 9 42 79 181 18 8 12 77 533 St. Marylebone 3 42 3 — 4 20 1 — 152 218 64 48 111 117 131 81 16 60 261 1,332 Waterloo House 3 — 2 — 3 1 7 — 5 246 156 1 54 50 54 — 1 — 47 630 Westminster 2 — — — — — — — — 319 91 14 55 2 2 — — — 51 536 Total 66 127 23 5 54 73 20 — 237 1,244 494 130 574 795 872 292 125 298 912 6,341 Grand Total 96 157 49 30 152 135 40 — 326 2,538 1,199 220 1,144 1,256 1,835 456 238 486 1,388 11,745 (a) The following have no accommodation for the sick:—Public Health Institution St. Leonard's. Public Assistance Institutions : Bromley House, Camberwell, Christchurch, Lambeth Home for Aged Poor, Swaffield Road Woolwich. Deaths occurring in these institutions are not included in the table. (6) Rheumatism includes acuto rheumatism, chronic arthritis (non-infective), and non-articular manifestations of so-called "rheumatism" (muscular rheumatism, fibrositis, lumbago and sciatica), (c) Includes normal labour. (d) Including healthy infants, etc., discharged from sick care and undefined conditions 60 General Hospitals—continued. Table VII—Tuberculosis—Classification, according to principal site, of in-lreatments of tuberculosis terminated by discharge or death, 1934. Hospital. Respiratory system. BraiD and spinal cord. Intestines, peritoneum, etc. Genitourinary system. Bones and Joint*. Glands. (a)• General, disseminated. Other. Total. Discharges. Deaths. Vertebral column. Hip. Knee. Other. Archway 361 3 4 5 11 3 — 1 3 1 1 393 238 155 Bethnal Green 160 — 1 — 4 4 — 1 1 1 — 172 113 59 Dulwich 233 5 4 2 4 3 1 6 1 — 259 161 98 Fulham 107 3 6 1 7 2 1 2 9 — 132 78 54 Hackney 212 5 8 2 13 9 3 4 5 1 2 264 173 91 Hammersmith 127 1 1 3 4 5 — 4 6 5 — 156 120 36 Highgate 166 — 1 1 5 3 — 3 3 1 — 183 115 68 Lambeth 166 5 3 4 3 5 1 3 9 6 1 206 141 65 Lewisham 198 7 8 7 4 4 3 4 4 1 240 156 84 Mile End 171 3 3 — 3 3 — 2 2 i — 188 132 56 New End 20 — 1 — 6 1 — — 1 — — 29 22 7 Norwood children's 7 2 — 1 — — 2 — — 12 10 2 Paddington 129 3 2 3 2 3 1 2 2 2 — 149 102 47 Queen Mary's, Sidcup (6) 8 — 1 2 7 3 — 3 2 1 — 27 27 St. Alfege's 164 7 6 4 3 5 1 4 3 5 — 202 135 67 St. Andrew's 231 8 2 2 4 — 8 11 5 1 272 186 86 St. Bonedict's (b) 4 3 2 6 2 — 1 — — 18 18 — St. Charles' 302 1 1 2 1 7 1 3 — 4 2 325 217 108 St. George-in-the-East 129 1 2 1 4 2 2 5 — — 146 102 44 St. Giles' 313 9 4 4 21 8 3 2 10 3 3 380 252 128 St. James' 317 15 3 6 10 8 4 3 5 9 1 381 228 153 St. John's 3 — — — 1 — — — — — — 4 3 1 St. Leonard's 116 — 1 2 4 — 1 1 1 126 78 48 St. Luke's, Chelsea 167 3 2 2 2 2 2 2 — 182 116 66 St. Mary Abbots 89 5 2 5 10 2 1 2 1 2 2 121 77 44 St Mary, Islington 69 5 3 1 4 — 1 2 3 — 7 95 68 27 St. Nicholas' 168 6 4 9 5 5 2 2 — 201 120 81 St. Olave's 211 6 3 2 2 3 5 2 3 2 2 241 166 75 St. Pancras 32 1 1 2 1 1 3 2 43 31 12 St. Peter's 100 1 2 1 4 2 3 1 1 115 88 27 St. Stephen's 220 2 4 2 4 2 2 2 3 3 1 245 172 73 Total 4,700 107 82 72 163 96 27 75 95 62 28 5,507 3,645 1,862 (a) Excluding abdominal and mediastinal, etc., glands, which are included in intestines and respiratory system respectively. (6) Convalescent cases. 61 General Hospitals—continued. Table VIII (o)—Malignant neoplasms.—Discharges and. deaths classified according to type of growth, sex and age, 1934. Type of growth. Sex. Age group. Total. 0- 15- 25- 35- 45- 55- 65- 7, 75- 85 + Discharges Deaths. Carcinoma M. 2 15 42 75 345 768 936 336 19 1,082 1,456 F. — 6 58 290 521 698 662 309 42 1,314 1,272 Sarcoma M. 4 1 6 7 15 32 17 1 1 38 46 F. 3 2 9 1 18 24 14 4 2 44 33 Rodent ulcer M. — — 1 2 5 13 9 21 3 51 3 F. — — — 1 2 14 16 2 28 7 Undefined M. — — 1 1 5 3 6 1 1 13 5 F. — — — — 3 10 3 1 — 9 8 Total M. 6 16 50 85 370 816 968 359 24 1,184 1,510 F. 3 8 67 292 542 734 693 330 46 1,395 1,320 Grand Total 9 24 117 377 912 1,550 1,661 689 70 2,579 2,830 Table VIII (6)—Malignant neoplasms.—Discharges and deaths classified according to site and sex, 1934. Site of growth. Males. Females. Total. Site of growth. Males. Females. Total. Alimentary tract— Female genital organs— Above stomaoh 624 74 698 Above uterus 118 118 Stomach, pylorus 385 245 630 Uterus 689 689 Intestines 246 289 535 Below uterus — 65 65 Rectum, anus 289 212 501 Breast 11 544 555 Respiratory system 409 89 498 Other sites 541 390 931 Prostate 189 — 189 Total 2,694 2,715 5,409 62 General Hospitals—continued. Table IX—Operations carried out in the general hospitals during the year ended 31s£ December, 1934. Operation. (Locality and nature or purpose.) Archway. Bethnal Green. Dulwich. Fulham. Hackney. Hammersmith. Highgate. Lambeth. Lewisham. Mile End. New End. Norwood children's. Paddington. Queen Mary's, Sidcup. St. Alfege's. St. Andrew's. St. Charles'. St. George-in-the-East. St. Giles'. St. James*. St. John's. St. Leonard's. St. Luke's, Chelsea. St. Mary Abbots. St. Mary, Islington. St. Nicholas'. St. Olave's. St. Pan eras. St. Peter's. St. Stephen's. Total. Skull and Brain— Cerebral decompression - 1 5 - 1 3 1 3 2 1 1 - 1 - - 3 1 1 1 - - - 2 - - 1 1 1 1 2 33 Drainage of cerebral abscess 2 — 1 — 4 — 4 1 — 1 — — — — — 4 1 — 4 9 — — — 1 1 1 2 — — 1 37 Removal of intracranial tumour — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 1 4 For fracture of skull 1 — 1 — 1 — — — 1 1 2 — — — — — 1 — — 4 — 2 — — 3 1 4 1 — 23 Other - - 2 - - - - - 1 - - - — — — — — — — 2 — 1 - — — 2 1 1 — 2 12 Spine and Spinal Cord— Laminectomy — — — — — — — 1 — — — — 1 — — 1 — — — — — — — — — 1 - 1 1 - 6 For spina bifida — — — — 1 — — — 1 — — — — — — — — — — — — — — — — — — — — — 2 Other (excluding spinal puncture) — — — — — — — 1 1 - — - 1 - - 2 1 — — — — — — — 1 3 3 — — — 13 Nerves— Phrenic evulsion — — — 2 1 5 4 6 3 — — — — — 1 17 1 — — 9 - — 1 — — — 1 — — — 51 Other - 1 1 1 - 1 - - 5 2 - - 1 - 1 1 - - 3 3 - — — 2 1 — 3 — 5 1 32 The Eye— On lids 1 1 3 — 5 1 4 4 2 1 1 — 3 — 2 2 3 — 5 4 — — — — — 6 16 1 — 4 69 For cataract - 2 4 - 5 - 2 10 6 - - - 2 - 2 - 7 - 5 2 - - - - 8 1 19 1 - 1 77 Other — — 8 - 10 1 3 9 18 — - — 2 — 4 1 9 2 11 6 ~ 2 ~ 2 8 9 39 3 — 8 155 The Ear— Myringotomy 4 9 4 2 33 3 41 29 18 11 3 - 7 - 12 - 2 3 5 2 - 10 - 8 1 4 7 - - - 218 For mastoiditis 6 26 53 8 45 10 18 45 68 45 19 5 35 — 29 22 44 3 50 57 — 21 16 17 29 16 40 3 9 15 754 Other - 3 1 5 5 1 4 13 5 1 1 1 2 — — 8 4 5 21 6 — 6 1 1 1 2 6 1 — 2 106 The Neck— Thyroid — 2 — 1 2 1 1 2 — — 64 — 1 — 5 1 2 — 3 — — — 3 — — 1 — — 1 — 90 Other (operations for suppurative adenitis and for abscess classified as such—see below) — 2 22 1 2 2 — — 1 — 3 — — — 11 3 1 2 2 13 — 1 1 — 3 7 — 2 1 3 83 The Nose— Polypus — 2 1 — 1 3 _ 5 — 1 1 — 1 — 1 4 1 — 4 4 — 1 1 — 2 1 2 1 1 — 38 Deflected septum — 3 10 2 2 - 4 2 8 4 - 1 - 2 5 2 - 6 6 - 4 3 3 — 2 - - 2 2 73 On turbinate bones — 2 1 2 2 1 i — 3 1 1 — — — — — — — 1 1 — — 2 — — 1 1 — 1 1 22 For suppuration _ _ 7 3 4 6 4 4 1 2 — 3 — 1 16 1 1 2 4 — 1 5 — 4 — 2 1 1 1 74 Other 2 11 1 7 - 23 - 4 9 13 - - - - - 4 2 - 7 5 - 13 1 2 — 4 — — - 4 112 The Larynx and Trachea— Tracheotomy and laryngotomy 1 6 4 _ 1 1 3 2 _ 1 — 2 1 — 1 1 — — 3 7 — 1 5 1 2 1 3 1 — 1 49 Other 2 1 2 3 — 1 — — 1 — — — — — — — — — 2 — — 16 — — 2 — 2 — — — 32 63 Table IX—continued. Operation. (Locality and nature or purpose.) Archway. Bethnal Green. Dulwich. Fulham. Hackney. Hammersmith. Highgate. Lambeth. Lewiaham. Mile End. New End. Norwood children's. Paddington. Queen Mary's, Sidcup. St. Alfege's. St. Andrew's. St. Charles'. St. George-in-the-East St. Giles'. St. James'. St. John's. St. Leonard's. St. Luke's, Chelsea. St. Mary Abbots. St. Mary, Islington. St. Nicholas'. St. Olave's. St. Pancras. St. Peter's. St. Stephen's. total. The Thorax— Lobectomy - - - - - 10 - - - - - - - 5 - - - 2 - - - - - - - - - - 17 Thoracoplasty — — — 1 — — 16 4 — - - - - — 29 — - — 18 — - — - — — — - - — 68 For empyema 7 13 37 13 25 — 16 — 16 8 2 — 9 — 17 19 18 2 20 60 — 7 2 7 19 6 20 5 1 10 359 Other (excluding exploration and aspiration) 2 — — 1 1 — 2 — — — — — — — 1 40 — — — 12 — — — — 4 1 1 1 - — 66 The Lips— For epithelioma — — — — — — — 4 — — — — — — 1 — —-— — — — — — — — — — — — — — 5 Other — — — — — — — 1 1 — — — — — 1 — — 1 1 — — — — — — — — — — — 5 The Mouth and Salivary Qlands— Alveolar abscess 1 30 4 — 1 3 3 2 8 — — — 1 - 3 1 — — — 7 — 7 8 5 1 1 5 — — 1 92 Other (excluding dental extractions) - 1 - 3 6 - 6 - 3 3 - - 1 - - 1 - 1 2 3 - 3 - 5 3 6 - 1 1 1 49 Plastic operations on Face and Mouth— For hare Up — — — — — 2 1 - - - - - - - - 1 _ 1 - 13 - - - - - - - - - - 18 For cleft palate — — — — — — — 1 — — — — — — — 1 — — — 6 — — — — — — — — — — 8 For cicatricial deformity — 1 — — — 17 — — 2 — — — — — — — — 1 — 7 — — — — — — — — — — 28 Other - 3 1 - - 9 - - - - - - 2 - 3 - - - - 25 - - - - - 1 - - - - 44 Fauces and Pharynx— Removal of tonsils and/or adenoids 17 92 147 57 131 72 35 73 176 167 59 50 36 — 207 265 118 12 169 259 21 52 64 77 53 120 92 4 13 66 2,704 Other 2 1 — — 29 — 7 - 1 — — — 1 - — - 1 — 1 9 - 9 - — — — 2 — — — 63 (Esophagus — — — — 2 — — — — — — — — — — — 1 — 2 — — 2 — — — — — — — — 7 Stomach— Gastrostomy 4 1 1 3 1 1 2 2 3 - - - - - 1 - 3 2 3 4 - 1 2 - 3 3 - - - 1 41 For ulcer—Gastrectomy - 1 4 - - - - 1 - 4 - - 5 - 10 - 3 - 3 1 - - 1 - - - 8 2 - - 43 Gastrojejunostomy 1 4 10 - 2 — 2 5 — 4 — — 1 — 1 4 1 - 4 3 — 2 — 4 3 — 8 2 - 7 68 Excision of ulcer — 3 1 3 — — — 4 — — — — - — 1 8 — — — — — - — 1 — — — — 2 — 23 Other — 12 — — 1 — — — — — — — 2 — 1 1 — — — — — — — — 1 — 1 — — 1 20 For perforated ulcer (see also below under intestine) 2 — 20 9 17 2 2 18 12 1 2 4 6 8 10 2 21 17 ~~ 2 5 4 9 14 11 1 — 4 203 For carcinoma—Gastrectomy — 1 - - — — — — 1 — — — — — — 1 1 2 3 1 — — — 2 12 Gastro - j ej unostomy _ _ 6 _ 2 _ — 8 _ 1 _ — 1 _ 1 — — _ 5 2 — — — — — 3 2 — _ _ 31 Other _ _ _ _ _ _ 2 2 7 Other - - 2 2 - - 1 - 8 - - - - - - - - - 2 4 - - - 1 3 23 Intestine— Gastro-jejunostomy for duodenal ulcer - 1 9 — 4 3 — — — 1 1 — 1 — 8 — — 3 6 6 — — 2 1 4 1 — - 2 4 57 For perforated duodenal ulcer 1 1 4 5 5 — — — 11 9 3 — 2 - 8 1 6 — 6 25 — 1 5 — 2 1 5 2 — 7 110 For appendicitis 15 68 228 106 179 104 56 66 301 96 57 — 122 — 193 94 103 52 209 313 — 46 64 109 97 102 178 18 25 126 3,127 Hadioal cure of hernia—Inguinal 3 20 32 21 39 32 5 40 49 30 8 - 8 - 48 38 8 16 56 46 - 13 9 20 11 26 42 7 11 25 663 Femoral — 2 6 4 2 2 — 1 6 3 4 — 1 - 2 5 1 1 9 6 3 2 2 4 4 12 1 4 — 87 Umbilical 2 — — 1 2 — 2 2 2 7 2 — — — 3 3 2 4 5 1 J 1 2 1 1 1 6 — 1 2 53 Incisional — 4 — 8 3 2 1 8 2 1 — — 2 — 1 — 5 — 4 2 — — 1 — 2 — — 2 — - 48 Other 1 1 — 2 — 1 — - 1 _ ~ — 1 1 1 2 2 1 — 1 — 1 3 — — — 19 64 Table IX—continued. General Hospitals—continued. Operation. (Locality and nature or purpose.) Archway. Bethnal Green. Dulwich. Fulham. Hackney. Hammersmith. Highgate. Lambeth. Lewisham. Mile End. New End. Norwood children's. Paddington. Queen Mary's, Sidcup. St. Alfege's. St. Andrew's. St. Charles'. St. George-in-the-East. St. Giles'. St. James' St. John's. St. Leonard's. St. Luke's, Chelsea.. St. Mary Abbots. St. Mary, Islington. St. Nicholas'. St. Olave's. St. Pancras. St. Peter's. St. Stephen's. Total. Intestine—continued. For strangulated hernia—Inguinal – 6 18 7 10 11 2 4 10 1 3 – 6 – 8 2 2 1 8 21 – 4 3 2 12 4 – 8 3 4 160 Femoral 4 6 8 7 8 – 4 8 3 1 – – 2 – 14 4 4 1 8 20 – 5 1 5 8 2 3 5 1 3 135 Umbilical – 2 2 1 1 – 3 1 2 – 1 – 3 – 1 1 – – 4 4 – 1 – – – – 1 – – 1 29 Incisional – – 1 – – 1 – – 2 – – – 1 – 2 – – – 1 6 – 1 1 – — — 2 2 — — 20 Other – – – – 1 1 – – – 3 – – – – 1 1 – 1 – 1 – – – – 6 1 – – – – 16 For intestinal obstruction— Adhesions and bands – 4 11 4 9 9 3 2 4 4 1 – 2 – 3 3 4 1 6 15 – 3 2 – 2 6 11 – 1 3 113 Intussusception – 1 1 2 2 3 1 – 4 4 1 – 2 – 3 2 2 1 1 5 – 1 1 1 2 2 2 – – 2 46 Volvulus – – 3 – – – 3 1 3 – – – – – – 1 1 – 1 3 – – – 1 1 – – – – – 18 Carcinoma— Colostomy 6 1 23 5 3 2 1 9 4 7 2 – 8 – 11 – 7 – 7 22 – 2 – 1 6 7 11 2 4 3 154 Cæcostomy – 2 1 4 3 1 1 5 6 – 1 – 3 – 3 2 7 1 7 16 – 3 4 5 7 1 4 2 2 2 93 Other 1 2 2 3 5 – 1 – 3 3 – – – – 2 1 – 4 6 14 – 1 – 1 2 – 6 2 – 5 64 Other – 1 – 2 – – 1 1 4 – – – 1 – 1 1 2 1 5 16 — 2 1 – 4 2 — 1 2 – 48 Other – 2 – 2 – – 10 6 5 – 1 – 5 – 4 – 4 – 1 – – 1 – – 14 1 – 4 – – 60 Rectum and Anus— For hæmorrhoids 5 12 13 9 8 8 4 4 13 3 3 – 4 – 7 20 4 2 14 17 – 5 9 14 5 8 15 3 6 11 226 For ischio-rectal abscess – 6 17 2 5 3 8 4 10 3 1 1 8 – 8 – 2 2 15 15 – 7 3 10 8 2 12 – 4 3 159 For fistula-in-ano – – 6 2 1 7 1 3 4 1 1 – 5 – 3 – – – 4 1 – 3 1 3 1 2 3 – – 6 58 For fissure – 2 1 – 2 – – – 1 2 – – – – 1 – – – – – – 1 – 3 – – 1 1 – – 15 Colostomy for carcinoma – 3 1 2 – 2 1 – 2 – 1 – – – 6 3 – 2 6 – – – – 13 4 7 1 1 – – 55 Other – 6 4 5 6 l – 2 6 1 2 – 2 – 3 10 2 2 4 6 – 4 4 1 1 – 10 – 1 2 85 Liver, Gall-bladder and Ducts— For cirrhosis – – – – – – – – – – – – – – – – – – – – – – – – – – – – – 2 2 For cholecystitis and cholelithiasis— Cholecystectomy – 11 14 7 8 5 2 15 12 19 3 – 1 – 18 7 9 9 11 20 – 3 7 9 14 8 20 3 4 4 243 Cholecystostomy 1 – 15 4 6 1 1 1 2 – 1 – 5 – 11 – 3 – 3 2 – 2 1 7 4 6 11 1 1 – 89 Other – – – – – – – 1 – – – – – – – – – – – 7 – 1 1 – – 1 – 1 – 1 13 For carcinoma – – – 1 – – 1 – 1 – – – – – – 1 – – – 1 – – – – 1 3 1 – – – 10 Other – 1 – 1 1 1 – – 1 2 – – – – – – – – 1 – – – – – – 2 1 1 – – 12 Pancreas— For acute pancreatitis – 1 4 2 – – 1 – 1 – 1 – – – 1 1 1 – 1 – – – – 1 – – – – – 1 16 For carcinoma – 1 – 2 – 1 – – 1 2 – – – – – 2 – – – – – – – 1 1 3 2 1 – 1 18 Other – – – – 1 – – – 1 – – – – – – – 1 – – – – – – – – – – – – – 3 For peritonitis (other than cases included under a local lesion such as appendicitis, etc.) For pelvic abscess 2 2 15 6 1 – – – 3 4 – – 8 – 4 – 4 – 1 22 – 5 3 1 9 9 4 1 2 1 107 For subphrenic abscess – 1 1 1 – – 1 1 – 1 – – 2 – – – – – – 5 – 1 – 1 2 1 – – – – 18 Other – 3 – 5 – 2 2 – 5 1 6 – – – – – 4 – 4 5 – 1 1 – 1 – 12 1 – – 53 65 Table IX—continued. Operation. (Locality and nature or purpose.) Archway. Bethnal Green. Dulwich. Fulham. Hackney. Hammersmith. Highgate. Lambeth. Lewisham. Mile End. New End. Norwood children's. Paddington. Queen Mary's, Sidcup. St. Alfege's. St. Andrew's. St. Charles'. St. George-in-the-East. St. Giles'. St. James'. St. John's. St. Leonard's. St. Luke's, Chelsea. St. Mary Abbots. St. Mary, Islington. St. Nicholas'. St. Olave's. St. Pancras. St. Peter's. St. Stephen's. Total. Exploratory laparotomy— For malignant disease 3 3 19 4 8 — 1 — 1 2 — — 1 — 18 9 2 — 9 7 — — 4 — 7 4 2 — 7 6 117 For other reason 5 4 35 4 16 25 1 17 11 8 3 — 8 — 12 8 1 14 5 18 — 4 6 61 8 20 13 3 1 5 316 Spleen. Lymphatics— Splenectomy — — — — — — 1 — — 1 — — — — 1 — 1 — 2 2 — — 1 — — — — 1 1 1 12 Excision of lymphatic glands— For tuberculosis — — — 1 2 3 — — 2 — — — 1 — 1 2 — — 1 1 — — 2 2 1 — — — — — 19 For malignant disease — 1 — — — — — — — — — — — — 1 1 — — — 1 — — — — — — — — — — 4 For other reason — 1 — 1 8 — — — — — — — — — — — — — 1 2 — — — — — — — — — — 14 Incision for adenitis (under general anæsthesia) — 6 — — 40 1 36 — 2 — — 11 3 — — — — — 40 — — — 15 3 17 6 22 — — — 202 Blood Vessels— For varicose veins (excluding injections) — — — — — 1 — — — — — — — — 3 6 1 — — — — — — — 1 — — — — — 12 Periarterial sympathectomy — 1 — 1 — — — — 1 — — — — — — — 1 — — — — — 1 — 1 — — — — 1 7 Other — — — — 2 — 1 — — 5 — — 1 — 1 1 — — — 7 — 1 — — 2 — 2 — 2 1 26 Kidney and Ureters— Nephrectomy — — 4 4 2 2 4 3 4 — 1 — 1 — 4 6 1 1 2 7 — 2 2 3 — 2 6 1 1 3 66 Removal of calculus 1 2 3 — 4 — 1 2 3 2 1 — 1 — 8 1 — — 1 1 — 1 1 5 2 — 4 1 2 2 49 For perinephric abscess — 2 5 1 1 — — — 2 1 — — 1 — 1 1 2 1 2 2 — — 1 1 6 2 2 2 4 1 41 Other 2 1 1 — — — 1 — 2 1 2 — 1 — 1 1 — 3 3 3 — 5 2 2 — 2 2 — — — 35 Bladder— Cystostomy 9 10 24 8 6 — 5 5 15 4 6 — 12 — 8 9 17 3 8 33 — 23 10 15 19 10 11 2 9 9 290 Removal of calculus — — 6 — 1 — — — 2 — — — — — 2 — 2 — — — — — — 2 — 1 — — — — 16 For new growth — — — 3 9 — — 4 2 — — — 1 — 6 4 — 2 — 3 — — — 6 16 2 3 — — 1 62 Other — — 10 3 — — — — 2 — — — — — — 4 4 2 1 11 — 3 — 1 2 — — — 1 — 44 Prostate— Prostatectomy—Suprapubic 2 5 21 5 5 6 2 10 7 3 2 — 1 — 7 — 2 2 9 29 — 5 2 8 8 2 2 3 3 2 153 Perineal — — — — — — — 1 — — — — — — — — 2 — — — — — — — — — — — — — 3 Diathermy 5 — — — — 12 — — — — — — — — 10 — 1 — — — — — — 1 — — 1 — — — 30 Endothermy — 3 — — 4 — — 4 8 — — — 1 — — — — — 1 4 — 8 — 9 — — — — — — 42 Other — — — — — — — — — — — — — — 4 — — — — 3 — — — 6 — — — — — — 13 Urethra— For stricture — 13 35 13 13 1 5 12 1 — — — 7 — 21 — 18 15 1 70 — 23 3 33 6 4 — 6 4 4 308 Other — 5 1 — 1 3 1 3 4 1 1 — — — — 1 — 1 1 3 — — — 2 3 1 — — 1 — 33 Penis and Testicle— Circumcision 6 40 14 25 9 14 8 18 43 16 7 8 16 1 260 37 12 12 20 39 — 7 16 8 29 53 40 10 8 7 783 Varicocele — 4 2 1 2 — — 1 1 — — — — — 5 2 4 1 1 2 — — — 3 1 5 5 — 1 — 41 Hydrocele — — 3 2 12 3 — 3 9 — 2 — 2 — 5 6 — 1 3 10 — 9 1 2 2 4 2 — 7 1 89 Epididymectomy, orchidectomy — — 4 — 1 — — 1 3 — — — — — 2 2 2 — 4 1 — — — 1 — — 2 1 1 1 26 Undescended testicle — — 2 — 4 — — 1 — 2 — — — — 2 2 — — 3 2 — 1 — 2 — 2 — — — 1 24 Other — — 5 — 4 2 — — 1 1 — — — — 3 — — 1 14 2 — 3 2 3 — 3 — — — 4 48 66 Table IX—continued. General Hospitals—continued. Operation. (Locality and nature or purpose.) Archway. Bethnal Green. Dulwich. Fulham. Hackney. Hammersmith. Highgate. Lambeth. Lewisham. Mile End. New End. Norwood children's. Paddington. Queen Mary's, Sidcup. St. Alfege's. St. Andrew's. St. Charles'. St. George-in-the-East. St. Giles'. St. James' St. John's. St. Leonard's. St. Luke's, Chelsea. St. Mary Abbots. St. Mary, Islington. St. Nicholas'. St. Olave's. St. Pancras. St. Peter's. St. Stephen's. Total. Female Genital Organs— Preast—For mammary abscess 3 22 33 2 62 – 9 21 14 69 4 – 15 – 7 26 6 26 97 27 – 8 4 21 12 3 18 9 9 9 536 Amputation for—Carcinoma – 1 2 2 1 2 – 14 7 2 3 – 3 – 3 3 – – 4 3 –- 1 4 2 – 1 1 – 1 – 60 Other causes – – – – – – 1 – – 1 – – 2 – – – – 1 2 1 — — — — — — 1 — — — 9 Other – – – 3 2 2 1 – 7 1 1 – – – – – – 1 2 1 – — – 2 3 1 2 — — 1 30 Ovaries and fallopian tubes— For ovarian cyst 1 2 7 6 7 1 2 7 8 2 1 — 4 — 7 5 6 1 8 11 — 1 9 11 7 6 15 2 1 8 146 For malignant disease – – – 1 – – – – – – – – 1 – – – 2 – – – – – 2 – – – 1 – – – 7 Forsalpingo-oophoriti8or pyosalpinx ... 18 9 8 4 24 12 1 6 3 7 6 2 1 11 21 _ 4 4 19 4 2 6 7 1 14 194 For ectopic gestation 1 1 3 3 2 4 3 7 2 7 2 - 4 - 5 4 5 1 7 10 - 3 1 2 11 3 2 - - 3 96 Other — 1 — — — — — _ 1 — 1 — 1 — 7 — — — — — — — 2 3 1 — — 1 — — 18 Uterus— Hysterectomy—For carcinoma... - - 8 - - - 1 1 _ _ - - - - 2 2 1 - - 2 - 1 1 2 - 2 3 - - 1 27 For other causes ... 2 7 6 3 8 14 4 7 9 4 7 — 8 — 10 11 6 — 6 22 — 3 7 22 4 7 9 3 3 3 195 Curettage (including for abortion and retained products) 33 80 136 29 129 68 50 134 146 106 24 73 92 97 59 22 147 193 _ 80 30 49 81 46 98 95 59 48 2,204 Myomectomy - - 4 2 - 1 - 1 - 3 - - - - 3 - - 1 4 2 - - 2 4 - 2 1 - - - 30 Removal of uterine polypus — — 2 2 3 1 2 1 3 2 3 — 1 — 3 1 — 4 5 4 — 1 3 3 3 4 — 1 — — 52 Amputation of cervix - 1 _ 1 - 1 1 _ _ 2 - - 2 — 2 1 3 1 — — - - 4 5 1 1 — - 2 2 30 Trachelorraphy ... - - — — — 1 - — — — - — - - - 1 - - - - 2 1 - - - - — - 5 For prolapse of uterus ... — — 4 1 — 1 — 1 — — 1 — - — 6 — — 1 1 2 — — — 2 3 1 — — — — 24 For retroversion ... _ 1 _ _ 4 1 _ 14 1 _ 1 _ _ — _ 3 1 — — — - 1 2 — — 2 1 2 — 9 43 Other I 7 11 3 4 3 6 1 4 1 5 _ 2 _ 3 3 3 3 4 4 — 20 3 11 3 3 3 — — 3 114 Vagina, Vulva and Perineum— For abscess of Bartholin's gland _ 2 ' 1 - 5 3 - _ - _ 3 - 6 - 1 1 1 1 - 4 - 1 — 5 2 - 1 - - — 37 Colporrhaphy and /or perineorrhaphy 4 6 1 15 1 2 7 6 2 1 4 3 7 2 10 _ 5 15 3 2 6 4 4 5 115 Other — 1 _ 6 3 _ _ _ 16 1 _ — 2 _ 1 1 1 4 — 7 — 5 — — — 3 5 1 — 4 61 The Locomotory Apparatus— Bones— For acute periostitis and osteo myelitis 11 3 5 9 2 8 16 15 1 2 2 7 8 3 11 17 26 _ 4 10 6 10 11 8 3 1 199 Sequestrectomy ... 4 2 11 3 15 8 3 2 12 2 1 - 6 - 10 8 2 7 9 15 - 3 - 8 9 3 23 - 4 10 180 Excision of myeloma 4 Osteotomy ... — 1 4 — 2 _ — 1 — 3 3 — 2 — 2 — 2 1 1 2 — — 1 1 — 2 9 — 2 — 39 For hallux valgus I 1 _ 1 1 _ _ _ 3 2 2 _ _ — 6 2 4 1 1 1 — — 2 2 3 4 5 — 3 4 49 For fracture— Manipulation (including application of splints and plaster) under anaesthetics 11 68 79 74 134 105 6 79 132 68 31 42 91 79 73 100 67 67 1 90 45 88 47 86 87 99 29 94 1,972 Plating or wiring ... - 5 18 9 18 1 2 8 7 18 9 - 8 - 13 3 8 6 3 108 - 20 15 2 20 3 13 4 12 6 339 Bone grafting — — _ — 4 4 — _ 1 — — — 1 — 3 — — 3 2 1 — 1 - 2 — — 1 — — — 23 Other... 3 7 _ 2 2 2 6 _ _ 3 _ — 1 _ 3 11 3 2 9 11 — 4 — 2 1 14 12 1 1 3 103 Other 1 _ 4 _ _ _ _ 7 1 3 _ 4 _ 1 _ 4 2 - — - - - 1 1 2 - 1 — — 32 Joints— For tuberculous arthritis 1 1 3 1 1 — - 2 - — 4 — 2 — 1 - - 1 17 For acute suppurative arthritis _ _ 4 _ 10 _ 6 2 1 1 _ — - _ 1 - - 3 6 9 - 1 1 9 6 1 2 1 1 1 00 Reduction of dislocation 2 36 1 4 29 2 _ 7 28 _ — — 16 — 5 9 — 5 8 26 — 11 9 — 7 8 16 8 19 7 263 For internal derangement — 1 2 1 6 1 1 1 1 3 — — 1 — 12 3 — 2 7 4 — 6 — 2 3 6 3 — 2 — 68 Other i l — 9 — — 5 — 2 _ — _ _ — 7 5 2 18 4 13 _ — _ 2 3 _ _ 2 _ 2 76 67 Table IX—continued. . Operation. (Locality and nature or purpose.) Archway. Bethnal Green. Dulwich. Fulham. Hackney. Hammersmith. Highgate. Lambeth. 1 Lewisham. MOe End. New End. Norwood children's. Paddington. Queen Mary's, Sidcup. St. Alfege's. St. Andrew's. St. Charles'. St. George-in-the-East St. Giles'. St. James'. St. John's. St. Leonard's. St. Luke's, Chelsea. St. Mary Abbots. St. Mary, Islington. St. Nicholas'. St. Olave's. St. Pancras. St. Peter's. St. Stephen's. total. The Locomotory Apparatus—continued. Bursae, Fasciae, lendons, etc.— For acute bursitis 1 1 15 _ 7 1 2 3 2 6 3 4 __ 3 12 3 _ 8 21 _ 2 _ 6 6 1 14 - 1 3 125 Excision of bursæ _ 2 3 1 17 4 _ 3 6 _ 3 _ 1 _ 7 _ 5 3 1 1 — — 2 1 1 — 2 — 3 2 68 Repair, etc., of tendons _ 2 2 1 12 1 7 4 4 7 5 _ _ _ 7 6 - 3 7 6 — 3 3 2 - 12 8 4 1 3 110 Other l _ 2 2 _ _ _ _ 1 _ 2 _ _ _ 9 _ 3 3 1 1 - 1 - 3 - 2 2 2 - - 35 Amputations- Through forearm _ _ _ _ _ _ 3 1 - _ _ _ _ 1 1 — — — — — — 1 — - 1 — - — 1 y Through wrist - - - - - - - - 1 - - - - - - - - - - - - - - - - - - - - - 1 Of finger _ 11 5 3 14 2 2 3 7 2 1 _ 1 _ 4 7 1 1 8 6 — 2 5 3 - 10 21 — 3 3 126 Through thigh 4 4 6 3 5 _ 6 12 6 4 _ _ 4 _ 9 2 3 1 6 8 — 5 6 6 2 2 11 2 5 2 124 Through leg 2 1 1 4 4 2 _ 3 _ _ 1 _ _ _ _ 1 2 2 3 3 - - - - 8 1 3 1 - 1 43 Of loot 1 2 _ _ _ 1 _ _ _ — — — — — — — — — — — — 3 — — — 3 — 10 Of toe _ _ 1 1 3 2 _ 1 _ _ _ _ 1 _ 2 _ 2 _ 1 2 _ 4 — 4 — 2 8 1 1 4 40 Other _ 29 _ - - 1 - - 4 - 1 - 1 4 - - - - - - 1 - - - 41 The Skin and Cellular Tissue- For carbuncle 5 _ 9 5 16 1 1 8 — 1 5 — 4 — 2 12 Z 3 1 y 6 i o i i o o * 119 For innocent growth 1 6 _ 7 43 _ 4 9 10 3 _ 3 — 1 5 3 2 7 13 — 5 3 9 4 10 19 2 11 9 189 For malignant growth 1 6 _ 7 43 _ 4 _ _ _ _ _ _ _ _ 2 2 _ 4 21 _ 1 _ _ 1 2 — — — — 34 Skin grafting 1 4 15 _ 6 _ 2 _ 1 3 3 _ _ _ 6 5 2 _ 10 9 _ 5 _ 4 2 1 8 1 1 3 92 For cicatricial deformity _ _ _ 1 _ 91 _ _ 1 _ 3 - 1 - - - _ _ _ 3 _ _ 3 _ 1 1 _ _ 1 _ 106 Suture of wounds (under general anaesthesia) 3 26 23 6 32 31 6 28 29 11 10 _ 5 _ 11 20 15 19 21 80 1 29 8 18 12 12 28 10 10 20 524 Incision of abcess (under general anaesthesia) 68 168 122 71 393 54 42 176 246 158 31 11 86 6 241 247 102 101 103 296 _ 78 5 44 29 64 540 47 47 69 3,645 Other 4 41 3 15 98 _ 18 _ 28 2 5 _ 1 _ 28 26 1 14 12 61 12 40 4 1 26 — 50 7 7 12 516 Obstetric operations _ 11 _ 1 1 _ _ _ _ _ _ _ _ _ _ 1 _ _ _ _ _ _ _ _ _ _ _ _ _ _ 14 Embryulcia _ 2 4 1 18 2 _ 11 3 15 7 _ 4 _ 9 8 2 3 13 12 _ 7 _ 2 11 _ 10 _ 1 1 146 Cæsaream section Miscellaneous _ 2 4 1 18 2 __ 11 3 15 7 _ 4 _ 9 8 2 3 13 12 _ 7 _ 2 11 _ 10 _ 1 1 146 Ventriloculography 1 1 2 _ _ 1 __ _ _ _ — 29 1 — 2 24 — — — 3 — — — — 2 — 66 Bronchoscopy 13 1 _ _ _ _ _ 43 1 — 6 16 83 Bronchiolograpny Artificial pneumothorax- 5 38 7 76 10 16 8 _ _ _ 3 — 14 11 1 8 5 4 — 5 5 — — 13 41 1 — - Z l i Induction 31 g 60 137 97 150 42 _ _ _ 20 _ 148 137 24 56 38 — — 3 29 — — 267 574 — — — 1,821 Refill 1 1 2 1 12 5 1 _ _ — 7 2 3 - 1 5 - 4 2 5 2 1 4 - 1 2 62 (Esophagoscopy 4 6 3 5 5 13 34 17 19 1 _ - - 15 4 24 4 10 28 - 2 5 35 10 12 9 3 6 11 285 Sigmoidoscopy 1 6 _ 1 _ — — — — — — — — 3 — 3 — 21 — 1 1 — 13 — 50 Urethroscopy ... 21 38 49 15 36 45 13 86 53 34 __ _ 10 _ 54 35 35 30 48 104 — 44 27 143 48 46 55 29 39 46 1,183 Cystoscopy A 20 2 28 0 3 4 5 12 8 13 10 29 _ 6 _ 66 7 14 4 4 14 6 279 Pyelography (instrumental) ... § 13 42 26 l 9 22 4 8 23 16 6 9 6 _ 52 35 6 8 12 50 - 8 12 32 19 10 42 - 7 17 487 Blood transfusion Insertion of radium tubes 1 114 - - - - 2 - - - 4 - — - — — — — — 1 ~~ 122 Total 355 1197 1678 773 2103 1150 724 1633 1933 1133 503 89 757 7 2057 1751 955 716 1690 2935 35 910 610 1254 974 1277 2611 508 502 869 33,689 * Other than shown under Face and Mouth. 68 General Hospitals—continued. Table X—Massage or physio-therapeiitic departments. Work done during the year 1934. Hospital or Institution. Patients treated. Treatments given. Massage. Electrical. Light. Radiant Heat Other. Total. Archway 102 1,063 -_ 1,063 Bethnal Green 416 5,589 1,809 900 2,345 3,548 14,191 Dulwich 509 6,292 881 1,946 3,408 — 12,527 Edmonton colony 150* 3,000 50 — — 700 3,750* Fulham 448 8,080 1,274 683 1,050 1,047 12,134 Hackney 1,120 14,500 3,032 1,197 5,364 2,558 26,651 Hammersmith 606 6,927 2,968 1,431 4,161 — 15,487 Highgate 551 5,467 3,768 1,178 t 9 10,422 Lambeth 984 21,919 5,740 4,404 8,251 40,314 Lewisham 905 15,649 3,427 743 4,981 246 25,046 Mile End 1,057 6,480 1,792 1,267 3,642 2,106 15,287 New End 239 3,419 331 37 336 — 4,123 Norwood children's 130 1,442 — 103 — — 1,545 Paddington 395 11,056 2,526 380 1,448 952 16,362 Queen Mary's, Sidcup 506 5,639 1,530 3,134 3,733 1,545 15,581 St. Alfege's 765 14,846 1,894 483 4,490 4,287 26,000 St. Andrew's 1,214 18,376 1,942 6,954 6,746 1,110 35,128 St. Benedict's 325 3,209 3,067 654 749 7,679 St. Charles' 386 6,270 998 419 2,846 2,944 13,477 St. George-in-the-East 1,214 5,363 4,051 2,188 t 3,762 15,364 St. Giles' 822 8,531 880 816 4,956 160 15,343 St. James' 628 10,618 2,456 59 1,356 — 14,489 St. John's 106 2,814 1,444 301 1,081 — 5,640 St. Leonard's 377 2,816 1,410 500 688 6 5,420 St. Luke's, Chelsea 285 4,211 387 628 562 363 6,151 St. Mary Abbots 534 9,334 4,319 490 804 14,947 St. Mary, Islington 676 8,755 1,199 818 3,423 — 14,195 St. Nicholas' 889 10,501 2,464 1,617 6,718 2,653 23,953 St. Olave's 1,384 7,185 1,688 1,339 7,065 7,657 24,934 St. Pancras 575 10,536 1,980 1,207 364 201 14,288 St. Peter's 540 5,499 1,875 1,775 1,095 456 10,700 St. Stephen's 795 8,727 2,308 445 5,295 2,068 18,843 City of London institution 27 782 6 630 1,418 Total 19,660 254,895 63,496 38,096 86,034 39931 482,452 * Approximately, + Included under electrical. 69 General Hospitals—continued. Table XI—X-ray work in the general hospitals, 1934. Hospital. Diagnostic. Therapeutic. Number of patients. Number of films and X-ray negative papers. Number of patients. Number of treatments. In-patients. Out-patients treated by the hospital. Out-patients sent to the hospital for X-ray examination only Archway 1,430 _ 12 2,240 Bethnal Green 1,756 873 33 3,741 _ — Dulwich 3,533 115 131 6,346 _ — Fulham 2,110 137 1 6,245 — Hackney 3,971 2,454 — 8,457 52 250 Hammersmith 1,580 291 202 3,959 — — Highgate 1,426 51 — 2,328 2 8 Lambeth 4,739 686 44 3,617 547 10,816 Lewisham 2,236 1,224 166 7,258 4 25 Mile End 1,342 895 366 4,278 23 53 New End 784 144 78 2,076 — — Paddington 1,776 511 15 5,585 — — St. Alfege's 2,920 720 341 5,318 — — St. Andrew's 2,593 1,439 206 7,404 — — St. Charles' 1,988 42 67 3,341 — — St. George-in the-East 1,725 1,000 4,920 21 80 St. Giles' 2,055 414 26 3,467 — — St. James' 3,539 416 417 7,943 — — St. John's 105 17 2 336 — — St. Leonard's 1,391 573 44 3,167 — — St. Luke's, Chelsea 1,242 179 25 2,186 — — St. Mary Abbots 2,244 71 246 5,476 — — St. Mary, Islington 2,207 94 — 3,409 — — St. Nicholas' 1,532 2,548 — 7,339 — — St. Olave's 2,506 2,141 1,050 9,728 — — St. Pancras 1,948 210 3,534 — — St. Peter's 1,355 212 147 3,109 — — St. Stephen's 1,707 165 50 4,023 — — Total 57,740 17,622 3,669 130,830 649 11,232 79,031 70 71 GENERAL HOSPI TALS—continued. Table XII.—Return of dental work in general hospitals during the year ended 31st December, 1934. (For analysis of out-patients who received dental treatment see table XIII.) Hospital. Number of patients seen by dentist. Extractions. Number of patients. Anaesthetic administrations (general). Conservative treatment (including scaling) Number of patients. Fractures of jaw dealt with by dentist. Other cases seen by dentist. F = full. Dentures. P = partial. R - repairs. In-patients. Out-patients. Total. In-patients. Out-patients. Total. Patients. Attendances. Patients. Attendances. Patients. Attendances. Inpatients. Outpatients. Total. Inpatients. Outpatients. Total. Inpatients. Outpatients. Total. F. P. R. F. P. R. F. P. R. Archway 241 317 19 42 260 359 115 3 118 20 _ 20 2 2 1 14 2 4 7 21 2 4 Bethnal Green 120 179 84 141 204 320 83 47 130 67 30 97 9 2 11 i 25 10 4 5 16 4 10 26 8 15 Dulwich 513 664 151 167 664 831 138 77 215 142 46 188 239 59 298 — — 9 5 2 7 5 3 16 10 5 Fulham 1206 310 J218 328 J424 638 211 173 384 174 146 320 50 30 80 i 7 22 2 1 25 1 3 47 3 4 Hackney 185 520 245 533 430 1,053 170 154 324 68 88 156 62 44 106 5 14 1 3 inc. under P 22 25 inc. under P 23 28 inc. under P Hammersmith J120 332 112 494 232 826 196f 132f 328f 30 16 46 196 302 498 — — 17 2 11 33 2 5 50 4 16 Highgate 207 547 5 11 212 558 150 3 153 29 — 29 52 — 52 1 20 18 I 6 — — — 18 1 6 Lambeth 199 378 50 138 249 516 356 126 482 347 121 468 174 32 206 1 — 3 16 2 8 — 4 11 16 6 Lewisham 157 311 154 384 311 695 83 123 206 51 113 164 12 19 31 1 90 4 — 3 23 6 2 27 6 5 Mile End 108 128 178 230 286 358 105 187 292 146 115 261 , t 4 4 — — 12 — 2 — — 1 12 — 3 New End 93 40 8 12 101 J152 41 16 57 41 13 54 — — — 1 — 2 — 2 — — — 2 — 2 Norwood 14 14 — 14 14 11 — 11 11 — 11 0 Paddington 106 277 164 336 270 613 76 100 176 12 4 16 23 94 117 3 31 13 1 2 4 5 4 17 6 6 Queen Mary's, Sidcup 611 1,220 5 5 616 1,225 479 5 484 56 56 43 — 43 1 150 — — 2 — — — — — 2 St. Alfege's 86 427 262 541 348 968 76 182 258 14 10 24 36 68 104 1 2 2 3 5 11 4 8 13 7 13 St. Andrew's 367 386 1,045 1,051 1,412 1,437 276 1,038 1,314 257 997 1,254 — — — 3 **53 — — — 5 — 2 5 — 2 St. Benedict's St. Charles' 219 674 82 149 301 823 194 82 276 278 130 408 97 16 113 1 — 8 10 7 — — — 8 10 7 Edmonton colony 284 680 — — 284 680 87 — 87 — — — 143 — 143 1 23 23 22 63 — — — 23 22 63 Brentwood colony 636 679 — — 636 679 135 — 135 — — — 55 55 1 11 14 22 11 14 22 St. George-in-the-East 148 148 348 439 496 587 107 348 455 71 309 380 30 85 115 5 12 — — — 1 — — 1 — St. Giles' 282 422 +594 892 |876 1,314 248f 377f 625f • * 394 11 9 20 — — 23 4 4 28 8 30 51 12 34 St. James' 348 1522 228 {342 576 J864 216 109 325 96 96 106 42 148 4 — 2 — 1 — — — 2 — 1 St. John's 271 321 271 321 60 60 26 26 180 — 180 — 31 — 1 3 — — — — 1 3 St. Leonard's 242 402 73 149 315 551 88 31 119 62 8 70 9 38 47 2 45 4 3 3 15 2 5 19 5 8 St. Luke's, Chelsea 102 230 63 152 165 382 61 48 109 4 2 6 32 13 45 — 13 5 2 2 — 4 1 5 6 3 St. Mary Abbots 321 354 219 257 540 611 170 107 277 27 10 37 151 112 263 2 2 7 1 4 16 1 9 23 2 13 St. Mary, Islington 254 404 86 127 340 531 200 67 267 170 52 222 14 6 20 — — 4 2 1 4 — — 8 2 1 St. Nicholas 89 194 160 324 249 518 51 80 131 34 38 72 9 5 14 4 17 5 2 1 24 — 13 29 2 14 St. Olave's ++162 ++968 ++120 ++670 ++282 1,638 263+ 357+ 620+ 263 330 593 — — — 3 2 4 — 3 208 9 47 212 9 50 St. Pancras 48 139 140 314 188 453 30 101 131 4 6 10 12 66 78 1 25 — 3 9 9 3 10 9 6 19 St. Peter's 97 146 156 224 253 370 131 f 153f 284f 108 118 226 3 7 10 — 76 23 2 3 — — — 23 2 3 St. Stephen's 299 369 391 424 690 793 346f 277f 623| 340 251 591 5 — 5 1 164 Totals (estimated) 7,135 12,802 5,360 8,876 12,495 21,678 — — §2,948 §2,953 6,295 1,755 1,053 2,808 45 702 246 105 173 466 79 157 712 184 330 * Not separately recorded. ** Borough T.B. cases. + Number of attendances for extractions. % Estimated. § Excluding St. Giles' hospital, f Including St. Giles' hospital. 72 GENERAL HOSPITALS—con tinned. Tabi.e XIII—Return of dental work during the year ended 31St December, 1934—Analysis of classes of out-patient treated referred to in Table XII Hospital. Number of out-patients seen by dentist. Dentures supplied to out-patients. P = Pull. P a Partial. R — Repairs. Assistance Institutions. JrUDIlC Health ' Institutions. Outrelief. Antenatal. Others. Total. Out-patients. Public Assistance Institutions. Public Health Institutions. Outrelief. Antenatal. Others. Total. Patients Attendances Patients Attendances Patients Attendances. Patients. Attendances. Patients. Attendances. Out- patients. Attendances. F. P. R. F. P. R. F. P. R. F. P. R. F. p. R. F. P. R. Archway — 19 42 — 19 42 - - - 7 - — 7 Bethnal Green 40 45 — — 40 92 1 1 3 3 84 141 4 2 b - - — 12 2 o - - - _ _ 16 4 10 Dulwich — — 73 89 — — 78 78 — — 151 167 - - - 7 5 3 - - - - _ _ _ 7 5 3 Fulham — — 60}. 92 — — 281 42 1301 194 2181 328 - - - 7 1 1 - - - 4 - - 14 _ 9 25 1 3 Hackney — — 75 195 30 50 90 184 50 104 245 533 — 17 25 inc. under P. 5 22 25 inc. under P. Hammersmith — — 30 60 82 434 — — — — 112 494 - - - - — 33 2 5 33 2 Highgate - — — — — — — — 5 11 5 11 — - ~ - - - - - - - — Lambeth - - - - - — 6 11 44 127 50 138 — - — - - — - - - - - - 8 _ 4 8 4 Lewisham — — 3 5 16 46 62 146 73 187 154 384 — 2 - - 2 4 _ 19 2 2 23 6 2 Mile End 27 29 12 12 99 139 35 45 5 5 178 230 1 - - - - - - - - - — 1 New End — — 8 12J - 8 12} Norwood — — — — — — — — — - - - - - — - - - - _ _ _ _ . Paddington — — — 24 46 132 274 8 16 164 336 — 2 - 2 2 5 2 - _ _ 4 5 4 Queen Mary's, Sidcup — — — — — — — — 5 5 5 5 - - - - - — - - - - - - - _ _ St. Alfege's 37 67 18 39 19 59 82 J71 100 205 262 541 5 1 1 - - 4 4 - - - 3 2 2 - 1 11 4 8 St. Andrew's 36 42 432 432 8 8 569 569 1,045 1,051 _ _ _ _ 5 - 2 _ _ _ _ _ _ 5 _ 2 St. Benedict's — — — — — — — — — — — — - - - - - — - _ _ _ _ _ _ _ _ _ _ St. Charles' 82 149 _ _ _ _ _ _ _ _ 82 149 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Edmonton colony _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Brentwood colony _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ St. George-in-the-East 1 1 25 25 2 2 320 411 348 439 _ _ _ _ _ _ _ _ _ _ _ _ 1 _ _ _ _ _ St. Giles' 318+ 478 it 2 281 42 1441 215 1031 155 5941 892 28 7 30 - - — - - - - 1 - _ _ _ 28 8 30 St. James' 99 147J 85 128J 10 15J 25 381 9 14| 228 342} — - - - - — _ St. John's — — — — — — — — — — - - _ - - — - - - - - - - - _ St. Leonard's — — 6 15 42 56 2 5 23 73 73 149 - - - 1 - 3 5 1 - - - 9 2 1 15 2 5 St. Luke's, Chelsea 41 119 4 5 10 18 8 10 63 152 _ 4 1 _ _ _ _ _ _ _ _ _ _ _ _ 4 1 St. Mary Abbots — — 92 111 89 103 38 43 — — 219 257 - - - 8 1 6 8 - 3 _ _ _ _ _ _ 16 1 9 St. Mary, Islington 38 51 1 1 40 62 2 2 5 11 86 127 1 - - - - — 3 _ _ _ _ _ _ _ _ 4 St. Nicholas 40 130 — — 48 61 13 19 59 114 160 324 15 - 13 - - — 2 - - - - - 7 _ _ 24 13 St. Olave's * * * * * * * * * * •120 670 1(1 - 16 * * * * * * * * * 168 9 31 208 9 47 St. Pancras 78 151 48 144 14 19 140 314 _ _ _ 9 _ 7 _ _ _ 3 2 1 9 3 10 St. Peter's * * * ♦ * * • * * * *156 224 — - St. Stephen's 206 235 — — — — 60 64 125 125 391 424 - - - - - - - - - - - - - - - - - - Estimated total ... 5,360 8,876 Total 460 79 157 No record. Estimated average figure. * Not separately recorded. 73 Special Hospitals. Statistical tables. For full statistical information with regard to the patients in the special hospitals tables I to XXIX on pages 119 to 148 should be consulted. Condensed statistics of the patients treated in the special hospitals during the year 1934 are as follows :— Unit. Remaining on 31st Dec. 1933 (a) Admissions. Live births. Discharges. Deaths. Remaining on 31st Dec. 1934 (a) Smallpox 13 165 - 177 1 ___ Other fever 6,205 53,412 1 53,462 1,484 4,672 Tuberculosis— Pulmonary 1,341 3,618 — 3,325 188 1,446 Non-pulmonary 611 898 — 824 22 663 Children's diseases 1,931 7,519 — 7,352 53 2,045 tCarcinoma of the uterus North-Western— 4 27 _ 30 1 _ Venereal disease— Sheffield-street— Women 75 299 — 305 1 68 Babies ... 19 15 134 147 4 17 *Congenital syphilis— St. Margaret's— Children 12 9 — 21 - — Ophthalmia neonatorumSt. Margaret's— Women accompanying their babies 7 149 _ 147 _ 9 Babies 13 248 — 239 4 18 V ulvo-vaginitis— St. Margaret's— Children 7 58 — 50 _ 15 Post-encephalitis lethargica— Northern 257 42 — 27 5 267 Total 10,495 66,459 135 66,106 1,763 9,220 (a) Including patients on leave. t Unit transferred to Lambeth hospital on 3rd March, 1934. * „ „ „ St. John's „ ,, 24th May, 1934. 1.—INFECTIOUS HOSPITALS.—(A) FEVER HOSPITALS. Condensed statistics of the patients in the infectious diseases hospitals for the ten years from 1925 to 1934 are as follows :— 1925. 1926. 1927. | 1928. 1929. 1930. 1931. 1932. 1933. 1934. On books on 1st January. 4,521 5,108 4,740 5,792 5,068 6,430 4,229 4,148 4,495 6,205 Admitted during the year. 28,952 30,403 30,404 36,800 34,431 35,348 31,361 43,769 49,217 53,413 Discharged during the year. 27,304 29,735 28,432 36,237 31,843 36,481 30,710 42,060 46,598 53,462 Died during the year 1,061 1,036 920 1,287 1,223 1,067 732 1,362 909 1,484 Remaining on 31st December. 5,108 4,740 5,792 5,068 6,429 4,229 4,148 4,495 6,205 4,672 Lowest number under treatment at any time prior to the seasonal rise. 3,233 (5th Sept.) 3,273 (11th Sept.) 3,466 (27th Aug.) 3,357 (1st Sept.) 3,227 (31st Aug.) 3,265 (12th Sept.) 2,926 (11th Sept.) 3,195 (10th Sept.) 3,928 (2nd Sept.) 3,419 (1st Sept.) Highest number under treatment at any time during the seasonal rise. 5,495f (24th Nov.) 5,033 (7th Dec.) 5,915 (29th Dec.) 5,201 (20th Nov.) 6,430 (30th Dec.) 4,442 (27th Nov.) 4,237 (8th Dec.) 4,745§ (22nd Nov.) 6,328* (4th Dec.) 4,740 (16th Dec.) * The number subsequently reached 7,621 on 4th April, 1934. The number subsequently reached 5,589 on 2nd March, 1926. t The number subsequently reached 6,064 on 28th February, 1928. § The number subsequently reached 6,204 on 5th April, 1933. 74 Incidence of infectious diseases. The year 1934 was one of exceptionally high incidence of infectious disease. The total number of cases admitted to the Council's infectious hospitals during the year was 53,413, the highest on record, the previous highest having been 49,217 in 1933. The number of infectious patients under treatment at any one time rose to 7,621 on 4th April. At the beginning of the year the number of cases of scarlet fever under treatment was higher than at the beginning of any year since 1922. The number of patients admitted suffering from this disease, though lower than during 1933, remained generally throughout the year higher than for some years past. The number of cases of diphtheria admitted during 1934 was also higher than in any year since 1930. The usual biennial epidemic of measles commenced at the end of 1933, and its progress followed the normal course of such epidemics, the number of cases admitted being, however, much higher than in previous years. The number under treatment reached 3,696 on 11th April, 1934, compared with 2,767 on 10th April, 1932, the previous highest number. In March the average number of cases of measles admitted each day was 115 for the first two weeks, and 120 for the latter two weeks, compared with the previous highest average, for fortnightly periods, of 99. When the pressure on the accommodation for measles became acute, in order to ensure that the accommodation available for infectious cases was utilised to the best advantage for those patients most needing it, arrangements were made for the admission of scarlet fever patients to be limited to those cases in which hospital treatment was, in the opinion of the borough medical officer of health concerned, required, owing to the severity of the case or to the home conditions, or both. Joyce Green hospital was in use for fever throughout the year, and the Orchard hospital from 13th February to 12th July, 1934. The Lower Southern hospital was in occupation for infectious cases until 18th Mav, 1934. Isolation accomodation. The annual reports for 1932 and 1933 contained accounts by the medical superintendent of the North-Western hospital (Dr. Joe) of the work done in the isolation chamber unit at that hospital, the account in the report for 1933 also dealing with the work of the " bed isolation " unit. The following is a further report by him on the subject:— During the year, 464 cases were admitted to the chamber isolation unit. This number exceeds the admissions for 1933 by 58, and the strain on this type of accommodation during the early part of the year, owing to the measles epidemic, was very great. The cases were classified as follows:— Scarlet fever 51 Scarlet fever and diphtheria 12 Scarlet fever and measles 21 Scarlet fever and erysipelas Scarlet fever and chickenpox 15 Scarlet fever and whooping-cough 1 Scarlet fever and rubella 1 Scarlet fever and mumps 4 Scarlet fever, diphtheria and tuberculous meningitis 1 Scarlet fever, diphtheria and measles 2 Diphtheria 42 Diphtheria and chickenpox 7 Diphtheria and whooping-cough 2 Diphtheria and mumps 1 Diphtheria and measles 15 Diphtheria and rubella 1 Diphtheria, measles and whooping-cough 1 Measles 68 Measles and whooping-cough 21 Measles and mumps 1 Measles and chickenpox 10 Chickenpox 12 Chickenpox and mumps 2 Chickenpox and whooping-cough 1 Whooping-cough 28 Mumps 9 Mumps, diphtheria and measles 1 Paratyphoid B and measles 1 Rubella and whooping-cough 2 Meningococcal meningitis and mumps 1 Local uterine sepsis 1 Local uterine sepsis and scarlet fever 1 Whooping-cough, chickenpox and measles 1 Rubella 24 Non-infectious disease 102 Total 464 Of the 48 cases of chickenpox and 142 of measles, either singly or in combination with other diseases, 38 of the former and 123 of the latter were admitted during the first week of the disease and during the maximum period of infectivity. Cross infection occurred in 5 instances, a cross infection rate of 1.07 per cent., 4 cases being infected with measles, and 1 with chickenpox. All took place within a period of almost exactly two months from the middle of March to the middle 75 of May. It was found that this outbreak of cross infection coincided with the spell on duty in this particular unit of a certain member of the staff, and on her removal to a less exacting form of work these unsatisfactory occurrences ceased. During the year chickenpox cases complicated with another intercurrent infectious disease, for which an open ward was available were transferred to the appropriate ward on the 10th day of chickenpox in 3 cases, on the 11th in 1 case, on the 12th day in 1 case, on the 13th day in 2 cases, and on the 14th day in 3 cases, without causing secondary infection. During the year, 290 cases passed through the " bed isolation" unit, their classification beine as follows :— Scarlet fever 29 Scarlet fever and diphtheria 9 Scarlet fever and measles 3 Scarlet fever and rubella 1 Scarlet fever and whooping-cough 2 Scarlet fever and chickenpox 1 Diphtheria 25 Diphtheria and measles 1 Diphtheria and whooping-cough 3 Diphtheria and rubella 1 Diphtheria and mumps 1 Diphtheria, measles and mumps 1 Measles 14 Measles and chickenpox 4 Measles and whooping-cough 1 Rubella 31 Whooping-cough 7 Chickenpox 4 Mumps 1 Mumps and rubella. 1 Erythema infectiosum 2 Non-infectious diseases 148 Total 290 Cross infection occurred in 12 cases (i.e., 4'I per cent.): 2 cases contracted diphtheria, 1 case scarlet fever, 1 case chickenpox, and 8 cases measles. The chickenpox and measles cases arose as a result of the admission of cases in the incubation period of these diseases, and the group of measles cases has derived from one case. A note is also made of the fact that 19 cases of rubella in the first 3 days of disease, 7 cases of whooping-cough within the first 14 days of disease, and 4 of mumps within the first 7 days of disease were successfully nursed throughout their illnesses in this unit without cross infection. The possibility of contracting infectious diseases additional to those for which the patients are admitted still bulks largely in the minds of the public as one of the serious disadvantages of the fever hospitals, and it is one of the greatest difficulties that has to be faced in the administration of such a hospital. Figures showing the cross infection rate for the Council's fever hospitals generally are not available, but it is probable that from 96 to 97 per cent, of patients mostly at susceptible age periods pass through the wards of those hospitals without receiving additional infection, and those responsible for the management of fever hospitals are entitled to ask that a reasonable view should be taken of this matter. It is unfair to assume that every case of secondary infection is the result of ignorance or carelessness on the part of some member of the staff, since all but a negligible proportion of secondary infections are the result of introduction of infection (1) by a patient suffering from one disease and incubating another such as chickenpox or measles, and (2) by carriers of droplet infection such as the causal organisms of scarlet fever and diphtheria. To secure a proper perspective in this matter the state of affairs existing in fever hospitals should not be compared with some hypothetical community in which the transmission of infectious disease never occurs, but with that obtaining in any institution or community in which provision is made mainly for children, e.g., in the general medical or surgical wards of a children's hospital. The twc factors referred to above are bound to operate with similar effect in such hospitals and indeed in all communities in which children are congregated. Cross infection. Unfortunately, figures are not readily available from non-infectious institutions but it is the firm conviction of all who have practical experience of infectious medicine that comparative figures would reveal very little difference. Apart from other important difficulties caused by cross infection, the wastage of bed accommodation resulting from quarantine periods imposed after ward outbreaks of secondary infections is a serious loss from the economic standpoint. An attempt has been made to estimate this wastage at the North-Western hospital during the two years 1933-34, inclusive. The figures given below were obtained by taking the number of unoccupied beds in any given ward in quarantine on each day of the quarantine period, and the sum of these during the period of closure entailed by the quarantine represents the minimum number of bed days lost as a result of the quarantine. This of course understates the actual loss of bed days as many cases are retained in hospital until the quarantine has expired, who nor- 76 mally would have gone home. To some extent this is offset by the admission of cases suffering from the primary disease for which the ward is open, and who also have satisfactory evidence of immunity to the secondary infection, e.g., cases of scarlet fever showing definite chickenpox scars can be safely admitted to a scarlet fever ward in quarantine for chickenpox, but this has a small effect in reducing the wastage. The following figures are, however, set forth in the hope that they may give some indication of the minimum percentage of loss that we may reckon on meeting with in a two-yearly period. Since this loss is greatly influenced in London by the regular appearance of a measles epidemic every two years, any period of years not a multiple of two would be unsatisfactory for the purpose. Disease. 1933. 1934. Total in bed-days. Chickenpox 1,649 996 2,645 Scarlet fever 705 660 1,365 Measles 459 2,062 2,521 Chickenpox and measles 293 236 529 Measles and scarlet fever 112 43 155 Chickenpox and scarlet fever — 176 176 Mumps — 211 211 Total 3,218 4,384 7,602 From the above table it is evident that chickenpox, measles, scarlet fever, and combinations of these are almost entirely responsible for the loss of bed-days resulting from quarantine. The minimum total loss works out at 7,602 bed-days in two years, i.e., 5.07 per cent, of the available bed-days in the hospital. Expressed in another way, and allowing 38 bed-days per case of scarlet fever, this means that during the two years in question, but for the necessity for quarantine, accommodation could have been found for 200 more cases of scarlet fever. As might be expected the loss shows a definite seasonal variation which may be noted from the following table:— Month. 1933. 1934. Total. January 513 519 1,032 February 365 540 905 March 289 1,016 1,305 1st quarter, 3,242, or 8.7 per cent. April 523 844 1,367 May 379 334 713 June 491 263 754 2nd quarter, 2,834, or 7.6 per cent. July 97 346 443 August 242 152 394 September 60 69 129 3rd quarter, 966, or 2 • 5 per cent. October 73 52 125 November 43 37 80 December 143 212 355 4th quarter, 560, or 1 • 4 per cent. Total 3,218 4,384 7,602 From the above it is obvious that the seasonal loss operates to the disadvantage of the hospital in that it occurs at the time of maximum pressure on the accommodation. Acute poliomyelitis. Of the 24 cases of acute poliomyelitis under treatment during the year at the Western hospital, where there is a special unit for this disease, 3 were discharged cured, 13 were transferred to Queen Mary's hospital for children, Carshalton, 1 was transferred to St. Mary Abbots hospital, and 7 were still under treatment on 31st December, 1934. During the year 20 cases of poliomyelitis were admitted, but 77 none was sent in before the onset of the paralytic symptoms. In three instances the symptoms were of sufficiently recent date to justify giving the convalescent serum, supplied by the Lister Institute, a trial, but the results were inconclusive. Cerebrospinal meningitis. The number of notifications of cerebro-spinal meningitis during 1934, excluding duplicate notifications and military cases, was 137, compared with 216 in 1933. The numbers of notifications during the past ten years are shown in the following statement:— 1925. 1926. 1927. 1928. 1929. 1930. 1931. 1932. 1933. 1934. Number of notifications 93 83 93 70 121 88 175 247 216 137 Notifications Of four cases admitted to the Eastern hospital during the year two died. The serum used for their treatment was a polyvalent serum. Treatment. Ihe medical superintendent of the North-Western hospital (Dr. Joe) has reported as follows :— In 1934 a somewhat smaller number than usual of cases of meningococcal meningitis came under treatment, viz., 8, of whom 3 died. In 6 cases the infecting organism was typed by Dr. Scott of the Ministry of Health, 4 cases showing a group I, and 2 a group II meningococcus. Of recent years since cerebro-spinal fever has only appeared in sporadic form in London it has, fortunately, not been possible to study this disease on any large scale. In the North-Western hospital during the years 1932, 1933 and 1934, exactly 50 cases have been admitted. The gross fatality rate was 50 per cent., a disappointing result, made however more encouraging for the future by the observation that in fatal cases sometimes a very small margin seems to separate failure from success. It has occasionally appeared that this margin would be covered by the more intensive drainage and opportunity for serum administration afforded by more frequent lumbar, cisternal and ventricular puncture, and by the use of the intravenous route. On the whole, however, whilst these have sometimes appeared advantageous when evaluated on clinical grounds in individual cases, it cannot be said that they have improved the fatality statistics to any great extent. In the series of 50 cases mentioned an attempt has been made to estimate the main factors affecting prognosis. These appear to be the age of the patient and the type of infecting organism. With regard to the age of the patient the most favourable age period was between 5 and 20, 17 patients in this group showing a case fatality rate of 29'4 per cent. Those under 5, 17 in number, showed a fatality rate of 58-8 per cent., whilst in 16 patients over 20 it was 62-5 per cent. Typing was carried out in 41 of the 50 cases, 28 belonging to group I and 13 to group II. In group 1 infections the case fatality was 42.8 per cent., whereas in group II, it reached the high figure of 84-6 per cent. The importance of these two factors must be borne in mind in evaluating the effect of any form of therapeutics. Surprisingly, the day of disease on which serum administration was begun did not seem to bear out the commonly accepted view that advantage is derived from the early injection of serum, for in 22 cases in which serum was given on or before the 3rd day, the case rate fatality was 45.4 per cent, as against 53.5 per cent, after the 3rd day, a difference which is not statistically significant. To those who understand the nature of meningococcal infection, however, this is readily explicable, on the ground that the group containing the early treated cases will also contain the fulminating types of the disease. In these, medical aid and admission to hospital are promptly sought, but treatment can do little to avert a rapid and fatal termination. Four patients suffering from cerebro-spinal meningitis were under treatment at the Brook hospital during the year, of whom three died. Three of the patients showed a group I meningococcus ; in the remaining one the meningococcus was not typed. In three out of the four cases an experimental antitoxin was used. The small number of cases does not justify any definite conclusions, but the results seem to point to the fact that it is not more efficacious than the serum previously employed. Puerperal fever. A report by the medical superintendent of the North-Western hospital (Dr. Joe) and the obstetrician (Mr. J. M. Wyatt, F.R.C.S.) on the work of the puerperal unit at that hospital during 1934, on the lines of similar reports which have appeared in Vol. IV, Part I, of the report for the years 1931-3, appears in Vol. IV., Part III, of this report. Research into chronic encephalitis lethargica. The medical superintendent of the Northern hospital (Dr. G. A. Borthwick) has reported that the research work in the special unit at that hospital into the F 78 treatment of chronic encephalitis, with a view to limiting the progression of the chronic infection, has again proved unsatisfactory, and that, although, amongst other forms of treatment, many cases were given injections of colloidal sulphur, no definite limitation of the progression has been produced. The symptomatic treatment of Parkinsonism in general has been continued by giving stramonium, in some cases, in very large doses. It has been observed that effective doses of stramonium for Parkinsonism retain their beneficial effect for long periods, and in many cases without any deleterious effect on the patient; but, in one or two cases lately where the patient has suddenly retrogressed under this treatment, it has been considered that the continued administration of stramonium for many years may ultimately produce a deleterious effect. No definite progress has been made in the treatment of the cases of behaviour disorder, and, as stated in previous annual reports, bulbocapnine continues to be the only drug of any practical value for the subduing of outbursts of misbehaviour amongst the patients. Infectious disease following tonsillectomy. Reference has been made in previous annual reports to cases of infectious disease following tonsillectomy. Four such cases of scarlet fever were admitted to the South-Eastern hospital during the year. Reference to cases admitted to the North-Eastern hospital is made in the report of the medical superintendent of that hospital (Dr. Harries) which appears below. Type of disease, use of serum and duration of stay of Eatients in ospital. Scarlet fever. The medical superintendent of the North-Eastern hospital (Dr. Harries) has reported as follows :— There occurred only 4 deaths from scarlet fever, from which it may be inferred that the type of the disease continued to be very mild : really toxic cases were rarely seen and cases of septic type were very few in number. As in recent years, the majority of patients were treated with anti-streptococcal serum (Belmont). Usually a dose of 10 c.c. was found to be sufficient; a few patients received 20 c.c., and in rare instances 30 c.c. or more. The practice of adding a prophylactic dose of diphtheria antitoxin to the scarlet fever antitoxin was continued, and was justified by the low incidence of diphtheritic rhinitis in the scarlet fever wards. An analysis has been made of 1,089 consecutive completed cases of scarlet fever under treatment during the year, the diagnosis having been confirmed in every instance. Of this series, which falls somewhat short of the whole number under treatment during the year, but which is quite unselected, 1,000 patients were treated with anti-streptococcal serum. Eighty-nine received no serum either because the attack was so mild and indefinite on admission that further investigation, e.g., Dick or Schultz-Charlton tests and plating of faucial swabbings for the haemolytic streptococcus, was necessary in order to confirm the diagnosis, or because they were admitted in the stage of desquamation when the injection of serum would be useless. The two series differ numerically and clinically so greatly that no statistical comparison is attempted. (A) Non-serum Series. Main complications. Otitis media. Adenitis. Albuminuria. Arthritis. Early cases (68) 4 4 1 4 Late cases (21) 1 — — — Total 5 4 1 4 (B) Serum Series. (i) Age distribution.—The following table shows the age distribution of 1,000 consecutive cases treated with scarlet fever antitoxin :— Age. Cases. Percentage. 0—5 years 381 38.1 5—10 284 28.4 10—15 122 12.2 Over 15 213 21.3 Total 1,000 100.0 79 It will be noted that the age distribution reveals an exceptional proportion of adolescents and adults. This is not necessarily an indication of the age distribution of scarlet fever in the community, but is probably connected with the problem of finding accommodation for older patients during the measles epidemic. (ii) Serum rashes.—These occurred in 28.9 per cent, of the series, an incidence which is somewhat high in the case of concentrated serum in the dosage employed, but which is in part explicable by the high proportion of adults. (iii) Post - tonsillectomy and surgical scarlet fever.—In the series analysed there were 4 cases of post-tonsillectomy scarlet fever, and 4 cases of surgical scarlet fever. Although both conditions arise as the result of infection of wounds, surgical or otherwise, it is interesting to note that in the post-tonsillectomy cases, as in ordinary scarlet fever, pure cultures of the hsemolytic streptococcus are recovered from the throat; in the surgical cases cultures from the throat are negative, but pure cultures are obtained from the surface of the wound. This was true in each of the 4 cases of surgical scarlet fever here recorded. Otherwise surgical scarlet fever is clinically indistinguishable from scarlet fever arising from a naso-pharyngeal focus. (iv) Complications.-—The percentage incidence of the main complications was as follows (since exactly 1,000 cases were included the actual numbers need not be stated):— Otitis media. 5-8 Adenitis. 5 Albuminuria. 2-8 Acute nephritis. 0-8 Polyarthritis. 0-8 36 The few cases of polyarthritis occurred amongst adults and were, with little doubt, " rheumatic." A previous history of rheumatic manifestations, either arthritis, carditis, or chorea was obtained in 1-7 per cent, of the series. Clinically and administratively otitis media may be considered as the most important complication of scarlet fever at the present time. The incidence at all ages in the series analysed was low (5'8 per cent.), and might in part be attributed to the high proportion of adult patients. But an analysis of the incidence of this complication in the various age groups shows that this is not an adequate explanation, since the incidence in all groups is low. Thus :— Age. Scarlet fever. Otitis. Percentage incidence. 0—5 years 381 33 8.6 5—10 284 16 5.6 10—15 122 6 4.9 Over 15 213 3 1.4 All ages 1,000 58 5.8 The low incidence of otitis media in each age group is to be ascribed to several factors : (a) the mild clinical type of scarlet fever; (&) the possible influence of scarlet fever antitoxin; (c) maintenance of adequate bed-spacing, 12 feet between bed centres being adhered to throughout; (d) prompt barrier nursing of all patients with grossly infective foci, e.g., suppurative adenitis, paronychia, impetigo and otitis media. Cases of impetigo and otitis media were removed as soon as possible either to cubicles or special ear wards. As to the relative importance of each of these factors the following observations may be made:— (а) Clinical type.—In the series under review there were only 5 examples of the septic type of disease. (б) Scarlet fever antitoxin.—Probably most observers are agreed that scarlet fever antitoxin does tend to diminish the incidence of complications, but the complication which is least likely to be affected by this measure is otitis media, which is the result of extension of either the primary upper respiratory tract infection, so often seen in the septic type of the disease, or of a re-infection of the upper respiratory tract. Since the serum is purely antitoxic, the specific effect can only be indirect, and it is notable that scarlatinal otitis media, save in the septic type, tends to be a late manifestation when the acute phase is at an end. (c) Bed-spacing.-—With a space of 12 feet between bed centres it is true that viral infections such as the common cold and allied influenzal conditions, measles in the early catarrhal stage and chickenpox in its earliest stages, may, with great probability, be transmitted from bed to bed by droplet spray. But it cannot be seriously contended that bacterial infections of the upper respiratory tract are transmitted in effective dosage by droplet spray through this distance. Droplet spray as a mode of dissemination of streptococcal infections from bed to bed being eliminated, there remain for practical purposes two modes of transmission of an upper respiratory tract infection from one patient to another, viz., close personal contact when the patients are in the convalescent stage and are up and about, and mediate transference either upon the fingers of the attendants or upon utensils. In the case of younger children especially, given adequate bed spacing, the latter is undoubtedly the common mode of infection; as exemplified in the case of impetigo, when it spreads to another child. 80 Adequate bed spacing, the maintenance of 12 feet between bed centres, the minimum standard of the Ministry of Health for infectious diseases hospitals, ensures two things : (i) the elimination of the factor of droplet spray in the dissemination of bacterial infections from bed to bed and a fortiori amongst patients more remote from the potential focus of infection, (ii) the limitation of t he number of patients in the ward and therefore of the potential foci of infection which renders manual transference less likely by a staff which is not overworked, and is thus in a position to take essential precautions in passing from one patient to the next. It is clear that if the total load of infective material in the ward is limited the likelihood of transference by any means is much diminished. (d) Barrier nursing of certain cases.—If as an additional precaution any patients with obvious and gross foci of infection are strictly barrier nursed, or, preferably removed from the ward altogether, the likelihood of transference of infection is still further diminished. Considerable evidence has been produced by other observers in the Council's infectious diseases service that relapses and the extraneous septic type of complications in scarlet fever are the result of re-infection, possibly by hemolytic streptococci of different types or strains, and it is perhaps significant that in the series of 1,000 cases analysed, in spite of the fact that all were treated with serum, which has been held by some to hinder the production of active immunity as the result of the attack, there were only 4 instances (- 4 per cent.) of relapse of disease. Consideration of these various factors leads to the conclusion that, other things being equal, adequate bed spacing and segregation or removal of patients with gross potential foci of infection are of the utmost importance in securing a low incidence of complications, e.g., otitis media, which may be brought about in part, at least, by re-infection of the upper respirator}- tract. It may well be that the disparity in the effects upon the complication rate in serum-treated cases of scarlet fever recorded by different workers depends not only upon such factors as age distribution, variability of clinical type, potency, dosage and route of administration of antitoxin but upon bed spacing and the prompt segregation of those patients who may constitute the reservoirs from which extraneous infection is derived and disseminated by one means or another. The removal of cases of otitis media from main wards to special wards is infinitely preferable to allowing them to remain as reservoirs of infection, but is not ideal unless each patient in the ear ward is rigorously " barrier nursed." If this is not done, re-infection of the upper respiratory tract, not necessarily with the streptococcus, may take place in exactly the same way as in ordinary open wards. In one such ear ward, nursed as an open ward, it was observed that the introduction of a fresh case of otitis media was liable to be followed by the lighting up of other cases which were either actually quiescent, or were becoming so. The only feasible explanation is to be found in reinfection of the upper respiratory tract, the most likely mode of transference, under the conditions obtaining, being manual. There seems to be no escape from the conclusion that patients with gross potential foci of infection should, on medical and administrative grounds, be nursed either in separate chambers or in very small wards with the most rigorous aseptic nursing technique if the likelihood of re-infection of the upper respiratory tract is to be reduced to minimal proportions. What has been written above about scarlet fever applies with even greater force to measles, because younger children suffer risk from infections and re-infections of the upper respiratory tract which may result not only in otitis media, which has been found more difficult to treat successfully than the corresponding complication in scarlet fever, but in bronchopneumonia.* When the new isolation blocks are constructed at this hospital it will be possible to segregate scarlatinal and measles otitis media to an extent which is not at present feasible. The medical superintendent of the North-Western hospital (Dr. Joe) states that, at that hospital, scarlet fever appeared on the death certificates in seven cases. The salient features of the fatal cases are given below and in only four (cases 3, 4, 5 and 6) can the death be directly attributable to scarlet fever, as in the other cases some other serious condition was already present at the onset, or developed late in convalescence and played a predominating part in producing the fatal result. Corrected in this way, therefore, the case fatality rate is 4 per cent. The details are as follows:— (1) A.P., aged 4, male. Mongolian idiot. Was suffering from bronchopneumonia for some time before contracting scarlet fever, and died within 24 hours of admission. (2) G.W.C., aged 2, male. Death due to measles bronchopneumonia following scarlet fever. (3) I.B., aged 2, female. Death due to scarlatina anginosa and enteritis. (4) O.W., aged 2, female. Death due to endocarditis following scarlet fever. (5) F.W., aged 86, female. Death due to chronic bronchitis and scarlet fever. Patient very enfeebled owing to age. (6) K.H., aged 3, male. Death due to scarlatina maligna. (7) D.P., aged 10 months, male. Death due to acute miliary tuberculosis, intercurrent scarlet fever and nasal diphtheria. * This point was alluded to in the special report upon the Measles Epidemic of 1933-34, together with other observations upon measles. 81 In the annual reports for the years 1931-3, there have appeared reports by the medical superintendent of the North-Western hospital (Dr. Joe) on the length of stay in that hospital of scarlet fever cases. The following is a further contribution from him on the subject:— The following table sets forth the duration of stay of 852 scarlet fever patients, who were discharged direct from, or who died in, the North-Western hospital, and whose period of isolation was not interfered with by concurrent or intercurrent disease. As the number of deaths was on])' 7, the figures may be accepted as giving accurate representation of the duration of stay 8-2 per cent, discharged by the end of 4 weeks. 36-3 between 4 and 5 weeks, i.e. 44-5 per cent, within 5 weeks. 26-6 5 and 6 71.1 6 13-2 6 and 7 84-3 7 6-1 7 and 8 90-4 8 2-9 8 and 9 93-3 9 1-5 9 and 10 94-8 10 Of the 852 cases mentioned above 212, i.e., 25 per cent., were treated by anti-streptococcal serum, in practically all cases by the intramuscular route ; of those 32.1 per cent, showed one or more of the complications of arthritis, otitis, rhinitis, and adenitis. In these cases, one of late albuminuria was present, but none was complicated by nephritis. Serum sickness, in the form of rash in practically every instance, appeared in 33-5 per cent, of cases. In the 640 non-serum treated cases, the complication of arthritis, late albuminuria and nephritis, otitis, rhinitis and adenitis appeared either singly or in combination in 25-3 per cent, of cases. It should be pointed out that anti-streptococcal serum was only given to the more severe cases and that the complication rates given for serum and non-serum treated cases are not intended to be comparative. The medical superintendent (Dr. Pereira) has reported that, at the Eastern hospital, during the year, there were four deaths among the patients admitted with scarlet fever. The causes of death were as follows :— (1) Toxic scarlet fever. (2) Advanced pulmonary tuberculosis, plus scarlet fever. (3) Cardiac failure following severe faucial diphtheria. (4) Acute rheumatic fever and scarlet fever. Patients (2), (3) and (4) were all admitted suffering from both diseases. The use of anti-streptococcal serum was limited to the more severe type. These numbered 37. Serum treatment did not appear to have any effect on the toxic case which ended fatally. The medical superintendent of the Park hospital (Dr. Banks) has reported as follows:— In last year's report a short account was given of the results of the treatment of scarlet fever with intravenous serum as compared with non-serum treatment. As the results were considered to be outstandingly in favour of intravenous serum treatment, the latter was adopted as the routine method during 1934. During the last three months of the .year, however, a further departure took place in the use of serum by the intraperitoneal route, and for this purpose the wards were divided into two groups, having an approximately equal age and sex distribution of cases. In one group the intravenous and in the other group the intraperitoneal route was employed as the standard method, due regard, however, being always paid to the special needs of individual cases. While the results of intraperitoneal serum treatment as shown below appear to be highly satisfactory, experience with it is too limited to admit of generalisation at present, and this work is being continued. In both the intravenous and the intraperitoneal series the policy of short stay in hospital was continued as in 1933. As by this treatment the acute stage was shortened, nutrition relatively unimpaired and complications few, it is considered that no advantage was to be gained by keeping these fit and healthy patients in hospital longer than an average period of two to three weeks. No evidence has been obtained that complications occur at a later date when they are so discharged and " return " cases appear to occur almost indifferently, whether after a long or short stay. It is the " long stay " patients who are at a disadvantage in scarlet fever wards. The majority of young children are not yet immune to infectious diseases, and are consequently liable sooner or later to be re-infected with scarlet fever, tonsillitis or other strep toeoccal infection, or to contract another infectious disease from patients admitted to the ward in the incubation stage of the other disease. Such a combination of infectious diseases, sustained 82 within a short interval of one another may have the most damaging results to a child's health. Any method which gives promise of avoiding them in great part is therefore worthy of serious consideration. Of the 1,587 completed cases discharged, 1,010 had received intravenous antitoxin, 193 had intraperitoneal antitoxin, 86 had intramuscular antitoxin and 298 had no antitoxin. The intravenous and intraperitoneal series, although very unequal in numbers and seasonal incidence, had an approximately equal age and sex distribution, and they are, therefore, reasonably comparable. The following table shows the salient facts with regard to those two groups. In calculating the average duration of residence, cases detained in hospital on account of intercurrent disease or other condition unassociated with scarlet fever have been excluded from each series:— " Intravenous " series. " Intraperitoneal " series. Number of completed cases 1,010 193 Period Whole year 1st October—31st December Average duration of residence in hospital 17.4 days 20.7 days Number of deaths *1 None Complications oocurring after admission. Number. Per cent. Number. Per cent. Purulent otitis media 24 2.4 1 1 Albuminuria and nephritis 2 0.2 2 1 Rheumatism 3 0.3 — — Carditis — — — — Adenitis 28 2.8 5 2.6 Tonsillitis 10 10 2 1 Abscess 3 0.3 2 1 Minor septic foci 13 1.3 4 2 Relapse 4 0.4 — — Other 22 2.2 4 2 Total 109 10.9 21 10.6 The above are exclusive of those developing other infectious diseases, viz :— Nasal diphtheria 3 0-3 — — Chickenpox 8 0-8 3 1-5 Rubella 6 0-6 — — Whooping-cough 4 0-4 — — Measles 8 0-8 — — t Excluding 47 cases detained for conditions unassociated with scarlet fever. t .. 10 * 9th day case, died 4 hours after admission. The age and sex grouping was as shown below. Since a large proportion of the complications of soarlet fever occur in children below the age of five years, the percentage of these in any series is of prime importance. Age and grouping. Age groups. " Intravenous " series. " Intraperitoneal " series. Total. Percentage. Total. Percentage 0—5 years 249 24-9 60 31 5—10 370 37 0 77 40 10—20 237 23-7 41 21 Over 20 154 15-4 15 8 (a) Complications occurring after discharge from hospital.—As reported last year, the parents of each " short stay " case were asked to send a specimen of urine to the Southern group laboratory on or about the 24th day of the disease. Since the beginning of this scheme in 1933 to the end 83 of 1934, the number of specimen bottles issued was 1,553 and 1,445 or 93 per cent, of those issued were returned. During 1934 the number containing red cells or casts in the centrifuged deposit was : intravenous series, 13 or 1.3 per cent. ; intraperitoneal series, 3 or 1.5 per cent. On receipt of these " abnormal" specimens, a simple enquiry was made by post as to the patient's health, and request made for a further specimen to be sent. Of the 13 abnormal cases who received antitoxin by the intravenous route, 12 became normal within 14 days and the remaining case could not be traced after 14 days. Of the 3 abnormal cases in the intraperitoneal series, 2 became normal within 14 days and 1 within 28 days. None of these cases exhibited any symptoms of illness and presumably the condition would have passed unnoticed had it not been for the searching microscopic test of the centrifuged urine. In so far as this scheme is concerned, no evidence was obtained of clinical nephritis occurring after discharge from hospital. Three cases in the intravenous series (.3 per cent.) were re-admitted for complications on information obtained from other sources, viz., 1 case of albuminuria and nephritis with mild pyrexia but no symptoms, 1 case of acute otitis media, and 1 case of catarrhal otitis media. (6) " Return " cases.—In the " intravenous " series there were 27 presumed infecting cases, or 2-7 per cent., and these gave rise to 28 " return " cases. The duration of stay in hospital of the infecting cases was : 7 to 14 days, 6 cases ; 14 to 21 days, 13 cases ; 21 to 28 days, 6 cases ; over 28 days, 2 cases. In the " intraperitoneal " series there were 4 presumed infecting cases, or 2 per cent., and these gave rise to 5 " return " cases. The duration of stay in hospital of the infecting cases was : 14 to 21 days, 2 cases ; 21 to 28 days, 2 cases. These " return " cases rates are not above the average for London, and do not appear to show any very significant relationship with the duration of stay in hospital. (c) " Intramuscular " and " no antitoxin " groups.—These are small groups not strictly comparable with the above because they consist largely of selected cases, viz. (i) those deemed on admission to be too mild for serum treatment; (ii) very young children in whom intravenous injection was difficult or impossible ; and (iii) those who reacted to the preliminary intradermal test with horse serum and were consequently considered to be unsuitable for intravenous injection. This series is therefore distinctly loaded with children of the younger ages in whom complications might be expected, but on the other hand it contains larger numbers of very mild cases than the intra venous and the intraperitoneal groups. The results obtained in the " intramuscular " and " no serum " groups, although not strictly comparable are nevertheless highly instructive. " Intramuscular " series. *' No antitoxin " series. Number of completed cases 86 298 Average duration of residence in hospital |25.6 days J28.3 days Number of deaths Nil 4 Complications occurring after admission. Number. Per cent. Number. Per cent. Purulent otitis media 8 9-3 25 8.4 Albuminuria and nephritis 1 1.2 6 2.1 Rheumatism — — 5 1.6 Carditis — — 1 .3 Adenitis 8 9.6 14 4.6 Tonsillitis — — 5 1.6 Abscess 1 1.3 3 1.3 Minor septic foci 2 2.6 1 .3 Relapse 1 1.3 1 -3 Other 4 4.8 8 2.6 Total 25 29.1 70 23.4 The above are exclusive of those developing nasal diphtheria, viz. 4 4.6 27 7.8 Age grouping— 0- 5 years 62 72 111 37.2 5-10 19 22 100 33.5 10-20 5 6 53 18.0 Over 20 — — 24 8.1 + Excluding 12 cases detained for conditions unassociated with scarlet fever. ,, 42 ,, ,, ,, >. i, 84 Even if due allowance be made for the unfavourable age grouping in these series, the results appear to be vastly inferior to those obtained in the "intravenous" or "intraperitoneal" series. For example, the comparative figures for the important complication of acute suppurative otitis media are :— Primary suppurative otitis media in scarlet fever. Series. Age group. 0—5 years. 5—10 years. 10—20 years. Over 20 year*. Cases. Per cent. Cases. Per cent. Cases. Per cent. Cases Per cent. Intravenous (1,010 cases) 10 4 11 3 2 0.9 1 0.6 Intraperitoneal ( 193 „ ) 1 1.7 1 1.3 — — — — Intramuscular ( 86 „ ) 7 11.1 2 10.5 — — — — No serum ( 275 „ ) 20 16.5 4 4.0 1 1.9 — — In view of the fact that the "intramuscular" and "no-serum" groups consisted largely of mild cases, the difference in the percentage incidence of otitis media under 5 years of age between those and the " intravenous " and " intraperitoneal " groups becomes very striking. It suggests that the incidence of otitis media at the younger ages may be very considerably reduced by the use of intravenous or intraperitoneal serum in treatment. On a review of the year's work in scarlet fever it may be fairly claimed that the results of routine intravenous serum treatment continue to be unsurpassed and that a promising vista has been opened in regard to the use of the intraperitoneal method. Three deaths from scarlet fever occurred at the South-Eastern hospital during 1934, and the medical superintendent (Dr. Ronaldson) has submitted the following particulars with regard to them :— (1) Female, aged 11 years. Scarlet fever complicated bv streptococcal peritonitis. Transferred from another hospital for immediate operation. Patient only survived for a few hours after operation. No serum had been given. (2) Male, aged 4 years. Admitted in a post-eruptive stage with pyaemia and suppurative arthritis. Serum given. (3) Female, aged 4 years. Admitted with moderate attack of scarlet fever. Serum given. Subsequently discovered to have been exposed to measles before admission; developed measles on the sixth day in hospital. Cause of death, bronchopneumonia. Dr. Ronaldson adds that, while the almost nominal mortalities from scarlet fever at the South-Eastern hospital during the past four years, viz., -2 per cent, in 1931, -3 per cent, in 1932, and -2 per cent, in 1933 and in 1934 are an index of the comparatively mild nature of the prevailing type of the disease and very low figures were recorded by all the London infectious hospitals, the gratifyingly low figure for the South-Eastern hospital for the four-year period suggests that the intensive serum therapy employed has materially contributed to the result. He expresses the opinion that the low incidence of complications, including an almost complete disappearance of acute nephritis, and a low return case rate, are even more significant. A detailed account of the work done is being prepared for publication. Two of the cases under treatment during the year at the South-Eastern hospital were examples of toxic scarlet fever. The medical superintendent reports that one of them had an unusual complication, viz., a toxic auricular fibrillation, which cleared up completely after serum treatment. Another unusual manifestation in this case was the recovery of anaerobic streptococci from the blood. The organisms present in the throat were aerobic hemolytic streptococci (type ii). Both cases recovered. The medical superintendent of the Grove hospital (Dr. J. H. Whitaker) has reported that six deaths were attributed to scarlet fever at that hospital during the 85 year. Of these, death was due in four cases to causes other than scarlet fever. Of the two patients who died from the disease, one was a Mongolian imbecile who had a moderately severe attack of scarlet fever and died rather suddenly. The other, who was also suffering from a moderately severe attack, had, on admission, hsemorrhagic nephritis and apparently had been ill with septic tonsillitis for a week previously. This patient was not critically ill, but she collapsed suddenly. The medical superintendent of the Brook hospital (Dr. Armstrong) has reported as follows:— During the year 1,518 cases were under treatment, of whom 8 died, giving a fatality rate of -59 per cent. The cause of death in the 8 fatal cases was as follows:— (1) L.V., female, 2 years 10 months. 20 c.c. A.S.S. (anti-streptococcal serum) on admission. Developed measles 9 days after admission (exposed before admission) from which she died 18 days after admission. (2) P R., male, 11/2 years. No serum on admission. Died of nephritis 55 days after admission. (3) B.J., male, 4 years. No serum on admission. Admitted with mastoiditis complicated bv septic meningitis following scarlet fever. Died 5 days after admission. (4) J.K., male, 3 years 8 months (mentally defective child). No serum on admission. Died of bronchopneumonia 40 days after admission. (5) D.M., male, 18 years, 20 c.c. A.S.S. on admission. Died of tuberculous bronchopneumonia 17 days after admission. (6) M.S., female, 6 years. 40 c.c. A.S.S. on admission. Admitted with appendicitis and pelvic peritonitis. Died 4 days after admission. (7) N.D., male, 12 years. 10 c.c. A.S.S. on admission. Died of infective endocarditis (following scarlet fever) 58 days after admission. (8) K.W., male, 7 years. No serum on admission. Admitted with purpura hæmorrhagica after an illness at home which was almost certainly scarlet fever. Died 4 days alter admission. It will be seen from this list that in three cases (nos. 1, 5 and 6) death was in no way caused by scarlet fever; whilst in two others (nos. 2 and 7) the fatal complication was established before admission. Apart from these cases, the type of scarlet fever admitted has on the whole remained mild, and the practice of giving anti-streptococcal serum on admission only to those patients who seemed likely to have an attack of more than average severity was continued. Actually about 45 per cent, of the admissions received serum, always by the intramuscular route and in doses ranging from 10 to 20 c.c., depending on the severity of the attack. Second doses of serum were rarely, if ever, given. The serum cases were not segregated, each ward containing a proportion of both serum and non-serum cases. A series of 1,168 cases, comprising most of the admissions for the year has been analysed, and an attempt has been made to draw comparisons between the two groups of serum and nonserum cases. Only those cases which remained at the Brook hospital until discharged have been included, transfers to the convalescent hospitals being excluded. The details are as follows :— cases treated with serum, 531 (average length of stay 40-3 days); cases not treated with serum, 637 (average length of stay 46-2 days). Of these, 354 of the serum cases and 377 of the nonserum cases were uncomplicated, and the average length of stay in both these groups was 29 days. The remaining 177 of the serum group (33-3 per cent.) and 260 of the non-serum group (42-4 per cent.) either developed scarlet fever complications or intercurrent diseases. Of the latter there were 44 in the serum group and 110 in the non-serum group. These cases with intercurrent disease should really be excluded in calculating the length of stay in hospital of the scarlet fever cases, and, by doing so, the following results are obtained :—serum group, 487 (including 133, or 27-3 per cent., with complications)—average length of stay 35-8 days ; nonserum group, 527 (including 150, or 28-4 per cent., with complications)—average length of stay 36-8 days. It will be seen that there is no real difference in these two groups either as regards percentage of complications or length of stay in hospital. They are not, of course, strictly comparable, but it is interesting to note, in assessing the value of anti-streptococcal serum, that patients in the serum group, although comprising all the worst cases, were not longer in hospital and did not show a higher complication rate than the non-serum cases, as one might reasonably expect if the serum had no effect at all. The following table shows an analysis of complications and intercurrent diseases occurring in all the serum and non-serum cases:— 86 Serum group. Month. ! Total cases admitted. Cases with Complications. Intercurrent diseases. Rheumatism. Kidney. Ear. Simple rhiniti«. Other complications. Total complications. Diphtheria. Other intercurrent diseases. Total intercurrent diseases. Complications. Intercurrent disease. Total. Heart. Arthritis. ! Cervical adenitis. Albuminuria. j Nephritis. Relapse. Otitis media. Mastoid. Rhinitis. Throat. Ear. Measles. Chickenpox. Jan. 30 7 5 12 - 2 4 1 - - 2 - 1 2 12 1 - - 2 _ 2 5 Feb 13 1 1 2 _ _ 1 _ _ _ _ _ _ _ 1 1 - - - _ - 1 Mar 23 3 7 10 - - - 2 - - 3 _ - 2 8 5 _ _ _ 1 - 7 April 13 2 5 7 1 - 2 1 - - 1 - _ 1 6 2 - _ - 1 2 5 May 22 4 5 9 1 - 2 - - - 1 1 - 4 9 3 - 1 - - 1 5 June 42 8 4 12 - 2 1 - - - 3 - - 3 9 1 1 _ 2 _ _ 4 July 35 4 4 8 _ - 3 1 - - 2 - - 2 8 3 - _ 1 _ - 4 Aug. 60 6 5 11 - 1 3 1 - 1 3 - 1 4 14 - - _ 2 1 2 5 Sept. 39 17 1 18 1 - 6 2 1 - 3 1 2 4 20 - - - - _ 1 1 Oct. 80 24 3 27 - 3 6 3 1 4 1 - 5 5 28 1 - - _ - 2 3 Nov. 86 30 2 32 - - 14 3 - 2 4 - 7 7 37 - - _ _ 1 1 2 Dec. 88 27 2 29 2 2 12 2 - - 4 1 5 7 35 _ _ _ _ _ 2 2 Total 531 133 14 177 5 10 54 16 2 7 27 4 21 41 187 17 2 1 7 4 13 44 yon-serum group. Jan. 105 21 23 44 3 1 9 - 1 1 11 - 4 1 31 9 1 1 4 6 2 23 Feb. 70 20 21 41 - - 7 - 3 - 9 1 6 3 29 11 3 - 1 6 - 21 Mar 52 12 20 32 1 - 6 1 2 2 12 1 - 7 32 11 1 - 3 5 _ 20 April 24 1 6 7 1 - 1 - | 1 ___ 2 1 - | 1 7 4 - - 2 1 - 7 May 34 4 17 21 1 _ 1 - - 1 8 1 - 2 14 8 2 3 2 2 - 17 June 33 3 6 9 - - 1 - - 1 7 - - 2 11 4 - - 2 - - 6 July 41 8 3 11 - 2 5 _ - 1 1 - - 2 11 1 - - 1 - 1 1 3 Aug. 27 3 1 4 - - 1 1 - 1 1 - - _ 4 - 1 - - - _ 1 Sept. 31 7 1 8 - 1 2 _ 1 - 2 - 2 1 9 1 _ _ _ _ _ 1 Oct. 68 22 3 25 1 4 6 1 _ 2 2 - 8 6 30 _ - - - 2 1 3 Nov. 80 25 6 31 1 - 7 1 2 3 5 1 8 3 11 _ 1 - _ 1 4 6 Dec. 72 24 3 27 - 1 11 1 1 2 4 - 6 7 33 _ _ _ _ _ 2 2 Total ... 637 150 no 260 8 9 57 5 1 1 4 34 5 (4 15 242 49 9 4 15 23 10 110 87 The first point of interest about the table is the remarkable diminution (one might almost say disappearance) of diphtheritic rhinitis, in the second half of the year. This coincided with the introduction in June of the practice of giving 2,000 units of diphtheria antitoxin to all the cases receiving anti-streptococcal serum. Cases not receiving that serum did not receive diphtheria antitoxin. The drop in diphtheritic rhinitis is, however, equally noticeable in the non-serum (control) series of cases, and it might therefore be argued that the diphtheria antitoxin cannot have had anything to do with the change in either series. It will be remembered, however, that each ward contained both serum and non-serum cases, and therefore that any measure which prevented the development of diphtheria in the serum group (as the diphtheria antitoxin must have done if only for a period of 2 to 3 weeks after admission) would thus help to reduce the concentration of infected cases in the ward and would thereby reduce the chances of the non-serum cases acquiring diphtheria. Another point in favour of the diphtheria antitoxin being the decisive factor in the change is the fact that in both series the incidence of rhinitis itself did not materially diminish in the second half of the year, the only difference being that after the introduction of diphtheria antitoxin, the rhinitis was no longer associated with, or caused by, the diphtheria bacillus. This fact will be apparent by studying columns 9 and 12 of the foregoing table in both series. Rhinitis incidence. Month. Serum group. Non-serum group. Total cases adm. Simple rhinitis. Diphtheritic rhinitis. Percent age for first 7 mnths. Total cases adm. Simple rhinitis. Diphtheritic rhinitis. Percent age for first 7 mnths. No. of cases. Per cent. No. of cases. Per cent. No. of cases. Per cent. No. of cases. Per cent. Jan. 30 1 3.3 1 3.3 105 4 3.8 9 8.5 Feb. 13 — — 1 7.7 70 6 8.5 11 15.7 Mar. 23 — — 5 21.7 52 — 11 21.1 April 13 — — 2 15.3 24 — 4 16.9 May 22 — — 3 13.6 34 — 8 23.5 June 42 — — 1 2.3 33 — 4 12.1 July 35 — — 3 8.5 41 — 1 2.4 178 16 8.9 359 48 13.3 Aug. 60 1 1.6 — 27 — — — — Sept. 39 2 5.1 — 31 2 6.4 1 3.2 Oct. 80 5 6.2 1 1.2 68 8 11.8 — — Nov. 86 7 81 — 80 8 10 — — Dec. 88 5 5.6 — 72 6 6.3 — — Total 531 21 3.9 17 3.2 637 34 5.3 49 7.6 It will next be seen from the foregoing table that there is a definite difference in the percentage incidence of diphtheritic rhinitis in the serum and non-serum groups for the first seven months of the year (8.9 per cent, against 13.3 per cent.). This was before diphtheria antitoxin was being given, and it may possibly suggest that the anti-streptococcal serum itself may have had some effect in controlling the incidence of this form of rhinitis, though obviously not to a large extent, as the real drop did not occur until the diphtheria serum was given. This difference in the incidence of diphtheritic rhinitis in the two groups for the first seven months could, however,be explained equally well by suggesting that the anti-streptococcal serum by aborting the attack of scarlet fever shortened the period during which the patient was particularly susceptible to intercurrent disease and thus inter alia reduced the incidence of diphtheritic rhinitis. This point, however, was not fully investigated and no attempt was made to Schick-test new cases before or after the anti-streptococcal serum was given. There might also, of course, be a difference if all serum cases had been put together in a ward and non-serum cases excluded. Cases which develop diphtheritic rhinitis have to stay in hospital for very long periods— in 1934 the average length of stay of the 66 cases of diphtheritic rhinitis was 120 days. The average length of stay of the 55 cases complicated by simple rhinitis only was 57.8 days. Any measure, therefore, which reduces the incidence of rhinitis cases in hospital is well worth while, and I have adopted the practice of giving diphtheria antitoxin to nearly every case of scarlet fever admitted. As a consequence, diphtheria continues to be practically non-existent in the scarlet fever wards, the occasional case which arises generally occurring in a patient who, for some reason, has not received diphtheria antitoxin. These results are certainly unusual, as my previous experience of scarlet fever has been that diphtheritic rhinitis has always been a most frequent occurrence, so much so as to be almost a usual complication. 88 Actually at the Brook hospital, in the early part of 1934, there were two main wards full of patients suffering from the combination of scarlet fever and diphtheria. Referring back to the first table, it is interesting to note that the percentage incidence of otitis media in the non-serum group is double that in the serum group (10 per cent, against 5 per cent.). Also the number of so-called relapses is greater in the non-serum group. This is in accord with expectation, as research work suggests that most of them are really re-infections with a different type of streptococcus, and it would seem that the non-serum treated case, owing to the fact that it usually has a more prolonged illness, would therefore be more susceptible to secondary infections. There is also a definite difference in the incidence of nephritis in the two groups, it being much higher in the non-serum group. The part of the table devoted to intercurrent diseases, shows that diphtheria, measles and chickenpox between them accounted for the bulk of the cases. The fact that the intercurrent diseases raised the average length of stay in the serum group from 35-8 days to 40-3 days, and in the non-serum group from 36-8 days to 46-2 days, in a series of over 1,000 cases, is enough to show what a serious factor intercurrent diseases can be in the treatment of scarlet fever in open wards. The general conclusion which I have drawn during 1934 as regards the treatment of scarlet fever by serum is that serum is definitely efficacious. It should, however, be given as far as possible to every case, as (1) the practice of having wards containing both serum and non-serum cases is not satisfactory and (2) the arbitrary selection of cases for serum treatment results in many cases not receiving it who should (or, as often happens if a mild case gets worse after admission, it receives serum late when its action is very doubtful). As to whether the dose of serum should be larger or whether the intravenous route is better than the intramuscular, I am unable from the year's work to draw any definite conclusions, but I feel that either of these factors might still further reduce the morbidity of scarlet fever and is worth a trial. Research work. A paper by Dr. W. A. Brown, senior assistant medical officer, Brook hospital, and Dr. V. D. Allison, medical officer of the Ministry of Health, on "An investigation into the relationship between discharge and return cases in scarlet fever from the bacteriological and serological point of view " appeared in the Journal of Hygiene for June. 1935. They will shortly publish a further paper on " the bacteriological examination of doubtful cases of scarlet fever with a view to determining whether negative findings might allow of such cases being discharged from hospital more rapidly." The findings in this paper are now being applied at the Brook hospital, and doubtful cases of scarlet fever are being discharged early if two cultures negative to hemolytic streptococci are obtained from nose and throat. Dr. Brown and Dr. Allison are also carrying out (i) an investigation into the effect of intravenous serum on the infectivity of scarlet fever and (ii) a bacteriological investigation of wards in quarantine for scarlet fever in order to decide the minimum quarantine period required. Type of disease. Diphtheria. The medical superintendent of the North-Western hospital (Dr. Joe) has reported as follows :— Whilst it cannot be said that, when estimated by case fatality rates, diphtheria has shown a phenomenal increase in severity, the tendency to more severe forms of the disease noted in 1933 continued during 1934. Diphtheria, including bacteriological diphtheria, appeared in the death certificates of 36 cases, but in 7 it played little or no part in producing the fatal result, and the " corrected " case fatality rate therefore on 666 discharges, transfers and deaths works out at 4.35 per cent. Of the 29 deaths, 1 received antitoxin on the 1st day, 3 on the 2nd day, 9 (3) on the 3rd day, 6 (2) on the 4th day, 5 on the 5th day, and 5 on or after the 6th day. The figures in brackets represent the number of cases in which bacteriological confirmation of the diagnosis was awaited before notification. It should be stated that no great accuracy is claimed for the day on which antitoxin was first given. The reasons for this have been discussed in previous reports, but it can always be assumed that the time interval between the onset of disease and the administration of serum is never overstated. It is consequently somewhat depressing to report once again that more than half the fatal cases did not receive antitoxin until the 4th day or after. The age periods in which these deaths occurred bring out the usual features, 3 occurring at the period 1 to 2, 3 at 2 to 3, 4 at 3 to 4, 5 at 4 to 5, 11 at 5 to 10 years, and 1 each in the periods 10 to 15, 15 to 20, and 20 to 30 years. Only two of the fatal cases were of the hemorrhagic type, and so far as my observation goes, this form of the disease has not become more prevalent among the cases admitted to the North-Western hospital during the past two years when the clinical severity as a whole was on the up-grade. Two of the deaths resulted from respiratory paralysis. The Bragg Paul pulsator, which was supplied to the 89 hospital during the year, was available in the treatment of one of the cases. The respiratory failure was improved by the application of the apparatus, but a well-marked toxic myocarditis was present in addition and undoubtedly brought about the sudden syncope which was the terminal feature. It is of importance to note that the patient was not distressed nor showed any intolerance of the apparatus. During 1934 the investigation into the correlation of the clinical form of the disease with the bacteriological classification of strains of the diphtheria bacillus has been continued in conjunction with Dr. W. Mair, of the Northern group laboratory. The cases completed up till the time of making this report number 176, and were unselected except that only faucial and nasopharyngeal forms in which there could be no doubt about the clinical diagnosis were chosen for investigation. As was inevitable, this has resulted in a relatively larger number of severe and moderate cases being included in the total than would be found in any consecutive series, as by the time many of the mild cases of faucial diphtheria, diagnosed chiefly on bacteriological grounds, arrive in hospital an absolute clinical diagnosis is impossible. This is reflected in the comparatively high case-fatality rate of the series, viz., 10.2 per cent. Excluding 4 cases in which more than one type of organism was present, the gravis and intermediate types predominated and were present in 83 per cent, of the total. The cases in which the gravis type was present numbered 66 and showed a case fatality of 9 per cent., whilst the paralysis rate in the recovered cases was 10-6 per cent. In cases showing the intermediate type, 77, the case fatality was 14'2 per cent, and the paralysis rate in recovered cases 22 per cent. Only 29 of the cases were of the mitis type. None was fatal, and none showed paralysis, nor did anv of them fall into the severe clinical types. It should also be stated that whilst 74 of the cases examined were of the mild clinical type, 52 were almost equally distributed among the gravis or intermediate strains. Thus it seems fairly clear that whilst the fatal cases were exclusively associated with gravis and intermediate types, it was by no means the case that the mild non-fatal forms were related to mitis strains, and whether the investigation of a higher proportion of mild clinical types would have revealed a higher proportion ot mitis organisms is at least doubtful. The fact that diphtheria in London has not taken on the characters of an epidemic type of exalted gravity, in spite of the predominance of infective organisms which have been assumed to possess specially high invasive properties, must be attributed to the natural herd immunity following on years of prevalence of the disease. The question of how best to secure the universal application of the practical measures necessary to increase this immunity remains the central problem in diphtheria. The case mortality rate for verified clinical diphtheria at the Park hospital in 1934 was 4 per cent., compared with 2-98 per cent, in 1933. These figures—the medical superintendent (Dr. H. S. Banks) suggests—become intelligible only when each year's series of cases is classified to show the proportion of hypertoxic and toxic cases, and also the proportion of laryngeal cases, since almost all the deaths occur in these groups. In the absence of any agreed scheme of classification of diphtheria, he has continued to use that referred to in the last annual report (Vol. IV, Part I, p. 115), and the following are the discharges, transfers and deaths for the year, thus classified :— Classification. Discharges. Transfers. Deaths. Diphtheria, faucial—- Hypertoxic 14 2 22 Moderately toxic 94 3 10 Slightly toxic 392 18 — Non-toxic 280 11 — Diphtheria, nasal 191 34 1 „ laryngeal 24 2 I „ combined— Hypertoxic 2 — 8 Moderately toxic 7 — 4 .Slightly toxic 24 6 1 Non-toxic 17 6 — Diphtheria, aural 4 — — 1 Total 1,049 82 47 When the cases so classified are compared with those of last year, it is seen that the proportion of hypertoxic and moderately toxic cases treated in 1934 was 90 considerably higher. The death-rate in each of these groups was actually lower, and the proportion of laryngeal cases and deaths is almost identical. Hypertoxic (A) diphtheria. Moderately toxic (B) diphtheria. Laryngeal diphtheria (excluding combined). Year. Percentage of series. Percentage of deathrate in group. Percentage of series. Percentage of deathrate in group. Percentage of series. Percentage of deathrate in. group. 1933 2.8 66.6 7.8 14.1 2.2 5.2 1934 4.1 62.5 10.0 11.9 2.4 3.7 Dr. Banks states that it is thus apparent that the cause of the increased crude mortality rate for the year (4 per cent.) is a greater proportion of severe toxic cases, and that results of treatment of these cases has actually improved. The combined groups A and B which represent the dangerously toxic cases have risen from 10.1 per cent. to 14.1 per cent. of the total, and the mortality rate of these groups combined has fallen from 28 per cent. to 26.5 per cent. Laboratory evidence shows that the increase in the severe cases was associated with the prevalence of the "gravis" strain of C. diphtheria during the latter part of the year. It is satisfactory to note that the increased prevalence of severe cases and the accompanying larger number of deaths were not associated with any increase in the mortality rate of these cases. Dr. Banks can only attribute this result to the intensive use of intravenous antitoxin which, with one or two notable exceptions, has proved to be reasonably satisfactory for the " gravis " type of case in the London district. The medical superintendent of the Brook hospital (Dr. Armstrong) has reported as follows:— The type of case admitted has remained severe although the fatality rate (3.02 per cent.) is a little lower than last year when it was 4.6 per cent. In no less than 24 of the fatal cases, toxic myocarditis following faucial diphtheria was the determining cause of death; 5 deaths occurred as a result of laryngeal diphtheria and one as a result of measles complicated by bronchopneumonia and empyema. Of 136 cases of bacteriological diphtheria under treatment during the year, 2 died, one as the result of scalds received before admission and the other from Neimann-Picks disease. In the hope of reducing the fatality rate of faucial diphtheria, many more cases than before have been given intravenous antitoxin and glucose on admission. Towards the end of the year, however, a very serious type of toxic faucial diphtheria began to show itself, against which even the most intensive intravenous therapy seemed to be of no avail. Even when admitted at a comparatively early stage of their illness, some of these cases failed to show any real response to treatment and rapidly progressed to a fatal issue. The day of disease on which the 24 fatal cases of faucial diphtheria came under treatment is shown below:— 4 came under treatment on 2nd day of disease. 4 ,, ,, 3rd ,, ,, 10 „ „ 4th „ „ 4 „ „ 5th „ „ 1 „ „ 6th „ „ 1 „ „ 8th „ „ 24 6 of these cases died within 24 hours of admission. 11 „ „ during first week in hospital. 7 „ „ during second week in hospital. The following table shows the main complications which occurred in the 826 cases of clinical diphtheria admitted during the year:— Cases admitted Myocarditis. Palatal paresis. Pharyngeal paresis. Diaphragmatic paresis. Ciliary paresis. Strabismus. Faucial paresis. Percentage of complications to admissions. 1st half of year 371 25 (10 died) 18 - 1 2 3 1 12.0 2nd half of year 455 47 (14 died) 27 2 - 1 3 1 17.7 91 Practically all the above complications occurred after faucial diphtheria, but it is interesting to note that two cases of myocarditis and two of palatal paresis occurred after attacks of nasal diphtheria. The table shows the high incidence of myocarditis as a complication, thus confirming my previous statement as to the severity of the cases admitted during the year. In the last four annual reports there have appeared accounts of the treatment at the North-Western hospital of laryngeal diphtheria by suction after peroral endoscopy. There have been no striking developments in the method of treatment during 1934, but minor improvements in technique continue to be made. The results of the treatment are summarised below :— Number 'scoped only 5 Number 'scoped and aspirated 25 Number in which aspiration probably obviated operation 4 Number in which aspiration required to be followed by operation 11 Treatment of laryngeal diphtheria. As in the past, intubation remains the operation of choice in laryngeal diphtheria at the North-Western hospital, and of the 11 cases in which operation was performed intubation was done in 9, and tracheotomy in 2. Of the intubations 5 were performed by the direct method, i.e., by means of the laryngoscope, whilst in 4 the indirect method formerly employed was carried out. The data set forth below continue those of previous years, the general diphtheria fatality rate being the percentage of all diphtheria deaths in 1934, calculated on the total of diphtheria admissions for that year:— Diphtheria excluding bacteriological diphtheria 712 Diphtheria fatality rate 4.63 per cent. Laryngeal diphtheria 41 Operation cases 11 Cases requiring operation 27 per cent. Deaths 3 Fatality of operation cases 27 per cent. Details of the three fatal cases are as follows:— (1) M.S., aged 11 months. Admitted with laryngeal diphtheria and contact of measles and whooping-cough. Diagnosis of laryngeal diphtheria confirmed and aspiration and direct intubation performed twice. Whooping-cough developed on the 8th day in hospital, and measles on the 16th day, the child finally succumbing to bronchopneumonia on the 20th day. (2) P.S., aged 4 years. Admitted with faucial and laryngeal diphtheria and aspiration performed, but some time later owing to sudden complete obstruction immediate tracheotomy was performed with relief. Acute meningitis due to hæm. influenzae developed on the 4th day in hospital, and the child died of this complication on the 24th day. (3) G.H., aged 1 year 8 months. Admitted with severe faucial and laryngeal diphtheria on the 6th day of illness. Aspiration performed twice. Owing to the presence of toxic myocarditis further repeated aspiration was considered inadvisable, and tracheotomy was performed. Death from heart failure occurred 36 hours after admission. During 1934, 5 cases of acute laryngeal obstruction due to other infections, mainly streptococcal, were laryngoscoped. Also during the year one patient developed chronic laryngeal stenosis following tracheotomy performed before admission to hospital. Since the ideal to be arrived at in the treatment of laryngeal diphtheria is the avoidance of operation as far as possible, advantage was taken of the presence in the hospital of an oxygen tent, kindly lent by Dr. E. P. Poulton for other purposes, to make trial of its usefulness in the treatment of laryngeal diphtheria. In such a tent atmospheres containing up to 40 or 50 per cent. of oxygen are available, and it was considered that patients with the varying degrees of asphyxia encountered in croup would derive benefit from respiration in such atmospheres. What is believed to be a new departure in the treatment of this condition was thus initiated, and of several patients one or two showed definite amelioration of symptoms. One female patient aged 14 months, suffering from nasopharyngeal and laryngeal diphtheria and bronchopneumonia, admitted to hospital in a state of collapse, presented a remarkable degree of improvement in 24 hours and was removed from the tent after 3 days to complete an uneventful convalescence. 92 The medical superintendent of the Park hospital (Dr. Banks) reports that the use of the Luer tracheotomy tube with open pilot has rendered the operation of tracheotomy in young children less dangerous, and easier to perform. During the year 27 operations of tracheotomy were performed in laryngeal diphtheria cases at the Park hospital, with 25 recoveries and 2 deaths. In 4 cases intubation preceded tracheotomy but proved insufficient. The medical superintendent of the North-Eastern hospital (Dr. Harries) reports that cases of laryngeal diphtheria were not numerous at that hospital during the year, and that of those admitted as such the diagnosis was not confirmed in many, as the following note upon the value of direct laryngoscopy in diagnosis, based on the observations of Drs. M. Mitman and N. D. Begg, senior assistant medical officers, and Dr. Hilda M. Linford, assistant medical officer, shows :— Direct laryngoscopy is used in laryngeal diphtheria for two purposes (i) for diagnosis (ii) for treatment. When employed for diagnosis, the clinical appearances of the larynx and adjacent trachea can be ascertained. In addition, direct swabbing of the larynx may provide bacteriological evidence of the presence of diphtheria, when other signs are doubtful or negative. Following such diagnostic examination, attempts are made in suitable cases to treat the local condition through the laryngoscope. Removal of membrane and mucus by aspiration and direct intubation are the two procedures employed. At the North-Eastern hospital this method has been in use for over two years. Detailed records of each case have been kept and it is proposed to publish the findings in due course. The diagnostic value of the method is indicated from the figures given below of the bacteriological findings in 57 cases notified as suffering from laryngeal diphtheria. The diagnosis was confirmed bacteriologically in 34 cases by the presence of the diphtheria bacillus in the nose, throat or larynx. Organisms present. No. of cases. Diphtheria bacilli 28 Diphtheria bacilli and hsemolytic streptococci 6 Pneumococci 4 Pneumococci and hsemolytic streptococci 2 Pfciffer bacilli 3 Pfeiffer and hsemolytic streptococci 2 Hsemolytic streptococci (pure) 5 Streptococcus viridans 1 No organisms 6 Total 57 34 positives. 23 negatives. The 34 positive cases are further analysed to indicate the sites where the organisms were found:— Site. No. of cases. Larynx only 7 23 positive laryngeal swabbings. Larynx and throat 12 Larynx and nose 1 Larynx, nose and throat 3 Nose only 4 11 negative laryngeal swabbings. Throat only 4 Nose and throat 3 Total 34 Electrocardiograph. Very great use has been made at the North-Eastern hospital of the electrocardiograph in the early detection of impending cardiac complications, and in the control of clinical observations upon the failing heart in the severer cases of faucial diphtheria. Four of the acute wards in the permanent blocks at that hospital are wired to the cardiograph which is housed in one of the small side wards. A system of light signals facilitates the taking of records from patients in any of the four wards. During the latter part of the year a portable electro-cardiograph of a new type, in which a visible tracing of the curve is produced by the use of a cathode tube and fluorescent screen, was lent to one of the assistant medical officers at the Brook hospital (Dr. Thompson), who has made considerable use of it in the study and 93 early diagnosis of myocarditis in diphtheria. It was found very useful for this as prolonged observations can be made without any disturbance of the patient. Dr. Thompson proposes to embody the results he has obtained in a short paper. In the annual report for 1933 (Vol. IV, Part I, p. 114), reference was made to an investigation of the value or otherwise of accessory glucose and insulin therapy in the treatment of toxic diphtheria by Dr. Norman D. Begg, senior assistant medical officer, North-Eastern hospital. Dr. Begg's observations were embodied in an article, to which a note by Dr. Harries, medical superintendent of the hospital was appended, which appeared in The Lancet for 2nd March, 1935 (p. 480). Accessory glucose and insulin therapy. The medical superintendent of the North-Eastern hospital (Dr. Harries) has reported that, as in previous years, diphtheria carriers have been received from other infectious diseases hospitals of the Council's service. During 1934 the work of the carrier wards was under the immediate charge of Dr. Norman D. Begg, senior assistant medical officer. The total number of patients admitted to the carrier wards during the year was 162, compared with 170 in 1933. With the exception of 8 cases, which were derived from the acute diphtheria wards of the NorthEastern hospital, all were cases transferred from other hospitals. No patient so transferred was regarded as a carrier until a positive and virulent culture had been obtained at this hospital. Carriers. Of the total of 162 reputed carriers 58 (35.7 per cent.) never yielded positive cultures after transfer and were discharged after three consecutive negative cultures from nose and throat, taken at bi-weekly intervals, had been obtained. (This figure compares with 52 (30.5 per cent.) of 170 reputed carriers admitted in 1933.) In explanation of these figures it may be suggested that the patients were transferred as carriers just at the point of becoming free from infection, but the high percentage makes this unlikely as a general explanation. Much more probable is it in Dr. Harries' opinion that many of these patients were really contact carriers as the result of their stay in convalescent wards, and that with segregation and the consequent avoidance of re-infection the carrier state came to an end. As in previous years special carrier wards were provided. No acute cases of diphtheria were admitted to these wards. Carriers whose carrier state had been terminated as the result of treatment were, if considered unfit for discharge on physical grounds, transferred to a negative ward, and thus escaped the possibility of re-infection when up and about pending discharge. Dr. Harries points out that it is significant, in view of what was written last year (Annual Report, 1933, Vol. IV, Part III, p. 7), that this precaution eliminated entirely the "intermittent" carrier who, in his opinion, is usually the product of re-infection by his fellow carriers. As previously reported, the reception of diphtheria carriers from other hospitals had from time to time been followed by outbreaks of scarlet fever in carrier wards. It was found that a proportion of transferred diphtheria carriers had a recent history of scarlet fever, and were in fact double carriers of the diphtheria bacillus and the hsemolytic streptococcus. A special ward is maintained at the NorthEastern hospital into which are received only Schick and Dick immune double carriers. Since this measure was instituted no case of scarlet fever has occurred in the diphtheria carrier wards. Dr. Begg has reported as follows upon the 104 true carriers of virulent diphtheria bacilli under treatment during the year:— The site of infection was either the nose, throat or ear, alone or in combination. It was always possible to demonstrate some pathological change at the site affected. Rhinitis, frequently of a mild type with fine crusting on the nasal mucous membrane, was common. Less common, but far more difficult to treat was rhinitis of atrophic type with large adherent crusts. Excessive adenoid growth and unhealthy tonsils were common foci of infection. In three instances the carrier state was maintained by the presence of a foreign body in the nose. Deflected septa and other anatomical abnormalities in the nose were found to be important only in so far as they were accompanied by inflammatory changes. Paranasal sinusitis was noted in two nasal carriers, but in neither instance was it found that the unhealthy sinus was the actual reservoir of the diphtheria bacillus. G 94 The following were the methods and results of treatment in various types of carrier:— (а) Tonsillar—Pure tonsillar carriers occurred in 9 (8.6 per cent.) of the total treated. The carrier state was terminated by— Cases. Removal of tonsils and adenoids 5 „ „ „ and dimol snuff treatment 1 Dimol snuff alone 3 Total 9 The average period of treatment of patients in this category was 4½ weeks. (б) Nasal—There were 43 purely nasal carriers (41.3 per cent.). Termination of the carrier state was brought about as follows:— Cases. One course of dimol snuff 32 Dimol snuff, douches, etc. 6 Dimol snuff and operative measures 5 Total 43 An average period of treatment of just over 4 weeks was necessary for these nasal carriers. (c) Combined tonsillar and nasal carriers—In 49 instances (47.1 per cent.) tonsils and nasal mucosa were the sites of infection. These were successfully treated as follows:— Cases. One course of dimol snuff 27 Dimol snuff, douches, etc. 12 Removal of tonsils and adenoids after clearance of nasal infection by local treatment 10 Total 49 These cases required an average period of treatment of 6 weeks. (d) Other sites—The middle ear was infected in three cases: in one case alone; in one in conjunction with the nose; and in one with both nose and throat. Two of the three cases cleared up after local treatment, but the other (nose, throat and ears) only after removal of tonsils and adenoids. As regards the bacteriological standard of cure, six consecutive negative cultures from nose and throat, taken twice weekly, were required before carriers were discharged from hospital. Three sets of negative cultures were obtained during treatment and three were required (except after tonsillectomy) after treatment before release. Thus a minimum course of treatment lasted for 10 days if the response was immediate. The average time for any one course of treatment was 14 days. The longest period of treatment found necessary for any one case was 15 weeks and the average period for the 104 carriers treated was just over 5 weeks. There was no failure to clear a carrier ; in 22 cases some operative procedure upon the nose and throat was necessary before a cure could be effected. Prophylactic inoculation of nurses and domestic staff. Following on his reports referred to in the annual reports for 1931, 1932 and 1933, the medical superintendent of the North-Western hospital (Dr. Joe) states that immunisation against diphtheria was continued as in previous years in the nursing staff, all entrants, to the number of 89, being Schick-tested. Of these 55 were Schick negative and 34 Schick positive, the latter being given two injections of formol toxoid. Twenty-eight were completely protected, 5 left during the course of immunisation, and in 1 case immunisation had not been completed at the end of the year. In addition the immunisation of 7 nurses still undergoing the course of injections at the end of 1933 was finished. In the latter year the number of protective inoculations was reduced from 3 to 2, the interval between being increased to 4 weeks. The results of this method have proved highly satisfactory during 1934, 92.5 per cent. becoming immune 4 weeks after the second injection as against 73.3 per cent. immune 4 weeks after the third injection of the former course, in which the interval between inoculations was 2 weeks. During 1934 only one day's duty was lost as a result of immunisation. Observations were continued on the reliability of the Maloney test by Dr. R. Swyer, and a detailed account of these will probably be published, but the general conclusions were that whilst a positive Maloney test almost invariably meant that the reactor was sensitive to toxoid injections, a negative reaction did not mean that the possessor would be free from reactions during the course of immunisation. During the year one nurse lost 32 days' duty 95 as a result of mild faucial diphtheria. She had been found Schick negative 16 months previously after 3 injections of formol toxoid, but on being warded with diphtheria was found to be pseudo-positive. No antitoxin was given, her throat cleared up in about 24 hours, and no sequelae occurred. The strain of C. diphtheriæ isolated by Dr. Mair was reported as a non-fermenter of starch and corresponded to the mitis type of the Leeds workers. Another case was also a mild faucial diphtheria in a ward sister who had been protected in 1926 and found Schick negative. She left the hospital but returned in 1931, and on retest was found Schick positive. She then received two doses of alum toxoid and was afterwards Schick negative. On complaining of sore throat she was examined and the appearance of typical membrane was not in doubt, but on being Schick-tested she was again Schick negative. A virulent strain of a starch fermenting diphtheria bacillus was found in the throat, corresponding to the gravis type of the Leeds workers, and 20,000 units of antitoxin given. The membrane disappeared in the course of a few days, and the main feature of the subsequent course of the illness was severe serum sickness which resulted in a loss of 55 days' duty. Another nurse came under observation as a possible case of diphtheria, and although virulent K.L.B. were cultured from her throat the clinical appearances were equivocal, her Schick test was negative, and a final diagnosis of catarrhal sore throat in a diphtheria carrier was made. At the Brook hospital seven nurses contracted diphtheria during the year. Five of the seven nurses had been only partially immunised, two because they had refused to complete the course of injections, and the other three (probationer nurses) because their courses of injections had not been completed owing to the fact that they had not been long enough at the hospital. The remaining two were not Schick negative and in each case the diagnosis of clinical diphtheria was doubtful. One of them did not receive antitoxin. Half way through the year, active immunisation was offered to the domestic staff at the Brook hospital, and all but a few have now been Schick-tested and immunised. Alum precipitated toxoid (Mulford's) has been used and the results have been as follows:— Cases Schick-tested. Schick negative. Schick positive. 77 61 16 Of the 16 positive cases, 14 received one injection of alum precipitated toxoid. Of these 11 were negative when Schick-tested six weeks later, one was positive but became negative after a further five weeks, one was positive and re-inoculated. She became negative four months later. One was faint positive but was negative on retest two months later. The probable explanation of the high percentage of Schick negative reactors amongst the domestic staff is the fact that there had been comparatively few changes in the personnel, the majority having been on the staff for a long time. They thus had had time to acquire a degree of immunity by constant contact with infection. An investigation was made at the North-Eastern hospital by Dr. N. Begg, senior assistant medical officer, in conjunction with Dr. W. Mair, assistant director of research and pathological services, of the Northern group laboratory, in an attempt to assess the incidence of streptococcal and diphtheria carriers amongst the nursing staff. Incidence of carriers amongst nursing staff. For this purpose the staff were divided into two main classes : (a) permanent staff with at least three months service who were known or assumed to be immune to scarlet fever and diphtheria, and (b) new candidates. It is convenient to describe these two classes separately. Field examination of permanent staff.—In all 173 members of the nursing staff were examined, these included 21 sisters, 82 staff nurses and 70 probationer nurses. The examination consisted of a swab from nose and throat for hsemolytic streptococci and a corresponding examination for diphtheria bacilli. Two such 96 examinations were made at an interval of six weeks. Streptococci found on swabbing were graded into three classes: (a) few colonies; (6) numerous colonies; (c) nearly pure cultures. This grading indicated the number of colonies on a blood plate. Percentage incidence of carriers.—It will be seen from the following table that 77 of the nurses examined were found to be streptococcal carriers whereas a comparatively negligible number were revealed to have virulent diphtheria bacilli in nose or throat. Streptococcal carriers. Total diphtheria carriers. Few colonies. Numerous colonies. Nearly pure cultures. Total. 173 nurses 26.5 per cent. (46 cases) 16.3 per cent. (28 cases) 1.7 per cent. (3 cases) 44.5 per cent. (77 cases) 1.2 per cent. (2 cases) The finding of a few colonies of streptococci in an examination is a common event; and, whilst it is not suggested that such a result is without significance, it is thought that danger mainly lies in those carriers who yield fairly profuse growths of streptococci on blood agar plates. For this reason attention was directed principally to the 31 nurses who revealed numerous colonies or nearly pure cultures of streptococci, and to the 2 nurses from whom virulent diphtheria bacilli were recovered. A table showing the type of ward in which these 33 nurses were employed is subjoined. It will be seen that streptococcal carrying was most common in those nurses working in scarlet fever wards; carriers of pure cultures were found exclusively there just as the two diphtheria carriers were found in diphtheria wards. Type of ward. Numerous colonies of streptococci Nearly pure cultures of streptococci Virulent diphtheria bacilli. Scarlet fever 67.1 per cent. (16 cases) 100 per cent. (3 cases) - Diphtheria 32.2 per cent. (9 cases) - 100 per cent. (2 cases) Other diseases, e.g. measles 10.7 per cent. (3 cases) - - (28 cases) (3 cases) (2 cases) Further it was possible to examine clinically all but a minority of the 173 nurses who formed the subject of this investigation. It was found that the percentage with unhealthy mucous membranes was higher amongst the carriers than amongst the non-carriers. These percentages are tabulated below:— Of 96 nurses who had no hæmolytic streptococci, 38.5 per cent. had unhealthy mucous membranes. Of 46 nurses who had a few colonies of hæmolytic streptococci, 67.5 per cent. had unhealthy mucous membranes. Of 28 nurses who had numerous colonies of hæmolytic streptococci, 75 per cent. had unhealthy mucous membranes. Of 3 nurses who had nearly pure cultures of hæmolytic streptococci, all had unhealthy mucous membranes. Of 2 nurses who had virulent diphtheria bacilli, both had unhealthy mucous membranes. Finally, an impression was gained that streptococcal carrying to any degree did not appear to take place amongst the older members of the staff. In order to test this, the 33 carriers were divided into three classes according to the length of their hospital service: (a) over 3 months and under 1 year; (b) 1 to 3 years; (c) over 3 years. 97 The results are recorded in the table below, and show that the highest incidence of carrying falls in the first year of service. This would seem to indicate that, with intimate contact over a period of years, some degree of anti-bacterial immunity develops. Period of service. Numerous colonies of streptococci. Nearly pure cultures of streptococci. Virulent diphtheria bacilli. 3/12—1 year 42.8 per cent. (12 cases) 100 per cent. (3 cases) 100 per cent. (2 cases) 1—3 years 32.2 per cent. (9 cases) — — Over 3 years 25 per cent. (7 cases) — — (28 cases) (3 cases) (2 cases) It will be noted that no reference has been made to the first 3 months of service. Nurses in this group have, as originally stated, been dealt with separately and these will be considered below. Examination of new candidates.—41 new candidates were examined ; these included 27 probationer nurses, 12 staff nurses and 3 sisters. All save the last three were doing infectious nursing for the first time. The procedure was essentially the same as in the previous group except that examinations were undertaken at more frequent intervals. Further, the swab results could now be correlated with the result of a Dick and a Schick test. The first swab was taken before the candidate commenced ward work, and subsequent swabbing took place at fortnightly intervals up to a period of three months from the date of joining hospital. Percentage incidence amongst new candidates.—In the subjoined table, a contrast is made between the percentage carrier incidence of all new candidates on joining and the average incidence over the whole three month period. It will be seen that a marked increase in streptococcal carrying took place after contact with infectious cases. cases. Diphtheria carriers were again a minority and only one was revealed. Few colonies of streptococci. Numerous colonies of streptococci. Nearly pure cultures of streptococci. Total streptococcal carriers. Percentage Dick negative reactors. Diphtheria bacilli carriers. On joining 31.7 per 24.4 per 56.1 per 6.4 per cent. cent. cent. cent. (13 cases) (10 cases) (23 cases) Whole 3-month period 24.4 per 61.0 per 7.3 per 92.7 per 74 per 2.4 per cent. cent. cent. cent. cent. cent. (10 cases) (25 cases) (3 cases) (38 cases) (1 case) Two factors influenced this increase. In the first place a somewhat increased rate, both absolute and relative, was experienced in those nurses working in scarlet fever wards as compared with that experienced in other wards exemplified in the table set out below, where it is also shown that the incidence of streptococcal tonsillitis is higher amongst staff in scarlet fever wards. It is, however, apparent that an increase in carrying takes place on contact with non-scarlatinal cases, although this may not be so marked. A second factor must therefore be operative. Unhealthy mucous membranes were again found to be of the first importance. New candidates who were found on admission to have enlarged tonsils or an unhealthy nasal mucosa soon showed a relative increase in the number of streptococci or 98 became carriers for the first time, irrespective of the type of ward in which they were stationed. Number with unhealthy mucosa. Percentage carrying streptococci on joining. Percentage carryin streptococci after two months' service. Percentage who developed tonsillitis. Scarlet fever wards 19 47.3 ( 9 cases) 100 (19 cases) 26.3 (5 cases). Other wards 22 63.3 (14 cases) 86.3 (19 cases) 13.6 (3 cases). Cross infections of streptococcal tonsillitis are still unfortunately not rare. Unlike diphtheria it cannot be prevented by passive immunisation, so that the problem of carriers is a very real one. There can be no doubt that staff carriers are occasionally responsible for cross infection, and an outbreak of streptococcal tonsillitis in a negative ward which was traced to such a source is described. Ward outbreak of tonsillitis. A probationer nurse was found to be Schick and Dick negative on joining, and a swab of nose and throat was negative for hæmolytic streptococci and diphtheria bacilli. Her tonsils were moderately enlarged and pitted. She was allocated to an acute scarlet fever ward, and within a week developed an acute sore throat with confluent exudate on both tonsils from which a nearly pure culture of hæmolytic streptococci was obtained. Recovery was uneventful and on discharge a few colonies only of hæmolytic streptococci were present in the throat swab. After a period of sick leave she commenced work again in a ward containing twelve negative cases. A field swabbing of the ward population had been done at that time for another purpose and revealed a few colonies of hæmolytic streptococci in the throats of three children—the nursing staff were negative. Two days after her return to work the suspect nurse contracted a severe "cold," and five days later another nurse was removed from the same ward with streptococcal tonsillitis. For this reason the suspect was re-swabbed and now showed numerous colonies of hæmolytic streptococci in nose and throat. She was promptly removed from the ward, but not before she had infected four of the children who developed typical attacks of streptococcal tonsillitis within a week. The medical superintendent of the North-Eastern hospital (Dr. Harries), who has submitted this report, states that the streptococcus is world-wide in distribution, and it is not always possible to assess its pathogenicity in an individual case. Nevertheless certain strains, commonly found in human carriers, are capable of producing well defined diseases such as scarlet fever and tonsillitis. The results of this investigation show that streptococcal carriers abound in the nursing staff of a fever hospital, and that these carriers betray certain characteristics by which they may be suspected or recognised. For that reason some control is possible by allocating nurses to appropriate wards, not only on the result of a Schick and Dick test, but on the evidence of these tests combined with repeated swab results and an examination of the nose and throat for pathological abnormalties. This practice has been pursued at the North-Eastern hospital with success. Dr. Harries summarises the conclusions as follows:— (1) A high percentage of nurses in a fever hospital are shown to carry hæmolytic streptococci in contrast to a negligible percentage of diphtheria carriers. (2) Newly joined nurses are more likely to become carriers than staff with long experience of infectious work. (3) Unhealthy mucous membranes and intimate contact with streptococcal diseases are important factors in determining the carrier state. (4) Outbreaks of streptococcal diseases are occasionally traceable to staff carriers and some control is possible. In Dr. Harries' opinion this is an important investigation. So far as diphtheria is concerned it is clear that active immunisation of the staff does not increase the 99 carrier rate, an effect, which it has been stated, is produced in residential institutions for children. It is to be noted, however, that nurses sleep not in dormitories with exiguous bed spacing but in separate bedrooms. As regards the hæmolytic streptococcus, it may be added that Dr. V. D. Allison, of the Ministry of Health, kindly typed the strains which were recovered from the field swabbings alluded to above. They comprised 38 strains, 19 of which (50 per cent.) fell into the types frequently associated with scarlet fever, tonsillitis, puerperal fever, and other hsemolytic streptococcal infections. Diphtheria and scarlet fever. In continuation of the report on the protective inoculation of nursing and domestic staff contained in the annual report for 1933, the medical superintendent of the North-Eastern hospital (Dr. E. H. R. Harries) has reported as follows:— During the year all new members of the nursing and domestic staff have been offered the Schick and Dick test and immunisation has been offered to those found to be positive reactors. No member refused these tests or the subsequent immunisation. Protective inoculation of nursing and domestic staff. Cases of diphtheria and scarlet fever amongst the staff in the year are tabulated below:— Diphtheria. Scarlet fever Staff cases. Total days off including sick leave. Average days off. Staff cases. Total days off including sick leave. Average days off. 3 163 54.3 3 139 46.3 Three cases of diphtheria occurred amongst the staff in 1934. One occurred in a Schick positive nurse within a few days of joining the hospital staff. One occurred in a nurse just after she had completed her immunising course and before there had been time to retest her. The last case was that of a senior technician in the Northern group laboratory who had joined the hospital staff before Schick-testing and active immunisation were practised. Of the three cases of scarlet fever, one occurred in a probationer nurse within a few days of joining the service. The other two cases occurred in Dick positive reactors who had both had the first injection only of an immunising course—one case was that of a probationer nurse and the other was a domestic assistant. As in the previous year formol toxoid supplied by the Belmont laboratory was used exclusively in active immunisation against diphtheria. In the case of scarlet fever, a course of 3 injections of toxin (B.W.) was used until the middle of the year when a scarlet fever prophylactic from the Belmont laboratory was introduced. In contrast with B.W. toxin a full course of Belmont prophylactic consisted of five injections—given at intervals of one week. It will be seen that the results, as indicated by the production of an active immunity are equally good, nor were any untoward reactions recorded. The details of the numbers tested and immunised during 1934 are as follows:— (i) Schick test and active immunisation with toxoid (Belmont). Schick test—Negative 126 Positive 75 (37.3 per cent.) Total 201 Of the 75 Schick positive reactors, 11 left before completing an immunisation course, 2 developed diphtheria (vide supra), and 62 were immunised and retested. Of the 62 who had been given a complete course of 3 injections of .1, .2 and .3 c.c. of toxoid, 59 had become Schick negative on retest and in the other 3 the test was still positive. All 3 became negative after a further injection of toxoid. (ii) Dick test and active immunisation against scarlet fever:— Dick test—Negative 164 Positive 37 (18.4 per cent.) Total 201 Of the 37 Dick positive reactors, 3 left before completing an immunisation course, 3 developed scarlet fever {vide supra), and 31 were immunised and re-tested. In 15 cases, toxin (B.W.) was used. Eleven had become negative after the full immunising course of three injections and four remained positive. Of these, three became negative after a further injection of toxin (B.W.) and the other, who was strongly positive, was given a full immunising course of five injections of Belmont prophylactic and then became negative. 100 Belmont prophylactic was used in the remaining 16 cases. Of these 15 became negative after the full course of five injections. The other remained strongly positive and was given three injections of toxin (B.W.) with the production of the desired negative result. X-ray work. Dr. M. Mitman, senior assistant medical officer at the North-Eastern hospital, who also acted as radiologist at the hospital, the X-ray department of which serves all the Council's infectious hospitals except the Northern hospital, has reported that the volume of work undertaken during the year was maintained at the usual level, although the department was disorganised for a short period while alterations were being made. These consisted of the replacement of the old apparatus by a modern and more powerful plant, capable of performing the work more efficiently and with greater ease. The examinations most commonly undertaken—radiography of the skull and of the chest in children—require high power apparatus capable of working at high currents. The increased facilities provided by the new apparatus will permit certain investigations, formerly incapable of performance, to be carried out. The figures for the last two years are set out below :— Year. 1933 1934 Total number of patients examined. 233 226 Number of films taken. 442 473 Chest examinations. 73 82 Mastoid examinations. 37 38 The Drinker respirator. The medical superintendent of the North-Eastern hospital (Dr. Harries) states that there can be no doubt that the Drinker respirator, the forthcoming provision of which at that hospital was referred to in the last annual report, has saved the lives, which otherwise would inevitably have been lost, of patients suffering from post-diphtheritic diaphragmatic paralysis. The following is a brief note on the use of the apparatus The Drinker respirator is a mechanical device for administering artificial respiration over long periods. It consists essentially of a warmed and lighted metal chamber into which the trunk and limbs of the patient are introduced ; an almost airtight joint being formed by a rubber diaphragm through which the patient's head is passed to rest upon a rubber cushion outside the apparatus. A variable negative pressure within the chamber is maintained by means of a bellows actuated by an electric motor. The pressure, which is read off upon a water manometer, is adjustable by metal diaphragms at the distal end of the chamber, and the rate per minute at which the bellows work, so creating the rhythmic alterations of atmospheric pressure within the chamber, which assist the feeble respiratory efforts of the patient, is adjustable by means of a dial. The best pressure and rate of respiration are ascertained by observation for the individual patient and cautiously maintained or varied in accordance with the clinical requirements. The apparatus, which is the first to be acquired by the Council, is stationed at the NorthEastern hospital, and has been requisitioned from time to time by other of the infectious diseases hospitals of the service. The present model is to a certain extent experimental and is to be replaced shortly by another which will incorporate improvements and modifications which experience has shown to be desirable. Hitherto, the Drinker respirator has been employed elsewhere in the treatment of respiratory failure in acute anterior poliomyelitis. It was originally employed for post-diphtheritic diaphragmatic paralysis by Dr. J. E. Gordon, formerly of Detroit. At the North-Eastern hospital, the primary use of the apparatus has been for the treatment of this grave complication of diphtheria, but it has also been used to assist expansion of the lung in cases of empyema thoracis. Of eight patients with post-diphtheritic diaphragmatic paralysis treated in the apparatus there were five recoveries. In some of these cases pharyngeal paralysis was co-existent, and here the electric pump intended primarily for laryngeal suction 101 through the direct laryngoscope in the treatment of laryngeal diphtheria was used in conjunction with the respirator and afforded great relief to the patient. Some of these patients had to remain in the apparatus owing to the persistence of the paralysis for periods of 12 days or more, which is in itself an indication of the impossibility of maintaining artificial respiration by means other than mechanical, and there is no question that without the apparatus the lives of these children would not have been saved. The use of the Drinker apparatus in empyema is quite original, and is due to Dr. M. Mitman, senior assistant medical officer at the NorthEastern hospital. The results which attended its employment in two cases were so obvious and striking that it appears that a new and valuable field for the machine has been discovered. Streptococcal toxin and anti-streptococcal sera. Dr. L. J. M. Laurent, senior assistant medical officer at the Western hospital, has continued to carry out, as in past years, various tests in connection with the standardisation of streptococcal toxin and the filtration of streptococcal antitoxin. North-Western hospital—Radium unit for cancer of uterus. In May, 1933, it was decided to transfer to the Lambeth hospital the unit which had been established at the North-Western hospital in June, 1928, for the treatment, by radium, of cancer of the uterus. Effect was given to this decision in March, 1934. The unit at the North-Western hospital had worked under the disadvantage that there was at that hospital no X-ray equipment, and, since both forms of therapy were necessary, patients had had to be transferred to Lambeth hospital to complete their treatment. (b) smallpox hospitals. Use of hospitals. Long Reach hospital continued in use until 12th July, after which it remained unoccupied to the end of the year. Joyce Green hospital was open for fever cases throughout the year, and the Orchard hospital from 13th February to 12th July. Admission of patients. At the end of 1933 there were 13 cases of smallpox under treatment. During the year 163 cases certified to be suffering from smallpox were admitted to the receiving station at South Wharf, and in addition two babies not suffering from smallpox were admitted to hospital with their mothers who had the disease. Twenty-five of these cases were discharged from the receiving station as the diagnosis was not confirmed. One patient died from encephalomyelitis which followed the attack of smallpox. The last patient was discharged on 12th July, since which date there have not been any smallpox cases under treatment, though during the last six months of 1934 nine cases were sent to the receiving station, none of which proved to be smallpox. Smallpox cases admitted to hospital. At the end of the year 1933, 696 patients were under treatment in Joyce Green hospital. During 1934, 5,908 patients were admitted to Joyce Green and Orchard hospitals, of whom 1,204 were received in the Orchard hospital. At the end of the year 137 remained under treatment in Joyce Green hospital. Fever cases admitted to Joyce Green and Orchard hospitals. The Orchard hospital was opened on 13th February to receive patients suffering from scarlet fever, and was closed on 12th July. During less than 5 months the hospital dealt with 1,524 patients, of whom 1,204 were admitted direct and 320 transferred from Joyce Green. Of the total of 5,908 patients admitted to the hospitals during the year, 2,794 were admitted during the months of March, April and May, and during January, February and March 428 female staff and 38 male staff joined or were transferred to this section of the fever service. The year under review is therefore a very typical example of the extreme fluctuation in numbers of patients and staff to which these hospitals are accustomed. 102 At the end of the year Joyce Green hospital was in process of being closed, and the staff which had been brought together and had advanced some way towards a satisfactory corporate life were in process of dispersion. History of recent smallpox epidemic. The medical superintendent of the smallpox hospitals (Dr. A. F. Cameron) has submitted an interesting account of the history of the recent epidemic of smallpox. He points out that the middle of the year 1934 was the end of a well-defined epidemic period of smallpox in London which lasted for 61 years. It began in January, 1928, reached its point of highest incidence in the spring of 1930, and thereafter steadily declined until the admission of cases ceased in June, 1934. During these years upwards of 14,000 cases of smallpox, including extra-metropolitan cases, were treated in hospital. The course of the disease throughout London during this period of 6| years is indicated in the following table, in which is set out year by year the boroughs from which over 50 cases per annum were received :— Smallpox—Course of the disease. Cross marks the year during which over 50 cases were admitted. 1928. 1929. 1930. 1931. 1932. 1933. 1934. East extra-metropolitan — x x x x — — Poplar x x x x x x — Stepney — x x x — — — Bethnal Green — x x x Hackney — x x — — — — Shoreditch — x x x — — — Islington — x x x x — x Stoke Newington — — — — — — — Finsbury — — x x x — — City — Woolwich — Greenwich — — — — Deptford — — — — x — — Bermondsey — x — — Southwark — x x x x Lambeth x x — x x x — Camberwell — x x x x x Lewisham Holborn — St. Pancras — x x — St. Marylebone — — — — — — — Westminster — Kensington — — — — — — — Chelsea — — — — — — — Fulham — — Hammersmith — — x Paddington — — — — — — — Hampstead — — — — — — — Battersea — — Wandsworth x — — — — — — Before January, 1928, the disease was already established in the extra-metropolitan districts of Essex, and in 1928 it appeared in Poplar and Lambeth, and also in Wandsworth where a localised outbreak occurred. During the succeeding four years a heavy incidence of the disease was maintained in the same extrametropolitan districts whence came more than one-third of the total cases admitted in 1929, and more than one-fifth of the cases treated throughout the epidemic period of 6½ years. In 1929, the disease gradually spread throughout almost all the boroughs on the north of the river to the east of the City, and throughout Lambeth, Southwark and Camberwell. The comparative immunity throughout the period under review, of Woolwich, Greenwich, Deptford, Bermondsey and Lewisham boroughs which are contiguous to severely infected areas, is remarkable. 103 These boroughs contributed the relatively small total of 509 cases during the epidemic period. It is also remarkable that, after 1928 (with the exception of limited outbreaks in St. Pancras and Holborn during 1929 and 1930, and in Hammersmith during 1931), only sporadic cases of the disease appeared in the boroughs to the west of Islington, Finsbury and Lambeth. The total number of cases admitted throughout the period from the 14 boroughs which contributed less than 50 per annum during every year of the period was 381. During the period 37 patients suffering from smallpox died. Three of the fatal cases occurred among the passengers and crew of a liner which brought the infection of the severe toxic type of the disease from Bombay, and 34 were patients infected by the mild type of the disease then prevalent in Greater London. In 12 of these the fatal result was primarily due to the toxaemia of smallpox, and in 22 the attack of smallpox was at most a secondary and adjuvant cause of death, which was primarily due to serious organic disease, to premature birth or to senility. In previous annual reports, covering the period under review, reference has been made to the type of the disease, i.e., to the low degree of virulence which is demonstrated by the case fatality throughout the whole epidemic period. This cardinal feature was maintained with no appreciable variation for upwards of six years in greater London, just as it had been maintained throughout the provinces since 1919, when the type was noted in the eastern counties. There has been no evidence of any exacerbation of virulence either in the clinical features of the disease or in the case fatality of our modern native smallpox. Cases of this mild type, cases of the severely toxic type and cases of vaccinia are all mutually protective. The severe cases of the disease, carrying the highly virulent infection brought from India in the spring of 1929, were accommodated in the wards of the hospital which were already occupied by cases of the mild type prevailing at that time in London. The only distinction between the two types lies in the virulence of the infection, i.e., in the severity of the reaction of the patient to the virus, a distinction which cannot usually be recognised in individual cases, but only by observation of case severity and case fatality extending into at least the second generation of an outbreak of the disease. Under any conditions, in dealing with smallpox, varicella (chickenpox) is the disease which gives rise to the greatest difficulty in diagnosis, and, when the prevailing type of the disease is mild, it is inevitable that the number of cases in which difficulty occurs must increase. Experience during the period under review showed that in a proportion of cases, more especially when leave to use vaccination for diagnostic purposes was refused, differentiation became too entirely a matter of opinion to be administratively reliable. It is satisfactory to note that the use of the variolavaccinia flocculation reaction, in the technique perfected by Professor W. J. Tulloch, of St. Andrew's University, was found to be a reliable diagnostic criterion. Experience at the smallpox receiving station suggests that this test might, with advantage, be more extensively used in the differentiation of variola before removal of a suspected case to the receiving station, particularly in patients who refuse the protection of vaccination. Responsibility for the treatment of infectious diseases. From time to time difficulties had arisen with extra-metropolitan local authorities as to the responsibility for the treatment of inhabitants of London who had contracted infectious disease while temporarily resident outside the county. The Council therefore decided to ask the Minister of Health to consider the possibility and desirability of issuing regulations under Section 130 of the Public Health Act, 1875, dealing with the matter. On 25th June, 1934, the Minister issued such regulations (which came into force on 1st July, 1934), the operative clause in which is as follows :— The London County Council, the council of every borough or urban or rural district, and every Joint Hospital Board constituted under the Public Health Act, 1875, and having the powers of Section 131 of that Act, shall have the same powers and duties in relation to the provision of hospitals or temporary places for the use of persons who are for the time being within their county, borough or district, as the case may be, and are suffering from infectious disease, as they have for the use of the inhabitants of that county, borough or district. 104 (c) medical instruction. During the year 551 students, of whom 66 were women, attended courses of instruction in fevers, and 47 attended courses of instruction in hospital administration for the diploma in public health. Arrangements were also made when cases of smallpox were under treatment for the giving of demonstrations in the diagnosis, etc., of that disease. Ophthalmia neonatorum. (d) hospital for ophthalmia neonatorum and vulvo-vaginitis. During the year 248 babies were admitted to St. Margaret's hospital, accompanied by 149 mothers, and 4 of the babies died from the following causes :— Cause of death. Babies. Prematurity 3 Congenital heart disease 1 Total 4 The numbers discharged were 239 babies and 147 mothers. The condition of the eyes of the babies on admission and on discharge or death is shown in the following statements :— (i) On admission. Clear. Hazy. Abrasions or ulcerations. Perforated ulcers. Blind. Total. One eye. Both eyes. One eye. Both eyes. 162 313 12 = 4 = 1 - - 496 12 eyes 8 eyes (248 patients) (ii) On discharge or death. Clear. Impaired sight. Blind. Treatment not completed. Total One eye. Both eyes. Scar. One eye. Both eyes. One eye. Both eyes. 473 3 = 2 = 1 eye - - 3 = 1 = 486 3 eyes 4 eyes 3 eyes 2 eyes (243 patients) Vulvovaginitis in infants and young girls. In May, 1934, approval was given to the removal to St. John's hospital, Wandsworth, of the cases of congenital syphilis at St. Margaret's hospital and the carrying out of the necessary alterations and improvements to enable a unit of 31 beds to be established at St. Margaret's hospital for cases of vulvo-vaginitis in infants and young girls and the work was in progress at the end of the year. In consequence the nominal accommodation for patients at the hospital was fixed at 31 beds for vulvo-vaginitis and 44 beds for ophthalmia neonatorum, an increase of 15 beds. During the year 666 midwives attended the hospital for instruction. Sheffield Street hospital. (e) hospital for venereal diseases. The medical officer (Dr. Millicent Hamilton-Johnstone) has reported as follows on the work done at Sheffield Street hospital:— During the year 299 adults and 14 infants were admitted to the hospital; 134 infants were born alive and 3 were stillborn. The diseases from which the patients admitted suffered were as follows :— Adults. Infants. Gonorrhœa 185 Congenital syphilis 5 Gonorrhæa and syphilis 80 Ophthalmia neonatorum 2 Syphilis 25 Vulvo-vaginitis 1 Free from signs of venereal disease 9 Non-venereal 6 Total 299 Total 14 105 Of the adult syphilitic cases, all were secondary except the following:— One pregnant woman suffering from congenital syphilis and gonorrhoea, had received treatment during pregnancy and gave birth to an infant with negative Wassermann and Kahn reactions. Three cases of tertiary syphilis. Of these, one woman aged 36 suffering from locomotor ataxia, who had not received any treatment for syphilis until her admission six weeks before her confinement, gave birth to a full-term infant whose blood was negative at birth, and remained so when examined two months later; another woman admitted with a gumma of the soft palate, who did not give any history of primary or secondary syphilis, and whose only treatment was one injection a week before her confinement, gave birth to a syphilitic infant; the third woman, who had gummatous ulceration of the legs and was admitted with a syphilitic infant, had not had any treatment. There was one case of latent syphilis in a woman aged 40. There was a history of live births in 1919, 1921, 1924, but in 1926, 1929, 1931, 1932 she had had miscarriages. Her blood was examined a fortnight before admission at an ante-natal clinic, and again on admission, and found to give positive Wassermann and Kahn reactions. She gave birth a month after admission to a full-term infant with negative blood, the mother's blood still remaining positive. Of the gonorrhoeal cases, as usual, the disease was well established before admission, and only one case was received within the first month of infection, seven were suffering from arthritis, all of whom were pregnant and had not received treatment for gonorrhoea prior to admission; in five cases inflammation subsided with recovery of joint function ; in two cases of arthritis of wrist joint, where the onset was several weeks before admission, the result was ankylosis of joint with normal movements of fingers. There were 22 cases of salpingitis and 20 of Bartholinitis. Of the 9 cases found free from venereal disease, 3 were girls admitted with a history of a positive Wassermann. On admission they were found free from clinical signs of V.D., and repeated Wassermann and Kahn tests, after provocative injections, were negative. Six were suffering from B. coli cervicitis. As regards general diseases complicating venereal disease, there were: one case of bronchopneumonia, four cases of epilepsy, four cases of valvular heart disease, one case of myocarditis, and 50 cases suffering from scabies. Of the 134 infants born alive, 26 were suffering from congenital syphilis. Nine of these were infants of mothers admitted in labour and who had not received any ante-natal treatment for syphilis. The remaining 17 were born of mothers who had only received treatment during the last month of pregnancy. Seventeen women who had received a course of treatment before the 7th month of pregnancy gave birth to healthy infants. Two infants, of mothers admitted in labour and suffering from gonorrhœa for which they had not sought treatment, developed ophthalmia neonatorum. In the three cases of still-births, the mothers were admitted in labour: one was suffering from untreated syphilis and the remaining two from gonorrhoea. The sources from which patients were received were as follows :— Adults. Infants. Public assistance institutions 105 11 Voluntary hospital clinics 108 3 Social workers 19 — Police court probation officers 65 — Private doctors 2 — During the year the numbers of cases discharged were : adults, 305; infants, 146. One adult and four infants died. The cause of death in the adult was myocardial degeneration (syphilis). Three of the infants died from congenital syphilis and prematurity and the other from convulsions. 2.—hospitals for tuberculosis. Heatherwood hospital, Ascot. In December, 1929, the United Services Fund offered to transfer Heatherwood hospital to the Council as a free gift after the cessation of the fund in about eight years time from then, and this generous offer was gratefully accepted. During 1934, at the request of the United Services Fund, the Council agreed to take over the hospital on 1st October, 1934, on the understanding that the hospital should continue to be available for the treatment of children of ex-service men and women (who would have preference) as well as others resident in the county of London, suffering from orthopaedic conditions. The Chairman of the Council of Management of the United Services Fund, Major-General Lord Loch, C.B., C.M.G., D.S.O., M.V.O., D.L., formally handed over the title deeds of the hospital to the Chairman of the Hospitals and Medical Services Committee at the hospital on 2nd November, 1934. Transfer to the Council. 106 The hospital, which has accommodation for 136 patients, was established in 1920 by the Council of Management of the United Services Fund for the benefit of those children of their ex-service comrades in the Great War who were suffering from surgical tuberculosis and other orthopaedic diseases. At that time the facilities for the form of treatment that could be provided at Heatherwood hospital did not exist to the same extent throughout the country generally as they do to-day. At the date of transfer, the number of patients admitted to the hospital since its establishment amounted to 1,564, drawn from all parts of the country, and of these 1,452 had been discharged. In 1,096 cases, the disease had been arrested and in other cases the condition had been improved. Investigations made as to the final results of the cases discharged have shown that a remarkably high percentage of complete recoveries has taken place, many of the earlier cases now being in full-time employment. A clinic held in London every two weeks undertook until 30th September, 1934, the after-care of cases residing in and near London. These clinics are now held at the County Hall. The hospital consists of three ward blocks, one for children of both sexes up to the age of seven, and one each for girls and boys over that age. There is a light treatment block in which the most up-to-date types of lamps are installed. The hospital stands in fifty-five acres of grounds, partly wooded and partly laid out as gardens, and is practically self-contained, having its own lighting and heating plant, laundry and workshops ; also a sewage disposal works. All splints and other surgical appliances required by patients are made in the hospital workshops, in which a few suitable patients were formerly employed as apprentices. All extensive market garden supplies the hospital with most of its requirements in vegetables and fruit, important items in the children's diet. Four teachers work under the direction of the head teacher, and the hospital school is recognised as such by the Board of Education and the Ministry of Health. Recently at an International Exhibition of Cripples' Work at Bristol, the hospital secured 6 first class diplomas, 10 second class diplomas, and 16 third class diplomas for the work of the children. There are active Boy Scout and Girl Guide troops in the hospital. The nursing staff are accommodated in the original mansion on the estate, which is situated a little distance from the wards. It is proposed to extend the buildings so as to accommodate 100 additional patients. The following work was done in the special departments of the hospital during the year:—301 plasters applied, 67 casts taken, 512 X-rays taken, 24 clinical photographs taken, 4,017 plaster bandages used, 178 operations performed, 71 dental extractions, 44 dental anæsthetics, 60 dental fillings, 11,335 light treatments given, and 6,432 treatments by massage and remedial exercises; while in the hospital workshops 328 splints were made and 103 repaired for in-patients and 254 made and 98 repaired for out-patients seen at the after-care clinic. Reservation of beds for Middlesex cases. The Middlesex County Council had an arrangement with the United Services Fund whereby 25 beds at the hospital were reserved for their patients. It was agreed that these beds should continue to be reserved for Middlesex County Council cases for two years from 1st October, 1934, or until such earlier time as that County Council could make other satisfactory arrangements, subject to the full cost of maintenance being paid for each bed, whether occupied or not. Treatment of tuberculosis. The medical superintendent of King George V. sanatorium (Dr. Watt) has reported that there was no substantial change in the character of the cases treated. As in former years, the proportion of early cases of pulmonary tuberculosis admitted for treatment was about a quarter of the whole. He states that the modern tendency is to attack more actively than formerly disease that has damaged the lungs considerably, that there are, of course, many failures among these more or less advanced cases, but that, on the other hand, there are a good many brilliant successes. He adds that a higher percentage of cases than formerly leave King 107 George V. sanatorium with sputum T.B. negative, and that there is reason to believe that the survival rate after five years is about 10 per cent. higher than it was 10 or 12 years ago. In this work the facilities provided by the opening of the operating theatre and new X-ray department in the autumn of 1933 have proved invaluable. During 1934, 3 operations of thoracoplasty, 8 of apicolysis, 30 of phrenic evulsion, 38 of phrenic crushing, and 18 of thoracoscopy for cutting adhesions were performed by the visiting chest surgeon. In addition the visiting ear, nose and throat surgeon performed 4 tonsillectomies, 1 radical mastoid operation, and 1 submucous resection. Treatment by artificial pneumothorax is carried out in approximately a third of all the cases. The exact number commenced in 1934 was 143, and the total number of refills was 3,657. Sanocrysin or other salt of gold was used in 37 cases. The medical superintendent of Pinewood sanatorium (Dr. Fowler) has reported as follows:— Full use, as far as the clinical material demands it, is being made of artificial pneumothorax treatment, gold salts, and phrenic nerve paralysis. The idea of obtaining a really good collapse, both clinically and anatomically, is increasingly pursued by means of thoracoscopy and adhesion section. Oleothorax has been little used because of the diffidence of institutions dealing with the patients after they leave here to carry on with the occasional refills required. Some of the old cases of oleothorax come up to Pinewood regularly for observation and refills, and all of them are doing well. The medical superintendent of Colindale hospital (Dr. Heaf) has reported as follows :— Treatment has been continued along the same lines as in 1933, but in a more intensive manner. Collapse therapy has been applied to cases wherever possible and major surgical procedures have been used more extensively, due regard always being taken of the resistance of the patient to the infection. Considerable benefit has been obtained from temporary paralysis of the diaphragm by crushing the phrenic nerve instead of permanently eliminating its action by evulving the nerve. This treatment is particularly valuable when combined with absolute rest. Treatment by gold salts is still considered beneficial in certain cases. The throat department has still been favoured by the help of Sir James Dundas Grant. Ultra-violet light therapy has been supplied directly to the larynx in 25 cases, and it has been noted that it gives some relief to dysphagia and favours the formation of fibrous tissue in areas of infiltration. This work is being continued. The number of ex-patients continuing their artificial pneumothorax treatment at the hospital was 82 during the year. This number is gradually increasing. The following statistics show the number of cases treated by special methods during 1934 :— Major surgical methods— S.M. resection 1 1st stage thoracoplasty 12 Antrum washout 1 2nd stage thoracoplasty 9 Kromayer U.V.L. application to 3rd stage thoracoplasty 2 larynx and ulcers on tongue, etc.403 Apicolysis (wax implant 2 Out-patients attending for throat Adhesion sections 17 paintings 9 Thoracoscopy 4 X-ray department— Orchidectomy 1 X-ray photographs 1,228 Inguinal hernia 1 ,, ,, staff 112 Minor operations— Out-patient department— Phrenic evulsion 33 No. of patients for A.P. refills 82 Phrenic crushing 45 „ attendances for A.P. refills 625 Rib resection 2 „ patients for throat treatment 9 Aspirations and minor operations 112 „ attendances for throat treat- A.P. refills 2,311 ment 72 Throat department— patients for sanocrysin 2, — Cauterisation of larynx 8 attendances 24 „ ear 1 Mercury V. U.V.L. 400 Injection of superior laryngeal nerve 5 Infra-red radiant heat 396 Application of chaulmoogra oil and Dental department— Argyrol, 50 per cent. 437 No. of patients received treatment 647 The weekly clinic, at which cases requiring special treatment are discussed, has been held regularly throughout the year and has been attended by 64 visitors. The clinic is becoming increasingly valuable in checking over-enthusiasm for any special line of treatment and in making a more accurate prognosis of cases. 108 The medical superintendent of Grove Park hospital (Dr. Logg) has reported as follows:— The work in the X-ray, surgical and out-patient departments showed a material increase during 1934, and in particular it should be noted that although comparatively the same number of fresh patients (i.e., those who have not received in-patient treatment formerly) have attended, the total number of out-patient attendances was 659, compared with 397 during the preceding year. Further, despite the number of operations carried out by the resident staff, there has been a material increase in the visits made, and operations done, by the consulting thoracic surgeon. During 1934 there has been a materially increased pressure upon the nursing and medical staff in view of (a) the higher percentage of more seriously ill patients requiring attention, (6) the increased number of patients requiring orthopaedic appliances and more detailed nursing in the non-pulmonary unit, (c) the number of minor thoracic operations in addition to routine artificial pneumothorax work (approximately one patient in six has been having pneumothorax or other special surgical treatment), and (d) the material increase in the number of out-patient attendances and the necessity for fitting in these attendances to suit the convenience of patients who are now following remunerative occupations. The medical superintendent of St. Luke's hospital, Lowestoft (Dr. Colvin), has reported as follows :— Treatment for the patients has been carried out in accordance with the accepted principles, my only matter for comment in this respect being the increased use of gold salts in certain types of non-pulmonary tuberculosis. The amount of work carried out here in non-pulmonary tuberculosis has not as yet been so extensive as to allow us to form any valuable or incontrovertible opinion regarding the value of gold salts. At the same time, the results so far obtained in certain types of glandular tuberculosis are distinctly promising and give encouragement to persevere more extensively with this form of treatment in the future. The number of operations performed during 1934 was 679. There is again a decided increase in the number of cases of spinal tuberculosis requiring aspiration of abscesses. During the year 186 plaster of Paris splints were applied by the medical staff, while 388 splints or appliances were either made, altered or repaired in the splintmaker's workshop during 1934. This figure includes the fitting and assembling of 74 spinal frames and 20 hip abduction frames. The number of artificial light treatments given during 1934 totalled 15,261 to 193 patients. Of these, 3,032 treatments were local applications with the Kromayer lamp. As regards discharged patients who had received artificial hght treatment during their stay in the hospital (not necessarily in 1934), the following table indicates the results obtained in 173 cases of tuberculosis :— Type of case. Numbers treated. Treatments. Percentages. Local. General. Quiescent. Improved. Not improved. Spine 39 283 3,876 67 15 18 Hip 17 57 1,079 65 23 12 Knee 16 133 1,082 88 12 — Other joints 25 439 2,310 68 28 4 Abdominal 32 287 1,795 82 6 12 Glands 22 948 1,069 68 32 — Skin (lupus) 4 56 151 25 75 — Other 18 446 975 50 33 17 The medical superintendent of the Northern hospital (Dr. Borthwick) has reported that the treatment of cases of pulmonary tuberculosis at that hospital by courses of gold salts has been continued, over 100 cases having been thus treated during the year, and the dosage and results correlated, particularly with regard to the amount of sputum, presence and absence of tubercle bacilli and X-ray changes. Reference was made in the last annual report to the fact that the future of Princess Mary's hospital for children, Margate, which was established for the treatment of surgical tuberculosis, was then under consideration. During recent years the demands for admission to this hospital have been diminishing and, in the summer of 1933, part of the accommodation was used for school journey parties, and subsequently a portion of the hospital was in occupation by convalescent children until August, 1934, when they were replaced by adult convalescent women who 109 benefited greatly by their stay. In all 98 women were admitted. Following their departure, child convalescents were again admitted in November. A number of school holiday children were received during the summer as in the previous year. It has now been decided to transfer the children suffering from surgical tuberculosis to Heatherwood hospital, Ascot, as soon as that hospital has been enlarged, and to transform Princess Mary's hospital for children into a convalescent hospital for women. The medical superintendent (Dr. Johnstone) has stated that, of the 227 children in the surgical tuberculosis unit who were discharged from the hospital during the year, 180 were discharged with the disease arrested, in 12 cases the diagnosis was not confirmed, 25 were transferred to fever hospitals and 10 to other special hospitals. The results of treatment of cases of surgical tuberculosis have been uniformly satisfactory. Again there were long spells of fine sunny weather, of which full advantage was taken by exposing the patients on the sun verandahs. There is an increasing number of cases being admitted with a diagnosis of tuberculosis which cannot be confirmed after observation and investigation. The explanation, in the opinion of the medical superintendent, lies in the fact that a steadily increasing number of cases are being admitted very early after the incidence of trouble, which after a period of time proves to be non-tuberculous. This is matter for congratulation and is as it should be. Coupled with this, an increasing number of cases are sent for observation, proving that the advantages of early reporting are being realised. The medical superintendent reports that the proportionately large percentage of cases developing genito-urinary disease in 1932 and 1933 has not been maintained. Only one case was transferred to the genito-urinary clinic at Queen Mary's hospital during the year. At one time it was mooted that one of the contributory causes of this complication was exposure of the patient to sun or artificial light treatment. Bearing in mind the two very fine summers of 1933 and 1934, during which the patients' total exposure to radiant energy, natural and artificial, was very high, Dr. Johnstone has come to the conclusion that it plays no part. He is convinced that the main factors are immobilization and posture employed during treatment of active disease. Account must be taken of the time factor and the seat of the active bone lesion. However, investigation is proceeding with regard to cases under treatment. The following table shews the number of visits paid by patients to the X-ray department during the last four years :— 1931. 1932. 1933. 1934. 462 708 896 797 During the year 1,047 areas were skiagraphed, involving the use of 1993 films, and 990 reduced prints were made. The work done in the plaster room is shewn by the following figures, viz., plasters applied 291, casts taken 77, bandages used 3,757, celluloid splints completed 68, plasters removed 226, plasters repaired 91. In the dental department there were 1,019 examinations, 137 fillings and 273 extractions. In the artificial light department 534 general and 2,272 local treatments were given. The fall in the number of general treatments given is partly due to the decline of suitable cases, but in the main to the restricted facilities which the existing apparatus provides. The approaching change in the use of the hospital precludes the expenditure which would be involved by the provision of improved facilities for this form of treatment. In the splint workshop 442 pieces of new apparatus were made and 933 repairs effected during the year. While there was a decided increase in splint and boot repairs over those carried out in 1933, due to the extended use of Thomas' abduction frames with their leather attachments, combined with increased surgical boot wear and tear, there was a reduction of almost one-third in the number of new splints made owing to the decline in the number of cases of surgical tuberculosis suffering from bone and ioint disease. H 110 Pulmonary tuberculosis in children. The medical superintendent of High Wood hospital for children (Dr. Reade) has reported an increase in the number of positive sputum cases being admitted. Whereas, on 31st December, 1933, there were 62 children in the hospital with tubercle bacilli in the sputum, on 31st December, 1934, there were 100 such cases (excluding those in which the presence of tubercle bacilli was only demonstrated by the gastric lavage method), and on 31st December, 1933, there were 38 cases undergoing artificial pneumothorax treatment, while on 31st December, 1934, there were 50 such cases. During 1934 a larger number of operations have been performed. For instance, in 1933, there were only four operations of phrenic evulsion, whereas in 1934 there were 11. In 1933 there was' one operation of thoracoscopy and division of adhesions and in 1934 there were four. For this operation a new type of thoracoscope, of small bore suitable for children, was designed and used during the latter part of 1934 with great success. There was also an increase in the number of ear, nose and throat operations, viz., 54 in 1934 as against 19 in 1933. Double artificial pneumothorax was done in five children with beneficial results, and it was found that the children stood the reduction of pulmonary ventilation very well. Research in tuberculosis. The medical superintendent of King George V sanatorium has collected data for about 300 cases treated at that sanatorium by sanocrysin in recent years, from which, he states, the main fact emerges that about 50 per cent. of those having complete courses of gold treatment lost the tubercle bacilli from their sputum. He hopes to submit details when he has examined a control series. He adds that his colleagues in the other tuberculosis hospitals who have collected statistics find a similar result and are convinced of the value of gold salts in treatment. The following researches have been carried out at King George V sanatorium during the year, viz.:— (a) Correlation of the blood sedimentation rate, the Von Bonsdorff count and the differential leucocyte count; (b) Analysis of the results of treatment by sanocrysin ; (c) Survey of acquired pigmentation and its relation to prognosis ; (d) Investigation of the value of tuberculin in treatment; (e) Characters of tuberculous pleural effusions. The medical superintendent of Colindale hospital (Dr. Heaf) has reported that research has been continued at that hospital along the same lines as indicated in the last annual report. He adds that the value of Houghton's blood index is becoming more evident by increased use, and expresses the opinion that the relation of streptococcal infection to tuberculosis may have an important bearing on treatment. The work on cadmium therapy referred to in the last annual report has advanced and a non-toxic preparation is now ready for the treatment of patients in place of gold salts. The consulting ear, nose and throat surgeon (Mr. R. Scott Stevenson) has reported that at Colindale hospital during the year the researches into the value of local application of chaulmoogra oil and of the local application of ultra-violet light to the larynx were continued. It is still too early to make a definite statement of these methods of treatment, but promising results were obtained, and it is hoped that the improvements shown in many cases will be maintained. Chaulmoogra oil was applied 437 times, and the Kromayer ultra-violet light applied locally to the larynx and tuberculous ulcers of the tongue on 403 occasions. Eight cases had the larynx cauterised by the galvano-cautery, and five cases had the superior laryngeal nerve injected. One case had a sub-mucous resection of the nasal septum done and one an intra-nasal antrum operation. The consulting ear, nose and throat surgeon (Mr. R. Scott Stevenson) has reported that the routine method of anaesthesia for operations on children at High Wood hospital for children has been evipan by the intravenous route. In eight cases 1ll ether was employed for one reason or another, usually because the child's veins were so small that it was difficult to administer evipan. The usual dose of evipan has been 5 to 10 c.c., and the average dose about 7 c.c.; in every case the dose was calculated by doubling the amount found effective to cause sleep. The experience gained of evipan anaesthesia in children with chest disease was entirely satisfactory. All the 26 cases with pulmonary tuberculosis or pulmonary fibrosis were given evipan intravenously, and there were no pulmonary complications or other unfavourable sequelae. At Pinewood sanatorium research work is being carried out on cardiograms in pulmonary tuberculosis and on pulse pressures. Occupational therapy. During the year a printing shop was erected at Colindale hospital out of funds provided by the handicrafts account. It will be necessary to provide further accommodation for other industries and to improve the equipment of the shops. Colindale hospital—Cinematograph apparatus. In February, approval was given to the cinematograph projector, which had some time ago been presented for installation in the recreation hall at this hospital, being converted into a " sound " machine. Through the instrumentality of a gentleman connected with the firm which made the original gift the conversion was carried out at small cost to the Council. After-care clinics for surgical tuberculosis. The after-care clinics held at the County Hall for ex-patients of Princess Mary's hospital for children and St. Luke's hospital, Lowestoft, have continued to expand, and during the year decisions have been made on various points of administration with a view to facilitating the work of the clinics, and the prompt supply or renovation of splints or other surgical appliances required by the patients. The after-care work for Heatherwood hospital, the control of which was taken over by the Council during the year, was transferred from the Farringdon dispensary to the County Hall. Two afternoon sessions are held each month on the same lines as those for the other two clinics. In addition to patients treated under the Council's tuberculosis scheme, the medical superintendent sees patients who have received residential treatment at the hospital under agreements with the Middlesex County Council and other out-county authorities. As in the case of the clinic for Princess Mary's hospital for children, a representative of the Invalid Children's Aid Association also attends this clinic, and gives valuable assistance in advising parents or communicatine with other persons interested in the cases. The following statement gives an indication of the work done at the clinics during the year :— Hospital. No. of patients on register. No. of attendances. Appliances renovated or altered. St. Luke's hospital, Lowestoft 288 522 55 Princess Mary's hospital for children 212 891 198 * Heatherwood hospital 146 98 28 * For three months ending 31st December, 1934. The clinics now play a very important and helpful part in the scheme of treatment of tuberculosis, and that they are greatly appreciated is shewn by the fact that practically all cases discharged from the hospitals attend regularly. From the administrative aspect, the clinics are of great help, as they form a means of assessing the value of lines of treatment given during the patients' stay in hospital, and also offer a ready means of checking progress and detecting at an early date any possible relapse. 112 3.—children's hospitals. Accommodation for patients. In the report for 1933 it was mentioned that, owing to the incidence of infectious disease, it was necessary in October of that year, to remove the non-infectious convalescent children from the lower Southern hospital, and to obtain special authority for expenditure for placing children in convalescent homes not under the control of the Council. It became possible, in May, 1934, to resume the use of the lower hospital for non-infectious patients, and greater use has been made of the accommodation than in former years. The highest number under treatment in the lower hospital during the year was 313. Since the enlargement of Queen Mary's hospital for children in 1931, when the nominal accommodation for patients was increased from 900 to 1,274 beds, certain minor improvements have been effected with a result that, at the beginning of 1934, the accommodation was still further increased to 1,284 beds. Ringworm. At the beginning of 1934 there were 44 cases of ringworm in the Goldie Leigh hospital, Abbey Wood ; during the year 369 were admitted, 381 discharged and 32 remained under treatment on 31st December. The assistant physician for X-ray work (Dr. Cochrane Shanks) has reported the following:— Total Cases X-rayed 208 Cases of incomplete defluvium requiring re-raying 13 Cases re-rayed because of re-infection 1 Endothrix cases 15 Cases from other institutions :— Fountain mental hospital16 Exmouth training ship 10 West Sussex County Council 1 Case of marked hydrocephalus 1 It will be noted that there were 15 endothrix cases, the largest number which has occurred in one year in the hospital during the last ten years. Another feature of his report is the 13 cases of incomplete defluvium. These are balanced by the absence in the report of any case of X-ray dermatitis or injury from the rays. The X-ray treatment of ringworm still remains the most delicate and difficult of X-ray operations. With our present knowledge and methods, and in spite of the most up-to-date X-ray apparatus kept in perfect working order and used almost entirely for the one purpose, the margin of error between an underdose and an overdose is so narrow that it is advisable to err on the safe side, even though an under-exposure may occur with incomplete defluvium, rather than to take the risk of an excessive dosage. Skin diseases. At the beginning of 1934 there were 82 cases of skin diseases other than ringworm in Goldie Leigh hospital; during the year 146 were admitted and 138 discharged, leaving 90 cases under treatment on 31st December. The consulting physician for skin diseases (Dr. J. M. H. MacLeod) has reported that the majority of the cases of skin diseases treated in the hospital during 1934 were either some form of eczema or septic dermatitis. As many of the cases of eczema have their origin in a simple septic dermatitis which has become eczematised through scratching or rubbing, it is difficult to make a hard and fast distinction between these two groups. Cases in which the eczematous changes affect the scalp pro ve most intractable, and it may be years before the scalp resistance has sufficiently improved for healing to take place. During the year the following skin affections have been treated: alopecia areata, dermatitis (seborrhœic and septic), eczema, folliculitis (septic), ichthyosis, ichthyosis bullosa, impetigo, molluscum contagiosum, moniliasis, pemphigus perleche, pityriasis rosea, psoriasis, scabies, warts (verruca vulgaria and plana), xeroderma. 113 In addition to the usual common types of dermatitis there have been several cases of sufficient interest to be worthy of notice. Ichthyosis bullosa.—At present in the hospital there are two cases of this rare condition, a boy, admitted at the age of 10 months and now aged 10 years, and a girl, admitted at the age of 5, now 14 years old. Both these cases are gradually healing. This unusual congenital condition forms a connecting link between ordinary ichthyosis and epidermolysis bullosa, and is characterised by a coarse thickening of the horny layer of the skin, especially in the extremities and lower parts of the back. This horny thickening becomes raised up from time to time by the formation of flaccid bullae beneath it. These lead to the separation of the epidermis in sheets leaving raw, moist surfaces. The eruption of the bullae is aperiodic and no special reason for their occurrence has yet been ascertained, except that in some instances they may have been caused by friction or injury. Occasionally the formation of bullae is associated with a general toxic condition and a rise in temperature, possibly caused by their becoming septic. As usually occurs in ordinary ichthyosis, a definite improvement takes place with the growth of the child, the bullae become less frequent, and the skin less vulnerable and less liable to secondary septic infection. In the case of the girl the improvement during the last year has been so marked that it is hoped that by the time she reaches the age limit and leaves the hospital, her skin condition and general health may be so improved as to enable her to earn a living. For this happening considerable credit is due to the unremitting care and skilled attention of the nursing staff. Perleche.—There was one instance of this somewhat unusual affection in a boy. The condition is characterised by circumscribed patches of scaly erythema surrounding the mouth and extending for a short distance on the cheeks. It is of septic origin and usually associated with cracks at the commissures of the mouth which are kept open and infected by organisms in the saliva. These cases are extremely intractable, and so long as the cracks persist the surrounding inflammation remains. Such remedies as Friar's balsam and nitrate of silver are of uncertain value in healing them, and the most satisfactory treatment is one or more exposures to X-rays, giving an initial dose of a half pastille unscreened, repeated if necessary a fortnight later. Pityriasis rosea.—There have been two cases of this elusive affection and both from one residential school. This disease is of very rare occurrence in the hospital, and it is an odd coincidence that the two cases should have been admitted simultaneously, and from the same school, as there is no evidence that the condition is infectious. During 1934 there was an excessive number of cases of scabies, and a larger number of cases of molluscum contagiosum than usual. In a certain number of the molluscum cases the lesions were present on admission, but there have been several in which they appeared in hospital in cases admitted for other conditions. Molluscum is one of the most difficult skin affections in which to prevent spreading. When cases are admitted they are isolated in bed until cured ; they are not allowed to use the bathrooms and every precaution is taken to avoid indirect contacts. In spite of these precautions sporadic cases keep cropping up among the patients. These may be possibly due in some instances to infection being present on admission, the lesions, however, being so small as to be unrecognised. Non-tuberculous chest conditions in children. During the year a block for non-tuberculous chest conditions such as fibrosis and bronchiectasis was opened at High Wood hospital for children. This has made it possible to retain in the hospital debilitated children who, although not suffering from pulmonary tuberculosis, nevertheless need fresh air and the sanatorium type of treatment for three or four months. In doubtful cases of fibrosis and bronchiectasis, lipiodol examinations have been made. A special curved cannula, which will not easily slip out of the trachea, is being used for this purpose. 114 Research work. The research work undertaken at Queen Mary's hospital for children during the year has been as follows :— Etiology of rheumatism,.—In conjunction with Dr. Stuart Harris of St. Bartholomew's hospital, and Dr. L. W. Cann of Guy's hospital, bacteriological and pathological investigations were commenced in 1934. The work is still in hand, and it is hoped to carry it further during the year 1935. Acid metabolism in rheumatic children.—Investigations as to the acid metabolism in cases of acute and subacute rheumatism, rheumatic carditis and chorea, as shown by analysis of the urine, is being undertaken in conjunction with Dr. Wilfred Payne, of the Hospital for Sick Children, Great Ormond Street, London. The investigation is at present incomplete, and will be continued during the present year. Anthropometric investigation of rheumatism.—In conjunction with Dr. Matthew Young, of the Department of Anatomy and Embryology of University College, London, a large number of rheumatic children have been investigated anthropometrically. Interesting data have been obtained, but the lack of accurate knowledge of the anatomical dimensions of English children between the ages of 5 and 16 greatly reduces the value of this work. Immunisation against diphtheria.—During 1933 and 1934 a large number of trials have been carried out to test the efficacy of certain preparations containing diphtheria toxoid. It has been suggested that by the simple method of inunction children could be rendered immune to diphtheria. The results obtained were most disappointing, and it would appear that the preparations used in this investigation are of very little, if any, value. Insufflation of iodine and boric acid in otitis media.—This method of treatment of chronic otitis media was commenced in 1933, as stated in the last annual report, and was continued during 1934. The results obtained have been favourable, and it is now used as the standard method of conservative treatment. Urinary calculi.—An investigation has been conducted, in conjunction with the Council's chemist, into the composition of urinary calculi in children, particularly those occurring in association with treatment by recumbency. 115 List of Special Hospitals. Name of hospital. Where situated. Date of opening. Acreage (approx.) Accommodation (31st December, 1934). Medical superintendent. Matron. Steward. Number of beds in special wards (isolation, separation, discharge etc.). Number of beds in ordinary wards. Total number of beds. Infectious hospitals. Brook hospital (fever) (a) Shooters-hill, S.E.18 31st August, 1896 29¼ 104 448 552 J. V. Armstrong, m.d., D.P.H. Miss M. E. Quinlan, A.R.R.C. H. W. Lowe. Eastern „ „ Homerton-grove, E.9 1st February, 1871 (Enlarged in April, 1921, by the purchase from the City of London Guardians of the adjoining institution standing on a site of about 6 acres). 15 91 470 561 H. M. Pereira, l.r.c.p., l.r.c.s., l.r.f.p.s. d.p.h. Miss Barcham W. W. Spencer. Grove ,, ,, Tooting-grove, Tooting Graveney, S.W.17. 17th August, 1899 22¾ 124 432 556 J. H. Whitaker, m.d., d.p.h. Miss M. H. Griffith. W. B. Simpson. North-Eastern ,, hospital. St. Ann's-road, S. Tottenham, N. 15. 8th October. 1892 28 124 537 661 E. H. r. Harries, m.d., d.p.h. Miss A. Evans H. P. Austin. North-Western ,, hospital. Lawn-road, Hampstead, N.W.3. 25th January, 1870 12¼ 67 343 410 A. Joe, d.s.o., m.d., d.p.h. d.t.m. & h. Miss S. M. Kelly J. S. Gibson. Park hospital ,, Hither Green, S.E.13 8th November, 1897 23 132 480 612 H. S. Banks, m.a., m.d., d.p.h. Miss J. H. Balsillie. W. C. Oakshett. South-Eastern ,, hospital. Avonley-road, New Cross, S.E 14. 17th March, 1877. (Reconstructed 19041906 and reopened 2nd July, 1906.) 13 96 384 480 G. W. Ronaldson, m.d., d.p.h. Miss F. M. Campbell. G. Gay. South-Western „ hospital. Landor-road, Stockwell, S.W.9. 31st January, 1871. 8½ 65 258 323 N. W. Walmsley, m.d., d.p.h. Miss A. Fraser R. C. Letts. Western hospital „ Seagrave-road, Fulham, S.W.6. 10th March, 1877 13¾ 158 363 521 J. D. Rolleston, m.a., m.d., f.r.c.p. Miss E. Clarke G. A. Ward Northern hospital (b) (convalescent fever) Winchmore Hill, N.21 25th September, 1887 35¾ 60 *652 712 G. A. Borthwick, m.d., d.p.h., d.t.m. & h. Miss A. Roberts H. Hooper. Southern Upper hospital (convalescent fever) Dartford, Kent October, 1890 160 138 639 777 G. L. Thompson,m.b.,ch.b. Miss A. T. Hyde S. H. Flinn. Southern Lower hospital (c) (convalescent fever Dartford, Kent Erected 1902 36 731 767 *Including 100 beds for tuberculosis shown separately below. 116 Special Hospitals—continued. Name of hospital. Where situated. Date of opening. Acreage (approx.) Accommodation (3lst December, 1934). Medical superintendent. Matron. Steward. Number of beds in special wards (isolation, separation, discharge etc.) Number of beds in ordinary wards. Total number of beds. Joyce Green hospital (fever or smallpox) Dartford, Kent. The River hospitals. 28th December, 1903 254 150 836 986 A. F. Cameron, m.a., m.d., c.m., d.p.h. Miss C. A. Morris, a.r.r.c. W. H. Golden. Orchard hospital (fever or smallpox ) Erected 1902 63 24 640 664 Long Reach pier buildings (smallpox). 27th February, 1902 24¼ — 48 248 Long Reach „ hospital. Hospital reconstructed 1928-29 200 J ‡St Margaret's hospital (ophthalmia neonatorum and vulvo-vaginitis) Leighton-road, Kentish Town, N.W.5. 16th September, 1918 - 75 - 75 Miss D. M. Howard b.a., l.m.s.s.a. (visiting medical officer). Miss K. M. Hosken - Sheffield St. hospital (venereal) Kingsway, W.C.2 21st June, 1920 - 82 - 82 Miss M. Hamilton-Johnstone, b.a., m.b., b.ch., b.a.o., d.o.m.s. (visiting medical officer). Miss G. M. W. Nash. - Hospitals for Tuberculosis. King George V sanatorium Nr. Godalming, Surrey. 8th June, 1922 62 — 232 232 j. Watt, m.a., m.d., ch.b., d.p.h. Miss M. Sheehan F. C. Barkway. Pinewood sanatorium Wokingham, Berks. 7th July, 1919 (Used Sot male patients until 29th Nov., 1921, then closed and reopened for female patients on 8th March, 1922.) 82 - 160 160 W. C. Fowler, m.d., b.s. Miss K. Skinner E. J. Brady. Colindale hospital Colindale-avenue, Hendon, N.W.9. 1st January, 1920 24½ - 349 (d) 349 F. R. G. Heaf, b.a., m.d. Miss W. P. Solomon. J. Watts. Grove Park hospital Lee, S.E.12 9th February, 1926 52 — 322 322 M. H. Logg, m.d., ch.b. Miss E. A. T. O'Brien. H. Parker. Heatherwood hospital Ascot, Berks 1st October, 1934 (Founded in 1922 by and formerly under control of the United Services Fund) 55¼ 14 136 150 E. S. Evans, f.r.c.s. m.b., b.s. Miss M. Campbell F. Duffett. ‡Transferred to General Hospitals on 1st April, 1935. 117 Special Hospitals—continued. Name of hospital. Where situated. Date of opening. Acreage (approx.) Accommodation (31st December, 1934). Medical superintendent. Matron. Steward. Number of beds in special wards (isolation, separation . discharge etc.). Number of beds in ordinary wards. Total number of beds. St. George's home Milman's -street Chelsea, S.W.10. 14th May, 1914 — — 50 50 (Under control of medical superintendent, Colindale.) Miss E. Worden. — St. Luke's hospital Lowestoft, Suffolk 9th May, 1922 — — 210 210 h. j. A. Colvin, m.b., ch.b. Miss E. M. Edmunds. A. S. Martin. Princess Mary's hospital for children. Cliftonville, Margate, Kent. 26th June, 1898 (Reconstructed 19141919 and reopened October, 1919.) 4 - 271 271 J. G. Johnstone, o.b.e., m.c., m.b., ch.b. Vacant K. Belsham. High Wood hospital for children. Brentwood, Essex 26th July, 1904 (Used for ophthalmia until 1918, then for sane epileptics from Aug., 1918, until November, 1919.) 35 - 426 (e)426 A. G. L. Reade, o.b.e., m.r.c.s., l.r.c.p. Miss Q. C. J. Shaw. H. C. Self. Millfield Rustington, Littlehampton, Sussex. 6th April, 1904 7 - 98 98 C. E. Last, m.r.c.s., l.r.c.p. (visiting medical officer). Miss B. G.Vivian J. F. Morgan. Northern hospital (part of) Winchmore Hill, N.21 See above — — 100 (f)100 See above. Children's Institutions. Queen Mary's hospital for children (sick children). Carshalton, Surrey 29th January, 1909 136½ - 1,284 1,284 W. T. Gordon Pugh, m.d., f.r.c.s. (Eng). Miss M. A. Cole J. R. Earnshaw. The Downs hospital for children (sick children). Sutton, Surrey 26th February, 1903 (Used as ringworm school until 1913, then as sanatorium for tuberculosis until 1922.) 42¾ - 360 360 C. Price, m.r.c.s., l.r.c.p. Miss A. M. Pugh C. E. Lee. St. Anne's home (seaside convalescent home). Heme Bay, Kent 26th December, 1897 2½ - 127 127 Malcolm Foster, m.b., ch.b. (visiting medical officer). Miss G. Fox C. A. F. Davies. 118 Special Hospitals—continued. Name of hospital. Where situated. Date of opening. Acreage (approx.) Accommodation (31st December, 1934). Medical superintendent. Matron. Steward. Number of beds in special wards (isolation, separation, discharge etc.). Number of beds in ordinary wards. Total number of beds. Goldie Leigh hospital (ringworm and other skin diseases). Abbey Wood, S.E.2 1st November, 1914 32 — 248 248 J. M. H. MacLeod, m.a., m.d., f.r.c.p. (consulting physician for skin diseases). Miss A. B.Russell, a.r.r.c. W. Cadman. White Oak hospital (ophthalmia and interstitial keratitis). Swanley, Kent. 20th March, 1903 49 - 364 364 M. S. Mayou, f.r.c.s. (ophthalmic surgeon)(g) Miss E. M. Kennett. H. Cloake. Wharf and Pier South wharf Trinity-street, Rotherhithe, S.E.16. Purchased December, 1883. 2¼ — 24 24 A. f. Cameron, m.a., m.d., c.m., d.p.h. Miss C. A. Morris, a.r.r.c. - (a) Closed temporarily from August, 1923, to 4th November, 1925. (b) The number of beds given includes 100 beds for tuberculosis and 274 beds for persons suffering: from the after effects of encephalitis lethargica. (c) When not in use for fever cases 250 beds are available for convalescent children. (d) Including 40 beds on ward balconies available for use during the creator part of the year. (c) Includes 206 beds allocated to the treatment of rheumatic diseases. (f) See note (b). (g) Mr. Mayou died on 20th July, 1934, and temporary arrangements only were made for the remainder of the year. 119 Special Hospitals—continued. Infectious Diseases Statistics. Table I—Admissions, discharges, deaths and, transfers to other hospitals in the same section during 1934. Cerebro-Spinal Fever. Classification. Brook. Eastern. Grove. NorthEastern. Northwestern. Park. SouthEastern Southwestern. Western. Joyce Green. Southern (Lower). Total. Northern. Southern (Upper) Total. Grand Total. In hospital 1st January, 1934 — - — 1 2 3 3 1 2 — — 12 — — — 12 Admissions 4 8 1 4 8 21 2 3 4 — — 55 — - — 55 Total under treatment 4 8 1 5 10 24 5 4 6 — — 67 — - — 67 Discharges (a) direct 1 6 1 4 6 14 4 2 2 — — 40 — - — 40 (b) transferred to other L.C.C. hospitals - - - - - - - - - - - - - - - - Deaths 3 2 — 1 3 8 1 1 4 — — 23 — - — 23 In hospital 31st December, 1934 - - - - 1 2 - 1 - - - 4 - - - 4 Diphtheria—(o) Clinical diphtheria. (b) Bacteriological diphtheria (see note). Classification. Brook. Eastern. Grove. NorthEastern. Northwestern. Park. SouthEastern. Southwestern. Western. Joyce Green. Southern (Lower). Total. Northern Southern (Upper). Total. Grand Total. a b a b a b a b a b a b a b a b a b a b a b a b a b a b a b a b In hospital 1st January, 1934 166 8 152 28 163 9 273 8 101 6 189 9 142 8 112 12 151 2 1 — - — 1450 90 49 4 113 8 162 12 1612 102 Admissions 826 129 1072 363 876 55 1354 151 712 125 1198 105 986 90 902 95 1217 48 4 - 2 — 9149 1161 201 20 1233 151 1434 171 10583 1332 Total under treatment 992 137 1224 391 1039 64 1627 159 813 131 1387 114 1128 98 1014 107 1368 50 5 - 2 - 10599 1251 250 24 1346 159 1596 183 12195 1434 Discharges (a) direct 687 101 587 231 720 48 1286 120 594 109 1049 95 633 69 692 76 571 46 4 - — — 6823 892 224 20 1218 141 1442 161 8265 1056 (b) transferred to other L.C.C. hospitals 100 13 308 120 82 2 5 2 37 2 82 8 239 23 143 23 508 1 - - 2 - 1506 194 16 2 3 - 19 2 1525 196 Deaths 30 2 59 3 43 1 55 1 35 1 47 2 43 1 40 1 66 - - - - - 418 12 - - - - - - 418 12 In hospital 31st December, 1934 175 21 270 37 194 13 281 36 147 19 209 9 213 5 139 7 223 3 1 - - - 1852 150 10 2 125 18 135 20 1987 170 Note.—In cases diagnosed as bacteriological diphtheria, bacteriological evidence of diphtheria was found either before or after admission, but there was no clinical evidence of diphtheria. The deaths shown were due to concurrent diseases. 120 Special Hospitals—continued. Table I—continued. Enteric Fevers (including para-typhoid). Classification Brook. Eastern. Grove. NorthEastern. NorthWestern. Park. SouthEastern. SouthWestern Western. Joyce Green. Southern (Lower). Total. Northern Southern (Upper). Total. Grand Total. In hospital 1st January, 1934 1 — 4 1 1 2 — 1 — — — 10 — — — 10 Admissions 3 1 5 2 11 — — 5 2 — — 29 — — — 29 Total under treatment 4 1 9 3 12 2 — 6 2 — — 39 - - - 39 Discharges (a) direct 4 1 9 3 8 2 — 6 2 — — 35 — — — 35 (b) transferred to other L.C.C. hospitals - - - - - - - - - - - - - - - - Deaths — — — — 2 — — — — — — 2 — — — 2 In hospital 31st Dec., 1934 - - - - 2 - - - - - - 2 - - - 2 Measles. Classification Brook. Eastern. Grove. NorthEastern. NorthWestern. Park. SouthEastern. SouthWestern. Western. Joyce Green. Southern (Lower). Queen Mary's Hospital for Children. Total. Northern Southern (Upper) Total. Grand Total. In hospital 1st January, 1934 — 58 59 66 26 64 76 27 44 — — — 420 - 4 4 424 Admissions 1,028 971 1,164 1,527 845 1,207 1,159 716 667 1,553 1,411 34 12,282 44 1,583 1,627 13,909 Total under treatment 1,028 1,029 1,223 1,593 871 1,271 1,235 743 711 1,553 1,411 34 12,702 44 1,587 1,631 14,333 Discharges (a) direct 833 806 992 1,454 805 1,151 1,080 581 524 1,508 431 32 10,197 44 1,562 1,606 11,803 (b) transferred to other L.C.C. hospitals 119 155 149 60 24 37 84 111 122 28 972 2 1,863 - 7 7 1,870 Deaths 76 68 82 79 42 81 71 49 65 17 8 — 638 — 8 8 646 In hospital 31st Dec., 1934 - - - - - 2 - 2 - - - - 4 - 10 10 14 121 Table I—continued C lassification. Puerperal Fever. Puerperal Pyrexia. Poliomyelitis. Encephalitis Lethargica. NorthWestern Park. South Western Total. NorthWestern. SouthWestern. Total. Park. SouthEastern. Western. Total. Park. In hospital 1st January, 1934 14 — — 14 — — — — 1 4 5 — Admissions 163 1 2 166 31 3 34 1 1 20 22 2 Total under treatment 177 1 2 180 31 3 34 1 2 24 27 2 Discharges (a) direct 154 1 1 156 30 3 33 — 1 17 18 2 (b) transferred to other L.C.C. hospitals - - - - - - - 1 - - 1 - Deaths 15 — 1 16 1 - 1 — 1 — 1 — In hospital 31st December, 1934 8 - - 8 - - - - - 7 7 - Scarlet Fiver. Classification. Brook. Eastern. Grove. NorthEastern. NorthWestern. Park. SouthEastern. SouthWestern. Western. Joyce Green. Southern (Lower). Total. Northern Southern (Upper). Total. Grand Total. In hospital 1st January, 1934 212 160 223 203 143 179 189 114 170 695 347 2,635 146 442 588 3,223 Admissions 1,306 895 1,141 1,513 980 1,520 1,330 731 1,178 4,263 665 15,522 1,255 1,860 3,115 18,637 Total under treatment 1,518 1,055 1,364 1,716 1,123 1,699 1,519 845 1,348 4,958 1,012 18,157 1,401 2,302 3,703 21,860 Discharges (a) direct 1,145 439 1,015 1,263 932 1,548 769 594 602 4,733 358 13,398 1,272 2,127 3,399 16,797 (b) transferred to other L.C.C. hospitals 167 470 120 246 54 32 601 145 612 83 653 3,183 10 10 20 3,203 Deaths 8 4 6 5 7 7 3 7 5 10 1 63 — 5 5 68 In hospital 31st December, 1934 198 142 223 202 130 112 146 99 129 132 - 1,513 119 160 279 1,792 122 Special, Hospitals—continued. Table I—continued. Whooping-Cough. Classification. Brook. Eastern. Grove. NorthEastern. NorthWestern. Park. SouthEastern. SouthWestern. Western. Joyce Green. Southern (Lower). Total. Northern Southern (Upper). Total. Grand Total. In hospital 1st January. 1934 24 45 55 32 31 16 — 16 16 — — 235 — 8 8 243 Admissions 181 263 296 224 105 186 126 143 186 1 — 1,711 79 182 261 1,972 Total under treatment 205 308 351 256 136 202 126 159 202 1 — 1,946 79 190 269 2,215 Discharges (a) direct 130 235 208 198 105 130 78 89 109 1 — 1,283 79 181 260 1,543 (b) transferred to other L.C.C. hospitals 19 25 49 25 1 7 32 37 55 - - 250 - 3 3 253 Deaths 25 38 38 23 11 15 15 15 23 — — 203 — 3 3 206 In hospital 31st December, 1934 31 10 56 10 19 50 1 18 15 - - 210 - 3 3 213 Zymotic Enteritis. Classification. Brook. Eastern. Grove. NorthEastern. NorthWestern. Park. SouthEastern. SouthWestern. Western. Joyce Green. Southern (Lower). Total. Northern. Southern (Upper). Total. Grand Total. In hospital 1st January, 1934 — - — - — — — — — — — — — - — — Admissions 1 — 1 — — 1 — — — — — 3 — - - 3 Total under treatment 1 — 1 — — 1 — — — — — 3 — — - 3 Discharges (a) direct 1 — — — — — — — — — — 1 — — — 1 (b) transferred to other L.C.C. hospitals - — — - - - - - - — — — — — - — Deaths — - 1 - — 1 — — — — — 2 — — — 2 In hospital 31st December, 1934 — — — — — — — — — — — — — - — — 123 Table I—continued. Other Diseases. Classification. Brook. Eastern. Grove. NorthEastem NorthWestern. Park. SouthEastern SouthWestern. Western. Joyce Green. Southern (Lower). Total Northern. Southern (Upper). Total. Grand Total In hospital 1st January, 1934. 72 30 54 55 62 61 19 23 42 — — 418 — 142 142 560 Admissions 632 729 662 808 678 659 572 719 529 87 16 6,091 9 569 578 6,669 Total under treatment 704 759 716 863 740 720 591 742 571 87 16 6,509 9 711 720 7,229 Discharges (a) direct 584 678 632 801 661 605 538 612 531 75 12 5,729 7 669 676 6,405 (b) transferred to other L. C. C. hospitals 26 17 31 10 8 37 8 79 16 8 4 244 - 16 16 260 Deaths 11 7 2 13 17 17 13 4 2 — — 86 — 3 3 89 In hospital 31st December, 1934. 83 57 51 39 54 61 32 47 22 4 - 450 2 23 25 475 Total. Classification. Brook Eastern. Grove. NorthEastern. NorthWestern. Park. SouthEastern. SouthWestern. Western. Joyce Green. Southern (Lower). Queen Mary's Hospital for Children Total. Northern Southern (Upper). Total. Grand Total. In hospital 1st January, 1934 483 473 567 639 386 523 438 306 431 696 347 - 5,289 199 717 916 6,205 Admissions 4,110 4,302 4,201 5,583 3,658 4,901 4,266 3,319 3,851 5,908 2,094 34 46,227 1,608 5.578 7,186 53,413 Total under treatment 4,593 4,775 4,768 6,222 4,044 5,424 4,704 3,625 4,282 6,604 2,441 34 51,516 1,807 6,295 8,102 59,618 Discharges (a) direct 3,486 2,983 3,625 5,129 3,404 4,597 3,172 2,656 2,404 6,321 801 32 38,610 1,646 5,898 7,544 46,154 (b) transferred to other L. C. C. hospitals 444 1,095 433 348 126 204 987 538 1,314 119 1,631 2 7,241 28 39 67 7,308 Deaths 155 181 173 177 134 178 148 118 165 27 9 — 1,465 — 19 19 1,484 In hospital 31st December, 1934 508 516 537 568 380 445 397 313 399 137 — - 4,200 133 339 472 4,672 124 Special Hospitals—continued. Table II—Direct discharges and deaths, quarterly, during 1934. Disease. In hospital 1st January, 1934 Admissions. Discharges and Deaths. Case mortality percentage. In hospital 31st Dec ember, 1934. January-March. April—June. July-September. October-December. Total. Cages. Deaths. Cases. Deaths. Cases. Deaths. Cases. Deaths. Cases. Deaths. Diphtheria 1,612 9,058 2,399 108 2,015 100 1,993 85 2,276 125 8,683 418 4.71 1,987 Diphtheria (bacteriological) 102 1,136 239 1 253 8 271 1 305 2 1,068 12 1.09 170 Enteric fevers 10 29 10 1 8 — 7 1 12 — 37 2 6.06 2 Measles 424 12,039 3,980 338 6,875 290 1,452 13 142 5 12,449 646 5.28 14 Puerperal fever and puerperal pyrexia 14 200 59 6 57 5 52 3 38 3 206 17 8.37 8 Scarlet fever 3,223 15,434 5,173 32 3,782 22 3,590 7 4,320 7 16,865 68 0.42 1,792 Whooping-cough 243 1,719 483 94 587 72 411 17 268 23 1,749 206 11.88 213 Other diseases 577 6,490 1,617 39 1,690 43 1,499 14 1,775 19 6,581 115 1.76 486 Total 6,205 46,105 13,960 619 15,267 540 9,275 141 9,136 184 47,638 1,484 31.7 4,672 125 Special Hospitals—continued. Table III (a)—Acute Hospitals*—Mistaken diagnosis.—Discharges and deaths during 1934 in which the disease finally diagnosed differed from that stated on the admission certificate. Disease or condition on admission finally diagnosed. Disease certified on admission. Cerebrospinal fever. Chicken pox. Continued fever. Diphtheria. Dysentery. Encephalitis lethargica. Enteric. Typhoid. Paratyphoid. Erysipelas. Measles. Mumps. Poliomyelitis and polioencephalitis. Puerperal fever. Puerperal pyrexia. Rubella. Scarlet fever. Typhus. Whoopingcough. Zymotic enteritis. Other. Total. Cases. Deaths. Infectious diseases : Cerebro-spinal fever - - - - - - - - - - 1 - 1 - - - - - - - 2 2 Chickenpox - - - - - - - - - - 7 - - - - - 23 - 1 - - 31 1 Continued fever - - - - - - - - - - - - - - - - - - - - - - - Diphtheria — — — — - - — — - — 10 1 — — — 1 45 — 3 — 1 61 3 Diphtheria (bacteriological) - - - - - - - - - 1 - - - - - 3 - 4 - - 8 — Dysentery - - - - - - - - - - - - - - - - 1 - - - - 2 — Encephalitis lethargica - - - - - - - - - - - - - - - - - - - - - - Enteric fevers— Typhoid - - - 1 - - - - - - - - - - - 1 - - - - 2 — Paratyphoid A - - - - - - - - - - - - - - - - - - - - - - - „ B - - 1 - - - - - - - - - - - - - - - - - - 1 — „ C - - - - - - - - - - - - - - - - - - - - - - - Erysipelas - - - - - - - - - - - - - - - - 3 - - - - 3 2 Measles 1 1 — 48 — — — — — — — 1 — — — 33 229 — 19 — 1 333 13 Mumps — — 1 5 - - - - - - 3 - - - - 5 - - - - 14 — Poliomyelitis 1 - - - - - - - - - - - - - - - - - - - - 1 — Polioencephalitis - - - 1 - - - - - - - - - - - - - - - - - 1 1 Puerperal fever - - - - - - - - - - - - - - - - - - - - - - - Puerperal pyrexia - - - - - - - - - - - - - - - - 1 - - - - 1 — Rubella — — — — — — — — — — 504 — — — — — 259 — — — — 763 — Scarlet fever — 3 — 128 — — — — — — 76 — — — 1 27 — — 1 — 1 237 5 Typhus - - - - - - - - - - - - - - - - - - - - - - - Whooping-cough — — — 7 1 — — — — — 19 — — — — 1 5 — — — — 33 5 Zymotic enteritis - - - - - - - - - - - - - - - - - - - - - - - Other infectious diseases 2 — 1 27 1 1 1 — 1 - 18 — 1 1 — 1 43 — 4 — 1 103 2 Other diseases : Nervous 5 — — 16 — 1 — — — — 23 1 4 — — 1 21 - 1 — 1 74 5 Circulatory — 2 — 8 — — 1 — — — 3 16 — — — — 9 — — — — 39 1 Respiratory 1 1 — 270 — — — — — — 142 1 — — — — 82 — 81 — 1 579 27 Digestive 1 2 — 1,356 10 1 3 4 2 - 40 3 - 1 2 5 429 — 5 — 2 1,866 15 Genitourinary — — — 3 — — 1 — - — 4 - - 4 1 - 4 — 1 — — 18 1 Skin, bones, muscles — 64 - 3 - - 1 - 1 - 228 1 1 1 2 17 366 - 7 - 1 698 5 Other (including no disease) 6 19 - 64 2 - 4 1 2 - 80 - 2 2 1 5 92 - 22 1 - 303 11 Total Cases 17 92 3 1,938 14 3 11 5 6 — 1,159 24 9 9 7 91 1,621 — 149 1 9 5,168 — Deaths 6 1 — 28 2 1 2 - - - 25 1 1 1 - - 21 - 9 — 1 - 99 *Including cases admitted direct to convalescent hospitals. 126 Special Hospitals—continued. Table III (b)—Acute Hospitals*—Errors in diagnosis, 1934. Errors in diagnosis. Diphtheria (including bacteriological) and membraneous croup. Enteric fevers. Measles. Rubella. Scarlet fever. Whooping cough. Number of errors in diagnosis 1,938 11 1,159 91 1,621 149 Total cases 11,795 50 13,867 1,109 18,310 1,894 Percentage errors 16.4 22.0 8.4 8.2 8.9 7.9 *Including acute cases admitted direct to convalescent hospitals. Table IV—Smallpox hospitals.—Admissions, discharges and deaths during 1934 including cases erroneously certified. Classification. Joyce Green or Long Reach. South Wharf. Total. In hospital on 1st January, 1934 13 - 13 Admissions 140 25 165 Discharges 152 25* 177 Deaths 1 - 1 In hospital on 31st December, 1934 — — — *Direct discharges only, remainder discharged to Long Reach. Table v—Smallpox hospitals.—Summary of discharges and deaths during 1934 grouped according to borough of residence of patient. Borough of residence. Number of cases. Borough of residence. Number of cases. Smallpox. Other. Total. Smallpox. Other. Total. North— East— Paddington — — — Shoreditch 2 1 3 Kensington — 1 1 Bethnal Green — 2 2 Hammersmith - - — Stepney 9 3 12 Fulham — — — Poplar 2 — 2 Chelsea - - - Westminster, City of — — — South— Southwark 19 7 26 Bermondsey 11 — 11 West— Lambeth 2 4 6 Battersea 1 — 1 St. Marylebone — — — Wandsworth — — — Hampstead — - - Camberwell 22 — 22 St. Pancras - 1 1 Deptford 1 — 1 Islington 70 2 72 Greenwich — 1 1 Stoke Newington - - - Lewisham 2* 1 3 Hackney 1 1 2 Woolwich — — — Central— Tottenham urban district - - - Port of London — — — Holborn — — - Beyond metropolitan area 2 3 5 Finsbury 6 1 7 Total 150 28 178 City of London — — — * Includes one death. 127 Special Hospitals—continued. Table VI (a)—Smallpox hospitals.—Condition as to vaccination of patients suffering from smallpox who were discharged or who died during 1934. Type of case. Cases. Deaths. Vaccinated— ½ and upwards of ½ square inch total area of cicatrices 11 — ⅓ but less than ½ square inch total area of cicatrices 6 — Less than ⅓ square inch total area of cicatrices 4 — Area not recorded — — Total vaccinated cases 21 - Unvaccinated or doubtful 129 1* Total 150 1 * See table VII. Table VI (b) Smallpox hospitals.—Classification of condition as to vaccination according to age of patients suffering from smallpox who were discharged or who died during 1934. Age group. Evidence of vaccination. Other cases, i.e., not vaccinated. Total. Present. Not noted. Doubtful. Stated to have been re-vaccinated with no evidence. Cases Deaths. Cases. Deaths. Cases. Deaths. Cases. Deaths. Cases. Deaths. Cases. Deaths. Under 1 year - - - - - - - - 2 - 2 - 1— 5 years - - - - - - - - 9 — 9 — 5—10 „ — — — — 1* — — — 20 - 21 - 10—15 „ — — — — — — - — 29 - 29 - 15—20 „ - - - - - - - - 30 1 30 1 20—25 „ — — — — — — — — 15 - 15 - 25—30 „ 2 — - — — — — — 9 — 11 - 30—35 „ — — — — — — — — 4 - 4 - 35—40 „ 3 — — — — — - - 2 - 5 - 40—45 „ 1 — — — — — - — 4 - 5 - 45—50 „ 3 — — — — — - - 1 - 4 - 50—55 „ 3 — — — — — — — 1 - 4 - 55—60 „ 4 - - - - - - - - - 4 - 60—65 „ 2 — — — — — — - 2 - 4 - 65—70 „ 2 - - - - - - - - - 2 - 70—75 „ 1 - - - - - - - - - 1 - 75—80 „ - - - - - - - - - - - - 80—85 „ - - - - - - - - - - - - 85 and over - - - - - - - - - - - - Total 21 — — — 1 — — — 128 1 150 1 *Number of scars not recorded. Table VII—Smallpox as a factor of fatality.—Deaths during 1934. Date of death. Age. Sex. Cause of death. Primary factor. Secondary factor. 18th, February 1934 16 years Male Encephalo-myelitis Discrete smallpox 128 Special Hospitals—continued. Table VIII—Smallpox hospitals.—Mistaken diagnosis.—Summary of discharges and deaths during 1934 in which the diagnosis of smallpox on the notification certificate was found to be incorrect. Disease diagnosed in hospital. Joyce Green and Long Reach South Wharf. Total. Chickenpox - 12 12 Vaccinia - 1 1 Diseases of the skin 1 12 13 Other diseases - - - No disease, admitted with mother, diagnosis not confirmed, etc. 2 — 2 Total 3 25 28 Table IX—Post-encephalitis lethargica.—Admissions, discharges and deaths during 1934 Northern hospital (part of). Males. Females. Total. Remaining under treatment, 1st January, 1934 148* 109 257 Admissions 22† 20 42 Discharges— Reason for discharge. Males. Females. Total. Much improved — — — Unlikely to benefit by further treatment - - - Orthopaedic treatment — — — Removed by parents, etc., not against medical advice 1 - 1 Removed by parents, etc., against medical advice 7 12 19 Absconded — — — Not diagnosed as post-encephalitis lethargica - - - Unsuitable or unmanageable - 1 1 Transferred to another institution 4‡ 2 6 Deaths 12‡ 15 27 4 1 5 Total discharges and deaths 16‡ 16 32 Remaining under treatment, 31st December, 1934. 154 113 267 * Includes one case on leave. †Two cases admitted from fever unit. ‡Includes two cases transferred to fever unit and subsequently readmitted. 129 Special Hospitals—continued. TUBERCULOSIS INSTITUTIONS. Table X—Tuberculosis Institutions—General table showing the total admissions, discharges and deaths during 1934. Institution. In hospital (midnight) 31st December, 1933†. Admissions. Discharges. Deaths. In hospital (midnight) 31st December, 1934. Direct. By transfer. Men. Women. Children. Total. Men. Women. Children. Total. Men. Women. Children. Total. Men. Women. Children. Total. Men. Women. Children. Total. Men. Women. Children. Total (l) For pulmonary tuberculosis— Colindale hospital, Hendon (male adults, advanced) 337 - — 337 785 — — 785 688 — — 688 9 — - 9 79 — — 79 346 - - 346 St. George's home, Chelsea (female adults) - 35 - 35 - 471 2 473 - 242 - 242 - 215 2 217 - - - - - 49 - 49 King George V sanatorium, Godalming (male adults, early) 215 - - 215 453 - — 453 428 — — 428 13 — — 13 1 — — 1 226 - - 226 Pinewood sanatorium, Wokingham (female adults, early) - 160 - 160 — 285 — 285 — 281 — 281 — 3 — 3 - 2 — 2 - 159 - 159 **High Wood hospital, Brentwood (part of) (children, early) 5 2 180 *187 - 9 437 446 1 5 291 297 2 5 63 70 1 1 11 13 1 - 252 253 Northern hospital, Winchmore Hill (part of) (females, advanced and intermediate) - 87 - 87 - 287 1 288 - 261 - 261 - 4 - 4 - 11 1 12 - 98 - 98 Grove Park hospital, Lee, S.E. (part of) (adults, advanced) 137 146 - 283 404 431 1 836 335 395 - 730 17 2 1 20 55 26 — 81 134 154 - 288 **Millfield, Littlehampton (part of) (children) — - 37* 37 — - 52 52 - — 51 51 - — 11 11 - - - - - - 27 27 Total 694 430 217 1,341 1,642 1,483 493 3,618 1,452 1,184 342 2,978 41 229 77 347 136 40 12 188 707 460 279 1,446 (ii) For non-pulmonary tuberculosis— St. Luke's hospital, Lowestoft (adults) 106 92 — 198 139 106 — 245 126 107 — 233 4 2 — 6 6 6 — 9 109 86 — 195 Grove Park hospital, Lee, S.E. (part of) (adults) 9 12 - 21 12 20 - 32 9 21 - 30 - - - - 2 - - 2 10 11 - 21 Princess Mary's hospital, Margate (children) - - 174 *174 2 3 169 174 2 3 215 220 — — 7 7 - — — - - - 121 121 **Queen Mary's hospital, Carshalton (part of) (children) 11 8 175 *194 2 — 201 203 4 7 183 ‡194 5 — 14 19 - — 10 10 4 1 169 174 **High Wood hospital, Brentwood (part of) (children) — — 18 18 - — 54 54 - - 37 37 - — 16 16 — — 1 1 — — 18 18 ** Milltield, Littlehampton (part of) (children) - - 61 *61 - - 34 34 - - 21 21 - - 12 12 - - - - - - 7 7 **Heather wood — — — — — 1 155 156 — 1 28 29 - - - - - - - - - - 127 127 Total 126 112 373 611 155 130 613 898 141 139 484 764 9 2 49 60 8 3 11 22 123 98 442 663 Grand Total 820 542 590 1,952 1,797 1,613 1,106 4,516 1,593 1,323 826 3,742 50 231 126 407 144 43 23 210 830 558 721 2,109 ** These figures relate to the units for tuberculous patients only; for movements of non-tuberculous patients see children's hospitals section of this report. †Includes patients on leave. ‡Includes 28 cases transferred to the general section of the hospital. §Transfers to other of the Council's tuberculosis institutions only. * Revised figures. The hospital was transferred from the United Services Fund to the Council on 1st October. The admissions include 109 patients in the hospital on that date. 130 Special Hospitals—continued. Table XL—Pulmonary tuberculosis, duration of treatment terminated by (a) direct discharge and (b) death—durinq 1934. Institution. Duration of stay. (a) Direct discharges. (b) Deaths. Under 4 weeks. 4 and under 13 weeks. 13 and under 26 weeks. 26 and under 52 weeks. Over 12 months. Total. Average duration of stay in days. Under 4 weeks. 4 and under 13 weeks. 13 and under 26 weeks. 26 and under 52 weeks. Over 12 months. Total. Average duration of stay in days. Colindale hospital 41 166 235 228 18 688 157 14 30 28 6 1 79 95 St. George's home 82 159 1 — — 242 32 — — — — — — — King George V sanatorium 16 61 163 152 25 417 179 — — 1 — — 1 120 Pinewood sanatorium 8 28 121 105 15 277 192 — — 1 — 1 2 298 High Wood hospital for children 36 48 81 63 29 257 186 1 2 2 4 4 13 397 Northern hospital (part of) 31 72 86 67 3 259 131 1 6 2 3 — 12 105 Grove Park hospital (part of) 49 191 324 154 10 728 134 16 33 25 6 1 81 93 Millfield 2 5 21 17 6 51 199 — — — — — — — Total 265 730 1,032 786 106 2,919 148 32 71 59 19 7 188 118 Table XII—Pulmonary tuberculosis.—Discharges during 1934.—Immediate results of treatment. Classification. Class A T.B. minus. Class B T.B. plus Group 1. Class B T.B. plus Group 2. Class B T.B. plus Group 3. Not classed. Total colindale hospital. Quiescent — — — — — — Improved 34 12 366 65 — 477 No material improvement 2 1 42 125 — 170 Died in institution 2 — 12 65 — 79 Resident less than 4 weeks 2 2 28 9 — 41 Total 40 15 448 264 — 767 st. george's home. Quiescent — — — — — — Improved 6 4 110 7 — 127 No material improvement 3 1 24 5 — 33 Died in institution — — — — — — Resident less than 4 weeks 2 2 63 15 — 82 Total 11 7 197 27 — 242 kinG george v sanatorium. Quiescent 60 48 89 — — 197 Improved 10 13 113 — — 136 No material improvement 3 2 56 7 — 68 Died in institution — — 1 — — 1 Resident less than 4 weeks 3 2 9 1 1 16 Total 76 65 268 8 1 418 131 Special Hospitals—continued. Table XII—continued. Classification. Class a T.B. minus. Class B T.B. plus Group 1. Class B T.B. plus Group 2. Class b t.b. plus Group 3. Not classed. Total. pinewood sanatorium. Quiescent 54 15 10 — — 79 Improved 25 20 123 6 — 174 No material improvement 2 1 9 4 — 16 Died in institution — — 2 — — 2 Resident less than 4 weeks 3 — 4 — 1 8 Total 84 36 148 10 1 279 high wood hospital for children. Quiescent 78 3 — — 3 84 Improved 67 5 9 — 36 117 No material improvement 7 2 7 3 1 20 Died in institution 3 3 5 1 1 13 Resident less than 4 weeks 22 — — 2 12 36 Total 177 13 21 6 53 270 northern hospital. Quiescent — — — — — — Improved 17 2 123 9 — 151 No material improvement 2 1 63 11 — 77 Died in institution — — 9 3 — 12 Resident less than 4 weeks 3 — 22 6 — 31 Total 22 3 217 29 — 271 grove park hospital. Quiescent 2 — — — — 2 Improved 47 34 413 3 — 497 No material improvement 5 3 124 48 — 180 Died in institution 3 — 4 74 — 81 Resident less than 4 weeks 14 5 27 3 — 49 Total 71 42 568 128 — 809 132 Special Hospitals—continued. Table XIII—Pulmonary tuberculosis.—Patients discharged during 1934. Capacity for work on discharge. Classification. Class A T.B. minus. Class B T.B. plus Group 1. Class B T.B. plus Group 2. Class B T.B. plus Group 3. Not classed Total. colindale hospital. Fit for work 1 — 1 — — 2 Fit for light work 24 11 229 27 — 291 Unfit for any work 13 4 206 172 — 395 Not stated — — — — — — Total 38 15 436 199 — 688 st. georoe's home. Fit for work — — — — — — Fit for light work — — — — — — Unfit for any work 11 7 197 27 — 242 Not stated — — — — — — Total 11 7 197 27 — 242 kino george v sanatorium. Fit for work 55 43 75 — — 173 Fit for light work 12 14 91 — 1 118 Unfit for any work 9 8 101 8 — 126 Not stated — — — — — — Total 76 65 267 8 1 417 pinewood sanatorium. Fit for work 42 12 19 — — 73 Fit for light work 35 23 105 4 — 167 Unfit for any work 7 1 22 6 1 37 Not stated — — — — — — Total 84 36 146 10 1 277 high wood hospital for children. Fit for work or school 73 1 — — 30 104 Fit for light work or sp. school 44 4 5 — 6 59 Unfit for any work or school 46 5 10 5 10 76 Not stated 11 — 1 — 6 18 Total 174 10 16 5 52 257 northern hospital. Fit for work — — — — — — Fit for light work 1 1 21 1 — 24 Unfit for any work 21 2 187 25 — 235 Not stated — — — — — — Total 22 3 208 26 — 259 grove park hospital. Fit for work — 4 5 — — 9 Fit for light work 23 13 137 — — 173 Unfit for any work 45 25 422 54 — 546 Total 68 42 564 54 — 728 Note.—The classification is that of the Ministry of Health. 133 Special Hospitals—continued. Table XIV—Hon-pulmonary tuberculosis.—Age and sex of patients and localisation of disease. Summary of discharges and deaths for all institutions during 1934. Localisation. 0-5 5-10 10-15 15-20 20-30 30-40 40-50 Over 50 Total. Grand total. M F M F M F M F M F M F M F M F M F (a) Discharges. Spine 1 — 19 19 13 8 13 6 14 9 4 11 3 2 4 — 71 55 126 Hip 3 2 17 12 16 20 2 9 12 9 — 1 — 1 1 — 53 54 107 Knee 3 3 11 4 5 10 4 2 6 7 — — 2 1 — — 31 27 58 Other joints and limb bones 6 9 5 4 8 5 6 3 6 6 3 — 2 — 1 3 37 31 68 Abdominal 5 5 18 7 13 12 7 9 7 16 4 8 1 1 3 2 58 60 118 Peripheral glands 20 5 39 31 30 16 7 5 4 8 2 6 — 2 — 2 102 75 177 Other 1 2 6 1 9 6 7 3 37 6 7 5 2 2 1 — — 38 22 60 Total 39 26 115 78 94 77 46 55 61 20 30 10 8 11 7 390 324 714 Grand Total 65 193 171 83 116 50 18 18 714 — (6) Deaths. Spine — — 1 — 1 — 1 — 1 — — — — — — — 4 — 4 Hip 1 — — — 1 2 — — — — 1 — — — — — 3 2 5 Knee — — 1 — — — — — 1 — — — 1 — — — 3 — 3 Other joints and limb bones 1 — — — — — — — — 1 — — — — 1 — 2 1 3 Abdominal — 1 — — — — — — — — — — — — — — — 1 1 Peripheral glands — — — — — — — 1 1 — — — — — — 1 1 2 Other — — 1 1 — — — — — — — — — — 1 1 2 2 4 Total 2 1 3 1 2 2 1 1 3 1 1 — 1 — 2 1 15 7 22 Grand Total 3 4 4 2 4 1 1 3 22 — Mortality percent. 4.4 2.0 2.3 2.3 3.3 2.0 5.3 14.3 3.0 — 134 Special Hospitals—continued. Table XV—Non-pulmonary tuberculosis—Surgical operations under anaesthetics during 1934. Condition, or reason for operation. Name of operation. Queen Mary's Princess Mary's High Wood St. Luke's Grove Park Heatherwood Total. (1) Tuberculosis of— spine Incision, aspiration of abscess 50 5 — 446 — — 501 Excision of abscess — — — 1 — — 1 hip Tenotomy, tensor fascia femoris — 1 — — — — 1 Incision, aspiration of abscess 61 59 — 80 1 2 203 Sinus curettage — 1 — — — — 1 Arthrodesis 1 — — — — — 1 Excision 1 — — — — — 1 Macewen's osteotomy 1 — — — — — 1 Subtrochanteric osteotomy 2 — — 1 — — 3 Sequestrectomy — — — 12 — — 12 Hibb's fusion — 1 — — — — 1 knee Incision, aspiration of abscess — 6 — 2 — 3 11 Excision 1 — — 14 — — 15 Exploration — — — 1 — — 1 Amputation and re-amputation — — — 4 — — 4 ankle Incision of abscess 2 2 — — — — 4 Sinus curettage — 1 — — — — 1 Sequestrectomy — — — 2 — — 2 Amputation of foot — — — 4 — — 4 Excision of ankle — — — 2 — — 2 femur Incision of abscess — 1 — — — — 1 Excision of scar — 1 — — — — 1 Sinus curettage — 1 — — — — 1 Sequestrectomy — 1 — — — — 1 os calcis Curettage 1 — — — — — 1 foot Incision, aspiration of abscess — 8 — — — — 8 Sinus curettage — 1 — — — — 1 wrist Incision, aspiration of abscess 3 1 — 8 — 2 14 Exploration of sinus — 1 — — — — 1 finger Amputation — 1 — — — — 1 hand Incision of abscess — — — 1 — — 1 Sequestrectomy — 1 — — — — 1 Sinus curettage — 1 — — — — 1 Excision of scar — — — 1 — — 1 elbow Incision, aspiration of abscess — 3 — 5 — 1 9 Sequestrectomy — — — 1 — — 1 arm Incision, aspiration of abscess — — — 4 — — 4 tibia Planefaction — 1 — — — — 1 pubic bone Aspiration of abscess — 8 — — — — 8 great trochanter Incision of abscess 1 — — — — — 1 Sequestrectomy — — — 1 — — 1 shoulder Incision, aspiration of abscess 2 1 — 1 — — 4 Exploration of sinus — 1 — — — — 1 Arthrodesis — 1 — — — — 1 Manipulation of elbow — 3 — — — — 3 Sequestrectomy — — — 1 — — 1 sacro-iliac joint Aspiration of abscess — — — 6 — — 6 Sequestrectomy — — — 2 — — 2 Exploration — — — 1 — — 1 Dilation of sinuses — — — 4 — — 4 ribs Incision, aspiration of abscess — — — 6 — — 6 Curettage — — — 1 — — 1 Sequestrectomy — — — 1 — — 1 peritoneum Paracentesis 2 — — — — — 2 Examination, P.V. — — — 1 — — 1 Laparotomy — — — 1 — — 1 peripheral glands Incision, aspiration of abscess 10 5 1 8 — 2 26 Curettage — — — 3 — — 3 Excision 1 13 — 9 — — 23 Excision of scars 1 — — — — — 1 ischio-rectal abscess Incision, aspiration of abscess — — — 3 1 — 4 skin Skin graft — — — 1 — — 1 Curettage and cauterisation — — — 12 — — 12 Excision of lupus 1 — — 4 — — 5 Curettage of ulcers 2 — — — — — 2 buttock Incision, aspiration of abscess — — — — — 2 2 135 Special Hospitals—continued. Table XV—continued. Condition, or reason for operation. Name of operation. ' Queen Mary's Princess Mary's High St. Wood Luke's Grove Park Heatherwood Total Tuberculosis of (ctd.) kidney Passage of sounds 2 — — — — — 2 Nephrectomy 2 — — — — — 2 Cystoscopy 16 — — 2 — — 18 epididymis Cystoscopy — — — 2 — — 2 Orchidectomy — — — 2 — — 2 Epididymectomy 3 — — — — — 3 multiple abscesses Incision — — — 1 — — 1 2) Other conditions Mastoiditis Mastoidectomy — — — 1 — — 1 Pleural effusion Aspiration 5 — — — — — 5 Enlarged tonsils and adenoids Removal 3 12 — — — — 17 Pyonephrosis Drainage 1 — — — — — 1 Appendicitis Appendicectomy 1 — — 1 — — 3 Renal calculus Nephrectomy 2 — — — — — 2 Cystoscopy 8 — — — — — 8 Pvelolithotomy 2 — — — — — 2 Ureteric calculi Removal 2 — — — — — 2 Vesical calculi Lithotrity 1 — — — — — 1 Phimosis Circumcision 2 4 — — — 6 Bladder Cystoscopy — 1 — — — — 1 Lipoma of bladder Cystoscopy and fulguration 4 — — — — 4 Hand Removal of ganglion — — — 1 — — 1 Removal of nail — 1 — — — — 1 Tibia Osteoclasis — — 1 1 Lipoma Removal — — — 1 — — 1 Cyst Removal — — — 2 — — 2 Knee Supracondylar osteotomy — — 1 1 Septic finger Incision — — — 2 — 1 3 Wrist Manipulation and plaster — — — — — 1 1 Various Dressings and replastering 17 — — — — — 17 Total 214 148 1 670 2 19 1,054 136 Special Hospitals—continued. Table XVI—Non-pulmonary tuberculosis patients—Deaths during 1934. Localisation. Complication. Queen Mary's hospital. High Wood hospital. Grove Park hospital. St. Luke's hospital, Lowestoft. Total. Spine Amyloid disease, cardiac failure 1 — — — 1 Amyloid disease, uraemia 1 — — — 1 Amyloid disease, pulmonary tuberculosis — — — 1 1 Amyloid disease, tuberculous-enteritis and neck glands — — 1 — 1 Hip Tuberculous meningitis 2 — — — 2 Tuberculous spine and kidney 1 — — — 1 Renal calculus 1 — — — 1 Suppurative arthritis of hip — — — 1 1 Knee Tuberculous meningitis 1 — — — 1 Pulmonary tuberculosis — — — 1 1 Pulmonary tuberculosis, tuberculous spine — — — 1 1 Fingers Generalised tuberculosis 1 — — — 1 Ankle Pulmonary tuberculosis, tuberculous knee — — — 1 1 Streptococcal septicfemia — — — 1 1 Peritoneum Tuberculous meningitis, pelvic abscess — — — 1 1 Tuberculous enteritis — 1 — — 1 Sacro-iliac joint Acute pyelo-nephritis — — — 1 1 Kidnev Tuberculosis of bladder 1 — — — 1 Rib Generalised tuberculosis 1 — — — 1 Cervical glands Generalised tuberculosis — — — 1 1 Cold abscess, chest Chronic nephritis, pneumonia — — 1 — 1 Total 10 1 2 9 22 137 SPECIAL HOSPITALS FOR CHILDREN. Table XVII—Summary of admissions, discharges and deaths during 1934. Hospital. In hospital 31st December, 1933. Admissions. Discharges. Deaths. In hospital 31st December, 1934. Direct. By transfer to other L C.C. children's hospitals. I. Hospitals for Children— *Queen Mary's, Carshalton †874 2,131 1,930 191 29 855 The Downs, Sutton 325 1,412 1,227 178 18 314 Princess Mary's (part of) 13 36 33 — — 16 *Heatherwood — § 8 2 — — 6 II. Seaside and Convalescent Hospitals— St. Anne s, Heme Bay 105 947 951 12 — 89 Goldie Leigh, Abbey Wood (part of) 40 117 126 8 — 23 *Millfield, Littlehampton (part of) † 52 338 1 340 — 49 Southern Lower, Dartford — 1,181 986 1 — 194 *Princess Mary's, Margate 47 318 304 38 — 23 III. For diseases of the Skin and Scalp— Goldie Leigh, Abbey Wood (part of) 126 515 502 17 — 122 IV. For certain Eye Diseases— White Oak, Swanley 203 263 211 30 — 225 V. For Rheumatism and its after effects—- *High Wood, Brentwood 146 253 260 4 6 129 Total 1,931 7,519 6,533 819 53 2,045 * Excluding tuberculosis patients shown in Table X of tuberculosis section. + Corrected fierure. § The hospital was transferred from the United Services Fund to the Council on 1st October. The admissions include 3 patients in the hospital on that date. 138 Special Hospitals—continued. Table XVIII—Queen Mary's Hospital for Children.—Non-tuberculous orthopasdic cases.— Discharges and deaths during 1934.-—Principal disease or condition treated. Disease. Discharged. Transferred to other L.C.C. children's hospitals. Died. Total. Diseases of bones— Abscess 4 — — 4 Kohler's disease 1 — — 1 Osteitis 1 — — 1 Osteochondritis 8 — — 8 Fibrocystic disease 2 — — 2 Periostitis 3 — — 3 Osteomyelitis 77 — 1 78 Diseases of joints, etc.— Arthritis, septic 20 1 2 23 „ other 1 — — 1 Congenital dislocation of hip 1 — — 1 Coxalgia 5 — — 5 Grating scapulae 1 — — 1 Arthrogryposis 1 — — 1 Slipped epiphysis 5 — — 5 Synovitis 1 — — 1 Perthe's disease 4 — — 4 Deformities due to nervous system— Diplegia, cerebral 4 — 1 5 „ spastic 2 1 — 3 Poliomyelitis 52 2 1 55 Polioencephalitis 1 — — 1 Hemiplegia 15 1 — 16 Paraplegia 5 — — 5 Erb's paralysis 3 1 — 4 Other paralyses 4 1 1 6 Other 4 — — 4 Other deformities— Knock knees 26 — — 26 Curved tibiæ 26 — — 26 Talipes 6 — — 6 Kyphosis, scoliosis 13 — — 13 Torticollis 2 — — 2 Spina bifida 2 — — 2 Flat feet 11 — — 11 Other 13 — — 13 Injuries— Fracture 7 1 — 8 Other 2 2 Total 333 8 6 347 139 Special Hospitals—continued. Table XIX-—Queen Mary's Hospital for Children.—Non-tuberculous cases other than orthopcedic. Discharges and deaths during 1934.—Principal disease or condition treated. Disease. Discharged. Transferred to other L.C.C. children's hospitals. Died. Total. Infectious diseases— Rubella 1 — — 1 Non-malignant neoplasms 2 — — 2 Rheumatism, etc.— Acute rheumatism 450 60 — 510 Rickets 143 4 1 148 Diabetes 8 — — 8 Rheumatoid arthritis 4 — — 4 Anaemia 1 1 — 2 Hodgkin's disease 1 — — 1 Hyperthyroidism 2 — — 2 Cretinism 2 — — 2 Acidosis 1 — — 1 Nervous system— Chorea 253 43 — 296 Diseases of eye 3 — — 3 Other 1 — — 1 Circulatory system— Heart disease, rheumatic 344 20 13 377 „ „ other 1 — — 1 Adenitis 18 5 — 23 Respiratory system— Bronchitis 33 7 — 40 Pneumonia 4 5 1 10 Pleurisy, empyema 8 1 — 9 Asthma 7 1 — 8 Fibrosis of lung 13 8 — 21 Other 1 — — 1 Digestive system— Tonsils, adenoids 3 — — 3 Enteritis 4 — — 4 Hernia 2 — — 2 Other 6 1 2 9 Genito-urinary system— Nephritis 8 1 1 10 Other 4 1 — 5 Skin, bones, etc.— Skin disease 38 6 — 44 Other 1 — — 1 Diseases of infancy— Congenital heart disease 9 — 1 10 Congenital malformation 7 — — 7 Marasmus 65 — 4 69 Injury 5 1 — 6 Debility 143 18 — 161 Other 1 — — 1 Total 1,597 183 23 1,803 140 Special Hospitals—continued. Table XX—Surgical operations under anaesthetics during 1934. (Non-tuberculous patients.) (a) Queen Mary's Hospital for Children Condition or disease. Nature of operation. No. Ear—- Acute mastoiditis Schwartz' operation 1 Acute otitis media Paracentesis of drum 1 Eye— Traumatic cataract Needling 1 Purulent conjunctivitis Cauterisation 1 Digestive system— Adenoids, tonsils Enucleation 51 Acute appendicitis Appendicectomy 3 Appendix abscess Drainage 1 Inguinal hernia Radical cure 1 Stricture of rectum Digital dilatation 11 Genito-urinary system— Phimosis Circumcision 56 Urethral stricture Passage of sounds 14 Hæmaturia Cystoscopy 8 Renal calculus Pyelolithotomy 1 Ectopia testis Replacement 2 Skin, bones, etc.— Abscess Incision and drainage 38 Acute prepatellar bursitis Incision and drainage 3 Chronic prepatellar bursitis Excision of bursa 1 Paronychia Avulsion of nail 9 Whitlow Incision 9 Chronic osteomyelitis Sequestrectomy and planefaction 39 Drainage of bone abscess 4 Amputation through thigh 2 Amputation through hip 1 Tendon lengthening 1 Curettage of sinus 1 Excision of adherent scar 7 Ligature of femoral artery 1 Septic arthritis of hip Excision of hip 3 Subtrochanteric osteotomy 3 Tenotomy of adductors 1 Manipulation and plaster 1 Septic arthritis of knee Mace wen's osteotomy 1 Manipulation and plaster 1 Congenital dislocation of hip Manipulation and plaster 2 Shelf operation 2 Pleating of capsule 1 Insertion of pin 2 Deformities due to nervous system— Poliomyelitis Sub-astragaloid arthrodesis 9 Tendon lengthening 5 Manipulation and plaster 13 Open correction of foot 1 Steindler's operation 1 Macewen's osteotomy 1 Spastic paralysis Tendon lengthening 10 Manipulation and plaster 2 Stoffel's operation 1 Spina bifida Tendon lengthening 2 Meningocele Excision 1 141 Special Hospitals—continued. Table XX—continued. Condition or disease. Nature of operation. No. Other deformities— Rickets: Curved tibiae Osteoclasis 28 Knock-knees Macewen's osteotomy 2 Removal of femoral condyle 1 Club-foot Open correction 1 Manipulation and plaster 28 Elongation of tendo Achilles 2 Arthrodesis 3 Osteotomy of tibia 1 Flat foot Elongation of tendo Achilles 2 Manipulation and plaster 1 Coxa vara Subtrochanteric osteotomy 1 Torticollis Tenotomy of sterno-mastoid 1 Scoliosis Spinal fixation 1 Hammertoes Excision of joint 1 Hallux valgus Excision of metatarsal head 3 Ingrowing toe-nails Plastic operation 1 Hare lip Repair 5 Cleft palate Repair 10 Removal of stitches 2 Injuries— Crushed fingers Repair 1 Burn scars of abdomen Plastic operation 2 Burn scars of elbow Plastic operation 1 Fractured radius and ulna Reduction 2 Fractured humerus Reduction 1 Other— Anaesthetics for investigations - 4 Dressings under anaesthetics - 61 Replasters under anaesthetics - 4 Total 501 142 Special Hospital—continued. Table XX—(6) Princess Mary's Hospital for Children. Non-tuberculous patients. Condition. Nature of operation. Total. Osteomyelitis of ilium Sequestrectomy 1 Sinus curettage 1 Osteomyelitis of femur Planef action 2 Sequestrectomy 4 Manipulation of knee 2 Aspiration of abscess 1 Osteomyelitis of tibia Planefaction 1 Sequestrectomy 2 Sinus curettage 1 Osteomyelitis of humerus Planefaction 1 Sequestrectomy 1 Aspiration of abscess 1 Incision of abscess 1 Sinus curettage 1 Osteomyelitis of radius Sequestrectomy 1 Incision of abscess 1 Sinus curettage 1 Osteomyelitis of scapula Spastic paraplegia Incision of abscess 1 Neurectomy 2 Tendon lengthening 2 Infantile paralysis dangle foot Infantile paralysis pes cavus Sub-astragaloid arthrodesis 1 Steindler's operation 1 Other conditions— Mastoiditis Radical cure 1 Labia Excision of abscess 1 Furunculosis Incision of abscess 1 Tonsils and adenoids Removal 5 Whitlow Removal of nail 1 Total 39 143 Special Hospitals—continued. Table XXI.—Queen Mary's Hospital for Children. Causes of death during 1934. (a) Non-tuberculous cases other than orthopœdic. Disease. Complication. Number. Acute rheumatism Rheumatic carditis 9 Endocarditis, lobar pneumonia 1 Rheumatic heart disease Endocarditis 1 Cardiac failure 2 Congenital heart disease - 1 Marasmus Bronchopneumonia 1 Bronchopneumonia Cardiac failure 1 Pseudohypertrophic muscular paralysis Hypostatic pneumonia 1 Coeliac disease - 1 Infective gastro-enteritis Inanition 1 Acute appendicitis Fæcal fistula, toxaemia 1 Scarlet fever Chronic nephritis 1 Prematurity Inanition, cardiac failure 1 Total 23 (6) Non-tuberculous orthopœdic cases. Disease. Complication. Number. Rickets Measles, bronchopneumonia 1 Septic arthritis of hip Diphtheria 1 Surgical shock, following operation for excision of hip 1 Acute osteomyelitis Toxaemia 1 Congenital cerebral diplegia - 1 Poliomyelitis Acidosis, cardiac failure 1 Total 6 Table XXII—The Downs Hospital for Children.—Diseases of the ear.—Discharges and deaths during 1934. Disease. Discharged. Transferred to other L.C.C. children's hospitals. Died. Total. Otitis media, acute 3 1 - 4 ,, „ chronic 1 - - 1 „ „ not stated 46 4 - 50 Mastoiditis, acute 16 1 1 18 „ chronic 257 5 1 263 „ not stated 5 — — 5 Total 328 11 2 341 144 Special Hospitals—continued. Table XXIII—General diseases of children.—Discharges, transfers and deaths during 1934. (a) The Downs Hospital for Children. Disease. Discharged. Transferred to other L.c.c. children's hospitals. Died. Total. Rheumatism, etc.— Rheumatism and chorea 30 4 1 35 Rheumatism 1 3 — 4 Rheumatoid arthritis 1 — — 1 Rickets 15 — — 15 Anæmia 3 1 — 4 Nervous system— Cerebral abscess 1 — — 1 Paraplegia — 1 — 1 Post-encephalitis lethargica 1 — — 1 Circulatory system— Heart disease 339 38 12 389 Adenitis 7 5 — 12 Enlarged glands 1 — — 1 Respiratory system— Chronic rhinitis 2 — — 2 Bronchitis 28 7 — 35 Pneumonia — — 1 1 Fibrosis of lung (non-tuberculous) 14 7 1 22 Asthma 2 — — 2 Sinusitis 2 — — 2 Thoracic sinus 1 — — 1 Digestive system— Tonsils, adenoids 19 8 — 27 Gastritis 1 — — 1 Inguinal hernia 1 — — 1 Appendicitis 1 — — 1 Oenito-urinary system— Enuresis 1 — — 1 Skin diseases— Whitlow 1 — — 1 Cellulitis 1 — — 1 Diseases of infancy— Marasmus, malnutrition 39 7 — 46 Cleft palate 1 — — 1 Other— Laceration 1 — — 1 Incipient whooping-cough 3 — — 3 Miliary tuberculosis — — 1 1 Fibro-sarcoma 1 — — 1 Granuloma — 1 — 1 Parotitis — 1 — 1 Fracture 1 — — 1 Debility 380 84 — 464 Total 899 167 16 1,082 145 Special Hospitals—continued. Table XXIII—(6) Princess Mary's Hospital for Children. Disease. Discharged. Transferred to other L.C.C. children's hospitals. Died. Total. Rickets 14 — — 14 Nervous system-— Infantile paralysis 1 — — 1 Spastic hemiplegia 1 — — 1 Spastic paraplegia 1 — 1 Otitis media 1 — — 1 Bones, joints, etc.— Osteomyelitis 10 — — 10 Infective arthritis 1 — — 1 Other 2 — — 2 Fracture 1 — — 1 Other 1 — — 1 Debility 304 38 — 342 Total 337 38 — 375 146 Special Hospitals—continued. Table XXIV—The Downs Hospital for Children—Surgical operations under anesthetics during 1934. Condition. Nature of operation. No. Diseases of the ear— Acute otitis media Paracentesis 12 Mastoiditis, acute (1) Conservative mastoid operation (a) Cortical 11 (6) Heath's, no flap 3 (c) Epitympanic 1 (2) Radical (a) No flaps 3 (6) With flaps 5 Mastoiditis, chronic (1) Conservative (o) Heath's, no flaps 7 (6) Heath's, with flaps 44 (c) Heath's, with incudectomy 1 (d) Cortical with muscle graft 20 (e) Epitympanic 1 (2) Radical (o) No flap 103 (6) With flap 110 Mastoid wound Removal of granulations 31 Plastic, various, 6 Perichondritis Incision, drainage 2 Mastoid abscess Incision, drainage 2 Furunculosis Incision, drainage 1 Polypi Removal 3 Foreign body Removal 2 Diseases of throat and nose— Enlarged tonsils and adenoids Removal by guillotine 137 Removal by dissection 11 Adenoids Removal by curette 2 Antral infection Antrostomy 3 Deviated septum Submucous resection 1 Other conditions— Bursitis Removal 1 Blepharitis Epilation 1 Abscess Incision, drainage 3 Hernia Herniotomy 1 Carbuncle Incision 1 Onyohia Removal of nail 5 Phimosis Circumcision 5 Cellulitis of finger Incision 1 Exploratory Lumbar puncture 2 Ganglion Removal by dissection 1 Total 543 Table XXV—Causes of death during 1934.—Non-tuberculous diseases, (a) The Downs Hospital for Children. Principal disease. Complication. Number Rheumatic heart disease Cardiac failure 7 Pericarditis 2 Bronchopneumonia, acute pericarditis 1 Acute rheumatism Mitral stenosis 1 Chorea, mitral incompetence, bronchopneumonia 1 Rheumatic carditis 1 Rheumatic carditis and pericarditis 1 Otitis media Streptococcal meningitis 1 Mastoiditis Septic meningitis 1 Tuberculous bronchial glands Miliary tuberculosis 1 Chronic splenomegaly Bronchopneumonia 1 Total 18 147 Special Hospitals—continued. Table XXV—(6) High Wood Hospital for Children. Disease. Complications. Number Rheumatic heart disease Pulmonary embolism 1 Pericarditis 1 Cardiac failure 2 Acute rheumatism Rheumatic carditis and pericarditis 1 Pericarditis, bronchopneumonia 1 Total 6 Table XXVI—St. Anne's home—Treatment of debility—Discharges and deaths during 1934. Discharged 951 Transferred to other L.C.C. children's hospitals 12 Diedd — Total 963 Table XXVII—Goldie Leigh Hospital.—Discharges and deaths during 1934.—Principal disease or condition treated. Disease or condition. Discharged. Transferred to other L.C.C. children's hospitals. Died. Total. Diseases, etc., of the skxn— Acne vulgaris 1 — — 1 Dermatitis 13 1 — 14 „ seborrhœic 7 1 — 8 „ septic 38 4 — 42 Eczema 31 2 — 33 Endothrix 27 — — 27 Icthyosis 2 — — 2 Impetigo 9 — — 9 Inflamed skin 1 — — 1 Pityriasis 2 — — 2 Pemphigus 2 — — 2 Prurigo 1 — — 1 Psoriasis 7 1 — 8 Ringworm 333 7 — 340 Scabies 11 — — 11 Scurfy scalp 4 — — 4 Seborrhœa 2 — — 2 Septic sores 5 — — 5 Urticaria 1 — — 1 Xeroderma 1 — — 1 Other diseases or conditions— Alopecia 4 1 — 5 Debility 126 8 — 134 Total 628 25 — 653 148 Special Hospitals—continued. Table XXVIII—White Oak Hospital.—Diseases of the eye.—Discharges, transfers and deaths during 1934. Disease. Discharged. Transferred to other L.c.c. children's hospitals. Died. Total. Blepharitis and conjunctivitis 96 16 112 Conjunctivitis, chronic 10 — — 10 „ follicular 3 — — 3 „ phlyctenular 26 5 — 31 „ other 3 2 — 5 ,, not stated 8 — — 8 Interstitial keratitis 22 2 — 24 Trachoma 19 3 — 22 Corneal ulcer 15 2 — 17 Superficial keratitis and corneal ulcers 3 — — 3 Cyclitis 1 — — 1 Dacryocystitis 1 — — 1 Glaucoma 1 — — 1 Spring catarrh 1 — — 1 No acute disease 2 — — 2 Total 211 30 — 241 Table XXIX—High Wood Hospital for Children.—Non-tuberculous cases.—Discharge.* and deaths during 1934. Condition or disease. Discharged. Transferred to other L.C.C. children's hospitals. Died. Total. Rheumatism, etc.— Rheumatism, acute 65 1 — 66 „ undefined 40 — — 40 Nervous system— Chorea 75 2 2 79 Otorrhœa — 1 — 1 Circulatory system— Valvular heart disease 12 — 2 14 Rheumatic carditis 17 — 2 19 Rheumatic endocarditis 3 — — 3 Other— Convalescent 48 — — 48 Total 260 4 6 270 149 Matters affecting both General and Special Hospitals. Planning and development. The report for 1933 contained a detailed account of the works of improvement and development which had been carried out in the general hospitals during the period from 1st April, 1930 to 31st December, 1933. General hospitals and institutions. It is only necessary, therefore, in this report to record the progress achieved in these directions during the year 1934. Comparison with the previous report will reveal that certain works appear in both lists. This is explained by the fact that in an endeavour to make the report for 1933 as complete as possible, mention was made of certain works of improvement which, although nearing completion, were not actually completed before 31st December, 1933. They are, therefore, included again in this report as the dates of their completion fell within the period under review. In a number of instances a necessary improvement concerns all the wards in a hospital. In other cases some form of development is called for in a number, or even in all, of the hospitals. In such eventualities it is frequently necessary to arrange programmes with a view to spreading the work over a number of years. Many of such programmes were advanced a further stage during 1934, and in some instances the year saw the completion of works which had been systematically carried on, in annual stages, for some years. The programmes dealt with diverse forms of improvement and development such as, in the case of wards, rewiring (including provision of power plugs), reflooring, plastering of walls, installation of lavatory basins in wards and modernisation of kitchens and sanitary annexes. I. major works. Archway hospital. Rebuilding of operating theatre and X-ray department. Erection of a sanitary tower to one block. Bethnal Green hospital. Erection of a new block containing X-ray and massage departments on the ground floor and a hospital laboratory on the first floor. Constance Road institution. Adaptation of a block (C) previously occupied by healthy inmates to provide for 140 sick patients. This involved the erection of a sanitary tower, the installation of a lift, reflooring, plastering the walls, rewiring and equipping with modern appliances. Adaptation of two blocks (A and D) to form mental observation units, one for each sex, for the southern part of London. Each block contains 39 beds. Dulwich hospital. Erection of a new ante-natal department. Hackney hospital. An extensive scheme of improvements has been carried out under one contract including the erection of the following new departments:— (а) Out-patients' department with treatment rooms, theatre for minor operations and surgery for ophthalmic, ear, nose, throat and dental cases. (a) Ante-natal department. (c) X-ray department. (d) Two operating theatres. (e) Dining rooms for the medical officers and the sisters. (g) Hospital laboratory. Hammersmith hospital. Adaptation of a block (institution F) to provide accommodation for 42 nurses. Lambeth hospital. Reconditioning of the wards of X block (east) (institution) to provide accommodation suitable for 108 acute cases. This work included the formation, on each of the three floors, of a ward kitchen and two bathrooms, a dressings room and a blanket store ; the improvement of the sanitary arrangements by the separation ot the nurses' section from the patients' bathroom and W.C.s; reflooring in hardwood; plastering and new dividing screens where necessary; installation of hospital type radiators; rewiring to provide for wall brackets, night lights, power plugs and synchronised clocks. Adaptation of former institution laundry to form a central laundry for both the hospital and institution blocks. Conversion of former hospital laundry into a waiting room for visitors. Lewisham hospital. Erection of a new ward block to accommodate 164 patients. The block comprises the following:— (a) A maternity department containing 63 beds with a receiving section and 5 labour rooms. 150 (6) Children's wards containing in all 35 cots. (c) Two general wards which, with the single-bedded wards attached, will accommodate 66 patients. Mile End hospital. Extension of nurses' home to provide messrooms, kitchen and 82 bedrooms. Paddington hospital. Erection of new ante-natal department. Erection of new X-ray and massage departments. St. Charles' hospital. Erection of new X-ray and massage departments. St. Giles' hospital. Rebuilding and enlargement of theatre. Erection of new block comprising:— (а) Receiving wards. (б) Theatre tor minor operations. (c) Ante-natal department. (d) Eye, ear, nose, throat and dental departments. (e) Massage department. (/) Dispensary. (g) Quarters for medical staff. St. Mary Abbots hospital. Reconditioning along lines indicated in respect of Lambeth hospital of institution block C, previously occupied by healthy inmates, to provide accommodation for 100 sick patients. Adaptation of a block (institution K) as accommodation for 39 nurses. Adaptation and extension of former maternity unit to provide the group laboratory for the western area of London. St. Mary, Islington, hospital. Erection at first floor level of:— (а) Operating theatre. (б) X-ray department. (<•) Laboratory. Provision of ante-natal and out-patient accommodation by conversion of disused theatre and X-ray room. II. minor works, classified under hospital departments and services. 1. Wards and their annexes. (a) General wards. Fulham hospital. Provision of glass verandah for children's ward. Mile End hospital. Provision of open-air balconies for the male and female block (south ends). Formation of day room for male patients suffering from tuberculosis. St. Leonard's hospital. Provision of children's baths in children's wards. St. Olave's hospital. Improvement of sanitary annexes in one block (3 wards). Division of children's isolation ward (A.ll) into completely self-contained cubicles. Completion of programme of providing open-air verandahs to wards. (Two wards so improved in 1934.) (b) Maternity ivards. Bethnal Green hospital. Provision of infants' baths. Dulwich hospital. Adaptation of a side room (E.l) as receiving ward for maternity department and erection of a bathroom and sanitary annexe. Mile End hospital. Provision of an additional labour room (and of a nursery and babies' baths for maternity department). Formation of night nurseries. New End hospital. Provision of babies' bathroom in nursery. St. Giles' hospital. Provision of sterilisers throughout maternity department (also large dressings steriliser). 151 St. Leonard's hospital. Provision of babies' bathroom. St. Pancras hospital. Adaptation ot a side ward as ward kitchen. (c) Venereal wards. St. Stephen's hospital. Enlargement of female V.D. unit by provision of a day room. (d) Chronic wards. City of London institution. Reconditioning of three wards including reflooring, plastering, rewiring, improving the ventilation, which owing to the windows being fixed was very inadequate, and improving the sanitary fittings. Hackney institution. Rewiring and replacement of obsolete sanitary fittings in sick block. St. Pancras institution. Reconditioning annexes of institution day rooms to provide accommodation for 36 sick patients. (e) Convalescent wards. St. Benedict's hospital. Erection of two shelters in grounds for patients. 2. Special departments. (а) Receiving and caeualty departments. Fulham hospital. Erection of two casualty treatment rooms, one attached to each receiving ward. St. Charles' hospital. Improvement of receiving ward bathrooms. St. Mary, Islington, hospital. Adaptation and extension of male receiving ward by the erection of a one-storey building. (б) X-ray departments. Fulham hospital. Erection of dark room for X-ray department. Lambeth hospital. Extension of deep X-ray therapy unit. St. John's hospital. Adaptation of disused store as X-ray developing room. (c) Dental departments. Lewisham hospital. Improvement of dental accommodation. St. Charles' hospital. Provision of dental surgery and orthopaedic room by conversion of a day room. St. Pancras hospital. Provision of dental surgery by adaptation of receiving ward. (d) Mortuaries. Constance Road institution. Enlargement of the mortuary especially to provide better accommodation for relatives to view the dead. Edmonton colony (now St. David's hospital). Adaptation of an existing building as a mortuary. 3. Staff accommodation. (a) Medical staff. St. John's hospital. Erection of two additional sitting rooms and bedrooms for assistant medical officers. (b) Nursing staff. Constance Road institution. Reconditioning and tiling of sanitary accommodation and provision of an additional bathroom. Replacement of gas lighting by electric. 152 Hackney hospital. Conversion of former laboratory into nurses' lecture room. Lambeth hospital. Formation of a servery and scullery for the nurses' messroom, and of a sisters' messroom. St. Benedict's hospital. Conversion of disused kitchen into sports pavilion. New End hospital. Provision of nurses' lecture room. St. Leonard's hospital. Improvement of airing court. St. Luke's hospital, Chelsea. Adaptation of two houses (formerly matron's and steward's quarters) as accommodation for 16 nurses (c.) Domestic staff. Constance Road institution. Erection of a messroom and cloakroom for the laundry staff. St. Olave's hospital. Formation of new scullery for domestic staff messroom by partitioning. St. Pancras hospital. Modernisation of domestic assistants' cloakroom. 4. Administrative services. (a) Offices. St. Charles' hospital. Provision of new offices for the medical superintendent and medical superintendent's clerk. (b) Stores. Constance Road institution. Conversion of outdoor W.C.s and urinals into household storerooms. Lewisham hospital. Improvement and enlargement of steward's stores. Queen Mary's hospital, Sidcup. Provision of store for empties. St. Nicholas' hospital. Conversion of former boiler house into steward's stores. St. Pancras' hospital. Provision of store for empties. (c) Dispensaries. Holborn and Finsbury institution. Enlargement of dispensary store. (d) Cold storage for bulk meat. Cold storage plant has been installed in the following six hospitals and institutions:—Dulwich, Holborn and Finsbury, Mile End, New End, St. Charles, and St. Leonard's. (e) Mam kitchens. In addition to the renewal, reorganisation and increase of kitchen equipment at many hospitals, the main kitchens were tiled at the following three hospitals:— Mile End. Paddington, and St. Peter's. (/) Laundries. Hackney hospital. Improvement of ventilation. Holborn and Finsbury institution. Erection of a partition with new airing facilities. Laundry machinery has also been increased or modernised at the following six hospitals and institutions:—Highgate, Holborn and Finsbury, Mile End, St.George-inthe-East, St. Leonard's, and South Grove (now under the management of the Public Assistance Committee). 153 5. Mechanical equipment. (a) Lifts. Six new bed lifts were installed at the following hospitals:—Hackney, Highgate (2), Lewisham, St. Pancras, and St. Peter's. In addition, lifts were modernised at St. Charles' and St. Mary Abbots hospitals. (b) Telephones. Internal automatic telephone systems were installed in the following six hospitals:—Hammersmith, St. Alfege's, St. George-in-the-East, St. Giles', St. James', and St. Mary, Islington. (c) Fire Alarm Systems. The following eight hospitals were equipped with modern automatic fire alarm systems:—Hammersmith, Highgate, St. Andrew's, St. Charles', St. George-in-theEast, St. Luke's, Chelsea, St. Nicholas', and South Grove. The arrangement adopted has been a dual one of " essential " and " relay " bells. " Essential " bells ring in staff residential quarters, laundries, workshops, etc., over the entire hospital or institution, but not in wards or their annexes. " Relay " bells ring adjacent to wards solely in the block from which the alarm is actually given. (d) Heating Systems. New End hospital. Installation of heating in night nurses' quarters (C block). Queen Mary's hospital, Sidcup. Enclosure and heating of verandahs. St. Olave's hospital. Provision of central heating in one block (3 wards). 6. Miscellaneous. Hammersmith hospital. Construction of new road, weighbridge and gates. Lambeth hospital. Provision of lavatory accommodation for visitors. St. Charles' hospital. Formation of additional entrance and roadway for goods. Enlargement of main entrance and provision of glazed shelter for ambulances. As was pointed out in the annual report for 1931, the problems raised by the Special transfer of the general hospitals did not arise in regard to the special hospitals, hospitals These hospitals, which were formerly administered by the Metropolitan Asylums Board, formed a homogeneous group, and no considerable alterations, either by way of adaptation or enlargement, were immediately necessary. Certain improvements have, however, been effected, and are here considered under the following headings (a) alterations and additions to patients' accommodation ; (b) alterations and additions to staff accommodation, and (c) other works. (a) Patients' accommodation.—The programme of the provision of additional isolation accommodation at the infectious hospitals was further advanced. The new block at the Western hospital was practically completed by the end of the year, and substantial progress was made in the erection of the block at the Eastern hospital, work was begun on the schemes at the Grove and the Park hospitals, and also on the division into 20 single bed isolation wards of ward block 11 at the SouthEastern hospital which was composed' of a series of four large rooms. Plans were approved for the alteration and enlargement of ward block G at the South-Western hospital by which 64 isolation beds will be added to the hospital accommodation, representing a net addition to the accommodation of 40 beds, there being a loss of 24 ordinary beds ; the scheme includes certain re-allocating of staff accommodation, whereby the additional nursing staff required can be housed in existing buildings, to which the necessary structural alterations will be made. The increase of the isolation accommodation at the North-Eastern hospital is dealt with in the following paragraph. 154 A comprehensive scheme of reconstruction and modernisation work at the North-Eastern hospital was adopted. This hospital contains 661 beds, and 32 of the wards, containing in all 509 beds, and a number of other buildings are temporary buildings constructed about 40 years ago. Under the scheme, the temporary buildings will be demolished and the wards replaced by eight general blocks of 62 beds each, each block including 22 isolation beds, and by two isolation blocks of 56 beds each. The total accommodation of the hospital will be increased by 99 beds to 760 beds. Other buildings to be erected are an operation and X-ray block, patients' receiving section, discharge block, changing block for female non-resident domestic staff and centralised clothing and furniture stores block in which will also be included messroom accommodation for non-resident male staff. Certain structural alterations were carried out at St. Margaret's hospital to enable effect to be given to a decision that the treatment there of cases of congenital syphilis should be discontinued, and a unit for the treatment of vulvo-vaginitis in young girls and infants established instead. Plans were approved of the addition of verandahs to four more cottage blocks at High Wood hospital, and of the internal alterations to those blocks required to adapt them better for the classes of case now treated at that hospital. Similar additions and alterations have already been carried out to the other blocks in which patients are accommodated. Electric bed lifts were installed in four of the patients' blocks at Grove Park hospital, including the two referred to in the annual report for 1933, the provision of which was delayed owing to the contractor's inability to execute the work. (b) Staff accommodation.—The plans of the proposed nurses' home at Pine wood were approved, and it is expected that the work will shortly be begun. (c) Other works.—Approval was given to a plan of a building to be erected at King George V sanatorium to serve as a canteen and tea room with store and kitchen, for the service mainly of refreshments to visitors to patients, also a lavatory for visitors and a patients' library. The cost of this building, which will take the place of a wooden hut hitherto used for the purpose, but now inadequate for present requirements, will be met from the profits of the canteen except that the lavatory and library will be paid for by the Council. Owing to the greatly increased work undertaken in connection with the scheme of group laboratories the accommodation at the Southern group laboratory, which was built to meet the requirements of the services of the late Metropolitan Asylums Board, has become insufficient, and it was decided to carry out an enlargement of that laboratory and plans for an extension of the buildings providing additional laboratories, offices and storage accommodation were adopted. The main kitchen at the Eastern hospital having been found to be too small for satisfactory working under present conditions and the plant and ancillary accommodation being inadequate in certain respects, a scheme of enlargement was decided on, and in connection herewith the installation of refrigerating plant, to permit as at other hospitals the supply of meat in bulk, was also approved. The work was in hand at the end of the year. The programme for the installation of central heating at Goldie Leigh hospital was continued by the installation of plant in two more of the cottage blocks. Improvements were carried out at various hospitals to electric lighting installations, laundry machinery and other engineering equipment, and as usual many minor development works of a varied nature were executed. Nurses' homes. Standard size of bedrooms. The Council on 3rd July, 1934, decided that bedrooms in new nurses homes and extensions of nurses' homes at hospitals and institutions under the management of the Hospitals and Medical Services Committee should be normally of an area of approximately 99 square feet for nurses, and 110 square feet for sisters, in cases in which there is no site or other restriction on the planning, and from 96 to 99 square feet for nurses and 107 to 110 square feet for sisters in other cases, according to local conditions and exigencies of planning. 155 Pathological laboratory services. As stated in the annual report for 1933, the establishment of the five additional group laboratories and the central histological laboratory, included in the scheme for an organised laboratory service to meet the needs of the hospitals and institutions under the control of the Hospitals and Medical Services Committee, was completed in the early months of 1934. The antitoxin establishment (Belmont laboratories) was originally designed (in 1907), to provide accommodation for the preparation of diphtheria antitoxin and swabbing outfits for the hospitals under the control of the Metropolitan Asylums Board. Since the Council assumed control, the laboratories have also undertaken the preparation of streptococcus (scarlatina, etc.) antitoxin, prophylactics for diphtheria and scarlet fever, toxins for determining susceptibility to diphtheria and scarlet fever and other test solutions, to meet the requirements of the whole of the Council's hospitals services (including the mental hospitals), and of the residential schools and children's homes under the control of the Education Committee. The work now carried out has outgrown the very limited accommodation at these laboratories, and the difficulty has only been partially overcome by the completion (in July) of the extension, of temporary construction, referred to in last year's annual report. The Council has authorised the preparation of a scheme for building new premises designed and equipped on up-to-date fines to meet the present needs, and to provide facilities for further extension of the work in the immediate future. Progress has been made towards the completion of the scheme for providing all acute general hospitals with adequate pathological laboratories. Improved accommodation at Bethnal Green hospital and a new laboratory at St. Luke's hospital, Chelsea, will be opened early in 1935. Laboratories at Highgate, St. James', St. Leonards and St. Peter's hospitals are either under construction or arrangements are in hand for the commencement of the work. When these are completed all general hospitals for the acute sick will have been provided with laboratories, where they did not already exist, with the exception of St. Nicholas hospital where suitable accommodation for adaptation is not yet available. In addition to the provision of new laboratories certain of the laboratories taken over from the late boards of guardians have been replaced by more suitable quarters and furnished with modern equipment. One or two of the older laboratories still remain to be dealt with, and will be brought up to a more modern standard, when the more ursrent works have been completed. The following is a summary of the number 01 examinations carried out during recent years in the hospital, group and central histological laboratories. Detailed statistics will be found in the tables on pages 162 to 174. Examinations carried out in Year. Hospital laboratories. Group laboratories. Central histological laboratory (including post-mortem examinations). External laboratories. Total. General hospitals. Special hospitals. Five group laboratories (General hospitals) (including post-mortem examinations). Two group laboratories (Special hospitals) (including post-mortem examinations). 1930 40,308 not available. — 20,407 — 14,072 74,787 1931 47,429 8,712* 24,433 600* 25,946 107,120 1932 69,349 126,275 48,492 23,631 5,231 8,869 281,847 1933 76,385 115,691 68,839† 38,906 9,751 692 310,264 1934 70,731 141,324 108,380 44,719 15,670 Nil 380,824 Examinations carried out in the laboratories. * Three group laboratories and the central histological laboratory were opened on 1st October, 1931. †Two additional group laboratories were opened in 1933—on 4th September and 2nd October, respectively. 156 Consultative service. The pathologists have maintained co-operation with the hospital clinicians; and the appointment of the assistant pathologists and of the additional histologist, to which reference was made in the last annual report, has enabled this valuable liaison to be extended to include, not only consultations on particular cases, but also regular visits by the pathologists and their assistants to the hospitals within their respective groups. The histologists attached to the central histological laboratory act in a consultative capacity to all the hospitals and institutions under the control of the Hospitals and Medical Services Committee. Special investigations and research. There are obviously wide nelds tor research in this growing service, but the performance of the routine work, the supervision of the work of the subordinate staff and the organisation of the service generally have left little or no time for work of this nature. The desirability of conducting such research as has been possible has, however, been kept in view; and a number of important investigations, many of them of a research nature, have been, or are being, undertaken, references to which appear in the appended summary of the reports presented by the directors, the pathologists and the histologist. Post-mortem examinations. During the year, 1,435 post-mortem examinations were earned out by the pathologists and histologists. For various reasons the pathologists and the histologists also attended a number of post-mortem examinations performed by others. Museum at the central histological laboratory. The central histological laboratory, in February, moved into the premises provided for it at the Archway hospital. Important additions have been made during the year to the collection of histological sections and morbid anatomical specimens in the museum attached to this laboratory. Supplementary editions of the index of sections, which was first issued in 1931, are printed annually and distributed to the hospitals for the information of the medical staff. Laboratory technicians. Reference has been made in previous annual reports to the recruitment and training of young women of good education for employment in the hospital laboratories as " women hospital laboratory technicians." Twenty appointments were made under this scheme ; but, owing to the period of training required, great difficulty was experienced in filling vacancies which arose owing to retirement or the sudden expansion of work, and this scheme of recruitment has had to be abandoned. The special grade of " women hospital laboratory technician " has been abolished. Technicians employed in the hospital laboratories have been graded as " laboratory technicians (grade B) " and have been made interchangeable with technicians of the same grade working in the group laboratories, so that they may obtain a wider experience of the work. Up to the present no difficulty has been experienced in filling vacancies for this grade of technician. During the year an additional technician (grade B) was appointed to five of the laboratories to undertake relief work in the hospital and erouD laboratories. Attendance of students at group laboratories Students working for the diploma of bacteriology at the London School of Hygiene and Tropical Medicine attended the group laboratories for a period of one week in 1933 to obtain experience of the technique and administrative methods employed. Professor W. W. C. Topley, who is in charge of the Division of Bacteriology and Immunology at the School, later stated that the scheme had been a great success, and eight students attended the group laboratories in June, 1934, for a period of two weeks. Agreement with the Stepney Borough Council. The agreement with the former board of guardians under which pathological work was carried out at the group laboratory at Mile End hospital for the metropolitan borough of Stepney had been renewed from time to time since 1930. The arrangements made under this agreement were reviewed in consultation with the borough medical officer of health and a new agreement was drawn up to come into force as from 1st July, 1934. Media, stains, sera, etc. During the year several important additions were made to the products prepared at the Southern group laboratory to which reference is made later in this section of the report. Apparatus. Laboratory apparatus such as glassware, which is in common use in the laboratories, has been standardised, and several new items have been added during the year to the central stock (at the Southern group laboratory) for issue as required. 157 As is already known to many who will peruse this report, the Council's hospital service, and especially that branch of the organisation which is directly concerned with the pathological service, suffered a severe blow by the death in April, 1935, of Dr. J. A. Braxton Hicks, who had held the post of pathologist in charge of the group laboratory at Lambeth hospital since October, 1931. Dr. Hicks had proved himself to be a most capable organiser, and much of the success which has accompanied the development of the pathological service is due to his advice and help. Dr. Braxton Hicks. The reports of the pathologists contain references to the progressive increase in the work in the group and hospital laboratories. Dr. Goodhart (group laboratory, St. Mary Abbots hospital) states that the new buildings of the group laboratory were opened on the 8th March, but that it was not until some weeks afterwards that the group laboratory at Archway hospital could be relieved of the work that had been undertaken there for the general hospitals in the western area of London. Summary of reports submitted by the directors, pathologists inil histologist in charge of the main laboratories. Dr. J. M. Alston (group laboratory, Archway hospital) reports as follows :— Cases of pernicious anaemia are collected in a special unit at St. Mary, Islington, hospital, and during the year some 35 of these were very fully investigated in order first to establish that the diagnosis was correct and, if so, to test the efficacy of four new preparations of liver extract. Reports were made on the results of the test. Dr. R. F. L Hewlett undertook most of the worn in this connection. During February and March the incidence of brucella abortus infection among the dairy cattle on the estate farm at one of the Council's mental hospitals was investigated. By agglutination tests of blood serum and milk it was determined that 86 out of 222 (38 per cent.) of the cows showed evidence of the infection. By the very valuable co-operation of Dr. W. M. Scott, Ministry of Health, unusually full facilities have been made available for investigating the bacterial cause of outbreaks of food poisoning. During 1934, material from 14 outbreaks has been thoroughly examined. In several cases the material was obtained by the kind co-operation of the medical officers ol health of the metropolitan boroughs. A short paper on an outbreak of food poisoning due to B. dysenteries (Sonne), by Dr. J. M. Alston, pathologist, Archway group laboratory, and Dr. J. R. Tree of Highgate hospital, will be published in vol. IV, part III, of this report. The infection of sewer workers with leptospira ictero-heemorrhagise has been enquired into. With the help of the chief engineer's department, rats and slime from the sewers have been examined, and in specimens of both the presence of virulent leptospira ictero-haemorrhagise has been demonstrated. The clinical and pathological reports of three cases of the infection which have been treated in the Council's hospitals are being prepared for publication. Four cases of a rare infection with an organism which has been provisionally named actinomyces necrophorus have been detected, and it is hoped that there will be an opportunity to make a full study of the organism and its pathogenicity. The swabbing of midwives who have been in attendance on parturient women, notified as suffering from puerperal fever, has been carried out at the group laboratory, Lambeth hospital, and the late Dr. J. A Braxton Hicks reported as follows :— The routine has been to swab the throat, nose and fingers of these midwives and to follow up the bacteriological history of the parturients whom they have attended. The results have been as follows : 30 midwives swabbed, and of the 26 who were found to be completely free from haemolytic streptococci, the parturients in 10 cases showed haemolytic streptococci in cultures taken from the cervix. One of these parturients gave a positive blood culture. Four midwives and the parturients attended by them were found to have haemolytic streptococci in the swabbings examined, one of the parturients gave also a positive blood culture; in only one of these four midwives was the haemolytic streptococcus from the throat identical with that obtained from the cervical culture from the parturient. All the children selected for adoption from the Council's residential schools were sent to the group laboratory at Lambeth hospital for serological tests for syphilis. Of the 32 children tested during the year, one was found to be positive. Adoption was not allowed in this case. As in previous years the reports on post-mortem examinations made at Lambeth hospital have been classified, together with those at St. James' and St. Giles' hospitals, the two last named being classified by Drs. Piggot and Mitchell, respectively. 158 These classifications have been printed and circulated throughout the hospital service and they have been of assistance to medical men both within and outside the Council's service. The special pathological work carried out at the group laboratory at Mile End hospital is summarised in the following report from Dr. A. B. Rosher:— The bacteriological work for the borough of Stepney has been continued; and, in connection with the examination of swabs for diphtheria bacilli, some new culture methods have been tried. They have proved to be an important supplement to the older methods and the use of a tellurite medium has been adopted as a routine measure, in addition to Loeffler's serum. In February, the services of the pathologist were placed at the disposal of the medical officer of health of a neighbouring borough in order to assist in the investigation of an outbreak of food poisoning. Time for original work has naturally been restricted, but it has been possible to continue the investigation in relation to the etiology of influenza, and some work has been carried out in conjunction with Professor G. S. Wilson concerning an unusual organism which was isolated from a case of sub-acute bacterial endocarditis. This organism is of interest in view of its extreme pleomorphism and it is proposed to publish a full account of it shortly. In addition, in view of the recent work on Addison's disease suggesting that the suprarenal has a controlling influence on the sodium metabolism of the body, attention has been paid to diphtheria to see if certain symptoms of this infection can in any way be accounted for by the damage which is inflicted on this gland by the toxin of the Klebs Loeffler bacillus. Preliminary experiments have been carried out and it is hoped to continue this work in the future. Dr. E. N. Allott has reported as follows on the special work carried out during the year at the group laboratory at Lewisham hospital:— The establishment of a diabetic clinic was referred to in my previous report. The work in connection with this clinic has grown substantially during the year and patients undergoing treatment at one of the other hospitals in the group have been controlled from this laboratory. Towards the end of the year a Sanborn-Benedict basal metabolism apparatus was acquired and a technician trained in its use ; the employment of this apparatus in fathoming the metabolism in patients undergoing treatment has increased considerably in the hospitals of this group and it was also possible to assist medical officers in other hospitals by applying the test. A number of tests for the presence of poisons and other unusual chemical investigations were also carried out for the other group laboratories. Dr. W. G. Barnard, histologist in charge of the central histological laboratory, has reported as follows:— The histological laboratory at Archway hospital was taken over by me in February, 1934; and, although the number of specimens sent in for examination was almost twice that of the previous year, there has been little congestion and no delay in sending out reports. All the reports of specimens have been classified and an index of histological sections supplementary to those previously printed will be issued in due course. As was anticipated, this store of available material has already proved of value to workers in this branch of pathology. Spare material which could be used for teaching and research purposes has been sent to the School of Pathology, Cambridge, and to pathological institutes and departments at a number of London voluntary hospitals. Specimens of particular interest have been shown by the histologists at meetings of the Pathological Society of Great Britain and Ireland and at the Pathological Section of the Royal Society of Medicine. Dr. Cowan, government pathologist to Penang, worked as a voluntary assistant in the laboratory from September to December. Up to the present time, some 400 specimens have been permanently mounted and placed in the museum, and it is anticipated that these will be arranged and catalogued during the coming vear. The museum is primarily intended for the use and instruction of the medical officers in the Council's service, and therefore caters for the qualified medical man. It is for this reason that it has been decided to group the specimens, photomicrographs and illustrations in order that they may provide clear-cut impressions of abnormal processes as a whole and of their effects on the whole body. All organs affected by a particular pathological process, and all organs affected by a particular disease will be grouped together. In this way the emphasis will be laid on the disease or process and at the same time the student will learn the patient's response to it. Specimens which do not lend themselves to this treatment will, for the time being, be classified anatomically. To collect the specimens required for this scheme will take many years, but even in its present incomplete state the museum should prove of considerable use and interest to medical officers, particularly to those who are reading for examinations for higher qualifications. In addition to the specimens prepared for this or other museums, a certain number are mounted and returned to the Council's hospitals where they are used for the teaching of nurses. In time each of the Council's teaching hospitals will be provided with a small collection which will be useful in the teaching and training of nurses. By courtesy of the London coroners, one of the histologists is permitted to be present at all the post-mortem examinations carried out on patients who have died while under anaesthetics in the Council's hospitals. 159 During the year the following research work was carried out:—The efficiency of the Zondek Ascheim reaction and a g;neral investigation of Weil's disease (in conjunction with Dr. Alston); and the classification and spread of bronchial tumours (in conjunction with Mr. Nelson). Dr. J. E. McCartney, director of research and pathological services, states that Dr. Mair has continued his investigation at the Northern group laboratory on the varieties of the diphtheria bacillus, and the correlation of the different types with differences in clinical severity. A preliminary account of the results obtained was given at a meeting of the Fever Group of the Society of Medical Officers of Health in January, 1934. Since then the work has been extended to include a serological investigation of the different types, and for the last six months all strains isolated from acute cases of diphtheria have been submitted to serological study. This work is, however, not yet completed. Dr. Begg, of the North-Eastern hospital, is engaged on an investigation into the carbohydrate tolerance of patients in severe diphtheria by blood sugar estimations. He found that marked changes in the sugar tolerance curve occur in severe diphtheria, and the degree of these changes is a useful guide in prognosis, but so far he is unable to show that the administration of insulin has any effect on the course of the disease. The biological examination of samples of milk under the Milk and Dairies (Consolidation) Act, 1915, was continued at the Southern group laboratory. During the year, 1,765 samples of milk were examined; this is a decrease of 957 over the previous year. The samples were taken from churns or tanks arriving in London by rail or road, and a small proportion from the milk supplies to the Council's hospitals and institutions. The results are set out in vol. III., part I., of this report. Briefly, they are as follows:— Total number of samples received 1,765 Number of incomplete examinations 90 Number reported on 1,675 Number of samples found tuberculous 196 Percentage of positives 11.7 During the year, 983 of these samples of raw milk were also examined for the presence of brucella abortus. It was found that 41.5 per cent, showed the presence of this infection. The preparation of adult serum for measles prophylaxis was extensively carried out during the year in connection with the epidemic of measles. Outfits for bleeding are supplied to the various hospitals, etc., and the blood so obtained was sent to the laboratory where the serum was separated, filtered, tested for sterility, and ampouled in 10 c.c. amounts. The technique used was that described in the report published by the Council on the measles epidemic, 1931-1932. The quantity of serum issued was 2,733 ampoules of 10 c.c., compared with 3,200 in the previous epidemic. Details of its use and of the results obtained will be published in the report on the measles epidemic, 1933-34, which is in course of preparation. Convalescent measles serum, when obtainable, was also prepared, and during the year 396 x 5 c.c. ampoules and 297 x 10 c.c. ampoules were issued. The " follow-up " examination of urine samples from discharged scarlet fever cases is being continued for the Park hospital. The results obtained are contained in the report on the treatment of scarlet fever at the Park hospital by the medical superintendent, Dr. H. S. Banks (see p. 82). Dr. Evelyn M. Holmes concluded her investigations on the cultural isolation and typing of tubercle bacilli. Details of the method and the main conclusions of her work were given in last year's report. A full account was published in the Journal of State Medicine, 1934, Vol. XLII., No. 10. Voluntary Workers. Dr. Adolf Beck, who was sent to the laboratory in April by Dr. F. L. Golla, of the Central pathological laboratory of the mental hospitals department, is investigating, under a Rockefeller Foundation grant, bacteriological and serological problems in mental diseases. 160 In the opinion of some clinicians, particularly French workers, certain types of mental disease such as schizophrenia (dementia praecox) are due to a tuberculous manifestation. It has therefore been claimed that the tubercle bacillus could be isolated from the blood and cerebro-spinal fluid of these cases. Dr. Beck has tested this hypothesis and has proved conclusively that there is no connection between tuberculosis and schizophrenia. He has also enquired into the demonstrability of tuberculous bacillsemia in experimental tuberculosis, and has shown that it is possible both in human beings and in animals to detect tubercle bacilli in the blood stream. In order to account for the onset of certain mental diseases some authors have stated that the bacillus coli plays an important role. Dr. Beck has carried out work in this direction, and he has shown that the B. coli agglutination test, using 76 sera of psychotics, does not differ in any way from that observed in normal persons. The general result of his observations would indicate that there is no causative connection between the B. coli infections and mental diseases. Supply of media, etc. inuring trie year additional products, sucn as media, vaccines, stains and solutions have been prepared at the Southern group laboratory for issue to the Council's hospitals and institutions (including the mental hospitals). Various items have been added to the stock of standard laboratary apparatus (e.g., glassware) which is kept at this laboratory for issue to the various laboratories as required. At the end of the year 524 different items were available for issue from this laboratory:— (1) Standardised laboratory apparatus (e.g., glassware) 193 items. (2) Culture media 125 „ (3) Stock vaccines 80 „ (4) Stains and chemical solutions 71 „ (5) Agglutinating and blood grouping sera, bacterial suspensions, tuberculin, etc. 29 „ (6) Solutions for intravenous use 26 „ During the year 97 hospitals, institutions, or departments were supplied with material. The work of manufacture and supply of media, vaccines, etc., has been very much hampered by lack of accommodation, as the demands for these products have increased considerably in the last few years. Thus, the amount of media made in 1934 was almost double that of 1932, while the amount of stains has increased by 60 per cent, over the same period. The Council has approved a scheme for the enlargement of the laboratory and the extension, which will be completed in 1935, will provide the much needed additional accommodation. Substantial increases were made during 1934 over the previous year in the issues of laboratory stores, culture media, agglutinating sera, and stock vaccines, etc. For example, the number of containers of culture media issued (bottles and tubes) has increased from 86,761 to 114,171; stains and solutions from 1,064 to 1,246 litres; grouping sera for blood transfusion from 2,742 to 5,520 tubes; tuberculin for Mantoux tests, from 1,340 to 2,514 ampoules. Since July the supply of solutions for intravenous injection, e.g., saline, glucose and gum solution, etc., has been undertaken. The solutions are carefully prepared, tested for sterility and toxicity, and are issued in sealed screw-capped bottles. The demands for the solutions greatly increased towards the end of the year; and, durine the 5 months since its inception, 118A litres in 3.293 containers were supplied Belmont laboratory. Dr. R. G. White, director of the anti-toxin establishment (Belmont Laboratory), has reported as follows:— The temporary extension of the premises which was completed early in July relieved only to a limited extent, and in only a section of the work, the pressure due to lack of sufficient accommodation at these laboratories, and the fact that it was possible to supply all the demands made upon the laboratories was to no small extent due to the manner in which the various members of the staff continued to adapt themselves to their restricted conditions. 161 The returns of the products prepared and issued during the year together with those for previous years are given in table X, page 172. In the report for 1933 attention was drawn to the fact that the output of diphtheria antiI oxin alone constituted a record annual output for these laboratories, the amount issued, namely, 103 million units, being 40 million units more than the issues made in the epidemic year, 1921. Owing to the continued prevalence of diphtheria of a type necessitating in many cases larger doses of antitoxin, the output of diphtheria anti-toxin during 1934 has exceeded that of 1933 by more than 40 per cent., 579 million units having been issued. The diphtheria antitoxin is issued as a refined and concentrated globulin solution of antitoxin in sealed ampoules of 2,000, 8,000 and 20,000 units in 1, 4 and 10 c.c. ampoules, respectively. The numbers of the various ampoules issued were as follows:—6,200 of 2,000 units, 61,400 of 8,000 and 3,700 of 20,000. The demands for streptococcus antitoxin show a steady increase, being 14 per cent, greater than for the previous year. This product is issued in sealed ampoules of 10 c.c. and 5 c.c.; approximately 28,000 of the. former and 3,000 of the latter were issued in the course of the year. The actual volumes of diphtheria and of streptococcus antitoxins issued were as follows: diphtheria antitoxin, 289 litres; streptococcus antitoxin, 291 litres; a total of 580 litres of refined and concentrated antitoxins. The corresponding figures for 1933 were: diphtheria antitoxin. 201 litres ; streptococcus antitoxin, 254 litres ; a total of 455 litres. In order to meet various requests and after consultation with the medical superintendents, it was decided to make the following additions to the list of products prepared for issue: 20,000 unit ampoules of diphtheria antitoxin and 5 c.c. ampoules of streptococcus antitoxin. Dr. E. W. Todd has continued his investigations of haemolytic streptococcal infections. The problem of serum therapy against haemolytic streptococci is complicated by the fact that antibacterial sera are strictly type specific in their action, and are therefore of doubtful use in the treatment of disease due to a multiplicity of types. The observation that the haemolysin of streptococci is antigenic, which was published by Dr. Todd in 1932, is being put to practical use for the diagnosis of infection by haemolytic streptococci particularly in rheumatic disease. Potent antistreptolysin serum has been prepared in these laboratories which in a dilution of 1 in 100,000 neutralises streptococcal haemolysin. The effect of this serum on infection with haemolytic streptococci is now under investigation. Dr. L. F. Hewitt has continued his work on serum proteins, paying special attention to the problems encountered in the preparation of antitoxins. All the copies of the first edition of Dr. Hewitt's monograph on " Oxidation Reduction Potentials in Bacteriology and Biochemistry " having been sold, advantage was taken of this opportunity to prepare a new edition brought up to date, and this was published in the early part of the year. The work in connection with active immunisation against diphtheria of children in the Council's residential schools, children's homes and residential special schools, referred to in previous reports, was continued during the year, and subjoined are particulars of the work done up to 30th June, for which period alone completed statistics are available. In the fifteen residential schools and homes and in the ten residential special schools included under the scheme, 1,208 children were tested for their susceptibility to diphtheria and 448 gave a positive reaction. Of these, 400 received the full course of inoculations and were afterwards found to give a Schick-negative reaction. For various reasons the remaining 48 were not tested, most of these children having left the schools before the inoculations were completed. For the clinical comparative tests constantly required in connection with the work, thanks must be accorded for the valuable services rendered by the medical superintendents and medical officers of various hospitals and especially to Dr. Rolleston, medical superintendent of the Western hospital, who granted the necessary facilities, and to Dr. Laurent, senior medical officer of the hospital, who carried out various standardisation tests. Dr. Greenfield, assistant medical officer, formerly at Joyce Green hospital, and later at the Eastern hospital, also assisted in this work. This opportunity is again taken of expressing thanks to the Medical Research Council for providing regular supplies of standard diphtheria antitoxin. 162 PATHOLOGICAL SERVICES. Table I.—Group Laboratory at Archway hospital. Record of examinations, etc., completed during the year ended 31st December, 1934. Hospital or Institution, etc. Pathological. Bacteriological. Biochemical. Post-mortem examinations by pathologist. Attendance at post-mortem examinations. Histological. Miscellaneous. Total Blood. Urine. Fæces. C.S.F. Fluids, exudates, etc. Identification of micro-organisms. Gonococci. T.B. Agglutination per organisms. Wassermann reaction. Kahn test. Other complement fixation tests. Vaccines. Animal inoculation. Blood sugar and urea. Other blood. Urine. Fæces. Test meals. C.S.F. Full count. Hb.,R.B.C. or W.B.C. diff. Other hæm. tests. General. Lange, etc. General. General. Archway 227 42 107 224 2 93 22 32 730 33 882 91 251 213 21 2 62 139 14 65 29 26 14 — 19 — — 3,340 Highgate 158 43 69 263 3 44 15 69 1194 59 306 72 181 160 5 8 39 145 14 187 124 41 9 — 4 — — 3,212 Holborn & Finsbury institution — — — — — — — — 48 — 9 — — — — — 2 — — — — — — — — — — 59 New End — 2 6 — — 4 12 4 61 — 6 17 585 550 151 4 42 1 23 5 3 — — — 1 — — 1,477 St. Leonard's 142 22 33 200 7 54 10 52 718 84 403 24 733 703 432 22 58 151 29 259 91 9 5 — 3 — — 4,244 St. Mary, Islington 538 43 317 708 6 191 57 168 2478 104 845 105 892 805 384 15 123 274 54 83 189 87 33 — 6 — — 8,505 St. Pancras 3 1 7 16 1 7 14 8 88 7 18 8 802 764 570 12 54 25 19 24 8 2 1 — 2 — 2 2,463 Group laboratories and other hospitals, etc. 1 2 — 3 — 12 71 1 439 — 3 14 1094 941 1001 4 149 8 6 4 1 — 2 — — — — 3,756 Total 1069 155 539 1414 19 405 201 334 5756 287 2472 331 4538 4136 2564 67 529 743 159 627 445 165 64 — 35 — 2 27,056 Total for 1933 692 66 17 1335 147 433 221 314 4953 602 2822 432 4272 3918 686 33 288 864 160 659 395 86 118 1 22 — 2 23,538 163 PATHOLOGICAL SERVICES-continued. Table II.-Group Laboratory at Lambeth hospital. Record of examinations, etc., completed during the year ended 31st December, 1934 Hospital or Institution, etc. Pathological. Bacteriological. Biochemical. Post-mortem examinations by pathologist. Attendance at post-mortem examinations. Histological. Miscellaneous. Total. Blood. Urine. Fæces. C.S.F. Fluids, exudates, etc. Identification of micro-organisms. Gonocooci. T.B. Agglutination, per organisms. Wassermann reaction. Kahn test. Other complement fixation tests. Vaccines. Animal inoculation. Blood sugar and urea. Other blood. Urine. Fæces. Test meals. C.S.F. Full count. Hb.,R.B.C. or W.B.C. diff. Other hæm. tests. General. General. General. Lange, etc. Lambeth 332 260 266 457 — 266 34 83 927 1535 1199 279 2944 2722 319 8 26 242 17 66 236 134 3 654 — 1138 3 14,140 St. Benedict's 50 6 49 49 — 3 2 — 69 2 30 3 46 43 4 2 2 13 3 1 5 — — — — 1 1 384 St. Giles' — 2 7 20 — 6 16 4 46 — 7 160 2271 2216 38 9 31 9 1 19 7 2 — 73 71 83 1 5,099 St. James' 236 60 204 536 2 252 27 60 1043 51 765 187 1607 1441 11 6 53 338 29 64 66 51 1 6 36 543 2 7,677 St. John's 20 2 13 3 — 2 — — 41 2 8 9 12 11 1 — 1 8 — 3 —1 — — — — 52 2 191 Other hospitals — — — — — — — — — — — — — — — — 3 — — — — — — — — 3 — 6 Total 628 330 539 1065 2 529 79 147 2126 1590 2009 638 6880 6433 373 25 116 610 50 153 315 187 4 733 107 1820 9 27,497 Total for 1933 332 193 18 1042 2 477 100 172 1599 1195 2283 740 6548 6211 391 38 102 531 80 147 379 199 1 729 — 1716 10 25,235 164 PATHOLOGICAL SERVICES—continued. Table III.—Group Laboratory at Lewisham hospital. Record of examinations, etc., completed during the year ended 31st December, 1934. Hospital or Institution, etc. Pathological. Bacteriological. Biochemical. Post-mortem examinations by pathologist. Attendance at post-mortem examinations. Histological. Miscellaneous. T otal. Blood. Urine. Fæces. C.S.F. Fluids, exudates, etc. Identification of micro-organisms. Gonococci. T.B. Agglutination per organisms. Wassermann reaction. Kahn test. Other complement fixation tests. Vaccines. Animal inoculation. Blood sugar and urea. Other blood. Urine. Fæces. Test meals. C.S.F. Full count. Hb.,R.B.C. or W.B.C. diff. Other haem. tests. General. Lange, etc. General. General. Dulwich 3 — 16 14 2 2 24 2 101 1 9 11 948 911 27 7 19 116 39 78 1 3 5 1 1 228 5 2.674 Lewisham 377 94 145 690 4 83 17 62 1504 44 730 100 292 266 9 3 31 1256 225 336 86 35 14 184 — 646 14 7,247 Norwood children's 2 — — 12 — 10 1 — 423 6 24 — 6 4 — — 12 — — — — — — — — 1 — 501 Queen Mary's, 13 7 15 2 2 2 31 4 124 10 33 31 1 — 1 15 1 3 44 — — — 10 349 Sidcup St. Alfege's 5 6 70 16 7 9 36 8 167 3 29 93 385 339 21 7 56 203 91 57 33 4 14 1 — 279 11 1,950 St. Nicholas' 62 41 10 219 1 66 34 25 519 17 644 60 276 234 12 3 16 131 18 80 81 17 8 1 I 141 1 2,718 St. Olave's 5 — 29 31 2 27 3 125 3 23 66 637 594 86 14 106 8 34 12 8 1 1 — — 426 16 2,263 Ladywell institution 1 — — 1 — — — — 20 2 3 — 2 2 — — 1 4 — — — — — — — — — 36 Other services — — — — — — — — — — — — — — — — — — 10 — — — — — — — 14 Total 468 150 270 998 16 176 141 102 2890 80 1586 440 2581 2383 156 34 242 1733 418 566 253 60 42 187 2 1731 47 17,752 Total for 1933 584 194 321 1282 123 264 88 200 2577 106 2099 233 1742 1608 100 15 88 1099 222 586 573 100 36 2 3 616 10 14,871 165 PATHOLOGICAL SERVICES—continued. Table IV.—Group Laboratory at Mile End Hospital. Record of examinations, etc., completed during the year ended 31 st December, 1934. Hospital or Institution, etc. Pathological. Bacteriological. Biochemical. Post-mortem examinations by pathologist. Attendance at post-mortem examinations. Histological. Miscellaneous. Total. Blood. Urine. Faeces. C.S.F. Fluids, exudates, etc. Identification of micro-organisms. Gonococci. T.B. Agglutination, per organisms. Wassermann reaction. Kahn test. Other complement fixation tests. Vaccines. Animal inoculation. Blood sugar and urea. Other blood. Urine. Fæces. Test meals. C.S.F. Full count. Hb.,R.B.C. or W.B.C. diff. Other haem. tests. General. General. General. Lange, etc. Bethnal Green 9 3 12 23 — 28 26 7 258 36 23 55 449 421 13 7 34 161 20 7 17 16 24 — — — 8 1,657 City of London institution 1 — — 4 — 1 — 1 20 1 10 — — — — — — — 1 — — — 1 — — — — 40 Hackney 6 9 14 12 8 10 51 18 435 16 60 150 390 339 7 22 44 445 80 24 25 8 79 — 4 — 39 2,295 Mile End 190 88 97 401 — 28 9 53 1551 110 878 112 211 203 2 11 40 116 15 57 75 27 21 — 2 — 22 4,319 St. Andrew's 3 9 22 — — 97 107 4 157 3 2 37 290 194 — 3 24 22 12 4 5 — 79 — — — 22 1,096 St. George-in-the- East 6 14 25 16 3 14 14 1 199 10 14 62 196 181 2 12 34 216 82 26 7 15 15 — 1 — 5 1,170 St. Peter's 238 63 73 213 6 59 39 18 877 27 806 218 361 320 20 4 10 745 53 167 99 50 44 — — — 50 4,560 South Grove institution 5 — 1 — — — — 1 — — 6 — 7 7 — — — — — — — — — — — — — 27 Bromley House institution — — — — — — — — 12 — — 30 — — — — — — — — — — — — — — — 42 Stepney Borough Council — — — — — — — — 2959 — — 11 — — — — 42 — — — — — — — — — — 3,012 Group laboratories, other hospitals, etc. 1 — — — — — — — 31 — — 6 3 3 4 — — — 4 — — — — — — — — 52 Total* 459 186 244 669 17 237 246 103 6499 203 1799 681 1907 1668 48 59 228 1705 267 285 228 116 263 — 7 — 146 18,270 * As the laboratory was not opened until 4th September, 1933, there are no comparable figures for that year. 166 PATHOLOGICAL SERVICES—continued. Table V.—Group Laboratory at St. Mary Abbots Hospital. Record of examinations, etc., completed during the year ended 31st December, 1934. Hospital. Pathological. Bacteriological. Biochemical. Post-mortem examinations by pathologist. Attendance at post-mortem examinations. Histological. Miscellaneous. Total, Blood. Jrine. Faeces. C.S.F. Fluids, exudates, etc. Identification of micro-organisms. Gonococci. T.B. Agglutination, per organisms. Wassermann reaction. Kahn test. Other complement fixation tests. Vaccines. Animal inoculation. Blood sugar and urea. Other blood. Urine. Faeces. Test meals. C.S.F. Full count. Hb.,R.B.C. or W.B.C. diff. Other haem. tests. General. I General. ] General. Lange, etc. Fulham 5 – 2 13 10 17 29 6 226 10 9 29 444 413 – 7 27 3 14 3 6 — 2 – 2 70 3 1,348 Hammersmith 96 12 4 185 18 38 21 26 674 25 389 40 111 99 — 5 15 124 15 37 35 13 6 — — 36 13 2,037 Heatherwood — — — — — — — — 20 — 6 — — — — — 1 – – — — — — — — — 27 Paddington 20 6 5 8 5 5 7 4 58 11 11 16 132 122 — — 17 8 7 11 15 — 1 — — 30 — 499 St. Charles' 13 3 1 9 7 5 7 5 225 1 10 54 510 492 — 4 28 10 15 8 15 — 1 — 2 83 10 1,518 St. Luke's, Chelsea 151 18 12 197 17 50 31 27 690 58 753 25 122 114 — 3 19 78 17 147 18 7 10 — — 23 4 2,591 St. Mary Abbots 384 136 36 2396 123 71 26 43 2824 77 364 144 311 285 — 20 44 379 48 487 56 14 17 53 23 161 16 8,538 St. Stephen's 1 – – 5 2 3 27 4 73 3 2 97 496 450 — 2 13 — 4 2 3 1 — — — 59 — 1,247 Total* 670 175 60 2813 182 189 148 115 4790 185 1544 405 2126 1975 — 41 164 602 120 695 148 35 37 53 25 462 46 17,805 * As the laboratory was not opened until 2nd October, 1933, there are no comparable figures for that year. 167 PATHOLOGICAL SERVICES—continued. Table VI.—Central Histologica Laboratory. Statement showing the number of specimens dealt with, the work done in connection with postmortem examinations and the number of specimens mounted for hospitals and museum during 1934. Hospital or group laboratory. Histological (i.e., report and stained section) Specimens mounted for Postmortem examinations carried out by histologists. Histologist present at postmortem examinations on anæsthetic deaths. Routine Special. Hospital. Museum. Group laboratory— Archway hospital Archway 1,921 73 – 20 112 2 Highgate 1,848 77 1 14 120 — New End 737 6 1 9 18 — St. Leonard's 579 25 3 7 21 1 St Mary, Islington 1,514 66 — 11 13 3 St. Pancras 461 9 1 6 2 4 Group laboratory— Lambeth hospital Lambeth 46 3 5 5 – 1 St. Giles' 44 – – – – 5 St. James' 20 — 1 1 — 2 Group laboratory— Lewisham hospital Dulwich 24 – – 1 – 1 Lewisham 102 9 3 3 2 — Queen Mary's, Sidcup 9 — — — — — St. Alfege's 74 4 — 4 2 — St. Nicholas' 36 — — — — 3 St. Olave's 519 40 6 10 5 2 Group laboratory— Mile End hospital Bethnal Green 153 5 – – – 2 Hackney 1,164 50 1 7 46 3 Mile End 680 14 1 8 22 — St. Andrew's 463 27 1 2 1 3 St. George-in-the-East 474 9 2 2 1 — St. Peter's, Whitechapel 147 1 — 1 — 1 Group laboratory— St. Mary Abbots hospital Fulham 444 18 1 2 10 5 Hammersmith 308 10 8 7 5 1 Paddington 208 4 9 3 1 1 St. Charles' 475 24 — 3 13 2 St. Luke's, Chelsea 293 7 — 1 2 2 St. Mary Abbots 795 8 — 5 25 3 St. Stephen's 574 10 4 5 27 2 Southern and Northern group laboratories— Brook 60 6 — — 4 — Colindale 56 — 1 2 1 — Eastern 36 — — — 2 — High Wood King George V 4 — 1 — — — sanatorium 2 — — — — North-Eastern 6 — 1 — — — North-Western 30 — — — 1 — Northern 24 — — — 1 — Park 58 — — — 4 — Pinewood sanatorium 1 — — — — — Queen Mary's, Carshalton 28 — 4 1 — — St. Luke's, Lowestoft 8 — 1 1 — South-Eastern 24 — — — 1 — Western 4 2 2 — — — Total 14,453 507 58 141 462 49 Total for 1933 8,749 576 67 88 235 36 168 169 PATHOLOGICAL SERVICES—continued. Table VII.—SOUTHERN GROUP LABORATORY. Record of examinations, etc., completed during the year ended 31st December, 1934. Hospitals, etc. Bacteriological. Pathological. Biochemical. Photographs, negatives and prints. Total. Diphtheria Group. Typhoid Group. Agglutinations. Identification of organisms. Gonococci. T.B. Wassermann. Other complement fixation tests. Special vaccines. Animal inoculation. Blood. Urine. Fæces. C.S.F. Blood sugar and urea. Other blood. Urine. Fæces. Histological. Miscellaneous. Milk samples. Virulence. Microscopic. Fæces. Urine. Full count. Diff. count. Culture. General. General. General. Lange, etc. No, of blocks. Special hospitals:— Brook 425 1027 9 9 20 233 6 3 6 4 2 – 1 – 5 26 1 22 – – – 1 – 5 4 – 54 1863 Colindale — — — — 6 – – 2 32 31 – – – – – 1 – 1 1 – – – – 4 – – 23 101 Downs 4 16 – – 7 5 34 2 13 11 1 – 1 1 – 1 – 5 – – – – – 9 – – – 110 Eastern – – – – 1 – – 2 1 – – – – – – – – 1 – – – – – 16 – – 21 Goldie Leigh 38 1017 — – — – — – – – — – 1 – – – – – – – – – – – – – – 1056 Grove 107 121 3 3 25 46 1 2 2 3 2 – – – 2 7 – 5 – 1 – – – 5 10 – – 345 Grove Park 2 12 – 1 6 77 3 3882 31 28 – 3 7 11 – 55 9 20 2 19 8 – 14 16 8 – – 4214 Highwood 1 6 2 – – 13 – 1 9 9 1 21 – – – 2 – 5 1 3 – – – 31 – – – 105 Joyce Green 125 167 4 – 15 8 5 2 4 3 – 1 – 3 7 6 – 2 – – – 40 11 – – 403 King George V — — — – – 13 – 4 1 – 1 10 – – – 3 – 16 – – – – – – – – – 48 Millfield – 19 – – – 13 – – – – – – – – – – – – – – – – – – – – – 32 Northern – – – – – – – – 4 4 - — – – – 1 – – – – – – – – – – 6 15 North- Eastern – – – – – – – – 14 14 – — – – – – – – – – – – – – 1 – 18 47 North-Western – – – – 2 – – – 11 10 – – – – – – – – – – – – – 29 11 – 11 74 North - Western (Radium centre) – – – – – – – – – – - – – – – – – – – – – 13 – – – 13 Orchard 29 – 1 – – – – – – – – – – – – – – 2 – – – – 4 – – – 60 Park 165 11790 23 2 43 149 2 13 2 3 1 – – 3 3 1019 2 169 – 1 – – 31 24 – 42 13495 Pine wood – 1 – – – 2 – – 3 3 - Z – – – 1 – – – – – – 5 – – 12 28 Princess Mary's 18 92 – – 3 22 1 11 9 8 9 1 – 1 1 13 2 1 – 3 – – 1 1 – – 218 Queen Mary's, Carshalton 46 149 7 — 16 61 6 16 6 6 5 20 75 — 11 10 101 2 5 — 77 29 – 34 44 20 — — 726 Sheffield Street – – – – – – – – – – - – – – – 1 – – – – – – – – – – Southern 315 163 1 – – 8 – 1 2 2 2 – – 2 – 17 – 2 – 2 – – – – – – 517 South-Eastern 243 231 3 – – 28 1 1 6 7 3 1 – – 5 4 1 12 – 3 – – 8 13 – – 570 South- Western 104 218 26 18 37 44 – 2 1 1 4 – – 2 2 11 – 21 – – – – 23 16 – – 530 St. Anne's home 6 12 – – – 4 – – – – - — – – – 4 – – – – – – – – – 26 St. George's home – – – – – 48 – 427 – - – – – – – – – – – – – – – – – 475 St. Luke's, Lowestoft – 1 – – 3 47 – 42 221 2 50 – – 2 30 – 3 – 3 – – 2 – – 851 St. Margaret's – – – – – 8 162 – 71 4z 5 - – – – – 2 – – – – – – – – – – 312 Western 10 11 – – – 10 – – 4 69 - – – – – – – 1 – – – – 11 8 – – 58 White Oak 6 127 — — – 3 1 1 80 76 1 1 — 2 – – – – – – – – – – – – 298 General hospitals 9 1 1 1 3 12 — 5 7 7 - — — 4 — – 1 — — — — 1 2 – — 94 148 Group laboratories 100 6 — — — 5 — 5 6 2 - 1 – – – – – – – – – – – 14 — 43 182 Central pathological laboratory—Mental Hospitals Other services:— — – – – – 2 – – – - 7 – – – – – – – – – – – – – – 9 Milk Supply (Tuberculosis) – – – – – – – – – - – – – – – – – – – – – – – 1765 1765 Residential schools and education services 341 337 1 — — 3 — 4 — i - — – – – 9 – – – – – – – – – – 695 Other departmental services – 2 1 – – – – – – – 1 – – – – – – – – – – – 3 3 – – 7 Miscellaneous – – – – – – – – 2 29 7 – – – – – – – – – – – – – – – 38 Total 2094 15550 82 34 186 865 222 4426 549 759 42 193 10 33 37 1315 17 297 5 114 44 3 49 305 157 1765 303 29456 Total for 1933 1796 12739 54 40 211 576 57 4980 683 547 23 152 10 18 30 842 21 228 15 73 65 15 2 374 99 2722 370 26742 170 PATHOLOGICAL SERVICES—continued. Table VIII.—Products prepared at and issued from the Southern Group Laboratory, Park Hospital, 1930—1934. Year. Media. Solutions for intravenous injections.* Stains and solutions. Stock vaccines. Grouping sera for blood transfusions. Tuberculin for Mantoux test. Measles serum. Adult. Convalescent. Litres. Number of containers. Litres. Number of containers. Litres. Number of c.c.s. Number of capillary tubes. Number of 1 c.c. Number of 10 c.c. ampoules. Number of 5 c.c. ampoules. Number of 10 c.c. ampoules. 1930 593 45,088 — — not available not available — — — 135 102 1931 809 50,580 — — not available 2,254 986 364 — 138 104 1932 1,181 57,490 — — 750 not available 2,098 1.352 3,200 280 210 1933 1,697 86,761 — — 1,064 3,662 2,742 1,340 Nil 116 87 1934 2,055 114,171 118½ 3,293 1,246 4,239 5,520 2,514 2,733 396 297 * Commenced July, 1934. 171 PATHOLOGICAL SERVICES—continued. NORTHERN GROUP LABORATORY. Table IX—Record of examinations, etc., completed during the year ended 31st December, 1934. Hospital. Bacteriological. Pathological. Biochemical. Diphtheria Group. Typhoid Group. Agglutinations. Ident. of organisms. Gonococci. T.B. Wassermann. Other Comp. fix. Special vaccines. Animal inocul. Blood. Urine—General. Fæces—General. C.S.F. Blood sugar and urea. Other blood. Urine. Fæces. Histological— No. blocks. Milk samples. Total. Virulence. Microscropic Fæces. Urine. Full cnt. Diff. cnt. Culture. General. Lange.etc. Eastern 335 610 2 2 6 149 11 11 2 3 — — 3 19 — — — — — 4 — 1,157 Northern 39 43 — — 7 15 1 170 — — 1 1 — — — 3 3 — — — — — — — — 283 North -Eastern 1321 4518* 23 3 30 4186 34 26 — — — 1 22 16 10 72 61 36 2 4 2 4 1 36 2 10,410 North -Western 287 242 48 37 83 504 4 9 — — 9 — — 1 23 96 5 33 2 — — — — — — 1,383 Western 282 284 9 4 30 170 17 19 — — 1 1 — 5 — 3 — 28 — 2 — — — — — 855 Edmonton colony — — — — — — — — — — — — — — — — — — — — — — — — — 9 Sheffield-street — — — — — 1 1156 —— — — — — — — — — — — — — — — — — — 1,158 South-Eastern 6 2 — — — — — — — — — — — — — — — — — — — — — — — 8 Total 2270 5699 82 46 159 5025 1223 241 — — 13 3 25 22 33 175 72 116 4 6 2 4 1 40 2 15,263 * Includes 2,877 "carrier" cultures. 172 PATHOLOGICAL SERVICES—continued. BELMONT LABORATORIES. Table X—Quantities of Antitoxin, Serum Tubes, Swab Tubes, etc., supplied, 1909 to 1934. Year Total number of diphtheria antitoxin units supplied. Antistreptococcus serum. Number of serum tubes (Lœffler). Number of swab tubes. Schicktest toxin and control. No. of sets. Dick-test toxin and control. No. of sets. Diphtheria prophylactic (Formol toxoid). No, of ampoules. Scarlet fever prophylactic. No. of ampoules. Mixed diphtheria and scarlet fever anti-toxin No.of 5 c.c. ampoules. SchultzCharlton test solution. Number of ampoules. Horse serum. Desensitising doses of 1 c.c. Normal horse serum c.c. Horse blood c.c. Number of ampoules of 10 c c. Number of ampoules of 5 c.c. 1909 81,980,000 – – 38,625 20,038 – – – – – 1910 68,488,000 — — 28,235 15,328 – — — — — — — — — 1911 107,172,000 — — 37,516 20,092 – — — — — — — — — 1912 97,816,000 — — 42,542 30,712 – — — — — — — — — 1913 108,520,000 — — 48,725 34,262 – — — — — — — — — 1914 148,560,000 — — 54,450 41,550 – — — — — — — — — 1915 160,444,000 — — 52,550 27,660 – — — — — — — — — 1916 150,084,000 — — 44,311 19,600 – — — — — — — — — 1917 144,948,000 — — 38,100 21,806 – — — — — — — — — 1918 129,000,000 — — 31,050 27,850 – — — — — — — — — 1919 161,092,000 — — 41,250 36,412 – — — — — — — — — 1920 243,526,000 — — 78,330 68,574 – — — — — — — — — 1921 363,075,000 — — 106,965 91,390 – — — — — — — — — 1922 359,775,000 — — 102,842 100,334 – — — — — — — — — 1923 214,428,000 — — 64,793 65,341 – — — — — — — — — 1924 228,318,000 — — 81,751 82,788 – — — — — — — — — 1925 269,975,000 — — 113,418 119,371 – — — — — — — — — 1926 300,508,000 — — 160,553 163,555 – — — — — — — — — 1927 270,230,000 — — 163,062 164,712 – — — — — — 300 — — 1928 271,898,000 — — 162,950 163,850 – — — — — — 412 — — 1929 280,718,000 2,200 — 152,310 153,036 – — — — — — 600 — — 1930 347,046,000 3,882 — 184,483 182,272 – — — — — — 600 3,140 3,750 1931 235,852,000 3,275 — 126,459 129,507 98 — 18 — — — 325 4,360 5,025 1932 291,952,000 15,603 — 131,048 139,786 2,176 844 1,181 — — 60 662 7,435 17,250 1933 402,788,000 25,435 – 132,814 152,810 3,213 2,592 1,555 46 100 382 1,925 28,275 16,050 1934 579,012,000 27,785 2,683 141,166 178,134 3,561 3,951 1,569 264 2,050 490 1,777 28,410 25,850 173 PATHOLOGICAL SERVICES.—continued. Table XI (a)—Record of examinations completed in hospital laboratories and post-mortem examinations performed by medical staff at the general hospitals during the year ended 31st December, 1934. Hospitals, etc. Pathological. Identification of micro-organisms (except gonococci and T.B.) Gonococci. Bacteriological. Other complement fixation tests. Vaccines. Animal inoculation. Blood sugar and urea. Other blood. Biochemical. C.S.F. Post-mortem examinations. Histological. Miscellaneous. Total. Full count. Blood. Other Hæm.tests. Urine Fæces C.S.F. Fluids, exudates, etc. T.B. Agglutination, per organisms. Wassermann reaction. Kahn test. Urine. Fæces. Test meals. Hb., R.B.C. or W.B.C. diff. General. General. General. Lange, etc. Archway – – – – – – – – – – – – – – – – – – – – – – 114 – – 114 Bethnal Green 157 63 7 239 1 22 31 862 18 684 66 – – – – – 4 — 299 43 13 17 87 7 — 2620 Dulwich 371 185 — 428 20 65 38 839 66 690 33 – – – – – 218 — 52 142 36 62 135 – 38 3418 Fulham 417 40 14 861 — 76 36 2963 169 799 63 – – – – 294 – 109 45 11 8 132 – – 6037 Edmonton colony — — — — — 1 — — — 6 — — — – – – – – – – – 1 1 6 – 15 Hackney 305 398 102 1104 52 259 132 3461 213 1491 72 – – – – – – – 263 909 158 – 116 – – 9035 Hammersmith — – – – – – – – – – – – – – – – – – – – – – 103 – – 103 Highgate – – – – – – – – – – – – – – – – – – – – – – 42 – – 323 Lambeth – – – – – – – – – – – – – – – – – – – – – – 87 – – 87 Lewisham – – – – – – – – – – – – – – – – – – – – – – 108 – – 108 Mile End – – – – – – – – – – – – – – – – – – – – – – 46 – – 46 New End 169 64 7 394 2 26 27 1016 116 272 39 – – – – – 394 1 306 57 22 11 46 – 9 2,994 Norwood children's – – – – – – – – – – – – – – – – – – – – – – 62 – – 2 Paddington 199 183 7 492 — 49 32 1197 167 533 27 – – – – – 130 1 106 8 6 32 2 – – 3204 6 10 – – – – – – 3 15 – – – – – – – – – – – – 35 – 12 75 St. Alfege's 296 329 57 549 58 102 55 931 93 724 118 – – – – – 351 – 166 190 49 3 29 – – 4161 St. Andrew's 301 88 132 637 30 75 47 1205 41 1387 – – – – – – 122 6 191 48 61 8 90 – 24 531 437 88 49 519 4 75 18 2054 407 921 10 – – – – 232 8 85 206 80 3 128 – – 5331 299 199 72 624 15 55 15 818 33 510 48 — — — — — 6 6 112 96 36 — 105 — 1 3003 178 375 61 409 17 125 413 1617 47 904 64 — — — — — 162 20 210 26 20 2 58 265 — 5172 St. James' — — – — — — — — — — –— — — — — — — — — — – — 555 — — 555 St. John's – – – – – – – – – – – – – – – – – – – – – – 133 – – 133 St. Leonard's 22 10 — 1 – – – 1 – – 1 – – – – – – – – – – – 91 – – 126 St. Luke's, Chelsea – – – – – – – – – – – – – – – – – – – – – – 103 – – 103 St. Mary Abbots – – – – – – – – – – – – – – – – – – – – – – 7 – – 7 St. Mary, Islington* 89 16 — 19 — 1 1 59 6 77 14 – – – – – 8 — 3 14 14 – †271 – – 592 St. Nicholas' — — — — — — — — — — — — — — – – – – – – – – 79 – – 79 St. Olave's 452 276 275 1780 21 129 124 3954 116 1803 49 – – –– – – 516 – 557 199 90 243 180 – – 10787 St. Pancras 151 203 44 543 5 21 22 974 39 554 23 – – – – – 178 – 136 349 49 15 37 – 2 3346 St. Peter's — — — — — – – — — — — — — – — – – – – – – – 46 – – 46 St. Stephen's 322 140 59 423 25 113 29 1016 1076 651 59 – – – – – 130 – 177 126 114 2 100 – 3 4578 4171 2667 886 9022 250 1194 1020 22,967 2610 12302 716 – – – – – 2745 79 2772 2458 759 407 3339 286 81 70,731 * From 12th November, to 31st December, 1934. † Total for whole year. 174 PATHOLOGICAL SERVICES—continued. Table XI (b)—Record of examinations completed in the laboratories at the special hospitals during the year ended 31st December, 1934. Hospital. Blood counts. Fæces. General. Urine. General. Identification of microorganisms, except diphtheria and T.B. Diphtheria. t.b. Postmortem exams. Miscellaneous. Total. Brook - 16 31 11,708 2 19 - 11,776 Colindale 688 - 117 145 3 4,795 2 103 5,853 Downs 6 - — 20 1,802 3 6 4 1,841 Eastern Done at Northern group laboratory. — 36 8,616 1 14 7 8,674 Grove 24 - 55 12 16,141 5 14 20 16,271 Grove Park Examinations carried out in Southern group laboratory. — 12 — 12 High Wood 12 6 79 13 470 900 10 4,015* 5,505 King George V 1,259 — 14 12 1 3,557 1 1,291 † 6,135 Northern 1 — 15 — 2,066 734 4 — 2,820 North-Eastern 25 — 70 12 19,750 2 23 900 20,782 North-Western 75 — 105 259 9,119 1 24 126 9,709 Park Examinations carried out in Southern group laboratory. — 28 — 28 Pinewood 2 - 5 - - 1,720 2 98 1,827 Princess Mary's, Margate 14 - 79 40 87 5 - 12 237 Queen Mary's, Carshalton 25 - 142 26 2,211 4 18 32 2,458 River 6 — 8 9 7,928 6 11 4 7,972 St. Luke's, Lowestoft 27 — — 1 — 2 4 4 38 Southern — — — 1 7,538 — — — 7,539 South-Eastern 23 — 20 50 11,410 1 8 7 11,519 South-Western - - - 4 10,669 - - — 10,673 Western 19 — 67 157 9,306 25 50 31 9,655 Total 2,206 6 792 828 118,825 11,763 250 6,654 141,324 Total for 1933 1,002 53 1,200 1,127 97,174 14,755 168 612 115,691 • Includes 4,000 estimations of sedimentation rate of the red blood cells. † 1.259 „ „ „ „ 175 Supply and repair of artificial limbs. The arrangement with Queen Mary's hospital, Roehampton (Ministry of Pensions) for the supply and repair of artificial limbs for Council patients continued to work in a most satisfactory manner. It will be observed from the figures submitted below that the number of cases dealt with tends to increase. It should be borne in mind that the figures shown in brackets are for a period of fifteen months, whereas the other figures relate to the year 1934. During the year, 181 applications for the supply and repair of limbs were received from various sources and referred to Queen Mary's hospital, Roehampton. In addition, nineteen pylons were supplied by the chief officer of supplies for patients who were originally recommended for attention at Roehampton. The total amount due to the Ministry of Pensions for the work carried out during the year for the Council was approximately £1,085, compared with £950 in 1933. The following is an analysis of the work carried out at Queen Mary's hospital, Roehampton, during the year 1934 (the figures in brackets are those for the period September, 1932, to December, 1933):— (i) Supply of artificial limbs (cases completed)— Sex—Male 60 (47) Female 13 (11) 73 (58) Site of amputation— Legs—Below knee —Right 17 (7) „ Left 10 (8) Above knee—Right 23 (16) „ Left 19 (11) Arms—Below elbow—Right - (-) „ Left 2 (1) Above elbow—Right - (2) „ Left 1 (2) No information as to exact site of amputation 2 (11) 74* (58) * One patient was supplied with two limbs. N.B.—Of the 74 (58) limbs supplied, 12(11) limbs were sent for repair but were replaced. Origin— Hospital 43 (32) Public assistance department 27 (24) Other sources 3 (2) 73 (58) Nineteen pylons were supplied through the chief officer of supplies. (ii) Repair of artificial limbs (cases completed)— Sex—Male 31 (20) Female 10 (7) 41 (27) Origin— Hospital 13 (6) Public assistance department 24 (17) Other sources 4 (4) 41 (27) (iii) Supply and repair of artificial limbs (cases not completed on 31st December, 1934)— Sex—Male 27 (24) Female 10 (13) 37 (37) Site of amputation (new limbs only)— Legs —Below knee —Right 7 (8) „ Left 4 (4) Above knee —Right 8 (7) „ Left 11 (11) Arms—Below elbow—Right 1 (-) „ Left 1 (1) Above elbow—Right - (-) „ Left - (-) Repairs 7 (6) 39* (37) * One patient is being supplied with two artificial arms and another with two artificial legs. 176 Origin— Hospital 27 (20) Public assistance department 9 (14) Other sources 1 (3) 37 (37) Donations. From time to time small donations are made to the hospitals and institutions in recognition of the treatment of patients and inmates. During the year such gifts were received at thirty-one of the general hospitals and institutions, amounting to a total sum of £305 2s. 8d. The individual sums varied from 1s. to £25. The highest total was received at St. Mary Abbots hospital, to which £38 12s. 6d. was given, while at certain hospitals and institutions situated in poorer districts no donations were recieved. These are apart from the legacy from Mr. James Foster previously mentioned (page 34). In the special hospitals donations were received at nineteen hospitals, amounting to a total of £90 16s. 3d. The individual amounts varied between 1s. 6d. and £12 10s. The highest total sum was received at the Queen Mary's hospital for children, Carshalton, to which £26 17s. 6d. was given, while certain of the hospitals received no donations. Funerals of persons of Moslem faith. The Council considered an application from the Indigent Moslem Burial Fund for assistance towards the cost of the funerals of poor Moslems who die in the Council's hospitals and institutions. A special burial ground for this purpose exists at Brookwood, and the provision for the burial of such patients includes a funeral according to the Islamic law and the erection of a simple monument. The Council decided to assist the Fund by the grant in the case of each funeral of a sum equivalent to the cost of a contract funeral by the Council. Information for the press. As a result of representations made to the Council by certain of the press agencies, it was decided that the medical officer of health should be authorised to arrange for information with regard to the condition or identity of patients or inmates in the hospitals and institutions to be given by the heads of the establishments to accredited representatives of the press, provided that in each case the consent of the patient or inmate or, if he was incapable of giving it, of the relatives, was first obtained. With a view to reducing the number of enquiries made, two of the largest press agencies agreed to make the enquiries on behalf of their constituent newspapers. Departmental Committees. Hospital standards. In April, 1930, immediately following the transfer of the functions of the former poor-law authorities of London to the County Council under the Local Government Act, 1929, a departmental committee was set up by the medical officer of health with the following order of reference:— "To consider what general standards, if any, should be adopted for the structure, equipment and maintenance, including staffing, and methods of heating, lighting and ventilation, of the public hospitals of London ; and to consider also what hygienic standards, if any, should be adopted for the institutions, homes and poor law schools transferred to the Council under the Local Government Act, 1929." The original committee was enlarged from time to time and was eventually composed of the following members:— Dr. W. Brander, principal medical officer, public health department. Dr. J. A. H. Brincker, principal medical officer, public health department. Dr. H. W. Bruce, area medical officer, public health department. Dr. A. F. Cameron, chief medical superintendent of the infectious hospitals service, medical superintendent, River hospitals, Dartford. 177 Dr. W. A. Daley, principal medical officer, public health department. *F. R. Hiorns, Esq., F.S.A., F.R.I.B.A., architect's department. Dr. W. Knobel, senior medical officer, public health department. †J. Malcolm, Esq., B.Sc., divisional engineer (public institutions division), chief engineer's department. †L. J. J. Murfin, Esq., B.Sc., chief engineer's department. Dr. H. Nockolds, D.S.O., medical superintendent, Lewisham hospital. R. H. P. Orde, Esq., B.A., director of Central Bureau of Hospital Information, hon. secretary British Hospitals' Association. Dr. W. T. Gordon Pugh, chief medical superintendent, children's and surgical tuberculosis services, medical superintendent, Queen Mary's hospital for children, Carshalton. *R. Robertson, Esq., F.R.I.B.A., late chief divisional architect. ‡A. Scott, Esq., M.B.E., F.R.I.B.A., chief architect, Ministry of Health. ‡Dr. F. R. Seymour, medical officer, Ministry of Health. Dr. W. A. Daley was appointed to be chairman of the committee. Reference has been made to the work of this committee in annual reports from time to time, and in the report for 1933 it was pointed out that the Minister of Health had appointed a departmental committee to consider "costs of hospitals and other public buildings," whose order of reference and functions would traverse certain ground which had been covered by the Hospital Standards Committee. The committee's interim report was submitted to the medical officer of health, in January, 1934. It was emphasized in the covering letter that the report had been precipitated by the appointment of the government's departmental committee, which included three members of the Hospital Standards Committee, and that many of the important questions which had been under discussion had not been subjected to that exhaustive examination which would justify an authoritative opinion, based upon experimental trial, to be expressed. It was pointed out, however, that there were advantages in collecting together the tentative conclusions of the committee which had been reached during the course of nearly four years' work, and in putting forward their recommendations as suggestions for discussion and further consideration. The point was stressed that in no sense could hospital standards be regarded as static, in view of the fact that modern standards of design, material and equipment were constantly changing, and that variants to suit individual preferences or local needs must be taken into account. It was conceived to be the main duty of the committee to lay down fundamental data for the use of architects and engineers engaged in the erection of hospitals, and advantage was taken departmentally from time to time of the results of the committee's discussions when the planning of hospital extensions was under consideration. It was pointed out, however, that the building of each new hospital or hospital extension was a separate problem, and, apart from " fundamentals," variety and individualism might be desirable. It was fully recognised that the report necessarily had its limitations, and that certain of the committee's suggestions would need amendment in the light of further experience or enquiry, but having regard to the unique character of the composition of the committee, containing as it did, architects, engineers, clinicians and administrators with experience of both municipal and voluntary hospitals, it was hoped that the presentation of their combined views and experience, tentative though they might be, would be of some value to those responsible for the erection of hospital buildings or extensions. The report was submitted to the Central Public Health Committee with a note of caution having regard to the afore-mentioned considerations, and was later referred to the General Purposes Committee who authorised the submission of the interim report to the Departmental Committee on the Costs of Hospitals and other Public Buildings on the understanding that it was purely an informal arrangement * By invitation and by courtesy of the architect to the Council. † By invitation and by courtesy of the chief engineer of the Council. ‡ By invitation and in advisory capacity, by courtesy of the Ministry of Health. 178 for the departmental committee's convenience, was not to be regarded as committing the Council in any way or as constituting evidence either as to facts or policy on behalf of the Council, and should not form a precedent. Dr. W. A. Daley, Chairman of the Hospital Standards Committee and two other members of the committee, viz., Mr. J. Malcolm, a divisional engineer, and Mr. F. R. Hiorns, an assistant architect, were appointed to attend before the government committee to assist them with information in connection with the interim report strictly limited to facts and the demonstration of provisional plans, and subject to the condition that no official record should be made of their evidence. As the interim report contained some 160 foolscap sheets of typewritten matter it would clearly be impracticable for want of space to present even a brief summarised description of the committee's discussions and conclusions. Furthermore, the fact that the Council has not yet considered the report and pronounced its views thereon as a matter of general policy precludes the publication of the document even in a condensed form. It would, however, not be inappropriate to give a synopsis of the report as an indication of the extent and scope of the committee's discussions. The report is arranged as follows:— Section I.—General considerations of hospital provision.—Amount of accommodation; types of hospital; optimum size of hospitals; site, accessibility and acreage; lay-out of a typical general (or convalescent or recovery) hospital; general structural considerations, viz.:—(i) type and materials of construction; (ii) form of planning (horizontal or vertical); (iii) treatment of internal surfaces; (iv) engineering services. Section II.—Detailed consideration of the several units necessary in a general hospital.—Entrance, porter's lodge and receiving block; administration block and offices; staff quarters (including nurses' home); main kitchen; ward blocks; operating theatre unit; technical store-rooms, dispensary, etc.; massage and orthopaedic section; artificial sunlight department; maternity department; children's section; X-ray department; isolation block; ophthalmic department; throat, nose and ear department; dental department; venereal diseases department; laboratory; out-patients' department; laundry; disinfector; ambulances and ambulance stations; mental obsersation wards; mortuary and post-mortem room; means of communication between administration and other blocks; means of escape from fire and precautions against an outbreak; chapel. Section III.—Provision of special hospitals.—Maternity; convalescent or recovery; tuberculosis. Section IV.—Costs of hospital construction. Section V.—Standardisation of hospital supplies and equipment. Section VI.—Plans. Section VII.—Appendices.—Bed accommodation; emergency accommodation; unoccupied beds; orientation of buildings; internal finishing treatment; ward dimensions; ophthalmic clinic; suggested specification of a large laboratory for a teaching hospital or for use as a group laboratory; economies effected by (i) bulk purchasing; (ii) standardisation of supplies; number and position of telephones required in a 720 bed general hospital; automatic telephones; steam boiler plants in L.C.C. hospitals; electric lifts installed in L.C.C. hospitals and institutions; mechanical ventilation and heating; accommodation provided or to be provided in mental observation wards at two institutions; electric lighting and power installations in L.C.C. hospitals and institutions; examples of lighting in hospital wards in L.C.C. hospitals. Thirty-four type plans and drawings of the various arrangements described in the report illustrate in a general way the more essential requirements, relative to one another, of the different portions or departments of a hospital. Each case in 179 practical application would be subject to variation as necessary to suit local circumstances. In this sense, and having regard to the progressive nature of both medical and building technique, it will be apparent that the laying down of absolute standards is neither possible nor desirable. The constitution and order of reference of the departmental committee, which was appointed in January, 1932, to compile a pharmacopoeia suitable for use in the Council's hospitals, were set out in the annual report for 1932 (Vol. IV., Part I, p. 30). In February, 1934, Professor E. Mellanby, M.D., D.Sc., F.R.S., became a member of the committee, and his advice, especially on matters relating to diets, was most valuable. The pharmacopœia. During the year eighteen meetings were held, discussion being devoted to revision of the formulae and to compilation of sections of the appendix. A provisional formulary was drawn up after obtaining the comments of medical superintendents of the hospitals, medical officers of institutions and district medical officers, and was issued in July, 1934, for use in conjunction with the new contract schedules for drugs and pharmaceutical preparations. The new edition of the British Pharmaceutical Codex, which was published in October, 1934, necessitated modifications in the provisional formulary as drawn up. The medical superintendents of general, special and mental hospitals, as well as the pharmacists, were accordingly asked to state their views on the suitability of the formulary as a result of several months' experience, and their suggestions were taken into account in compiling the final list with due regard to the alterations occasioned by the publication of the new British Pharmaceutical Codex. In addition to the formulary, the pharmacopoeia will contain information on various subjects which it is desirable to make available for medical officers and nurses. An endeavour has been made to present the information in a condensed form convenient for ready reference, as much of it is likely to be required in emergencies and cannot readily be found in text-books. Hospital Staff. The fixed establishment of medical staff in the general and special hospitals was determined by the Council in the years 1931 and 1932, respectively. During 1934 a review of these establishments was carried out, and the conclusion was reached that the general principles on which they were based were sound, but that developments in the hospitals service rendered certain additions necessary. Medical staff— Establishment and conditions of service. The Council was informed that a continually increasing amount of acute and operative work had to be carried out in the general hospitals, where, moreover, the general standard of medical care was constantly rising. Improved facilities for pathological work created by the new laboratory service enabled more elaborate investigations to be undertaken with a consequent increase in the demand on the time of the clinical staff. A wider use of consultants also had the effect of raising the standard of treatment and increasing the care and time devoted to the cases. Developments in out-patient work, including that in ante- and post-natal and other specialised clinics, also involved greater demands on the medical staff. These considerations led the Council to approve an increase in the establishment of medical staff in general hospitals to the extent of four senior assistant medical officers, grade II, twenty assistant medical officers, grade II, and seven positions of house physician, house surgeon or clinical assistant. At the same time one position of assistant medical officer, grade I, was discontinued. The survey of the medical staff employed at special hospitals also proved that additions were necessary. The original establishment provided at most hospitals for a normal allocation of four permanent whole-time assistant medical officers, the numbers being increased in times of epidemic, partly by the allocation of permanent officers employed on a floating staff and partly by the engagement of temporary officers. In order to secure a proper balance between permanent and temporary staff during the heavy seasonal increases in the number of patients, some increase in the permanent establishment was deemed necessary. 180 At hospitals for the treatment of pulmonary tuberculosis, again, additional staff was found to be required in consequence of the changes in the treatment of this disease in recent years. The various forms of collapse therapy and chemotherapy, and the greatly increased use of radiological examination and blood examinations in guiding treatment and estimating prognosis, have made treatment more individual and intensive, thereby increasing the work of the medical staff. The net effect of the variations in the establishment following this survey was an increase in the special hospitals staff by two positions of senior assistant medical officer, grade II, and five positions of assistant medical officer, grade II. At the same time some change was introduced in the conditions of employment of the junior grades of medical staff. The appointments of assistant medical officers, grade II, had hitherto been limited to one year. It had been found, however, that this limitation was unsatisfactory to the Council because of the need for frequent appointments and because officers left the service at a time when they became most useful. The limitation was also disadvantageous to the officers, who often wished to stay in the service if no other openings were available. The Council accordingly decided to authorise the extension of the appointment of officers in this grade for a further period of one year, on condition that the second year was spent in another hospital, or if this was not practicable that the duties were varied during the second year. Experience showed that there was difficulty in filling vacancies in the positions of house physician, house surgeon and clinical assistant, and that the officers appointed often stayed only for a short period. It had become apparent that the Council's hospitals did not attract, at the existing salaries, the type of medical officer for which these positions were intended. It was felt to be desirable to maintain the positions, and the Council accordingly decided to increase the rate of pay from £80 with residential emoluments for house surgeons and house physicians to £120 a year with the same emoluments. The rate for clinical assistants (nonresident), formerly £100 a year, was raised to £150 a year. Laboratory services— Fixed staff. During the year a further measure of unification was introduced in the staffing of the hospital laboratory services. The subordinate technical work at hospital laboratories (as opposed to that at the group laboratories where the major pathological work is performed) had formerly been carried out by women hospital laboratory technicians. These officers had been appointed in pursuance of a scheme for securing and training a number of suitably qualified persons to staff the hospital laboratories on their establishment. Difficulty having been experienced in filling vacancies in this staff owing to the time taken in training, it was decided to merge the women technicians in the hospital laboratories in the general pool of technicians in the laboratory services. The positions of women hospital laboratory technicians were replaced by an equivalent number of positions of laboratory technicians (grade B) (62s. by 4s. to 90s. a week), which can be filled either by men or by women. At the same time the numbers of subordinate technical staff in the laboratories were reviewed, and some increases were authorised in order to cope with the growing work of this branch of the service. Dental staff— Rates of pay. The dental services provided by the late poor-law authorities were based partly on the service of whole-time dental officers and partly on the engagement of part-time dentists who were free to engage in other employment outside the Council's service. In formulating a scheme for the provision of dentistry in the Council's hospitals, it was necessary to consider the relative advantages of the whole-time and the part-time system. There were found to be undoubted advantages in employing part-time local staff in outlying hospitals because of the saving of time and travelling expenses. On the other hand, dentists in private practice were sometimes unwilling to visit special hospitals in which infectious diseases are dealt with. In large areas where hospitals are within convenient distance of each other a wholetime service is of definite advantage. It was accordingly decided to maintain both principles, and to apply them according to the special needs and circumstances of the various hospitals. 181 The dental staff consists of two grades, qualified dentists and dental assistants. Full-time dentists are paid on a scale of salary of £500 by £25 to £650 a year. Part-time dentists receive £90 a year for one session of approximately hours a week for 52 weeks a year, and at the rate of £65 a year for each additional session. All dentists are required to possess a degree or a recognised diploma in dental surgery. The remuneration of dental assistants, often known as dental mechanics, is 60s. by 5s. to 90s. a week, with an additional 5s. a week to an employee in charge of a workshop when more than one dental assistant is employed. Dentists are required to perform extractions and conservative work, to prepare mouths for dentures, to take moulds and fit dentures. Dentures are obtained centrally from the Council's dental workshop. The male domestic staff in the Council's hospitals is now grouped into seven main grades, namely, foreman porter, gate porter, mortuary porter, general porter, storesman, barber and gardener. There are, in addition, certain miscellaneous grades of male staff, such as agricultural labourers, motor drivers, tradesmen, etc., for whom designations and scales of pay have not yet been approved. During 1934 the Council fixed the numbers of male staff falling within the seven groups mentioned above to be emploved in the various general hospitals. Male domestic staff. The standard of staffing on 1st April, 1930, at the hospitals taken over from the former poor-law authorities varied widely. Attempts had been made since that date to remove, to some extent, the inequalities in staffing by means of increases in the staff at individual hospitals and by not filling vacancies at others. In assessing the number of staff required, each hospital has to be dealt with individually, consideration being given to such factors as lay-out of buildings, the numbers and type of lifts, the levels of the various floors and the situation of the stores and of the kitchen. A factor tending to reduce the number of staff required was the transfer from male domestic staff to nursing staff of all such duties as the bathing of patients and their supervision in receiving wards. In fixing the number of staff to be employed, all temporary positions where the work was of a permanent nature were included. The net result was an increase of 55 permanent units. In accordance with the scheme of grading, a foreman porter (class I) is to be employed at the larger hospitals, and a foreman porter (class II) at hospitals of intermediate size. In order to provide a suitable grade of staff to take charge of the porters at the smallest hospitals, and to assist the foreman porters at the largest hospitals, an additional grade of senior porter has now been created, with remuneration of 59s., rising to 64s. (56s., rising to 60s. at hospitals in seaside areas and at Pinewood sanatorium). As a rule not more than three gate porters are employed in any one hospital, though where the number of entrances is exceptionally large this number is exceeded. A mortuary porter has been allocated to every hospital where there is a mortuary. The staff of general porters includes existing positions of male telephone operators. At most of the hospitals the establishment of staff for stores duties includes one position of storesman and one of assistant storesman, graded according to the size of the hospital. The barbering work at some hospitals is not sufficient to justify the employment of a full-time barber, and half a unit has been allocated to these hospitals on the understanding that a full-time officer will be employed at two hospitals requiring half a unit each. Where the work has hitherto been performed by contract, the arrangements have not been disturbed. A position of gardener has been allocated to every hospital where the ground under cultivation is two acres or more, the gardener being assisted, where necessary, by porters. Where no gardener is employed, the gardening work is undertaken by the general porters. On 1st October, 1934, the Council assumed control of Heatherwood hospital which had formerly been under the management of the United Services Fund, who generously transferred it to the Council. The agreement for the transfer of the hospital, which was originally intended to take place in 1937, included a proviso that the Council would appoint persons on the staff at the time of transfer, who Heatherwood hospital. 182 had been in the service of the Fund for a continuous period of three years, to the permanent staff of the Council with the remuneration in force for corresponding grades in the Council's hospital service. The staff were accordingly transferred to the Council's service and appointed to the permanent staff, subject to their passing a medical examination. Those who were receiving rates of pay in excess of those appropriate to the corresponding grades in the Council's classifications, and who had at least three years' service on 1st October, 1934, will continue to receive their present rates until 30th September, 1937, that is, the date of transfer originally contemplated. Members of the staff with less than three years' service were placed on the Council's scales. Those who were receiving rates lower than those approved by the Council had their pay raised in accordance with the Council's scales. The arrangements for the training of probationer nurses at the hospital have been assimilated to those in the Council's service generally, and appropriate transitional arrangements were made for those undergoing training at the time of transfer. The scale of salary approved for the positions of medical superintendent and steward of the hospital are as follows:— Medical superintendent £900 by £50 to £1,150 a year, with unfurnished house or quarters and payment by the Council of rates. Steward £315 by £15 to £390 a year. Supervisory nursing staff. From time to time since 1930 the Council has found it necessary to increase the number of nurses employed in the hospitals in order to bring the staffing arrangements up to an adequate standard. In 1931 the Council approved increases in the numbers of supervisory nursing staff, but in view of the general financial situation further proposals of this character were not proceeded with. A further revision of the supervisory nursing staff of the 27 acute general hospitals recognised as training schools for nurses was carried out in 1934. The Council was informed that in order to secure the standard of staffing at such hospitals necessary for the nursing to be adequately performed and supervised and the probationer nurses properly trained, it would be necessary to increase the staff by one position of sister housekeeper, nine of administrative sister and ninety-five of ward sister. The addition of these 105 positions was considered to be adequate for normal requirements, but in order to ensure that, at each of the larger hospitals, one ward sister not normally allocated to definite duties should be available in cases of sickness or other emergencies, either at her own or at one of the smaller hospitals, a further addition of 20 positions of ward sister was found to be necessary; these last-mentioned positions are allocated normally to hospitals with a bed accommodation of 500 or over, but are available for temporary transfer elsewhere when necessary. White Oak hospital— Medical staff. The medical staff at White Oak hospital (for children suffering from ophthalmia) consisted of a visiting assistant medical officer, who visited for two consecutive hours on four days a week, and received a salary of £250 a year and travelling expenses. This staff was found to be insufficient and had to be supplemented by the services of a local private practitioner. On the death of the visiting medical officer the staffing arrangements were reconsidered, and it was decided to associate the hospital with High Wood hospital so far as the eye work was concerned. A resident woman medical officer on a part-time basis was appointed at White Oak, with the duty of acting also as visiting oculist at High Wood hospital. The salary attached to the position is £200 a year with residential emoluments at White Oak, and travelling expenses in connection with visits to High Wood hospital. Psychiatric social workers. The appointment of psychiatric social workers at hospitals where a number of mental patients are dealt with was found to have beneficial results. In view of the value of the work carried out by these officers, it was decided in 1934 to appoint a similar officer to the centralised mental unit in west London, conducted at Fulham hospital and Westminster institution, where female and male cases, respectively, are treated. The officer appointed divides her time between the male and female units as necessary. 183 At Queen Mary's hospital, Sidcup, which accommodates convalescent patients, a small unit has been formed to accommodate patients who are wholly or partly bedridden by reason of some incurable disease or an accident in early life. The problem of providing occupation and entertainment for patients of this class is a difficult one, and the Council has now decided to appoint an officer to act in the dual capacity of a handicraft instructor for such patients and a recreation officer for the hospital generally. Entertainments are organised for the convalescent patients including whist drives, concerts, cinema shows and billiard tournaments during the winter months. In the summer such games as cricket and bowls are also introduced. The appointment of the recreation officer will be for an experimental period of one year in the first instance at a salary of £225 a year. Recreation officer. With a view to improving the dietetic arrangements in the Hospitals, arrangements were made for six selected nurses to undergo a one year course of training in dietetics at King's College for Household and Social Science and the College of Nursing. It was intended that these nurses on completion of training should be employed as dietitians with remuneration ranging from £150 to £200 a year. It was subsequently discovered that the diploma in dietetics granted at King's College would be issued only to students who had completed a two years' course, but the training received by the six nurses was of sufficient value to enable them to carry out the supervisory work which it was originally intended to entrust to them. It was, however, decided, that their designation should be "food supervisor," and that the salary applicable to the positions should be that prescribed for trained housekeepers, which is slightly lower than that originally approved. Dietitians. Further consideration was given to the grading and classification of male nursing staff, as the result of which the Council decided to revise the grading and remuneration of male nurses in accordance with the following scheme, which indicates the main outlines of the present conditions:— Grade (non-resident). Weekly rate. Head or charge nurse £4 12s. by 5s. to £5 12s. „ „ (mental) £3 19s. by 5s. to £4 9s. Staff nurse £3 12s. by 5s. to £4 12s.* „ „ (mental) £2 19s. by 4s. to £3 7s. Ward orderly, class 1 £2 17s. by 4s. to £3 5s. „ „ „ II £2 12s. 6d. by 1s. to £2 16s. 6d. Probationers—1st year £2 7s. „ 2nd year £2 10s. „ 3rd year £2 13s. „ 4th year £2 16s. * Staff nurses holding approved mental qualifications receive an additional 2s. a week when employed on work requiring this special training. Male nursing staff. In addition to the cash remuneration quoted, male nurses are provided with meals when they are on duty and with uniform and the laundering thereof. The radiological department of the new British Postgraduate Medical School at Hammersmith hospital is to be a consultative centre for the whole of the hospital service. The Council has created a position of director of the department and consulting radiologist to the Council's hospitals. It was desirable to proceed with the appointment in order that the officer's services might be available on questions relating to the equipment and planning of the department. Radiologist. It was important that the holder of the position should be of outstanding ability in this branch of the medical profession, as his opinion would be sought by all the other consulting radiologists, and the Council appointed Mr. J. Duncan White, M.B., Ch.B., D.M.R.E., radiologist to the Royal Infirmary, Edinburgh, and also lecturer in radiology at the University of Edinburgh, to the position. The salary has been fixed at £1,500 a year (no emoluments), and conditions of appointment and service attaching to the position have been laid down. In continuation of the practice of the late authority, a part-time physicist has been employed as required at Lambeth hospital since 1st April, 1930, in connection with the X-ray plant. Since the new X-ray department at this hospital came into operation on 1st October, 1934, the work performed by the physicist has considerably increased. As the services of a physicist would eventually be required Physicist. 184 for the radiological department to be established at Hammersmith hospital in connection with the British Postgraduate Medical School, the Council has approved the creation of a position of full-time physicist to work primarily at Hammersmith and Lambeth hospitals under the immediate direction of the director of the radiological department at Hammersmith hospital. It was also thought desirable for the physicist to have the assistance of an electro-medical technician in the research laboratory and workshop to be established at Hammersmith hospital. Scales of pay and conditions of appointment for these positions have been approved. The scales of pay are as follows:— Full-time physicist.—£750 a year, rising by annual increments of £50 to £1,000 a year (no emoluments). Electro-medical technician.—70s. a week, rising by annual increments of 5s. a week to 90s. a week, and thence after eight years' service in all in the grade, if specially recommended, by annual increments of 5s. a week to 100s. a week. The following statement shows the duties of the full-time physicist:— (1) To keep X-ray instruments and tubes up to standard. (2) To standardize new tubes or tubes that have been re-adjusted, and to test quality and depth dose measurement. (3) To measure the output of the X-ray tubes and to check the voltage measurement. (4) To measure the quality of the rays and to report observation on the scattered radiation present in different parts of the department during working hours, and to measure the depth dose. (5) To carry out research work in regard to the Sieverts dosimeters. (6) To carry out research work in the radiant heat and light department, and to ascertain the quality of the rays given off and to measure the intensity of the different wave lengths. (7) To advise generally on all physical problems in connection with the use of radium. (8) To carry out any physical calculations or estimations required in connection with the use of radium, and to advise and assist if necessary in the search for lost radium. In view of his unique experience at Lambeth hospital and elsewhere, the services of the part-time physicist, to be displaced as the result of the appointment of a full-time officer, are to be retained in a consultative capacity for a period of six months in the first instance. Consultant and specialist services. In 1933, the Council reviewed the whole of its consultant and specialist services and created a new service to meet the normal requirements of its hospitals. Particulars of the scheme, which was to be subject to review at the end of a year, appeared in the annual report of the Council for 1933, vol IV, part I, page 164. The review took place in June, 1934, when the Council approved the continuance of the existing arrangements, with certain additions and alterations, which are summarised below. The most important alteration made has been greater financial recognition of emergency visits by consultants and specialists. A fee of £2 12s. 6d. a visit is now paid for all emergency visits by consultants and specialists in excess of the number of routine visits for which they are normally employed. Authority has been given for the payment of a fee for each attendance by a consultant or specialist when called upon to advise on special matters outside his normal duties, e.g., the provision of specialised equipment, the establishment and management of special units, etc. The existing fee (34s. a session) paid to consulting anaesthetists for general purposes has been found to be too low, and one panel of consulting anaesthetists has been formed for all purposes at a fixed fee of two guineas a session, except as regards 185 anaesthetists employed in connection with thoracic surgery at the outlying medical tuberculosis hospitals. Double fees have been paid to the latter in view of the time involved in travelling. Remuneration at the rate of £95 a year for one session a week and conditions of appointment for part-time refractionists, and conditions of appointment for fulltime radiologists for whom remuneration had already been prescribed, have been approved. During the year, the positions of consulting orthopaedic surgeon to Queen Mary's hospital for children, Carshalton, and consulting ophthalmic surgeon to White Oak and St. Margaret's hospitals fell vacant owing to the lamented deaths of the holders of these offices, and the opportunity has been taken of revising the salaries and conditions of appointment and service attached to these positions in order to bring them into line with the rates, etc., laid down under the Council's new scheme. The salaries, etc., attached to the positions are as follows:— Consulting orthopaedic surgeon, Queen At the rate of £150 a year in respect of two Mary's hospital for children, Car- sessions' work a fortnight, with additional shalton. payment for emergency visits. Consulting ophthalmic surgeon— (i) White Oak hospital £300 a year in respect of one visit a week and as required, or if already employed as a part-time consultant or specialist in the hospitals service, £250 a year. (ii) St. Margaret's hospital £125 a year in respect of one visit a week and as required, or if already employed as a part-time consultant or specialist in the hospitals service, £75 a year. Consequent on the taking over from the United Services Fund of Heatherwood hospital on 1st October, 1934, the Council reviewed the arrangements in existence for consultant and specialist services at that hospital. The basis of remuneration paid to consultants and specialists at that hospital was different from that in the Council's hospitals; but, as the arrangements had worked well in the past, and in order to enable some experience of the working of the hospital to be gained and to obviate any more disturbance at the hospital than was unavoidably necessary, no alterations have been made for the time being. Custody of valuables belonging to staff. With a view to preventing, as far as possible, the theft of property belonging to members of the resident staff in the hospitals and the institutions, the Council decided that all resident officers should be provided with the following minimum standard of safe custody for their valuables:—(a) a lock on the door of the bedroom; (b) a lock on a wardrobe; and (c) a lock on a drawer in an article of furniture. The necessary steps were taken to bring the equipment at the various establishments up to this standard, and arrangements were made for a notice to be exhibited pointing out that, as each officer was provided with the necessary facilities in which to lock up his or her valuables, the Council would not accept any liability for the loss of, or damage to, such property. It was also decided that locks fitted to bedroom doors should be of the "slam" type. London Ambulance Service. Within the administrative county of London the Council provides ambulances, free of cost, for the conveyance to (a) hospitals or private residences (except in the City of London*) of:— (i) Persons meeting with accidents or suffering from sudden illnesses in the streets, public places, places of employment, etc.; (ii) Persons meeting with accidents in their homes; (iii) Persons suffering from illnesses in their homes if a medical practitioner certifies that the case is one of life or death, and provided that arrangements have been made for the reception of the patient in a hospital; *The Corporation of the City of London maintains its own ambulance service for dealing with cases of accident and illness occurring in the streets within the City area. 186 (iv) Parturient women, if the case is one of urgency, whether from the home, place of business or elsewhere, on the application of a qualified medical practitioner or certified midwife, provided that either a doctor or midwife accompanies the case; and (v) Non-urgent cases of parturition if the call is made between the hours of 11 p.m. and 8 a.m.,†and provided that admission to a maternity bed has previously been arranged and a card (issued by the Council to hospitals, maternity homes, etc.) for such admission obtained ; (b) the Council's hospitals for infectious diseases of patients subject to the fulfilment of certain conditions; and (c) the Council's hospitals and institutions for noninfectious cases of patients when application is made:— (i) through the Council's public assistance department; and (ii) by, or on behalf of, the Council's special, general, and mental hospitals. Ambulances and ambulance omnibuses are also provided by the Council, when not required for the purposes stated above, on payment of charges, as laid down from time to time by the Council, for the conveyance of infectious and non-infectious cases between private houses, hospitals (other than to the Council's hospitals, etc., under the provisions of (a), (b) and (c) above), and nursing homes, and for examinations, consultations and treatment by specialists or at special establishments. The minimum charge is at the rate of 12s. 6d. between any two addresses within the administrative county of London, or 1s. 6d. a mile if any portion of the journey extends beyond the county boundary. The conveyance of private persons between addresses both of which are outside the administrative county of London is not undertaken, except in circumstances of exceptional urgency. Ambulance staff. Numbers. The following is a statement of the number of staff employed as at 31st December, 1934 Accident section. Grade. Permanent. Temporary. Total. Leading driver (acting) 1 1 Deputy leading driver (one vacancy) — — — Senior attendants (three vacancies) 9 — 9 Drivers (F.l)‡ 43 4 47 „ (E.1) 2 9 11 Attendants (F.l)‡ 51 — 51 (E.1) 41 12 53 Total 147 25 172 General section. Ambulance station. Superintendent. Senior ambulance clerk (man). Ambulance clerks (men). Permanent. Drivers and attendants. Washers and helpers, etc. Total. Permanent. Temporary. Eastern 1 1 5 45 2 54 North-Western 1 1 4 30 10 1 47 Western 1 1 4 29 5 1 41 South-Western 1 1 4 35 3 — 44 South-Eastern 1 1 4 35 2 1 44 Brook 1 1 3 22 1 1 29 Relief duties — _ 2 — — — 2 Total 6 6 26 196 23 4 261 † These facilities will be extended to any hour of the day or night as from 1st April, 1935. ‡ Drivers qualified to carry out ordinary running repairs and attendants ordinarily in charge of a shift are placed in grade (F. 1) under the scheme of grading recommended by the London District Council of the Joint Industrial Council for Local Authorities' Non-Trading Services (Manual Workers). 187 Vehicles. The number of vehicles authorised is as follows:— *147 ambulances 20 ambulance omnibuses 3 staff cars 1 ambulance tender Works. A new emergency exit has been provided from the Brook ambulance station, and improvements have been effected to the existing main entrance in respect of additional fire precautionary works. Brook ambulance station. Miscellaneous. The charges and additional charges in respect of the hire by private persons and public authorities of the Council's ambulances and ambulance-omnibuses have been reviewed, and it has been decided to continue the existing charges, including the flat rate of 12s. 6d. a journey for private removals within the county of London, pending further review of the latter when the actual costs for the year 1933-34 have been ascertained. Use of ambulances for private hire— charges. During the year 1934, 95 charges for the hire of ambulances were remitted, the total amount being £57 3s. 6d. Ambulance hire charges —Remission of fees. The Council has had under consideration the question whether the free ambulance facilities provided should be extended to include the conveyance of non-urgent maternity cases to hospitals, etc., in the daytime. As a result, it has been decided to extend the ambulance service as soon as the necessary facilities shall have been made available, to include the conveyance, without charge, of parturient women resident in London in non-urgent cases to hospitals and municipal institutions between the hours of 8 a.m. and 11 p.m. These arrangements will be subject to similar conditions to those at present applicable to such cases removed between the hours of 11 p.m. and 8 a.m., viz.—(1) that the patient shall have made arrangements for her admission to a hospital or municipal institution ; (2) that she shall be accompanied by a doctor, nurse or female friend, and (3) that she shall be wrapped in blankets ready for removal. Conveyance of maternity cases. Attention has been drawn to the growing number of cases in which ambulances of the London Ambulance Service were called by telephone to what were said to be street accidents, but where, on the arrival of the ambulance, no case could be traced. Malicious calls. In consequence it was decided that legislation should be promoted in the session of Parliament, 1935-36, to render liable to a penalty, any person who, without proper justification, gives or is responsible for giving to the Council or to an employee thereof, false information from which it may be inferred that it is necessary or desirable for the Council to send an ambulance of the London Ambulance Service to any place. Pending the entering into of uniform reciprocal arrangements with all authorities contiguous to the county of London, authority was given for the making of arrangements of a temporary nature, in order to obviate the transfer of patients from one ambulance to another at the County boundary. These arrangements provide that persons incapacitated by reason of street accidents or sudden illness, resident in the area of the adjoining out-county authority, who are removed by the London Ambulance Service, and who desire to be taken to their homes, or who are taken by the London Ambulance Service to hospitals in the county, and after treatment, within less than twenty-four hours after reaching the hospital, require to be removed to their homes, shall be conveyed by the London Ambulance Service to their homes or to hospital within the area of the adjoining out-county authority, and shall not be transferred from one ambulance to another at the county boundary. Similarly, cases resident in the county of London and conveyed by Reciprocal arrangements with outcounty authorities for the transfer of patients. *To be increased to 153 on 1st April, 1935. 188 an ambulance belonging to the adjoining out-county authority shall be conveyed by that authority to their homes, etc., within the county of London. In some cases, however, the authorities concerned have felt unable to enter into mutual arrangements on this basis. Demands by Police for use of ambulance. It has been arranged that demands on the driver by the Police for the immediate use of any ambulance shall be complied with, if practicable, the Police being informed if the ambulance was conveying or had conveyed an infectious case. The measles epidemic. The measles epidemic, combined with the high incidence of infectious diseases generally, necessitated the taking of measures for utilising to the greatest advantage the accommodation at the various hospitals, and thereby threw additional work upon the Council's ambulances, the work being further increased by direct admissions to the hospitals at Dartford and to Queen Mary's hospital, Carshalton. The following table shows the weekly mileage run by the vehicles of the general ambulance section:— Four (or five) weeks ended— 25th November, 1933 40,325 miles a week. 30th December, 1933 (5 weeks) 39,059 ,, 27th January, 1934 42,166 ,, 24th February, 1934 47,665 ,, 31st March, 1934 (5 weeks) 51,904 ,, 28th April, 1934 46,142 ,, 26th May, 1934 39,789 ,, 30th June, 1934 (5 weeks) 36,743 ,, 28th July, 1934 33,492 ,, 25th August, 1934 28,048 ,, The maximum weekly mileage was 54,458 during the week ended 17th March, 1934, when 3,883 journeys were undertaken. This compares with a maximum mileage of 48,594 during the epidemic of 1932 when 3,372 journeys were undertaken. Similar maximum figures for the four previous years are as follows:— 1930—week ended 22nd November 34,110 1931 do. 14th February 36,481 1932 do. 19th March 48,594 1933 do. 25th November 41,191 The highest mileage run on any one day during the epidemic period was 9,274, on 28th March, 1934, the number of admissions to the infectious hospitals being 217. The highest mileages during the preceding years were:— 1931— 7th December 6,224 1932—25th April 8,614 1933—11th December 7,395 In order to deal with the situation it was necessary to bring into service 16 additional ambulances which are held in reserve for unusual eventualities. Ambulance stations. The following is a list of the ambulance stations.— Name of Station. Address. Battersea 119, Battersea-rise, S.W.ll. Bloomsbury 19, Herbrand-street, Tavistock-place, W.C.I. Brook Shooter's-hill, S.E.18. Eastern Brooksby's-walk, E.9. Elephant & Castle 15, St. George's Market, London-road, S.E.I. Hackney Paragon-road, Mare-street, Hackney, E.9. Highbury Corsica-street, Highbury, N.5. Lee 142, High-road, Lee, S.E.13. North Kensington Silchester-mews, North Kensington, W.10. North-Western Lawn-road, N.W.3. Old Kent-road Canterbury road, S.E.15. Paddington Lyons-place, St. John's Wood, N.W.8. Poplar 7, Woolmore-street E.14. 189 Name of Station. Address. Shoreditch 5, Montclare-street, E.2. South-Eastern New Cross-road, S.E.14. South-Western Landor-road, S.W.9. Streatham Mountearl-gardens, Wandsworth, S.W.16. Western Seagrave-road, S.W.6. Westminster 93, Regency-street, S.W.I. Woolwich High-street, Woolwich, S.E.18. Statistics. The following statement shows the work undertaken by the service during the year:— Number of persons conveyed Total mileage run (all vehicles) Accident section. 43,648 225,728 General section. 324,165 1,976,371 Total. 367,813 2,202,099 The number of calls received by the accident section during the year 1934 (44,844) showed an increase of 2,460 above previous year, and was the highest number received during any one year since the inauguration of the service in 1915. The previous highest number was 44,178 during the year ended 31st March, 1930. In July, 4,283 calls were dealt with, the highest number ever recorded in any one month. The number of cases as distinct from calls dealt with (46,583) was also the highest number dealt with in any one year since the inauguration of the service. The average time taken to reach cases was 6.5 minutes. In 1933 the average time was 6.3 minutes, the lowest average time recorded since the service was inaugurated, the previous lowest average time being 6.5 minutes in the years 1930-31 and 1931-32. The highest number of calls dealt with in any one district (3,706) was again in the City of Westminster where the number dealt with has been the highest in any one district during each of the past 10 years. The number of cases taken to hospitals and within 24 hours removed by the service to other institutions or to patients' homes, which had declined from 4,933 in 1927-28 to 2,400 in 1933, increased to 2,563 in 1934; but having regard to the increase in 1934 of the total number of cases dealt with, this represents an increase in the proportion of cases removed from one institution to another of only .06 per cent. The mileage run by ambulances (208,168) was also the highest recorded in any one year. Accident section. 190 LONDON AMBULANCE SERVICE. The following tables show, in the case of the accident section, the work carried out during the year ended 31st March in respect of the years 1930-31 and 1931-32, and during the year ended 31st December in respect of the years 1932, 1933 and 1934. In the case of the general section the year ends on 31st December. A—Accident Section. Table I—Number of calls dealt with by each accident station since 1 st April, 1930. Station. 1930-31. Number of calls. 1931-32. 1932. 1933. 1934. Class A (double stations)— Blooms bury 5,915 5,542 5,001 5,121 5,317 Elephant and Castle 5,311 4,738 4,403 4,614 4,896 Class B (single stations)— †Fulham and Western 3,533 3,708 3,322 2.994 3,082 Shoreditch 3,282 3 154 2.958 3,116 3,111 Lee 2,400 2.486 2,643 2,763 3,048 ||Brixton 2,929 1,975 — — — ||South-Western (opened 13.10.30) 633‡ 1,836 ‡ 2,923 3,149 3,249 Poplar 2,200 2,045 1,991 1,959 2,183 Highbury 3,060 3,086 3,000 2,896 3,063 Paddington 3,436 3.416 3,293 3,120 3,274 Battersea 2,909 2,675 2,548 2,628 2,864 Woolwich 1,572 1,522 1,513 1,516 1.665 Hackney 2,167 2,129 1,960 2,179 2,367 Class C (subsidiary stations)— Westminster 2,472 2,139 1,751 1,828 1,837 Old Kent-road 1,916 1,922 1.918 2,002 2,116 ||Streatham — 254 917 929 1,098 *North Kensington — — 427 1,466 1,558 General ambulance section 11§ 45 § 70 § 104 § 116§ Total 43,746 42,672 40,638 42,384 44,844 * North Kensington station was placed in commission on 1st September, 1932. † Fulham station closed 19th January, 1931, and ambulance transferred to Western station. ‡ The ambulance at this station was, up to 17th December, 1931, used for removals to other areas. § These figures include cases removed by ambulances when passing scene of accident. || Streatham station was placed in commission on 17th December, 1931, when Brixton station was closed and the South-Western station became a single station instead of a subsidiary station. 191 LONDON AMBULANCE SERVICE—continued. Table II—Hourly record of calls. Hours. 1930-31. 1931-32. 1932. 1933. 1934. a.m. 12-1 1,495 1,416 1,352 1,448 1,639 1-2 919 1,026 912 993 1,127 2-3 747 746 759 801 898 3-4 626 640 699 782 879 4-5 577 610 672 711 778 5-6 529 653 599 695 757 6-7 615 749 683 695 743 7-8 986 1,040 987 1,063 1,206 8-9 1,335 1,335 1,269 1,314 1,346 9-10 1,587 1,571 1,486 1,461 1,451 10-11 1,745 1,736 1,829 1,818 1,876 11-12 2,266 2,159 2,293 2,253 2,280 p.m. 12-1 2,552 2,484 2,513 2,565 2,786 1-2 2,492 2,416 2,411 2,584 2,652 2-3 2,427 2,369 2,188 2,240 2,401 3-4 2,666 2,555 2,412 2,445 2,527 4-5 2,587 2,584 2,454 2,482 2,582 5-6 2,518 2,514 2,328 2,447 2,480 6-7 2,692 2,598 2,470 2,525 2,603 7-8 2,668 2,429 2,328 2,422 2,608 8-9 2,425 2,272 2,110 2,195 2,367 9-10 2,200 2.214 1,861 2,031 2,180 10-11 2,762 2,368 2,078 2,287 2,373 11-12 2,330 2,188 1,945 2,127 2,305 Total 43,746 42,672 40,638 42,384 44,844 Table III—Calls on each day of the week. Day. 1930-31 1931-32. 1932. 1933 1934. Sunday 4,282 4,103 3,803 4,201 4,378 Monday 6,369 6,420 6,037 6,387 6,846 Tuesday 6,297 6,076 5,819 5,983 6,315 Wednesday 6,294 6,286 5,971 6,283 6,411 Thursday 6,053 6,268 5,834 5,912 6,433 Friday 6,817 6,484 6,397 6,550 6,972 Saturday 7,634 7,035 6,777 7,068 7,489 Total 43,746 42,672 40,638 42,384 44,844 Table IV—Monthly summary of calls received. Month. 1930-31. 1931-32. Month. 1932. 1933. 1934. April 3,577 3,264 January 3,244 3,332 3,481 May 3,865 3,895 February 2,892 2,822 3,261 June 4,160 3,830 March 3,311 3,267 3,637 July 3,823 3,987 April 3,071 3,371 3,529 August 4,177 3,993 May 3,341 3,714 3,816 September 3,807 3,495 June 3,662 3,800 3,733 October 3,818 3,711 July 3,698 3,965 4,283 November 3.548 3,404 August 3,804 3,939 3,952 December 3,517 3,646 September 3,392 3,647 3,850 January 3,232 3,244 October 3,424 3,539 3,906 February 2,949 2,892 November 3,165 3,456 3,546 March 3,273 3,311 December 3,634 3,532 3,850 Total 43,746 42,672 Total 40,638 42,384 44,844 M 1 192 LONDON AMBULANCE SERVICE—continued. Table V—Summary of calls dealt with in the City of London and each Metropolitan Borough. Metropolitan borough. 1930-31. 1931-32. 1932. 1933. 1934. Battersea 1,324 1,305 1,242 1,296 1,376 Bermondsey 997 981 967 967 1,012 Bethnal Green 659 632 494 535 635 Camberwell 1,809 1,797 1,942 1,908 2,133 Chelsea 434 489 392 439 534 City of London 6 15 19 24 29 Deptford 875 830 743 855 997 Finsbury 975 891 797 788 799 Fulham 961 1,039 962 958 1,059 Greenwich 890 876 724 862 1,030 Hackney 1,733 1,679 1,576 1,798 1,892 Hammersmith 1,515 1,457 1,325 1,441 1,553 Hampstead 594 544 537 570 617 Holborn 854 840 747 750 703 Islington 2,986 2,915 2,843 2,679 2,834 Kensington 1,229 1,248 1,283 1,443 1,483 Lambeth 3,405 3,415 3,010 3,265 3,528 Lewisham 1,602 1,636 1,751 1,780 1,893 Paddington 1,656 1,665 1,680 1,623 1,470 Poplar 1,478 1,374 1,403 1,389 1,496 St. Marylebone 1,271 1,275 1,123 1,279 1,348 St. Pancras 2,243 2,191 2,026 2,134 2,304 Shoreditch 1,020 1,017 1,092 1,081 1,019 Southwark 2,415 2,193 2,141 2,204 2,286 Stepney 1,985 1,914 1,756 1,894 2,082 Stoke Newington 361 386 361 416 383 Wandsworth 2,583 2,658 2,684 2,831 2,949 Westminster, City of 4,403 3,951 3,500 3,621 3,706 Woolwich 1,443 1,405 1,478 1,521 1,609 Out-county 40 54 40 33 36 Total 43,746 42,672 40,638 42,384 44,844 Table VI—Analysis of cases dealt with in above tables. Nature of ease. 1930-31. 1931-32. 1932. 1933. 1934. Street accidents 17,789 16,956 16,870 17,799 18,142 Other accidents 6,287 6,298 4,948 4,852 5,144 Illness (other than epilepsy) 8,152 7,955 7,844 8,164 8,055 Epilepsy 2,510 2,112 1,863 1,762 1,661 Parturition 3,325 3,907 4,156 4,416 4,977 Attempted suicide 543 582 650 653 602 Assaults 730 604 448 569 643 Special cases 356 644 381 877 1,861 Removals (See table VIII) 3,227 2,881 2,627 2,400 2,563 Ambulance not required 2,725 2,353 2,504 2,758 2,935 Ambulance unavailable 1† – – – – Total 45,645 44,292 42,291 44,250 46,583 † Case near county boundary. Ambulances from adjacent stations both engaged. Removal effected by Croydon ambulance. 193 LONDON AMBULANCE SERVICE.—continued. Table VII—Return of number of cases (including removals) taken by the service to hospitals, etc. Class of hospital. 1930-31. 1931-32. 1932. 1933. 1934. Voluntary hospitals 21,551 20,076 18,956 19,127 18,447 Military hospitals 40 53 42 31 38 Children's hospitals 72 81 104 108 127 Lying-in hospitals 1,916 1,944 1,690 1,648 1,703 *Council hospitals and institutions 15,881 16,552 16,286 18,021 20,771 Other hospitals 56 78 109 85 82 Outside county 54 69 75 47 57 Patients' homes 3,445 3,039 2,485 2,363 2,362 Mortuaries 49 47 40 62 61 * Includes hospitals or institutions of late boards of guardians. Table VIII—Return of cases taken to hospitals and within 24 hours removed by the service to other institutions or to patients' homes. Whence removed. 1930-31. 1931 -32. 1932. 1933. 1934. Patients' homes. Other institutions. Patients' homes. Other institutions. Patients' homes. Other institutions. Patients' homes. Other institutions. Patients' homes. Other institutions. Voluntary hospitals 1,147 1,387 1,080 1,093 1,139 753 1,115 640 1,271 608 *Council hospitals and institutions 618 24 630 15 689 17 551 21 525 52 Out-county hospitals 49 2 58 5 29 — 64 9 96 11 Total 1,814 1,413 1,768 1,113 1,857 770 1,730 670 1,892 671 3,227 2,881 2,627 2,400 2,563 * Includes hospitals or institutions of late boards of guardians. 194 LONDON AMBULANCE SERVICE—continued. Table IX—Average lime in minutes taken to reach case and hospital. Station. 1930-31. 1931-32. 1932. 1933. 1934. Case. Hospital. Case. Hospital. Case. Hospital. Case. Hospital. Case. Hospital. Class A— Bloomsbury 6.1 12.3 6.0 12.7 6.2 12.9 5.8 12.3 6.3 13.6 Elephant and Castle 5.2 12.0 5.0 12.0 5.3 12.7 5.3 12.7 5.5 13.6 Class B— Fulham and Western 6.9 13.5 7.5 15.4 7.7 15.7 71 15 .1 7.2 16.0 Shoreditch 6.2 12.3 6.4 13.2 6.4 13.4 6.4 12.7 6.3 13.0 Lee 7.5 15.7 7.3 16.6 7.2 16.7 6.8 15.9 7.0 16.7 Brixton 7.1 15.3 7.1 16.2 – – – – – – South.Western 10.0 21.8 7.7 18.2 7.3 16.8 6.9 16.7 7.2 17.7 Poplar 6.2 13.1 6.1 14.3 6.2 14.1 6.1 14.2 6.1 14.8 Highbury 6.2 13.6 6.3 15.2 6.3 14.9 6.2 14.7 6.5 15.8 Paddington 7.0 15.3 7.2 16.7 7.0 16.2 6.3 14.9 6.8 16.1 Battersea 7.1 15.6 7.4 17.7 7.6 17.7 7.3 17.2 7.2 17.4 Woolwich 6.6 14.6 7.1 16.3 7.3 17.0 6.8 16.4 7.0 16.7 Hackney 6.6 13.4 6.5 14.6 6.3 14.8 5.9 14.4 5.9 14 4 Class C— Westminster 6.2 11.7 6.0 12.5 5.9 13.1 5.5 12.8 5.1 13.6 Old Kent.road 6.8 13.4 6.9 14.4 7.1 14.8 6.6 14.2 6.8 14.9 Streathara – – 8.1 18.3 7.4 17.3 6.9 16.6 7.3 17.6 North Kensington – – – – 6.9 14.3 6.6 14.0 6.5 14.4 General service – 13.0 – 5.1 – 6.9 – 6.9 – 7.8 All stations *6.5 *13.6 *6.5 *14.6 6.7 14.9 6.3 14.4 6.5 15.2 * Excluding South-Western station, which was used for removals to other areas, up to 17th December, 1931. Table x—Mileage run by ambulances of accident section. Month. 1930-31. 1931-32. Month. 1932. 1933. 1934. April 15,735 14,323 January 14,765 15,740 16,457 May 17,577 16,793 February 13,391 11,851 16,091 June 18,462 16,786 March 14,771 14,679 17,431 July 17,142 18,154 April 14,289 15,173 15,978 August 17,896 17,753 May 15,635 16,736 17.031 September 16,750 15,760 June 16,575 17,251 17,889 October 16,671 17,010 July 16,861 18,683 19,280 November 15,624 15,124 August 17,320 17,608 17,706 December 15,210 17,099 September 15,220 15.971 17,500 January 15,683 14,765 October 15,082 15,316 17,417 February 13,051 13,391 November 14,374 15,837 17,052 March 14,581 14,771 December 16,328 16,120 18,336 Total 194,382 191,729 Total 184,611 190,965 208,168 195 LONDON AMBULANCE SERVICE—continued. B. General Section. *Table XT—Number of miles run by General Ambulance Section and number of persons conveyed for the years 1930-1934. Year. Miles run. Persons conveyed. Conveyance of Total. Patients. Relatives and friends of patients, staff, etc. Total. Patients. Goods, staff, etc. 1930 1,361,518 50,525 1,412,043 141,396 59,085 200,481 1931 1,556,636 25,909 1,582,545 186,176 85,538 271,714 1932 1,802,229 36,486 1,838,715 208,204 92,219 300,423 1933 1,802,952 35,464 1,838,415 217,053 99,301 316,354 1934 1,954,850 21,521 1,976,371 226,780 97,385 324,165 * See Note (i) on p. 196. Table XII—Particulars of persons conveyed for the years 1933 and 1934. 1933. 1934. (i) Admissions to Council's establishments— Infectious hospitals 41,874 45,953 General hospitals 76,398 76,264 Hospitals for tuberculosis 3,680 3,580 Hospitals for sick children 5,785 7,717 Mental hospitals 3,644 3,737 Others 1,066 617 132,447 137,868 (ii) Transfers 35,824 35,760 (iii) Discharges 19,523 23,754 (iv) Returned—Mistaken diagnosis 119 35 (v) Removals—For accident section 68 71 (vi) „ Education service 12,263 12,685 (vii) „ Public assistance service 1,969 1,830 (viii) Members of Council 324 302 (ix) Sick staff 255 296 (x) Visitors to patients 127 119 (xi) Staff (not sick staff) 9,668 8,982 (xii) Other journeys 135 274 (xiii) Upon payment for hire 14,450 14,207 (xiv) Friends accompanying patients, etc. 89,182 87,982 Total 316,354 324,165 196 LONDON AMBULANCE SERVICE—continued. Table XIII—Mileage run from each General Ambulance Station for the years 1933 and 1934. Service. Eastern. North-Western. Western. South-Western. South-Eastern. Brook. 1933 1934 1933 1934 1933 1934 1933 1934 1933 1934 1933 1934 Council's establishments 351,423 338,932 270,668 303,240 274,387 303,608 286,435 306,055 273,370 339,323 195,033 191,494 Between places other than Council's establishments 25,679 32,692 45,530 48,393 30,108 28,311 29,793 28,166 17,576 19,142 14,807 12,718 Conveyance of stores, etc. 501 319 1,311 990 1,370 738 170 103 221 145 281 705 Conveyance of members of Council's staff (not sick staff), etc. 7,236 6,727 1,848 1,961 1,902 1,681 678 765 4,968 5,196 2,760 2,191 Total 384,839 378,670 319,357 354,584 307,767 334,338 317,076 335,089 296,135 363,806 212,881 207,108 Notes.—(i) The figures for 1930 include the work carried out by the ambulancc and transport service of the late Metropolitan Asylums Board prior to its absorption in the London Ambulance Service on 1st April, 1930, and by the vehicles of the late boards of guardians subsequent to their absorption in the London Ambulance Service at varying dates during 1930. No figures are available as to the work carried out by those vehicles prior to the dates of their absorption. (ii) The greatest total numbers of miles run, persons conveyed and journeys made on any one day during the years 1933 and 1934 were as follows:— 1933 Miles run 7,395 Monday, 11th December. 1934 „ 9,274 Wednesday, 28th March. 1933 Persons conveyed 1,362 Thursday, 26th January. 1934 „ 1,333 Thursday, 29th March. 1933 Journeys 574 Monday, 16th January. 1934 „ 662 Monday, 5th March. 197 INDEX page Adenoids and tonsils 19 Admission of patients 14, 101 Adoption of Children Act, 1926 32 After-care clinics for surgical tuberculosis cases 111 Artificial limbs, Supply and repair of 175 Artificial pneumothorax refills 19 Boarded-out cases 23 Casual wards 30 Cerebrospinal meningitis 77 Ceremonial openings of new blocks 14 Chest conditions, Non-tuberculous 113 Children under 3 years of age 32 Cinematograph apparatus 111 Classification of patients and inmates 10 Cross infection 75 Dental services 21 Departmental committees 176 Dietaries 21 Diphtheria 88, 99 District medical work 24 District nursing 26 Donations 176 Drinker respirator 100 Electro-cardiographs 20,92 Electro-medical apparatus 20 Encephalitis 77 Epileptics 18,24 Funerals of persons of Moslem faith 176 General hospitals, List of 36 Grouping of hospitals and institutions 9 Heatherwood hospital, Transfer of 105,181 Hospital standards, Departmental committee on 176 Hours of rising, retiring and meals of inmates 23 Ichthyosis bullosa 113 Incidence of infectious diseases 74 Infectious disease following tonsillectomy 78 Infectious diseases, Responsibility for treatment of 103 page Information for the press 176 Isolation accommodation 74 Legacy 34 London Ambulance Service 185 Maternity 15 Medical education 33, 104 Mental observation wards 17 Occupational therapy 111 Ophthalmia neonatorum 104 Out-patients 21 Oxygen therapeutic service 19 Pathological laboratory services 155 Perleche 113 Pharmacopoeia, Departmental committee on the 179 Pityriasis rosea 113 Planning and development 149 Poliomyelitis, Acute 76 Postgraduate school 34 Puerperal fever 77 Radium treatment 20, 101 Research work 34,77,88,110,114 Ringworm 112 Scarlet fever 78,99 Skin diseases 112 Smallpox 101 Special hospitals, List of 115 Special units at general hospitals 15 Staff of hospitals, etc. 179 Statistical tables- General hospitals 13,45 London Ambulance Service 190 Pathological services 162 Special hospitals 73,119 Streptococcal toxin and antistreptococcal sera 101 Tonsils and adenoids 19 Tuberculosis 105 Venereal diseases 18,104 Vulvo-vaginitis 104 X-ray treatment 20,100 Window cleaning 35 London County Council ANNUAL REPORT OF THE COUNCIL, 1934 Vol. IV (Part II) PUBLIC HEALTHHOSPITAL FINANCE (Year to 31st March, 1935) 800. (MeC. 12141-6) 18-1-36. CONTENTS PAGE Introduction 1 Inventory records 1 Stock books 1 Regrading of staff (arrears of pay affecting costs) 1 Obsolete and redundant stocks 1 Outdoor dispensary service 2 Costings and financial statistics 2 Main factors in costing 2 The cost tables 3 Sub-beads of tables 4 Out-patients' departments 5 Antitoxin establishment and pathological laboratories 5 District medical service 5 Ambulances 5 Laundries 5 Conclusion 6 Grouping of hospitals 6 Means and averages 6 Bed accommodation and occupation (Table A) 8-9 Costs—General Hospitals (Tables B to D) „ Special Hospitals (Tables E to H) „ Ambulance Service (Table I) „ Hospital Laundries (Table J) following page 11 London County Council ANNUAL REPORT OF THE COUNCIL, 1934 VOL. IV (Part II) PUBLIC HEALTH (Hospital Finance) (Year to 31st March, 1935) REPORT ON THE FINANCIAL RESULTS FOR THE YEAR ENDED 31st MARCH. 1935, OF ADMINISTERING THE HOSPITALS, ETC., UNDER THE CONTROL OF THE HOSPITALS AND MEDICAL SERVICES COMMITTEE. By Sir Frederick Menzies, K.B.E., M.D., LL.D., F.R.C.P., F.R.S.E., County Medical Officer of Health and School Medical Officer. Introduction This report for the year ended 31st March, 1935, is the fifth since the transfer to the Council on 1st April, 1930, of the hospitals and institutions used as hospitals, and the district medical, ambulance and laboratory services previously maintained by the Metropolitan Asylums Board and the London boards of guardians. The steady progress referred to last year in the direction of unifying the administration of the various hospitals, etc., has been maintained, but many of the variations in cost resulting from differing scales of remuneration, standards of staffing and various other matters of administration in the services of the late authorities, to which the Council is committed by the terms of the Local Government Act, 1929, still obtain, and will, as previously stated, take some years to work themselves entirely out. So long as they persist they will hinder the attainment of uniform costs where uniformity might otherwise be expected. Inventory records The work of initially checking and, where necessary, rewriting the inventory records of the hospitals and institutions was completed within the year and, although it was carried out under difficult conditions due to building alterations and reconditioning of premises, was completed well within the estimated period. With regard to the future, it is proposed to maintain a certain number of clerks as a peripatetic staff to be allocated to hospitals from time to time in connection with the annual checking of the inventory stocks. Amongst this number an assistant technically qualified to deal with the stocks of surgical equipment will be included. Stock books The new forms of stock records mentioned in last year's report have proved so successful in use that consideration is being given to the introduction of a third book in substitution for the present records of issues of staff uniforms. Considerable detail is necessary with regard to these stocks, issues of which are made to individuals and not in bulk to units as in the case of other stocks. It is anticipated that the new form will be more economical and efficient than the old. Regrading of staff (arrears of pay affecting costs) The process of regrading the hospital staffs was continued during the year under review, and certain expenditure incurred in 1934-35 was in respect of arrears of pay for services rendered prior to 1st April, 1934. The figures representing the arrears are separately shown in the cost tables appearing in this volume as in previous reports. In some cases the amount is sufficiently substantial to be important when a true commrison is sought between the total costs of two or more vears. Obsolete and redundant stocks The Council took over from the previous authorities considerable stocks of engineering and building materials, and it was found in many instances that the quantities held were far in excess of requirements for maintenance purposes for a reasonable period. During the year a review of these stocks, in which the chief engineer and the chief officer of supplies have collaborated, has been in progress, with two main objects:—(1) the disposal of such stocks as are of obsolete type or which represent spare parts of machinery since disposed of; and (2) the transfer elsewhere of usable stocks which are in excess of the reasonable requirements of the particular hospital concerned. 1 2 As a result, large quantities of stock have either been transferred, thereby obviating the purchase of new materials, or disposed of by sale. It has been found possible to reduce the quantities of stock of all kinds held at hospitals at any one time, representing a reduction of value from approximately £250,000 in 1930/31 to £145,000 in 1934/35. Outdoor dispensary service On 1st July, 1933, the opportunity to supply medicines to out-door cases in certain districts was thrown open to all local chemists, instead of being limited to certain approved firms. The following figures indicate the extent to which advantage has been taken of the scheme :— Year ended Prescriptions dispensed. Value Average cost per prescription 31st March, 1933 43,700 £1,593 8.7d. 31st March, 1934 66,756 £2,427 8.7d. 31st March, 1935 85,466 £3,134 8.8d. The number of chemists who have availed themselves of the arrangement is already 780 (73 before the change) and the area covered is being extended, thus accounting for the increase in the number of prescriptions dispensed. Costings and financial statistics It was pointed out in previous reports that, as a result of the greatly differing standards of expenditure and practice adopted by the late authorities, and prevailing both at the date of transfer and in the subsequent transitional period when salary, wage and dietary scales varied so much, the costing figures published for the Council's earlier years of control could not be regarded as affording fair bases for critical comparison of one hospital with another, though they do in fact reflect the actual conditions which prevailed during those years. For this reason, changes in practice and in accounting should be borne in mind and allowance made therefor when comparing, in detail, the tables in this report with those published for earlier years. Apart from these changes, the costs are still affected by the differing standards and conditions referred to above (p. 1), and the rectification of differences of cost will be continued until such uniformity as is possible is attained. The financial tables embodied in this report distribute the total net expenditure on in-patient treatment for each hospital for the year 1934-35 under selected sub-heads. The heads relating to expenditure upon staff pay show in total over the past five years an increase in cost per patient per week. This is due to the necessity for strengthening the staff in certain directions, mainly nursing staff, and to the regrading of the numerous classes of staff taken over from the late authorities. The full effect of these operations will not be seen until the staffs have been well established in the new grades and equilibrium has been attained, i.e., the point reached at which the balance between new staff and those at the maximum of the scales is normal. Main factors in costing Important factors influencing cost of maintenance per patient per week in a hospital are:— Percentage occupation of the available beds. Salaries and wages of staff. Engineering and works services (including wages). Cost of provisions, drugs and dressings. Percentage occupation of the available beds— Given a reasonably level expenditure on the main services, the most important single factor influencing the weekly cost of maintaining a patient in hospital is the relation between the number of beds provided and the average number occupied. A comparison of percentages of occupation and an understanding of the reasons for, and effects of, variation in them is therefore essential if costs are to be judged correctly. With the exception of provisions, drugs and dressings, all major cost items depend on the number of beds provided and not on the number occupied, but, as the weekly cost per patient is arrived at by dividing total expenditure by the number of beds occupied, the influence of percentage occupation on the weekly cost per patient is apparent. There are so many factors not within the control of the hospital which 3 affect this cost that deductions as to the efficiency or otherwise of hospital administration must be drawn from the stated costs with caution. The chief causes of variation in percentage occupation are :— (i) Closing of wards or blocks for alterations or quarantine; degree of classification of patients according to age or disease; extent to which wards are reserved for certain types of cases. (ii) Situation of hospital as regards locality, accessibility, proximity of other municipal or voluntary hospitals. (iii) Length of stay. This is the most important cause and it depends on many factors which are not equally applicable to all hospitals. Some of these factors are:— (a) The proportion of beds reserved for special types of cases, such as plastic surgery, chronic sick and tuberculosis cases. The number of beds normally occupied by maternity, surgical or medical cases. (b) Facilities for transferring chronic sick easily and regularly from an acute hospital to an appropriate chronic hospital. (c) Facilities for transferring patients as soon as possible from acute to convalescent hospitals. (d) Facilities available in the district for home nursing of minor ailments; in poor areas the number of admissions of such cases is greater than in better circumstanced districts, and the average length of stay is shorter. Salaries and wages of staff— Salaries and wages account for about 50 per cent, of the cost of the average hospital; in exceptional cases the proportion rises to 60 per cent. The amount depends on two factors:— (i) The number of staff in proportion to the number of patients and the proportion of probationers and juniors to senior nursing and other staff. (ii) The rates of pay of these various grades of staff. The number of staff depends on:— (a) The type of work done. (b) The arrangement of wards and of the hospital generally as regards convenience and ease of working. (c) The standard set up or tradition followed in the past at the particular hospital under consideration. To a great extent these are not within local control. The prevailing rates of pay are still less under local control. Engineering and works services (including wages)— Approximately 18 per cent. of the average weekly cost per patient is expended on these services. The figures for various hospitals differ very markedly. Costs of heating and lighting and maintenance of buildings depend on the layout, the situation and surroundings of the hospital, the age of the fabric, and the character and efficiency of the plant. The "works" figure depends on the amount of reconstruction or improvement that has been undertaken. The number of maintenance staff and rates of pay have also a bearing on these figures. Cost of provisions, drugs and dressings— The proportion of total cost in respect of provisions for patients, drugs and dressings, while substantial is smaller than might be expected. On patients' food it is under 11 per cent., excluding cooking and service. The amounts spent in the various hospitals still show divergencies, but they are less marked than in previous years. The average cost of drugs and dressings is about 3.6 per cent. of the total cost. The Cost Tables. The introductory table A is designed to draw attention to certain factors which influence, in varying degrees, the cost of treatment in hospitals. The factor of percentage occupation, already referred to on p. 2 et seq., is important in its effect on the average daily cost per patient, but the number of admissions and the average 4 length of stay in hospital are in some measure a reflection of the intensity of work at the hospital and of the demands upon the staff, which in turn are likely to affect the numbers of such staff. The figures relating to the average length of stay in hospital (column 7) become, obviously, of paramount importance when the object is to ascertain, not the daily cost of treatment per patient, but the average cost of treating a patient to completion. It is clear, for example, that the cost of treating each individual patient to completion at a hospital where the average length of stay is considerably above the general average, though the daily cost is comparatively low, may be substantially greater than at a hospital where the average length of stay is low, but the daily cost high. Attention may here be drawn to the necessity for distinguishing between a hospital in group G.I. and another of the same name in group G.II. In all such cases the latter hospital adjoins or is within the same curtilage as the acute hospital of the same name in Group G.I. and is linked with it for certain services, but is in general only adapted for the treatment of chronic and similar cases. The following tables are provided with a series of explanatory notes, and may be compared with the tables published in respect of voluntary hospitals in the annual reports of the King Edward's Hospital Fund. It will be seen, however, that the tables given in this report are in a more detailed form than those appearing in the King Edward's Hospital Fund report. For example, in the Council's tables the general head of " provisions " is divided between patients' provisions and staff rations ; salaries and wages and domestic supplies are in each case allocated to appropriate sub-heads, while as regards the main fuel-consuming services, those such as heating and lighting which are dependent upon the character and extent of the buildings, are clearly distinguished from the laundry, which is largely dependent upon the numbers of staff and patients. Regard should therefore be had to the proper grouping of the several sub-heads relating to the London County Council hospitals when comparisons are being made with the voluntary hospitals' tables. Some sub-heads, such as " funerals " and " patients' clothing," necessarily have no counterpart in voluntary hospital practice, while certain sub-heads which are found in connection with voluntary hospitals have no counterpart in the Council's system, e.g., cost of appeals for funds. For the purposes of more accurate comparison between years the tables include at the foot a statement as to the previous year's percentage occupation, in addition to the costs per " occupied bed " for that year, and as a guide in the appreciation of the varying staff costs there is shown at the head of each column the numbers and the proportions to bed establishment of the two main classes of staff. Sub-heads of tables The following observations are made in explanation of certain of the sub-heads adopted by the Council and what they comprise:— Salaries and wages.—This sub-head includes the actual cash payments made to the section of the staff named, whether they live in or out of the hospital. In the case of the former the costs of rations and laundry appear under the appropriate heads, but in the case of the latter the payment of allowances in lieu of board, lodging, etc., is included as part of their cash remuneration. In the tables these allowances are shown for convenience under a separate sub-head ("non-residential allowances"). Hospitals showing a higher cost under this head may be expected to show lower costs under the heads of rations, laundry, etc. With regard to adjustments of pay on regrading, see page 1. The term "workrooms" indicates needlerooms, tailors' shops and similar services, but does not include occupational or training workshops. "Miscellaneous" includes such officers as chaplains, organists, instructors and a few special appointments, together with such staff as motor drivers who are employed only at certain hospitals. Surgery and dispensary.—Surgical equipment, appliances and repairs.— This sub-head includes all purchases for replacement of, and additions to, surgical equipment, instruments and appliances which are held as inventory stock. 5 Laundry.—In certain cases, where the hospital has a laundry which carries out washing for other establishments, the cost of laundrywork for the hospital itself may appear unduly low. This is due to credit for the laundrywork performed for the other establishments being set off against the local cost at a fixed rate, year by year, this charge including an annual proportion in respect of special works to maintain the laundry, which are only required at intervals of some years and of which the expenses are defrayed in the year in which they are incurred. In considering comparative costs in the case of a large group of hospitals, it must be borne in mind that there are, and always will be, in each individual hospital many influences at work affecting the cost per bed which cannot be curtailed or removed even by the most determined of economists, except to the detriment of the patients. These factors are, of course, well known to all experienced hospital administrators, but are apt to be overlooked by those who study hospital finance from a purely statistical point of view. Out-patients' departments During the year organised out-patients' treatment was provided at 23 of the general hospitals, and the allocable expenditure upon these departments has been excluded from the total expenditure in computing the costs per in-patient. Antitoxin establishment and pathological laboratories The cost of the Belmont antitoxin establishment, the group laboratories and the histological laboratory is spread over the hospitals to which sera and other material are supplied, and for which specimens are examined and other services rendered, and is, therefore, included as part of the cost of maintenance of those hospitals. Smaller laboratories are maintained at a number of the general and special hospitals, and the cost is included in the expenditure of those hospitals. District medical service The cost of the district medical service is kept distinct from, and is not included in, the expenditure of the hospitals. The total cost of this service during the financial year was £40,024. Ambulances The costs of maintaining the two sections of the London ambulance service for the financial year 1934-35 are set out in table I in this volume. No allowance for depreciation has been made, as the cost of supplying new vehicles to replace wastage during the year has been included in the figures. During the period in question a system of mutual support between the two branches of the ambulance service was put into operation with a view to securing greater flexibility. This entailed overlapping of the functions of the two branches and has naturally affected the costs. The cost is based on the total work performed by each branch, but at the same time particulars of the work properly belonging to each branch are shown. Laundries Table J in this report provides a comparative return for the year ended 31st March, 1935, of the results of the laundry service. It will be seen that this table includes not only cost figures but other statistical information of general interest. The table is based on patients' washing, including clothing, bedding and house linen and on staff washing, including house linen, etc., uniforms and personal clothing. When considering this table it should be borne in mind that a number of laundries wash for establishments other than the hospital at which they are situated. In calculating the costs of washing in a laundry all the washing done is taken into account, but in calculating the number of pieces washed per occupied bed, for example, only the washing which relates to the occupied beds at the hospital concerned is included, so that it will not be practicable to reconcile the figures in certain columns with the items appearing in other columns of the table. There are certain other elements depending upon purely local conditions, types of patient and the like, which cannot be dealt with adequately in tabular form or indeed in any brief form which would enable a reader unacquainted with the local conditions to assess them satisfactorily. For example, the output per head of laundry staff is based strictly on the paid staff and takes no account of the number of inmates employed, which is given in the last column. This results, in one or two cases, in an 6 apparently extraordinary output per head of the laundry staff, but, on the other hand, it is not practicable to attempt to attach a value in units of efficient workers to any number of unpaid inmates employed, who may vary from very useful assistants to individuals employed merely to keep them occupied. Conclusion It is quite clear that some years yet must elapse before many obligations inherited from the metropolitan poor-law authorities, which involve the Council in substantial cost, can be extinguished. Moreover, in the process of reorganisation of the service it has become obvious that both economy and efficiency can be ultimately attained only by the provision of much new plant and equipment, structural alterations, additional staff, etc. All this means considerable immediate expenditure, a large portion of which, in accordance with the Council's policy, is chargeable to annual maintenance costs, and is therefore reflected in the cost per bed. The heads of account mainly affected during any one year by such special expenditure above the average are surgery and dispensary (surgical or X-ray equipment, and the like); furniture and equipment (bedsteads, lockers and other ward equipment); and "special works" (substantial non-recurring minor alterations or extensions). Grouping of hospitals. In the grouping of the hospitals in the following tables a notable departure from the procedure of former years will be apparent. Under the provisions of the London County Council (General Powers) Act, 1934, section 58, the Council has become empowered to group establishments wholly maintained by the Council, in cases where the activities are similar, to permit the application of a flat rate of charge for maintenance in respect of each group for all purposes of recovery of cost of maintenance under prior statutes, and the tables in this volume are therefore arranged in conformity with the revised groupings. This grouping for the purpose of applying a "flat-rate" charge has one important administrative result—that where it is desirable for medical reasons to send a patient for special treatment to another hospital within the same group, objections on the part of the patient do not arise on the grounds of difference in cost. Detailed particulars of the work carried out at each hospital are shown on the pages facing the corresponding tables. Means and averages. Columns have been provided in the majority of the tables showing in respect of the weekly costs at the hospitals within each group (i) the means of the costs in the group, and (ii) the average cost per patient for the group. The costs under (i) are provided to show at which of the hospitals the costs are above or below the "mean." This information is valuable for purposes of administrative control, inasmuch as it shows, not only as regards the total costs but also as regards the detailed heads at each hospital, the extent of the deviation from the mean of that detail cost. The average costs under (ii) represent the net expenditure at all the hospitals comprised in each group divided by the total number of patient-days in each group, and they therefore show under all heads of expenditure the "average weekly cost" to the Council of maintaining a single patient in that group of hospitals. 7 General Notes on the Tables following page 11. The cost per week per occupied bed (or per patient—columns headed P) is arrived at by taking the exact average cost of one day's maintenance of a patient and not the average daily number of patients stated, which is correct only to one decimal place. The cost per available bed is based on the average daily accommodation stated. The cost per available bed (columns headed B) is given under appropriate sub-heads, so that in the case of hospitals where the pressure on the accommodation is seasonal, the occupation has not been for the whole year, or the percentage occupation has been low, a truer comparison of running costs may be made after taking into acoount the actual conditions obtaining. The "establishment charges" referred to in item 8 in the tables include pensions of officers superannuated from the service, central office and supervisory staff salaries and wages, provision and maintenance of central offices, and general expenditure on supplies and servioes connected therewith, such as printing and stationery, hire of motor cars, etc. 8 9 TABLE A TABLE A Year: 1st April, 1934 to 31st March 1935. BED ACCOMMODATION AND OCCUPATION DURING THE YEAR. This table gives information in connection with relative capacity and activity which it is important to bear in mind when comparing costs at the several hospitals. Classification and name of hospital. Beds. (Excluding cots in maternity wards.) in-patients. (Excluding infants in maternity wards.) classification and name op hospital. Beds. (Excluding cots in maternity wards.) in-patients. (Excluding infants in maternity wards.) Average daily accommodation. Average daily number occupied. Percentage of beds occupied. Admissions. Discharges and deaths. Average daily accommodation. Average daily number occupied. Percentage of beds occupied. Admissions. Discharges and deaths. Number. Number. Average days in hospital. Number. Number. Average days in hospital. GENERAL HOSPITALS. Group G. I (acute). SPECIAL HOSPITALS. Group S. I (infectious— fever) Archway 568 348.2 61.3 3,509 3,528 37.0 Brook 560 436.9 78.0 4,036 4,156 38.8 Bethnal Green 650 461.8 71.0 4,929 4,932 34.9 Eastern 565 459.5 81.3 4,319 4,430 38.0 Dulwich 733 667.0 91.0 6,435 6,403 41.0 Grove 556 468.9 84.3 3,967 4,149 39.7 Fulham 562 464.4 82.6 4,777 4,717 42.7 †Joyce Green and Orchard 1,650 624.0 37.8 3,773 5,193 44.0 Hackney 774 651.6 84.2 7,452 7,430 32.1 North-Eastern 661 512.0 77.5 5,066 5,321 34.2 Hammersmith 373 232.9 62.4 2,798 2,788 33.7 North-Western 410 368.6 89.9 3,578 3,595 36.1 Highgate 555 414.3 74.6 2,812 2,951 60.0 Northern 712 529.6 74.4 1,955 2,023 59.5 Lambeth 915 731.1 79.9 – – – Park 612 390.3 63.8 4,383 4,583 30.3 Lewisham 701 613.7 87.5 6,367 6,258 36.6 South-Eastern 480 389.3 81.2 3,927 4,036 32.5 Mile End 539 394.7 73.2 5,660 5,576 26.0 South-Western 323 297.3 92.0 3,207 3,235 31.5 New End 260 211.9 81.5 2,119 2,134 39.2 †Southern 1,544 640.8 41.5 6,750 7,290 29.8 Paddington 603 494.8 82.1 4,768 4,717 34.9 Western 479 378.3 79.0 3,733 3,789 34.7 St. Alfege's 643 525.5 81.7 6,425 6,470 28.9 8,552 St. Andrew's 620 476.9 76.9 7,009 6,906 23.4 St. Charles' 754 539.7 71.6 5,684 5,583 34.2 St. George-in-the-East 410 305.6 74.5 3,843 3,783 27.7 St. Giles' 810 688.3 85.0 8,545 8,447 30.3 Group S. II (infectious and smallpox). St. James' 902 858.1 95.1 12,044 12,007 26.7 St. Leonard's 574 442.7 77.1 4,055 4,099 42.4 Long Reach River Ambulance Service 272 2.4 0.9 49 67 17.8 St. Luke's, Chelsea 391 296.1 75.7 2,918 2,898 35.5 St. Mary Abbots 555 379.7 68.4 5,273 6,249 28.1 St. Mary, Islington 858 758.3 88.4 7,514 7,468 36.5 St. Nicholas' 334 310.3 92.9 3,710 3,665 30.8 St. Olave's 686 596.8 87.0 6,842 6,814 30.4 St. Pancras 380 267.5 70.4 4,349 4,288 23.1 Group S. III (infectious- other diseases). St. Peter's 404 258.7 64.0 3,161 3,130 30.5 St. Stephen's 718 580.9 80.9 5,142 5,154 37.2 *Sheffield Street 98 89.0 90.8 465 475 70.8 16,272 ø Group G. II (chronic and other cases). Group S. IV losis). City of London 623 456.7 73.3 991 1,133 – Constance Road 817 674.8 82.6 921 962 – Colindale 355 340.2 95.8 802 146.3 Fulham 475 361.9 76.2 299 269 – Grove park 330 317.0 96.1 916 810 124.2 Hackney 1,116 830.9 74.5 783 879 – King George V. 235 231.5 98.5 464 913 171.1 Hammersmith 501 236.9 47.3 126 476 – Pinewood 160 159.4 99.6 284 463 194.3 Holborn and Finsbury 978 751.1 76.8 1,069 1,119 – St. George's home 48 46.5 96.9 464 282 36.2 Lambeth 395 376.7 95.4 – – – St. luke's Lowestoft 214 208.3 97.3 270 463 274.8 St. Alfege's 846 680.1 80.4 1,215 1,265 – 1,342 268 St. John's 637 549.5 86.3 1,289 1,270 179.7 St. Leonard's 174 89.2 51.3 50 67 – St. Mary Abbots 605 456.1 75.4 824 827 – St. Pancras 1,202 897.8 74.7 1,449 1,488 – Group S.V (for childien). §South Grove 678 578.2 85.3 – – – The downs 360 339.5 94.3 1,572 1,571 83.8 9,047 Goldie Leigh 248 159.4 64.3 643 651 76.7 ¶heatherwood 140 131.1 93.6 210 75 – Group G. III (convales- cent). High wood 402 400.3 99.6 726 743 167.0 ‡Norwood 220 149.7 68.0 1,355 1,350 32.8 Princess Mary's 271 197.5 72.9 579 614 142.2 Queen Mary s, Sidcup 500 459.4 91.9 3,564 3,586 47.2 Queen Mary's carshalton 1,332 1,121.7 84.2 2,843 2,861 141.1 St. Benedict's 320 293.9 91.8 1,960 1,975 59.1 White Oak 364 231.8 63.7 317 259 372.4 820 3,337 Group G. IV (sane epileptics). St. David's 328 312.7 95.3 132 126 313.3 Group S. VI (convalescent children). St. Faith's 437 356.1 81.5 118 129 886.9 765 Millfleld 98 92.8 94.7 442 439 78.6 St. Anne's 127 112.4 88.5 963 968 43.6 Group G. V (certain children's diseases). 225 *St. Margaret's 66 39.9 60.5 457 457 37.7 Grand Total Groups I-V 26,970 Grand Total Groups I-VI. 13,826 ø See second paragraph on page 4. § For the period 1st April, 1934, to 31st December, 1934, when the institution was transferred to the control of the Public Assistance Committee. Total average daily accommodation at all hospitals—40,796 beds. * Including infants (cots) in maternity wards. † Sections of the hospital were closed during part of the year. ‡ A general hospital comparable with the other hospitals in this group and therefore shown in group with which it is included for the ascertainment of a flat rate of charge for maintenance. ¶ For the period 1st October, 1934, to 31st March, 1935. The hospital was transferred from the united Services Fund to the Council on 1st October, 1934. 10 Note.—For vital statistics and farther details as to the activities of the various hospitals and institutions see Annual Report of the Council 1934, Vol. IV (Part I). See also General Notes on the Tables on page 7. General Hospitals—Group G.I. Archway hospital.—X-ray, electrical, massage and dental departments. Training school for female nurses. Laundry. Group laboratory serving a number of hospitals in the northern area. Histological laboratory for all the general and special hospitals. Bethnal Green hospital.—Special provision for Jewish patients. Venereal wards for female patients. X-ray, electrical, massage and dental departments. Maternity department, ante-natal clinic and training school for midwives. Out-patient department. Training school for female nurses. Laboratory. Laundry. Dulwich hospital.—Maternity department and ante-natal clinic. X-ray, electrical, massage and dental departments. Training school for female nurses. Laboratory. Laundry. Fulham hospital.—Mental observation ward for female patients, with mental consultant. Maternity department, ante-natal clinic and training school for midwives. X-ray, electrical, massage and dental departments. Training school for female nurses. Nursery for healthy infants. Laboratory. Laundry in institution adjacent. Hackney hospital.—Maternity department, ante-natal clinic and training sohool for midwives. X-ray, electrical, massage, electro-cardiograph and dental departments. Out-patient department. Training school for male and female nurses. Laboratory. All domestic services (lighting, heating, baking and laundry) provided by adjoining Hackney institution. Hammersmith hospital.—Postgraduate medical school. Maternity department and ante-natal clinic. X-ray (diagnostic) and deep X-ray therapy, electrical, massage, dental and electro-cardiograph departments. Out-patient department. Training school for female nurses. Laundry. Extensive special works have been carried out and expenditure incurred recently at and in connection with the hospital and the current costs of maintenance should not be regarded as representative of normal conditions. Highgate hospital.—X-ray, electrical, massage and dental departments. Training school for female nurses. Laboratory. Laundry. Lambeth hospital.—Venereal wards for male and female patients. Radium, X-ray (diagnostic) and deep X-ray therapy, electrical, massage and dental departments. Maternity department, ante-natal clinic and training school for midwives. Training school for female nurses. Laundry. Bakery (which also supplies three other establishments). Group laboratory serving a number of hospitals in the south-western area. The hospital includes Lambeth hospital (institution)—(Group G II) and the essential services are common to the two. It is not therefore practicable to state separately the numbers of staff employed. Lewisham hospital.—Maternity department, ante-natal clinic and training school for midwives. X-ray, electrical, massage and dental departments. Out-patient department. Training school for female nurses. Laundry for foul washing only. Instruction in obstetrics to students of St. George's and King's College hospitals medical schools. Group laboratory serving a number of hospitals in the south-eastern area. Mile End hospital.—Special provision for Jewish patients. Maternity department, ante-natal clinic and training school for midwives. X-ray, electrical, massage, dental, and electro-cardiograph departments. Out-patient department. Treatment of school children for tonsils and adenoids. Aural clinic. Diabetic clinic. Psychiatric out-patient clinic. Training school for female nurses. Instruction in obstetrics to students of London hospital medical school. Nursery for healthy infants. Laundry. Group laboratory serving a number of hospitals in the eastern area. New End Hospital.—Unit for treatment of "Graves's" and allied diseases. Maternity department, ante-natal clinic and training school for midwives. X-ray, electrical, massage and dental departments. Centre for dental treatment of school children. Training school for male and female nurses. Laboratory. Laundry. Paddington hospital.—Maternity department, ante-natal chnic and training school for midwives. X-ray, electrical, massage and dental departments. Out-patient department. Training school for female nurses. Laboratory. Laundry. St. Alfege's hospital.—Mental observation wards for male patients, with mental consultant. Maternity department, ante-natal clinic and training school for midwives. X-ray, electrical, massage, dental and electro-cardiograph departments. Out-patient department. Training school for female nurses. Laboratory. Laundry in institution adjacent. St. Andrew's hospital.—Maternity department, ante-natal clinic and training school for midwives. X-ray, electrical, massage and dental departments. Thoracic surgery unit. Out-patient department. Training school for female nurses, and maternity training given in wards. Instruction in obstetrics to students of St. Bartholomew's hospital medical school. Laboratory. Laundry. 11 St. Charles' hospital.—Venereal ward for male patients. X-ray, electrical, massage and dental departments. Treatment of school children for tonsils and adenoids. Psychiatric out-patient clinic. Training school for female nurses. Laboratory. Laundry. St. George-in-the-East hospital.—Maternity department, ante-natal clinic and training school for midwives. X-ray, electrical, massage and dental departments. Out-patient department, including diabetic clinic. Training school for female nurses. Laboratory. Laundry. St. Giles' hospital.—Maternity department, ante-natal clinic and training school for midwives. X-ray, electrical, massage, dental and electro-cardiograph departments. Out-patient department. Training school for female nurses. Instruction in obstetrics to students of St. Bartholomew's hospital medical school. Laboratory. Laundry. Electricity generating plant. St. James' hospital.—Plastic surgery and thoracic surgery units. Maternity department, ante-natal clinic and training school for midwives. X-ray, electrical, massage and dental departments. Out-patient department. Training school for female nurses. Central dental laboratory. Laundry for foul washing only. St. Leonard's hospital.—Maternity department, ante-natal clinic and training school for midwives. X-ray, electrical, massage and dental departments. Training school for female nurses. St. Luke's hospital, Chelsea.—X-ray, electrical, massage and dental departments. Training school for female nurses. Laboratory. St. Mary Abbots hospital.—Mental observation wards for female patients. Maternity, department, ante-natal clinic and training school for midwives. X-ray, electrical, massage, electro-cardiograph and dental departments. Training school for female nurses. Instruction in obstetrics to students of Middlesex hospital medical school. Laundry in institution adjacent. Group laboratory serving a number of hospitals in the western area. St. Mary, Islington, hospital.—Pernicious anaemia and urological diseases units. Maternity department and ante-natal clinic. X-ray, electrical, massage, dental and electro-cardiograph departments. Psychiatric out-patient clinic. Training school for female nurses. Laboratory. Laundry. St. Nicholas' hospital.—X-ray, electrical, massage and dental departments. Maternity department and ante-natal clinic. Out-patient department. Training school for female nurses. Laundry. St. Olave's hospital.—X-ray, electrical, massage and dental departments. Maternity department, ante-natal clinic and training school for midwives. Out-patient department. Training school for female nurses. Laboratory. Laundry. St. Pancras hospital.—Maternity department, ante-natal clinic and training school for midwives. X-ray department, electrical, massage and dental departments. Training school for female nurses. Laboratory. Laundry in institution adjacent. St. Peter's hospital.—Special provision for Jewish patients. Venereal wards for male patients. X-ray, electrical, massage and dental departments. Out-patient department, including diabetic clinic. Training school for male and female nurses. No laundry. St. Stephen's hospital.—Rheumatism unit. Venereal wards for male and female patients. Certified for the reception of mental defectives suffering from venereal disease. Maternity department, ante-natal clinic and training school for midwives. X-ray, electrical, massage and dental departments. Training school for female nurses. Laboratory. Laundry. Electricity generating plant. TABLE B GENERAL HOSPITALS—Group G. I (Twenty-seven hospitals)—For the ANALYSIS OF COST PER WEEK (IN PENCE) of maintenance during the year 1st April, 1934, to 31st March, 1935. The cost per per available bed or "Bed" under B. To facilitate comparison Figures in brackets are sub-divisions of the inclusive heads. Archway. Bethnal Green. Dulwich. Fulham. Hackney. †Hammersmith. Highgate. Lambeth. Lewisham. Mile End. New End. Name of hospital Number of beds nominally available 568 650 733 562 774 373 555 915 701 539 260 Average daily number of patients 348.2 461.8 667.0 464.4 651.5 232.9 414.3 731.1 613.7 394.7 211.9 Percentage occupation 61.3 71.0 91.0 82.6 84.2 62.4 74.6 79.9 87.5 73.2 81.5 Normal establishment of staff— Medical and nursing 147(2.6) 200(3.1) 223(3.0) 171(3.0) 264(3.4) 122(3.3) 172(3.1) 304† 293(4.2) 177(3.3) 86(3.3) Other, excluding engineering and teaching (Totals and, in brackets, numbers per ten beds.) 144(2.5) 147(2.3) 168(2.3) 119(2.1) 178(2.3) 116(3.1) 126(2.3) 313† 229(3.3) 202(3.7) 81(3.1) 1. In-patients, Maintenance of— P B P B P B P B P B P B P B P B P B P B P B Provisions and stimulants 71.1 – 74.9 – 65.1 – 60.6 – 67.1 – 100.5 – 74.9 – 64.8 – 65.8 – 73.2 – 72.4 – Surgery and dispensary 37.8 – 35.9 – 36.5 – 35.5 – 39.5 – 100.2 – 34.1 – 66.3 – 50.4 – 49.0 – 50.6 – including Drugs, dressings, sundries, etc. (21.1) – (20.7) – (22.8) – (18.2) – (22.4) – (52.2) – (18.6) – (20.7) – (32.9) – (27.9) – (32.6) – Surgical equipment, appliances and repairs (11.2) – (9.1) – (8.5) – (10.5) – (10.6) – (34.9) – (8.1) – (40.7) – (10.2) – (13.8) – (10.2) – Salaries and wages (5.5) (3.4) (6.1) (4.4) (5.2) (4.7) (6.8) (5.6) (6.5) (5.5) (13.1) (8.2) (7.4) (5.5) (4.9) (3.9) (7.3) (6.4) (7.3) (5.3) (8.3) (6.8) Antitoxin establishment and pathological services 17.2 – 6.0 – 3.0 – 5.8 – 7.3 – 11.0 – 16.5 – 17.5 – 13.3 – 11.9 – 15.4 – Clothing 5.0 – 5.0 – 2.8 – 2.7 – 4.0 – 5.7 – 3.7 – 5.3 – 2.4 – 6.4 – 2.7 – Funerals 4.2 – 2.7 – 2.9 – 4.2 – 3.0 – 3.9 – 2.9 – 3.8 – 1.0 – 3.8 – 2.8 – 2. Staff— Salaries and wages (with Council's contributions under National Insurance Acts) 340.9 209.0 351.3 249.5 276.9 251.9 287.6 237.7 346.6 291.7 517.4 323.0 330.8 247.0 349.9 279.6 322.3 282.1 409.3‡ 299.7 371.2 302.5 including Medical service (57.9) (35.5) (45.5) (32.3) (41.5) (37.7) (55.4) (45.8) (44.6) (37.5) (102.4) (63.9) (44.9) (33.6) (46.7) (37.4) (43.7) (38.2) (49.9) (36.5) (75.3) (61.3) Nursing service (97.7) (59.9) (124.9) (88.7) (107.3) (97.6) (94.4) (78.0) (110.9) (93.3) (153.9) (96.1) (110.7) (82.6) (97.8) (78.2) (108.7) (95.2) (122.7) (89.9) (130.0) (105.9) Steward and clerical service (21.4) (13.1) (21.0) (14.9) (12.1) (11.0) (14.9) (12.3) (14.7) (12.4) (24.8) (15.5) (18.3) (13.7) (16.2) (12.9) (16.1) (14.1) (23.9) (17.5) (20.3) (16.6) General domestic service (134.8) (82.7) (126.2) (89.7) (83.4) (75.9) (94.0) (77.7) (127.0) (106.9) (189.4) (118.3) (108.9) (81.3) (147.9) (18.2) (126.8) ( 110.9) (177.2) ( 129.8) (111.7) (91.0) Kitchen service (9.8) (6.0) (11.3) (8.0) (7.8) (7.1) (8.8) (7.3) (5.4) (4.6) (23.1) (14.4) (14.1) (10.5) ( 8.8) (7.0) (12.8) (11.2) (17.5) (12.8) (13.1) (107) Workrooms (7.5) (4.6) (5.5) (3.9) (5.2) (4.8) (5.4) (4.4) (6.0) (5.0) (10.8) (6.7) (3.5) ( 2.6) ( 2.9) (2.3) ( 5.8) ( 5.1) (6.6) ( 4.8) ( 7.1) ( 5.8) Miscellaneous (6.7) (4.1) (4.4) (3.1) (3.6) (3.3) (9.7) (8.0) (1.8) (1.5) (7.9) (4.9) (3.7) ( 2.8) ( 4.9) (3.9) ( 3.5) ( 3.1) ( 4.7) ( 3.4) ( 4.4) ( 3.6) Non-residential allowances (5.0) (3.0) (11.5) (8.2) (13.2) (12.0) (4.1) (3.4) (21.6) (18.2) (3.2) (2.0) (26.3) (19.6) (23.0) (18.4) ( 4.3) ( 3.8) ( 6.8) ( 5.0) ( 5.1) (4.2) Adjustment of pay on grading (1930-1934) (0.1) (0.1) (1.0) (0.7) (2.8) (2.5) (0.9) (0.8) (14.6) (12.3) (1.9) (1.2) (0.4) ( 0.3) ( 1.7) (1.3) ( 0.6) ( 0.5) — — ( 4.2) ( 3.4) Rations 37.1 22.7 34.0 24.2 27.4 24.9 30.6 25.3 27.4 23.1 54.9 34.3 36.2 27.0 14.4 11.5 40. 6 35.6 35.4 25.9 43.1 35.1 Uniforms and dresses 5.8 3.5 5.0 3.5 4.3 3.9 4.6 3.8 6.1 5.1 9.5 6.0 7.0 5.3 3.8 3.0 .5 6.6 8.9 6.5 6.7 5.4 3. Buildings, services and supplies— Furniture and equipment 28.4 17.4 16.2 11.5 9.8 8.9 10.6 8.7 17.6 14.8 28.6 17.9 15.4 11.5 15.3 12.2 11.2 9.8 16.1 11.8 16.6 13.6 Cleaning and domestic materials 5.6 3.4 6.2 4.4 4.0 3.6 3.5 2.9 6.3 5.3 10.5 6.6 4.6 3.4 5.1 4.0 5.1 4.5 6.8 5.0 7.5 6.l Bedding and house linen 9.8 6.0 11.1 7.9 7.0 6.4 7.0 5.8 11.9 10.0 16.0 10.0 6.8 5.1 7.0 5.6 11.6 10.2 13.0 9.5 10.7 8.7 Crockery and hardware 5.6 3.4 6.2 4.4 3.5 3.2 3.0 2.5 5.0 4.2 5.5 3.4 5.0 3.7 3.0 2.4 4.9 4.3 4.8 3.5 5.5 4.4 Heating, lighting, etc. 62.9 38.6 50.2 35.6 45.3 41.2 45.9 37.9 48.3 40.7 80.0 49.9 59.6 44.5 51.3 41.0 72.2 63.3 90.0 65.9 76.1 62.0 including Wages of engineering maintenance staff (19.2) (11.8) (15.0) (10.6) (12.3) (11.2) ( 8.5) ( 7.0) ( 2.6) ( 2.2) (12.0) ( 7.5) (14.3) (10.7) (14.2) (11.3) (20.2) (17.8) (33.2) (24.3) (23.6) (19.3) Fuel (24.0) (14.7) (24.4) (17.4) (20.8) (18.9) (21.1) (17.4) (14.8) (12.5) (41.2) (25.7) (24.4) (18.2) (18.9) (15.2) (30.3) (26.5) (34.1) (25.0) (29.4) (23.9) Gas, electricity, water (19.7) (12.1) (10.8) ( 7.6) (12.2) (11.1) (16.3) (13.5) (30.9) (26.0) (26.8) (16.7) (20.9) (15.6) (18.2) (14.5) (21.7) (19.0) (22.7) (16.6) (23.1) (18.8) Laundry 53.2 32.6 43.8 31.1 35.6 32.4 43.9 36.3 46.7 39.3 67.6 42.2 41.8 31.2 27.6 22.1 42.8 37.4 58.8 43.0 38.1 31.1 including Wages (38.2) (23.4) (30.1) (21.4) (24.9) (22.6) * * * * * * (27.1) (20.3) (19.8) (15.8) †( 9.5) †(8.3) (46.4) (34.0) (26.4) (21.5) Works (plant and buildings)— Maintenance: Wages 15.3 9.4 12.6 9.0 7.8 7.1 6.4 5.3 6.4 5.4 15.8 9.8 14.3 10.7 8.9 7.1 16.7 14.6 27.3 20.0 14.1 11.5 Minor contracts, materials, etc. 20.4 12.5 26.7 19.0 5.6 5.1 12.1 10.0 7.5 6.3 43.2 27.0 13.2 9.9 11.1 8.9 23.4 20.5 18.1 13.2 29.3 23.9 Special works 78.2 47.9 47.0 33.4 14.7 13.4 29.3 24.2 13.4 11.3 199.7 124.7 36.3 27.1 11.6 9.3 10.1 8.8 64.7 47.4 75.4 61.4 Gardens and grounds— Wages 8.8 5.4 1.8 1.3 3.6 3.3 3.3 2.8 1.3 1.1 – – 1.8 1.3 – – 4.7 4.1 6.1 4.5 – – 4. Rates, Taxes and Insurance 38.6 23.7 29.3 20.8 17.6 16.0 19.0 15.7 18.0 15.1 25.1 15.7 7.6 5.6 15.2 12.1 31.1 27.2 23.7 17.4 22.0 17.9 5. Miscellaneous expenditure— Printing, stationery, postage, telephones, etc. 9.6 5.9 8.2 5.9 5.0 4.5 6.9 5.7 6.7 5.6 38.6 24.1 5.6 4.2 9.8 7.8 6.9 6.0 9.3 6.8 14.5 11.8 Travelling and sundry expenses 1.8 1.1 0.3 0.2 0.4 0.4 0.5 0.4 0.4 0.4 0.9 0.6 1.2 0.9 – – 0.5 0.4 0.4 0.3 0.3 0.3 Items 1 to 5—total cost per occupied bed 71s. 5.3d – 64s. 6.4d – 48s. 2.8d – 51s. 11.0d – 57s. 6.5d. – 111s. 2.6d. – 59s. 11.3d. – 57s. 7.7d. – 62s. 0.5d. – 78s. 1.0d. – 72s. 11.0d. – Deduct for sundry receipts, credits for transfer services and balances on farm or industrial accounts 0s. 6.5d – 0s. 8.6d – 0s. 5.0d – 0s. 1.5d. – 0s. 11.5d. – 1s. 2.8d. – 0s. 5.2d. – 0s. 3.6d. – 0s. 8.6d. – 0s. 7.1d. – 0s. 11.6d. – Net cost per occupied bed— £ s. d. £ s d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. per day 10 2 9 1 6 10 7 5 8 1 15 9 8 6 8 2 8 9 11 1 10 3 per week 3 10 11 3 3 10 2 7 10 2 11 10 2 16 7 5 10 0† 2 19 6 2 17 4 3 1 4 3 IT 6 3 11 11 per year 184 17 9 166 8 6 124 14 2 135 2 9 147 10 5 286 15 9 155 2 6 149 9 6 159 18 1 202 1 1 187 9 11 Net cost per occupied bed per week, 1933-1934 3 0 8 2 12 7 2 11 10 2 10 11 2 15 1 3 5 8 2 12 7 ¶ 2 18 10 3 16 11 3 5 11 6. Superannuation Fund (Council's contributions) p B P B P B P B P B P B P B P B P B P B P B 48.4 29.7 53.3 37.9 37.8 34.4 33.5 27.7 37.4 31.5 50.7 31.7 38.6 28.8 41.5 33.1 46.8 41.0 61.7 45.2 52.1 42.4 7. Annual charge in respect of capital outlay 68.6 42.0 41.5 29.5 32.1 29.2 38.5 31.8 34.4 28.9 45.8 28.6 14.6 10.9 29.4 23.4 61.8 54.1 35.9 26.3 43.3 35.3 8. Establishment charges—Pensions 34.4 21.1 34.8 24.7 20.6 24.2 25.9 21.4 30.9 26.0 47.1 29.4 31.8 23.7 27.5 22.0 31.7 27.7 43.6 31.9 36.3 29.6 Other 51.5 31.6 51.5 36.6 51.5 46.9 51.5 42.6 51.5 43.4 51.5 32.2 51.5 38.5 51.5 41.2 51.5 45.1 51.5 37.7 51.5 42.0 £ s. d. £ s d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. Inclusive cost per occupied bed per week, 1934-35 4 7 10 3 18 11 3 0 2 3 4 3 3 9 5 6 6 3 3 10 11 3 9 10 3 17 4 4 13 7 4 7 3 Inclusive cost per occupied bed per week, 1933-1934 3 15 6 3 5 5 3 4 6 3 3 6 3 7 9 3 18 0 3 3 1 ¶ 3 14 8 4 12 8 4 0 7 Percentage occupation, 1933-34 63.5 81.6 80.5 77.5 79.5 87.6 81.0 ¶ 92.1 70.5 78.5 NOTES (see also General Notes on page 7), __The cost per available bed (B) is not shown where the expenditure is strictly dependent upon the number of patients. An asterisk (*) indicates † See note referring to this hospital on page 10. ‡ Includes value of certain emoluments which was recovered TABLE B—continued treatment of acute medical and surgical patients, including children. of IN-PATIENTS, under the several heads of expenditure, week is shown per occupied bed or "Patient" under P, and by reading across, the former costs are printed in heavy type. of hospital  Paddington. St. Alfege's. St. Andrew's. St. Charles'. St.George-in-East. St.Giles'. St. James'. St. Leonard's. St.Luke's, Chelsea. St. Mary Abbots. St. Mary, Islington. St. Nicholas. St. Olave's. St. Pancras. St. Peter's. St. Stephen's. ||Mean of Group. ||Average of Group.  Number of beds nominally available 603 643 620 754 410 810 902 574 391 555 858 334 686 380 404 718 603 603 Average daily number of patients 494.8 525.5 476.9 539.7 3.5.6 688.3 858.1 442.7 296.1 397.7 758.3 310.3 596.8 267.5 258 580.9 480.4 480.4 Percentage occupation 82.1 81.7 76.9 71.6 74.5 85.0 95.1 77.1 75.7 68.4 88.4 92.9 87.0 70.4 64.0 80.9 78.2 79.7 Normal establishment of staff— Medical and nursing 193 (3.2) 208 (3.2) 213 (3.4) 229(3.0) 126 (3.1) 256(3.2) 320(3.5) 168(2.9) 128(3.3) 198(3.6) 263(3.1) 128(3.8) 223(3.2) 119(3.1) 142(3.5) 232(3.2) 192(3.3) 192(3.2) Other, excluding engineering and teaching (Totals and, in brackets, numbers per ten beds.) 152 (2*5) 178 (2.8) 190 (3.1) 156(2.1) 129 (3.1) 185(2.3) 160(1.8) 133(2.3) 97(2.5) 123(3.2) 154(1.8) 89(2.7) 156(2.3) 68(1.8) 125(3.1) 131(1.8) 144(2.5) 144(2.4) 1. In-patients, Maintenance of— P B P B P B P B P B P B P B P B P B P B P B P B P B P B P B P B P B P B Provisions and stimulants 67.4 – 60.8 – 76.1 – 73.0 – 66.2 – 71.0 – 64.2 – 69.8 – 77.2 – 75.8 – 64.5 – 64.6 – 71.9 – 72.8 – 80.1 – 75.8 – 71.2 – 69.8 – Surgery and dispensary 39.8 – 49.7 – 44.4 – 37.7 – 44.8 – 51.8 – 36.4 – 39.2 – 40.1 – 73.4 – 36.5 – 58.2 – 41.0 – 49.3 – 63.6 – 43.9 – 47.6 – 45.7 – including Drugs, dressings, sundries, etc. (26.0) – (29.3) – (26.9) – (23.1) – (20.2) – (29.3) – (21.0) – (22.7) – (18.8) – (44.8) – (19.7) – (33.0) – (24.5) – (29.9) – (39.8) – (26.0) – (26.8) – (25.5) – Surgical equipment, appliances and repairs (6.1) – (9.6) – (12.5) – (8.3) – (18.5) – (13.5) – (10.4) – (10.7) – (14.8) – (20.0) – (11.5) – (17.1) – (9.0) – (12.3) – (14.3) – (10.8) – (13.6) – (13.3) – Salaries and wages (7.7) (6.3) (10.8) (98.8) (5.0) (3.9) (6.3) (4.5) (6.1) (4.5) (9.0) (7.6) (5.0) (4.8) (5.8) (4.5) (6.5) (4.9) (8.6) (5.8) (5.3) (4.7) (8.1) (7.5) (7.5) (6.5) (7.1) (5.0) (9.5) (6.1) (7.1) (5.7) (7.2) (5.6) (6.9) (5.5) Antitoxin establishment and pathological services 2.3 – 5.0 – 4.4 – 5.2 – 7.2 – 6.2 – 7.4 – 13.3 – 8.5 – 25.1 – 11.5 – 8.0 – 6.1 – 14.1 – 15.4 – 4.7 – 10.0 – 9.3 – Clothing 5.2 – 5.0 – 5.9 – 5.8 – 8.5 – 5.1 – 3.8 – 5.4 – 6.0 – 4.9 – 3.0 – 5.2 – 5.0 – 4.4 – 5.2 – 4.0 – 4.8 – 4.6 – Funerals 5.1 – 3.0 – 2.0 – 5.7 – 2.3 – 3.9 – 3.7 – 3.5 – 4.5 – 8.0 – 3.8 – 4.7 – 2.5 – 9.0 – 7.3 – 5.0 – 4.0 – 3.8 – 2. Staff— Salaries and wages (with Council's contributions under National Insurance Acts) 332.0 272.4 355.3 290.4 344.7 265.2 314.1 224.9 379.4‡ 282.7 283.1 240.6 251.2 239.0 293.8 226.6 326.3 247.1 365.2 249.8 266.2 235.3 363.2 337.5 321.9 280.0 335.3 236.1 553.0 354.1 292.5 236.7 343.8 266.4 328.6 261.9 including Medical service (55.0) (45.1) (53.7) (43.9) (59.0) (45.4) (45.1) (32.3) (55.1) (41.1) (46.0) (39.1) (39.4) (37.5) (45.4) (35.1) (57.2) (43.3) (68.0) (46.5) (35.0) (31.0) (57.4) (53.4) (39.8) (34.6) (60.8) (42.8) (63.7) (40.8) (41.0) (33.2) (53.0) (40.9) (49.4) (39.3) Nursing service (123.2) (101.1) (115.7) (94.6) (107.4) (82.6) (109.5) (78.4) (112.7) (84.0) (100.1) (85.1) (86.4) (82.6) (105.1) (81.1) (118.3) (89.6) (127.5) (87.2) (92.8) (82.0) (118.5) (110.1) (120.2) (104.6) (120.9) (85.1) (160.7) (102.9) (118.6) (95.9) (114.7) (89.2) (110.8) (88.3) Steward and clerical service (15.3) (12.6) (15.3) (12.5) (20.3) (15.6) (20.2) (14.4) (18.6) (13.8) (15.3) (13.0) (13.5) (12.8) (17.9) (13.8) (18.1) (13.7) (20.0) (13.7) (13.3) (11.8) (21.6) (20.1) (16.2) (14.1) (13.5) (9.5) (25.5) (16.3) (15.6) (12.6) (17.9) (13.9) (17.0) (13.6) General domestic service (100.3) (82.3) (141.4) (115.6) (127.9) (98.4) (96.2) (68.8) (159.5) (118.9) (102.9) (87.4) (67.6) (64.3) (98.9) (76.3) (96.8) (73.3) (110.6) (75.6) (80.4) (71.0) (91.5) (85.1) (118.9) (103.4) (98.6) (69.4) (261.0) (167.1) (77.0) (62.3) (120.6) (92.6) (114.4) (91.2) Kitchen service (10.8) (8.9) (15.9) (13.0) (7.5) (5.8) (8.6) (6.2) (12.3) (9.5) (8.9) (7.5) (9.2) (8.7) (17.3) (13.3) (16.8) (12.7) (9.9) (6.8) (6.3) (5.6) (16.5) (15.3) (6.6) (5.7) (12.1) (8.5) (21.9) (14.0) (9.9) (8.0) (12.0) (9.2) (10.9) (8.7) Workrooms (5.9) (4.8) (6.4) (5.2) (10.4) (8.0) (5.1) (3.7) (10.7) (8.0) (5.3) (4.6) (6.1) (5.8) (3.9) (3.0) (5.8) (4.4) (4.5) (3.1) (4.9) (4.3) (7.3) (6.7) (6.2) (5.3) (2.4) (1.7) (10.1) (6.5) (5.4) (4.4) (6.2) (4.8) (5.8) (4.7) Miscellaneous (3.9) (3.2) (3.7) (3.0) (5.8) (4.5) (4.3) (3.1) (7.9) (5.9) (2.9) (2.5) (3.0) (2.9) (2.4) (1.9) (4.9) (3.7) (6.9) (4.7) (2.3) (2.1) (3.3) (3.0) (5.6) (4.9) (5.7) (4.0) (5.9) (3.8) (3.9) (3.2) (4.7) (3.7) (4.4) (3.5) Non-residential allowances (15.0) (12.3) – – (6.0) (4.6) (23.0) (16.5) (0.6) (0.4) (1.2) (1.0) (22.2) (21.2) (1.4) (1.0) (1.2) (0.9) (13.9) (9.5) (27.9) (24.6) (45.8) (42.5) (5.0) (4.4) (20.5) (14.5) (2.8) (1.8) (16.4) (13.3) (12.1) (9.9) (13.1) (10.4) Adjustment of pay on grading (1930-1934) (2.6) (2.1) (3.2) (2.6) (0.4) (0.3) (2.1) (1.5) (1.5) (1.1) (0.5) (0.4) (3.4) (3.2) (1.5) (1.1) (7.2) (5.5) (3.9) (2.7) (3.3) (2.9) (1.3) (1.3) (3.4) (3.0) (0.8) (0.6) (1.4) (0.9) (4.7) (3.8) (2.6) (2.2) (2.8) (2.2) Rations 28.2 23.2 32.0 26.2 35.2 27.1 35.0 25.0 29.7 22.1 32.0 27.2 28.0 26.7 36.4 28.1 37.2 28.1 47.6 32.6 24.8 21.9 31.9 29.6 33.6 29.2 35.4 24.9 43.0 27.6 27.4 22.2 34.0 26.3 32.2 25.6 Uniforms and dresses 8.2 6.7 6.3 5.1 7.7 5.9 6.7 4.8 6.3 4.7 5.4 4.6 3.6 3.4 6.0 4.6 7.5 5.7 8.4 5.8 3.8 3.4 7.1 6.5 5.9 5.1 4.9 3.4 5.7 3.6 4.3 3.5 6.2 4.8 5.9 4.7 3. BUILDINGS, SERVICES AND SUPPLIES— Furniture and equipment 14.5 11.9 11.3 9.2 12.2 9.4 9.8 7.0 18.2 13.6 10.9 9.3 6.3 6.0 18.6 14.4 11.7 8.8 23.8 16.3 8.8 7.8 11.4 10.6 12.2 10.6 7.1 5.0 17.2 11.0 12.9 10.5 14.6 11.1 13.6 10.8 Cleaning and domestic materials 4.9 4.0 5.3 4.3 5.5 4.2 4.7 3.3 5.0 3.7 4.6 3.9 3.8 3.6 5.3 4.0 5.3 4.0 5.7 3.9 4.4 3.9 5.2 4.8 6.0 5.2 5.4 3.8 8.1 5.2 4.6 3.7 5.5 4.2 5.2 4.2 Bedding and house linen 12.9 10.6 11.2 9.2 10.2 7.8 14.0 10.0 9.1 6.8 11.2 9.5 7.0 6.7 9.5 7.3 14.5 11.0 15.5 10.6 7.5 6.6 8.9 8.3 9.3 8.1 11.0 7.8 10.7 6.9 7.6 6.2 10.4 8.1 10.0 8.0 Crockery and hardware 3.6 3.0 3.8 3.1 3.5 2.7 4.4 3.1 3.6 2.7 8.0 2.6 3.6 3.4 4.8 3.7 4.7 3.6 6.6 4.5 3.0 2.6 4.5 4.2 4.6 4.0 3.0 2.1 5.9 3.8 4.7 3.8 4.4 3.4 4.2 3.4 Heating, lighting, etc 63.8 52.3 49.5 40.4 81.6 62.8 47.7 34.2 76.7 57.2 44.7 38.0 37.5 35.7 50.4 38.9 71.2 53.9 71.9 49.2 40.9 36.1 47.4 44.1 61.1 53.2 51.7 36.4 93.1 59.6 48.1 38.9 60.0 46.3 56.5 45.0 including Wages of engineering maintenance staff (13.7) (11.2) (9.8) (8.0) (23.9) (18.4) (10.7) (7.7) (22.0) (16.4) (13.7) (11.6) (8.6) (8.2) (10.3) (7.9) (16.8) (12.7) (14.3) (9.7) (6.4) (5.7) (13.1) (12.2) (10.4) (9.1) (9.9) (7.0) (31.6) (20.2) (13.0) (10.5) (15.0) (11.5) (13.7) (10.9) Fuel (29.3) (24.0) (20.1) (16.4) (26.0) (20.0) (19.6) (14.0) (26.7) (19.9) (18.3) (15.6) (14.5) (13.8) (16.8) (13.0) (27.0) (20.4) (32.5) (22.3) (21.1) (18.6) (11.1) (10.4) (25.9) (22.5) (21.1) (14.9) (30.7) (19.7) (27.1) (21.9) (24.1) (18.6) (23.0) (18.3) Gas, electricity, water (20.8) (17.1) (19.6) (16.0) (31.7) (24.4) (17.4) (12.5) (28.0) (20.9) (12.7) (10.8) (14.4) (13.7) (23.3) (18.0) (27.4) (20.8) (25.1) (17.2) (13.4) (11.8) (23.2) (21.5) (24.8) (21.6) (20.7) (14.5) (30.8) (19.7) (8.0) (6.5) (20.9) (16.2) (19.8) (15.8) Laundry 38.9 31.9 43.9 35.9 54.4 41.8 36.5 26.2 51.4 38.3 37.1 31.5 44.2 42.0 34.6 26.7 46.7 35.4 74.9 51.3 32.1 28.4 41.1 38.2 32.3 28.1 48.1 33.9 53.6 34.3 32.6 26.3 44.5 34.4 42.5 33.9 including Wages (28.8) (23.6) * * (42.4) (32.6) (25.5) (18.2) (36.6) (27.3) (25.4) (21.5) *(8.2) *(7.8) (24.2) (18.7) *(19.9) *(15.1) * * (21.3) (18.8) (28.9) (26.9) (24.9) (21.6) * * * * (21.7) (17.6) – – – – Works (plant and buildings) — Maintenance: Wages 10.8 8.9 8.6 7.1 22.7 17.5 6.7 4.8 27.7 20.7 12.4 10.5 3.1 2.9 11.3 8.7 10.8 8.2 12.8 8.7 6.9 6.1 7.8 7.2 10.6 9.3 11.6 8.1 25.9 16.6 7.1 5.7 12.7 9.7 11.5 9.1 ,, Minor contracts, materials, etc. 16.8 13.8 12.3 10.1 27.6 21.2 17.8 12.7 27.5 20.5 11.2 9.6 9.5 9.0 10.2 7.9 21.1 16.0 20.1 13.7 23.4 20.6 10.2 9.5 31.1 27.0 22.2 15.6 22.1 14.2 9.7 7.9 18.6 14.2 17.1 13.6 Special works 50.1 41.1 32.7 26.7 47.4 36.5 49.9 35.7 535 39.8 43.6 37.0 16.7 15.9 29.1 22.4 24.0 18.2 21.8 14.9 36.4 32.2 45.5 42.3 22.0 19.1 26.4 18.6 62.2 39.8 10.6 8.6 42.7 31.8 35.7 28.5 Gardens and grounds— Wages 2.2 1.8 2.8 2.3 4.9 3.7 3.3 2.4 3.0 2.2 1.1 0.9 1.8 1.7 – – 0.9 0.7 – – 1.1 1.0 2.7 2.5 1.3 1.2 – – 0.5 0.3 – – 2.8 2.2 2.1 1.7 4. Rates, Taxes and Insurance 22.8 18.7 17.8 14.6 40.5 31.1 16.8 11.9 25.0 18.7 25.3 21.5 17.1 16.3 16.0 12.3 17.4 13.2 16.2 11.0 21.0 18.6 19.3 18.0 33.4 29.0 12.7 9.0 26.0 16.6 17.9 14.5 21.9 17.1 21.7 17.3 5. MISCELLANEOUS EXPENDITURE— Printing, stationery, postage, telephones, etc. 10.6 8.7 12.4 10.1 9.4 7.3 7.2 5.1 8.8 6.5 5.5 4.6 5.4 5.2 7.2 5.6 6.8 5.1 11.1 7.6 7.1 6.3 9.4 8.8 6.4 5.6 10.5 7.4 10.1 6.5 8.4 6.8 9.5 7.2 8.5 6.8 Travelling and sundry expenses 0.7 0.5 0.4 0.4 0.4 0.4 0.4 0.3 0.9 0.7 0.3 0.2 0.4 0.3 0.5 0.4 0.5 0.4 0.3 0.2 0.3 0.3 0.8 0.7 0.5 0.4 0.7 0.5 §14.5 §9.3 0.4 0.3 1.1 0.8 0.8 0.6 ITEMS 1 to 5—total cost per occupied bed 61s. 8.8d. – 60s. 9.1d. – 70s. 0.7d. – 58s. 6.2d. – 71s. 2.8d. – 55s. 9.4d. – 46s. 2.7d. – 55s. 4.9d. – 61s. 10.9d. – 74s. 1.1d. – 50s. 7.0d. – 63s. 1.1d. – 59s. 10.7d. – 61s. 3.6d. – 93s. 7.2d. – 51s. 10.2d. – 64s. 1.6d. – 60s. 9.3d. – Deduct for sundry receipts, credits for transfer services and balances on farm or industrial accounts 0s. 3.9d. – 0s. 8.7d. – 0s. 5.5d. – 0s. 6.8d. – 1s. 1.1d. – 0s. 5.7d. – 0s. 11.8d. – 0s. 9.9d. – 0s. 2.9d. – 0s. 11.0d. – 0s. 1.7d. – 0s. 9.3d. – 0s. 2.2d. – 0s. 2.5d. – 0s. 9.4d. – 0s. 4.1d. – 0s. 7.1d. – 0s. 6.8d. – Net COST per occupied bed— £ s. d. £ s. d. £ s. d. £ s. d. £ s d £ S d £ s d £ s d £ s d £ s d £ s d £ s d £ s d £ s d £ s d £ s d £ s d £ s d per day 8 9 8 7 9 11 8 3 10 0 7 11 6 6 7 10 8 10 10 5 7 2 8 11 8 6 8 9 13 3 7 4 9 1 8 7 per week 3 1 5 3 0 0 3 9 7 2 7 11 3 10 2 2 15 4 2 5 3 2 14 7 3 1 8 3 13 2 2 10 5 3 2 4 2 19 6 3 1 1 4 12 10 2 11 6 3 3 6 3 0 2 per year 160 2 5 156 8 7 181 8 3 150 19 11 182 18 8 144 5 4 117 19 6 142 6 1 160 15 6 190 15 1 131 8 10 162 10 3 155 15 8 159 5 1 242 0 7 134 5 4 165 11 1 156 17 3 Net cost per occupied bed per week, 1933-1934 2 19 7 2 13 9 3 7 9 2 19 11 3 6 2 2 10 10 2 4 4 2 10 1 2 18 4 3 6 10 2 5 3 3 0 10 2 19 8 3 1 0 4 8 8 2 9 0 ¶ ¶ P B P B P B P B P B P B P B P B P B P B P B P B P B P B P B P B P B P B 6. Superannuation Fund (Council's contributions) 41.0 33.6 44.2 36.1 50.5 38.8 35.1 25.1 52.4 39.1 38.8 32.9 31.3 29.7 41.3 31.8 41.6 31.5 42.6 29.1 33.8 29.9 47.4 44.0 45.2 39.3 34.4 24.2 66.4 42.6 39.6 32.0 44.0 34.2 42.3 33.7 7. Annual charge in respect of capital outlay 45.1 37.0 29.6 24.2 49.3 37.9 34.8 24.9 37.7 28.1 46.5 39.6 35.7 34.0 27.3 21.1 35.5 26.9 33.7 23.0 44.4 39.2 29.8 27.7 28.3 24.6 26.7 18.8 37.9 24.2 37.1 30.0 38.0 29.7 37.9 30.2 8. Establishment charges—Pensions 32.5 26.7 32.3 26.4 37.5 28.8 29.3 21.0 40.5 30.2 28.7 24.4 22.6 21.5 28.5 22.0 30.5 23.1 32.5 22.2 24.8 21.9 36.7 34.1 31.2 27.1 29.6 20.8 50.9 32.6 27.5 22.3 32.8 25.4 31.2 24.9 Other 51.5 42.3 51.5 42.1 51.5 39.6 51.5 36.9 51.5 38.4 51.5 43.8 51.5 49.0 51.5 39.7 51.5 39.0 51.5 35.3 51.5 45.5 51.5 47.9 51.5 44.8 51.5 36.3 51.5 33.0 51.5 41.7 51.5 40.5 51.5 41.1 £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. Inclusive cost per occupied bed per week, 1934-35 3 15 7 3 13 2 4 5 4 3 10 6 4 5 4 3 9 1 2 17 0 3 7 0 3 4 11 4 6 6 3 3 4 3 16 1 3 12 9 3 12 11 5 10 1 3 4 6 3 17 4 3 13 9 Inclusive cost per occupied bed per week, 1933-34 3 13 10 3 6 4 4 3 10 3 12 6 4 1 1 3 3 9 2 15 10 3 1 3 3 11 3 3 19 6 2 17 8 3 14 7 3 12 9 3 12 7 5 4 8 3 1 2 ¶ ¶ Percentage occupation, 1933-34 78.1 83.1 72.4 68.9 73.9 84.4 87.5 83.8 74.2 70.2 85.4 89.7 82.1 68.0 62.6 81.2 ¶ ¶ that the service, inclusive of labour, was rendered and charged ior by another establishment, from staff—see deduction for receipts below. || See page 6. § Includes conveyanoe of nursos living out or at ctlu^r institutions. H Conditions not comparable. General Hospitals—Group G.II. City of London institution.—Mental observation wards with mental consultant. Treatment for skin diseases. Electrical and massage departments. Laundry. Constance Road institution.—Mental observation wards with mental consultant. Nursery for healthy infants. Laundry. Bakery (which also supplies two other establishments). Fulham hospital (institution).—Adjoins Fulham hospital (Group G.I). Laundry. Electricity generating plant. Bakery (which also supplies two other establishments). Hackney hospital (institution).—Laundry. Electricity generating plant. Bakery. Provides all the domestic services—laundry, electricity, heating, etc.—for the adjoining Hackney hospital (Group G.I), and bread for four establishments. Hammersmith hospital (institution).—Adjoins Hammersmith hospital (Group G.I). Laundry. Holbom and Finsbury institution.—Nursery for healthy infants. Laundry. Bakery (which also supplies two other establishments). Lambeth hospital (institution).—Forms an integral part of Lambeth hospital (Group G.I) and the essential services are common to the two. It is not, therefore, practicable to state separately the numbers of staff employed. St. Aljeqe's hospital (institution).—Adjoins St. Alfege's hospital (Group G.I). Female mental observation wards with mental consultant. Nursery for healthy infants. Laundry. Bakery. St. John's hospital.—Congenital syphilis unit. Mental observation wards with mental consultant. X-ray, electrical, massage and dental departments. Laundry. Electricity generating plant. St. Leonard's hospital (institution).—Adjoins St. Leonard's hospital (Group G.I). For female inmates only. Bakery. St. Mary Abbots hospital (institution).—Adjoins St. Mary Abbots hospital (Group G.I). Nursery for healthy infants. Laundry. St. Pancras hospital (institution).—Adjoins St. Pancras hospital (Group G.I). Mental observation wards with mental consultant. Nursery for healthy infants. Laundry. Bakery (which also supplies four other establishments). South Grove institution.—Special provision for Jewish patients. Laundry. Central bakery, which also supplies eight other establishments. Transferred to the control of the Public Assistance Committee on 1st January, 1935. Staffing arrangements are not comparable with those of other hospitals for this year. TABLE C GENERAL HOSPITALS—GROUP G. II—For the treatment of chronic medical and surgical patients, including children, and of other inmates.‡ ANALYSIS OF COST PER WEEK (IN PENCE) of maintenance of IN-PATIENTS, under the several heads of expenditure, during the year 1st April, 1934 to 31st March, 1935. The cost per week is shown per occupied bed or "Patient" under P, and per available bed or "Bed" under B. To facilitate comparison by reading across, the former costs are printed in heavy type. Figures in brackets are sub-divisions of the inclusive heads. Name of hospital City of London. Constance Road. Fulham. Hackney. Hammersmith. Holbom and Finsbury. Lambeth. St. Alfege's. St. John's. St. Leonard's.§ St. Mary Abbots. St. Pancras. South Grove. ††Mean of ††Averagc of group Number of beds nominally available 623 817 475 1,116 501 978 395 846 637 174 605 1,202 678 696 696 Average daily number of patients 456.7 674.8 361.9 830.9 236.9 751.1 376.7 680.1 549.5 89.2 456.1 1,202 678 696 696 Percentage occupation 73.3 82.6 76.2 74.5 47.3 76.8 95.4 80.4 86.3 51.3 75.4 897.8 578.2 533.8 533.8 Normal establishment of staff— 74.7 85.3 75.3 76.7 Medical and nursing 100 (1.6) 123 (1.5) 20 (0.4) 55 (0.5) 16 (0.3) 94 (1.0) 0 88 (1.0) 142 (2.2) 6 (0.3) 51 (0.8) 75 (0.6) 0 77 (0.9) 77 (1.1) Other, excluding engineering and teaching (Totals and, in brackets, numbers per ten beds.) 63 (1.0) 92 (1.1) 65 (1.4) 126 (1.1) 60 (1.2) 110 (1.1) 0 130 (1.5) 130 (2.0) 10 (0.6) 66 (1.1) 77 (0.6) 0 84 (1.2) 84 (1.2) 1. In-patients, Maintenance of— P B P B P B P B P B P B P B P B P B P B P B P B P B P B P B Provisions and stimulants 50.7 — 48.2 — 43 4 — 46.0 — 59.6 — 43.2 — 48.0 — 42.3 — 51.0 45.1 — 46.1 — 47.7 — 50.0 — 47.8 XJ 47.2 — Tobacco, sweets, and snuff 5.1 — 2.2 — 3 8 — 4.9 — 7.1 — 3.9 — 3.5 — 4.4 — 0.3 3.8 — 2.7 — 4.1 — 5.2 — 3.9 3.8 — Surgery and dispensary 6.8 — 7.4 — 51 — 4.7 — 5.0 — 5.2 — 5.9 5.5 — 12.3 3.1 — 4.0 — 3.3 — 5.8 — 5.7 5.8 — including Drugs, dressings sundries, etc. ( 3.6) — ( 3.7) — ( 4-2) — ( 3.6) — ( 4.0) — (1.8) — (1.8) ( 3.8) — (3.7) (1.5) — (3.4) — (2.2) — (2.8) — (3.1) (3.1) — Surgical equipment, appliances and repairs ( 1.4) — ( 1.6) ( 0-2) ( 0.5) — (0.2) — ( 2.2) — (3.6) ( 0.4) — (4.3) (0.3) — (0.4) — (0.6) — (0.5) — ()1.2 (1.3) — Salaries and wages ( 1.8) ( 1.3) ( 2.1) ( 17) ( 0-7) 0.5) ( 0.6) ( 0.4) (0.8) ( 0.4) (1.2) ( 0.9) (0.5) ( 0.5) ( 1.3) (1.0) (4.3) ( 3-7) (1.3) (0.7) (0.2) ( 0.2) (0.5) — (2.5) (2.2) (1.4) ~; (1.4) (1.0) Clothing 7.4 — 3.9 5 9 — 7.8 — 6.1 — 6.2 — 5.3 8.3 — 4 0 9.9 — 6.0 — 5.7 (0.4) 8.1 — 6.5 ( 1-1) 6.3 — Funerals 2.4 — 1.2 — 0-2 — 1.3 — 2.0 — 1.3 — 2.6 — 0.8 — 2.5 _ — — 2.7 — 0.6 — 1.7 — 1.6 1.4 — 2. Staff— Salaries and wages (with Council's contributions under National Insurance Acts) 256.5 188.0 193.9 160.2 99.3 75.7 71.3 53.1 135.4 64.1 118.6 91.1 198.1 188.9 127.8 102.8 256.3 221.1 102.7 52.6 103.6 78.1 91.6 68.4 120.4† 102.7 144.3 including Medical service (20.7) (15.2) ( 6.7) ( 6.5) ( 1.7) ( 1.3) ( 1.0) ( 0.7) (2.5) (1.2) (5.6) ( 4.3) (13.0) (12.4) (1.4) (1.1) (25.5) (22.0) ( 2.6) (1.3) (2.0) (1.5) (1.8) (1.4) (2.0) (1.7) (6.7) lil-o 140.9 107.9 N ursing service (128.4) (94.1) (71.7) (59.2) (23.4) (17.9) (26.6) (19.8) (51.6) (24.4) (34.9) (26.8) (73.5) (70.1) (42.8) (31.4) (85.8) (74.0) (16.8) (8.6) (38.3) (28.8) (37.9) (28.3) (41.1) (35.1) ( 51.8) ; 5-3) (6.4) (4.9) Steward and clerical service (12.5) ( 9.2) (10.1) ( 8.3) (13.2) (10.0) ( 9.5) ( 7.0) (12.9) (6.1) (10.2) ( 7.8) (12.1) (11.5) (7.9) (6.4) (14.3) (12.3) (15.8) (8.1) (12.5) (9.4) (8.9) (6.6) (12.2) (10.4) (11.7) (40-1) (51.6) (39.5) General domestic service (38.8) (28.4) (55.5) (45.9) (43.7) (33.3) (29.2) (21.7) (50.2) (23.8) (45.6) (35.1) (66.3) (63.2) (55.2) (44.4) (67.3) (58.0) (33.4) (17.1) (17.7 (13.4) (29.7) (22.2) (49.5) (42.2) (44.8) ; 8-7) (10.9) (8.3) Kitchen service ( 8.6) ( 6.3) ( 6.0) ( 4.9) ( 3.1) ( 2.4) ( 1.2) ( 0.9) (8.5) (4.0) (2.8) ( 2.1) (6.3) ( 6.0) (8.2) (6.6) (9.7) 8.4) (13.0) (6.7) (4.3) (3.3) (3.6) (2.7) (7.3) (6.2) (6.3) (34-5) (44.1) (33.8) Workrooms ( 2.2) ( 1.6) ( 6.5) ( 5.4) ( 1.0) ( 0.8) ( 2.7) ( 2.1) (3.7) (1.8) (3.4) ( 2.6) (2.7) ( 2.6) (5.2) (4.2) (7.8) 6.8) (6.5) (3.3) (1.3) (1.0) (3.6) (2.7) (5.7) (4.8) (4.0) 4-7) ( ^ -1 ^ (5.5) (4.2) Miscellaneous ( 7.6) ( 5.6) ( 5.1) ( 4.3) ( 2.6) ( 1.9) ( 1.0) (0.8) (4.4) (2.1) (3.4) ( 2.6) (1.7) ( 1.6) (2.7) (2.2) ( 6.0) 5.2) (6.2) (3.2) (1.8) (1.3) (1.4) ( 1.0) (2.4) (2.1) (3.5) ( 3 L) (4.0) (3.1) Non-residential allowances (13.1) ( 9.6) (31.8) (26.3) ( 7.0) ( 5.3) — — (0.7) (0.3) (6.7) ( 5.2) (21.3) (20.3) (2.7) (2.2) (31.5) '27.2) (8.3) (4.2) (18.8) (14.2) (3.2) ( 1.0) — — ( 11.2) ( 2-6) (3.2) (2.5) Adjustment of pay on grading (1930-1934) (24.6) (18.0) ( 0.5) ( 0.4) ( 3.6) (2.8) (0.1) ( 0.1) (0.9) ( 0.4) (6.0) ( 4.6) (1.2) (1.2) (1.7) (1.3) ( 8.4) 7.2) (0.1) (0.1) (6.9) (5.2) (1.5) (2.4) (1.1) (0.2) (0.2) (4.3) (4.3) 9-0) 3-3) (11.0) (4.2) (8.4) ( 3.2) Rations 11.0 8.0 9.6 7.9 7.2 5.5 7.0 5.2 8.9 4.2 11.5 8.8 12.8 12.2 12.4 9.9 19.6 16.9 4.2 2.2 9.7 7.3 5.8 4.3 3.4 2.9 9.5 7-3 9.7 7-4 Uniforms and dresses 3.8 2.8 2.7 2.3 1.2 0.9 1.3 1.0 1.1 0.5 2.2 1.7 3.2 3.1 1.8 1.4 4.5 3.9 1.3 0.6 3.8 2.9 1.1 0.8 1.9 1.6 2.3 1-8 2.3 1-8 3. Buildings, services and supplies— Furniture and equipment 10.4 7.6 10.0 8.2 4.4 3.3 5.1 3.8 5.5 2.6 11.7 8.9 12.0 11-5 7.8 6.3 13.2 11.4 4.1 2.1 8.6 6.5 4.1 3.1 8.5 7.3 8.1 c.i 8.3 Cleaning and domestic materials 3.5 2.6 3.3 2.8 4.1 3.1 4.0 3.0 5.3 2.5 3.1 2.4 4.0 3-8 4.6 3.7 4.0 3.4 3.3 1.7 3.0 2.3 2.2 1.6 2.4 2.1 3.6 b-4: 3.5 b'o 2.7 Bedding and house linen 5.3 3.9 7.5 6.2 2.0 1.5 5.0 3.7 4.3 2.0 6.7 5.2 5.5 5-3 9.2 7.4 7.5 6.5 3.7 1.9 5.0 3.8 4.1 3.0 4.9 4.1 5.4 2 *7 5.8 A .A Crockery and hardware 1.5 1.1 2.3 1.9 1.5 1.1 2.3 1.7 1.3 0.6 2.1 1.6 2.4 2-3 2.1 1.7 3.1 2.7 0.8 0.4 1.9 1.5 1.6 1.2 1.5 1.3 1.9 15 2.0 1 -4 1 *5 Heating, lighting, etc 43.3 31.7 27.4 22.6 26.1 19.9 19.7 14.6 54.8 25.9 30.0 23.1 29.3 27-9 25.8 20.8 37.4 32.2 68.4 35.1 38.3 28.8 23.6 17.7 36.1 30.8 35.4 25-5 30.8 23-6 including Wages of engineering tenance staff (11.9) ( 8.7) ( 7.1) ( 5.9) (12.0) ( 9.2) ( 8.1) (6.0) (18.3) ( 8.6) (7.9) (6.1) (6.1) ( 5-8) ( 5.7) (4.6) (13.8) (11.9) (14.8) (7.6) (7.8) (5.9) (5.4) (4.0) (13.7) (11.7) (10.2) ( 7.4"\ (9.0) Fuel (20.5) (15.0) (10.3 ( 8.5) ( 6.2) ( 4.7) (10.0) (7.4) (24.0) (11.4) (12.3) (9.5) (12.1) (11-5) ( 9.0) (7.2) (16.9) (14.5) (33.2) (17.0) (19.0) (14.3) (12.8) (9.6) (14.0) (12.0) (15.4) ( ' ■*) (13.4) V 0 J) 11 r"». ON Gas, electricity, water (10.9 ( 8.0) (10 0 ( 8.2) ( 7.9) ( 6.0) (1.6) (1.2) (12.5) ( 5.9) (9.8) (7.5) (11.1) (10-6) (11.1) (9.0) ( 6.7) 5.8) (20.4) (10.5) (11.5) (8.6) (5.4) (4.1) (8.3) (7.1) (15.4) (11-0) ( 7. i \ (8.4) (1U-J) ( ft. Laundry 21.6 15.8 (23.2) 19.1 2.8 2.1 1.6 1.2 11.7 5.5 21.0 16.2 19.5 18-6 23.9 19.2 33.5 28.9 16.4 8.4 11.6 8.7 6.9 5.1 21.4 18.2 (9.8) ( ' i) 12-8 16.3 ( " °) 12-5 including Wages (15.3) (11.2) (17.4) (14.4) — — — — — (13.3) (10.2) (13.0) (12.4) (18.3) (14.7) (20.3) (17.5) * * — — (5.4) (4.0) (16.3) (13.9) 16.5 — Works (plant and buildings)— Maintenance:Wages 11.2 8.2 8.7 7.2 10.6 8.0 9.2 6.9 18.4 8.7 7.3 5.6 8.9 8.5 7.2 5.8 10.7 9.2 10.2 5.2 6.6 5.0 5.8 4.3 16.0 13.6 10.1 7-4 9.2 7-0 Do. Minor contracts, materials, etc. 14.8 10.9 10.4 8.6 9.1 7.0 10.0 7.4 10.1 4.8 10.2 7.8 11.1 10.6 6.2 5.0 10.5 9.1 17.7 9.1 7.6 5.7 7.8 5.8 11.0 9.4 10.5 7-8 9.8 7.5 Special works 23.9 17.6 76.7 63.3 15.8 12.1 15.5 11.6 13.0 0.2 6.4 4.9 11.6 11.1 11.9 9.6 23.0 19.8 26.1 13.3 14.4 10.8 14.3 10.7 13.3 11.4 20.5 15-6 20.9 16-0 Gardens and grounds— Wages — — 3.1 2.6 — — — — 3.1 1.5 — — — — — — 1.5 1.3 — — — — — — 1.3 1.1 2.2 1-6 0.6 0-5 4. Rates, taxes and insurance 12.9 9.5 11.0 9.1 18.0 13.7 8.2 6.1 21.6 10.2 23.5 18.0 15.4 14.7 13.8 11.1 15.0 12.9 13.0 6.7 13.9 10.5 7.0 5.3 14.2 12.1 14.4 10-8 13.6 10-4 5. Miscellaneous expenditure— Printing, stationery, postage, telephones, etc— 5.0 3.7 3.1 2.6 2.6 2.0 3.1 2.3 6.7 5.2 2.5 1.9 3.2 3.0 2.6 2.1 4.9 4.2 4.3 2.2 5.5 4.2 2.0 1.5 2.4 2.1 3.7 2-7 3.3 2-6 Travelling and sundry expenses 1.1 0.8 2.4 2.0 0.2 0.2 0.6 0.5 0.2 0.1 0.2 0.1 — 0.1 0.1 0.4 0.4 0.2 0.1 0.1 0.1 0.2 0.2 0.3 0.2 0.5 0-4 0.5 0-4 Items 1 to 6—total per occupied bed 41s. 6.2d. — 38s. 2.2d. — 21s. 11.3d — 19s. 0.6d. — 31s. 9.2d. — 26s. 4.8d. — 33s. 6.3d. — 26s. 6.5d. — 42s. 11.2d — 28s. 2.3d — 24s. 7.1d. — 19s. 11 5d — 27s. 5.8d. — 29s. 4.7d. 28s. 6.0d. Deduct for sundry receipts, credits for transfer services and balances on farm or industrial accounts 0s. 11.6d — 0s. 3.0d. — 0s. 3.9d. — 0s. 9.9d. — 2s. 9.3d. — 0s. 6.6d. 7— 0s. 9.4d. — 0s. 11.8d — 0s. 7.1d. — 0s. 2.1d. — 0s. 4.5d. — 0s. 1 Id. — 0s. 4.6d. — 0s. 8.4d. 0s.7.4d. net COST per occupied bed— £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ d. £ d. £ d. £ d. £ s. d. per day 5 10 5 5 3 1 2 7 4 2 5 1 4 8 3 8 6 1 4 0 3 6 2 10 3 10 4 1 4 0 per week 2 0 7 1 17 11 1 1 7 18 3 1 9 0 1 5 10 1 12 9 1 5 7 2 2 4 1 3 0 1 A 0 19 10 1 1 8 8 1 7 11 per year 105 16 2 98 17 1 56 5 5 47 11 7 75 12 2 67 0 85 7 8 66 14 0 110 7 5 73 0 0 63 4 6 51 14 2 1 70 4 12 1 2 74 14 9 72 15 8 Net cost per occupied bed per week, 1933-34 2 4 7 1 9 6 1 2 0 16 5 1 3 3 1 4 3 ¶ 1 4 11 1 19 11 1 10 10 18 5 18 8 1 7 0 ¶ ¶ P B P B P B P B P B P B P B P B P B P B P B P B P B P B P B 6. Superannuation fund (Council's contributions) 31.9 23.4 16.6 13.7 16.1 12.3 14.6 10.9 15.0 7.1 14.6 11.2 22.0 21.0 18.4 14.8 30.9 26.7 15.6 8.0 14.4 10.8 12.4 9.2 16.0 13.7 18.3 14.1 17.9 13.7 7. Annual charge in respect of capital outlay 14.3 10.5 20.8 17.2 36.9 28.1 15.3 11.4 40.9 19.4 21.3 16.4 29.7 28.3 23.5 18.9 31.0 26.8 20.6 10.6 29.3 22.1 14.6 10.9 21.6 18.4 24.6 18.4 22.7 17.4 8. Establishment charges—Pensions 23.9 17.5 19.2 15.9 14.6 11.1 11.3 8.4 18.6 8.8 12.1 9.3 27.5 26.3 14.5 11.6 24.8 21.4 10.3 5.5 13.7 10.3 9.6 7.2 14.4 12.3 16.5 12.7 15.9 12.2 Other 24.5 17.9 24.5 20.2 24.5 18.7 24.5 18.2 24.5 11.6 24.5 18.8 24.5 23.3 24.5 19.7 24.5 21.1 24.5 12.6 24.5 18.5 24.5 18.3 24.5 20.9 24.5 18.4 24.5 18.8 £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ R. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. inclusive cost per occupied bed per week, 1934-35 2 8 5 2 4 8 1 9 4 1 3 8 1 17 3 1 11 11 2 1 5 1 12 4 2 11 7 1 13 11 1 11 1 1 4 11 1 13 6 1 15 8 1 14 8 Inclusive cost per occupied bed per week, 1933-34 2 11 8 1 15 8 1 9 4 1 1 6 1 8 10 1 10 1 ¶ 1 10 10 2 8 1 16 10 1 4 10 1 3 6 1 13 3 ¶ ¶ Percentage occupation, 1933-34 64. 4 85.1 76.3 78.6 82.3 3 7 8.4 ¶ 84.8 89.8 50.1 66.5 77.3 85.3 ¶ ¶ NOTES (see also General Notes on page 7).— The cost per available bed iB) is not shown where the expenditure is strictly dependent upon the number of p itients. An asterisk (•) indicates that the service, inclusive of labour, was rendered and charged for by another establishment. In many cases the labour of inmates was utilised. } See second paragraph on page 4. 0 See note referring to this hospital on page facing. t Includes value ol certain emoluments which was recovered from staff—see deduction for receipts below. § Undergoing partial reconstruction during the year. tt See page 0. H Conditions not comparable. General Hospitals—Group G.III. Queen Marys hospital, Sideup.—A hospital for male convalescent patients. Massage, dental and light-treatment departments. Occupational therapy. No laundry. St. Benedict's hospital.—A hospital for female convalescent patients. Unit for cardiac cases. Massage and electrical departments. No laundry. General Hospitals—Group G.IV. St. Faith's hospital, previously Brentwood colony.—For sane epileptic female patients. Dental department. Various occupations available for patients (e.g., poultry keeping and vegetable and fruit growing, gardening, rug-making and weaving). Laundry. Bakery. Milk and bread supplied to other establishments. St. David's hospital, previously Edmonton colony.—For sane epileptic male patients. Dental department. Occupations for patients: brushmaking, bootmaking, basketmaking, carpentry, farming, vegetable and fruit growing, tending and rearing stocks of farm animals. Industrial departments—many articles made and repaired for other establishments. Laundry. General Hospital—Group G.V. St. Margaret's hospital.—For (i) ophthalmia neonatorum (mothers admitted with their infants), and (ii) vulvo-vaginitis (children). Allocated to the General Hospitals service on 1st April, 1935. General Hospital—See Group S.V. Norwood hospital for children.—For the treatment of children's diseases. Attached to the Norwood children's home, which if administered by the Education Committee. Dental department. Sunlight and massage department. Unit for treatment of rheumatism in children. Open-air shelters. Nursery for healthy infants. Isolation block. Not a recognised training school for nurses. Engagements of probationer nurses limited to two years. No laundry. This hospital is comparable with the children's hospitals included in Special Hospitals group S.V, and therefore for the calculation of averages and means and for the ascertainment of a flat rate of charge for maintenance, the hospital is shown in that group. TABLE D GENERAL HOSPITALS—Group G. Ill—For convalescent patients. Group G. IV—For sane epileptic patients. Group G. V—For certain children's diseases. ANALYSIS OF COST PER WEEK (IN PENCE) of maintenance of IN.PATIENTS, under the several heads of expenditure, during the year 1st April, 1934, to 31st March, 1935. The cost per week is shown per occupied bed or "Patient" under P, and per available bed or "Bed" under B. To facilitate comparison by reading across, the former costs are printed in heavy type. Figures in brackets are sub.divisions of the inclusive heads. GROUP G. III GROUP G. IV GROUP G. V Name and type of hospital Queen Mary's, Sidcup. (iconvalescent) St. Benedict's (convalescent) ffMean of group III. ft Average of group III. St. David's (sane epileptics) i St. Faith's (sane epileptics) tfMean of group IV. ft Average of group IV. St. Margaret's. Number of beds nominally available 500 320 410 410 328 437 382 382 66 Average daily number of patients 459.4 293.9 376.6 376.6 312.7 356.1 334.4 334.4 39.9 Percentage occupation Normal establishment of staff— 91.9 91.8 91.8 91.9 ^ * 95.3 81.5 88.4 • 87.4 60.5 Medical and nursing 81 (1.6) 61 (1.9) 71 (1.7) 71 (1.7) 33 (1.0) 34 (0.8) 33 (0.9) 33 (0.9) 23 (3.5) Other, excluding engineering and teaching (Totals and, in brackets, numbers per ten beds.) 105 (21) 66 (2.1) 85 (2.1) 85 (2.1) i!7 (0.8) 50 (11) 38 (0.9) 38 (1.0) 15 (2.3) 1. In.patients, Maintenance of— P B P B P B P B P B P B P B P B P B Provisions and stimulants 85.8 — 60 8 — 73 3 — 76 0 — 57.2 — 45 7 51 5 511 53 0 Tobacco, sweets and pnuff 10 10 0.6 7.2 0.5 3.8 36 Surgery and dispensary 10 1 11 0 10 5 10.4 5.7 3 6 4.7 4.6 363 including Drugs, dressings, sundries, etc. ( 5.4) — ( 6 5) — ( 5.9) — ( 5 8) — ( 5.2) — (3.3) — ( 4.3) — ( 4.2) (14 0) Surgical equipment, appliances and repairs ( 2.0) ( 18) ( 1.9) ( 1.9) ( 0.5) ( 0 3) ( 0.4) ( 0.4) (14 9) Salaries and wages ( 2.7) 2.5) ( 2.7) ( 2.4) ( 2.7) ( 2.4) ( 2.7) ( 2.4) — — ( 7.4) ( 4.5) Antitoxin establishment and pathological vices 0.4 — 11 — 0 8 — 0 6 0.1 — 0 2 0 1 0 2 9 7 Clothing 12.0 — 10 6 6 7.7 __ 15.7 9.2 12.5 12.3 82 Funerals 1.3 — 0 2 — 0 7 0 9 0.2 0 1 0 1 0 1 2. Staff— Salaries and wages (with Council's contributions under National Insurance Acts) 224.6 206.4 234 2 215.1 229 4 210.8 228 4 209.8 138 9 132.4 ' 92 0 75.0 115 5 103.7 113 9 99.6 390 0 235.6 including Medical service (23.5) (21.6) (27.9) (25.6) (25.7 (23.6) (25 2) (23.2) ( 5.1) ( 4.9} ( 5.1) 4.1) ( 51) ( 4.5) ( 5.1) ( 4.4) (39 8) (24.0) Nursing service (33.8) (31.1) (710) (65.2) (52 4 (48.2) (48 4 (44.4) (80 3) (76.5) (27.8) (22.7) (54.1) (49.15) (52.4) (45.8) (165 7 (100.1) Steward and clerical service (12.3) (H.3) (18 4) (16.9) (153 (14.1) (14.7) (13.5) (130) (12.4) (16.4) (13.4) (14.7) (12.9) (14 81 (130) (12 4 ( 7.5) General domestic service (128.4 (118.0) (86 2) (79.2) (107 3 (98.6) (1119) (102.8) (151) (14.4) (19.9) (16.2) (17.5) (15.3) (17.6) (15.4) (124 0) (74.9) Kitchen service (16.3) (15.0) (10.7) ( 9.H) (13.5) (12.4) (141) (130) ( 7 4) ( 7.0) ( 2.8) 2.3) ( 5.1) 4.6) ( 4.9; ( 4.3) (14 2 ( 8.6) Workrooms (3.7) ( 3.4) ( 3.9) ( 3.6) ( 3 8) ( 3.5) ( 3.8) ( 3.4) ( 5.6) ( 5.4) ( 0 9) 0.7) ( 3 3) ( 3.1) ( 3.1) ( 2.7) (15 0 ( 9.1) Miscellaneous ( 3.0 ( 2.7) ( 3.9) ( 3.6) ( 3 5) ( 3.1) ( 3 3) ( 3.1) t( 3 1) ( 2.9) ( 7.0) 5.7) ( 5 0) ( 4.3) ( 5.2) ( 4.5) ( 4.6) ( 2.8) Non.residential allowances — (11.2) (103) ( 5.6) ( 5.2) ( 4.4) ( 4.0) ( 8 9) ( *.5) (11.9) 9.7) (10.4) ( 91) (105) ( 9.2) (14.3) ( 8.6) Adjustment of pay on grading (1930.19?4) ( 3.6 ( 3.3) ( 10) ( 0.9) ( 2.3) ( 21) ( 2.6) ( 2.4) ( 0.4) ( 0.4) ( 0.2) ( 0.2) ( 0 3) ( 0.3) ( 0 3) ( 0.3) Rations 21.2 19.5 23 2 21.3 22.2 20.4 22 0 20.2 0 9 0.9 9 7 7.9 5 3 4.4 5 6 4.9 56 9 34.4 Uniforms and dresses 3.9 3.6 5.2 4.8 4 6 4.2 4.4 4.1 1.6 1.5 16 1.3 16 1.4 1.6 1.4 8 5 5.2 3. buildings, services and supplies— Furniture and equipment 12.0 11. 0 6 3 5.8 9 1 8.4 9 8 9.0 5 3 5.1 7 3 5.9 6 3 5.5 6 4 5.6 63 6 38.4 Cleaning and domestic materials 3.3 3.0 4 8 4.4 4 1 3.7 3.9 3.6 2.7 2.6 27 2.2 27 2.4 2.7 2.4 6 6 4.0 Bedding and house linen 6.3 5.8 2 6 2.4 4 4 4.1 4.9 4.5 3 9 3.7 3 3 2.7 3 6 3.2 3 6 3.1 23 6 14.2 Crockery and hardware 2.9 2.7 1.7 1.6 2 3 2.1 2.4 2.2 16 1.5 20 1.7 18 1.6 1.8 1.6 6 9 4.2 Heating, lighting, etc 62.0 57.0 45 5 41.8 53 8 49.4 55 6 611 27 0 25.8 323 26.3 29 6 26.0 29 8 26.1 68 0 41.1 including Wages of engineering maintenance staff (14.0) (12.9) (16 6, (15.3) (15 3, (14.1) (150) (13.8) (106) (101) ( 91) ( 7.4) ( 9.8) 8.7) ( 9.8) ( 8.5) (16 0) ( 9.7) Fuel (29.9 (27.5) (16 7 (15.3) (23 3 (21.4) (24 8) (22.7) (11.4) (10.9) (14.2) (11.5) (12.8) (11.2) (12 9) (11.3) (251) (15.1) Gas, electricity, water (18.1 (16.6) (122 (11.2) (15 2 (13.9) (15.8) (14.6) ( 5 0) ( 4.8) ( 9 0) ( 7.4) ( 7.0) 6.1) ( 71) ( 6.3) (26 9) (16.3) Laundry 17.3 15.9 17 9 16.4 17 6 16.2 17 5 16.1 10 4 9.9 102 8.3 10 3 9.1 10 3 9.0 79 1 47.8 including Wages * # — — — — — — ( 4.7) ( 4.5) ( 6 0) ( 4.9) ( 5.3) ( 4.7) ( 5.4) ( 4.7) • • Works (plant and buildings)— Maintenance: Wages 11.4 10.5 10 0 9.2 10 7 9.8 10 9 10.0 13 2 12.6 7.7 6.3 105 9.5 10 3 9.0 6 8 4.1 Do. Minor contracts, materials, etc. 13.6 12.5 13 0 11.9 13 3 12.2 13 4 12.3 3 8 3.6 15 4 12.5 9 6 8.0 9 9 8.7 46 3 27.9 Special works 5.6 5.2 18.5 17.0 12 0 11.1 10 7 9.8 9 0 8.6 5 4 4.4 7.2 6.6 7 1 6.2 256 6§ 155.0 Gardens and grounds— Wages 8.3 7.6 6 5 5.9 7.4 6.8 7 6 C.9 30 2.8 7 2 5.8 5 1 4.3 5 2 4.5 4. Rates, taxes and insurance 6.8 6.2 17 7 16.3 12 2 11.2 11 0 10.1 20 8 19.8 182 14.8 19 5 17.3 19 4 170 25 8 15.6 5. Miscellaneous expenditure— Printing, stationery, postage, telephones, etc. 3.9 3.6 5 4 4.9 4 6 4.2 45 41 9 4 9.0 88 7.2 9 1 8.1 9 1 8.0 81 4.9 Travelling and sundry expenses 0.6 0.5 0 2 0.2 0 4 0.3 0 4 0.4 0 4 U.4 2.4 2.0 14 1.2 15 1.3 0 0 0.4 Items 1 to 5—total per occupied bed Deduct for sundry receipts, credits for transfer 42s. 10 3d — 40s. 6 8d. — 41s. 8.5d. — 41s. 11.6d. — 28s. 2 Od. — 23s. 9 5d. — 25s. 11 8d — 25s. 10 Id ~ 96s. 2 6d. — services and balances on farm or industrial accounts... 1s. 0.8d. — 0s. 9 4d. — 0s. 11 Id. — 0s. 11 5d, 0s. 10 8d 0s. 3 2d. 0s. 7 Od. . 0s. 6 8d. . Os.O 9d. — Net COST per occupied bed— £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. per day 6 0 0 5 8 5 10 5 L0 3 11 3 4 3 8 3 7 13 9 per week 2 1 10 1 19 9 2 0 9 2 1 0 1 7 3 1 3 6 1 5 6 1 5 3 4 16 25 per year 109 1 4 103 12 8 106 4 10 106 17 10 71 0 11 61 5 4 66 6 4 65 16 7 250 14 5 Net cost per occupied bed per week, 1933.34 2 1 0 1 19 1 2 0 0 2 0 3 1 9 7 1 2 6 1 6 0 1 5 9 3 3 8 aaaaaaa P B P B P B P B P B P B P B P B P B C. Superannuation fund (Council's contributions) 28.2 26.0 30 7 28.2 29 4 27.1 29 2 26.8 17 6 16.8 14 8 12.0 16 2 14.4 16 1 14.1 37 5 22.7 7. ANNUAL CHARGE IN RESPECT OF CAPITAL OUTLAY 11.8 10.8 34 8 31.9 23 3 21.4 20 8 19.1 33 9 32.3 29 2 23.8 31 5 28.0 81 4 27.4 45 7 27.6 8. Establishment charges—Pensions 20.9 19.2 21 6 19.9 21 3 19.5 21 2 19.4 14 8 13.9 11.9 9.7 13 3 11.8 13 2 11.5 33 2 20.1 Other 51.5 47.3 51 5 47.3 51.5 47.3 51 5 47.3 24 5 23.3 24.5 20.0 24.5 21.7 24 5 21.4 41 1 24.7 £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. Inclusive cost per occupied bed per week, 1934.35 2 11 2 2 11 4 2 11 3 2 11 3 1 14 10 1 10 3 1 12 6 1 12 4 5 9 3§ Inclusive cost per occupied bed per week, 1933.34 2 9 11 2 10 4 10 1 10 1 17 5 8 11 13 2 12 9 3 16 2 Percentage occxivation, 1933.34 89.7 90.8 90 2 901 907 826 866 861 666 NOTES (see also General Notes on page 7).—The co«t per available bed (B) is not shown where the expenditure is strictly dependent upon tlienumberof patients An asterisk (•) indicates that theservice,inclusiveoflabour, was rendered and charged for by another establishment. In the hospitals in group U.1V the labour of inmates is utilised. t Includes teachers and instructors, ft See page ti. § Exceptional cost mainly due to provision of a special department. Brook hospital Eastern hospital Grove hospital *North-Eastern hospital †North-Western hospital ‡Park hospital South-Eastern hospital South- Western hospital Western hospital Special Hospitals—Group S.l. Acute fever hospitals. Men, women and children admitted. Owing to seasonal fluctuations in the incidence of infectious diseases the numbers of patients under treatment at these hospitals vary considerably throughout the year and it is only for limited periods that the beds are fully occupied. Average user of beds varies at the different hospitals. Numerous diseases treated. Necessary classification by age, sex, and disease involves distribution of patients in many wards, which cannot all be kept full. Many cases have, for medical reasons, to be treated in single bed wards. Joyce Green hospital.—-Used for fever or smallpox, as required, when the accommodation provided at other hospitals for these diseases is insufficient. Opened for the reception of fever cases from 28th June, 1933, to 16th February, 1935. Certain of the essential services of Joyce Green and Orchard hospitals are operated in common with Long Reach hospital (Group S.II). It is not, therefore, practicable to state separately the numbers of staff employed. Orchard hospital.—An emergency hospital. Opened for the reception of fever cases on 13th February, 1934, and closed on 11th July, 1934. Northern hospital.—Used for three classes of patient:—(i) convalescent fever cases (men, women and children); (ii) pulmonary tuberculosis, advanced (women) (iii) post-encephalitis lethargica (men, women and children). Observations (above) r iser of beds at fever hospitals apply also to fever unit at Northern hospital. Southern hospital.—(1) Upper hospital—For convalescent fever cases (men, women and children). User of beds variable for reasons given above. (2) Lower hospital-— Acute fever cases are treated there in times of pressure on the accommodation in the town hospitals. Used for non-infectious convalescent cases (children) when not required for fever cases. The lower hospital was opened, for acute infectious cases, on 28th October, 1933, and closed on 19th May, 1934. *The Northern Group laboratory serving a number of hospitals is situated at the NortliKastern hospital. †There is at the North-Western hospital a puerperal fever unit. ‡The Southern Group laboratory serving a number of hospitals is situated at the Park hospital. TABLE E SPECIAL HOSPITALS—Group S. I—Infectious: Fever. ANALYSIS OF COST PER WEEK (IN PENCE) of maiiitenance of IN-PATIENTS under the several heads of expenditure, during the year 1st April, 1934 to 31st March, 193"). The cost per week is shown per occupied bed or " Patient " under P, and per available bed or Bed " under B. To facilitate comparison by reading across, the former costs are printed in heavy type. Figures in brackets are sub-divisions of the inclusive heads. Name and type of hospital Brook. (acute) Eastern. (acute) Grove. (acute) Joyce Green and Orchard. North-Eastern. (acute) North-Western. (acute) Northern. (convalescent) Park. (acute) South-Eastern. (acute) South-Western. (acute) § Southern. (convalescent) Western. (acute) tf Mean of group. f-f- Average of group. Number of beds nominally available 560 565 556 (acute) 1,650 661 410 712 612 480 323 1.544 4 79 713 713 Average daily number of patients 436*9 459-5 468-9 624-0 512-0 368-6 529-6 390-3 389-8 297-3 640*8 378-3 458-0 458*0 Percentage occupation ... 78*0 81*3 84-3 37-8 77-5 89-9 74-4 63-8 81-2 92*0 41 -5 7Q.0 7^..1 Normal establishment of staff— Medical and nursing 194 (3-5) 223 (3-9) 208 (3-7) •» 223 (3-4) 162 (4-0) 186 (2-6) 171 (2-8) 179 (3-7) 131 (41) 263 (1-7) lav 175 (3-7) IO 1 192 (3-4) 192 (3-1) Other, excluding engineering and teaching (Totals and, in brackets, numbers per ten beds.) 162 (2-9) 196 (3-5) 196 (3*5) 194 (2-9) 139 (3-4) 195 (2-7) 173 (2-8) 162 (3-4) 131 (4-1) 226 (1-5) 163 (3-4) 176 (3-1) 176 (2-8) 1. In-patients, Maintenance op— P B P B P B P B P B P B P B P B P B P B P B P B P B P B Provisions and stinjulants 611 — 59 2 — 62 9 — 54 9 — 56*7 — 59 9 86 6 565 61*2 69 9 59*7 64 2 62*7 62-7 t Surgery and dispensary ... ... _ 13 7 12'8 10 0 6 2 — 20 5 — 17 6 — 13 7 — 16 6 — 11 3 145 6 6 15 6 13 3 12 8 including Drugs, dressings, sundries, etc. ... ( 4-9 — ( 63 — ( 4 2 ( 2*0) ( 5-9) ( 7*2 — ( 8 8 — (5*9) — ( 51) — ( 6 0) ( 2 5) ( 6-0) ( 5*4) ( 5-2) burgical equipment, appliances and repairs ( 4 0 — ( 3 3 ( 2 0 ( 0 9) (10 0) ( 6 0 — ( 2*3) — ( 6-7) ( 2*3) ( 3 6) ( 0 9) ( 3'7) ( 3'8) ( 3 6) Salaries and wages ... pofhalni'ipbl qprvif»f*-i ( 4 8 **•1 ( 3-7) ( 3-2 1 -9 ( 2'6) ( 3 8 i n ( 3-2) ( 3-3) 1 .o ( 1*2) ( 4-6) i4.i ( |3 6) ( 4-4 ( 3-9) ( 2 6) ( 2 0) ( 4*0) ( 2-5) ( 3*9) ( 3-2) ( 4*9) ( 4-6) ( 3*2) ( 13) ( 5-9) ( 4-7) ( 4*1) ( 3-0) ( 4*0) ( 2-6) rabuuiugiuiii oci viucs ... ... ... ... o ± 1 u 14 4 4 — 0 4 — 12 4 — 2 0 2 3 0 9 2-5 4 0 3 9 Antitoxin establishment 8 9 — 15 1 6-2 — 5-6 — 15*1 — 6 3 — 0 4 — 10 1 29 8 14 3 14 17-4 10-9 100 Clothing 5*3 4 3 2 9 — 3*0 — 4-4 — 2 3 — 11-7 — 45 — 1-7 — 55 92 45 4 9 5 2 j. staff— Salaries and wages (with Council's contributions under National Insurance Acts) 305 5 238-4 343 3 279-1 325 4 274-4 349 8 132-3 302 9 234*6 372 5 334-9 282 8 210-4 339 2 216-3 355 3 288-5 392 2 361-0 273 8 113-6 339 4 268-0 331 8 246*0 326 4 211*8 including Medical service (381 (29*7) (37-9 (30-8) (40-5 (34*2) (45-7^ (17 *3) (36*4) (28-2) (51 4 (46-2) (38 4 (28-6) (44*3) (28-2) (41-2) (33-4) (47-1) (43*3) (26 6) (11-0) (42 0) (33-2) (40-8) (30-3) (39-9) (25-9) Nursing service (140 8 (109-8) (141 8 (115-3) (158 2) (133-4) (141-8) (53-6) (147-7) (114*4) (144*1 (129-5) (104 3) (77-6) (146 4) (93-3) (148 2) (120-4) (131*0 (120*6) (132 3 (54*9) (157*5) (124-3) (140 9) (103*9) (140 3 (91-1) Steward and clerical service (22 6 (17-7) (.21 6 (17-6) (185 (15*6) (21 2) ( 8*0) (19-5) (15-1) <19 3 (17 4; (13 6) (10-1) (28-4) (18-1) (22*2) (18-0) (23 4 (21-6) (20 4) ( 8-5) (25*3) (20-0) (21*4) (15*7) (21 0: (13-6) General domestic service (84 4 (65-8) (117 3 (95-4) (90 8 (.76-6) (110*5) (41*8) (80 3 (62-2) (134 7 (121-1) (103 0 (76-6) (102 4) (65-3) (115 7) (94-0) (113 4) (104*4) (69 7 (28-9) (98 9) (78-1) (101*8) (75*9) (99 7) (64-7) Kitchen service ... Workrooms ... ... ... ( 9 6 ( 7-5) (10 5 ( 8-5) ( 5-5) ( 4-6) ( 7*4) ( 2*8) ( 7-8) ( 6*0) (12 4 (H-2) ( 7*5 ( 5-5) ( 7-6) ( 4-9) (12 8) (10*4) ( 6 0 ( 5*5) ( 9-2) ( 3-8) ( 9 0) ( 7-1) ( 8-8) ( 6-5) ( 8 7 ( 5-6) ( 7-2 ( 5-6) ( 9-2 ( 7-5) ( 7-5 i B'3) ( 6*4) ( 2-5) ( 6-8) ( 5-3) ( 7 6 ( 6*8) ( 5-2) ( 3-9) ( 7*3) ( 4-7) (12*1) ( 9*8) ( 3 8 ( 3*5) ( 3 9) ( 16) ( 3-2) ( 2-5) ( 6*7) ( 5-0) ( 6 6 ( 4-3) Miscellaneous N on-residential allowances ... ( 2 5 ( 2-0) ( 2 4 ( 1*9) ( 2-4 ( 2-0) (16-4) ( 6-2) ( 2 3) ( 1-8) ( 3 0 ( 2-7) $(10-7) X( 8-0) ( 2*8) ( 1-8) ( 2 6) ( 2-1) ( 3-7) ( 3*4) (10 3 ( 4*3) ( 3 0) ( 2-4) ( 5*2) ( 3-2) ( 5 8) ( 3-7) ( 2-5, ( 2"0) ( 1*5) ( 1*2) ( 2-0) ( 1-5) (63-4) (58-3) ( VP) ( 41 ( °*7) Adjustment of pay on grading (1930-1934) ( 0 3 ( 0-3) ( 0 1 ( 01) ( 0 5) ( O S) < 0 4) ( 0-1) ( 0-1) ( 0-1) ( 0*1) ( 01) ( 0 5) ( 0-4) ( 0-4) ( 0-4) v i 6) ( 0-2) \ u °J ( 01) ( 0 5) ( 0-4) ( O o) ( 0 3) (. ° a) ( 0-2) v * A) ( 0 3) v. *'i) ( 0«2) Rations 556 43-4 68 *5 55-7 66 9 56*4 57-5 21*8 52 0 40*3 59 3 53-3 47 4 35-3 61 2 39-0 62 6 50-8 62 7 57-7 60 *7 25-2 64 6 51-0 59 9 44-2 59-5 38-6 Uniforms and dresses 11-4 8-9 11 3 9-2 10-7 9-0 6 0 2-3 8 8 6-9 9 7 8-7 6 5 4-8 9 8 6-3 7 0 5-7 10 2 9*4 7 8 3-2 10*8 8-6 9*2 6-9 9 0 5*9 3. Buildings, services and supplies— Furniture ano Equipment 18 1 14-2 23 4 19-0 7 0 5-9 9 5 3-6 19 4 15-0 14 9 13-4 26 8 19-9 24 1 15-4 17-7 14-4 18 3 16<8 17-2 7-2 16 0 12-7 17-7 13-1 17*7 11-5 Cleaning an } ^mestic materials 6 1 4-8 8 3 6-7 7 3 6-2 5 6 2-1 7 3 |5*7 7 5 6*7 7 3 5-5 7*7 4-9 7 3 5*9 8 1 7-4 6 6 2-7 6 9 5-5 7-2 5-3 71 4-6 Bedding aD use linen 11 8 9-2 121 9-8 9 3 7-8 7 9 3-0 11 2 8-7 9 4 8-5 9 1 6-8 10 9 6-9 10 5 8-5 8 3 7-7 10 0 4-2 12*7 10-0 10*3 7-6 10 2 6*6 Crockery a .u hardware ... 7-8 6-1 6-2 5-1 51 4-3 5 0 1-9 4*7 3*6 5 6 5-0 6 4 4-7 42 2-7 5 0 4-1 8 8 8-1 6 5 2-7 6 1 4-8 5 9 4-4 5 9 3-8 Heating, lighting, etc ... 78 0 60-8 67-2 54-7 68 6 57-9 108 4 41-0 59*2 45*8 81 1 73-0 65 0 48-4 77 8 49-6 66 8 54-3 82 3 75-7 81 4 33-8 87 8 69-4 77 0 55-4 77 0 50-0 including Wages of engineering maintenance Staff ... (19 8 (15-4) (148 (121) (22-9) (18-8) (22 4) ( 8-5) (168) U30) (192 (17 3) (12*7) ( 9-4) (21 6) (13-8) (14 6) (11-8) (20 4 (18-7) (23*3) ( 9-7) (14*8) (11-7) (18 6) (13-4) (18-7) (121) Fuel (38 9 (30-3) (36 2 (29-4) (37 1 (31-3) (55 2) (20-8) (28 9 (22-4) (41 0 (36*9) (36 5) (27-2) (47-2) (30-1) (35 3) (28-7) (40 0) (3G-8) (34 7 (14-4) (54-8) (43-3) (40*5) (29*3) (40 1) (26-1) Gas, electricity, water (19 3 (151) (16 2 (13-2) ( 9-2) ( 7-8) (30 8) (11-7) (135) (10-4) (20 9 (18-8) (15 8 (118) ( 9 0) ( 5-7) (16 9) (13-8) (21 9) (20-2) (23-4) ( 9-7) (18-2) (14*4) (17-9) (12-7) (18 2) (11-8) Laundry ... ... ... ... 39 6 30-9 35 '9 29*2 28 0 23-6 14*3 5 *4 33 *5 26*0 32 4 29*1 25 9 19-2 39 8 25-4 40 5 32-9 36 4 33-5 16 3 6-8 36 7 29-0 31 6 24-2 30 3 19-6 including Wages (28 4 (22-2) (26 1 (21-2) (18 0 (15-2) ( 7-9) ( 3-0) 0(25-4) 0(19-7) *( 91 *( 8-2) (18 4) (13-7) (29-4) (18-7) (28-7) (23-3) (24-7) (22-8) ( 9-2) ( 3-8) (24 9) (19-7) (20 9) (16-0) (20 0) (130) Works (plant and buildings)— Maintenance: Wages 10 5 8-2 17 0 13-8 9 4 7-9 36 0 13-6 11 0 8-6 12 6 11-3 12 5 9-3 112 71 15 8 12-8 14 8 13-6 14*5 60 12 9 10-2 14 8 10-2 15-2 9-9 Do. Minor contracts, materials, etc. ... 14 0 10-9 27 3 22-2 19 9 16-8 142 5-4 32 3 45-0 11 6 10-4 25 7 19-1 21*1 13-5 23 4 19-0 32-1 29 5 15 4 6-4 19-6 15-5 21*4 16-1 21-1 13*7 Special works 23 2 18-1 51-5 41-9 28 4 23-9 10 0-4 8 6 6-6 11 5 10-3 36 2 26-9 22 8 14-5 31 3 25-4 11-9 10 9 13 9 5-8 8-8 6-9 20*8 16-0 20*7 13-4 Gardens and grounds— Wages 6 9 5-4 6 7 5*4 6 4 5-4 72 2-7 7-8 6-0 4 1 3-7 6 4 4-7 73 4-7 3 9 3-2 52 4-8 6 0 2*5 7*1 5-6 6 2 4*5 6 3 4-1 4. Rates, taxes and insurance 63 6 49-6 45 9 37-3 40 2 33-9 59 8 22*6 30 1 23-3 36 5 32-8 24 8 18-4 487 311 46 5 37-8 422 38-8 28 6 11-9 45 5 36-0 42 7 31-2 42 0 27-3 5. Miscellaneous expenditure— Printing, stationery, postage, telephones, etc. ... 62 4-9 6 0 4-9 5 7 4-9 80 3-0 6 4 5-0 65 5-8 7 3 5-5 6 7 4-3 5 9 4-8 7 6 7-0 15 8 6-5 6 4 5-0 7*4 5-1 7-7 5-0 Travelling and 6undi7 expenses 0 4 0-3 0 5 0-4 0 2 0-2 14-7 5*5 0-5 0-4 0 4 0-3 18 1-4 0 4 0-2 0 5 0-4 0 5 0*4 8 5 3-5 0 3 0-2 2 4 11 2 9 1-9 Items 1 to 5—total per occupied bed Deduct for sundry receipts, credits for transfer 62s. 8 8d. — 68s. 7-7d. — 60s. 1 5d. — 64s. 7 8d. 58s. 10 5d. — 63s. 10 Id — 58s. 8 7d. 66s. 1 Od. - 67s. 2 Od. - 70s. 8 Id. ~ 55s. 0 8d. 65s. 5 8d. - 63s. 6 Id. 62s. 9 6d. - services and balances on farm or industrial accounts Is. 0 8d. — Is. 7-7d. 0s. 11 8d. — 2s. 1 3d. Is. 5 4d. 2s. 1 6d. — 0s. 11 Od — Is. 5 6d. — Is. 10 2d. — 2s. 2 5d. Is. 1 8d. Is. 0 2d. Is. 6 Od. Is. 5 5d. Net cost per occupied bed— £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. per day 8 10 9 7 8 5 8 11 0 8 2 8 10 8 3 9 3 9 4 9 9 7 8 9 3 8 10 8 9 per week 3 1 8 3 7 0 2 19 2 3 2 6 2 17 5 3 1 8 2 17 10 3 4 7 3 5 4 3 8 6 2 13 11 3 4 6 3 2 0 3 1 4 per year 160 15 6 174 13 7 154 5 1 162 18 11 149 13 10 160 15 6 150 15 7 168 7 7 170 6 8 178 11 9 140 11 4 168 3 3 161 12 10 159 18 1 Net cost per occupied bed per week, 1933-34 ... 2 14 7 3 0 6 2 13 3 2 14 5 2 10 fi 4 2 18 0 2 13 8 2 17 3 2 19 3 3 3 9 1 19 3 3 0 7 2 15 5 2 13 10 P B P B P B P B P B P B P B P B P B P B P B P B P B P B 6. Superannuation fund (Council's contributions) 50 6 39-5 51 3 41-7 47 3 39-8 41 8 15-8 45 1 B4-9 49 4 44 4 37 5 27-9 50 4 32-1 51 9 42-1 54 4 50*1 36 1 15-0 58 2 46-0 47 8 35-8 46-7 30-3 7. Annual charge in respect of capital outlay ... 109 1 85-1 88 6 72-0 81 2 68*5 95 8 36-2 49 7 B8-5 73 3 65-9 53 6 39-8 95 8 611 77 9 63-3 83 8 771 63 8 26*5 93 5 73-8 80 5 59*0 79 1 51-3 8. Establishment charges—Pensions 30 2 23-6 32 7 26-6 31 0 26-2 36 0 13-6 30 3 y3-5 34 1 30-7 27 0 20-1 32 9 21-0 33 8 27-4 36 9 33*9 27 9 11-5 32 5 25-7 32*1 23-6 31*7 20-6 Other 41 1 32-1 41 1 33-4 41 1 34-6 41 1 15-6 41 1 (31-8 41 1 36-9 411 30-6 41 1 26-2 411 33-4 41 1 37*8 41*1 17-0 41 1 32-5 41 1 30-2 41 1 26-7 £ s. d. £ s. d. £ s. d. £ s. d. £ s. <'• £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. Inclusive cost per occupied bed per week, 1934-35 4 0 11 4 4 10 3 15 L0 4 0 5 3 11 3 3 18 2 3 11 1 4 3 0 4 2 5 4 6 6 3 8 0 4 3 3 3 18 10 3 17 11 Inclusive cost per occupied bed per week, 1933-34 3 11 9 3 16 11 3 8 5 3 9 5 3 2 ii 14 2 3 6 0 3 13 9 3 14 11 4 0 11 2 10 1 3 18 6 3 10 8 8 7 Percentage occupation. 1933-34... 840 861 B'JO a*-A 90 3 770 700 863 933 54 6 806 7 91 740 NOTES (see also General Notes on page 7).—The coat per available bed (B) is not shown where the expenditure is strictly dependent upon the number of patients. • Part of the washing was done at another hospital. 0 Services rendered for another hospital also. t See also " Antitoxin establishment " below. ft See page G. ♦ Includes teachers and instructors. $ Calculated on the period of occupation. •• See note on page facing. Special Hospitals—Group S.II. Long Reach hospital.—A smallpox hospital (men, women and children). User varies with fluctuations of incidence of smallpox. Rarely fully occupied. Certain of the essential services of this hospital are operated in common with Joyce Green and Orchard hospitals. It is not, therefore, practicable to state separately the numbers of staff employed. Joyce Green hospital.—See group S.I. Orchard hospital.—An emergency hospital. See group S.I. The cost of the receiving station, South Wharf, operated in connection with the smallpox hospitals, is included in the expenditure indicated for Long Reach hospital. Special Hospitals—Group S.III. St. Margaret's hospital.—For (i) ophthalmia neonatorum (mothers admitted with their infants), and (ii) vulvo-vaginitis (children). Allocated to the General Hospitals service on 1st April, 1935. See group G.V. Sheffield-street hospital.—For venereal diseases (women). TABLE F SPECIAL HOSPITALS—GROUP S. II—Infectious: Smallpox. SPECIAL HOSPITALS—GROUP S. Ill—Infectious: Other diseases. ANALYSIS OF COST PER WEEK (IN PENCE) of maintenance of IN-PATIENTS under the several heads of expenditure, during the year 1st April, 1934, to 31st March, 1935. The cost per week is shown per occupied bed or "Patient" under P, and per available bed or "Bed" under B. To facilitate comparison by reading across, the former costs are printed in heavy type. Figures in brackets are sub-divisions of the inclusive heads. Group S. H Group S. III Name of hospital Long Reach and South Wharf. Sheffield Street. Number of beds nominally available 272 98 Average daily number of patients 2.4 89.0 Percentage occupation 0.9 90.8 Normal establishment of staff— Medical and nursing Ø 14 (1.4) Other, excluding engineering and teaching Ø 13 (1.3) (Totals and, in brackets, numbers per ten beds.) P B* P B 1. In-patients, Maintenance of— Provisions and stimulants 820 - 43. 6 - Surgery and dispensary 32-4 - 14.2 - including Drugs, dressings, sundries, etc. (32.4) - (14.0) - Surgical equipment, appliances and repairs - - (0.2) - Salaries and wages - - - - Pathological services 5. 7 - 8.7 - Clothing 5. 7 - 10 4 - 2. Staff— Salaries and wages (with Council's contributions under National Insurance Acts) 9696.7 - 162.0 147.1 including Medical service (179.3) - (36.3) (33.0) Nursing service (1601.8) - (67.6) (61.3) Steward and clerical service (753.2) - (5.8) ( 5.3) General domestic service (6815.3) - (41.4) (37.6) Kitchen service (244.1) - (8.3) ( 7.5) Workrooms (85.8) - (2.6) (2.4) Miscellaneous (17.2) - - - Non-residential allowances - - - - Adjustment of pay on grading (1930-1934) - - - - Rations 1386.3 - 14.5 13.2 Uniforms and dresses 175.5 - 3.0 2.7 3. Buildings, services and supplies— Furniture and equipment 160.2 - 4.0 3.6 Cleaning and domestic materials 120.1 - 5.8 5.3 Bedding and house linen 137.3 - 5.1 4.6 Crockery and hardware 143.0 - 1.8 1.6 Heating, lighting, etc. 3968.3 - 93.6 85.0 Including Wages of engineering maintance staff (1607.5) - (34.6) (31.5) Fuel (1329.1) - (37.6) (34.1) Gas, electricity, water (1031.7) - (21.4) (19.4) Laundry 364.2 - 7.0 6.4 including Wages (150.6) - † † Works (plant and buildings)— Maintenance: Wages 1937.4 - 10.6 9.6 Do. Minor contracts, materials, etc. 1228.1 - 13.0 11.8 Special works 411.9 - 5.8 5.3 Gardens and grounds— Wages - - - - 4. Rates, taxes and insurance 3329.5 - 32.3 29.4 5. Miscellaneous expenditure— Printing, stationery, postage, telephones, etc. 280.3 - 5.2 4.7 Travelling and sundry expenses 68.7 - 0.2 0.1 ITEMS 1 to 5—total per occupied bed 1961s. l.3d. - 36s. 8-8d. - Deduct for sundry receipts, credits for transfer services and balances on farm or industrial accounts 125s. 2.6d. - 0s. 0.4d. - net cost per occupied bed— £ s. d. £ s. d. per day 13 2 3 5 3 per week 91 15 11 1 16 8 per year 4786 9 11 95 11 11 Net cost per occupied bed per week, 1933-34 16 6 1 1 11 11 P B P B 6. Superannuation fund (Council's contributions) 867.6 - 23.5 21.3 7. Annual charge in respect of capital outlay 4451.7 - 74.6 67.7 8. Establishment charges—Pensions 1054.5 - 16.4 15.0 Other 41. 1 - 41.1 37.3 £ s. d. £ s. d. Inclusive cost per occupied bed per week, 1934-35 118 10 6 2 9 8 Inclusive cost per occupied bed per week, 1933-34 19 8 6 2 3 9 Percentage occupation, 1933-34 9.4 96.6 NOTES (see also General Notes on page 7).—The cost per available bed (B) is not shown where the expenditure is strictly dependent upon the number of patients. * Sections of the hospital were closed during part of the year, †f Indicates that the service, inclusive of labour, was rendered and charged for by another establishment. ØSee note on page facing. Special Hospitals—Group S.IV. Colindale hospital.—Pulmonary tuberculosis in men—advanced cases. Wood and leather, etc., workshops for patients. Training school for nurses. Accommodation well occupied. Two-storey blocks. Laundry. Grove Park hospital.—Pulmonary tuberculosis—advanced, men and women. Small number of surgical cases also treated. Long term treatment. Training school for nurses. Accommodation well occupied. Three-storied blocks. Laundry. King George V sanatorium..—Early pulmonary tuberculosis in men. Occupational therapy—poultry and pig farming, woodwork, leatherwork, etc. Treatment three months and upwards. Training school for nurses. " Trainee " scheme for employment on staff of ex-patients from Pinewood sanatorium, etc. Accommodation usually fully occupied. Situated in country. Extensive grounds. Mainly single-storey pavilions. Generates electricity. No laundry. Pinewood sanatorium.—Early pulmonary tuberculosis in women. Handicrafts section for occupational therapy. Poultry and pig farming. Treatment three months and upwards. Training school for nurses. Accommodation usually fully occupied. Situated in country. Extensive grounds. Two-storied blocks and single-storey pavilions. Generates electricity. No laundry. St. George's home.—Pulmonary tuberculosis in women. Largely used for short stay observation cases. No laundry. St. Luke's hospital, Lowestoft.—Surgical tuberculosis in men and women. Long term treatment. Training school for nurses. Accommodation fully occupied. Exposed position on east coast. No laundry. TABLE G SPECIAL HOSPITALS—GROUP S. IV—Tuberculosis. ANALYSIS OF COST PER WEEK (IN PENCE) of maintenance of IN-PATIENTS, under the several heads of expenditure, during the year 1st April, 1934, to 31st March, 1935. The cost per week is shown per occupied bed or "Patient" under P, and per available bed or "Bed" under B. To facilitate comparison by reading across, the former costs are printed in heavy type. Figures in brackets are sub-divisions of the inclusive heads. Name of hospital Colindale. Grove Park. King George V Sanatorium. Pinewood Sanatorium. St. George's Home. St. Luke's, Lowestoft. †Mean of group. †Average of group. Number of beds nominally available 355 330 235 160 48 214 224 224 Average daily number of patients 340.2 317.0 231.5 159.4 40.5 208.3 217.1 217.1 Percentage occupation 95.8 96.1 98.5 99.6 96.9 97.3 97.4 97.1 Normal establishment of staff— Medical and nursing 80 (2.3) 83 (2.5) 41 (1.7) 23 (1.4) 12 (2.5) 54 (2.5) 49 (2.1) 49 (2.2) Other, excluding engineering and teaching (Totals and, in brackets, numbers per ten beds.) 119 (3.4) 99 (3.0) 60 (2.6) 41 (2.6) 15 ( 3.1) 56 (2.6) 65 (2.9) 65 (2.9) P B P B P B P B P B P B P B P B 1. In-patients, Maintenance of— Provisions and stimulants 111.9 - 120.1 - 109.6 - 109.2 - 98.9 - 119.7 - 111.6 - 113.9 - Surgery and dispensary 24. 4 - 22.6 - 24.6 - 32.3 - 7.8 - 28.9 - 23.4 - 25.1 - including Drugs, dressings, sundries, etc. (13.0) - (13.8) - (11.9) - (16.1) - (3.0) (13.9) - (11.9) - (13.2) - Surgical equipment, appliances and repairs (7.5) ( 3.4) - (5.7) (3.4) - (2.1) (3.7) - (4.3) - (4.9) - Salaries and wages (3.9) (3.8) (5.4) (5.2) (7.0) (6.8) (12.8) (12.7) (2.7) (2.6) (11. 3) (11.0) (7.2) (7.0) (7.0) (6.8) Pathological services 1.2 - 8.7 - 0.5 - 0.3 - 6.1 - 5.6 - 3.7 3.7 - Clothing 0.6 - 0.6 - 0.3 - 0.7 - 0.1 - 0.6 - 0.5 - 0.5 - 2. Staff— Salaries and wages (with Council's contributions under National Insurance Acts) 281.0 269.3 247.2 37.4 233.5 230.0 204.3 203.6 279.6 270.9 230.4 224.3 246.0 239.3 246.8 239.6 including Medical service (42.4) (40.7) (40.2) (38.6) (63.4) (62.5) (63.5) (63.3) (31.7) (30.7) (52.3) (50.9) (48.9) (47.8) (49.4) (48.0) Nursing service (83.0) (79.5) (77.3) (74.2) (59.9) (59.0) ( 48.0) (47.9) (98.9 (95.8) (75.8) (73.7) (73.8) (71.7) (72.6) (70.5) Steward and clerical service (22.6) (21.6) (25.0) (24.0) (18.8) (18.5) (18.0) (17.9) (11.3 (10.9) (15.8) (15.4) (18.6) (18.0) (20.4) (19.8) General domestic service (100.6) ( 102.1) (79.8) (76.7) (65.8) (64.8) (43.9) (43.8) (99.1) (96.0) (69.9) (68.1) (77.5) (75.3) (79.0) (76.7) Kitchen service (10.2) (9.8) (10.2) (9.7) (12.6) (12.4) (12.0) (11.9) (18.4 (17.8) (11.6) (11.3) (12.5) (12.1) (11.4) (11.0) Workrooms (7.0) (6.7) (5.6) (5.4) (2.2) (2.1) (7.2) (7.2) (12.3) (12.0) (2.3) (2.3) (6.1) (6.0) (5.3) (5.1) Miscellaneous (6.0) (5.8) ( 7.3) (7.0) (10.7) (10.6) (4.6) (4.5) (7.9) (7.7) (2.6) (2.5) (6.5) (6.4) (6.5) (6.3) Non-residential allowances ( 1.6) (1.5) (1.8) (1.8) - - (6.9) (6.9) - - - - (1.7) (1.7) (1.7) (1.7) Adjustment of pay on grading (1930-1934) (1.7) (1.6) - - (0.1) (0.1) (0.2) (0.2) - - (0.1) (0.1) (0.4) (0.3) (0.5) (0.5) Rations 40.5 38.8 37.6 36.1 30.6 30.2 25.6 25.4 35.2 34.1 36.1 35.2 34.3 33.3 35.3 34.3 Uniforms and dresses 6.8 6.6 5.6 5.4 3.7 3.7 3.9 3.9 4.0 3.8 5.5 5.4 4.9 4.8 5.3 5.2 3. Buildings, services and supplies— Furniture and equipment 16.0 15.3 9.2 8.9 13.2 13.0 14.5 14.4 13.4 12.9 8.9 8.6 12.5 12.2 12.4 12.1 Cleaning and domestic materials 5.5 5.2 6.4 6.2 5.6 5.5 3.7 3.7 3.7 3.6 5.7 5.5 5.1 4.9 5.5 5.3 Bedding and house linen 9.2 8.9 8.7 8.4 5.0 4.9 6.7 6.6 9.6 9.3 6.1 5.9 7.5 7.3 7.5 7.3 Crockery and hardware 6.5 6.3 4.5 4.3 4.8 4.7 3.3 3.3 3.0 2.9 4.5 4.4 4.4 4.3 4.9 4.7 Heating, lighting, etc. 58.5 56.0 64.8 62.3 47.8 47.1 62.9 62.7 37.6 36.4 75.8 73.8 57.9 56.4 60.7 58.9 including Wages of engineering maintenance staff (18.4) (17.6) (19.6) (1 8.8) (16.8) (16.5) (21.5) (21.4) (0.5) (0.5) (22.5) (21.9) (16.6) (16.1) (18.8) (18.2) Fuel (24.1) (23.1) (33.8) (32.5) (23.3) (23.0) (29.1) (29.0) (17.6) (17.0) (37.3) (36.3) (27.5) (26.8) (28.8) (28.0) Gas. electricity, water (16.0) (15.3) (11.4) (11.0) (7.7) (7.6) (12.3) (12.3) (19.5) (18.9) (16.0) (15.6) (13.8) (13.5) (13.1) (12.7) Laundry 28.0 26.8 24.5 23.5 28.0 27.6 26.6 26.5 31.1 30-1 39.8 38.7 29.7 28.9 29.0 28.1 including Wages (17.2) (16.5) (17.0) (16.3) * * - - * * - - - - - - Works (plant and buildings)— Maintenance : W ages 13.6 13.0 12.9 12.4 9.0 8.8 9.6 9.6 4.0 3.8 10.1 9.8 9.9 9.6 11.2 10.9 Do. Minor contracts, materials, etc. 22.6 21.6 19.3 18.6 11.2 11.1 22.2 22.1 17.6 17.1 17.0 16.6 18.3 17.8 18.7 18.1 Special works 24.4 23.4 74.4 71.4 18.5 18.2 53.7 53.5 8.3 8.1 18.6 18.1 33.0 32.1 37.6 36.5 Gardens and grounds— Wages 5.9 5.7 10.2 9.8 4.2 4.1 10.7 10.6 - - - - 7.7 7.5 6.1 5.9 4. Rates, taxes and insurance 29.5 28.3 40.1 38.5 19.8 19.5 8.9 8.9 23.4 22.7 14.7 14.3 22.7 22.0 25.3 24.5 5. Miscellaneous expenditure— Printing, stationery, postage, telephones, etc. 5.7 5.4 5.0 4.8 5.6 5.5 8.9 8.9 9.9 9.6 5.1 4.9 6.7 6.5 5.9 5.8 Travelling and sundry expenses 0.5 0.5 0.4 0.4 3.9 3.9 6.1 6.1 0.8 0.8 3.7 3.6 2.6 2.6 2.3 2.2 Items 1 to 5—total per occupied bed 57s.8.3d. - 60s,2.8d. - 48s, 3.4d. - 51. 2.1d. - 49s. 6.1d. - 53s. 0.8d. - 53s 3.9d. - 54s. 9.7d. - Deduct for sundry receipts, credits for transfer services and balances on farm or industrial accounts 1s.7.4d. - 0s. 8.4d. - 1s. 5.8d. - 1s. 0.2d. - 0s. 7.6d. - 0s. 4.0d. - 0s. 11.7d. - 1s. 0.7d. - net cost per occupied bed— £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. per day 8 0 8 6 6 8 7 2 7 0 7 6 7 6 7 8 per week 2 16 1 2 19 6 2 6 10 2 10 2 2 8 11 2 12 9 2 12 4 2 13 9 per year 146 4 4 155 2 6 122 2 0 130 15 10 127 10 8 137 10 6 136 8 10 140 2 8 Net cost per occupied bed, per week, 1933-34 2 17 11 2 16 1 2 3 8 2 5 6 2 6 0 2 13 4 2 10 5 2 12 3 P B P B P B P B P B P B P B P B 6. Superannuation fund (Council's contributions) 34.2 32.7 31.4 30.1 29.8 29.3 24.7 24.6 32.5 31.5 34.2 33.3 31.1 30.3 31.5 30.6 7. Annual charge in respect op capital outlay 61.4 58.9 80.3 77.1 55.0 54.2 17.3 17.2 49.5 47.9 18.9 18.4 47.1 45.6 52.2 50.7 8. Establishment charges—Pensions 27.3 20.2 25.0 24.0 22.0 21.7 21.2 21.2 22.9 22.2 21.8 21.2 23.4 22.7 24.0 23.3 Other 57.3 54.9 57.3 55.0 57.3 56.4 57.3 57.1 57.3 55.6 57.3 55.8 57.3 55.8 57.3) 55.7 £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. Inclusive cost per occupied bed per week, 1934-35 3 11 1 3 15 8 3 0 6 3 0 2 3 2 5 3 3 9 3 5 7 3 7 6 Inclusive cost per occupied bed per week, 1933-34 3 13 8 3 12 9 2 17 4 2 16 1 2 19 6 3 4 9 3 4 0 3 6 5 Percentage occupation, 1933-34 93.5 95.7 98.0 99.6 91.4 97.5 95.9 96.0 NOTES (see also General Notes on page 7).—The cost per available bed (B) is not shown where the expenditure is strictly dep endent upon the number of patients. An asterisk (•) indicates that the service, inclusive of labour, was rendered and charged for by another establishment. † bee page 6. Special Hospitals—Group S.V. The Downs hospital for children.—For non-tuberculous cases and for convalescent cases still requiring medical or nursing attention. Cases of acute ear disease are admitted and there are 180 beds for rheumatic children. School. Laundry. Ooldie Leigh hospital.—For cases of ringworm and contagious diseases of the skin and scalp. The hospital is divided into three sections:—(a) for cases of ringworm of the scalp; (6) for cases of skin disease; and (c) for convalescent children. School. Laundry. Heatherwood hospital.—Surgical tuberculosis. School. Training school for nurses. Laundry. Transferred from the United Services Fund to the Council on 1st October, 1934. High Wood hospital for children.—272 beds for pulmonary tuberculosis. 154 beds for rheumatic diseases. Long term treatment. School. Patients' workshops. Training school for nurses. Laundry. Norwood hospital for children.—A. general hospital comparable with the other hospitals in this group and therefore shown in this group for the calculation of averages and means and for the ascertainment of a flat rate of charge for maintenance. See note facing table D. Princess Mary's hospital for children.—Surgical tuberculosis. Open air verandah wards. Long term treatment. School. Training school for nurses. Laundry. Queen Mary's hospital for children.—A hospital for all acute non-pulmonary tuberculous cases and various non-tuberculous cases requiring active or operative treatment. There is a large rheumatic section of 390 beds, and also an orthopaedic section. Unit for congenital malformations. These necessitate special provision both as regards staff jind treatment. As the children receive education, there is a large teaching staff. Training school for nurses. Laundry. White Oal: hospital.—For cases of contagious and other diseases of the eye. The hospital is divided into three sections:—(o) for cases of trachoma ; (6) for cases of contagious diseases other than trachoma; and (e) for non-infectious cases, including interstitial keratitis. School. Laundry. Special Hospitals—Gkouf S.VI. Millfield.—Convalescent home mainly for pulmonary and non-pulmonary tuberculous cases. Sea-bathing and helio-therapy. School. Open position on south coast. No laundry. St. Anne's home.—A seaside convalescent home for children. SchooL No laundry. TABLE H SPECIAL HOSPITALS—Group S. V—Hospitals for children. Group S. VI—Hospitals for convalescent children. ANALYSIS OF COST PER WEEK (IN PENCE) of maintenance of IN-PATIENTS under the several heads of expenditure, during the year 1st April, 1934, to 31st March, 1935. The cost per week is shown per occupied bed or "Patient" under P, and per available bed or "Bed" under B. To facilitate comparison by reading across, the former costs are printed in heavy type. Figures in brackets are sub-divisions of the inclusive heads. GROUPS. V groups. vi Name of hospital Downs. Goldie Leigh. Heatherwood. High Wood. Norwood. Princess Mary's. Queen Mary's, Carshalton. White Oak. ||Mean of group. ||Average of group. Millfleld. St. Anne's Home. ||Mean of group. ||Avcrage of group Number of beds nominally available 360 248 140 402 220 271 1,332 364 417 417 98 127 112 112 Average daily number of patients 339.5 159.4 131.1 400.3 149.7 197.5 1,121.7 231.8 341.4 341.4 92.8 112.4 102.6 102.6 Percentage occupation 94.3 64.3 93.6 99.6 68.0 72.9 84.2 63.7 80.1 81.8 94.7 88.5 91.6 91.2 Normal establishment of staff- Medical and nursing 85 (2.4) 25 (1.0) 46 (3.3) 84 (2.1) 41(1.9) 59 (2.2) 366 (2.7) 19 (0.5) 91 (2.0) 91 (2.2) 17 (1.7) 13 (1.0) 15 (1.3) 15(1.3) Other, excluding engineering and teaching (Totals and, in brackets, numbers per ten beds.) 103 (2.9) 71 (2.9) 46 (3.3) 92 (2.3) 24 (1.1) 76 (2.8) 312 (2.3) 107 (2.9) 104 (2.6) 104 (2.6) 22 (2.2) 30 (2.4) 26 (2.3) 26 (2.3) 1. In-patients, Maintenance of— P B P B P B P B P B P B P B P B P B P B P B P B P B P B Provisions and stimulants 54 9 - 504 - 49.8 - 55.3 - 55.3 - 56.2 - 58.0 - - - - - 56.4 - 57.2 - 56.8 - 56.8 - Surgery and dispensary 14.4 - 12.7 - 90.2 - 12.3 - 23.6 - 18.7 - 8.1 - - - - - 1.3 - 3.1 - 2.2 - 2.3 - including Drugs, dressings, sundries, etc. (7.0) - (10.7) - (32.4) - (5.1) - (11.8) - (7.4) - (5.4) - - - - - (1.0) - (2.6) - (1.8) - (1.9) - Surgical equipment, appliances and repairs (3.4) - (2.0) - (40.5) - (3.0) - (2.5) - (3.6) - (2.7) - - - - - (0.3) - (0.5) - (0.4) - (0.4) - Salaries and wages (4.0) (3.8) - - (17.3) (16.2) (4.2) (4.2) (9.3) (6.8) (7.7) (6.4) - - - - - - - - - - - - - - Pathological services 0.8 - 2.9 - 0.9 - 1.0 - 1.7 - 1.1 - 1.9 - - - - - 0.2 - 0.3 - 0.2 - 0.2 - Clothing 9.2 - 12.9 - 6.6 - 18.4 - 6.2 - 8.8 - 21.4 - - - - - 14.6 - 19.9 - 17.3 - 17.5 - 2. Staff— Salaries and wages (with Council's contributions under National Insurance Acts) 236.8 223.3 292.9 188.2 280.4 262.7 202.2 201.4 326.5 238.0 233.7 96.8 205.2 130.7 - - - 175.8 166.5 225.8 99.8 200.8 183.1 203.2 185.3 including Medical service (42.3) (39.9) (34.1) (21.9) (53.8) (50.5) (28.1) (28.0) (57.2) (41.7) (25.4) (21.4) (10.6) (6.8) - - - - (6. 6) (6.3) (9.3) (8.2) (8.0) (7.2) (8.1) (7.4) Nursing service (68.3) (64.4) (58.2) (37.4) (82.4) (77.2) (53.5) (53.3) (88.5) (64.5) (86.0) (72.4) (37.6) (23.9) - - - - (58.1) (55.0) (44.9) (39.7) (51.5) (47.4) (50.9) (46.4) Steward and clerical service (16.6) (15.6) (27.8) (17.8) (42.2) (39.5) (14.4) (14.3) (25.8) (18.8) (12.6) 10.6) (18 3) (11 7) - - - - (17.9) (16.9) (16.4) (14.5) (17.1) (15.7) (17.0) (15.5) General domestic service (72.0) (67.9) (123.4) (79.3) (42.5) (39.8) (52.3) (52.1) (75.3) (54.9) (55.8) (47.0) (74.4) (47.4) - - - - (35.9) (34.1) (85.3) (75.5) (60.6) (54.8) (63.0) (57.5) Kitchen service (6.9) (6.5) (1.4) (0.9) (6.7) (6.3) (6.5) (6.5) (12.2) (8.9) (4.4) (3.7) (8.7) (5.5) - - - - (9.0) (8.5) (14.8) (13.0) (11.9) (10.7) (12.1) (11.1) Workrooms (8.1) (7.7) (11.0) (7.1) (13.4) (12.5) (7.0) (7.0) (15.1) (11.0) (10.9) (9.2) (7.4) (4.7) - - - - (2.5) (2.3) (17.8) (15.8) (10.2) (9.1) (10.9) (9.9) Miscellaneous †(22.6) †(21.3) †(36.9) †(23.7) †(39.4) †(36.9) †(39.3) †(39.1) †(49.4) †(36.0) †(36.2) †(30.5) †(46.0) †(29.3) - - - - †(45.8) †(43.4) †(24.6) †(21.8) †(35.2) †(32.6) †(34.2) †(31.2) Non-residential allowances - - - - - - - - (3.0) (2.2) (2.3) (1.9) - - - - - - - - - - - - - - Adjustment of pay on grading (1930-1934) - - (0.l) (0.1) - - (1.1) (1.1) - - (0.1) (0.1) (2.2) (1.4) - - - - - - (12.7) (11.3) (6.3) (6.6) (7.0) (6.3) Rations 37.0 34.9 35.6 22.9 34.1 32.0 24.4 24.3 41.7 30.4 39.6 33.4 30.7 19.6 - - - - 31.6 30.0 19.9 17.6 25.7 23.8 25.2 23.0 Uniforms and dresses 5.9 5.6 5.6 3.6 4.9 4.5 5.2 5.1 4.0 2.9 5.5 4.7 2.5 1.6 - - - - 3.4 3.2 3.2 2.8 3.3 3.0 3.3 3.0 3. Buildings, services and supplies— 530. 5 361.0 Furniture and equipment 16.0 15.1 20.6 13.2 5.8 5.4 14.6 14.5 10.4 7.6 10.2 8.6 13.1 8.3 - - - - 39.0 37.0 5.8 5.1 22.4 21.1 20.8 19.0 Cleaning and domestic materials 5.1 4.8 5.3 3.4 10.6 10.0 4.5 4.5 4.5 3.3 4.6 3.8 5.5 3.5 - - - - 3.6 3.4 3.2 2.8 3.4 3.1 3.4 3.1 Bedding and house linen 7.5 7.0 7.0 4.5 6.1 5.7 12.0 11.9 4.6 3.4 8.4 7.1 5.1 3.2 - - - - 4.4 4.1 4.8 4.2 4.6 4.2 4.6 4.2 Crockery and hardware 3.4 3.2 3.6 2.3 3.2 3.0 4.2 4.2 3.8 2.7 4.5 3.8 4.9 3.1 - - - - 3.2 3.1 2.5 2.3 2.9 2.7 2.9 2.5 Heating, lighting, etc. 42.9 40.4 54.4 35.0 98.1 91.8 34.6 34.5 56.3 41.1 42.8 36.0 46.2 29.4 - - - - 35.4 33.5 26.9 23.8 31.2 28.7 30.8 28.1 including Wages of engineering maintenance staff (11.4) (10.7) (19.9) (12.8) (42.4) (39.7) (7.3) (7.2) (22.0) (16.0) (10.8) (9.1) (13.3) (8.4) (5.2) (5.0) (4.5) (3.9) (4.9) (4.4) (4.8) (4.4) Fuel (19.3) (18.2) (21.3) (13.7) (49.0) (45.9) (9.6) (9.6) (16.6) (12.2) (16.7) (14.0) (15.8) (10.1) - - - - (15.3) (14.4) (9.3) (8.3) (12.3) (11.4) (12.0) (11.0) Gas, electricity, water (12.2) (11.5) (13.2) (8.5) (6.7) (6.2) (17.7) (17.7) (17.7) (12.9) (15.3) (12.9) (17.1) (10.9) - - - - (14.9) (14.1) (13.1) (11.6) (14.0) (12.9) (14.0) (12.7) Laundry 19.6 18.4 28.7 18.4 24.4 22.8 25.5 25.4 24.3 17.7 29.4 24.7 18.6 11.8 - - - - 21.7 20.6 17.7 15.7 19.7 18.1 19.5 17.8 including Wages ‡(15.8) ‡(14.9) (16.9) (10.9) (12.4) (11.6) ‡(18.0) (17.9) ‡(16.0) ‡(11.7) (17.0) (14.3) ‡(14.8) ‡( 9.4) - - - - - - * * - - - - Works (plant and buildings)— Maintenance: Wages 7. 8 7.3 10.2 6.6 10.4 9.7 4.1 4.1 8.0 5.9 7.5 6.3 11.3 7.2 9.5 9.0 2.7 2.4 6.1 5.7 5.8 5.3 Do Minor contracts, materials, etc. 10.6 10.0 9.1 5.8 8.9 8.4 11.7 11.6 8.0 5.8 10.3 8.7 14.6 9.3 - - - - 26. 4 25.0 31.6 28.0 29.0 26.5 29.2 26.7 Special works 21.7 20.4 21.2 13.6 8.1 7.6 1.9 1.9 10.2 7.4 19.2 16.2 3.8 2.4 - - - - 2.2 2.1 2.3 2.0 2.2 2.1 2.3 2.1 Gardens and grounds— Wages 5.6 5.3 14.7 9.4 37.3 34.9 4.9 4.9 4.3 3.1 3.7 3.1 13.8 8.8 - - - - 13.9 13.2 4.2 3.7 9.1 8.4 8.6 7.8 4. Rates, taxes and insurance 24.0 22.7 58.5 37.6 32.7 30.6 18.2 18.2 14.9 10.9 23.2 19.5 40.7 25.9 - - - - 15.9 15.1 11.5 10.1 13.7 12.6 13.5 12.3 5. Miscellaneous expenditure— Printing, stationery, postage, telephones, etc. 5.3 5.0 3.5 2.3 15.3 14.4 5.4 5.4 12.5 9.1 5.2 4.4 2.4 7.1 6.7 16.9 15.0 12.0 10.8 12.4 11.4 Travelling and sundry expenses 3.1 3.0 0.8 0.5 1.5 1.4 2.6 2.6 4.9 3.6 4.5 3.8 1.6 9.7 9.2 5.2 4.6 7.4 6.9 7.2 6.6 Items 1 to 5—total per occupied bed 44s. 3 .6d. - 54s. 2.6d. - 60s. 9.3d. - 38s. 7.0d. - 44s. 2.5d. - 52s. 1.7d. - 44s. 9.1d. 42s. 3.8d. - 47s. 7.9d. - 45s. 0.5d. - 39s. 7.3d. - 38s. 8.7d. - 39s. 2.0d - 39s. 1.5d. - Deduct for sundry receipts, credits for transfer services and balances on farm or industrial accounts 0s. 10.6d. - 0s. 9.5d. - 0s. 10.4d. - 0s. 10.8d - 0s. 8.4d. - 1s. 0.2d. - 0s. 7.6d. 1s. 3.9d. - 0s. 10.8d - 0s. 9.8d. - 0s. 1.9d. - 1s. 2.8d. - 0s. 8.4d - 0s. 9.0d. - Net cost per occupied bed— £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. per day 6 2 7 8 8 7 5 5 6 3 7 4 6 4 5 9 6 8 6 4 5 8 5 4 5 6 5 6 per week 2 3 5 2 13 5 2 19 11 1 17 8 2 3 6 2 11 1 2 4 2 2 1 0 2 6 9 2 4 3 1 19 5 1 17 6 1 18 6 1 18 4 per year 113 3 10 139 5 4 156 4 3 98 4 1 113 8 3 133 3 8 115 3 0 106 17 10 121 17 8 115 7 4 102 15 4 97 15 4 100 7 6 99 18 10 Net cost per occupied bed per week, 1933-34 2 0 9 2 11 5 - 1 19 10 1 14 8 2 11 1 2 1 4 2 5 4 1 16 3 1 16 0 1 16 1 1 16 1 P B P B P B P B P B P B P B P B P B P B P B P B P B P B 6. Superannuation fund (Council's contributions) 37.6 35.4 38.2 24.5 47.9 44.9 22.9 22.8 17.2 11.7 39.6 28.9 32.6 27.4 31.9 20.3 33.5 27.0 32.1 26.2 24.3 23.1 25.4 22.5 24.8 22.8 24.9 22.7 7. Annual charge in respect of capital outlay 51.7 48.7 92.8 59.6 26.3 26.6 33.1 32.9 15.1 10.2 24.7 18.0 49.7 41.8 80.8 51.5 46.8 35.9 48.3 39.4 32.2 30.5 19.2 17.0 25.7 23.7 251 22.9 8. Establishment charges—Pensions 23.6 22.3 28.2 18.2 31.8 29.7 19.6 19.6 18.5 12.6 31.5 23.0 22.6 19.0 22.4 14.2 24.8 19.8 23.3 19.0 16.3 15.4 18.8 16.6 17.6 16.0 17.6 16.1 Other 32.1 30.3 32.1 20.7 32.1 30.1 32.1 32.0 51.5 35.1 32.1 23.4 32.1 27.1 32.1 20.5 34.5 27.4 33.2 27.1 32.1 30.5 32.1 28.5 32.1 29.5 32.1 29.4 £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. Inclusive cost per occupied bed per week, 1934-35 2 15 6 3 9 4 3 11 5 2 6 8 2 12 0 3 1 9 2 15 7 2 14 11 2 18 5 2 15 8 2 8 2 2 5 5 2 6 10 2 0 0 Inclusive cost per occupied bed per week, 1933-34 2 12 1 3 6 6 - 2 9 10 2 2 6 3 1 10 12 0 3 7 3 4 4 2 3 7 2 3 11 2 3 11 Percentage occupation, 1933-34 94.2 68.8 - 87.3 73.1 81.5 88.2 57.8 - - 99. 3 88.1 93.7 93.0 NOTES (see also General Notes on page 7).—The cost per available bed (B) is not shown where the expenditure is strictly dependent upon the number of patients. An asterisk (•) indicates that the service, inclusive of labour, was rendered and charged for by another establishment. †Includes teachers and instructors. ‡ Services rendered for other hospitals also. || See page 6. TABLE I LONDON AMBULANCE SERVICE. Analysis op costs. Year 1st April, 1934, to 31st March, 1935. General Section. Accident Section. 1,766,885 miles. 144,848 journeys. 210,959 patients. 222,518 miles. 44,532 journeys. 43,423 patients. Cost per mile Cost per journey Cost per patient Cost per mile Cost per journey Cost per patient d. d. d. d. d. d. Staff— Salaries, wages and insurance— Operating and control staff 7.90 99.39 67.09 32.02 165.84 168.28 Nursing service 1.59 19.98 13,49 - - - Uniforms of operating staff 0.16 1.98 1.33 0.70 3.64 3.70 Stations— Repairs (ordinary) to buildings, furniture, etc. 0.14 1.71 1.16 0.35 1.83 1.86 Rents, rates, taxes, lighting, heating, water and insurance 0.46 5.75 3.88 1.52 7.89 8.00 Stores and cleaning 0.12 1.54 1.04 0.42 2.18 2.21 Vehicles— Repairs, including renewal of tyres 2.11 26.47 17.86 2.21 11.44 11.61 Stores, petrol and sundry expenses 1.83 22.94 15.48 1.40 7.26 7.37 Insurance 0.25 3.19 2.15 0.52 2.72 2.76 Replacement of vehicles 0.97 12.16 8.21 1.58 8.21 8.32 Special charges— Special works at stations, new stations, etc. 0.02 0.24 0.16 - - - Miscellaneous— Telephones, etc. 0.05 0.69 0.46 0.95 4.91 4.98 Stationery, postage, travelling and incidental expenses 0.10 1.22 0.83 0.18 0.93 0.94 d. s. d. s. d. s. d. s. d. s. d. Total 15.70 16 5.26 11 1.14 3 5.85 18 0.85 18 4.03 Deduct miscellaneous credits 0.18 2.31 1.56 0.32 1.67 1.70 Net running cost (excluding depreciation but including replacement of vehicles) 15.52 16 2.95 10 11.58 3 5.53 17 11.18 18 2.33 Overhead charges— Superannuation fund (Council's contributions) 0.68 8.57 5.78 1.46 7.55 7.66 Annual charge in respect of capital outlay 0.47 5.95 4.02 - - - Establishment charges—Pensions 0.74 9.25 6.25 - - - Other 0.43 5.40 3.64 1.95 10.10 10.25 Inclusive cost 1s. 5¾d. per mile 18s. 8d. per journey 12s. 7d. per patient 3s. 9d. per mile 19s. 5d. per journey 19s. 8d. per patient Average : 12 .20 miles per journey. Average : 4 .59 miles per journey. Comparative figures for year 1933-34— Total mileage 1,996,809 198,674 Inclusive cost per mile 1s. 3d. 4s. 7¾d. per journey 16s. 3d. 21s. 4d. per patient 10s. 11½d. 21s. 10d. Average mileage per journey 13.04 miles. 4.58 miles. NOTE.—The service statistics of mileage, journeys, patients and miles per journey refer to the total work proper to the section named. The cost per mile, per journey, and per patient are calculated on the total work carried out by the section named whether proper to itself or to the other section, as, for flexibility in operation, a system of mutual support has been put into force. It is not to be expected, therefore, that certain figures in the table can be calculated from the others shown. TABLE J HOSPITAL LAUNDRIES—Particulars of work and running costs. The costs include only laundry staff labour, uniforms and other emoluments, fuel, gas, electricity, water, washing materials, laundry fabrics and plant repairs. Period—Twelve months to 31st March, 1935 Name of hospital. Mean of number of patients for whom washing was done. Mean of number of staff for whom washing was done. Average number of articles sent to be washed weekly. Number of articles washed per week. Per occupied bed per week. Total number of articles washed during the year. Cost per 1,000 articles washed. Consumption per 1,000 articles washed. Mean of number of paid laundry staff. Output per head of paid laundry staff per week. Mean of number of inmates employed in laundry. Patients' washing. Per patient. Staff washing. Per member of resident staff. X Average total number of articles washed. Cost of average total number of articles washed. Salaries and , emoluments (laundry staff only). Washing materials laundry fabrics. Fuel, gas, electricity, water and plant repairs. Total. Soap and soap in soap powder. Soda and soda in soap powder. Resident. Nonresident. GENERAL HOSPITALS No. No. No. No. No. No. No. s. d. No. £ s. d. s. d. £ s. d. £ s. d. lbs. lbs. No. No. No. SOUP G.I Archway 343 137 149 18,438 40 34 54 4 4 958,794 2 18 9 4 6 0 17 8 1 0 11 11.4 16.9 23 802 - Bethnal Green 477 184 196 20,663 32 29 43 3 5 1,074,464 2 15 3 6 3 0 18 2 3 19 8 18.6 23.9 23 898 - Dulwich 690 187 176 26,368 30 30 38 2 11 1,371,158 2 15 3 4 0 0 17 8 3 16 11 11.8 8.2 30 879 - Fulham 466 206 91 19,235 32 22 41 * * * ; * * * * * * * * Hackney 672 299 134 27,177 31 22 40 * * * * * * * * * * * Hammersmith 236 112 34 13,659 44 30 58 * * * * * * * * * * * High gate 409 143 137 19,608 38 29 48 3 5 1,019,626 2 8 2 4 4 0 19 5 3 11 11 10.7 18.6 20 980 - Lambeth 1,126 214 429 30,517 20 35 27 2 0 1,586,863 2 12 11 4 4 0 17 11 3 15 2 8.9 23.8 34 898 - Lewisham 656 262 - 26,086 30 25 40 3 1 §479,989 §2 15 6 §5 4 §0 17 2 §3 18 0 §14.1 §42.8 § 9 §1,026 - Mile End 418 165 54 19,549 36 28 47 4 7 1,016,536 3 18 2 4 0 0 15 8 4 17 10 8.2 16.7 29 674 - New End 250 95 90 8,257 23 25 33 2 8 439,626 2 15 2 3 9 1 3 1 4 2 0 6.9 18.7 10 845 - Paddington 506 147 103 19,467 28 35 38 3 1 1,017,183 3 0 9 4 5 0 16 9 4 1 11 10.6 16.0 25 782 - St. Alfege's 546 170 196 20,785 29 28 38 * * * * * * * * * * * St. Andrew's 502 209 161 22,779 33 29 45 4 4 1,184,500 3 14 6 4 1 0 17 10 4 16 5 7.6 17.4 32 712 - St. Charles' 533 172 216 20,500 28 32 38 3 0 1,065,979 2 16 71 3 11 0 17 7 3 18 1 8.9 27.2 27 759 - St.. George-in-the-East 318 125 128 16,104 37 34 51 4 4 897,401 3 0 0 3 3 1 1 7 4 4 10 6.2 10.8 18 895 - St. Giles' 726 260 147 35,460 37 34 49 2 11 1,843,899 2 1 0 3 9 0 14 2 2 18 11 7.3 30.3 29 1,223 - St. James' 895 282 111 34,676 32 21 39 2 11 §571,503 §2 14 6 §3 8 §0 16 9 §3 14 11 §9.3 §15.8 §13 §845 - St. Leonard's 457 161 130 16,626 28 25 36 2 10 936,602 2 15 5 4 10 0 19 0 3 19 3 13.4 20.7 20 901 - St. Luke's, Chelsea 297 116 - 10,874 25 31 37 * * * * * * * * * * * St. Mary Abbots 450 173 117 23,869 40 35 53 * * * * * * * * * * * St. Mary, Islington 777 206 67 28,986 30 27 37 2 6 1,507,991 2 6 4 3 1 0 18 11 3 8 4 4.2 16.7 28 1,035 2 St. Nicholas' 322 96 120 13,841 31 39 43 3 4 719,741 2 13 11 4 6 0 19 9 3 18 2 10.2 19.0 15 923 - St. Olave's 623 231 185 25,138 28 33 40 2 7 1,323,582 2 8 11 3 10 0 12 5 3 5 2 8.4 19.4 23 1,107 - St. Pancras 271 97 73 12,254 35 29 45 * * * * * * * * * * * St. Peter's 261 115 177 10,325 27 28 40 * * * * * * * * * * * St. Stephen's 595 186 182 22,449 28 30 38 2 8 1,167,366 2 7 10 5 7 0 16 8 3 10 1 10.9 15.8 23 976 - SOUP G.II City of London 456 47 117 10,208 18 38 22 1 9 680,818 2 17 0 6 0 17 11 3 18 5 4.2 20.8 12 851 - Constance Road 649 44 159 19,175 27 45 30 2 1,208,530 2 10 5 4 5 0 17 4 3 12 2 7.1 36.5 24 968 - Fulham 359 78 - 4,593 11 9 13 2 0 1,435,054 2 13 7 3 8 0 18 3 3 15 6 6.6 18.5 30 920 - Hackney 830 99 121 12,135 13 16 15 1 1 2,699,666 2 11 1 3 9 0 16 6 3 11 4 7.2 12.9 56 927 2 Hammersmith 237 13 30 5,210 19 53 22 1 9 984,093 2 16 4 4 1 0 18 5 3 18 10 8.2 26.9 24 789 11 Holborn and Finsbury 755 101 26 20,849 24 28 28 1 9 1,092,042 1 19 8 3 2 0 19 9 3 2 7 6.5 11.0 19 1,105 8 St. Alfege's 680 85 164 16,027 21 23 24 2 1 1,916,927 2 14 11 5 4 1 5 11 4 6 2 13.0 35.6 45 819 6 St. John's 543 164 78 21,145 28 35 39 2 10 1,157,210 2 4 11 5 2 1 1 6 3 11 7 10.9 29.6 20 1,113 - St. Leonard's 89 3 25 1,317 13 48 15 * * * * * * * * * * St. Mary Abbots 460 37 35 10,754 21 35 23 1 10 1,801,397 2 13 2 5 2 1 1 8 4 0 0 10.8 37.1 41 845 1 St. Pancras 896 53 59 12,464 12 33 14 0 11 1,292,395 1 17 10 4 5 1 0 9 3 3 0 10.2 29.2 21 1,184 33 SOUP G. III Queen Mary's, Sidcup 452 55 130 6,194 10 33 14 * * * * * * * * * * * St. Benedict's 294 66 - 5,104 11 30 17 † † † † † † † † † † † SOUP G. IV St. David's 313 11 42 3,642 11 16 12 0 9 189,395 1 12 2 3 9 1 4 4 3 0 3 6.5 19.2 2 1,821 4 St. Faith's 350 34 36 6,445 15 33 18 1 0 338,399 1 8 4 5 7 1 0 6 2 14 5 12.0 24.3 3 2,169 26 An asterisk (*) indicates that the washing was done at, and charged for by, another hospital or institution. † Washing done under contract. § Foul washing only. ‡ Owing to local conditions or capacity of laundry, the amount of washing done for non-resident staff varies considerably at the several hospitals. This column, therefore, for uniformity, represents the total staff washing apportioned over the resident staff only. [Continued on next page. TABLE J— continued. Period—Twelve months to 31st March, 1935 Name of hospital. Mean of number of patients for whom washing was done. Mean of number of staff for whom washing was done. Average number of articles sent to be washed weekly. Number of articles washed per week. Per occupied bed per week. Total number of articles washed during the year. Cost per 1,000 articles washed. Consumption per 1,000 articles washed. Mean of number of paid laundry staff. Output per head of paid laundry staff per week. Mean of number of inmates employed in laundry. Patients' washing. Per patient. Staff washing. Per member of resident staff. ‡ Average total number of articles washed. Cost of average total number of articles washed. Salaries and emoluments (laundry staff only). Washing materials and laundry fabrics. Fuel, gas, electricity, water, and plant repairs. Total. Soap and soap in soap powder. Soda and soda in soap powder. Resident. Nonresident. SPECIAL HOSPITALS No. No. No. No. No. No. No. s. d. No. £ s. d. s. d. £ s. d. £ s. d. lbs. lbs. No. No. No. Group s.i Brook 437 273 122 22,289 36 24 51 3 3 1,172,747 2 5 8 3 5 0 14 7 3 3 8 5.2 15.9 22 1,025 - Eastern 451 341 119 22,113 29 26 49 3 0 1,155,189 2 5 0 4 0 0 12 5 3 1 5 9.5 15.0 21 1,058 - Grove 465 371 72 25,287 37 21 54 2 6 1,314,931 1 13 9 3 7 0 10 0 2 7 4 6.1 16.2 20 1,264 - Joyce Green 544 356 2 18,299 20 21 34 1 9 967,929 1 18 10 3 11 0 9 6 2 12 3 6.2 25.2 20 931 - North-Eastern 506 315 129 23,651 33 21 47 3 0 1,549,884 2 9 5 3 3 0 12 5 3 5 1 5.6 14.8 29 1,038 - North-Western 365 212 60 19,092 37 27 52 2 1 876,383 1 4 9 3 6 0 12 2 2 0 5 6.0 19.0 8 2,107 - Northern 524 258 102 18,031 23 24 34 2 2 937,604 2 6 5 4 4 0 12 5 3 3 2 8.1 19.6 17 1,061 - Park 390 288 81 19,182 28 28 49 3 3 997,460 2 9 11 3 3 0 13 9 3 6 11 4.2 14.2 19 1,010 - South-Eastern 388 275 111 21,372 39 23 55 3 6 1,111,355 2 5 9 3 8 0 13 11 3 3 4 6.0 19.6 22 971 - South-Western 297 180 109 13,778 31 26 46 2 11 724,858 2 4 1 3 8 0 15 7 3 3 4 4.7 21.6 13 1,072 - Southern 635 476 69 23,853 21 22 38 1 10 1,240,372 1 15 2 3 2 0 10 5 2 8 9 4.7 12.7 21 1,136 - Western 372 300 60 17,551 29 23 47 3 1 980,144 2 5 4 4 2 0 15 11 3 5 5 8.6 16.5 19 992 - Group s. iv Colindale 339 121 74 12,673 27 29 37 2 3 659,007 1 18 9 3 11 0 18 0 3 0 8 6.3 18.3 10 1,267 - Grove Park 316 139 57 11,151 23 29 35 1 11 579,856 2 0 4 3 11 0 11 1 2 15 4 6.8 18.3 10 1,115 - King George V 230 70 - 5,651 17 26 25 * * * * * * * * * • * Pinewood 160 38 - 1,280 4 16 8 † † † † † † † † † † † St. Luke's, Lowestoft 208 90 - 5,089 15 23 24 † † † † † † † † † † † Group s.v The Downs 338 137 80 12,782 29 23 38 2 0 968,625 1 18 7 3 4 0 11 3 2 13 2 5.7 13.7 14 1,331 - Goldie Leigh 159 63 35 5,182 24 23 33 2 4 269,482 2 3 5 4 8 1 3 8 3 11 9 9.3 24.2 5 1 036 - Heatherwood 131 69 19 3,367 12 25 26 2 5 87,548 2 18 10 4 5 1 10 6 4 13 9 9.2 6.2 5 673 - High Wood 399 98 73 13,059 25 30 33 2 3 791,766 2 6 8 4 4 0 18 0 3 9 0 9.6 17.6 15 1,015 - Princess Mary's 199 87 66 5,172 16 23 26 2 0 395,329 2 10 7 3 7 1 4 3 3 18 5 5. 6 12.6 8 950 - Queen Mary's, Car- shalton. 1,094 529 190 56,484 41 21 52 2 6 2,937,158 1 9 0 3 1 0 15 8 2 8 3 4.5 16.4 39 1,448 - White Oak 231 78 42 7,312 24 21 32 2 3 702,296 2 9 7 4 9 0 15 9 3 10 1 10.3 21.4 13 1,039 - Group s. vi Millfield 93 30 - 2,028 14 23 22 † † † † † † † † † † † St. Anne's 112 22 9 1,665 11 22 15 * * * * * * • • * * * An asterisk (•) indicates that the washing was done at, and charged for by, another hospital or institution. † Washing done under contract. ‡ Owing to local conditions or capacity of laundry, the amount of washing done for non-resident staff varies considerably at the several hospitals. This column, therefore, for uniformity, represents the total staff washing apportioned over the resident staff only. Year ending 31st March. Total number of articles washed in laundries during the year. Average cost per 1,000 articles washed. Average consumption per 1,000 articles washed. Average daily number of paid laundry staff. Average output per head of paid laundry staff per week. Salaries and emoluments (laundry staff only). Washing materials and laundry fabrics. Fuel, gas, electricity, water and plant repairs. Total. Soap and soap in soap powder. Soda and soda in soap powder. No. £ s. d. s. d. £ s. d. £ s. d. lbs. lbs. No. No. 1933 55,911,508 2 10 1 4 7 0 16 10 3 11 6 8.1 22.3 1,133 949 1934 55,614,171 2 8 3 4 3 0 16 6 3 9 0 7.9 22.6 1,116 958 1935 55,187,934 2 8 2 4 0 0 16 10 3 9 0 8.2 20.3 1,078 985 London County Council ANNUAL REPORT OF THE COUNCIL, 1934 Vol. IV (Part III) PUBLIC HEALTH—MEDICAL SUPPLEMENT TO THE REPORT ON THE HOSPITAL SERVICES Compiled under the direction of the County Medical Officer of Health, Sir Frederick Menzies, K.B.E., M.D., LL.D , F.R.C.P., F.R.S.E. 550 (M.C. 11961.) 10.12.35 3 CONTENTS Special Hospitals. Purpura hemorrhagica and scarlet fever Notes on an outbreak of food poisoning caused by B. dysenterise. Gastric lavage in tuberculous children... Oleothorax Disorders of cardiac rhythm in scarlet fever. The Drinker respirator in diphtheria, empyema and pulmonary collapse. Vulvo-vaginal diphtheria An analysis of a series of cases of meningococcal meningitis. The periodic investigation of the erythrocyte sedimentation rate in rheumatic children. Venereal Diseases. Observations on the gonococcal fixation test. Reports on Special Units. Puerperal fever unit: North-Western hospital. Radium centre for carcinoma of the uterus : Lambeth hospital. Radiotherapeutic clinic: Lambeth hospital. Plastic surgery unit: Hammersmith hospital St. James' hospital Goitre clinic: New End hospital Diabetic clinic: St. Peter's hospital Pernicious anaemia unit: St. Mary, Islington, hospital. page W. A. Brown, M.D., D.P.H., 5 and G. E. Breen, M.D., D.O.M.S. J. R. Tree, M.D., and J. M. 10 Alston, M.B., M.R.C.P.E. R. H. Fish, M.B., M.R.C.S., 12 M.R.C.P. C. E. H. Anson, M.B., B.S., 16 M.R.C.S. J. T. Wybourn, M.B., B.S., '20 D.P.H. Norman D. Begg, M.D.. 24 D.P.H., and Maurice Mitman, M.D., M.R.C.P., D.P.H., D.M.R.E. W. A. Brown, M.D., D.P.H., 34 and J. E. McCartnev, M.D., Ch.B., D.Sc. J. C. Blake, M.B., B.S., 36 D.P.H., M.R.C.S. R. S. C. McDade, M.A., M.B., 38 B.Ch. W. Ralston, B.Sc., M.R.C.S., 43 L.R.C.P., E.I.C. A. Joe, D.S.C., M.D., Hilda 49 M. Davis, M.B., D.P.H., and J. M. Wyatt, M.B., B.S., F.R.C.S. (Eng.). Sir Comyns Berkeley, M.A., 57 M.C., M.D., F.R.C.P., F.R.C.S. (Eng.), M.M.S.A., F.C.O.G., and Arnold Walker, M.A., M.B., B.Ch., F.R.C.S.(Eng.), M.C.O.G. George F. Stebbing, M.B., 62 B.S., F.R.C.S. (Eng.), P. Berry, M.D., B.S., M.R.C.S. L.R.C.P., and T. M. Robb. M.R.C.S., L.R.C.P. Sir T. Carey Evans, M.G., 75 M.D., F.R.C.S. (Eng.), L.R.C.P. W. L. Maccormac, M.B., 75 Ch.B., F.R.C.S. (Edin.). R. H. Swindells, M.B., Ch.B., 77 F.R.C.S. (Edin.). B. A. Young, M.D., M.R.C.P. 80 B. Barling, M.D., B.S., 83 M.R.C.P., M.R.C.S. 4 Reports on Special Units—ctd. Thoracic surgery units • St. Andrew's hospital St. James' hospital Maternity. Maternal deaths in the Council's hospitals General Hospitals. Signs, symptoms and sequelae of subarachnoid haemorrhage due to ruptured congenital aneurysms. A case of polyarteritis nodosa A case of abdominal actinomycosis Prolonged retention of artery forceps in the abdomen. A case of granulosa-cell carcinoma of ovary. Virilism : Unilateral adrenalectomy Treatment of fractures of the neck of the femur. End results of fractures Suprapubic prostatectomy Trauma in relation to disseminated sclerosis. Chemical Branch. The investigation of atmospheric polution Investigation as to possible danger from inhaling phosgene gas through the use of fire extinguishers of the carbontetrachloride type. page J. W. Linnell, M.C., M.D., 85 M.R.C.P., and H. P. Nelson, M.A., M.D., F.R.C.S. (Eng). W. L. Maccormac, M.B., Ch.B. 86 F.R.C.S. (Edin.). Letitia Fairfield, C.B.E., 88 M.D., Ch.B., D.P.H. B. Barling, M.D., B.S., 101 M.R.C.P., M.R.C.S. B. Barfing, M.D., B.S., 107 M.R.C.P., M.R.C.S. K. F. D. Waters, B.A., B.M., 109 B.Ch., F.R.C.S. (Edin.). A. J. Watson, M.B., B.S., 112 F.R.C.S. (Eng.)., and J. A. Braxton Hicks, M.D., M.R.C.P., D.P.H. R. Kelson Ford, M.D., 114 M.M.S.A. J. R. M. Whigham, M.C. 116 M.S., F.R.C.S. (Eng.). James C. Gillies, M.B., Ch.B., 117 F.R.C.S. (Edin.). MajorMeurice Sinclair, C.M.G., 120 M.B., Ch.B. K. F. D. Waters, B.A., B.M., 122 B.Ch., F.R.C.S. (Edin.). A. Turner, M.R.C.S., L.R.C.P. 125 J. H. Coste, F.I.C., F.Inst.P. 126 E. T. Shelbourn, F.I.C., and 127 C. L. Bennett, B.Sc., A.I.C. Articles Published Elsewhere 128 PURPURA HEMORRHAGICA AND SCARLET FEVER. By W. A. Brown, M.D., D.P.H., Senior Assistant Medical Officer, Brook Hospital; and G. E. Breen, M.D., D.O.M.S., Senior Assistant Medical Officer, Northern Hospital. The occurrence of purpura hsemorrhagica in the course of scarlet fever has been recognised for some considerable time, and many cases have been reported in the literature. The time of onset is usually the third, sometimes the fourth, week of the disease, and is not associated as a rule with a severe attack of scarlet fever. Frequently the purpura supervenes without premonitory symptoms, but in some cases it is preceded bv cervical adenitis, albuminuria and some constitutional disturbance. Bleeding from mucous surfaces, especially epistaxis, is fairly frequent. In a few instances Henoch's purpura is simulated and colic, associated with gastrointestinal disturbance, is present. The etiology is still a matter of dispute. It appears fairly settled that the toxin of the scarlet fever streptococcus has a selective action on the capillaries, as evidenced by the rash and the staining which often persists in the flexures after the rash has disappeared. It is said that as a result of an .attack of scarlet fever a state of anaphylaxis to this toxin develops. Any fresh introduction of toxin, whether by a secondary infection or by lysis of organisms still in the body (i.e., an endotoxin), may precipitate a reaction. When the capillary wall is damaged, platelets are called upon to provide thrombokinase and to line the gap, and the issue will depend on the severity of the lesion and on the capacity of the marrow to provide a sufficiency of platelets rapidly enough to cope with the situation. Whether this view be correct or not, the blood picture very often shows a large reduction in the platelet count. There is usually also a secondary anaemia with a leucocytosis, mainly polymorphonuclear. Although the case here reported cannot be stated definitely to have been scarlet fever, the history is suggestive of a mild attack of that disease. K. W., male, aged 7 years and 7 months. History : About one month before the onset of purpura he had a slight rash on the legs but no constitutional disturbance. He was kept in bed for ten days and was apparently quite well and healthy until 22nd October, when he developed a left cervical adenitis, headache, pains in the limbs and slight pyrexia. On examination he was found to have a suspicion of desquamation on the feet and was removed to hospital certified to be suffering from scarlet fever. On admission, 23.10.34: Heart, lungs and fauces normal. Abdomen retracted. Spleen not palpable. Dry condition of skin of abdomen (not consistent with history of scarlet fever). Ecchymoses right leg and both feet. Annular haemorrhagic bulla? on first three toes left foottense, tender, superficial. Complained of abdominal pain. Urinary examination disclosed a marked degree of hematuria. Irritable. Mentally unstable. Temperature normal. 24.10.34.—Bullae on feet and toes more extensive. Fresh purpuric areas on calf and back. Haemorrhage into right upper eyelid. Marked dysuria with almost pure blood on micturition. No fever. 25.10.34.—Some improvement in general condition. Bright erythematous area around calf. Urine much clearer. Existing ecchymoses unchanged, no fresh haemorrhage. No fever. 26.10.34.-—Much improved. No ha>maturia. No further haemorrhages, but patches of erythema around existing purpuric areas. 8.30 p.m.—Condition much worse. Increased htemorrhages, buttocks, left side neck. Bullae on toes ruptured. Haematuria again marked. No fever. 27.10.34.—General condition unchanged. Colour waxy, lips cyanosed, pulse imperceptible. Abdominal pain and tenderness, no swellings or subcutaneous hemorrhages visible. Purpuric areas extended downwards over thighs and upwards over sacral region. 10.13 a.m. Death. Treatment consisted of daily injections of haemoplastin (2 cc.) intramuscularly and administration of liquid liver extract (= 1 lb. fresh liver in twenty-four hours). Examination of the blood on 26.10.34 showed: Haemoglobin, 62 per cent.; red cells, 3,800,000 per c.mm. ; colour index, -8 ; white cells, 8,760 per c.mm. Differential white cell count: Polymorphonuclears, 41.5 per cent.; small lymphocytes, 35.0 per cent.; large lymphocytes, 8.0 per cent.; large hyalines, 13.5 per cent; eosinophils, 1.5 per cent. ; basophils, 0.5 per cent. ; platelets, 5,600 per c.mm. (5) 6 fig. 1. The post-mortem examination revealed the following macroscopic and microscopic changes:— (1.) Subcutaneous haemorrhages lower limbs, feet, buttocks, left mastoid area, left side of neck, right upper eyelid. Haemorrhage and slight acute inflammatory infiltration of skin and subcutaneous tissue. (2.) Tonsils enlarged, pale anaemic, chronic tonsillitis. (3.) Heart pale, petechial haemorrhages into endocardium. (4.) Liver—pale, enlarged, hydropic degeneration. (5.) Spleen—large, cedematous subacute toxic condition with degeneration of centres of Malphigian bodies. (6.) Kidneys enlarged, haemorrhage in and around pelvis of left kidney. (7.) Retroperitoneal haemorrhage in perinephric area. (8.) Haemorrhage into bladder wall. Slight inflammatory changes in wall of bladder. (9.) Haemorrhage into right testis. (10.) Small luemorrhage into dura just deep to anterior fontanelle. (11.) Sinus catarrh of lumbar lymphatic glands which were enlarged. (12.) Chronic inflammation with areas of necrosis in left cervical gland. (13.) Considerable haemorrhage into whole of abdominal and thoracic walls. (14.) Bone marrow of femur normal. As has previously been noted, the occurrence of purpura at a distance of three to four weeks from a fleeting rash, coupled with sufficient malaise to have necessitated liis being kept in bed for ten days, suggest very strongly that this is a case of scarlet fever. It is true that there was no history of either a primary or secondary sore throat (which is of interest in view of the suggestion that such purpuras are allergic in origin), but the presence of the tonsillar lymphadenitis, which was of the streptococcal type, is not readily explicable on any other basis. Furthermore, the presence of islands of normal skin throughout the purpuric areas surrounded by zones of hyperemia, as manifested in this case, has already been described as being in a measure peculiar to the purpura of scarlet fever.1 Clinically, the case is interesting from several points of view. The course was extremely rapid—five days in all from admission to the fatal termination. At no time was there any fever, although the lesions on the toes looked gangrenous and 7 microscopically showed an invasion of white cells. Following treatment with hoemoplastin and liver extract, the general condition improved enormously; on the morning of 26th October, apart from the skin condition, the patient appeared normal; twelve hours later he collapsed with dramatic suddenness. The complaint of abdominal pain, which had been attributed to the intestinal haemorrhages described by Henoch, was found post-mortem to have been due to bleedings into the muscles of the abdominal wall. The mental irritability and instability noted on admission may be correlated with the subdural haemorrhage ; such a complication is very unusual. A feature of interest in the blood picture is the complete absence of the customary leucocytosis, the great reduction in the polymorphonuclear, and the remarkable increase in the large hyaline cells. The reduction of the platelets almost to vanishing point agrees with the accepted findings, as also the absence of any reparative activity in the bone marrow in a case so rapidly fatal. So far as could be ascertained, there was no family history of the haemorrhagic diathesis, nor had the boy himself given any previous evidence of it. Reference. 1 McCririck, T. British Journal of Children''s Diseases, 1912, IX, 154; and Hobson, F. G., and Gibson, A. G., The Lancet, 1932, I, 509 NOTES ON AN OUTBREAK OF FOOD POISONING CAUSED BY B. DYSENTERIC (SONNE). By J. R. Tree, M.D., Assistant Medical Officer, Highgate Hospital, and J. M. Alston, M.B., M.R.C.P.E., Pathologist, Archway Group Laboratory. In the civilian populations of the countries which have the best sanitary conditions, the transmission of bacillary dysentery is usually by a series of infections in which the excreta of any one patient infect only a small number of people, and for this reason the course of an epidemic can often be traced from individual to individual or from an individual to a group, with intervals between the successive infections corresponding to incubation periods. But if an infected person (whether a sufferer or carrier) prepares or handles the food of others, he may by contaminating it be the cause of a much more wide and rapid spread of dysentery infection. Outbreaks of this latter kind may be spoken of as food poisoning, and they resemble, epidemiologically and clinically, those which are caused by certain bacilli of the genus Salmonella, to which on account of the relative frequency with which they give rise to such epidemics the name of food-poisoning bacilli is applied. An instance of the way in which a dysentery infection may take on the character of a food-poisoning outbreak is provided by an epidemic due to B. dysenierice (Shiga) in a French village.4 The first case was that of a soldier who had been infected at a military camp in a neighbouring county, and for the first week after he returned home the infection spread only to relatives who attended him, and to the members of a family which shared a privy with them. This was the family of the only baker in the village and, a few days after it became infected, cases occurred rapidly in all parts of the village and in the surrounding district. Thirty-one cases were traced, with six deaths, in a population of 600. An indication of the relative frequency of dysentery bacilli in food poisoning, in Great Britain, is given by the fact that only 4 out of 100 outbreaks were definitely traced to these organisms by Savage and Bruce White5. The bacillus was the Sonne type in three instances, and the Flexner type in one. The number of cases identified in these four outbreaks was 46 in all, and five deaths occurred. Large epidemics due to transmission of dysentery infection by food are recorded from time to time. In 1919, 150 children in a Hamburg orphanage were infected with B. dysenterice (Flexner) by milk, and five died3. In Aberdeen, over 1,000 cases, with 72 deaths, were caused by milk infection with the Flexner type of bacillus2. It was clearly shown that the epidemic began in the household of a dairy farmer to which infection had probably been brought by a relative who had nursed dysentery cases in Salonica. The infection of milk with the Sonne type of bacillus occurred at a dairy farm near St. Andrew's, and 150 cases of dysentery were identified in that town1. No deaths occurred in that outbreak. At San Quentin State Prison, in California, 946 out of 4,246 inmates were attacked during the course of 16 days with dysentery caused by the Flexner type of organism7. The source of infection was considered to be a physician who, as a convict, was employed in cutting and distributing bread ! This report is written to record and comment on some of the clinical and bacteriological features of an outbreak of food poisoning due to the contamination of pease-pudding with B. dysenierice (Sonne). The epidemiology of the occurrence has been reported6, and will therefore be mentioned only briefly. On Saturday evening, 7th October, 1933, 18 or 20 people bought pease-pudding in quantities of five or six ounces at a shop in the borough of St. Pancras. Thirteen cases are known of very acute illness, which commenced a few hours after the pudding had been eaten. On the next day six of the patients were admitted to Highgate hospital and one to University College hospital. B. dysenterice (Sonne) was isolated from the suspected food and strong presumptive evidence was obtained that the (8) 9 daughter of the shopkeeper was a carrier of the organism and had infected the pudding with her fingers. No chemical poison was detectable in the pudding, nor in unused portions of the ingredients of which it was made, nor in the vessels in which it was prepared or stored. This report deals chiefly with the patients treated at Highgate hospital, and these include the only two who died. Accounts of the two fatal cases may be summarised thus:— A. S., aged 11 years. History. On 7th October, 1933, at 8 p.m., patient bought some pease-pudding. He returned home and at once ate the pudding and went to bed in apparently normal health. At 3 a.m., on 8th October, he was awakened by abdominal pain, he vomited green fluid several times and later diarrhoea set in. Stools were frequent, watery and contained bright blood. Dr. C. O'Brien, who was summoned, diagnosed acute food poisoning and sent the child to Highgate hospital. No other member of the family ate pease-pudding or was subsequently affected. Condition on admission: At 1.20 p.m. (8th October), the boy appeared drowsy and dehydrated. Lips were pale and cyanosed and the skin warm. Cardiovascular system: Marked tachycardia (140) but no enlargement or murmurs detected. Poor quality sounds with tic-tac rhythm at the apex. Pulse tension low. Digestive system: Tongue slightly furred. Slight abdominal pain and tenderness in the epigastric region. Stools passed soon after admission contained much blood and mucus. No abnormal physical signs were found in the other systems of the body. Subsequent course: At 2.50 p.m. the breath smelled strongly of acetone, lips and extremities were cyanosed, pulse barely felt and heart sounds extremely feeble. There was mild delirium. A pint of intravenous saline was given with marked improvement, the colour becoming almost normal; the pulse tension raised and mental condition clearer. Diarrhoea continued and many offensive stools containing blood and mucus were passed. At 7 p.m. there was a sudden relapse—features cyanosed, pulse not palpable, air-hunger and delirium. Coma developed and death ensued at 7.30 p.m. A post-mortem examination was performed by Sir Bernard Spilsbury (who has kindly consented to reference being made to the findings). The outstanding lesion was intense acute inflammation of the mucosa and sub-mucosa of the colon in almost its whole length. In the lower part of the small intestine, there was a slight degree of inflammation. The stomach showed no abnormality, and cloudy swelling was the only evidence of toxic damage to the kidneys and liver. The spleen was normal. There was congestion of the vessels of the brain. In a specimen of feces passed in hospital numerous polymorph, leucocytes were present in a slightly bile-coloured mucous stool. B. dysenteries (Sonne) was isolated from this specimen and from the mucous contents of the colon taken after death. The organism was fully identified by bacteriological and serological methods. J. W. A., aged 13 years. History. On 7th October, 1933, at 9 p.m., patient ate pease-pudding and went to bed in apparently normal health at 10.30 p.m. At 1.30 a.m., 8th October, the patient was wakened by severe abdominal pain, frequent vomiting of green fluid and diarrhoea. The patient's sister who also took pease-pudding was similarly affected. They were admitted to Highgate hospital at 11.30 a.m. Condition on admission: The patient was drowsy and dehydrated in appearance, hps cyanosed and temperature 102-8°F. Cardiovascular system:—Heart normal in size but rapid (130), apical sounds wpre of poor quality and had a tic-tac rhythm. Pulse tension was low. Digestive system:—Tongue slightly furred and odour of acetone in breath. No features of note were found in other systems of the body. Subsequent course. Frequent watery, offensive stools passed, containing mucus and green pigment. Cyanosis became more marked, the pulse tension fell and air hunger was apparent. Half-a-pint of intravenous saline was given with difficulty owing to the restless condition of the patient, but the general condition did not improve and death took place at 8.30 p.m. The post-mortem findings were almost exactly the same as those of A. S., but the content of the colon was pink muco-pus. No stool, passed before death, was examined, but B. dysenteries (Sonne) was obtained from the colon at the post-mortem examination and was not found in the bile nor in the contents of the small intestine. More clinical and pathological observations were made on the patients who recovered. These were L. A., 15 years (sister of J. W. A.); G. C., 16 years; W. C., 12 years; and D. E., 10 years. 10 The quantity of pease-pudding eaten is recorded of two only—G. C. had two teaspoonfuls and D. E. half-a-pint. The onset in the survivors was similar to that in the fatal cases, and in all six the first symptoms were observed from 2 or 3 up to 7 hours after the pease-pudding was eaten (4| and 61 hours in the cases of the two who died). In the survivors although on the day of admission the maximum pulse rate in each case was 132 to 156, and the temperature 102° F. to 103-6° F., there was less circulatory collapse (as shown by better colour and pulse tension, and regular heart rhythm), and less dehydration, compared with the patients who died. The temperature returned by lysis to normal in about 72 hours from the onset of the illness, and, by the same time, the frequency of stools had become almost normal and convalescence was very rapid. The infecting organism was isolated from the faeces of each patient on 8th or 9th October, but it very soon became undetectable on careful examination and was not found in specimens passed later than 48 hours after the onset of symptoms. The examination was repeated at intervals of a few days during the ensuing fortnight or three weeks, and no more dysentery bacilli were isolated, although aperients were given before the last stool tested. Blood cultures of G. C. and W. C., and of D. E., made on 8t,h October, were sterile. The urine of all four was cultured on 9th October and no pathogenic organisms were found. Leucocyte counts of L. A., G. C. and D. E. were on 8th October, 75,600 per c.mm. (polymorphs 91 per cent.), 12.000 (polymorphs 85 per cent.), and 14,200 (polymorphs 91 per cent.), respectively. Later counts of L. A. were, on 9th October, 56,800 (polymorphs 92 per cent.) and on the 11th, 14,200 (polymorphs 63 per cent). On the 11th, also, the corresponding figures for G. C. were 9,600 (polymorphs 68 per cent.), and for W. C. 12,800 (polymorphs 62 per cent.). On 16th October, the serum of each patient was tested for agglutinins against two different strains of B. dysenterice (Sonne), one of which had been isolated from the patient and the other a stock laboratory strain. No evidence of agglutinins against either strain was found, although both of them were agglutinable by specific serum. A few comments may be offered. In food poisoning due to almost any of the organisms which may cause it, it is recognised that there may be present in the poisoned food, at the time it is ingested, living pathogenic bacteria with a varying amount of toxin formed by them ih the food, or toxins without viable bacteria. This second possibility is most often realised in the case of foods (especially canned foods) which have been infected before cooking and in which treatment by heat has killed the bacteria but not destroyed the toxins already formed which are often thermo stable under heat conditions which kill the bacteria. Toxins formed in the food before its ingestion cause all symptoms which arise during the first few hours. In cases due to a single ingestion of toxin without living bacteria the illness is usually over within three days if the patient survives the first 24 hours. If the toxin is in low concentration, insufficient may be absorbed through the wall of the gastrointestinal tract for symptoms to occur other than those referable to the alimentary system. In the cases under review it would appear that although living bacteria were found in the food the symptoms were mainly due to preformed toxins, as is to be judged by the early onset of symptoms and the commencement of recovery of those who survived and the death of the other two within 24 hours of the time the food was eaten. The causative organism was not found in the stools of the survivors later than 72 hours after its ingestion, nor in the blood or urine during the acute stage. A feature of the outbreak is that B. dysenterice (Sonne) is usually associated with mild dysenteric infections involving a very low rate of mortality as compared with the Flexner and especially the Shiga type. The high fatality of dysentery infections brought about by food poisoning is referred to in some of the papers mentioned above, and, as in the pease-pudding example, is no doubt due to the food providing a suitable culture medium for a large amount of toxin to be formed. 11 In this case the pudding was made during the afternoon and evening of the day on which it was sold. After it was ready it was kept warm and was from time to time stirred with hot water and it has been suggested that the contamination took place at about 7.30 or 8 p.m. by the shopkeeper's daughter who is known to have taken up some of the pudding with her fingers and who is believed to have been a dysentery carrier at that time. Since, however, the pudding was sold to and eaten by the patients in less than two hours after this, it is difficult to believe on bacteriological grounds that the contaminating organism produced large amounts of toxin in the short space of up to three hours before it was eaten, or, if the toxin production is considered as continuing in the stomach, within 4—5 hours after contamination, when the first symptoms of poisoning occurred. Such an hypothesis merits experimental test, but without it, other possibilities more in keeping with bacteriological knowledge may be sought. It is known that previous pease-puddings had been prepared, and although Friday's preparation was stated to have been sold out, if some remains of it had been contaminated on that day, there would be time for multiplication and great toxin production to have occurred by Saturday evening. The addition of this to the new pudding just before sale would explain the circumstances more clearly than the hypothesis that the significant contamination occurred by fingers at about the same time. References. 1 Fyfe, G. M. (1927.) J. Hyg., 26, 271. 2 Kinloch, J. P. (1922-3.) J. Hyg., 21, 451. 3 Lorenz, F. H. (1920.) Z. Hyg. Infektkr, 90, 423. 4 Louste, A., and Godlowski, H. (1919.) Soe. Med. d. hôp. de Paris, 43, 1022. 6 Savage, W. G., and Bruce White, P. (1925.) Sp. Hep. Ser., Med. Res. Coun. No. 92. 7 Sowden, G. (1933.) Brit. Med. J., ii, 712 and 836. 8 Stanley, L. L., Garfinkle, F. K., and Goddard, W. P. (1930.) J. Amer. Med. Assoc., 94, 857. GASTRIC LAVAGE IN TUBERCULOUS CHILDREN. (A Preliminary Report.) By R. H. Fish, M.B., M.R.C.S., M.R.C.P., Senior Assistant Medical Officer, High Wood Hospital for Children. The use of gastric lavage as a means of detecting tubercle bacilli in the sputum of children suspected of pulmonary tuberculosis was first described by Meunier1 in 1898. During recent years the method has been practised by a considerable number of different workers, and its value is becoming increasingly recognised. The main principle involved is the extraction of swallowed sputum from the stomach after coughing. The product of the lavage is treated so as to reduce its bulk to a minimum; it may then be examined in direct smears, or tubercle bacilli may be sought for by culture on a suitable medium and by inoculation of a guinea-pig. Some of the results obtained by different exponents of the method are set out below. Armand-Delille2 examined "homogenised" gastric lavage from 500 children by the direct smear method, and was able to demonstrate tubercle bacilli in 60 per cent, of children with radiological shadows suggesting pulmonary tuberculosis. He also used the method of obtaining sputum by tickling the back of the child's throat, and found this much less effective. Poulsen3 obtained 53 positives among 110 tuberculous suspects ; Wallgren4 obtained 47 among 95 children with erythema nodosum and positive Mantoux reactions. Both the latter workers used guinea-pig inoculation. Also using the guinea-pig method, Opitz demonstrated tubercle bacilli in the gastric lavage in 28 out of 30 cases of "epi-tuberculosis," 1 out of 7 cases of "interlobar pleurisy," 3 out of 24 cases of "hilus tuberculosis," 7 out of 12 cases of tuberculous meningitis, 2 out of 6 cases of tuberculous knees, and 1 out of 3 cases of enlarged cervical glands. Others who have obtained similar results are Druker5, Ivereszturi6, Friedlander7, Bie8 and Collis9; further details of their work will be found in an excellent account of the whole subject given by Collis and Brockington9. Work at High Wood hospital. Gastric lavage was first introduced into High Wood hospital by Dr. C. D. Agassiz, late medical superintendent, towards the end of 1932. In collaboration with Dr. E. W. Farquharson, late house physician, he investigated a considerable number of cases by this method. The present writer has been carrying on this work, but it is not yet completed. It is proposed to publish a final report of the present investigation, as well as the results obtained by Drs. Agassiz and Farquharson, in collaboration with the latter workers, at a later date. The following account is based on the present writer's results onlv. Present investigation. The work is being undertaken with three main objects in view. These are as follows:— (1) To determine to what extent, if any, the method of gastric lavage is of assistance in the diagnosis of pulmonary tuberculosis in children. (2) To determine the relative value of the three methods of detecting tubercle bacilli in the product of the lavage, viz., direct examination of smears, culture, and guinea-pig inoculation. (3) To advance knowledge of the pathology of certain special types of juvenile tuberculosis by determining to what extent tubercle bacilli have access to the bronchi in these cases. With regard to the last of these three objects the work at present centres mainly round cases of the type showing, on radiological examination of the chest, either increased hilar shadows on one or both sides, or a shadow extending outwards from the hilum into the lung. Other types of cases that have been investigated are miliary tuberculosis, pleural effusion, pulmonary fibrosis, and erythema nodosum. In no instance had the sputum been found positive previous to the date of the lavage, although in three of the cases tubercle bacilli were detected in it some time afterwards. Owing to the heterogeneous nature of the cases and their relatively (12) 13 small number, it would not serve any useful purpose at this stage to give a detailed analysis of the results with regard to all the different forms of disease investigated. Gastric lavage is now being carried out as a routine in all cases of the hilar type that are admitted to the hospital, and figures relating to a much larger number of cases of this class should be available by the end of next year. The details of the technique in use at present are described in an appendix. The children tolerate the operation well, and there seems no reason why it should not be repeated two or three times if necessary, although this was not done in any of the present series. The whole procedure, including guinea-pig inoculation, is now being carried out at High Wood hospital, but in a considerable number of the earlier cases the pathological work was carried out at the Council's Southern group laboratory. The following table summarises the findings ; it will be seen that the culture was omitted in some of the cases and guinea-pig inoculation in others. At the present time, as a special class of case is being investigated, all the material is being inoculated into a guinea-pig except the small amount necessary to cover a slide. In 7 cases the guinea-pigs have not yet been killed. The results of direct smear examination in these cases are included in the table. Table I. Number of cases. T.B. present. Percentage. Total cases 45 13 28.8 Direct smear 44 4 9.0 Culture 33 3 9.0 Guinea-pig 27 12 44.4 It will be seen that a much higher number of positive findings was obtained by guinea-pig inoculation than either by direct examination of smears or by culture. It must be pointed out, however, that in the combined technique a considerably larger part of the material was injected into the guinea-pig than the amount used to inoculate the culture medium. Despite this, in one case a positive culture was obtained when no tuberculosis developed in the guinea-pig. Further, among the series in which guinea-pig inoculation was omitted are to be found a relatively high proportion of probably non-tubercular or quiescent cases. It is felt therefore that, although the direct smear method is definitely inferior to the other two, the relative merits of culture and guinea-pig inoculation have not yet been fully explored. The most important question to be answered, before the value of gastric lavage can be established as a method of diagnosis in pulmonary tuberculosis, is whether or not the tubercle bacilli found are derived from the pulmonary and bronchial excretions. It is, of course, impossible to exclude for certain the chance of an accidental tubercle bacillus being swallowed and then later aspirated from the stomach, but in the present investigation the most important source of this error, i.e., the ingestion of tubercle bacilli in milk or milk foods, was avoided by the exclusion of such foods from the diet for 48 hours before the lavage.* Further, organisms derived from milk are usually of bovine type, whereas in five cases in which typing was carried out in the present series, human type tubercle bacilli were demonstrated in every instance. While positive findings were common among cases diagnosed on clinical and radiological grounds as definitely suffering from active pulmonary tuberculosis, in cases considered probably non-tubercular tubercle bacilli were not demonstrated. This is not a result that would be expected if the accidental introduction of tubercle bacilli from outside was a common cause of a positive gastric lavage finding. It seems probable, therefore, that where tubercle bacilli were obtained they originated from swallowed sputum, not from contaminated food, tuberculous tonsils, or any of the other possible sources that adverse criticism might suggest. A point that is of interest in the above connection is the relationship between the gastric lavage findings and the activity of the disease as estimated by the blood sedimentation rate. This point requires further investigation, but, as far as the * See Appendix. B 14 present results go, it would appear that in a definitely tubercular case the blood sedimentation rate is just as important, if not more so, than the extent of disease seen radiologically in determining the likelihood of a positive gastric lavage result. This point is illustrated by the accompanying figs., 1 to 4. In each case the most significant feature in the skiagram is an abnormally large hilar shadow on the right side. In the cases depicted in figs. 1, 2 and 3 the blood sedimentation rate was raised and the gastric lavage finding positive. In the last case, however, although the skiagram, fig. 4, is no less suggestive of tuberculosis than the other three, the blood sedimentation rate was within normal limits. In this case the gastric lavage finding was negative ; later, however, the child's condition relapsed, and a rise in the blood sedimentation rate coincided with the finding of tubercle bacilli in the sputum. The blood sedimentation rates were determined by the Westergren method. The figures represent the length of clear plasma in millimetres in a column of blood 200 mm. long at the end of one hour. A figure of 10 or under is considered within normal limits. FIG. 1.-SKIAGRAM OF CHEST. BLOOD MENTATION RATE 90 (WESTERGREN METHOD). GASTRIC LAVAGE POSITIVE. FIG. 2.-SKIAGRAM OF CHEST. BLOOD SEDI- MENTATION RATE 70. GATERIC LAVAGE POSITIVE. FIG. 3.-SKIAGRAM OF CHEST. BLOOD MENTATION RATE 49. GASTRIC LAVAGE POSITIVE. FIG. 4.-SKIAGRAM OF CHEST. BLOOD MENTATION RATE7. GASTRIC LAVAGE NEGATIVE. IN THIS CASE THE SEDIMENTATION RATE ROSE TO 40 LATER AND TUBERCLE BACILLI WERE FOUND IN THE SPUTUM. Summary and conclusions. An account has been given of the method of demonstrating tubercle bacilli in children by gastric lavage. Following a brief summary of previous investigations the work ou the subject in progress at High Wood hospital is described. The results obtained so far suggest that the method is of definite value. I wish to thank Dr. A. G. L. Reade, medical superintendent of High Wood hospital, for allowing me to carry on this investigation and for the encouragement he has given 15 me throughout. I owe a large debt of gratitude to Dr. Agassiz and Dr. Farquharson, as the experience gained through knowledge of their work has greatly lightened my own task. I am grateful to Dr. J. E. McCartney, Dr. H. A. Ash, and Dr. Evelyn Holmes, both for the work they have done themselves at the Southern group laboratory and for the advice they have given me with regard to my own share; and also to Miss F. I. Alford, laboratory technician at High Wood hospital, for her invaluable assistance with the routine work. References. 1 Meunièr, H. Presse Md., 1898, VI, 81. 2 Armand-Delille, P. F. Hull. de I'Acart. de Med., 1930, CIV, 732. 3 Poulsen, V. Amer. Jour. Dis. Child., 1931. XLI, 783. 4 Wallgren, A. Amer. Jour. Dis. Child., 1931, XLI, 816. 5 Druker, P. Acta Pæd.., 1930, II, 415. 8 Kereszturi, C., Mishulow, B. A., Schick, B., and Behner, D. Jour. Amer. Med. Assoc., 1932, XCVI1I, 1879. 7 Friedlander, A. Jahrb. f. Kinderh., 1930, CXXVII, 178. 8 Bie, V. Ugesk. f. Looger, 1931, XXII, 587. 9 Collis, W. R. F., and Brockington, C. F. The Lancet, Jan. 21, 1933. Appendix. Technical Details of the Method Used in the Present Investigation. (1) All cow's milk is excluded from the diet for 48 hours before the morning of the lavage. In young children a dried milk mixture is given as a substitute. (2) On the two davs preceding the lavage the following mixture is given t.d.s.:— R Pot. Iod gr. ii Ammon. Carb. gr. i Vin. Ipecac. m. iii Glycerine m. x Aqua ad 3i (This dose for children under 5 years—larger doses for older children.) (3) First thing in the morning before any food is given, the child is encouraged to cough for 20 minutes. (4) He is then given four to six ounces, according to age, of boiled water to drink. (5) Fifteen minutes later a stomach tube is passed, with aseptic precautions in order to avoid possible introduction of tubercle bacilli from the hands of the operator, and the fluid which regurgitates by the natural retching of the child is collected in a sterile flask. It is not found that aspiration with a syringe assists the operation to any appreciable extent. (6) The product of the lavage is centrifuged. The deposit is treated with three times its bulk of 4 per cent, sodium hydroxide and incubated for thirty minutes, during which time it is shaken repeatedly ; this procedure destroys organisms other than tubercle bacilli. The material is then neutralised to litmus paper with 8 per cent, hydrochloric acid and re-centrifuged. Part of the deposit is used for making a film on a slide which is stained by Ziehl-Neelsen and examined direct for tubercle bacilli; part is used for culture on Jensen's modification of Loewenstein's medium prepared at the Southern group laboratory in McCartney screw-capped bottles. The remainder is made up to 1 c.c. bulk with supernatant fluid and injected under the skin of the abdominal wall of the guinea-pig, the needle pointing towards the inguinal glands. The pig is killed as soon as appreciable glandular enlargement can be detected. Failing this it is left for three months. In a certain number of cases, where the material was sent to the Southern group laboratory for examination, the guinea-pigs were killed after one month irrespective of glandular enlargement. A diagnosis of tuberculosis is not made unless definite tubercle bacilli are seen in stained material from the glands or other organs affected in the animal. OLEOTHORAX. A survey of cases treated during the years 1930 to 1935. By C. E. H. Anson, M.B., B.S., M.R.C.S., Senior Assistant Medical Officer, Pinewood Sanatorium. The use of oleothorax as an adjunct to artificial pneumothorax was first advocated by Bernou in 1922, and good results have been reported by Gilbert and others in selected cases. In recent years, however, this method of treatment has fallen into disuse to a degree which in my experience is unjustified. It would appear that the application of the treatment to unsuitable types of cases, with resultant failure to secure clinical improvement, has contributed in no small measure to the stigma under which oleothorax has fallen. The following series of cases treated at Pinewood sanatorium between the years 1930 and 1934 therefore seems worthy of record, as it appears to us to demonstrate clearly that in carefully selected cases treatment by oleothorax may be of great and lasting benefit to the patient. Before proceeding to detailed summaries of these cases, the indications for the treatment and the technique adopted may be considered with advantage. Indications for oleothorax. The indications for oleothorax may be summarised thus:— Partial oleothorax.—Indications : mediastinal laxity, combined with excessive pleural elasticity in a case being treated by pneumothorax. Complete oleothorax.—Indications : (1) obliterative pleurisy in pneumothorax, or incomplete collapse of the lung, or an underlying cavity not due to adhesions; (2) as a substitute for artificial pneumothorax. Numerous authorities have also advocated oleothorax in the following conditions : pleurisies complicating pneumothorax ; pleuro-pulmonary perforations. Gilbert1 in 1930 divided the clinical types in which oleothorax was indicated into two main classes, viz.:—(1) As a means of disinfection in chronic or relapsing sero-fibrinous bacillary pleurisies, in severe tuberculous pleurisies, in certain purulent effusions. (2) As a means of preventing adhesions in order not to lose the good effects of artificial pneumothorax which until then had been effective. The experience quoted here, while providing evidence of the value of oleothorax in the second class of case, does not justify any conclusions on its use in cases belonging to the first group or in cases with a pleuro-pulmonary perforation. Good results have also been obtained with a partial oleothorax in cases showing laxity of the mediastinum as mentioned above. There is little doubt, however, that the recent progress made in the surgical treatment of pulmonary tuberculosis and the complications of artificial pneumothorax by operative measures have removed from the lists many cases in whom a few years ago oleothorax would have been indicated and advised in the absence of any better form of treatment. In all cases selected for this form of treatment, the contralateral lung should be free from any appreciable degree of active disease. Technique. In all cases as complete an artificial pneumothorax as possible was secured before the introduction of oil. In all cases liquid paraffin containing gomenol oil in a concentration of from 2 to 5 per cent, was used. A preliminary injection of 5 c.c. was first given to test the susceptibility of the patient. If no intolerance was observed further injections of 25, 50, 100 and then 300 to 500 c.c. were given, allowing a few days to elapse between the injections, until the air in the pneumothorax space had been completely replaced by oil. For the injections of the larger amounts of oil a two-way Dieulafoy's syringe of 100 c.c. capacity, or the special apparatus designed for the introduction of large quantities of oil by Dr. W. C. Fowler was used. The oil was run in at body temperature, through a short needle having a bore of from 1 to 1½ mm., inserted in one of the lower intercostal (16) 17 spaces. While the oil was being introduced, the air in the pneumothorax space was slowly removed through another needle, inserted in the first or second intercostal space, by a reversal of the bottles of the pneumothorax apparatus. The intrapleural pressure at the end of each injection was adjusted to zero. In some cases where difficulty is experienced in removing the last traces of air when completing the oleothorax, the patient may be placed on the side with the buttocks raised, and the head and shoulders low, and the needle coupled to the pneumothorax apparatus inserted in the costo-phrenic angle. By this means the last traces of air can be completely removed. In cases being treated by partial oleothorax from 40 to 100 c.c. of oil only are required. In my experience the after-care of all cases treated by a complete oleothorax is of the first importance, and wherever possible the medical officer responsible for the induction of the oleothorax should personally undertake the after-care and refills, if the best results are to be obtained. Careful routine X-ray and clinical examinations, including blood sedimentation tests, and periodic observations of the intra-pleural pressure, and the giving of small refills should this begin to fall, are essential. Should fluid develop under the oil, it should, if serous, be removed and replaced by gomenol-paraffin. Should it persistently reform, or be found to be purulent, on more than one occasion after replacement, the oleothorax should be terminated The following eight cases, treated by complete oleothorax, serve to illustrate some of the foregoing remarks. Throughout the series the blood sedimentation readings refer to the fall at the end of two hours. Cases treated. Case 1.—Aged 20 years. Admitted 25.6.29. History.—Previously treated at another sanatorium, 1928. Relapsed with cough and loss of weight in June, 1929. On admission.—Impaired percussion note with prolonged expiration and post-tussive crepitations over the upper half of the right lung. Sputum positive. Blood sedimentation 50. X-ray.—15.7.29. Infiltration over the upper half of the right lung, with small apical cavity. Left lung clear. Treatment.—Right A.P. induced 23.7.29, full collapse prevented by adhesions. Adhesions divided 6.5.30. Improved collapse, but base adherent. To prevent the obliterative process, oleothorax, using 5 per cent, gomenol in paraffin, was induced on 20.7.30. By 7.8.30 in all 500 c.c. of oil had been given, when patient developed a severe reaction with hyper-pyrexia and pain, and signs of acute nephritis, with blood and casts in the urine. The oleothorax was at once abandoned, and all the oil removed from the right chest, which later filled with clear fluid, which slowly organised. The urine cleared, and patient was discharged on 20.6.31 much improved, with sputum negative, blood sedimentation 20, and signs only of pleural thickening over the right side. Subsequent history.—In-patient for two months at Royal Free hospital with recurrence of urinary symptoms in November, 1931. Diagnosed as renal tuberculosis. Last seen 4.1.35, free from urinary and pulmonary symptoms, clinical signs and X-ray diffuse pleural thickening over right side. Case 2.—Aged 29 years. Admitted 15.11.29. History.—Left-sided pleurisy and small haemoptysis six weeks prior to admission. On admission.—Impaired note and some moist sounds over the upper third of the right lung. Sputum positive. Blood sedimentation 26. X-ray.—4.2.30. Deposits over the upper half of the right lung. Left lung clear. Treatment.—Right A.P. induced 10.2.30. Complete collapse prevented by adhesions. These were divided on 6.10.30. A small basal effusion developing, oleothorax was induced on 11.10.30 to prevent an obliteration of the A.P. as a result of adhesions forming at the base after the absorption and organisation of the basal effusion. Discharged 17.4.31 with a complete oleothorax, no symptoms, sputum nil, blood sedimentation 34. Subsequent history.—While attending dispensary she developed fluid under the oil. It was at first serous, but not being treated or replaced by oil it became purulent. Re-admitted to I'inewood 29.4.32. Right chest drained and pleural wash-outs given. Gelatinothorax started 12.8.32, completed 23.8.32. Discharged much improved 23.2.33. Re-admitted with recurrence of pus in the right chest on 22.8.33. Transferred to Brompton hospital for thoracoplasty after a course of pleural wash-outs to promote pulmonary re-expansion on 11.5.34. Thoracoplasty 1st stage 25.5.34, 2nd stage 8.6.34. Returned for convalescence and was finally discharged in moderate health on 1.2.35. Case 3.-—Aged 21 years. Admitted 27.6.30. History.—Recent haemoptysis. On admission.—Impaired note with some moist rales and prolonged expiration over the upper third of the right lung. Sputum positive. Blood sedimentation 12. 18 X-ray.—14.7.30. Deposits over the upper half of the right lung. Treatment.—Right A.P. induced 12.8.30. Complete collapse prevented by apical adhesions. Cauterisation of adhesions at Brompton hospital 24.11.30 to 20.2.31. On her re-admission it was found that as a result of a small haemothorax which developed after her cauterisation there was danger of her pneumothorax obliterating. Oleothorax was started 5.3.31 and completed 19.4.31. She was discharged on 4.9.31 free of symptoms, with a complete oleothorax—sputum nil, blood sedimentation 10. Subsequent history.-—Has remained free of symptoms since discharge. In business for past 3 J years. Last seen 25.1.35. Complete oleothorax, no symptoms. Case 4.—Aged 30 years. Admitted 17.4.31. History.—Haemoptysis at intervals for past five years. On admission.—Impaired percussion note with post-tussive crepitations over the upper half of the left lung, and also over the right apex. Sputum positive. Blood sedimentation 21. X-ray.—24.7.31. Diffuse deposits with softening over the upper half of the left lung, with a few scattered deposits in the right middle zone also. Treatment.—Left A.P. induced 12.8.31. Course of sanocrysin (5.9 grammes) completed 8.12.31. A small effusion developed in the A.P. space on 12.10.31, and was replaced on several occasions. It had practically disappeared by February, 1932, but to prevent obliteration of the A.P. as the result of this effusion, oleothorax was started on 24.2.32, and completed 8.3.32. Discharged with no symptoms and a complete oleothorax on 26.4.32. Sputum nil. Blood sedimentation 8. Subsequent history.—Uninterrupted progress since discharge. Last seen 7.12.34, no pulmonary symptoms, complete oleothorax ; has been at business for past year. Case 5.-—Aged 21 years. Admitted 30.6.31. History.—Persistent cough since influenza in November, 1930. On admission.-—Impaired percussion note with post-tussive crepitations over the upper half of the right lung. Sputum positive. Blood sedimentation 32. X-ray.—13.8.31. Diffuse deposits over the upper half of the right lung. Treatment.-—Right A.P. induced 21.9.31, good collapse resulted. Effusion (serous) developed 29.11.31, gas-replaced 23.1.32. Very little re-accumulation occurred, but owing to risk of obliterative processes oleothorax was started on 3.4.32, and completed 26.4.32. Discharged 31.5.32 free of symptoms, complete oleothorax, no fluid, sputum nil, blood sedimentation 17. Subsequent history.-—Married against medical advice soon after discharge. Seen every three months, and kept well till 25.8.33. Then failed to attend till 15.5.34, was confined during the interval, and while feeding the child developed severe breast abscesses. When seen on 15.5.34 she was free of pulmonary symptoms; oleothorax complete. Between 4.9.34 and her last visit in January, 1935, she had had a second pregnancy terminated on medical grounds, but was still free from any pulmonary symptoms, and the lungs had stood the excessive strain of the two pregnancies in such a short interval of time excellently, although her general health was impaired to some extent. Case 6.-—Aged 25 years. Admitted 1.1.32. History.—Small haemoptysis December, 1931. On admission.—Impaired percussion note with bronchial breath sounds, increased vocal resonance and post-tussive crepitations over the upper half of the right lung. Sputum positive. Blood sedimentation 28. Larynx : infiltration of both cords with interarytenoid deposits. X-ray.—14.1.32. Infiltration and fibrosis over the upper two thirds of the right lung, with large cavity in the middle zone. Left lung clear. Treatment.—Right A.P. induced 18.1.32. Complete collapse prevented by apical and basal adhesions. Adhesions at apex cauterised 18.4.32. A small fluid effusion followed, subsequently partly organised, while thoracoscopy on 23.4.32 showed that the division of further basal adhesions was impracticable. Oleothorax was therefore started on 1.8.32, to prevent the march of the obliterative process at the base of the pneumothorax, and was completed on 3.9.32. Discharged free from symptoms with a complete oleothorax on 12.9.32. Sputum negative. Blood sedimentation 28. Larynx healed. Subsequent history.-—Remained well since discharge. Last seen 22.8.34. No symptoms. Complete oleothorax, blood sedimentation 4. Plays a round of golf with comfort and no latigue. Case 7.—Aged 17 years. Admitted 1.3.32. History.—Left-sided pneumonia 1931, left A.P. induced at St. Thomas's hospital August, 1931. Transferred to Pinewood, March, 1932. On admission.—Clinical signs of a left-sided artificial pneumothorax. Heart displaced slightly to right. Impaired percussion note and fine crepitations over right apex. Sputum nil (positive before A.P.). Blood sedimentation 17. X-ray.—10.3.32. Good A.P. (left), some deposits over the upper half of the right lung with apical softening. Treatment.-—Sanocrysin (5-9 grammes) completed 21.6.32. Developed fluid in A.P. space 30.5.32. Gas-replaced on several occasions, and small amounts of gomenol-paraffin introduced 100 c.c. in all being given. Fluid became purulent, and persisted in that state despite the presence of the oil. On 16.9.32 oleothorax was therefore abandoned, and a gelatinothorax started on 1.11.32. Small sinus discharging thin pus developed over the 7th space posteriorly 19 on 31.1.33. Frequent pleural wash-outs with 1 in 4,000 acriflavine in saline were given, and the gelatinothorax abandoned. Discharged 16.6.33 with slight discharge from the sinus, general condition poor, blood sedimentation 11. Subsequent history.—Unknown, but unimportant from the point of view of oleothorax. Case 8.—Aged 26 years. Admitted 18.10.32. History.—Haemoptysis six years previously Treated at two other sanatoria from February, 1929, to February, 1931. Right A.P. started during this time. "Influenza" in December, 1931. A.P. abandoned early 1932 "as she had had it for three years." Relapsed with recurrence of positive sputum in August, 1932. On admission.—Impaired note with crepitations and bronchial breath sounds over the upper, middle and lower zones of the right lung. Sputum positive. Blood sedimentation 19. X-ray.—25.10.32. Fibrosis and deposits over all zones of the right lung, with apical softening and cavitation. Treatment.—Right A.P. re-induced on 10.1.33, after a small haemoptysis (2 ounces). Moderate collapse resulted with great clinical improvement. The apex and base of the lung were adherent to the chest wall, and as complete obliteration at any early date seemed probable an oleothorax was started on 24.2.33, and completed on 3.4.33. Discharged to Papworth village settlement on 22.5.33, free of symptoms, complete oleothorax, sputum nil, blood sedimentation 23. Subsequent history.—Not known. Case not seen since transfer. In the above series of cases, with the exception of cases 1, 2, 7 and 8, the patients have been kept under personal observation at three to four months intervals from the time of their discharge from the sanatorium to the date of the last report quoted. During this time they have also attended their dispensaries for observation, but subsequent refills, where necessary, or observations on the intra-pleural pressure in the oleothorax, have all been carried out personally. Discussion. Analysing these results it is apparent that of seven cases treated by oleothorax, with a view to preventing premature obliteration of the pneumothorax which had given great clinical improvement, one case had to be abandoned owing to severe local reaction and nephritis before the oleothorax was completed; one case developed fluid, which later became purulent while out of our care, which necessitated abandoning the oleothorax ; while the remaining five cases were greatly improved and have remained well without relapse for periods up to three and a half years after their discharge from the sanatorium. In four of these cases, the patients have been engaged for a year or more in normal life or business posts. It is of interest to note that in case 1 of the series 5 per cent, gomenol was used, while in all the rest, except case 7, 2| per cent, gomenol was used. In the former the acute nephritis was attributed to the strength of the gomenol, causing inflammation of the renal tubules during its excretion, as no evidence of tuberculosis affecting the urinary tract was found during the patient's stay in the sanatorium. Case 2 serves to emphasise the importance of personal observation of all cases treated by oleothorax, if complete. In the only case (case 7) in which oleothorax was used as a treatment for a persistent effusion in a pneumothorax space, the result was a complete failure. With the exception of case 1, no complications attributable to the oil were met with in this series of cases. The cases treated at Pine wood sanatorium for the years 1930 to 1935 by complete oleothorax are reviewed, and the indications for oleothorax, and the results in this series of cases are recorded. Summary. I am indebted to Dr. W. C. Fowler for permission to publish these cases. Reference. 1 Gilbert, M., Tubercle, 1930, 11, 385. DISORDERS OF CARDIAC RHYTHM IN SCARLET FEVER. By J. T. Wybourn, M.B., B.S., D.P.H., Assistant Medical Officer, South-Eastem Hospital. Introduction. Cardiac arrhythmias of all varieties are not infrequently met with in the severer forms of diphtheria, but are rarely encountered in the other common infectious diseases. A number of examples have, however, been reported in acute rheumatism, influenza and the several forms of pneumonia. Scarlet fever. From the fact that such terms as "Scharlach-herz" figure prominently in continental literature, one might suppose that cardiac affections are among the common complications of scarlet fever; but, in actual point of fact, the role of scarlet fever in the production of cardiac damage is a comparatively minor one. Less than 1 per cent, of all cases of heart disease are caused by scarlet fever, and of this 1 per cent, half are preceded by an arthritis. The chief interest of the cardiac complications of scarlatina lies in their possible relationship to rheumatism. The heart may become affected in any of the following ways: (i) long continued fever; (ii) direct action of toxin; (iii) in association with nephritis, rheumatism or pyaemia. The characteristic and common lesion produced is a benign endocarditis or myocarditis. Joe, in an analysis of 24,000 cases, reported 61 cases (.25 per cent.) with cardiac lesions, while Zischinsky found only 10 cases (.05 per cent.) with heart complications in his series of 20,000 cases. As many of these figures were derived from the clinical records of hospital cases, and uniformity in the methods of examination and in the criteria of what constituted a cardiac affection was not possible, statistical variations were inevitable. Schamberg and Kolmer discovered only two examples of endocarditis in 2,213 cases. In his investigation of 670 cases, Jamieson found 20 instances of cardiac involvement; but, in Rosenbaum's series of 1,770 cases, this complication occurred 106 times, 88 of them being cases of myocarditis and 4 of them cases of endocarditis. The above writers mention only one example of cardiac arrhythmia—a case of incomplete heart block. In his thesis on cardiac arrhythmias in the infectious diseases, Tournafond describes a number of illustrative cases, but none of them was scarlatinal. Text books mention toxaemia as a cause of arrhythmia, but even such authorities as Mackenzie, Price and White make no reference to scarlet fever as a causal agent. The condition would seem to be very rare in scarlet fever. To obtain some information as to the relative frequency of arrhythmias, I investigated the hearts of 2,300 cases diagnosed as scarlet fever at the South-Eastern hospital from August, 1933, until the end of 1934. Only four cases of arrhythmia could be discovered in the series. The following are the clinical details:— Case 1.—L. Charles M., aged 30. Admitted 30th November, 1934, at 4 p.m. Previous history.—Measles, whooping-cough and chickenpox (in childhood). No previous rheumatism, syphilis, tonsillitis or suspicion of heart disease. Present illness.—Illness commenced with pains in lower limbs, headache and sore throat, 20th November, 10 days before admission. The sore throat persisted and three days before admission he had a general bright rash. On admission, 10th day.—-General condition : very ill, fading punctate erythema. Tongue peeled, fauces markedly injected. Patient restless but rational. Heart: regular, rate 110-120, A.B. V.N.L. 5th space; sounds soft, no murmurs. 40 c.c. anti-scarlet serum injected intramuscularly. Ilth day.—Patient much more restless, violent and irrational. Pulse small volume; rate rapid, rhythm completely irregular. Extremely ill. Heart: diffuse pulsation over whole praecordium. A.B. diffuse, cardiac area enlarged, rhythm irregular, first sound at apex muffled, (20) 21 rate 120-140. Liver enlarged and tender on palpation. Blood pressure: 110 mm. Throat culture : hemolytic streptococci, type ii. Blood culture: aerobic staphylococci, anaerobic nonhemolytic streptococci. Blood urea: 22 mgms. per 100 c.c. 30 c.c. anti-scarlet serum and 30 c.c. glucose, 50 per cent, given intravenously. Digitalin given orally. 12th day.-—Heart condition showed no change. 20 c.c. anti-scarlet serum and 30 c.c. glucose, 50 per cent, given intravenously. 13th day.—Marked improvement, fairly rational. Heart: rhythm more regular, A.B. V.N.L. occasional extra-systoles heard. Blood culture: sterile. 40 c.c. glucose 50 per cent, given intravenously. 14th day.—Quite rational and very much improved. Profuse general desquamation. Heart: regular, sounds normal, rate 84.92. Blood pressure: 115 mm. 17th day.—Blood culture: sterile. Patient continued to improve and was discharged fit on the 39th day, 29 days after admission. Case 2.—Lilian C., aged 12. Admitted 3rd October, 1934. Previous history.—Measles in infancy. No previous heart trouble. Present illness.—Commenced 1st October with headache and sore throat. On admission: typical scarlet fever with heart sounds normal. 40 c.c. anti-scarlet serum given intramuscularly. 4th day.—Heart: rhythm irregular with frequent extra-systoles. Temperature 101°. Pulse 128. The temperature settled to normal within twenty-four hours, but the cardiac irregularity persisted until the 35th day, when the heart was found to be normal upon examination. Patient was then allowed up for short periods. 40th day.-—Attack of praecordial "aching," with temperature 99.8°. Pulse rate 110.120. Heart examination revealed irregular rhythm with frequent extra-systoles and slight dilatation. The patient was returned to bed and the heart was examined daily. The heart was found to be normal on the 60th day, and the patient was discharged fit on the 75th day. Case 3.—Stanley E., aged 8. Admitted 30th December, 1934. Previous history.—Measles in infancy. No previous heart trouble. Present illness.—Commenced with headache and sore throat, 30th December. Admitted 1st day.—Well marked scarlet fever rash present. Temperature 102°. Heart: rhythm and sounds normal. 40 c.c. anti-scarlet serum given intramuscularly. The temperature became normal and the rash cleared up within 48 hours. 9th day.—Sudden attack of praecordial pain with temperature 100.2°. Heart: rhythm irregular with frequent extra-systoles present. Pulse irregular in rhythm with rate 124. Blood pressure: 100 mm. Patient treated with quinidine sulphate, an initial dose of gr. iiss., followed after twelve hours by gr. iii every three hours for six doses, and by Nativelle's digitalin. The heart was examined daily, and on the 20th day the heart sounds were found to be pure with no extra-systoles, and the rhythm was regular. From now onwards the heart remained normal and the patient got up on the 39th day. He was discharged on the 53rd day. He was then quite fit and no cardiac abnormality could be detected. Case 4.—Thomas M., aged 4. Admitted 4th May, 1934. Previous history.—Measles in infancy. No previous heart trouble. Present illness.—Vomiting and sore throat 3rd May. Admitted second day of disease with bright rash present. Heart: normal. 5 c.c. antiscarlet serum given intramuscularly. Patient made a quite normal progress until the 21st day, when he was permitted to get up. 22nd day.—The pulse was found to be irregular. Heart: rhythm irregular, with very frequent extra-systoles. In spite of all forms of treatment, the cardiac irregularity persisted, with frequent extra-systoles, until the 80th day, when upon examination the heart was found to be normal. Subsequently the rhythm remained regular, there were no extra-systoles and the patient was discharged on the 87th day. The above cases were the only examples of arrhythmia in the series. In a number of cases symptomless murmurs were audible. These appeared during the course of the disease, and were heard most frequently at the pulmonary area, but their transient nature suggested that they were the result of a temporary cardiac dilatation. The murmurs all disappeared before the patients were discharged. Commentary. Brelet (1920) stated that, in scarlet fever, tachycardia was frequently found in children, and bradycardia quite commonly in adolescents. Examples of tachycardia were not infrequent among my cases, but with the exception of one case, which had a tachycardia (110-140) persisting until the 40th day, this symptom does not appear to be associated with a definite carditis. Bradycardia was not met with. There was also one instance of cardiac irregularity, in which extra-systoles occurred in association with a pulmonary systolic murmur, but as there was a history of previous cardiac damage, this case has not been described. In each case the onset of arrhythmia was sudden, in a heart previously regular with normal sounds. The rate of the cardiac apical beat—by auscultation—varied Clinical signs. 22 between 90 and 120. The heart sounds were very variable with periodical softening or muffling of the first sound at the apex. At times it was impossible to distinguish between systole and diastole. Signs of some cardiac dilatation were present, as was evidenced by extension of the right border of the heart upon percussion. In the first case such signs of back pressure as an enlarged tender liver and pulsating jugular veins were found. Diagnosis. Tournafond found that a few forms of cardiac arrhythmia which are not apparent clinically are shown to be present by means of the electrocardiograph. My cases all showed definite auscultatory phenomena, and although electrocardiographic examination might have given further information, it was not necessary to establish a diagnosis. Indeed, the experience of Faulkner, Place and Ohler, who investigated by means of the electrocardiograph 171 cases of scarlet fever, suggests that electrocardiograms are not so helpful in scarlet fever as thev are in many other conditions. In 17 of their cases where cardiac damage could be demonstrated by clinical examination, the electrocardiographs failed to show any abnormality. These arrhythmias must be distinguished from the sinus arrhythmias due to the influence of respiratory movements or to the administration of certain drugs. The extra-systoles were not sporadic, but were accompanied by a definite and persistent irregularity of rhythm, the extra-systolic beats being premature, occurring before the regular beat and being followed bv a relatively long pause. Treatment. Cardiac arrhythmias in scarlet fever as in other infectious diseases do not invariably respond to specific therapeutic measures. Salicylates were tried but did not seem to be definitely effective in any of my cases. Rest in bed produced beneficial results, as in other cardiac affections. Quinidine, digitalis and strophanthin were also used, of which quiniaine seemed to produce the best results. The first case, however, showed rapid improvement after serum injection. Serum was given in all the cases, but its results were more particularly obvious in this toxic example. Prognosis. Gushing investigating the cardiac condition following scarlet fever found 24 per cent, with disorderly action of the heart, some of which he states persisted for five years. But this result is unusually high, and is not the experience of any other investigator. Faulkner, Place and Ohler examined 600 cases 1 to 3 years after being in hospital with scarlet fever, and of these they found seven with cardiac disease, of which only three had no antecedent history. In these three cases the lesions were indistinguishable clinically from "rheumatic" heart disease. The severity of the infection of scarlet fever does not always seem to bear a direct relationship to the occurrence of arrhythmia. Apart from the first, which was undoubtedly a severe toxic one, my cases were all of a mild nature. In every case the arrhythmia appeared abruptly, and as abruptly cleared up. The duration of the arrhythmias was transient, varying from two to 80 days. The prognosis seems to be favourable. Upon discharge all the hearts seemed normal, and it would therefore appear that, in the absence of an underlying rheumatic basis, an arrhvthmia is not likely to lead to permanent cardiac damage. Conclusions. (1) In a series of 2,300 cases of scariet fever, the only instances of cardiac arrhythmia were: one of auricular fibrillation and three of simple arrhythmia with extra-systoles. There were no cases of heart block, paroxysmal tachycardia or auricular flutter. In none of these cases was there a previous history of any heart disease, or of any disease, such as diphtheria, acute rheumatism, tonsillitis or pneumonia, which might produce a cardiac disorder. Nor by careful questioning could any history of "occult " rheumatism be elicited. In addition, they were all uncomplicated by either nephritis or arthritis. Arrhythmias are therefore rare in scarlet fever. (2) As almost all cases at the hospital are treated by intensive serum therapy, one must conclude that the low incidence of all forms of cardiac disorders was not 23 unconnected with the method of treatment. The early use of serum undoubtedly seems to prevent cardiac damage. (3) The older view that scarlet fever plays an important part in the production of cardiac disorders requires some modification. The present type of scarlet fever is admittedly of a comparatively benign nature ; but there are good grounds for believing that, with an extension of serum therapy, cardiac complications, which are other than rheumatic in origin, will become increasingly rare in scarlet fever. I wish to acknowledge my indebtedness to Dr. G. W. Ronaldson, medical superintendent of the South-Eastern hospital, for granting me the facilities to undertake this investigation and for his suggestions in the preparation of this paper. References. Brelet, M. Medical Science, 1920, ii, p. 156. Burnett, C. T. and Piltz, G. F. Journ. Amer. Med. Assocn., 1929, XCIII, pp. 1120-1126. Cushing, R. W. Medical Officer, 1931, XLV, p. 263. Duchosal, P. and Sciclounotf, F. Arch, du Mai. du Coeur, 1934, XXVII, pp. 109—416. Faulkner, J. M., Place, E. H. and Ohler, W. R. Amer. Journ. Med. Sci., March 1935, p. 352. Jamieson, R. A. Can. Med. Assocn. Journ., 1924, XIV, pp. 1087-1088. Joe, A. Edinb. M. J., 1924, XXXI, pp. 341-349. Place, E. H. New Eng. Journ. Med., 1932, CCVII, pp. 864-874. Rosenbaum, H. A. Arch. Int. Med., 1920, ii, pp. 424—430. Thomson, D. and Thomson, R. Ann. Pickett-Thomson Research Lab., 1930, VI, pp. 358-359. Tournafond, P. These de Paris, 1933, No. 134. Zischinsky, H. Jahrb. f. Kinderheilk., 1933, CXXVII, 337. THE DRINKER RESPIRATOR IN DIPHTHERIA, EMPYEMA AND PULMONARY COLLAPSE. By Norman D. Begg, M.D., D.P.H., and Maurice Mitman M.D., M.R.C.P., D.P.H., D.M.R.E., Senior Assistant Medical Officers, North-Eastern Hospital. The Drinker respirator is a mechanical device for administering artificial respiration over long periods. The principle involved is to induce inspiration by applying regularly and intermittently a negative pressure to the outside of the chest and abdomen. In normal respiration the active stage is inspiration. The muscles of respiration increase the capacity of the thorax and the consequent negative intrathoracic pressure causes air to enter through the mouth and nose. The Drinker respirator seeks to reproduce this in patients whose respiratory muscles are, for one reason or other, out of action. It may be contrasted with other, less physiological, methods of artificial respiration, where expiration is induced by positive pressure exerted from outside. The apparatus consists essentially of a bed on which the patient lies, with the whole of his body except the head enclosed in an air-tight metal chamber. Artificial inspiration is induced by rhythmically changing the pressure inside from atmospheric to negative by means of bellows worked by an electric motor. The magnitude of the negative pressure and, therefore, the depth of inspiration can be varied by means of valves ; and the rate of the artificial respiration is controlled by a mechanical device. In America the apparatus has been employed since 1929 for paralysis of respiration in poliomyelitis, alcoholic coma, drug poisoning, drowning, and asphyxia neonatorum. Gordon, Young & Top (1933) reported two cases of post-diphtheritic respiratory paralysis treated in the respirator. They were impressed by the possibilities of the use of the apparatus for this condition. Since February, 1934, the first respirator purchased by the London County Council for its infectious hospitals has been stationed at the North-Eastern hospital. This paper is a report on the use to which the apparatus has been put at that hospital. A preliminary note has already been published. In the present series eight cases of diphtheria, three of empyema thoracis and one of pulmonary collapse were treated. Diphtheria* To assign diaphragmatic paralysis to its proper place in diphtheria, a simple classification of the manifestations of the disease may be helpful. According to the anatomical distribution of the membrane the disease may be classified as : (i) nasal and naso-pharyngeal; (ii) oro-pharyngeal; (iii) laryngeal and laryngotracheal. The severity of the disease and the probability of complications varies directly with the original extent of the membrane, although pharyngeal membrane is more dangerous than a similar amount situated elsewhere, if obstructive manifestations are excluded. In the milder types of oro-pharyngeal diphtheria—the so-called "faucial"—membrane is limited to one or more of the structures bounding the opening of the oro-pharynx, usually to the tonsils. In the most severe types all the structures at the opening are involved: the tonsils, the pillars of the fauces, the margins of the palate and the uvula ; in addition, there is a variable extension, forwards on to the palate and backwards on to the pharyngeal wall. It is this type of diphtheria, alone or combined with others, which is responsible for a large percentage of the calamities which occur in this disease. Three definite danger periods exist. These we have named according to their principal manifestations. In our view there is a pathological basis for this division, but we do not propose to go into the evidence here. The time given for these stages is somewhat arbitrary and varies from case to case. (24) 25 (1) The toxcemic stage : ls£ week.—Evidence of toxic effects on all organs and on metabolism. (2) The cardiovascular stage: 2nd, and, to less extent 3rd weeks.—A period of circulatory disturbance with clinical and/or electro cardiography evidence of damage to the heart. The commonest lesion is myocarditis. This is associated in many cases with evidence of conductive lesions : intra-ventricular block, bundlebranch block and complete heart block. These changes often disappear before the next stage is reached. Sometimes they persist into the next stage, and may erroneously be thought to arise then. Occasionally they may persist for months or years. (3) The paralytic stage: 3rd to 6th weeks.—The manifestations suggest lesions of the nervous system. Although opinion is still divided, our view is that these lesions are central in origin, not peripheral. Cardiovascular manifestations such as premature beats, gross irregularity of the heart and hypopiesis may occur at this stage, but must be clearly distinguished from lesions of the previous stage, because we attribute all the disturbances of this stage to a central (bulbar) effect. This point is of importance because Wilson (1932) in discussing the types of respiratory failure in poliomyelitis, expressed the view that those of bulbar origin were the least amenable to treatment in tne respirator. Death may occur in any one of these stages. A patient who has had severe manifestations in the earlier stages and has survived will, in all probability, have trouble in the later ones as well. In the paralytic stage structures tend to be affected in a more or less regular sequence—the palate, the eyes, the heart, the pharynx and the diaphragm being a common order. The last two often occur together. Thus, diaphragmatic paralysis is a late complication of severe diphtheria and tends to be associated with involvement of the pharynx. Death in this stage may be due to concomitant circulatory failure, but is commonly the result of respiratory failure or bronchopneumonia. Involvement of the lung is of some importance in this paper. It depends either directly upon the paralysis of the respiratory muscles, or is secondary to accumulation of mucus in a paralysed pharynx. Therefore at this stage of the disease, the problem with which we are confronted is a failure of respiration which depends upon a paralysis of the musculature. The Drinker respirator replaces or augments the failing musculature. In table I the cases are summarised. The severity of each is indicated by the distribution of the membrane, the amount of antitoxin administered and its route, and the manifestations in the three stages of the disease. Below, clinical details are given of the paralytic stage in each case at the time the respirator was employed; and a comment is added in which the experience culled is recorded. Case 1 was of severe diphtheria with dangerous manifestations in each stage of the disease. On the 46th day diaphragmatic paresis, mainly right sided, appeared. Although the patient was not in acute distress, he was put in the respirator. The rate of the machine was 18 cycles per minute and the pressure 0 to-—18 cm. of water. On the 47th day he was tried outside the respirator, but as his breathing was now distressed and purely intercostal, he was put back again. On the 48th day breathing was still intercostal and he could not remain out of the respirator for more than half an hour without becoming uncomfortable. On the 50th and 51st days he managed most of the day outside the apparatus and was returned only at night. On the 52nd day respiration was normal and he was removed from the machine. Further progress was uneventful. This, the first case, was put into the respirator at the earliest sign of diaphragmatic paralysis. His respiratory rate adjusted itself readily to that of the apparatus and he was quite comfortable throughout. It is impossible to say how he would have fared had he not had the assistance of the respirator, but the severity of his previous manifestations and the distress which appeared when he was left out for short periods suggest that the result might not have been so fortunate. We were not convinced, however, that this case would necessarily have died. 26 Table 1. Case no. Initials, age and sex. Day of disease admitted. Distribution of membrane. A.D.S. administered (units and route). Toxæmic stage. Cardiovascular manifestations (Day of onset). Paralytic manifestations (Day of onset). Drinker operating. Result. Day of disease. Duration in days. 1 A.C., 6, M. 4th Oropharyngeal 56,000 I.M. Severe Complete heart block (12) Palate (31) 46th 7 Recovery. 64,000 I.V. Eyes (45) Diaphragm (46) 2 V.A., 6, F. 4th Oropharyngeal 120,000 I.M. Severe Myocarditis (9) Palate (37) 49th 1 Death. Nasal. 40,000 I.V. Intraventricular block (10) Heart (44) Pharynx (44) Diaphragm (49) 3 H.C., 16, M. 3rd Oropharyngeal (mixed streptococcal infection). 112,000 I.M. + Moderate - Palate (43) 50th 1 Death (P.M.). 20 c.c. A.S.S. Pharynx (47) Diaphragm (50) 4 E.D., 3, F. 3rd Oropharyngeal 56,000 I.M. Severe Complete heart block. Palate (17) 45 th 7 Recovery. Nasal. 36,000 I.V. Myocarditis (7) Pharynx (17) Heart (34) Eyes (41) Face (44) Pharynx (44) Diaphragm (44) 5 P.L., 2 5/12, F. 6th . Oropharyngeal 56,000 I.M. Severe Intraventricular block. Palate (36) 44th 4 Recovery. 40,000 I.V. Myocarditis (9) Pharynx (36) Heart (42) Diaphragm (42) Eyes (44) Face (47) 6 B.B., 3, M. 5th Oropharyngeal 64,000 I.M. Moderate - Heart (40) 47th 8 Recovery. Pharynx (47) Diaphragm (47) 7 N.F., 4, F. 4th Oropharyngeal 96,000 I.M. Moderate - Palate (38) 44th 2 Death. Pharynx (44) Diaphragm (44) 8 T.S., 5, M. 4th Oropharyngeal Nasal. 80,000 I.M. Severe Myocarditis (7) Palate (21) 37th 15 Recovery. 64,000 I.V. Pharynx (29) Eyes (32) Diaphragm (36) A.D.S.—Antidiphtheritic serum. A.S.S.—Antiscarlatinal serum. I.M.—Intramuscularly. I.V.—Intravenously. 27 Case 2 was one of severe diphtheria. Toxaemic and cardiovascular manifestations were marked. The paralytic stage commenced on the 27th day with paralysis of the palate. On the 44th day the rhythm of the heart was tic-tac in character, and the pharynx was paralysed. On the 49th day she became pyrexial; respirations became rapid and jerky ; diaphragmatic excursion was poor. She was put in the respirator but was undoubtedly worse. Her respiratory rate was 40, and failed to adjust itself to that of the machine. An attempt was therefore made to adjust the rate of the respirator to hers. This also failed, firstly because the respiratory rate was irregular, and secondly because it was too rapid. In an attempt to get some degree of synchronisation between the two rates, that of the respirator was diminished to 20, that is, half the patient's, in the hope that alternate respirations would be assisted by the apparatus. This also failed. In consequence, she was struggling against the action of the machine. She became restless and her colour worse. Moreover, mucus was accumulating in the paralysed pharynx. Attempts to keep this clear by the use of an electrically operated aspirator were in some measure successful. Nevertheless, after four hours in the respirator her condition was worse and she was removed and was never put back. On the 50th day definite signs of consolidation appeared in the lungs, particularly at the right base, and on the 52nd day she died. Permission for a post-mortem examination was refused. From this case valuable experience was gained and can be classified under three headings: (1) The first is concerned with the synchronisation of the two rates, that of the patient and that of the machine. We realised that some patients could not adjust their rate to that of the respirator and that attempts to make the machine conform with the patient were unlikely to succeed. In such cases, no assistance, but rather actual harm, must be expected and a bad prognosis anticipated. (2) The second is concerned with the concomitant pharyngeal paralysis which occurs frequently with the diaphragmatic. The accumulation of mucus in a paralysed pharynx can be controlled by postural drainage through the nose (by raising the foot of the bed), by aspiration, and by manual removal. Since our respirator could not be tilted (see fig. 1), we were deprived of the valuable procedure of postural drainage, and frequent aspirations were necessary to keep the pharynx clear. (Respirators which can be tilted are now in use in the Council's hospitals—see fig. 2.) (3) The third is concerned with the prognostic significance of exudative changes in the lungs. It was soon obvious that this case, showing pneumonic signs and a rapid respiration rate, was going to do badly. Case 3 was complicated by a super-added streptococcal infection. There was ulceration as well as membrane on the fauces. Eight days later this had healed. On the 43rd day after the patient had been allowed up, paralysis of the palate appeared: he was put back to bed. The pharynx was involved four days later. On the 50th day he became critically ill with signs of diaphragmatic paralysis and exudative changes in the lungs. Mucus accumulated in the pharynx; coarse rales appeared at both bases; the percussion note at the left base was impaired; breathing was chiefly intercostal; the temperature rose to 101°, and the respiratory rate to 30. That afternoon he became acutely dyspnceic and death appeared imminent. He was put into the respirator, but his respiratory rate did not alter, he became restless, and obtained no relief. After half an hour a transient improvement occurred; his breathing became a little easier and his colour improved. His pulse, however, gradually failed and he died 5 hours after entering the machine. A post-mortem examination revealed fairly extensive bronchopneumonia. In this case, the severity of the paralytic manifestations was greater than was anticipated. The patient was not put into the respirator until late, by which time there was definite evidence of lung involvement. Our experience in this case was in conformity with that of case 2. In addition, the danger of delaying the use of the respirator was emphasised. Case 4 was critically ill on admission, and her general condition was extremely poor. During the cardiovascular stage she had uncontrollable vomiting and subsisted for eight days on intravenous glucose, without which she would have died. The paralytic stage commenced on the 17th day with involvement of the palate and pharynx. Ocular and facial manifestations followed. On the 44th day the diaphragmatic movements were impaired for the first time. She was put in the respirator, the pharynx was aspirated regularly, and she was fed nasally. Next day the paralyses of the pharynx and diaphragm were complete. The rate of the respirator was 18 cycles per minute and the pressure 0 to -—16 cm. of water. Her response was immediate and striking. Before, she was a restless and difficult child, sleeping badly and breathing with 28 fig. 1. fig. 2. 29 considerable difficulty. In the respirator her respiratory rate responded to the instrument, she became quiet and peaceful and slept readily. Without the respirator she was incapable of breathing for even short periods. On one occasion when the apparatus was stopped for the purpose of giving a nasal feed, she rapidly became acutely dyspnoeic and cyanotic, but was immediately relieved when the motor was restarted. For the next four days no diaphragmatic movement could be detected. On the 50th day there were signs of a commencing return and on the 51st day she was removed from the instrument. This was the most severe case in this series. There can be no doubt that the patient would not have survived without the assistance of the respirator. She was put in at the first sign of paralysis and her respiratory rate responded immediately— a good prognostic sign. Moreover, the sedative effect of relieving her of the effort of breathing was most marked. Before this case we had considered it advisable to stop the motor when giving a nasal feed. From this case we learnt that, not only was it unnecessary, but it might be positively dangerous to do so. Case 5 had severe diphtheria with multiple paralyses in the third stage. On the 42nd day the intercostal muscles began to overact. She was given one nasal feed a day. . On the 44th day the diaphragmatic paralysis became more marked and she was put in the respirator, with pressure of 0 to —16 cm. of water at a rate of 18 per minute. She accommodated herself immediately to the rate of the respirator and received immediate relief from her respiratory distress. By the 46th day she was able to stay out of the respirator for short periods and next day, diaphragmatic movement having largely returned, she was removed. Thereafter progress was uneventful. We were, by now, conversant with the type of case suitable for the respirator, with the accessory lines of treatment necessary, and with the probable prognosis. This case, although severe, gave rise to little anxiety, yet she could not have survived without the respirator. Case 6 was one of moderate severity, but was complicated by the presence of old pulmonary trouble. Coarse rales were scattered over the chest and persisted throughout the illness. He had a history of two previous attacks of pneumonia. Clinical and radiological evidence suggested early bronchiectasis. The diphtheria responded to treatment, but on the 35th day the cough became more frequent and the moist sounds on the chest increased. No evidence of consolidation was detected. On the 40th day he vomited ; his colour became poor, and the heart rhythm was rapid and tic-tac in character. The ala; nasi were working. On the 47th day he developed a pharyngeal paralysis with a typical cough. Diaphragmatic movement was poor and the intercostals were overacting. He had an attack of dyspnoea with accumulation of mucus in the pharynx and was put in the respirator. The respiratory rate, which was 40, settled at once to that of the machine, which was 22. Pressures employed were 0 to —12 cm. of water. Nasal feeding and aspiration of the pharynx were instituted. He experienced immediate respiratory relief and the tall in respiration rate was accompanied by a fall in pulse rate. On the 48th day no diaphragmatic movement could be detected and he became dyspnoeic and restless without the respirator. On the 49th day, owing to a mechanical defect, the respirator broke down, and we had an unwelcome opportunity of seeing what he was like without the machine. He rapidly became dyspnoeic and cyanosed and during one severe attack of dyspnoea he looked like dying. Fortunately, after about half an hour the defect was remedied, the machine was restarted and he rapidly improved again. The return of diaphragmatic movement was slow. By the 51st day he was able to do without the respirator for short periods, and on the 53rd day he was removed. He ultimately recovered completely. In this case we did not consider the prognosis good because of the moist sound in the lungs. These, however, were due to previous chest trouble and were not the result of the disease. He was put into the respirator early, and it seems a reasonable inference that he was saved from an attack of bronchopneumonia with a probable fatal result. The rapid response of his respiratory rate was a good prognostic sign. The accompanying fall in pulse rate was in itself valuable, as it entailed less work for the heart. That he could not have lived without the respirator was convincingly demonstrated during the short time the apparatus failed. Case 7 was one of moderate severity and made good progress until the 38th day, when palatal paralysis appeared. On the 44th day the pharynx was paralysed, the heart rhythm was tic-tac, and she commenced vomiting. That night respirations became jerky and diaphragmatic paresis appeared. Although not acutely distressed, she was put in the respirator and remained comfortable for the next twelve hours. She had bouts of dyspnoea associated with accumulations of mucus in the pharynx, but c 30 these were relieved by aspiration. Nevertheless. the pulse became very poor, cardio-vascular weakness increased and she died 30 hours after entering the machine. Diaphragmatic involvement was never marked in this case. The striking feature was the progressive cardio-vascular failure, which in this stage of the disease we believe to be of central (bulbar) origin. Case 8 was one of severe diphtheria in all stages of the disease. Paralysis appeared early, with involvement of the palate on the 21st day. Complete pharyngeal paralysis developed on the 29th day and was followed three days later by ocular paralysis. On the 36th day diaphragmatic movement was impaired for the first time. He was put in the respirator next day, although some diaphragmatic movement could still be detected. On the 38th he could not remain out of the machine without respiratory distress appearing, and by the 39th day diaphragmatic failure was complete. Whilst in the respirator he received complete relief, but it was necessary to keep him in until the 51st day. As the result of our accumulated knowledge, this severe case gave rise to no anxiety. He was put in the respirator early, responded well, and cleared up in fifteen days, a longer period than had been necessary in any of the other cases. The experience culled from the series is summarised below:— (1) Cases must be put in the respirator early, as soon as diaphragmatic paralysis is suspected, otherwise there is considerable danger of bronchopneumonia developing. (2) When exudative changes are present in the lungs, the respirator is of little or no value (3) The pharyngeal paralysis which so frequently accompanies the diaphragmatic must be treated thoroughly. Owing to the fact that the respirator employed was not tiltable, the valuable procedure of postural drainage could not be employed. Mechanical aspiration and manual removal of mucus are, however, adequate if carried out thoroughly. Nasal feeding is usually necessary and should be done without stopping the machine. (4) The patient should be retained in the respirator continuously. Among the recoveries, the shortest period necessary was 4 days and the longest 15 days. This provides valuable, and hitherto unknown, information concerning the natural duration of diaphragmatic paralysis in diphtheria. When there are signs that movement of the diaphragm is returning, the patient can be tried without the apparatus for short periods. (5) If the respiratory rate of the patient is grossly abnormal, no attempt should be made to synchronise the respirator with it; rather, the apparatus should be adjusted to a rhythm of about 20 per minute in the expectation that this will be imposed upon the patient. (6) Positive pressures are without advantage and sometimes produce discomfort. Negative pressures need not be great. A variation of from 0 to -16 or -18 cm. of water is usually the maximum required. Hyper-ventilation, which has been practised in America to produce periods of apnoea whilst the patients are receiving attention, was not attempted in our series. (7) A patient who is going to improve responds in a definite manner: (a) his respiratory rate adjusts itself almost immediately to that of the machine; (b) cyanosis and dyspnoea rapidly disappear ; (c) restlessness, due largely to violent respiratory efforts and the consequent embarrassment of a heart already labouring under difficulties, disappears. The rate of the pulse falls, its quality improves, and not infrequently the patient falls into a restful slumber. This sedative effect can be most striking. Cases which fail to respond in this way are unlikely to derive benefit from the respirator. Such cases are usually those in whom bronchopneumonia has appeared. (8) The equable and slightly raised temperature which was maintained inside the respirator by the heating lamp appeared to have a beneficial effect upon the circulatory collapse which occurs in this stage of the disease. Of the five cases which recovered, four would certainly have died without the assistance of the respirator. Of the three deaths, two had evidence of commencing bronchopneumonia before entering the respirator. In both the respiratory rate of the patient failed to adjust itself to that of the machine; in consequence, no relief 31 was provided. One was in for four hours only, the other for five hours. In the third case the respiratory distress was relieved, but death appeared to be due to circulatory failure of bulbar origin. We have been unable to find any reference in the literature to the use of the Drinker respirator in empyema. The three cases here described suggest a new and valuable field for the use of the apparatus. Empyema. Case 1.— The first case was that of a child of 1¾ years, admitted for measles and bronchopneumonia. A localised pneumococcal empyema in the right middle and outer pulmonary zone was treated by aspiration and later by rib resection. Progress was extremely slow, and 54 days after the operation the wound was still discharging. Repeated X-ray examinations showed that the only abnormality present was a collapsed lung, which, owing to its failure to expand, prevented the cavity from closing. As the child was too young to be taught to inflate its lungs by respiration against resistance, it occurred to one of us (M. M.) that the respirator might be usefully employed to expand the lung by negative external pressure. The healthy side of the chest was strapped and the patient put in the respirator for one hour daily at pressures of 0 to -18 cm. of water. Four such treatments sufficed to expand the lung and the wound healed six days later. A later X-ray showed only a narrow band of opacity to indicate the site of the former cavity. The success which attended this experiment was so immediate and so striking that it was decided to try another case which was proving troublesome. This was not a simple case such as the one just described. Nothing definite was hoped for and, as it happened, a successful issue was not obtained, but definite improvement occurred. Case 2 was a female of 4 years who had previously suffered from asthma and several attacks of pneumonia. She was admitted for whooping-cough and pneumonia. Six weeks after admission she developed a pneumococcal, interlobar empyema which ruptured into a bronchus and infected the general pleural cavity. Despite a rib resection, progress was negligible ; the wound continued to discharge and she remained desperately ill for weeks. Several X-rays revealed an empty cavity in the mid-pulmonary field with collapse of the base of the lung. As all efforts at inflation failed to expand the lung, she was treated in the respirator on the same lines as case 1. The discharge diminished at once and her general condition improved. An X-ray showed that the basal collapse had largely disappeared and treatment was discontinued. The discharge immediately increased in amount, but diminished when treatment in the respirator was restarted. After seven days' treatment, the discharge only amounted to an occasional bead of pus, and an X-ray showed evidence of permanent fibrotic changes in the lung. At the request of her parents she was allowed to attend an out-patient department. We are of the opinion that this case derived definite benefit from the respirator. The beneficial effect was due to the fairly rapid disappearance of the pulmonary collapse. All the other abnormalities were unaffected by the apparatus. Case 3 was a male of 6. years admitted for scarlet fever. Six days before admission he was operated upon for a right-sided pneumococcal empyema. Ten days after admission he was still pyrexical and the wound was discharging profusely. An X-ray examination revealed collapse of the right base, and an injection of lipiodol demonstrated an air-containing empyema cavity. 24 days after the operation there was no diminution in the discharge. He was put in the respirator daily as in the two previous cases. After three such treatments there was marked improvement in his general condition and the discharge had diminished in amount. At the time of writing he has been in the respirator 10 times and is making marked progress. The discharge has almost ceased and there is radiological evidence of expansion of the lung and closure of the cavity. B. H., aged 5 years, was a case of partial, acute pulmonary collapse who did not respond to treatment in the respirator. Six days before admission he had an anaesthetic (gas) for the extraction of a tooth. The day before admission he developed a sore throat and a harsh cough, and on 6.5.35 was sent to the North-Eastern hospital as a case of laryngeal diphtheria. On direct laryngoscopy no membrane was seen, but the larynx was injected. Swabs showed a few colonies of hœmolytic streptococci, but no diphtheria bacilli. The diagnosis of diphtheria was, therefore, not confirmed. He made satisfactory progress for 10 days, except for the persistence of the cough. He had been pyrexial on the day of admission only. On the 11th day there was a recurrence of pyrexia and the cough increased in frequency. Fourteen days after admission (20.5.35) an X-ray examination was performed and a small triangular area of collapse found at the right base obscuring the cardiophrenic angle. He was put in the respirator for half-an-hour and re-X-rayed immediately afterwards, when the appearances suggested a slight improvement. Next day he was again put in. Three hours later his temperature rose to 104° and the cough became more troublesome. On clinical examination the right base was found to be impaired and air entry diminished. The temperature settled next day and he was X-rayed again. He now had a much more extensive collapse of the right base. It was decided to discontinue the use of the respirator. In the next five days he was mildly pyrexial. After this the temperature Idiopathic pulmonary collapse. 32 remained normal and the cough diminished in amount. Fourteen days after the extension of the pulmonary collapse the physical signs had cleared up and an X-ray showed complete reexpansion of the lung. There is no doubt that, although undergoing treatment in the respirator, an extension of the pulmonary collapse occurred in this case. The association in time was sufficiently close to render the treatment suspect. If the respirator is held responsible, the question arises as to whether it was unwise to institute treatment during the acute pyrexial phase; or whether this type of case is unsuitable for treatment along these lines. With our limited experience we can say that, in empyema, where the collapse is due to external compression, the respirator acts almost magically; with collapse due to some intrapulmonary cause, our experience in one case has not been so happy. Summary. 1. The use of the Drinker respirator in eight cases of diphtheritic diaphragmatic paralysis is described. Such practical points as the type of case, the most suitable time for commencing treatment, and the details of the working of the apparatus are recorded. The conclusion is reached that the respirator is a necessary adjunct to the treatment of this complication. 2. A new and promising use for the respirator is described. In three cases of empyema in which the lung failed to re-expand after operation, a few short treatments in the apparatus were sufficient to produce rapid re-expansion. A case of collapse of the lung of intrapulmonary origin was not benefited by the respirator. We desire to acknowledge our indebtedness to Dr. W. Gunn for placing his American experience of the apparatus at our disposal; and to Dr. E. H. R. Harries, medical superintendent of the North-Eastern hospital, for his valuable co-operation and encouragement, and for his permission to publish these cases. BIBLIOGRAPHY. 1929. Drinker, P., and McKhann, C F. The use of a new apparatus for the prolonged administration of artificial respiration. 1.A fatal case of poliomyelitis. J.A.M.A., 92:16581660 (May 18). 1929. Drinker, P., and Shaw, L. A. An apparatus for the prolonged administration of artificial respiration. 1. Design for adults and children. Clin. Investigation, 7:229-247 (June 20). 1929. Shaw, L. A., and Drinker, P. An apparatus for the prolonged administration of artificial respiration. 2. A design for small children and infants with an appliance for administration of oxygen and carbon dioxide. Jour. Clin. Investigation, 8:33—46. (Dec.) 1929. Wightman, H. B., and Shaughnessy, T. J. A case of respiratory failure treated in the Drinker respirator. J.A.M.A., 93:456-457 (Aug. 10). 1930. Shambaugh, G. E., Jr., Harrison, W. G., Jr., and Farrell, J. I. Treatment of the respiratory paralysis of poliomyelitis in a respiratory chamber. Report of three cases with one recovery. J.A.M.A., 94:1371-1373 (May 3). 1930. Murphy, D. P., and Coyne, J. A. The use of a modified Drinker respirator in the treatment of asphyxia neonatorum. J .A.M. A., 95:335-338 (Aug. 2). 1930. Drinker, P., Shaughnessy, T. J., and Murphy, D. P. The Drinker respirator, Analysis of case reports of patients with respiratory failure treated from October, 1928, to June. 1930. J.A.M.A., 95 : 1249-1252 (Oct. 25). 1931. Murphy, D. P., Wilson, R. B., and Bowman, J. E. The Drinker respirator in the treatment of the immediate asphyxia of the new born. With a report of 35 cases. Am. J. Obst, and Gysnœc. 21:528-536 (April). 1931. Murphy, D. P., Drinker, C. K., and Drinker, P. The treatment of respiratory arrest in the Drinker respirator. A clinical and experimental study. Arch. Int. Med. 47 : 424-435 (Mar.). 1931. Wilson, J. L. Treatment for respiratory paralysis in poliomyelitis with the Drinker respirator. Tr. Am. Pediat. Soc., 43 : 35-36 (April 15-17). 1931. Drinker, P. Prolonged administration of artificial respiration. Lancet, i. 11861188 (May 30). 1931. Wilson, J. L. Types of respiratory failure in poliomyelitis. Indications for use of the Drinker respirator. New England J. Med., 205: 597-598 (Sept. 17). 1932. Wilson, J. L. Acute anterior poliomyelitis. Treatment of bulbar and high spinal types. New England J. Med., 206:887-893 (April 28). 1932. Wilson, J. L. Respiratory failure in poliomyelitis. Treatment with the Drinker respirator. Am. J. Dis. Child., 43:1433-1454 (June). 1932. Murphy, D. P., and Sessums, J. V. Asphyxia neonatorum. Its causes and treatment by prolonged artificial respiration : report of 66 cases. Surg. Gynœc. and Obst., 55:432439 (Oct.). 33 1933. Legg, A. T. The use of the Drinker respirator in the after care of infantile paralysis. J.A.M.A., 100:647-648 (Mar.). 1933. Smith, E. Respiratory failure and the Drinker respirator in poliomyelitis. J.A.M.A., 100 : 1666-1670 (May 27). 1933. Drinker, P., and Wilson, J. L. Room sized respirator. New England J. Med., 209:227-230 (Aug. 3). 1933. Wolfe, E. F., and Murphv, D. P. Relief of cardiac dyspnoea by Drinker respirator. J.A.M.A., 101:593 (Aug. 19). 1933. Brahdy, M. B., and Lenarsky, M. Treatment of respiratory failure in acute epidemic poliomyelitis. Am. J. Dis. Child. 46 : 705-729 (Oct.). 1933. Gordon, J. E., Young, D. C., and Top, F. H. Management by mechanical respirator of post-diphtheritic respiratory paralysis. J. Pediat., 3:580-585 (Oct.). 1934. Crone, N. L. Treatment of acute poliomyelitis with respirator. New Eng. J. Med., 210:621-623 (Mar. 22). 1935. Mitman, M., and Begg, N. D. A note on the value of the Drinker respirator in diphtheria, empyema and pulmonary collapse. Lancet, i. 1438-40 (June 22). VULVO-VAGINAL DIPHTHERIA. By W. A. Brown, M.D., D.P.H., Senior Assistant Medical Officer, Brook Hospital; and J. E. McCartney, M.D., Ch.B., D.Sc., Director of Research and Pathological Services. Diphtheritic infection of the genital organs in the female has been recorded at irregular intervals in the medical literature for the past 40 years. In a search covering a period of 30 years up to 1923, van Saun1 was able to find reports of 26 cases. The value of a considerable number of these was diminished by the fact that, in many instances, no bacteriological confirmation was produced, and in others the morphological diphtheria bacilli found were not subjected to virulence tests. Of the 26 cases collected, positive cultures were obtained in 15, virulence tests performed in 6 and 4 deaths occurred. In most of the cases the local lesion was preceded by nasal or faucial infection, but in 6 instances a primary genital origin was suggested. It is stated in the Medical Research Council's monograph2 on diphtheria, in referring to infection of the genitals, that " no instance in the literature has come to our notice in which the identity of the bacillus has been completely established." Since 1923 Unseld3, Smordinzeff4, Grant5, Wallfield and Litvak6, and other writers have recorded cases. Ker7 mentions a case of primary vulval diphtheritic infection in a woman during the puerperium. The following clinical notes and post-mortem findings refer to a case admitted to the Brook hospital:— M. E. W., aged 10 years. History.—18th November: Abdominal pain. 20th November: Redness and swelling of vulva. Pain on micturition. 21stNovember: Vaginal discharge. 22nd November: Vulvar inflammation and swelling increased. Ulceration of skin behind anus. Pain on micturition and defœcation. 23rd November: Condition became slowly worse during the following week. 1st December: Admitted to a general hospital. 4th December: Cultures showed the presence of diphtheria bacilli and patient was transferred to the Brook hospital. On admission—Extensive oedema, inflammation and superficial ulceration of the whole vulva, extending upwards to pubic area. The affected area was covered with a patchy purulent deposit which in parts showed evidence of thin membrane formation. Ulcers, about the size of a florin, were present on the gluteal region, intergluteal sulcus and immediately behind the anus. There was a profuse, thin, purulent vaginal discharge. The inguinal area showed purplish discolouration with adenitis and periadenitis. Examination of the labia minora and vaginal orifice was impossible owing to marked pain and tenderness. General condition of patient satisfactory. No evidence of diphtheritic toxœmia. Temperature 100.4° F., falling to normal in 24 hours. Pulse rate 100-110. Bacteriological examination showed:—Nose, non-virulent diphtheria bacilli present; throat, no diphtheria bacilli found; vulva, virulent diphtheria bacilli present; vulval smear, no gonococci seen. 7th December.—Local condition somewhat improved—vulva much cleaner. Patient's general condition good—appetite normal—-sleeping well. 8th December.—Sudden collapse and death in a few seconds without warning. Treatment.—24,000 units of. diphtheria antitoxin intramuscularly on admission, repeated in 24 hours. Locally—-Irrigation with sod. bicarb, solution and boric fomentations four hourly. Post-mortem examination. The post-mortem findings were as follows:— External.—On separating the labia the whole of the vulva and labia minora were found to be extremely congested and covered with definite yellowish fibrinous membrane. The inflammatory condition had spread upwards into the vagina. The heart showed evidence of right-sided failure. The right auricle was markedly dilated, filled with blood and dark purple in colour. The right ventricle was also distended with blood in contrast to the left ventricle which was in systole. The superior and inferior vense cavse were distended with blood, and the other mediastinal veins were prominent. The heart muscle was pale in colour. Extensive ante-mortem clot was present in the right auricle and ventricle. There was also a small amount of ante-mortem clot in the left side. The valves were normal and there was no evidence of congenital abnormalities. Trachea and bronchi.—Congested. The lungs were voluminous, dark in colour but not consolidated. On section there was considerable congestion and oedema, but no evidence of disease. (34) 35 Thymus.—Normal. Stomach and intestines.—Normal, slightly congested. The suprarenals were very dark in colour and appeared somewhat enlarged. On section marked congestion was found. The kidneys were very congested and there was a definite pyelitis on both sides. The liver was dark in appearance and congested on section. The spleen was small, firm and showed very little congestion. Bladder.—On opening the bladder a definite congestion and cystitis was demonstrated. Uterus.—The cervix showed intense congestion and excoriation, and there was evidence of the remains of fibrinous membrane around the external os. Brain.—Not examined. A microscopical examination showed:— Heart.—Severe toxic myocarditis. Many fibres were vacuolated and had lost their nuclei, while others showed marked nuclear degeneration. The blood vessels were congested. Adrenal.—Very congested. There was marked toxic degeneration of the cells of both the cortex and the medulla. Kidney.—Congestion, marked tubular nephritis and commencing proliferation of Bowman's capsule were present. Liver.—Very congested, and showed marked cloudy swelling. Lung.—Extreme congestion, no consolidation, a little oedema. Many of the alveoli contained endothelial cells. The bronchi were normal. Ovary.—Congestion, particularly of the vessels of the hilum, was present. Uterus.—Very congested, with some desquamation of the mucous membrane. Vagina and os uteri.—There was congestion, desquamation of the epithelium and fibrin formation with granulation tissue. Microscopical examination Apart from the localisation of. the disease the interesting feature of this case was the satisfactory general condition of the patient in spite of such an extensive infection of the genitals. The absorption of toxin from the affected area must have been considerable and yet the patient showed no signs of a severe toxaemia. Death was due to cardiac failure consequent upon a severe toxic myocarditis. The weakened heart muscle became dilated, assisted, no doubt, by the suprarenal exhaustion. The toxic nature of the condition is seen in the severe degenerative changes in the various organs. References. 1 van Saun, Anna I., 1923, J. Infect. Die., 33, 124-129. 2 Medical Research Council, 1923, Diphtheria, 230. 3 Unseld, E; 1933, Monatschr. f. Geburtsh. u. Gvnak., 93, 177. 4 Smordinzeff, N. A., 1932, Zentralb. f. Gynak., 56, Aug. 27. 6 Grant, J., 1934, Brit. Med. Journ., I, 1,074. 6 Wallfield, M. J., and Litvak, A. M., 1933, J. Pedial., 3, 756. 7 Ker, C. B., 1929, Infectious Diseases, 392. AN ANALYSIS OF A SERIES OF CASES OF MENINGOCOCCAL MENINGITIS. By J. C. Blake, M.B., B.S., D.P.H., M.R.C.S., Senior Assistant Medical Officer, Eastern Hospital. This small series comprises the cases under my charge at the Eastern hospital during the period from March, 1932, to the date of writing this article. Nineteen patients were treated. Statistics from so small a number of cases cannot be of much significance, but they may be of value when added to those published by other observers. It is intended in this article to emphasise certain points in the treatment of this disease. The death-rate in this series was 36.8 per cent. The accompanying table gives the rate in age groups. The oldest patient treated was 29 years of age. Table I. Age. Number of patients. Deaths. Death rate per cent. 0-5 years 6 2 33.3 5-20 „ 7 1 14.3 Over 20 years 6 4 66.6 The following facts are also given in tabular form for the sake of brevity:— Table II. Average duration of illness. Average number of days illness prior to treatment. Average total dosage of serum. Bacteriological findings. Group I. Group II. Meningococcus present, but not isolated. Recoveries 63 days 6 . 1 days 120 c.c. 2 cases 2 cases 8 cases Deaths 15 days 3.3 days 100 c.c. nil 4 cases 3 cases From the above table it would appear that the length of illness prior to treatment is not necessarily a factor of importance in prognosis. This depends more on the type of disease, as borne out by the fact that five out of seven deaths had purpuric or petechial rashes on admission to hospital, whereas only one of the recoveries developed a rash during the course of the disease. The percentage of group II infections is unusually high. Complications. Complications were not frequent if transient cranial nerve palsies are excluded. They comprised two cases of unilateral facial paralysis, one of ptosis, also unilateral, one external rectus palsy, and one of diplopia in which no weakness of external ocular muscles could be detected. Two cases of nerve deafness were observed, both occurring during the first week of the disease. One made a complete, the other a partial, recovery. One child, aged four, had marked spastic ataxy which improved slowly. There was one case of chronic hydrocephalus. Arthritis accompanying serum sickness occurred in two cases. Treatment. The multivalent concentrated serum obtained from the Lister Institute was used in all cases, and the majority responded rapidly to its use. In the earlier cases, serum was given by the intramuscular and intrathecal routes only, except in one instance. Latterly, all cases received serum intravenously in addition. I am now convinced that every case should be given serum intravenously, even though the septicæmic symptoms are slight. It is my practice to give at least two intravenous injections at eight to twelve hours' interval. In cases with purpuric rashes, and other symptoms of general infection, intravenous therapy must be more prolonged. (36) 37 Cistern puncture was performed in four cases and on eleven occasions. each instance, a dry lumbar puncture was previously obtained at several levels. three cases the cistern eventually became dry with development of internal hydro cephalus. In the fourth case, after two cistern punctures, continuity with the spinal suprachoroid space was re-established, the patient made a good recovery and was in good health six months after discharge from hospital. In Cistern In puncture. The amount of serum given by the intrathecal route should be governed by the amount of the fluid withdrawn, the volume of the former being slightly less than the latter. Serum treatment is continued until meningococci disappear from the cerebrospinal fluid. If special media are not available, the treatment can be controlled by incubating the cerebrospinal fluid and examining it each day before the next puncture is performed. By this method only one unnecessary dose of serum is given and the risk of producing a serous meningitis is minimised. Daily examination of the fluid should be continued until it becomes clear. Better results might be obtained by the use of monovalent serum. This has been impracticable up to the present, owing to the time taken to type the organism. The monovalent precipitin reaction described by Maegraith (Lancet, 9th March, 1935), if it became generally available, would appear to solve this difficulty. It is hoped to apply this method of diagnosis at this hospital. Dosage of serum. THE PERIODIC INVESTIGATION OF THE ERYTHROCYTE SEDIMENTATION RATE IN RHEUMATIC CHILDREN. By R. S. C. McDade, M.A., M.B., B.Ch., Assistant Medical Officer, High Wood Hospital. The decision as to whether or not a case of rheumatism in a child is active, is in many instances a matter of very considerable difficulty ; and it has been felt that some reliable routine test which would supplement the clinical findings in such cases would be of real value in the treatment of the disease. During the last few years several writers—Bach and N. Gray Hill1,3, W. W. Payne2, C. Bruce Perry4 and others—have shown how closely the erythrocyte sedimentation rate parallels the clinical course of rheumatic carditis, and have indicated the value which this test may prove to have in the estimation of the activity of such cases. During the last eight months at High Wood hospital, erythrocyte sedimentation rate estimations have been performed each month on every case of rheumatism, with a view to assessing the value of the test as a routine measure in the treatment of cases of this kind. The method employed has been the Westergren method, and any reading higher than 10 on the Westergren scale has been considered abnormal. Each reading is taken once only, at the end of one hour. The test has been carried out on 246 cases, and in each case several monthly readings have been obtained and charted. Some of these were cases which had been in hospital some little time before the routine sedimentation tests were introduced, and in which activity had appeared to have ceased. Others were admitted after the introduction of the tests, and a series of monthly readings is being obtained throughout the whole length of their stay in hospital. It has, moreover, been the custom to carry out the erythrocyte sedimentation rate test on the day preceding the ordinary routine examination of the patient, and it has, therefore, been possible to obtain an outline of the clinical picture at the •time each test was performed. Out of the 246 cases on which the test has been periodically carried out, 85 showed at some time during the last eight months clinical evidence of activity. Out of these 85 cases 76 (i.e. 89 per cent.) showed E.S.R. readings which were above 10 over a definite period. The remaining 9 cases (i.e. 11 per cent.) showed no rise in the E.S.R. reading. The nature of these 9 cases was as follows:— In seven cases active chorea was present, but no other rheumatic manifestation. In one case rheumatic carditis was present, but in this case, although some clinical evidence of activity appeared to be present, there was considerable doubt as to whether the disease really was active. The ninth case was one of carditis, in which activity had apparently ceased before the periodic E.S.R. tests were commenced, and a series of normal E.S.R. readings was obtained. The patient then had a very severe relapse during which the signs of congestive oedema rapidly appeared and the patient died. The E.S.R. did not in this case rise above 10 after the relapse had taken place, when the carditis was undoubtedly active. The E.S.R. test, however, was not carried out during the short interval between the onset of the relapse and the appearance of the congestive oedema; and this may be a possible explanation of the failure of the E.S.R. to rise. C. Bruce Perry4 has described two cases of congestive oedema, occurring in cases of active rheumatic carditis, in which the E.S.R., which during the period of activity had been raised, fell below 10 when the oedema appeared. In one of these cases the patient recovered, and the E.S.R. rose again with the disappearance of the (38) 39 œdema. Perry explains this by assuming a change in the plasma proteins coincident with the oedema, and there is abundant evidence that these play an important part in the sedimentation rate of the blood. Thus it will be seen that, of the 9 cases in which there was evidence of activity with a normal E.S.R., 7 cases had chorea only—no carditis or other rheumatic manifestation. And of the 2 cases in which carditis was present, in one the activity of the rheumatism was not definitely established, and in the other congestive oedema was present. The 76 cases, in which clinical evidence of activity was combined with a raised E.S.R. reading over a definite period, have been divided into three groups according to their activity as judged by the ordinary clinical standards. Group “A” were very active cases. These numbered 27. In all these cases, with the exception of one, the E.S.R. readings were over 50; and in all of them the readings were over 40. The clinical evidence of activity was based on the following considerations:— (1) Pulse rate.—(a) During the day. In all the cases in this group the pulse rate taken when the child was awake, but at rest during the day, was between 110 and 142. In 9 cases out of the 27 it was over 130 ; and in only 5 cases was it less than 118. (b) During sleep. The sleeping pulse rate in this group varied between 80 and 122. (2) Temperature.—This was raised in 20 cases out of the 27. In 17 cases there was an evening temperature of 100° or higher. In 3 cases there was an evening temperature which varied between 99° and 100°. The 7 remaining cases were afebrile. (3) Cardiac change.—(a) The appearance of a murmur. An apical systolic murmur, which was conducted out into the axilla, appeared in each case in this group. In 9 cases a double mitral murmur was present, and in 4 cases a presystolic murmur was associated with a pre-systolic thrill. In 5 cases both mitral or aortic lesions were present. (b) Cardiac enlargement. This was present in 23 cases. (c) Pericarditis was present in 5 cases. (4) Arthritis occurred in 12 cases out of the 27 in this group. (5) Muscular pains were present in 5 cases. (6) Active chorea was not present in any of the cases in this group. (7) Rheumatic nodules were not to be found in any of the 246 cases upon which the E.S.R. was periodically carried out, although a careful search was made for them at each routine examination. (8) An erythematous eruption developed in 1 case. (9) Loss of weight.—This could not be estimated in most of the cases in this group as the majority of the cases were admitted as recumbent cases with definite signs of activity and were put to bed without being weighed. In 2 cases, however, the activity recurred while the patient was at High Wood and has now ceased, and in both these cases loss of weight has been found to have taken place. Group “B” were moderately active cases. These numbered 16. In 14 of these cases the E.S.R. readings varied between 18 and 55. In 2 cases they were over 100. The clinical evidence of activity, based on the same considerations as in group “A” was as follows:— (1) Pulse rate.—(a) During the day. The pulse rate taken with the child at rest during the day varied between 100 and 110 in the cases in this group with the exception of two cases, when it was 122 and 128 respectively. (b) During sleep. The pulse rate varied between 80 and 90, with the exception of the same two cases, in each of which it was 100. 40 (2) Temperature.—Thirteen cases in this group were afebrile, 1 case ran an evening temperature of 100°, 2 cases ran an occasional evening temperature which, however, was not maintained. In one case this did not go higher than 99.0°, but in the other it sometimes reached 101.4°. (3) Cardiac change.— (a) The appearance of a murmur. An apical systolic murmur. conducted out into the axilla, appeared in 15 out of the 16 cases. In 5 cases a double mitral murmur was present, ana in 2 cases a. pre-systolic murmur was associated with a pre-systolic thrill. In 2 cases both mitral and aortic lesions were present. (b) Cardiac enlargement. This was present in 14 cases, hut in only 2 cases was it considerable. (c) Pericarditis. This was not present in any of the cases in this group. (4) Arthritis was not present in any of these 16 cases. (5) Muscular pains were not present in any of the cases in this group. (6) Active chorea was present in 1 case. (7) Rheumatic nodules were not found in any of the cases. (8) No skin eruptions appeared in any of the cases in this group. (9) Loss of weight.—Out of the 16 cases in this group, 4 cases were not weighed, 6 cases lost weight, and 6 cases which had previously been gaining weight ceased to gain when activity recurred. Group “C” consisted of less active cases. These numbered 33, and the E.S.R. readings were in every case between 14 and 30. The clinical evidence of activity has been based on the same considerations as in group “A” and group “B.” (1) Pulse rate.—(a) During the day. The resting pulse rate in the cases in this group varied between 90 and 110. In 27 cases the pulse rate was maintained between 90 and 100 over a considerable period. In 6 cases it varied between 100 and 110. (b) During sleep. The sleeping pulse varied between 70 and 90, except in 1 case, when it reached 100. In 25 cases it was between 80 and 90. In 7 cases it was between 70 and 80. (2) Temperature.—29 cases in this group were afebrile. In 4 cases there was an occasional evening rise of temperature, which never exceeded 99.0° in any case in this group. (3) Cardiac change — (a) The appearance of a murmur. An apical systolic murmur, conducted out into the axilla, developed in 29 out of the 33 cases in this group. In 1 case there was a basal systolic murmur which was conducted into the neck. A double mitral lesion was present in 6 cases and in 1 case a mitral lesion was associated with an aortic one. (b) Cardiac enlargement was present in 16 cases, but in no case was the enlargement very marked. (c) Pericarditis was not present in any of the cases in this group. (4) Arthritis was not present in any of these 33 cases. (5) Muscular pains were present in 1 case. (6) Active chorea occurred in 3 cases. (7) Rheumatic nodules were absent in all these cases. (8) No skin eruptions appeared in any of the cases in this group. (9) Loss of weight.—This occurred in 10 cases out of the 33. In the remaining cases (with the exception of 3 cases which gained weight steadily throughout their stay in High Wood) there was failure to gain weight, but no actual loss during the period of activity. 41 The above findings are summarised in the following table:— Evidence of activity. Group "A." (27 cases.) Group " B." (16 cases.) Group " C." (33 cases.) Erythrocyte sedimentation rate. Over 50 in 26 cases. 40 in 1 case. Between 18 and 55 in 14 cases. Over 100 in 2 cases. Between 14 and 30. Raised pulse rate— During day 110-142 100-110 (in 2 cases over 120). 90-100 During sleep 80-122 80-90 (in 2 cases over 100). 70-90 Raised temperature In 20 cases. Percentage 74 In 3 cases. Percentage 19 In 4 cases. Percentage 12 Cardiac change— Murmurs In every case. 100 In 15 cases. 94 In 30 cases. 91 Enlargement In 23 cases. 85 In 14 cases. 87 In 16 cases. 48 Pericarditis In 5 cases. 18 In no case. 0 In no case. 0 Arthritis In 12 cases. 44 In no case. 0 In no case. 0 Muscular pains In 5 cases. 18 In no case. 0 In 1 case. 3 Active chorea In no case. 0 In 1 case. 6 In 3 cases. 9 Rheumatic nodules In no case. 0 In no case. 0 In no case. 0 Skin eruptions In 1 case. 4 In no case. 0 In no case. 0 Loss of weight Not estimated. _ 4 cases not weighed. — 10 cases lost weight. 30 6 cases lost weight. 50 20 cases failed to gain 60 6 cases failed to gain weight. 50 weight. 3 cases gained weight. 10 0 cases gained weight. 0 42 Of the 161 cases, therefore, which have shown no clinical evidence of activity during the last eight months, in 84 per cent. the series of E.S.R. readings has never been above 10, and in 94 per cent has been above 10 in only one isolated instance in each series. Further, out of 161 cases only 3 showed E.S.R. readings which persisted above 10 on more than two occasions. (These figures are exclusive of a few cases in which a transitory rise in the E.S.R. was accompanied by some obvious intercurrent infection, e.g. tonsillitis.) It is perhaps worthy of note that 6 out of the 7 cases of active chorea in which the E.S.R. remained constantly below 10 were definitely more active than any of the 4 cases where the E.S.R. was above 10. Conclusions. (1) In practically every case of active rheumatic carditis the erythrocyte sedimentation rate is abnormal: and the degree of abnormality of the reading obtained would appear to be an index of the activity of the disease. (2) A single abnormal erythrocyte sedimentation rate reading may not indicate activity of the rheumatic condition. (3) The erythrocyte sedimentation rate would not appear to offer any indication of the activity in cases of chorea; but a high erythrocyte sedimentation rate reading in a case of chorea might suggest the presence of some other active rheumatic lesion. (4) There would appear to be some evidence that in cases of congestive oedema the erythrocyte sedimentation rate may be within the normal limits in spite of the presence of active rheumatic carditis. I should like to express my thanks to Dr. A. G. L. Reade, medical superintendent of High Wood hospital, for permission to publish this work. References. 1 Gray Hill, N. British Journal of Child I Its., 1932, XXIX, 181. 2 Payne, W. W. The Lancet, 1932, I, 74. 3 Bach and Gray Hill. The Lancet, 1932, I, 75. 4 Perry, C. Bruce. Archives of Diseases in Children, October, 1934. 5 Struthers, R. R., and Bacal, H. L. Canadian Med. Assoc. Jour., Montreal, 1933, XXIX, 470. 6 Kahlmeter, G. Rheum. Diseases (Bath Conference), 1928, 219. 7 Peterman, M. G.. and Seager, S. J. Amer. Jour. Dis. Child.., Chicago, 1929, XXXVII, 693. 8 Warner, E. C. Proced. Roy. Soc. Med., Land., 1934, XXVII, 903. 9 Akerren, Y., Uppsala, 1931, X, 473. 10 Faxen, N., Rev. Franc de pediat, Paris, 1934, IX, 809. OBSERVATIONS ON THE GONOCOCCAL FIXATION TEST. By W. Ralston, B.Sc., M.R.C.S., L.R.C.P., F.I.C., Assistant Pathologist, London County Council (Whitechapel) Clinic. After more than 17,000 sera had been tested, the control tubes in the gonococcal fixation test failed to show the customary complete haemolysis in a certain batch of sera which had been set up in the usual way. This was considered to indicate that the titre of the guinea-pig serum had been incorrectly determined, and therefore too little complement had been used. This batch of sera was retested the following day with another supply of complement. A critical discussion of the experience gained in the titration of the complement in this particular guinea-pig serum may be useful to other pathologists who are working with this test, or who are contemplating its introduction as a routine practice. To avoid confusion the discussion has been arranged in sections as follows:— 1. Technique for titration of complement in guinea-pig serum. 2. The construction of a table to convert unit volumes of dilutions of guinea-pig serum into units or doses of complement. 3. The particular titrations described. 4. Critical examination of the results obtained in the titration of guinea-pig serum. 5. Other possible sources of abnormal results. 1. Technique for titration of complement in guinea-pig serum.—A brief resume is written to avoid frequent references to Prices's monograph1 on this test, and the diagram illustrates the titration under discussion. From the above diagram it will be seen that there are four rows of tubes in the rack. Each tube first receives one volume of that dilution of complement (guineapig serum) indicated at the foot of its column. This is followed by one volume of .9 per cent. saline solution in the back and second rows of tubes, the front tubes receiving two volumes. One volume of normal serum is next added to each tube of the back and third rows only, and then the tubes of the third and second rows receive one volume of diluted gonococcal antigen. Each tube should now contain 3 volumes of mixture and the rack is rapidly examined to check this, when any inequality—perhaps due to a cracked or broken tube—will be detected. After shaking well, one volume of 3 per cent. sensitised red cells is added to each front row tube, and the rack is placed in a water-bath at 37.5° C. after another good shaking. The progress of the laking in the front tubes is noted approximately every 5 minutes, and the preliminary titre is read after 30 minutes. The other three rows of tubes are incubated for a further 30 minutes and then one volume of sensitised red cells is (43) added to each of these tubes. After shaking well, incubation is continued for another 30 minutes, and the laking judged as before. The readings of these tubes should support the preliminary titre, or indicate the necessity for some slight modification. This titration may be further illustrated by the table below Mixtures for titration of complement. Row. Complement dilution vol. 0.9 pep cent. saline vol. Normal serum vol. Antigen vol. Red blood cells. 4(back) 3 2 1 1 1 1 nil 1 1 1 nil nil 1 1 Incubate for 1 hour, then add 1 volume per tube. 1 (front) 1 2 nil nil Add 1 vol. at once. Read finally after 30 minutes. Total mixture = 3 volumes per tube. In the above description it will be noted that— (a) the saline solution is used so that the mixtures in each tube amount to 3 volumes before the red cells are added ; (b) the front row tubes contain complement and sensitised red cells only, and since serum is absent they have no place in the test proper ; but (c) since the 4th or back row tubes contain one volume serum and one volume of a complement dilution, these tubes are represented by the front row tubes (controls) in the test proper; and, similarly, (d) since the 3rd row tubes in the titration contain serum, complement and dilute antigen, these tubes are represented by the two diagnostic rows of tubes in the test proper ; (e) the second row of tubes gives a measure of the anti-complementary property of the antigen. It will be apparent from the above notes why the 3rd and 4th rows of tubes in the titration of complement are of such great importance. 2. Construction of a table to convert unit volumes of dilutions of guinea-pig serum into units or doses of complement.—It may be helpful first to define clearly the meaning of the terms used. Guinea-pig serum is generally used in these fixation tests as the source of supply of complement which is quantitatively estimated by titration as described above. The unit dose (minimum hæmolytic dose) of complement is that quantity (in guinea-pig serum) which is just sufficient to lake completely in 30 minutes the unit volume of 3 per cent. red cells sensitised with 5 M.H.D. of amboceptor. The standard unit volume for this test is .11 c.c. The titre indicates the number of doses of complement present in the unit volume of undiluted guinea-pig serum. As this serum is used diluted with .9 per cent. saline, the titre can also be expressed as that factor which indicates the number of times the serum must be diluted to give a solution containing one dose of complement per volume. For example, a titre 60 means there are 60 doses of complement in one volume of the guinea-pig serum, and it also denotes the dilution factor 60, since by diluting the serum 60 times the solution will contain one dose per volume. When the titre is known the serum can be diluted to contain a given number of doses per volume, or the doses per volume contained in a known dilution can be calculated. Thus from the above definition of titre the following formula is derived ; and, if any two of its terms are known, the third can readily be found: Titre = doses per volume of guinea-pig serum dilution multiplied by the dilution factor (= d x f). 44 45 Examples:— 1. Suppose the titre of a serum is 60, and a solution with 3 doses per volume is required. Find the dilution factor, f. Answer:f = titre given doses =60 3 = 20. 2. Suppose the same serum to be diluted 50 times. Find the doses of complement in one volume of the solution. Answer : d titre factor =60 50 = 1.2 dose per volume. Table 1 has been prepared to facilitate the full appreciation of the detailed discussion of the titration, and to show quantitatively why laking occurs most rapidly in the tubes with most complement, and slows down as the titre strength at 30 minutes is approached, until finally it ceases in the tubes with less than one dose of complement. These latter tubes, therefore, show partial laking of the red cells, ranging from almost complete lysis to only a faint trace (if any) with the weakest solutions. Table I. Showing for different titres the doses of complement present in one volume of the dilution used in each tube for the titration. Doses of comp. per vol of guinea-pig serum Titre. Tubes with one volume of diluted guinea-pig serum. (Numbers indicate tubes and also dilution factors.) 10 20 30 40 50 60 70 80 90 100 Doses of complement per tube. 57 5.7 2.85 1.9 1.42 1.14 .95 .81 .71 .63 .57 60 6.0 3.0 2.0 1.5 1.2 1.0 .88 .75 .67 .6 63 6.3 3.15 2.1 1.57 1.26 1.05 .9 .79 .7 .63 66 6.6 3.3 2.2 1.65 1.3 1.1 .94 .8 .73 .66 69 6.9 3.4 2.3 1.7 1.4 1.15 .98 .86 .77 .69 78 7.8 3.9 2.6 1.95 1.56 1.3 1.1 .97 .9 .8 N.B.—Underlined tubes show partial lysis, becoming less, since complete lysis can only occur when the minimum haemolytic dose (by definition above) or more is present. When setting up the tubes for the titration the rack is marked in tens, thus:— 20, 30, 40, etc., to indicate the dilution factors for each column of tubes, and the tubes in the table are similarly indicated. The titres are read in multiples of three because of the use of 3 M.H.D. of complement in the diagnostic tubes of the test, and so it is convenient to have the titre number divisible by three. Table I shows only a few possible titres for different specimens of guinea-pig serum, but a full table can be similarly prepared to include all titres usually obtained, ranging from 33 to 99. Such a table will show that, for each of the seven dilutions from 40 to 100, there is a range of three or four titre-values within which the amount of complement per volume varies from 1 dose to 1.15 dose as a maximum. For any particular dilution of a serum (say, diluted 60 times), laking would be complete within the range, but it would be no more than complete at the lowest titrevalue, which is therefore (by definition) the true titre for the serum. This is shown in table I by the unit dose being placed opposite and under the same figure for the titre as for the dilution factor. Opposite the higher titre-values of the range for the same dilution, more than a unit dose of complement is shown, and in such cases D 46 the excess would be left in the tubes after laking had been completed. Such specimens of sera require greater dilution to give one dose per volume (for example, 63, 66, or 69 times), or in other words their true titre is one of these values higher in the range. If for any such serum within the range a lower titre-value was used as the working-titre instead of its true and higher value, this would result in using an excess of complement; but the table shows that the excess at the maximum value would not exceed .15 unit for each dose. After some experience it has been found possible to perform this test efficiently with any such lower value, providing the excess over one dose is limited to .1 dose. It is important always to choose the working titre-value so that the complement is used in excess, and never less than the number of doses required. Since dilutions corresponding to the higher values (not being the true titre, which is lower) would all contain less than one dose per volume (as shown in the table), a higher value must never be chosen instead of the lower. Since the anti-complementary property is variable with different sera, laking might not be complete with such dilutions, and by using less than 3 M.H.D. in the test proper the results would not be reliable. 3. The particular titrations described.—On the occasion referred to in the introduction, the guinea-pig serum had been titrated for complement as usual, but the preliminary titre given by the front row tubes was so much higher than the confirmatory titre (as obtained by considering the readings of the other three rows) that the latter readings were considered unreliable. It was consequently decided to use the unmodified preliminary titre, with the result that the readings for the whole batch were unsatisfactory. On the following day, using another specimen of guinea-pig serum and a fresh suspension of sensitised red cells, the titre given by the front row tubes was read as 1:78 (see diagram), but when the readings of the other three rows of tubes were considered this titre was modified to 1:60. This modification gave reliable results when the test was repeated later with the same batch of sera. The readings of this titration are tabulated below in table II, using table I and 1ts method of construction to give the doses of complement corresponding to each reading. Table II. Titration of complement. Row of tubes. Mixtures used in each tube. Reading of complete laking. Doses of compt. corresponding. Excess over front row. Back Complement + Blood + Serum (normal) 1: 30 2.6 1.6 3rd Do. + do. do. + antigen 1: 24 3.3 2.3 2nd Do. + do. + nil + do. 1: 21 3.7 2.7 Front Do. + do. + nil + nil 1: 78 1.0 - Assuming that the unit volume of red blood cells requires the same amount of complement for laking as is used in the front row tubes, it will be seen that the excess necessary for the tubes of the other rows (as shown in the end column of table II) must be due to the anti-complementary property of the other ingredients added, thus: 1 vol. control serum uses 1.6 dose more complement, and 1 vol. diluted antigen uses 2.7 doses more complement; but, when these volumes of serum and antigen are mixed, only an extra 2.3 doses of complement are required, instead of 4.3 doses which might have been expected. This seems to show the presence of some substance in the serum which to some extent neutralises, or corrects, the anti-complementary body or bodies in the antigen. This is a constant observation when performing these titrations. The unusual feature in this particular case is the fact that so much complement was inactivated as to require the preliminary titre to be modified from 1:78 to 1:60. This point will be considered in detail later. 47 4. Critical examination of the results obtained in the titration of guinea-pig serum.—There was no apparent reason to doubt the accuracy of the reading of the front row tubes (containing dilutions of guinea-pig serum and sensitised red cells only), so it may be assumed that 1:78 was the true titre. Dilution of this serum 26 times should therefore give a solution containing 3 doses (M.H.D.) of complement per volume. Referring to table II, the mixture in the back row of tubes is similar to that present in the front row (control) tubes of the test proper with normal sera. It will also be seen that approximately 2.6 doses of complement would be inactivated by a normal serum and by the action on the red cells, thus leaving only .4 dose, of the 3 doses used in the test proper, to allow for variations between different sera. This is important, especially in those which are positive. Thus, laking in the control tubes of strongly positive sera is often very noticeably delayed in comparison with control tubes of normal sera. In addition, excess of complement is advisable to ensure a rate of lysis which will enable the reaction to be completed within a reasonable time. This also enables the end point to be judged more accurately. An allowance of one dose over that required for the red cells and the serum is found to be a sufficient excess to cover all the above points, and should be present when 3 doses of complement are used as the standard minimum amount chosen for the test. Thus it is obvious that with only .4 dose available as the excess instead of one dose, even if complete laking occurred in a control tube, it would proceed in the final stages at a very slow rate, and also that laking would not be completed with some of the strongly positive sera at the end of the test (30 minutes). Reliable results could not be recorded with such controls, and what has been said of the control tubes applies even more to the diagnostic tubes, to which the third row of tubes in the complement titration corresponds, as these contain antigen as well as serum. Table II shows the third row of tubes required 3.3 doses of complement for complete laking (when the true titre is used), and whereas complete laking might occur in some of the control (front row) tubes of the test proper, it could not be expected to occur in the diagnostic (middle row) tubes with only 3 doses of complement; some negative sera in such cases would be read as false positives. In the tubes with 5 doses of complement (back row of test proper) laking would occur where the sera were negative or weakly positive, because the extra 2 doses of complement over that in the diagnostic tubes would be more than sufficient to cause complete laking of all the red cells. The foregoing explains why the test gave unreliable results on the occasion mentioned when the complement titre was read from the front row of tubes alone. The results obtained by using the modified titre 1:60 can now be similarly examined. Since the serum and the red cells in the back row tubes of the complement titration (see table II) usually require about 2 doses of complement for complete laking, the reading 1:30 could be considered as an indication that a nominal 2 M.H.D. complement had been used in this tube. It follows, therefore, that the corresponding working titre should be 1:60. The third row tube with 1:20 dilution would thus contain 3 M.H.D., so that the reading 1:24 would correspond with a nominal 2.5 doses at which strength it was considered that lysis would have been complete. Thus a titre of 1:60 should ensure complete lysis with normal sera in the diagnostic tubes of the test proper. But since the true titre was read as 1:78, the dilution 1:60 actually contained 1.3 dose per volume instead of one dose. The 1:20 dilution similarly contained 3.9 doses per volume, and the 1:12 dilution 6.5 doses instead of the standard 3 and 5 doses respectively (table I). By using the working titre 1:60 in the test proper, the back row (quantitative diagnostic) tubes had 6.5 minus 3.9, or 2.6 doses more than the middle row (diagnostic) tubes, instead of the usual amount of 2 doses. The middle row tubes and the control tubes contained 3.9 doses instead of 3 doses. But since the complement 48 titration proved that with normal serum at least 2.6 doses were required for complete lysis, the excess in the control tubes was 1.3 dose and that in the diagnostic tubes was 3.9 minus 3.3, or .6 dose. In view of these excesses the laking could be expected to proceed at a reasonable rate in the control tubes, a little more rapidly in the back row tubes (with the nominal 5 doses), and with a little delay in the middle row tubes (containing the nominal 3 doses). This indeed actually did occur. The middle row tubes contained an excess of .6 dose which is below the allowable amount of one dose, and in the back row tubes the excess was 2.6 doses above that contained in the middle row tubes. Therefore the total excess in the back row tubes over the amount required for laking was 2.6 plus .6, or 3.2 doses, instead of the allowable 3 doses, and thus these latter tubes contained approximately their usual amount of 2 doses more than the diagnostic tubes. The above figures show that by using 1:60 as the working titre only the standard excesses of complement were used, and why the test proper gave reliable results and thus justified the adoption of the modified titre. 5. Other possible sources of abnormal results.—An excessive degree of inactivation of complement in the mixtures with antigen may sometimes be due to the use of too much antigen, and so in such cases the titre of the antigen should be redetermined. The titre of the antigen used in the above titrations was re-determined, and in consequence was re-adjusted from 1:30 to 1:40. It was then found that with the greater dilution of antigen subsequent titrations of complement gave normal readings; that is, the working titre as found from the readings of the third and back rows of tubes was identical with the true titre as determined by the front row tubes of the titration. Thus the back row of tubes showed that with a normal serum something less than 2 doses of complement were required to lake one volume of sensitised red cells, and therefore, by using 3 doses of complement in the control tubes of the test proper, there would be an excess of at least one dose. Also the third row tubes showed that such serum and antigen would require not more than 2 or 2.1 doses to lake the red cells completely, so that by using 3 doses of complement in the diagnostic tubes of the test proper there would again be a sufficient excess of complement to make the results of the test reliable. Abnormal results may arise from using a control serum which has deteriorated, by becoming infected or otherwise, and this should be suspected if the degree of inactivation of complement in the back row of the titration is excessive. Otherwise, too low a reading may be chosen for the working titre which would cause too much complement to be used in the test proper, and so the detection of some of the doubtful sera would fail. If the correct working titre has been chosen, this will be proved by any negative sera in the batch being tested laking within 10 minutes, but the diagnostic tube of the bad normal (?) serum used as the control will probably require 15 minutes or even more. The condition of the sheep's red cells and of the amboceptor used to sensitise them has also to be considered. Summary. This paper shows the necessity for the extra rows of tubes set up in titrating guinea-pig serum so as to check the reading of the front row tubes for the titre. These extra rows of tubes also act as a measure of the influence of the different ingredients used in the test proper, both singly and when acting together. This enables one to modify the reading of the front row tubes and assists in choosing the titre best suited to the prevailing conditions. A table is outlined to facilitate the conversion of dilutions of guinea-pig serum into definite units or doses of complement per volume. A titration is discussed with these units to show how a modified titre was justified. The advisability of re-estimating the titre of the antigen and consideration of the quality of the normal control serum, the sheep's red cells and the amboceptor are mentioned. Reference. 1 Price, I.N.O., London County Council publication, 1933, No. 2995. PUERPERAL FEVER UNIT: NORTH-WESTERN HOSPITAL. Report for the Year ending 31st December, 1934. By A. Joe, D.S.C., M.D., Medical Superintendent; Hilda M. Davis, M.B., D.P.H., Assistant Medical Officer; and J. M. Wyatt, M.B., B.S., F.R.C.S.(Eng.), Obstetrician, North-Western Hospital. Subjoined are particulars of the discharges from the unit during the year:— Total number 200 (2 re-admissions). Multiparas, 118 Primiparæ, 82 Of the total number there were:— Deliveries at term 166 Abortions 34 (17 per cent.) Of 165 cases of puerperal sepsis there were:- Following normal labour 107 ,, instrumental delivery 30 „ abortions 28 (17 per cent.) Number of deaths, 16. Multiparæ, 15. Abortions, 2 Term, 13 Primiparæ, 1. Term, 1 Death rate, 8 per cent, of total cases. The 200 cases may be classified as follows :— 1. Local uterine sepsis 128 2. Local uterine sepsis plus pelvic cellulitis 7 3. „ „ „ ,, pelvic peritonitis 10 4. ,, ,, ,, ,, pelvic cellulitis and pelvic tonitis 3 5. ,, ,, ,, general peritonitis 5 6. ,, ,, ,, septicaemia 4 7. ,, „ „ general peritonitis and cæmia 2 8. ,, ,, ,, ,, pelvic peritonitis and septicaemia 2 9. „ „ „ „ other complications 4 10. No local uterine sepsis, other diseases 35 Total 200 1. Local uterine sepsis.—Total number, 128 (term, 104; abortions, 24). A. Multiparæ. Total number, 70. (a) Normal labour, 47 (vaginal examinations not made in 17 of these). Cultures from cervical swab : hæmolvtic streptococci ... 27 other organisms 13 sterile 7 (b) Instrumental delivery, 4. Cervical swab : hæmolytic streptococci 2 other organisms 2 (c) Abortions, 19. Cervical swab : hæmolytic streptococci 1 other organisms 14 sterile 4 B. Primiparae. Total number, 58. (a) Normal labour, 35 (vaginal examinations not made in 13). Cervical swab : hæmolytic streptococci 17 other organisms 9 sterile 9 49) 50 (b) Instrumental delivery, 18. Cervical swab : hæmolytic streptococci 6 other organisms 9 sterile 3 (c) Abortions, 5. Cervical swab : hæmolytic streptococci 0 other organisms 4 sterile 1 In total of 128 cases haemolytic strep, present in cervix: 53 or 41.4 per cent. In 82 normal „ „ „ „ „ 44 „ 53.6 „ In 22 instrumental „ „ „ „ 8 „ 36.3 „ In 24 abortions „ „ „ „ 1 „ 4.0 „ In 30 normal cases with no vaginal examination 18 „ 60.0 „ 2. Pelvic cellulitis.—7 cases (term, 5 (all occurred in multipara); abortion, 2 (no fatal cases)). Pelvic cellulitis also occurred in 3 additional cases in conjunction with pelvic peritonitis, which are dealt with under a separate heading in section 4. (a) Normal labour, 4 (vaginal examinations not made in 2 of these). Cervical swab: hæmolytic streptococci 3 other organisms 1 (b) Instrumental delivery in 1 case (vaginal examination made). Cervical swab : other organisms. (c) Abortions, 2 (vaginal examination not made in 1). Cervical swab in both: other organisms. Total occurrence of hæmolytic streptococci, 3, or 42.8 per cent. 3. Pelvic peritonitis.—10 cases (multiparæ, 5 (all were at or near term); primiparae, 5 (no fatal cases)). Pelvic peritonitis occurred in 5 additional cases. 3 in conjunction with pelvic cellulitis and 2 with septicaemia. (а) Multiparae. 5. (i) Normal labour, 4 (vaginal examinations not made in 3). Cervical swab : hæmolytic streptococci 3 other organisms 1 (ii) Instrumental delivery in 1 case (vaginal examination made). Cervical swab : hæmolytic streptococci. (б) Primiparae, 5. (i) Normal labour, 3 (no vaginal examinations made). Cervical swab: hæmolytic streptococci 2 sterile 1 (ii) Instrumental delivery, 2 (vaginal examinations made in both). Cervical swab : hæmolytic streptococci 1 other organisms 1 Total occurrence of haemolytic streptococci in cervix, 7, or 70 per cent. 4. Pelvic cellulitis and pelvic peritonitis.—3 cases (all were at term and all recovered). (a) Multiparae, 1. Normal delivery (no vaginal examination made). Cervical swab : hæmolytic streptococci. (b) Primiparae, 2 (vaginal examinations made in both). 1 normal and 1 instrumental delivery. Cervical swab in both : hæmolytic streptococci. Total occurrence of hæmolytic streptococci, 3, or 100 per cent. 5. General peritonitis. 7 cases. Multiparae, 5 (term, 3; abortions, 2); primiparae, 2 (at term). In two of these cases septicaemia also occurred and they are classified in the septicaemia total. All were fatal. 51 Laparotomy was performed in 6 cases, the 7th being a case with initial scarlet fever, which developed bilateral empyema and succumbed following rib resection. Extensive suppurative peritonitis found at post-mortem examination. (Hsemolytic streptococci in cervix at onset). There were 5 cases at term (all normal deliveries—vaginal examinations not made in 2). Four had laparotomy and hsemolytic streptococci were isolated from the peritoneal exudate. Hsemolytic streptococci were isolated from cervix in all 5. Particulars of the 2 abortions are as follows (i) Cervix and peritoneal exudate: B.coli. (ii) Cervix : B. coli and non-hsemolytic streptococci. Blood : non-hæmolytic streptococci. No culture from peritoneal exudate. Analysis of 7 cases in which general peritonitis occurred:— Para. Delivery. Vaginal exam. Cervical swab. Additional diagnosis. Operation. Multipara Normal Made Hæmolytic strep. Septic endo- and perimetritis Laparotomy Hæm. strep. Multipara Normal Made Hæmolytic strep. Suppurative parotitis (terminal) Laparotomy Hæm. strep. Primipara. Normal Made Hæmolytic strep. Perineal and vaginal sepsis Laparotomy Hæm. strep. Primipara Normal — Hæmolytic strep. Scarlet fever Bilateral empyema. Rib resection. Multipara Abortion Made B. coli Pelvic abscess Pyelo-nephritis. Laparotomy B. coli. Multipara Normal Made B. coli Septicaemia (staph, albus) Laparotomy Hsem. strep. Multipara Abortion Curetted before adm. Made B. coli and non-haem. strep. Septicaemia (non-haemolytic strep.) Pelvic abscess. Laparotomy (no culture). 6—8. Septicemia.—8 cases (2 occurred plus general peritonitis, and 2 plus pelvic peritonitis). (a) Multiparse, 7. Normal delivery 5 Instrumental delivery 1 Abortion 1 (curetted before admission). (b) Primiparse, 1. Instrumental delivery. Blood culture was positive in 7 of the cases, sterile in the remaining one, a clinical septicaemia with generalised septic arthritis. Two cases recovered. In one pneumococci were cultured from the cervix, blood stream and pus from a cellulitis of the elbow. In the other hsemolytic streptococci were obtained from the cervix, blood stream and exudate from laparotomy wound (drainage of pelvic peritonitis). Organisms present in 7 positive blood cultures:— Hsemolytic streptococci 3 Non-hsemolytic streptococci 1 B. coli 1 Pneumococcus 1 Staphylococcus 1 Total 7 The 4 cases classified in sections 7 and 8 are included in the above. 52 Analysis of cases of septicaemia (10). (First 2 cases included under" other diseases.") Para. Delivery. Vaginal exam. Cervical swab. Blood culture. Clinical features. Result. Multipara Normal Made Sterile Strep, viridans No uterine sepsis. Infective endocarditis, cerebral embolism and hemiplegia. History of heart trouble during pregnancy. Death. Multipara Normal 7 mos. (S.B.) Made Not taken Haem. strep. Influenzal pneumonia onset 3 days before delivery. No uterine sepsis. Death. Multipara Normal Made Hsem. strep. Staph, albus. Laparotomy, general peritonitis, haem. strep, in pus. Death. Multipara Normal Made Haem. strep. Sterile Clinical septicaemia. Septic endometritis and general septic arthritis. Death. Multipara Normal. Made Hsem. strep. Haem. strep. Local uterine sepsis, severe anaemia. Death. Multipara Normal Made Hsem. strep. Haem. strep. Septic thrombosis pelvic veins. Pelvic peritonitis, pericarditis (P.M.). Death. Multipara Normal Made Pneumococcus (same Pneumo- coccus type) Cellulitis elbow pus: pneumococcus. Recovery. Multipara Abortion. Curetted before adm. Non-hsem. strep, and B. coli. Nonhaem strep. Laparotomy, general peritonitis and pelvic abscess. Death. Multipara Instrumental. Made B. coli B. coli... Septic endometritis. Pyelitis. Enterocolitis. Death. Primipara Instrumental. Made Haem. strep. Hsem. strep. Pelvic abscess, vaginal and perineal sepsis. Pelvic peritonitis. Laparotomy. Hsem. strep, exudate from wound. Recovery. 9. Cases not included in above classification.—There were 4 cases showing local uterine sepsis plus other complications:— (i) Scarlet fever and septic arthritis of shoulder (multipara, normal delivery, hsom. strep, in cervix). Fatal. (ii) Septic endometritis and lobar pneumonia. Fatal. (Multipara, normal delivery, ccrvix sterile). (iii) Fibroid uterus with septic thrombosis of pelvic veins with septic infarct of lung and empyema. Fatal. (Multipara twins still-born 8 months. Cervix staph, albus.). (iv) Thrombosis of pelvic veins and cerebral embolus. (Multipara,, normal delivery, cervix sterile). Recovered. Femoral thrombosis.—11 cases. (a) Multipara, 7. Normal delivery 6 Abortion 1 (b) Primipara, 4. Normal delivery 2 Instrumental delivery 2 Thrombosis occurred in left leg only in 7 cases, and was bilateral in 4. Cervical swab : Hemolytic streptococci in 6 cases. Streptococcus viridans 1 ,, B. coli „ 2 „ Staphylococcus „ 2 „ (both instrumental). Local uterine sepsis was present in all cases and only two presented other complications: one case of pelvic peritonitis with pelvic and bilateral femoral venous thrombosis. The other, a case of h Hemolytic streptococci general peritonitis with thrombosis of the left saphenous vein, was the only fatal case in this series. 53 10. Other diseases admitted to the puerperal ward, but found to have no evidence of pelvic sepsis. 35 cases. 7 cases of acute mastitis. 6 Primipara (5 bilateral). (1 left side only). 1 Multipara, severe bilateral (multiple abscesses). Later developed bronchitis and pyelitis (B. coli). Staph, aureus. 3 pyelitis (2 B. coli, 1 staph, albus). 2 B. coli bacilluria. 1 dysuria. 1 retained placenta, removed, P.P.H. no sepsis. 3 incomplete abortions. 2 complete abortions. 1 normal pregnancy, 3½ months. 1 normal pregnancy, 3 months, and acute gastro-enteritis. 1 constipation and tonsillitis. 1 tonsillitis. 1 suppurative arthritis knee (hæn. strep.). 1 scarlet fever. 2 erythema. 1 subluxation of symphysis pubis with osteomyelitis of pubic bone and abscess formation (B. coli). 1 pulmonary tuberculosis acute progressive (sputum —). 4 no obvious disease. 11 influenza pneumonia and haem. strep, septicaemia. Fatal 1 infective endocarditis, septicaemia (strep, viridans) with cerebral embolism and hemiplegia. B. coli urinary infections (excluding cases under heading "other diseases"). B. coli were found on urine culture in 28 cases. Of these 13 were bacillurias, 13 pyelitis, and 2 cystitis. Urine cultures positive for B. coli were found in association with:— Local uterine sepsis 13 cases (abortion 1, normal 7, instrumental 5). Pelvic peritonitis 3 ,, Pelviocellulitis 3 ,, Pelvic thrombosis 1 „ General peritonitis 1 ,, Septicaemia 3 „ (2 haem. strep, and 1 B. coli). Femoral thrombosis 1 „ Acute mastitis 2 ,, Osteomyelitis of pubic bone 1 „ (B. coli in pus). In 8 cases B. coli were also present in the cervical swab, but in 23 other cases B. coli were found in the cervix but not the urine. Of the 31 cases in which B. coli were found in the cervix— 16 followed abortion 10 „ normal delivery 5 „ instrumental delivery Bacteriology.—Cervical cultures. Haemolytic streptococci present in 79 cases. Normal 66 Instrumental 12 Abortion 1 B. coli present in 27 cases. Normal 8 Instrumental 5 Abortions 14 54 Other organisms (i.e., staph, albus, non-hsem. strep., strep, viridans, diphtheroids, B. proteus, B. subtilis, pneumococcus) were present in 36 cases. Normal 16 Instrumental 11 Abortions 9 Sterile in 23 cases. Normal 17 Instrumental 2 Abortions 4 The complications in 165 cases of puerperal sepsis are set out below:— Delivery. Perineal and vaginal sepsin. Pelvic abscess. Pelvic cellulitis. Pelvic peritonitis. Septicemia. General peritonitis. Septic endo and perimetritis. Thrombosis. Pyelitis. Cystitis. Bacilluria. Severe jinipmia. [#/##] Femoral. Pelvic. Normal 6 1 5 9 5 5 3 8 4 5 4 6 7 Instrumental 11 2 2 5 2 1 1 2 — 8 2 2 7 Abortion - 1 2 1 1 1 1 - 3 - 1 5 Total 17 4 9 15 8 7 4 11 4 16 6 9 19 Septic erosion of cervix 3 Lobar pneumonia 1 Cellulitis of calf 3 Septic infarct lung 1 Cellulitis of arm 2 Empyema 2 Abscess buttock 1 Otitis media 2 Furunculosis 1 Herpes facialis 1 Paronychia 2 Tonsillitis 3 Acute mastitis— Acute nasopharyngitis 5 Normal 7 Cerebral embolism 1 Instrumental 2 Toxic dermatitis 1 — 9 Belladonna dermatitis 1 Suppurative parotitis 1 Pericarditis 1 Infective arthritis 5 Mania 3 Pleurisy 2 Entero-colitis 1 Bronchitis 5 Jaundice 1 Bronchopneumonia 1 The following associated diseases were present on admission: asthma, pernicious anaemia, Grave's disease, hydatid cyst of liver, trigeminal neuralgia, chronic nephritis and hypertension, rheumatic endocarditis, syphilis (3), gonorrhoea (2). The value of bladder lavage in B. coli infections of the urinary tract has been under investigation during the past year. Encouraging results have been obtained and we think the treatment has some value in reducing the signs and symptoms of urinary infections, although in some cases bacilluria is apt to persist. The following case is presented in detail as showing features of unusual interest:— Primipara, aged 24 years. Normal delivery, 11 hours, labour 1° tear. Normal puerperium except for complaining of stiffness in hips and difficulty in walking, which caused pain in pubis. Discharged from nursing home on 14th day. Stayed in bed at home on account of pain. Admitted North-Western hospital 17th day of puerperium. T. 103°, swelling and acute tenderness over pubis. Uterus well involuted, os closed, mucoid discharge only. Vaginal and urine culture B. coli. X-ray" destruction and wide separation of symphysis pubis." 21st day, incision and drainage of large abscess cavity extending from both sides of vulva up to symphysis. Culture pus B. coli, diphtheroids and staph. By 57th day incisions had closed, all swelling and pain subsided and temperature normal for two weeks. Fitted with canvas belt. 72nd day, X-ray showed that subluxation was reduced. Up on 80th day and remained normal. 55 Analysis of deaths in 165 cases of puerperal sepsis. (14 deaths = 8.5 per cent.) No. of case. Age. Para. Previous history. Delivery. Vaginal examination. Diagnosis on admission. Complications. Course of disease. Bacteriology. Post-mortem findings. 22 32 IV Term Poor health and vaginal discharge during pregnancy Normal 6 hours labour. + Septic endo- and para-metritis. General peritonitis onset 7th day. Onset of pyrexia 3rd day post partum. Cervical culture and peritoneal exudate hæm. metritis. General peritonitis with pus in pelvis and in broad ligaments septic metritis 198 29 II Term Normal pregnancy Normal 5 hours labour. + Scarlet fever. Local uterine sepsis. Septic arthritis shoulder 7th day. Generalised oedema ? serum reaction. Onset of scarlet fever 3rd day post partum Admitted 5th day. Death 11th day. Cervical culture hæm. strep. Endometritis, septic spleen, oedema of lungs, kidney, brain. 147 23 II Term Normal pregnancy Normal 7 hours labour. + Septicaemia General peritonitis onset 14th day. Onset of pyrexia 4th day post partum. Admitted 10th day. Laparotomy 14th day. Death 20th day. Cervical and peritoneal culture hæm. strep. Blood culture staph. albus. No. P.M. 728 32 II Term Normal pregnancy Normal 5 hours labour. + Septic endometritis. Clinical septicaemia. Generalised arthritis 6th day. Onset of pyrexia 2nd day post partum. Admitted 5th day. Death 10th day. Cervical culture hæm. strep. Blood culture sterile. No P.M. 992 28 IV Term Poor health during pregnancy. Normal 6 hours labour. Portion of placenta retained. None Septic endometritis. Lobar pneumonia. - Onset of pyrexia 4th day post partum. Admitted 5th day. Death 6th day. Cervix sterile Left lower lobe, grey hepatization. Uterus bulky, septic endometritis, adherent fragment of placenta. 1753 26 I Term Normal pregnancy Normal 8 hours labour. None Scarlet fever. Local uterine sepsis. Pleural effusion bilateral empyema onset 30th day ? peritonitis. Onset of scarlet fever 4th day post partum. Onset pyrexia 10th day. Admitted 12th day. Death 60th day. Rib re-section 60th day. Cervix (hæm.). Throat (strep.). Blood culture sterile. Extensive bilateral empyema. Anterior mediastinitis. Extensive recent omental adhesions, pockets of pus in lower abdomen. 1517 31 III Abortion at 6 weeks (spontaneous) + General peritonitis. Pyelitis Onset of pyrexia 5th day post partum. Admitted, and 1st laparotomy 8th day. 2nd laparotomy 42nd day, death 43rd day. Cervix (B. coli). Urine (B. coli.). Peritoneal fluid (B. coli.). General peritonitis, pelvis full of pus tracking up to liver. Tubes normal, uterus fibrotic, no evidence of injury. Liver and spleen septic. Acute haemorrhagic pyelonephritis. 1897 21 II Term Always delicate. Normal pregnancy. Normal B.B.A.— P.P.H. 11 hours labour. None Septicæmia anaemia. - Onset of pyrexia 4th day post partum. Admitted 5th day. Death 17th day. Cervix Hæm. None. Blood strep. 56 No. of case. Age. Para. Previous history. Delivery. Vaginal examination. Diagnosis on admission. Complications. Course of disease. Bacteriology. Post-mortem findings. 1683 40 V Term Septicaemia after 2nd pregnancy. Poor health during pregnancy. Anaemic prolapse of uterus. Wore ring pessary until delivery. Normal 2½ hours labour. Severe P.P.H. + Uterine sepsis and thrombosis pelvic veins. Arthritis shoulder 12th day. Pelvic peritonitis 20th day. Septicæmia 42nd day. Pericarditis 45th day. Onset of pyrexia 3rd day post partum. Admitted 8th day. Death 53rd day. Cervix: hæm. strep. Urine : hæm. strep, and B. coli. Blood : hæm. strep. Pelvic peritonitis, septic thrombosis of uterine and ovarian veins. Acute pyelonephritis and pericarditis. Œdema and congestion of lungs. Sepsis in all abdominal organs. 2317 29 II Term No ante-natal care In labour 3 days before admission to hospital. Forceps 4 days in labour. Liquoi amnii offensive T. 101. Still-born. + Septic endometritis. Pyelitis. Septicæmia 7th day Enterocolitis 9th day. Pyrexia before delivery. Admitted 5th day. Death 12th day. Cervix B. coli. None. Urine Blood J 2124 33 VII Threatened abortion at 6 weeks. Bleeding 2 weeks before admission to hospital. Curetted before admission to N.W.H - Septicæmia. Severe anæmia. Pelvic abscess 12th day. General peritonitis 18th day. Onset of pyrexia 1st day. Admitted 3rd day. Death 23rd day. Laparotomy 21st day. Cervix: B. coli and non hæm. strep. Blood: non hæm. strep. Peritoneal fluid: B. coli and staph, aureus. General peritonitis. Large abscess rightbroad ligament tracking up to liver and down to ischio-rectal region. All organs septic. Septic metritis 3217 35 I 7 months Nephritis during pregnancy. S B. twins. Normal 4 hours labour. - Uterine sepsis ? septic pneumonia. Empyema 14th day Onset of pyrexia 2nd day post partum. Admitted 3rd day. Aspiration chest 15th day. Death 17th day. Cervix: staph, albus. Urine : B. coli pus and casts. Blood and pus chest : sterile. Right lung septic infarct, empyema right base. Fibroid uterus septic thrombosis cervical veins. 3439 35 IV Term Normal pregnancy Normal 16 hours labour. - Uterine sepsis and general peritonitis. Suppurative parotitis (terminal). Onset of pyrexia 2nd day post partum. Admitted 5th day. Laparotomy 6th day. Death 7th day. Cervix: hæm. strep. Peritoneal fluid: hæm. strep. Blood: sterile. None. 3355 32 1 7 months. Normal pregnancy Normal 9 hours labour. - Perineal and vaginal septic tears (Lochia purulent). Septic endometritis. General peritonitis 12th day. Thrombosis left saph. vein. Onset of pyrexia 4th day post partum. Admitted 5th day. Lapparotomy 13th day. Death 15th day. Cervix and peritoneal fluid: haem. strep. Blood sterile. None. RADIUM CENTRE FOR CARCINOMA OF THE UTERUS: LAMBETH HOSPITAL. Report for the year ending 31st December, 1934. By the Consulting Gynœcological Surgeon—Sir Comyns Berkeley, M.A., M.C., M.D., F.R.C.P., F.R.C.S.(Eng.), M.M.S.A.(Hon.), F.C.O.G., with whom is associated the Gynœcological Surgeon—Arnold Walker, M.A., M.B., B.Ch., F.R.C.S.(Eng.), M.C.O.G. Since a centre for the treatment by radium of carcinoma of the uterus was established by the Metropolitan Asylums Board in 1928 and taken over by the London County Council in 1930, five reports have been issued, and this is the sixth. In the first five reports the clinical condition of every patient treated was duly set down showing how they were classified into the four international groups. In this report these clinical details have been omitted and there remains only the grouping. Research workers and others interested in the reports from this centre will, by reference to the former reports, know exactly how the patients are classified in this centre, and there now seems no reason, therefore, to overload these reports in the future with such a mass of clinical detail. It is as well to mention, however, that it has been the custom in this centre from the start, when there is the least doubt as to the group to which a patient should be allocated, to include such a patient in what one may term a better group, that is, in a group in which by the international grouping there should be more chance of a cure. It necessarily follows that by such a method groups 1 and 2 are loaded with cases which, statistically, must make the survival rate worse than if such cases, where there is a genuine doubt, were allocated to the worse groups, namely 3 and 4. A comparison of statistics from various centres must, and always will, be difficult to evaluate, since the clinical acumen of, and the decision to which group certain patients should be allocated by various surgeons, may differ considerably. If comparison is to be made by groups, such a difficulty cannot be entirely obviated, although some of it may be, by a knowledge of the practice of the individual surgeon in charge of the centre. It might be thought that a fair comparison could be made by taking the total survival rate of all the groups combined, but here a further difficulty arises, since at some centres patients may not be treated because it is decided that the disease is too far advanced, while at other centres such cases would be treated and allocated to group 3 or 4 as the case might be. In addition, the class of patient, so far as the local condition is concerned, varies at different centres. Cancer patients arrive at a centre by various routes; some without any recommendation, some are sent by doctors and some by other hospitals, and, with respect to the two latter routes, it all depends on the personal factor of those who are recommending the patient as to whether the disease is thought to be too far advanced or not; that is, patients sent by these routes may undergo a process of selection so that some centres may be receiving more patients in whom there is a chance of cure and vice versa. Moreover the practice of surgeons at the various centres differs, and, perhaps unknowingly, there is a process of selection, so that a patient who would be treated at centre A would be refused treatment at centre B. Instances of such a selection are marked in some foreign centres. It will, therefore, be seen how difficult it is to compare the results of one centre with another, and the only method of arriving at a decision of the value of radium in the treatment of cancer is to take a large sample, say some thousands of cases, from various centres. This will give a fair estimate since, although it may be that there are centres where the results are better than when such a total result is taken, it is impossible for every patient to be treated at such a centre, even only because of its geographical position. (57) 58 It has been the custom, since this centre was started, to treat patients even when there seems no chance of cure, and the medical officers of the Council's hospitals are asked to leave the decision to us, no matter how bad the patient seems. At any rate, treatment by radium does relieve advanced cases by arresting haemorrhage and relieving some of the distress, and now and again a cure results in apparently the most hopeless case, or a life is markedly prolonged. Whether the latter is an advantage may be a matter for debate, but there must be many cases in which a prolongation of life is of vital importance to the patient or to his or her dependants. The reasons why treatment has been refused at this centre have always been stated in these reports. This centre is peculiar, as has been pointed out in former reports, in that it receives patients only from the Council's hospitals, the majority of whom have undergone a process of selection before they reach the centre, having been refused treatment, either surgical or radiological, at other hospitals, and have found their way into the Council's hospitals to die. Now that the Council's hospitals have been reorganized, it may be that in future years the average case treated at this centre will not be so far advanced ; but, since most patients seeking advice and suffering from carcinoma of the uterus are seen first in the out-patient departments at the voluntary hospitals, it may be a long time before this centre ceases to be loaded with such advanced cases, since the early cases are kept for treatment by the voluntary hospitals. Since this centre was started, it has received 753 patients. Of these, 523 were cases of carcinoma of the cervix, and, of these, 379 were treated. During the year one patient died as the direct result of the application of radium, the cause of death in this case being general peritonitis. During the whole period 16 patients have died as the result of treatment. When this centre was situated at the North-Western hospital there were no facilities for X-ray treatment following the application of radium. At the time the centre was set up it was not the custom, in most centres, to give X-ray treatment in addition, the published results from the well-known centre of Stockholm, for example, where X-rays were not used, being as good as those from centres where X-rays were employed ; and for the first 5 years at this centre X-rays were not used. However, in view of improved methods of treatment, it has gradually become recognised by the medical profession that the addition of X-ray treatment certainly leads to an improvement in the survival rate. When this centre was, therefore, transferred to Lambeth, it had available this additional method of treatment, the centre being situated adjacent to one of the best X-ray departments in the country, under the care of Mr. Stebbing, and, with the two departments working most amicably together, the patients at this centre suffering from carcinoma of the uterus have, during the last 9 months, had the benefit of being treated with X-rays after the radium treatment was completed, and only a few patients have refused. It must be remembered that the combined treatment takes some time, and the marked improvement in the condition of most of the patients after treatment with radium makes some of them hesitate or unwilling to proceed with further treatment. However, the resident staff, both medical and nursing, are so tactful that in most cases this difficulty has been overcome. Lastly, the result of the " follow up " is very satisfactory and amounts to nearly 99 per cent., only 6 patients having been lost sight of since the centre was established. This result is due to two factors. One, that the Council allows its ambulances to fetch the patients and return them home if they wish, and the other the great trouble the secretary of the centre takes in tracing the patients. I have described in former reports the steps which are taken to trace a patient who has " disappeared," including letters to everyone who it is thought might give some information—the Council's hospitals, private doctors, relatives, local agencies such as the post office and clergyman of the parish, and so on. There must always, however, be a certain number of patients who disappear, no matter what method is devised to ascertain their present address, since, unlike the law in some foreign countries, people in this country do not have to report to the police a change of address. 59 The following is an analysis of cases sent to the centre during 1934 :— Carcinoma— Cervix uteri 88 Corpus uter 8 Vagina 4 Vulva 1 Carcinoma of rectum 1 Recurrence of cervix after radium elsewhere 1 Recurrence of cervix after operation 1 Recurrence of body after operation 1 Sarcoma of vagina 1 — 106 Not diagnosed as carcinoma— Menopausal haemorrhage 3 Senile endometritis 2 Incomplete abortion 2 Fibroids 2 Vaginitis 1 Menorrhagia 1 Delayed menopause 1 Pelvic cellulitis 1 Senile pyometra 1 Fibrosis uteri 1 Chronic cervicitis 1 Undiagnosed 13 — 19 Total number of patients sent to the centre 125 The following statistical data are set out according to the rules drawn up by the Radiological Sub-Commission of the League of Nations. Cases admitted up to February, 1935, were treated by radium alone. From that time, radium treatment has been followed by a course of X-rays, details of which are given to date. For statistical purposes the cases treated must now be divided into— (a) Those completely treated by radium and X-rays. (b) Those completely treated by radium or X-rays only. (c) Those incompletely treated by one or both methods. During the period under review, 88 cases of carcinoma of the cervix were admitted, and were grouped as follows :—Stage 1, 6 ; stage 2, 18 ; stage 3, 34 ; stage 4, 30. Of these, 77 were accepted for treatment: stage 1, 6 ; stage 2, 18 ; stage 3, 32; stage 4, 21. Of these, 47 were completely treated by radium and X-rays : stage 1,4; stage 2, 12 ; stage 3, 22 ; stage 4, 9. In addition, one stage 1 case was treated by radical operation and X-rays. Ten were completely treated by radium only : stage 2, 5 ; stage 3, 3 ; stage 4, 2. Six were completely treated by X-rays only : stage 3, 4 ; stage 4, 2. Thirteen were incompletely treated by one or both methods : stage 1,1; stage 2, 1 ; stage 3, 3 ; stage 4, 8. Eleven cases were not treated : stage 3, 2 ; stage 4, 9. The 10 cases completely treated by radium alone did not receive a full course of X-rays for the following reasons : too ill for X-rays, 5 ; refused, 4 ; discharged before commencement of routine X-ray treatment, 1. The 6 cases treated by X-ray alone did not receive a full course of radium treatment for the following reasons : too ill, 3 ; refused, 2 ; died, 1. Treatment was not completed in the 13 cases for the following reasons : too ill, 5 ; died, 4 ; refused, 4 ; and the 11 cases were not treated for the following reasons : too advanced, 9 ; refused treatment, 2. Eight cases of carcinoma of body of uterus were admitted : completely treated, 5 ; too ill for completion, 2 ; unfit for any treatment, 1. Four cases of carcinoma of vagina were admitted : completely treated by 60 radium and X-rays, 1 ; completely treated by radium alone, 1 ; completely treated by X-rays, 1 ; too ill for any treatment, 1. The case of carcinoma of the vulva was incompletely treated by X-rays, being too advanced for further treatment. The case of sarcoma of the vagina was incompletely treated by X-rays and died before completion. The case of carcinoma of the rectum refused further treatment after one application of radium. The case of recurrent carcinoma of the body of the uterus after operation was completely treated by X-rays. The case of recurrent carcinoma of the cervix after previous radium elsewhere received one further application of radium. The ages of cases of carcinoma of the cervix were :— 30-34 years 3 55-59 years 10 35-39 „ 10 60-64 12 40-44 „ 10 65-69 „ 7 45-49 „ 11 70-74 „ 5 50-54 „ 15 75-80 5 Radium treatment.—Description of apparatus. 1. Radium containers. — Substance. Content in milligrammes. Shape Dimensions. Material. Thickness of wall. Uterus Radium 21 mg. el 2 tubes 25 mm. x 2.75 mm. Platinum 0.5 mm. Vagina Radium 5 mg. el. 16 tubes 12 mm. x 1.2 mm. Platinum 0.5 mm. 2. Internal applicators. — Number. Shape. Dimensions. Material. Thickness of wall. Milligrammes used. Uterus 1 Bent tube 70 mm. x 7 mm. Silver 2.15 mm. 42 Vagina 2 Flat boxes 28.5 mm. x 21 mm. Silver 1.15 mm. 80 — Number of treatments Interval of treatments. Duration of application. Dosage at each troatment. Uterus 3 One week between 1st and 2nd Three weeks between 2nd and 3rd 20 hours 42 mg. el. (or 20 hrs. Vagina 3 One week between 1st and 2nd Three weeks between 2nd and 3rd 20 hours 80 mg. el. for 20 hrs. Average total dosage : 7320 mg. el. hours = 54.9 mulicunes destroyed. The internal applicators are enclosed in indiarubber bags. Thickness of material, I mm. Total screenage : in terms of lead, uterus, 3 mm. ; vagina, 2 mm. X-ray treatment. The routine treatment given to these patients is as follows :—The whole of the cavity of the true pelvis is irradiated through 5 or 6 fields, the number used depending upon the amount of fat and the patient's muscular resistance to displacement of viscera. The total dose delivered on the skin of the patient varies, an attempt being made to deliver 4500 r. to every part of the cavity of the pelvis. Daily treatments are given, Sundays excepted, each field is treated in rotation and 300 r. given daily. K.V. is 200, the filter is 4 mm. of tin, 5 mm. of copper and the intensity varies from 5 to 15 r. per minute, some cases being treated on each of these intensities. The results of treatment are shown in the following table. Year. No. treated. Alive at end of year. Died of cancer by end of year. Lost sight of by end of year. Died of other cause by end of year. Survival rate at the end of year. 1st 2nd 3rd 4 th 5 th 6th 1st 2 nd 3rd 4 th 5 th 6th 1st 2nd 3rd 4th 5 th 6th 1st 2nd 3rd 4th 5th 6th 1st 2nd 3rd 4th 5th 6th 1.11.28 to 31.12.28 Csrvix uteri.—Stage 1. Confirmed histologically. 1 1 1 1 1 1 1 0 0 0 0 0 0 — — — — — — — — — — — — 100 100 100 100 100 100 1929 6 4 3 9 2 2 — 2 3 4 4 4 — — — — — — — — — — — — — 66 5< 33 33 33 — 1930 3 3 3 2 2 _ _ 0 0 1 1 — — — — — — — — — — — — — — 101 I0( 6b 6b — — 1931 4 4 3 2 — — — 0 1 2 — — — — — — — — — — — — — — — I0< 75 50 — — — 1932 9 2 2 _ — _ _ 0 0 — — — — — — — — — — — — — — — — 100 100 — — — — 1933 2 1 — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 1.11.28 to 31.12.28 Cervix uteri. Stage 2. Confirmed histologically. 6 1 1 1 1 0 0 9 5 5 5 6 6 — — — — — — — — — — — — 66 17 17 17 0 0 1929 11 8 5 3 3 3 — 3 6 7 7 7 — 0 0 1 1 1 — — — — — — — 73 45 30 30 30 — 1930 21 17 1 1 6 6 _ — 4 10 15 15 — — — — — — — — — — — — — — 81 52 29 29 — — 1931 26 14 10 6 — _ — 11 15 19 — — — 1 1 1 — — — — — — — — — 56 40 24 — — — 1982 22 14 9 — — _ — 8 13 — — — — — — — — — — — — — — — — 64 41 — — — — 1933 22 19 — — — — — 3 — — — — — — — — — — — — — — — — — 86 — — — — — Not confirmed histologically. 1932 1 1 0 — — — — 0 1 — — — — — — — — — — — — — — — — — — — — — 1.11.28 to 31.12.28 Cervix uteri —Stage 3. Confirmed h istologically. 8 3 2 2 2 1 1 5 6 6 6 7 7 _ _ _ — _ — — — — 37 25 25 25 12 12 1929 28 15 7 6 6 5 — 13 21 21 21 22 — 0 0 1 1 1 — — — — — — — 54 25 22 22 18 — 1930 14 0 2 2 9 — — 8 12 12 12 — — — — — — — — — — — — — — 43 14 14 14 — — 1931 31 16 1 2 8 — — — 15 19 23 — — — — — — — — — — — — — — — 52 39 26 — — — 1932 28 11 8 39 29 — — — — 1933 28 18 — — — — — — — — — — — — — — — — — — — — — — — — — — — — — Not confirmed histologically. 1928 1 — — — — — — 1 — — — — — — — — — — — — — — — — — — — — — — — 1930 1 — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 1931 1 — — — — — — — — — — — — — — — — — 1 — — — — — — — — — — — 1.11.28 to 31.12.28 Cervix uteri. -Stage 4. Confirmed histologically. 3 0 0 0 0 0 0 3 3 3 3 3 3 — — — — — — — — — — — — 0 0 0 0 0 0 1929 20 10 4 2 2 2 — 10 16 18 18 18 — — — — — — — — — — — — — 50 20 10 10 10 — 1930 9 2 2 2 2 — — 7 7 7 7 — — — — — — — — — — — — — — — — — — — — 1931 11 3 2 0 — — — 8 9 11 — — — — — — — — — — — — — — — 27 18 0 — — — 1932 7 2 I — — — — 5 6 — — — — — — — — — — — — — — — — — — — — — — 1933 13 5 — — — — — 8 — — — — — — — — — — — — — — — — — — — — — — — — Not confirmed, histologically. 1932 1 — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 1.11.28 to 31.12.28 Carcinoma of body of uterus. Confirmed histologically. 0 — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 1929 9 1 9 2 2 •) — 4 6 6 6 6 — 0 1 1 1 1 — — — — — — — 55 25 25 26 25 — 1930 8 4 4 4 4 — — 4 4 4 4 — — — — — — — — — — — — — — 50 50 50 50 — — 1931 4 2 2 1 _ — — 1 1 2 — — — 1 1 1 — — — — — — — — — 66 66 33 — — — 1932 4 1 0 — — — — 3 4 — — — — — — — — — — — — — — — — 25 — — — — — 1933 7 6 — — — — — 1 — — — — — — — — — — — — — — — — — 86 — — — — — primary carcinoma of vagina. 1.11.28 to 31.12.28 1 1 0 0 0 0 0 0 1 1 1 1 1 — — — — — — — — — — — — — — — — — — 1929 9 1 1 1 1 0 — 1 1 1 1 2 — — — — — — — — — — — — — — — — — — — 1930 1 l 1 1 1 — — 0 0 0 0 — — — — — — — — — — — — — — — — — — — — 1931 1 1 0 0 — — — 0 1 1 — — — — — — — — — — — — — — — — — — — — — 1932 9 0 0 — — — — — — — — — — — — — — — — — — — — — — — — — — — — 1933 2 1 — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 1.11.28 to 31.12.28 Secondary carcinoma of vagina. Confirmed histologically. 1 1 1 1 1 1 1 0 0 0 0 0 0 — — — — — — — — — — — — — — — — — — 1929 1 1 0 0 0 — — 0 1 1 1 — — — — — — — — — — — — — — — — — — — — 1930 — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 1931 — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 1932 — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 1933 1 0 — — — — — 1 — — — — — — — — — — — — — — — — — — — — — — — 1.11.28 to 31.12.28 Sarcoma of uterus. — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 1929 — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 1930 1 I 1 1 1 — — 0 0 0 0 — — — — — — — — — — — — — — — — — — — — 1931 1 0 0 0 — — — 1 1 1 — — — — — — — — — — — — — — — — — — — — 1932 — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 1933 — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 1.11.28 to 31.12.28 Carcinoma of vulva. Not proved histologically. — _ — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 1929 1 0 0 0 0 0 — 1 1 1 1 1 — — — — — — — — — — — — — — — — — — — 1930 1 1 0 0 0 — — 0 1 1 1 — — — — — — — — — — — — — — — — — — — — 1931 — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 1932 1 1 1 _ _ — — 0 0 — — — — — — — — — — — — — — — — — — — — — — 1933 2 0 — — — — — 2 — — — — — — — — — — — — — — — — — — — — — — — (61) 42 RADIOTHERAPEUTIC CLINIC : LAMBETH HOSPITAL. Report for the year ending 31st December, 1934. By George F. Stebbing, M.B., B.S., F.R.C.S.(Eng.), Surgeon Specialist; P. Berry, M.D., B.S., M.R.C.S., L.R.C.P., Senior Assistant Medical Officer: and T. M. Robb, M.R.C.S., L.R.C.P., Assistant Medical Officer, Lambeth Hospital. During the year ending 31st December, 1934, 550 new patients were placed on the records of the radiotherapeutic clinic, excluding those who were treated in the special department for carcinoma of the uterus. Most of these patients were in the hospital for at least a few weeks and some of them for several months. During the year, 1,007 patients suffering from malignant tumours were discharged from, or died in, Lambeth hospital. This number includes all cases in which the diagnosis of a malignant tumour was made, although many of them had tumours in such a position or of such a nature that neither surgery nor radiation could offer them any relief. For some of them the diagnosis was only made at the post-mortem examination, and in other cases the patient was treated entirely by surgery. Whenever any member of the staff thought that there was a possibility of radiotherapy being the treatment of choice for the patient, the patient was sent to the radiotherapeutic clinic. Some patients for whom it was proposed to undertake radiotherapy treatment did not in fact receive any treatment, either because the necessary preparation could not be made owing to the patient's feeble condition, or because the patient was unwilling to co-operate in the treatment. In previous reports it has been pointed out that a large number of patients sent to the clinic are suffering from malignant tumours in an advanced stage, sometimes even with widely spread metastases, and some are so infirm from constitutional disease that treatment is extremely difficult, even when there is a prospect of making the patient more comfortable by it. There are also sent to the clinic a large number of patients who have already had treatment for a malignant tumour, either by surgery or by radiotherapy, at some other hospital, and this type of case is increasing in number as compared with previous years. The table that has been prepared this year to show the result of treatment has been very much simplified, as it was found, that with increasing numbers, the clerical work of preparing a table on the Stockholm principle was too great to be undertaken. Table II shows the number of patients that have started treatment in each year since April, 1930, for each disease or stage of disease, and gives their crude survival number at the end of each year after the commencement of treatment. No attempt has been made to correct these figures or to produce the survival rate after the deduction of untreated cases, untraced cases, or patients that have died of an intercurrent disease, but the number of these has been entered in the end column. Such a table is published so that comparison may be made with those of other clinics, but it does not show the value of radiotherapy in the palliation of disease which has gone beyond the stage of recovery. A very large proportion of those who have been treated during the year, and many of those treated in previous years, although not completely recovered from their growth, have been rendered comfortable, and often even symptom free, for periods of many months on end. although the disease proved fatal in the end. This palliative action of radiotherapy needs to be emphasised. There is a growing demand for statistical evidence of the value of any particular treatment in disease, and this demand has been largely created by the radiotherapists, who were the first to make compilation of such statistical records a principal feature of the clinics in which they worked. Given a very large number of patients, observed over a period of many years, the value of a treatment as a life-saving measure can be very accurately gauged from carefully compiled statistics. It is important, however, to remember that there are many things which are not capable of statistical expression ; and even in the best and (62) 63 most carefully analysed statistics, a number of facts remain unstated. The relief that can be given to a patient during the last few months of his life is of immense importance to the patient, and the clinician finds it difficult to express this in statistical form. There is a further point that must be kept in mind in dealing with statistics of disease, and that is that such statistics cannot show the general constitution, etc., of the patients in whom the disease occurs. Many of the earliest cases of carcinoma that have been treated at the radiotherapeutic clinic have only been seen at this clinic because they have been in such poor general health that other clinics have not considered it within their province to treat them. During the year the X-ray department of the clinic has been extended by the provision of two generators, each working a tube at 200 K.V. in a cannon of the Holfeldor type. This apparatus has been so constructed that the two generators i can be used to work a 400 K.V. tube in a cannon of the same type. This latter tube has been in use during the year, but there have been several interruptions, and treatment with it has not yet become a regular feature of the clinic. The X-ray work of the clinic is done, therefore, by three Holfeldor cannons working at 195 K.V. with a Thoreas filter (0.5 mm. copper, 0.4 mm. tin and 1 mm. aluminium) at intensities varying from 5 to 15 r. per minute, and two 200 K.V. Holfeldor cannons with the same filter and same intensities. Throughout the year we have continued to treat unselected patients at varying intensities, and it is hoped that we shall soon have a large enough number treated at each intensity to enable us to make a reliable comparison. As the cases for these different intensities are not in any way selected, it will be necessary to have a very large number before any reliable conclusions can be drawn from statistical compilation about them. It may be noted, however, that as a means of palliation in advanced cases, the lower intensities are clearly more useful than the higher ones. There has been no radical change in the general principles of treatment at the clinic during the year, but small modifications are continually being made to make use of new suggestions and ideas. The superiority of the results obtained by surface applications of radium when the distance of the radium from the surface is considerable, has led us to increase, as far as the radium at our disposal allows, the distance of surface applications. A great variety of materials have been used in the making of these surface applications, Columbia paste, dental composition, sponge rubber, cardboard boxes, wooden blocks and other materials all play their part, and are used as may be most convenient for any particular case. A growing use has been made of surface applications of radium combined with X-ray treatment, and this is particularly true of those surface applications in which the surface is within a cavity of the body, such as the mouth, oesophagus, rectum and uterus. In all of these cases it is the rule to use X-ray therapy followed by a surface application. When surface applications cannot be used, if the tumour is accessible, it is treated by X-ray therapy followed by interstitial needling of the tumour ; or, when the tumour has disappeared during the X-ray treatment, needling of the tumour site. X-rays alone are only used for those tumours which are too deep for any form of surface application and too inaccessible for radium needling. The majority of all carcinomatous ulcers can be made to heal by X-rays or radium, or both, but in a certain number recurrences at the site of the primary growth occur, and in a still greater number distant metastases form, if the patient lives long enough. To secure the final and complete disappearance of the tumour all that is needed is that we should obtain the most accurate information about the radiosensitivity of the tumours we are treating, and methods of delivering to every part (that is to say to every cell) of the tumour the amount of radiation that is necessary to effect a " cure." Great progress has been made in both these directions. Firstly, although the histological study of tumours is disappointing and seldom of much value to the clinician, a careful clinical study of tumours and of the tissues in which they occur, is affording considerable information as to the amount of irradiation necessary to be delivered under any special circumstances to ensure the destruction of the tumour. Secondly, during the year there have been published 64 many very valuable treatises dealing with the measurement of irradiation that is delivered under given circumstances to the different parts of any irradiated area. In the treatment of cases of carcinoma at the clinic an attempt has been made to estimate the number of r. delivered to every part of the irradiated area, whether the treatment be by means of X-rays or radium, and an attempt is always made to deliver at least 6,000 r., in from 3 to 6 weeks, to every part that may be presumed to be infested by the tumour. When a patient is to be treated by X-rays only, this is not always possible, the local reaction being too violent to allow that dose to be reached. When part of the treatment is by radium and part with X-rays, and still more when only radium is used, it is generally possible to reach and even to exceed 6,000 r. to every part of the tumour. An attempt is also made to limit the reaction caused by such treatment to superficial lesions that heal in from three to six weeks after the end of the treatment, but it is inevitable that a small percentage of the cases treated get reactions that are more serious than was intended, and troublesome ulcers may result. These are often very trying, but will generally yield to treatment by diathermy, excision or U.V.R. The metastatic deposits of tumours present two problems, the first to prevent them occurring, and the second to treat them when they have occurred. As regards the latter, it is generally easier to treat secondary deposits than the primary tumour from which they come, providing that the deposit is accessible to radium or X-rays. With the exception of a small minority, metastatic deposits generally require a smaller dose of radiation to cause them to heal than the primary tumour. The prevention of secondary deposits, however, is a very formidable problem. When it is remembered that cancer cells may spread from the primary growth either by a direct infiltration into the tissues that surround it, or by growing along or flowing along the lymph vessels which lead away in all directions, or by travelling in the blood stream to distant parts of the body, the factors that are concerned in the occurrence of secondary deposits must clearly be very complex, and some of them probably not within our control. It is well known that secondary deposits are much more likely to occur with some forms of growth than with others, e.g., in tumours of the breast, the greater the proportion of fibrous tissue the less likely are secondary deposits to occur, but while this is true it must be remembered that a carcinoma may change its characteristics of growth the moment it invades a new tissue ; so that while one part of the growth may be little likely to cause metastases another part may be continually doing so. There are, however, two methods of preventing metastases which should always be employed. It should be a cardinal rule that no growth should be incised or wounded, or in any way disturbed by unnecessary surgery, and, secondly, that the part of the body in which the growth occurs should be rested as far as possible. In many cases this is difficult to accomplish, as in growths about the mouth and throat, but it may be done for carcinoma of the breast and sarcomata of the extremities. It is in the hope of lessening the incidence of metastases that it is preferable always to start treatment of tumours by external irradiation (radium or X-rays). It is hoped that by so doing any tumour cells, that may be dislodged during the manipulations necessary for the surface or interstitial applications of radium, may suffer devitalisation to prevent them forming a secondary deposit. In addition to the cases of sarcoma and carcinoma many other diseases have been treated at the radiotherapeutic clinic. With the exception of metropathia hemorrhagica, uterine fibroids and exophthalmic goitre, the statistical analysis of these cases is not made for more than two years after treatment. In many of these conditions X-rays and radium are valuable agents for treatment, and give nearly perfect results with little inconvenience to the patients. Painful corns and callosities, warts, nsevi and a very large number of skin lesions can be made to heal satisfactorily, and a large number of these have been treated during the year. In osteoarthritis and many chronic inflammations, the effusions are absorbed and pain is relieved without discomfort to the patient. It is proposed to collect and analyse particulars of these non-malignant conditions for a subsequent report. 65 We should like to express acknowledgements of the hard and efficient work which the staff of the department have done during the year. Radiotherapy is an exacting form of treatment and can only be carried out efficiently by a staff whose keenness and good team work are of a high order. We have been very fortunate in the staff that we have had during the year to work with us. Table 1. Disease. Male. Female. Improved. Not improved. Died. Improved. Not improved. Died. Melanotic sarcoma and carcinoma — 1 1 1 — 1 Sarcoma of muscle — — 1 — — — „ lymphatic glands — — 1 2 1 1 „ retroperitoneal 1 — — — — — „ periosteum 1 — — 1 — — „ femur 1 — — 1 — — „ scapula — — — 1 — — „ humerus 1 — — — — — pelvic bones 2 1 3 — — — ,, tibia — — — 2 — — Glioma of cerebrum 1 — — 1 — 2 Tumour of pineal gland — — 1 — — — „ brain — — 2 — 1 2 Meningeioma — — — — — 2 Rodent ulcer 25 1 1 15 1 1 Carcinomatosis — — — — — — Carcinoma—primary unknown — — — 1 — — „ conjunctiva 1 — — — — — „ middle ear 3 — . 1 — — „ nasal fossa — — — 1 — — „ maxillary antrum 1 — 2 8 — 2 .Malignant disease of nasopharynx 2 — — — — — Carcinoma of larynx 2 1 2 — — — „ extrinsic 12 1 5 — — — Branchial cyst 2 — — — — — Carcinoma of bronchus 5 1 12 — — 2 „ lung (primary) 4 3 11 — 1 — Malignant disease of mediastinum 1 — 1 1 — — Carcinoma of lip 15 — 1 2 — — „ buccal mucous membrane 3 — 1 — — — „ floor of mouth 22 1 7 1 — 2 Malignant disease of jaw — — — 1 — — Carcinoma of parotid 4 — 1 1 — 1 „ palate 8 2 3 — — — „ tongue 41 1 15 4 1 3 l,ymphoepithelioma (Schmincke) 2 — 1 — — — Carcinoma of pharynx 6 2 3 — — — „ tonsil 13 8 7 — 1 — „ hypopharynx 3 — 3 1 — — „ cesophagus 13 1 15 2 — 2 „ stomach 4 — 16 3 2 4 ,, pylorus — — — — — 4 appendix — — — 1 — — Carcinoma of colon, intestinal obstruction (caecum) — 1 3 2 1 2 „ „ (ascending colon) 1 1 — — — — „ „ (transverse colon) 1 — 2 2 — 1 „ „ (pelvic colon) 1 — 2 2 2 7 „ „ (general peritonitis) 1 — — — — — ,, „ (rectum) Carcinoma of anus 22 3 11 17 5 7 1 — 1 2 — — „ pancreas — — 4 — — 4 Malignant disease of liver — — 2 — — 2 Carcinoma of gall bladder — — — 1 — — „ bile duct — — 1 — — — 66 Table I—continued. Disease. Male. Female. Improved. Not improved. Died. Improved. Not. improved. Died. Malignant disease of peritoneum i — 5 1 1 „ „ lymphatic glands — — — 1 — — Carcinoma of glands of neck 7 — 5 3 — — „ thyroid 1 — — — — 2 Hypernephroma — — — — — — Carcinoma of kidney 1 — 1 1 1 3 „ bladder 3 — 7 1 — 2 „ urethra — — 1 — — 2 „ prostate 8 1 2 12 — — — „ penis 12 3 — — — „ testis 4 — — — — — Malignant disease of ovary — — — 6 1 8 Carcinoma of body of uterus — — — 2 1 3 „ cervix of uterus — — — 113 60 27 vagina — — — 3 2 — „ vulva — — — 8 9 3 breast 3 -1- 1 67 9 24 Paget's disease of nipple 1 — — — — — Malignant disease of skin (nature not stated) 2 — 1 — — — Carcinoma (squamous) of skin — — — 4 — — „ of lupus scar — — — 1 — 1 „ skin of leg (ulcer) 1 — — 3 — 1 „ cheek — — — 1 — — „ skin of face 4 — — — 1 — „ pinna 1 1 — 1 — — „ skin of neck — — — 1 — — „ scrotum 3 — 1 — — — Total 278 33 174 299 94 129 Grand Total 1,007 Table II. Total survival rate. Disease. Year. No. treated Alive at end of Remarks. 1st year. 2nd year. 3rd year. 4th year. Rodent ulcer 1930 4 3 2 2 2 1 died intercurrent disease. 1931 26 22 17 15 — 3 died intercurrent disease. 1932 24 15 13 — — 7 died intercurrent disease. 1933 30 22 — — — 4 died intercurrent disease. 1 un traced. 1934 34 — — — — — Carcinoma, skin of scalp. 1930 1 1 0 — — 1931 1 0 — — — — 1932 1 0 — — — 1 died intercurrent disease 1933 — — — 1934 — — — — — — Carcinoma, skin of pinna. 1930 — — — — — — 1031 3 2 0 — — — 1932 5 4 4 — — 1 untreated. 1933 1 0 — — — 1 died intercurrent disease. 1934 2 — — — — — 67 Table II—continued. Disease. Year. No. treatec Alive at end of Remarks. 1st year. 2nd year. 3rd | year. 4th year. Carcinoma, skin of face and neck. 1930 3 1 1 1 1 — 1931 9 4 4 2 — — 1932 6 2 2 — — — 1933 11 7 — — — — 1934 8 — — — — — Carcinoma, skin of trunk. 1930 — 1931 — 1932 2 2 2 — — — 1933 2 I — — — — 1934 2 — — — — — Carcinoma, skin of forearm. 1930 1 0 — — — 1931 — — — — — — 1932 1 1 1 — — — 1933 1 0 — — — — 1934 1 — — — — — Carcinoma, skin of hand. 1930 1 1 1 0 — — 1931 4 3 2 2 — — 1932 1 1 1 — — — 1933 1 — — — — 1 untreated. 1934 3 — — — — — Carcinoma, skin of thigh 1930 — — — — — — 1931 — 1932 1 0 — — — — 1933 1 1 — — — — 1934 2 — — — — — Carcinoma, skin of leg- 1930 1 1 0 — 1931 2 1 1 1 — — 1932 4 3 3 — 1933 3 3 — — — — 1934 2 — — — — — Carcinoma, skin of foot. 1930 2 1 1 1 1 — 1931 — — — — — — 1932 — — — — — — 1933 — — — 1934 — — — — — — Carcinoma, penis 1930 1 0 1931 3 3 3 2 — 1 untraced, 3rd year. 1932 1 1 1 — — 1933 6 5 — — — — 1934 8 — — — — — Carcinoma, scrotum 1930 — — — — — — 1931 3 1 0 — — — 1932 1 0 — 1 died intercurrent disease. 1933 1 1 — — — — 1934 2 — — — — — Carcinoma, vulva 1930 5 1 1 1 1 1931 3 0 — — — 1 untreated. 1932 5 1 1 — — — 1933 5 1 — — 1934 9 — — — — — 68 Table 11—continued. Disease. Year. No. treated Alive at end of ks. 1st year. 2nd year. 3rd year. 4th year. Carcinoma, middle ear. 1930 2 1 1 1 1 1 died intercurrent disease. 1931 1 0 — — — — 1932 — 1933 1 0 — — — — 1934 3 — — — — — Carcinoma, nasal fossae. 1930 2 0 — — — — 1931 2 0 — — — — 1932 2 1 1 — — — 1933 1 0 — — — 1934 1 — — — — — Malignant disease of naso-pharynx. 1930 3 0 — — — — 1931 — — — — — 1932 4 3 3 — — — 1933 2 2 — — — — 1934 3 — — — — — Carcinoma, maxillary antrum. 1930 3 1 0 — — — 1931 2 0 — — — — 1932 7 1 1 — — 2 died intercurrent disease. I !♦:{:{ 4 1 — — — 1934 6 — — — Carcinoma, lip 1830 6 5 2 2 2 1931 4 2 2 1 — 1 died intercurrent disease. 1932 9 2 1 — — — 1933 7 5 — — — 1 died intercurrent disease. 1934 13 — — — — — Carcinoma, buccal mucous membrane of cheek. 1830 4 2 0 — — 2 died intercurrent disease. 1931 3 1 0 — — — 1032 1 0 — — — — 1933 1 0 — — — 1934 4 — — — — Carcinoma, palate 1930 2 1 0 — 1931 4 0 — — — — 1932 6 4 1 — — — 1033 9 3 — — — — 1934 5 — — — — — Carcinoma, tongue Stage I. 1930 5 3 2 2 2 — 1931 5 3 2 2 — — 1932 5 1 0 — — — 1933 8 3 — — — — 1934 4 — — — — — Carcinoma, tongue Stage II. 1930 — — — — — — 1931 7 2 — — — 1932 7 3 1 — — 1 died intercurrent disease. 1933 11 0 — — — — 1934 10 — — — — — Carcinoma, tongue Stage III. 1930 12 2 0 1 died intercurrent disease. 1031 12 5 2 2 — — 1932 16 2 1 — — — 1933 15 1 — — 1934 14 — — — — — 69 Table 11—continued. Disease. Year. No. treated Alive at end of Remarks. 1st year. 2nd year. 3rd year. 4th year. Carcinoma, tonsil Stage I. 1930 1 1 1 1 1 — 1931 1 1 0 — — — 1932 — — — — — — 1933 — — — — — — 1934 — — — — — — Carcinoma, tonsil Stage II. 1930 6 1 1 1 1 — 1931 2 1 0 — — — 1932 4 1 1 — — — 1933 7 2 — — — 1934 5 — — — — Carcinoma, tonsil Stage III. 1930 — — 1931 1 0 — — — 1932 5 2 1 — — — 1933 7 3 — — — — 1934 13 — — — — — Carcinoma, pharynx Stage I. 1930 4 0 — — 1931 1 0 — — — — 1932 1 0 — — — — 1933 1 1 — — — — 1934 2 — — — — — Carcinoma, pharynx Stage II. 1930 2 0 — — 1931 1 0 — — — — 1932 5 1 0 — — 1 untreated. 1933 3 1 — — — — 1934 2 — — — — — Carcinoma, floor of mouth. Stage I. 1930 2 1 1 0 — — 1931 1 0 — — — — 1932 6 3 3 — — — 1933 3 1 — — — — 1934 2 — — — — Carcinoma, floor of mouth. Stage II. 1930 4 0 — 1931 4 1 1 1 — — 1932 2 0 — — 1933 9 2 — — — — 1934 3 — — — — — Carcinoma, floor of mouth. Stage III. 1930 5 2 2 2 2 — 1931 4 1 0 — — 1932 6 2 1 — — 1 untreated, 1 untraced. 1933 10 4 — — — 1 untreated. 1934 10 — — — — — Carcinoma, pyriform fossa. 1930 2 1 0 1 died intercurrent disease. 1931 1 0 — 1932 4 0 1 died intercurrent disease. 1933 1 1 — — — — 1934 1 — — — — — Carcinoma, parotid 1930 — — — — — — 1931 1 1 1 1 — — 1932 2 2 1 — 1933 6 4 — — — — 1934 5 — — — — — 70 Table II—continued. Disease. Year. No. treated Alive at end of Remarks. 1st year. 2nd year. 3rd year. 4th year. Carcinoma, hypo— pharynx. 1930 1 0 1931 1 0 — — — — 1832 4 2 2 — — — 1933 12 2 — — — — 1934 7 — — — — — Carcinoma, larynx Stage I. 1930 1 0 1931 5 2 0 — — 1 died intercurrent disease. 1 untreated. 1932 4 1 1 — — 1 untreated. 1933 7 3 1 1 untreated. 1934 6 — — — Carcinoma, larynx Stage II. 1930 — 1931 2 0 — — — — 1932 1 0 — — — — 1933 1 1 — — — — 1934 2 — — — — — Carcinoma, epiglottis 1930 2 1 0 — — — 1931 — — — — — — 1932 — — — — — — 1933 1 1 — — — — 1934 1 — — — — — Carcinoma, oesophagus. 1930 5 0 — 1931 15 1 0 — — 1 untreated. 1 died intercurrent disease. 1932 14 0 — — • — 3 untreated. 1 died intercurrent disease. 1933 11 0 — — — 1 untreated. 1934 19 — — — — — Carcinoma, thyroid 1930 1 0 — 1931 2 0 — — — 1 died intercurrent disease. 1932 3 0 — — 1933 2 0 — — —. 1 died intercurrent disease. 1934 3 — — — — — Mediastinal neoplasms 1930 3 1 0 — — — 1831 3 1 0 — — 2 untreated. 1932 5 2 — — — 1 untreated. 1933 17 3 — — — 1 untreated. 2 untraced. 1934 17 — — — — — Carcinoma, stomach 1930 — — — — — — 1931 — — — — — — 1932 2 0 — — — 2 untreated. 1933 2 0 — — — — 1934 3 — — — — — Carcinoma, colon and caecum. 1930 — — — — — — 1931 1 0 — — — — 1932 1 1 0 — — — 1933 I 0 — — — — 1934 10 — — — — — Carcinoma, rectum 1930 12 6 2 1 1 2 untreated. 1931 25 10 3 1 — 6 untreated. 1 untraced. 1932 18 7 3 — — 1 untreated. 1 untraced. 1933 30 9 — — — 3 untreated. 1934 29 — — — — — 71 Table II—continued. Disease. Year. No. treatec Alive at end of Remarks. 1, j year. 2nd year 3rd year 4th year. Carcinoma, anus ... 1930 1 — — — — — 1931 6 1 — 1932 4 2 2 — — 1 untraced. 1 untreated. 1933 1 0 — — — 1934 3 — — — — — Carcinoma, prostate 1930 7 3 1 1 1 — 1931 4 4 2 1 — 1932 4 1 0 1 untreated. 1933 12 4 — — — 1934 12 — — — — — Carcinoma, bile ducts, etc. 1930 — — — — — — 1931 — — — — — — 1932 — — — — — — 1933 1 1 — — — — 1934 1 — — — — — Carcinoma, kidney 1930 — — — — — — 1931 — — — — — — 1932 2 2 2 — — — 1933 1 0 — — — — 1934 3 — — — — — Carcinoma, bladder 1930 — — — — — — 1931 7 3 1 0 — — 1932 6 0 — — — — 1933 ' 4 1 — — — 1934 15 — — — Carcinoma, urethra 1930 2 1 1 1 i 1 untreated. 1931 1 0 — 1932 2 0 — — 1933 1 0 — — — 1934 1 — — — — — Carcinoma, ovary 1930 1 1 1 1 0 — 1931 2 0 — — — 1932 4 1 1 1 untreated. 1933 3 1 — — — 1934 11 — — — — Carcinoma, testis... 1930 2 0 1931 3 2 2 1 — 1 untraced. 1932 2 1 1 __ 1933 3 3 — 1934 3 — — — — Carcinoma, corpus uteri. Stage I. 1930 2 2 2 2 2 — 1931 — — — — — — 1932 2 2 0 — — — 1933 3 2 — — — — 1934 3 — — — — — Carcinoma, corpus uteri. Stage II. 1930 2 1 1 1 1 — 1931 — — — — — — 1932 3 2 1 — 1933 2 0 — 1934 2 — — — — 72 Table II—continued. Disease. Year. No. treated Alive at end of Remarks. 1st year. 2nd year. 3rd year. 4th year. Carcinoma, cervix uteri. Stage I. 1930 — — — — — 1931 2 1 1 1 — — 1932 4 2 1 — — 1 untraced. 1933 2 1 — — — — 1934 1 — — — — — Carcinoma, cervix uteri. Stage II. 1930 1 1 0 — — — 1931 — 1932 6 1 1 — — — 1933 1 0 — — — — 1934 2 — — — — — Carcinoma, cervix uteri. Stage III. 1930 2 0 — — — 1 untreated. 1931 8 1 1 1 — 1 died intercurrent disease. 1932 8 1 0 — — 1933 11 2 — — — 1934 9 0 — — — Carcinoma, cervix uteri. Stage IV. 1930 — — — — — — 1931 1 0 — — — 1932 2 0 — — — — 1933 4 0 — — — — 1934 7 — — — — — Carcinoma, vagina 1930 — — — — — — 1931 — 1932 1 1 1 — — 1933 4 2 — — 1 untreated. 1934 2 — — — — Carcinoma, breast ... Stage I. 1930 2 2 1 1 1 1 died intercurrent disease. 1931 8 4 4 3 — 1 died intercurrent disease. 1 untreated. 1932 7 6 5 — — 1 died intercurrent disease. 1933 6 5 — — — 1 untreated. 1934 10 — — — — — Carcinoma, breast... Stage II. 1930 9 4 2 2 2 2 died intercurrent disease. 1931 36 11 6 5 1 died intercurrent disease. 8 untreated. 1932 37 17 11 — — 1 died intercurrent disease. 1 untreated. 1933 33 9 — — — 2 untreated. 2 untraced. 1934 46 — — — — — Carcinoma, breast... Stage III. 1930 6 1 0 — — 1931 10 6 4 2 — . 1 untreated. 1 died intercurrent disease. 1932 14 9 7 — — 1 untreated. 1933 22 7 — — — 2 untreated. 1934 13 — — — — Carcinoma, glands of neck. 1930 4 0 — — 1931 6 2 0 — —. 2 untreated. 1932 10 1 1 — — 1 untreated. 1933 11 3 — — — I untreated. 1 untraced. 1934 10 — — — — — 73 Table II—continued. Disease. Year. No. treated Alive at end of Remarks. 1st year. 2nd year. 3rd year. 4th year. Carcinoma, lupus scar. 1930 1 1 1 1 1 — 1931 — — — — — — 1932 — — — — — — 1933 1 1 — — — — 1934 1 — — — — — Tumour of brain 1930 — — — 1931 1 1 — — — 1 untraced, 2nd year. 1932 1 1 1 — — — 1933 1934 2 1 0 — — — — Pituitary tumour 1930 — — — — — — 1931 — — — — — — 1932 1 1 1 — — — 1933 1 1 — — — — 1934 1 — — — — — Melanoma 1930 — 1931 — — — — — — 1932 3 2 2 — — 1 untraced. 1933 8 2 — — — — 1934 3 — — Sarcoma of lymph glands. 1930 2 1 1 1 1 — 1931 1 0 — — — — 1932 4 0 — — — — 1933 4 1 — — — — 1934 5 — — — — — Sarcoma of jaw ... 1930 — 1931 — 1932 1 0 — — — — 1933 2 0 — — — — 1934 — — — — — — Sarcoma of vertebrae. 1930 — — — — — — 1931 — — — — — — 1932 — — — — — — 1933 — — — — — — 1934 1 — — — — — Sarcoma of pelvis... 1930 — 1931 3 1 1 0 — — 1932 2 1 0 — — — 1933 4 I — — — — 1934 — — — — — — Sarcoma of clavicle 1930 — — — — — — 1931 1 0 — — — — 1932 — — — — — — 1933 — — — — — — 1934 — — — — — — Sarcoma of humerus 1930 — — — — — — 1931 1 1 1 0 — — 1932 — — — — — 1933 — — — — — — 1934 — — — — — — Sarcoma of femur 1930 — — 1931 3 1 0 — — — 1932 2 0 — — — 1 untreated. 1933 1 0 — — — 1934 1 — — — — — 74 Table II—continued. Disease. Year. No. treatec Alive at end of Remarks. 1st year. 2nd year. 3rd year. 4th year. Sarcoma of tibia 1930 — — — — — — 1931 — — — — — — 1932 — — — — — — 1933 — — — — — — 1934 3 — — — — — Osteitis deformans and sarcoma. 1930 1 — — — — 1 untraced. 1931 — — — — 1932 — — — — — — 1933 I — — — — 1 untreated. 1934 2 — — — — Sarcoma of muscle, etc. 1930 2 1 0 — 1931 — 1932 2 9 0 — — 1933 4 1 1 untreated. 1 untraced. 1934 2 — — — — Myeloma 1930 2 1 1 1 1 — 1931 1 1 1 1 — — 1932 2 2 2 — — — 1933 — 1934 1 — — — — — Hodgkin's disease and lymphadenoma. 1930 2 1 0 0 0 — 1931 3 2 2 1 — — 1932 4 2 2 — 1933 9 7 — — — 1934 8 — — — — — Miscellaneous— malignant. 1930 1 0 — — — — 1931 2 0 — — — — 1932 — 1933 — — — — — — 1934 6 — — — — — Metropathia hemorrhagica. 1930 4 3 3 3 3 1 untraced. 1931 4 2 2 2 — 1 untraced. 1 untreated. 1932 8 6 6 — — 1 untraced. 1933 7 7 — — 1934 10 — — — — — Uterine fibroids 1930 1 1 1 1 1 — 1931 9 1 1 1 — 1 untreated. 1932 — — — — — — 1933 2 2 — — — — 1934 3 — — — — Exophthalmic goitre 1930 — — — — — — 1931 3 3 3 3 — — 1932 — 1933 1 1 — — — — 1934 2 — — — — — Miscellaneous—nonmalignant. 1930 3 2 9 2 2 1 not followed. 1931 5 1 1 1 — 1 not followed. 1932 7 5 5 — — 1 not followed. 1933 17 6 — — — 2 untreated. 3 not followed. 1934 15 — — — — — Grand total 1,745 PLASTIC SURGERY UNIT. Honorary Chief Surgeon—Sir Harold Gillies, C.B.E., F.R.C.S.(Eng.). Plastic Surgeon—T. P. Kilner, M.B., B.S., F.R.C.S.(Eng.). Assistant Plastic Surgeon—A. H. McIndoe, M.Sc., M.S., F.R.C.S.(Eng.). (1) Hammersmith Hospital. Report for the period from 1st January to 15th August, 1934 By Sir Thomas Carey Evans, M.C., M.D., F.R.C.S.(Eng.), L.R.C.P., Medical Superintendent, Hammersmith Hospital. The volume of work during the first eight months of this year has shown an increase on the corresponding period for the year 1933. During the eight months 97 patients were admitted, and upon them 167 operations were performed. The conditions requiring treatment showed no relative change as compared with those admitted in the previous years. A most satisfactory point noted during this period was that the number of patients reaching completion of their treatment became considerably greater, and now that the unit has been established for three years, this should remain a more permanent state of affairs. In other words, there has been a greater number of patients returning for their final operative stage, after an interval of from 6 to 18 months to allow of complete convalescence. Expansion of the unit was limited on account, firstly, of the probability of early transfer of the work to another hospital, and secondly, of the demands made by general surgery on the time of the medical officer in charge. In spite of this there were times when almost the whole capacity of the available wards was utilised to the exclusion of general surgical work. This, of course, was dealt with elsewhere in the hospital. The maximum number of patients in hospital at one time was 40, and this gives some indication of the demand for beds for this work. Anaesthesia.—There was no great change in the methods employed, and the results continued to be excellent. This is entirely due to the skill of the visiting consultants. Speech training.—60 sessions were given, comprising 267 individual lessons. During the latter part of the period the number of sessions per week became insufficient, in view of the increased number of patients requiring tuition. Records and museum.—Records continued to be kept on a large scale, but the foundation of a museum was postponed until after the transfer. Dental laboratory.—65 units of work were completed, exclusive of the necessary adjustments. (2) St. James' Hospital. Report for the period from 15th August to 31st December, 1934, By W. L. Maccormac, M.B., Ch.B., F.R.C.S.(Edin.), Medical Superintendent, St. James' Hospital. As the result of the removal of the unit from Hammersmith to St. James' hospital, there was some dislocation of the routine. This was mainly due to the fact that it was impossible to transfer the dental laboratory until 1st October ; and, without prior dental treatment, a proportion of patients were unable to be admitted for operation. As the result of the transfer it was found possible to reconstitute the unit. The medical officer who has been in charge of the patients at Hammersmith was relieved of all other duties, and allowed to concentrate on plastic surgery alone. The patients are segregated in " bays," and though increasing work makes the present accommodation inadequate, every endeavour is made to keep all patients requiring treatment under the charge of the same nursing staff. A staff nurse and one junior nurse were allocated for plastic work only in both the male and female wards. As a result of these measures the efficiency of the unit was immediately increased, and the volume of work commenced to rise. (75) 76 During the last four months of the year the number of patients admitted was almost equal to the number admitted in the first eight months, i.e., 90 as compared with 97. Upon these 90 patients 96 operations were performed, in spite of the fact that Sir Harold Gillies was in America on leave for approximately six weeks. Anaesthesia.—In spite of an increased number of operation sessions, it has been found possible to continue to make use of the services of those anesthetists who were available at Hammersmith. Basal anaesthesia with Evipan or Nembutal has been more freely used, and the results have been uniformly good. Speech training.—The number of sessions per week has been increased ; 48 sessions have been held, comprising 164 lessons in all. This department is handicapped by lack of accommodation, which precludes the installation of many appliances which would be very useful both from the standpoint of records and of teaching. For the latter purpose advantage was still taken of the hospitality of University College, to whose phonetic department the unit is much indebted. Dental laboratory.—The new laboratory is a great improvement on the old. It is well equipped and easily accessible. Eighteen units of work were completed in the period covered by this report. GOITRE CLINIC: NEW END HOSPITAL. Report for the year ending 31st December, 1934. By R. H. Swindells, M.B., Ch.B., F.R.C.S.(Edin.), Medical Superintendent, New End Hospital. The work of the unit during the year has been almost entirely surgical, and a brief resume is subjoined :— Number of operations in year 64 Number of patients operated on 54 Sex of patients Females 50 Males 4 Age range of patients 14 to 67 years Patients requiring 2 operations 8 Patients requiring more than 2 operations 1 Preliminary ligature of vessels 5 Average time in hospital 26-6 days Average time in hospital after operation 15-8 days Anaesthesia employed— Avertin—Gas and oxygen 59 Scopolamine—Morphine—Gas and oxygen 3 Morphine—Gas and oxygen. 1 Planocaine (local only) 1 Origin of patients— County of London 35 Out-county cases 19 Deaths 4 The out-county cases came from the following areas :— Cornwall 2 Warwickshire 1 Yorkshire 2 Essex ... 1 Lancashire 1 Gloucestershire 1 Bedfordshire 1 Middlesex 1 Cambridgeshire 1 Surrey ... 1 Hampshire 1 North Wales 1 Berkshire 1 South Wales 1 Northern Ireland 1 1 patient came from East Africa for operation. 1 „ „ „ India „ „ Of the deaths— 1 occurred 16 hours after operation (1 lobe only removed). 1 35 ± ,, uir ,, ,, ,, 1 20 1 ,, 5 days ,, ,, from sudden cardiac failure in a patient who was apparently progressing satisfactorily and in whom the wound was well healed. The surgeons concerned were Sir Thomas Dunhill (35 operations) and Mr. Geoffrey Keynes (29 operations). Appended are notes of some of the cases :— The patient requiring more than two operations was a woman, aged 30, who came from Case reports. Penzance. She had been ill 8 years and had been in bed for 15 weeks prior to coming into hospital. The gland was very large, she had marked exophthalmos, her pulse on admission was 160, she had lost weight considerably, tremor was present, she had difficulty in swallowing and complained of diarrhoea. She was prepared for operation (preliminary ligature of vessels) on 25.5.34 and avertin was given—the pulse rate went up to 216 and the operation was postponed. First operation on 8.6.34. Under morphine and scopolamine with local infiltration, the superior vessels were ligated. Second operation on 22.6.34. The right lobe was removed. Third operation on 6.7.34. The left inferior artery was ligated. Operation on the left lobe was arranged for 20.7.34, but two hours before operation the patient became restless and the pulse rose to 150. Operation was postponed. (77) r 78 On 25.7.34 she was discharged home improved with a pulse of 110-120, and instructed to return in October. She was readmitted on 12.10.34, and had her fourth operation on 19.10.34, when the left lobe was dealt with. She was discharged home on 7.11.34 when her general condition was good, pulse 90-100, free from symptoms and generally much improved. The patient who died 20 hours after operation was a girl of 14 years who had been at Carshalton for 11 months prior to coming to New End hospital. Her condition was very serious, her pulse rate had been continually high for months, from 110 to 160. A preliminary ligature of the superior vessels was done with benefit, and 27 days afterwards half the gland was dealt with, but the patient died 20 hours after operation. The following was a case of parathyroid tumour :— Emily F., aged 60, was transferred to New End hospital from one of the Council's hospitals as a case of fibrocystic disease of bone—? hyperparathyroidism. History.—Fracture of humerus in 1930. Fracture of right humerus and left femur on 19.9.33. On 13.11.33 fracture of right femur after a fall. X-Ray examination revealed characteristic fibrocystic disease of bone " indistinguishable from the hype rpara thyroid type of charge." Operation on 18.5.34 by Sir Thomas Dunhill. The thyroid gland was displayed through a collar incision. The right lobe was explored and found to be normal. The left lobe was then explored—the posterior margin of this was thicker than usual, but otherwise normal. Behind and to the outer side of the lower margin of the thyroid and behind the common carotid artery a mass was felt. This was enucleated from the surrounding tissues. It was really situated in the upper part of the thorax—it was large, U to 2 inches in diameter, three-cornered in shape and slightly lobulated. The bulbous portion of the left lobe of the thyroid was excised as it was of unusual shape. Lateral drainage was provided for and the neck wound closed in layers. The pathologist's report on a section of the parathyroid tumour was as follows :—" A typical adenoma of the parathyroid gland. The histological structure recalls that of the parathyroid and presents compact columns of epithelium with several alveolar arrangements of varying sizes, the alveoli being lined by cuboidal cells." Progress after operation.—Calcium sodium lactate was given by mouth, calcium lactate intravenously. Parathormone, 3 c.c., given intramuscularly every second day. Progress was satisfactory. On the 6th day after operation she had slight twitching and spasm of the ulnar sides of hands. On the 9th day after operation the wound was healed—there was no evidence of tetany and her general condition appeared satisfactory, but she was depressed and anxious to be transferred back to the hospital from which she came in order to be near her friends. Eleven days after operation she was transferred, developed signs of tetany later, and died. At autopsy the following conditions were found : Transverse operation scar over thyroid perfectly healed. Gross deformity of L. femur due to old fracture, similar deformity of R. femur, but less marked. Deformity of R. humerus, also due to old break. (Edema of both lower limbs. Postural kyphosis with secondary lordosis—no fracture of spine. Old healed superficial ulcer of right leg. Every bone examined was the seat of fibro-cystic disease, especially the femora, humerus and skull bones. The fractures were all firmly united, but with deformity. The right lobe only of the thyroid was found. No trace was found of the left parathyroid body. The right one was doubtful. The pituitary gland was notably enlarged, as were the adrenals which had a greater amount of lipoid than normal. The colloid of the thyroid was perhaps in excess. Results. The immediate results of operation are almost uniformly good. A post-operative reaction occurs and the pulse rate increases and persists for usually about 48 hours and then commences to fall slowly. At the end of 7 to 14 days the rate has fallen to the normal for the particular patient. The patient almost invariably feels improved, and weight is gained. After results. A follow-up scheme has been instituted and many patients report personally and others report on the special form sent out periodically. The results as ascertained in these ways are as follows :— (a) Considerable improvement 30 (b) Slight improvement 10 (c) No information 8 (d) Recurrence of symptoms 1 (a) These patients all report definite improvement indicated by improved health, gain in weight and freedom from, or diminution of, symptoms previously complained of, with increased capacity for work. Expressions such as " vastly improved," " general improvement," " very much better " are used in some of the reports. 79 (b) This heading includes patients who still complain of poor health which, in several cases, cannot be attributed to a thyroid condition. One of these patients had a definite psychosis. (c) These cases were well on discharge, but no reports have been received from them. (d) This is a case of a female, aged 28, who was seriously ill when admitted to hospital. A preliminarv ligature of vessels was done, and at a second operation the gland was dealt with. She is following her occupation (clerical), but complains of recurrence of tachycardia, mental depression and nervous svmptoms. There is regrowth of the gland to some extent, and she is being kept under observation. DIABETIC CLINIC: ST. PETER'S HOSPITAL. Report for the year ending 31st December, 1934. By B. A. Young, M.D., M.R.C.P., Senior Assistant Medical Officer, St. Peter's Hospital. During the last year there has been a considerable increase in the number of patients receiving treatment at the clinic and in the wards. In December, 1934, 67 diabetics were attending as out-patients and, during 1934, 62 were admitted to the wards. For the same periods in 1933 the numbers were 38 and 49, respectively. The cause of the high incidence of diabetes in the hospital district is suggested in Joslyn's statements that the obese individual is at least twice, and at some ages forty times, as liable to diabetes as is the normal individual, and that over-weight is most common among females and Jews, two groups most prone to the disease. Of our cases 72 per cent. are females, the large majority Jewish, and, in spite of their poor financial circumstances, obese. Poverty and diabetes When poverty and diabetes are associated the treatment is difficult, prognosis poor, and the disablement produced considerable. This fact has been emphasised by continental writers with wide experience of diabetes among the poor, whose opinions have recently been summarised by Wislicki.15 Pryll,9 in a reference in this paper, states that the progress of the diabetic is inversely proportional to his income. Gottschalk2 rates intelligence and perseverance first and social conditions second in controlling the fate of the diabetic. In my experience these three factors unfortunately vary directly with one another. The only diabetic fatalities among children in Joslyn's clinic in 1931 were dependent on aid from town, city or state.6 Principles of treatment. The majority of patients at present attending the clinic fall into the group with poor social conditions and low intelligence. The adaptation of modern lines of diabetic treatment to their modest capabilities has been the object of the work during the last year. The principles of treatment which were suggested in the last report as most suitable for this type of patient have been followed and developed, and are in short (1) frequent attendance and constant supervision at the clinic; (2) diets of the inexpensive high-carbohydrate, low-fat, low-calorie type, made as simple as possible; and (3) all new patients and re-admissions to the wards are instructed in the visual method of quantitative measurement of food by means of models. The results have been encouraging. In December, 1934, 87 per cent. of the patients were constantly without glycosuria, 4 per cent. showed occasional and 9 per cent. constant glycosuria. There have been no cases of gangrene or diabetic coma requiring admission from the regular attendants at the clinic. The diet. Subjoined is a short description of the type of diet in use, and the method employed for its quantitative measurement. It is now generally accepted that the high-carbohydrate, low-fat and low-tomoderate calorie diet is superior to diets with low-carbohydrate, high-fat and highcalorie content of the past. Lawrence7 has defined the carbohydrate content of a diabetic diet as low when it contains below 80 grammes; as moderate between 100 and 150 grammes; as high when more than this is given. Rabinowitch11,12,13 advocates as much as 250 grammes of carbohydrate, with very low fat and low caloric values. Easton and Lyon1 give moderately high amounts of 150 grammes, and Lawrence7 considers such quantities advisable. Leyton8 states that in all but very severe cases 200 grammes may be given. The carbohydrate content of the diets in use in the clinic vary from 150 to 190 grammes. With increase in carbohydrate there has been reduction in the fat and total caloric value of the diabetic diet. Rabinowitch11 gives as little as 50 grammes, finds no deleterious effect on the patient's health and a considerable increase in his sugar tolerance. Other authorities1,3 consider such a low fat content unnecessary and advise average amounts of 120 grammes. As a large number of the clinic patients are over-weight, I find 85 to 100 grammes of fat usually sufficient. The total calories used rarely exceed 2,000, or 27 to 30 calories per kilogramme of body weight, except in children, heavy manual labourers, or where diabetes is complicated by pulmonary tuberculosis. A woman with a sedentary occupation receives 1,500 to (80) 81 1,700 calories. The average for a man of middle height and sedentary work is 1,700 to 1,900 calories, and for a manual labourer 2,000 to 2,500 calories. The advantages of such a diet are many. It is cheap, an obvious advantage to the poor patient. The patient's sugar tolerance is improved, and hypoglycæmia and glycosuria are more readily controlled. The general health of the patient and sense of well being increases, and there is less liability to ketosis. With the increased carbohydrate the insulin dosage need not, in the majority of cases, be increased and in many may be decreased, provided the fat and calories are kept low. Simplicity of the diet is of great importance for even "the average individual will follow a prescribed diet only in direct proportion to its simplicity."14 Diet A is typical of those used in the clinic. diet A. (Foods prescribed in ounces.) Calories 1,817. Carbohydrate, 166 grms. Protein, 79 grms. Fat, 93 grms. (arranged for insulin "b. d.") C. P. F. Breakfast:— Egg: 1 0 6 6 Bread: 3 oz. 54 9 0 Butter: ¾ oz. 0 0 18 Milk: 4 oz. in 2 cups unsweetened tea or coffee 6 4 4 60 19 28 Dinner :— Lean meat 0 24 15 or chicken: 3 oz 0 (24) (12) or fish: 4½ oz. 0 (27) 0 (With fish take ½ oz. butter or fat) 0 0 (12) Potato: 1½ oz. 9 1½ 0 Vegetables: 6 oz. greens, lettuce, cabbage, cauliflower, or 4 oz. Brussels sprouts, turnips, tomatoes, or 3 oz. carrots, leeks, onions 5 0 0 Apple or orange: 2½ oz. 5 0 0 19 25½ 15 Tea:— Bread: 1 oz. 18 3 0 Butter: ½ oz. 0 0 12 Milk: 2 oz. in unsweetened tea 3 2 2 Egg:1 0 6 6 21 11 20 Supper:— Lean meat 0 12 8 or chicken: 1½ oz. 0 (12) (4½) or fish: 3 oz. 0 (18) 0 (With fish take ¼ oz. butter or fat) 0 0 (6) Vegetables: As for dinner 5 0 0 Bread: 2½ oz. 45 7½ 0 Butter: ¾ oz. 0 0 18 Apple or orange: 5 oz. 10 0 0 Milk: 4 oz. in 2 cups unsweetened tea or coffee 6 4 4 66 23½ 30 Total 166 79 93 Supper (Alternative): — Cheese: 1 oz. 0 8 11 or eggs: 2 0 (12) (12) Tomatoes: 4 oz. or large helping of lettuce 5 0 0 Bread: 2½ oz. 45 7½ 0 Butter: ¾ oz. 0 0 18 Apple or orange: 5 oz. 10 0 0 Milk: 4 oz. in 2 cups unsweetened tea or coffee 6 4 4 66 19½ 33 DIET B. (Food prescribed in portions.) Egg: 1. Bread: 3 portions (No. 1). Butter: 1½ portions (No. 3). Milk: 4 oz. in 2 cups of unsweetened tea or coffee. Lean meat, or chicken : 2 portions (No. 5), or fish: 3 portions (No. 5). (With fish take 1 portion of butter (No. 3) ). Potato: ½ size No. 6. Vegetables: 4 tablespoons (or more) of greens, lettuce, cabbage, cauliflower, or 3 tablespoons of Brussels sprouts, tomatoes, turnips, or 2 tablespoons of carrots, leeks, onions. Apple or orange: ½ size No. 7. Bread: 1 portion (No. 1). Butter: 1 portion (No. 3). Milk: 2 oz. in unsweetened tea. Egg: 1. Lean meat or chicken: 1 portion (No. 5). or fish: 2 portions (No. 5). (With fish take ½ portion of butter (No 4) ). Vegetables: As for dinner. Bread: 2 portions (No. 1). ½ portion (No. 2). Butter: 1 portion (No. 3). ½ portion (No. 4). Apple or orange: 1 size No. 6. Milk: 4 oz. in 2 cups unsweetened tea or coffee. N.B.—The figures in parenthesis refer to the number of the model used in estimating the size of a portion of the given food (see below). 82 Method of quantitative measurement of diet. Meticulous accuracy in the weighing of the diabetic diet has been criticized by several authorities on the treatment of this disease.4,7,11 Such accuracy is not justified owing to the variations in the carbohydrate, protein and fat content of food materials, which in different samples of the same material may vary by as much as 25 per cent.10 The use of scales, and the accurate weighing of every article of diet, also requires a degree of intelligence and perseverance not found in the majority of hospital patients. A means must be found which will combine a rough degree of accuracy with simplicity of execution. A method of visual estimation of portions of food by means of wood and cardboard models, and ordinary household utensils, has been evolved by Rabinowitch. This was described in 1930,11 and fully elaborated in his text book on diabetes mellitus published in 1933.14 The method has been used in the large clinic for diabetes at the Montreal general hospital for several years with considerable success. The combination of simplicity of execution and graphic demonstration of food quantities which it provides commends itself particularly to the patient of low intelligence. The patient is supplied with the following models, representing unit quantities of various foods which, with some modification, are described by Rabinowitch, and full details of the method may be found in this reference:— Model No. 1.—A block of wood, 3½ ins. square by ½ in. thick, representing one portion of bread weighing 1 oz. Model No. 2.—A half portion of bread, weighing ½ oz. Models Nos. 3 and 4.—A portion and a half portion of butter weighing ½ oz. and ¼ oz., respectively. Model No. 5.—A portion of lean meat, chicken or fish of any kind weighing 1½ oz. Models Nos. 6 and 7.—Discs of cardboard, no. 6 representing a potato weighing 3 oz., and no. 7 an apple or orange weighing 5 oz. The models are labelled "No. 1: One portion of bread," "No. 6: One potato," etc. Vegetables, rice and oatmeal are measured in ordinary household tablespoons, and a cheap glass measure is obtained graduated in fluid ounces. The diet sheet supplied to the patient is "translated" from ounces into terms of portions and tablespoons, and diet A (prescribed in ounces) will appear in the form of diet B (prescribed in portions). Patients are instructed in the wards in the use of this method. To the patient of limited intelligence, the visual picture of food quantities given by the models forms a standard of guidance more graphic and comprehensible than does a diet prescribed in weights. In my experience the method has proved cheaper, simpler and more efficient than the use of scales in the measurement of the diabetic diet. References. 1 Easton, J., and Lyon, D. M. Lancet, 1933, 1, 743. 2 Gottschalk, Klin. Wchnschr., 1931, 10, No. 26, 1208. 3 Graham, G., Clark, A., and Robertson, H. E. N. Lancet, Nov. 5th, 1932, 990. 4 Himsworth, H. P. University College Hosp. Mag., Jan. 1934. 5 Joslyn, E. P. New Eng. Jour. Med., 1933, 209, 519. 6 Joslyn, E. P., Med. Clin. N. Amer., 1933, 16, 793. 7 Lawrence, R. D. B.M.J., 1933, 2, 517. 8 Leyton, 0. "Diagnosis and treatment of Diabetes Mellitus." Adlard & Son, Ltd., London, 1933. 9 Pryll. Sociale Medizin, 1928, 1. 152. 10 Rabinowitch, I. M. Canadian Med. Assoc. Journ., 1925, 15, 1106. 11 Rabinowitch. Ibid, 1930, 23, 489. 12 Rabinowitch. Ibid, 1932, 26, 141. 13 Rabinowitch. Ibid, 1933, 28, 162. 14 Rabinowitch. "Diabetes Mellitus," Macmillan Co. of Canada, Ltd., Toronto, 1933. 15 Wislicki, L. Lancet 1934, 2, 717. PERNICIOUS ANÆMIA UNIT: ST. MARY, ISLINGTON, HOSPITAL. Report for the year ending 31st December, 1934. By B. Barling, M.D., B.S., M.R.C.P., M.R.C.S., Senior Assistant Medical Officer, St. Mary, Islington, Hospital. In January, 1934, a unit was established at St. Mary, Islington, hospital, under the auspices of the Medical Research Council, for the therapeutic testing of parenteral injections of liver extracts. During the period under review, forty-two cases were examined for this investigation, ten male and thirty-two female. The scheme used followed that laid down by the Medical Research Council, which was an adaptation of the method in use in the Department of Clinical Investigation and Research at the University and the Royal Infirmary, Manchester. In all cases the diagnosis was confirmed by a full blood count and the presence of achylia gastrica. Van den Bergh and Wassermann reactions were performed also, and in addition, in some cases, an X-ray examination of the stomach was made. Cases with a blood count of under two million red cells were considered the most suitable. As far as possible patients who had had no previous treatment, or those to whom no anti-anaemia treatment had been administered at so recent a date as to allow it to be effective, were chosen for the investigation. In all cases there was a control period of a minimum of seven days, during which time the red blood cell count and hæmoglobin percentage were examined. Only those patients whose blood count remained stationary or diminished and in whom the reticulocyte count remained at a low level during this period were considered suitable. In each case the intramuscular injection was given for three days and a satisfactory reticulocyte response expected by the tenth day, together with a steady rise in red cells and haemoglobin. The investigation was of great interest, not only because it revealed how impotent or relatively impotent a preparation might be, but also because it gave an opportunity of examining in detail cases that had clinically simulated pernicious anaemia. Furthermore, it was possible to make observations on the general treatment of the disease, and more especially the effect of treatment on sub-acute combined degeneration. Among the cases clinically simulating pernicious anaemia were two of idiopathic steatorrhœa (Gee's disease) with hyperchromic achlorhydric anaemia, which are being recorded elsewhere, one case of syphilitic anaemia and one of microcytic achlorhydric anaemia with multiple telangiectasia. In treating the cases one fact was clearly established that the manufacturer's note that the 2 c.c. of liver preparation was extracted from 20 grammes of liver or 100 grammes of liver meant nothing to the therapeutist. For, in some cases, contrary to what might be expected, the 2 c.c. extracted from 20 grammes was more potent than that extracted from 100 grammes. Furthermore, there is no definite dose of liver extract, neither for treatment nor for the maintenance of a normal blood count. The quantity necessary depends entirely on the patient under review. In one of the cases 10 c.c. of a potent extract were administered when the red blood count was only 600,000, and in six weeks with no other treatment the red count was over five million. In others, it has been found that with 2 c.c. given daily for the same period the blood count has remained stationary between three to four million red cells, and it has been necessary to double the dose before adequate progress has been made. Theoretically, liver is the treatment for the macrocytic anaemias, i.e., pernicious anaemia, and iron for the microcytic types, but it was found in practice that in some cases of pernicious anaemia, whereas the red cells rapidly and steadily increase in number, the haemoglobin fails to keep pace or having reached a definite percentage, say 60 per cent. cannot be increased by liver alone. Iron administered as a scale preparation or as Blaud's pill in adequate dosage rapidly increases the percentage of haemoglobin. (83) 84 Reviewing the cases it was found that the symptoms and prognosis in subacute combined degeneration of the spinal cord could be divided clinically into two distinct groups. In the one, where the lesion was early and the symptoms consisted of mild paraesthesiæ in the hands and feet and were more in the nature of a peripheral neuritis rather than a cord lesion, the prognosis was excellent on adequate liver dosage. Where, however, there was involvement of the posterior or lateral columns, no improvement could be expected in spite of massive doses of liver and iron, but it was found that if the adequate amount of liver or extract were administered, the disease would remain stationary. Owing to the inability of the manufacturers and the Medical Research Council to come to some definite arrangement on the scheme originally formulated, the work has consisted in the examination of extracts indirectly from two manufacturing houses through the Research Council. The work has only been made possible by the untiring assistance of Dr. Alston of the Archway group laboratory; for, during the year, a very large amount of pathological investigation has been necessary, which included well over two hundred and fifty full blood counts alone. THORACIC SURGERY UNITS.—(1) ST. ANDREW'S HOSPITAL. Report for the year ending 31st December, 1934. By J. W. Linnell, M.C., M.D., M.R.C.P., Consulting Physician, and H. P. Nelson, M.A., M.D., F.R.C.S.(Eng.), Consulting Thoracic Surgeon, St. Andrew's Hospital. The work at this centre has steadily increased ever since it began in September, 1932. During 1934, no less than 70 cases were operated upon, some of them on more than one occasion, and many bronchoscopies were performed, either for diagnosis or by way of treatment. The average number of cases in hospital at one time varied from 18 to 25. Many of the cases seen at the clinic presented the rarer and more difficult chest conditions, some of which had been complicated by previous operations. In some the outlook appeared almost hopeless. Even the few successes experienced among this latter group are encouraging. The majority of cases were those of chronic pulmonary tuberculosis, where artificial pneumothorax had failed altogether, had only resulted in a partial collapse leaving the cavities on the lung unclosed, or the complication of pyopneumothorax had supervened. Thus, on looking through the list of cases of chronic pulmonary tuberculosis sent for one reason or another, it is found that 9 underwent thoracoplasty, either partial or complete, 13 phrenic evulsion, 7 thoracoscopy and division of adhesions, 4 prolonged pleural drainage and irrigation preparatory to thoracoplasty, and 1 apicolysis. In this connection we would say advisedly that, judging by our own experience here and elsewhere, there must be many patients in the Council's hospitals the victims of unilateral pulmonary tuberculosis uncontrollable by artificial pneumothorax, who could be restored by thoracoplasty to such a degree of health as would allow them to earn their own living. It is far from being the deforming operation it is generally believed to be ; when dressed indeed, a patient appears normal, and, moreover, is capable of doing light work. The principal use of a phrenic evulsion as a solitary procedure is in the treatment of early soft tuberculous lesions or thin walled tuberculous cavities where artificial pneumothorax has not been successful. In cases treated by artificial pneumothorax, where the apex of the lung is adherent, healing is greatly facilitated by the paralysis of the diaphragm, and we believe that in almost all cases of artificial pneumothorax the diaphragm should be paralysed before the lung is allowed to expand. The division of pleural adhesion by cautery is often of the greatest value in cases which are being treated by artificial pneumothorax, for thereby an unsatisfactory collapse can frequently be converted into a satisfactory one. In pure tuberculous empyemata or secondary infected tuberculous empyemata the only method of treatment likely to give any chance of success is, in our opinion, one whereby the lung is encouraged to expand and obliterate the pleural cavity to such an extent that a satisfactory thoracoplasty is possible. In those cases that are not secondarily infected the cavity is best treated by pleural irrigations by the two needle method, but once a secondary infection has occurred intercostal drainage is usually essential. Air replacement has no place in the treatment of a pyothorax. Apicolysis has a limited use in the treatment of apical cavities when other methods have failed and thoracoplasty is contra-indicated on account of bilateral disease. We have treated 8 cases of chronic non-tuberculous empyema during the year, and on the whole with considerable success. These cases are, as is well known, some of the most troublesome in surgery, requiring long continued drainage and Dakins irrigations, followed by a modified thoracoplasty operation. Their commonest cause by far is the premature removal of the drainage tube in the first instance, and (85) 86 it cannot be repeated too often that, in an acute empyema, the tube should never be removed finally until the lung has completely expanded and entirely obliterated the cavity. Abscess of the lung always carries a high mortality, and of our 9 cases 5 died. In two of the fatal cases there was widespread gangrene of the lung at the time of operation ; one patient (with a chronic cavity) was successfully treated by lobectomy; two others, treated by more conventional methods, are well on the way to recovery, and another left the hospital very much improved. It is a moot point whether these lung abscess cases would not have a better chance if they could be transferred to the centre by ambulance as soon as they are diagnosed. How long one should continue conservative measures such as postural drainage and bronchoscopy, etc., is always a difficult question, but on the other hand it must be remembered that the more chronic a pulmonary cavity is, the poorer the chances are of complete success by drainage. Three cases of bronchiectasis were treated by lobectomy. One case in which the disease was localised to the lower lobe has been completely cured, another in which the upper lobe was also affected has been improved, while a third unfortunately died. We feel that more advance has been made in the treatment of this disease than in that of any other thoracic condition. In unilobar cases, lobectomy is the procedure of choice. This operation now has a standardised technique and a mortality in the region of only 10 per cent. In bilateral cases, or cases where surgery is out of the question continuous postural drainage based on the anatomical distribution of the disease has produced remarkable amelioration of symptoms (vide Nelson H. P., B.M.J., Aug. 11th, 1934, vol. II, p. 25). Several cases at St. Andrew's hospital have been treated by this method in the past year with very gratifying results. All our 8 cases of intrathoracic neoplasm died, for all were malignant. There are, indeed, few cases reported in the literature where operation has effected a cure. One of our patients, in whom complete removal was accomplished by an upper lobectomy, lived for four months after the operation, and at the post-mortem examination, though metastases were found to be present in the chest wall, there was none in the mediastinum. We are anxious to see all cases of intrathoracic neoplasm at the clinic. Cases in which no tumour can be seen through a bronchoscope and yet there is an X-ray opacity with a rounded convex margin should be subjected to exploratory thoracotomy. It is in this type of bronchial carcinoma that removal is sometimes possible. Innocent intrathoracic neoplasms too, always produce more or less spherical opacities on the X-ray film, and all of them require surgical treatment. (2) ST. JAMES' HOSPITAL. By W. L. Maccormac, M.B., Ch.B., F.R.C.S. (Edin.), Medical Superintendent, St. James' Hospital. The thoracic unit, under the direction of Mr. Tudor Edwards, is a new departure, hence the number of cases treated during the year ended 31st December, 1934, is small; yet, small as it is, the diversified nature of the cases gives a fair representation of those diseases of the chest to which surgery can be wisely applied because reasonably safe and offering a good prospect of cure. The four main diseases with which this type of surgery deals are all represented— abscess, tuberculosis, bronchiectasis, neoplasm-tuberculosis predominating. The smooth convalescence of the two one-stage lobectomies carried out for that pestilential malady bronchiectasis, as also the large margin of safety and sureness displayed in the removal of a fibroma of the mediastinum, was a revelation of the astounding advance that has been made in thoracic surgery since the War, aided materially as it has been by the greater accuracy in diagnosis afforded by the use of lipiodol and modern radiology. Also one must not omit the developments in anaesthesia that have enabled the surgeon to advance so rapidly and profitably. 87 A large proportion of the cases were for advanced tuberculosis of the lung, with cavity formation, which without surgery have a terribly high mortality. The contribution of surgery is becoming more and more accepted by many authorities as the most successful advance that has been made in the treatment of pulmonary tuberculosis since sanatorium treatment was introduced, bringing hope where pessimism has previously prevailed and with a degree of tolerance on the part of the patient, having regard to the radical nature of the operative interference, that is really remarkable, always providing the operation is expertly performed and graded in stages to the strength of the individual patient. The team of co-workers to whom the success of the establishment of the unit is due is composed of Mr. Tudor Edwards, assisted by Mr. O'Shaughnessy, with Dr. Machray as anaesthetist. During the year eighty patients have been treated. In addition to special examinations, such as intra-tracheal lipiodal injections, the following operations have been performed: 2 lobectomies; 1 excision of mediastinal fibroma; 1 removal of foreign body from chest; 1 penetrating injury of chest; 6 thoracotomies for pulmonary abscess; 8 phrenic evulsions; 21 thoracoplasties; 2 pericarditis with effusion; 12 chronic empyemas; 21 bronchoscopies; 4 cesophagoscopies; and 1 paravertebral block for angina pectoris. MATERNAL DEATHS IN THE COUNCIL'S HOSPITALS. Report for the year ending 3l3t December, 1934. By Letitia Fairfield, C.B.E., M.D., Ch.B., D.P.H., Senior Medical Officer, Public Health Department. The strenuous efforts made by all concerned to improve at all points the maternity services rendered by the London County Council hospitals have been rewarded by an increased demand for admission to the wards and also by a lowered death rate affecting almost every group of patients. During the year a total of 13,253 births took place in the hospitals representing an increase of 1,336 on the numbers for the previous year. Year. Live. Still. Total. 1931 9,696 495 10,191 1932 10,974 451 11.425 1933 11,414 503 11,917 1934 12,738 515 13,253 The improvement in the mortality rate is shown in the following table :— - 1933. 1934. Deaths. Rate per 1,000. Deaths. Rate per 1,000. A. Deaths of women confined in hospitals (after the 28th week) 84 7.2 66 5.1 (a) Death due to pregnancy or confinement 57 4.9 47* 3.6 (1) Ante-natal care at L.C.C. clinic 31 3.2 24 2.1 (2) Ante-natal care, other sources, or nil ... 26 13.1 23 14.1 (b) Death associated with pregnancy or confinement 27 2.3 19 1.5 (1) Ante-natal care at L.C C. clinic 6 0.6 7 0.6 (2) Ante-natal care, other sources, or nil 21 10.5 12 7.4 B. Confined before admission (after 28th week) 21 — 17 — C. Abortions (cases treated in hospital) 3,008(1933). 3,417(1934) 50 — 50 — D. Ectopic gestation (cases treated) 151 (1933). 109 (1934). 8 - 9 - * Includes one death from nephritis at 24th week. Ante-natal care. Comment has been made in previous reports on the impossibility of comparing the rates for the Council's hospitals with the mortality rate for the country generally or with other institutions practising midwifery. The Council's hospitals remain the chief resort for cases of abortion and they also receive an undue proportion of pregnant woman suffering from general diseases. The consequent effect on the death rate needs no further stressing. The proportion of women confined who had received ante-natal care at the Council's clinics has risen from 83 per cent. in 1933 to 87.5 per cent. in 1934. The number of attendances per patient is shown in table III. It should be realised that the great majority of the patients recorded as making one attendance only are more or less regular attendants at borough clinics conducted under the Maternity and Child Welfare Act, and have only come to the Council's clinic for the one special examination, which the Council's staff demand for all "booked" patients. The amount of ante-natal care given in fact reaches a very high standard, and the readiness with which the women co-operate is a matter of comment at all hospitals. The divided responsibility for maternity care in London has created many difficulties, but the past year has seen a marked improvement in co-operation with the borough authorities in many minor points, such as the supply of extra nourishment. (88) 89 At the Council's clinics the major problem is avoidance of congestion, for the decision to take Wassermann tests of all women attending for the first time, and the greatly increased number of blood pressures recorded, has naturally resulted in larger attendances. The differential death-rate suggests, however, that these precautions are well worth while. Ante-natal care. Total cases. Total deaths. Rate per 1,000. Deaths due to pregnancy or confinement. Rate per 1,000. Rate per 1,000. L.C.C. clinic 11,436 31 2.71 24 2 .10 7 0.61 Other sources, nil or not stated. 1,630 35 21.47 23 14.11 12 7.36 Total 13,066* 66 5.05 47 3.60 19 1.45 * Includes four cases where the third stage only was conducted in a Council's hospital, and one case where death from toxaemia of pregnancy occurred before the 28th week. A careful investigation is made of the circumstances attending every maternal death in the Council's hospitals. The autopsy, which is obtained whenever possible, is now performed by, or under the personal supervision of, Dr. Barnard, of the histological laboratory, or his assistant. The results are of the greatest interest and suggest that surveys of maternal mortality without this check on clinical reports may easily go astray. Maternal deaths. The subjoined tables show that puerperal sepsis remains the commonest single cause of death in the Council's wards, as it is elsewhere. The rates are as follows (deaths from sepsis following abortion are excluded):— 1931 2 per 1,000 births. 1933 1 .54 per 1,000 births. 1932 1.05 per 1.000 births. 1934 1 .18 per 1.000 births. Puerperal sepsis. These figures cover all maternal deaths after the 28th week from sepsis, whatever the associated condition or original cause. They include five deaths supervening after operations for Cæsarean section (q.v.), and two from septicaemia due to mastitis, which are not always included in returns of puerperal sepsis. Deaths from true uterine sepsis numbered eight only (.61 per 1,000 births), and of these five only occurred in patients whose labours had been conducted entirely in the Council's hospitals (.43 per 1,000 births). The remaining three had had prolonged interference or frequent vaginal examinations before admission, e.g., a woman of 42, weighing 22 stone, who had been in labour six days with ruptured membranes before admission. Another patient, a 2-para of 38, with a persistent occipito-posterior presentation, was sent in to hospital as a "failed forceps." Part of the cervix had been torn away, and the uterus ruptured. The child was delivered with great difficulty after craniotomy, and a hysterectomy was performed a few hours later. The patient rallied, but developed peritoneal sepsis. Deaths from sepsis. Nature of labour or pregnancy. Labour conducted entirely in L.C.C. hospitals. Labour conducted partially outside. (1) Normal 4 0 (2) Abnormal or complicated— Csesarean section 4 1 Severe perineal tear (precipitate labour) and vaginal discharge 1 0 Placenta prævia 0 1 Delayed labour, forceps and retained placenta 0 1 Rupture of uterus and failed forceps 0 1 Obstructed and delayed labour 0 1 Rupture of uterus from tumour of pelvis 0 1 Total 9 6 90 In only one case of sepsis was there evidence of the source of infection. This patient had been in contact with two other patients suffering from heemolytic streptococcal infection who recovered. This small "outbreak" was mentioned in last year's report. There was fortunately nothing of the nature of an epidemic of sepsis in any hospital in 1934, but the prevalence of mastitis in certain localities (not confined to the Council's hospitals) continues to give rise to anxiety. In no case was infection of any sort traced to an attendant, though very thorough investigation is made in every instance. It will be noted that, so far as the much-discussed cause of sepsis—" instrumental interference"—is concerned, the Council's service is blameless. The forceps rate in the hospitals is remarkably low (average 3.54 per cent.). In the only two fatal cases in which forceps had been applied after admission, other factors present were undoubtedly responsible for the development of sepsis. Probably one of the most important factors in the prevention of sepsis is the early detection and isolation of all cases of pyrexia or other suspicious signs of early sepsis occurring in a maternity ward. Improved accommodation is permitting this precaution to be carried out with increasing success in the Council's hospitals. Hæmorrhages. There were 86 cases of accidental haemorrhage admitted to the wards. Only one mother died (a woman who arrived moribund and died in 35 minutes), 37 of the children were stillborn, and 33 of the patients had some degree of albuminuria. There were 98 cases of placenta prcevia and 3 deaths. One patient had had several vaginal examinations before she came into hospital and died of sepsis. Another patient, an 8-para, had been bleeding only 3½ hours before admission, was admitted exsanguinated and died in 2 hours. The third patient, 6-para, had been admitted to the wards at the 32nd week for slight bleeding which soon ceased completely. She fell into labour a few days later and had a violent haemorrhage from which she never rallied. Thirteen Cæsarean sections were performed for this condition without a death. Six deaths were attributed to postpartum haemorrhage, but three patients were delivered outside the hospital and were admitted in a shocked and exsanguinated state with the placenta in situ and died in a few hours. One of these proved to be a case of the rare condition, placenta accrela. Of the three patients whose delivery was entirely conducted in the hospitals, one had a severe degree of acute thyrotoxicosis which was as much responsible for the fatal result as the haemorrhage. One patient, a 10-para of 43, had marked hydramnios and a persistent occipitoposterior presentation necessitating a forceps delivery. The third fatality occurred in an 8-para of 35, who had neglected all advice during pregnancy and, when admitted to the antenatal ward, took her own discharge. She had marked debility and very septic teeth. Delivery was normal, but the placenta required manual removal; sharp postpartum haemorrhage followed, from which she was unable to rally. "Accidents of childbirth." Excluding the deaths already noted under the heading of "puerperal sepsis, there were four fatalities included in the category "accidents of childbirth." Only one occurred in a patient who had ante-natal care from the Council, i.e., a woman of 28 who died of shock after craniotomy. The other three patients were admitted in extremis. Two were "failed forceps" of a familiar type, and one patient was found to have a shoulder presentation and a ruptured uterus on arrival. Anæsthesla. One death attributable to anaesthesia occurred during the year. The patient was a primipara of 27 with a small round pelvis, who was about to have a Csesarean section performed early in the second stage of labour. She was given percaine and a gas, oxygen and ether mixture was administered by an experienced anaesthetist. Death took place five minutes later, without warning, and before the operation had begun. The cardiac muscle showed degeneration microscopically. Out of 13,061 deliveries in the wards, 4,424 are reported as being given light intermittent anaesthesia (mainly by means of chloroform capsules), 850 had a general anaesthetic, 58 had local anaesthesia. Analgesia by drugs was given to 325 patients in association with some form of anaesthetic and to 837 patients who had no anaesthetic. No untoward effects are recorded with the exception of the death abovementioned. 91 Caesarean section was performed on 136 patients with 9 deaths. The indications for which the operation was undertaken were as follows Indications. No. of operations. Deaths of mothers. Contracted pelvis and disproportion 84 3 Heart disease 19 1 Placenta prsevia 13 0 Concealed accidental hæmorrhage 2 0 Obstruction due to ovarian cysts 3 1 „ „ tumours 1 1 „ „ hydrocephalus 1 0 Eclampsia 3 0 Other forms of toxaemia 6 3 Epilepsy, phthisis, extended breech, contraction ring 4 0 Total 136 9 Csesarean sections. The stage at which the operations were performed was as follows:— Before labour 74—5 deaths. Early in labour 30—2 deaths. Late in labour 32—2 deaths. The mortality rate was lower than in the two previous years (1931—3 per cent. 1932—8.5 per cent., 1933—8.6 per cent. 1934—6.6 percent.), 6.6 percent. of the children were stillborn and 9-6 died within 10 days. The deaths of the mothers in this year's series showed some curious features. Four of the nine were due entirely to the condition for which the operation was performed and the remainder were all due to sepsis. Of the four patients who died from concomitant disease, one had very severe heart disease, another had chorea gravidarum, a third fulminating toxaemia (acute yellow atrophy of the liver) and the fourth (an emergency case) a large pyelonephrosis. Her kidneys were found post-mortem to be riddled with abscesses. In none of these cases could any other course have been taken to save the patient. The five deaths from sepsis occurred as stated below. Two followed complicated operations. In one case a huge fibro-neuroma of the sciatic nerve was found blocking the pelvis. It was dissected out with difficulty and the disturbance of tissues involved made sepsis a likely sequence. In the other case a cyst of the broad ligament was the obstructing factor, and was removed at the time of the operation. Three deaths followed simple operations for contracted or deformed pelvis. Cask 1.—An emergency case in a primipara of 19 who had been in labour for two days and had had many examinations by doctor and midwife before admission. She died with an acute hsemolytic streptococcal infection. Case 2.—At the same hospital a fortnight later an operation was performed on a primipara of 27 with scissor-like deformity of the legs. The time elected was the beginning of spontaneous labour. Acute sepsis developed, as in the previous case. The two cases had never been in contact, there was no other sepsis in the ward, and the source of infection could not be discovered. Case 3.—Delayed labour in an 8-para of 38, who had had ante-natal care. No difficulty was anticipated at the confinement and the cause of the delay was never clear. After three days in labour an operation was performed, but abdominal sepsis developed. Eclampsia. The figures for eclampsia and for toxaemia are watched with eager interest as it is now accepted that this group of diseases is to a large extent preventable, and the rate serves as an indicator of the efficiency of ante-natal care. It is possible that this argument may be pushed too far. Two complicating factors have always to be considered—the patient may fail to recognise the significance of early symptoms however clearly she is instructed, or the disease may be of the rare fulminating type which gives little or no warning and is resistant to all treatment. Where the incidence of a disease is now approximately 1 in 1,000 among clinic patients and the mortality 1 in 6,000 (as is the case with eclampsia), it is no easy task to improve the situation. In 1934, 41 cases of eclampsia were admitted to the wards. Every parturient woman who had convulsions however transient was included, except one oldstanding case of diabetes. 92 Twelve of the women had had ante-natal care in the Council's clinics, and of these two died. (v. inf.). Twenty-nine had had care from other sources or none, and of these six died. Two women had been confined at home and were brought in moribund. Twelve patients were admitted comatose, and of these five died. Two women died undelivered. Five patients were under treatment for toxaemia in the wards when the fits developed. One of this group died. The time at which the fits developed is of interest as illustrating the very grave prognostic significance of cases where the first fits were post-partum Onset before labour 11 cases—2 deaths. Onset during labour 22 cases—2 deaths. Onset after labour 8 cases—4 deaths. Thirty-four of the women were primiparae 6 deaths. Seven of the women were multiparae 2 deaths. Five of the patients showed only a "trace" of albuminuria at any time; none of them died. One woman only never had any albuminuria at all and she died (v. inf.). The remainder all showed a marked degree of albuminuria once the fits began, but in some instances the urine had been tested only a few days before and nothing abnormal had been found. It is clear that periodic urine testing, even if done weekly, would not provide an adequate warning in every instance. Eight women still had a "trace" of albumen on discharge. The blood pressure is a valuable guide in prevention, though this also is not 100 per cent. efficient as a warning. The maximum blood pressures in the 41 cases varied from 120 to 250, but only one was below 130. The records suggest that, once above the 130 level, the maximum readings have little prognostic significance, for patients with blood pressures of 200+ recovered, while others with 140 died. The two deaths among the 11,436 patients who attended the Council's ante-natal clinics are worthy of note. One patient was a primipara of 27 at the 28th week, who had made three attendances and had been normal in every respect. Her last attendance was fifteen days before admission. Eight days before admission she began to have oedema and epigastric pain, but she did not seek advice. She arrived at the hospital badly cedematous, her urine loaded with albumen, and a blood pressure of 196. Four hours later, in spite of energetic treatment, she fell into a series of fits, and died in three hours. The other patient was a primipara of 29, who had attended one of the Council's ante-natal clinics on nine occasions, and had been perfectly well. Two weeks before term she suddenly developed a pain in the right side which was diagnosed as diaphragmatic pleurisy. She was admitted to the ward, and her pulse, temperature and urine were found norma). Next day she fell into labour, which was delayed from rigidity of the os. Immediately before delivery she had a mild convulsion lasting thirty seconds, and fell into a coma, from which she never emerged. She died in two hours. Necropsy showed acute necrosis of the liver. Other forms of toxaemia. Four "booked" patients and four emergency cases died from other forms of toxaemia, in which group kidney diseases have been included. Of the booked patients, one had acute yellow atrophy, one had long-standing diabetes and one developed very acute pyelonephritis. The fourth patient was ill for three weeks with vomiting and had had anuria for three days before she reported at hospital. Of the "emergency" patients two died with chorea gravidarum after in-patient treatment, one had a large pyelonephrosis, and the fourth had a very acute nephritis supervening during a miscarriage at the twenty-sixth week. Of the eight patients only one death could be considered as possibly preventable. The others had all had full and adequate ante-natal care from the hospital or elsewhere. Deaths associated with pregnancy and confinement The group of deaths associated with pregnancy and confinement includes every woman who died from any cause between the twenty-eighth week of pregnancy and four weeks after delivery. It will be noted that the degree of association varies from those in which child-bearing admittedly played an adverse part, e.g., pneumonia and heart lesions, to purely coincident deaths, e.g., those due to neoplasm. Two points here call for comment. This group has little to do with 93 obstetrics, and is subject to fluctuation from external causes such as influenza epidemics. As the total numbers are comparatively small, a quite extraneous cause might easily affect the maternal mortality rate, and create fallacious alarm about the efficiency of maternity services. Secondly, over-meticulous certification might easily over-weight the figures and give a misleading impression. Instances have been found of women dying from phthisis or heart disease many weeks after child-birth, whose death has been allocated as a "maternal death." Adverse comparisons with a foreign country or with mortality rates of past years might well follow. The possibility of death having been due to any truly obstetrical cause, including sepsis, has been definitely excluded in every case allocated to this group, and all such deaths have been classified as due to pregnancy. The case of "aplastic amemia," for example, was known to have been gravely ill from this condition long before she became pregnant. The close enquiries undertaken into every maternal death in the Council's hospitals show that no obvious or easily eliminated cause for a high mortality rate exists. There is very rarely any evidence of failure of ante-natal care, of avoidable sepsis, of unnecessary interference, or of failure to provide efficient obstetrical aid at the proper time. Samples of the many and diverse obstetrical problems which defy easy and automatic solution are now being dealt with. A steady improvement of staffing, accommodation and organisation, as well as loyal co-operation on the part of the patient, offer the only possibility of a further reduction in the mortality rate. Conclusion. Table I—General Hospitals and Institutions—Maternity Departments, 1934. Hospital or institution. No. of maternity beds. Births. Ante-natal clinic. Post -natal clinic. Live. Still. Total. No. of new cases. Attendances. No. of new cases. Attendances. Archway - 1 - 1 - - - - Bethnal Green 18 305 10 315 309 1,398 177 267 Dulwich 20* 550 13 563 619 4,061 293 307 Fulham 12 374 9 383 404 2,819 131 132 Hackney 38 820 35 855 898 5,434 307 338 Hammersmith 33 138 4 142 111 416 102 119 Highgate — 1 — 1 — — — — Lambeth 32 645 30 675 591 2,903 133 141 Lewisham 64 951 50 1,001 1,073 5.263 370 382 Mile End 46 624 19 643 639 4,661 99 733 New End 19 315 11 326 371 1,240 5 5 Paddington 20 483 19 602 405 2,413 120 146 St. Alfege's 35 612 27 639 648 3,820 220 220 St. Andrew's 36 660 29 689 708 2,825 208 218 St. Benedict's — — — — — — — — St. Charles' — 9 1 10 — — — — St. George-in-the-East 25 270 15 285 313 1,457 68 69 St. Giles' 52 945 33 978 926 5,843 495 998 St. James' 55 1,099 53 1,152 1,193 6.532 238 245 St. John's - 1 - 1 - - - - St. Leonard's 23 452 13 465 412 2,305 105 301 St. Luke's. Chelsea — 2 — 2 38 332 19 42 St. Mary Abbots 48 853 31 884 859 3,823 159 182 St. Mary, Islington 20 504 33 537 470 1,939 185 251 St. Nicholas 19 354 20 374 462 3,321 106 121 St. Olave's 28 539 13 552 476 3,923 254 259 St. Pancras 25 530 21 551 467 3,335 113 189 St. Peter's 13 146 4 150 203 1,055 54 230 St. Stephen's 26 453 19 472 470 2,134 117 118 12.636 512 13.148 St. Marylebone institution 16 102 3 105 — - — — Total 723 12,738 515 13,253 13,065 73,142 4,078 6,013 * One ward of 20 beds additional, used as emergency accommodation. G 94 Table II—Maternal deaths—(A) Confined in General Hospitals and Institutions. (a) Death due to pregnancy or confinement. Hospital, etc. No. of births (including stillbirths) Ante-natal care. L.C.C. clinic. Deaths. Ante-natal care, other sources, nil or not stated. Deaths. Total deaths. Archway 1 - - - - - Bethnal Green 315 — — — — — Dulwich 563 — — Obstetric shock, failed forceps 1 1 Fulham 383 — — Eclampsia (1) Acute nephritis (1) 2 2* Hackney 855 Puerperal sepsis (breast abscess) (1) Puerperal septicaemia (normal labour) (1) 2 Ante-partum haemorrhage (1) Puerperal sepsis (obstructed labour) (1) 2 4 Hammersmith 142 — — Placenta prævia 1 1 Highgate 1 - — — - — Lambeth 675 Puerperal sepsis (Cæsarean) (1) Post-partum haemorrhage (adherent placenta)(1) P.P.H and thyrotoxicosis (1) 3 Puerperal sepsis (Cæsarean) 1 4 Lewisham 1,001 — — — — — Mile End 643 Toxæmia (Cæsarean section) (1) Heart disease (Csesarean section) (1) Puerperal insanity (1) 3 - - 3 New End 326 Puerperal sepsis (rupture of uterus) (1) Pyelonephritis (1) Puerperal sepsis (Cæsarean section) (1) 3 - - 3 Paddington 502 - — Puerperal sepsis (pulmonary em bolus) 1 1 St. Alfege's 639 - — — — — St. Andrew's 689 Puerperal sepsis (perineal tear) 1 Heart disease and chorea (Ca'sarean section) 1 2 St. Charles' 10 — — Ruptured uterus (obstructed labour) 1 1 St. George-in-theEast 285 — — - — — St. Giles' 978 Puerperal sepsis (Caesarean section) (1) P.P.H. (adherent placenta) (1) Puerperal sepsis (1) 3 - - 3 St. James' 1,152 Anæsthesia (Cæsarean section) 1 Puerperal sepsis (forceps, adherent placenta) (1) Suppurative nephritis (Cæsarean section) (1) "Status epilepticus" (1) P.P.H. (adherent placenta) (1) 4 5 St. John's 1 — — — — — St. Leonard's 465 Toxaemia and diabetes 1 — — 1 St. Luke's, Chelsea 2 — — — — — St. Mary Abbots 884 Eclampsia (1) Obstetric shock, contraction ring (1) 2 P.P.H. (adherent placenta) (1) Puerperal sepsis (failed forceps, ruptured uterus)(1) 2 4 * Includes 1 death at 24th week 95 Table II—Maternal deaths—continued. (a) Death due to pregnancy or confinement. Hospital, etc. No. of births including stillbirths ) Ante-natal care, L.C.C. clinic. Deaths. Ante-natal care, other sources, nil or not stated. Deaths Total deaths. St. Mary, Islington 537 — Eclampsia (2) Obstetrical shock (obstructed labour) (1) Placenta prævia (1) 4 4 St. Nicholas' 374 Myocarditis (and adherent placenta) 1 — — 1 St. Olave's 552 Puerperal sepsis (Cæsarean section) 1 — - 1 St. Pancras 551 Acute nephritis 1 Puerperal sepsis (placenta prævia) (1) Eclampsia (1) 2 3 St. Peter's 150 P.P.H. (hydramnios) 1 — — 1 St. Stephen's 472 Eclampsia 1 Chorea gravidarum 1 2 Institutions— St. Marylebone 105 — — — — — Total 13,253 24 23 47 Summary of above table. Cause of death. Ante-natal care, L.C.C. hospital. Ante-natal care, other sources, nil or not stated. Total. Puerperal sepsis 9 6 15 Hæmorrhage Accidental - 1 1 Placenta prævia - 2 2* Post-partum 4 2 6† Toxaemia Eclampsia 2 4 6 Pyelitis or nephritis 2 2 4 Other forms 2 2 4 Rupture of uterus - 1 1 Obstetrical shock 1 2 3 Anæsthesia 1 - 1 "Status epilepticus" - 1 1 Puerperal insanity 1 - 1 Heart disease and Cæsarian section 1 - 1 Myocarditis and adherent placenta 1 - 1 Total 24 23 47 * One placenta prævia case is included in the deaths from sepsis. † In 3 cases child delivered outside hospital, admitted for third stage only. Table II (b)—(A) (b) Death associated with pregnancy or confinement Hospital. Ante-natal care at L.C.C. clinic. No. Ante-natal care other sources, nil or not stated. No. Total. Dulwich — — Tuberculous laryngitis and phthisis. 1 1 Fulham Tuberculous meningitis 1 Ulcerative endocarditis and septic thrombosis. 1 2 Hackney — — Heart disease (mitral stenosis) (1) Carcinoma of colon (1) 2 2 Lambeth — — Malignant tumour of the bronchus 1 1 Lewisham — - Mitral stenosis 1 1 St. Alfege's — - Bronchopneumonia 1 1 St. George's-inthe-East. — — Acute pneumonia and empyema 1 1 96 Table II (6)—(^4) (6) Death associated with pregnancy or confinement.—contd. Hospital. Ante-natal care at L.C.C. clinic. No. Ante-natal care other sources, nil or not stated. No. Total. St. James' Heart disease (1) Aplastic anaemia (1) 2 Influenzal pneumonia 1 3 St. Leonard's — — Heart disease 1 1 St. Mary Abbots Heart disease (mitral stenosis). 1 - — 1 St. Mary, Islington. — — Strangulated diaphragmatic hernia. 1 1 St. Nicholas' Phthisis and bronchopneumonia. 1 - — 1 St. Olave's Primary thrombosis of mesenteric vein. 1 Hæmorrhagic bronchopneumonia 1 2 St. Pancras Bronchopneumonia 1 - — 1 Total 7 12 19 Summary of above table. Cause of death. Ante-natal care at L.C.C. clinic. Ante-natal care other sources. nil or not stated Total. Valvular heart disease 3 4 7 Acute pneumonia — 2 2 Bronchopneumonia 1 2 3 Phthisis 1 1 2 Neoplasms - 2 2 Aplastic anæmia 1 - 1 Strangulated hernia — 1 1 Primary thrombosis of mesenteric vein 1 — 1 Total 7 12 19 Table [I (c)—(B) Delivered before admission. Hospital. Cause of death. No. Dulwich Puerperal sepsis 1 Fulham Acute pneumonia 1 Hammersmith Ulcerative endocarditis 1 Lambeth Puerperal sepsis 1 Lewisham Puerperal sepsis (2) 3 Eclampsia Mile End Acute nephritis 1 St. Alfege's Acute yellow atrophy 1 St. Charles' Puerperal sepsis 1 St. Giles' Puerperal sepsis 1 St. James' Puerperal sepsis (2) 5 Eclampsia (1) Acute inversion of uterus (1) Primary thrombosis of mesenteric vein (1) St. Mary Abbots Puerperal sepsis 1 Total 17 Summary of above table. Cause of death. No. Puerperal sepsis 9 Eclampsia 2 Acute pneumonia, acute yellow atrophy, inversion of uterus, primary thrombosis of mesenteric vein, nephritis, ulcerative endocarditis (1 each) 6 Total 17 97 Table III—Cases confined in general hospitals and institutions ami discluirged or died during 1934 (including deaths undelivered)—Attendances at L.C.C. ante-natal clinic. Attendances. Number. Per cent, of total. 0 1,615 12.37 1 671 5.14 2 888 6.80 3 1,118 8.56 4 1,355 10.37 5 1,437 11.00 6 1.489 11.40 7 1.224 9.38 8 1,082 8.28 9 767 5.87 10 and over 1,403 10.74 Not known 12 .09 Total 13.061 100.00 98 Table IV.—Method of delivery after 28th week.—All hospitals. Mode of termination of pregnancy. Complication of labour or reason for interference. Total. Eclampsia. Pyelitis pyelonephritis. Other toxaemias. Disproportion and contracted pelvis. Other obstructed deliveries, † Malpresentation. Placenta praevia. Other A. P. hemorrhage. Uterine inertia and shock. Post-maturity. Other conditions of pregnancy. * Concurrent disease. Discharges. Deaths. Cases. 1. Natural (i.e., unaided)— Without stated complications of labour, but including concurrent diseases—Live - - - - - - - - - - - - 11,071 16 11,087 Still - - - - - - - - - - - - 196 1 197 Total - - - - - - - - - - - - 11,267 17 11,284 With stated complications of labour—Live 2 3 13 8 1 108 19 12 71 1 119 — 356 1 357 Still 2 - 5 3 1 22 14 9 4 — 26 — 83 3 86 Total 4(1) 3 18 (2) 11 2 130 33 (1) 21 75 1 145 — 439 4 443 2.By interferemce Cæsarean-Live 2 1 5 70 - 4 14 - - — — 31 120 7 127 Still - 1 1 4 - - 1 1 — — 1 — 7 2 9 Surgical induction-Live 1 6 38 52 - 10 6 4 - 24 18 6 164 1 165 Still 2 - 10 - - 6 8 4 — — 8 — 37 1 38 Forceps following surgical induction—Live 2 - 5 6 — — 1 — 4 — — — 18 — 18 Still 2 - - 1 - - - - - 1 — — 4 — 4 Forceps—Live 4 - 4 62 21 62 1 1 144 5 58 4 363 3 366 Still 1 2 1 13 5 18 3 1 12 1 18 — 68 7 75 Version during labour:— External —Live - - - 1 — 25 2 — 1 — 1 - 30 — 30 Still - - - - - 5 1 - - - - - 6 — 6 Internal—Live - - - - 1‡‡ 12 — — — - 1 — 13 1‡‡ 14 Still - - - 1 - 9 10 1 1 - 3 — 24 1 25 Embryulcia, craniotomy—Live - - - - - - - - - - - - - - - Still 1 - - 3§ 1 4¶ — 1 1 - 1§ — 8¶ 4¶ 12 Medical induction—Live - 4 39 95 — 18 2 1 10 139 38 6 351 1 352 Still - - 3 1 - 5 2 — — 4 1 — 16 — 16 ‡Other—Live - - 1 9 6 15§§ 9 — — 2 7 1 50§§ — 50 Still — — — 1 1 7§ 2 2 — — 3§ — 16 — 16 Total—Live 9 11 92 295 28 146 35 6 159 170 123 48 1,109 13 1,122 Still 6 3 15 24 7 54 27 10 14 6 35 — 186 15 201 Total 15 (2) 14 (2) 107 (1) 319 (3) 35 (2) 200 (3) 62(1) 16 173 (3) 176 158 (5) 48 (6) 1,295 28 1,323 3. Died undelivered (over 28 weeks gestation) 2** 1†† 3 — — — 1 — — — 1 300 — 11 11 Grand total — — — — — — — — — — — - 13,001 60 13,061 † Mainly cases of rigidity of perineum or soft parts. * Chiefly cases of foetal or maternal distress, high blood pressure, foetal abnormalities and premature ruptured membranes. ‡ including failed induction, failed forceps, failed version, episiotomy. § One case of failed forceps before admission. ¶ Two cases of failed forceps before admission. ** Includes one case of surgical induction. Medical induction attempted. ‡‡ Following failed forceps. §§ One case of failed forceps. 00 One case of Caesarean section after death. N.B.—Figures in brackets are deaths included in total ; the condition under which a death is classified is not necessarily the proximal cause of death. A multiple confinement has been counted as one case delivered ; where a live and still (twin) birth occurred, the delivery has been classed as a live birth. 99 Table V.—General Hospitals and Institutions—Staled previous pregnancies in maternity cases (discharges and deaths) in relation to legitimacy.—Year ended 31 st December, 1934. Legitimacy. Labour in hospital. Previous pregnancies. Total. 0 1 2 3 4 5 6 7 8 9 10+ Legitimate 4,851 2,999 1,483 759 473 317 220 173 123 73 145 11,616 Illegitimate 1,003 312 53 19 17 7 6 4 2 - 1 1,424 Total oases 5,854 3,311 1,536 778 490 324 226 177 125 73 146 13,040* Total deaths 24 6 3 — 1 4 2 4 — 3 1 48* * Patients discharged or died during 1934. Table VI.—General Hospitals and Institutions.—Stated termination of maternity cases (discharges and deaths) in relation to age of mother.—Year ended 31 st December, 1934. Termination. Labour in hospital. Age of mother. Total women delivered. Gravida. Total births. 15- 20- 25- 35- 45 + No. Deaths. Legitimate—Live birth Primi 4,714 561 2,315 1,719 118 1 4,674 10 Multi 6,610 85 1,472 3,705 1,300 48 6,513 14 Still birth Primi 185 22 61 89 13 — 177 7 Multi 266 1 26 136 100 3 252 10 Illegitimate—Live birth Primi 974 176 501 269 28 — 963 6 Multi 421 12 125 231 50 3 408 — Still birth Primi 43 6 16 16 5 — 40 1 Multi 16 2 2 8 4 — 13 — Total 13,229 865 4,518 6,173 1,618 55 13,040 - Deaths — 4 7 21 14 2 — 48 Table VII.—Still-births and neo-nalal deaths in relation to type of labour. (The rates are calculated upon the number of confinements, not on the number of births.) Type of labour or aid. Infant. Total confine ments. Percentage of infants. Deaths among Born dead. Dying with in 10 days. Living after 10 days. Born dead. Dying within 10 days. Living after 10 days. Number. Per cent. Caesarian 9 13 114 136 6.6 9.6 83.8 9 6.6 Surgical induction 38 8 157 203 18.8 3.9 77.3 2 1.0 Forceps following surgical induction 4 1 17 22 18.2 4.5 77.3 - - Forceps* 81 15 353 449 18.0 3.3 78.7 13 2.9 Version 31 3 40 74 41.9 4.0 54.1 1 1.4 Other aid† 38 8 393 439 8.7 1.8 89.5 3 0.7 Unaided 283 199 11,245 11,727 2.4 1.7 95.9 21 0.2 Total 484 247 12,319 13,050 3.7 1.9 94.4 49 0.4 * With or without version, including failed forceps. † Including medical induction, failed induction, unless followed by forceps, and failed version, craniotomy, etc. 100 Table VIII (a).—General Hospitals and Institutions.—Summary of completed treatments for abortion,* etc., prior to admission or in hospital—discharges and deaths. Year ended 31st December, 1934. Name of hospital or institution. Abortions, moles. Ectopic gestation. Sepsis. Sepsis. Discharges Deaths. Cases. Total Discharges. Total Deaths. Total Cases. Discharges. Deaths. Cases. Total Discharges. Total Deaths. Total Cases. Archway 2 1 3 52 1 53 - - - 1 - 1 Bethnal Green 9 1 10 96 2 98 — — — 1 - 1 Dulwich 5 3 8 142 4 146 — — — 4 - 4 Fulham 5 1 6 93 2† 95 — — — 4 - 4 Hackney 7 1 8 193 1 194 — - — 1 - 1 Hammersmith 3 — 3 91 — 91 — — — 6 1 7 Highgate 2 1 3 68 1 69 — — — 3 — 3 Lambeth 9 4 13 204 4 208 — — — 7 - 7 Lewisham 35 — 35 163 — 163 — — — 4 — 4 Mile End 4 1 5 103 1 104 — — — 7 - 7 New End 5 1 6 51 1 52 - — - 2 - 2 Paddington ... 4 3 7 110 3 113 — — 3 3 St. Alfege's 2 3 5 109 3 112 — — — 4 1 5 St. Andrew's 9 1 10 98 1 99 — — — 2 1 3 St. Charles' 1 3 4 99 3 102 — — — 5 1 6 St. George-in-the-East 2 2 4 46 2 48 — — — — 1 1 St. Giles' 15 2 17 264 2 266 — — 10 1 11 St. James' 32 3 35 324 3 327 — — — 11 1 12 St. John's - — - 1 - 1 — — - - - - St. Leonard's - - - 80 1 81 - - - 3 - 3 St. Luke's, Chelsea 3 1 4 49 1 50 - - - - - - St. Mary Abbots 4 1 5 146 1 147 — — - - 1 1 St. Mary, Islington 13 4 17 244 5 249 — — — 12 - 12 St. Nicholas' 3 1 4 72 1 73 1 - 1 3 - 3 St. Olave's 1 2 3 131 2 133 - - - 3 1 4 St. Pancras 6 1 7 161 1 162 — — — 1 - 1 St. Peter's 5 3 8 67 3 70 - - - - - - St. Stephen's — 2 2 108 2 110 — — — 3 - 3 St. Marylebone institution - — — 1 — 1 — — — — - — Total 186 46 232 3,366 51 3,417 1 — 1 100 9 109 * Including Caesarian section or hysterectomy terminating pregnancy, under 28 weeks, † Includes one case in table II (a) i.e. a death from nephritis at 24th week. Table VIII (6).—Abortions, etc.—Deaths and case-mortality rates, 1934. Puerperal sepsis. Other conditions. Total number. Cases. Case rate per 1.000. Deaths. Death rate per 1,000. Case mortality per cent. Deaths. Death rate per 1,000. Abortions, moles 3,417 232 67.90 46 13.46 19.83 5* 1.46 Ectopic gestations 109 1 9.17 — _ — 9 82.57 Total 3,526 233 66.08 46 1305 19.74 14 3.97 * Includes 1 case in table If (a) i.e. a death from nephritis at 24th week. SIGNS, SYMPTOMS AND SEQUELÆ OF SUBARACHNOID HÆMORRHAGE DUE TO RUPTURED CONGENITAL ANEURYSMS. By B. Barling, M.T)., B.S., M.R.C.P., M.R.C.S., Senior Assistant Medical Officer, St. Mary, Islington, Hospital. Advance of physiological and pathological knowledge of an organ or structure brings certain clinical conditions from the obscurity of our previous ignorance and illuminates them with the light of our better understanding. With knowledge comes interest, and with interest keener observation, so that erstwhile unobserved symptoms leap into significance. Intracranial hæmorrhage of all types has entered the sphere of better understanding. Bleeding from the middle meningeal artery is readily recognised and treated, and recent light on the subdural hæmatoma has saved many a victim that previously had been allowed to perish. And now with the information gained during the past ten years on the effects of subarachnoid bleeding, we are able to avert in a proportion of cases their demise. In this paper, it is desired to review the signs and symptoms of subarachnoid hæmorrhage, and more particularly the subarachnoid hæmorrhage that follows a ruptured congenital aneurvsm of the cerebral vessels. The arachnoid is a delicate membrane investing the brain and spinal cord and lying between the pia internally and the dura mater externally. It is separated from these structures on the one hand by the subarachnoid cavity and on the other by the subdural space. The cerebral portion of the arachnoid invests the brain loosely, and does not dip into the sulci nor the fissures, with the exception of the longitudinal fissure. The subarachnoid cavity contains the cerebro-spinal fluid and the cerebral blood vessels, the space itself being small on the surface of the hemispheres; but on the base where the contour is less regular, the spaces produced in bridging over these irregularities are larger and termed cisterna. These cisterna themselves bear a certain relationship to the present discussion, for they emphasise the lack of tissue support of the cerebral vessels and furthermore are preformed sacs for the accumulation of escaping blood. The subarachnoid space is not in communication with the subdural space, but is with the ventricles of the brain through the foramina of Luska and Majendie in the roof of the fourth ventricle. The spinal portion of the arachnoid invests the medulla spinalis loosely and is continuous above with the cerebral arachnoid and below it widens out and surrounds the cauda equina and the nerves proceeding from it. Before leaving the question of the anatomy of the arachnoid, mention must be made of the arachnoid villi, for although they play no part in the production of haemorrhage, the recent work of Winkleman and Fay2 suggests that it is the blocking of these villi, through which the cerebro-spinal fluid is normally absorbed, that gives rise to certain sequelae. Weed3 has shown that the cells of the arachnoid show reaction and proliferation to the irritation set up by red cells, which suggests therefore a method of blockage of the villi. The presence of blood in the subarachnoid space affords an easy diagnosis, for by means of the cistern or lumbar puncture, it is possible to withdraw fluid and study its composition. Anatomy. Birth injuries arise from difficult labour and consequent excessive moulding of the foetal head. There is tearing of the dura and arachnoid in the region of the tentorium cerebelli and blood flows into the subarachnoid space. The majority of these cases die at birth. Of the others, their ultimate destiny is difficult to determine, as in few cases has the presence of the haemorrhage been ascertained during the life of the child. Traumatic causes. Other traumatic causes are injuries and blows received in accidents with or without fracture of the skull. The subarachnoid bleeding may be local in the region of the injury, or on some distant part of the brain as the result of contra coup. (101) 102 After the recovery from the initial shock, it is the presence of this subarachnoid blood which gives rise to the cortical irritation which is so often difficult to treat, and furthermore this blood, as has been pointed out above, affects the absorption of C.S.F. by the arachnoid villi and so gives rise to the post-traumatic mental disturbances which in many cases have been labelled neurasthenic headaches. These cases are frequently summarily dismissed as functional or compensation headaches as no fracture can be demonstrated by the X-ray, when the use of the lumbar puncture needle at the time of the injury would have shown clearly the presence of subarachnoid bleeding and have elucidated the cause of the pain. Of the spontaneous causes, blood may reach the subarachnoid space by divers routes. In the usual type of cerebral hæmorrhage where there is rupture of the lenticulostriate artery, the force of the escaping blood may be so great as to tear the brain tissue or burst through the pia mater, or the haemorrhage may burst into the cerebral ventricles pass via tbe iter to the fourth ventricle where it enters the subarachnoid space through the foramina of Luska and Majendie. And finally we have bleeding from vessels actually situated in the subarachnoid space itself, and it is to these that I wish more especially to direct attention. Etiology and pathology. The variety of pathological circumstances which give rise to this condition may be divided from the etiological standpoint into general and local, although this can be taken by no means as a barrier with unyielding boundaries. In the group of general or remote as opposed to local factors, are included the hæmorrhagic diseases and will be peremptorily dismissed, so that the attention is narrowed down to diseases and defects affecting the subarachnoid vessels themselves. Since 1859, when in the Guy's hospital reports Sir William Gull4 published his paper on intracranial aneurysms, it has been recognised that the subarachnoid vessels are peculiarly liable to aneurysmal formation, and from that time controversies have waged as to the etiology of the condition. Eppinger5 1887 considered that these aneurysms were due to an inherent or congenital defect in the vessel wall, a condition which has since been termed by Strauss, Globus and Ginsburg6 as a " vascular dyscrasia." Much supporting evidence has been forthcoming to substantiate this theory, for other vascular defects have been found in cases in which cerebral aneurysms were present. Parkes Weber7 presented a specimen to the Museum of the Royal College of Surgeons in which there was congenital aortic stenosis and ruptured congenital aneurysm. Green8 had a case of stenosis of the aortic isthmus and a bicuspid aortic orifice in addition to cerebral aneurysms, and both Greenfield9 and Hall10 have encountered spontaneous intracranial hæmorrhage in different members of the same family. This evidence, in addition to the fact that these aneurysms may occur in young children, supports the view as to their congenital origin, as also does the presence of other congenital abnormalities in the arterial tree, such as coarctation of the aorta, absent aortic valves and telangiectases. From the microscopic aspect, Fearnsides11 states that they are not inflammatory and that there is "a congenital weakness in the arterial walls at junctional points." Turnbull12 gives as his opinion, that these aneurysms are the result of an inherent weakness in the vessels—" on section, the elastic and muscular tissue of the media is found to be absent." Forbes13 has called attention to the muscular defects in the media of cerebral vessels at the point of their bifurcation, which constitute, as he said, the locus minoris resistentiæ and are considered by him to be of congenital origin. As to other causes of intracranial aneurysm, periarteritis nodosa is rare, inflammatory, and not confined to the cerebral vessels. Syphilis stands out pre-eminently as a possibility, but it is found that the majority of these cases have a negative Wassermann reaction and must, therefore, be excluded. Mycotic aneurysms exist only as a commensal of septic conditions as infective endocarditis and their etiology is therefore apparent. As to arteriosclerosis and 103 atheroma being factors of consequence, Strauss6 emphasises them as of etiological import, but the absence of these conditions elsewhere in the vascular tree rather discredits this hypothesis. The gross morbid anatomical findings in these cases are interesting, for it is by their study that it is possible to explain the variety of symptoms that present themselves. The majority of these aneurysms are small and for that reason were termed miliary aneurysms by Charcot and Bouchard.14 They are situated for the most part on the larger cerebral vessels at points of bifurcation or junction with other vessels. In the one case their presence is easily detected, but in the other it is only by careful dissection of the vessels and gentle teasing of the brain substance that they are revealed. It is considered that in cases of spontaneous subarachnoid haemorrhage, where no cause can be found, the fault lies in the too perfunctory search for their presence. The more common sites for their occurrence are the junction of the posterior communicating artery with the posterior cerebral artery, the junction of the middle cerebral with the anterior cerebral artery, and the anterior cerebral artery at its union with the anterior communicating artery. The aneurysms themselves are usually about the size of a split pea, but may attain the size of a cherry. Occasionally, however, they are found to be larger, and it is in these cases that careful examination reveals that the tumour consists mainly of blood clot. The aneurysm has slowly leaked, the escaping blood clotting round the aneurysm so as to give a false appearance of its actual size. In some cases the history of previous attacks of subarachnoid haemorrhage before the final and terminal rupture will direct attention to the actual condition. Of the aneurysms that rupture, about half do so into the subarachnoid space. Of the others, the force of the escaping blood tears up the brain tissue so that a hæmatoma is formed. The frontal lobe is not an unusual site and occasionally the ventricular system is found full of blood from haemorrhage which has burst into one or other lateral ventricle. Before proceeding further a word must be said concerning the usual etiological factors that are discussed in investigation of disease. The age of the patient at which the aneurysm leaks or ruptures has such wide limits as to encompass the whole range of life. It is, perhaps, most common between the years of 25-40, but it is also met between the ages of 10-70. As to sex, race, trauma, or other predetermining causes, nothing of value can be said. In the main it is true to say that these aneurysms give rise to no symptoms before rupture. Collier and Adie15 state that they may simulate the presence of a cerebral tumour, but for the most part these are aneurysms that have slowly leaked, and have increased in size in the manner stated above. Moreover, haemorrhage, which has occurred into the frontal lobe, has on occasions been mistaken for a tumour in that region, but here again it is after rupture. Symptomatology. Few cases, therefore, reach the surveillance of the clinician before the wall of the aneurysm has given way; and, as the escape of blood may vary from a gentle ooze to a sudden forceful rupture, the symptomatology correspondingly varies. If due to a slow leak, the small opening may be shut off periodically, giving rise to headaches which are often mistaken for migraine. When the escape is more free, the blood becomes mixed with the cerebro-spinal fluid in the arachnoid space and gives rise to irritation. It may flow towards the opening in the spinal theca, the film becoming deposited round the roots of the spinal and cranial nerves. The symptoms and signs that arise are produced by the irritant action of the blood on the structures with which it comes in contact, together with a raised intracranial tension. Headache is a constant feature, the pain being frequently occipital in position and neuralgic in type, extending down into the region of the neck, and accompanied in most cases by nausea and vomiting. 104 The escaping blood is, however, not limited to the brain and cervical region, and may affect the whole cord and the plexuses, so producing pain and hypertonia of the back and limbs. Adie18 has described herpes occurring in this condition, due to the irritant action of the escaped blood on the nerve roots. The symptoms, therefore, at this stage may be summarised as headaches, nausea, vomiting and stiffness of the neck. When the escape is more free the signs are those of cerebral irritation without focal localisation. The patient may be found curled up on the side complaining bitterly of headache. There is cervical rigidity, and both Kernig and Brudzinski signs may be present. The presence of escaped blood into any part of the body after a short period gives rise to fever. To this rule, the subarachnoid space is no exception, and it is this accompanying irregular pyrexia which frequently embarrasses the uninitiated. Lumbar puncture will reveal, however, the correctness of the diagnosis; the characteristics of the fluid obtained are pathognomonic. On withdrawal of the stilet from the lumbar puncture needle, the fluid is found to be under some increased tension ; it is blood-stained, the blood being intimately mingled with the cerebrospinal fluid. On allowing the fluid to stand, there is no tendency for the blood to clot, and the cells precipitate to the bottom of the tube. Should the puncture be performed some hours after the haemorrhage has commenced, the supernatent fluid above the cells will be discoloured, due to hæmolysed red cells. If a cell count is made, it will be found that the white cells are present in a larger proportion than the red cells, as they are not destroyed so rapidly. A differential count, however, on the white cells, shows them to be in the same proportion as they are in the blood. This apparent leucocytosis in the cerebro-spinal fluid occasionally gives support to the erroneous impression that the patient is suffering from meningitis, until checked by the differential count on the blood. In the third type of case, there is sudden bursting of the aneurysm without warning. The patient has just time to cry out and then falls unconscious. When seen, the victim again presents signs of a cerebral catastrophe without localisation signs. Experience of this condition leads one to an arbitrary sub-division. The one group is deeply unconscious from the beginning with widely dilated pupils, stertorous respiration and general flaccidity. Lumbar puncture does not improve the condition, and necropsy reveals the force of the haemorrhage to have torn up the brain substance and to have filled the ventricular system. The other group, although unconscious, are not so deeply so, and may be slightly if only temporarily aroused, and more especially is this true after lumbar puncture. On stimulation they respond with "I'm tired, leave me alone,'' resent and often resist examination, to slip back to their somnolent state when the investigation is completed. Examination reveals a widespread variety of physical signs, none of which can be considered constant and few pathognomonic. Peshaps the following classification will assist in this description:- Meningeal signs.—The restlessness, headache, vomiting, and even coma, have already been described, and therefore there is no need to reiterate them. Ophthalmic signs.—(a) Pupillary changes are frequent. They vary in size, being small or large, equal or unequal, and generally reacting to light, but sluggishly. As has already been mentioned, in the large and fatal haemorrhages the pupils are widely dilated and fixed. (b) Changes in eye-grounds. Here, there is a manifestation, which although present in less than 20 per cent. of cases, is of full pathognomonic import, speaking of the subhyaloid haemorrhage (Riddoch and Goulden).17. This, however, is not the only fundal change to be found, for papillitis is sometimes present. Cranial nerve palsies.—The third, fourth, and sixth nerves are the more frequently involved, although others may also be affected, but the findings are inconsistent and of little diagnostic value per se. 105 Reflex alteralions.—Cervical rigidity is included under this heading, as also is alteration of tone in the limbs. In the more severe cases there is general flaccidity, but where the lesion is confined to the subarachnoid space and not invading the brain tissue, spasticity is found. In this type it is that Kernig and Brudzinski's signs may be found. The Babinski sign is a variable finding. Other more local lesions have been described such as hemiparesis motor asphasia. The presence of fever and the nature of the cerebro-spinal fluid have both already received attention, but perhaps one of the more curious manifestations that may present itself to the investigator is the occurrence of albuminuria. It has been described by certain French writers as massive albuminuria; and, although this may occur at times, according to the majority of observers it is rare and in some series of cases no single example could be found The majority of the first cases described were those that had reached a fatal termination. Symonds,18 however, pointed out in 1924 that it did not signify that all the cases ended that way. Sequelæ and prognosis. About 45 to 50 per cent. of the patients in which the aneurysm ruptures die or the condition. Of the survivors, after a more or less critical illness lasting, perhaps, for hours, days or weeks, about 30 per cent. recover, never as far as is known to be troubled again. The remainder are the unfortunate victims of protean sequelae, varying in severity from occasional headaches to death. Of the cases that it has been possible to trace over a number of years, many are found to be quite symptomless. A. J. Hall10 reports a case that lived in good health for 17 years after her attack of haemorrhage. On the other hand, a surprisingly large number have second attacks which may come on quite shortly after the primary haemorrhage or be delayed for periods up to years. The second lesion is often fatal, though not necessarily so, for J. R. O'Brien19 describes a case where a patient had her first haemorrhage in December, 1926, and made an apparently good recovery, only to be struck down four months later with a second attack. The victim became cyanosed, had epileptiform convulsions, and ran a temperature between 99° and 102° for four weeks, but recovered. One curious feature about the case, however, was the fact that in a comparatively short period, the patient put on three stones in weight, and that in 1932, although enjoying good health, was suffering from pituitary obesity. Another case that was considered to be making a fair recovery died one month after the initial lesion, and the necropsy revealed, in addition to recent hæmorrhage in the subarachnoid space, a hæmatoma in the frontal lobe, which, from its appearance, had been present since the primary hæmorrhage. Of the less severe symptoms, headache is the most common, being brought on by physical effort, mental work, or in some cases, by a "change in the weather." Of the mental changes themselves, many have been noted. Partial loss of memory for a period after the catastrophe is not exceptional.23 In addition, loss of memory associated with the recounting of pseudo-reminiscences, the symptom complex known as Korsakoff's psychosis, has been described by Goldflamm20 as being a sequel of subarachnoid haemorrhage. Bageley21 has mentioned a case where restlessness, irritability and insomnia were marked signs, and another observer where the intellectual and emotional disturbance approached confusional psychosis. Another victim,23 after a serious haemorrhage during which she was semiconscious for several days, developed a steadily rising blood-pressure, which commenced at 140 m.m., hg., and crept up until it reached above 250 m.m., and remained above 200 m.m. in spite of all measures taken to reduce it. Some weeks later she developed delusional insanity, which necessitated her removal to the observation ward. This gives rise to an interesting point. The majority of the specimens of congenital cerebral aneurysms in the Royal College of Surgeons museum have been obtained from the mental hospitals, which leads one to think, in the absence of other history, as to whether the presence of the aneurysm might not have been 106 the cause of the abnormal mental state. It must remain, however, a mere fascinating speculation, although the case described by Brain and Strauss22 is not without bearing on the subject. Their patient, who had haemorrhage from an aneurysm on the anterior cerebral artery which invaded the left frontal lobe, became maniacal and had to be certified as insane. Later, after release from a mental hospital, she had a second and fatal haemorrhage. It is apparent, therefore, that although sequela: may be expected, they are so widespread in their variety as to render classification a problem of some difficulty. It nevertheless is apparent that the majority are in the nature of a disturbance of the higher mental functions. Once the presence of a congenital cerebral aneurysm is suspected, prognosis becomes a matter of consummate difficulty. Not that every case will prove fatal, but that it is impossible to prognosticate even when a patient has apparently recovered from an attack, whether, if ever, a second catastrophe might carry him off. Conclusions. The congenital theory as to the origin of intra-cranial aneurysms is supported. The symptoms, as far as it has been found possible, have been classified. The sequelae have been described and it has been pointed out that in the main it is on the higher functions that their effects mainly fall. It is also emphasised that accuracy of prognosis in the early stages is not only difficult, but in many cases a matter of impossibility. References. 1 Gray's Anatomy. P. 870, 21st ed., 1920. 2 Winkleman, N. W., and Fay, T. Trans. Ann. Neurol. A., 55, 274-497, 1930. 3 Weed. Physiological Reviews, 1922. Vol. II, pp. 171-103. 4 Gull, Sir William. Guy's hospital reports, 1859. 5 Eppinger. Arch. f. Klin. dict. Vol. 21, 41 p., 1928. 6 Strauss, Globus and Ginsburg. Spontaneous Subarachnoid Hæmorrhage, Arch. Neur. Psych., Vol. 27, 1080, 1932. 7 Parkes Weber. Royal College of Surgeons Museum Specimen 4932-2. 8 Green, F. H. K. Quart. Jour. Med., Vol. 21, 41 p., 1928. 9 Greenfield, J. G. International Clinics, Vol. II, lines 39, quoted by Weber and Bode, O.B. 10 Hall, A. J. Lancet, May 25th, 1932 p. 1135. 11 Fearnsides, E. G. Brain, 1916, xxxix, 224. 12 Turn bull, H. M. Quart. Jour. Med., 1915, viii, 201. 13 Forbes, W. B. Aneurysms of the superficial cerebral arteries. Bull. Johns Hopkins hosp., 47, 239, 1930. 14 Charcot and Bouchard. Nouvelles recherches sur la pathologie de P'hæmorrhagie cerebral. Arch, de physiol. Norm, et Path., 1, 110, 1868. 15 Collier, J., and Adie. Price's medicine, p. 135, 1925. 16 Adie, W. J. Lancet, vol. I, p. 124, 1926. 17 Riddoch, G. Goulden, C.B. Brit. Jour. Ophthal., 1915, ix, 209. 18 Symonds, C. P. Spontaneous Subarachnoid Hæmorrhage. Quart. Journal of Medicine, 18-93, 1924. 19 O'Brien, J. Lancet, June 4th, 1932, p. 1230. 20 Goldflamm, S. Deut. Zeit. v. Nervenheilk. L, xxvi, 58, 1923. 21 Bageley, C. Arch. Neurol and Psych., vol. 27, 1133, 1932. 22 Brain, W. R. Strauss, E. B. Recent advances in Neurology, 1930, 92. 23 Barling, B. London County Council Annual Report, 1930, Vol. iv, part iii, 128-132. A CASE OF POLYARTERITIS NODOSA. By B. Barling, M.D., B.S., M.R.C.P., M.R.C.S., Senior Assistant Medical Officer, St. Mary, Islington, Hospital. Polyarteritis nodosa is interesting clinically as the symptomatology is so protean as to simulate other diseases. It is essentially a primary vascular disease, of unknown etiology, which is heralded by mild fever, sore throat, vague pains in the limbs and trunk and accompanied by leucocytosis, together with progressive loss of weight, fatigue and weakness. The variation of the symptoms and signs depends upon the localisation of the arteries involved. In one case the cerebral symptoms may predominate, in others the cardiac, pulmonary or renal. The superficial vessels may also be involved so that it is possible to ascertain the presence of the nodules on the vessels by palpation. G. A. H., aged 16 years, whilst employed as a tricycle messenger was knocked down by a car. He received some degree of concussion and was sent to hospital the next day. When admitted, he complained of generalised headache and vomiting. On examination, his condition was found to be good. He was quite conscious and able to answer questions. Case history. Cardio-vascular system: Pulse regular 68. Heart no abnormal physical signs except a soft systolic bruit over the pulmonary area. Respiratory and gastro-intestinal systems—no signs of disease. The examination of the central nervous system revealed a slightly larger left pupil than right. They both reacted briskly, and the fundi were normal. All reflexes were present and brisk. Occupying almost the whole of the vertex of the skull was a large fluctuating cephal hæmatoma. The skull was X-rayed that day, but no fracture was demonstrable. He was treated in bed and the hæmatoma steadily became absorbed. 27th April, eighteen days after admission he complained of headache and sore throat, the temperature shooting up to 104° and the pulse to 118. The fauces were congested and a swab taken at the time was found to be negative for K.L.B. By the 29th the temperature had subsided to normal and the throat felt better. Four days later, 3rd May, the temperature rose to 100° and the pain and congestion of the throat increased. This was followed by pain on the left side of the neck, with a very tender diffuse swelling in the posterior triangle low down above the clavicle on that side. This swelling subsided in ten days, but the throat, although it felt less painful, remained congested and inflamed. The temperature from the date of the recrudesence of the sore throat remained up, fluctuating between 103° and 99°, the pulse rate varying between 76 and 108. 30th May.—The fauces were still infected and the cervical glands enlarged, in addition, he complained of pains across the loins and there was some hæmaturia. The urine contained albumen and a moist film of the deposit showed large numbers of red blood corpuscles, a few pus cells and some epithelial cells. Staphylococci and diphtheroids were present in the Gram film. He was pale and a little drowsy. The tongue clean and dry and the fauces infected. The pulse rate had increased to 133, but no bruits were detected in the heart and no abnormal physical signs were found in the lungs. On examination of the abdomen, the tip of the spleen could be felt and although the kidneys were not palpable, they were both very tender. The examination of the central nervous system revealed only some congestion of the vessels of the fundi. The report on a blood count made that day was as follows: red blood corpuscles, 4,120,000 per c.mm.; haemoglobin, 72 per cent.; white blood cells, 38,000 per c.mm.; polymorphs neut., 89 per cent.; eosinophils, 2 per cent.; lymphocytes, 9 per cent. Red blood corpuscles normal in appearance. As the renal tenderness was mainly right, the blood count suggested peri-nephritic abscess, but at no time could a mass be demonstrated. From then onwards the urine contained albumen and blood each day, but there was no reduction in the quantity of urine passed and on some occasions the urinary excretion actually reached one hundred ounces in the twenty-four hours. The blood urea was 87 mgm. per 100 c.c. 9th June a baffling symptom presented itself. The right arm became completely paralysed, with loss of all reflexes. There was weakness of all muscles below the shoulder except the biceps and coraco-brachialis. Anæsthesia to pin-prick and cotton wool was present along the ulna border of the forearm from the elbow to the fifth finger. There were no abnormal findings in the left arm. The abdominal reflexes were all present and active. The knee jerks and ankle jerks were present and active, and the plantar reflexes flexor. A lumbar puncture was performed. The pressure of cerebro spinal fluid was 280 mm. of water. The result of examination of the fluid was: cells, less than 1 per c.mm.; total protein, .3 per cent.; chlorides, 640 mgm. per cent.; no organisms seen in Gram film; no tubercle bacilli found; culture, no growth; Lange curve, 2223332000. The Wassermann and Kahn reactions were negative. (107) 108 Three days later he complained of a feeling of tightness across the chest and the sputum was blood stained. Examination of the sputum was negative for tubercle bacilli. Throughout the illness he was noticeably becoming weaker and emaciated, the loss of weight being out of proportion for the duration of the illness. On 21st June he sank into a semicomatose state from which he did not rally. Post-mortem findings. The post-mortem findings were as follows:— The body was pale and emaciated and there was a small purpuric patch over the dorsum of the left foot. On incising the tissues of the head the remains of a subaponeurotic effusion of blood was found on the surface of the skull. There was no fracture of the skull. On opening the cranium the remainder of a small subarachnoid haemorrhage was seen on the under surface or the frontal lobes. Heart.—The pericardium showed blood stained pericardial effusion and both sides of the heart were distended with post-mortem clot. There was some thickening above the coronary vessels. Pleurce and lungs.—The pleurae were extremely œdematous giving the appearance of masses of jelly surrounding the lungs. The lungs were congested and œdematous with small scattered areas of hæmorrhage and thrombosis throughout them. Stomach and intestines.—The stomach and intestines were normal, but there was some enlargement of mesenteric lymphatic glands. Liver.—The liver was congested and weighed 83 ounces. Kidneys.—The kidneys weighed 11½ ounces each and were congested with small hæmorrhagic areas. Spleen.—Was congested and slightly enlarged. Microscopic examination (for which I am indebted to Dr. W. G. Barnard):— Heart.—Polyarteritis nodosa of the coronary vessels. Lungs.—Focal acute inflammation of the lung, mainly interstitial, often peri-vascular. Thrombi in a few pulmonary vessels. Spleen.—This organ showed polyarteritis nodosa and chronic inflammatory infiltration, whilst the kidneys, liver and a small artery near the carotid showed polyarteritis nodosa. A case is reported of polyarteritis nodosa, illustrating by its history the difficulties encountered in diagnosis. A CASE OF ABDOMINAL ACTINOMYCOSIS. By K. F. D. Waters, B.A., B.M., B.Ch., F.R.C.S. (Edin.), Deputy Medical Superintendent, St. Stephen's Hospital. The patient was a general labourer, aged 22, and was transferred to St. Stephen's hospital from St. Luke's for operation as a case of acute appendicitis. The history was typical of this condition, with the exception that the temperature was abnormally high, being 102.8° on admission. It is rare for the temperature to be above 101° in acute appendicitis in an adult; in fact, a pyrexia higher than this would cast doubt on the diagnosis, and necessitate a close scrutiny of the signs and symptoms before it could be regarded as settled. Condition on admission, 21.9.34. The man was of medium habit and looked pale and ill. T. 102.8°. P. 98. R18. His tongue was very dry and slightly furred, and some carious teeth were present. He complained of continuous abdominal pain most marked in the right lower quadrant. His heart, lungs and urine were normal. The abdomen was resistant all over, and rigid and tender on palpation in the lower half, especially in right iliac fossa. Rectal examination was negative. The diagnosis of acute appendicitis with peritonitis was made, and immediate operation performed under percaine anæsthesia. The appendix was acutely inflamed, and there was turbid free fluid in its neighbourhood. The fluid was mopped up, the appendix removed, and the wound closed except that a drainage tube was inserted down to the cæcum. Case report. 23.9.34. The drainage tube was removed. The patient felt much better; he was free from pain, the abdomen was soft, and an enema gave a good result. T. 103°. P. 106. 26.9.34. Not much change except that the general condition was better. The abdomen was soft and moved freely, and the bowels were opened naturally. There was a small amount of purulent discharge from the site of the drainage tube. T. 102.° P. 100. 30.9.34. Better. Appetite good. No pain. Abdominal condition quite satisfactory. Bowels open. Some purulent discharge from the part of the wound through which the drainage tube had been inserted. T. 101°. P. 96. 3.10.34. Still pyrexia to 100°. P. 90. The patient still said that he felt quite well. Appetite good. No pain or tenderness. A rigor occurre1 the previous evening when T. rose to 101°. Urine clear and sterile. Abdominal and rectal examination negative. Heart and lungs normal. Wound clean. The cause of the pyrexia was very obscure, as there appeared to be nothing in the chest and abdomen to account for it. W.B.C. 20,000. Actinomycosis was now suspected, and a smear taken from the wound, but only B. coli and non-hæmolytic streptococci were found. 5.10.34. T. rose to 102° the previous night, but still no symptoms. No swelling or tenderness detected anywhere in the abdomen. The patient was seen by the consulting surgeon, but he was unable to account for the pyrexia. 10.10.34. Still the same degree of pyrexia, but the patient complained of headache and vomited once: he was inclined to be constipated and had some flatulent distension, which was relieved by a turpentine enema. The Widal reaction was negative to the enteric group and brucella abortus. Skiagrams showed no evidence of subphrenic abscess, or of pneumonia, empyæma or tuberculosis. The operation wound was healed. 12.10.34. The patient was seen by the consulting physician, who considered that at least the cause of the pyrexia was not above the diaphragm. 14.10.34. In the evening there was another rigor lasting ten minutes, during which T. rose to 104°. No other symptoms or abnormal signs were present, except that general condition was not so good. The T. was now definitely swinging between 103° at night and 100° in the morning. 17.10.34. Still the same swinging pyrexia. Blood culture negative W.B.C. 21,000, of which 89.5 per cent. were polymorphs. 18.10.34. Slight dullness low down over the right chest. An exploring needle was inserted through this area, but no fluid either clear or purulent was obtained. 19.10.34. Height of pyrexia increasing. Now definite but slight tenderness over the liver just to the right of the gall bladder. The stools were examined tor dysentery, but no amoebae were found. 22.10.34. The percussion note over the right lower chest was rather more impaired. Still the same pyrexia T. 104°. P. 130. 24.10.34. Skiagrams of the chest showed haziness of the right lower lobe, but the diaphragm moved freely. T. 101°. P. 108. 26.10.34. Right chest was again explored, but no pus was found. T. 102°. P. 120. The tenderness over the liver was more marked. The patient was seen in consultation with the consulting surgeon and physician, who agreed that it was advisable to explore the liver. Under gas and oxygen anaesthesia, transpleural laparotomy was performed. The pleura was normal and no free fluid was present in the pleural cavity. As the two layers of the pleura were not adherent, the parietal was sewn to the diaphragmatic over a circular area, in the centre of which the diaphragm was incised, the peritoneal cavity opened and the liver exposed. (109) h 110 There was excess of clear serous fluid round the part of the liver exposed, but no subphrenic abscess. A large bore exploring needle was thrust into the liver, and thick yellow pus, smelling strongly of B. coli, was reached at a depth of 1¼ inches. This area of liver was packed off with gauze, and a pair of forceps pushed into the liver alongside the exploring needle; when the blades were opened more pus gushed out. The cavity was explored with the finger. It appeared to be part of a suppurative pylephlebitis. A drain was inserted into the cavity, and some pus sent for examination. 27.10.34. The condition was unchanged and the pyrexia markedly remittent. 29.10.34. No improvement. Emaciation becoming marked. Still same pyrexia. Pus draining freely from the tube and still very offensive. 2.11.34. Not much change. Still same pyrexia. The discharge was now chiefly bilious and no longer offensive. 5.11.34. Condition deteriorating. T. 101.8°. P. 116. Discharge lessening, clear and bile stained. 9.11.34. Condition worse. T. 102°. Stools pale. Discharge watery and bile stained. 12.11.34. Not so well. Patient complained of sharp intermittent pain in the region of the umbilicus. Slight general abdominal distension. T. last night 104°. Chest wound healing. Very little discharge from the liver abscess now. Bowels open and stools normal in colour. Pathological report from the pus from the liver abscess states that "cultures from this pus have grown a Gram-negative streptothrix strictly anærobic, and in spite of its staining reaction must be considered as a form of actinomyces." Large doses of potassium were administered. In spite of this, the patient continued rapidly to go downhill, and he died on 18.11.34. Post-mortem examination. A post-mortem examination of the abdomen only was obtained, but it showed nothing grossly abnormal except the liver. There were no localised masses of the granuloma in the right iliac fossa or loin. The liver was riddled with groups of abscesses, which appeared to follow the course of the portal vein. They were encapsuled and loculated, but did not present the characteristic honeycomb appearance, but were larger cavities doubtless due to the confluence of small ones, and were filled with thick greenish yellow pus. A slice of the liver was sent to the group laboratory, which reported "multiple abscesses in the liver, with the typical histological appearances of actinomycosis. The mycelium, however, stains Gram-negative, as did the streptothrix isolated from the pus." Actinomycosis is a common disease in cattle, though rare in man; it belongs to the group of infective granulomata, and is caused by the actinomyces or ray fungus, which belongs to the group of streptothriceæ, more than one species of which may produce the disease. In the common form the mycelium stains Grampositive. The particular species in the case here recorded stained Gram-negative, but it produced the typical histological appearances of actinomycosis. The mode of infection is doubtful, though it is usually attributed to eating infected corn or grasses. This patient was closely questioned on this point, but he was a Londoner born, and had hardly ever been in the country, and was positive that he had never plucked and eaten any form of corn. At any rate the parasite gains entrance through the alimentary canal and enters the tissues perhaps through carious teeth, and causes lesions in four different sites, 60 per cent. in the head and neck, 20 per cent. in the gastro-intestinal tract usually in the caecum and appendix, 15 per cent. in the lungs and the remainder in the skin. In this case it is probable that the site of infection was in the appendix, and that spread to the liver occurred via the portal vein, as there were no granulomata in the abdomen, and no involvement of the abdominal wall with sinus formation as is usual in such cases. Moreover, the nests of abscesses in the liver had a distribution similar to that found in portal pyæmia. The clinical course was interesting. It began with an unusually high temperature for an acute appendicitis. This is a point which I noted in my only other personal case, that of a girl, aged 11, who presented all the usual signs of acute appendicitis, except that on admission to hospital her temperature was 106°. An immediate operation was performed and a gangrenous perforated appendix removed. The operation wound healed, and she was discharged apparently cured, but returned a month later with actinomycotic granulomata in the right iliac fossa. The initial pyrexia, in the case now recorded, never subsided, although otherwise the patient's condition for some time appeared satisfactory. This continued remittent fever was obscure, as none of the usual causes could be found. It was presumed to be due to some infection, and there was a persistent polymorph leucocytosis. The diagnosis was eventually revealed by the formation of liver abscesses. The course of the disease was steadily downhill and treatment was without effect. 111 A case of actinomycosis of the liver is recorded due to a Gram-negative strepto- Summary, thrix, which began as a case of acute appendicitis and continued as an obscure pyrexia for some weeks before liver abscesses formed and the organism was isolated therefrom. I am indebted to the medical superintendent, Dr. D. S. Sandiland, for permission to record this case. PROLONGED RETENTION OF ARTERY FORCEPS IN THE ABDOMEN. By A. J.Watson, M.B., B.S., F.R.C.S. (Eng.), Asst.Medical Officer, St. Giles' Hospital. and J. A. Braxton Hicks, M.D., M.R.C.P., D.P.H., Group Pathologist, Lambeth Group Laboratory. A series of 44 instances of surgical instruments accidently left in the abdomen at surgical operations has been described by Clifford White in 1923. In the majority of these cases, the instruments were recovered within a few weeks or days after the operation. He recorded the longest interval as having been nineteen years. The following two instances of artery forceps left in the peritoneal cavity at operation are of interest because of the length of time elapsing before they were discovered and the comparative freedom from serious symptoms of the patients during that time. Case reports. Case 1.—E. T., aged 70 years. Admitted to St. Giles' hospital 16th July, 1934, with symptoms of subacute intestinal obstruction probably in the small intestine. The patient gave a history of appendicectomy in September, 1921. From the previous notes it would appear that the patient had suffered from chronic appendicitis, and the appendix had been removed through a "Battle" incision. Except for some infection of the wound, convalescence had been normal, and the patient had left hospital with the wound well healed. She was re-admitted in December, 1921, with symptoms of subacute obstruction. A mass, thought to be a gland, was felt in the right iliac fossa at this time. The symptoms subsided and the lump disappeared without further surgical intervention, and the patient left hospital apparently quite well. Her general condition had remained good since that time, except for occasional attacks of abdominal pain, but she had recently lost a lot of weight, and had developed a cough with shortness of breath and also a vaginal discharge. For two weeks prior to admission in 1934 the abdomen had become distended and the patient had vomited. Her bowels had been opened quite freely. Clinical examination.—Patient rather wasted. A scar of a "Battle" incision in right lower abdomen generally distended. Visible coiling in centre of abdomen with active peristalsis— no tumour felt. Pelvic examination revealed four inches of closed metal blades protruding through the posterior fornix of the vagina. Patient also had signs of myocardial degeneration with cardiac failure, and chronic bronchitis. X-ray showed a 5-inch pair of artery forceps lying with the handles in the right iliac fossa, and the blades running vertically downwards into the pelvis. Although the general condition of the patient improved while in hospital, the distention and symptoms of obstruction remained. It was, therefore, decided to attempt to relieve the obstruction and, if possible, to remove the forceps. Operation by Mr. R. M. Handfield-Jones, consulting surgeon to St. Giles' hospital, under gas-oxygen anæsthesia, 24th July, 1934.—On opening the abdomen through a right paramedian incision, greatly distended small intestine was found. The handles of the forceps could be felt in the right iliac fossa. A loop of small intestine was adherent to the medial aspect of the caecum, and one handle was found to be lying in the lumen of this loop. The other handle lay inside the caecum. There appeared to be a fistulous communication between this loop and the caecum. There was no obvious point of obstruction. A small incision was made in the small intestine loop, and one handle was withdrawn from the bowel, the other handle was removed from the caecum via the fistula between the small bowel and the cæcum. The blades lay apparently in a mass of adhesions on the side wall of the pelvis, and were withdrawn easily. The opening in the bowel was sutured and the wound closed. A small rubber tube was inserted up to the vault of the vagina and along the track of the blades. The patient stood the operation well, but the distension remained, and she died six days later apparently from paralytic ileus. Post-mortem revealed no further information. The adherent loop of small intestine was about six feet from the duodenojejunal flexure. There had been no leakage from the enterotomy, and no peritonitis. There was marked degeneration of the heart muscle, and congestion at the bases of both lungs. Case 2.—Aged 48 years. Admitted to Westminster hospital in February, 1922, under Dr. de Souza, to whom we are indebted for permission to publish the clinical notes of the case. Complaining of loss of strength since the death of her husband 3 months previously. Also shortness of breath and giddiness. She gave a history of two operations at another hospital seventeen years previously—one for ovariotomy, and one for appendicectomy. Since then she had been perfectly well except for chronic constipation. (112) 113 Clinical examination.—Patient a lemon-yellow colour. Mucous membranes blanched. Body flabby. Systolic murmur at apex. Nothing abnormal found in the abdomen or central nervous system. A trace of albumen in the urine. Blood count serum to corpuscles 5:1, serum yellow. H/B. 28 per cent. R.B.C. 1,410,000 C.I=1. W.B.C. 6,400. Lymphocytes 42 per cent. Poikilocytosis and anisocytosis. Polychromasia. Stippling. No nucleated R.B.C. seen. Temperature remittent between 100•2° and 99•2°. Patient gradually went downhill in spite of all treatment and died in March, 1922. Post-mortem (J. A. B. H., Westminster hospital).—Very pale. Conjunctivae yellow. Two old scars almost invisible, one 1 inch in right iliac fossa, the other 4 inches in mid-hypogastric region. Plenty of subcutaneous fat in the body. Heart flabby and showed an extreme degree of tabby cat striation. Lungs.—Engorged. Nil else. Liver.—Large, fatty and gave a well marked iron reaction. Spleen.—Pale and large. Hæmolymph glands along the aorta prominent. Bone marrow of sternum and femur red and soft. Appendix missing and both ovaries. The lower coils of the ileum, ileo-cæeal valve and caecum were hopelessly matted together and were spread over the contents of the right half of the pelvis. Inside the lower coil of the ileum was an ordinary pair of short Spencer-Wells artery forceps which at the upper toothed clip were thickly encrusted with a stercolith, but elsewhere were merely discoloured and rusty. The lower part of these forceps had pouched the bowel, i.e., ileum, down into the right half of the pelvis, and the tip of the forceps and the terminal ¾ inch were embedded within the bowel in a very dense mass of fibrous tissue which was so hard as to suggest malignant disease, but a subsequent section proved it to be entirely inflammatory fibrous tissue. These forceps must have originally been left behind at the ovariotomy operation 17 years before, and had gradually worried their way, as such foreign bodies appear to do, into the lumen of the gut. From the clinical notes it is quite obvious that the patient had never suffered the slightest inconvenience (unless constipation is to be regarded as such) or pain from the presence of this comparatively large foreign body, and she died from pernicious anaemia which cannot really be attributed to this foreign body. These instruments have therefore been in situ in these two patients for thirteen and seventeen years, respectively. Comment. In the first case it seems probable that an abscess formed round the forceps at the time of her second admission to hospital three months after her operation, and this ruptured into the adjacent bowel leaving the handles of the forceps lying in the lumen of the bowel. In the second case the forceps presumably eroded their way into the bowel without causing any acute attack of inflammation. It is remarkable that the presence of these large metallic foreign bodies can remain in the lumen of the bowel for so long without causing irritative or obstructive symptoms. A CASE OF GRANULOSA-CELL CARCINOMA OF OVARY. By R. Kelson Ford, M.D., M.M.S.A., Medical Superintendent, St. Olave's Hospital. Granulosa-cell carcinoma of the ovary is of sufficient rarity to justify at present the reporting of every case observed. Case report. Mrs. A. A. (30565), aged 51, was admitted to hospital in a very exsanguinated condition. It was stated that the patient, who had had four children, had ceased to menstruate for two years. Vaginal haemorrhage had. however, appeared three months previously and had persisted. the patient becoming steadily weaker until she had fainted. Apart from evidence of serious loss of blood, and some gingivitis, general physical examination revealed no abnormality. On pelvic examination, the cervix was normal, the uterus somewhat enlarged and displaced to the right, and a slightly movable cystic swelling was palpable in Douglas' pouch. Following blood transfusion, sufficient improvement was made to justify operation, and low median laparotomy was performed. A dark, thin-walled cyst was found in the left meso-salpinx, and this proved on section to be a simple epoophoric cyst. In addition, there was what appeared to be a large, thick-walled cyst of the right ovary, somewhat incarcerated in the pelvis, of about the size fig. 1. fig. 2. of a grape-fruit, which was also removed. Apart from a little post-anaesthetic bronchitis, the patient made an uninterrupted recovery and radio-therapy at Lambeth hospital was arranged. She was seen again one year after operation, when she appeared well, and stated that she felt better than for many years. Pathological Findings (kindly provided by Dr. W. G. Barnard, director, Central histological laboratory): Macroscopic appearance.—Pieces of tissue making up a mass 10.5 by 8.5 by 2.5 cm. and representing half of an oval tumour. The capsule is smooth and pearly white, and to it is attached the terminal 5 cm. of Fallopian tube. The cut surface is mostly smooth and creamy white, in it are a few red dots and streaks. Beneath the capsule and around the border nearest the Fallopian tube are numerous spongy areas and throughout there are cysts (varying in size from 1.5 cm. to 0.5 cm. in diameter) containing thin watery fluid. Microscopic appearance.—Five pieces of the tumour were embedded in paraffin and sections were stained by Ehrlich's hæmatoxylin and eosin and by Van Gieson's method and counterstained by iron hæmatoxylin. The tumour is made up of alveoli, solid acini and trabeculæ of polygonal cells separated by scanty fibrous tissue. The majority of the trabeculæ are two or more cells thick and some of the spaces in the alveoli contain pink homogeneous material. Both the acini and alveoli contain rounded spaces and in a few of these there are large ova-like cells. The polygonal cells for the most part have abundant protoplasm and round or fat oval nuclei, the nuclei having a sharp outline, scanty chromatin net and distinct chromatin nodes. (114) 115 The above distinctive details are illustrated in the accompanying microphotographs (figs. 1 and 2). The first report of an ovarian tumour of a similar type was in 1895 by von Kahlden. Since then, some 60 further cases have been reported. A summary of the findings was delivered by Lepper, Baker and Vaux, and appeared in the Proc. Royal Society of Medicine XXV. 8 (June, 1932), p. 1241. A number of articles have been published since then, in some of which aspects such as secondary sex changes (Novak) and metastases (Holmer) have been reported and discussed. Discussion. These tumours may be met with at various stages in growth, the largest reported being nearly 12 inches long. They are enclosed in a tough fibrous capsule, which shows no tendency to form adhesions. On section, the substance is spongy, partly solid and partly cystic. Yellow or hæmorrhagic patches, spots or streaks are often to be seen. The microscopical appearances have been divided into three groups or types:— (1) Follicular, in which the appearances resemble those of Graafian follicles, or may be much larger; (2) Cylindroid, in which trabeculæ are prominent, containing a fibrous tissue core covered by columnar, cubical or polygonal cells; (3) Irregular, in which, though one or other of the former patterns is present on search, the predominant pattern is of epithelial cells irregularly arranged in a scanty fibrous tissue stroma. Though usually occurring in patients who have experienced the menopause, this is not an inevitable rule. In any case, however, the history is usually one of a period of amenorrhœa followed by metrorrhagia which may be prolonged. Metastatic development is rare, but may occur. As to treatment, simple removal should be followed by radio-therapy. In the event of encountering secondary deposits, they also should be removed. VIRILISM: UNILATERAL ADRENALECTOMY. By J. R. M. Whigham, M.C., M.S., F.R.C.S. (Eng.), Surgeon, St. Andrew's Hospital. The patient, a woman L.P., aged 26, was sent to the hospital by Dr. G. 0. Mitchell and was admitted to the wards under the care of Dr. R. M. Maher. There had been symptoms suggestive of phthisis in the past for which she had been kept under observation, but she now sought advice for a growth of hair on the face and chin and irregularity of menstruation. The patient was a brunette, 5 ft. 1 in. in height, rather thick set, and weighed 8 at. 9 lb. A firm growth of hair was present on the cheeks and chin; the legs were hairy and over the lower abdomen the suprapubic hair reached up to the umbilicus, simulating the distribution in the male. The bodily contour presented no marked features, except that the breasts were ill developed. The voice was low pitched. The psychological outlook was feminine. Menses had commenced at 14½ years, lasting 3 days every 3 weeks. At 21 they had diminished and lasted only 2 or perhaps 1 day at a time. They had also become painful and associated with fainting attacks. The external genitalia appeared normal. On further investigation it was noted that the B.P. was 120/90, the W.R. negative, and the Kahn reaction negative. The blood count returned the following figures:—hæmoglobin, 60 per cent.; red blood corpuscles, 5 millions; colour index, 0.6; leucocytes, 8,400; polymorphs, 60 per cent.; eosinophils, 6 per cent.; basophils, 1 per cent.; lymphocytes, 30 per cent.; large hyalines, 3 per cent. The blood urea was 40 mg., blood sugar 97 mg., and blood calcium 8.26 mg. per 100 c.c. The sugar tolerance test gave the following figures:— fasting, 65 mg. per 100 c.c.; ½ hr., 101 mg. per 100 c.c.; 1 hr., 91 mg. per 100 c.c.; 2 hrs., 82 mg. per 100 c.c. (Miss K. M. Collis.) There was slight hypochlorhydria as shown by the test meal. An X-ray examination showed no abnormality in the skull, pituitary fossa, chest or abdomen. An ophthalmological examination revealed myopia with astigmatism, but the media were clear, the retinae healthy and the fields full (Mr. Jeremy). The case was diagnosed as one of adrenal virilism (hirsutism), due probably to cortical tumour or hyperplasia. As there was no indication as to which gland was involved, laparotomy was decided upon, and this was performed on the 2.3.34. The gland on the left side was definitely palpable and slightly enlarged, but no tumour was discovered; on the right side the gland could not be identified by the examining finger. Small cysts were present in both ovaries; the uterus was rather smaller than normal. The patient made a smooth and uninterrupted recovery from the operation, and on 17.4.34, six weeks afterwards, a left adrenalectomy was performed through a subcostal incision excising the last rib, following Bleicher's technique. The operation was performed with the patient in the right lateral position, the knees being slightly flexed, the right more than the left. A pillow was inserted below the costal margin to open out the left loin. The patient was anæsthetised with rectal paraldehyde and gas and oxygen inhalation. The skin incision followed the direction of the last rib extending from the erector spinæ mass posteriorly along the costal margin to the mid axillary line in front. The skin, fasciæ and muscles were divided down to the level of the 12th rib. In the anterior end of the wound the muscles of the abdominal wall, the external oblique, the internal oblique and the transversalis were seen, and the latissimus dorsi, the erector spina? mass, and the serratus posticus inferior posteriorly. The periosteum over the last rib was incised and the rib resected subperiosteally. This was done with due regard to its tendinous and aponeurotic attachments and respect for the subjacent pleura. The rib was divided close back to the vertebral column, and when removed the lower limit of the pleura, covered by oblique aponeurotic fibres, was revealed, with the 11th dorsal nerve running obliquely forwards across it. The 12th nerve runs parallel and lower down. A little blunt dissection with firm retraction of the wound edges exposed the extra-peritoneal fat and the perirenal fascia. The latter was incised and the incision enlarged, thus allowing the kidney to be brought into the floor of the wound so that its anterior surrace could be explored and the reno-adrenal junction sought for. At this stage the operation was being conducted at some depth from the surface, but with the bleeding well controlled and satisfactory retraction, the exposure was adequate. The gland was identified by its shape and distinctive yellow colour, though it is apt to be obscured by the surrounding fatty tissue. As the kidney is retracted the adrenal gland tends to remain in the roof of the dissection, where the gland should be sought. The capsular vein running down to the renal vein may also serve as a guide to the situation of the gland. The preadrenal fascia was next incised and the hilum containing the capsular vein clamped and divided. The gland was then removed by clamping the surrounding tissue which was then ligated to control haemorrhage. The wound was closed by layers, and drainage instituted for 24 hours. The convalescence was uneventful and the wound healed soundly without complications. The histological report on the gland removed was as follows: "fuchsinophil granules (Ponceau fuchsin stain) are present in a moderate number of the cells of the adrenal cortex" (Dr. A. B. Bratton). The patient, when seen recently, nearly a year after the operation, stated that she occasionally had pain in the operation area, that the hair on her face had improved, and that she had since got married. References. L. R. Broster and H. W. C. Vines. "The Adrenal Cortex." H. K. Lewis & Co., Ltd., London, 1933. M. Bleicher. "Technique operatoire de la surrenalectomie basee sur l'anatomie. Archives Franco-beiges de chirurgie, 33. 1931-2. (116) TREATMENT OF FRACTURES OF THE NECK OF THE FEMUR. By James C. Gillies, M.B., Ch.B., F.R.C.S. (Edin.), Assistant Medical Officer, Hackney Hospital. The Whitman plaster has for years been recognised as standard treatment for fractures of the upper end of the femur. The application of a Whitman plaster is a formidable procedure and many of the patients are too old and infirm to stand it. The Whitman position of abduction and inversion, the position of choice, can be attained and maintained by a simpler and more generally applicable procedure. In 1927 Wilkie published an account of an apparatus which maintained abduction and inversion. The apparatus I have been using for the last four years at Hackney hospital was adapted from Wilkie's. It is simpler, cheaper and more adaptable. It consists of a straight steel bar and two metal plates. The bar is rigid, forty inches long, half an inch broad and three-sixteenths of an inch thick, perforated towards its ends by four holes, each hole large enough to admit the screw of one plate. The plates are of zinc, five inches square, with rounded corners, and with a long screw and wing-nut projecting vertically from the centre of each (see fig. 1). The plates can be moulded to fit the leg. fig. 1.-showing abduction bar and one plate. fig. 2.—fractured side left. showing wing nuts in position and inversion of foot. fig. 3.—fractured side left. showing abduction and inversion of left lower extremity with bar applied. The splint is applied in bed and very little assistance is required, no more than can be supplied by one nurse. In many of the cases the only anæsthetic used has been morphia gr. ¼ administered twenty minutes before the beginning of procedure. Any pain caused by manipulation is momentary and not severe. In younger and more muscular subjects spinal anaesthesia, induced by 1.5 c.c. of spinocaine, has been used. In intertrochanteric fractures a local anæsthetic of 20 c.c. of 2 per cent. novocaine has proved very satisfactory. A plaster casing is applied to the sound leg over wool, from the toes to below the knee, with one zinc plate incorporated so that the screw of the plate projects directly backwards about eight inches above the heel. On the fractured side the plaster is applied from the toes to above the knee, and the screw of the included plate is made to project medially and backwards at the same level as the screw on the sound side. All this part of the proceedings can be done without causing any pain. When the plaster has hardened, the sound leg is abducted as far as possible, the screw slipped through a hole at one end of the bar and the wing-nut adjusted. The fractured limb is now grasped firmly, a strong pull is maintained and the limb abducted and inverted slowly and steadily until the screw can be inserted into an (117) i 118 appropriate hole at the other end of the bar. The wing-nut is applied and the procedure is complete. The patient is now fixed in a rigid apparatus with the lower extremities widely abducted and the fractured limb inverted (see figs. 2 and 3). As the feet project beyond the edges of the bed, I have found it an advantage to rest the bar on a broad board with holes cut in it to receive the projecting wing-nuts. fig. 4.—showino fracture of neck of femur in woman aged 74 years. fig. 5.—same fracture after application of abduction bar without anæthetic. fig. 6.-intertrochanteric fracture of femur in woman aged 60 years. fig. 7.—same fracture after application of abduction bar and extension under loca1 anæthetic. 119 In intertrochanteric fractures extension is necessary to maintain a good position. In these cases a strapping extension is fitted to the fractured limb before the application of the plaster and the sole of the foot is left free from plaster so that a weight can be applied. This assures fixed abduction and weight extension. The advantages of the bar method over a hip spica plaster can be summarised as follows:— (1) Ease of application in bed without a special table and prolonged manipulation. No patient is too old or feeble to stand this procedure. (2) Comfort and ease of nursing. My ward sisters have expressed their preference for this method of treatment over any other in facilitating the nursing of these patients. (3) The patient can sit up. This is a material advantage in preventing and combatting the chest complications so liable to occur in these cases. (4) The thighs are uncovered and massage can be carried out from an early date. (5) The hip is not obscured by plaster and clear X-ray pictures can be obtained. The abduction is maintained usually for sixteen weeks, after which a walking caliper splint is fitted. In sub-capital fractures non-union occurs in many cases, as with all methods of treatment, but fibrous union in good position is obtained and there is never any eversion of the foot. I submit this account of this method of treating fractures of the neck of the femur in the hope that it will prove an addition to the armamentarium of surgeons called on to treat these difficult cases. In my experience the abduction bar method, as advocated by Wilkie, is not sufficiently widely known. Apart from its use in hospital, surely it would be a great help in the treatment of these cases where hospitalisation is not possible. I have been using my bar for four years and I have found it extremely useful and satisfactory. My thanks are due to Dr. Wilson, medical superintendent of Hackney hospital, for permission to publish this article; to Miss Weill, for the X-ray plates (figs. 4 to 7); and to Mr. Smith, the hospital splint-maker, for much valuable attention to the design of the apparatus. Reference. D. P. D. Wilkie. Surgery, Gynaecology and Obstetrics, 1927, 529. END RESULTS OF FRACTURES. By Major Meurice Sinclair, C.M.G., M.B., Ch.B., Consulting Orthopædist, St. James' Hospital. The subjoined table gives an analysis of the results of the treatment of fractures in patients who were treated at St. James' hospital, Balham, in the years 1931, 1932 and 1933, and who presented themselves for examination as to the end result. The number examined and analysed is rather more than a third of the total cases treated in the relevant period. Site. Age groups. Total number of cases under review. Temporarily incapacitated. Permanently incapaci tated. Remarks. A1. *A2. A3. Recovery of full normal activities. Recovery of limited activities. Number Number. Average incapacity in weeks. Number. Average incapacity in weeks. (1) (2) (3) (4) (5) (6) (7) (8) (9) Metatarsals and /or 16 and under 2 1 9 - 1 - phalanges Adults 11 8 16 1 6 2 - 70 and over — — — — — — — Tarsals 16 and under - - - - Adults 5 1 66 1 15 3 70 and over — — — — — — — Tibia and fibula— into ankle joint 16 and under 8 8 17 - - - - Adults 71 45 23 13 33 13 - 70 and over 14 7 21 5 32 2 A2, walking in comfort. 1 of A3, 82, the other 83 years old. shaft 16 and under 18 18 13 — — Adults 56 30 34 10 60 16 70 and over 5 2 25 1 52 2 A2, was 82 years old. A3 (1) an amputatation for ulcer, and (2) a nerve lesion. into knee joint 16 and under - - - - - - Adults 20 8 24 7 52 5 70 and over — — — — — — — Patella 16 and under - - - - Adults 14 10 30 2 39 2 - 70 and over — — - — — — — Femur— into hip joint 16 and under 3 3 50 - - - - Adults 25 7 55 1 102 17 A2, had nerve lesion superimposed. A3, two cases were mentally afflicted and two had cancer. 70 and over... 11 2 80 9 A 2, both had nerve lesions. The ages were 82 and 85. shaft 16 and under 21 18 19 - 3 _ Adults 11 8 37 — - 3 - 70 and over 1 - — — — 1 — lower third 16 and under _ - - - - Adults 5 3 50 — — 2 — 70 and over — - - - — — — (120) 121 Site. Age groups. Total number of cases under review. Temporarily incapacitated. Permanently incapacitated. Remarks. A1. *A2. A3. Recovery of full normal activities. Recovery of limited activities. Number. Number. Average incapacity in weeks. Number. Average incapacity in weeks. (1) (2) (3) (4) (5) (6) (7) (8) (9) Femur-continued. into knee joint 16 and under 3 3 29 - - - - Adults 5 2 44 2 111 1 A2, delayed union two 70 and over 1 - - - - 1 - Pelvis 16 and under - - - - - - - Adults 13 8 19 - - 5 A2, case was 78 years of age. 70 and over 1 - - 1 9 - Spine 16 and under - - - - - - - Adults 6 - - - - 6 - 70 and over - - - - - - - Ribs and sternum 16 and under - - - - - - - Adults 18 12 8 4 10 2 A3, one of them was 80 years old. 70 and over 3 - - 1 9 2 Skull 16 and under 6 5 19 1 3 - Mother states that child acts peculiarly at times. Adults 17 11 12 1 20 5 70 and over 2 - - - - 2 Mandible 16 and under - - - - - - - Adults 2 2 6 - - - - 70 and over - - - - - - - Shoulder girdle 16 and under 6 6 7 - - - - Adults 24 18 7 3 27 3 - 70 and over 5 2 6 2 7 1 - Humerus- into shoulder joint 16 and under 3 3 7 - - - - Adults 7 4 11 - - 3 - 70 and over 5 2 10 - - 3 - shaft 16 and under 4 3 9 - - 1 A3, multiple injuries, skin graft. Adults 3 2 20 1 32 - 70 and over 2 1 8 1 5 - - into elbow joint 16 and under 7 7 10 - - - - Adults 2 2 21 - - - - 70 and over - - - - - - - Ulna and / or radiuselbow 16 and under 1 1 8 - - - - Adults 5 2 22 1 52 2 A3, one non-union and the other myositis. 70 and over - - - - - - shaft 16 and under 13 11 8 1 10 1 A2, a nerve lesion. A3, an amputation. A3, non-union. Mental. Adults 10 7 15 2 88 1 70 and over 1 - - - - 1 wrist 16 and under 1 1 5 - - - - Adults 24 17 21 3 13 4 A2, two patients had osteo-arthritis. A3, one had multiple injuries and another suffered from tuberculosis. 70 and over 6 - - 3 11 3 A2, the ages were 78, 79 and 85 years. Carpal bones 16 and under - - - - - - - Adults 2 2 54 - - - - 70 and over 1 - - - 12 - A2, age 85 years. Metarcarpal and phalanges 16 and under 2 2 4 - - - - Adults 11 10 16 - - 1 - 70 and over - - - - - - - * The A2, category is made up of those not fit for full work or full normal activities because of some disability existing before the fracture but able to return to the same work or activities as before the fracture. SUPRAPUBIC PROSTATECTOMY. By K. F. D. Waters, B.A., B.M., B.Ch., F.R.S.S. (Edin.), Deputy Medical Superintendent, St. Stephen's Hospital. Suprapubic prostatectomy is an operation which is so frequently necessary in elderly men, whose general health is usually poor, that any modifications of technique, which reduce the mortality and the incidence of complications, especially of sepsis, become of great importance. The cases on which this paper is based number 63. They were consecutive cases and entirely unselected. The youngest patient was aged 48, and the eldest 82, and there were three others aged 80 or more ; 29 of the patients were 70 or over, and the average age was 67.5. There was one death from heart failure one month after operation; and only 3 cases had complications. One developed a slight epididymitis, which soon subsided, and the other two, diaphragms across the internal urinary meatus. These were easily relieved by the passage of a metal catheter. Preliminary investigation The blood urea was always examined and if it was over 50 a two-stage operation was performed. If retention of urine was present, it was relieved by tying in a catheter, and 15 ozs. of urine were drawn off every 4 hours until the bladder was empty. The bladder was washed out twice daily with mercury oxycyanide 1 in 4,000 both through and alongside the catheter to prevent the urethritis which otherwise occurs. The catheter was removed as soon as the patient was able to pass urine normally. Every patient was given a 10-day course of acid sodium phosphate and hexamine, and saline aperients. When catheterization was necessary to relieve retention the blood urea was not determined until the end of 10 days. At the end of that period every patient who still had cystitis or blood urea over 50 had the operation performed in two stages, the bladder being drained until the cystitis cleared and/or the blood urea fell to within normal limits. During this period, also, attention was given to the general condition of the patient. Chronic bronchitis was treated by ammonium carbonate and belladonna mixture, and myocardial weakness by digitalis. Technique. The night before the operation the patient was given 7 to 10 grains of medinal to ensure a good night's rest. On the day of operation an injection of 1 c.c. of omnopon or grain of heroin was given one hour before operation. Immediately before operation grain 1/6 of ephredine was given intramuscularly, followed in two minutes by spinal anaesthesia by means of 1.5 c.c. of stovaine or 12 c.c. of percaine. Spinal anaesthesia was always used because of the perfect muscular relaxation obtained, of the absence of shock, and of the fact that many of these patients were not suitable subjects for general anaesthesia. The bladder was never distended with fluid before operation in order to avoid the passage of a catheter, as the ideal was if possible to operate on the case before ever a catheter had been passed, though of course this was not possible in a case that had retention of urine. A 3-inch incision was made above the pubes just to the left of the mid line, its exact situation depending upon whether the operation was to be done in one or two stages. In a one-stage operation the incision began over the pubes and extended upwards for 3 inches ; in the two-stage operation the incision began 1 inch nearer to the umbilicus, the reason for this being that when the second stage was done, sometimes weeks later, only a small sinus surrounded by scar tissue was left, and by incising directly downwards from the sinus to the pubes there was no fear of opening the peritoneum. It was found to be unnecessary to excise the scar tissue round the sinus as the wound healed perfectly without so doing. After the skin incision the anterior rectus sheath was incised just to the left of the mid line, the rectus drawn outwards, and the finger inserted in the lower end of the incision and the prevesical fat and peritoneum swept upwards with a swab and pushed out of the way under the upper end of the wound, being kept in place there by the swab. The bladder was thus exposed and two catgut slings inserted through a bloodless area, (122) 123 the bladder drawn up and opened sufficiently to admit one or two fingers, and the prostate enucleated in the usual way with either the forefinger or the fore and middle fingers of the right hand. The enucleation is made very much easier if the prostate is pushed up from the rectum by two fingers of the left hand. I have never found this lead to any sepsis, though if I have to insert the fingers of my left hand in the rectum I leave the assistant to close the wound. After the prostate has been separated, it is either withdrawn from the bladder whole or split up inside the bladder in two pieces if it is very large, a big opening in the bladder being thus avoided, because a small incision through the bladder wall promotes rapid closing. When the prostate has been removed the bladder is irrigated for two or three minutes with mercury oxycyanide at 120 degrees to check haemorrhage. A large tube f inch in diameter is inserted into the bladder and is so placed that it is about 1 inch off the base and is sutured to the skin to keep it in this position. The swab holding back the peritoneum is now removed. While the wound is being closed the irrigation with hot antiseptic fluid is continued through the large drainage tube. The catgut slings are tied together round the tube, and this is usually sufficient to close the opening in the bladder wall, but if it is not so, the bladder must be sutured snugly round the tube. A small tube is placed in the prevesical space behind the pubes and the wound closed, the rectus sheath by one or two interrupted catgut sutures and the skin with one or two salmon gut sutures. The irrigation is then stopped and the wound dressed. In the two-stage operation the first stage merely consists in the insertion of a de Pezzer self-retaining catheter to drain the bladder. The second stage only differs from the operation described above in that a scalpel is inserted through the sinus into the bladder and cuts down on to the pubes. The bladder is irrigated through the tube four hourly during the patient's waking hours for the first 24 hours if there is bleeding, otherwise only twice, and after that daily. The prevesical tube is removed after 48 hours, the large tube from the bladder on the fifth day. The daily irrigations are continued through the sinus until it is too small for the fluid to escape properly. Acid sodium phosphate and hexamine are continued as before operation and large quantities of bland fluid are given to drink. No Hamilton Irving apparatus is applied, but the wound is dressed with sterile gauze which is changed as soon as it is soaked through, and if the wound becomes at all sloughy it is filled with boracic crystals. It is not necessary to keep the patient in bed for more than a week, though as the patients are liable to be very wet with this method of dressing they are more comfortable if kept in bed until the sinus is healed. The patient usually passes urine normally from the tenth to the fifteenth day after operation ; if he has not done so by the twenty-first day a catheter is passed. This was only necessary on two occasions, and in each case a diaphragm had formed as mentioned above. The suprapubic sinus is usually closed not later than the end of the third week. There were no cases of abnormal haemorrhage. There were no cases of septic complications except one very mild case of epididymitis. Aftertreatment. The feature of this technique is the fact that a catheter is not passed from start to finish of the case, unless it is absolutely necessary by reason of retention of urine before operation or failure to pass urine by the twenty-first day after operation. Nor is a haemostatic bag inserted to check haemorrhage, but reliance is placed upon irrigation with hot antiseptic fluid. It seems from this series of cases that sepsis with its grave complications is due, not to the bruising resulting from the fingers in the rectum pushing up the prostate, but from the insertion into the bladder of foreign bodies, such as catheters and Pilcher's bags. It is true that this is only a small series, but, even so, the mortality of 1.6 is remarkably low, and the percentage of septic complications 1.6 is also far below that of any previous recorded series. Commentary. A series of 63 cases of suprapubic prostatectomy is recorded with a mortality of 1.6. The one fatal case died one month after operation from heart failure. Technique differs from that usually adopted in the fact that a catheter is never Summary. 124 passed either before or after operation unless absolutely necessary, and in a slight difference in the incision in a two-stage operation to avoid inadvertent opening of the peritoneum. There was only one mild case of epididymitis, and no other septic complications. It is considered probable that many cases of sepsis after operation are due to the passage or presence of a catheter. The low mortality obtained in this series was due to the absence of septic complications obtained by this technique. TRAUMA IN RELATION TO DISSEMINATED SCLEROSIS. By A. Turner, M.R.C.S., L.R.C.P., Senior Assistant Medical Officer, Fulham Hospital. The difficulties of diagnosis in the following case seem to merit description:— Miss F. A., aged 50 years, was admitted on 6.11.34 as a case of spinal concussion. History—She had fallen on her back on 3.11.34 in the street, having slipped on a steel road stud of a pedestrian crossing. She was positive that she had been quite well before this fall, also that she had not struck her head in falling. She was able to get up. and then made her way home with assistance. The next day she found she had lost power and feeling in her lower limbs. Her doctor duly sent her into hospital on 6.11.34 with the diagnosis of spinal concussion. On admission—She was a well-nourished healthy looking woman, intelligent, but rather deaf. Temperature 103°, which subsided to normal next day. On examination, the knee jerks were brisk, with a double Babinski and absent abdominal reflexes. There was fair range of movement of the lower limbs, but sensation to pin-prick and cotton wool were somewhat delayed; occasional incontinence of urine; no nystagmus or intention tremor, and the optic discs appeared normal. The cerebrospinal fluid was under increased tension but quite clear. Appearance: colourless, clear, waterlike. Protein: 40 mg. per 100 c.c. Globulin: no increase. Chlorides: 775 mg. per 100 c.c. Colloidal gold: 123431000. W.R. and K.R. both negative. The blood Wassermann reaction was also negative. By 14.11.34 there had developed a spastic paresis with loss of sensation up to an indefinite level—about D6 for pin-prick and about D8 for cotton-wool. Compression paraplegia following trauma appeared a probable diagnosis. As improvement was very slow a cistern puncture with injection of Lipiodol was done, but the X-ray showed no evidence of any obstruction. On 28.11.34 there appeared to be a general improvement all round, the sensory level to pin-prick having faded down to Dll/12. The double Babinski was still present. Signs of cystitis developed about 9.12.34 with a swinging temperature until death. On 12.12.34 there was practically no neurological change, and the general condition was stationary. The acute cystitis persisted. On 25.12.34 the patient suddenly collapsed and died. Post-mortem report on spinal cord—Areas of degeneration were found in: (1) anterior part of right centrum semi-ovale; (2) antero-lateral column in 5th cervical segment of spinal cord; (3) postero-lateral column in 5th thoracic segment; (4) lateral column in 9th thoracic segment; (5) both antero-medial columns and one lateral peripheral zone in 3rd lumbar segment. On other organs. (1) chronic cystitis; (2) purulent ascending pyelo-nephritis; (3) congestion and cloudy swelling of liver; (4) oedema and very slight acute inflammatory infiltration of spleen; (5) oedema of lung. I wish to express my thanks to Dr. C. D. Coyle, medical superintendent, for permission to publish this case and for his help and counsel; also to Dr. D. Brinton, consulting neurologist, for his most courteous assistance in a very baffling case. u25) THE INVESTIGATION OF ATMOSPHERIC POLLUTION. (* Summary of a Paper read at the Ninth International Congress of Pure and Applied Chemistry, Madrid, April, 1934.) By J. H. Coste, F.I.C., F.Inst.P., Member of the Atmospheric Pollution Research Committee of the Department of Scientific and Industrial Research; Chemist, London County Council. The products of the combustion of fuel and of industrial operations which constitute atmospheric pollution are emitted either as gases and vapours, which mix freely with the air, or as aggregates ranging in dimensions from condensation nuclei of diameters of the order of 4.5 X 10-6 cm. to particles of coke and ash which are so large as to fall to the ground near their source. Gases and vapours thus emitted become so diluted that the classic gas volumetric methods are useless, and ad hoc methods in which large volumes of air are brought in contact with suitable reagents are used. Trustworthy processes for carbon dioxide and monoxide, sulphur dioxide, oxides of nitrogen and the vapours of many organic substances are available. The finer dispersions of liquids and solids, which are kept in the air by Brownian movement, are difficult to capture. Methods based on thermal, electrical and mechanical separation, the effective masses of the particles often being increased by the adiabatic deposition of water, have proved useful. Filters have also given valuable results. Larger particles may be collected by allowing them to fall under the influence of gravity, on suitable surfaces. The amounts of impurity found may be expressed as the mass or volume in a specified volume of air, or as the quantity deposited on a specified area of land or of an absorbing surface. The relation between results expressed in these two ways is obscure, but each has its advantages, according to the object of the investigation. Organisation of general and special investigations and the treatment of results are discussed and actual results of investigations are given. * The full paper will appear in due course in the proceedings of the Congress. (126) INVESTIGATION AS TO POSSIBLE DANGER FROM INHALING PHOSGENE GAS THROUGH THE USE OF FIRE-EXTINGUISHERS OF THE CARBON-TETRACHLORIDE TYPE. By E. T. Shelbourn, F.I.C., Assistant Chemist, London County Council, and C. L. Bennett, B.Sc.(Lond.), A.I.C. The question of possible danger from inhaling phosgene gas through the use of fire-extinguishers of the carbon-tetrachloride type having been raised by the chief officer, London Fire Brigade, it was decided to make experiments with some halogen compounds, which may be or are used for the purpose of extinguishing fire. These were carbon-tetrachloride, pentachlorethane, methyl bromide, trichlorethylene, chloroform, and the liquid from a fire extinguisher (containing pentachlorethane and methyl bromide). These compounds were in turn subjected to the following treatment to simulate as far as possible what actually takes place in treating a fire, the products being examined for the presence of phosgene gas (COCl2) and the amount determined (а) when mixed with burning petrol, (b) when the vapour, mixed with air, was passed through a red-hot silica tube; (c) when passed through a heated iron tube; (d) when passed through a burning cigarette. It was found that in the first experiment the amount of phosgene produced ranged from 6 pts. per million in the case of chloroform to 14 pts. per million with pentachlorethane. This amount is not great, being considerably less than it is considered fatal to inhale. It is, however, conceivable that this amount might cause unpleasant symptoms. These conditions are similar to those which might occur in putting out a small petrol fire, except that if the fire were in the open, the amount of phosgene would be very considerably reduced, owing to rapid diffusion into the surrounding air. When however the vapours mixed with air came in contact with red hot silica (b), or hot iron (c), the results were very different, except that, in contact with hot silica, carbon tetrachloride gave only 5 pts. per million and pentachlorethane only 11 pts. per million of phosgene, whereas the other compounds gave amounts ranging from 136 pts. per million (methyl bromide) and 1,830 pts. per million (chloroform). The test with red-hot silica was intended to simulate what actually happens when the vapours come in contact with any hot material, other than metals, in an ordinary fire. In the final experiment (d), which was undertaken to prove how far it is possible to produce dangerous conditions due to the production of phosgene (as has been alleged) through smoking a cigarette in proximity with the vapour of these compounds, a concentration of 10 per cent, by volume of the vapour was used. In the first experiment using carbon tetrachloride, the vapour was passed through a glowing cigarette, but no trace of phosgene was found. Using trichlorethylene, however, and drawing two litres of vapour and air through the cigarette so that it was completely burned in five minutes, a very slight trace of phosgene was found amounting to not more than 5 pts. per million. It appears therefore improbable that any harmful effects due to phosgene would accrue from smoking in the vicinity of these vapours. In the case of the bromine compounds used in these experiments ((a), (b) and (c)), there was the formation of the bromine compound (COBr2) analogous to phosgene, which is very much less toxic than phosgene, and this rather suggests that it is safer to use fire extinguishers containing methyl bromide in all cases where the fire is in an enclosed space. In all the experiments, the method used for' the determination of phosgene gas was one that is specific for that compound. (127) ARTICLES PUBLISHED ELSEWHERE. Articles published elsewhere by members of the Council's medical and technical staff, include the following:— General Public Health. W. Allen Daley, M.D., B.S., B.Sc., M.R.C.P., D.P.H.: “Public agencies which exist for the prevention of disease.” Lancet, 9th and 16th June, 1934. W. Allen Daley, M.D., B.S.. B.Sc., M.R.C.P., D.P.H: “Problems in hospital administration arising out of the Local Government Act, 1929.” Proc. Roy. Society of Medicine, Vol. XXVII, p. 67. School Medical Service. F. C. Shrubsall, M.A., M.D., F.R.C.P., B.Ch.: "The value of the treatment of mental deficiency." Proc. Roy. Society of Medicine, Vol. XXVII, October, 1934. E. J. Boome. M.B., Ch.B., M.R.C.P., D.P.H.: "Some aspects of stammering." Mental Welfare, October, 1934. Bertram Samuel, L.D.S.: "Orthodontics and the elementary school child." Trans, of the Brit. Soc. for the Study of Orthodontics, 1933-34. Gerald Slot, M.D., B.S., M.R.C.P., D.P.H.: "Absenteeism in the physically defective child." Public Health, June, 1934. Arnold Sorsby, M.D., Ch.B., F.R.C.S.(Eng.).: "The pre-myopic state." Trans, of the Ophthal. Soc. of the United Kingdom, Vol. LIV. p. 459. Arnold Sorsby, M.D., Ch.B., F.R.C.S.(Eng.): "Anophthalmos." Brit. Jour, of Ophthal., Vol. XVIII, p. 469. Special Hospitals. J. P. Marsden, M.A., M.D., B.Ch., M.R.C.S.: "Acute perivascular myelinoglasis." Lancet, 1934, ii, p. 871. J. P. Marsden, M.A., M.D., B.Ch.. M.R.C.S.: and C. R. M. Greenfield, M.B., B.S., M.R.C.S.: "Inherited smallpox." Archives of Disease in Childhood, Vol. IX, No. 53. J. D. Rolleston, M.A., M.D., B.Ch., F.R.C.P.: "Discussion on the nervous complications of the acute fevers and exanthemata." Archives of Disease in Childhood, Vol. IX. No. 53, p. 1421. J. D. Rolleston, M.A., M.D., B.Ch., F.R.C.P.: "Venereal disease in literature." Brit. Jour, of Ven. Dis., Vol. X, p. 147. J. 1). Rolleston, M.A., M.D., B.Ch., F.R.C.P.: "Foreign appreciations of the London Congress." Nat. Temp. Quart, and Med. Rev., 1934, Vol. XII, p. 325. L. J. M. Laurent, M.B., B.S., M.R.C.S. : " Discussion on the nervous complications of the acute fevers and exanthemata." Proc. Roy. Society of Medicine, Vol. XXVII, p. 1433. J. M. H. MacLeod, M.A., M.D., C.M., F.R.C.P.: "Lupoid variety of cutaneous leishmaniasis." Jour, of Tropical Medicine and Hygiene, 1934, p. 358. J. Watt, M.A., M.D., D.P.H.: "Difficulties in the early diagnosis of pulmonary tuberculosis." Jour, of State Medicine., Vol. XLII, No. 5, p. 274. J. H. Fisher, M.B. : " Two cases of agranulocytic angina." Lancet, 1934, ii, p. 1217. T. H. Whittington, M.D., B.S., M.R.C.P.: "The nursing of eye cases with special reference to cataract cases and others operated on under local anaesthesia." Nursing Mirror, 2nd and 22nd January, 1934. J. G. Yates Bell, M.B., B.S., F.R.C.S.(Eng.): "The enlarged prostate: considerations for advising surgical treatment." Med. Press and Cir., 4th April, 1934. J. G. Yates Bell, M.B., B.S., F.R.C.S.(Eng.): "The after-treatment of the urological patient." Clinical Journal, June, 1934. J. G. Yates Bell, M.B., B.S., F.R.C.S. (Eng.): "Rare causes of frequency in the male." King's College Hosp. Gazette, Clinical Supplement, July, 1934. C. E. H. Anson, M.B., B.S., M.R.C.S.: "Sanocrvsin therapy: A survey of one hundred consecutive cases." Tubercle, June, 1934. C. E. H. Anson, M.B., B.S., M.R.C.S.: "A case of delayed pleural shock following an artificial pneumothorax refill and presenting some unusual features." Tubercle, April, 1934. Laboratory Services. R. F. L. Hewlett, M.R.C.S., L.R.C.P.: "Vaccine treatment." Med. Press and Cir., Feb., 1934. E. N. Allott, M.A., B.Sc., B.M.. B.Ch., M.R.C.P. : Third revised edition of Richter's Organic Chemistry, Vol. I. A. B. Bratton, D.S.O., M.C. M.A., M.B., M.R.C.S., L.R.C.P., and A. B. Field, B.A., M.B., B.Ch., M.R.C.S., L.R.C.P.: "A case of Simmond's disease." Lancet, 1934, ii, p. 806. W. G. Barnard, M.R.C.P, and W. M. Burbury, M.R.C.S., D.P.M., L.R.C.P.: ' Gangrene of the fingers and toes in a case of polyarteritis nodosa." Jour, of Path, and Bact., Vol. XXXIX. E. W. Todd, M.A., M.D., B.Ch.: "A comparative serological study of streptolysins derived from human and from animal infections, with notes on pneumococcal hæmolysin, tetanolysin and staphylococcus toxin. "Jour, of Path, and Bad., Vol. XXXVIII, p. 299. (128) 129 L. F. Hewitt, Ph.D., B.Sc., A.I.C.: "Chemistry of antibodies and serum proteins (I) Nitrogen distribution and amino acids, (II) Protein carbohydrate groups." Biochemical Journal, Vol. XXVIII, p. 2080. L. F. Hewitt, Ph.D., B.Sc., A.I.C.: "Note on the alleged reversal of the denaturation of serum- albumin." Biochemical Journal, Vol. XXVIII, p. 575. J. E. McCartney, D.Sc., M.D., and T. J. Mackie, M.D., D.P.H.: "An introduction to practical bacteriology." Fourth edition. E. M. Holmes, M.B., Ch.B.: "The value of culture in the solution of problems of tuberculosis." Jour, of Stale Medicine, Vol. XLII, No. 10. A. Beck, M.D. (Marburg) and F. Coste: "The streptococcal complement fixation reaction in rheumatic diseases.'' Brit. Jour, of Experimented Path., Vol. XVI, No. 1, p. 20. General Hospitals. Marv B. Walker, M.B., B.Ch., M.R.C.P.: "Treatment of myasthenia gravis with physostigmine." 'Lancet, 1934, i, p. 1200. J. C. Heather, M.B., B.S., M.R.C.S., L.R.C.P.: "Addison's disease associated with syphilis and fracture of the first lumbar vertebra." Proc. Roy. Society of Medicine, Vol. XXVII, p. 388. W. Gordon Sears, M.D., M.R.C.P.: "Addison's disease treated with common salt." Lancet. 1934, i, p. 950. W. Gordon Sears, M.D., M.R.C.P.: "Carcinoma of the lung." Clinical Journal, 1934, Vol. LXIII, p. 328. G. W. Theobald, M.D., F.R.C.S.(Edin.): "The alleged relation of hyperfunction of the posterior lobe of the hypophisis to eclampsia and the nephropathy of pregnancy." Clinical Science. 1934, i, p. 225. G. W. Theobald, M.D., F.R.C.S.(Edin.): "An account of obstetric methods at St. Mary Abbots hospital." British Medical Journal, 1934. ii, p. 850. G. W. Theobald, M.D., F.R.C.S.(Edin.): "The repetition of certain experiments on which Molitis and Pick base their water centre hypothesis and the effect of apparent nerve stimuli on water diuresis." Jour, of Physiology, Vol. LXXXI, p. 243. B. Barling, M.D., B.S., M.R.C.P., M.R.C.S.: "A summary of the modern methods of treatment of anaemia." Pharmaceutical Jour., Aug., 1934. Arnold Sorsby, M.D., Ch.B., F.R.C.S.(Eng.): "Three groups of unusual fundus lesions." Proc. Roy. Society of Medicine, Vol. XXVII, p. 694. Arnold Sorsby, M.D., Ch.B., F.R.C.S.(Eng.): "Retinal abiotrophy." Trans, of the Opthal. Soc. of the United Kingdom, Vol. LIV, p. 160. Arnold Sorsby, M.D., Ch.B., F.R.C.S.(Eng.): "The distrophies and degenerations of the macula." British Medical Journal, 1934, ii, p. 270. Arnold Sorsby, M.D., Ch.B., F.R.C.S.(Eng.) and T. R. Hill, M.D., B.S., M.R.C.P.: "Two groups of the Laurence Biedl syndrome." Proc. Roy. Society of Medicine, Vol. XXVII, p. 1613. Arnold Sorsby, M.D., Ch.B., F.R.C.S.(Eng.): and R. R. James, F.R.C.S.: "Richard Banister." Brit. Jour, of Ophthal., Vol. XVIII, p. 469. INDEX OF SUBJECTS page Abdomen, Prolonged retention of artery forceps in the 112 Abdominal actinomycosis 109 Adrenalectomy, Unilateral 116 Aneurysms, Subarachnoid haemorrhage due to ruptured congenital 101 Atmospheric pollution 126 Carcinoma 57, 62, 114 Cardiac rhythm in scarlet fever, Disorders of 20 Diabetic clinic: St. Peter's hospital 80 Diphtheria, The Drinker respirator in 24 Diphtheria, Vulvo-vaginal 34 Drinker respirator in diphtheria, empyema and pulmonary collapse, The 24 Empyema, The Drinker respirator in 24 Erythrocyte sedimentation rate in rheumatic children, The periodic investigation of the 38 Food poisoning caused by B. dysenteriae (Sonne) 8 Fractures, End results of 120 Fractures of the neck of the femur 117 Gastric lavage in tuberculous children 12 Goitre clinic: New End hospital 77 Gonococcal fixation test 43 Granulosa-cell carcinoma of ovary 114 Maternal deaths in the Council's hospitals 88 Meningococcal meningitis 36 Oleothorax 16 Ovary, Granulosa-cell carcinoma of 114 Pernicious anaemia unit: St. Mary, Islington, hospital 83 Phosgene gas, Danger from inhaling 127 Plastic surgery unit: Hammersmith and St. James'hospitals 75 Polyarteritis nodosa 107 Prostatectomy, Suprapubic 122 Puerperal fever unit: North-Western hospital 49 Pulmonary collapse, The Drinker respirator in 24 Purpura hæmorrhagica and scarlet fever 5 Radiotherapeutic clinic: Lambeth hospital 62 Radium centre for carcinoma of the uterus : Lambeth hospital 57 Rheumatic children, The periodic investigation of the erythrocyte sedimentation rate in 38 Scarlet fever, Disorders of cardiac rhythm in 20 Scarlet fever, Purpura hæmorrhagica and 5 Sclerosis, Trauma in relation to disseminated 125 Subarachnoid haemorrhage due to ruptured congenital aneurysms 101 Thoracic surgery units : St. Andrew's and St. James'hospitals 85 Trauma in relation to disseminated sclerosis 125 Tuberculous children, Gastric lavage in 12 Virilism: Unilateral adrenalectomy 116 Vulvo-vaginal diphtheria 34 (130) INDEX OF AUTHORS page Alston, J. M 8 Anson, C. E. H. 16 Barling, B. 83, 101, 107 Begg, Norman D. 24 Bennett, C. L 127 Berkeley, Sir Comyns 57 Berry, P. 62 Blake, J. C 36 Breen, G. E. 5 Brown, W. A. 5, 34 Coste, J. H 126 Davis, Hilda M. 49 Evans, Sir Thomas Carey 75 Fairfield, Letitia .88 Fish, R. H 12 Ford, R. Kelson 114 Gillies, James C.117 Hicks, J. A. Braxton 112 Joe, A 49 Linnell, J. W 85 page McCartney, J. E.34 Maccormac, W. L. 75, 86 McDade, R. S. C 38 Mitman, Maurice 24 Nelson, H. P 85 Ralston, W. 43 Robb, T. M 62 Shelbourn, E. T.127 Sinclair, Meurice 120 Stebbing, George F 62 Swindells, R. H. 77 Tree, J. R 8 Turner, A.125 Walker, Arnold 57 Waters, K. F. D 109, 122 Watson, A. J. 112 Whigham, J. R. M.116 Wyatt, J. M 49 Wybourn, J. T. 20 Young, B. A. 80 (131) London County Council ANNUAL REPORT OF THE COUNCIL, 1934 Vol. III (Part II) PUBLIC HEALTH (Report for the year 1934 of the School Medical Officer) Published by the LONDON COUNTY COUNCIL, and may be purchased, either directly or through any Bookseller, from P. S. KING AND SON, Limited, 14, Great Smith Street, Victoria Street, Westminster, S.W.I. Agents for the tale of the Publications of the London County Council. 1935. No. 3125. Price ls. 6d. London County Council ANNUAL REPORT OF THE COUNCIL, 1934 Vol. III (Part II) PUBLIC HEALTH (Report for the year 1934 of the School Medical Officer) CONTENTS page Staff 6 Co-ordination 7 School Hygiene 7 Results of Medical Inspection 9 Following-up 18 Medical and Dental Treatment 20 Stammering Children 32 Left-handedness in Children 32 Rheumatism Scheme 33 Personal Hygiene Scheme 37 Chronic Invalidity 38 Infectious Diseases in Schools 39 Open-air Education 49 School Journeys 53 Physical Education 53 Provision of Meals 54 Co-operation of Voluntary Bodies 61 Defective Children 62 Ponton Road Remand Home 71 Child Guidance 73 Nursery Schools 77 Medical Inspection and Treatment—Day Continuation Schools, Evening Institutes and Junior Instruction Centres 78 Medical Inspection at Secondary and Trade Schools 80 The Teaching of Hygiene 81 Special Inquiries and Reports 82 Wage-earning Employment of School Children 86 Examinations of Employees in the Education Service and Scholars 87 Statistical Tables.— I. Medical Inspections 91 II. Defects 92 III. Exceptional Children 94 IV. Treatment of Minor Ailments 95 V. Medical Inspection—Number of Children Examined 96 VI. Medical Treatment—Number of Cases Treated 96 VII. Medical Inspection of Students in Higher Education Institutions 97 Index 99 900 (MºC 11089-6) 27-6-35. . London County Council ANNUAL REPORT OF THE COUNCIL, 1934 VOL. III (Part II) REPORT OF THE SCHOOL MEDICAL OFFICER FOR THE YEAR 1934. By Sir Frederick Menzies, K.B.E., M.D., LL.D., F.R.C.P., F.R.S.E., County Medical Officer of Health and School Medical Officer. Introduction. The progress of the school medical service and the improvement in the condition of the school children of London during His Majesty's reign. In recording the work of the school medical service each year it is inevitable that comparison should be made with the past. As this report will appear during the Jubilee celebrations it is appropriate that a brief record should be made of the changes and improvements which have taken place in the health of the school children during His Majesty's reign. His Majesty has abundantly shown his concern and affection for the nation's children and in particular for the school children of London. One of the most unforgettable events in connection with the Coronation festivities was the fete on 30th June, 1911, at the Crystal Palace, where their Majesties entertained one hundred thousand children from the elementary schools of London. The children of those children are now in the schools. It is fitting to note that the organisation and growth of care for the children's health in the London schools are exactly contemporaneous with the reign. Preparatory work had been done throughout the previous reign, but it was not until the year of His Majesty's accession that the school medical service of London took shape, and the gradual growth began of facilities for attending to the children's health which, step by step, has produced such an improvement as the early pioneers of the work did not dream could be attained in their lifetime. It was not until His Majesty had ascended the throne that the first school treatment centre in London was opened in Hampstead in 1910. In 1911 provision existed (excluding dental treatment) for the treatment of 27,647 children. In 1934 there were 74 treatment centres and provision was made (again excepting dental treatment) for 167,910 children. In 1900 the School Board for London by special resolution put on record their grave concern that 96 per cent, of scholarship children were found with advanced dental decay. At that time nothing could be done about it, as there was no provision for dental treatment and no power to provide it. In 1910 the first dental centre was opened. Now, there is provision for the treatment of 150,000 children annually, and only 4 per cent, of the scholarship candidates are found with advanced dental decay. The growth in the provision for dental treatment is shown in the diagram (fig. 1) on page 23. In 1910 there were 68 school nurses. In 1920 these had increased to 285 in number and in 1934 to 380. The effect of the nurses' patient and unremitting work is shown in the improvement in the appearance and cleanliness of the children. In 1912, 39.5 per cent, of the children in the schools were infected by parasites, in 1920 this percentage was reduced to 13.8 and in 1934 to 4.5. Ringworm of the scalp, formerly one of the greatest scourges of school children, is now rarely found. In 1911 there were 6,214 new cases of this disease, in 1920 there were 3,983, but in 1934 only 265. In 1912 the proportion of children with subnormal nutrition in London was 12 8 per cent. By 1934 it had been reduced to 4.6 per cent. ; but these figures do not tell the whole story of improvement, for the children now returned as subnormal (5) 6 in nutrition are practically all slight cases, whereas formerly a large proportion were severe. It may help the reader to visualise the improvement which has taken place in this respect more accurately when it is pointed out that in the winter of 1909-10 the school doctor in a single school in Bethnal Green counted 91 children very seriously ill-nourished ; this number is more than three times as great as those found illnourished to the same degree in 1934 by all the school doctors in all the schools of London. A diagram (fig. 2) on page 26 shows the gradual reduction of the number of children with discharging ears. The early reports of the school medical inspectors showed that visual defect was serious, that its incidence was much heavier upon girls than upon boys and that it advanced very rapidly in girls during school life. With improvement in school hygiene, the vision of the children, particularly the girls, has greatly improved and the girls no longer suffer from worse vision than the boys. The percentage excess of defective vision in 12 year old girls over 12 year old boys was, in several years, as follows :— Percentage excess of defective vision Year. in girls. 1913 17.6 1918 11.0 1922 9.3 1927 5.3 1931 2.7 1933 0.0 1934 0.0 His Majesty's reign is distinguished from all those that went before by consideration for the health of the children. The above figures and facts serve merely to illustrate the great advance which has already been made. The school children, many of whom were formerly unhappy, ill-nourished, defective, unclean and prematurely old, have been replaced by a generation which approaches more nearly to the ideal of a population healthy, wholesome and full of the joy of living. The Shakespearean description is at last out of date : the schoolboy of to-day no longer whines, nor creeps like snail unwillingly to school. 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 and dental 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. R. H. Simpson) ; north (divisional medical officer, Dr. Margaret C. Hogarth) ; north-east (divisional medical officer, Dr. G. Chaikin); south-east (divisional medical officer, Dr. H. R. Kidner); south-west (divisional medical officer, Dr. E. J. Boome). The remaining staff in 7 this branch of the school medical work includes 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. Barbara Tchaykovsky) ; one divisional medical officer for ophthalmic work, nursery schools, etc. (Dr. Elizabeth M. McVail); *21 whole-time assistant medical officers ; 6 assistant medical officers giving six sessions a week ; 53 assistant medical officers giving three sessions a week ; additional temporary medical assistance for 123 sessions a week ; 9 medical officers (part-time) at open-air schools ; 68 parttime inspecting dental surgeons. There are 262 part-time doctors, surgeons and anaesthetists, and 99 part-time dental surgeons engaged at the hospitals and school treatment centres under the Council's scheme. These appointments are made by the authorities of the hospitals and treatment centres. 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 Home Office 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. J. M. Bickerton); two divisional medical officers (Drs. A. C. Williams and Jessie G. Duncan) and an assistant medical officer who is attached part time to Pontonroad remand home. The duties of consulting surgeon for aural disease in this section are rendered by Mr. A. G. Wells. The duties of Miss D. E. Bannon, matron-in-chief in the public health department, include the superintendence of the school nursing staff in addition to the supervision and organisation of the nursing and certain other staff at hospitals and institutions. The school nursing service comprises at present five assistant superintendents, 71 nursing sisters and 304 nurses. The loss during the year through retirement of Dr. A. W. Sikes, for many years divisional medical officer in the north-west division, and of Mr. Bishop Harman, consultant ophthalmological surgeon, is recorded with much regret. Particulars of Mr. Bishop Harman's work in connection with the formation of sight-saving classes will be found on page 69. Co-ordination. Arrangements for co-ordinating the work with that of the local sanitary authorities and with the hospital authorities of London were set out in detail in last year's report. The provision of milk to school children under the scheme of the Milk Marketing Board, which commenced on 1st October, 1934, necessitated further conference and combined action with the medical officers of health of the metropolitan borough authorities, who are jointly with the school medical officer responsible for the supervision of the quality of the supplies of milk and for the approval of the vendors (see p. 58). School hygiene. Very great improvements are taking place in the structural character of the school buildings, and many new amenities are being introduced with the object of rendering school conditions healthier and of keeping pace with advancing knowledge of hygiene. The provision of medical inspection rooms is being rapidly carried out in schools, both provided and non-provided, in which hitherto there have been no special facilities. The decision to introduce running hot water in children's lavatories, as well as in medical inspection rooms and teacher's rooms, is an important advance. Since 1925 the improvement of schools has been carried out in accordance with 3-year programmes. Two such programmes were carried through successfully, but the third programme, for the years 1930-33, was checked by the financial crisis of August, 1931. During 1934 a resumption of the three-year programme procedure was decided upon by the Council. * Two vacancies—also one medical officer temporarily seconded for work under the Mental Deficiency Acts and two for work under the Housing Acts (equivalent substitutes authorised). 8 On 30th October, 1934, the Council approved a new "standard planning" for elementary schools, in which great improvements are made in regard to hygiene. This standard will be used not only for new schools to be built but also in connection with the reconstruction and remodelling of those which are out of date. In addition to ten remodellings of schools included in the developments for 1934-35, the new programme includes, during 1935-38, the rebuilding or modernisation of 30 additional schools, 22 of which were built before 1880. Further, a new feature has been included in the programme, viz., for the reconditioning of premises and for pushing forward the provision of the conveniences and amenities included in the new standard planning by a systematic overhaul of schools in which rebuilding or remodelling is not necessary. It is the aim to make some approach in all schools to the level of the schools built on the new standard planning by providing medical inspection rooms, hot water systems for lavatories, provision for drying clothes in cloakrooms, indoor sanitary conveniences for babies, improved natural lighting, etc. The Council's scheme for the reduction of accommodation of classrooms to a maximum of 40 for older pupils and 48 for infants is almost complete, 99.6 per cent, of classrooms in provided schools and 94.5 per cent, of those in non-provided schools being now on this basis. While many of the advances in the standard planning are designed to improve educational facilities, some of these have important hygienic bearings and other advances are purely for hygienic reasons. The increased floor space to be provided in every type of department will give much healthier conditions and will diminish the risk of spread of contagious and infectious diseases. Under the new planning the floor space per child of classrooms in all departments will be increased by 8 or 9 per cent. Floor space in rooms for " under fives " will be increased by 25 per cent. A separate waiting room will be provided in connection with all medical inspection rooms ; some wash-basins will be provided near the water closets, thus giving opportunity for hygienic habits. In suitable cases a physical training room will be provided of 1,800 square feet floor space, and this will be provided with separate changing rooms and shower baths for girls and boys ; improvements will be made in the layout of playgrounds, increased area of playgrounds will be provided for infants (20 square feet per child instead of 16), and a separate playground of 800 square feet or more near the babies' room. Drinking water points will be provided on each floor. Increased space will be given in cloak rooms, giving 10 inch spacing of pegs in two rows, while a much needed improvement is introduced in the provision of drying facilities. The programme provides also for advances in equipment. It is proposed to supply a large number of tables and chairs in lieu of fixed dual desks. The table tops at present supplied measure 3 feet 5 inches by 1 foot 4 inches but it is hoped that, with the introduction of the new standard planning, it will be possible to supply larger tables. The heights ot tables and chairs at present authorised tor children aged 5 years and upwards are in 5 ranges as follows :— Table 1. Size No. Height of top of table from floor. Height of chair seat from floor. Suitable for children aged (approximately). 1 29 inches 17 ½ inches 12 years and upwards 2 27½ „ 16 „ 10-12 years 3 24½ „ 14 „ 8-10 „ 3a 22 „ 13 „ 7-8 „ 4 20 „ 12 „ 5-7 „ There are in addition smaller tables and chairs provided for babies' classes. 9 The results of medical inspection in 1934. The year showed great activity in medical inspection. The change in the statutory age groups to be examined foreshadowed in the last report took effect in Januarv. Age groups. In order to secure a better distribution over school life of the incidence of routine medical inspections, and to bring them into organic relation with the great periods of educational change under the Hadow reorganisation scheme, the examination at age 8 was altered to examination at age 7, and that at age 12 to examination at age 11. The routine groups to be examined thus became (i) on entrance, (ii) at age 7 (corresponding to the transference from infants' to junior departments), (iii) at age 11 (corresponding to the transference from junior to senior departments), and (iv) before leaving at approximately age 13 ½ As the sudden alteration from age 8 to age 7 would leave a group of children unexamined between entrance and age 11, in which case this group would have suffered unduly, it was decided that a " preliminary survey " should be made of the whole of the 8-year-old group during which vision testing, examination of the teeth and noting of any obvious defects would be carried out, while those children, who during the survey were considered to need detailed examination, were to be submitted to a complete examination in the usual way, after invitation to the parents to attend. Only after the completion of the 8-year-old group in this manner was the detailed examination of the new 7-year-old group to be begun. It was considered that the change over from age 8 to age 7 would take about five years. Much greater progress with the change over was effected than was anticipated, thanks to the energy which all concerned put into the work ; and, instead of only a fifth of the seven-year-old group coming under examination as was anticipated, well over a third were completed ; and this in spite of the fact that an abnormally large leaver group was due for examination and completed during the year. At this rate the change over should be completed within 3 years instead of the 5 years originally contemplated. In view of the special character of the examination of the 8-year-old-group, the results of their inspection will be separately treated in the following analysis of the results. In accordance with the precedent of previous years, the results of inspection of the leaver group will also be separately analysed. The number of elementary school children examined in the three statutory age groups (entrants, children aged 7 and children aged 11) during the year 1934 was 138,549. These were made up of 58,638 entrants, 26,359 children aged 7, and 53,552 children aged 11. The children aged 8 coming under preliminary survey by the school doctors was 47,001, of whom 3,739 were referred for detailed examination. In addition, 63,633 children were examined in detail in the term prior to that in which they were due to leave school, and 1,598 children in special schools were examined on reaching their respective age groups. The leaver group was by far the largest age group of children inspected during recent years, being 7,000 more than in 1933, itself a heavy year. In addition to routine groups, children referred by nurses, school teachers, care committee workers, divisional officers, etc., for examination for special reasons numbered 91,880; and 44,197 were examined in connection with outbreaks of infectious disease. The total inspections amounted to 386,858, which represents an increase on the numbers in the previous year, namely 377,167. To this must be added the children, 146,620 in number, who were re-inspected because of some previously noted defect. As inspections of all kinds and re-inspections totalled no less than 533,478 it is clear that, although some duplicate inspections are included, very few indeed of 10 the children in school escaped coming under the eye of the doctor in some way or another during the course of the year. Parents are invited to be present at all routine inspections, and attended in 77.6 per cent, of the examinations in the three statutory age groups compared with 74.1 per cent, in 1933 and 68.5 per cent, in 1932. At the inspection of entrants, the proportion was 91 per cent., and in the " leaver " group 42 per cent. It is most satisfactory to be able to note each year a very distinct advance in the interest of the parents in the inspections. The presence of the parent has a very considerable effect, and relieves very greatly the task of following-up, as it eliminates the necessity for home visiting and correspondence. Refusals. Refusals of parents to submit children for medical inspection are so few in number as to be almost negligible. During the year 1934, the parents of 65 children (31 boys, 34 girls), compared with 89 in 1933, refused to allow them to be examined by one of the Council's assistant medical officers. Nine objections were subsequently withdrawn, and in 10 instances either medical record cards were completed by a private medical practitioner or medical certificates as to physical fitness were produced. The cases were distributed amongst the divisions as follows : N., 4 ; N.E., 9 ; N.W., 17 ; S.E., 11 ; S.W., 24. Thus not only do parents attend the inspections in greater numbers each year, but refusals to allow inspection dwindle each year. The number of children subjected to routine inspection in the three statutory age groups who were referred for treatment was 58,521, 42.3 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 15.5, compared with 16 - 7 in the previous year, and 17.5 in 1932. This quite considerable drop shows the healthy conditions which prevailed in 1934. Each age group has its own peculiar constitution, by which liability to different ills varies from age to age. The change in age groups inspected makes less certain the comparisons hitherto possible from year to year over the whole length of time, now twenty-four years, during which inspections have been carried out in the three groups—entrants, children aged 8 and children aged 12. The smaller number of children in the 7-year group submitted to inspection also makes less valid the combined figures for all the age groups, as they are underweighted in respect to this age group, which normally is specially productive of certain types of defect. The state of nutrition of the children. Unremitting attention has been given to the state of nutrition of the children in school. Acute anxiety lest the children should suffer has been the key note of the past three years. In the words of The Lancet, " the fear of underfeeding its children is haunting the conscience of the nation." By precept and instruction the question has been kept continually before the school doctors. It is therefore satisfactory to note that there has been no decline in the nutritional state of the children attending elementary schools in London. The Board of Education syllabus provides for every child to be marked during routine inspection as " 1," "2," "3" or "4" ; 1 being exceedingly good nutrition, 2 normal, 3 subnormal, and 4 definite pathological malnutrition. Complete surveys by the school doctors exist for about a quarter of a million children examined each year since 1912. In that year the number returned in classes 3 and 4 taken together formed 12.8 per cent, of the total examined. This proportion was gradually reduced until in 1930 the proportion was 4.8 per cent., and in 1931 this proportion remained unchanged. In 1932 there was a very slight setback to 4.9 per cent., the result mainly of an increase in ill-nourishment in the entrants who had just been through a very severe epidemic of measles. In 1933 the proportion of poorly nourished children was 4.7 per cent and in 1934 the proportion is 4.6 per cent., which is the lowest figure ever attained in London. 11 The figures in detail for each sex in each statutory age group are given in the following table:— Table 2. Nutrition subnormal—Percentage of children examined. Age group. 1920. 1925. 1926. 1927. 1928. 1929. 1930. 1931. 1932. 1933. 1934 Entrant boys 6.4 5.7 5.7 5.0 5.0 4.6 4.4 4.4 5.1 4.4 4.4 „ girls 5.9 5.0 4.8 4.0 4.1 4.0 3.5 3.6 3.8 3.8 3.8 Eight-year-old boys 9.0 8.5 8.2 7.3 6.7 6.7 6.3 6.6 6.3 6.4 *7.1 „ girls 7.8 7.2 6.6 6.1 5.2 5.2 5.1 5.0 5.0 5.0 *4.6 Twelve-year old boys 6.3 6.5 6.7 5.4 5.3 6.0 5.1 5.2 5.0 4.8 †5.0 „ girls 5.6 6.3 6.3 4.8 4.4 4.9 4.5 4.2 4.3 4.2 †4.1 All above age groups 6.7 6.3 6.2 5.3 5.1 5.2 4.8 4.8 4.9 4.7 4.6 * 7.year-old children. † 11-year-old children. The number of children found in category 4, i.e., definitely malnourished, was again insignificant, viz., 21 out of 138,549 examined. What is most to be remarked about the above figures is the steadiness maintained age by age in each of the six groups, and sex by sex, during the five years 1930 to 1934. Too much attention must not be paid to minute variations of a decimal point in the totals, as a preponderance of numbers of one particular age group in which subnutrition is relatively high would affect the total without reflecting any change in the nutritional state of the children. The 7-year-old children inspected in 1934 formed a small group, and subnutrition at this age amongst boys is constantly more apparent than in the other groups ; the total result of 4.6 per cent. is thereby affected and the small diminution in the amount of subnutrition found is therefore not a real one. Dr. Alison Glover has pointed out that there seem to be " crises " of nutritional state at certain ages. It will be noticed that this is shown constantly in the London figures for the boys of the 8-year-old group, and it is more marked than usual in the 7-year-old boys examined during the past year. The seventh and eighth years appears to be critical ages for boys from this point of view. At all the age periods boys show a greater amount of subnutrition than girls, but this is intensified at the ages seven and eight. This is manifest not only in the figures but also is apparent when the children are surveyed en masse in the schools. A special report by Dr. Neustatter, which was the result of attention being drawn to the poor appearance of the junior boys in a Bermondsey school, bears this out. It seems that the superior sex is more sedate, serene and sedentary than their brothers at this age, while the latter engage in a feverish activity which overtaxes their immature strength and takes toll of their nutritional state. The boys lose their infantile chubbiness and overdo it. Taken as a whole the figures for nutrition are reassuring, and give no cause for anxiety with regard to the condition of the school children of London ; on the other hand it is disquieting to find amongst its entrant infants an increase in the number of those with rickets, which up to this year had shown a steady decline. The percentage of children found free from even traces of nits or pediculi in Cleanliness, the hair was 96.5 compared with 96.2 in the previous year. This is the best result ever obtained. 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 was still further improved in 1932, when the high level of 95.8 per cent. was obtained. 12 Unfortunately the percentage in this group, which has always been chosen as the index group, fell back one unit in 1933 to 94.8, a disappointing result when the condition of the other groups was better in this respect than ever before. The reason why the 12-year-old girls were chosen as an index is that they have always given the worst result of all the groups, for mothers expect the older girls to look after their personal cleanliness themselves. In the year 1934 the percentage of 11-year-old girls entirely free from vermin is 94.8, being exactly the same as that of the 12-year-old girls in the previous year. It must be remembered that the parents are warned of the medical inspections upon which these figures are based, and the children appear spick and span for the occasion. The figures given in these results are therefore better than would be the case at surprise inspections, such as those carried out by the nurses in their rota visits to the schools. It is now very 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. Only 65 children were found in the age groups to be affected by body vermin in 1934, or less than one in 2,300. The remarkable progress since the inauguration of the school medical service 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. Clothing and footwear. When the children are undressed by the nurse preparatory to the medical inspection, she enters on the medical record card a note of the condition of the clothing and footwear. At a time of stress it is likely in most instances that the first sign of struggle will be a deterioration in clothing rather than in nutrition. In the following table the figures for 1934 are compared with those for 1921 :— Table 3 Age group. 1921. 1934. Good. Fair. Bad. Good. Fair. Bad. Entrant boys 62.3 35.9 1.8 52.7 46.7 0.6 „ girls 62.7 35.8 1.5 54.7 44.7 0.6 Eight-year-old boys 58.6 38.5 2.9 *53.0 *46.1 *0.9 „ girls 58.9 39.1 2.0 *54.9 *44.4 *0.7 Twelve-year-old boys 54.4 41.9 3.7 †53.7 †45.6 †0.7 „ girls 57.6 40.7 1.7 †55.3 †44.3 †0.4 * 7.year-old children. † 11.year-old children. It is found that while bad clothing and footwear are distinctly less frequent than formerly there has been a transfer from the "good" column to the "fair" column of from one to eight per cent. The indications from this survey are that while indigence and neglect have been alleviated things are "tighter" amongst those above the poverty line, and that clothing has suffered to some extent in order to provide sufficient food. Dental decay. Following upon the smaller numbers of children reported as treated for dental defect in 1933, the proportion of children found during 1934 in a satisfactory dental condition has declined, being 65.7 compared with 67.4 per cent. in 1933 and 1932 respectively, but is still better than that for former years, e.g., 64.4 per cent. in 1931, and 62.9 per cent. in 1930. 13 Details are set out below:— Table 4. Age group. 1924. 1927. 1930. 1933. 1934. 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 56.1 11.6 54.3 11.3 „ girls 58.4 12.4 50.7 15.2 52.2 14.9 55.3 11.7 54.3 11.4 8-year-old boys 58.5 10.0 61.1 8.1 66.7 6.8 70.7 4.5 *68.7 *5.0 „ girls 58.0 10.2 60.9 8.3 65.4 6.8 69.9 4.4 *67.6 *5.5 12-year-old boys 68.0 3.4 70.6 2.7 73.1 2.1 75.8 1.3 †75.9 †1.5 „ girls 70.5 2.6 72.3 2.3 75.3 1.6 77.0 1.1 †77.9 †l.2 All above age groups 62.1 8.5 60.3 9.3 62.9 8.6 67.4 5.8 65.7 6.3 * 7.year-old children. † 11.year-old children. N.B.—Serious decay means four or more carious teeth requiring treatment. It will be seen that the condition of the teeth of the 11-year-old children examined in 1934 does not differ very appreciably from that of the 12-year-old children examined in 1933, and that the 7-year-old children of 1934 are distinctly worse than the 8-year-old group of 1933, while the entrants of 1934 have smaller percentages with sound teeth than those of 1933. The halt in progress and, worse, the definite regression in the condition of the teeth is the one great blot which the returns show in 1934. It will be noted, however, that it is the younger children who are chiefly concerned, and that the older children who have longer been under the influence of school conditions and have had the benefit of school dentistry do not reveal the same falling away. The revelation last year of the setback in the numbers of children attending for treatment at the dental centres acted as a whip to those engaged in propaganda work and following-up, and the treatment results given on a later page show an improvement during 1934, which cannot fail to produce better results in the condition of the teeth as found at routine inspections. Each year children other than entrant infants have their visual acuity tested by means of the Snellen cards, those whose defects have been corrected having their vision tested wearing their glasses. The entrants of course cannot be tested as they do not know their letters. It was one of the reasons for ante-dating the inspection of the second group, that school children generally would have their first vision test a year earlier—at seven instead of eight. It is interesting therefore to compare the results of the 7-year test with those of the 8-year-old children inspected last year. In the 7-year-old boys inspected during 1934, 40.1 per cent. failed to reach normal vision, while in 1933, 39.7 of the 8-year-old boys failed; amongst the 7-year-old girls in 1934, 40.5 per cent. failed compared with 40.4 per cent. of the 8-year-old girls in 1933. The close approximation between these results is remarkable. It was feared that possibly a worse result might have been attained amongst the 7-year-old children owing to greater unfamiliarity with the letters, and that some allowance would have to be made for this. It appears now, however, that the 7-year-old test of vision is quite reliable. The earlier correction of defects resulting from the change should make an appreciable difference later. Amongst the 11-year-old group in 1934, 33.9 per cent. of the boys and 35.4 per cent. of the girls failed to pass the normal vision test, while in 1933 in the 12-year-old group 35.9 per cent. boys and 37.5 per cent. girls were unable to do so. There has been in recent years a considerable improvement in the numbers of children reaching normal vision, and a tendency for the visual acuity of the girls, which was formerly far worse, to approximate more closely to that of the boys. B Vision. 14 Defects of a more serious character (i.e., vision of 6-12 or worse in either eye) occurred in 12.9 per cent. of 7-year-old boys and 12.4 per cent. of 7-year-old girls, and in 16.1 per cent. of both 11-year-old boys and girls in 1934. In 1933 more serious defects occurred in 14.7 per cent. boys and 14.4 per cent. girls in the 8-year-old group and 17.7 per cent. boys and 17.4 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 defects, 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 18.5. The improvement is most marked among the older girls, and there is little doubt that the importance of the early correction of visual defect is becoming more widely recognised among the parents. The lower proportion of 7-year-old boys and girls with serious defects suggests that a saving in deterioration of vision will result through the earlier examination now carried out. The exact equality in 1934 of the sexes at eleven years in regard to more serious defects is a noteworthy feature. Hitherto all examinations of the older children in the schools have shown a preponderance of vision defects in girls over boys. The figures this year suggest that the relative increase in girls takes place after eleven years of age. The decrease in the preponderance of visual defects amongst the older girls is a testimony to the efficacy of the measures taken by the education authority to ensure better lighting in the classrooms and to prohibit sewing by artificial light. Enlarged tonsils and adenoid growths. In the statutory age groups 6,297 children were referred for some form of treatment of enlarged tonsils or adenoid growths; this is 4.5 per cent. of the children examined, compared with 4.1 per cent. in 1933, 6.6 per cent. in 1931, 6.7 per cent. in 1930, and 7 per cent. 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 in the individual age groups in 1934 were : entrant boys 7.8, girls 7.0; 7-year-old boys 4.0, girls 4.3; 11-year boys 1.3, girls 1.8. There has been a continued fall in recent years in the percentage of children referred for treatment for enlarged tonsils and adenoid growths, the increase in 1934 being due to the alteration in the age of the children examined. The older the children the fewer there are that suffer from ear, nose and throat defects. The proportion of those recorded as having enlarged tonsils and adenoid growths who were referred for treatment was 38 per cent., the same proportion as in 1933, compared with 43 per cent. in 1932. Of the 6,297 children referred for treatment for these defects, 4,252 were referred for enlarged tonsils only, 507 for adenoids growths only, and 1,538 for both enlarged tonsils and adenoid growths. Otorrhœa and hardness of hearing. Otorrhœa was noted in 1,187 children, or .9 per cent. of those examined, compared with .8 per cent. in 1933 and in 1932, and 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; in 1927 the percentage was 1.3, and in 1913 it was over 2 per cent. The increase by one in a thousand shown in 1934 is also due to the alteration in the age groups examined, as this defect is most prevalent amongst entrant infants and diminishes during school life year by year. Hardness of hearing was found in 221 children, or only .2 per cent. of those examined. This compares favourably with 383 in 1933, 453 in 1930, and 868 in 1927, and again equals the best result yet obtained. 15 Mention is made in another part of this report (page 29) of the use of the audiometer, which brings to light many minor degrees of hardness of hearing and cases of unilateral deafness, which, while not interfering with education, are sometimes the indication for active preventive treatment. Heart defect (functional or organic) was reported in 2,570 children or 1.9 per cent., the same percentage as in 1933 and 1932, compared with 1.8 per cent. in 1931, and 2 per cent. in 1930. As usual, older girls presented a percentage (2.2) in excess of older boys (1.7). 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 in the female sex. Anæmia was found in 1,336 cases, or 1.0 per cent., compared with .9 per cent. in 1933, an improvement upon the years 1931 and 1932, when the percentage was 1.1 and upon 1930, with 1.2 per cent. Heart and anæmia. Lung defects were noted in 3,013 children (2.2 per cent.), compared with 2.0 per cent. last year. The increase of .2 per cent. is due to the preponderence of entrant infants in the numbers examined this year in consequence of the small numbers of 7-year-old children examined, and is not a true increase. There is always amongst the entrant infants a certain amount of bronchitis found to be associated with errors in feeding. The 7-vear-old children were in fact better than the 8-year-old children in 1933. Lung defects. The bulk of the cases are provided by the entrants (3.9 per cent. boys and 3.4 per cent. girls). 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. There were 60 children in the three age groups reported to have symptoms indicative of pulmonary tuberculosis, but only 6 of these were not already under treatment. In addition, 24 children had other forms of tuberculosis. The incidence of tuberculosis in any form found at routine inspections is .6 per thousand. For many years the amount of tuberculosis amongst school children has been very small. Tuberculosis. Epilepsy was noted in 36 cases, compared with 61 in 1933, 52 in 1932, 65 in 1931, 60 in 1930 and 73 in 1929 ; chorea in 95 cases, compared with 132 in 1933, 158 in 1932, 170 in 1931, 186 in 1930 and 178 in 1929; paralysis in 55 children, compared with 56 in 1933, 63 in 1932, 81 in 1931, 76 in 1930 and 122 in 1929. Nervous diseases. Symptoms of rickets or the effects of early rickets were noted in 683 children. This is .5 per cent., compared with .3 per cent. in 1932, and .4 per cent. in 1931 and 1930. Infant boys had an incidence of 1.0 per cent., compared with .7 per cent. in 1933, .9 per cent. in 1932, and infant girls .5 per cent., compared with .3 per cent. in 1933, ana .4 per cent. in 1932. The stigmata of early rickets tend to disappear as growth proceeds. It appears therefore that there has been an increase in rickets, which is a nutritional disease, amongst children below school age. Rickets. Spinal curvature accounted for 527 cases (.4 per cent.), the same proportion as last year. Of these 222 (.8 per cent. of those examined) were among the 11-yearold girls, while the 11-year-old boys showed .5 per cent. Other deformities, mainly flat foot were present in 1,449 children (1.0 per cent.). This is an increase of .1 per cent. on 1933. Deformities. For the reason mentioned earlier it was decided that the 8-year-old group should, during 1934, be dealt with by means of a "preliminary survey" in which the school doctors would rapidly see all the children individually without undressing them, would note the obvious defects and refer for detailed examination in the presence of their parents any children who appeared during the preliminary survey to need this procedure. There were 47,001 children in the group (23,234 boys and 23,767 girls). Of these 3,739 (1,781 boys and 1,958 girls) or 7.95 per cent. were referred for detailed examination. The 8-year group. 16 Naturally those referred for detailed examination produced a higher proportion of defects than a normal age group, as they were specially selected cases. For instance, of the specially referred boys 12.4 per cent. were found to have enlarged tonsils and adenoid growths, whereas in the whole 8-year group in 1933, 8.4 per cent. of boys were so found. Of the referred children (boys and girls) 4 per cent. had heart disease, compared with 1.8 per cent. in the 8-year group in 1933. But if the children found defective are related to the whole group from which they were derived, it will be seen that this method is not to be compared in efficiency with the normal complete medical examination usually carried out. Of the whole group, enlarged tonsils and adenoid growths were recorded in 3.8 per cent. of the boys compared with 8.4 per cent. of the 8-year boys in 1933, while heart disease in the whole group (boys and girls) was found in .5 per cent. compared with 1.8 per cent. in the 8-year group in 1933. It is clear therefore that, as similar figures are reported for every ailment charted, large numbers of defects were not discovered, particularly those which are slight and in their early stages, when it is so important to discover them, for the service is primarily a preventive one. It is well to put this apparent failure to discover the whole of the defects in this group on record. In times of national stress and difficulty it is often proposed that medical examinations should be curtailed or carried out in some more cursory way such as this. It is even sometimes suggested that it would be sufficient for the teachers to bring before the medical officer such children as they note to be ailing. The experience with the shortened method of inspection which has been employed in the past year confirms previous experiences of the same kind, and proves that it is impossible, if proper service is to be given and justice done to the children, to substitute superficial inspection for the detailed examination of every individual child. One of the most important reasons for not missing out the children born in 1926 was the fact that they would have had no investigation of their visual acuity until reaching the age of eleven. All the children were tested in the usual way and referred for treatment if defective. For this purpose the preliminary examination was quite effective, as 8.5 per cent. of the children in the group were referred for refraction. As the figure for the detailed examination of the 8-year-old group in 1933 was 8.3 per cent., it is clear that in 1934 no 8-year-old child failed to receive the usual attention in regard to visual acuity. Special examinations. The number of children, not m the age groups for routine examinations, submitted to the school doctors as special cases was 91,880, an increase of 6,520 over that for the previous year, and this figure does not include another 44,917 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 the number seen in the routine age groups, yet in the case of many diseases the actual numbers found to be suffering thereform in the former generally exceed those in the latter. Thus 1,865 children with scabies were referred for treatment at special inspections, compared with 91 only at routine inspections. Heart trouble requiring treatment was detected in 282 children at special inspections, compared with 271 at routine inspections. In regard to epileptics 82 first came to notice at special inspections, compared with 39 at routine inspections, and 297 children with chorea were seen at special inspections, compared with 101 at routine examinations. This is evidence that considerable advantage is being taken of the doctors' visits to the schools to present to them promptly really ailing children. The health of the leaving child. The Council has undertaken the examination of a fourth age group, namely, children who are leaving school. This examination takes place in the term prior to that in which the children are due to leave school. The results of this examination are available at the school-leaving conference, and are of assistance in determining the choice of a suitable occupation. Coming at the end of the school career, the examination is useful in estimating the results of medical attention received since the children entered school. This year's "leaver" group was formed of the children born in the year 1920-21 and consequently the numbers are again, in consequence of the high birth-rate at 17 that time, larger than in the previous year. They comprised 31,801 boys and 31,832 girls. In nutrition they were found to be better than the younger groups, only 3.5 per cent. of the boys and 3 per cent. girls being classed as subnormal. They compared with 3.7 per cent. boys, and 2.7 per cent. girls in the previous year. In personal cleanliness this group also shows an improvement on the 12-year-old group, 98.7 per cent. boys and 96.6 per cent. girls having perfectly clean heads. The dental condition of this group was found to be slightly inferior to that of the 12-yearold group, for both boys and girls, the percentage with satisfactory mouths being 75.1 in the case of boys, and 75.8 in the case of girls, compared with 75.9 and 77.9 respectively in the 11-year-old group. In other respects the "leaver" children showed an improvement in health over the 11-year-old group. Spinal curvature in the "leaver" girls was reported in .8 per cent. of the cases, identical with the percentage at age 11; on the other hand, heart defect in the " leaver " girl was 2.1 per cent., compared with 2.2 in the 11-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 in all cases to the children aged 12 and 13 years, but ceases at the age of eleven in many schools. This should be remedied by the increased dental inspections which are to be carried out under the 3-year programme shortly commencing. The reorganisation of the tops of schools has also caused some difficulty in the way of following up the older children. 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 doctors' observation of the percentage of children having vaccinal scars: entrants, 45.9; 7-year-olds, 50.4; 11-year-olds, 55.1; and "leavers" (13½), 52; compared with, in 1933, entrants, 46.6; 8-year-olds, 49.3; 12-year-olds, 50.7; and "leavers" (13½) 55.1. 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. Vaccination. In 1934 a condition was noted chiefly in the north-eastern division which was apparently epidemic amongst the children in some schools. It had never previously come under the notice of the school medical service of London. It consisted in painful warts on the soles of the feet. Dr. Chaikin, the divisional medical officer, followed up the cases and has written the account which follows:— It was reported from a school in this division that there were several children suffering from warts of a painful nature, on the feet, and that one of these children and others were under the care of the local foot hospital. Four children were found at this school, two of whom were attending the foot hospital, one, the London hospital, and one not under treatment. Twelve others were, also, on the books of the hospital, but only five could be traced to Council schools. All were examined by Dr. G. W. Bamber, who diagnosed the condition as plantar warts. The Council's consultant dermatologist was consulted and X-ray treatment was recommended. The local foot hospital authorities were agreeable to this, and arrangements were made for treatment at the London hospital of those whose parents were willing, subject to the form of treatment being decided by the physician of the skin department of that hospital. It was ascertained that each child at the school, who went to swim, had a separate towel. The children atfected discontinued attendance at the swimming lesson. The view of the Council's consultant dermatologist on the subject was as follows : " All three common varieties of warts, namely, juvenile flat-warts, ordinary warts, and plantar warts, are contagious and auto-inoculable, but not every individual is susceptible to them. Since the classical experiments of Wile and Kinger, in 1921, it has been generally accepted that all warts are due to a filter-passing virus. Whether or not the viruses of plantar warts and ordinary warts of the hand are identical, has yet to be decided. Plantar warts occur at all ages, and in epidemic form, in schools. It seems to me most probable that the virus is locally inoculated in walking on an infected cork or wooden grid in the bathroom. "With regard to prevention, it is important that children should not run about wards or bathrooms with bare feet, and after the bath it is better that they should stand on a concrete floor than on a wooden grid or cork mat. The ideal is for each child to have its own towel to stand on. If there are cases in an institution, it would be well for the feet of the children using the same bathroom to be sponged with methylated spirit after the bath. It is advisable, also, to have the shoes swabbed out occasionally with a 1 in 40 lysol solution. Plantar warts. 18 "At Goldie Leigh hospital all cases of plantar warts are treated by X-rays, a pastille dose and a half is given, the skin around the warts being completely screened. If that is not sufficient, a second dose is given after the lapse of a month. Other effective treatments are the actual cautery and surgical removal after freezing with carbon dioxide. If the warts are very superficial they can sometimes be got rid of by the continuous application of 30 per cent. salicylic plaster. At Goldie Leigh hospital there are generally a few cases, but there has never been any serious epidemic. "It is a curious fact, connected with all warts, that certain drugs, such as green iodide of mercury, and large doses of magnesium sulphate, may cause them to disappear. The explanation of this is a problem which must be left to the biochemist, in the same way as the explanation why warts not infrequently disappear, apparently spontaneously." The medical officer of the borough in which the school was situated from which the cases were reported was informed with regard to the question of swimming baths, and he wrote to the school medical officer that the floors of the dressing boxes of the baths are all tiled and are flushed after each occupation, and no grids or mats of any kind are used in the baths. The bath surrounds, which are tiled and sloping about one inch in three feet, are frequently flushed and the drains are treated with izal. Periodically the bath surrounds are, also, treated with chloros. The foot bath accommodation is ample and carbolic soap is provided for use by bathers and all towels issued to bathers are boiled. All the cases in the above-mentioned outbreak cleared up after treatment. The probable average duration was 8 months, and the duration of treatment before cure months. A further recent case has arisen in the same school, and a number of scattered cases have been reported from other schools including one secondary school. It is remarkable that all the cases reported have been girls, and that all were regular visitors to public swimming baths. 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 1934, 138,654 children were re-inspected, a decrease of 23,496 on the number for 1933. At the first re-inspection 89,869 cases of defects requiring treatment (some children having more than one defect) were reviewed. At the second re-inspection 48,785 cases not cleared up at a first re-inspection were again reviewed. By combining the results of both reinspections it is found that 75.1 per cent. of the children re-inspected were treated or discharged as no longer requiring treatment. This figure is not in gross so good as that of the previous years. In 1933 the figure was 82.2 per cent. It is the dental cases, however, which during the past year contributed more than one half of the cases to be followed-up, that cause the most difficulty and give the worst results. If these be eliminated the cases of defect satisfactorily dealt with at the time of the second re-inspection reached the proportion of 84.8 per cent. Table 5 First Re-inspections, 1934. (Percentages are given in italic type.) Defect treated. No. of cases. Treated. Untreated. By private doctor. Under Council's scheme. At other hospitals. Discharg'd Improved. For observation only. Still needing treatment. Discharg'd Not discharg'd Discharg'd Not charg'd Discharg'd Not discharg'd Refraction 17,334 148 81 4,443 2,043 523 359 1,491 3,482 4,764 .8 .5 25.6 11.8 3.0 2.1 8.6 20.1 27.5 Minor ailments 5,599 118 21 1,067 295 322 129 1,568 929 1,150 2.1 .4 19.0 5.3 5.8 2.3 28.0 16.6 20.5 Nose and throat 10,880 34 11 3,260 152 574 92 1,516 1,774 3,467 .3 .1 30.0 1.4 5.3 .8 13.9 16.3 31.9 Teeth 46,575 1,287 303 17,830 805 1,595 130 3,567 1,030 20,028 2.8 .6 38.3 1.7 3.4 .3 7.7 2.2 43.0 Other ailments 9,481 177 68 597 586 771 648 2,171 3,070 1,393 1.9 .7 6.3 6.2 8.1 6.8 22.9 32.4 14.7 Total 89,869 1,764 484 27,197 3,881 3,785 1,358 10,313 10,285 30,802 2.0 .5 30.3 4.3 4.2 1.5 11.5 11.4 34.3 19 Second Re-inspections, 1934. Refraction 11,697 46 22 2,220 1,263 275 199 1,224 2,857 3,591 .4 .2 19.0 10.8 2.4 1.7 10.4 24.4 30.7 Minor ailments 2,797 46 19 376 214 129 96 774 661 482 1.6 .7 13.4 7.7 4.6 3.4 27.7 23.7 17.2 Nose and throat 6,282 11 7 1,269 93 336 51 1,212 1,168 2,135 .2 .1 20.2 1.5 5.3 .8 19.3 18.6 34.0 Teeth 21,266 621 156 6,468 348 642 71 2,403 630 9,927 2.9 .7 30.4 1.7 3.0 .3 11.3 3.0 46.7 Other ailments 6,743 110 36 496 494 421 384 1,566 2,090 1,146 1.6 .5 7.4 7.3 6.2 5.7 23.3 31.0 17.0 Total 48,785 834 240 10,829 2,412 1,803 801 7,179 7,406 17,281 1.7 .5 22.2 4.9 3.7 1.6 14.7 15.2 35.5 The following-up of children found to be in need of treatment or special observation is carried out by the school care organisation, consisting of upwards of 5,000 voluntary workers aided and supervised by a staff of paid organisers. 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 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 was formerly expected to visit the home of every child recommended for medical treatment (except where satisfactory arrangements had been made with the parents at the actual inspection) but in 1933 a method of written communication was introduced as an experiment and this was so successful that it is now the rule in an increasing number of schools. Only when no response is obtained or refusal is given does the social worker visit. Children's care committees. During 1934, 538 cases, involving 647 defects, were reported to the National Society for the Prevention of Cruelty to children: these included 351 dental defects, 162 vision cases, 48 nose and throat affections and 12 cases of ear disease or deafness. Cases referred to the N.S.P.C.C. The influence of the acute infectious fevers on the production of aural disease is shown by the high proportion of children who are deaf and partially deaf, in whom the trouble can be traced originally to an attack of measles or scarlet fever. One of the most important means therefore of preventing deafness and hardness of hearing is the after-care of children when they are discharged from the fever hospitals. An arrangement has been made whereby 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 850, of which 419 were forwarded to Borough Councils or other local authorities. Of the cases followed up at school, 16 were found on the first examination to have otorrhcea, and of the cases seen at second examinations the condition persisted in six. All the cases not cleared up are being kept under observation. In view of the importance of this procedure, efforts were made to secure fuller notification of cases. That these were successful is shown by the fact that the number of notifications from the isolation hospitals was more than double that of the previous year, but the large increase was chiefly in children below school age who were therefore not under the school care organisation. Aural disease and the acute infections. 20 It is reported that there is an increasing tendency on the part of employers to reject applicants with discharging ears. Medical and dental treatment. The arrangements for medical and dental treatment of children attending public elementary schools and scholars and pupils at secondary, trade and continuation schools, have proceeded very satisfactorily and the attendances of patients are once again on the up grade. No new centres were established during the year, the number where special arrangements for treatment obtain remains at 74 centres and 17 hospitals, together with the special in-patient centre at the Cyril Henry centre, Woolwich, and the dental centre for the children resident at the King's Canadian camp school, Bushy Park. During the previous year, 1933, there was a drop of 9,500 in the total number of children dealt with at the various centres compared with the year 1932, but in 1934, 0,858 more children received treatment than in 1933. The following table sets out the provision made and the actual numbers treated during 1934:— Table 6. Ailment. Provision made in 1934. Numbers treated 1934. Numbers treated 1933. Eye 43,102 40,284 40,434 Ear, nose and throat 17,667 12,622 14,145 Ringworm 424 195 178 Minor ailments 79,777 114,809 110,600 Teeth 150,150 138,140 133,835 Total 291,120 306,050 299,192 Eye defects. The number of case3 treated in the eye departments of the centres and hospitals during the year was 40,284 of which it is estimated that 2,000 were cases in which definite diseases of the eye were treated, the remainder being cases requiring correction for errors of refraction. It will be seen that this number is slightly less than that for 1933. During the year the number of cases in which spectacles were prescribed was 29,599, and spectacles were obtained in 27,497 cases, a similar percentage (92.9) to the year 1933. Ear, nose and throat. Once again there has been a reduction in the number of ear, nose and throat cases attending the centres and hospitals. During the year 12,622 cases were seen and 8,860 operations performed, compared with 14,145 and 10,008, respectively, during the year 1933. An analysis of the cases shows that in 7,686 the operation was for both tonsils and adenoids, in 700 cases for enlarged tonsils only, and in 443 cases for adenoid growth only. The remaining 31 cases were mainly operations for nasal defects in which cauterisation was required. Reference was made last year to the introduction of passive immunisation against scarlet fever and diphtheria at the Cyril Henry centre where the work is carried out directly by the Council. Particulars are given in the section of the report upon infectious diseases (p. 43). Ringworm. The incidence of ringworm of the scalp among the 500,000 children in the London schools is now comparatively rare. During the year only 195 cases were dealt with at the centres and hospitals of which 118 were treated by X-rays. Minor ailments. The number of minor ailments cases dealt with during the year was 114,809, including 13,087 cases seen by nurses only. This compares with 110,600 and 11,876, respectively, during the year 1933. The total number of attendances made by the children at the various centres was 1,400,908. Dental No additions have been made during the year to the 69 dental centres in treatment. London. This number does not include the experimental centre at the Berkshireroad school, which is organised and maintained by the Manor Charitable Trust specially for the children attending the school. Dental inspections have been held 21 in the schools contributory to the various centres and during the year 2,492 inspection sessions have been held by the 68 inspecting dental surgeons. As a general rule children in the age groups examined by the school doctors, viz., entrants, children aged 7 and 11 and leavers, are not inspected by the dentist; but, in connection with certain of the centres, where the inspection of the schools on the rotas is completed in less than one year, it is the practice for the dentists to inspect children of all ages. It is intended that the scheme shall be extended so that by the conclusion of the next three years, children of all ages in all the schools in London will be inspected by the dentists at least once a year. The number of children inspected by the school dentists during 1934 was 273,672, compared with 275,213 during 1933. The number found to require treatment was 176,509 or 64.5 per cent. Table IV, group IV, at the end of this report shows the number of children of the various ages inspected, as well as the details of the treatment given at the hospitals and centres included in the scheme. The total number of children treated was 138,140 compared with 133,835 during the year 1933, an increase of 4,300. Included in the total is the number of children (3,710) from the schools allocated to the Eastman clinic who were treated at the clinic and 22 scholarship cases, as well as 488 cases dealt with at Berkshire-road school. The 1933 figures were compiled on a similar basis. In addition to the above there were 7,023 children from unallocated schools treated at the Eastman clinic. The number of sessions including general anaesthetic sessions held during the year was 18,211, compared with 18,713 during the previous year. It will be seen that, although some 500 sessions less were held, there were 4,300 more cases dealt with during the year. This is accounted for by the reduction in the number of sessions devoted to general anaesthetics, and it may be noted that there were 66,424 administrations of general anæsthectics, compared with 69,683 during 1933. This reduction has been effected by the more general use of local anaesthetics, especially in the treatment of the older children. Of recent years a considerable change of outlook towards the use of local anaesthetics in dental therapy has taken place throughout the dental profession. Efforts have been and are being made to use local anaesthetics more generally in the school treatment centres in suitable cases, and most of the dental surgeons have now adopted the practice with very good results. Moreover, the extraction of one or two teeth on the spot under a local anaesthetic saves another visit to the centre for gas treatment; and, apart from this economy of time, the child is not subjected to the nervous anticipation of further treatment, and the work is completed. During the year 31,945 local anaesthetics were given. The aim of the school dental service is conservative in character, and as a general principle every saveable tooth should be preserved. It is indicative of the progress of the dental scheme in London that year by year the number of saveable teeth is increasing, whilst the number of unsaveable teeth is decreasing. This is shown in the following table by the steady increase in the number of fillings undertaken, save for the slight setback in 1933, and the decrease in the number of extractions. Table 7. Year. No. of cases. No. of fillings. No. of extractions. 1928 129,255 116,818 406,748 1929 129,952 115,904 315,838 1930 138,280 122,120 410,419 1931 139,723 132,237 393,579 1932 134,769 138,857 352,234 1933 133,835 134,678 332,146 1934 138,140 139,513 321,961 A problem that is ever present is that of the "casual" case—that is the child Casual cases. whose parents do not take advantage of the facilities offered at the school inspections, and who is only brought forward by the parent when acute toothache is the cause. 22 Such cases account mainly for the large number of permanent teeth extracted at the centres, since earlier attention would probably have saved these teeth from the forceps. In London this problem is further complicated by the fact that at many voluntary hospitals a dental department is maintained, and the parent who declines, for his child, the advice offered by the school dentist can without great difficulty obtain the emergency treatment which later on becomes necessary. There is also the factor that the charge made by voluntary hospitals to dental out-patients is less than that charged to the parent under the Council's scheme. Whilst the aim of the dental surgeons employed at the Council's treatment centres is to preserve particularly the permanent teeth during the child's school life, yet there are still a great number of parents who do not appreciate the value of conservative dentistry and consider extraction the only method which need be carried out. Orthodontics. No special facilities have hitherto been provided by the Council for dealing with orthodontic cases. Any requiring such treatment that have been discovered, either at the inspections in the schools or at the treatment centres, have been referred to the dental hospitals or the Eastman clinic for treatment. The Council has always felt that the cost of equipment and staff for a special dental workshop for the purpose of the school medical service alone was not justified. The position has altered since the transfer to the Council of the general hospitals under the provisions of the Local Government Act, 1929. The Council now maintains a special dental workshop primarily for its general hospitals where dentures and dental appliances are made by dental mechanics. As an experiment, for 6 months, 3 special orthodontic centres have been established at the Deptford, Hammersmith and Prunella (St. George-inthe-East) centres. The children are seen at a special session devoted entirely to orthodontic work, impressions are taken and the casts are sent to the Council's dental workshop at St. James' hospital, Balham, where the necessary appliances are made. These are forwarded by post to the centres, and the children attend periodically for observation and adjustment of the appliances. The estimated average cost to the Council of the appliances is 12s., and, during the experimental period, it has been decided that a uniform charge of 12s. shall be made to the parents for the whole course of orthodontic treatment including the appliance. This is in addition to the ordinary dental charge. In necessitous cases the school care committees are empowered to reduce the charge or to remit it altogether. The accompanying diagram (fig. 1) shows the growth in numbers of children annually treated for dental decay from the time that dental treatment of school children commenced in the first year of the King's reign. The two periods during which progress was arrested, viz., in 1922 and in 1932-33, were associated with unemployment and increased charges to the parents. Charges to parents. Under Section 81 of the Education Act, 1921, the Council is bound to make a charge not exceeding the cost for any medical or dental treatment given under its school medical arrangements. The charges prescribed for such treatment to children attending elementary schools, special schools and nursery schools, and for foundation scholars in aided secondary schools are substantially lower than the full cost. Parents, who, while not able to pay the fees of a private practitioner, are able and willing to pay the full cost of the medical or dental treatment of their children, are enabled to do so. The Council on 6th February, 1934, decided that, as an experiment for one year from 1st April, 1934, arrangements should be made for medical inspection and treatment of students attending the day continuation schools and three junior evening institutes. Fee paying pupils at secondary schools may under certain conditions avail themselves of the Council's school medical and dental treatment arrangements. The charges for these cases are the full cost as determined year by year. Machinery is however, in existence whereby reductions or remissions can be obtained where the circumstances justify such a course. 23 The calculated full cost during 1934 for each class of ailment treated was:— Enlarged tonsils and adenoids, 18s.; Minor ailments, 7s. 5d.; Dental treatment, 7s.; X-ray treatment for ringworm, 26s. 4d. For many years the prescribed charge made by the Council to parents of children in elementary schools in respect of medical and dental treatment of school children was 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. The charge for operative treatment of enlarged tonsils and adenoids was increased from 2s. to 5s. in April, 1932. All children operated on under the Council's scheme are retained in the various centres as in-patients. 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. In those dental cases where extensive treatment is undertaken, including the administration of an anaesthetic, 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. So far as those parents who are unable to pay are concerned, it is made clear to 24 them that the care committees will reduce the charge by 50 per cent., or remit it altogether. The "slight-treatment" cases in the dental departments, in which the charge of 1s. is made, numbered, in 1934,15,297, an increase on the figures for 1933, when they amounted to 13,393. No charge is made for refraction of the eyes in the case of defective vision. This is looked upon as an extension of medical inspection rather than as treatment. The cost of spectacles however in the case of children attending elementary schools (but not special schools where the Council bears the cost) falls upon the parents, assisted where necessary from voluntary funds. London Central Spectacles Committee. The care of the children in this respect is supervised by the voluntary London Central Spectacles Committee, who, in 1932, pointed out that the figure for that year showed a drop in the number of spectacles obtained; this was disappointing, but understandable in view of the hard times. The percentage, 88.6, of the spectacles ordered, was the lowest since 1926, and it was hoped that the lost ground would be regained in the succeeding year. The falling off in 1932 led to redoubled efforts on the part of the care committees in 1933, and the hope that the lost ground would be regained was amply fulfilled, as in the latter year the percentage of children obtaining spectacles who needed them was 92.9, the highest ever yet achieved ; this percentage was repeated in 1934. In their 13th annual report the London Central Spectacles Committee state :— This recovery of lost ground pays tribute to the sustained efforts of all concerned through a period of very real difficulty. It must also be remembered that this percentage, excellent though it is, may not represent the full total. The figure given is arrived at from information available from all sources, but it is known that, in a certain number of cases, the fact that the spectacles have actually been obtained is not reported, and the percentage would be higher still if complete information had been received. The work of following up the cases and the collection and repayment of loans falls upon the care committees, and only those who have had experience can realise the weight of the burden they have to shoulder. The arrangement for co-operation with the Public Assistance Committees is now running more smoothly, and there is less delay in obtaining spectacles for children whose parents are in receipt of out-relief. Many reports from the districts record increased demands upon their funds, but side by side with these are encouraging accounts of repayment by parents. It is not possible to give the exact figure of the sum collected in each area, owing to the different forms in which the reports are sent in, but the following are the figures available:— Amount collected, £401 18s. Id. Repayments by parents, £329 Is. 8d. These figures must not be taken as representing the full amounts, as several reports give no details of their financial position, and in certain districts funds for spectacles are combined with boots and clothing funds, so the actual sum devoted to spectacles can be only roughly estimated. Otorrhcea. When medical inspection of school children commenced in London in 1906, it was found that large numbers of children in the schools suffered from otorrhoea. Most of these cases were in a very offensive condition and the smell in the classrooms was often disgusting. The education authority had no power to provide treatment and the children attended out-patients' departments at hospitals in a haphazard fashion ; in the intervals of attending the hospitals, the cases were left to the mothers, who were quite incapable of keeping the ears in a wholesome condition. It was clear that the hospitals' out-patients' departments were quite inadequate to deal with this work. By the Education (Administrative Provisions) Act, of 1907, local education authorities were given the power of providing treatment. The Education Committee were very impressed with the need of supplementing hospital out-patient treatment by some more appropriate scheme, and about 1909 the experiment was made of employing the district nurses to visit the homes of children who were found in school to have otorrhœa. It was found, however, that, although the ears were kept in a more hygienic condition, the cost per case was considerable, and there was the objection that the nurses' work was not under medical direction. About 1913, minor ailment departments were introduced at school treatment centres. At these the district nurses worked under medical direction; there was 25 no time lost in visiting homes (often to find that the children were out) and it was possible to give skilled nursing assistance to every child once, or even twice, every weekday. This led to a great improvement in the conditions and the old trouble of offensive ears in the classroom was got rid of. Gradually minor ailment departments increased in number, until there are now 70 covering the whole of London. The doctors in charge of minor ailments were, however, not specialists in otology, and, though a much larger number of discharging ears were cured than formerly, the departments still tended to be clogged up by cases which remained uncured. In order to ascertain whether something could not be done to reduce the chronicity of these cases, it was arranged for Dr. Wells, who was then a school doctor in the south-west division, to give up one session a week to carry on an "ear inspection clinic," and to this were referred cases from the surrounding minor ailment departments for special investigation and advice. Through his connection with the Metropolitan Asylums Board, Dr. Wells was able to secure in-patient treatment for those children who could not hope to be cured of otorrhoea except by mastoid operation or other in-patient treatment. The special inspection clinic proved to have great possibilities, and the system was gradually extended to other areas. Dr. Eichholz of the Board of Education, who always took much interest in the development of aural work from the point of view of prevention of deafness, pointed out about 1920 the possibilities of zinc-ionisation treatment which Dr. Friel had advocated. The Education Committee in 1920, in sanctioning the extension of the inspection clinics, approved the introduction into them of the zinc-ionisation method of treatment. Dr. Friel himself was employed in the service, and the number of clinics, grew. At each of them an aural surgeon of experience was appointed. By this, time Dr. Wells had received a special appointment which allowed him to give his. whole time to the development of the work. He also held an appointment with the Metropolitan Asylums Board, and himself carried out the operations at the Cleveland Street infirmary. In the first instance cases from the minor ailments departments which did not clear up after three months treatment were brought to the special ear clinics for investigation. Those suitable for ionisation were subjected to it; those needing operations were sent to Cleveland Street. It was found desirable, however, to obtain advice at the special clinics at an earlier stage in many cases ; and in 1925 the school medical officer addressed a memorandum to the honorary secretaries of the treatment centres on this point, asking that all cases which did not clear up within a month should be referred for specialist examination. There was still, however, a tendency on the part of the minor ailment departments to retain cases unduly, and the principle was adopted of working through all ear cases on the lists of the minor ailment centres in turn. This is the practice which still obtains. All through the development of the scheme the importance of ready and prompt transference of children needing it to in-patient treatment has been borne in mind ; and the Council's school medical service has worked in close co-operation with the Metropolitan Asylums Board's and latterly the Council's special hospitals. In the early years, before this liaison had been established, the work was very greatly hampered through the long waits for hospital beds which made any preventive scheme very difficult indeed. With the provision at Cleveland Street this difficulty disappeared. When the Downs hospital was made available for this work—largely to meet the demands of the school medical service—Cleveland Street was closed. Children returning from the Downs hospital are kept under observation. This was done at Leighton Road after-care clinic by Mr. Wells, but the geographical position of the clinic was unsatisfactory, and some two years ago the work was moved to a more central position at St. George's dispensary, Blackfriars Road. As. 26 the children are attending elementary schools and properly are being supervised by the responsible authority, the Education Committee, the work was transferred from the special hospitals division to the school medical service. The success of the work can be deduced from the accompanying diagram (fig. 2) giving the reduction in incidence of otorrhœa found at routine inspections from 1911 to 1934. Aural clinics. Statistics. Dr. A. G. Wells reports on the special aural work as follows:— The following tables give the figures for the otorrhoea and the deaf cases treated at the special aural clinics, and returned bv the divisional treatment organisers for the vear :— Table 8.—Ear, nose and throat, excluding partly deaf cases. Division. Total no. of examinations made. New cases. Cases carried over from 1933. Old cases returned. Cases examined, but no treatment required. Cases cured. Lost sight of. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. S.E. 4,123 4,857 388 475 176 202 278 320 36 56 501 608 61 78 N.W. 2,235 2,832 203 259 127 154 144 166 57 72 235 290 34 42 N.E. 2,808 3,343 215 271 114 132 183 207 38 48 294 339 23 30 N. 3,490 5,454 318 418 144 173 266 334 82 138 374 470 81 97 S.W. 3,741 4,769 434 612 147 223 226 244 112 223 460 554 35 42 Total 16,397 21,255 1,558 2,035 708 884 1,097 1,271 325 537 1,864 2,261 234 289 From these figures it will be seen that each child averaged approximately five attendances. Table 9.—Deaf cases. Division. Total no. of examinations made. New cases. Cases carried over from 1933. Old cases returned. Cases cured. Cases partially relieved. Cases unrelieved. Cases requiring no treatment. Lost sight of. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. Patients. Ears. S.E. 211 377 30 56 6 12 8 13 18 35 1 2 - - 6 12 1 2 N.W. 299 560 29 53 8 16 9 14 8 15 4 8 2 4 2 4 3 5 N.E. 108 203 28 52 2 4 1 2 8 15 5 10 — — 1 2 1 1 N. 236 433 23 42 19 38 7 13 10 20 2 3 1 2 1 2 5 10 S.W. 80 152 18 34 8 15 1 2 5 10 1 2 — — — — 3 6 Total 934 1,725 128 237 43 85 26 44 49 95 13 25 3 6 10 20 13 24 27 From these figures it will be seen that the percentage of "cases cured" was 26.6, 1.6 per cent. " partially relieved," 7 per cent. " unrelieved," 7 per cent were lost sight of, the remainder being still under treatment at the end of the year ; and that each child averaged approximately attendances. In addition to the above, 384 cases were treated for defects of the nose, ear and throat. The following table gives a detailed analysis of all the cases of otorrhœa treated, and shows the number of acute ears, the cause of the persistence of discharge in chronic ears, the number cured, the number requiring operation, those lost sight of, and the number still under treatment on 31st December, 1934. This table includes the otorrhoea cases of the children from residential schools. Table 10—Analysis of Otorrhœa cases. Cause of suppuration. Total ears. Cured. Referred for mastoid operation. Lapsed. Still under treatment. Acute otitis media suppurativa 255 213 5 10 27 Chronic otitis media suppurativa due to (I) Tympanic Conditions (a) Tympanic sepsis (T.S.) 1,698 1,248 — 76 374 (b) T.S. +granulations 234 130 21 17 66 (c) T.S. +polypi 46 22 7 4 13 (d) T.S. + caries 18 1 3 3 11 (e) T.S. + other conditions 9 3 — 2 4 (II) Tympanic Conditions + (a) Tonsils and adenoids 192 136 — 19 37 (b) Nose conditions 270 206 — 16 48 (c) Mouth conditions — — — — — (III) Tympanic Conditions + (a) Attic disease 76 20 27 6 23 (b) Mastoid disease (no operation yet done) 166 4 151 4 7 (c) Mastoid disease (operation already done) 586 298 43 49 196 (IV) Tympanic Conditions 4 + (a) External otitis 49 40 — 1 8 (b) Stricture of meatus 2 2 — — — External otitis 100 85 — 6 9 Cause undetermined — — — — — Total 3,701 2,408 257 213 823 From these figures it will be seen that the percentage of "cases cured" is approximately 69. The residential school otorrhœa and other cases continued to be transferred to Norwood children's home to attend for treatment at the after-care clinic at St. George's dispensary, 86, Blackfriars road, as required. The following are the details of these cases:— Total number of ears treated 164 „ „ „cured 128 „ „ „ referred for mastoid operation 12 „ „ „ lost sight of 4 Still under treatment on 31st December, 1934 20 These figures show that 78 per cent. of the cases were "cured." 28 In addition to these cases of otorrhœa, there were a number who attended and were found to be free from ear discharge. The following are the details:— Children requiring no treatment 21 „ „ operation for tonsils and adenoids 3 „ „ „ „ adenoids 1 „ „ removal of wax 1 ,, „ treatment for deafness 2 „ „ „ ,, defects of nose 2 „ „ „ „ dry perforation healing 2 „ lapsed 1 After-care clinic. The work done at the after-care clinic mainly consisted of the after-treatment of mastoid operation cases, and the treatment of the residential school children suffering from defects of ear, nose and throat. The details of the work done at the clinic are as follows:— Total attendances during the year 7,600 Number of ionisation treatments 2,517 „ „ ultra-violet radiations 218 „ „ dressings 4,814 Patients. Ears. Total number of patients seen 506 583 Number requiring no treatment 51 51 „ diastolisation only 6 — „ referred to Downs hospital 20 24 „ treated and discharged cured 326 385 „ continuing treatment at end of year 90 109 „ treated—later lapsed 13 14 Total 506 583 Patients. Ears. Discharged from Downs hospital in 1934 230 250 Continuing treatment from 1933 54 60 Total 284 310 Detailed analysis— Patients. Ears. Discharged from Downs hospital—no further treatment required 27 27 Treated (at clinic) and discharged cured 147 164 Referred back to Downs hospital for further operation 13 14 Lapsed after treatment 10 11 Still under treatment at end of year 60 67 Transferred to other L.C.C. clinics —now well 3 3 „ „ „ „ still under treatment 18 18 „ „ „ „ since lapsed 6 6 Total 284 310 Cases not requiring operations (excluding residential school)— Patients. Ears. Treated and discharged cured 78 92 Continuing treatment at end of year 22 30 Total 100 122 29 In the last annual report the value was stressed of the gramophone audiometer for the detection of hearing defects in elementary school children, and an extension of its use was recommended. The Council considered the matter and approved a scheme put forward which comprised the full-time services of one nurse to do the actual testing and perform other duties connected with the work; and the services of an otologist for two sessions a week, to deal with the clinical examination of "failed" children, and the treatment where possible, of those cases in need of treatment, for the purpose of relieving the hearing defect. With this "unit" it is hoped that about 30,000 children may be dealt with each year. A second unit will be formed in April, 1935, and a third in April, 1936. When all three units are in full working order it is computed that about 90,000 children will be tested during each year. Certain difficulties existed in the efficient working of this scheme, but an effort is being made to surmount them. The first difficulty arises after test II, when it becomes necessary to make a clinical examination of the "failed" children. Hitherto this examination has been conducted at one of the special aural clinics, and a notice was sent to parents requesting their attendance with their children for the clinical examination. It was found that a not inconsiderable proportion of such children failed to attend, which considerably reduced the value of the work done. This difficulty has been overcome by arranging for the examination to take place in the schools. The parents are invited to be present with their children and the care committee worker of the school is also asked to be present. Should the otologist, at this examination, find any defect to exist which seemed to account for the loss of hearing, and to be of the opinion that some form of treatment would be likely to relieve the condition, the position is, there and then, explained to the parent, whose acquiescence in the treatment is asked for. The care committee worker then follows the case up, and when treatment is completed, notifies the nurse, who then arranges for test III, to see if the treatment obtained has produced the desired result. For the purpose of conducting test III the nurse asks the head teacher of the school of any child concerned, to arrange for the child to attend at the school in which the nurse happens to be carrying out the audiometric testing, which as a rule can be arranged at a school in the neighbourhood. Hitherto, not only did many children fail to attend the clinical examination at the special aural clinic, but of those who did attend many failed to obtain the treatment recommended, the result being that the number available for test III was only a small proportion of those who failed in test II. With the new plan, it is found that a considerably higher percentage of children are obtaining treatment and the real object of the work, viz., the detection and alleviation of defects of hearing in their earlier stages, thus preventing in many cases the onset of permanent loss of hearing, is being attained to a material extent. There is, of course, a percentage of parents who, unaware of any hearing defect in their child, are not willing to have the treatment recommended, but doubtless as the object of this work is more understood and appreciated by parents, this number will grow less. There are a number of pitfalls in the testing which are revealed by experience, such as extraneous noises, inattention of the children, imperfect application of the telephone to the ear, which tend to vitiate the results obtained, but a careful watch is being kept for these, and means of eliminating them sought for. It is not proposed to deal in great detail with this now, but the matter will be fully discussed in the report next year, when more experience will be available. The new scheme was only started on 5th November, 1934, consequently the numbers for that year are not large. Only children in the senior departments are being tested at present, but as many as forty children can be tested at a time. Special tests have been devised by the Research Committee working at the London School of Hygiene and Tropical Medicine, for the testing of children of the infant departments. These consist of a series of pictures of familiar objects in sliding frames, e.g. cow, ball, which are spoken by the voice from the gramophone record and on hearing the names of these objects the child presses on the appropriate frame and eliminates the picture from view. When the child no longer does this correctly, the point has been reached where his hearing fails. As in the records for testing the older children, the record is graded in decibels. Only a few children can be tested at a time by this method. It is in use in Tottenham and works quite successfully. Whatever objections may be advanced against the gramophone audiometer, none can be regarded as serious, and indeed most that have been put forward are quite remediable by careful attention to conditions of testing. In any case it is without equal as a method of sorting out C Audiometer. 30 children with hearing defect expeditiously, and it is especially useful in detecting unilateral defects of the less severe grade which would in all probability be overlooked without its aid. The results of the examination of 4,061 children are here recorded in graph form. Fig. 3 indicates the percentage of passes and failures of boys, girls and all children in three separate groups. Fig. 4 shows the same thing in " ears " instead of children. Fig. 5 shows the hearing acuity for all ears by groups. These are divided into four groups :—(1) —3 to +6, which represents all the passes, (2) a separate group of the +9, this group being what may be described as the "border-line failure group," (3) 12 to 18, and (4) 21 to 30. 31 Fig. 6 is a differential analysis of the better ear of the failed children, before and after treatment. It is a guide to the educational impairment existing, but modification of education for individual children depends on whether deafness persists after treatment. Fig. 7 is a differential analysis of all ears before and after treatment. The results of the tests show that 91 per cent. of the children had normal hearing, or less than 9 decibels loss of hearing, and 9 per cent. had 9 or more decibels loss. In terms of ears 93.9 per cent. have normal hearing or less than 9 decibels loss, 2.2 per cent. had 9, and the remainder had more than 9 decibels loss. The clinical defects found amongst the children with 9 or more decibels loss on the second test, who presented themselves at the clinical examination were as follows:— Catarrhal condition of middle ear, 75; wax, 53; otorrhœa, 35; tonsils and adenoids, 17; dry perforation of tympanic membrane, 10; nothing found, 7; scars in tympanic membrane, 6; rhinitis, 5; adenoids, 3; old mastoid operation, 2; debility, 1; deflected septum, 1; foreign matter, 1; nasal catarrh, 1; sclerosis middle ear, 1. In the latter part of the year, an audiometric examination with the Pure Tone (2B) audiometer of all the deaf and partially deaf children, was commenced. It was found impossible C I 32 to complete this work by the end of the year, and those remaining will be dealt with in the early part of 1935. All children are being tested by both air conduction and bone conduction and audiograms made. A certain number are also being tested with calibrated tuning forks and the 4A gramophone audiometer to compare the results of the three methods. From the examinations already made, some very interesting and important facts are being revealed, but this will form the subject of a report when all the children have been tested. Stammering children. At the eight centres maintained for the treatment of stammerers a total of 373 children attended during the year ; of these, 91 were discharged as cured, while 66, 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 states that he is more than ever convinced that stammering is curable, in spite of the length of time taken in certain cases, and he reiterates the importance of never giving up a case. He has reported as follows:— It has frequently been found advisable when a child has been attending a centre for a long time to discharge him temporarily so soon as he shows sufficient signs of improvement to warrant this. The confidence engendered will often result in a further advance after which another short term at the centre may complete the cure. This system of temporary discharge from a centre is now being applied to those cases that are still lacking in self-confidence although they have practically ceased to stammer. If the child realises that he can return to the centre at a moment's notice, he feels a sense of security which increases his confidence. An instance occurred recently in which a boy A., who had really ceased to stammer, was obviously alarmed at the thought of leaving the centre. It was found that another boy at A's school, who was due to leave school shortly was badly in need of treatment but there was no vacancy at the centre. A was asked to give up his place to his school fellow for one term, but was told that the vacancy would be kept for him. By the end of the term A had realised that he was " self supporting " and required no further help. Later reports confirmed the completeness of A's cure. A further advance has been made in the study and practice of relaxation and its effects on conditions other than stammering are proving to be more far reaching with the growth of experience. Enuresis, for instance, appears to yield to treatment by relaxation with remarkable rapidity. In fact it very seldom persists in these stammerers beyond the first month of attendance at a centre. It is more than ever apparent, however, that complete relaxation can only be taught by those who themselves have mastered the art, and who understand the psychological and physiological processes involved. As there continues to be a large number of applicants wishing to avail themselves of the facilities offered by the Council for experience in the treatment of stammerers, it is now being realized that attendance alone at a centre—although essential to the student—is not sufficient training. This has been particularly demonstrated by the more mature and experienced students who complained of the lack of systematised training. An experimental course of one year was therefore initiated to supply this need and a beginning was made in September, 1934, with six students. This course is in no way intended to be a full training for the beginner. It is essentially a supplementary course for those with previous experience in dealing with children. The right personality and suitability generally for this type of work were taken into consideration when approving candidates. In order that these students may get the greatest possible advantage from their year's course, it is considered advisable to transfer them from one centre to another at stated intervals. Visits have been made to the centres by individuals from all parts of the world interested in the treatment of stammering. Left-handedness in children. The existence of a number of children who appear to be naturally left-handed and the effects upon them of attempts to correct what appears to be a disadvantage in a world consisting mainly of right-handed persons have always been of great interest to school hygienists. The question has become rather prominent during the last three or four years owing to the struggle for work which has resulted from wide-spread unemployment. There has, in consequence, been a general demand on the part of the teachers in London for guidance on the subject. Mr. G. E. Wear of the Ministry of Labour 33 addressed, at the Council's request, a special enquiry to juvenile advisory committees on the question and a summary of the results follows:— General Post Office.—In the case of candidates for appointment as telephonist or girl probationers, no applications are considered from those who cannot write easily and legibly with the right hand. Clerical.—Left-handedness was reported generally to be a bar by employers engaging staff where handwriting is essential; left-handed juveniles are stated to be poor and slow. From one area it is reported that employers will not consider left-handed juveniles where bookkeeping and ledger work is involved. It is also understood that the banks definitely will not engage left-handed persons. Engineering.—It was reported generally to be a definite bar where juveniles are required to operate machines and to work in a "team." Needle Trades.—It was reported generally a bar. It would appear to be chiefly due to the fact that left-handed and right-handed girls cannot work together. It is reported from one area that the largest employer of machinists states that his best workers are left-handed, but the difficulty is in the training; the girls take much longer to learn and require more patience in teaching. Other trades where left-handedness is reported to be a bar are cabinet-making, piano-making, sports goods, bookbinding and hairdressing. The consultative committee of head mistresses of girls' schools drew attention to advice which had in certain cases been given to head teachers regarding the method which it was considered desirable to adopt in dealing with left-handedness in children, and asked that similar information should be conveyed to all head teachers. The request was referred to the chief inspector, who appointed a committee of inspectors to inquire into the matter and to ascertain whether, and if so in what degree, left-handedness is a handicap in industry and commerce. The question was also discussed with the medical officer, on whose advice the letters referred to by the consultative committee were written. It appeared desirable that head teachers should have some guidance in the treatment of left-handed children, and it was suggested by the chief inspector that a circular should be issued in the following terms:— There are exceptional children who appear to be naturally left-handed. There are also many children who have acquired left-handedness, though in many of these cases the exact cause may be obscure. But whether left-handedness in any particular case is innate or acquired, the tendency to use the left hand is often firmly fixed before school age. The conventions in writing are, however, arranged to suit right-handed people, and anyone who writes with the left hand will work under a definite, if slight, handicap all his life. There is evidence also that left-handedness is a handicap in certain commercial and industrial occupations. It would, therefore, appear to be desirable that some attempt should be made, particularly in the early stages of teaching writing, to encourage all children to use the right hand. Many lefthanded children have learnt to write with the right hand without any apparent disadvantage. It will be appreciated that in cases in which the left-handedness is either natural or well established, there may be some danger in exercising any pressure in this matter. The medical officer points out that school hygienists are agreed that there certainly should be no attempt to make children right-handed by means of punishment or ridicule. He states further that pressure is likely to result in producing a harmful degree of emotional disturbance. This has been found in some cases to result in nervous symptoms, including stammering. It will be recognised, therefore, that in any attempts to encourage children to be right-handed, it is very necessary to proceed with great caution, and to desist if any signs of abnormal emotional disturbance are shown. The Council agreed that the head teachers should be advised in the above terms, but directed that stress should be laid upon the words printed in italics. Rheumatism scheme. Dr. A. B. Raffle was seconded during the course of the year to the housing section and his place in charge of the rheumatism scheme was taken by Dr. C. E. Thornton. A slight decrease in the number of children nominated for institutional treatment under the scheme is recorded, 1,571 being nominated this year, as against 1,845 in 1933. The decrease is entirely confined to the group of mild or latent cases dealt with by supervisory centres, out-patient departments and school doctors. The nominations received from the in-patient departments of the voluntary hospitals show a nearly 50 per cent. increase over those of the previous year (348 compared 34 with 244); and, as these are the more severe and acute cases, it is clear that no notable decrease in the incidence of rheumatism or chorea can be visualised at present. During the first half of the year it became increasingly evident that, if the growth of an abnormally long waiting list were to be avoided, with a consequent delay in admitting cases, a more rigorous sifting of the nominations would have to prevail. In the very mild or doubtful cases, therefore, local supervision at a supervisory centre or out-patient department was advised, and numbers of slightly more definite cases were dealt with by means of supervised convalescence. For this purpose greater use was made of the Lower Southern hospital at Dartford. As a result of these measures it has again become possible to admit the majority of cases within ten days of nomination, and the more urgent cases immediately. The system of having the children who are nominated for treatment under the scheme examined by "referees" specially selected for this work is clearly of the utmost value in preventing undue congestion of the rheumatism units with unsuitable cases. Of the 1,571 nominations for institutional treatment received, the voluntary hospitals were responsible for more than half (804), the majority of the rest being sent in by school doctors (320) and supervisory centres (313). A certain number of parents refuse to accept treatment when they understand that it involves the child being away from home for six months or more. As many of the children do not appear very obviously ill, this attitude on the part of the parents is perhaps understandable, but even so the total number of refusals during the year was relatively small, being 111 only. The figures showing the conditions present in the children admitted to the rheumatism units and convalescent homes (table 12) show the usual preponderance of girls as sufferers from rheumatic infections (662 girls;434 boys). The percentage of those cases in which the heart had become implicated is almost exactly the same in the two sexes (boys 38, girls 37), indicating that, although girls are obviously more susceptible to the rheumatic infection than boys, there is no sensible difference in the severity of the type of attack experienced. That evidence is present of the heart being affected in nearly 40 per cent. of the cases admitted is certainly disquieting, but happily in many cases the degree of involvement is slight; and, what is still more gratifying, an analysis of 1,094 unselected cases discharged during 1934 revealed the fact that, of the 600 who showed signs of cardiac involvement on admission, 149 (i.e. nearly 25 per cent.) had no signs of cardiac disease on discharge. Even allowing for the possibilities of observational variations, these figures afford striking evidence of the value of prolonged rest in cases of rheumatic carditis. Furthermore, of the 490 cases without cardiac complication on admission, only ten developed signs of cardiac involvement whilst in hospital, and seven of these were of a very mild or even doubtful type. The case of those who insist that the prevention of cardiac crippling depends on the early and prolonged treatment of juvenile rheumatism becomes even stronger as information about this obscure disease accumulates. Herein lies the value of the present rheumatism scheme. Rheumatism cannot be prevented until more has been discovered of its aetiology, but there is good hope that its devastating effects on the heart can be minimised or avoided altogether by early and prolonged rest. Unfortunately many of the cases have well-established heart disease before they come under treatment, and in table 13, showing the recommendations made with regard to education in the 1,226 cases discharged from Carshalton, High Wood and the Downs hospitals in 1934, it will be seen that 198 (i.e., 16 per cent.) were found fit to attend a school for the physically defective only, and 28 were unfit for any form of education. Of the 128 who were over school age on discharge, a proportion also were only fit for the very lightest work on account of cardiac disease. In considering the incidence of rheumatism and chorea separately it is difficult to come to any definite conclusions. The diseases are closely related, and, in a large majority of mild cases of chorea, careful enquiry elicits the presence of 35 rheumatic symptoms ; conversely many cases of subacute rheumatism not labelled chorea exhibit a nervous instability verging on this condition. The analysis referred to previously of 1,094 cases discharged during 1934 did, however, show that permanent damage to the heart is relatively rare in cases of chorea in which there is no history of symptoms suggestive of rheumatism in the ordinarily accepted sense of the word. Of the 637 girls, 143 (i.e., 22.5 per cent.) were cases of "pure" chorea, and of these only 13 showed signs of permanent cardiac damage. Of the 457 boys, 77 were cases of "pure" chorea (i.e., 17 per cent.) and only seven of them developed permanent cardiac lesions. It is noteworthy that the percentage of cases developing definite cardiac disease was almost exactly the same (9 per cent.), in the two sexes. A similar fact has been noted when dealing with its relative incidence as a complication in boys and girls in the case of rheumatic infections generally (boys 38 per cent.; girls 37 per cent.). The statistics relating to the work of the supervisory centres are shown in tables 11 and 14. An increase is shown both in the number of cases attending the centres for the first time in 1934, and in the total number of attendances throughout the year. A new centre at the Bermondsey Medical Mission was opened in the early part of the year, and three new centres, one in Camden Town (in connection with the Hampstead General hospital), and also one in Poplar and one in Deptford are to be opened in 1935. At certain of the centres not connected with hospitals, the doctors expressed a desire for facilities to be provided to enable them to obtain an orthopædist's opinion on certain types of case. Arrangements have been made whereby these cases may be referred to the orthopaedic consultants attached to the Council's general hospitals. In addition to the 5,466 children under supervision at the supervisory centres, 1,803 are kept under supervision by the school doctors, who furnish a report on each case at regular intervals to the divisional medical officer. Immediate action can thus be taken to obtain further treatment should necessity arise. Ancillary to the work of actually treating and supervising children suffering from rheumatism, a constant endeavour continues to be made to deal as far as possible with unsatisfactory environmental conditions at home. In this connection the care committee visitors perform an invaluable service in reporting on the home conditions of the children. In 1934 following these reports (nearly a thousand in number), 159 cases of unsatisfactory housing conditions were referred to the borough medical officers of health. In a large proportion of these cases reports were subsequently received intimating that the defects complained of (chiefly dampness) had been satisfactorily dealt with. Table 11. Particulars. 1932 1933 1934 Total number of nominations 1,234 1,845 1,571 Nominations received from voluntary hospitals 635 1,017 804 „ „ „ rheumatism supervisory centres 275 352 313 „ „ ,, school doctors 185 293 320 „ „ „ other sources 139 183 134 Number of children admitted to special hospitals 953 1,447 1,096 Cases seen by medical referee in voluntary hospitals 257 244 348 „ „ „ „ „ in their homes 501 720 561 „ „ „ „ „ at rheumatism supervisory centres 291 394 329 „ „ „ „ ,, at County Hall 109 357 248 „ „ at County Hall on discharge 597 817 867 Number of cases under supervision by school doctors 1,188 1,481 1,803 Reports made by care committees on home conditions 814 1,147 995 Number of rheumatism supervisory centres 16 16 17 Number of sessions at rheumatism supervisory centres 686 999 1,051 Number of children attending rheumatism supervisory centres for first time 2,001 1,973 2,187 Total number of attendances at supervisory centres 12,883 14,880 15,340 Number of cases reported to medical officers of health re dampness, etc., or to valuer for better accommodation 152 230 159 36 Table 12.—Admissions to special hospitals and convalescent homes during 1934. Hospital or home. Boys. Girls. Rheumatism and /or chorea with no apparent cardiac involvement Rheumatism or chorea with cardiac disease Rheumatism and/or chorea with no apparent cardiac involvement Rheumatism or chorea with cardiac disease. Total Queen Mary's hospital, Carshalton 167 115 195 141 618 High Wood hospital 21 14 73 58 166 Downs hospital 60 34 97 45 236 Lower Southern hospital 15 3 32 2 52 Holy Cross convent 5 — 19 — 24 Total 268 166 416 246 1,096 Table 13.-—Recominendations on discharge as to future education. Hospital. p.d. school. Elementary school. Totally unfit. Over school age Removals from l.C.C. area. Total. Queen Mary's, Carshalton 127 540 5 92 17 781 High Wood 24 110 20 18 16 188 Downs 47 183 3 18 6 257 Total 198 833 28 128 39 1,226 Table 14.—Rheumatism supervisory centres. Name of rheumatism supervisory centre. Number of children attending during 1934. Number of new cases. Attendances of old cases. Total attendances. Average number per session. Number of children from the centre who received hospital treatment or convalescence under the rheumatism scheme. Bermondsey Medical Mission 191 166 189 355 11.8 18 Downham 340 131 499 630 14.3 20 "Elizabeth Bullock" 270 103 450 553 13.2 15 Eltham 226 88 381 469 11.4 12 Hammersmith 322 122 587 709 17.3 10 Hospital for Sick Children (Great Ormond-street) 368 138 1,824 1,962 6.5 7 King's College hospital 417 166 862 1,028 19.8 16 Lewisham 393 155 482 637 13.6 18 Princess Elizabeth of York hospital (Shadwell) 419 176 703 879 17.9 25 Putney 189 82 266 348 15.1 11 Queen's hospital 570 158 1,342 1,500 19.2 28 Royal Free hospital 261 170 1,561 1,731 38.5 35 Royal Waterloo hospital 754 232 2,430 2,662 31.0 9 St. George's hospital 203 81 303 384 9.1 1 St. Marylebone dispensary 88 38 429 467 11.1 2 Stoke Newington 173 67 537 604 13.7 7 Woolwich 282 114 308 422 9.8 7 Total 1934 5,466 2,187 13,153 15,340 14.6 241 1933 figures 5,093 1,973 12,907 14,880 14.9 297 37 Personal hygiene scheme. For the purpose of assisting at medical inspections, each school nurse is allocated to a group of schools. Each school in the group is also visited by the school nurse on a rota, in order that she can carry out the inspection of the personal hygiene of the children. At each rota visit all the children in the school are so inspected; each school is visited at least once a term, the schools where conditions are below normal receiving two or more such rota visits each term. Thus every child is seen at least three times a year. In 1934, 1,720,469 examinations of children were made at these rota visits. In 148,960 cases the child was noted as verminous, i.e., in 8.6 per cent. of the examinations, compared with a percentage of 9.0 on the similar figures for 1933 and 9.8 for 1932. From the records made on this basis a consistent improvement has been shown in the condition of the children's personal hygiene year by year; but, in accordance with the desire of the Board of Education, arrangements were made, by means of a small index card, to determine the number of individual children found unclean during the year, thus eliminating the possibility of counting separately the second or third record of uncleanliness in respect of any one child. The number of individual children so recorded was 83,207 (about 13 per cent. of the children on the school rolls compared with 15 per cent. in 1933), a figure which represents all those children who were noted infested with live vermin or their ova. About 54 per cent. of the cases in which verminous conditions were recorded at the rota visits are stated to be infested with nits only. The bases of the Council's cleansing scheme are emphasis upon the parents' primary responsibility, followed by compulsion, where necessary, as provided by section 87 of the Education Act, 1921. In the earlier stages of the procedure parents are advised of the trouble, and invited to avail themselves of the facilities provided by the Council. It is only after a child has been seen by at least two different nurses that a statutory notice is issued to the parents. These notices are served through the attendance branch of the education officer's department, and are either handed to the parents in person or forwarded by means of a registered letter. There are 10 Council centres, 20 borough council centres, and 9 centres organised by voluntary committees; but, as the last named are limited to head cleansings, these are not equipped with sterilisers or baths. The following particulars for 1934 are in respect of the cleansing scheme operated from the Council's and Borough Councils' centres (as distinct from the " head " cleansing centres):— 1934 1933 Number of advice cards issued to parents 80,260 85,808 Number of children attending voluntarily at bathing centres after advice cards 40,079 42,833 Number of statutory notices served in accordance with section 87 of the Education Act, 1921 22,302 23,954 Number attending bathing centres after statutory notices— (а) voluntarily 4,749 4,970 (b) compulsorily 14,016 15,916 Number of cases in which police court proceedings were taken 465 304 At the head cleansing centres 23,171 cases attended during the year compared with 25,051 in 1933. The figures in the above tabular statement are obtained from records kept on a terminal basis at each of the centres, and, as is the case with the rota inspection figures, a child may be recorded more than once in the same year. The individual record cards at the centres show that in 1934 a total of 73,903 children attended the bathing and head cleansing centres. Not all these children were, however, referred under various stages of cleansing schemes, but a certain number attended voluntarily before their departure for the residential schools, country holidays, etc., or at the request of parents, teachers and others. 38 Children taken for compulsory cleansing are either accompanied to the centre by the school nurse or, in the case of outlying schools, are taken by ambulances. In 1934, 11,531 children were conveyed in the ambulances. Children suffering from scabies and impetigo are treated at the bathing centres. The total of such cases was 5,545 for the year, a slight increase on the number for the previous year (5,311). 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 31,742 compared with 32,610 in 1933. Scabies. The continued high incidence of scabies which shows no sign of abatement gives cause for concern. The difficulties in dealing with this scourge are great. While school children can be, and are, inspected, the disease which is very contagious affects older and younger members of the family who cannot be inspected; and, although they are offered facilities for treatment by the local sanitary authority, there is no means other than persuasion of ascertaining their condition or of bringing pressure upon them to take advantage of the facilities. The school children, who have been treated, return to homes where other members of the family are untreated and reinfection is frequent. The co-operation of the sanitary departments of the Borough Councils in respect of simultaneous disinfection of homes is gratefully acknowledged. Chronic invalidity. The school attendance department reports each month the names of children who have been absent from school for three months or more 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 returns were formerly dealt with at the head office, but in 1934, it was found more convenient for them to be received at the local divisional medical offices, where action could be more quickly taken in appropriate cases. The reduction in the numbers shown in the subjoined table is due to the fact that the majority of the children who are ill for long periods are dealt with at the Council's special children's hospitals. In 1933 these were recognised by the Board of Education as hospital schools. The children who are at these hospitals are therefore no longer accounted "out of school," and no longer appear as in former years in the returns. The subjoined table shows the number of children reported to have been out of school for more than three months in November, 1934, 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 17 cases of epilepsy and 5 of encephalitis lethargica) accounted for 59 children. 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 56 cases, and ear disease for 26. On account of the greater incidence of the rheumatic diseases upon girls (191 as against 129 in boys), the total invalidity amongst girls is greater than that amongst boys (468 to 420). There were 22 boy cripples and 17 girl cripples. 39 Table 15.—Census of chronic invalids, November, 1934, and the four preceding years. Ailment. Cases. Percentage of total. 1930. 1931. 1932. 1933. 1931. 1930. 1931. 1932. 1933. 1934. Rheumatism, heart disease and chorea 678 546 550 608 320 32.82 33.67 31.87 33.40 36.00 Nervous disorders 99 93 65 95 59 4.80 5.74 3.76 5.20 6.64 Tuberculosis (all forms) 295 212 219 209 79 14.28 13.07 12.68 11.50 8.90 Anaemia and debility 129 52 77 75 40 6.24 3.21 4.46 4.10 4.53 Ringworm 22 9 5 4 5 1.06 0.55 0.29 0.22 0.56 Skin complaints (excluding ringworm) 49 38 45 51 25 2.37 2.34 2.61 2.80 2.82 Eye disease 72 70 63 76 8 3.49 4.31 3.65 4.10 0.91 Infectious diseases 73 34 90 70 45 3.53 2.10 5.22 3.80 5.07 Other defects 649 568 612 632 307 31.41 35.01 35.46 34.88 34.57 Total 2,066 1,622 1,726 1,820 888 100 100 100 100 100 Infectious diseases in schools. The numbers of cases of infectious illness reported by head teachers as occurring among school children during 1934, compared with similar figures reported during the preceding six years, are shown below:— Day elementary schools. Table 16. Year. Diphtheria. Scarlet fever. Measles and German measles. Whooping cough. Chickenpox. Mumps. Scabies. Ophthalmia. 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 1933 4,446 11,357 14,130 8,373 10,863 9,591 1,091 427 1934 5,439 8,850 37,701 5,029 10,283 6,354 1,131 554 The number of cases of smallpox notified (and confirmed) among school children during the year was 46, compared with 419 in 1932 and 170 in 1933. Special investigations into the occurrence of the infectious diseases specified in the following table were carried out by the school medical staff during the year:— Table 17. 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 of visits. Number of children examined. N.E. 30 26 2,994 27 25 3,522 - - N. 22 18 1,369 37 33 4,819 2 340 N.W. 38 30 3,458 28 22 3,133 — — S.W. 59 43 5,258 73 56 9,918 1 80 S.E. 32 26 2,311 69 55 6,995 — — Total 181 143 15,390 234 191 28,387 3 420 The children in four schools were also specially examined from time to time on account of outbreaks of ophthalmia. In addition to investigations by medical officers, valuable work was done by the school nursing staff in following up in the schools the medical officers' visits in connection with the occurrence of scarlet fever, diphtheria, smallpox and ophthalmia, as well as in the special visitation of the schools where there were outbreaks of whooping-cough and chickenpox, mumps, measles, German measles and scabies. 40 Diphtheria. Diphtheria appeared in epidemic form in parts of London during the autumn, and this is reflected in the increase in the number of cases reported from the schools —2,727 cases during the first seven months of the year, and 2,712 during the four months of the autumn and winter terms. During the year 4,985 children attending elementary schools were examined by swabbing of the throat and nose (and of the ear in a small number) for the presence of diphtheria bacilli. Of these 4,728 proved negative and 257 yielded positive results, i.e., 5.1 per cent. of those swabbed. Re-examination of positive or doubtful cases was made in 54 cases and diphtheria bacilli were found to be still present in 34 of these. The results of biological virulence tests applied to the 257 diphtheria cultures showed 225, or 87.5 per cent., to be virulent and 32 avirulent (i.e., of all the children swabbed 4.5 per cent. were virulent carriers). Among 38 school teachers who were home or class contacts of diphtheria, two only yielded diphtheria bacilli one proving avirulent in 3 successive swabbings and the other virulent in the primary swab but avirulent in two subsequent reswabs. School investigations. There were 181 special visits by assistant medical officers to 143 school departments for the investigation of the occurrence of diphtheria in the various classrooms. The children in 20 schools were kept under special supervision for various periods by the school nurses. In the course of the visits of the assistant medical officers a total of 15,390 children were examined and 3,390 swabbed. At the time of the visits 127 children were excluded on account of suspicious conditions of the throat and nose. In 110 of those swabbed, or 3.1 per cent., diphtheria bacilli were obtained, 105 of the cultures proving virulent and only 5 avirulent. Of the remaining children other than those examined in the course of special investigations, one group included 1,361 children who were swabbed as selected cases by doctors or school nurses in schools or at treatment centres owing to some suspicious defect of throat, nose or ear. In this group of 1,361, diphtheria bacilli were obtained in 142 (or 10.4 per cent.), 116 (or 8.5 per cent.) proving virulent and 26 avirulent. The other group consisted of 234 children who were swabbed preparatory to their being sent to convalescent homes as a safeguard to exclude chance diphtheria carriers being admitted to the homes. In 5 of the 234 swabbed, diphtheria bacilli were found, four proving virulent and one avirulent. The three groups of school children may be summarised as follows:— Table 18. Group. Numbers swabbed Diphtheria bacilli present in Virulent Avirulent Virulent diphtheria carrier rate. School investigations 3,390 110 105 5 per cent. 3.1 Selected children 1,361 142 116 26 8.5 Convalescent home entrants 234 5 4 1 1.7 Total 4,985 257 *225 32 4.5 *87.5 per cent. of those in whom diphtheria bacilli were present. In the five respective divisions the subjoined table presents a comparison of the results of school investigations including the apparent diphtheria carrier rate, as well as the diphtheria incidence and case mortality in the total boroughs included in each division. The figures for diphtheria incidence are provisional and subject to correction in the various boroughs concerned. 41 Table 19. Division. Population. No. of visits to Schools. No of depts. visited. No. of children examined. No. of children swabbed. Diphtheria bacilli present in No. virulent Carrier rate per cent. Diphtheria rates (all ages.) Total notifications Case rate. Total deaths. Mortality rate. Case mortality rate. per 1,000 per 100,000 Per cent. N.E. 765,000 30 26 2,994 543 22 21 3.9 2,570 3.36 85 11.1 3.3 N. 814,700 22 18 1,369 386 16 16 4.1 2,142 2.63 89 10.9 4.2 N.W. 900,000 38 30 3,458 686 25 24 3.5 2,075 2.31 102 11.3 4.9 S.W. 980,500 59 43 5,258 1,162 28 26 2.2 2,605 2.66 107 10.9 4.1 S.E. 937,500 32 26 2,311 613 19 18 2.9 2,487 2.65 90 9.6 3.6 Total 4,397,700 181 143 15,390 3,390 110 105 3.1 11,879 2.70 473 10.76 3.98 In all, 5,439 cases of diphtheria were reported from schools, representing an attack rate of 10.3 per 1.000 of the 527,283 children on school rolls. 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 1934. Diphtheria "carrier" clinics. Reports have been 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 biological tests, and that efforts have been made, more especially during the last three months of the year, to limit the cases referred for treatment to those who might be regarded as persistent "carriers." The clinic at the London hospital is under the care of Mr. Francis Muecke, who has submitted the following summary of cases for 1934:— On arrival 38 cases were found to be positive and 42 negative. The following is an analysis of these cases:— Table 20. Result. Positive on arrival. (26 operations.) Negative on arrival. (1 operation.) Total. Discharged cured 37 41 78 Ceased to attend 1 1 2 Total 38 42 80 Dr. L. W. Cann has furnished the following statement regarding the work carried out at the special clinic at Guy's hospital:— During the year there were 95 new cases, while 13 cases were carried over from 1933 and are included in the following summary. Six cases still attending are not included. K.L.B. present. Virulent—tonsils 10, tonsils and nose 4, nose 24, total 38 (including 4 cases notified as nasal diphtheria). Non-virulent—tonsils, 3, nose 8, total 11. Not tested—nose 1, total 1. Total cases with morphological K.L.B., 50; Hofmann only found, 18 (two virulence tests). Other diphtheroids found, 5 (three virulence tests). No diphtheroid organisms, 29. There has been no alteration in the standards used or treatment employed. It is again obvious that the majority of cases sent to the clinic are not persistent carriers. Many have already lost their K.L.B., by the time they reach the clinic and the majority of the remainder become clear after a few attendances. It would be unwise to attribute this to any treatment. The 10 cases carrying virulent K.L.B., in the tonsils only, cleared rapidly except for two. In both of these latter tonsillectomy was done about one month after the last swab taken at the clinic. In one case subsequent superficial and deep cultures from each tonsil were negative for K.L.B. It would have been well to have swabbed the child again after admission to the ward, before tonsillectomy. 42 The second case gave negative cultures from one tonsil, a fair number of K.L.B. in the other, whilst the adenoids gave an almost pure heavy growth of K.L.B. This although striking is the only occasion upon which the adenoids from a carrier have been cultured. One case was a persistent carrier for six weeks at the end of which time a brother was removed to hospital with diphtheria. As home conditions made it impossible to keep the child isolated he was notified and sent to the carrier unit at the North-Eastern hospital. The only case not recorded in the above list was the best case since the clinic commenced. He was not placed in the above list as he was a dental surgeon who had recently qualified at Guy's and was not really eligible for the clinic. On his first attendance at the end of February, he was greatly worried as his wife and two patients had recently contracted diphtheria—both the latter with an interval of four days after the extraction of teeth. On his next attendance a few days later he brought the more convincing evidence that two further cases, whose teeth he had extracted a day or two before his first visit here, had developed diphtheria. In each case the interval was again four days. After enquiry he said there had been no other case of diphtheria in the neighbourhood except for one man, another of his patients, who contracted diphtheria about three weeks after extraction of teeth. He had a cleft palate with a history of infected nasal infection and chronic catarrh. Three sets of swabs from right tonsil, left tonsil, right nostril and left nostril showed K.L.B. only in the left nostril and not in large numbers. A virulence test was positive. It was thought likely that the left antrum was the chief focus. With intensive local treatment including the use of Dimol snuff three negative sets of swabs were obtained by the end of the month. As nothing has been heard from him since discharge, it is presumed that no further infection has occurred. It is of interest that (i) the case gives almost conclusive evidence of repeated infection within a few days; (ii) 5 out of the 6 cases had only one contact with the carrier so that the interval could be accurately assessed. In 4 out of the 5 the interval and presumptive incubation period was four days. These 4 cases were all children, the 5th being an old man. Generalised Schick-testing and immunisation are awaited to end this clinic. Dr. A. B. Porteous, who is in charge of the clinic at St. Mary's hospital, has submitted the following report:— During the year, 36 cases were referred to St. Mary's hospital diphtheria carrier clinic, compared with 22 in the previous year. Of these, 2 were adults and the remainder were children in ages ranging from 14 months to 14 years. 17 cases were consistently negative. 6 ,, gave suspicious organisms in throat only. 9 „ „ „ „ „ nose only. 2 „ ,, „ ,, ,, both nose and throat. 1 „ „ „ „ „ ear only. 1 „ „ „ ,, „ nose, throat and ear. Virulence tests were carried out in 10 cases, and 5 were positive. Vaccines were used in 7 cases, and 3 were referred to the throat department for tonsillectomy and other treatment. The case which was under treatment longest during the year lasted 13 weeks. Two cases were returned patients who had previously been discharged as negative from fever hospitals. Active immunisation against diphtheria. Facilities for Schick-testing and immunisation against diphtheria were provided in three more metropolitan boroughs during the year, making a total of 18 boroughs in which this work is now carried out at the infant welfare or special centres, or by special arrangement with medical practitioners. The Council has assisted in propaganda in connection with this work by authorising the use of the school organisation for the distribution of leaflets issued by the Borough Councils. A reference to the Schick-testing and active immunisation against diphtheria of children in the Council's residential schools and homes appears at the end of this section of the report. Scarlet fever. Although the incidence of scarlet fever did not reach epidemic proportions, the number of cases reported from the schools was high throughout the year ; and 234 special visits were paid to 191 school departments by assistant medical officers. In 24 schools the children were kept under observation by the school nursing staff for various periods. In the course of the special investigations 28,387 children were examined, and 405 excluded from school owing to suspicious conditions of the throat, nose or ears, or skin—but only 8 cases were notified as suffering from scarlet fever at the time of visit. 43 The distribution among the five divisions was as follows:— Table 21. Division. Visits paid. Numbers examined. Numbers excluded. Cases of scarlet fever and deaths, all ages. Cases Deaths. No. Per, 1,000 No. Per 100,000 N.E. 27 3,522 33 3,102 4.1 13 1.7 N. 37 4,819 95 2,942 3.6 11 1.4 N.W. 28 3,133 48 3,037 3.4 10 1.1 S.W. 73 9,918 107 4,306 4.4 13 1.3 S.E. 69 6,995 122 4,885 5.2 19 2.0 Total 234 28,387 405 18,272 415 66 1.5 In all 8,850 cases were reported in the schools, representing an attack rate of 16.8 per 1,000 of children on school rolls, or 18.8 per 1,000 of those in attendance. The figures with regard to the incidence and case mortality are provisional and subject to correction in the various boroughs concerned. Reference was made in the last annual report to the practice which had been adopted at the Cyril Henry treatment centre of immunising children against scarlet fever and diphtheria before tonsil and adenoid operations, with a view to the prevention of the occurrence of those diseases after the operations had been performed. The practice was continued during 1934 subject to parental consent being obtained in each case. The following report on the results obtained has been received from Dr. H. R. Kidner, divisional medical officer:— Scarlet fever. Cyril Henry treatment centre. Pre-operation immunisation against post-operation scarlet fever and diphtheria has beer continued throughout the year 1934. No case of either disease was reported as following the operation in any child who received the injection, but two children, who were not injected because they had suffered from previous attacks of diphtheria, were certified as suffering from scarlet fever and removed to fever hospitals two days and five days, respectively, after the operation. One other child was admitted tc the South-Eastern fever hospital seven days after operation, notified as suffering from diphtheria, but it was proved on bacteriological tests to be streptococcal tonsillitis. Statistics for the year are as follows—- 1,523 children attended for operation. 216 „ were deferred for operation on that day as unfit. 938 „ were injected with the combined serum. 276 „ were not injected because they had had previous attacks of scarlet fever or diphtheria. 93 parents refused consent. Two children had a serum rash during the two days stay in the centre, and 87 were reported by the nurses visiting the homes subsequently as suffering from a "reaction," usually an urticarial rash; the parents are all warned that this may happen and in no case was the child reported as being seriously affected. The operating surgeons are satisfied that the inoculation is of value. One reports definitely fewer cases of pyrexia, to which he was called after the operation, in the proportion of roughly 6 to 1, and he has adopted the procedure in his private practice. The sister-in-charge reports fewer post-operative complications such as haemorrhage and sepsis. During the year, 144 cases of smallpox were notified (and confirmed), and of these 46 were among school children. All these cases occurred during the period January to June. The few cases notified after June proved not to be smallpox. The following statement shows the number of cases occurring among school children grouped in school terms, for each division:— Smallpox among school children. Table 22. Division. Spring term. Summer term. Autumn and winter term. Total. N.E. - - - - N. 25 5 — 30 N.W. — — — — S.W. 2 — — 2 S.E. 10 4 — 14 Total 37 9 — 46 44 The cases were all of the mild type and without exception occurred amongst unvaccinated children. 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, 70 children in one school 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, was continued. These contacts were kept under daily supervision by the school nurses, whose services have again been used in connection with the daily surveillance of schools attended by children notified as cases of smallpox. The following table summarises the reports submitted by the school nurses in connection with this work:— Table 23. 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. 16 (9) - - 4 5 5 N. 535 (27) 7 29 87 34 344 N.W. - — — — — — S.W. 109 (6) — — 13 4 34 S.E. 160 (11) — — 28 39 74 Total 820 (53) 7 29 132 82 457 Experience of the type of mild smallpox again showed the difficulties arising from the numbers of missed cases, and efforts were directed to ascertaining at the earliest possible moment the reasons for absence from school. As a result of intensive investigation and close co-ordination between the officers of the school medical and nursing service, the school attendance staff and the borough health services, a few previously undetected cases were brought to light. Measles. The biennial epidemic of measles, which began in London in the autumn of 1933, continued until July, 1934. During the period of the epidemic (9 months) 38,949 cases were reported from the schools, compared with the 35,705 reported during the epidemic (9 months) of 1931-32. A special report dealing with various aspects of the epidemic, such as incidence, mortality, treatment, administrative measures, use of serum, is being prepared for publication. Whoopingcough, chickenpox, mumps. The following are the numbers of schools kept under daily supervision for varying periods by the school nursing staff on account of the diseases mentioned : whooping-cough, 38; chickenpox, 134; mumps, 111. In the course of their visits to these schools, the school nurses inspected the children and advised the head teachers as to exclusion or re-admission to school. Scabies. A reference to the action taken in connection with the ascertainment and treatment of cases of scabies appears elsewhere in this report. The children at two schools were kept under special observation for a time by school nurses on account of the occurrence of several cases of the disease amongst the children. Ophthalmia. Minor outbreaks of ophthalmia occurred during the year at four schools. The children in the affected schools were kept under supervision by the school medical and school nursing staffs, working in close co-operation with the borough health services. Measures were taken to obviate the spread of infection through the use of school towels. 45 The following table shows the number of cases of ringworm of the scalp among Ringworm, the children in the Council's schools dealt with during 1934 compared with the figures for preceding years:— Table 24. 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 1933 336 334 86 68 1934 265 281 65 73 During the year, 603 specimens of hair from school children, were examined for ringworm at the laboratory at the County Hall. Ringworm fungus was found in 195 of these (132 small snore and 63 large spore) Two cases of favus were discovered after microscopical examination. 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 have continued 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. Favus. Play centres. The special arrangements were continued for the medical examination of children before departure for school journeys. Particulars of the general arrangements made for school journeys during 1934 are set out on page 53. School journeys. There was a minor outbreak of chickenpox at Mile Oak school in the spring. No other cases of infectious illness occurred in the approved schools. Nine cases of diphtheria occurred during the year at the Ponton-road remand home. As a result of swabbing, 2 virulent carriers were found. References to the progress of active immunisation against scarlet fever at the Mayford school and of active immunisation against diphtheria at Mile Oak school appear later in this section of the report. Approved schools and remand home. A lew sporadic cases ot diphtheria, scarlet lever and chickenpox occurred in the three residential open-air schools. The few cases of infectious diseases that occurred amongst the children in the residential special schools do not call for special comment. Reference to the scheme of active immunisation against diphtheria in these schools appears later in this section of the report. Residential open-air schools. Residential special schools. As stated in the last annual report, children to be admitted to a receiving home who are known to have been in contact with infectious disease are sent in the first instance to a " contact" block at Earlsfield House receiving home. Contacts of infectious diseases at the three receiving homes have also been admitted to this block. With regard to the latter group, the restricted accommodation of the contact block necessitated a careful selection of contacts being made. These arrangements have worked satisfactorilv and will be continued. Residential schools, children's homes and children's receiving homes. During the year, 153 children were admitted to the " contact" block at Earlsfield House under these arrangements; of these 30 developed the disease to which they had been stated to have been exposed and 8 developed other diseases. A brief review of the incidence of infectious illnesses in the residential schools, children's homes and children's receiving homes during 1934 is set out below. The cases of infectious illness (except scabies and impetigo) were removed to one or other of the Council's hospitals. All practicable steps were taken in close cooperation with the officers of the schools and homes with a view to preventing the spread of infection. D 46 Diphtheria.—During the year 75 children were transferred to the fever hospitals as cases of clinical or bacteriological diphtheria. Of these 20 proved to be purely bacteriological, 28 were diagnosed as suffering from clinical or faucial diphtheria, and 14 as nasal diphtheria. In the remaining 13, the diagnosis of diphtheria was not confirmed. In connection with these cases 572 children were swabbed in 16 of the schools, diphtheria bacilli being found in culture from the throat or nose in 53, and, of these, 50 proved to be virulent and only three avirulent. The virulent cases were removed to hospital. Re-examination of 18 children showed diphtheria bacilli to be present in 14. In addition, 28 adults employed in the schools and homes were swabbed, all proving negative except one, in whom virulent diphtheria bacilli were found. The results of examinations in 1934 of children in the residential schools and homes may be compared with those of the two previous years, as follows:— Table 25. Year Number of children swabbed. Diphtheria bacilli found. 1934 572 *53 1933 791 56 1932 1,622 98 *50 virulent; 3 avirulent. Scarlet fever.—Cases of scarlet fever of mild type occurred in several of the schools and homes. A minor outbreak occurred at one of the receiving homes, but its spread was speedily arrested. Measles—The effects of the measles epidemic were felt in most of these establishments during the first half of the year. German measles—An outbreak of German measles occurred in one school, and there were groups of cases at three others. Whooping-cough—A few cases of whooping-cough were reported from some of the schools. Chickenpox—Outbreaks of chickenpox occurred in four of the schools, and more or less isolated cases were reported from some of the other establishments. Mumps.—There was a series of cases of mumps in each of two schools, and some isolated cases elsewhere. Scabies—Cases of scabies were reported from six of these establishments. Impetigo—There were cases of impetigo in six of the schools. Ophthalmia and conjunctivitis—A group of cases of ophthalmia and conjunctivitis occurred in one school. Ringworm—A few cases of scalp ringworm occurred in these establishments. As stated in the last annual report, a Wood's glass analytical lamp has been provided at each of the schools and homes where electric current is available, and all new entrants are "lamped" as a routine. Specimens of hair stumps taken from suspected cases were microscopically examined from time to time in the laboratory at the County Hall. Out of 24 specimens examined, ringworm fungus was found to be present in 5 (4 small spore and one large spore). As stated in the last annual report an outbreak of body ringworm occurred amongst the boys on the training ship "Exmouth," during the winter months of 1933-34, which necessitated the evacuation of the ship (on 29th January) and the temporary transfer of the boys to the Hanwell residential school which was then empty. The first cases occurred at the end of September, 1933, but such preventive measures as the daily inspection of the boys, the immediate removal to the shore infirmary of suspected cases and the disinfection of clothing, bedding, etc., appeared to have little effect on the spread of infection, and it was decided that all the cases should be immediately removed to Goldie Leigh or Queen Mary's hospital and that one of the Council's dermatologists (Dr. J. M. H. MacLeod), who is also visiting 47 consultant to Goldie Leigh hospital, should visit the ship from time to time for the purpose of examining the boys and advising as to preventive measures to be taken. On Dr. MacLeod's recommendation the heads of all the boys on the ship were examined from time to time, specimens from suspected cases being microscoped. Additional medical staff was provided to assist Dr. Vickerman Smith, the medical officer of the ship, with the daily examinations. A certain amount of washing of clothing, etc., had been carried out on board the ship. This was, however, discontinued; all laundrywork being sent, after disinfection, to one of the Council's hospital laundries. Special care was taken to prevent the promiscuous wearing of caps and clothing. Dr. MacLeod kept the cases (which were treated by X-rays) under observation at both the hospitals named above, and on his recommendation the boys who had suffered from the disease were kept in quarantine for a period of three weeks after they had been stated to be cured. Dr. MacLeod reported that the disease was in the form of small red patches, some of which were dotted over with yellow heads which were distributed on the skin, in most cases on covered parts of the body, and that, though the lesions had all the appearance of being due to a ringworm fungus, it was impossible from their appearance to decide the exact fungus, and that on cultivation for a week the fungus was found to be the trichophyton crateriforme (Sabouraud), one of the ringworm fungi of the endothrix group which grows on the human skin and scalp and is not of animal origin. He further stated that endothrix ringworm had been until recently a rare variety of ringworm in this country, forming only four per cent. of the total cases, and that it is more difficult to exterminate than the ordinary microscopic type for the following reasons:—(i) it is more difficult to diagnose on the scalp, as it commences in minute patches so small as to be difficult to find, and the broken hairs do not form stumps but break off so short as to resemble blackheads; (ii) the infected hairs do not fluoresce with Wood's glass light; (iii) it is impossible to diagnose it with certainty without a microscopical examination and possibly a culture; (iv) it differs from microsporon ringworm in not dying out on the scalp at the age of puberty. Dr. MacLeod recommended that, as ringworm spores in the dry state remain viable for at least six months, the ship should be evacuated. Before entering the Hanwell school, every possible precaution was taken to ensure that all the boys and their gear, etc., were free from any suspicion of infection, but one boy was slightly infected with the same type of ringworm three weeks after arrival at Hanwell. The necessary cleansing and disinfection of the ship was completed during February and March, and the boys returned in batches during the week ending 7th April. No case of the endothrix type of ringworm occurred amongst the boys after that date. In all, 122 boys were reported as suffering from body ringworm during the outbreak. The arrangements for the schick-testing and active immunisation against diphtheria of the children in the residential schools have been described in previous annual reports. Active immunisation against diphtheria in the residential schools, etc. The progress of the work during 1934 is shown in the following table Residential schools and children's homes. Residential special schools. Number tested for susceptibility to diphtheria 1,850 169 Number of susceptibles found 760 48 Number of susceptibles whose course of immunisation had not been completed during 1933 116 10 Number who completed the full immunising course and gave Schick negative reactions on re-test 611 48 Number who left the schools before course of injections had been completed 81 1 Number outstanding on 31st December, 1934, who had received one or more injections and whose course of immunisation was to be completed in 1935 184 9 D 1 48 The numbers of children residing in these schools and homes on 31st December, who had not been Schick-tested, were as follows:— Residential Residential schools and special children's schools. homes. New admissions194 23 Parental consent refused155 34 Not tested for other reasons81 6 Total430 63 The medical officers of the schools state generally that there has been little or no local or general reaction to the formol toxoid, that the process of immunisation has not interfered with the ordinary routine of the children in their home and school life and that the percentage of parental refusals is comparatively small. They further state that there is often delay in receiving consents, due apparently to lack of interest on the part of the parents. The following report made by Dr. A. W. Soper, the medical officer of Anerley residential school, is of interest, as it shows the results obtained in one of the largest of the Council's residential schools and children's homes:— Active immunisation was commenced at this school early in 1934:— Number of children Schick-tested 459 „ „ positive 147 „ ,, negative 312 „ who left before completion of immunisation 16 „ of parental consents refused 28 „ of children completely immunised (re-Schick negative) 131 Eleven children were admitted to the infirmary with slight pyrexia, the longest time in the infirmary being three days. One child developed diphtheria on the 3rd day after the Schick test. The introduction of the scheme of active immunisation against diphtheria at Mile Oak approved school, with accommodation for 150 boys, was authorised by the Education Committee on 25th April, 1934, after the consent of the Home Office had been obtained. The work, which was begun in August, was undertaken for the first few weeks by Dr. L. J. M. Laurent of the Western hospital, and was taken over by Dr. F. H. Allfrey, the medical officer of the school, in October. During the year, 167 boys were Schick-tested and of these, 43 gave positive reactions, 121 were negative and 3 left before the result of the test was read. The course of three injections was completed, followed by negative re-tests in the cases of 34 boys, 3 left the school before immunisation had been completed, and there remained 6 for completion of the immunising process in 1935. Twelve boys had not been Schick-tested at the end of 1934. Active immunisation against scarlet fever. Active immunisation against scarlet fever of the children at the Shirley residential school was commenced on 1st February, 1934. Dr. C. M. Jones, the medical officer of the school, took over the work in April from Dr. L. J. M. Laurent of the Western hospital. Active immunisation against scarlet fever has been continued at Mayford approved school by Dr. L. G. Higgins, the medical officer of the school. The progress of the work at these two schools during 1934 is shown in the following table:— Shirley residential school. Mayford approved school. Number tested for susceptibility for scarlet fever 469 45 Number of susceptibles found 66 15 Number who completed the full immunising course and gave negative reactions on re-test 52 7 Number who left the schools before immunising course had been completed 3 - Number outstanding on 31st December, 1934, who had received one or more injections and whose course of immunisation was to be completed in 1935 11 8 49 Open-air education. Provision for education in the open air includes nine day open-air schools (non-tuberculosis) with accommodation for 1,460 children, and six day open-air schools (tuberculosis) accommodating 515 children. There are also seven country and seaside convalescent camp schools, accommodating 520 children for periods varying from one to three months, through which 4,432 children pass annually; and 220 open-air classes in playgrounds and parks providing for upwards of 6,000 children. Provision. The nine day open-air schools for non-tuberculous children maintained by the Council have continued their excellent work. The following table gives the roll of these schools on 19th December. 1934:— Open-air schools for non-tuberculosis children. Boys. Girls. Total. Aspen House 89 58 147 Bow Road 109 82 191 Brent Knoll 84 48 132 Charlton Park 86 59 145 Downham 94 51 145 Holly Court 179 115 294 Stowey House 156 116 272 Upton House 86 60 146 Wood Lane 85 58 143 Total 968 647 1,615* *Note—The roll of an open-air school may be 20 per cent. above the nominal accommodation. Interesting reports are invariably received from the school doctors regularly siting the day open-air schools (Type 0). Two such reports on the work of the ar are set out below. Dr. T. Legge has reported as follows upon Holly Court en-air school:— Number on roll, January, 1934 241* Number admitted during the year 136 Children removed from roll during 1934— Fit for elementary school and over age 67 Removals from district 10 Transferred back to elementary school at parents' request 11 For periods at convalescent hospitals 17 Miscellaneous 9 114 *Note—Admissions exceeded discharges during the year by about 50. As a site for an open-air school in London, Holly Court cannot be beaten. It lies on a ithern slope of the " northern heights," on the borders of Parliament Hill Fields, Kenwood and Hampstead Heath. This unsurpassed situation gives great scope for many delightful rambles for nature study and for open-air geography. Physical activities have been largely incorporated into the lessons. A considerable proportion of the work consists in gardening, woodwork, building construction, nature rambles, dancing, singing and games. The new Board of Education syllabus of physical training has been adopted with slight modifications, the more strenuous exercises being omitted. For these ysical activities the classes are organised into boy's and girl's sections separately, whereas for the ordinary school work the classes are " mixed." The summer of 1934 being particularly sunny, progressive sun bathing was much indulged during the warmer months on the school lawn; the special sun bathing costumes being designed and made at the school. A marked feature of the school is the small number of children who contracted infectious diseases, there being only three cases of notifiable disease during the year. About 12 to 20 is the average number of minor ailments treated daily by the sister at the school. Steps are now being taken to improve the facilities for drying wet clothes at the school; and the voluntary boot club continues to function in a satisfactory manner. Much thought has been given by the head master and staff, to the question of the children's diet. It has been possible to improve and vary the menus considerably. Particularly have the amounts of milk, fresh fruit, vegetables and salads been increased. That bane of institutional feeding, the stereotyped weekly menu, with the same dishes re-appearing on the same days of the week invariably and ad nauseam, has been done away with. Here the children never know beorehand what the pitce-de-resistance and "afters" for mid-day dinner are going to be. This Holly Court open-air school. 50 fact undoubtedly increases the appetite and gusto for food; indeed, the astonishingly large helpings that the older children will put away, should be seen to be believed. Of the many benefits this open-air school regime confers on these young developing souls, the sum total of which is of incalculable value to them, it seems to me that the most important single physical factor—the sine qua non—is the wholesome and adequate feeding which these hungry youngsters get. Upton House open air sohool. Dr. J. L. Newman has reported as follows upon Upton House open-air school:— The number of children on the roll of the school has stood fairly consistently throughout the year 1934 at about 130. Room could actually be found for some 20 more, but it is fortunate that the maximum number has not been maintained, since with a margin to spare, there is no risk of urgent cases being kept waiting. The defects from which the 130 are suffering are made up as follows— Infections (styes, boils, otorrhœa) 4 Adenitis, cervical 7 Lung diseases— Asthma 3 Recurrent coughs, simple 15 „ „ with signs of bronchitis 16 „ „ with signs of more gross lung damage 10 Mediastinal adenitis 2 — 46 Skeletal defects— Postural 7 Old tuberculous 1 8 Nervous disorders— Organic 1 Functional 11 — 12 Tuberculosis contacts 20 Miscellaneous (anaemia, debility, delicate) 33 Total 130 The 66 children who make up the first four and a half groups in this classification are all suffering from some defect which is either interfering with their school work and attendance, or may be expected to do so if curative measures are not undertaken. All have done well, and even of the ten who show signs of fibrosis of the lung with or without bronchiectasis, none has given any evidence of that progressive deterioration, and sometimes rapid decline, which is only too often seen in the out-patient departments of our hospitals. The group of tuberculosis contacts consists of those who have recently been in an unsatisfactory state of health, or who are living under bad home conditions from which it is desirable to remove them as far as possible. None of them has shown any signs of active tuberculosis. There remains the large group of children, 44 in number, who are suffering from functional nervous disorders or have been labelled anaemic, debilitated or delicate. These are fundamentally healthy children, who may be considered under two headings. First there are those whose home conditions are so prejudicial as to interfere with their education, and, of these, the following are typical cases:— P.Q. was nervous, tearful and could not concentrate. No physical abnormality. Father, suffering from "war neurasthenia," worries her and assaults her mother. X.Y. was always ailing" and often away from school. No physical abnormality. She is one of 15 living in a basement flat. Under the second heading comes a large group of children who are pale, thin or dark under the eyes, and, although they show no evidence of disease, they are a source of anxiety to parents, teachers and sometimes even to nurses and physicians. They are easily, often too easily, labelled anaemic, debilitated and delicate ; and, from their being often spoken of in this way, the confidence of all concerned in their physical welfare is undermined, and the foundations of a neurosis are laid. For such children as these, a course at an open-air school is of great value, since a period of close physical supervision combined with a graph showing a satisfactory gain in weight is much the best way of demonstrating a real freedom from disease, and at the same time, it does occasionally allow the diagnosis of debility to be amended to one of organic disease. Moreover, there is always the educative value of life at such a school as this, for even in these days of intensive health propaganda, the beneficial and not unpleasant effects of currents of fresh air, no less than the other items in the regime, have often to be experienced to be believed. Of the 35 children returned to elementary schools during the year, 32 were of this latter kind, and the other discharges were made up as follows:—at age of 14, 33 : at parents request, 3; left district, 4; while 17 were transferred to other special schools, convalescent homes, etc. 51 In addition to the provision of treatment for tuberculous children in residential institutions, the Council continued the use of the open-air schools (type T) specifically for children with quiescent tuberculosis and for those suspected to be suffering from tuberculosis or living in conditions rendering them particularly liable to the disease. The tuberculosis officers of the areas in which the schools are situated serve as medical officers of the schools and pay weekly visits to them. Open-air schools for tuberculous children The six schools—Elizabethan (Fulham), Geere House (Stepney), Kensal House (Paddington), Springwell House (Battersea), Stormont House (Hackney), and Nightingale House (Bermondsey) have a total nominal roll of 618. The number on the roll on 31st December, 1934, was 572, and the average attendance for the year was 494.4. 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 1934, 216 children were admitted and 214 discharged. Of the latter, 50 were transferred as fit to attend elementary schools, 112 were fit for work, 3 were transferred to institutions for residential treatment for tuberculosis or admitted to hospitals for various reasons, 25 moved away, 15 were transferred to special schools, and 9 were discharged for other reasons (e.g., the distance was found to be too great for the children). Efforts were made to secure that, during 1934, every child in attendance at these schools should have a holiday out of London either by means of private arrangements or through the education school journey organisation. The following school journeys were made during the year, through the ordinary school journey organisation:— Table 26. School Period. Place visited. No. of children. From To Elizabethan open-air school 1.6.34 14.6.34 Whitstable 21 2.7.34 15.7.34 „ 24 Geere House 15.6.34 29.6.34 Chelmsford 25 Kensal House 15.6.34 29.6.34 Whitstable 25 31.8.34 13.9.34 „ 25 Nightingale House (Boys) 22.6.34 5.7.34 Littlehampton 45 „ (Girls) 10.7.34 24.7.34 „ 35 „ „ (Mixed) 3.9.34 16.9.34 „ 40 Stormont House 16.5.34 28.5.34 Broadstairs 70 Springwell House 31.8.34 13.9.34 Isle of Wight 80 In addition, provision was made for a further 56 children in accommodation specially set aside for the purpose at Princess Mary's hospital for children, Cliftonville, Margate. They went in two parties for a fortnight each, from 8th September to 6th October. The accommodation thus utilised was designated for the period, "The Holiday School." Only a very small residue of children failed to receive a holiday for various reasons, such as removal from district, private arrangements for holiday failing to material etc. The numbers of children passing through the residential convalescent camp schools during 1934 were: boys, 2.860; girls, 1,572; total, 4,432. Convalescent camp schools. The experimental camp school for mentally defective children, at Loughton has already been described (Annual Report for 1932, Vol. Ill, Part II, p. 38). In detail the numbers were:— Provided schools:— Boys. Girls. King's Canadian school, Bushy Park 2,835 — George Rainey, St. Leonards — 574 Wanstead House. Margate — 533 Total2,835 1,107 52 Non-provided schools:— Boys Girls Fairfield House, Broadstairs — 173 Russell Cotes school, Bournemouth — 239 St. Vincent's, Hastings — 28 Loughton 25 25 Total 25 465 The actual number of children away at these schools at one time in November, 1934, was: Bushy Park, 270; Margate, 64; St. Leonards, 64; Bournemouth, 30; Broadstairs, 36; Hastings, 4. Total, 468 children, of whom 198 were girls and 270 boys. The head master of the King's Canadian residential open-air school has submitted the following account of the physical activities:— In addition to the physical training taken in the ordinary class-work, 1,579 boys, out of a total of 2,835 admitted to the school, received further exercises. Of these, 521 boys received special corrective exercises. With regard to general training, difficulties arise owing to the great differences of age of boys in the same class. This difficulty has been overcome, however, and new progressive courses for four and six weeks have been made to suit the younger boys, while giving ample scope to the senior boys. Special remedial work does not present this difficulty, as each child is given individual attention. Cases for treatment are chosen by the school doctor and include boys having a tendency towards kyphosis, lordosis, scoliosis, torticollis and flat feet. Serious cases of flat feet are followed up after leaving the school. Such cases have totalled 30. Special cards of corrective exercises are issued to flat feet cases for use in the home, while cards giving general instructions with regard to carriage, posture and breathing are issued to the remainder. In this way an effort is made to further and complete the work done in the school. A pleasing feature of the work is the interest and enthusiasm shown by the parents of the children, and this assists the work considerably. As in 1933, the physical standard of boys from Paddington, Peckham and Deptford is considerably below that of the remaining districts visiting the school. Below is a summary of cases treated at the school:— Total on roll 2,835 Total taken for general remedial exercises 1,579 Total taken for special remedial exercises 521 The numbers of special cases treated were: kyphosis, 180; lordosis, 74; scoliosis, 48; torticollis, 2; flat feet, 179; mouth breathing, 37; knock knee, 1. The average increase in weight (four weeks) was 2.5 lb. Of the 2,835 boys admitted in 1934, it was possible to grant extensions to 179 for health reasons. During the year 22 boys suffering from infectious diseases were transferred to appropriate hospitals while 3 others were admitted to hospital for other serious illness. During the year 18 were nursed in the sick ward at the school. The number of separate treatments for minor ailments given by the school nurses was 19,332. It has been found possible to continue at the school the treatment of 30 stammerers. Particulars of dental treatment carried out during the year are as follows Total number of bovs treated1,624 Extractions (a) under gas 243 (6) local anaesthetic 143 Fillings 1,077 Scalings 636 Gum treatment number of boys 189 Fairfield House, Broadstairs. The children on their return from the camp schools are kept under observation by the school care committees. An analysis of notes made by them in regard to a number of children who went to Broadstairs shows that, in 90 per cent. of the cases, not only were the children remarkably improved on return from their stay, but that this improvement in health was maintained for many months, and indeed as long as observation has been kept up, extending in some instances into after-school life. The children at Broadstairs are examined at the beginning and end of their stay for the haemoglobin content of the blood. An examination of a number of the records on the return of the children shows that there was an average increase of 8.7 per cent. in haemoglobin. Open-air classes in parks and playgrounds. The number of open-air classes held in connection with the elementary schools in 1934 was 220, an increase of 11 compared with 1933. Of these 12 were of type A (children selected on medical grounds from a group of schools); 85 were of type B (children selected on medical grounds from the various classes of a single school); 53 34 were of type C (consisting of a single class from one school, educated continuously at one open-air station); and 89 of type D (consisting in a rotation of classes from one school occupying one open-air station). Nine classes are permanent, that is to say they are outside the yearly programme and do not need re-authorisation each year. In addition, 62 classes were continued throughout the winter, where the suitability of the sites had been approved by the school medical officer. About one-third of the classes were held in parks, gardens, playing-fields and other open sites, while the others were held in school 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 anaemic, and require special care. They may be termed for shortness the bronchitic type and the rheumatic type. The former thrive only on open-air treatment of the sanatorium type, and for these the more exposure they get the better they are, 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. Forty-six 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 beneficial effect upon the health of the children, a few do not give such satisfactory results. Dr. A. B. Francklyn has made a careful study of the heights and weights of the children in two open-air classes—those at Barlby-road and Essendine-road schools, and has compared the rate of growth of the children with that of poorly nourished children retained in the ordinary school, who were given milk in school on the doctor's advice. This report is printed under "special enquiries" on page 85. Barlby-road and Essendine-road open-air classes. School journeys. In 1934, 407 school journeys were made (compared with 358 in 1933), and the children taking part were medically examined in all cases before departure. In all 13,569 children were examined (the corresponding figure for 1933 being 12,185); and of these 72 were excluded as unfit to take part in the journeys on various grounds, including the following (the figures in parenthesis refer to the year 1933):—otorrhoea, 7 (10); infectious disease or contacts, 4 (2); tonsillitis and kindred ailments, 12 (9); temperature, 11 (11); personal hygiene, 2 (0); skin diseases, 14 (14). Several children were provisionally rejected on grounds connected with personal hygiene but were subsequently passed after visiting a bathing centre. Separate figures are given on page 51 respecting the school journeys from open-air schools for tuberculous children. Physical education. Complete particulars of the arrangements for physical education in the London elementary schools were given in the last annual report. The organisers report biennially. In January, 1934, a circular was issued to all schools drawing attention to the Board of Education's syllabus of physical instruction for schools, 1933, and explaining its use. Mention has been made (page 8, of the advanced provision for physical education now being included in plans of new and remodelled schools. Formerly the standard rules for playgrounds merely gave the area of the playground, viz.: 30 square feet for older children and 16 square feet for infants. This took no account of the shape of the playground, and it was found that, although the requisite area was provided, the shape of the playground was often such as to render much of the space useless. The new standard planning adopted by the Council in 1934 takes into account the lay-out of the playground as well as its area. The new standard is: shape to permit 54 of 1 pitch. 160 by 110 feet, or 2 pitches each 110 feet by 60 feet; 2 concrete cricket wickets for net practice for boys; a jumping pit; a garden plot of about 100 square yards; 20 square feet per head to be provided for infants, with separate playground of 800 square feet or more near the babies' room. Provision of meals. Dinners are provided for necessitous children attending school, and follow menus which have been approved by the school medical officer. Samples of meals provided are taken from time to time and submitted for analysis by the Council's chemist. Forty-two samples (representing 21 two-course meals) were examined during the year, the required standard being that each complete meal should contain 25 grammes protein and have a heat value of 750 calories. It is the function of the school care committee to place upon the feeding list every necessitous case requiring additional nourishment in order to profit by the education provided. It is considered reprehensible to wait until ill-nourishment due to lack of food has occurred to the extent that it requires the intervention of the school doctor. The head teacher of the school is empowered immediately to place any necessitous child provisionally upon the dinner list, without waiting either for the care committee's consideration of the case, or for the school doctor's visit. The arguments which led the Council to adopt economic rather than medical grounds for feeding necessitous school children were as follows:— (a) If no action is taken until the child shows signs of malnutrition, the child must already have gone through a stage of suffering unalleviated, in which he or she was unable to take full advantage of the education provided and unnecessary suffering is inflicted, which the Education Committee refused to contemplate. A wise education authority will prevent malnutrition, not wait until it is established. (b) The sudden cessation of food supply to a vigorous, well-nourished child immediately produces suffering, and prevents that child taking full advantage of the education provided even within a few hours, although a doctor could find nothing wrong. The child is hungry and obviously cannot pay attention to its lessons, and the more vigorous and healthy the child is the greater his suffering. It would be cruel to deny such a child food, yet no doctor could find anything more than any lay person, i.e., a medical examination is unnecessary. It is well known that ill-nourished children do not suffer to the same extent. By a merciful dispensation of providence after the pangs of the first week or so the body sinks into a dull tolerance of the condition and the children cease to feel hunger ; and, although malnutrition will after some time become apparent on medical examination, the failure of the children to take full advantage of the education provided is less obvious than it is when the condition is acute and the children's vigour still present. While children are placed upon the school dinner list as soon as there is social need, and before malnutrition has had 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 by the care committees and the school doctors and are weighed regularly by the school nurses. The practice of giving milk under the powers of the Education (Provision of Meals) Act, 1906, to children found at medical inspection to be debilitated began in London in 1909. In the winter of 1909-10, Dr. Hawkes a part-time school doctor working in Bethnal Green called attention to the children of one school (Wolverley-street). Most of them belonged to large families dwelling in small 55 houses, in almost chronic destitution, the mothers often being the bread-winners and the fathers out of work. At the medical inspection a list was recommended to the school care committee as suitable for extra meals of milk and cod-liver oil. Of 91 children who had been assessed as "nutrition 4," i.e., definite malnutrition, who had been placed on milk, only 9 were so assessed at the end of the year. Thus commenced a practice which proved of great importance. It rapidly spread from school to school in London and became a recognised part of the Council's measures for combating ill-nourishment in school children. Later the example of London was followed by many of the provincial authorities. Under the Milk Act, 1934, the scheme of the Milk Marketing Board was introduced for the supply of milk at reduced prices to all children attending school in October, 1934. Particulars of the scheme so far as it affects London are given later in this section. The number of official milk meals supplied in elementary schools by the Council in 1933-34 was nearly 4¾ millions, of which rather more than 2½ millions were paid for out of the rates. The price now charged to parents in a position to pay for the official milk meals is that fixed under the Milk Marketing Board Scheme, viz. ½d. for one-third pint bottle. The numbers of individual children receiving each type of meal were as follows:— Table 27. Meal. May, 1934 (21 school days). November, 1934 (22 school days). December, 1934 (14 school days). For payment. Free. For payment. Free. For payment. Free. Dinners 1,249 6,934 1,604 5,892 1,495 5,725 Milk 12,696 14,513 11,768 14,997 11,235 15,691 Cod-liver oil and malt... 3,272 2,136 3,028 2,234 3,014 2,190 The monthly averages of individual children fed for the calendar year, 1934, were: for payment, 16,214; free 20,686. The numbers of individual children fed in December, 1933, were:— Table 28. Meal. On payment. Free. Dinners 1,284 7,190 Milk 12,641 12,775 Cod-liver oil and malt 3.816 2,094 There was thus a decrease of 14.3 per cent. in children on dinners, an increase of 5.9 per cent. in those on milk and a decrease of 11.9 per cent. in those on oil and malt in December, 1934, compared with the number in December, 1933. The children who are given milk in school on the advice of the school doctor are kept under very close observation. They are all children whose nutritional state gives, or has given, some cause for anxiety. Notes on the improvement of such children are given in Dr. Francklyn's report on page 85. In the north-eastern division, Dr. Chaikin has given very close attention to the following up of the children on "official" milk, and he has supplied a very detailed statistical report on the results of the re-inspections of the children during 1934, from which the following summary is compiled. Records of 5,849 current cases were available for analysis, comprising 2,977 boys and 2,872 girls. Dr. Chaikin's report on children oa milk. 56 The length of time the children had been on milk and the ages (years of birth) of the children are given in the following tables :— Table 29. Year of birth. Meals commenced in the following years and under observation since : 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 Boys (milk being continued) 1919 — 1 — 1 2 1 — — — — 1 1920 9 4 12 7 — 3 4 4 2 2 — 1921 41 110 27 25 18 31 17 14 5 5 1 1922 35 46 26 18 46 31 27 23 6 — — 1923 44 60 28 68 25 25 23 4 — — — 1924 31 79 107 60 47 41 16 4 — — — 1925 56 173 69 68 50 33 3 1 — — — 1926 101 99 82 66 23 9 - - - - - 1927 105 134 78 31 10 - - - - - - 1928 100 116 58 10 - - - - - - - 1929 91 68 25 1 - - - - - - - 1930 28 17 - - - - - - - - - 1931 5 - - - - - - - - - - Total 646 907 512 355 221 174 90 50 13 7 2 Girls (milk being continued). 1919 1 2 1 5 - - - - - — — 1920 9 12 19 9 6 6 6 3 2 2 — 1921 51 95 41 34 15 30 17 5 9 3 — 1922 53 57 41 34 46 20 20 16 2 2 — 1923 62 51 30 69 29 17 20 5 2 - - 1924 46 60 98 45 38 51 12 5 — — — 1925 61 159 61 55 40 17 5 - - - - 1926 110 75 82 58 19 3 - - - - - 1927 85 117 79 34 8 1 - - - - - 1928 93 106 46 11 - - - - - - - 1929 90 65 15 1 - - - - - - - 1930 37 21 - - - - - - - - - 1931 4 - - - - - - - - - - Total 702 820 513 355 201 145 80 34 15 7 — A number of children, at the inspections in the last term of 1934, were found no longer to require official meals, which they had been receiving. There were 232 girls and 203 boys. The following table shows the distribution according to the year of birth, the state of nutrition, and the number in each year:— Table 30.—Children discharged from official milk scheme. Year of birth. Number. 1 Excellent. State of Nutrition. 4 Malnourished. 2 Normal. 3 Slightly sub-normal. Boys. 1919 6 2 4 — — 1920 7 — 7 — — 1921 15 2 13 — — 1922 15 4 10 1 — 1923 34 6 27 1 — 1924 38 7 31 — — 1925 29 5 24 — — 1926 23 4 18 1 — 1927 15 3 12 — — 1928 17 2 14 1 — 1930 4 — 4 — — Total 203 35 164 *4 — Percentage 17.2 80.8 2.0 — *In these cases it was found that milk did not suit the children and convalescence or reference to hospital for treatment was advised. 57 Year of birth. Number. State of Nutrition. 1 Excellent. 2 Normal. 3 Slightly sub-normal. 4 Malnourished. Girls. 1920 6 1 5 - - 1921 28 8 20 - - 1922 25 7 18 - - 1923 30 3 27 - - 1924 31 9 22 - - 1925 45 8 35 2 - 1926 31 8 23 - - 1927 17 3 14 - - 1928 12 2 9 1 - 1929 7 3 4 - - Total 232 52 177 *3 - Percentage - 22.4 76.3 1.3 — *In these cases it was found that milk did not suit the children and convalescence or reference to hospital for treatment was advised. The range of years of commencement of the above "official" meals was from 1927 to 1934. The subjoined table shows the comparative state of nutrition of 6,284 boys and girls in the current and discharged groups, the percentages being given in italics:— Table 31. Group. State of nutrition. Border-line cases. Total. 1 2 3 4 1/2 2/3 3/4 Discharged boys 35 164 4 - - - - 203 17.2 80.8 2.0 - - - - - Current boys 75 1,688 984 18 5 207 - 2,977 2.5 56.7 33.1 0.6 0.2 6.9 - - Discharged girls 52 177 3 - - - - 232 22.4 76.3 1.3 - - - - - Current girls 67 1,668 883 19 4 230 1 2,872 2.33 58.08 30.74 0.65 0.14 8.01 0.04 - Total 229 3,697 1,874 37 9 437 1 6,284 Percentage 3.66 58.83 29.82 0.59 0.14 6.95 0.01 - It will be noted that a small percentage of children with "excellent" nutrition continued to receive milk. These were children whose parents were unable to pay for milk in school, and who were formerly of poor nutrition. The school doctors noted the progress of the children, and their remarks have been collected into three groups or classes which are:— Group A.—Those with the best progress. Group B.—Those with fair, "average" or slight progress. Group C.—Unsatisfactory. Particulars in regard to children who continue to receive milk are set out below:— Table 32. Sex. A. Definite improvement. B. Slight improvement. C. Stationary or unsatisfactory. Number Per cent. Number Per cent. Number Per cent. Boys 1,656 60.1 877 31.9 219 8.0 Girls 1,674 62.5 834 31.2 168 6.3 58 The following are the corresponding figures for children to whom milk is no longer given:— Table 33. Sex. A. Definite improvement. B. Slight improvement. C. Stationary or unsatisfactory. Number Per cent. Number Per cent. Number Per cent. Boys 182 90.5 14 7.0 5 2.5 Girls 220 96.1 9 3.9 - - The heights and weights of the children placed on milk were ascertained by a random sampling of the records of 100 boys and 100 girls born in 1925 (aged 9), and in the following tables are compared with the average heights and weights of London children at the same age:— Table 34. Sex. Height. Weight. Milk children London averages. Milk children. London averages. cms. c.ms. kilos. kilos. Boys 125.8 125.2 25.8 25.5 Girls 128.1 124.7 23.6 25.0 The increase in physical measurements over a period of one year is shown in the following table:— Table 35. Sex- Increase in height. Increase in weight. Milk children. London averages. Milk children. London averages. cms. cms. kilos. kilcs. Boys 4.66 4.7 2.59 2.0 Girls 5.30 4.5 2.05 2.1 It is curious that the boys did better than normal children in increase in weight, while the girls did better than normal children in increase in height. Disparity in numbers of free meals. In 1932 the comptroller of the Council commented on the disparity between the number of dinners provided, free of charge, for children of certain neighbouring schools. A detailed inquiry was subsequently carried out by the education officer and the school medical officer jointly. After considering the result, the Special Services Sub-Committee decided that similar investigations should be made in other narts of London. Such an inquiry was conducted during 1934 by Dr. R. H. Simpson, who had carried out similar previous investigations, and was concerned with three provided schools suggested by the Shoreditch local association: The Laysterne, Crondallstreet and St. John's-road. Scheme of Milk Marketing Board. In July the proposals became known, which the Government had in view, under the Milk Bill, 1934, to make provision for the supply of milk to schools at prices below the regional prices fixed for other customers by the Milk Marketing Board. The Bill became law, and the scheme was put into force on 1st October, 1934. The scope of the scheme is as follows: milk is supplied in one-third pint bottles with straws, at a charge to the consumer of ½d. a bottle, to all full-time schools or courses for children recognised by the Board of Education for grant. The scheme applies only to milk supplied in one-third pint bottles drunk directly by the children in schools, and not to that used for cooking or instructional purposes. The vendors and the quality of the milk supplied must be approved by the local medical officers of health in consultation with the school medical officer. During September a conference was held between the Council's medical officers and the medical officers of health of the Borough Councils, and as a result it was decided that only pasteurised milk should be approved for the purpose of the scheme in London. There had been for a number of years voluntary milk clubs at very many schools, run mainly under the auspices of a scheme of the National Milk Publicity Council, and before the new scheme came into operation there were more than 100,000 children in London day schools who were supplied through these clubs each school 59 day with one-third pint bottles of milk costing 1d. each. It appeared, therefore, that the best way of working the new scheme would be by expanding the voluntary organisation. The Council, under the "feeding" clauses of the Education Act, was also supplying milk ordered to debilitated children by the school doctors. This milk had hitherto been supplied in bulk and the standard amount supplied was a half-pint daily. Over 20,000 children were receiving milk in this way and in a great proportion of the cases it was free. It was decided that the standard amount of milk to be given as milk meals ordered by the school doctors under the official scheme should be two-thirds of a pint, given in the one-third pint bottles twice daily. In spite of the difficulties of organising such an immense scheme in the short space of time available between the end of the summer vacation and the commencement of the scheme, the new procedure was brought into being on 1st October. This would have been impossible but for the enthusiasm and voluntary efforts of the teaching staff. So successful were they that it was reported that, during the week ended 12th October, 1934, there were no fewer than 364,157 children having milk in school through the voluntary clubs, an increase of 256 per cent. In November there were also 26,765 debilitated children receiving "official" milk on the recommendation of school doctors. Some curiosity was displayed as to the reasons why some 27 per cent. of the children in the schools were not taking the milk provided at reduced charges in school. A questionnaire was issued by the education officer to the head teachers, and replies were received showing the reasons why 85,447 children were not taking the milk. The reasons and the percentage of the total number giving each reason were as follows: Poverty of the parents, 25; distaste for milk, 33; parents consider that children have enough nourishment at home, 24; "milk spoils the appetite for midday meal," 4; indifference of parents or children, or money spent on sweets, etc., 4; children object to cold milk, 2; children consider themselves too old, 1.5; parents object on principle, 2.5; children have cod-liver oil or dinner, and this considered sufficient, 1.5; milk causes sickness or is against doctor's orders, . 5. In assigning the reason for children not having milk to the poverty of the parents, the head teachers felt that in many cases the real cause was often apathy or indifference. The school care committees were advised that when the only reason, known or supposed, for a child not having milk was poverty, the earliest opportunity should be taken of consulting the school doctor as to whether or not the child should have official milk meals. This has led to an increase of 23 per cent. in the number of milk meals given free of cost to children in school. The inauguration of a scheme of this magnitude was bound to have its difficulties There was doubt in some quarters as to whether the injunction that all milk to be supplied should be "pasteurised" meant that the milk should be sold as pasteurised milk and labelled as such. Steps have been taken to make it quite clear to all that this is indeed the intention. One of the criticisms frequently made has been that the milk should be heated. The school medical officer has consistently held that this is unnecessary. When the cool milk is imbibed slowly through straws no discomfort is felt subsequently. The irregular heating of milk would tend to destroy its peculiar properties, which make it so valuable to children and which constitute the chief reason for giving milk in school. Teachers are advised that the milk must not be subjected to heat treatment, but that the chill should be taken off the milk by allowing it to stand, in cold weather, near the radiators. Many ingenious wirework devices have been evolved for draping the bottles upon the radiators for this purpose. The effect of milk on school children has been demonstrated several times on a large scale. It stimulates growth in a remarkable way. This special effect is confined to raw or pasteurised milk, and is lost on cooking. Cooked-milk is merely a fattening food. Eaw or pasteurised milk provides a stimulus to growth, and does not appear to produce obesity. Formerly it was thought that the forces of growth in height were purely congenital, and could not be affected in a positive direction by any means within our 60 disposal, although a negative result in the way of stunting could be produced by improper feeding, as is the case when children suffer from rickets. It now appears, however, that by taking milk the child can add, if not a cubit, at any rate, some inches to his stature. Whether this means that the forces of growth are stimulated to increased activity for a time, but that growth will end at an earlier period, or whether it means that the children will be really taller as adults is not known. The stimulus to growth in height rather than to the production of fatness is seen in records relating to Dr. Chaikin's debilitated girls mentioned above. Dr. C. E. Thornton has made two sets of observations upon normal children having milk in school, compared with controls not having milk. In the first series, the children were all in the same school, the Oliver Goldsmith; the number of milk cases was 53, and the number of controls of the same age was 91. The period under observation was six months. The average gain in weight was—milk cases, .69 kilograms ; controls, .94 kilograms; the average gain in height was—milk cases, 2.26 centimetres; controls, 2.17 centimetres. A second series was watched over 11 months in two schools, one Athelney-street in which the milk cases were, and the other Elfrida-street, in which were the controls. The schools were of similar character. The results were: average gain in weight— 93 milk cases, 2.64 kilograms; 90 controls, 2.91 kilograms; average gain in height— milk cases, 6.9 centimetres; controls, 4.2 centimetres. These results were all in relatively small groups; but, if they are proved to be general, they should go far to remove the fears of the not inconsiderable number of children, principally girls, who refuse milk, not because they really dislike it, but through the abhorrence of the idea that thev may become fat. Nutrition centres. The Committee of the Jewish Health Organisation established, towards the end of the year a voluntary dietetic service at the East London child guidance clinic. The part-time services of a qualified dietitian with hospital training and experience in lecturing on the subject is utilised. The work of the dietitian consists in explaining to the parent, on the basis of the doctor's findings, where the child's food habits are wrong, in pointing out the importance of different kinds of food and how they should be used to avoid errors of diet, and in giving practical assistance in the construction or choice of dietaries. In cases of malnutrition resulting from ignorance on the part of the parents or from the economic condition of the family, the endeavour of the dietitian is to instruct the parents as to which foods, within the means of the family, make a dietary best suited to the growth and development of the child. It is hoped that it may also be possible to give information and make suggestions in the course of these interviews as to food values and methods of cookery which will be of practical use, not only in the feeding of the child, but also to the dietary of the whole family. It was anticipated that the dietitian would be able to handle a greater number of cases than the East London clinic could supply, and the Jewish Health Organisation was desirous that children in the Council's elementary schools should also be allowed to attend the clinic for the dietitian's service only, and suggested that such children should be referred to the clinic by the Council's school medical officer and school doctors. During the initial period no charge is being made for the attendance of these school children, but the number of such children is limited and determined from time to time by experience as to the demand for and capacity of the service. It has been considered advisable at first, so far as children sent direct by school doctors are concerned, to limit the service to the north-eastern division and to extend the area by degrees. For the time being, the dietitian's sessions are held after school hours. The Education Committee considered that an experiment on the lines suggested would be welcome, and arranged that parents of children in suitable instances should be recommended to avail themselves of this service. In the programme for the year 1935-36 the Council has determined to establish five experimental nutrition centres, one in each division. These are to be worked in conjunction with a scheme for the regular weighing and measuring of the children in school twice a year by the school nurses. This is proposed in order that a watch shall be kept upon the rate of growth of each individual child with a view to bringing 61 under medical examination at an early stage every child who does not show normal progress in physique. As the result of recent nutrition surveys in the schools it was found that certain children, found to be undernourished after extremely careful examination by an experienced physician, were sent to voluntary general hospitals by the school care committees. They were found at the hospitals to have no disease and were sent away with nothing done. The parents were dissatisfied, as well as the school care committees, and the suggestion was made that the school service referred to hospital very trivial conditions " which wasted the time of the hospital physicians." On the other hand, a strong public opinion has grown up, which holds that the local education authorities should be doing more for the ill-nourished child, especially in the very earliest stages of malnutrition. It was therefore decided, in a tentative and experimental way, to include in the programme of the school medical service for the year 1935-36 additional provision for special investigation of such children referred from the ordinary school medical inspections at special inspection centres and, as the children concerned are those who show failure to reach the normal condition of nutritional state for reasons not immediately apparent, the arrangements proposed were termed " nutrition centres." As, during the experimental period, they should be immediately under the observation of the divisional medical officer, a centre has been chosen in each division as near as possible to the divisional medical offices. The divisional medical officers have each nominated from the staff engaged in their divisions an assistant medical officer (part-time) with special experience in paediatrics. To each centre an experienced nurse will be allotted and a specially selected organiser with experience in social economics. At each centre it is proposed during the first year to hold one session per week. The function of the centres has been set out above. It is intended to carry out a more extended enquiry into the causes of the failure to reach a satisfactory nutritional state in certain children than can be carried out in the press of the ordinary school medical inspection. Careful investigation will be made of the family budgets and dietaries, and advice on the latter given to the parents. Simple observations such as urine testing and haemoglobin estimation will be carried out at the centres, but in special cases, if more extended bio-chemical investigations are needed, these can be made in conjunction with the Council's laboratories. The centres will, during the experimental period, work under the immediate observation of the divisional medical officers, who will report and compare notes at the regular conferences which are held at the County Hall with the senior medical officer in charge of the school medical service. The organiser at the centre will be in close and continuous touch with the school care committees, who, by personal visitation, will keep in touch with the children both at home and school and will report to the organiser for the doctor's information. In any case where a period of observation in hospital is desired, this will be arranged at the Council's special hospitals for children, e.g., Queen Mary's, Carshalton, or High Wood. The selection of children will be carried out by the divisional medical officer from nominations by the school doctors. The primary cases to be included are those at present under observation by the school doctors for nutritional defect who at the periodical re-inspections and weighings at school have not shown improvement. Co-operation of voluntary bodies. The general care of the children in the London elementary schools is carried on by a social service, consisting of voluntary workers organised into school care committees, which are assisted and directed by paid organisers. This system prevents the work of medical inspection and treatment and the wider work of general physical E Social care organisation. 62 care of the child becoming stereotyped and bureaucratised, a fault which might otherwise be difficult to avoid. Friendliness and co-operation with the parents are the key notes of this social service. The teachers whenever possible give much assistance, and in many cases it is entirely owing to their help and devotion that the care committee work in the schools is possible. The services of the National Society for the Prevention of Cruelty to Children are freely given in the supervision of unsatisfactory families. The Invalid Children's Aid Association gives unstinted help in the care of the crippled children and in convalescing children recovering from acute disease. Co-operatior with voluntary hospitals. London is abundantly rich in voluntary hospitals which provide extensive services for the poor. It has been the aim of the school medical service to work harmoniously in co-operation with these. While some of them are definitely included in the authority's scheme for medical treatment, others are only linked with the service by voluntary arrangements. At a number of hospitals a liaison officer or officers, consisting of a member or members of the Council's care committee organising staff, attends regularly and keeps the hospitals in touch with the social services of the schools. The presence of the organiser at the hospital ensures following-up for all the children under the scheme, and influences the proper care and following-up of children attending the hospitals not under the scheme, too, for "non-Council" ailments, as the organiser is appealed to on behalf of these also. The association of the organisers with voluntary hospitals makes a great difference in the results of hospital treatment, and generally speaking the condition of children attending hospitals where the Council's organisers attend is satisfactory, whereas the condition of children attending hospitals outside the scheme where no organiser attends is as regards following-up often quite unsatisfactory. The scope of the work in those hospitals in which the Council maintains an organiser or organisers is shown in the following report dealing with Guy's hospital Guy's hospital. There are three assistant organisers working in Guy's hospital, in the aural, eye, orthopedic and skin departments, and the diphtheria carrier clinic. These organisers form a link between the hospital physicians and surgeons and the school care committees. The care committees are supplied with up-to-date information about children attending these departments and they furnish reports for the information of the hospital doctors. In departments where there is no organiser, the almoner obtains reports for the care committees and divisional officers. In the aural department 1,308 new children were seen during the year;619 were discharged cured, 16 left school and 22 were reported well by the care committees. During the year 1,061 new children attended the eye department; 979 were tested for glasses, and of this number 743 had glasses prescribed and 81 were found not to require glasses. In regard to the other 155, no change in glasses was necessary. During the year, 724 pairs of glasses were obtained but some of these were prescribed in 1933. In the orthopaedic department 165 new children were seen, of whom 5 were found not to require treatment; 28 children were discharged cured, 76 left school, 4 left London and 6 were referred to other departments for treatment. A number of children were referred to the massage department for treatment, and the organiser checks their attendances once a fortnight and reports to the care committees if they do not attend as directed. Twelve children had minor operations performed in the out-patient department, and there are 573 children attending periodically for supervision. During the year 609 new children attended the skin department, which is a slight decrease on last year's numbers. Of these, 15 were suffering from ringworm of the head and 87 from scabies. The ringworm cases were referred to the light department of the hospital for X-ray treatment, and the majority of the scabies cases to the school bathing centres. There were 95 new cases in the diphtheria carrier clinic during the year, with a total of 375 attendances. The majority of children attending in the aural, eye and skin departments were treated at home, but in some cases arrangements were made for them to have daily treatment at the school treatment centres. The numbers of children referred to the school medical officer for special examination were as follows:—Schools for the physically defective, 11; partially sighted class, 4; hard-of-hearing school, 3; White Oak hospital, Swanley, 5; while 8 children were recommended for re-examination with a view to their transfer from schools for the physically defective to elementary schools. Defective children. Examinations with a view to the admission of children to special schools, other than hospital schools, were made in 4,598 cases. The following table shows the number of children nominated for examination and the recommendations made:— 63 Table 36. Defect. Number nominated. Suitable for admission to Returned to elementary school. Invalided as for the time unfit for any school. Notified under M.D. Acts. Boys. Girls. Blind school. Partially sighted. Swanley. Boys. Girls. Boys. Girls. Boys. Girls. Boys. Girls. Boys. Girls. Boys. Girls. Ocular 507 638 1 4 63 82 87 71 338 472 18 9 — — Deaf school. Hard of hearing class. Boys. Girls. Boys. Girls. Aural 123 106 26 21 19 15 78 69 — 1 — — Physically defective P.D. school. Day open-air school. Residential P.D. school. Boys. Girls. Boys. Girls. Boys. Girls. 817 719 522 482 26 15 61 33 166 141 42 48 — — M.D. school. Boys. Girls. Mentallv defective 896 660 302 263 508 330 46 35 *40 *32 Epileptic colony. Boys. Girls. Epileptic 60 72 14 14 27 33 19 25 — — Total cases 2,403 2,195 1,121 1,000 1,117 1,045 125 118 40 32 4,598 2,121 2,162 243 72 *Of these 30 boys and 25 girls were imbeciles; 7 boys and 4 girls were idiots; and 3 boys and 3 girls were feeble-minded. The numbers of children actually attending special schools will be found in table III of the statistical tables at the end of this report. The following statement shows the nature of the conditions found among the children certified as suitable for admission to schools for the physically defective at the admission examinations during the year:— Table 37. Morbid conditions. Boys. Girls. Total. Infantile paralysis 29 29 58 Cerebral paralysis 11 17 28 Various paralyses 15 13 28 Tuberculosis of bones and joints 73 65 138 Osteomyelitis 31 11 42 Rickets and resulting deformities 3 2 5 Congenital deformities 18 11 29 Scoliosis 1 9 10 Traumata and amputations 22 6 28 Non-tuberculous arthritis and synovitis 22 6 28 Rheumatism and chorea 18 37 55 Various chest conditions—fibrosis, bronchitis, asthma 80 38 118 Heart diseases— Congenital 26 15 41 Acquired valvular 194 217 411 Non-valvular 18 23 41 Anæmia 3 5 8 Pseudo-hypertrophic muscular dystrophy 10 1 11 Various nervous conditions, ataxia, etc. 1 3 4 Other diseases—chiefly medical 8 7 15 Total 583 515 1,098 EI 64 Children returned to elementary schools or invalided. The following statement gives an analysis of the 397 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 for the time unfit for any school:— Table 38. Morbid conditions. Elementary school. Invalided. Infantile paralysis 8 4 Cerebral paralysis 5 5 Various paralyses 9 8 Tuberculosis of bones and joints 16 4 Osteomyelitis 7 1 Rickets and resulting deformities 5 — Congenital deformities 6 1 Scoliosis 4 1 Traumata and amputations 18 6 Non-tuberculous arthritis and synovitis 4 — Rheumatism and chorea 47 6 Various chest conditions—fibrosis, bronchitis, asthma 31 8 Heart diseases— Congenital 14 6 Acquired valvular 75 19 Non-valvular 19 7 Anæmia 16 1 Pseudo-hypertrophic muscular dystrophy 1 2 Various nervous conditions, ataxia, etc 3 1 Other diseases—chiefly medical 19 10 Total 307 90 Rota visita 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 16,159, and in addition 601 special examinations were made of children already on the rolls of special schools in connection with applications for non-enforcement of attendance and for similar reasons. As a result of the rota examinations the following re-classifications took place :— Table 39. Transferred from schools for Re-classified for transfer to— P.D. school. M.D. school. Partially sighted school. Blind school. Deaf school. Partially deaf school. Open- air school. Epileptic colony. Physically defective - 13 - - - 1 6 4 Mentally defective - - 2 - - 1 - - Partially sighted 1 2 - 1 - - - 1 Blind - - 14 - - - - - Deaf - - 1 - - 4 - - Partially deaf - - - — 8 — - - After trial in a special school, 78 children were excluded (39 as imbecile, 16 as feeble-minded ineducable, 4 as "special circumstances" and 5 as feeble minded " detrimental ") and 18 were invalided on medical grounds. 65 There were also 653 cases returned, on improvement, to elementary schools, or, when over 14 years of age, deemed to be no longer certifiable. The details are as follow:— Table 40. Action taken. Special school classification. p.d. m.d. Blind. Partially sighted. Deaf. Partially deaf. Total. Returned, on improvement, to elementary schools 210 13 - 15 3 8 249 Over 14 years of age and excluded as no longer certifiable 229 65 2 106 2 - 404 Total 439 78 2 121 5 8 653 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 :— Decertification of physically defective children. Table 41. Morbid conditions. Cases deemed no longer certifiable. Cases deemed fit to return to elementary schools. Infantile paralysis 17 7 Cerebral paralysis 1 — Various paralyses ... ... ... ...'• 3 1 Tuberculosis of bones and joints 26 19 Osteomyelitis 7 8 Rickets and resulting deformities — 6 Congenital deformities 10 12 Scoliosis ... ... 1 — Traumata and amputations 4 8 Non-tuberculous arthritis and synovitis 6 14 Rheumatism and chorea 22 26 Various chest conditions—fibrosis, bronchitis, asthma 2 2 Heart diseases— Congenital 3 7 Acquired valvular ... 97 67 Non-valvular 26 24 Anaemia — 2 Various nervous conditions—ataxia, etc. — 1 Other diseases—chiefly medical 4 6 Total 229 210 Table 36 (p. 63) indicating the number of children examined to determine whether some form of special education might be desirable appeared to indicate some difference in sex distribution in the case of those diagnosed as mentally defective or epileptic and of those suspected of being physically defective. To inquire further into this point Dr. Shrubsall and Dr. Williams have taken the records of the children Sex distribution in defective children. 66 examined between the years 1926 and 1933, inclusive, and the proportion of the sexes nominated, those found suitable for a special school and those for the time being unsuited for school attendance are shown in the following table:— Table 42. Type of defect. Percentage of sexes in those Nominated for examination. Passed for a special school. Invalided. Deemed ineducable. M. F. M. F. M. F. M. F. Physically defective 50.2 49.8 50.2 49.8 50.1 49.9 - - Epileptic 52.1 47.9 58.0 42.0 45.7 54.3 - - Mentally defective 58.3 41.7 56.7 43.3 - - 54.4 45.6 These figures seemed to indicate an excess of boys over girls in the epileptic and mentally defective classes. The proportion of the sexes attending the ordinary elementary schools at the beginning of 1933 was male, 50-6; female, 49.4. As the figures for the physically defective are very similar it is evident that there is no clear sex selection in this field where also the proportions of the sexes among those found defective and those nominated are reasonably constant. A little over 69 per cent, of those put forward as physically defective are found suited for special school education, and just over 8 per cent, of either sex found temporarily unfit for school attendance. That about 78 per cent, of the nominees are found unfit for the ordinary school shows that the nominations are soundly based. In the case of the epileptics the distribution is more irregular; more boys than girls are nominated and more boys are accepted for special school education, but more girls are invalided for a period. If the two groups are added it is found that there is no material sex difference in suitability of selection, 65.1 per cent. in the case of boys and 65.8 per cent. in the case of girls, of those nominated being found to evince such manifestation of epilepsy as to render them unfit for education in ordinary schools, though the proportions among those accepted show a slight preponderance of males. This question of sex distribution in epilepsy is one on which there is some difference of opinion, most English text books stating that there is a slight preponderance of females and most American text books that there is a preponderance of males. This is a question on which the accommodation available, and even the number of persons actually admitted to schools, throws little light. Special school accommodation for epileptics is entirely of a residential character, and children are only sent subject to the consent of their parents. This is an important feature, for the dissatisfied parent of a child placed therein against his will could upset the equanimity of other parents on visiting days, and this in turn would react adversely on the children, for placid and equable conditions play an important part in the treatment of epilepsy. It is true that attendance could be enforced by law if it could be shown that the refusal of the parental consent was unreasonable, but, as this refusal is not to be held unreasonable if withheld in a bona fide belief that it is for the child's benefit, and as it is not difficult for any parent to get a medical certificate that a child would be better at home lest he should fret if removed, it is in effect useless, save in most exceptional cases, to attempt such action. The preceding tables indicate clearly that while there is little difference in the sex incidence of epilepsy of such a degree as to interfere with ordinary schooling there is a much greater willingness on the part of parents to allow boys to be sent to boarding schools. This may be partly due to special affection for the girls, but is more probably connected with the greater difficulties in early life which arise from the unstable behaviour of epileptic boys. In the case of the mentally defective the proportion of boys is greater in all the categories but is greatest in the numbers nominated and smallest in those deemed 67 to be ineducable. Although the number of girls nominated is smaller the proportion of those nominated who are deemed to need special education is slightly greater: 42.7 per cent. girls compared with 40 per cent. boys. This may depend on several factors, probably the most important is instability of behaviour. In early years the mentally defective boy is likely to be a somewhat greater nuisance in the school and to the community than is the mentally defective girl, and it has always been found that active or aggressive aberrant behaviour attracts attention, while mere placid failure to make progress tends to be overlooked or to be for a considerable time accepted as backwardness or shyness. It may be, too, that the woman teacher exercises patience under the adversity of endeavouring to teach the seriously retarded for a longer period than her male colleague. When it comes to a later phase there is some evidence that the woman teacher seeks the protection afforded by the Mental Deficiency Acts for her seriously retarded girls more readily than the man who is hopeful for the temporary employability of the boys in unskilled work unless they' show aggressive anti-social traits. The proportion of the sexes among the mentally defective who are in some way being cared for by the Council under the Mental Deficiency Acts, viz., 50.3 per cent, males and 49.7 per cent. females, is so similar to the proportion of the sexes in the elementary schools as a whole, viz., 50.6 per cent. boys to 49.4 per cent. girls, as to show there is no real sex difference, but the proportion for whom the stricter form of community control, institutional care or guardianship is required, 52 per cent, males to 48 per cent. females, shows the slight difference which may be accounted for by anti-social behaviour. The prevalance of instability in the children sent to schools for the mentally defective is noteworthy. Of course, naughtiness and lack of discipline are common in those of normal intelligence; but, when with marked intellectual retardation there co-exists irresponsible and irrational behaviour, there is the more reason for special care. In the school medical officer's report for 1922, in referring to the later history of defectives, it was noted that social and industrial failure were much more marked when both features were present, e.g., a lad of extreme stupidity but of stolid type might keep a simple job, while one of the same intellectual capacity but irresponsible or slightly lacking self-control would be dismissed from every post after a few weeks. That temperamental instability plays an important part even in the earlier years is shown by further inquiries made by Dr. A. C. Williams into the differences between children nominated for examination and as a result either passed into special schools for the mentally defective or returned for a further trial in the ordinary elementary school. Special schools have been functioning in London since the middle of the eighteennineties, and this educational provision has been accompanied by an increasing degree of medical and social supervision. In the earlier years, the greater number of children found in the schools to need treatment were of necessity referred to voluntary hospitals and in this connection the help given by the voluntary workers of the Invalid Children's Aid Association proved invaluable in the matter of the persuasion of parents, arrangements for regular attendance at hospital and for the interchange of information between the medical officer visiting the school and the physicians or surgeons of the hospitals concerned. With the establishment of care committees, after the coming into force of the Education (Administrative Provisions) Act, the extent of the social services which could be rendered materially increased, while the introduction of medical inspection into the elementary schools secured the attendance at special schools of a number of children who might not all have been ascertained under the previous system. Gradually arrangements were made for supplementing the efforts of the voluntary hospitals, largely through the use of the facilities of the Metropolitan Asylums Board. Cases of ophthalmia were dealt with at the White Oak hospital and later this provision was rendered available for cases of interstitial keratitis and other affections of the eye Treatment and following up of children with incapacitating defects. 68 which required prolonged treatment but which did not entirely prevent education so far as this could be carried out on the hospital premises. At a later date, certain ear cases were received at the Downs hospital. Admission to these hospitals was not exclusively or even chiefly through the school organisation, since the Metropolitan Asylums Board naturally received cases direct from the institutions of the poor-law guardians. In a similar manner largely but not exclusively, through the intermediation of the Board, arrangements were completed for dealing with cases of tuberculosis both pulmonary and surgical, and later for sufferers from osteomyelitis, polioencephalitis and encephalitis lethargica. Such cases were often admitted from hospitals; but, so far as they were passed through the school organisation, the children were seen by the consultant medical officers in the public health department of the Council and arrangements made for their re-examination so soon as notification of their discharge from hospital had been received, to determine the most suitable provision for their further education. As a result of the consolidation of services brought about by the Local Government Act, 1929, the Council now controls a wide range of hospitals and institutions, so that the procedure for following up and interchange of records has been simplified. Large numbers of children still naturally attend voluntary hospitals for treatment; but, when residential care for long periods is required, these hospitals usually apply to the Council for the transfer of the children, and in all cases the facilities available are kept before the notice of the professional and social service staffs. Cases may be admitted to the Council's special hospitals direct from either voluntary or the Council's general hospitals, but more cases than formerly are now seen by the Council's consultant officers attached to the school service, thus ensuring a somewhat more continuous record of observation should the children subsequently attend a day special school. It has been possible to arrange that from certain of the special hospitals the children shall come to the County Hall on their discharge, and at the same time be seen and have the necessary notes made on the special school record card if they are proposed for such form of subsequent education. In any case, a recommendation is made by the head of the special hospital as to the type of schooling suggested, and in some cases a certifying officer pays regular visits to the hospital to determine the most desirable schooling, just before the discharge of the patient, and notes the findings on the special school card. On discharge those children who have been admitted to special hospitals from voluntary hospitals are referred for after-care or supervision to their hospital of origin. Those who have been at the Princess Mary's or the Heatherwood hospital are seen at after-care clinics which are held by the superintendents of those hospitals at the County Hall. On these occasions minor repairs or adjustments to appliances can be carried out, or the necessary data noted by the mechanic if more is required. If necessary, children return to the hospital for further treatment or adjustment of appliances. In the case of the Queen Mary's hospital, Carshalton, children whose appliances need repair or readjustment return perhaps only for the day, perhaps for a few days, according to the amount of attention required. In these after-care clinics there is a close liaison with the school service ; and, where the clinic is held at the County Hall, the surgeon can consult at once with a certifying officer if he has any suggestions to make as to the modification of the educational provision. It is now quite usual for orthopaedic cases to commence their treatment in the special hospitab before attaining school age, and to attend day special schools for the first time on their discharge. In older days a child was often in attendance at a day special school for some time before admission to a hospital, or was attending school with a limb or back immobilised for long periods, visiting a hospital out-patient department from time to time for supervision by the surgeon in charge of his case. Such instances are now very rare, those children who need prolonged immobilisation are got away to special hospitals where they obtain the advantages of country air and surroundings with education, even though they be for a long 69 time bedridden. The provision directly provided by the Council for children is as follows:— Hospital. Type of case. Accommodation. Queen Mary's, Surgical tuberculosis. Orthopaedic cases. Heart 1,284 Carshalton. disease. Congenital malformations. General. Princess Mary's, Surgical tuberculosis. Orthopaedic cases 221 Margate. Convalescence 50 Heatherwood, Ascot Surgical tuberculosis 126 The Downs, Sutton Ear diseases. Rheumatism and heart disease. General. 360 Convalescence. High Wood, Brentwood Rheumatism 206 Tuberculosis 220 Northern (part of), Encephalitis 84 Winchmore Hill. White Oak, Swanley Eye diseases 364 Goldie Leigh, Abbey Skin diseases. Convalescence 248 Wood. St. Anne's, Heme Bay General for cases needing seaside treatment and 127 convalescence. Millfield, Littlehampton Seaside convalescence 98 Southern (Lower), Convalescence 250 Dartford. Besides these, the Council contracts with various homes and hospitals for cases which may need country or seaside residence and supervision, but not in most cases active surgical treatment. Cases of chronic bronchitis and the like may be sent to residential open-air schools, such as the Sun Trap, Hayling Island, or St. Catherine's, Ventnor. Epileptic children of special school age, if of adequate mentality, are sent to the schools at the Lingfield, Chalfont, or Much Hadham colonies, admission being preceded by reports from the Council's certifying officers. During the year Mr. N. Bishop Harman, F.R.C.S., the consulting ophthalmic The blind surgeon, retired on reaching the age limit. Mr. Harman joined the service in 1903, and and was associated with the then medical officer (education) in the earlier develop- g^hted? ment of the schools for the blind and the partially sighted. His reports on the causes of blindness and seriously defective vision were for a long time the most authoritative statistical data available. His influence was largely responsible for keeping up official and public interest on the question of the prevention of blindness, which was shown by the making notifiable of ophthalmia neonatorum and by the establishment and setting up of committees on the question of the prevention of blindness. In the report of the Departmental Committee of the Ministry of Health, 1926, Mr. Harman was responsible for many of the data, and, in co-operation with others, for the classifications adopted. He showed that over one-third of cases of blindness had their incidence during the school years, and that certain of the conditions were capable of being alleviated by improved methods of notification and treatment. Recent statistics have shown the considerable fall which has taken place in blindness originating at, or before, the school age, as the result of the improved treatment of venereal disease including ophthalmia neonatorum and the closer supervision resulting from the inspection of a considerable number of infants in welfare centres and almost the entire school population during the school age. Mr. Harman is, however, best known for his work in connection with the classes for the partially sighted. In an historical retrospect in the report of the Committee of Enquiry into Problems Relating to Partially Sighted Children, which has recently been issued, it was pointed out that the initiation and development of the system of special education for partially sighted children in London was due in no fmall measure to the enterprise and foresight of Mr. Harman. His suggestions and the procedure adopted in London were discussed at international conferences and the procedure adopted by the Council gave a lead, not only to public authorities in England, but to the whole western world. In particular Mr. Harman's ideas have been taken up with enthusiasm in America where many "sight-saving classes" 70 exist and where suitable material, in the form of maps, diagrams and clear type text-books, has been published. A form of desk which he suggested for the prevention or limitation of stooping, was adopted in London schools, and, with minor modifications, elsewhere. In addition to this, Mr. Harman's work in the selection and subsequent oversight of suitable candidates for the residential ophthalmic school at Swanley, instituted by the Metropolitan Asylums Board and later taken over by the Council under the Local Government Act, 1929, has been most useful in the control and care of cases of ophthalmia and other contagious eye conditions, such as interstitial keratitis. Deaf children. During the year Mr. Wells examined 229 children with defective hearing, the decisions regarding whom are set out on page 63. The cause of deafness in the partially deaf, deaf and defective, and deaf, seen for the first time during the year, was found in 31 cases to be congenital, and in 177 cases acquired, while in 21 the cause was uncertain. The congenital cases were classified as follows:— Cause of deafness. True hereditary deafness 6 Sporadic deaf birth17 Aphasia 8 Total 31 The acquired cases were classified as:— Cause of deafness. Disease of the nervous system 9 Infective conditions 10 Other infectious disease 4 Nasal obstruction 43 Ear disease 106 Injury 5 Total 177 Mr. Wells also visited the schools for the deaf and partially deaf and examined all the children. As a result, 8 children in schools for the partially deaf and 3 children in schools for the deaf were returned to elementary schools as having improved. Two children in schools for the deaf were found to have improved, and being over 14 years of age were allowed to leave. The reclassification table on page 65 gives particulars of the re-allocation of children already in attendance at special schools. Mental Deficiency Acts. Cases notified to the local authority. The following table shows the number of cases notified by the education authority under section 2 (2) of the Mental Deficiency Act, 1913, as amended by the Mental Deficiency Act, 1927, during the year 1934 (the figures in brackets being those for the previous year):— (a) Feeble-minded— Boys. Girls. (1) Leavers 148 (169) 143 (186) (2) Detrimental 2 (3) 3 (3) (3) Special circumstances 2 (-) 2 (1) (4) Ineducable 8 (17) 11 (11) (b) Imbecilcs 55 (72) 43 (67) (c) Idiots 7 (5) 4 (3) 222 (266) 206 (271) Total 428 (537) After-careers The chief officer of the mental hospitals department has furnished the following return for the year 1934 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 71 further aid in the form of supervision, guardianship or institutional care under the Mental Deficiency Acts was necessary:— Table 43. Classification. Male. Female. Total. Grand total under headings. (1) Number of children born in or subsequent to 1916 who have left special schools and who were on the books of the supervision section on 31st December, 1934 366 221 587 587 (2) Number who after trial have proved themselves to be incapable by reason of mental or physical defect of undertaking remunerative employment 2 2 4 4 (3) Number employed as under:— (a) Industrial or manual occupations (i.e., factory work, trade or any part of a trade) 233 163 396 (b) Agricultural or rural occupations — — — (c) Domestic occupations— M. F. Total (1) Receiving remuneration 6 16 22 (2) Required for work at home 1 18 19 7 34 41 (d) Commercial, shop assistant, or selling behind a counter, office boys or girls 4 1 5 (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) 74 1 75 517 (4) Number judged to be employable but out of work 29 9 38 38 (5) Number whose careers have not been traced:— (a) Not visited and not seen at bureaux 5 — 5 (b) Visited but no information obtainable 12 11 23 28 (6) Cases dealt with in addition to above including those who have since:— (a) died 1 1 2 (b) attained the age of 18 years 203 71 274 (c) been dealt with under M.D. Act 20 17 37 (d) been lost sight of, or have left London 8 9 17 330 N.B.—In addition to the 587 after-care eases shown in the above return there were 453 boys and girls between 16 and 18 years of age who had left special schools and were under statutory supervision on 31st December, 1934. These also were on the books of the supervision section for placing in employment. Ponton-road remand home. The medical supervision of Ponton-road remand home has been carried out by Dr. C. N. Atlee. During the year 1934, 2,057 children and young people were admitted to the remand home, of whom 1,801 were boys, and 256 were girls. Amongst this number, out-county cases totalled 636. The number sent to hospital was 85, and 609 were found to be verminous and were cleansed. Special psychological and medical reports were called for in 269 instances by the magistrates and duly complied with; 82 children were persistent bedwetters. The number admitted and dealt with, shows an increase over last year of 729, of whom 145 were out-county. The reasons for admission are tabulated and have been abbreviated, stealing and allied offences accounting for the majority, as usual. There is an increase in the number noted under" needing care and protection," this being a useful measure for removing children from conditions likely to bring them into trouble and securing for them some means of supervision. "Suspected persons," and "breaking and entering with intent," appear to be common charges. The remainder do not seem to call for any special comment. Taken as a whole, the young people and children admitted, with a few exceptions, were representative of the usual type of normal elementary school child, such as one finds in the course of routine school work, with 72 normal temperament and mentality. The usual causes of delinquency were traceable in almost every case. They are lack of proper discipline, with inadequate parental control and general slackness, defective home and environment, bad companions, etc. The general health and physique were found to be fairly normal, in fact, the majority were well fed and in good health generally; even some young people who had "hitch hiked" to London from Wales and the North, in the hope of finding work here, showed no signs of food deprivation. The detention in the remand home seems to do the children good in more ways than one, the regular life and discipline exerting a very beneficial effect. The diet would appear to be adequate and well thought out. With regard to physical defects, no child was found to be suffering actually from the effects of insufficient food. The 178 cases who are noted as showing subnormal nutrition were mainly representative of the large class who are naturally and normally thin, probably from temperamental causes due to detective pancreatic secretion or other gland dysplasias. Weak feet, often associated with hammer toes, valgus and crooked toes, appeared to be common. The number of cases of undescended testicle may have been underestimated, this condition, which is very common, usually corrects itself by the age of puberty, but, tends to leave some permanent weakness, and possibly accounts for the large numbers of men who have definite inguinal hernia in later life. Strangely enough, there were five cases of partial hypospadias. The subject's attention was purposely not called to this defect which is occasionally found in a minor degree during school inspection. There was no active rheumatism, but all the fifteen heart cases were the result of a previous attack of the articular fever. The proportion of cases of mental defect was about the same as in previous years, 47 cases were feeble-minded or border-line. Many others were seriously retarded educationally. Several mentally defective children were found to have marked superadded psychotic tendencies of the nature of schizophrenia. Some very useful and correct summings up, unfortunately too few, of the character and disposition of certain of the children were sent in by their head masters. In order to arrive at a fair estimate of a child's make up, together with his general behaviour and reactions, it is necessary to observe him over some period, and there is every opportunity for this to be done at the remand home, given time, by the medical officer working in liaison with the superintendent and his officers. Table 44. Ponton-road remand home—Reasons for admission. Offences. Boys. Girls. Offences. Boys. Girls. Stealing and allied offences 1,021 74 Wilful damage 19 — Breaking and entering 282 4 Needing care and protection 82 102 Burglary 2 — Attempted suicide — 1 Suspected persons 71 1 Insulting words 2 1 Defrauding 10 — Loitering and trespassing 16 1 Begging 12 1 Sex offences 20 — Beyond control 119 35 Army or Navy deserters 3 — Breach of recognisance 39 7 Absconding from approved school 10 2 Wandering 22 6 Drunk and disorderly 1 — Assault 5 — Assault with firearms 1 — Total 1,782 247 Inflicting grevious bodily harm 7 — Miscellaneous 28 Arson 1 1 Grand total 2,057 Education Act offences 37 11 Table 45. Ponton-road remand home—Physical defects. Defect. Boys. Girls. Defect. Boys. Girls. Subnormal nutrition 171 7 Non-tuberculous lung catarrh 58 6 Subnormal physique 224 12 Epilepsy 3 — Vision— Defective speech 40 5 6/9 or 6/12 39 1 Enuresis 80 2 6/12 or less 215 40 Congenital syphilis 4 1 Eye disease 19 3 Gonorrhœa 2 — Squint and ptosis 55 12 Vaginal discharge — 5 Colour vision defect 18 1 Varicocele 30 — Teeth (three or more decayed) 116 19 Imperfectly descended testicles 120 — Nose and throat 139 11 Paitial hypospadias 5 — Ear disease 43 2 Abnormal feet, weak arches, etc. 130 15 Defective hearing 27 — Spinal deviations 45 9 Valvular heart disease 12 2 Congenital abnormalities 30 6 Congenital heart malformation 3 — Hare lip and cleft palate 1 — Skin disease 67 5 Spina bifida occulta 1 — Enlarged glands 90 10 Infantile paralysis 2 — Hernia 4 1 Osteomyelitis 1 - Tuberculous spine 2 — 73 During the year 665 children were seen who were reported siek, and, of these, 85 were sent to hospital. Most of the accidents were of a minor nature and were treated on the premises; several, however, of the nature of doubtful fractures, were sent to hospital for confirmation by X-rays and subsequent treatment. One case of diphtheria occurred of the serious "bull necked" variety, with a fatal issue after removal to hospital. The remaining cases of diphtheria were clinically certifiable, but not necessarily positive to bacteriological tests subsequently on further examination in the isolation hospitals. Sickness and casualties. With regard to the infectious diseases, it was not possible to trace any source of infection from the premises or from contacts there. In all these cases, systematic daily inspection of all the contacts was made, and swabs taken where necessary. Very little active venereal disease was found, most of the cases of vaginal discharge being due to a simple leucorrhcea, not uncommon in girls about the age of puberty. Table 46. Ponton-road remand home—Cases treated for sickness and casualties. Diphtheria 8 Tonsillitis 114 Scarlet fever 1 Glands enlarged 5 Chickenpox 1 Accidents 116 Otorrhœa 28 Epilepsy 3 Eye diseases 10 Post rheumatic valvular heart disease 2 Gastric diseases 11 Swabs taken 66 Ringworm 1 Incomplete abortion 1 Skin diseases 110 Vaginal discharge 10 Scabies 6 Gonorrhœa 2 Stomatitis 2 Colds with pyrexia 78 Tuberculosis of bone 1 Bronchial catarrh 85 Total 665 Influenza 4 The very able and kind co-operation of the superintendent, Mr. M. S. T. Jones, and his assistants in the work, and his skilled advice on many difficult matters is greatly appreciated by the medical officers who have worked at the remand home. Child guidance. The problem of the maladjusted or "difficult" child has for many years caused considerable anxiety to teachers, care committees and school doctors. The varying aspects of the case concern both the educational and medical authorities alike, and with the establishment of special child guidance clinics some attempt has been made to tackle the problem on a scientific basis. Speaking generally, the incidence of neuroses in children is mainly due to either some inherent disability or some undesirable environmental influence. Different methods of approach have been attempted by various schools of thought but the difficulty has always been to discover the hidden factor responsible for the peculiar mental outlook of the child under observation. The most satisfactory results appear to be obtained through the team work of the psychiatrist, the psychologist and the social worker, who, after careful observation of the child's reactions especially during periods of play when the child exhibits self-expression without hindrance, are able to suggest a mode of treatment best suited to the individual child and the peculiar problem. The assistance of the school authorities, medical staff and care committee workers is necessary to the child guidance authority in aiding the course of treatment recommended, and there is no doubt that work of very great importance is being carried out. The Council gives every facility available by way of intercommunication between child guidance clinics and the various branches of the school educational and medical services. Moreover, with the consent of the Board of Education five different child guidance clinics in London have been recognised under section 80 of the Education Act, 1921, in order that the attendances of school children at the clinics may be regarded as equivalent to attendance at school for registration purposes. The clinics referred to are (1) Maudsley hospital clinic, Denmark-hill, S.E.5; (2) London child guidance clinic, 1, Canonbury-place, N.l; (3) East London clinic, Jews' Free school, Whitechapel, E.l; (4) the Institute of Medical Psychology (Tavistock clinic), Mallet-place, W.C.I, and (5) the West End hospital for Nervous Diseases, 73, Welbeck-street, W.l. The subjoined information with regard to the work of the clinics has been submitted by the authorities of the clinics concerned. The work at this clinic has proceeded on the usual lines during the year. Cooperation with head teachers and school care committees has been very helpful, and useful information and recommendations have been exchanged between them and Maudsley hospital guidance clinic. 74 the clinic. The number of school children referred to the clinic during the year was 345, of which number 194 were boys and 151 girls. The majority of cases were referred by school care committees and hospital authorities, while a number of cases were sent by private doctors, education authorities and relatives of patients. The age distribution was: 5 to 8 years, 109; 9 to 11 years, 122; 12 to 14 years, 100; over 14 vears. 14. London child guidance clinic. Dr. Wm. Moodie, medical director of the clinic, reports that, during the year 1934, the number of school children dealt with at the clinic was 191. Of these, 125 were boys and 66 girls. The age distribution was: under 5 years, 7; 5 to 8 years, 66; 9 to 11 years, 69; 12 to 14 years, 46; and over 14 years, 3. A comparison of the intelligence quotients of the cases referred to the clinic shows that a larger proportion of children of high or average intelligence were referred compared with previous years. This is probably accounted for by the increased use which is being made of the clinic by head teachers for advice as to the treatment of backward children where the backwardness is not due to defects of intelligence. The work of the clinic generally has continued on the lines of (1) full service of intensive treatment, (2) special service with less intensive treatment and (3) diagnostic or advice service only. Each case, however, is given individual consideration, and treatment is designed to suit the particular needs of the case. Close co-operation has been maintained with both the school medical and educational services, and special tribute is paid to the work undertaken in this connection by the Council's district care organisers. The clinic does not restrict its activities to clinical work. It is also interested in the dissemination of knowledge of the aims and methods of child guidance. Monthly case discussions are held which are attended by teachers, care committees and social workers, and members of various professional groups. In addition discussions are arranged for special groups, and lectures outside the clinic are given by members of the clinic staff. The following tables show the sources of reference of the cases, and the reasons for reference:— Source of reference. Reasons for reference. Head teachers 34 Backwardness 31 District organisers 87 Nervousness 30 Parents, relatives and friends 23 Stealing and lying 30 Hospitals 13 Lying 2 Invalid Children's Aid Association 6 Enuresis 24 Private doctors 3 Unmanageable 19 Probation officer 5 Temper outbursts 9 Charity organisations 3 Speech difficulties 6 Barbican Mission to Jews 3 Truanting and wandering 4 Parent's employer 1 Sex difficulties 4 Bermondsey Medical Mission 3 Night terrors and fears 1 Welfare centres 2 Lack of concentration 4 Magistrate Screaming fits 1 Orphanages 1 Depression 1 Fulham child guidance clinic 1 Vocation guidance and psychological tests 4 Scout master 1 St. Margaret's day nursery 1 Sleeping difficulties 2 Children's house, Bow Sleep walking 2 St. Pancras dispensary Word blindness 1 Juvenile employment exchange Admission to Northampton home 2 Fears about school 2 Total 191 Advice re placement 2 Advice re management 1 Begging 1 Refusal to attend school 1 Quarrelsome 1 Heart attacks 1 Asthma 1 Incontinence 1 Constipation 1 Restlessness 1 Puts everything in his mouth 1 Total 191 75 The results of treatment were as follows:— Cases cloted. Adjusted or completed 76 Partially adjusted 5 Unadjusted 4 Placed 1 Cases still under treatment. Full service 57 Special service 42 Diagnostic service 4 Unallocated 2 Total 191 Dr. Emanuel Miller, director of the East London clinic, which was established in 1927 by the Jewish Health Organisation of Great Britain, reports that during 1934, there has been a very large increase in the number of cases referred to the clinic through the school services, especially in regard to educational backwardness anrl rc:idiner disabilities. East London clinic. He also mentions that play-room work has been further developed on systematic lines with the help of research students from the Institute of Education. During 1934, there were 178 new cases referred to the clinic from the schools and these, together with cases in hand at the beginning of the year, total 269 school children dealt with during the year. Of these, 177 were boys and 92 girls. The age distribution was : under 5 years, 7 ; 5 to 8 years, 61 ; 8 to 11 years, 91 ; 11 to 14 vears. 92 : and over 14 vears, 18. The following tables show the sources of reference of the cases during 1934, and the reasons for reference:— Source of reference. Reasons for reference. School doctors 109 Theft, pilfering 28 Head teachers 18 Nervousness, excitability 66 School care committees 25 Backwardness 36 Hospitals and clinics 31 Enuresis 16 Parents and friends 26 Beyond control 23 General practitioners 9 Unmanageable at school 12 Probation officer and children's courts 29 Aggressive, spiteful 15 Other agencies 22 Night terrors, sleep walking 11 Stammer 10 Total 269 Other speech defects 10 Temper tantrums 4 Lack of appetite 1 Headaches 1 Habit spasm 8 Truancy 9 Wandering 5 Solitariness 2 Masturbation, sex difficulties 2 Beading disability 1 Inability to keep job 4 Depression 3 Faecal incontinence 2 Total 269 An analysis of the results of treatment shows:— Discharged cases. Satisfactorily adjusted 78 Partially adjusted 28 Unsuitable or unadjusted 43* Advice only 14 Still under treatment. Progress satisfactory 32 No change 11 Too early to report 18 Failed to attend 16 Awaiting appointments at end of year 29 Total 269 *Including 19 cases which were found to be border line or mentally defective. 76 The Institute of Medical Psychology. Although the Institute of Medical Psychology (Tavistock clinic) has been dealing with maladjusted children for some considerable time, it was not until 1934 that the clinic sought and obtained recognition by the Board of Education, under section 80 of the Education Act, 1921, in order that the attendances of children might be regarded as equivalent to attendances at school. The clinic authorities pointed out that their work previously had been hampered by the lack of co-operation with the school organisation. This has now been adjusted and head teachers and care committee workers from the schools are giving ready assistance by attendance at clinic conferences, consultations with clinic workers, and co-operation in carrying out recommendations as to treatment, as well as supplying information in the initial stages. The number of school children dealt with at the elinir. rlnrimr 1934. was 82. of which number 47 were bovs and 35 cirls. The age distribution was: from 4 to 7 years, 19; 7 to 10 years, 26; 10 to 14 years, 32; and over 14 years, 5. Source of reference. Reasons for reference. Care committees 16 Neurosis 28 Head teachers 14 Behaviour difficulties ... 14 Hospitals 12 Stealing 12 Parents and friends 12 Enuresis 12 Medical practitioners 7 Speech difficulties 5 Religious institutions 6 Educational 4 Medical officer of health 5 Backwardness 4 Children's special worker 3 Sex difficulties 3 Infant welfare centres 2 Total 82 Probation officers 2 Education authorities 1 Other clinics 1 Publicity 1 Total 82 Results obtained,. Adjusted 9 Partially adjusted 9 Unadjusted 5 Unsuitable or unco-operative parents 11 Transferred to hospital 4 Placements 5 Still under treatment 33 Advice only 6 Total Total 82 West End Hospital for Nervous Diseases. The authorities of the West End Hospital for Nervous Diseases in 1932 organised a child guidance unit at the hospital, and the object of the unit was stated to be the diagnosis and treatment of emotional and behaviour disorders of children and young adolescents, cases of " nervous " children, the mentally retarded, the juvenile delinquent and the sufferer from the sequelae of encephalitis lethargica, referred by practitioners, school authorities, magistrates, etc. The children are first examined in the ordinary out-patient department of the hospital before being transferred to the guidance unit. The work is under the direction of Dr. Emanuel Miller, and the methods adopted conform very closely to those used at the Canonbury and East London child guidance clinics. Close co-operation has been established with care committees and head teachers in the district, and contact has been both effective and cordial. During 1934, with the consent of the Board of Education, the unit was recognised under section 80 of the Education Act, 1921, in order that the attendances made by children at the clinic might be recognised for school records. The work has continued during the year and a special organised play-room has been established in connection with the unit for the observation of children under treatment. A psychologist is also engaged to deal with special cases of backwardness in reading and arithmetic. 77 The number of children referred to the clinic during the year was 104, which, together with 64 cases in hand at the beeinnine of the year makes a total of 168 cases. The age distribution of the 104 new cases was : from 5 to 8 years, 46 ; 9 to 11 years, 34 ; 12 to 14 years, 21 ; over 14 years, 3. The following is an analysis of the cases dealt with :— Source of reference. Reasons for reference. From out-patient clinics of West End Tics and jerky movements 14 hospital 50 Stealing 13 School care committees 22 Backwardness 10 Other hospitals 14 Unmanageable 10 Juvenile courts 9 Anxieties 10 Other child guidance clinics 3 Restlessness 7 Private practitioners 2 Stammer and speech defects 6 Head teachers 2 Hysterical illnesses 4 Child guidance council 1 Intelligence tests only 4 Marylebone Health Society 1 Advice re school 3 Total 104 Sex difficulties 3 Niiht terrors 3 Solitariness 3 Enuresis 3 Enuresis and faecal incontinence 2 Faecal incontinence 1 Spitefulness 2 Screaming 2 Temper 2 Masturbation 1 Truanting 1 Total 104 Results obtained. Cases closed— Adjusted 41 Partially adjusted 10 Unadjusted or parents unco-operative 14 Transferred to other clinics 4 Unsuitable for treatment 5 Consultation only 21 Cases still under treatment 73 Total 168 Nursery schools. Much attention was given in 1934 to questions concerning nursery schools and their possible development. A summary is given below of the action taken by the Council in recent years and of the various ways in which the general question has recently been brought to notice. Voluntary nursery schools have been aided by maintenance grants from the Council since 1919. There are now twelve such schools in London recognised by the Council for grant. In 1921, the Council provided 100 nursery school places on the Stowage site, (Greenwich), where Miss Margaret McMillan had already established a voluntary nursery school which was aided by grant from the Council. Since Miss McMillan's death in 1931, the whole of the nursery school on the site has been maintained by the Council. For ten years the Council's school and the voluntary school had been organised together as one school under one superintendent. In 1930, two experimental detached nursery schools were opened : Columbiamarket and Old Church-road. Reports on the working of these schools were considered, and it was decided that, while in essentials the schools were fulfilling their purpose, further experience was necessary before any final conclusions could be reached on certain points of staffing and reorganisation, and also on the question raised by the consultative committee of head mistresses of infants' schools that nursery classes should be provided rather than detached nursery schools. F 78 In the same year, the Council had considered a circular from the Board of Education and the Ministry of Health on " children under school age." This circular urged local education authorities, in framing their programmes of educational development, to consider the provision of nursery schools and nursery classes. The Council decided, however, to make no departure from its previous policy until the extent of the commitments which might fall upon it as the result of the projected legislation for the raising of the school-leaving age was known. The Special Services Sub-Committee in November, 1933, received a deputation from the consultative committee of head mistresses of infants' schools, urging the provision, within infants' departments, of what they described as nursery wings. The deputation submitted the view that this method of providing for very young children was preferable to establishing detached nursery schools. A Report, issued in December, 1933, of the Board of Education's Consultative Committee, under the chairmanship of Sir W. H. Hadow, entitled " Infant and Nursery Schools," dealt fully with the various questions affecting the mental and physical development of children up to the age of seven. Many of its recommendations were in accordance generally with the Council's policy with regard to young children in its schools. With regard to nursery classes and nursery schools, local education authorities were recommended to survey the needs of their areas and to provide facilities, in consultation with the Board of Education, for the nurture and training in schools of children under five, whether in nursery schools or nursery classes. The report advised that where children under five are admitted to infants' schools, nursery classes should be the normal type of provision. The representative managers have recommended the provision of nursery schools, particularly in areas which have been scheduled for slum clearance and in, or adjacent to, the Council's housing estates ; and the Special Services Sub-Committee in April, 1934, received a deputation from the Nursery School Association of Great Britain, urging the reservation on housing estates of sites for nursery schools and better provision, on nursery school lines, for children in infants departments. Dr. E. M. McVail (divisional medical officer), Miss E. Stevenson (senior woman inspector) and Miss G. Sanson (inspector of infants' methods) were asked to report comprehensively upon the whole question. As a result of the consideration of their report, the Council has agreed to the principle of nursery school development in London, and provision for this has been made in the three-year programme 1935-38. Dr. E. M. McVail reports that accommodation in nursery schools has, during the year 1934, remained unchanged, viz., 1,044 places in 15 schools. Of this accommodation, 500 places in 3 schools are maintained, and 544 places in 12 schools are aided. Eight schools, including the 3 maintained, have a Council doctor, whilst 7 aided schools make their own arrangements. Children in all schools are seen at least once a year and in many once a term, special cases being examined more frequently. All except one aided school now have a Council nurse, who visits daily for treatment of minor ailments, advises as to suspected infectious disease and inspects for cleanliness. The number of visits paid by the medical officers was 210, and 3,079 examinations were made of the children. The Council's treatment centres are available for the treatment of nursery school children, and at most schools the parents co-operate well by having medical recommendations carried out. Children with rickets as a rule improve markedly with the nursery school regime—fresh air, exercise, milk, cod-liver oil and suitable food—and hospital treatment is only exceptionally necessary. Out of 1,585 children examined, 162 were noted to have rickets to a greater or less degree. Medical inspection and treatment—Day continuation schools, evening institutes and junior instruction centres. Day continuation schools and evening institutes. With a view to closing up to some extent the gap in physical care between school leaving and the commencement of provision of medical benefit under the national health insurance scheme the Council decided that, as an experiment for one year, arrangements should be made as from 1st April, 1934, for the medical 79 inspection and treatment of students attending the Council's day continuation schools and those attending three junior evening institutes, provided that the students were not more than sixteen years old at the time of the inspection and agreed to undergo such inspection or treatment. The Board of Education approved this proposal on the understanding that their approval was limited to the scheme then put forward, and that they would not necessarily be in a position to approve any extension of the proposal in future years. The results of medical inspections from 1st April, 1934, to 28th February, 1935, are set out below. The figures relate to all the 11 day continuation schools and to Shillington-street, the " Stewart Headlam," and Gopsall-street evening institutes :— Table 47. Sex. No. examined. Nutritional state. Condition of clothing and footwear Cleanliness skin and hair. Teeth. Vision. No. wearing glasses. Various other defects found. No. advised to have treatment. Excellent. Normal. Subnormal. Bad. Good. Fair. Bad. Clean. Dirty. Pediculi present. Sound. Less than 4 decayed. More than 4 decayed. Normal. Slightly subnormal. Treatment required. Day continuation schools. {Estimated number of students eligible—4,000.) Boys 1400 149 239 12 |362 37 1 397 3 286 111 3 304 47 49 69 94 114 Girls 357 149 192 15 1 348 9 — 345 11 1 261 87 9 260 46 51 57 104 92 3 selected evening institutes (estimated number of students eligible—900). Boys 162 32 111 19 133 29 – 161 1 — 126 33 3 *79 31 24 13 63 27 Girls 108 38 66 1 3 87 21 – 98 8 2 66 32 10 *57 25 13 7 104 81 ♦The vision of 28 boys and 13 girls has not yet been tested. The medical inspections at the evening institutes are limited to the winter season (September to April). Twenty-six students at day continuation school have been re-inspected for defects previously noted ; 12 defects had been satisfactorily treated and 4 were under treatment at the time of the re-inspection. Forty students from the day continuation schools applied for and received treatment for defects at the day school treatment centres. Some hesitation is apparent on the part of many of the students in accepting inspection. A number are at work with employers who provide medical care for illness and accident, but there is no periodical overhaul (except possibly on entry) with a view to discovering incipient defects. It will probably be some time before the advantages are appreciated fully by the students. The Ministry of Labour in a circular (A.C.6) issued in November, 1934, emphasized the desirability of securing the services of a school medical officer for the oversight of the juveniles at the junior instruction centres for unemployed boys and girls, especially those in regard to whom the superintendent desired advice, and drew attention to the fact that a local authority for higher education could at these courses arrange to provide, as medical treatment, milk at cheap rates foi those invpniles who were rnedicallv certified to he under-nourished. Junior instruction centres. The medical inspection of the juveniles began on Monday, 31st December, 1934. The medical officers were advised to interview all juveniles, to recommend milk for those obviously requiring it and to carry out a detailed medical inspection where it appeared desirable, provided the juvenile was willing. F1 80 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, bat 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 information at the end of each term. Including students in training colleges, 14,345 pupils were examined during the year, an increase of 716 compared with the previous year. Amongst these the number of routine age group examinations was 8,151 and of special examinations 6,224. Further details of the distribution of these students in the various institutions are given in the Appendix (table VII). In addition to the above, the records of 4,128 pupils not in the age groups 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, but in one case the clothing was found to be poor and in one infestation with head vermin was noted. Dental condition. The percentage of children, aged 12, with sound teeth was: boys, 82.5; girls, 78.8; but at the age of 15 this percentage had decreased by .4 per cent, among boys and increased by .6 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 1.7 and 1.3, respectively, compared with 1.4 and 1.0 in elementary schools at this age. Vision. At the age of 12, 71.1 per cent, of the boys and 68.5 per cent, of the girls were able to pass the vision test, compared with 69.2 and 65.8 in elementary schools; but, whereas in elementary schools the vision of children leaving 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 16.6 per cent, of the boys and 19.6 per cent, of girls were wearing glasses at the age of 12, but at the age of 15 the percentages were 18-7 boys and 22.9 girls. In spite of the much greater percentage wearing glasses at the age of 15, the number of pupils passing the vision test remained approximately the same, viz., 70.2 Der cent, amons bovs and 67.5 per cent, among eirls. Care of eyesight in secondary schools. Nutrition. In September, 1926, sight-saving education for myopic pupils was begun at Clapton and Peckham (now Honor Oak) county secondary schools for girls and at the Eaine's foundation school for boys and still continues. The nutritional state of the pupils in the secondary schools, as returned by the school doctors, reverses the sex incidence of subnutrition found in elementary schools. In the elementary schools, girls at each age are better nourished than boys, but in the secondary schools, while only 4.8 per cent, of the boys are reported as subnormal, amongst girls, 6 per cent, are so returned. On the much smaller figures supplied from the routine inspections in secondary schools, there is more room for the personal equations of the examiners to obtrude themselves, still the figures suggest that the prevailing sentiment in favour of "slimming" affects the question. It is stated that many girls refuse milk in school giving the reason that it will make them " fat." Defccts. The pupils 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 81 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. The re-inspection of 3,106 pupils in higher education institutions was carried out; 1,698 defects had been satisfactorily treated, 168 were under treatment, 832 had had treatment but needed further treatment, and in 887 cases, no treatment had been obtained. Re- inspection. The following-up of defects discovered at secondary schools is left to the head masters and mistresses. When the parent is not present, a letter recommending treatment is sent, generally in the name of the head master or mistress. The parents normally respond readily. Scholarship children attending secondary and trade schools are given the same facilities for medical treatment under the Council's arrangements as children in elementary schools. For fee-paying pupils at secondary schools who have been inspected by the Council's medical officers or doctors appointed by the governors, arrangements are made when necessary for medical treatment to be received under the Council's scheme provided that (i) the parents cannot afford to make private arrangements and (ii) navment is made therefor. Of the 878 students examined in training colleges, none was found to be suffering from extensive dental caries; 82.1 per cent, of the men and 77.7 of the women passed the vision test, but 38.8 per cent, of the men and 26.0 of the women were wearing glasses. Training colleges. The teaching of hygiene. The school medical staff is not directly identified with the work of teaching hygiene. In all elementary schools, however, formal teaching of hygiene takes a place in the syllabus. A considerable amount of informal help is given by the doctors and nurses. Applications for addresses by the medical staff to parents and children are numerous and are always met. No additional staff, however, has been allowed for this, and if applications were to increase to a great extent it would be impossible to accede to the requests with the present staff. The work of the school nursing service is very largely devoted to the practical inculcation of good habits of personal hygiene. As eighty per cent, of parents attend the medical inspection of their children at some stage during school life, the school doctors exercise a potent influence through their individual advice, and though the effect of this is incalculable it is probable that there is no greater influence for health at work in the population generally. At dental inspection a little homily is generally given by the dental inspector to the parents as a group on the importance of dental care. The scheme organised by the education officer for dental demonstrations in the schools by officers of the dental board is now a permanent feature of hygiene teaching in the London schools, and reports are received which show that these demonstrations awake great interest and are of much value. In many of the boroughs the medical officer of health takes great interest in the work of education in health. " Health week " is commonly associated with a mass attack, in which the school children are provided for by special addresses and demonstrations. The treatment centres are capable of becoming in truth health centres, and parents visiting them learn much in regard to the general care of their children. The Downham treatment centre proclaims itself as a health centre, and sets an example in this respect by organising public lectures including cinematograph displays. Red Cross "links" have been established in many schools particularly in the south-western division. These are intimately associated with the work of the school nurses, and give great assistance in creating enthusiasm and a " public opinion " amongst the school children in regard to cleanliness and hygienic living. 82 There is a demand for health instruction on the part of the population over school age. In the evening schools there are some 250 classes in infant care, health, home nursing and first aid with over 3,000 pupils. These classes are conducted by selected medical practitioners. There are also 46 courses of lectures provided by the Education Committee for mothers attending infant welfare centres, with an average attendance of 20 at each lecture. Advanced lectures are also given to teachers in the evenings, and the assistant medical officers who carry out medical inspection of the students in training colleges assist there with the teaching of hygiene which is a compulsory subject. Special inquiries and reports. Certain special inquiries and reports have been included in their appropriate sections. Reference has been made to Dr. R. H. Simpson's enquiry into the provision of school dinners (p. 58); Dr. G. Chaikin's enquiry into the effect of milk meals (p. 55); Dr. E. McVail's joint report with the education inspectors on nursery schools and classes (p. 78); Dr. A. G. Wells' report on the special aural work (p. 26) ; and Dr. C. E. Thornton's report on the rheumatism scheme ("p. 33). Mr. Lambrinudi's report on kyphosis. Mr. C. Lambrinudi, one of the Council's orthopaedists, has conducted a research into the incidence and causation of kyphosis in children in London schools. The schools visited were those in Southwark in close proximity to Guy's hospital. The results were published in the British Medical Journal of 3rd November, 1934. Mr. Lambrinudi found that it was common for children in school to possess short hamstring muscles, that this was more often unilateral than bilateral, and that in the former there was invariably rotation of the lumbar vertebrae towards the shortened side. His conclusions may be quoted in his own words :— I doubt if any but a few cases of adolescent kyphosis are the effect of congenital causes. The key to the problem lies in those mysterious fissures in the cartilage plate (of the spinal vertebrae), which I believe arise from flexion injuries. During the rough and tumble of play any child might sustain a flexion injury sufficient to produce these fissures, but I believe that the back of a child whose hamstring muscles are short is more susceptible to traumata of this nature, particularly if his general musculature is poor on account of previous debility or overgrowth. I would go even further, and say that not only do short hamstring muscles predispose to flexion injuries, but that they also give rise to rotation of the vertebrae and ultimately to scoliosis. If I have succeeded in convincing you that shortening of the hamstring muscles is an important factor, then we ought to agree that children with that condition should be watched with the utmost care and intelligence at school, and that toe-touching exercises in gymnastic classes should be condemned as a routine practice. Dr. Neustatter's report on physique of junior boys in a Bermondsey school. A member of the Education Committee noted that the junior boys in one Bermondsey school, at which she distributed the prizes, appeared to her to lack stamina to an exceptional degree which she had not noticed in other schools she had visited. Dr. Thomas visited the school and agreed with this opinion. The conditions referred to anaemia and posture rather than to malnutrition. The school is one that has no playing field within a distance which is within reach of younger boys. It has been stated in an earlier section of this report (p. 11), that junior boys are at a critical age, and that many types of defect reach their maximum amongst them. Dr. Neustatter, who is the school doctor at the school in question, was asked to pay special attention to the physique of the boys and he has submitted the following report:— There were four workers—two care committee workers, one nurse and the doctor. The investigation was carried out in a large room. The doctor sat in the middle with one of the care committee on his left. The nurse weighed and measured the children, and called out the weights to the second care committee worker, who sat beside her. She also made a note of the address of the child and its age. A class of about thirty was brought up, removed their shoes, but not their clothes, and were weighed and measured. The children were lined up in such a way that each child approached the doctor from the front, walking towards him for a distance of about five yards. This was considered a matter of some importance, as it allowed the doctor to get a good view of the " tout-ensemble " of the child's bearing, expression, comparative size, etc. 83 The child stood on the doctor's right, was inspected, and the remaining points in the form filled in. At the same time, if necessary, the child was referred to the care committee worker on his left, if milk or convalescence was indicated, for her to take the necessary particulars. Milk cards were filled in by the care committee worker and signed in a bunch at the end. Cases for convalescent treatment were referred as specials for the next medical inspection. In this fashion it was possible to see 240 children in just over two sessions (excluding an hour to an hour and a half preparing the scheme at the first session), equalling approximately 3J hours of actual inspection. In addition to this the headmaster and the care committee had picked out a selection of particularly unhealthy looking children preparatory to the investigation, who were inspected by the doctor before the routine examination was made. The following defects were noted :— Faces : (i) Pallor—particularly the rather greyish pallor that these children sometimes suffer from. (Care was taken not to confuse the pallor of anaemia with that of the blond or red-haired fair-skinned child) ; (ii) A flabby, pasty skin, especially bagginess under the eyes ; (iii) Expression—note was taken of the two extremes, the dull listless expression on the one hand, and the rather hectic look on the other ; (iv) Prematurely old and tired faces. General physique : This was judged by the growth, by the state of the musculature, by flabbiness, excessive thinness, and/or, stunted growth. Posture was also taken into account. These descriptions are not very precise, but it is not possible to do more than record a general impression, which is based on observation of the above points. For recording purposes some kind of classification was needed. The children were therefore placed in the following four categories:— (i) Exceptionally good physique—These cases were boys who were well grown, very well developed muscularly, had good colour, healthy skins, and an alert bearing. In popular language they were " A 1." (ii) Average physique—This comprised children, who, while not as exceptionally well developed as the others, nevertheless were bright and healthy, and had no obvious defects. They were quite satisfactory. (iii) Poor physique—These boys fell short of (ii) in so far as they had one or more of the defects enumerated above, which made them unsatisfactory. (iv) Bad physique—These were of such undoubtedly poor physique, that they would unhesitatingly be recommended for an open-air residential schoool such as Bushy, at a routine or special inspection. A record of height and weights was also made, in case some kind of objective record was needed. Little importance is attached to these findings, which are, however, included for completeness. Table 48. Classification. Age. Total. 7 years. 8 years. 9 years. 10 years 11 years Above average weight 10 41 41 39 10 141 Below „ „ 2 13 15 16 9 55 Above average height 9 39 40 46 15 149 Below „ ,, 3 16 16 17 10 62 Exceptionally good physique 1 1 5 7 0 14 Average physique 5 36 31 33 13 118 Total 6 37 36 40 13 132 Poor physique 6 14 18 14 8 60 Bad ,, 0 5 3 5 3 16 Total 6 19 21 19 11 76 Total number of cases showing dental caries, 33 ; anaemia, 46. N.B. Originally it was only intended to weigh and not to measure. Measuring was commenced on the second session. Therefore, owing to a certain number of absentees, the figures for weights and heights do not exactly correspond. Having classified the physique of the children as shown, an attempt was made to investigate the underlying factors and to see if anything emerged. A street analysis was made, but except in one instance, there was no evidence of markedly uneven distribution of the various groups. 84 A detailed inquiry into the factors tabulated below was made by the care committee. They paid a visit to each of the homes of the 60 cases recorded, which were selected as a "random" sample, and filled in a questionnaire, in each case, and from these, the following table is compounded: Table 49. Number of cases. Factors investigated. Average number of individuals in family. Average earnings. Average number of individuals in bedroom. Average number of individuals in 1 bed. Average hours of sleep. Standard of ventilation. Number of cases of damp houses. Whore child plays. Average hours out of doors daily. Estimate of feeding. 40 (36 of poor and 4 ot bad physique). 6 £2 6 4.3 2.5 11 29 good 3 fair 8 poor. 8 34 in yard 6 in parks. 3½ 30 good 7 fair 3 poor. 20 (all of exceptionally good physique). 5.5 £2 10 3 2 11 17 good 3 fair 2 17 in street 3 in garden 33 17 good 3 fair. Here again the table shows no significant difference between the two groups, though it shows the number of large families and general overcrowding. The largest family comprised 11 members, in 16 cases over 4 individuals shared a bedroom, the maximum being 8. In this case, 6 were in a bed ! In 6 cases, 3 shared a bed. In the family of 11, the physique of the child was bad. The records of the other cases show no outstanding cause for bad physique. It will be seen that the inquiry includes an estimate of the type of feeding ; as this was made by the care committee, it is very difficult to convey the standard, as the estimate is an expression of opinion by th( ir individual members. An example of the type of feeding described as good was as follows: breakfast—2 pieces of toast, egg, or cereal, or bacon; dinner—meat dish, vegetable, potatoes ; tea—bread and butter ; suuper—broth or meat. An example of "poor" is : bread and butter for tea, supper and breakfast (while the parent was out of work Quaker Oats or rice for dinner could not be afforded); meat puddings and vegetable for dinner. Obviously the opinion must be formed on the spot. The care committee, in summarising their results, say: "In most cases the children seemed to be getting enough to eat; there were three cases where the physical condition might have been due to under nourishment, and 6 where the children were finicky about food; on the other hand, a few cases were exceptionally well fed, porridge, meat, vegetables and fruit, forming a large part of the diet." They express the opinion that housing overcrowding seems to be the real difficulty. They conclude by saying that, in their opinion, in all the cases of the children of exceptionally good physique, although other circumstances are the same, "the mother is an extraordinarily capable and efficient manageress." As these families average 5J in size, and the income averages £2 10s., such a statement is a testimony to a high degree of skill on the part of the mother. Although none of the findings shows a direct setiological relationship to the case of poor and bad physique, probably the overcrowding and lack of suitable facilities for outdoor recreation (51 out of 60 of the children played in the street), play an important part in bringing about the condition of unsatisfactory physique; the more so as pallor was so often an outstanding feature. If these conditions could be altered, it seems a reasonable assumption that a number of the children now classed as " poor," would fall into the " average " class. The writer, moreover, would like to put forward two other theories as to the unsatisfactory condition of these boys. (i) A tentative suggestion that there is a psychological factor present, indirectly due to the overcrowding. Under the conditions in which these children live they are perpetually surrounded by others, they have no privacy; and, as is at times revealed by children, they are aware of and worried by the difficulties with which most of their parents have to contend. This, in conjunction with the noise, might be responsible for the strained expression and prematurely old faces of so many of these children. (ii) A more definite suggestion, often confirmed by findings at routine inspections, that these children frequently get insufficient sleep. These points might repay investigation. Finally, there is the question of diet. The care committee report reveals little actual shortage of food, though the quality of the food does not come up to a very high standard. At a time when the question of nutrition is to the fore, it is as well that other factors, such as those cited above especially fresh air and sunshine, should not be lost sight of. It must be emphasised that this enquiry was not into the question of malnutrition, but into the condition of physique, which as Dr. Robert Hutchinson has aptly pointed out, is quite a different matter. Dr. Neustatter's estimation of the nutritional state 85 of the boys examined shows that they do not differ materially in this school from the standard usually found in this respect. At a meeting of the Royal Society of Medicine in February, 1935, Dr. Robert Hutchinson remarked that there is still a great deal of confusion from failure to distinguish between physique and nutrition. Dr. A. B. Francklyn has made a short study of gains in height and weight at the Essendine-road and Barlby-road open-air classes, and has compared them with those of certain debilitated children receiving milk in school. Dr. Franc klyn's report on open-air classes. The object of this analysis is to determine, if possible, the actual improvement in the children's health by objective means. The first point that emerges on comparing the results obtained at Barlby-road open-air class, with those of Essendine-road open-air class is the superiority of results obtained at Essendine-road during the period for April to October, 1934 (see figs. 8 and 9). fig. 8. Graph comparing gains in weight fio. 9. graph comparing gains in height in the three groups, april to october, in the three groups, april to october, 1934. 1934. The average gains in weight and height, respectively, were 1.24 kilos., and 2.27 cms., at Barlby-road, compared with 1.49 kilos, and 41 cms. at Essendine-road. The superior gain in weight is almost negligible, but the gain in height is markedly above that of Barlby-road, and is significant. If the results of these two classes are compared with the results obtained from children on " official milk," it will be seen that the two open-air classes show a superiority in both height and weight for the summer session. The children on " official milk " only show an average gain of 0.9 kilo, in weight, and 1.9 cm. in height for the period from May to October. But on examining their records over longer periods the picture is found to be reversed. The children on milk gain steadily throughout the year at an almost uniform pace. Winter gains and summer gains are almost of a constant nature. Take for instance, this record for the past twelve months :—• Table 50.-—Gain in height and weight of children on "official milk." Period. Gain in Weight. Height. October to January 0.9 kilos. 1.8 cms. January to May 0.8 „ 2.0 „ May to October 0.9 „ 1.99 „ The fluctuations are slight and almost insignificant. If the average gains at Barlby-road open-air class are considered over the same period, marked fluctuations in weight and rate of growth are disclosed :— Table 51.—Gain in height and weight of children at Barlby-road open-air class. Period. Gain in Weight. Height. October to January 0.38 kilos 1.23 cms. January to May 0.3 „ 1.87 ,. May to October 1.2 „ 1.94 „ 86 The total yearly gains are all in favour of the children on "official milk "; they have an average greater increase in weight of 0.78 kilo, and of 0.75 cm. in height. Unfortunately there are no records of weight and height for the Essendine-road open-air class in the winter, as the children concerned return to in-door conditions. The results of the Essendine-road open-air class appear satisfactory. The improvements in height and weight compare favourably with the other two groups; and both parents and teachers give corroborative evidence of improvement in health. It is to be noticed that the gain is most marked during the holiday period and that there appears to be a correlation between the degree of nutrition and the rate of improvement. Debilitated children appear to put on weight at a faster rate than healthy children, given good conditions. On analysis of results of the Barlby-road open-air class, the average increase in weight over the summer is less than that obtained at Essendine-road open-air class by 0.25 kilo., and there is also a slower rate of growth; the average gains being 1.83 cm. behind those of Essendineroad. If Essendine-road open-air class is taken as the measure, the results at Barlby-road are not up to standard. They were so, however, for the period April to October, 1933. FIG. 10. GRAPH COMPARING MEAN GAINS IN WEIGHT AND HEIGHT, BARLBY ROAD OPEN-AIR SCHOOL AND GROUP OF SELECTED MILK CASES, JANUARY, 1933, TO OCTOBER, 1934. Again the improvement in 1934 is not as satisfactory as that of 1933. There is a smaller average gain in both height and weight for 1934, and these results are appreciably below those observed in a very similar group of children on "official milk "(see fig. 10), though their homes are very much the same as those of the Barlby-road open-air class. It seems likely that, in the case of the Barlby-road class, "food energy "is being spent on keeping up bodily heat in the winter months out of doors. The very excellent figures obtained in the "official milk "group are worthy of note. Wage-earning employment of school children. In the year 1934, 3,304 applications (3,274 boys and 30 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: 87 delivery of milk, 250; delivery of newspapers, 1,746 (14); carrying or delivery of goods or parcels, 541 (5); in or in connection with a shop, 295 (5); in a coal yard, 12; industrial work at home, 1; house work away from home, 16 (1); as a messenger, 43 (2); miscellaneous, 10 (1). In 234 cases the certificates were granted subject to medical treatment being obtained, and in 44 additional cases other conditions were imposed. Certificates on medical or other grounds were refused to 85 boys and 1 girl for the following reasons:rheumatism, 1; dental condition, 1; defective vision, 3; heart condition, 5; scoliosis, 3; poor general condition, 9; flat-foot, 3; bronchitis, 1; non-medical reasons such as "withdrawn, "illegal hours, under or over age, etc., 60. The number of licences granted to permit children to take part in entertainments during 1934 was higher than in any year since the Council first took over the duty of granting licences in 1920. This year there was an unprecedented demand for children to appear in pantomimes, and this was one of the causes of the increase. There were also more troupes of children appearing in cinemas and music halls throughout the year. The Council's decision that a child shall not take part in more than two performances a day has had its full effect in 1934, with the result that more children are being employed to act as substitutes so that the troupe may be able to perform three times a day in cinemas. Employment of children in entertainments. The number of medical examinations of children under the regulations governing the employment of children in entertainments was 723 (74 boys, 649 girls). Four children, girls, were rejected on medical grounds-one enlarged glands, one hernia, one chest trouble, and one heart disease. One hundred and twenty-six 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 77, visual defect 19, throat condition 3, skin affection 12, personal hygiene 8, anaemia 2, ear affection 3, and flat-feet 2. Examination of employees in the education service and scholars. In the year 7,266 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 Table 52. Status. Number examined. Number fit. Number rejected. Number who withdrew after being referred for remediable defects or were not due for reexamination until 1936. Male Female Male Female Male Female Male Female Permanent service 275 438 260 428 4 3 11 7 Teaching awards 145 383 143 372 1 3 1 8 Scholarships 3,059 2,991 2,917 2,890 21 6 121 96 3,479 3,812 3,320 3,690 26 11 133 111 Total *7,291 7,010 †37 244 * Including 6 permanent service cases (4 male, 2 female), 11 teaching awards (3 male, 8 female) and 8 scholarships (1 male, 7 female) referred from 1933. † The causes of rejection were mainly defects of vision, unsatisfactory general health and morbid conditions of the heart. 88 In addition to the above, 148 examinations were made of scholars (49 male, 99 female) with a view to determining their fitness to continue to hold awards, and of these 8 (2 male, 6 female) were found to be unfit. Re-examinations totalling 1,792, were made of entrants, scholars, etc., who were referred at the first examination for treatment for one or more remediable defects. The total number of examinations was 9.231. Cases specially referred There were also referred to the public health department 3,513 special cases in which medical advice was required. This figure includes 3,079 teachers (599 men, 2,480 women) and 434 schoolkeepers, cleaners, etc. (107 men, 327 women). In regard to recommendations governing sick leave to teachers, 2,015 or 71 per cent. of the teachers concerned were over 40 years of age; this shows a decrease of 1 per cent. on that of the previous year. Health of teachers. In connection with these cases, 18 home visits were paid during the year. The records for the years 1930 to 1934 (inclusive), of the deaths and premature retirements on account of ill-health, occurring among the teaching staff in elementary, excluding special, schools, have been specially examin ed by Dr. J. G. Duncan and Dr. A. C. Williams. Deaths of teachers. The causes of death and age at death are set out below:- Table 53. Disease Age Total 20-29 30-39 40-49 50-54 55-59 60- M F M F M F M F M F M F M F Respiratory system- Tuberculous 3 2 1 1 4 2 1 2 2 - - - 11 7 Non-tuberculous 2 1 2 6 5 5 4 1 4 2 1 17 16 Influenza - - - - - 3 - - - - - - - 3 Organic nervous disease - 2 1 3 2 1 - 4 4 3 1 4 8 17 Gastro-intestinal disease - - - 3 5 3 3 - 2 3 3 3 13 12 Circulatory diseases - 1 2 1 5 11 4 4 5 6 2 5 18 28 Septicaemia - - - - - 5 - 2 - - - - - 7 Cancer, etc. - - - 1 2 8 4 15 3 9 - 2 9 35 Accidents 2 - 2 2 1 4 4 - 4 2 - - 13 8 Kidney - - 1 1 1 1 1 1 3 1 2 - 8 4 Operations (site unknown) - 1 - 1 1 3 2 1 - 2 - - 3 8 *Miscellaneous - 1 - 2 2 1 1 1 2 1 - - 5 6 Cause unknown - - - 2 3 6 4 3 3 3 4 - 14 14 Total 7 7 8 19 32 53 29 37 29 34 14 15 119 165 Deaths at all ages-Yearly average 23.8 33.0 * One ease each of anæmia, debility, scarlet fever, streptococcal infection, diphtheria and lymphatic leukaemia, two cases of diabetes and three of death following childbirth. In 19 cases the teachers died from operations for known conditions and these have been entered under the appropriate heading. 89 The causes of retirement of teachers who have left the service on medical Breakdowns grounds are set out below:- Table 54. Disease Age Total 20-29 30-39 40-49 50-54 55-59 60 + M F M F M F M F M F M F M F Respiratory diseases- Tuberculous - - - 3 3 3 - 1 - - - 3 7 Non-tuberculous - - 1 1 1 1 3 6 4 11 - - 9 19 Nervous Diseases- - Organic - - - 1 - 4 1 2 2 2 - 1 3 10 Functional - - 3 5 2 18 5 25 9 45 2 1 21 94 Psychosis - - - 1 1 7 2 2 - - - - 3 10 Arthritis - - - 1 - 5 - 10 2 20 - 3 2 39 Gastro-intestinal disease - - - - 1 5 2 3 4 7 - 1 7 16 Kidney diseases - - - - - 2 - 2 1 1 - - 1 5 Circulatory - - - 1 1 15 1 17 2 41 - - 4 74 Cancer - - - - 2 6 - 5 - 6 - - 2 17 Deafness - - - 1 1 3 - 8 2 7 - 1 3 20 Defects of vision - - - - 1 - - 3 - 6 - - 1 9 Diseases of larynx - - - - 1 - - - - 2 - - 1 2 Exophthalmic goitre - - - - - 2 - - - 3 - - - 5 General debility - - - 1 - - - 1 1 6 - 1 1 9 *Miscellaneous - - - 4 1 i 3 - - 5 - - 4 10 Total - - 4 19 15 72 17 85 27 162 2 8 65 346 Yearly average 13 69.2 * One case of eczema, two of septicaemia, three of anaemia and four each of diabetes and uterine disorder. Comparing the incidence of "breakdowns" in the present series with that shewn in the table issued in the Annual Report for 1929 (vol. III, p. 143), the following interesting facts emerge:- (a) The total number of "breakdown" cases in each period is very nearly the same, i.e., 1930-1934, 411; 1925-1929, 417. (b) The cases of pulmonary tuberculosis are now considerably lower. (c) There is a considerable rise in the prevalence of rheumatic conditions during the period under review, and this was particularly obvious in the later months of 1934. (d) Ten teachers were obliged to leave the service on account of defective vision. In two cases the disabling condition was blindness from the effects of rapidly increasing myopia. There were also two similar cases of teachers at a secondary and a special school respectively, records of which are not included in the table. All these teachers had been passed into the service prior to the commencement of the present century. That the number of these cases is no higher is probably due to the fact that candidates suffering from severe myopia are rejected at the entrance examination, the standards used for which are in conformity with the advice of the Council of British Ophthalmologists. (e) The total number of teachers invalided out of the service on account of nervous and mental disorders did not differ greatly in the two quinquennia, but there is a greater tendency for the mild or functional type to preponderate over the graver organic disease. It is very difficult, from the records, to distinguish exactly between the classes; it is particularly common for a psychosis to be described in the early stage as a nervous breakdown. In both sexes the largest number of cases occurred in those who were suffering from definite physical disease, often of a depressing nature, e.g., thyroid disturbance, colitis, deafness, neuritis and rheumatic conditions and worry following operations. About one quarter of the total cases invalided out of the service were of the neurotic type. In seven of the men nervous trouble had first been 90 noted during War service, and most authorities state that War neurosis occurred almost exclusively in the constitutionally highly strung. It was noted, especially among the women, that home worries were an important factor, many of them having to bear heavy domestic responsibilities, often including the nursing of elderly parents and other sick relatives. (/) As shown below, the age group at which " breakdowns" took place was later in the second series :- Table 55. Years Age. 20-29 30-39 40-49 50-54 55-60- 1925-29 3 34 99 122 159 1930-34 0 23 87 102 199 This difference is also shewn in the age-distribution of the deaths:- Table 56. Years Age. 20-29 30-39 40-49 50-54 55-60- 1925-29 30 37 86 67 80 1930-34 14 27 85 66 92 Deaths from respiratory (tuberculous and non-tuberculous) disease were both somewhat fewer than in the earlier series. The influence of the 1929 influenza epidemic is to be noted, for in that year there were 3,118 deaths from the disease among the general population of London. (g)So far as influenza itself is concerned, there were only three deaths in the period under review, as compared with twenty-four during 1925-1929. (h) Accidents were twenty-one as against twenty-two in the former analysis. Thus, it will be seen that there has not been the rise that would be anticipated from the general increase in street fatalities. Duration of service The annual average number of elementary, excluding special, school teachers on the staff for the years under review was 5,649 men and 12,038 women, making a total of 17,687. The average number of elementary, excluding special, school teachers leaving the service on all grounds annually, was 925. The average number of those lost by disease, was 139 (56.8 deaths and 82.2 breakdowns), and those who left on account of other causes, 786, i.e., taking up other appointments, voluntary retirements at age 60.65, marriage, domestic circumstances, giving up teaching, going abroad, compulsory retirement, and miscellaneous reasons. It has been ascertained that in only a very few of these cases has ill-health been even a contributory factor. Thus it may be said that about 15 per cent, of the annual wastage is due to death or disease. It will be seen that the loss to the service through breakdown in the younger teachers was nil, and only slight (23 cases) in those up to 40 years of age. In this latter group also, the deaths were few and many of them were due to such causes as accidents, pneumonia and encephalitis lethargica, from none of which the young and healthy are immune. In 1929, it was noted that while women broke down more frequently than men, the deaths among men were relatively much more numerous. The figures for the present quinquennium illustrate these facts even more strongly, the yearly average shewing:- Males Females Deaths 1 in 237 1 in 365 Breakdowns 1 in 435 1 in 174 so that a woman is more than twice as likely to be obliged to retire on health grounds as a man (2.5 :1), but is less likely to die in the service (1 :1.5). In general, the findings support the suggestion put forward in 1929, that many men have family obligations and so struggle on when their health would indicate retirement. 91 Tuberculosis is the only disease that definitely kills more men than women, i.e., 11:7 in the period ended 1934, and 17:8 in the earlier period. The proportion of the sexes of the teaching staff under review is of the order 1:2. This indicates that tuberculosis is a more prominent cause of death in men, but the numbers are small and the differences may not be of great significance. The chief affections that are relatively, as well as absolutely, higher as causes of breakdown in women are arthritis, disease of the circulatory system and deafness. The numbers of "breakdowns" in schoolkeepers, 1930 to 1934, inclusive, are in themselves small, but they illustrate the tendency generally observed for the breakdown to be concentrated on arthritis and circulatory diseases in those of 60 years of age and over, or approaching that age. Particulars are set out below:- Breakdowns in schoolkeepers. Table 57 Disease. Age. 20-29 30-39 40-49 50-54 55-59 60 + Total. Respiratory diseases- Tuberculous - - - 2 1 3 Non-tuberculous - 1 - - 2 3 Nervous diseases- Organic - - - 2 - - 2 Functional - - - - 1 1 2 Psychosis - - 1 - - - 1 Gastro-intestinal - - - - - 1 1 Arthritis - - - 1 2 5 8 Circulatory diseases- Cancer, etc. - - 1 1 - - 2 Heart - - - 1 2 7 10 Arterio-sclerosis - - - - 2 8 10 Varicose veins - - 1 1 2 3 7 Deafness - - - 1 - 1 Vision - - - 2 - - 2 Hernia - - 1 - - 1 Genito-urinary - - - - 1 1 2 Total - - 5 9 12 29 55 During the year 360 applicants for admission to the Council's course of physical education were examined. Of these 28 were deemed to be either temporarily or permanently unfit to undergo the training on the following grounds: poor general condition, 8; varicose veins, 11; recent injury, 1; renal calculus, 2; post-operative disability, 2; hernia, 1; heart disease, 1; recurring dislocation of the shoulder, 1; fistula. 1. Teachers of physical education. STATISTICAL TABLES. Table I.-Medical Inspection, 1934. (a) Routine Inspections. Group. Boys. Girls. Total. Entrants 29,576 29,062 58,638 Age 7 13,353 13,006 26,359 Age 8 (preliminary survey only) 21,453 21,809 43,262 Age 8 (detailed examination) 1,781 1,958 3,739 Age 11 26,951 26,601 53,552 Leavers 31,801 31,832 63,633 Total elementary schools 124,915 124,268 249,183 „ special schools 888 710 1,598 (b) Other Inspections. Special inspections 46,056 45,824 91,880 Infectious disease enquiries - - 44,197 Re-inspections - - 146,620 92 Table II. (a) (1) Defects found at medical inspections of all children except those aged 8 years. Elementary and special schools. Disease or defect. Routine inspectionsDefects. Special inspectionsDefects. Requiring treatment. Requiring observation. Requiring treatment. Requiring observation. Elementary schools. Special schools. Elementary schools. Special schools. Malnutrition 1,278 8 824 4 775 305 Skin-Ringworm, head 1 - - - 12 6 „ „ body 23 1 - - 19 1 Scabies 91 - - - 1,865 7 Impetigo 123 - 1 - 346 7 Other disease (non-tubercular) 877 4 85 1 733 80 Eye- Blepharitis 725 5 60 1 226 14 Conjunctivitis 170 - 15 - 239 17 Keratitis - - - - 6 - Corneal opacities 3 - 4 - 14 - Defective vision, excluding squint 13,428 93 5,183 67 3,208 350 Squint 1,089 2 406 1 410 40 Other conditions 182 2 48 - 188 25 Ear- Defective hearing 156 3 93 1 149 38 Otitis media 971 10 307 3 473 99 Other ear disease or defect 389 4 119 1 193 62 Nose and throat- Chronic tonsillitis 4,904 12 5,902 10 1,142 341 Adenoids 557 1 278 1 202 16 Chronic tonsillitis and adenoids 1,636 2 613 - 454 36 Other conditions 684 3 220 - 493 100 Enlarged cervical glands 295 1 1,044 1 213 185 Defective speech 87 - 167 - 109 60 Teeth-Dental disease or defect 58,757 330 1,384 4 4,160 102 Heart and circulation, heart disease- Organic 34 1 69 - 2 2 Functional 26 - 173 - 14 12 Not stated 211 2 2,339 17 266 733 Anæmia 587 1 482 1 362 160 Lungs--Bronchitis 817 - 863 5 144 68 Other non-tubercular 233 1 528 - 125 163 Tuberculosis- Pulmonary definite 3 - 8 - 1 - „ suspected 10 - 57 - 8 29 Glands 5 - 6 - 6 3 Spine 1 - 1 - 1 2 Hip - - 1 - 1 1 Bones and joints - - 2 - 1 2 Skin 1 - 1 - - - Other forms 1 - 2 - 1 1 Nervous-Epilepsy 22 - 17 1 46 36 Chorea 57 2 44 - 183 114 Other conditions 207 3 232 1 137 80 Deformities- Rickets 83 - 54 - 14 21 Spinal curvature 497 6 211 4 59 21 Other 728 5 522 1 206 70 Other conditions 2,646 15 1,232 3 3,451 1,244 Total 92,595 517 23,597 128 20,657 4,653 93 (a) (2). Defects found at medical inspections of children aged 8 years. Elementary and special schools. Disease or defect. Routine inspections- Requiring treatment. Requiring observation. Elementary schools. Special schools. Elementary schools. Special schools. Malnutrition 174 - 55 - Skin-Ringworm, head - - - - ,, body 1 - - - Scabies 9 - - - Impetigo 43 1 - - Other disease (non-tubercular) 93 1 4 - Eye- Blepharitis 142 1 8 - Conjunctivitis 39 - 1 - Keratitis - - - - Corneal opacities - - - - Defective vision, excluding squint 3,992 10 881 5 Squint 170 1 32 - Other conditions 21 - 1 - Ear- Defective hearing 36 - 11 - Otitis media 167 1 22 - Other ear disease or defect 68 - 11 - Nose and throat- Chronic tonsillitis 1,009 5 421 - Adenoids 92 - 17 - Chronic tonsillitis and adenoids 250 1 20 - Other conditions 80 - 17 - Enlarged cervical glands 114 1 115 - Defective speech 28 - 8 1 Teeth-Dental disease or defect 11,395 41 145 1 Heart and circulation, heart disease- Organic - - 3 - Functional 1 - 5 - Not stated 34 3 152 - Anæmia 125 - 29 - Lungs--Bronchitis 32 - 34 - Other non-tubercular 29 - 41 - Tuberculosis- Pulmonary definite - - - - ,, suspected 2 - 4 - Glands 3 - - - Spine - - - - Hip - - - - Bones and joints 1 - - - Skin - - - - Other forms - 1 3 - Nervous-Epilepsy 4 - 2 - Chorea 17 1 10 - Other conditions 24 - 17 - Deformities- Rickets 1 - - - Spinal curvature 20 - 6 - Other 40 2 26 1 Other conditions 357 5 148 - Total 18,613 75 2,249 8 G 94 (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 58,638 8,445 14.4 Age 7 26,359 4,295 16.3 Age 8 (preliminary examination only) 43,262 5,893 13.6 Age 8 (in detail) 3,739 929 24.8 Ago 11 53,552 8,800 16.4 Leavers-age 13¾ 63,633 9,701 15.2 Total, elementary schools 249,183 38,063 15.3 „ special schools 1,598 199 12.5 Table III. (a) Exceptional children in London in 1934. Classification. At certified special schools. At public elementary schools. At other institutions* At no school or institution Total. Day Residential Blind children - 125 - 7 3† 135 Partially sighted children 720 - 17 17 - 754 Deaf children 283 241 - 7 6‡ 537 Partially deaf children 150 - 2 26 - 178 Mentally defective children- Feeble-minded children 3,604 261 5§ 9 7 3,886 Epileptic children- Children suffering from severe epilepsy - 122 - 34 13¶ 169 Physically defective children- Tuberculous children- Pulmonary 124 291 - 24 - 439 Non-pulmonary 344 455 - 13 - 812 Delicate children 1,964 515 6,159 9 - 8,647 Crippled children 1,758 351†† - 11 - 2,120 Children with heart disease 1,821 221 - 34 - 2,076 * Undergoing treatment in general hospitals, etc. †At time of report were awaiting admission to schools for the blind. †Under enforceable age. § At time of report were awaiting admission to M. D. schools. ¶Awaiting admission to certified schools. ††Includes 25 children at Northern hospital (post encephalitis lethargica). Of these 53 children were suitable for admission to open-air schools (O) but their parents refused to allow their transfer to such schools. The remainder could not be certified as incapable by reason of physical defect of receiving proper benefit from the instruction in the ordinary public elementary schools, but they might have benefited from a period of open-air treatment. (6) Return of children suffering from more than one defect, 1934. Defect. Type of School. At other institutions (Gen. hosp., etc.) At no schl. Total Day M.D. Residential M.D. Residential blind Day deaf Residential deaf Epileptic colony Day P.D. Certified hospital schls. M.D. and deaf 7 - - 1 8 - - 1 - - 17 M.D. and crippled 46 3 - - - - 2 16 2 - 69 M.D. and heart 38 - - - - - 1 - - - 39 M.D. and epileptic 26 - - - - 28 - - - - 54 M.D. and T.B - - - - - - 2 1 - 3 M.D., cripple and heart 1 - - - - - - - - - 1 M.D., crippled and deaf - - - - 7 - - - - - 7 Blind and epileptic - - 1 - - - - - - - 1 Blind and M.D. - - - - - - - 1 - - 1 Deaf and crippled - - - - 1 - - 1 - - 2 Deaf and heart - - - - 1 - - - - - 1 Epileptic and crippled - - - - - 1 3 2 - - 6 Epileptic and heart - - - - - 6 1 - - - 7 Epileptic and deaf - - - - - 1 - - - - 1 Heart and crippled - - - - - - 26 - - - 26 Heart and T.B - - - - - - - - 1 - 1 118 3 1 1 17 36 33 23 4 - 236 95 Table IV. Treatment table. (a) Group I.-Minor ailments, excluding uncleanliness, for which see group V. Disease or defect. Defects treated or under treatment. Under Council's scheme. Otherwise. Total. Skin- Scabies 3,409 - 1 5,545 Impetigo 2,136 Ringworm, head 195* 151 346† body Other skin disease Eye disease (external) and other (but excluding cases falling in group II) 114,809 880 115,689 Ear disease (cases in which operative treatment, e.g., mastoid operations, etc., is given, are excluded) Miscellaneous (minor injuries, bruises, sores, chilblains, etc.) 120,549 1,031 121,580 * 118 by X-ray. † 249 by X-ray. (6) 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) 38,284 1,653 41,937 Other defect or disease of the eyes (excluding those in group I) 2,000 (estimated) * Children for whom glasses were prescribed-under the Council's scheme, 29,599; otherwise 1,277 (estimated). Children who obtained or received glasses-under the Council's scheme, 27,497 = 92.9 per cent.; otherwise 992. * Included in Group I minor ailments. (c) Group III.-Treatment of defects of the throat and nose. Number of defects. Defect. Received operative treatment. Total. Received other forms of treatment. Total number treated. Under Council's scheme. Private practitioner or hospital. Tonsils 700 581 1,281 3,762 13,738 Adenoids 443 64 507 Tonsils and adenoids 7,686 241 7,927 Other 31 230 261 Total 8,860 1,116 9,976 (d) Group IV.-Dental defects. 1. Number of children who were:- (a) Inspected by the dentist-Age groups 5 years and under 17,958 273,672 6 „ 30,243 7 „ 28,323 8 „ 20,549 9 „ 38,223 10 „ 38,980 11 „ 18,519 12 „ 33,747 13 „ 31,584 14 „ and over 15,546 H 96 (d) Group IV.-Dental defects-continued. (6) Found to require treatment 176,509 (c) Actually treated 138,140 2. Half days devoted to inspection 2,492 20,703 „ „ „ treatment 18,211 3. Attendances by children for treatment 232,327 4. Fillings-permanent teeth 116,492 139,513 „ temporary teeth 23,021 5. Extractions-permanent teeth 57,604 321,961 „ temporary teeth 6. Administration of general anaesthetics for extractions 264,357 66,424 7. Other operations-permanent teeth 23,776 ,, „ temporary teeth (e) Group V.-Uncleanliness and verminous conditions. (a) Average number of visits per school made by school nurse during the year 1934 6 (6) Examinations of children in the schools by school nurses 1,720,469 (c) Number of verminous children noted 83,207 (d) Children cleansed under Council's arrangements 73,903 (e) Cases in which legal proceedings were taken under the Education Act, 1921 (section 87) 465 Table V. Medical inspection.-Number of children examined, 1924-1934. Year. Routine examinations Special examinations. Reinspections. Examination at special enquiries into outbreaks of infectious disease. Special ear inspection centre attendances. Rheumatism supervisory centre attendances. 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 1933 218,654 85,360 165,048 71,600 18,023 14,880 1934 250,781 91,880 146,620 44,197 17,331 15,340 Table VI. Medical treatment.-Number of cases treated under the Council's scheme and by other agencies, 1924-1934. 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.* 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 105,624 2,726 44,172 1,811 17,364 1,793 134,769 5,195 1933 116,089 1,322 40,434 1,827 14,145 1,312 133,835 4,806 1934 §120,549 880 40,284 1,653 12,622 1,116 138.140 4,805 * 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. † Includes skin and head ringworm cases. § Includes 13,087 " nurses' cases." 97 Table VII. Medical inspection of students in higher education institutions, 1934. Classification. Council secondary schools. Other secondary schools. Council and other junior tech. schools. Training colleges. Total. Boys. Girls. Boys. Girls. Boys. Girls. Male. Female Male. Female Number of institutions 12 16 14 10 16 14 1 4 43 44 I. Routine detailed examination at- (1) age 12 760 973 1,030 482 293 71 - - 2,083 1,496 (2) age 15 714 829 1,191 450 620 738 - - 2,525 2,017 II. Examination (not necessarily detailed) at other ages (i.e., specials) 1,189 1,599 868 592 503 595 67 811 2,627 3,597 III. Reviewals 739 1,594 862 434 274 210 - 15 1,875 2,253 IV. Re-inspections 429 1,036 795 355 163 310 - 18 1,387 1,719 99 INDEX PAGE After-care clinic 28 After careers 70 Anaemia 15 Approved schools 45 Blind children 69 Chickenpox 44, 46 Child guidance 73 Children's care committees 19, 61 Cleanliness 11 Clothing and footgear 12 Convalescent camp schools 51 Co-operation with voluntary bodies 61 Co-ordination 7 Day continuation schools 78 Deaf children 70 Defective children 62 Deformities 15 Diphtheria 40,46,47 Ears 14, 19, 20, 26 Employees, Examination of 87 Employment of school children 86 Evening institutes 78 Eyes 13,20,80 Favus 45 Heart 15 Hygiene, Personal 37 Hygiene, Sohool 7 Hygiene, Teaching of 81 Infectious diseases 39 Invalidity, Chronic 38 Junior instruction centres 79 Kyphosis 82 Left-handedness 32 Lungs 15 Measles 44, 46 Medical inspection 9, 18, 78, 80 PAGE Medical treatment 20, 78 Mental deficiency 70 Milk scheme 58 Mumps 44,46 Nervous diseases 15 Nursery schools 77 Nutrition 10, 54, 60, 80 Open-air education 49 Ophthalmia 44,46 Orthodentics 22 Otorrhoea 14, 24 Personal hygiene 37 Physical deficiency 65 Physical education 53 Physique of junior boys 82 Plantar warts 17 Play centres 45 Remand home 71 Residential schools 45 Rheumatism 33 Rickets 15 Ringworm 20,45, 46 Scabies 38, 44, 46 Scarlet fever 42, 46, 48 School hygiene 7 School journeys 45,61, 63 Secondary and trade schools 80 Smallpox 43 Spectacles 24 Staff 6 Stammering 32 Teeth 12, 20, 80 Tonsils and adenoids 14 Tuberculosis 16, 51 Vaccination 17 Whooping-cough 44, 46 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 post free Annual Report of the Council for 1933:Vol. I (Part I).-Powers and dutiesElections - Finance - Rating and Taxation-Public Protection-TrafficPublic Amenities-Domestic and Miscellaneous Services. 1s. 6d. No. 3104. Vol. I (Part II).-Public Assistance. 1s. No. 3103. Vol. II.-Public Health, General matters - as to public health, Main Drainage and * Housing. Is. No. 3102. Vol III (Part I).-Public Health, Report Of C'Hl nty Medical Officer of Health. 1s. No. 3064. VoL III (Part II).-Public Health, Report of School Medical Officer. 1s. 6d. No. 3054. Vol. IV (Part I).-General and Special Hospitals. 2s. 6d. No. 3073. Vol. IV (Part II).-Hospital Finance. ' Is. No. 3085. Vol» IV (Part III).-Medical Supple- ' irient, 5s. No. 3089. Vol. V.-Education. Is. No. 3072. Vol. VI.-Mental Hospitals. Is. No. 3081. Vol. VII.--Abstract of Accounts and Index. 6d. (in preparation). Archives op Neurology and Psychiatry from the Pathological Laboratory of the London County Mental Hospitals. Cloth:-Vol. I (out of print); Vol. II, 1903, No. 580, 17s. 6d.; Vol. Ill, 1907, No. 715, 17s. 6d.; Vol. IV, 1909, No. 152, 10s. 6d.; Vol. V, 1911, No. 1459, 10s. 6d.; Vol. VI, 1914, No. 1677, 10s. 6d.; Vol. IX, No. 2501, 1927, 15s.; Vol. X, No. 2823, 1931, 15s; Vol. XI, No. 3044, 1934, 15s. Accounts in Abstract.-Accounts of the Income and Expenditure of the Counoil from 1st April to 31st March. 1s. Issued annually. 1932-33. No. 3060. London Statistics.-Statistics relating to London and the publio services therein, with certain statistics of the adjacent districts. Issued annually. Vol. XXXVII. 1932-33. 15s. No. 3061. Statistical Abstract for London.-Comparative statistics for 10 years relating to parishes, metropolitan boroughs, poor law areas, electoral areas. Administrative County of London, Greater London, etc. -Education, rateable value, mental disorder, poor relief, fires, finance, population, rates, locomotion, etc. Vol. XXVI. 1923-33. 2s. 6d. No. 3082. Statistics of Metropolitan Boroughs.Population, vital statistics, electors, finance and rates, &c., for each boroughPrepared and published by the London County Council on behalf of the Metropolitan borough councils, and designed as a common appendix to their reports. 1d. 1933-34. No. 3069. 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 fortnightly. Containing full particulars of appointments, contracts, etc. Price 2d. Annual subscription, payable in advance, 6s. 6d. post free. 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