LCC 44 London County Council ANNUAL REPORT OF THE COUNCIL, 1935 Vol. III(Part I) PUBLIC HEALTH (Report for the year 1935 of the County Medical Officer of Health) Published by the LONDON COUNTY COUNCIL, and may be purchased, either directly or through any Bookseller, from P. S. KING & SON, Limited, 14, Great Smith Street, Victoria Street, Westminster, S.W.I, Agents for the sale of the Publications of the London County Council. 1936. No. 3212. Price 1s. London County Council ANNUAL REPORT OF THE COUNCIL, 1935 Vol. III (Part I) PUBLIC HEALTH (Report for the year 1935 of the County Medical Officer of Health) 850 (M°C. 12706—6) 18.9.36 CONTENTS Page Vital Statistics— Population 5 Infectious Diseases 13 Tuberculosis 24 Statistical Tables 29 Administration— Slum Clearance 35 Disposal and Utilisation of Food Waste and other Waste Materials 36 Milk and Dairies (Consolidation) Act and Tuberculosis Order 42 Venereal Diseases 43 Treatment of Tuberculosis 47 Mental Deficiency Acts 60 Blind Persons Act 61 Mid wives Acts—Nursing Homes Registration Act—Maternity and Child Welfare Contribution Schemes 61 Examination of Staff 66 Bacteriological Laboratory Work 66 Chemical Branch 67 Statistical Information 75 Sanitary Officers 77 (5) London County Council ANNUAL REPORT OF THE COUNCIL, 1935 VOL. III (Part I) REPORT OF THE COUNTY MEDICAL OFFICER FOR THE YEAR 1935 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. Population. 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 1935 to have been 4,185,200. The corresponding estimates for metropolitan boroughs are shown in table 37, and the rates given in this annual report are calculated upon these figures. The age and sex-distribution of this estimated population is as follows :— Table 1. Age group Males Females Total 0- 5 years 142,800 138,500 281,300 5-15 „ 300,200 296,400 596,600 15-25 „ 350,700 383,900 734,600 25-35 „ 342,300 381,700 724,000 35-45 „ 257,100 322,900 580,000 45-55 „ 233,000 288,600 521,600 55-65 „ 187,400 226,600 414,000 65-75 „ 101,300 136,900 238,200 75 years and over 33,400 61,500 94,900 Total 1,948,200 2,237,000 4,185,200 Marriages. The marriages registered in London during 1935 numbered approximately 44,090 or 21.1 per thousand of the population, the corrected rate for the preceding year being 20.4. Births. The live births in London during 1935 numbered 55,780, compared with 56,853 in the preceding year. The live birth-rate was 13.3 per thousand as against 13.4 6 in 1934. The births in the resident populations of each metropolitan borough during 1935 were as follows :— Table 2.—County of London—Births, 1935. Metropolitan boroughs Live-births Still-births Total Legitimate Illegitimate Legitimate Illegitimate Legitimate Illegitimate Western. Paddington 1,711 253 45 15 1,756 268 Kensington 1,992 235 61 12 2,053 247 Hammersmith 1,739 139 67 5 1,806 144 Fulham 1,886 103 58 7 1,944 110 Chelsea 532 55 18 4 550 59 Westminster, City of 923 138 25 3 948 141 Northern. St. Marylebone 782 115 22 6 804 121 Hampstead 911 88 34 3 945 91 St. Pancras 2,245 222 83 11 2,328 233 Islington 4,317 207 125 8 4,442 215 Stoke Newington 668 33 21 1 689 34 Hackney 2,858 102 97 8 2,955 110 Central. Holborn 229 42 10 2 239 44 Finsbury 890 42 19 — 909 42 City of London 67 5 2 — 69 5 Eastern. Shoreditch 1,247 43 47 4 1,294 47 Bethnal Green 1,397 41 39 1 1,436 42 Stepney 2,920 107 86 5 3,006 112 Poplar 2,156 59 73 1 2,229 60 Southern. Southwark 2,225 90 78 5 2,303 95 Bermondsey 1,448 40 38 3 1,486 43 Lambeth 3,570 254 120 6 3,690 260 Battersea 2,017 87 66 3 2,083 90 Wandsworth 3,599 179 114 12 3,713 191 Camberwell 3,015 141 90 6 3,105 147 Deptford 1,397 35 41 2 1,438 37 Greenwich 1,292 45 57 2 1,349 47 Lewisham 2,691 102 96 2 2,787 104 Woolwich 1,990 64 80 5 2,070 69 London, 1935 52,714 3,066 1,712 142 54,426 3,208 London, 1934 53,784 3,069 1,694 150 55,478 3,219 Deaths. The deaths in the total population of London during 1935 numbered 47,847 giving a death-rate of 11.4 per thousand, compared with 12.2 in 1934. This is the lowest death-rate in London since 1923. Of the total deaths 23,511, or 49.1 per cent., were among females. The distribution of deaths by ages in 1935 and recent preceding periods is shown in the following table :— Table 3 Period 0- 1- 2 - 5- 10- 15- 20- 25- 35- 45- 55- 66+ 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 1923-261 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 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 2,468 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 1935 3,229 365 436 466 385 569 987 1,986 2,413 4,722 8,400 23,889 47,847 7 The mild winter of 1935, following an even milder autumn, together with the absence of any periodic epidemic prevalence, such as measles, whooping-cough and influenza, were the chief causes of the marked decrease in deaths in 1935 upon the number in the previous year. The decrease in deaths from diseases of the respiratory system amounted to 1,564, from measles 836, and among infants under one year of age 603. Other causes of death showing considerable decline were diphtheria 210, and tuberculosis (all forms) 476. There was a noteworthy reduction in the number of fatal street accidents— Street from 752 in 1934 to 531 in 1935. A comparison of the age-distribution for the two accidents. years shows a relatively higher reduction in fatal accidents among the aged :— Table 4.—County of London—Deaths from street accidents. Year Age-group 0-5 5-15 15-25 25-45 45-65 65 + All ages. 1934 29 105 120 119 161 218 752 1935 22 73 85 89 122 140 531 Decrease per cent. 24 30 29 25 24 36 29 The death-rates from all causes and from certain specified causes in each metropolitan borough in 1935 and in London as a whole in 1935 and earlier years will be found in tables 37 and 39. The deaths from the principal causes by age and sex during 1935 in London are shown in table 38. The deaths under one year of age per thousand live births were 58 compared Infant with 67 in the preceding year. This is the lowest infant mortality rate recorded in mortality. London, the previous lowest being 59 in 1930 and 1927. The movement of the death-rate from the principal diseases at ages below one year since 1910 are shown in the following table :— Table 5. Cause of death leu to 1914 1916 to 1918 1919 to 1922 1923 to 1926 1927 to 1930 1931 to 1934 1931 1932 1933 1934 1935 Measles 3.40 3.84 1.64 2.02 2.07 1.44 0.44 2.44 0.28 2.60 0.07 Whooping-cough 3.63 4.45 2.50 2.60 3.14 2.27 2.15 2.59 2.45 1.88 1.77 Influenza 0.27 1.10 0.81 0.38 0.48 0.40 0.46 0.39 0.46 0.30 0.18 Tuberculosis 3.40 3.20 1.52 1.26 0.89 0.77 0.70 0.96 0.83 0.60 0.56 Bronchitis 6.41 6.72 4.42 2.91 2.30 2.16 2.56 2.09 1.50 2.48 1.90 Pneumonia 12.28 14.96 12.60 11.51 12.10 11.45 13.90 10.25 8.27 13.40 9.79 Diarrhœsa 24.28 16.10 12.16 9.36 8.87 10.86 8.94 11.78 10.70 12.01 10.61 Premature birth 18.16 17.42 17.00 14.74 14.17 14.91 15.24 14.51 15.23 14.65 14.11 Congenital defects 14.69 14.66 11.26 8.39 7.38 7.22 6.65 7.58 6.84 7.81 6.88 Other causes 21.48 20.55 15.09 11.83 12.60 13.52 13.96 14.41 13.44 11.27 12.01 All causes 10.8 103 79 65 64 65 65 67 60 67 58 8 The deaths among infants under one year of age in age groups from the causes included in the above table are shown by sex and according to legitimacy in the following table :— Table 6.—County of London—Infant Mortality, 1935. Cause of death Age at death Total Under 4 weeks 4 weeks to 3 months 3 months to 6 months 6 months to 9 months 9 months to 1 year Number Males Females Measles Leg. 1 1 1 1 4 3 1 Illeg. — — — — — — — — cough Leg. 1 16 23 35 18 93 46 47 Illeg. — — 4 2 — 6 3 3 Influenza Leg. — 1 ' 2 4 1 8 8 — Illeg. — — 1 — 1 2 1 1 Tuberculosis Leg. — 2 10 12 5 29 15 14 Illeg. — — 1 1 — 2 1 1 Bronchitis Leg. 7 28 25 19 10 89 48 41 Illeg. 1 2 9 3 2 17 10 7 Pneumonia Leg. 54 123 144 98 83 502 301 201 Illeg. 3 11 13 11 6 44 27 17 Diarrhoea Leg. 22 110 194 130 64 520 316 204 Illeg. 1 34 26 6 5 72 42 30 Premature birth Leg. 657 47 6 1 711 428 283 Illeg. 66 9 1 — — 76 45 31 Congenital defects Leg. 196 89 46 14 6 351 195 156 Illeg. 19 8 2 3 1 33 17 16 Other causes Leg. 280 93 96 63 40 572 354 218 Illeg. 69 7 13 4 5 98 59 39 All Causes (Leg. M. 728 296 328 220 142 2,879 1,714 1,165 F. 489 214 219 157 86 Illeg. M. 92 45 39 18 11 350 205 145 F. 67 26 31 12 9 Total, 1935 1,376 581 617 407 248 3,229 1,919 1,310 Total, 1934 1,404 723 717 550 438 3,832 2,151 1,681 1934 Leg. M. 707 346 366 294 229 3,434 1,942 1,492 F. 539 274 277 221 181 Illeg. M. 77 54 47 15 16 398 209 189 F. 81 49 27 20 12 Migration 1841-1931 The effect of intercensal movement upon the age distribution of the population enumerated in successive census years has been discussed in earlier reports particularly in that for 1913 (Vol. III, pp. 2-5), where the effect of such movements upon the age-distribution of the London population north and south of the Thames was contrasted, and the population moving into London was compared, as to age and sex, with that moving outward. The census of 1931 did not contain the necessary information for a similar discussion for the period 1921-30, but a series of life-tables contained in the Annual Report for 1923 (Vol. III, pp. 10-14) enables the intercensal movement to be shown, with a reasonable degree of accuracy, for the past 90 years. Further, by means of a formula devised by Mr. C. A. Gould, M.C., B.Sc., of my department, more accurate figures relating to the balance of inward and outward inter-censal movement at various ages may be calculated for recent periods. The results are discussed in the subjoined notes by Mr. Gould. An attempt has been made to assess the net result of the migration that has occurred by ages in the County of London during each intercensal period since the year 1841. 9 This net movement has been estimated by means of the two following methods, allowance having been made for any variation in the census dates:— (a) Life table—Advancing age group.—The expected survivors at the end of the period of a given age group as at the commencement of the period were obtained from the life table of the period and the actual survivors, i.e., those 10 years older, were taken from the census at the end of the period, the difference between these giving the net movement in or out of the county during the period of an advancing age group (see table 10). (5) Age at migration.—The net movement in or out of the county during the intercensal decennium was estimated according to age at migration. The method is based on the formula:— Table 7.—Total balance of migration during various intercensal periods, (+ = migration in, — = migration out.) Period Difference between natural and actual increase (decrease) of population during period Difference between expected and actual survivors according to the life table 1841-51 + 271,728 + 251,185 1851-61 + 188,813 + 173,530 1861-71 + 121,162 + 114,008 1871-81 + 109,584 + 112,558 1881-91 - 114,783 - 96,051 1891-1901 - 181,932 - 136,436 1901-11 - 553,993 - 523,091 1911-21 - 322,004 - 290,561* 1921-31 - 330,976 - 324,698 * Excludes 74,000 war losses. applied to each year of the period under consideration where M = the migration occurring between ages o—x each year. B = the births during the year. D — the deaths between ages o—x during the year. If there has been a net migration out of the community between ages o—x during the period, the summation of the above expression will be positive and if a net inward migration the result will be negative. For all ages the expression reduces to the difference between the " natural " increase (excess of births over deaths) and " actual " increase of the whole population during the period. The data required for the calculation are the populations at each census and the total births and deaths (o —x) during the period, as recorded by the Registrar-General. The migration at the various age groups is finally obtained by differencing. It was only possible to use this method after 1891, the requisite data not being available prior to that year (see table 11). It may be noted here that as regards any age group a movement in may mask a movement out, the net movement shown for the group being small. Generally speaking a movement only becomes apparent when it is greatly in excess of one in the opposite direction ; on the other hand, a negligible net movement one way or the other does not necessarily denote that there has been little or no migration within that age group. Similarly, a small total net movement (all ages) does not necessarily imply that there have not been considerable compensating movements in different age groups. An examination of tables 10 and 11 shows this. Since the life table is calculated on the assumption that death is the only decrement of population, migration being ignored, the effect is that in the case of migration out of the community the deaths calculated on this basis will exceed the actual deaths occurring in the community. As a consequence, the expected survivors according to the life table will therefore be less than the actual survivors plus the migrants out. Hence the difference between the expected and actual survivors will be less than the actual migrants out of the community. It can be similarly shown that when there has been migration into the community the difference between actual and expected survivors will be less than the actual migrants into the community. Hence method (a) will, in general, under-estimate the net migration whether in or out. The following table shows this to be the case. 10 When considering generally the question of London migration since 1841, various factors influencing population should be taken into account, such as changes in the county boundaries and fluctuations in the birth and death rates during the period, since all these react on the amount of the migration. In 1841, the metropolis, as it was then called by the Registrar-General, was composed of parishes and districts, the metropolitan boroughs not yet being in existence. It included Penge and Clerkenwell detached, which were taken from London, and excluded South Hornsey, which was added under the Local Government Act of 1890. The population statistics given here relate to the area comprising the present administrative county as defined by the Act, which since the year 1899 has not altered to any appreciable extent. During the period 1841-51, the birth rate was 31.6 and the death rate 24.8. The former then steadily increased reaching a maximum of 35.4 in the period 1801-71, after which there was a steady decrease except for a few years following the Great War; in 1931 the birth rate had fallen to 14.9. On the other hand the death rate has gradually decreased from 24.8 during the ten years 1841-51 to 12.3 in the year 1931. Both rates are, therefore, now only about onehalf of what they were in 1841. As a result of arising birth rate and immigration, the population of London increased from 1,949,277 in 1841 to a census maximum of 4,530,207 in 1901, the peak being attained about 1897 ; since then, however, on account of a falling birth rate and emigration, it has gradually decreased, until in 1931 the London population was only 4,397,003 persons. With regard to migration, it will be seen from the following table that the period 1841-1931 can be divided into two portions. During the first period, from 1841 to 1881, there was a net movement into the county; in the second, since 1881, soon after the birth rate had reached its maximum, there has been a net movement out. The influx of children under 15 and of adults of both sexes at the marriageable ages during the first period gives some indication of the rapid growth of London between the years 1841 and 1881. The second period coincides with the expansion of the outer ring of suburbs outside the county boundaries, which was greatest in the two decennia 1901-11 and 1921-31, i.e., the periods immediately before and after that of the Great War. Table 8.—Balance of migration. County of London—1841-1931 (+ = migration in, — = migration out.) Intercensal period Population at the beginning of period Net migration during period Migration : Rate per 1,000 mean population during period Outer ring Populat ion at beginning of period Increase during period 1841-51 1,949,277 + 271,728 + 12.9 286,067 + 31,327 1851-01 2,363,341 + 188,813 + 7.3 317,394 + 90,832 1861-71 2,808,494 + 121,162 + 4.0 414,220 + 210,019 1871-81 3,261,396 + 109,584 + 3.1 024,245 + 312,119 1881-91 3,830,297 - 114,783 - 2.8 936,364 + 469,488 1891-1901 4,227,954 - 181,932 - 4.2 1,405,852 + 039,283 1901-12 4,536,267 - 553,993 - 12.2 2,045,135 + 684,538 1911-21 4,521,685 - 322,004* - 7.0 2,729,673 + 266,005 1921-31 4,484,523 - 330,976 - 7.6 2,006,878 + 811,261 1931-+ 4,397,003 — — 3,806,939 — * Excludes 74,000 war losses. It will be observed that the rate of outflow of population from the county attained a maximum during the period 1901-11 when it almost equalled the rate of inflow during the years 1841-51 ; while on the other hand the increase in population of the outer ring was greatest in the period 1921-31. The more rapid growth of the latter during the post-war period has in fact been due to two movements, one out of the county and the other mainly inward from the depressed industrial districts of the north of England and of south Wales. Referring to table 10, it is seen that there has been a definite movement out of infants,children of school age and adults of both sexes over age 25 since 1801, representing the family " trek " to the outer suburbs. Prior to that year expansion outside the metropolitan area had hardly commenced. This movement became most noticeable after 1881 when, as has been shown above, the total movement in changed to a movement out, denoting that expansion within the area had then ceased. At each intercensal period there has also been apparently a significant influx of young people of both sexes between ages 15 and 20, and, to a lesser extent, between ages 20 and 25, except, it will be seen, in the case of males during the periods 1901-11 and 1911-21. Generally speaking, it can be assumed that this influx represents young persons seeking employment on leaving school as clerks, teachers, shop assistants and factory hands and, in addition, in the case of females, as nurses and domestic servants. 11 ' The maximum of this movement would appear to have been attained sometime during the years 1851-61 when there was a particularly heavy influx of persons of both sexes. The movement out of males during the two periods 1901-11 and 1911-21 may be ascribed as probably due in part to military service, but mainly to post-war migration out following the Boer War and Great War respectively. In calculating the male migration between ages 18 and 50 during the period 1911-21 in table 11, allowance has been made for the casualties of the Great War, which, in accordance with the Registrar-General's estimate of 645,000* for England and Wales, is about 74,000. These deaths were of course not recorded among the civilian deaths during these years. It will be observed, however, that in spite of this adjustment, table 11 shows that the movement of males out of the county was maintained during this period, partly as a result of post-war emigration. As regards table 10 also, the excess of cxpected over actual survivors at the end of the period is due to war losses and migration combined. The movement out of the child population under five years of age would appear to have increased during the war period as a result, no doubt, of air raids. According to table 11 there seems to have been a small net movement in of males aged 45-05 during the same period which may point to employment on munitions and other war work. Between the years 1921-31 the net movement out of persons of both sexes over the age of 25 increased, coinciding with a similar increase in that of children under 15. In this connection, as has been remarked above, there has been a large expansion in the population of the outer ring since the Great War. Table 9.—Balance of migration at various age.i expressed as a rate per 1,000 mean population of the age group during the period (+ = migration in, — = migration out.) Ape at migration Persons 1891-1901 Males Females 1901-1911 Persons Males Females 0- 5 vears - 11.0 - 10.9 - 11.2 - 24.3 - 24.1 - 24.4 5-15 „ - 9.8 - 11.1 - 8.6 - 13.2 - 14.5 - 11.9 15-20 ., + 30.3 + 16.0 + 43.0 + 12.5 - 0.9 + 24.0 20-25 „ + 10.4 + 4.1 + 15.6 - 5.3 - 14.0 + 1.8 25-45 „ - 7.9 - 3.2 - 12.1 - 16.7 - 13.0 - 19.9 45-65 „ - 12.0 - 9.3 - 14.3 - 13.9 - 11.8 - 15.8 65 + - 21.6 - 30.3 - 16.0 - 9.6 - 13.4 - 7.1 All ages - 4.2 -4.9 - 3.4 - 12.2 - 13.3 - 11 .3 Age at migration 1911-21 1921-31 Persons Males Females Persons Males Females 0- 5 years - 28.3 - 28.2 - 28.4 - 42.4 - 43.5 - 41.4 5-15 ,, - 2.1 - 3.8 - 0.4 - 8.0 - 8.9 - 7.1 15-20 „ + 9.8 8.0 + 25.9 + 20.3 + 6.1 + 33.2 20-25 ,, - 1.4 - 9.9 + 5.1 + 10.9 + 15.6 + 7.2 25-45 ,, - 12.8 - 7.5 - 17.1 - 14.6 - 10.0 - 18.3 45-65 „ - 3.5 + 0.4 - 6.9 - 5.9 - 4.7 - 6.8 65 + ,, - 2.3 - 4.2 - 1.0 - 4.1 - 6.8 - 2.3 All ages - 7.0 7.6 - 6.5 - 7.6 - 7.5 - 7.7 The table above, based on table 11, shows the net migration rates of the sexes by age, since 1891, expressed per 1,000 of the mean population in each decennium. The high rates of influx for both sexes between ages 15 and 25in the periods 1891-1901 and 1921-31 should be noticed. The total rate of movement out was highest during 1901-11, being 12.2 per 1,000 or about treble that of the years 1891-1901. In the following periods this was reduced by nearly one-half. On the other hand, the rate for children under 5 has been steadily rising, showing clearly the increasing extent to which Londoners are seeking new homes without the county boundaries. * See p. 14, General Report, 1921 Census. 12 Table 10.—County of London—Balance of migration during successive intercensal periods amongst persons attaining the ages stated at the end of each period. (+ = migration in, — = migration out.) Age at end of period 1841-51 1851-61 1861-71 Males Females Males Fomales Males Females 0—10 years +29,885 +31,953 + 16,343 + 18,972 + 2,611 + 5,568 10—15 „ +9,794 +6,802 +3,060 +3,486 -4,355 -3,619 15—25 „ + 34,831 +71,111 +241,763 +336,819 +22,534 + 71,264 25—35 „ +34,036 +31,462 -19,329 -34,906 +30,931 +25,037 35—45 ,, -1,491 -13,412 -56,885 -76,818 +331 -18,148 45—55 „ -1,118 -2,556 -52,654 -57,102 -3,408 -11,443 55—65 „ -480 + 2,351 -39,293 -43,279 -4,424 -5,555 65—75 „ +4,124 +6,595 -20,582 -27,230 +783 + 1,978 7o—85 „ + 1,978 +3,955 -6,513 -10,447 + 1,104 +2,177 85 + +379 +986 -593 -1,282 + 319 +323 Total + 111,938 + 139,247 +65,317 + 108,213 +46,426 +67,582 Age at end of period 1871-81 1881-91 1891-1901 Males Females Males Females Males Females 0—10 years -4,246 -1,937 -24,009 -19,276 -34,275 -32,831 10—15 „ -7,882 -3,704 -17,778 -15,134 -18,303 -18,003 15—25 „ +37,162 +86,916 + 18,329 +69,295 +7,955 +67,811 25—35 „ + 31,846 +23,480 +7,894 -1,357 + 1,062 +3,175 35—45 „ +456 -21,804 -18,579 -41,479 -19,922 -44,305 45—55 „ -4,631 -14,472 -10,743 -20,583 -9,845 -20,342 55—65 „ -5,177 -7,049 -8,504 -14,775 -8,003 -13,543 65—75 „ -279 + 1,246 -852 -1,447 -921 -276 75—85 „ +821 + 1,673 +695 + 1,667 +908 +2,373 85 + +41 +98 -12 +597 +212 +637 Total +48,111 +64,447 -53,559 -42,492 -81,132 -55,304 Age at end of period 1901-11 1911-21 1921-31 Males Females Males Females Males Females 0—10 years -59,960 -57,717 -37,910 -35,532 -52,396 -49,357 10—15 „ -30,918 -28,455 -16,106 -13,326 -19,978 -18,162 15—25 „ -33,239 +26,111 -46,668 +32,381 +282 +44,413 25—35 „ -43,806 -45,092 -52,277 -25,253 -3,824 -33,165 35—45 „ -48,857 -79,397 -47,636 -56,298 -33,768 -58,840 45—55 „ -28,709 -38,157 -7,561 -22,580 -13,788 -30,119 55—65 „ -18,662 -26,931 -8,739 -20,435 -16,385 -26,553 65—75 „ -4,433 -3,873 —2,311 -1,438 -6,254 -3,468 75—85 „ -1,071 -591 -1,782 -1,133 -1,767 -1,533 85 + +60 +606 -160 +203 -32 -4 Total -269,595 -253,496 - 221,150 -143,411 -147,910 -176,788 * Including 74,000 war losses. 13 Table 11.—County of London—Intercensal balance of migration by ages. ( + = migration in, — = migration out.) Age at time of migration 1891-1901 1901-1911 Persons Males Females Persons Males Females 0— 5 years -55,027 -27,081 -27,946 -116,954 -58,235 -58,719 5—15 „ -85,357 -47,832 -37,525 -112,173 -61,317 -50,856 15—20 „ + 130,117 +32,579 +97,538 +52,954 -1,730 +54,684 20—25 „ +47,091 +8,499 +38,592 -24,161 -28,594 +4,433 25—45 „ -104,852 -19,953 -84,899 -235,790 -84,837 -150,953 45—65 „ -75,691 -27,172 -48,519 -98,329 -38,932 -59,397 65 + -38,213 -21,217 -16,996 -19,540 -10,898 -8,642 All ages -181,932 -102,177 -79,755 -553,993 -284,543 -269,450 Age at time of migration Persons 1911-1921 1921-1931 Males Females Persons; Males Females 0— 5 years -122,294 -61,367 -60,927 -140,462 -72,725 -67,737 5—15 „ -17,768 -16,120 -1,648 -57,441 -31,842 -25,599 15—20 „ +41,034 -15,816 +56,850 +80,390 + 11,385 +69,005 20—25 „ -5,941 -18,095 + 12,154 +44,506 +28,282 + 16,224 25—45 „ -182,604 -48,481 -134,123 -193,321 -59,313 -134,008 45—65 „ -28,783 + 1,439 -30,222 -52,888 -19,732 -33,156 65+ „ -5,648 -4,207 -1,441 - 11,760 -7,899 -3,861 All ages -322,004* -162,647* -159,357 -330,976 -151,844 -179,132 * Estimated war losses of 74,000 excluded. Infectious Diseases. The notifications, attack-rates and death-rates of the principal infectious diseases in London in 1935 and earlier years are shown in tables 39 to 42, and for the constituent metropolitan boroughs in 1935 in table 37. Anthrax. Two cases of anthrax were notified during the year, one in each of the boroughs of Lambeth and Deptford. The case in Lambeth proved fatal. The following account of this case, which has been furnished by the medical officer of health of the borough of Lambeth, is of interest as it illustrates the care which is taken to ascertain the source of infection and to prevent further cases arising :— I received a notification of the case of anthrax on 9th July and information reached me at the same time that the man had died in the early hours of 7th July. From inquiries made it appears that a malignant pustule was noticed on the cheek on the afternoon of 3rd July, but unfortunately the family doctor was not sent for until 6th July, and on his arrival the man was moribund and died at home from anthrax septicaemia. His shaving brush which was found to contain anthrax spores and bacilli and had been purchased, according to the widow, two years or more before, was somewhat similar to, but, owing to its worn condition, not definitely identifiable as a brush missing from a consignment of twelve shaving brushes seized in June, 1932, all of which were found to contain anthrax spores. In connection with these, information was received from the medical officer of health of Stepney in 1932, that a man had died from anthrax contracted from a shaving brush purchased in that borough, and that shaving brushes from the same consignment had been sold to two shops in Lambeth. The brushes were immediately collected, but, unfortunately, one had been bought the day before by a chance customer who could not be traced. This shop is in the same street as the home of the deceased, two or three minutes walk distant. The hospitals in the district were warned at the time to be on the look-out for a malignant pustule in order that no time should be lost before serum was given, but as no case occurred, it was believed that the customer was not a Lambeth resident. Considerable difficulty was experienced in tracing the source of supply to the wholesale dealer in Stepney in 1932, but as the result of careful inquiry it transpired that a shopkeeper now in 14 Lambeth bought the brushes shortly after the War, and, when his business in Stepney was given up in 1930, the brushes which had been overlooked at the back of a drawer were sold with the rest ot the stock. The original owner stated that he had intended to destroy them, but forgot to do so. The country of origin had also been forgotten, but from various indications there seemed little reason to doubt that they were of continental origin. There also arises the difficulty that the man shaved with the brush at least once after the pustule was noticed, and it is possible that the brush may have been infected from the pustule and may, therefore, not be the primary cause. The man was a small cobbler in his own employ, and had purchased some leather on 2nd July. As the leather was tanned and dressed ready for soling it did not appear a likely source of infection, but samples, nevertheless, were taken for examination with the expected negative result. He almost invariably shaved himself and the last time he had been shaved by a barber was at least a fortnight before the onset of his illness, and after inquiry no suspicion was attached to the barber's utensils. The man's shaving brush would seem to have been the obvious source of the disease, but its prolonged use without giving rise to infection is amazing. The patient in Deptford, a woman aged 48 years, was taken ill on 24th November and was admitted to St. Alfege's hospital on 29th November. The medical officer of health of the borough of Deptford gave the following account of the case :— Two days after admission to hospital the temperature subsided and oedema of face resolved, leaving a black central scab surrounded by a ring of vesicles on an inflamed base about 2 inches in diameter. The patient is now recovering, but the scab has not yet separated. It appears to be a ease of infection with an anthracoid organism of low toxicity. " Direct smear negative; culture, morphological anthrax bacilli isolated but not confirmed by biological test." The medical superintendent of St. Alfege's hospital later reported that the case was clinically considered by various consultants to be one of mild anthrax, but the course of the disease was too prolonged and a positive Wassermann reaction was obtained. An ultimate diagnosis of gumma of the cheek was made. Smallpox. No case of smallpox was notified during the year. London has now been free from this disease since June, 1934. In March, one ship on which smallpox had occurred during the voyage arrived in the Port of London from Brisbane. The patient had been landed at Suez. The vessel called at Marseilles. The list of London addresses given by passengers who landed in order to proceed overland to London 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 case was reported. Information was also received from the Ministry of Health in March that a vessel had arrived at Marseilles with a suspected case of smallpox on board. A list of the names and addresses of passengers who landed at Marseilles and travelled overland to London was circulated to the medical officers of health of the metropolitan boroughs. Information was later received that the suspected case of smallpox had been diagnosed as chickenpox. Cerebrospinal (spotted) fever. During the year 105 notifications ot cerebrospinal fever were received, but in 16 of these the diagnosis was not confirmed. Of the 89 actual cases, 50 proved fatal. In addition, 19 deaths were recorded by the Registrar-General of cases which had not been notified, making a total of 69 deaths. Encephalitis lethargiea. The notifications ot encephalitis lethargica numbered 15. One case was not confirmed. Of the 14 actual cases, 4 proved fatal. In addition 26 deaths were recorded by the Registrar-General of cases which had not been notified, and 4 which had been notified in previous years, making a total of 34 deaths for the year. Particulars of cases admitted to the post-encephalitis lethargiea unit at the Northern hospital are given in Vol. IV (Part I) of this report. Poliomyelitis and polioencephalitis. Notifications of poliomyelitis and polioencephalitis numbered 85 ; the diagnosis was not confirmed in 3 of these. Of the 82 actual cases, 5 proved fatal. In addition, 4 deaths were recorded by the Registrar-General of cases which had not been notified, and 2 which were notified in previous years, making a total of 11 deaths during the year. Particulars of acute cases admitted to the Western hospital and of cases admitted when convalescent to Queen Mary's hospital for children, Carshalton, for treatment of the crippling effects of the acute stage, are given in Vol. IV (Part I) of this report. 15 The administrative arrangements for the collection and distribution of immune poliomyelitis serum, described in my last two reports, were continued during the year. The demand for serum was observed to diminish appreciably ; the reduction was due in part to the lowered incidence of the disease, but was possibly also caused by reason of the doubt which recent experimental and clinical investigations have thrown on the efficacy of the measure. The disease maintains the sporadic character it has generally manifest in Britain, imposing particularly difficult conditions for early diagnosis. Moreover, as long as it remains a comparatively infrequent disease, sufficient opportunities for the trial of the prophylactic are unlikely to present themselves. After receiving the data which have accumulated since the inception in 1932 of the scheme for the maintenance of a stock of immune serum, the informal committee, consisting of representatives of the Ministry of Health, the Medical Research Council and the Council, were unable to satisfy themselves that employment of the serum has resulted in a reduction of the number or severity of paralytic complications. The following statement shows (a) the numbers of known cases of the diseases specified (i.e. cases notified and subsequently confirmed, plus the number of unnotified cases recorded in the Registrar-General's death returns), and (b) the total numbers of deaths recorded in the Registrar-General's death returns :— Table 12. Year 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 Cerebro-spinal fever— (a) 93 100 107 88 138 104 203 282 227 139 108 (b) 07 71 66 59 85 84 131 148 110 78 69 Encephalitis lethargiea— (a) 250 195 137 105 103 94 70 79 49 51 40 (b) 131 90 76 51 63 72 51 59 53 36 34 Poliomyelitis and polioencephalitis— (a) 48 85 86 46 01 37 53 91 67 73 86 (b) 13 20 17 14 7 10 0 19 13 13 11 The following table shows the age incidence of actual cases of cerebro-spinal fever, encephalitis lethargiea and poliomyelitis (including polioencephalitis). Table 13. Age periods Under 3 3-5 5-10 10-20 20-30 30-40 40-50 50-60 Over 60 Total Cerebro-spinal fever 43 9 6 13 8 3 3 3 1 89 Encephalitis lethargiea — 3 — 2 1 3 2 2 1 14 Poliomyelitis and polioencephalitis 22 27 14 13 5 1 — — — 82 Infectious diseases made notifiable by local order. The following infectious diseases were notifiable in the metropolitan boroughs specified at the end of 1935 :— Measles. First cases in family : Battersea, Finsbury, Greenwich, Hampstead, Lambeth, St. Pancras, and Southwark ; cases under 6 years of age : Shoreditch and Stepney ; all cases : Fulham. 16 German measles. First cases in family: Finsbury, Greenwich, Lambeth, St. Pancras and Southwark. Acute rheumatism. Holborn, Kensington and Paddington. ChicJcenpox. Chelsea, Deptford, Islington, Paddington and City of London. Zymotic enteritis. Throughout year : Deptford, Finsbury, Fulham, Greenwich, Kensington, Paddington and Woolwich; periodical: Poplar (June to September) and Southwark (July to September). Whooping-cough. First cases in family: Battersea; all cases: Finsbury, Greenwich and Holborn. Measles. The deaths from measles in 1935 numbered 19 compared with 855 in 1934. The death-rate was • 00 per thousand. The death-rates in London and England and Wales in recent years have been as follows :— Table 14. Area. 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 London 0-29 0 07 0-20 0 04 0-30 0 05 0-23 0 03 019 002 0-20 England and Wales 012 014 0 09 009 011 009 011 0 08 0 08 0 05 0 09 As the year 1935 fell within the inter-epidemic period, few deaths from measles were expected, but the number which actually occurred, only nineteen, is much below that recorded in any previous inter-epidemic year. The biennial epidemic in London was due to begin in the autujnn of 1935, and, from the information furnished by the daily reports of the head teachers of the Council's elementary schools, it was evident that it had begun in certain areas towards the end of October. The following statement shows the numbers of cases reported from the schools during certain periods of this and the two preceding epidemics :— 1931-32 1933-34 1935-36 Nine school weeks preceding the Christmas holidays ... 1.568 1,899 1,032 First six weeks of school spring term ... 4,809 7,065 3,928 The special report on the measles epidemic of 1933-34 was published in April 1936* Whoopingcough. There were 166 deaths from whooping-cough in London during 1935 compared with 293 in 1934. The death-rate was .04 per thousand. The death-rates in London and England and Wales in recent years are show in the following table :— Table 15. Area 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 London 0.11 0.19 0.05 0.12 0.09 0.26 0.03 0.07 0.08 0.07 0.07 England and Wales 0.10 0.16 0.11 0.09 0. 08 0. 16 0.05 0 .06 0. 07 0.06 0. 05 * Report of the Medical Officer of Health and School Medical Officer on the Measles Epidemic, 1933-34. Obtainable from Messrs. P. S. King & Son, 14, Great Smith Street, Westminster, S.W.I. Price Is. 17 The movement of the death-rate from whooping-cough in London during past thirty years is broadly shown by the figures in the following table :— Table 10.—County of London—Decennial whooping-cough mortality since 1900. Age-group Mean alluvial death-rate per 1,000 of population of cacli age-group 1901-10 1911-1920 1921-1930 0-1 year 6.14 3.95 3.17 1-2 years 5.19 3.40 2.81 2-3 „ 1.77 1.39 1.04 3-4 „ .95 .72 .45 4-5 „ .50 .40 .28 5-10 „ .09 .07 .05 10-15 „ .00 .00 .00 15-20 „ .00 .00 .00 20 years and over .00 .00 .00 All ages—Males .30 .21 .13 „ Females .34 .20 .13 Total .33 .21 .13 Scarlet fever. There were 10,954 notifications of scarlet fever in 1935 (52 weeks), the corresponding figure for 1934 being 18,238. The attack-rate was 2.6 per thousand as against 4.3 in 1934. The deaths numbered 24, giving a death-rate of .01 per thousand of the population at all ages and a case-mortality of .2 per cent. The seasonal incidence, as shown by the notifications (uncorrected for errors of diagnosis) received in successive four-weekly periods during the year, was as follows :— Table 17. 1- 5- 9- 13- 17- 21- 25- 29- 33- 37- 41- 45- 49-52 1,071 950 887 851 755 761 637 701 024 810 1,052 995 848 The notifications (uncorrected for errors in diagnosis), deaths and crude casemortality during 1935 were as follows :— Table 18. Year 1935 Age-period Total 0- 1- 2- 3- 4- 5- 6- 7- 8- 9- 10- 15 + Notifications (52 weeks] 99 440 646 904 1,074 1,208 1,032 787 574 528 1,799 1,863 10,954 Deaths (365 days) 1 3 1 1 4 2 2 — 1 — 2 7 24 Crude case - mortality percentage 1.01 0.68 0.15 0.11 0.37 0.17 0.19 — 0.17 — 0.11 0.38 0.22 The death-rates in London and England and Wales in recent years are shown in the following table :— Table 19. Area 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 London 0.03 0.02 0.02 0.01 0.02 0.02 0.03 0.02 0.02 0.02 0.01 England and Wales 0.02 0.03 0.02 0.01 0.01 0.02 0.02 0.01 0.01 0.02 0.02 18 Diphtheria. Notifications of diphtheria numbered 9,294 in 1935 (52 weeks), compared with 11,782 in 1934. This gives an attack-rate of 2.2 per thousand as against 2.8 in the preceding year. There were 271 deaths, giving a death-rate of .06 per thousand living. The case-mortality was 2.9 Per cent., compared with 3.9 per cent. in 1934. 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:— Table 20. l- 5- 9- 13- 17- 21- 25- 29- 33- 37- 41 - 45- 49-52 1,133 989 820 751 659 537 501 539 470 699 768 797 631 The notifications (uncorrected for errors in diagnosis), deaths and crude casemortality during 1935 were as follows :— Table 21. Year 1935 Age-period Total 0- 1- 2- 3- 4- 5- 6- 7- 8- 9- 10- 15 + Notifications (52 weeks) 155 373 664 877 941 1,066 904 703 482 466 1,197 1,466 9,294 Deaths (365 days) 8 10 27 28 43 44 23 24 14 9 20 12 271 Crude case - mortality percentage 5.16 5.09 4.07 3.19 4.57 4.13 2.54 3.41 2.90 1.93 1.67 0.82 2.92 The death-rates in London and England and Wales in recent years are shown in the following table :— Table 22. Area 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 London 0.12 0.11 0.12 0. 09 0. 09 0. 08 0.10 0.06 0.07 0. 03 0.11 England and Wales 0.06 0.07 0.08 0. 07 0.08 0. 09 0. 09 0.07 0.06 0.07 0.10 Diarrhoea and enteritis. Diarrhoea and enteritis caused 631 deaths among children under two years of age, or 1131 per thousand live births. The corresponding rate in 1934 was 12.80. Puerperal fever and pyrexia. There were 241 notifications of puerperal fever and 652 notifications of puerperal pyrexia in 1935(52 weeks) compared with 254 and 758 respectively in 1934 (52 weeks). Maternal mortality The deaths from puerperal fever numbered 64 and from other puerperal causes 80, the deaths per thousand live-births being 1.15 and 1.43 respectively, giving a total maternal mortality rate of 2.58 compared with 2.80 in 1934. The maternal mortality rate in 1935 was the lowest hitherto recorded for London residents, the previous lowest being 2.76 in 1911. The lowest previous rate for puerperal fever deaths was 1.24 in 1913 and also in 1914. In regard to other causes, the rate for 1911 of 1.37 per 1,000 births to London women still remains the lowest recorded. The deaths from puerperal fever and other puerperal causes per thousand live births in each metropolitan borough and in the county of London in the periods 1920 19 to 1927 and 1928 to 1935, together with the deaths in childbirth in 1935, are shown in the following table :— Table 23. Metropolitan boroughs arranged in topographical order Childbirth deaths per 1,000 live births Number of deaths in ohildbirth 1920-27 1928-35 1935 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 2.1 4.0 3 5 8 Kensington 1.9 1.7 3.6 2.0 1.6 3.6 4 1 5 Hammersmith 2.1 1.7 3.8 1.9 1.6 3.3 1 1 2 Fulham 1.9 1.6 3.5 2.2 1.7 3.9 3 3 6 Chelsea 1.9 2.9 4.8 1.8 2.3 4.1 2 2 4 Westminster 1.5 2.9 4.4 2.5 2.6 5.1 1 - 1 Northern. •' St. Marylebone 2.1 2.6 4.7 2.5 2.5 5.0 2 _ 2 Hampstead 1.8 1.6 3.4 1.3 2.1 3.4 - 1 1 St. Pancras 1.4 1.7 3.1 1.4 1.9 3.3 5 7 12 Islington 1.4 1.5 2.9 1.6 1.7 3.3 4 7 11 Stoke Newington 2.5 1.9 4.4 1.4 3.2 4.6 — - - Hackney 1.8 1.6 3.3 1.3 1.9 3.2 2 7 9 Central. Holborn 2.9 0.6 3.5 2.4 1.4 3.8 1 - 1 Finsbury 0.9 1.4 2.3 1.7 1.0 2.7 1 — 1 City of London 2.0 1.0 3.0 6.7 — 6.7 1 - 1 Eastern. - Shoreditch 1.1 1.2 2.3 1.2 1.5 2.7 2 2 4 Bethnal Green 0.9 1.6 2.5 1.5 1.1 2.6 1 1 2 Stepney 1.0 1.4 2.4 1.0 1.6 2.6 2 3 5 Poplar 1.2 1.7 2.9 1.4 1.4 2.8 5 2 7 Southern. Southwark 1.3 1.4 2.7 1.6 1.4 3.0 2 5 7 Bermondsey 1.1 1.8 2.9 1.5 1.5 3.0 - - - Lambeth 1.8 1.3 3.1 1.3 1.3 2.6 4 6 10 Battersea 0.9 1.9 2.8 1.2 1.8 3.0 - 4 4 Wandsworth 1.6 1.7 3.3 2.0 1.9 3.9 5 5 10 .Camberwell 1.7 1.5 3.2 2.0 1.6 3.6 6 4 10 Deptford 1.6 1.7 3.3 1.9 1.3 3.2 - 1 1 Greenwich 1.0 1.4 2.4 1.7 1.9 3.6 3 2 5 Lewisham 1.1 1.9 3.0 16 1.6 3.2 3 9 12 Woolwich 1.2 1.6 2.8 1.8 1.8 3.6 1 2 3 London 1.44 1.64 3.08 1. 64 1. 69 3.33 64 80 144 The deaths in childbirth in 1933 are shown in the above table but not the deathrates, as, owing to the smallness of the figures, the rates for a single year may be misleading. The maternal mortality rates for each metropolitan borough in 1935 and for London as a whole annually since 1922 are set out in tables 37 and 39. It will be seen that the average annual deaths from childbirth per thousand live-births for the eight years 1928-35 is higher than for the eight years 1920-27. The increase in the puerperal fever death-rate is .20, or 14 per cent., and in other causes .05, or 3 per cent. The figures in the following tables have been prepared from information specially supplied by the Registrar-General relating to deaths attributed to childbirth among London residents in each metropolitan borough for the four years 1931-34. In one or two instances all the particulars required were not available, and for this reason the totals may be found to differ slightly from the corresponding totals of the Registrar-General's returns, but such differences are negligible. 20 In general, the figures, even for four years taken together, are too small to give rates which permit of anything but tentative conclusions. The boroughs arc arranged in the tables in topographical order, and it will be seen from the rates shown in table 27, third column, that among married women the maternal risk in the central and eastern areas, containing the poorest and most overcrowded populations, namely, Finsbury, Shoreditch, Bethnal Green, Stepney and Poplar, show a lower rate than the average for London as a whole. In general, the maternal death-rate varies with the social condition of the population, being higher among those of the more affluent groups of population. The result is much the same whether the populations are considered by social condition as measured by the proportion of children scheduled for elementary education, or according to the death-rate from all causes, or by the percentage of employed women who are in domestic service. There is no very marked difference in the percentage of still-births in regard to the social condition, nor of deaths occurring within the first seven days of birth, but the death-rate from abortions among married women is apparently higher in boroughs where the financial circumstances are bad. Table 24.—London—Deaths in childbirth and pregnancy : age distribution, 1931-34. Metropolitan borough Married women Unmarried women 15- 20- 25- 30- 35- 40- 45 + Total Death from sepsis All other deaths Abortion Other cases Abortion Other cases Western. Paddington — 6 6 8 5 1 — 26 3 5 1 17 9 Kensington 1 5 9 3 8 4 2 32 5 9 — 18 3 Hammersmith — 4 0 6 0 3 25 3 10 1 11 2 Fulham — 1 10 6 6 4 — 27 2 9 3 13 4 Chelsea — — 2 3 — — — 5 — 2 — 3 2 Westminster, City of — — 3 3 4 2 — 12 1 4 — 7 0 Northern. St. Marylebone — 2 4 4 3 2 — 15 3 3 1 8 3 Hampstead — 3 1 2 — — — 6 1 1 — 4 1 St. Pancras — 4 13 4 5 6 — 32 3 7 2 20 11 Islington 1 12 22 15 6 4 4 04 9 21 1 33 4 Stoke — 2 8 2 1 2 — 15 3 2 10 1 Newington Hackney 3 9 11 6 4 33 5 8 1 19 3 Central. Holborn 1 2 1 4 2 2 1 Finsbury — — 3 — 3 — — 6 1 1 4 1 City of London — — — — 1 — — 1 1 — — — — Eastern. Shoreditch — 2 3 4 2 1 12 2 2 2 0 2 Bethnal Green — 4 2 4 — 3 2 15 3 4 — 8 1 Stepney — 2 10 7 9 8 — 36 7 4 — 25 5 Poplar — 2 3 12 7 3 — 27 6 9 2 10 4 Southern. Southwark — 2 4 7 8 6 1 28 4 8 1 15 4 Bermondsey — 6 5 8 3 1 — 23 4 9 1 9 2 Lambeth 3 11 12 10 2 38 9 13 2 14 5 Battersea 1 5 10 9 2 2 29 5 7 1 10 3 Wandsworth 1 10 16 19 5 5 1 57 7 25 25 4 Camberwell 1 5 12 11 9 3 1 42 5 17 20 4 Deptford — 3 4 5 7 4 1 24 8 6 — 10 2 Greenwich — 1 6 4 5 4 1 22* 3 5 14 2 Lewisham — 4 5 10 9 7 — 35 5 13 17 2 Woolwich 2 5 4 0 3 2 — 22 3 10 — 9 1 London County 7 90 192 185 135 82 15 713* 111 216 19 367 92 * In one case in Greenwich the age was not stated. 21 Table 25.—London maternal deaths, 1931-34.—Place of death of married women dying in pregnancy and childbirth. Metropolitan borough Deaths Place of death Total l.C.C. general hospitals l.C.C. special hospitals Voluntary hospitals Nursing homes Abortions Other With maternity beds Other With maternity beds Other Home Western. Paddington 4 22 9 — 12 1 2 — 2 26 Kensington 5 27 11 2 13 — 3 — 3 32 Hammersmith 4 21 14 2 7 2 25 Fulham 5 22 13 1 7 3 1 2 27 Chelsea 5 1 2 2 5 Westminster 1 11 5 — 5 — 1 — 1 12 Northern. St. Marylebone 4 11 9 1 4 — — — 1 15 Hampstead 1 5 3 1 — — 2 — — 6 St. Pancras 5 27 15 1 12 2 1 — 1 32 Islington 10 54 18 9 32 2 — — 3 64 Stoke Newington 3 12 5 1 5 1 — — 3 15 Hackney 6 27 16 2 6 3 1 1 4 33 Central. Holborn — 4 — — 3 — 1 — — 4 Finsbury 1 5 1 1 4 — — — — 6 City of London 1 — — — 1 — — — — 1 Eastern. Shoreditch 4 8 9 — 3 — — — 12 Bethnal Green 3 12 7 — 8 — — — — 15 Stepney 7 29 20 1 13 — — — 2 36 Poplar 8 19 14 6 2 1 — — 4 27 Southern. Southwark 5 23 12 2 11 — — — 3 28* Bermondsey 5 18 16 4 3 — — — — 23 Lambeth 11 27 22 5 8 1 — — 2 38 Battersea 6 23 13 4 5 — 1 — 6 29 Wandsworth 7 50 29 12 4 2 4 — 6 57 Camberwell 5 37 19 5 12 — — — 6 42 Deptford 8 16 14 4 3 — — — 3 24 Greenwich 3 19 12 1 4 — 2 — 3 22 Lewisham 5 30 17 2 3 4 1 8 35 Woolwich 3 19 12 1 4 4 — — 1 22 London County 130 583 336 70 196 24 19 2 66 713 Table 26.—London—Maternal deaths, 1931-34. (a) Place of death of mother in pregnancy and childbirth (1) from sepsis, (2) from other causes. Place of death Deaths from sepsis Deaths from other causes Total Abortion Other Abortion Other L.C.C. general hospital 116 93 17 180 406 L.C.C. special hospital 12 60 1 73 Voluntary hospitals— (a) With maternity bods 13 66 1 126 206 (b) Other 4 7 16 27 Nursing homes— (a) With maternity beds — 1 18 19 (b) Other — 2 2 Home 2 13 5 52 72 Total 147 240 24 394 805 22 (b) Age-distribution of maternal deaths. Cause of death Age group 15— 20— 25— 30— 35— 40— 45— Not known Total Married women— Sepsis abortion — 13 27 36 24 9 1 1 111 childbirth 3 29 61 67 31 22 3 — 216 Other causes abortion — 1 3 9 4 2 19 childbirth 4 53 101 73 76 49 11 — 367 Total (married women) 7 96 192 185 135 82 15 1 713 Unmarried women— Sepsis abortion 12 16 1 6 — — 35 childbirth 3 5 3 7 4 1 — — 23 Other causes abortion — 2 2 1 — — — — 5 childbirth 5 9 7 1 1 4 — — 27 Total (unmarried) 8 28 28. 10 11 5 — — 90 * There were in addition two deaths in which the marital condition was not stated. Table 27. London*—Maternal deaths among married women per 1,000 live births (1) after abortion, (2) other deaths ; also still-births and neo-natal deaths per 1,000 live births among married women, 1931—1. Metropolitan borough Maternal deaths per 1,000 live-births Still-births and deaths under one week per 1,000 live-births Percentage of maternal deaths occurring in From abortion From all other causes Still-births Deaths Hospitals and institutions Nursing homes or at home Western— Paddington 0-58 319 35-5 26-8 84-6 15-4 Kensington 0-60 3-22 33-8 21-0 81-2 18-8 Hammersmith 0-56 2-96 29-7 21-4 92-0 8-0 Fulham 0-64 2-81 31-7 19-4 88-9 11-1 Chelsea — 2 04 27-7 20-4 100-0 — Westminster, City of 0-25 2-71 37-2 29-0 83-3 16-7 Northern— St. Marylebone 1*17 3-21 35-6 18-7 93-3 6-7 Hampstead 0-29 1-46 28-1 22-2 66-7 33-3 St. Pancras 0-51 2-76 30-5 20-1 93-7 6-3 Islington 0-53 2-87 33-3 19-1 95-3 4-7 Stoke Newington 1-08 4-34 34-3 18-1 80-0 20-0 Hackney 0-50 2-24 33 0 17-2 81-8 18-2 Central— Holborn — 3-43 37-8 27-5 75-0 25-0 Finsbury 0-25 1-23 31-4 16-7 100-0 — Eastern— Shoreditch 0-66 1-32 34-2 17-8 100-0 Bethnal Green 0-48 1-93 29-4 18-0 100-0 Stepney 0-51 2-09 32-0 17-8 94-4 5-0 Poplar 0-83 1-96 32-1 19-0 85-2 14-8 Southern— Southwark 0.50 2.32 33.3 18.8 89.3 10.7 Bermondsey 0.75 2.69 28.5 19.0 100.0 — Lambeth 0.70 1.72 31.4 21.1 94.7 5.3 Battersea 0.68 2.60 27.4 17.4 75.9 24.1 Wandsworth 0.46 3.26 35.0 21.6 82.5 17.5 Camberwell 0.38 2.80 30.5 15.5 85.7 14.3 Deptford 1.26 2.53 28.9 18.0 87.5 12.5 Greenwich 0.55 3.48 28.0 22.7 77.3 22.7 Lewisham 0.46 2.73 34.0 16.9 74.3 25.7 Woolwich 0.38 2.44 32.6 22.3 95.5 4.5 London County 0.57 2.55 22.1 19.6 87.8 12.2 * The City of London is omitted as the area is too small to give representative rates. 23 Enteric fevers. There were 187 notifications of fevers of the enteric group in London in 1935 (52 weeks) compared with 109 in 1934. The deaths in the calendar year numbered 17 as against 15 in 1934. The remarkable decrease in the mortality from enteric fever during the present century will be seen from the figures in table 39. 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:— Table 28. 1- 5- 9- 13- 17- 21- 25- 29- 33- 37- 41- 45- 49-62 12 7 10 13 10 9 4 14 34 38 18 11 7 In addition, there were 10 deaths recorded by the Kegistrar-General of cases belonging to London which had not been notified within the county. Eight of these were inmates of mental institutions. In August, information was received from the acting medical officer of health of Glasgow that an outbreak of enteric fever had occurred amongst a party of pilgrims from Scotland to Lourdes. The list of London pilgrims which was supplied from Glasgow was circulated to the metropolitan borough medical officers of health. So far as is known none of these London pilgrims contracted enteric fever. Influenza. The deaths from influenza during 1935 numbered 471, compared with 543 in 1934. Rheumatic fever. The deaths in London from rheumatic fever in 1935 numbered 127, of which 45 were among children under 15 years of age. The corresponding figures in 1934 were 145 and 71, respectively. Cancer. There were 7,091deaths from cancer in 1935, as against 7,276 in 1934. The death-rate per thousand was 1.69. There was an increase of 1 in the deaths among males and a decrease of 186 among females compared with the previous year. Food poisoning. In 1935 (52 weeks) particulars of 490 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 332 for the year 1934. Eight of the notified cases died. In some instances more than one member of a family was affected by the 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. In March, 34 students at a women's training college were mildly affected after eating roast lamb. The remains of the food had been placed in the stock-pot before any investigations were possible and it was difficult to trace the exact origin of the illness. The examination in the Council's laboratories of parts of the stock failed to reveal the presence of any chemical poison, either organic or inorganic. Pathological material from three of the patients was examined by the bacteriologist attached to one of the voluntary hospitals who isolated hæmolytic coliform bacilli of a toxic character and it would appear that these were the causal agents. In May, 64 students and staff at another training college were notified as cases of food poisoning. Examinations of various food stuffs and of specimens from the patients were made in the Council's laboratories, but no specific pathogenic organism was found. The only finding which was suggestive was large numbers of streptococcus fæcalis (enterococcus) in minced meat. These organisms have repeatedly been found in food suspected of causing illness, but no definite proof has been obtained that they are actually the cause of disease. Chemical examination revealed three parts per million of lead in tinned sardines similar to those which had been eaten, but this is considerably less than that frequently found in similar commercial samples. A fatal case of food poisoning occurred in Bermondsey in June. The borough medical officer of health reported as follows :— The cause of death was obscure and a post-mortem examination failed to reveal an adequate cause. Sausages eaten by the patient were suspected, but investigation failed to prove con- 24 tamination of the sausages. In the meantime, a specimen of faeces obtained before death was bacteriologically examined and cultures obtained were sent to Dr. Scott, pathologist to the Ministry of Health, who stated that bacillus aertrycke had been isolated and that he suspected that this was originally present in a duck's egg. It was then ascertained that the deceased had partaken of a duck's egg which was stated to be one of a consignment imported from the continent. Eight eggs of the consignment, however, failed to reveal organisms which could be considered pathogenic. It is interesting to note that about the same time three members of a family in Poplar were admitted to hospital suffering from food poisoning, and serological tests carried out in one of the Council's laboratories suggested that bacillus aertrycke was probably the cause. The food suspected in this instance was duck egg, probably imported. Five cases of botulism occurred in St. Pancras early in August as a result of the patients consuming " vegetable nut mixture." Four of the cases proved fatal, the patients dying on the day of admission to hospital. The fifth patient recovered. A further fatal case of botulism occurred in Hammersmith in August. The food suspected in this case was meat and potato pie. This case was in no way connected with the cases in St. Pancras. Botulism is a disease produced only by the eating of food containing the botulinus toxin. This toxin is produced by the bacillus botulinus growing in foods improperly processed ; that is to say, food contained in closed jars or cans which have not been subjected to adequate heat of sufficient duration or under sufficient pressure. Sporadic cases or groups of cases occur from time to time in all countries and always in relation to some perishable food product which has been so kept or preserved as to permit the development, under partial anaerobic conditions, of the bacillus botulinus, to the extent of forming the toxin that causes the disease. The following statement shows the age and sex incidence of the cases of food poisoning notified during the year:— Table 29. Age 0. 5. 15. 21. 35. 45. 55. 65. Total Male 11 15 43 37 32 14 14 13 179 Female 11 20 133 51 29 34 22 7 307 In 4 cases (2 male, 2 female) the ages were not stated. The causes of illness in the 490 notified cases were stated to be as follows:— Fish 111 Fruit 10 Tinned fish and paste 50 Tinned fruit 13 Meat 162 Miscellaneous 134 Tinned meat 10 Tuberculosis. The deaths from pulmonary tuberculosis in London during 1935 numbered 2,847, giving a death.rate of .68 per thousand living. This is the lowest death.rate from pulmonary tuberculosis ever recorded in London, the corresponding figures for 1934 being 3,227 and .76, respectively, and 3,530 and .82 for 1933. There were 359 deaths from other forms of tuberculosis in 1935 as against 455 in 1934 and 466 in 1933, the death.rates being .09, .11 and .11, respectively. The annual death.rates from pulmonary and non.pulmonary tuberculosis in recent years are shown in the subjoined table:— Table 30. Period Pulmonary tuberculosis death.rates Non.pulmonary tuberculosis death.rates Males Females Total Males Females Total 1922.24 1.28 0.78 1.01 0.22 0.17 0.19 1925.27 1.19 0.67 0.91 0.18 0.14 0.15 1928 1.14 0.68 0.89 0.17 0.12 0.14 1929 1.24 0.72 0.96 0.15 0.11 0.13 1930 1.13 0.64 0.87 0.13 0.11 0.12 1931 1.14 0.68 0.90 0.15 0.11 0.13 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 1935 0.90 0.49 0.68 0.10 0.08 0.09 25 The death.rate from all forms together in 1935 was also the lowest ever recorded in London. The number of primary notifications in metropolitan boroughs during the year 1935, 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 6,459, the corresponding figure for 1934 being 7,087. The following is an analysis of the notifications in London during the year 1935. Table 31. Form of tuberculosis notified Sex Number of formal primary notifications of new cases of tuberculosis Total notifica tions °. 1. 6. 10. 15. 20. 25. 35. 45. 55. 65 + Total all ages Pulmonary tuberculosis M. 4 30 52 62 236 384 708 530 519 353 143 3021 4047 F. 3 27 53 75 315 512 674 312 176 96 50 2293 3169 Other forms of tuberculosis M. 13 87 123 96 63 61 63 44 24 20 13 607 714 F. 10 64 79 63 62 78 96 42 20 10 14 538 633 All forms of tuberculosis M. 17 117 175 158 299 445 771 574 543 373 156 3628 4761 F. 13 91 132 138 377 590 770 354 196 106 64 2831 3802 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:— Table 32. Form of tuberculosis notified Sex New cases of tuberculosis coming to knowledge otherwise than by formal notification 0. 1. 5. 10. 15. 20. 25. 35. 45. 55. 65 + Total Pulmonary tuberculosis M. 2 6 3 12 28 69 154 101 77 64 44 560 F. 1 3 5 11 41 108 130 79 37 18 29 462 Other forms of tuberculosis M. 7 23 29 36 19 14 20 9 5 3 5 170 F. 5 22 21 13 17 24 27 16 7 4 9 165 All forms of tuberculosis M. 9 29 32 48 47 83 174 110 82 67 49 730 F. 6 25 26 24 58 132 157 95 44 22 38 627 The sources of information as to the unnotified cases shown in the above table were as follows:— Table 33. Source of information Number of cases Pulmonary Non .pulmonary Death returns from local registrars 166 49 transferable deaths from Registrar.General 100 46 Posthumous notifications 56 32 "Transfers " from other areas 683 202 Other sources 17 6 The returns received under the Public Health (Tuberculosis) Regulations, 1930, from the medical officers of health of the metropolitan boroughs show that there were 25,656 cases of pulmonary tuberculosis (14,580 males and 11,076 females) and 9,010 cases of other forms of tuberculosis (4,730 males and 4,280 females) on the registers of the metropolitan boroughs at the end of 1935. 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 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. 26 Table 34. Metropolitan boroughs in topographical order Cases on notification register at beginning of 1935 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 1935 Notification Otherwise Cured, removed, etc. Deaths Total Per 1,000 of population Western. Paddington 1,200 237 56 381 79 1,033 7.5 Kensington 969 186 54 342 88 779 4.4 Hammersmith 1,070 201 95 181 126 1,059 8.3 Fulham 1,742 253 30 117 130 1,778 12.4 Chelsea 370 88 35 93 50 350 6.1 Westminster, City of 1,400 201 28 102 53 1,474 11.8 Northern. St. Marylebone 896 109 43 111 79 858 9.3 Hampstead 435 83 39 77 40 440 4.9 St. Pancras 1,331 240 111 383 144 1,155 6.2 Islington 2,995 542 128 1,063 279 2,323 7.6 Stoke Newington 317 64 49 86 40 304 6.1 Hackney 1,866 302 106 263 149 1,862 8.8 Centred. Holborn 333 60 13 42 38 326 9.2 Finsbury 858 99 18 180 47 748 11.9 City of London 68 24 2 13 11 70 7.2 Eastern. Shoreditoh 1,596 135 37 140 90 1,538 17.4 Bethnal Green 1,309 141 42 144 80 1,268 12.7 Stepney 2,505 450 21 680 173 2,123 10.0 Poplar 1,165 198 46 168 145 1,096 7.6 Southern. Southwark 1,687 301 254 148 1,586 10.2 Bermondsey 1,002 163 22 139 114 934 9.1 Lambeth 2,529 467 59 324 205 2,526 9.0 Battersea 1,012 237 53 227 142 933 6.3 Wandsworth 2,088 504 161 365 274 2,114 6.2 Camberwell 2,130 324 89 237 194 2,112 9.0 Deptford 739 171 19 135 77 717 7.2 Greenwich 677 115 38 98 85 647 6.7 Lewisham 1,463 347 132 140 1,538 6.9 Woolwich 1,048 238 39 208 142 975 6.7 London 36.800 6,480 1,433 6,685 3,362 34,666 8.3 A paper was read by Dr. Bradford Hill before the Royal Statistical Society on 21st January, 1936, on the recent trend of mortality from phthisis at young adult ages. He considered generally the various factors which have been suggested to account for the observed changes, and particularly (1) the possibility of a decline of immunisation in childhood as a result of the fall in the death.rate from tuberculosis producing a lower level of infection in early life; (2) changes in the occupational. environmental conditions of young adults; and (3) changes in the regional distribution of young adults through the slackening of migration from the country districts to the towns. He found evidence implicating the third of these factors only, but concludes : " It certainly seems unlikely that change in migration is the only factor influencing the trend of a form of mortality which is of complex causation." In discussing the paper, Dr. Percy Stocks said: "The general conclusion seems to be that, in producing the local differences pointed out, local social economic conditions of life on the one hand, and the selection produced by migration to new spheres of work on the other, are both important factors, but neither of these factors, nor yet the larger scale of employment of young women in shops and offices, can account for the retarded fall of phthisis mortality in the country as a whole which was evident up to 1932." In the larger sense, therefore, the problem remains unsolved. 27 The localisation of disease and source of notification as stated on the weekly. return of notification of tuberculosis received from the metropolitan borough medical officers of health, has been classified by age for the two years 1933 and 1934, and the results are shown in the following tables:— Table 35.—County of London. Age distribution of primary notifications of tuberculosis according to localisation of disease, 1933 and 1934. Age group Respiratory system Spine Hip Knee Other limbs bones and joints Abdo. minal Peripheral glands Other sites Total Lungs Other 1933. 0. 1 year 4 2 — — — 3 1 11 21 1.5 years 42 2 9 12 12 17 10 49 48 201 5.10 ,t 82 11 12 22 4 19 31 109 22 312 10.15 „ 106 16 6 6 17 11 20 63 20 265 15.20 „ 616 12 18 6 11 27 47 41 23 801 20.25 „ 1,005 14 15 6 6 18 53 40 18 1,175 25.35 „ 1,524 19 15 11 5 15 55 40 23 1,707 35.45 „ 939 6 13 3 2 11 35 14 8 1,031 45.55 „ 831 3 4 3 3 14 20 10 6 894 55.65 „ 553 1 4 1 — — 14 9 5 587 65 + „ 182 1 1 — — 7 3 8 4 206 All ages 5,884 87 97 70 60 139 291 384 188 7,200 0. 1 year 3 1 19 34. 2 6 12 1. 5 years 57 9 12 14 9 21 12 59 46 239 5.10 „ 100 19 11 20 5 20 32 103 34 344 10.15 „ 183 25 10 11 10 9 31 54 22 355 15.20 „ 613 21 11 15 3 15 29 33 20 760 20.25 „ 1,067 13 21 14 5 14 30 31 13 1,208 25.35 „ 1,437 23 18 9 5 26 58 42 17 1,635 35.45 „ 890 4 8 10 6 7 14 11 4 954 45.55 „ 805 4 4 6 2 1 14 11 9 856 55.65 „ 483 1 5 4 2 3 9 9 6 522 65 + „ 208 3 2 2 — 7 5 5 1 233 Age not stated 5 . . . . . . . . 5 All ages 5,851 122 102 106 47 123 236 358 178 7,123 28 Table 36.—County of London. Age distribution of primary notifications of tuberculosis according to source of notification, 1933 and 1934. Tuberculosis of the respiratory system, 1933 and 1934. Age group Dispensary Hospital Private Poor.law Total 0. 1 year 1 4 1 3 9 1. 5 years 25 56 7 22 110 5.10 „ 61 110 16 25 212 10.15 „ 111 142 39 38 330 15.20 „ 367 307 434 154 1,262 20.25 „ 597 524 707 271 2,099 25.35 „ 860 742 970 431 3,003 35.45 „ 522 417 575 325 1,839 45.55 „ 387 319 551 386 1,643 55.65 „ 197 226 313 302 1,038 65 + „ 37 79 122 156 394 Age not stated — 2 3 — 5 All ages 3,165 2,928 3,738 2,113 11,944 Other forms of tuberculosis, 1933 and 1934. 0. 1 year 2 8 3 11 24 1. 5 years 78 159 30 63 330 5.10 „ 150 210 29 55 444 10.15 „ 75 133 32 50 290 15.20 „ 53 131 41 74 299 20.25 „ 52 126 48 58 284 25.35 „ 78 139 57 65 339 35.i5 „ 24 58 24 40 146 45.55 „ 18 37 22 30 107 55.65 „ 8 23 16 24 71 65 + „ 4 15 7 19 45 All ages 542 1,039 309 489 2,379 It should be observed that the returns from which these tables are prepared have been corrected for duplicate notification within each metropolitan borough, and do not therefore agree with the annual summary of primary notifications shown elsewhere. 29 Table 37. Vital statistics for the metropolitan boroughs and the County ot London in the year 1935. (Rates .per 1.000 of population ) Metropolitan boroughs arranged in topographical order Estimated resident population 1935 Live births Deaths Infant mortality (per 1,000 live births) Measles Scarlet fever Diphtheria Whooping cough Typhoid fever Diarrhoea and enteritis, age 0.2 (per 1,000 live births') Pulmonary tuberculosis Pneumonia Other resp. dis. Cancer Maternal mortality (per 1,000 live births) Notifications of infectious disease Scarlet fever Diphtheria Typhoid fever Erysipelas Cerebro spinal fever Acute pneumonia Western. Paddington 138,600 14.2 12.1 71 .01 .09 .04 - 16.3 .54 . 74. .53 1.70 4.07 1.93 1.52 0.05 .36 .05 .95 Kensington 178,300 12.5 12.1 79 .01 .11 .02 .01 25.6 .44 .68 .45 1.78 2.25 1.87 2.02 .04 .35 .01 .75 Hammersmith 128,100 14.7 11.9 70 — .02 .09 .05 .01 14.9 .86 .68 .53 1.69 1 .06 2.71 2.58 .05 .40 .02 .66 Fulham 143,600 13.9 11.6 51 — — .08 .03 - 9.6 .77 .58 .42 1.55 3.02 2.21 2.62 .06 .39 .01 .97 Chelsea 57,320 10.2 12.6 60 — .03 .02 .03 .02 13.6 .65 .49 .37 2.15 6.81 2.40 1.61 .10 .45 - .96 Westminster, city of 124,400 8.5 11.7 73 — — .04 .02 - 10.4 .51 .70 . 46 1.74 0.94 1.31 .81 .10 .31 .02 .27 Northern. St. Marylebone 92,200 9.7 11.9 56 - - .02 .04 .02 19.0 .68 .44 .34 1.96 2.23 1.64 1.29 .07 .38 .01 .35 Hampstead 90,600 110 11.2 49 — — - .01 - 7.0 .32 .75 .25 1.88 1 .00 1.29 .77 .06 .39 .02 .85 St. Pancras 185,300 13.3 12.1 63 .01 .01 .04 .06 .01 13.4 .67 .84 .46 1.76 4.86 1.89 2.39 .03 .50 .02 1.06 Islington 304,100 14.9 11.3 53 — — .04 .04 .00 11.9 .66 .83 .65 1.67 2.43 2.36 2.51 .02 .43 .03 .70 Stoke Newington 50,210 14.0 11.1 51 - - .02 - - 5.7 .68 .88 .36 1 .65 - 1.72 1.46 .06 .36 .02 .54 Hackney 210,600 141 10.6 48 .00 .00 .06 .02 .00 7.1 .57 .66. .34 1.70 3.04 3.00 2.21 .07 .52 .02 .70 Central. Holborn 35,400 7.7 11.9 89 . . .06 .06 - 14.8 .82 .90 .51 1.64 3.69 1.50 2.63 .06 .51 .03 .65 Finsbury 63,100 14.8 12.6 59 — .02 .02 .06 — 13.9 .79 .78 .78 1.92 1.07 3.29 3.58 - .52 - .75 City of London (a) 9,760 7.4 11.2 111 — — - - - 13.9 .82 .51 .41 2.05 13.89 2.98 2.05 .21 .51 .10 .21 Eastern. Shoreditch 88,400 14.6 11.3 52 - .02 .10 .05 .02 7.8 .72 .68 .62 1.66 3.10 3.73 3.64 .05 .44 0.3 .44 Bethnal Green 99,910 14.4 10.3 51 — .01 .10 .04 .01 11.1 .59 .71 .35 1.53 1.39 4.17 3.32 .01 .65 .01 .86 Stepney 211,500 14.3 11.3 61 - - .08 .03 .00 14.5 .70 .77 .46 1 . ^7 1.65 2.22 3.73 .02 .60 .05 .89 Poplar 143,700 15.4 11.1 47 .01 - .08 .04 .01 4.1 ..81 .48 .56 1.57 3.16 2.34 3.68 .01 .51 04 1.73 Southern. South wark 156,100 14.8 12.4 66 .01 .01 .09 .10 - 10.8 .83 .96 .49 1.82 3.02 3.30 2.68 .02 .60 .06 .65 Bermondsey 102,700 14.5 11.7 69 .04 .10 05 - 18.8 .95 .84 .68 1.45 - 3.58 233 .03 .51 .02 1.10 Lambeth 279,900 13.7 12.2 59 .01 — .06 .06 .00 8.9 .70 .68 .48 1.86 2.62 3.05 2.67 .01 .46 .01 .79 Battersea 148,200 14.2 12.0 65 — — .06 .06 - 9.0 .76 .57 .53 1.79 1.90 3.15 1.63 .14 .42 .04 1.91 Wandsworth 343,300 110 11.0 55 .00 .01 .04 .03 .00 9.8 .63 .52 .46 1.66 1.90 2.16 3.05 .03 .31 .02 .92 Camberwell 234,400 13.5 11 .8 61 .01 .00 .09 .06 - 12.0 .71 .67 .51 1.76 2.65 2.51 1.19 .03 .49 .02 .67 Deptford 99,500 14.4 11.1 52 .01 — .10 .05 - 11.2 ..83 .64 .61 1.68 0.70 2.52 1.48 .02 .61 .03 .78 Greenwich 96,600 13.8 10.8 60 — .01 .03 .01 .01 9.7 .73 .53 .50 1.65 3.74 3.12 2.91 .04 .43 .03 1.06 Lewisham 223,000 12.5 9.9 43 .01 .00 .06 .01 - 6.4 .59 .49 .32 1.54 4.30 3.66 3.81 .09 .31 .04 .89 Woolwich 146,400 140 10.2 44 .01 .01 .09 .01 - 7.3 .83 .57 .41 1.45 1.46 4.21 2.29 .06 .53 .01 1.86 London, 1935 4,185,200 13.3 11.4 58 .00 .01 .06 .04 .00 11.3 .68 .67 .48 1.69 2.58 2.62 2.23 .04 .45 .03 .89 London, 1934 4,230,200 13.4 12.2 67 .20 .02 .11 .07 .00 12.8 .76 .90 .61 1.72 2.80 4.32 2.79 .03 61 .03 1.32 (a) Including Inner and Middle Temple. 30 Table 38.—County of London—Principal causes of death by sex and age, 1935. Causes of death Sex All Ages 0— 1— 2— 5— 15— 25— 35— 45— 55— 65— 75— Typhoid and paratyphoid fevers. M. 5 1 1 2 1 — — F. 12 — — — — 2 3 4 2 1 — — Measles M. 8 3 3 2 — — — — — — — — F. 11 1 2 6 2 — — — — — — — Scarlet fever M. 7 1 2 3 — — 1 — — — — F. 17 1 2 4 4 3 1 1 1 — — — Whooping.cough M. 78 49 18 9 2 — — — — — — — F. 88 50 26 9 3 — — — — — — — Diphtheria M. 134 4 10 47 69 1 — — 1 1 1 — F. 137 4 9 51 65 3 — — 1 3 1 — Influenza M. 228 9 3 2 6 11 8 11 41 47 54 36 F. 243 1 1 3 4 9 9 19 17 46 65 69 Encephalitis lethargica. M. 18 — — 1 1 — 2 3 3 5 3 — F. 16 — — — — — 3 4 3 2 4 — Cerebro spinal fever M. 39 14 5 5 4 6 1 2 1 — 1 — F. 30 8 4 6 5 3 1 1 1 1 — — Tuberculosis of respiratory system M. 1,751 3 5 2 13 237 337 282 385 330 134 23 F. 1,096 3 3 2 21 342 279 179 112 88 50 17 Other tuberculous diseases M. 186 13 12 24 27 43 28 13 7 8 8 3 F. 173 12 11 18 35 37 23 10 8 6 10 3 Syphilis M. 136 13 1 — — — 3 7 42 45 20 5 F. 57 7 — — 1 — 4 5 10 16 11 3 General paralysis of the insane, tabes dorsalis. M. 187 — — — — 1 6 30 53 62 30 5 F. 46 — — — — — — 11 11 16 7 1 Cancer, malignant disease. M. 3,466 2 1 4 7 11 59 129 471 1,041 1,215 526 F. 3,625 1 3 2 4 13 74 218 601 952 1,025 732 Diabetes M. 225 — — — 1 3 5 5 11 61 95 44 F. 406 — — — 1 7 8 7 37 98 174 74 Cerebral haemorrhage M. 834 — — —1 — 1 15 65 201 315 236 F. 1,129 — — 1 3 6 18 73 213 395 420 Heart disease M. 6,046 — — 2 32 72 93 159 504 1,197 1,894 2,093 F. 7,021 1 — 1 54 97 144 172 358 863 1,956 3,375 Aneurysm M. 151 — — — 1 3 4 13 27 45 50 8 F. 110 — — — 2 2 1 6 17 33 27 22 Other circulatory diseases. M. 998 2 — — — 2 3 13 56 199 389 334 F. 1,206 2 — 1 — — 1 11 64 167 397 563 Bronchitis M. 859 58 3 4 3 7 8 41 105 161 219 250 F. 663 48 4 2 — 8 4 13 28 65 149 342 Pneumonia (all forms) M. 1,614 328 58 36 24 31 50 103 206 308 280 190 F. 1,197 218 57 29 22 23 28 51 96 175 239 259 Other respiratory diseases. M. 259 6 1 5 2 13 22 21 43 53 39 54 F. 222 4 3 6 5 5 9 14 18 25 38 95 Peptic ulcer M. 449 — — — — 3 29 44 116 140 89 28 F. 132 — — — — 1 6 14 20 40 36 15 31 Table 38—continued.—County of London—Principal causes of death by sex and age, 1935. Causes of death Sex All Ages 0— 1— 2— 5— 15— 25— 35— 45— 55— 65— 75— Diarrhoea, etc. M. 427 358 20 7 2 3 3 2 6 8 13 5 F. 327 234 19 2 2 7 9 10 8 11 10 15 Appendicitis M. 193 — 1 19 13 19 24 22 26 42 18 9 F. 157 — — 6 17 18 16 12 20 34 20 14 Cirrhosis of liver M. 102 — — — — 1 2 7 23 29 31 9 F. 71 — — — — 1 1 3 20 25 14 7 Other diseases of liver, etc. M. 83 1 — — — 2 5 2 11 16 30 16 F. 165 1 — — 1 3 6 7 22 46 47 32 Other digestive diseases. M. 502 48 7 6 16 18 18 25 68 106 106 84 F. 471 23 8 9 11 7 24 32 54 86 109 108 Acute and chronic nephritis M. 746 4 1 1 8 24 29 45 98 164 219 153 F. 780 1 1 2 10 18 28 49 69 157 236 209 Puerperal sepsis F. 64 — — — — 13 31 19 1 — — — F. 80 — — — — 11 39 30 — — — — Other puerperal causes Congenital debility, premature birth, malformation, etc. M. 875 853 3 3 2 5 1 5 1 2 — — F. 603 582 3 5 3 4 4 2 Senility M. 325 — — — — .— — — — 4 46 275 F. 590 — — — — — — — — 2 60 528 Suicide M. 365 — — — — 14 55 46 85 91 51 23 F. 210 — — — — 9 36 47 41 46 19 12 Other violence M. 1,048 59 15 26 104 156 121 83 87 133 126 136 F. 667 34 6 19 32 35 45 36 39 58 141 222 Other defined diseases M. 1,978 92 20 22 114 102 112 125 190 334 486 381 F. 1,676 74 15 22 91 83 110 153 235 286 324 283 Causes ill.defined, or unknown. M. 16 — — 1 — — 1 — 1 3 2 8 F. 13 — — — — — 1 — 2 3 4 3 All causes M. 24,336 1919 188 231 455 789 1032 12552733 4,836 5,964 4,934 F. 23,511 1310 177 205 396 767 954 1158 1989 3,564 5,568 7,423 32 Table 39.—County of London.—Principal vital statistics, 1891.1935. Period Annual rate per 1,000 living Mortality per 1,000 living Annual mortality per 1,000 live births Live 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 Pulmo. nary 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 0.10 000 0.29 0.42 0.22 1.39 0.48 1.49 1.22 0.22 1.26 1.11 0.10 114 23.8 1.46 1.47 1911-15 24.0 20.0 14.8 0.02 0.13 0.03 0.05 0.00 0.22 0.43 0.16 1.39 0.39 1.33 1.29 0.21 1.54 1.16 0.11 108 28.0 1.40 1.57 1916-20 20.0 20.1 15.1 0.04 0.17 0.02 0.03 0.00 0.20 0.28 1.01 1.43 0.34 1.38 1.30 0.19 1.70 1.28 0.09 92 15.4 1.64 1.72 1921-25 19.9 17.9 12.3 0.01 0.17 001 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 20.1 17.2 11.4 0.01 0.13 0.01 0.03 0.00 0.09 0.08 0.17 0.97 0.19 0.95 0.84 0.15 1.60 1.39 0.10 61 10.3 1.37 1.52 1924 18.6 17.2 12.2 0.01 0.12 0.01 0.03 0.00 0.11 0.29 0.37 0.98 0.18 1.16 0.98 0.15 1.69 1.42 0.10 69 8.7 1.24 1.84 1925 17.9 17.2 11.9 0.01 0.11 0.01 0.02 0.00 0.19 0.07 0.24 0.95 0.17 1.04 0.90 0.16 1.77 1.44 0.09 68 10.8 1.42 1.77 1926 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 12.1 0.01 0.09 0.01 0.02 0.00 0.09 0.30 0.13 0.89 0.14 0.93 0.59 0.16 2.22 1.52 0.12 67 10.3 1.59 2.00 1929 15.8 19.1 14.2 0.02 0.08 0.01 0.02 0.00 0.26 0.05 0.71 0.96 0.13 1.33 0.97 0.20 2.93 1.55 0.13 71 11.0 1.88 1.73 1930 15.8 19.5 11.6 0.02 0.10 0.01 0.03 0.00 0.03 0.23 0.08 0.87 0.12 0.78 0.44 0.12 2.51 1.57 0.12 59 9.9 1.93 1.40 1931 14.9 18.9 12.3 0.03 0.06 0.01 0.02 0.00 0.07 0.03 0.25 0.88 0.12 1.01 0.59 0.14 2.83 1.62 0.13 65 9.7 2.01 1.80 1932 14.3 18.1 12.3 0.03 0.07 0.00 0.02 0.00 0.08 0.19 0.28 0.82 0.12 0.84 0.47 0.14 2.91 1.61 0.13 67 12.5 1.33 1.66 1933 13.2 19.0 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 20.4 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 1.34 1.46 1935 13.3 21.1 (b) 11.4 0.02 0.06 000 0.01 — 0.04 0.00 0.11 0.68 0.09 0.67 0.36 0.11 3.12 1.69 0.15 58 11.3 1.15 1.43 (a) Comparable figures are not available for this period, (b) Provisional rate. 33 Table 40.—County of London.—Notifiable infectious diseases.—Notifications per 1,000 of population. Period Annual rated per 1,000 living Anthrax Cerebrospinal fever Continued fever Diphtheria Dysentery Encephalitis lethargica Enteric fever Erysipelas Malaria Ophthalmia neonatorum (per 1,000 live births) Pneumonia Polioencephalitis Poliomyelitis Puerperal fever (per 1,000 live births) Puerperal pyrexia (per 1,000 live births) Scarlet fever Smallpox Typhus 1891.95 (a) (a) .00 2.4 (a) (a) .78 1.54 (a) (a) (a) (a) (a) 2.17 (a) 5.3 .26 .00 1896.1900 (a) (a) .00 2.9 (a) (a) .82 1.24 (a) (a) (a) (a) (a) 2.03 (a) 4.4 .02 .00 1901.05 (a) (a) .00 1.9 (a) (a) .52 1.08 (a) (a) (a) (a) (a) 2.10 (a) 3.6 .46 .00 1906.10 (a) (a) .00 1.6 (a) (a) .28 .97 (a) (a) (a) (a) (a) 2.27 (a) 4.2 .00 .00 1911.15 .00 .05 .00 1.8 (a) (a) .17 .98 (a) (a) (a) (a) (a) 3.11 (a) 3.6 .00 .00 1916.20 .00 .07 .00 2.3 (a) (a) .09 .60 (a) 8.95 (a) (a) .02 3.00 (a) 2.7 .00 .00 1921.25 .00 .02 .00 2.86 .00 .05 .08 .43 .03 9.05 1.24 .00 .01 3.59 (a) 3.69 .00 .00 1926.30 .00 .02 .00 2.81 .01 .03 .08 .47 .01 9.89 1.46 .00 .01 4.10 (a) 3.28 .33 .00 1921 .00 .02 .00 3.62 .01 .05 .07 .47 .05 10.81 .96 .00 .01 3.55 (a) 7.27 .00 .00 1922 .00 .02 .00 3.38 .01 .01 .06 .43 .03 9.17 1.56 .00 .01 3.28 (a) 3.81 .02 .00 1923 .00 .01 .00 2.26 .00 .02 .07 .40 .02 8.33 1.04 .00 .02 3.84 (a) 2.21 .00 — 1924 .00 .02 .00 2.30 .00 .13 .09 .41 .02 8.36 1.47 .00 .02 3.43 (a) 2.50 .00 — 1925 .00 .02 .00 2.72 .00 .06 .09 .42 .01 8.58 1.18 .00 .01 3.83 (a) 2.66 .00 — 1926 .00 .02 .00 2.95 .00 .05 .07 .39 .01 8.97 1.22 .00 .02 4.24 (a) 2.68 .00 — 1927 .00 .02 .00 2.69 .01 .03 .07 .43 .01 11.11 1.49 .00 .02 3.57 12.21 2.91 .00 — 1928 .00 .02 .00 2.74 .01 .02 .13 .48 .02 10.19 1.38 .00 .01 4.09 10.67 3.45 .07 .00 1929 .00 .03 .00 2.68 .01 .02 .08 .49 .01 10.42 1.98 .00 .01 4.46 10.84 3.60 .43 — 1930 .00 .02 .00 301 .01 .01 .07 .54 .01 8.74 1.24 .00 .01 415 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 2.23 .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 — 1935 .00 .03 .00 2.23 .05 .00 .04 .45 .01 6.87 0.89 .00 .02 4.33 11.72 2.62 — . (a) Comparable figures are not available for this period. Table 41.—County of London.—Annual number of notifications of infectious disease, 1926.35. Year Anthrax Cerebrospinal fever Contmued fever Diphtheria Dysentery Encephalitis lethargica Enteric fever Erysipelas Malaria Ophthalmia neonatorum Pneumonia Polioencephalitis Poliomyelitis Puerperal fever Puerperal pyrexia Scarlet fever Smallpox Typhus 1926 8 83 4 13,526 13 224 302 1,799 52 705 5,589 10 85 333 293 12,293 5 - 1927 5 93 2 12,183 24 142 322 1,929 65 812 6,733 7 79 261 892 13,178 5 — 1928 3 70 17 12,155 39 100 580 2,146 73 733 6,118 9 45 294 768 15,297 295 2 1929 5 121 8 11,788 56 92 351 2,158 38 728 8,717 4 62 312 758 15,855 1,908 — 1930 1 88 6 13,411 40 60 291 2,387 29 617 5,531 8 29 293 740 16,699 5,149 2 1931 2 175 3 8,384 58 40 186 2,294 32 629 6,880 5 51 291 828 12,025 1,452 — 1932 3 247 4 8,087 79 47 195 2,230 41 687 5,673 10 79 218 741 14,119 1,131 — 1933 3 216 5 9,557 31 22 164 2,766 21 527 6,299 6 60 255 838 21,911 531 — 1934 3 137 4 11,782 58 29 109 2,586 30 467 5,569 8 66 254 758 18,238 144 — 1935 2 105 3 9,294 199 15 187 1,868 37 382 3,707 4 81 241 652 10,954 — 34 Table 42.—County of London.—Notifications of infectious disease during the 52 weeks ended 28th December, 1935. Metropolitan boroughs in topographical order Anthrax Cerebro. spinal fever. Continued fever Diphtheria (including membranous croup) Dysentery Encephalitis lethargica Enteric fever Erysipelas Malaria Ophthalmia neonatorum Pneumonia Polio- encephalitis Polio. mvelitis Puerperal fever Puerperal pyrexia Scarlet fever Smallpox Typhusp Western— Paddington — 7 1 210 12 — 7 50 3 11 131 —. 3 14 28 267 — — Kensington — 2 — 359 5 2 7 63 4 11 134 — 1 10 29 333 — — Hammersmith — 2 — 330 13 2 6 51 — 10 84 — 2 2 19 346 — — Fulham — 1 — 375 3 1 9 56 — 11 139 — 3 6 28 317 — — Chelsea — — — 92 2 — 6 26 1 2 55 — 2 6 7 137 — — Westminster, City of —. 3 — 101 12 — 12 38 5 1 33 —. 2 5 17 163 — — Northern— St. Marylebone — 1 — 119 3 6 35 1 10 32 1 3 9 13 151 — — Hampstead — 2 — 70 11 — 5 35 2 14 77 — 1 2 20 117 — — St. Pancras — 4 — 441 8 — 6 92 6 — 195 —. 3 24 18 349 — — Islington — 8 — 760 34 — 7 130 — 39 211 1 5 23 46 716 — — Stoke Newington — 1 — 73 1 — 3 18 — 1 27 . 1 6 14 86 — — Hackney — 5 — 465 8 —. 14 109 — 18 147 1 7 19 65 631 — — Central— Holborn — 1 — 93 6 1 2 18 2 4 23 — — 5 3 53 — — Finsbury — — — 225 3 1 . 33 1 15 47 — 1 2 11 207 — — City of London 1 — 20 . .— 2 5 . 2 2 — .— — 1 29 — — Eastern— Shoreditch — 3 — 321 14 — 4 39 3 15 39 — 4 6 9 329 — — Bethnal Green — 1 .— 331 11 . 1 65 . 6 86 — 2 7 14 415 — — Stepney — 11 .— 787 29 ] 5 127 2 6 187 — 2 11 27 469 — — Poplar — 6 .— 528 3 .— 2 73 . 10 248 — 3 8 25 336 — — Southern— South wark — 9 — 362 2 — 3 94 — 29 101 — 2 10 34 513 — — Bermondsey — 2 .— 273 3 .— 3 52 —. 5 113 — .— 3 20 367 — — Lambeth 1 3 — 455 5 2 4 128 2 41 221 1 9 24 43 852 — — Battersea — 6 2 451 4 .— 20 62 2 21 282 — 3 6 11 465 — — Wandsworth — 7 — 406 4 1 9 105 2 24 316 — 13 14 27 739 — — Camberwell — 4 — 345 1 .— 8 114 — 13 156 — 6 10 34 587 — — Deptford 1 3 — 289 — 1 2 61 — 11 77 — .— 1 9 250 — — Greenwich — 3 — 367 — .— 4 41 — 7 102 — .— 2 6 301 — — Lewisham — 8 — 311 1 2 21 70 1 4 199 — 1 4 34 814 — — Woolwich — 2 — 335 1 1 9 78 —. 18 243 — 2 3 40 615 — — Ages 0. — 28 — 155 13 — 1 34 — 382 201 — 3 — — 100 — — „ 1- — 27 — 2,855 72 3 13 49 — — 618 2 40 — — 3,063 — — „ 5- — 11 — 3,621 32 .— 18 57 — — 344 1 18 — — 4,129 — — „ 10- — 9 — 1,197 7 2 16 63 — — 137 — 8 — — 1,799 — — „ 15- — 8 — 425 5 1 26 78 — — 174 — 8 10 40 642 — — „ 20- — 4 — 396 16 1 33 78 4 — 209 1 1 57 195 454 — — „ 25- — 7 1 393 22 — 31 170 14 — 402 — 2 132 330 506 — — „ 35- — 5 — 137 11 4 22 244 7 — 420 — 1 42 86 180 — — „ 45- 2 3 ] 73 10 1 21 390 7 — 452 — — — 1 60 — — „ 55- — 3 — 30 4 2 6 360 5 — 388 — — — .— 13 — — „ 65- — — 1 10 6 1 _ 254 .— — 253 — — — —. 4 — — „ 75 + — — .— 2 1 — —. 91 — — 109 — — — —. 4 — — Total, 1935 2 105 3 9,294 199 15 187 1.868 37 382 3,707 4 81 241 652 10,954 —. —. Total, 1934 1 137 4 11,782 58 109 2,586 30 467 5,569 8 66 254 758 18,238 144 . 35 Administration. Slum clearance. During 1935 the pace of slum clearance set by the programme adopted in 1934 has been maintained, and representations have been made by medical officers of this department under section 1 of the Housing Act, 1930, to the Housing and Public Health Committee, as follows :— Areas Houses "Other Buildings;' included under the terms of sec. 62 (1) of the Housinq Act. 1935 During the year 1935 59 4,409 47 Total number under the 1930 Act up to 31st December, 1935 145 10,227 47 One improvement area—Treverton Street, Kensington, covering more than 11 acres and containing 238 houses and 10 "other buildings"—was represented under section 7 of the Housing Act, 1930, and declared by the Council in May. The total number of improvement areas declared is now 4, containing 843 houses. Notifications have been received during the year in accordance with section 16 of the Housing Act, 1930, of the intention of the various Metropolitan Borough Councils to deal with 2,238 houses in 142 areas, and the Council decided, for various reasons, to deal with 11 of these areas itself. During the year the number of medical officers engaged upon housing fieldwork has been increased from five to six. Three extra inspectors have been appointed, bringing the total inspectorial staff engaged on slum clearance to eighteen. Co.operation with the metropolitan boroughs has continued on a cordial footing, as is essential for the smooth working of the machinery of slum clearance. The Borough Councils are housing authorities equally with the Council, and it is imperative that misunderstandings or overlapping of schemes be avoided. In some cases the borough medical officers of health have informed me beforehand of intended action, and such an arrangement is much appreciated and frequently clears up difficulties in connection with official notifications under section 16 of the Housing Act, 1930. The outstanding event affecting housing activities during the year was the passing of the Housing Act, 1935, which makes overcrowding an offence after a date to be appointed by the Minister of Health. The Act placed on local authorities the obligation to undertake a survey of their districts and to provide the necessary additional houses to abate overcrowding. It also amended certain existing housing enactments and introduced certain changes of procedure. Existing by.laws concerning the number of persons permitted to occupy a house, let in lodgings, or occupied by more than one family remain effective until " the appointed day " for the enforcement of the new standard. Further points arise as to making by.laws applicable to houses occupied by one family only as well as to houses let in lodgings, and also for the prevention of nuisances in parts of premises where a closing order is in force. This latter power had already been obtained by the Royal Borough of Kensington by virtue of section 70 of the London County Council (General Powers) Act, 1933, as had also the power, now made general, to close (not merely for sleeping purposes), except for approved usage, any underground room, irrespective of its being let as a separate tenement. The Act of 1935 also entails some modification of practice in the preparation of maps for the purpose of representation under section 1 of the Housing Act, 1930. Thus under section 62 (1) houses, or other buildings, which are properly included by representation in a clearance area only on the grounds of their bad arrangement in relation to other buildings, or the narrowness or bad arrangement of the streets, must be excluded from a clearance order unless by reason of disrepair or sanitary defects they are deemed to be unfit for human habitation. This is a matter of consideration to owners of property, the defects of which, although now recognised as serious, are due only to the original bad arrangement on site, and were brought into being at a time when such inherent evils were given scant consideratiou. Such " other buildings " must now be indicated distinctively on the medical officers' representation maps and not, as previously, included in the same " red " colour as 36 the rest of the area. Moreover, section 59 restores the power of a local authority of require the demolition of obstructive buildings, which was repealed in the Act of 1930. One of the more important new procedures introduced in the Act of 1935 is the creation of what are known as " redevelopment areas," which must conform to the following conditions:—the area must contain at least 50 working.class houses, and it is necessary for at least one.third of these houses to be overcrowded, or unfit and incapable of being made fit at a reasonable expense, or congested in their arrangement; further, the local conditions must be such that the area should be used substantially for working.class housing, and lastly it must be expedient to re.develop the area as a whole. Although no " redevelopment area " has been declared during the year, much time has been devoted to consideration of possible areas and to preliminary surveys. Disposal and utilisation of waste food and other waste materials. An enquiry with regard to the disposal and utilisation of waste food and other waste materials has recently been made by the chief inspector of the department, and it is thought that his report will be of general interest. The origin and methods of disposal and utilisation of waste food and certain other waste materials have been investigated. Particulars and observations are submitted, as follows. Waste food. Enquiries nave been made at 26 premises (where informaiton was obtained witn regard to numerous branch establishments) covering the following businesses: hotels and caterers, 'wash' or 'swill' contractors, fat and bone dealers, tallow melters, glue and chemical works, feeding meal manufacturers. In several cases information was refused. In the cases where information was obtained the amounts are only approximate, and for varying periods. Waste food is dealt with under the following headings:— (1) Wash tor pig food. (2) Bones. (3) Fat. (4) Surplus meat. (5) Fish offal. (6) Stale bread, cakes and pastries. (7) Surplus and damaged green vegetables and root croDS. Wash for pig food. Wash, generally speaking, is the scrap food and leavings from hotel, restaurant, and caterers' kitchens, and it may be either cooked or uncooked. It is usually stored in metal bins or skips, and is disposed of by being fed direct to the firms' own pigs ; sold to a contractor who may either feed his own pigs with it or sell it to other pig breeders ; or placed in a bin and removed by the local authority as trade refuse. It is not processed in any way by the producers, and they know of no use to which it is put other than that of pig feeding. Where wash is sold to contractors, periodic removal takes place daily or twice or three times a week. The contractors, in the majority of cases, have depots in the home counties. Bones. Bones are obtained from the following sources:—meat markets, retail butchers' shops and provision stores, restaurants and hotels, Borough Council refuse depots. They are sold to fat and bone merchants, who in turn dispose of them to manufacturers who utilise them for other products, or are sent direct to such manuf acturers. They are used in the manufacture of: glue and size, fertilisers, charcoal, bone articles (such as buttons, knife handles, etc.), feeding meal for poultry. The fat extracted trom bone processing is disposed of as tallow, or utilised as such. It is the general practice in the case of butchers' shops for waste bones and fat to be sold together. This involves sorting by the dealer before dispatch to the manufacturers. Small quantities of bones are salvaged from Borough Council refuse depots and sold to glue and size manufacturers. Fat. The periodic removal from premises varies from once a day at large producers to once a week or once a fortnight where the production is on a small scale. Fat is derived from many of the same sources, and is collected and disposed of in the same manner as bones. It is used for the following purposes:—tallow (rough fat being rendered or treated in digesters and used in the manufacture ot soap), blended with heavy lubricating oils, stearine, glycerine, dripping for dog biscuits. The residues (greaves) derived trom the processing of fat are used in the manufacture of dog biscuits and feeding meals for cattle and poultry. Clean ox caul tat is rendered and sold as edible dripping; some catering firms render all the waste fat into dripping, and many retail butchers render, for this purpose, small quantities. Fat purchased by dealers is generally sorted before being sold to manufacturers. Periodic removal from premises coincides with that indicated for bones. Surplus meat, such as breast and scrag of mutton and clod and sticking of beef from wholesale and retail butchers and provision shops, is treated in a digester for fat extraction and the residues used for the same purposes as given above for fat extraction. Fat, bones, and surplus meat are collected from markets, butchers and provision shops, hotels, etc., by various dealers, some in only a small way of business, who dispose of the materials to larger firms. These in turn either sell them to manufacturers or process the materials themselves for tallow melting, etc. Surplus meat, stale bread, etc., and vegetables. 37 Stale bread and cakes, etc., are given to poor persons through the agency of charitable institutions. Some are sent to kennels and rat farms, manufactured into dog biscuits or disposed of with pig wash. Surplus green vegetables from wholesale markets are either sold for cattle fodder or used as manure. The sources of fish offal are: wholesale markets, wet and dry fishmongers, fish frying Fish offal, establishments, hotels, restaurants and catering firms. It is disposed of by being removed as trade refuse or sold to contractors. It is noteworthy that one large firm eventually obtains most of the fish offal in London, other contractors disposing of it to them. They utilise it for the following purposes : fish oil, feeding meals for cattle and poultry, fertilisers. Below are the amounts collected by this firm from various sources in 1935:— Billingsgate market 668 tons Direct collection from fishmongers, etc., in greater London 10,835 „ Purchased from other contractors in greater London 11,055 „ Of the last two amounts, about 13,802 tons (60 per cent.) were collected from premises situate in the county of London. Several large catering firms, and the majority of small dining room proprietors, place all waste food with the house refuse or have it removed by the local authority as trade refuse. Quantity of waste food handled. It has not been possible to obtain particulars from all firms, etc., visited, but information as set out in the following statement has been secured:— Table 43 Firm Wash Fat Bones Fat and bonos Fish offal Bread, etc. Restaurants, etc. A 1,210 skips per week 300 tons per annum 10,000 lbs. per week - 484 tons per annum Large amount 3 tons per week (in wash) B 72 galls, per day. Rendered for dripping. 3 tons per week - - C 3 tons per week 1 ton per week 3 tons per week Fat and bone dealers. D — — — 150 tons per week — — E — — 80 tons per week — - F — — — 75 tons per week - G — 50 tons per week - H — 35 tons per week - I — 6 tons per week - J 1 ton per week - Tallow meller. K — — — 50 tons per week — - Glue and size makers. L - 200 tons per week 300 tons per week - — - Feeding meals (fish offal). M - - - - 13,802 tons per annum - Wash contractors. N 14 tons per week - - - - - o 60 tons per week - - - - - P 50 tons per week 8 tons per week - - - - Borough Council depot. Q - - 11½ tons perannum - - - 38 Rags. Rags are derived from the following sources : private houses, tailors', shirtmakers' and dressmakers' workshops, dustbins, refuse dumps and refuse disposal works, the factories of clothing manufacturers, government departments (Military, Naval and Air Force redundant and obsolete stocks and badly worn and used materials), hospitals and institutions, public companies (railway, omnibus and tram depots). The purveyors of rags are: the itinerant rag and bone dealer, the retail rag dealer or marine store keeper and the wholesale rag merchant. The trade avenues through which household rags pass are briefly: (i) the householder, who disposes of household rags either to an itinerant rag and bone dealer or to a rag shop (retail rag merchant) or marine store; (ii) the itinerant rag and bone dealer, who either sells them to a retail rag merchant or marine store or to a wholesale rag merchant; (iii) the retail rag dealer or marine store keeper, who sells them to a wholesale rag merchant. Tailors, shirtmakers and dressmakers cuttings are either sold to the retail rag dealer or the wholesale rag merchant, the quantity for disposal being generally the deciding factor. Rags are reclaimed from dustbins and refuse dumps by individuals known as ' totters.' They sort the refuse for rags and dispose of them to retail rag dealers. This form of activity is the most unsavoury in the trade. The rags thus salvaged are usually dirty and wet, and most reputable wholesale rag merchants do not care to handle them. In some districts, where there arc several streets given over to a kerb collection of refuse, the ' totter ' constitutes a nuisance, and one local authority has successfully prosecuted certain of them, on the grounds that such salvaging was a form of theft since the refuse so deposited was the property of the local authority. It would appear that ' totting ' is not officially recognised by the sanitary authorities in London, but that it is done extensively is obvious. For instance, in one borough some 55 streets are subject to kerb collection, and the activities of the ' totter' in certain busy streets constitute a real nuisance. In two boroughs adjacent to London in which inquiries were made, salvaging is effected by the dustman, who removes the rags at the time of emptying the dustbin into the refuse collecting vehicle and places them in a basket suspended from the rear of the vehicle. Only one Metropolitan Borough Council carries out salvage operations at its refuse destructor works. The rags salvaged in these boroughs are usually sold to a wholesale rag merchant. All other forms of rag are sold direct to the wholesale rag merchant either by contract or by public auction. The itinerant rag and bone dealer does not usually sort his rags. The retail rag dealer sorts rags into from 12 to 15 grades. The wholesale rag merchant sorts into about 60 to 70 trade grades, but these may be further sorted into as many as 600 to 700 grades, depending on demand, colour, fineness of weave, etc. The wholesale rag merchant disposes of them as follows:— Woollens (knitts, serges, etc.) Yorkshire and foreign shoddy mills. Cottons and linens:— (а) fines Good quality note and bank note paper and artists' paper mills. (б) seconds Ordinary paper and blotting paper mills. (c) large pieces and mutton Garages, printing works and other establishments using cloths, etc machinery. Garments, waterflock, carpet and gunny Flock manufacturers. Low rags Roofing felt manufacturers. The only form of rag that is cleansed in any way is the wiper. This is the large piece of cotton or linen material sold for use in garages and machine shops for wiping the machines, etc. A large proportion of the rags used for this purpose is the knitted material used for protecting carcases of imported meat during transit. The finest cotton rags are sold to French polishers and kindred trades. One laundry is engaged solely in washing and cleansing rags. Approximately 100 tons a week are dealt with. The rags are subjected to the following process: (i) soaking in clean main water, (ii) washing and boiling in soft water and disinfecting chemicals including chloride of lime at 212° F. several times, (iii) drying with hot air at 260° F. by rotary machines which are fitted for dust extraction. It is stated that meat cloths lose 33.3 per cent., and ordinary rags 12.5 per cent., of their weight in washing. If required, a certificate of cleanliness and sterility is obtainable from the borough medical officer of health. After cleansing, the rags are returned to the wholesale rag merchants who pack them in paper and sell them by the pound. All other rags are baled under pressure, without cleansing, to facilitate ease of transport. Apart from the wiper, the trade generally is opposed to the idea of cleansing rags, maintaining that, broadly speaking, they are in a clean state (the amount of rags reclaimed from dustbins and refuse dumps and disposal works being relatively small), and that to whatever end they may be employed, the particular process to which they are then subjected invariably effectively sterilises them. Furthermore, it is considered that the subjecting of woollens to the strong chemical cleansing which would have to be applied, would be such as to denature them and would make them useless for the manufacture of shoddy. The cost of washing would also inflate the price to such an extent as to make it unprofitable to trade in them at current prices, and 39 would tend to cause the price of clothing materials to rise. (The cost of washing rags is said to be from £7 to £9 per ton.) There is also a serious loss in weight after washing (10 to 12 per cent.). Rag sorting is generally done by women and they usually concentrate on one particular branch of grading, i.e., knits, stockings, cuttings, garments, etc., the grading into ultimate grades being a skilled occupation. In the case of the better class rag, the seams are stripped and sold separately and all buttons and metal fasteners are removed. The most valuable rag is the white knit —mens' white sweaters, childrens' knitwear, etc. Silk cuttings and rags do not command a high price and are classed as low rags. Silk stockings are also a low rag, although until recently large quantities were exported to Italy where they were pulled, mixed with wool, and re-manufactured into light wearing materials. Materials impregnated with rubber are of no value generally and are destroyed, except by one firm which has a secret process for extracting rubber. No washing of rags is done on the premises of the wholesale rag merchants, but one firm carries out bleaching and dyeing. The purchase and disposal of rags is an industry of considerable importance, one firm alone employing 300 workpeople and dealing with 15,000 tons of rags per annum (value approx. £300,000). One industry, that of milling good class paper, is absolutely dependent upon the rag trade for its raw material. It is also considered that woollen garments would either be prohibitive in price or unobtainable if shoddy were not used, as it has been stated that the supply of wool is inadequate to meet the present day demands. No effective substitute for linen and cotton rags and shoddy have been found. As an indication of the quantity of rags dealt with, the following information obtained from several firms in London is of interest:— Firm. Weight of rags purchased Firm Weight of rags purchased. R 16,600 tons per annum. V 2,000 tons per annum. S 15,000„ „ „ W 300 „ „ „ T 10,000 „ „ „ X 150 „ „ „ U 5,000 „ „ „ An empty, used bottle may pursue one of three courses: the dustbin; the rag and bone Bottles, merchant; the shop where it was originally purchased. An empty, used sauce bottle or jam or pickle jar may either be placed in the dustbin or sold to a rag and bone merchant. If a bottle or jar placed in the dustbin be of a type likely to be re.used, such as a wine or spirit bottle or a standard jam or pickle jar, there is a possibility of its being salvaged by " totting " during the removal of the house refuse, at the refuse disposal depot of the local authority or on the refuse dump by a " totter." Such bottles or jars are then either sold direct to the bottle washer, or to a retail dealer who in turn sells them to the bottle washer. Bottles of a distinctive size, shape or cork fitting which are non.returnable to the manufacturers of the commodity originally contained in them, end their life on the refuse heap or in the furnace of the refuse disposal plant. Certain other bottles whose shape or cork fitting has become obsolete may also suffer this fate or may be used by manufacturers for containing some other product. A bottle or jar sold to a rag and bone merchant, or salvaged from a refuse dump or disposal depot, is then sold either directly to a bottle washer, or to a retail bottle merchant who in turn disposes of it to a bottle washer. A bottle returned to the shop where it was originally purchased full is returned to the bottlers or distillers, who either wash the bottle themselves or else send it to a bottle washer who is under contract to do the washing for them. The key man in the trade of second.hand bottles is the bottle washer, a number of whom have been interviewed. Briefly, the general practice throughout the trade both with regard to dealing in and washing bottles is as follows: Bottle washers use either the hand or the mechanical method of washing bottles or jars and usually concentrate on either washing wine and spirit bottles, or sauce bottles and jam and pickle jars. Some bottle washers also act as agents for new bottle manufacturers and in this connection undertake, in some instances, the washing of new bottles before delivery to the customer. The method employed generally by both the hand and mechanical washers is that involving the use of hot water and caustic soda (sodium hydroxide). One washer uses dry soap and spirits of salts (hydrochloric acid) for removing the crust from port bottles and paraffin and olive oil residues from bottles. The majority of washers, however, smash all bottles that have contained paraffin or similar pungent smelling substances. In the hand method the bottles or jars are immersed in a tub of warm caustic soda solution and cleansed with wire brushes. These brushes may be rotated by hand or mechanically. The mechanical method is generally on the principle of submitting the bottles to jets of hot water and caustic soda solution in a chamber. To facilitate working, the bottles are placcd on a continuous band which transports them over the jets and thence out of the chamber where they are hand examined. All bottles insufficiently washed are re.washed. Certain washers then sterilise the bottles under pressure. 40 After washing, bottles are sorted, and in the case of certain proprietory brands, are sold to the original owners. Certain washers hold sole agencies for the return of bottles belonging to certain firms, and this fact being known to the trade, all such bottles are delivered to them by the rag, bone and bottle merchants or by other washers. Standard wine and spirit bottles and standard jam and pickle jars are sold to the bottlers, distillers or manufacturers requiring them. Certain large concerns wash all bottles returned to them, but this does not prevent the reputable washer from returning them in a clean state. Other concerns contract with washers to do the cleansing and sterilising for them. On the other hand, one large firm of distillers, will not accept any returned bottle unless it bears their paper label intact. This naturally precludes washing. In the wine and spirit trade, the bottle being of a standard shape, it is imperative that the bottle be washed clean since it is not known at the time of washing whether the bottle will be returned to a concern that would or would not wash the bottles. Wine bottles which are contaminated in any way are absolutely useless, since the wine would sour, with consequent loss. All bottles cleansed by reputable firms are certainly spotlessly clean, and if delivered immediately would defy complaint. If stocks are held over and the bottles are soiled in any way, it is the custom to re.wash before delivery to the customer. The smaller man, who uses the hand method, cannot be said to be so scrupulous. His method of washing does not admit of the same degree of cleanliness as that attained by mechanical means, and it is doubtful whether bottles that have been in stock for some time are re.washed. A certain amount of interchange takes place between washers in order to fulfil orders when short, etc. If a bottle or jar be chipped or broken or tainted, it is broken and placed in the "cullett" hole. It is sorted into three colours, viz.: white (transparent), green and black, and sold to a glass bottle manufacturer, used in the manufacture of emery wheels or emery paper, or shipped abroad. As an indication of the quantity of bottles dealt with, the following information obtained from five firms in London is of interest:— Firm Number of bottles purchased Firm Number of bottles purchased Y 10,800 gross per annum Ab 30,000 gross perannum Z 30,000 „ „ „ Ac 104,000 „ „ „ Aa 30,000 „ „ „ Metals. The metals usually dealt with by the trade are the following : iron, copper, gunmetal, manganese bronze, brass, German silver, aluminium, duralumin, lead, zinc, pewter and tin residues. These are obtained from the following sources : private houses via the marine store, manufacturers having metallic residues, car breakers, and government disposal auctions. The majority of metal merchants deal only with non.ferrous metals which they dispose of as follows :— Lead.—Sold to mills or cast into pigs on the premises. Used in the manufacture of solder. Pewter.—Sold in bulk to mills or used in the manufacture of solder. Zinc.—Melted into spelter, used in the manufacture of brass, used in the manufacture of white metal for bearings, type, etc., and used for galvanising purposes. Tin.—Used in the manufacture of solder. Other metals.—These are generally graded and sold to mills and foundries. No merchant dealing exclusively in scrap metals has been interviewed, but as an indication of the quantities dealt with, the following information from four firms of rag and metal merchants in London is of interest:— Firm Weight of metals purchased Firm Weight of metals purchased Ad 100 tons per annum (non.ferrous). Af 2,000 tons per annum. 500 tons per annum (ferrous). Ao 9,000 „ „ „ Ae 30 tons per week. Waste paper. Inquiries have been made of one of the largest waste paper merchants in London. This firm is concerned in the business of purchasing waste paper and re.manufacturing it into millboard. The sources of supply, both inside and out of London are: offices, printing works, caretakers of large building blocks, wallpaper manufacturers, newspaper offices, government departments, and municipal authorities. The bulk of the paper goes to the parent company outside London for manufacture into millboard. The paper is sorted into a number of grades, the materials being first agitated to remove dust, and then run over picking belts to ensure the removal of string, tarred, rubbered, carbon and dirty paper. With the exception of string, these products are burnt. The sorted paper is baled in hydraulic presses before being passed on for manufacture. Clean paper shavings are used for packing purposes and the clean tailings of newspaper reels are guillotined and sold to retail tradesmen for packing purposes. 41 These tradesmen do not buy dirty paper, and in order to ensure this they have persuaded certain municipal authorities to canvass householders with a view to getting waste paper baled and tied and not placed in the dustbin. Some 2,500 tons of waste paper are dealt with weekly, of which 60 to 70 tons are destroyed as useless. In the county of London, the only salvaging plant in operation is that belonging to one of the Metropolitan Borough Councils. Rags, bones, paper and metals are salvaged and are disposed of to various contractors. A mechanical sifting plant is employed for screening the ash and clinker. Rags, bones, paper and scrap metal are carried on a belt conveyor and the scrap metal extracted by i rotary magnet. The salvaged materials are then baled and collected by the various contractors. No bottles are extracted because the bulk are broken during the screening process. An effort was made to induce householders to bale their waste paper separately, since clean paper commands a better price, but without success. Rags are not cleansed in any way, as the contractor prefers to deal with them in their original state. The quantity of reclaimable refuse is gradually decreasing despite the fact that the gross bulk of refuse is increasing. Materials salvaged from house refuse by sanitary authorities. During the year 1934.1935, the total refuse collected amounted to 47,948 tons. From this was salvaged:— Waste paper 974½ tons. Rags and sacking 41¾ „ Bones 11½ tons Scrap metal 514½ „ Inquiries have been made of two local authorities outside London who carry out salvage operations. Particulars are as follows:— (1) A large provincial city.—This city has means for salvaging saleable material at all of its five refuse disposal works. Extensive plant has been installed at these works and, in addition to ash and breeze, the following articles were salvaged during the year ended 31st December, 1935. Tons Value £ Non.ferrous metals— 114.5 2,220 Brass Accumulator lead Aluminium Copper Zinc Spelter Pewter Textiles— Bagging 1,000 15 2,212 Carpets Rags Cloth Woollens Rugs Miscellaneous— Bones 395 1,179 Glass (cullett) 765 473 Paper 226 246 Strawboards 225 186 Kraft paper 25 66 Bottles and jars 3,761 gross. 781 Light iron 395 283 Gold and silver ... 9 Miscellaneous - 57 Bundled scrap 5,261 6,229 Total materials sold 7,717 13,941 Total tonnage of refuse collected (excluding refuse put straight into incinerators.) 225,141 The salvaged materials are all disposed of to outside contractors. No attempt at cleansing is made except in the case of rags, which are dried and shaken by machinery before baling in order to get rid of moisture and superficial dirt. It is of interest to note that only 25 per cent, of the rags passing over the picking belts are considered to be worth salvaging, the remainder being conveyed with the tailings into the furnaces. The salvage department does not know of any mechanical washing of bottles establishment within the city, and doubts if any such exist. (2) An urban district council near London.—Bottles, jars, rags, paper and scrap metals are 42 reclaimed. These salvaged materials are taken from the refuse when the dustmen empty the bin into the refuse vehicle. The materials are then placed in a basket suspended at the rear of the vehicle. On arrival at the depot, the rags and bottles are sorted into grades. Metals are graded and paper bundled ; they are then disposed of to contractors. No cleansing of any kind is done, but four men are employed in grading the materials. For reclaiming saleable waste the dustmen receive 25 per cent, of the nett profit made on the sale of the materials. The foregoing information is not submitted as a complete account of " waste " materials produced and disposed of. It merely indicates in a general way materials constituting " waste " of particular trades or users, the utilisation of certain materials, and the ultimate disposal of others. Examination of milk. Milk and Dairies (Consolidation) Act, 1915, and Tuberculosis Order, 1925. Since 1st July, 1908, it has been the practice for the Council to take samples of liquid milk arriving by road or rail 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. The result of such sampling during 1935, as compared with work done in 1934, is as follows:— Table 44. Quarter 1934 1935 Completed examinations No. tuberculous Percentage Completed examinations No. tuberculous Percentage[.###] 1st 234 26 11.1 445 50 11.2 2nd 231 25 10.8 515 74 14.4 3rd 302 29 9.6 431 60 13.9 4th 504 45 8.9 489 53 10.8 Total 1.271 125 9.8 1,880 237 12.6 On account of the decision arrived at in 1934 that no useful purpose would be served by sampling milk brought into London in tanks on account of the practical impossibility of tracing the farm of origin, these figures relate to samples taken from churns only. The milk subject to sampling in 1935 was received from 29 counties. As a result of consequential investigations 119 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. The number of cows dealt with under the Tuberculosis Order, 1925, shows a marked increase over previous years. This increase may be put down to greater vigilance on the part of county authorities to whom notifications have been sent, as in verv few cases has it been found imnossible to trace the source of infection. Institutions under the control of th< Oounoil. 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:— Table 45. Department Approximate stock at 31st December, 1935 Visits by veterinary surgeon Samples taken of which examination completed Samples found to be tuberculous Cows with tuberculosis Cows with unhealthy conditions not tuberculous Cows Bulls Young stock Education 9 8 13 1 Mental hospitals 905 18 47 62 226 14 4 110 Public assistance 39 2 12 13 26 2 - 3 Public health 52 3 19 9 24 2 1 1 Total 1,005 23 78 92 289 *18 5 115 * Or 6. 6 per cent. 43 In the first instance cows are sampled in groups; 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. 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 169 visits in all. During these inspections 3,456 cows were examined of which 206 were found to be unhealthy, one suffering from tuberculosis of the udder, four in a state of tuberculous emaciation, 17 atrophied in one or more quarters and 185 with some other defect. Licensed cowsheds. In connection with these inspections 38 samples of milk were taken for biological examination in suspected cases, one of which was found to be positive, four were incomplete and the remainder negative. In addition to the special samples, 226 routine samples were taken, the examination of 11 of which was incomplete and of the remainder the results were:— Table 46 Quarter Total completed No. positive 1st 76 2nd 34 1 3rd 79 6 4th 26 1 Total 215 8 or 3.7 per cent 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. Venereal diseases. In the annual report for the year 1916, particulars were given of a scheme for the provision of the necessary facilities for the diagnosis and treatment of venereal disease which had been formulated as a result of conferences between representatives of the counties of London, Buckingham, Essex, Hertford, Kent, Middlesex and Surrey, and of the county boroughs of Croydon, East Ham and West Ham. The Local Government Board, in due course, signified its approval of the scheme, which came into operation on 1st January, 1917, and is known as the London and Home Counties Scheme. Hospitals. The general and special hospitals undertaking in.patient or out.patient treat. ment and other work under the scheme at the end of 1935, 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; the London County Council (Whitechapel) clinic (see page 46) 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. 44 The number of new patients attending the hospitals during the year 1935 was 28,403, of whom 3,930 were suffering from syphilis, 10,952 from gonorrhoea, and 350 from soft chancre, while 13,171 were diagnosed as not suffering from these diseases. A summary of the work done by the hospitals lor each of the areas in the joint, scheme during the year 1935 is shown in the following table:— Table 47 London Middlesex Essex Surrey Kent Herts Bucks East Ham West Ham Croydon Total "Other places" Grand total New patients— Syphilis 2,734 340 121 115 77 32 20 25 52 9 3,525 405 3,930 Soft chancre 235 7 16 7 4 2 9 — 280 70 350 Gonorrhoea 7,645 1,052 458 341 149 154 52 106 193 36 10,186 766 10,952 Not venereal 9,213 1,341 616 588 279 155 67 96 199 87 12,641 530 13,171 Total 19,827 2,740 1,211 1,051 509 341 139 229 453 132 26,632 1,771 28,403 Total attendances 863,948 94,266 64,635 28,320 12,155 9,206 3,008 15,231 29.498 2,006 1,122,273 16,219 1,138,492 No. of inipatient days 32,868 4,546 2,692 1,261 2,209 583 562 117 736 102 45,676 9,890 55,566 Arsenobenzene doses 42,567 6,725 2,904 2,420 1,186 706 290 605 1,266 93 58,762 2,051 60,813 Pathological Examinations. For or at centres— Spirochaetes 2,734 84 94 35 12 5 5 21 25 6 3,021 124 3,145 Gonococci 106,701 13,225 11,221 5,212 2,215 1,589 825 2,654 4,105 548 148,295 1,824 150,119 Wassermann 33,840 3,738 1,940 2,042 783 521 234 375 696 222 44,391 1,378 45,769 Others 39,986 4,030 4,174 2,233 909 484 246 841 1,548 253 54,704 1,666 56,370 Total 183,261 21,077 17,429 9,522 3,919 2,599 1,310 3.891 6,374 1,029 250,411 4,992 255,403 For practitioners— Spirochaetes 8 3 1 6 — — — — — 18 — 18 Gonococci 5,072 195 888 333 52 64 74 4 6 853 7,541 104 7,645 Wassermann 14,793 1,006 1,393 1,291 197 65 96 38 19 569 19,467 594 20,061 Others 7,186 236 1,282 675 15 21 10 26 16 799 10,266 364 10,630 Total 27,059 1,440 3,564 2,305 264 150 180 68 41 2,221 37,292 1,062 38,354 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 :— Table 48. Year New cases Total venereal cases Syphilis Soft chancre Gonorrhoea M. F. M. F. M. F. M. [ F. 1917 4,427 3,351 199 11 3,830 1,207 8,456 4,569 1918 3,764 3,002 116 13 4,844 1,940 8,724 4,955 1919 6,394 3,391 463 18 10,441 2,440 17,298 5,849 1920 6,988 3,579 766 25 10,669 2,427 18,423 6,031 1921 5,088 3,100 458 13 8,573 2,136 14,119 5,249 1922 4,207 2,600 309 12 8,233 2,402 12,749 5,014 1923 4,497 2,631 311 4 9,043 2,520 13,851 5,155 1924 4,174 2,452 301 4 8,565 2,785 13,040 5,241 1925 3,556 2,346 268 11 8,464 2,857 12,288 5,214 1926 3,725 2,013 301 2 8,825 2,858 12,851 4,873 1927 3,886 2,209 203 7 9,637 2,859 13,726 5,075 1928 3,433 1,837 229 6 8,249 2,647 11,911 4,490 1929 3,303 1,628 276 4 8,271 2,503 11,850 4,135 1930 3,389 1,836 347 12 8,620 2,503 12,356 4,351 1931 3,009 1,521 326 12 7,713 2,260 11,048 3,793 1932 3,270 1,671 172 15 8,566 2,656 12,008 4,342 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 1935 2,578 1,352 336 14 8,184 2,768 11,098 4,134 45 It will be seen that the number of new cases of syphilis was the lowest yet recorded. With regard to the new cases of venereal disease, information was obtained as to whether the infection was recently acquired in patients attending the clinics for the first time during the year 1935, 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 42 per cent, of the new patients the disease was in either a primary or secondary stage, and, in the case of gonorrhoea, in 82 per cent., the infection had taken place within a year. Cases of congenital syphilis not known to have received previous treatment, numbered 252. The age and sex distribution was as follows:— Table 49. 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. 21 20 16 10 26 20 43 96 106 146 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. Attendances. In past years the ratio of attendances has been stated as so many attendances to each new case of V.D. admitted to the clinics during the year. By this means an estimate, comparable year by year, is obtained of the efficiency of the work as measured by the continued attendance. For the year 1935 the total attendances of V.D. patients was 1,050,173, and the ratio of attendances of V.D. patients to new V.D. cases was 69, compared with 66 in 1934 and 59 in 1933. Comparative figures for the nmeteen years during which the scheme has been n force are shown in the following table:— Table 50. 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 1935 15,232 13,171 28,403 1,138,492 55,566 46 The increasing number of non-venereal patients who present themselves for examination indicates that the general public is appreciating more and more the efforts which have been, and are being, made to spread a knowledge of the serious nature and grave after.effects of the venereal diseases. Pathology and bacteriology Another point worthy of note is the total number of examinations made of pathological specimens. Comparative figures for the nineteen years are shown in the following table:— Year From treatment centres From medical practitioners Year From treatment centres From medical practitioners 1917 13,988 3,649 1927 107,512 27,046 1918 25,973 6,380 1928 107,410 29,785 1919 51,554 10,464 1929 114,840 32,605 1920 58,920 14,027 1930 125,177 33,309 1921 66,134 18,472 1931 161,092 35,498 1922 74,022 19,836 1932 196.357 40,626 1923 69,784 24,403 1933 219,852 39,649 1924 79,005 24,797 1934 261,116 37,286 1925 106,064 26,346 1935 255,403 38,354 1926 100,543 27,565 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 543, compared with 108 at the end of 1917, the first year of the operation of the scheme. Venereal disease ; hostel accommoda tion. 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 1935, the number of patients dealt with at these institutions from the areas in the scheme was 266, the aggregate number of days in residence being 28,727. Comparative figures for 1934 were 269 and 28,582. The hostels undertaking work in connection with the scheme for the year 1935, 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.park.road, N.W. (Royal Free Hostels Committee) ; Salvation Army Hostels, 122.124 and 126.128, Lower Clapton.road, E. The premises, 80, Stockwell Park.road, were discontinued as a V.D. hostel on 31st October, 1935. Rescue homes. The desirability of maintaining treatment and observation of girls and women for whom residence in hostels has been provided during the acute stages of venereal disease, engaged the attention of the Public Health Committee of the Council during the year 1928. As a result, arrangements were made with the authorities of certain rescue homes providing vocational training in domestic and other work, to receive up to eleven young women and girls who, although requiring continued treatment and observation, had been certified by the medical officer of a clinic as fit to reside in an institution without danger to other residents. These arrangements were completed in the autumn of 1928, but have not been utilised to the extent anticipated despite several circulars to V.D. clinics and hostels. During the year 1935 only one girl availed herself of these facilities. The total number of days in residence was 173. The London County Council (Whitechape clinic. On 1st July, 1930, tne 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. The premises are rented from the London hospital, but the 47 staff is appointed and the clinic maintained entirely by the Council. It remains open from 8 a.m. to 9 p.m. every week.day, and provision for intermediate treatment is available also on Sundays and Bank Holidays. Under the directorship of Dr. T. Anwyl Davies, assisted by a loyal and efficient staff, the clinic has been an unqualified success. For the last full year (1929) when the clinic was conducted by the London Hospital, a total of 2,020 new patients and 71,684 attendances were registered. During the first six months the clinic was in use, 1,527 new patients and 76,183 attendances were registered, whilst for the year 1935, the number of new patients was 3,698 and the attendances totalled 339,555. Of the new patients during 1935, 66 per cent, of the male and 51 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 1935 was 76,791. Of the 76,791 examinations, 9,354 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. Introduction Treatment of tuberculosis. The Council's tuberculosis scheme continued in operation during 1935 without variation in its main features. Previous reports, notably those of 1919, 1925 and from 1930 onwards to 1934, have reviewed the development of the scheme from its initiation in 1914 and it is not necessary, therefore, to recapitulate this development in the present report. It will be sufficient to state, in broad outline, that the scheme resolves itself into two main divisions, viz., (1) a tuberculosis dispensary service provided by the Metropolitan Borough Councils in accordance with general principles laid down by the Council, and (2) arrangements for residential treatment and various auxiliary services undertaken directly by the London County Council. As to (1), the tuberculosis dispensary service is under the administrative direction of the medical officer of health of each borough. The tuberculosis officers work in co.operation with the medical practitioners of their area, and their services are available for consultation. They also act as honorary consultants on the staff of the Council's general hospital which serves their area. The dispensaries are required to be linked with hospitals for special services, such as provision for X.ray examinations, and artificial pneumothorax refills. In this way equipment of the dispensaries with expensive apparatus is avoided, and the tuberculosis officers and the patients have the advantage of the co.operation of staff specially experienced in these matters. The Council's general hospitals and certain voluntary hospitals are available for these services. A tuberculosis care committee (or equivalent organisation) is associated with each dispensary. The constitution of these committees includes representatives of the various social service agencies, voluntary and public, operating in the borough to help families whose social and economic circumstances are disturbed owing to the presence of the disease in the family. With regard to (2), residential treatment is provided by the Council both in its own hospitals or sanatoria and in privately owned institutions. By this method the Council secures a wide choice of institutions of various types and is enabled to give attention, in addition to clinical considerations, to personal preferences of patients, an important factor in some cases, and to such matters as climatic conditions and social or religious amenities. Patients are, however, sent to the Council's hospitals and sanatoria if beds equally suitable are available, before accommodation is taken in voluntary institutions. The voluntary institutions used by the Council include Papworth village settlement and Preston Hall colony where suitable patients have the prospect of settlement and employment in the industries, and Burrow Hill sanatorium colony, which provides for youths between 14 and 18 years of age and, during treatment, trains them for clerical employment or for gardening work. 48 The arrangements and procedure for distribution and treatment of patients are described fully in the annual report for 1934 (pp. 40.2). Auxiliary services provided by the Council include the following:— (1) Dental treatment, dentures and spectacles certified to be essential during residential treatment. Patients are, however, required to contribute towards the cost any benefits to which they may be entitled under the National Health Insurance Acts or from societies to which they may be contributors. Essential clothing in necessitous cases is also supplied during residential treatment if not obtainable by patients from their own resources or from charity. (2) Arrangements for the boarding out of (i) children from heavily infected and overcrowded homes in order to remove them from risk of infection, and (ii) children who cannot otherwise be adequately cared for during the absence of the mother undergoing residential treatment. (3) Open.air schools for children suffering from pulmonary tuberculosis or from tuberculous glands who do not need residential treatment and for children suspected to be suffering from tuberculosis or living in contact with advanced cases of the disease. (4) After.care clinics for certain surgical cases treated in the Council's special tuberculosis hospitals. Operation of tuberculosis scheme during 1935. The following pages (pp. 48.60) indicate the operation of the tuberculosis scheme during the year 1935. Table 51—Beds occupied at end of year. Year Adults Children Total Year Adults Children Total 1914 722 90 812 1925 1,668 792 2,460 1915 544 241 785 1926 1,841 880 2,721 1916 481 320 801 1927 1,946 884 2,830 1917 526 375 901 1928 1,920 855 2,775 1918 816 376 1,192 1929 2,083 858 2,941 1919 1,308 557 1,865 1930 2,017 890 2,907 1920 1,636 704 2.340 1931† 2,255 898 3,153 1921 1,382 669 2,051 1932† 2,368 811 3,179 1922 1,370 655 2,025 1933† 3,216 787 4,003 1923 1,458 707 2,165 1934 3,574 781 4,355 1924 1,612 746 2,358 1935 3,673 813 4,486 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. The numbers of applications for residential treatment during each of the last five years were as follows:— Table 52 Year For first period of treatment Ex. service For further treatment Total Ex. service Civilian adults Children Civilian adults Children Male Female Male Female 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 1935 8 2,480 1,880 835 80 1,621 1,192 232 8,328 N.B.—As from 1933 cases formerly treated in general hospitals as " municipal" patients are included in these figures as tuberculosis scheme cases. 49 Patients recommended for treatment during 1935 were dealt with as follows :— Adults Children (a) Admitted to " observation " beds to determine diagnosis or suitability for sanatorium treatment 1,394 214 (6) Passed for admission direct to sanatoria or hospitals 5,755 815 (c) Not accepted for residential treatment 70 17 (d) Withdrawn after application but before decision was reached 42 21 Total 7,261 1,067 N.B.—The treatment offered was refused in the cases of 139 adults and 16 children. In 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 for cases up to 16 years of age was arranged in institutions for children. The extent of residential treatment and observation is shown below :— Table 53. Classification In institutions on 1st January, 1935 Admitted during the year Discharged during the year Died in institutions In institutions on 3lst December, 1935 Number of doubt- fully tuberculous cases admitted for observation. Adult males 54 206 205 6 49 Adult females 55 162 165 3 49 Children 7 249 246 2 8 Total 116 617 616 11 106 Number of patients suffering from pulJ monary tuberculosis. Adult males 1,870 4,284 3,271 1,014 1,869 Adult females 1,154 2,850 2,285 525 1,194 Children 282 301 239 29 315 Total 3,306 7,435 5,795 1,568 3,378 Number of patients suffering from nonpulmonary tuberculosis. Adult males 228 343 255 52 264 Adult females 213 345 285 25 248 Children 492 496 455 43 490 Total 933 1,184 995 120 1,002 Grand total 4,355 9,236 7,406 1,699 4,486 The distribution of patients in institutions on 31st December, 1935, is shown below, the figures for 1934 being given in brackets:— Table 54. Hospitals and institutions Ex-service men Civilian adults Children under 16 years Total London County Council special hospitals 1 (7) 1,346(1,375) 675 (650) 2,022 (2,032) London County Council general hospitals 10 (8) 1,219(1,122) 70 (50) 1,299(1,180) Voluntary institutions 18 (27) 1,079(1,035) 68 (81) 1,165(1,143) Total 29 (42) 3,644 (3,532) 813(781) 4,486 (4,355) 50 The following table shows the results of observation of doubtfully tuberculous cases discharged from observation hospitals :— Table 55. 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 30 29 27 19 44 17 12 ii 49 73 67 Non-tuberculous 90 42 29 58 47 79 2 1 5 12 5 68 162 95 181 Total 120 71 56 77 91 96 2 1 17 12 5 79 211 168 x t* The immediate results of the treatment of patients discharged during 1935 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 1935 there were 717 " A," 288 " B1," 2,843 " B 2 " and 1,536 " B 3 " cases discharged during the year. Of these numbers, 328 or 45.7 per cent. group " A," 103 or 35.8 per cent. group " B1 " and 179 or 6.3 per cent. group " B 2" cases were discharged as quiescent, totalling 610 quiescent cases, or 11.3 of the total number (5,384) of pulmonary cases discharged during 1935. Table 56.—Immediate results of treatment. Adults. Classification Quiescent Years Not quiescent Years Died in institution Years Totals Years 1933 1934 1935. 1933 1934 1935 1933 1934 1935 1933 1934 1935 A. Number 306 286 328 323 395 364 5 40 25 634 721 717 Percentage 48.3 39.7 45.7 50.9 54.8 50.8 0.8 5.5 3.6 100 100 100 Bl. Number 89 105 103 108 133 183 1 2 2 198 240 288 Percentage 44.9 43.8 35.8 54.5 55.4 63.5 0.6 0.8 0.7 100 100 100 192 191 179 2,445 2.558 2,601 53 110 63 2,690 2,859 2,843 Percentage 7.1 6.7 6.3 90.9 89.5 91.5 2.0 3.8 2.2 100 100 100 b3. Number — 3 — 666 787 593 183 1,024 943 849 1,814 1,536 Percentage — 0.2 — 78.2 43.4 38.6 21.8 56.4 61.4 100 100 100 Total Pulmonary 587 685 610 3,542 3,873 3,741 242 1,176 1,033 4,371 5,634 5,384 Percentage 13.4 10.4 11.3 81 1 68.7 69.5 5.5 20.9 19.2 100 100 100 ary 189 219 181 254 239 252 18 60 43 461 518 476 Percentage 41.0 42.3 38.1 55 1 46.1 52.9 3.9 11.6 9.0 100 100 100 776 804 791 3,796 4.112 3,993 260 1,236 1,076 4,832 6,152 5,860 Percentage 16.1 13.i 13.5 78 6 66.8 68.2 5.3 20.1 18.3 100 100 100 51 Children Classification Quiescent Years Not quiescent Years Died in institution Years Totals Years 1933 1934 1935 1933 1934 1935 1933 1934 1935 1933 1934 1935 A. Number 106 114 159 40 38 26 — 3 3 146 155 188 Percentage 72.6 73.6 84.6 27.4 24.5 13.8 — 1.9 1.6 100 100 100 bl. Number 6 5 10 2 2 8 1 8 7 19 Percentage 75.0 71.4 52.6 25.0 28.6 42 1 — — 6.3 100 100 100 B2. Number 8 4 18 13 7 5 1 — 31 14 11 Percentage 25.8 — 36.4 58.1 92.9 63.6 161 7.1 — 100 100 100 B3. Number 24 2 3 8 18 17 32 20 20 Percentage — — — 75.0 10.0 150 25.0 90.0 85.0 100 100 100 Total Pulmonary 120 119 173 84 55 44 13 22 21 217 196 238 Percentage 55.3 60.7 72.7 38.7 28.1 18.5 6.0 11.2 8.8 100 100 100 ary 360 359 354 67 44 52 15 16 13 442 419 419 Percentage 81.4 85.7 84.5 15.2 10.5 12.4 3.4 3.8 3.1 100 100 100 Grand Total 480 478 527 151 99 96 28 38 34 659 615 657 Percentage 72.8 77.7 80.2 22.9 16.1 14.6 4.3 6.2 5.2 100 100 Cases sent to the Papworth village settlement, Cambridge, and Preston Hall colony, Aylesford, Kent, are carefully selected to ensure that only those patients are admitted who are, or are likely to become, potential settlers in the associated industrial villages. In addition to the number of patients accepted as permanent settlers at the village settlements there are a certain number of settlers for whom, owing to their permanent disability, a weekly partial maintenance fee of from 10s. to 20s. is paid, and such settlers are regarded as continuing to receive residential treatment under the tuberculosis scheme. Papworth and Preston Hall village settlements. The average numbers of patients under the scheme at Papworth and Preston Hall, respectively, during the past eight years are shown below :— Table 57. 1028 1029 1930 1931 1032 1033 1034 1035 Papworth 9 16 33 61 90 109 118 140 Preston Hall 13 13 10 53 84 89 113 150 The youths between 14 and 18 years of age who are sent to Burrow Hill colony for treatment combined with training either for clerical work or gardening, are retained in the first instance for 12 months. In suitable cases the Council has granted a second year 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 is approved both by the Ministry of Agriculture and the Board of Education. During 1935, 15 youths were discharged from the colony. Of this number four completed a two years' course of training. The instruction given permits the youths to continue their general education during their period of residence. The high standard of the theoretical instruction in gardening is shown by the success attained by students who have studied for the examinations of the Royal Horticultural Society and been awarded the Society's certificate. The clerical course provides for skilled tuition for shorthand, typewriting, bookkeeping and business methods in addition to a sound general education. The students are prepared for the examinations set by Pitman's Institute for shorthand and by the Royal Society of Arts for other subjects. The percentage of passes at these examinations is high. In conjunction with this scheme, there is an arrangement whereby selected youths who have taken the gardening course are offered employment in the parks 52 department of the Council as " improvers." Since 1931, 20 youths have been accepted for employment, and only one left the service on health grounds, which is undoubtedly very gratifying. Three are now on the permanent adult staff and one other is eligible, but has not passed the medical examination for entrance ; he will be re-examined in October next. Two others are expected to qualify in horticulture before long, and will then be submitted for medical examination with a view to permanent appointment. In no case has a bad report been received. The boys are evidently keen to do well, and are rendering the Council good value in their work. Time lost owing to sickness has been approximately 4 per cent., which is considered very satisfactory. Following-up of discharged cases. Adults.—During the year investigations were made concerning the adult cases discharged from hospitals or sanatoria in 1929 ; the number investigated was 3,829, including 276 non-pulmonary 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 1928 cases :— Table 58. Classification Total Percentage ulive five years after discharge Percentage dead A 514 (579) 76.6 (75.1) 23.4 (24.9) B 1 169 (187) 72.1 (65.7) 27.9 (34.3) B 2 1,975 (2,149) 35.2 (34.6) 64.8 (65.4) B 3 895 (964) 4.4 (4.7) 95.6 (95.3) Non-pulmonary 276 (261) 74.3 (75.8) 25.7 (24.2) Particulars obtained in 1934 as to the fitness for work of the 1,455 surviving adult patients who were discharged from treatment in 1929 show that out of a total of 516 A and B1 cases, 68.4 per cent. were at work. The corresponding percentage for the A and B1 cases in the 1928 group was 74.2. The percentages at work in the other categories and also the corresponding figures for the 1928 group (shown in brackets) are as follows :—B2, 52.2 (54.3) per cent.; B3, 38.5 (34.8) per cent. ; and surgical, 63.4 (67.2) per cent. Of the total number of 1,455 in all categories, 59.2 (62.5) per cent. were at work, 6.5 (6.7) per cent. were fit for work but were unemployed, 29.3 (30.8) per cent. were unable to work (including cases receiving further residential treatment). Children.—The particulars obtained as to the after histories of children discharged under 16 years of age in 1929 relate to 592, of whom 173 are pulmonary and 419 non.pulmonary. The mortality records are as follows, the figures in brackets referring to year's enquiry into the 1928 cases :— Table 59. Classification Total Percentage alive five years after discharge Percentage dead A 132 (147) 91.7 (87.8) 8.3 (12.2) B 1 2 (1) 100.0 (100.0) -(-) B 2 22 (30) 45.5 (36.7) 54.5 (63.3) B 3 17 (28) 5.9 (.) 94.1 (100.0) Non.pulmonary 419 (475) 90.3 (94.1) 9.7 (5.9) The mortality rates of the non-pulmonary cases classified according to the location of the disease are as follows :— Table 60. Location of disease Total Percentage alive five years after discharge Percentage dead Hip 52 (70) 84.6 (91.5) 15.4 (8.5) Spine 40 (41) 75.0 (92.7) 25.0 (7.3) Other bones 108 (108) 94.5 (95.4) 5.5 (4.6) Glands 181 (233) 92.3 (95.3) 7.7 (4.7) Other parts 38 (23) 92.1 (87.0) 7.9 (13.0) 53 Of the 134 surviving pulmonary cases 37 were at school and 69 at work, and of 378 surviving non-pulmonary cases, 167 were at school and 115 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. Tuberculosis dispensary service. 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. In December, 1935, the Stepney Borough Council opened a new tuberculosis dispensary at Steel's-lane, Devonport-street, which replaced two of the original dispensaries in the borough. The two that were closed were 18, Great Prescottstreet and 208, High-street, Shadwell. The third (35, Stepney-green) has been reorganised as a branch dispensary to the new dispensary in Devonport-street. There are now 33 dispensaries in all, including 4 branch dispensaries. Of these, 25 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 54 and 55. 54 55 Table 61.—Tuberculosis Dispensaries.—Analysis of Returns, January-December, 1935. Metropolitan Borough On dispensary register. 1-1-35 Transferred during 1935 from other areas and cases returned after discharge Examined for first time during 1935 (a) New cases excluding contacts (b) Contacts (printed in italics) Total number (including contacts) under dispensary supervision during 1935 Removed from dispensary register during 1935. On dispensary register 31-12-35 Total attendances Visits to home for dispensary purposes by No. of specimens of sputum ex amined No. of X ray examina tions Number of T.B. 4- cases on dispensary register Definitely tubercular Diagnosis not confirmed Pulmonary Nonpulmonary Diagnosis not confirmed Nontuberculous Total (a) He- covered, (b) Non tubercular (printed in italics) («) Transferred to other areas or lost sight of (6) Died (printed in italics) Definitely tubercular Diagnosis not completed Adults Children Adults Children Adults Children Adults Children Adults Children Tuberculosis officers Nurses or health visitors Battersea 828 105 53 130 5 14 14 42 29 236 107 422 155 1,790 58 96 £00 108 3,863 340 4,035 622 204 395 2 3 4 90 128 95 132 636 92 908 Bermondsey 859 19 20 106 6 16 11 10 3 236 65 368 85 1,816 45 71 819 16 3,725 959 2,756 880 584 326 6 5 1 2 1 2 174 274 182 283 770 95 835 . Bethnal Green 744 12 31 101 3 16 14 13 5 170 109 300 131 1,408 28 122 721 13 3,600 144 3,216 390 428 273 3 1 1 1 110 74 114 76 472 52 73 4 Camberwell 1,663 17 63 148 7 19 9 11 — 352 128 530 144 3,113 36 142 1.672 17 5,894 591 9,255 1,256 756 769 55 1 1 2 5 1 271 360 332 364 1,126 120 1.689 Chelsea 313 2 37 61 3 10 2 2 1 199 113 272 119 866 23 64 307 3 2,204 48 3,420 274 518 125 2 1 55 65 56 67 439 30 310 Deptford 530 33 42 102 5 14 6 13 144 103 273 117 1,116 31 103 494 27 2,335 186 3,473 505 189 264 4 7 48 62 52 69 388 73 521 Finsbury 545 8 34 54 6 3 4 7 1 78 44 142 55 928 82 87 439 8 2,087 167 2,223 154 150 204 7 2 3 49 83 56 88 270 42 447 Fulham 795 8 58 136 8 16 13 10 6 230 258 391 285 1,792 36 142 749 16 4,570 448 2,993 717 350 344 1 2 1 142 109 143 112 756 93 765 Greenwich 558 19 24 73 3 14 8 1 2 215 130 303 143 1,193 35 78 529 3 2,387 139 3,025 253 533 252 6 1 71 67 77 69 483 65 532 Hackney 1,292 18 68 165 3 18 16 13 3 339 140 535 162 2,507 57 216 1248 9 5,489 320 2,932 909 592 539 9 1 1 3 1 246 771 258 174 899 78 1,257 Hammersmith 758 1 64 126 — 15 6 3 — 174 67 318 73 1,692 29 64 802 3 2,439 300 3,719 520 211 379 21 1 2 235 219 256 222 696 98 805 Hampstead 203 7 32 34 1 9 5 2 3 61 10 106 19 430 12 43 218 6 936 18 1,223 70 85 115 1 1 31 30 33 30 132 19 224 Holborn 232 30 3 1 2 1 8 1 40 6 337 2 27 226 1 1 I 673 61 991 109 43 11 4 2 27 26 31 28 62 19 227 Islington 1,272 7 123 283 23 42 25 5 1 302 56 632 105 2,629 63 245 1,356 7 7,974 379 6,353 808 575 702 27 6 1 4 2 222 229 251 239 815 143 1,363 Kensington 785 29 34 122 7 11 9 8 6 146 49 287 71 1,502 62 176 630 14 1,879 66 2,166 341 119 287 3 2 138 153 141 155 545 75 644 Lambeth 1,489 88 60 223 8 27 19 76 5 362 56 688 88 3,034 53 316 1,368 100 6,891 908 4,672 1,159 1,294 638 33 2 1 3 30 17 270 265 334 287 1,078 119 1,468 Lewisham 947 3 88 136 6 12 14 3 — 157 35 308 55 1,609 46 99 975 4 3,040 384 4,813 347 119 565 1 1 1 79 126 81 127 401 84 979 Paddington 956 16 29 114 5 20 23 3 11 310 306 447 345 2,034 21 238 871 14 7,015 453 5,461 362 267 249 4 1 4 117 115 122 119 848 42 885 Poplar 850 12 29 123 5 9 13 14 9 223 136 369 163 1,974 71 88 777 27 6,094 604 6,564 845 277 435 11 3 3 1 253 280 267 284 912 99 804 St. Marylebone 476 37 22 81 8 10 4 — — 59 30 150 42 830 23 112 412 7 2,366 134 1,966 179 90 209 5 2 3 2 41 50 49 54 223 53 419 St. Pancras 704 42 99 149 10 13 9 8 1 142 56 312 76 1,507 49 143 702 23 3,370 38 4,931 575 197 403 2 1 1 157 113 159 115 497 93 725 Shoreditch 673 19 39 73 7 7 7 13 7 215 111 308 132 1,408 30 89 622 22 3,778 161 2,917 843 190 268 2 1 2 105 127 109 128 582 63 644 Southwark 641 46 47 135 13 20 13 28 13 73 4 256 43 1,335 48 180 60s 45 3,125 368 4,199 439 113 364 9 4 2 4 142 141 151 151 360 94 653 Stepney 1,814 138 74 212 20 14 22 46 27 213 96 485 165 3,225 66 250 1,725 143 6,171 198 5,548 581 196 795 4 1 3 5 15 226 295 235 314 901 140 1,868 Stoke Newington 235 7 32 32 3 2 — 1 1 86 11 121 15 542 8 72 213 3 1,210 78 1,411 266 81 117 1 1 76 54 77 55 227 19 216 Wandsworth 1,371 38 106 264 10 35 20 25 — 365 246 689 276 2,851 79 202 1.378 26 4,933 885 4,238 1,367 224 802 14 2 1 169 185 183 188 1,003 163 1.404 Westminster 688 3 13 203 10 30 22 — — 59 41 292 73 1,177 5 234 f55 — 2,454 73 3,335 171 78 210 3 7 1 2 41 54 45 63 231 52 655 Woolwich 968 1 — 160 9 18 4 — 327 187 505 200 2,133 81 87 880 1 5,276 401 4,941 555 681 330 15 6 4 1 1 237 195 257 202 964 120 881 Total 23,189 735 1,321 3,576 197 434 314 358 137 5,481 2,695 9,849 3,343 46,778 1,179 3,786 22,196 666 105778 8,851 106776 15,497 9,144 10,477 248 52 10 36 66 57 3,822 4,050 4,146 4,195 16,716 2,235 22,862 56 The following is a summary, for purposes of comparison, of certain sections of the foregoing table :— Table 62. Metropolitan borough Deaths from tuberculosis Ratio of cases on dispensary register to cases on notification register Number per 100 deaths from tuberculosis in the 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 X-rav examinations Actual Per 1,000 inhabitants Definitely tuberculous per. sonson dispensary register. T.B ‡ cases on dispensary register Examinations per 100 new cases and contacts per 100 new cases New cases. Contacts Adults Children Battersea 126 .85 .97 635 313 457 75 104 4.3 .37 .37 4.4 25.4 35.4 Bermondsey 108 1.05 .89 758 301 419 168 262 4.5 115 .36 3.3 63.6 128.9 Bethnal Green 63 .63 .58 1,144 433 684 180 120 4.9 .20 .33 4.4 68.9 99.3 Camberwell 192 .82 .80 871 400 351 173 189 3.5 .35 .35 5.5 55.2 112.2 Chelsea 41 .72 .89 749 304 953 136 163 7.1 .15 .30 11.0 100.8 132.5 Peptford 89 .9 .73 555 296 438 58 77 4.5 .36 .17 6.7 37.0 48.5 Finsbury 54 .5 .60 812 377 364 103 162 4.7 .37 .56 5.0 44.0 76.1 Fulham 128 .89 .43 585 268 528 111 87 5.9 .59 1.18 3.9 37.6 51.8 Greenwich 78 .81 .82 678 323 571 98 88 4.5 .26 .56 5.7 90.0 119.5 Hackney 139 .66 .67 897 387 501 185 125 4.4 .25 .83 2.3 52.4 84.9 Hammersmith 119 .93 .76 673 318 328 215 186 3.0 .37 .97 4.6 24.3 54.0 Hampstead 38 .2 .51 573 302 328 86 78 4.2 .08 .46 5.5 45.2 68.0 Holborn 30 .5 .70 753 393 153 103 93 2.9 .27 .48 4.4 41.0 93.5 Islington 222 .3 .59 610 316 332 113 107 5.9 .28 .48 4.7 46.9 78.0 Kensington 89 .49 .83 707 322 402 158 174 2.9 .10 .37 3.4 18.2 33.2 Lambeth 218 .78 .58 627 292 355 153 131 4.7 .62 1.32 3.2 92.6 166.8 Lewisham 147 .66 .64 663 384 246 55 86 3.1 .39 .48 4.9 20.8 32.8 Paddington 88 .63 .6 989 283 900 138 135 7.9 .51 .31 6.2 25.8 33.7 Poplar 130 .90 .73 597 334 409 205 218 7.6 .75 .37 8.2 25.6 52.1 St. Marylebone 72 .78 .49 572 290 267 68 75 5.6 .32 .25 4.7 30.5 46.9 St. Pancras 139 .75 .63 505 289 279 114 82 4.6 .05 .27 6.8 29.8 50.8 Shoreditch 76 .86 .42 818 352 578 143 168 5.9 .25 .22 4.5 28.1 43.2 Southwark 146 .93 .41 416 249 204 103 103 4.8 .56 .35 6.4 18.8 37.8 Stepney 170 .80 .88 1,014 467 382 138 184 3.3 .11 .10 30 16.4 30.2 Stoke Newington 39 .77 .71 546 300 348 197 141 5.6 .36 1.53 6.5 30.2 59.6 Wandsworth 249 .72 .66 553 322 387 73 75 3.5 .63 1.24 3.0 16.8 23.2 Westminster 70 .56 .44 935 300 521 64 90 3.7 .11 .57 51 16.5 21.4 Woolwich 136 .93 .90 647 242 518 188 148 5.9 .46 1.34 5.6 58 5 96.6 London (excluding City) 3,196 .76 .66 693 327 412 129 131 4.6 .39 .58 4.7 42.5 69.3 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 (b), 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 1935 with the co-operation of the Association. There were 226 applications during 1935, concerning 369 children, of whom 252 were accepted, the remaining 117 being withdrawn or regarded as unsuitable. At the end of the year 107 children were being maintained under this scheme. The total number of children dealt with (252) is an increase over that for the previous year (246). The number still being cared for at the end of the year (107) is 33 less than the previous year's figure. Reference was made in last year's annual report (pp. 51-53) to an investigation conducted by Dr. F. J. Bentley, divisional medical officer, as to the proportion of cases of tuberculosis in which there had been known intimate association with a " Contact " investigation 57 previous case of the disease. This enquiry has been continued and information is now available in respect of 4,067 cases which have undergone residential treatment under the Council's scheme. Of these, it was noted that, in 2,827 cases, there was " no known contact " with a previous case of the disease, leaving 1,240 cases, or approximately 30 "5 per cent, which exhibited contact of some sort. The total figures now available in regard to the class T.B. -f- cases are shown in the subjoined tables. No conclusions additional to those arrived at last year present themselves in connection with these tables, but it may be worth while to reiterate the following (the current year's figures being substituted for those of 1934 in no. 2) :— (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) In the age groups 16 to 30, 22 per cent, of new male positive sputum cases and 25 per cent, of similar female cases arise from families in which there have been recent previously known cases 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—having regard to the frequency of the disease at this period of life—young adult contacts, of living positive sputum cases or of those recently dead from the disease. Table 63. 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 — 5 15 1 1 — 22 — Pulm. tub. class T.B. —, living — — — 1 — — 3 — Pulm. tub. (condition of sputum unknown) living — — 2 2 — — 4 — 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 1 7 10 3 1 — 22 — Total 1 13 29 8 3 1 55 20.2 Wife Pulm. tub. class T.B. +, living — — — 1 2 10 13 — Pulm. tub. class T.B. —, living — —- 1 — — 1 2 — Pulm. tub., dead within last 5 years — — — 2 7 0 15 — Total — — 1 3 9 17 30 110 Child Pulm. tub. class T.B. +. living — — — — 1 10 11 — Pulm. tub. class T.B. —, living — — — — 1 5 6 — Pulm. tub. (condition of sputum unknown), living — — — — 1 5 6 — Non-pulm. tub., living — — — — 2 1 3 — Non-pulm. tub., dead within last 5 years — — 1 — 2 1 4 — Pulm. tub., dead within last 5 years — — — 1 — 2 3 — Total — — 1 1 7 24 33 12.1 Brother or sister Pulm. tub. class T.B. +, living — 9 31 14 9 7 70 — Pulm. tub. class T.B. —, living — 1 4 1 — 9 — Pulm. tub. (condition of sputum unknown), living — — 1 2 4 3 10 — Non-pulm. tub., living — 2 1 3 1 2 9 — Non-pulm. tub., dead within last 5 years — 3 1 1 — — 5 — Pulm. tub., dead within last 5 years 1 5 19 4 11 11 51 — Total 1 20 56 28 26 23 154 56.6 58 Relationship Previously known case Age group of new cases Total Clinical classification 0-15 16-50 21-25 20-30 31-40 Over 40 No. Percent age Total relatives as above Pulm. tub. class T.B. +, living — 14 46 16 13 27 116 42.7 Pulm. tub. class T.B. —, living — 1 6 5 2 6 20 7.4 Pulm. tub. (condition of sputum unknown), living — — 3 4 5 8 20 7.4 Non-pulm. tub., living — 2 1 3 4 4 14 5.1 Non-pulm. tub., dead within last 5 years — 4 2 2 2 1 11 4.0 Pulm. tub., dead within last 5 years 2 12 29 10 19 19 91 33.4 Total 2 33 87 40 45 65 272 100.0 Other contacts 3 10 27 23 48 66 177 — No known contact 2 103 219 190 312 505 1331 — Total number investigated 7 146 333 253 405 636 1780 — Percentage showing important contact 28.0 22.6 26.1 15-8 111 10-2 — 15.3 Percentage showing any contact 71.4 29.4 31 .2 24-9 23 0 20 6 — 25.2 Table 64. Females. ( lass T.B plus. Parent Pulm. tub. class T.B. +, living 4 8 11 2 2 — 27 — Pulm. tub. class T.B. —, living — 1 3 — — — 4 — Pulm. tub. (condition of sputum unknown), living — — — — — 1 1 — Non-pulm. tub., living Pulm. tub., dead within last 5 years 1 1 17 2 16 1 5 2 3 42 — Total 5 27 32 3 7 3 77 28.1 Husband Pulm. tub. class T.B. +, living — — 1 7 2 4 14 — Pulm. tub. class T.B. —, living -— — — — — 1 1 — Non-pulm. tub., dead within last 5 yrs. — — — — 1 — 1 — Pulm. tub., dead within last 5 years — — 1 6 3 3 13 — Total — — 2 13 6 8 29 10.0 Child Pulm. tub. class T.B. living — — 1 3 5 9 — Pulm. tub. class T.B. —, living — — — — — 3 3 — Pulm. tub. (condition of sputum unknown), living — — 1 3 2 1 7 — Non-pulm. tub , living — 1 — 1 2 2 6 — Pulm. tub., dead within last 5 years — — — — — 1 1 — Total — 1 2 4 7 12 26 9.5 Brother or sister Pulm. tub. class T.B. +, living 2 10 20 10 8 1 51 — Pulm. tub. class T.B. —, living — 5 6 3 — 2 16 — Pulm. tub. (condition of sputum unknown), living — — 4 1 4 2 11 — Non-pulm. tub., living — 3 4 6 1 — 14 — Non-pulm. tub., dead within last 5 yrs. — - 2 — - — — — Pulm. tub., dead within last 5 years 2 12 13 13 8 — 48 — Total 4 30 49 33 21 5 142 51.8 Total relatives as above Pulm. tub. class T.B. +, living 6 18 33 19 15 10 101 36.8 Pulm. tub. class T.B. —, living — — 9 3 — 6 24 8.8 Pulm. tub (condition of sputum unknown), living — — 4 1 4 4 13 4.7 Non-pulm. tub., living — 4 7 9 3 1 24 8.8 Non-pulm. tub., dead within last 5 yrs. — — 2 — 1 — 3 1.1 Pulm. tub., dead within last 5 years 3 30 30 21 18 7 109 39.8 Total 9 58 85 53 41 28 274 100.0 Other contacts 1 21 23 27 37 30 139 — No known contact 15 145 221 165 159 109 814 — Total number investigated 25 224 329 245 237 167 1227 — Percentage showing important contact 36. 0 25.9 25.8 21.6 17.3 16.8 — 22.4 Percentage showing any contact 40.0 35.3 32.5 32.6 32.9 33.5 — 33.7 59 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 47 instances. 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. The balance of the fund is, however, being applied as indicated above. Supply of surgical appliances. 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 as children suspected to be suffering from tuberculosis or living in conditions rendering them particularly liable to the disease. The work of these schools is dealt with in the school medical officer's report (Vol. [II, Part II, p. 53). Open-air schools. 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. Tuberculosis care committee work. Social care and after-care work has been carried on with continued zeal and usefulness in connection with the Borough Council tuberculosis dispensaries, by the tuberculosis care committees and by the officers appointed for social services. Since 1st October, 1935, clothing for necessitous patients undergoing residential treatment has been supplied through the public health department instead of through the public assistance department of the Council. This has made little difference to the work of the care committees, as it is still incumbent upon them to try all possible sources of supply before making application to the Council. The activities mentioned in the last annual report connected with the raising of money by means of the " Christmas seal sale," organised by the National Association for the Prevention of Tuberculosis, have advanced a stage further, and the majority of the care committees have now acquired voluntary funds. Whilst not strictly necessary for the proper performance of a care committee's functions, the possession of funds results in enabling them to extend the scope of their efforts. Other charitable associations on which tuberculosis care committees have always had to rely when any problem involving expenditure of money has arisen, have to relieve other forms of distress besides such as arise through tuberculosis, and they are often obliged to refrain from giving assistance where no constructive purpose can be served. It is, unfortunately, true that owing to the chronic nature of tuberculosis there are many cases in which the application of a little much needed financial aid can only be palliative and not constructive. Since June, 1935, a useful link has been established between the London County Council and the borough tuberculosis care committees by the regular visits to the Council's tuberculosis hospitals of the Council's organiser of tuberculosis care work, who acts in the capacity of a visiting almoner and co-operates with the local care committees in dealing with the social problems which arise. The work of the handicraft classes has been carried on with keen interest for the benefit of patients who are unfit for ordinary work, thus providing them with ' occupations to relieve them of the evils resulting from idleness. No central exhibition and sale of their work was held last year, but sales were held by individual boroughs during the autumn with satisfactory results. There are now 13 handicraft classes, one of which serves two boroughs, and one, a recent addition, is a woodworking class which is held daily instead of weekly. For ten of these classes instructors are provided Tandicrnft lasses. 60 by the Council's education department. There are also two glovemaking classes for women which are conducted by the Central Fund for the Industrial Welfare of Tuberculous Persons. Membership of these is not confined to the two boroughs where the classes are held. The cookery classes which were instituted in two boroughs continue to be carried on with success. After-care clinics. Clinics are held at County Hall for the after-care of ex-patients by the medical superintendents of three of the Council's tuberculosis hospitals for cases of surgical tuberculosis, viz., St. Luke's hospital, Lowestoft, for adults, and Princess Mary's hospital, Margate, and Heatherwood hospital, Ascot, for children. The clinic for adults (ex-patients of St. Luke's hospital, Lowestoft) is held once a month, the average attendance being 40. The clinic conducted by the medical superintendent of Princess Mary's hospital is held every Monday, the average monthly attendance being 84. The clinic conducted by the medical superintendent of Heatherwood hospital is held twice a month. the average monthly attendance being 20. Copies of the case-notes made by the medical superintendents are forwarded to the borough medical officers of health for the use of the tuberculosis officers. Housing of tuberculous persons. As part of the Council's arrangements for the care of tuberculous persons, special consideration is given to housing applications from families in which there is a case of tuberculosis. If the existing home conditions are found to justify it, the Council's valuer is asked to deal specially with such applications and they are given preference over others in the allotment of vacancies. During the year 1935 approximately 220 families were rehoused under this scheme. Cases dealt with by the Council. Mental Deficiency Acts, 1913-27. On 31stDecember, 1935, there were being dealt with by the Council 10,284 cases. Of these 6,600 were in institutions, 253 under guardianship, 3,417 under supervision and 14 in places of safety awaiting action. During the year 1,216 cases were examined with the following results :— Table 65. Sex Source of notification Feebleminded Imbecile Idiot Morally defective Not defective Total Children Adults Children Adultsi Children Adults Children Adults Children Adults Children Adults Male Mental hospitals department, etc. 58 26 79 4 6 — — — 8 5 151 35 Special school leavers 323 — — — — — — — — — 323 — Public assistance 4 18 5 1 1 — — — 4 3 14 22 General hospitals 10 14 5 1 1 — — — 2 3 18 18 Sections 8 & 9 of M.D. Acts 15 48 1 3 — — — — — 1 16 52 Female Mental hospitals department, etc. 45 60 68 5 8 — — — 15 27 136 92 Special school leavers 251 — — — — — — — — — 251 — Public assistance 3 14 — 3 8 3 25 General hospitals 7 15 5 2 2 — — — 2 6 16 23 Sections 8 & 9 of M.D. Acts 3 14 — — — — — — — 4 3 18 719 209 163 19 18 — — — 31 57 931 285 Total 928 182 18 — — 88 1,216 61 Blind Persons Act, 1920. The following table contains particulars of applicants for registration or training under the provisions of the Blind Persons Act, 1920 :— Table 66. Description Registration of the blind Training of the blind Total m. f. m. f. (1) Applicants who were examined and were certified as blind 342 448 48 30 868 (2) Acceptance of certificates issued by hospital and private doctors 40 34 — — 74 (3) Acceptance of certificates issued by hospital and private doctors stating applicants were not certifiable as blind 4 — — — 4 (4) Applicants who were examined and not certified as blind 357 194 16 8 375 (5) Found blind but unfit for training — — 2* 1* 3* (6) Previously certified as blind and found fit for training 18 7 25 (7) Previously certified as blind and found unfit for training — — 3 6 9 Total 543 676 85 51 1,355 Blind persons. * Included in (1) above. Midwives Acts, 1902 to 1926, Nursing Homes Registration Act, 1927, and Maternity and Child Welfare Contribution Schemes. The Midwives Acts, 1902-1926, and the Rules of the Central Midwives Board Midwives. regulating the practice of midwives provide for :— (a) Prevention of the practice of midwifery by unauthorised persons. (b) Training of midwives. (The Council's scheme of training includes, apart from the full training provided in certain of the hospitals, (i) lectures to pupil midwives in 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. (/) Payment of proportion of the annual deficit incurred by Central Midwives Board. The twelfth 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, 1935. Certified midwives to the number of 974 gave notice of intention to practise within the county during the year, compared with 904 in 1934. Practising midwives, other than those who work entirely under medical supervision in hospitals approved by the Central Midwives Board 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 ; 2,590 visits were paid this year compared with 2,421 in 1934. 62 Infringements of the Rules of the Central Midwives Board to the number of 26 were reported during the year, compared with 42 in 1934. Of these 20 wcc slight, and an oral caution was deemed to be sufficient; 5 cases of a more serious nature were dealt with by a written caution, and one midwife was interviewed and cautioned by the Committee. Suspension of midwives. The Midwives Act, 1926, requires that, in the case of midwives suspended from practice in order to prevent the spread of infection, the local supervising authority must compensate the 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; 25 midwives were suspended from practice during the year in order to prevent the spread of infection, and 12 claimed and received compensation. The Midwives Act, 1926, amended section 1 (2) of the Midwives Act, 1902, so us 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 5 enquiries were made into cases of alleged contravention of the Act, compared with 6 in 1934. In 1 case a caution was administered ; in 4 cases no further action was considered necessary. Section 1 (1) of the Midwives Act, 1902, makes it an offence for any woman not certified under the Act to take any title or description implying that she is certified. During the year one woman was summoned for falsely describing herself as a " midwife " on a maternity benefit claim certificate. The magistrate dismissed the summons under the Probation of Offenders Act and allowed two guineas costs to the Council. Another uncertified woman has been kept under observation, following reports that she had been bound over for unlawfully using the initials " R.R.C." and " S.R.N." on her doorplate. The doorplate which had been alleged to contain also the initials " C.M.B." had been removed. IStill-births During the year there were 249 still-births reported to the Council by midwives in their practice, compared with 510 in 1925, 513 in 1926, 486 in 1927, 473 in 1928, 413 in 1929, 408 in 1930, 363 in 1931, 324 in 1932, 316 in 1933 and 274 in 1934. Of the cases reported this year 128 were male and 121 female ; 141 were reported as macerated, and 107 not macerated; 1 not described. Puerperal fever. During the year 242 cases of puerperal fever were investigated, compared with 257 in 1934. Of these cases 23 proved fatal, compared with 33 in 1934, a case mortality of 9.5 per cent., compared with 12.8 per cent. in 1934. The distribution of notified cases, with the mode of delivery, was as follows, deaths being shown in brackets : medical practitioners 52 (7); certified midwives 50 (4); hospitals and certified midwives 1 (0); hospitals 102 (10); medical students 3 (0); cases of miscarriage or abortion where no attendant was engaged 34 (2)—total 242 (23). Puerperal pyrexia. In July, 1926, the Ministry of Health made regulations requiring the notification of puerperal pyrexia, which is defined by the regulations to be " any febrile condition (other than a condition which is required to be notified as puerperal fever under the Infectious Diseases (Notification) Acts) occurring in a woman within 21 days after child-birth or miscarriage in which a temperature of 100.4° Fahrenheit (38° Centigrade) or more has been sustained during a period of 24 hours or has recurred during that period." The regulations were amended in 1928 and now require a medical practitioner to notify any such case on the approved form and transmit the notification to the medical officer of health of the district in which the patient is being attended at the time of notification ; but 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 1935 was 694, compared with 746 in 1934. The cases were distributed as follows, the deaths being shown in brackets : medical practitioners 87 (5); certified midwives 82 (1); hospitals and certified midwives 2 (0); hospitals 474 (15); Uncertified persons. 63 medical students 14 (0) ; cases of miscarriage or abortion where no attendant was engaged 35 (2)—total 694 (23). Thirty-two of the cases, with 4 deaths, were subsequently notified as puerperal fever, and are therefore shown in both tables. 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 4,822 such notices were received, compared with 5,362 in 1934. The estimated number of confinements conducted by midwives (other than in hospitals approved by the Central Midwives Board under rule E2) during the year was 17,000. This appears to indicate that medical aid was necessary in about 28.4 per cent. of the cases, compared with 26.6 per cent. during 1934. Medical aid. 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 medical attendance on account of a baby's eye affection. The number of claims for attending cases of eye affection during the year was 507 and the amount paid to medical practitioners in respect of the cases was £534, compared with £525 in 1934. Ophthalmia neonatorum. During the year, 799 notices were received from midwives indicating that medical aid had been summoned for inflammation of the eyes of infants, compared with 955 in 1934 ; 15 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 814 cases, 166 proved to be ophthalmia neonatorum, compared with 230 in 1934 ; 211 other cases that did not occur in midwives' practices were also notified, making a total of 377 cases during the year, the percentage occurring in the practice of midwives being 44.03 per cent., compared with 48.7 per cent. in 1934. All the midwives' cases were investigated, and it was found that 160 were completely cured; in one child the left eye was scarred and sight impaired ; 3 cases could not be traced owing to the removal of the parents; one child died; one child, progressing satisfactorily, was still in St. Margaret's hospital at the end of the year. Twenty-eight cases became in-patients at St. Margaret's hospital, compared with 46 during 1934. Inflammation of the eyes— Notices. During the year, 61 cases of pemphigus neonatorum occurred in the practice of midwives, compared with 24 during the previous year. 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 on the relationship of the midwife to the various health authorities should be given by the medical officer of health of the local supervising authority. Pemphigus neonatorum. Instruction of midwives. The Board approved the arrangements made by the Council tor 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 811. compared with 755 in 1934. 64 Maternal mortality. The arrangement made at the suggestion of the Ministry of Health whereby confidential reports are made on maternal deaths by medical officers of the Council and are exchanged with the metropolitan borough medical officers of health as described in the annual report for 1929, was continued during the year. Payment of medical fees. The Midwives Act, 1918, imposed upon the Council the duty of paying fees to medical practitioners called in by midwives in cases of emergency. The patient is required to reimburse the Council according to her means. The Minister of Health has laid down a scale of fees to which local authorities must adhere. In June, 1935, the Ministry of Health (circular 1488) directed that paragraph no. 8 of the scale of fees (circular 358) indicating the circumstances under which fees are not payable by the local supervising authority, must be regarded as having been deleted. Claims accepted during the year numbered 2,905, compared with 3,119 in 1934, the total amount involved being £3,487, compared with £3,625 in 1934. 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, 34 claims amounting to £44 13s. Od. were refused during 1935. Registration of nursing homes. The Nursing Homes Registration Act, 1927, came into operation on 1st July, 1928, and repealed Part II of the Midwives and Maternity Homes Act, 1926, and also so much of any local acts as provided for the registration of maternity homes. The Annual Report for 1928 (Vol. III, pp. 53-54) indicates fully the powers of the Council under the Act. A nursing home is defined as " any premises used or intended to be used for the reception of, and the providing of nursing for, persons suffering from any sickness, injury or infirmity and includes a maternity home." The definition of a maternity home is " any premises used or intended to be used for the reception of pregnant women or of women immediately after childbirth." Consequently such premises require registration as a maternity home even though the women go to some other place for the actual confinement. The number of nursing homes on the register on 1st January, 1935, was 211. During the year 1935, 19 homes were added, of which 8 had applied during 1934, and 1 in 1933, while 23 were removed on cancellation of the registration, leaving 207 on the register on 31st December, 1935. With one exception cancellations were made at the request of the persons registered and/or upon change of ownership. During the year proceedings were instituted against two persons for conducting premises as nursing homes without being duly registered in respect thereof. Both summonses were dismissed. In one case costs (£2 2s.) were awarded to the Council, and, in the other, costs amounting to £3 3s. to the defendant. In respect of one nursing home the registration of the keeper was cancelled by order of the Council on the grounds that (i) the keeper was not a fit person to conduct a nursing home, and (ii) the premises were unsuitable by reason of staffing and equipment. There were 33 applications for registration during the year, of which, at the end of the year, 15 had been withdrawn and 10 granted, 8 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 1935 the Council granted 111 exemptions from the provisions of the Nursing Homes Registration Act, 1927, in respect of premises not conducted for profit. These exemptions are for a period due to expire on 30th June, 1936 ; 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 staffing 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. 65 A special enquiry was made during the year as to the amount of midwifery work undertaken in registered nursing homes. The following information was obtained :— 1934 1935 (1) Number of nursing homes with maternity beds registered 150 150 (2) Number of beds provided for maternity patients in such nursing homes 1,299 1,310 Births (3) Number of births in such nursing homes :— 1934 1935 (а) With doctor engaged to attend 2,797 2,954 (b) With State certified midwife (no doctor being in dance) 899 1,174 (c) With State certified midwife and doctor summoned in emergency by the midwife 99 98 Total 3,795 4,226 Midwifery in registered nursing homes. 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. Maternity and childwelfare work by voluntary associations. 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 1935, 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 forty-nine voluntary associations. The current schemes provide for payment by the Council of grants amounting to £31,587 in the year 1935-36. 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 it also involves the employment of an inspector, who is detailed by the chief inspector from amongst his staff. During the year one baby home was closed and the baby home service was transferred to other premises. Increased grants were authorised in the case of one baby home and one mother and baby home, both in respect of the provision of additional maternity and child welfare services. The Council pays a grant of £222 a year, as the agent of the Middlesex County Council, to one association which has transferred the service of a branch home from the county of Middlesex to premises within the administrative county of London. 66 Examination of staff. During the year 10,375 examinations, including 253 home visits, members of the staff. These may be classified as follows :— were made of Entrants 2,096 Sickness cases 7,614* Casualties, illness, etc., at County Hall 665 * 1,871 of these were dealt with in the first instance by telephone and correspondence. Ninety applicants for appointment to the permanent service failed to pass the medical examination for the following reasons :— Males Females T otal Defective hearing and ear disease 3 3 6 Defective vision and eye disease 16 10 26 Poor physique and deformities 1 9 10 Cardio-vascular disease 10 15 25 Varicose veins 4 2 6 Rheumatism — 1 1 Kidney disease, albuminuria, &c. — 2 2 Tuberculosis and lung disease 2 3 5 tMiscellaneous 4 5 9 Total 40 50 90 t Including, in the males, two cases of hernia, and one each of goitre and post-operative debility, and in the females, one each of post-operative debility, goitre, skin disease, adenitis and organic nervous disorder. As a result of the examinations of the staff, 404 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 48 47 95 Disease of the bones and joints 12 15 27 Disability following trauma 4 5 9 Pulmonary tuberculosis 18 27 45 Disease of the lungs other than pulmonary tuberculosis 14 10 24 Malignant disease 9 2 11 Gastro-intestinal disorder 6 7 13 Renal disease 9 1 10 Functional nervous disorder 19 40 59 Organic nervous disorder 11 4 15 Senile decay 10 10 20 Post-operative disability 3 6 9 Sight and hearing defect 5 4 9 Endocrine disorder 1 5 6 Varicose veins and ulceration 1 6 7 Rheumatism 6 32 38 *Miscellaneous 4 3 7 Total 180 224 404 * Including, in the males, two cases of diabetes and one each of dermatitis and actinomycosis ; and, in the females, two cases of diabetes and one of dermatitis. Work done in the bacteriological laboratory at County Hall. The investigations carried out during the year 1935 are summarised below under the various headings. The work undertaken in this laboratory is chiefly associated with the control of infectious diseases in the Council's day and residential schools, and in addition a certain amount of bacteriological investigation is carried out on material such as water, milk, etc., submitted to the Council's chemist for analysis. 67 Diphtheria carrier investigation (see also Annual Report Vol. III, Pt. II, p. 42).— Inclusive of 80 re-examinations, a total of 4,686 culture swabs from throat and nose (with 15 from the ear) of children and adults were examined, yielding evidence of bacilli morphologically resembling diphtheria in 293, or 6.2 per cent., 4,393 proving negative. In 4,605 primary examinations the proportion of positive results was 5.6 per cent.; 370 positive or doubtful cultures were sent to the Southern group laboratory for further examination and virulence tests ; 272 were reported as true diphtheria bacilli, 215 being virulent and 57 non-virulent. Ringworm and favus.—An examination of 502 specimens of hair from the scalp showed the presence of ringworm fungus in 136 (109 small spore, 25 large spore). Favus was identified in two specimens. Sputum.—An examination was made of 44 specimens from 34 individuals for tubercle bacilli. In 34 primary examinations the tubercle bacillus was found in 21. In 10 subsequent specimens previous findings were confirmed. Miscellaneous.—In 36 smears from urethra and/or cervix, gonococci were identified in 3, and 6 were reported as doubtful. Eight specimens of urine showed presence of albumen in 4, pus cells in 3 and red blood corpuscles in 1 ; 7 of them were negative on bacteriological examination and one yielded a Gram positive diplococcus. Six throat and nose swabs examined for hsemolytic streptococcus were all negative but one. Water.—Qualitative and quantitative bacteriological examinations :— (a) from Council's establishments.—Of 521 samples examined from 35 establishments, those from 21 yielded 169 (64 per cent.) which were unsatisfactory insomuch as organisms of the B. coli group were present. In the case of the remaining 14, all the samples taken, numbering 257, were found satisfactory. (b) from swimming baths.—Of 12 samples examined from 7 swimming baths, 6 samples from 5 baths yielded satisfactory results. In 4 samples from one bath at different times, 2 were satisfactory and 2 unsatisfactory. In another locality, the women's swimming bath yielded unsatisfactory results while the sample from the men's bath proved fairly satisfactory. Milk.—Six specimens were examined, all being reported as " unsatisfactory." In the course of the year, about 85 litres of media, for cultural use, were prepared in the laboratory. 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 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 in tunnels, 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. A systematic determination is made of the amounts of sulphur in air both in London and in urban areas in connection with the scheme of the Department of Scientific and Industrial Research for the investigation of atmospheric pollution. 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. Central laboratory. 68 Examination of samples. The total number of samples examined in 1935 amounted to 18,747. The following table shows their classification :— Air 252 Gas—Dry cleaners 17 Asphalt 76 Greases 36 Building materials 58 Hospital equipment 26 Cable (tinning test) 683 Insecticides 3 Coal, ooke and ash 40 Meals 60 Cement 118 Metals— Chemicals 20 Solder 20 \ 32 Disinfectants 15 Various 12 ( Driers 21 Milk, condensed 6 Drugs and medical stores 972 „ schools and institutions 155 Dust (atmospheric pollution) 16 „ (cream) tinned 4 Enamelware 232 Oils- Fertilisers and feeding stuffs 216 Fuel 255 Floor oils and polishes 29 Lighting 22 Food (suspected poisoning) 9 Lubricating 187 Foods- Painting 21 Bacon 22 Miscellaneous 20 Baking and egg substitute powders 55 Oilman's sundries 21 Beef extracts 93 Paints, stains 596 Cakes, biscuits, bread 31 Petroleum (Petroleum Act, 1928) 111 Cheese 25 Rainwater, etc. (atmospheric pollution) 116 Cocoa 16 Rubber 28 Flavouring essences 50 Sewage 3,877 Fish 61 Sludge 1,300 Fish, tinned 4 „ gas, etc. (sludge digestion plant) 300 Flour 36 Soap and soap powders 71 Jam 8 Soil 10 Margarine 50 Sulphur determinations (air) 2,219 Miscellaneous foodstuffs 45 Turpentine and turpentine substitute 21 Mustard 8 Urine 1,955 Pickles 4 Varnish 30 Preserved meats 46 Water, boiler 1,094 Sugar 49 „ river 2,631 Syrup and treacle 17 „ drinking (from wells) 187 Vinegar 19 ,, and deposit (in leakage ) 15 Yeast 12 „ various 18 — 651 „ open-air baths 12 Miscellaneous 133 Of 596 paints, colours and varnishes examined, 550 were found to be satisfactory, and 46 were unsatisfactory. Observations continue to be 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 an oils:— Satisfactory Unsatisfactory Fuel 5 0 Lighting 21 1 Lubricating 103 84* Painting 21 0 Miscellaneous 19 1 * Either unsatisfactory or not suitable for Council's requirements. Various materials and apparatus for special purposes sent to the laboratory for examination during the year included :— (1) Foods.—During the year 651 samples were examined and, except in a very few instances, these were found to be of satisfactory quality. Amongst the cases commented on adversely were three samples of ground white pepper, the ash of which was found to be somewhat higher than the normal, the excess consisting largely of magnesia. A sample of tinned grape fruit contained a slightly excessive amount of tin (the unofficial standard is 2 grains per pound). A sample of sausage skins showed evidence of adhering dust and dirt. Several samples of baking powder and egg substitute powder, submitted by firms tendering for Council contracts, were 69 found to be considerably deficient in available carbon dioxide (standard—not less than 10 per cent.), and these tenders were thus not recommended for acceptance. (2) School meals.—In connection with the scheme for the provision of meals for necessitous children, 120 samples were examined during the year, representing 60 two-course meals. Some of the individual meals showed a considerable divergence from the standard, but such were not numerous and in each case advice was given as to the deficient constituents. On the whole the meals supplied may be said to have been well-balanced as well as satisfactory in quality and quantity. (3) Food poisoning.—Two outbreaks of suspected food poisoning were investigated during the year, and 9 samples were examined in connection with these. In no instance was there evidence of the presence of any organic or inorganic chemical poison. (4) Itching powder.—In consequence of the complaint of a parent of a child attending one of the Council's elementary schools, that skin trouble had been caused to the child's back by a substance called " itching powder " having been put down his back by another boy, a sample of the article in question was obtained and examined. It was found to be poor quality mucuna (cowhage), which consists of the hairs covering the fruit of a climbing plant growing in certain tropical localities. It has a very irritating effect on the skin and it was advised that its indiscriminate sale appears to be undesirable. (5) Specifications.—In addition to questions involving specifications mentioned elsewhere, those for the supply of battiste and jaconet for use in hospitals and institutions were completely revised during the year, and a new one was drawn up for the supply of the particular grade of soda lime required for use with an oxygen tent. (6) Enamelware.—The year 1935 was the second in which the revised specification (described in last year's report) had been in force. During the year, 232 samples were examined and of these 5 were rejected for not complying with the "acid resistance "test and 6 for containing antimony. The percentage of rejections was thus 4.7, as compared with 25 per cent. for 1934, showing the great improvement in quality of the articles of this ware now supplied by contractors for use in the Council's service. The importance of ensuring that these articles shall be free from antimony and other poisonous metals is again emphasised, as cases of poisoning have occurred through lemonade or similar liquids having been contaminated by contact with enamelware containing antimony. (7) Coal gas in air.—Consequent on a complaint as to an unidentified smell, a school was visited and a sample of air taken from a point on the floor at which the odour was most apparent. Analysis revealed the presence of a very appreciable amount of carbon monoxide indicating a serious leakage of coal gas. Investigation by the authority concerned revealed the fact that a gas main in the road was fractured and that the gas had percolated under an asphalt path and through the wall and thus gained access to the interior of the school. In another school situated in the vicinity of gas holders, complaint was made that the air was at times seriously contaminated by gas. It was arranged for samples of air to be taken when the alleged nuisance occurred and these were analysed. None contained more than the slight trace of carbon monoxide which is normally present in London air, and is derived from the exhaust gases of motor vehicles. There was consequently no evidence of any appreciable amount of coal gas gaining access to the school rooms. The total number of milk samples examined during the year in the laboratory at County Hall was 155. Of this number 47 were of milk supplied to children in residential schools, whilst 93 were from supplies to general, special and mental hospitals and public assistance institutions, under contracts which require a minimum of 3.25 per cent. of fat and 8.5 per cent. of other solids, except during the months of March and April, when the fat must not be less than 3 per cent., and 15 were from farms attached to institutions, etc. The quality of the supplies generally, has been less satisfactory than in recent years, 9 samples (6.4 per cent.) being deficient in fat. Milk samples. 70 The condition of the supplies in respect of extraneous matter was more satisfactory, for of the 140 contract samples examined, only 4 (under 3 per cent.) were found to contain an excessive amount. Since 1st October, 1934, the milk supplied to 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. 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 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 463 samples, of which 12 were deficient in fat. In addition to the above, results have been received of the bacteriological examination of 161 samples of pasteurised milk, of which 8 failed to comply with the standard laid down in the Milk (Special Designation) Order, 1923. In all the cases of unsatisfactory supplies by contractors the attention of the chief officer of supplies was called to the matter. Drugs. Of the 972 samples of drugs and medical supplies examined during the year, 70 (or 7.2 per cent.) were found to be either definitely unsatisfactory for use or below standard strength or quality. Satisfactory 902 Unsatisfactory or below standard— Deficient in active constituent 24 Tincture, etc., deficient in alcohol 3 Specific impurities found 16 Dirty or badly made 6 General deficiency 16 Misdescribed 5 70 Total 972 The percentage of samples reported upon adversely during the previous year was 9.3, so that the 1935 figures indicate some improvement in quality. Among the more notable rejections were a sample of tabs plumbi cum opio which was only about half the correct strength and weight, and two samples reputed to be salol which were actually salicin. Three samples of tragacanth were rejected as being of an inferior grade, not complying with the requirements of the British Pharmacopoeia. A consignment of reputed 1 oz. tins of ung. acid. boric. was rejected on account of the weight per tin being found to be seriously deficient after the contents of a number drawn at random from the bulk had been weighed. Similarly, two consignments of reputed 1 oz. bottles of liquor iodi mitis were also reported upon adversely. The number of rejections and such instances as these emphasise the need for regular examination in order that supplies of drugs shall be kept strictly up to the required standard. Fertilisers and feeding stuffs. A In connection with the provisions of the Fertilisers and Feeding Stuffs Act, 1926, 216 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 71 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 01 Deficient 25 Constituents in excess of guarantee 25 Guarantee incorrcct in form or no guarantee 18 Contained deleterious substances 3 Total 162 Samples of fertilisers. Complied with guarantee 18 Deficient 11 Constituents in excess of guarantee 19 Guarantee incorrect in form or no guarantee 6 Total 54 It will be observed that there are a number of firms who do not pay sufficient attention to the requirements of the Act, as to the form of the guarantee to be given. The Fertilisers and Feeding Stuffs Regulation, 1932, which in some particulars amended the Act of 1926, contained a clause to the effect that the application of the names " feeding meat meal " and " feeding meat and bone meal " shall not be applied to articles containing less than 55 per cent and less than 40 per cent. albuminoids (protein), respectively. During the year 2 samples of meat meal and 5 samples of meat and bone meal have been reported upon adversely for contravening this regulation. Two samples of linseed cake were found to contain small quantities of castor seed and were reported as being unsuitable for use as feeding stuffs. It appears to be the custom in the trade to regard the presence of castor bean, in amounts of not more than .006 per cent., as harmless, but having regard to the very poisonous nature of the seed and to its uneven distribution throughout the bulk, it is unwise to pass any sample as satisfactory if castor bean is found in any quantity. It is a large seed and is very easily removed from smaller seeds by screening. Several samples supplied as fish meal were commented on as containing a small proportion of mammalian bone meal. Though in the majority of cases the deficiencies were not great, the classification of the results in the above table indicates that on the whole they were rather worse than last year, the proportion of samples deficient under the guarantee being somewhat larger. The need for continued inspection and examination is thus emphasised. A regular chemical and bacteriological examination has been made of 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 187 samples have been examined chemically and 531 bacteriologically from 39 institutions, in 12 of which chlorinating plants are in operation. Three of these have been installed during 1935 in consequence of a slight degree of intermittent pollution which was found to occur in each case, though no immediate local cause was discovered. It is a recognised fact that in fissured formations, whether of chalk, limestone or sandstone, wells may yield water of unsatisfactory bacteriological quality, the pollution occurring at a source which may be several miles distant. Whether contamination is active or not may depend on several factors such as rainfall and the level of the underground water ; but, in an area such as that around London, the increase in population in the outer, semi-rural, districts with their, in many cases, rather primitive methods of sewage disposal, obviously creates potential sources of pollution of the water drawn from wells. At four institutions a thorough cleaning and chlorinating of the tanks or reservoirs was recommended, and after this treatment the quality of the water again became satisfactory. In one instance the repair of an underground reservoir was recommended to prevent the access of surface water drainage and consequent pollution. Drinking water supply. 72 Outfalls. The difficulties experienced in treating sewage by sedimentation during the unprecedented drought periods of 1933 and 1934 were again encountered during the shorter drought period of 1935. A lengthy investigation was carried out on the use of various chemicals and methods of their application to accelerate the sedimentation of the suspended solids present in sewage. Consideration of cost ruled out the use of some agents, and, of the others subjected to test, it was found that the best results were obtained by the use of ferric salts in solution, accompanied by not too violent agitation. Failure to obtain ferric salts in the quantities required (when added to the dry weather flow of London sewage a dose of only 1 grain per gallon requires the use of 18 tons per day) led to a method of preparation being worked out in the laboratory. This was followed by trials on a semi-manufacturing scale, and finally a full scale plant was designed and erected at the Southern outfall. The successful working of this plant was followed by the erection of an improved and larger plant at the Northern outfall. The activated sludge plant at the Northern outfall has continued to treat, with satisfactory results, ten million gallons per day of sedimented sewage. In connection with this plant, two types of sedimentation tank are used, and one type has consistently given inferior results to the other type. The inlets and outlets of the less satisfactory tanks have been radically altered, with the result that all the tanks now work equally well. The construction of five activated units, similar to the one now in use, is proceeding, and it is hoped that two units will be at work in the early summer of 1936. The experimental work at the Southern outfall on the digestion of sewage sludge in a covered concrete tank of 25,000 gallons working capacity was concluded in the early part of the year. During the three years in which this work was conducted the effects of variations in working temperature, detention period, stirring, etc., have been studied. From the lessons learnt, a plant of 1,800 tons working capacity has been designed, and is now being constructed at the Northern outfall. The dry matter in individual cargoes of sewage sludge sent to sea from the Northern outfall varied from 4 per cent. to 14 per cent., the average being 8.6 per cent.—practically the same as last year. In the case of the cargoes from the Southern outfall, the variations were from 3 per cent. to 12 per cent., with an average of 6.9 per cent., also similar to that of last year. The dry solids in the greater number of cargoes from both outfalls did not diverge much from the average. The condition of the river, which had been affected by the prolonged dry weather of 1933 and 1934, improved steadily after October when the increase in the rainfall made itself felt. The steps taken by the Council, described above, also contributed materially to the improved conditions. The new works of the Middlesex County Council at Mogden and the new units at the Northern outfall as they come into being will do much to restore the balance between oxygen absorption and re-absorption at the critical times of low flow of fresh water and high temperature. Vehicular tunnels. The systematic investigations, commenced in 1928, as to the condition of the air in Blackwall and Rotherhithe tunnels, were continued during 1935. As revealed by the periodical traffic census taken by the valuer, there has been a remarkable increase in the amount of motor traffic passing through each of the tunnels in the past few years, the figures for 1935 being more than double those for 1928. The results of the air examinations made in 1935 indicate that in spite of this increase the ventilating plant at Rotherhithe tunnel has, with a few exceptions, maintained the atmospheric conditions in a satisfactory state. Even when the carbon monoxide limit figure of 20 parts per 100,000 was exceeded, the excess was not large. 73 At the request of the Parks Committee a detailed report has been prepared covering all the better known methods of purifying the water used in swimming baths, and this will furnish data which may assist the Council when new open-air swimming baths are constructed or alterations or additions are made to existing pools. Swimming baths. The visibility in all directions from the fleche of County Hall for 1935 was, generally, about equal to the average for the five preceding years, September being, however, considerably above the average for that month. Very low visibilities were noted on several occasions during December, that of the 23rd being 55 yards. The maximum visibilities for all months were high, especially in respect of February and March. Observations taken from the sludge ships at places east of the Nore light indicate that the visibility in the estuary is, on the whole, much better than from County Hall. Visibility. The distance and direction of the furthest discernible object or objects on the day of maximum visibility are given in fig. 1 and clearly show the preponderant tendency towards the quadrant south to west. The accompanying diagrams (figs. 1 and 2) present the summarised results of all observations. 74 Fig. 1.—Diagram 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 1935. Fig. 2.—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 1935 and 1930-34 ; and observations taken from a sludge vessel at places east of the Nore light during 1935. 75 Table 67. County of London.— Statistics of the administrative work carried out by the Metropolitan Borough Councils during the year 1935. Sanitary authority Cowsheds Slaughterhouses Offensive trades Smoke nuisances Common lodging houses Cleansing of persons and rooms Water supply Milkshops Ice cream premises Restaurants and eating houses No. licensed No. of inspections No. licensed No. of inspections No. authorised No. of inspections Observations Intimations Complaints Notices Houses licensed No. of inspections Persona 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 — — — — — — 432 1 19 — 1 4 73 1,249 73 15 — 73 129 25 25 1,004 848 Battersea — — 2 127 3 7 20 5 5 1 3 69 194 3,791 1,651 411 20 314 445 229 191 125 240 Bermondsey — — — — 15 103 23 5 4 — 3 88 94 3,566 1,272 1,683 52 290 727 145 293 135 441 Bethnal Green 8 56 11 225 1 7 36 2 14 2 4 45 425 23 860 629 — 326 689 176 316 93 328 Camberwell 1 11 1 101 11 32 151 6 20 1 4 141 51 4,789 1,998 1,232 8 517 1,336 383 409 204 337 Chelsea — — 1 14 — — 20 — 6 — 2 22 7 527 263 502 — 71 166 35 36 70 69 Deptford — — 2 215 7 20 9 — — — 6 77 60 1,418 896 222 — 247 320 170 189 72 261 Finsbury — — 1 87 2 75 216 6 40 3 2 109 13 7 785 552 323 173 432 135 187 277 309 Fulham — — 1 90 — — 51 3 6 — 1 75 25 — 1,001 355 — 110 538 213 105 92 188 Greenwich 3 4 2 290 2 4 31 1 13 — 1 6 28 1,688 704 383 131 175 261 128 140 74 174 Hackney 3 44 9 676 11 22 1,548 14 30 1 3 55 330 3,436 2,008 833 24 580 808 327 377 188 246 Hammersmith — — 4 155 — — 158 16 14 4 1 23 205 2,427 787 49 41 163 1,040 183 204 198 578 Hampstead — — — — — — 8 — 4 — — — 41 820 1,236 109 52 92 167 94 20 74 22 Holborn — — 1 11 — — 82 5 4 — 4 33 131 — 260 97 2 152 207 25 26 309 464 Islington — 8 461 12 17 56 16 49 3 24 344 64 6,251 596 68 228 399 690 480 253 598 774 Kensington — — 2 — — — 61 4 14 — 3 67 545 4,556 997 527 96 140 521 221 453 170 754 Lambeth — — 3 140 3 52 80 42 42 — 3 180 243 — 4,416 846 73 557 1,441 455 1,480 258 479 Lewisham 1 3 6 397 — — 32 4 11 1 — — 2 1,034 1,530 159 — 132 276 190 201 135 239 Paddington — — 2 300 1 50 29 2 8 2 3 47 40 18 178 156 130 256 183 130 132 58 Poplar 2 26 8 51 4 40 58 9 10 2 5 88 118 3,062 1,084 634 1 111 347 237 270 885 1,999 St. Marylebone — — 1 14 1 22 255 10 10 — 3 77 2,730 2,898 430 1,039 10 150 260 93 126 224 426 St Pancras — — 3 205 2 51 337 12 10 4 1 15 2,762 5,880 878 225 98 426 636 321 291 297 554 Shoreditch 2 16 — — 1 5 30 — 2 — 4 39 9 — 870 131 60 280 894 168 291 238 473 Southwark — — 4 302 4 14 378 2 24 — 27 66 2,305 2,938 993 1,483 133 438 1,630 253 804 418 1,807 Stepney 19 128 — — 53 261 155 8 25 — 17 296 180 2 1,309 1,210 3 704 912 376 597 330 459 Stoke Newington — — 3 4 — 2 14 2 11 — — — — 2,395 256 223 6 109 254 66 79 35 107 Wandsworth 1 14 5 917 — — 110 22 33 2 — — 159 8 2,057 64 21 212 612 636 691 182 1,125 Westminster — — — — — — 830 22 47 — 5 183 615 622 556 94 4 229 374 89 98 1,411 1.465 Woolwich 8 65 4 16 1 4 16 1 6 — 9 71 13 2,421 1,109 1,481 4 74 211 205 265 186 380 Note.-In the columns above a dash signifies a nil return. Prosecutions.—Seamen's lodging houses—Bermondsey, 2 (11 inspections); Poplar, 3 (41 inspections); Stepney, 10 (256 inspections). Cowsheds—Stepney, 3. Smoke nuisances—Islington, 2. Common lodging houses—Paddington, 2; Islington, 1. Water supply to tenement houses—St. Pancras, 1; Paddington, 1; Hammersmith, 2; Shoreditch, 1; Islington, 1. Milk-shops—Poplar, 1; Stepney, 16. Ice-cream premises—Stepney, 9: Wandsworth, 1; Islington, 2. Restaurants and eating houses—Paddington, 1 ; Westminster, 1. 76 Table 68. Borough No. of houses Public Health Act Housing Acts 1925-1935 No. of houses inspectedon account of complaints or illness No. of statutory notices served No. of houses repaired No. of houses inspected Section 1 Housing Art 1930 Housing Act 1935 No. of houses for working classes erected during the year Underground rooms Houses let in lodgings In borough Occupied by the working classes Sections 17 & 18 No. of houses repaired Number of houses demolished Closing Orders Re-development schemes by owners No. of houses represented No. of houses demolished No. occupied but unfit No. closed or modified occupation approved No. in borough No. of inspections No. of prosecutions No. of complaints remedied No. made No. deter mined No. of houses No. of certificates issued by owners By L.A. Section 19 Voluntarily City of London 2,105 1,748 66 3 44 104 - - - - - 2 - - - - - 1 - 36 97 - 3 Battersea 28,140 25,750 6,415 1,436 5,868 1,021 — — 40 — — 60 — — — — 50 - - 66 843 — — Bermondsey 19,146 19,002 4,309 2.298 5,716 4,298 629 290 — — 4 10 — — — — 459 2,400 1 1,205 4,278 — 50 Bethnal Green 18,285 ‡ 6,904 2,722 6,005 983 153 31 - - - - - - - - 40 * — 280 1,216 6 — Camberwell 41,000 38,490 6,659 2,226 4,361 517 192 3 12 — 3 — 3 — — — — 43 5 249 229 — — Chelsea 12,577 5,112 809 66 362 139 — - — — 2 129 — - — — — — — 595 26 — — Deptford 18,572 116,700 2,159 698 3,255 1,470 - - 1 - 5 - - - - - - * 6 666 - - - Finsbury 10,503 10,000 2,016 296 2,340 840 — - — — 77 — — — — — ‡560 - 776 2,668 2 - Fulham 26,756 ‡ 3,508 683 2,201 909 — - 663 4 1 2 — — — — 27 flats 123 7 746 1,108 8 205 Greenwich 20,142 15,981 2,743 212 1,714 730 102 67 108 — — - 5 — — — 16 1 1 101 145 - - Hackney 37,532 15,815 6,059 1,166 5,092 1,492 287 110 7 3 — 33 — - - — 180 23 23 461 1,243 — 94 Hammersmith 23,490 20,823 7,096 1,309 3,735 108 39 - 1 - 1 - 10 - - - - 3 3 1,773 35 1 1 Hampstead 16,344 ‡ 50% 986 298 790 461 13 19 — — — 19 13 - - — 290 ‡4,000 3 1,559 1,037 3 — Holborn 6,462 3,832 468 45 223 66 - - 9 - 3 15 1 - - - - 583 2 460 739 - 31 Islington ‡ 46,000 ‡30,000 8,113 752 6,367 1,679 — 36 115 — 2 139 1 7 — — 8 * 105 983 5,748 10 821 Kensington 29,299 11,674 3,707 389 2,820 1,997 57 30 205 4 4 — 20 30 - - 55 flats - 59 3,161 8,272 4 828 Lambeth 48,873 48,184 11,168 155 4,227 145 — 25 196 — — — 3 5 — — — 37 14 - — - - Lewisham ‡ 50,000 ‡ 20,000 2,743 345 1,163 367 41 28 — — — — — — — — — - - 28 39 - - Paddington 21,092 12,100 2,084 1,124 1,725 — — — 266 — — — 12 — 1 — — * 203 1,376 5,474 17 2,811 Poplar 23,473 23,285 5,887 1,859 4,941 — 25 85 — 2 1 9 — — — — 98 7 7 267 1,033 3 24 St. Marylebone 18,645 8,638 2,568 38 1,309 724 - - - - - - - - - - - 815 25 1,055 7,107 - - St. Pancras 25,670 20,000 4,277 814 2,876 970 51 26 59 — 9 2 1 — — — — * 39 4,407 2,229 7 300 Shoreditch 13,925 13,818 1,242 640 4,609 132 35 9 44 — — 58 — - — — 30 flats 11 — 421 332 - — Southwark 29,253 27,810 1,835 1,431 3,472 2,386 126 — 400 — 2 — 12 1 — — 132 2,364 16 * * * * Stepney 37,766 31,717 5,050 3,451 11,852 703 105 112 — — 2 90 1 — — — 153 6,159 8 3,276 1,447 1 787 Stoke Newington 8,719 5,149 613 39 2,359 282 - 94 - - - - 9 - - - - - - 100 43 - - Wandsworth 77,755 50,114 7,387 822 4,242 1,800 25 69 - — 1 77 16 — — — — 27 1 340 1,533 - 84 Westminster City of 22,536 14,655 1,477 55 1,431 3,380 85 20 23 — 1 104 1 — — — 128 2,824 90 3,350 8,127 1 - Woolwich 34,503 29,803 4,558 539 2,296 1,008 135 63 4 1 7 359 — — — — 422 1 1 * 454 — — * Information not available. †Practically all. Note.—In the columns above a dash signifies a nil return. ‡ Estimated. 77 Table 69—Sanitauy Inspectors, 1935. Sanitary authority Population (Census) 1931 Male Female Health visitors Whole time Fart time Whole time Part time Whole time Part time City of London 10,999 28 1 - 2 - Battersea 159,552 11 — — 2* 10 2* Bermondsey 111,542 15 — — — 11 - Bethnal Green 108,194 11 - — — 13 - Camberwell 251,294 16 - 1 - 12 3 Chelsea 59,031 4 — — 1* - 1* Deptford 100,891 10 — — — 8 1 Finsbury 69,888 8 — 1 — 6 - Fulham 150,928 12 — 1 8 - Greenwich 100,924 7 — 1 — 7 - Hackney 215,333 21 — — — 18 - Hammersmith 135,523 9 — 1 — 4 - Hampstead 88,947 7 — — 1 4 1 Holborn 38,860 4 — — 1 1 1 Islington 321,795 23 4 2 — 9 - Kensington 180,677 15 — — — 9 - Lambeth 296,147 16 — 2 — 4 - Lewisham 219,953 10 — 1 — 11 - Paddington 144,923 15 — 2 — 9 2 Poplar 155,089 15 — 1 — 12 - St. Marylebone 97,627 11 — 1 2 6 4 St. Panoras 198,133 15 — 1 — 17 2 Shoreditoh 97,042 11 — 1 — 10 4 Southwark 171,695 17 — 1 — 9 - Stepney 225,238 22 — 1 — 10 - Stoke Newington 51,208 4 — — — 3 1 Wandsworth 353,110 17 - — — 10 - Westminster, City of 129,579 17 — 1 — 8 - Woolwich 146,881 13 — — 3 10 3 Total County of London 4,397,003 384 4 20 10 241 25 3* Act both as sanitary inspectors and health visitors. 78 INDEX Subject. Page Anthrax 13 Bacteriological Laboratory 66 Births 5 Blind Persons Act 61 Cancer 23 Cerebro-spinal Fever 14 Chemical Branch 67 Cowsheds 43 Deaths 6 Diarrhoea 18 Diphtheria 18 Drugs, Testing of 70 Encephalitis Lethargica 14 Enteric Fevers 23 Fertilisers and Feeding Stuffs 70 Food Poisoning 23 Housing Acts (Statistics) 76 Infant Mortality 7 Infectious Diseases 13 Influenza 23 Marriages 5 Maternal Mortality 18, 64 Maternity and Child Welfare 65 Measles 16 Medical Examination of Staff 66 Mental Deficiency 60 Midwives Acts 61 Migration of Population 8 Subject. Page Milk Examination 42 Milk Sampling 69 Nursing Homes 64 Ophthalmia Neonatorum 63 Polioencephalitis 14 Poliomyelitis 14 Population 5 Puerperal Fever 18, 62 Puerperal Pyrexia 18, 62 Rheumatic Fever 23 Sanitary Officers 77 Scarlet Fever 17 Slum Clearance 35 Smallpox 14 Street Accidents 7 Swimming Baths 73 Tuberculosis (Care Committee Work) 59 Tuberculosis (Contact Soheme) 56 Tuberculosis (Notifications) 24 Tuberculosis (Residential Treatment) 47 Tuberculosis (Dispensary Service) 53 Vehicular Tunnels 72 Venereal Diseases 43 Visibility 73 Vital Statistics 5 Waste Food and other Waste Materials 36 Water Examination 71 Whooping-cough 16 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. 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CONTENTS page Staff 5 School Buildings and Equipment 6 Results of Medical Inspection 7 Nutrition Centres 20 Following-up 26 Medical and Dental Treatment 28 Stammering Children 34 Rheumatism Scheme 35 Personal Hygiene Scheme 38 Chronic Invalidity 40 Infectious Diseases in Schools 41 Open-air Education 50 Convalescence 57 School Journeys 58 Provision of Meals 58 Defective Children 60 Ponton Road Remand Home 65 Child Guidance 67 Nursery Schools 73 Medical Inspection and Treatment—Day Continuation Schools, Evening Institutes and Junior Instruction Centres 74 Medical Inspection at Secondary and Trade Schools 77 Residential Schools and Children's Homes 78 Special Inquiries and Reports 81 Wage-earning Employment of School Children 87 Examinations of Employees in the Education Service and Scholars 88 Statistical Tables.— I. Medical Inspections 89 II. Defects 90 III. Exceptional Children 92 IV. Treatment of Minor Ailments 93 V. Medical Inspection—Number of Children Examined 94 VI. Medical Treatment—Number of Cases Treated 95 VII. Medical Inspection of Students in Higher Education Institutions 95 Index 96 London County Council ANNUAL REPORT OF THE COUNCIL, 1935 VOL. III (Part II) REPORT OF THE SCHOOL MEDICAL OFFICER FOR THE YEAR 1935. 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. Staff. The public health department is organised in three branches, (i) special hospitals including control of the acute infectious diseases and of the ambulance and pathological laboratory services, (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. C. N. Atlee). The remaining staff in 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 ; 54 assistant medical officers giving three sessions a week ; additional temporary medical assistance for 130 sessions a week ; 9 medical officers (part-time) at open-air schools ; 70 parttime inspecting dental surgeons. There are 262 part-time doctors, surgeons and anaesthetists, and 102 part-time dental surgeons engaged at the hospitals and school treatment centres under the Council's scheme. These last appointments are made by the authorities of the hospitals and treatment centres. The other section concerned with the school medical service (Dr. Verner Wiley, 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. Wiley 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 for school purposes are included the services of a part-time consulting orthopaedic surgeon (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 the Council's remand home. The duties of consulting surgeon for * Two vacancies—officers temporarily seconded for work under the Housing Acts (equivalent substitutes authorised). (15) 6 aural disease in this section are rendered by Mr. A. G. Wells, while Dr. McVail carries out the medical supervision of blind schools, schools for the partially sighted, etc. 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, 65 nursing sisters and 340 nurses. It is with the most profound regret that I record here the severe loss sustained by the department in the death, on 25th September, of Dr. F. C. Shrubsall, who had been connected with the service from January, 1909. His association with the development of the public care of mentally deficient persons gave him a unique position in this sphere. His high professional qualifications and great experience as one of the pioneers of the service were such that his death has made a gap in the ranks which can only with the greatest difficulty be filled. School buildings and equipment. A full account of the Council's new standard planning adopted in October, 1934, was printed in the last annual report. The new standard introduces great improvements in hygiene, including hot water supplies to lavatories, provision for drying clothes in cloak-rooms, medical inspection rooms, improved natural lighting, and advances in equipment. The standard is being applied not only to new schools but to the reconstruction and remodelling of those which are out of date. A three-years programme of development adopted for the years 1935-38 includes the erection of 15 new schools, the rebuilding or modernisation of 40 existing schools, the enlargement of 4 schools, the provision of further accommodation to meet housing developments, etc., and the acquisition of playing fields. A further feature of the programme is the reconditioning of premises and the provision of the amenities included in the new standard planning by a systematic overhaul of schools in which rebuilding or remodelling is not contemplated or due. By the end of the year 1935, considerable progress had been made. Three new schools or enlargements had been completed, and in five others building work was in progress. In six schools, scheduled for rebuilding or modernisation, building work was also in progress. The programme provided for 21 schools to be reconditioned, and those not already completed were in the builders' hands. The reorganisation of schools and the consequent segregation of children of different age groups in schools originally designed for children of all ages has produced difficulties. Desking has constantly to be watched as it not infrequently happens that older children are found seated in desks which are only suitable for younger children, and vice versa. The height of pedestals of closet seats is another difficulty which arises, and this is more difficult to adjust as considerable expenditure is involved in making alterations. A fault commonly found everywhere in England is the installation of pedestals which are of too great height. School pedestals should always be as low as possible. Had this principle been recognised in the past, the difficulties in this respect in the reorganisation of schools would not have arisen to the same extent. It has recently been decided, with the approval of the Board of Education, in future to limit the use of pedestals to three sizes only and to provide inserta pads instead of seats. The sizes are: babies', 8 inches ; infants', 10 inches ; others, 14 inches. Many of the older schools are still equipped with trough closets. The Council has decided to hasten the modernisation of all schools in this respect with a view to the complete eradication of trough closets from all schools by the end of five years after 1935 ; 20 schools will be dealt with in 1936-37. Reference was made in last year's annual report to the supply, under the new programme, of a large number of tables and chairs in lieu of fixed dual desks, and figures were given of the range of heights of tables and seats from the floor. During 1935, consideration has been given to the most suitable form of back-rest for chairs and the following specification has been adopted: a simple cross bar 3 inches to 4 inches in depth comfortably hollowed, whose lower margin is one half the distance 7 from the seat that the seat itself is from the floor; e.g., in a chair of 16 inches height of seat, the lower margin of the back-rest should be 8 inches from the seat. In conjunction with the Council's architect, a survey was made of the drinking fountains in school playgrounds. An inspection was made at each school, and particulars of the number of drinking fountains in the various elementary schools are set out below :— Old pattern with spring valves, bowls, cups and chains 3,207 New pattern with bubble jet valves 811 4,018 Additional fountains required to comply with full scale, based on recognised accommodation of schools, i.e., 1 to 100 boys or girls, 1 to 135 girls and infants 918 Number of fountains fixed against walls of offices or urinals:— Old pattern 573 Bubble jet pattern 222 795 After consultation with the architect as to the type of fountain to be provided in the schools, it was agreed that the use of the bubble jet pattern should be continued. With regard to the objection raised by a borough medical officer to bubble jet and other fountains being placed on the external walls of offices, it will be observed from the table that 795 fountains are so placed, as this position is economical as regards the provision of water supply and drainage. His view was that children should be encouraged to wash their hands before drinking, and for this reason the drinking water should be placed near the wash-hand basins and not near the sanitary conveniences. It was agreed that this object should be aimed at, and where it is economically possible to place the fountains away from the offices, recommended that this should be done. The cost of a bubble jet fountain may be taken as 38s. for the apparatus, to which has to be added the cost of water services and drainage, which varies considerably in each single case. When, however, a range is installed, these charges are proportionately reduced. To summarise the position, it was recommended that the provision of bubble jet fountains should be continued for drinking purposes in school playgrounds ; that, as fountains of the cup type become past repair, they should be replaced by those of the bubble jet type ; and that, as and when it is found economical and practical, existing fountains should be removed from the exterior walls of offices. Age groups. The results of medical inspection in 1935. The average roll of children in London elementary schools for the year 1934-5 was 534,611, and the average attendance 471,342. 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 formerly undertaken at age 8 was altered in January, 1934, to examination at age 7, and that at age 12 to examination at age 11. The routine groups to be examined thus became all children (i) on entrance to school, (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 school 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 8 change over from age 8 to age 7 would take about five years. Greater progress with the change-over was effected than was anticipated, thanks to the energy which all concerned put into the work; and during 1934, instead of only a fifth of the sevenyear-old group coming under examination as was anticipated, well over a third were completed; this rate of progress has been continued in 1935 and the changeover 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 1935 was 135,994. These were made up of 55,591 entrants, 31,965 children aged 7, and 48,438 children aged 11. The children aged 8 coming under preliminary survey by the school doctors were 17,495, of whom 2,185 were submitted to detailed examination. In addition, 53,209 children were examined in detail in the term prior to that in which they were due to leave school, and 1,203 children in special schools were examined on reaching their respective age groups. In addition to routine groups, children referred by nurses, school teachers, care committee workers, divisional officers, etc., for examination for special reasons numbered 125,199; and 21,713 were examined in connection with outbreaks of infectious disease. The total inspections amounted to 353,610. To these must be added the children, 158,686 in number, who were re-inspected because of some previously noted defect. As inspections of all kinds and re-inspections totalled no less than 512,296 it is clear that, although some duplicate inspections are included, very few indeed of the children in school escaped coming under the eye of the doctor in some way or another during the course of the year. Co-operation of parents. Parents are invited to be present at all routine inspections, and attended in 78.5 per cent. of the examinations in the three prescribed age groups, compared with 77.6 per cent, in 1934 and 74.1 per cent, in 1933. At the inspection of entrants, the proportion was 91.3 per cent., and in the "leaver" group 41.7 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. The reluctance of the older boys to be considered "tied to their mothers' apron strings " is shown by the poor attendance of parents at the inspections of leaver boys (33.9 per cent.) compared with attendance at inspections of leaver girls (49.7 per cent.). The very high percentage (91.3) of attendance of mothers at the inspection of entrant infants is a very important feature of the school medical inspections, as it affords an opportunity to the school doctor for imparting valuable advice at the outset of the children's school career, and enables much to be done to eradicate faults and defects which unfortunately are often already present before school life begins. Refusals of parents to submit children for medical inspection are so few in number as to be almost negligible. During the year 1935, the parents of 65 children (29 boys, 36 girls) being exactly the same number as in 1934, and compared with 89 in 1933, refused to allow them to be examined by one of the Council's assistant medical officers. Four 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., 8 ; N.E., 10 ; N.W., 15 ; S.E., 16 ; S.W., 16. The number of children subjected to routine inspection in the three prescribed age groups who were referred for treatment was 55,918, 41.1 per cent, of the number examined. This figure includes 41,357 cases noted by the school doctors for dental 9 treatment only, and, if these cases be excluded, the percentage is reduced to 15.8 compared with 15.5 in the previous year, and 16.7 in 1933. 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 formerly possible from year to year over the whole length of time, twenty-four years, during which inspections were 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. Acute anxiety lest the children should suffer has been the key note of the past four years. " The fear of underfeeding its children is haunting the conscience of the nation." 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. The analysis, with regard to nutrition, of the results of routine medical inspection in the elementary schools during 1935 are shown in the following table :- Table 1—Assessment of nutrition, 1935. Group. Numbers examined. Nutrition. 1. 2. 3. 4. Entrant boys 28,485 4,346 22,435 1,677 27 Entrant girls 27,106 4,797 20,869 1,419 21 Seven-year-old boys 15,869 1,926 12,603 1,312 28 Seven-year-old girls 16,096 2,683 12,367 1,034 12 Eleven-year-old boys 24,486 3,485 19,370 1,611 20 Eleven-year-old girls 23,952 4,377 18,112 1,442 21 Leaver boys 26,739 5,039 20,534 1,155 11 Leaver girls 26,470 6,271 19,191 996 12 Total 189,203 32,924 145,481 10,646 152 Percentage 17.36 76.89 5.67 0.08 On a careful clinical assessment of the state of the children's nutrition, 76.9 per cent, of the children fall into class 2 (nutrition normal), a further 17.4 per cent, are classed 1 (nutrition exceedingly good), making 94.3 per cent, whose nutrition is satisfactory. The remaining 5.7 per cent., whose nutrition was adjudged unsatisfactory, were mainly in class 3, nutrition subnormal (5.6 per cent.), but 152 (.08 per cent.) children out of 189,203 examined fell into class 4. Corresponding figures for the previous year are shown in the following table :— Table 2—Assessment of nutrition, 1934. Group. Numbers examined. Nutrition. 1. 2. 3. 4. Entrant boys 29,576 5,603 22,674 1,295 4 Entrant girls 29,062 6,097 21,854 1,105 6 Seven-year-old boys 13,353 2,008 10,400 943 2 Seven-year-old girls 13,006 2,467 9,936 600 3 Eleven-year-old boys 26,951 4,529 21,088 1,332 2 Eleven-year-old girls 26,601 5,448 20,072 1,077 4 Leaver boys 31,801 6,868 23,824 1,107 2 Leaver girls 31,832 8,365 22,506 959 2 Total 202,182 41,385 152,354 8,418 25 Percentage 20.49 75.3 4.2 .01 10 Comparison shows a small decrease, from 95.8 to 94.3, in the children who are satisfactory, an increase, from 4.2 to 5.7, in the " borderline " cases, and, though the numbers concerned are but small in comparison with the total inspected, an increase, from .01 to .08 in those definitely suffering from bad nutrition. It is important therefore that the position should be considered carefully with a view to determining whether the possible serious effect on some children of prolonged poverty of their parents due to continued unemployment, which was referred to in the annual report for 1933, is beginning to show in the results of school medical inspection. Representative school doctors who have been interrogated with regard to the returns are of opinion that there has been no deterioration in the children's general condition of nutrition. Enquiry shows that a very important factor in influencing the classification of the children has been the scheme of the Milk Marketing Board. In every group of children surveyed by the physician from the point of view of nutrition, there is always a certain proportion in which the classification is doubtful. These are " borderline " cases. Some of these children appear healthy and alert, but are under the average weight for their height. Formerly the judgment of the school doctor was unfettered. With the introduction of the milk scheme, however, the position was changed. The majority of the children in the schools are taking advantage of the milk scheme, their parents are paying and the milk is being supplied to them. Where poverty exists, however, the question whether the children should have the milk in school free of cost depended throughout 1935 upon the doctor. Only those whom he judged to be physically subnormal could obtain the milk free of cost. Thus there were three groups in the schools. Firstly, a large group of children having milk and paying for it; secondly, a smaller group having milk free on the doctor's advice ; and thirdly, a small group whose parents professed that they were unable to pay and who were not found subnormal by the doctor. This placed the doctor in a very responsible position, and he was naturally anxious to prescribe milk for children who were perhaps under weight, although apparently quite healthy and fit, and who were brought before him by teachers or members of care committees as deprived of milk by poverty. The consequence has been that a small increased percentage of children on or near the border line have been classified as subnormal, who would not have been so classified did nothing depend upon it. It follows from this that it might be anticipated that the number of children in the schools obtaining milk free should, in 1935, have increased. This is precisely what has occurred ; for, while the children receiving free milk in the schools in December, 1934, was 15,691, by December, 1935, it had increased to 20,300. It is possible that a similar explanation accounts for some, at least, of the increase, amounting to 127 in all, in the number of children classed in category " 4 " " definite pathological malnutrition." The school doctors are undoubtedly paying more attention to question of nutrition, and their standards are, perhaps unconsciously, being raised, and children on the border line between categories " 3 " and " 4 " are now probably all classed as " 4 " whereas formerly some would have been placed in " 3." Weighing and measuring. In consequence of the intense concern which is felt with regard to the welfare of the children, and the determination of the Council that no child in the schools should escape observation and assistance if necessary, it was decided that a height and weight chart should be commenced for every child in the schools who was below the age of 12 on 1st June, 1935, and that thenceforward the height and weight of each child for whom a chart had been begun should be recorded at six-monthly intervals throughout school life. Special charts were therefore prepared upon which the average height-weight curve of London children of school age was printed as a guide. The scheme came into operation in September, 1935, an addition of 22 nurses having been made to the staff to enable it to cope with an addition to the work of this great magnitude. 11 After some initial experience, the nurses were instructed to bring before the school doctors for special examination every child amongst the infants who was four kilogrammes, and, amongst the juniors, who was five kilogrammes, below the average for his height. The importance of the scheme will, however, only be fully felt when second and third weighings reveal the progress of each individual child, and children will be brought before the doctor not only because they are below the usual measurements but also because they are not making satisfactory progress. Another proposal in connection with the watch on the nutritional state of the children, which has aroused great interest, is the establishment of nutrition centres where the condition of children found in school not to make satisfactory physical progress can be intensively studied (see page 20). Cleanliness. After nutritional state, personal hygiene. This being the second of three great c indices—nutrition, cleanliness, clothing—by which social conditions and their improvement can be assessed. In 1935 the percentage of children in the three prescribed age groups found free from even traces of nits or pediculi in the hair was 97.0 compared with 96.5 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 from all traces of vermin 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. 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 (who now take the place of the 12-year-old group) entirely free from vermin was 94.8, being exactly the same as that of the 12-year-old girls in the previous year. This percentage has been raised to 95.1 during 1935. 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, however, impossible for the parents to eradicate at short notice the traces of persistent neglect. It is a pleasure to record that the mothers of the children, often harassed by household cares and financial worry, have responded so bravely to the persistent advice of the school nurses. 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 82 children were found in the statutory age groups to be affected by body vermin in 1935, out of 135,994 examined. 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. 12 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. The results of this classification for 1934 and 1935 are given below. Table 3—Clothing and footgear—Percentages. Age group. 1934. 1935. Good. Fair. Bad. Good. Fair. Bad. Entrant boys 52.7 46.7 0.6 56.5 43 0 0.5 Entrant girls 54.7 44.7 0.6 56.8 42.7 0.5 Seven-year-old boys 53.0 461 0.9 52.2 47.2 0.6 Seven-year-old girls 54.9 44.4 0.7 55.2 44.3 0.5 Eleven-year-old boys 53.7 45.6 0.7 52.0 47.6 0.6 Eleven-year-old girls 55.3 44.3 0.4 54.1 45.6 0.3 Leaver boys 52.4 470 0.6 51. 0 48.3 0.7 Leaver girls 55.1 44.5 0.4 55.0 44.8 0.2 Dental decay. The position with regard to the adequacy of clothing and footgear is now very satisfactory. In earlier years the percentages of children with insufficient clothing and inadequate footgear were much higher. Following upon the smaller numbers of children reported as treated for dental defect in 1933, the proportion of children in the three statutory age groups found during 1934 in a satisfactory dental condition declined, being 65.7 compared with 67.4 per cent, in 1933 and 1932 respectively, but was still better than that for former years, e.g., 64.4 per cent, in 1931 and 62.9 per cent, in 1930. Following upon the improvement in economic conditions and redoubled efforts on the part of social workers, there has been some recovery in 1935 of the lost ground. Not only has there been an increase in the number of children treated, but also an improvement in the figures derived from medical inspection. In 1935 the percentage of children found in the statutory age groups with sound teeth was 66-6. Details are given in the following table :— Table 4. Ago group. 1924. 1927. 1933. 1934. 1935. 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 56.1 11.6 54.3 11 .3 56.8 9.7 Entrants girls 58.4 12.4 50.7 15.2 55.3 11.7 54.3 11 .4 54.8 100 8.year-old boys 58.5 10.0 61.1 8.1 70.7 4.5 *8.7 *5.0 *70.1 *3.6 8-year-old girls 58 0 10.2 60.9 8.3 69.9 4.4 *67.6 *5.5 *69.4 *3.7 12.year-old boys 68.0 3.4 70.6 2.7 75.8 1.3 †75 .9 †1.5 †76.l †1.4 12.year-old girls 70.5 2.6 72.3 2.3 77.0 11 †77.9 †l.2 f77.3 †1.0 All above age groups 62.1 8.5 60.3 9.3 67.4 5.8 65.7 6.3 66.6 5.3 * 7-year-old children. † 11-year-old children. N.B.—Serious decay means four or more carious teeth requiring treatment. While the percentage of children with sound teeth has improved, the percentage of those with serious, as opposed to slight, decay has declined, and fewer " bad mouths " were found than ever before. Vision. All children in elementary schools, other than entrant infants, have their distant visual acuity tested by means of the Snellen cards, those whose defects have been corrected having their vision tested wearing their glasses. The results for 1935 are given in the table below in percentages, column 1 containing those with normal visual acuity, column 2 those with slight defect, and column 3 those with more serious defect. 13 Table 5. Age group. Visual acuity (percentages) 1935. Normal. Slight defect. More serious defect. Seven-year-old boys 63.4 25.2 11.4 Seven-year-old girls 62.8 25.1 12.1 Eleven-year-old boys 67.7 17.8 14.5 Eleven-year-old girls 65.7 18.9 15.4 Leaver boys 69.5 14.9 15.6 Leaver girls 66.7 16.6 16.7 Satisfaction was expressed in recent reports that the excessive incidence of visual defect on older girls compared with the boys, which was formerly such a striking result of school medical inspection returns, had diminished as the result, it was thought, of improvements in school hygiene such as by a rule of the Education Committee that sewing should not be done by artificial light unless the school medical officer has given his consent after examination of the lighting in each case. The figures for 1935 show that there is again a heavier incidence upon leaver girls. Enlarged tonsils and adenoid growths. In the prescribed age groups 6,214 children were referred for some form of treatment of enlarged tonsils or adenoid growths; this is 4.5 per cent, of the children examined, the same percentage as in 1934, compared with 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 1935 were: entrant boys 7.8, girls 6.7 ; 7-year-old boys 4.4, girls 4.2 ; 11-year-old boys 1.5, girls 1.9. There has been a fall in recent years in the percentage of children referred for treatment for enlarged tonsils and adenoid growths. The older the children the fewer there are that suffer from ear, nose and throat defects. Many cases found with slight degrees of defect are not referred for treatment but are placed under observation. The proportion of those recorded as having enlarged tonsils and adenoid growths who were referred for treatment was 39 per cent, compared with 38 per cent, in 1933 and 1934, and 43 per cent, in 1932. Of the 6,214 children referred for treatment for these defects, 4,186 were referred for enlarged tonsils only, 472 for adenoids growths only, and 1,556 for both enlarged tonsils and adenoid growths. Otorrhcea and hardness of hearing. Otorrhæa was noted in 1,073 children, or .8 per cent, of those examined in the prescribed age groups, compared with .9 per cent, in 1934, .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. This defect is most prevalent amongst entrant infants and diminishes during school life year by year. Hardness of hearing was found at routine medical inspections in 218 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. Mention is made in another part of this report (page 16) of the extended use of the audiometer in elementary schools, 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. Many of these cases are missed by the ordinary method of medical inspection, in which the test is the forced whisper at 20 feet. B 14 Heart and anaemia. Heart defect (functional or organic) was reported in 2,293 children in the prescribed groups or 1.7 per cent., compared with 1.9 per cent. in 1934 and 2 per cent. in 1930. As usual, older girls presented a percentage (2.0) in excess of older boys (1.5). 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 recorded in 984 cases, or .7 per cent., a very great improvement compared with 1.0 per cent. in 1934, 1.1 per cent. in the years 1931 and 1932, and 1.2 per cent. in 1930. Lung defects. As anaemia is associated with under-nutrition, this remarkable improvement in the figures for 1935 is noteworthy. Lung defects were noted in 2,808 children in the prescribed age groups (2.1 per cent.), compared with 2.2 per cent. last year. The bulk of the cases is provided by the entrants (3.4 per cent. boys and 3.3 per cent. girls). This is due largely to bronchial catarrh, which is especially prevalent amongst entrant infants who present ricketv manifestations. Tuberculosis. There were 60 children in the three age groups reported to have symptoms indicative of pulmonary tuberculosis, but only 8 of these were not already under treatment. In addition, 18 children had other forms of tuberculosis. The incidence of tuberculosis in any form found at routine inspections is .58 per thousand. For many years the amount of tuberculosis amongst school children has been very small. Nervous diseases. Epilepsy was noted in 28 cases, compared with 36 in 1934, 52 in 1932, 65 in 1931, and 73 in 1929 ; chorea in 104 cases, compared with 98 in 1934, 158 in 1932, 170 in 1931, and 178 in 1929 ; paralysis in 45 children, compared with 55 in 1934, 63 in 1932, 81 in 1931 and 122 in 1929. Rickets. Symptoms of rickets or the effects of early rickets were noted in 596 children in the prescribed groups. This is .4 per cent., compared with ,.5 per cent. in 1934, •3 per cent. in 1932, and .4 per cent. in 1931 and 1930. Infant boys had again, as last year, an incidence of 1.0 per cent., compared with .7 per cent. in 1933, and .9 per cent. in 1932, and infant girls .5 per cent., as last year, compared with .3 per cent. in 1933, and .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, affecting those entering school in the vears 1934 and 1935. Deformities, Amongst deformities, spinal curvature accounted, in the prescribed age groups, for 514 cases (.4 per cent.), the same proportion as last year. Of these 198 (.8 per cent. of those examined) were among the 11-year-old girls, while the 11-year-old boys showed .5 per cent. Other deformities, mainly flat foot, were present in 1,379 children (1.0 per cent.). This is the same percentage as in 1934. The 8-year group. During 1935, the school medical staff were in the midst of the change-over from inspection at 8 years to inspection at 7 years. In 1934, 26,359 children aged 7 had been examined. The remainder of the group were dealt with by preliminary inspection in 1935, followed by detailed examination of those selected by the doctor at the preliminary inspections as obviously requiring it. The number of 8-year-old children in the elementary schools who came up for preliminary inspection was 17,495, and of these 2,185 (12 • 5 per cent.) were submitted to detailed inspection. In 75 per cent. a parent attended this detailed inspection. The whole group of 17,495 children was tested for visual acuity. Of these, 1,426 children were referred for refraction, i.e., 8.2 per cent., while 4,958 (28.3 per cent.) were referred for treatment for dental caries. Special examination.5 The number of children, not m the age groups for routme exammations, submitted to the school doctors as special cases was 125,199, an increase of 33,319 over that for the previous year, and this figure does not include another 21,713 who came under inspection in the course of enquiries into outbreaks of infectious diseases. 15 The increase of 36 per cent. in the number of special examinations is remarkable, and is chiefly due to the solicitude aroused in regard to the nutritional state of the children generally, and to the desire that no child needing additional nourishment should be debarred from taking part in the scheme of the Milk Marketing Board. The additional work thus thrown upon the staff was equivalent to that of four whole-time school doctors, and explains why considerable strain was felt. It could not have been carried out had it not been that the age groups, particularly the leaver group, were smaller than in recent years. 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 therefrom in the former exceed those in the latter. Thus 1,009 children with scabies were referred for treatment at special inspections, compared with 120 only at routine inspections. In regard to epileptics 77 first came to notice at special inspections, compared with 32 at routine inspections, and 194 children with chorea were seen at special inspections, compared with 113 at routine examinations. Heart trouble requiring treatment was detected in 231 children at special inspections, compared with 252 at routine inspections. This is evidence that full advantage is being taken of the doctors' visits to the schools to present to them promptly really ailing children. The number of children amongst the special cases who were submitted to the school doctors on account of real or supposed nutritional defect was 53,066. At the resulting medical examinations the nutritional classification on the Board's scale of the children was as follows :— Table 6. Sex. Number. Nutritional classification. 1 2 3 4 Boys 25,915 458 11,900 13,119 438 Girls 27,151 580 12,972 13,210 389 Total 53,066 1,038 24,872 26,329 827 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 1921-22 and the numbers are, in consequence of the lower birth-rate at that time, fewer than in the previous year. They comprised 26,739 boys and 26,470 girls. In nutrition they were found to be better than the younger groups, only 4.4 per cent. of the boys and 3.8 per cent. girls being classed as subnormal. They compared with 3.5 per cent. boys, and 3.0 per cent. girls in the previous year. In personal cleanliness this group also shows an improvement on the 11-year-old group, 98.5 per cent. boys and 96 . 7 per cent. girls having perfectly clean heads. The dental condition of this group was found to be slightly inferior to that of the 11-yearold group, for both boys and girls, the percentage with satisfactory mouths being 751 in the case of boys, and 74.8 in the case of girls, compared with 76.1 and 77'3 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" girls was 1.7 per cent., compared with 2.0 in the 11-year-old group. The older girls invariably present more cases of spinal curvature and heart defect than do the older boys. B1 16 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 partly 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 defect in the system will be remedied by the increased dental inspections which are provided for in the 3-year programme now being carried out. The reorganisation of the tops of schools has also caused difficulty in the way of following up the older children. Co-operation between the school medical service and juvenile advisory committees. The Board ox Education forwarded an administrative memorandum (137), dated 16th September, 1935, directing the attention of local education authorities to the report of the Board's chief medical officer for 1933, in which he discussed the question of co-operation between the school medical service and juvenile employment and advisory committees. The Board had found that in many areas arrangements for such co-operation did not exist or, where they existed, were not on the lines which the chief medical officer suggested as likely to prove most useful. The matter is one to which the Ministry of Labour and the National Advisory Council for Juvenile Employment attach considerable importance. The Board agreed with the opinion expressed in their chief medical officer's report that the most useful form of advice is in terms related to the specific unsuitability of certain children for particular types of work, and they expressed the hope that local education authorities would be prepared to adopt the suggestion that a list of such terms should be printed for use by the medical officer at the last routine examination of the children. This question had already been discussed between the London school medical staff and representatives of the National Institute of Industrial Psychology and of the Ministry of Labour, when it was unanimously considered that the method of contra-indication was the best way of communicating the result of the examination in those cases where choice of employment should be limited by medical considerations. As the record card commences when the child enters school at 3 to 5 years of age, it will be some years before the record cards of leavers will contain the printed information but, in view of the Board's memorandum, it was decided immediately to print and issue " choice of employment " slips for supply to school doctors, with an intimation that a slip should be made out for every child who possesses some disability which affects choice of employment. These slips show the following occupational conditions and will be attached to the school-leaving form, thus being available at the school-leaving conferences :—heavy manual work ; sedentary confined work ; work involving exposure to bad weather ; work in a dusty atmosphere ; climbing; proximity to moving machinery; prolonged standing; eye strain ; work requiring acute distant vision or acute hearing ; handling of confectionery ; food preparation. Vaocination. The school doctor indicates any of these occupational groups for which a child is physically unsuitable. 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, 45.8; 7-year-olds, 47.7; 11-year-olds, 52.7; and " leavers " (13), 48.4 ; compared with, in 1934, entrants, 45.9 ; 7-year-olds, 50.4 11-year-olds, 55.1; and "leavers" (13£) 52. 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. Audiometric examination in elementary schools. In November, 1934, following experimental use, systematic audiometric examination of children in the elementary schools, by means of the gramophone audiometer was introduced by the Council. The object of this scheme is the ascertainment of defective hearing in one or both ears, especially in its early stages, so that (a) by means of timely treatment the defective condition may be remedied and permanent deafness in later life averted, and (b) the suitable educational environment for the child may be decided upon. One unit was established in the north-west division 17 of the county in November, 1934, and a second unit in the south-east division in May, 1935. A unit consists of one gramophone audiometer ; one full time nurse, who carries out the testing of the children in the schools, and is present at the clinical examination; an otologist, who conducts one clinical examination and one treatment session each week. The work is under the direction of Mr. A. G. Wells, to whom I am indebted for the following report:— The routine procedure is as follows. The nurse attends the school on an appointed day and proceeds to test all the children, except those in the infants' department. They can be tested at the rate of 40 a time, each test taking about 20 minutes, so that if there are no difficulties 120 children an hour may be tested. Any children with otorrhœa are cleansed before being tested, by washing the outer part of the ear with an antiseptic lotion to avoid contaminating the earphones. When a number of children have had their test, the test papers are corrected by the nurse from the master sheet, and those children who do not record correctly at the 6 decibel level or lower are regarded as failures. These children have a second test. It is always found that some of the children who failed in the first test are successful in the second. If the failures of the second test are children below the age of 11 years, they are given a third test, for it has been found, in children up to this age, that a further but smaller number may succeed in this test though they failed in tests 1 and 2. Children of 11 years and upwards do not require a third test. The final failures are then submitted to a clinical examination by the otologist, which is carried out at the school. The object of this clinical examination is to find out whether any pathological condition is present to account for the child's failure. If such be found, the position is explained to the parent, who is then asked to acquiesce in obtaining treatment. The case is followed up and, when treatment is completed, it is the nurse's duty to arrange for a final test to ascertain and record the result of treatment. It has already been stated that in children under 11 years of age a third test and sometimes a fourth is necessary before a decision of pass or failure can be made correctly. There appear to be various reasons for this, e.g., (1) lack of concentration; (2) backward children, who are slow to realise what they are asked to do, or in grasping and writing down the digits ; (3) unfamiliarity with the voice conveyed by telephone ; (4) lack of attention when being told what they have to do, or not wanting to take the trouble ; (5) nervousness ; (6) arrest of attention due to other people being in the room or lack of discipline of another child (slowness in recovering a train of thought after an interruption); (7) factors inherent in the gramophone record. For the younger children, the pause between the groups of digits at each intensity step is hardly long enough. Likewise the interval between each individual digit of the various groups is hardly sufficient, except for the brighter children. The younger children give the best results when tested in small numbers, so that the nurse is better able to keep a watchful eye on each child. They appear to feel themselves more in the nurse's grip and consequently pay greater attention, are not so easily distracted, concentrate more and show improved discipline. Younger children naturally show mind wandering more than older children and this is onhanced by environmental fators. The number of children tested during the year was 28,038, and the total number of individual tests was about 40,000. The percentage of children who failed was 7.8. These particulars are shown in the following table:— Table 7.—Routine audiometer tests. School. Total number tested. Total number of children failed. Number failed in Percentage of failures (either ear). One ear. Both ears. Boys 14,180 1,072 737 335 7.5 Girls Total 13,858 1,129 727 402 8.1 28,038 2,201 1,464 737 7.8 The subjoined table gives the total number of ears tested and shows the number falling in 4 separate groups, viz., —3 to 6 decibels = the passes ; 9 decibels = those who just failed ; 12 to 18 decibels = moderate degree of hearing loss ; 21 to 30 decibels = severer degree of hearing loss. Table 8. Total ears. Number of ears showing level of correct recording in decibels. —3 to 6. 9. 12 to 18. 21 to 30+. 56,076 53,138 1,192 1,157 589 18 With the object of obtaining the percentages of passes and failures at various ages, the records of 12,959 children were taken and the results are given in the subjoined table. It will be noticed that, on the whole, the greater percentage of failures is with the vounger children. Table 9. Age. Pass. Fail. Number. Percentage. Number. Percentage. 6 years 82 93.1 6 6.8 7 „ 813 91.7 73 8.2 8 „ 1,629 90.2 176 9.7 9 „ 1,818 92.5 146 7.4 10 „ 1,991 93.4 140 6.5 11 „ 1,697 93.1 124 6.8 12 „ 1,789 92.8 137 7.1 13 „ 2,326 96.4 85 3.5 This must not be taken to indicate a higher incidence of hearing defect in the younger children as compared with the older, indeed, the opposite is the case, but it is confirmatory evidence that correct recording by the younger children is influenced by some one or more of the factors already stated. Fig. 1 shows the differential analysis of all ears before and after treatment, and indicates clearly the improvement in hearing as the result of treatment. The clinical examination of the failed children conducted by the otologists revealed the following defects which were partly or wholly responsible for their loss of hearing:— Catarrhal condition of middle ear 964 Wax 487 Nasal defects (rhinitis, deflected septum, ethmoiditis) 446 Otonrhoea 304 Defects due to past suppuration 301 Tonsils and adenoids 145 Old mastoid operation 73 Adenoids 60 Foreign body 16 External otitis 4 Congenital malformations 2 Debility 2 Nothing found 59 Total 2,863 Among the 28,038 children tested, there were 66 who appeared to be possible cases for transference to a " partially deaf " school, that is to say, all these children showed a loss of 18 decibels or more in their better ear. As a result of treatment 24 of them were improved sufficiently to enable them to benefit from elementary school education. The remaining 42 were invited to County Hall for a special examination, and 5 of them were found to be suitable cases for a "partially deaf" school. Four were certified, while the remaining child who was due to leave school in 2 months was allowed to remain in elementary school. The special examination included voice tests, clinical examination, a pure tone audiometer test, tuning fork tests, and a consideration of the speech, language, lip.reading and mental ability of the child. Thus out of 28,038 children examined with the gramophone audiometer in the elementary schools, 5 or .017 per cent. were in an unsuitable educational environment. A careful comparison between the results of tests by the gramophone audiometer, pure tone audiometer and voice, shows that the relationship between these tests is not constant. It is quite clear that, although the audiometers (both gramophone and pure tone) and the tuning forks provide most valuable data, and may even be regarded as essentials in this work, they are quite insufficient without a complete investigation of a child, including the voice test, to make a " placing " examination satisfactory, that is to say, to make possible a correct decision as to whether a child needs educational training in an elementary school, a " partially deaf " school or a " deaf " school. There are certain cases in which it is quite impossible to use tuning forks or audiometers. Young and backward children are most difficult to deal with, and very little reliance can be placed on any response which they may feel inclined or be persuaded to give. Another type of child who is extremely difficult is the child who wilfully refuses to co-operate. Tuning fork tests and audiometer tests are impossible with such children, and the only way to deal with them is to use some device which will cause them to disclose the position, and this can most easily be done with the voice test in some form. One good example of this tvpe of case, was a child who refused to cooperate in any way. I asked questions, gave commands, tried to get him to count after me, to 19 20 History. Nutrition centres. As a result of nutrition surveys in the schools, it was ascertained 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 care committees, and the suggestion was made that the school service referred to hospitals very trivial conditions " which wasted the time of the hospital physicians." On the other hand, a strong public opinion had grown up which held that the local education authorities should do more for the ill-nourished child, especially in the very earliest stages of malnutrition. It was, therefore, decided to include in the 3-year programme, 1935-38, of the school medical service, additional provision for full investigation at special inspection centres of such children referred from the ordinary school medical inspections ; 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." It was decided to have five centres, one in each medical administrative division. Arrangements As, during the experimental period, it was desirable that they should be immediately under the observation of the divisional medical officer, a centre was chosen in each division as near as possible to the divisional medical offices. The divisional medical officers each nominated from the staff engaged in their divisions an assistant medical officer (part-time) specially qualified in this work. To each centre, an experienced nurse has been allotted and a specially selected organiser with experience in social economics. At each centre, during the first year, one session per week is being held. The location of the centres and the medical officers nominated are given in the following list. (The centres were established in May, 1935.) North-west division. Divisional medical officer—Dr. R. H. Simpson. Nutrition centre.—Paddington school treatment centre, 12, Maida Hill West, W.2. Physician-in-charge.—Lindsey Willett Batten, M.B., B.Ch.(Camb.), M.R.C.P. ; visiting medical officer, Children's hospital, Hampstead ; assistant physician. East London hospital, Shadwell. Session.—Thursday, 1.30 p.m. North division.—Divisional medical officer—Dr. Margaret Hogarth. Nutrition centre.—Hoxton school treatment centre, St. John's Road (M.D.) school, Crondall-place, N.l. Physician-in-charge.—Miss Evelyn Elizabeth Gourlay, M.D. (Gold Medal), London; assistant medical officer, Royal Northern hospital. Session.—Wednesday, 1.30 p.m. North-east division.—Divisional medical officer—Dr. G. Chaikin. Nutrition centre.—Poplar school treatment centre, 69, East India Dock-road, E.14. Physician-in-charge.—Mired. Claude Mitchell Elman, M.D. (London), M.R.C.P. ; assistant physician, Queen Mary's hospital for East End; physician, Margaret Street hospital for consumption. Session.—Wednesday, 1.30 p.m. South-east division.-—Divisional medical officer.—Dr. H. R. Kidner. Nutrition centre.—Divisional medical offices, 19, Breakspears-road, S.E.4. Physician-in-charge.—Geo. Douglas Morgan, M.A. (Cantab.), M.R.C.P.: registrar, West End hospital for nervous diseases ; assistant consultant, National children's home. Session.—Tuesday, 9.30 a.m. South-west division.—Divisional medical officer—Dr. C. N. Atlee. Nutrition centre.-—Divisional medical offices, Stowey House, Clapham-common, S.W.4. Physician-in-charge.—Miss Cicely May Peake, M.D. (London); senior physician, Elizabeth Garrett Anderson hospital; physician, Marie Curie hospital, etc. Session.—Tuesday, 9.30 a.m. The functions of the centres have been set out above. It is possible 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 ordinary school medical inspection. 21 Careful investigation is 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, are carried out at the centres ; but in special cases, when more extended biochemical investigations are needed, these are made in conjunction with the Council's laboratories. The centres are, during the experimental period, working under the immediate observation of the divisional medical officers, who 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 is in close and continuous touch with the school care committees, who, by personal visitation, keep in touch with the children both at home and school, and report to the organiser for the doctor's information. This arrangement ensures that the recommendations of the doctors are carried out. In any case, when a period of observation in hospital is desired, this is arranged at the Council's special hospitals for children, e.g., Queen Mary's, Carshalton, or High Wood, Brentwood. Reports on the activities of the centres between their establishment in May, 1935, and the end of the year have been received from the medical officers in charge, from the divisional medical officers and from divisional treatment organisers. Each of the centres was open on one session a week. The number of children who attended the centres was 303. Repeated attendances were necessary in the case of the majority of the children. Method of selection of children. It is intended, if the centres continue, that they shall deal with those children who, as the result of weighing and measuring at six monthly intervals, are found to be making unsatisfactory progress. The scheme for regular weighing and measuring of all children, however, only commenced in September, 1935, and during the period under consideration records of progress in physique were not available. Children sent to the centres were therefore partly those selected by the divisional medical officers from nominations by the school doctors and partly those selected by nutritional surveys in the neighbouring schools. In the northern division, Dr. Margaret Hogarth explored the soundness of selecting children on the basis of marked failure to approach the normal weight for height. Sixty-six such children were considered, but upon medical examination it was found that 41 (62 per cent.) were in a good physical state and living under good environmental conditions. Although they were " lanky," they were healthy. She therefore abandoned this method of selection in favour of a special survey in conjunction with the school doctor of the children in four neighbouring schools to the centre. Children were selected on clinical grounds as the result of observation of them in the classes where the contrast with normal children emphasized their poor appearance. The type thus selected was " distinguished by a grey look with unburnished appearance, their complexion lacking in the bloom that is noticeable in the skin of the healthy child ; they have a troubled expression very different from the happy alert expression in the clear shining eyes of the healthy child." It is true that in every case selected by this method the weight for height was below the normal standard, but the experience here confirms the opinion already expressed that deficiency of weight for height is, in itself, no criterion of nutritional state, but needs to be corrected bv a clinical examination. Attendance. Experience varied in the divisions with regard to securing attendance of selected children. In the northern division there were no failures, although, when approached, the mother in many instances protested that she did not consider her child ill or wanting in any particular. In the south-eastern division, one-third of those selected failed to attend. In the south-western division also, failures to attend were relatively high. Here it was reported that failures were due to cost in money or time to the parents, the distance of the centre from many homes and refusal on the part of parents to believe that there was anything wrong with their children. 22 Procedure at the centres. The investigation consisted in two parts—medical and social. On the medical side came the examination, history, family history and investigations. A complete clinical examination was made in every case, including also height, weight, urine-testing, muscle power (by means of the dynamometer) and the measurement in most cases of the haemoglobin percentage. In special cases further investigations were deemed necessary, such as Wasserman and Kahn reactions, blood counts, X-ray examinations, Mantoux tests. Such special investigations were carried out by the pathological departments at the Council's hospitals. The social investigations were carried out partly by the organisers at the centres and partly by the care committee workers in the homes, and were regarded as of extreme importance in judging the environmental influences on nutrition. They covered dietary points, economic circumstances, family budgets, and housing conditions. Results of medical inspection A considerable proportion of the children were found to present evidences of present or past disease or defect. Such conditions as dental caries, ear, nose and throat defect and visual defect do not appear to be greater in their incidence than in the normal population. Indeed, in some groups the total amount of such defect was less than might be expected. In the north division serious dental decay was remarkable by its comparative absence. Only 7 (out of 53 cases) showed dental decay in more than two teeth, and none in more than 3. In 26 there were no signs of decay. Anaemia was also surprisingly uncommon. Children with the appearance of pallor on ocular inspection were found on accurate measurement with the haemoglobinometer not really anaemic. In the northern division, the average haemoglobin content in all the children was 92.5 per cent. Dr. Batten (north-western division) states that, out of 40 children, whose haemoglobin content was estimated, it is remarkable that in only 3 was the percentage less than 80. Dr. Peake (south-western division) reports : " the children are not on the whole anaemic, many have good haemoglobin counts of 80 to 96 per cent." Postural defects were very frequently noted. Out of the 63 children definitely subnormal at the centre, Dr. Batten describes 37 with postural defects. In only five could posture be described as definitely good. Nearly all were noted as being " below normal in vitality, that is to say, they had an air of apathy, tiredness or timidity more or less pronounced." Predisposing causes. Careful enquiry was made into the previous history of all cases. Amongst the predisposing causes, prematurity of birth, low birth-weight, errors in infant feeding (often associated with rickety signs), severe past illnesses, such as pneumonia, acute bronchitis, infectious diseases, and rheumatism, were found in a certain proportion of the cases. Dietetic points. In all cases the home diets were minutely investigated. Ill-adjusted diets resulting from restricted incomes on the one hand, and ignorance of the dietetic needs of the child on the other, were often found. There was the usual tendency to feed the child on stodgy foods with excess of carbohydrates to the neglect of sufficient proteins, green vegetables and salads. It was, however, in many cases impossible to obtain a really accurate account of the individual child's diet. Social enquiries. The nature and extent of the enquiries which were carried out by the social workers are shown in table 10, which gives the results of enquiries made into the economic circumstances of the 62 children investigated at the Shoreditch centre (northern division). Housing conditions were unsatisfactory in many cases. In the north-eastern division the children were graded in regard to housing as : fair, 29; poor, 17; overcrowded, 9 ; no report, 1. In the south-eastern division housing conditions were held to be a factor prejudicially affecting the children in 12 out of the 46 cases. Dr. Peake (south-western division) remarks : " Parents have often become hopeless from disappointment in their search for better accommodation. Overcrowding, the need to wait for the whole family to go to bed before the children can 23 sleep, noise outside that precludes sleep unless the windows are shut, basement rooms, lack of air, light and sanitation, too many stairs for the sick parent, damp, bugs, rain coming in. These are some of the complaints." Table 10.—Shoreditch mUrition centre. Net income per head. Accommodation, including kitchen or scullery Father. Mother. Number of children. Under 5s. 5s. to 8s. 8s. to 10s. Over 108. 1 person per room. 1—2 persons per room. 2—3 persons per room. Over 3 persons per room. Regular work. Casual work. No work. Dead. Pensioned off. Employed. Unemployed. 1 Dead. Nutrition poor— 19 3 12 1 3 2 10 7 13 4 2 — 3* 16 — Nutrition very poor— 43 15 19 7 2 6 18 8 11 24 4 9 3 3 7 35 1 Total 62 18 31 8 5 8 28 15 11 37 8 11 3 3 10 51 1 * One of these mothers does home work only and one works 1£ days a week only. Consideration of the causes of malnutrition. Dr. Elman (north-eastern division) says : " It is quite obvious that to generalise on the causes of malnutrition is hopeless. Each case must be judged separately. So many factors are involved that it is difficult to hold any one responsible by itself. Poor housing, large families, bad early feeding are no doubt contributory causes. I am not sure that psychological factors are not involved, especially as to appetite. I am of opinion that a happy home is more conducive to good nutrition than an unhappy one, although the same economic conditions obtain. In the end one is drawn to the conclusion that there is close association between poverty and malnutrition, although in my series the best-off parents did not have the most robust children." Dr. Batten (north-western division) states : " It is reported that 4 children out of 55 were born prematurely and that 7 out of 24 weighed 6 lbs. or less at birth. In the normal group " (Dr. Batten considered 14 of the children referred to him as not to be suffering from malnutrition in any sense) " 2 out of 12 were premature, and 2 out of 6 weighed less than 6 lbs. at birth. There is no evidence, therefore, that prematurity is a factor of great importance. It has rarely been found possible to attribute ill-nourishment to a single and well defined cause. The following, however, is an attempt to classify the presumed aetiological factors under broad headings with some overlapping : constitutional, 24; environmental, 32 ; food, 8 ; present disease, 8 ; past disease, 11. " Constitutional defects and faulty environment predominate. By constitutional defect is meant a failure to grow, thrive and put on flesh according to expectation, due so far as can be ascertained to something inherent in the child. Environment is interpreted widely to include not only the child's material surroundings but all the external influences impinging upon him, in fact his home and his upbringing. It is noticeable that dietary faults were only detected with certainty in 8 children (and doubtfully in 4 others). In a fairly large proportion of cases, home surroundings were known to be comfortable and food abundant." Present defects were held responsible in 9 instances and past illness in 11 (together with 5 others in which there was some doubt). Dr. Morgan (south-eastern division) attempted to classify his 46 cases according to the primary cause of subnormality, with the following result: subnutrition due to insufficiency, 5 ; subnutrition due to incorrect feeding, 5 ; debilitating illnesses 24 (four with rickets), 10; syphilitic taint, 3; tuberculous diathesis, 2; cyclic vomiting (allergic diathesis), 10; spoilt child, 1; environmental conditions (bad housing or home), 5; catarrhal or septic infection, 2; congenital weakness, 1 ; other causes, 2. Dr. Gourlay's (north division) impression was that the under-nourished condition of the children coming before her was due in the main to social environment and in particular to three main causes, in order (1) life under impoverished conditions, (2) ignorance of dietetic principles on the part of the parent, (3) poor housing and overcrowding. Kecommendations and advice. Advice as to diet, daily routine and general hygiene was given to the mother. Means were devised in appropriate cases to supplement the dietary (including school milk, dinners, malt and oil, alteration in home diet, glucose, Parrish's Food). Treatment for defects was advised and in most cases carried out. Open-air school, open-air class and convalescence were frequently recommended. Ultra-violet treatment was obtained for several children. In the northern division, Dr. Gourlay worked out a weekly dietary, not indeed ideal but practicable, to form a basis upon which the mother could work. It was intended to show her how she could keep the child well if she spent her money wisely. A copy of this dietary was given to each parent, and it was obvious that the advice was appreciated and that efforts were made to follow it. The following is a summary of the recommendations made at all the centres and the results :— Recommendation. Made. Carried out. Supplementary nourishment— Milk in school 71 71 Malt and oil in school 40 38 Dinners in school 24 20 Glucose 15 15 Parrish's food, etc. 24 22 Treatment for dental and other defects 99 71 Treatment by ultra-violet rays 14 11 Convalescence, day or residential open-air school 108 79 Housing improvement 8 1 All the recommendations were iollowed up and arrangements are in hand for such as are outstanding. Failure to carry out recommendations was due in some cases to lack of parental co-operation, e.g., refusal to allow their children to have dinners in school, or to go to an open-air school. In the great majority of the cases, milk in school was already supplied to the children before their first attendance and this was, of course, continued. In some cases milk was refused or found impossible to retain owing to idiosyncrasy. In these cases malt and oil or other supplementary articles were substituted. Results and conclusions. The nutrition centres are an attempt toa blaze a new trail through uncharted territory. The medical officers in charge were given a free hand, although standardised records and procedure and consultations ensured that similar lines of enquiry were followed. It is clear that the groups of subnormal children differed in character, and the problems to be faced were also distinct in the five widely separated districts. In the north-western and south-eastern divisions a large proportion of the children referred to the centres were judged not to be cases of true nutritional deficiency; in the south-eastern division indeed the centre assumed the character in part of a child guidance clinic. In the north-eastern and northern divisions the children were all cases of nutritional deficiency ; but, while in the north-eastern (Poplar) division rickety manifestations were notable in frequency, in the northern division they were conspicuous by their absence, the remarkable freedom of the children from dental caries in this division being confirmatory evidence. 25 There is no doubt that at all the centres useful work was done and improvements effected by taking the parent into consultation in regard to the child's condition and by discussing ways and means and helping in the management of the weekly budget. The territory which is being explored is that containing the subnormal child who has no disease and yet does not thrive like his fellows at school. It is of course solely due to the school medical service that the existence of this group of children is recognised. When sent to hospital where the approach to all problems is from the standpoint of disease and not from that of health, the children are there regarded as normal. From the school standpoint where the children are seen in the company of normal children their subnormality is at once appreciated. One physician was only convinced of the reality of the problem by visiting the schools from which the children had come, and noting the appearance of the referred children in contrast to that of their normal classmates amongst whom they sat. Dr. Hogarth reports : " Parents and children are undoubtedly benefiting from the careful investigation and discussion of home difficulties. The parents' interest is being maintained by frequent periodic examination and by the encouragement they experience at the special interest taken in the child's progress by sympathetic social workers and a friendly doctor." Dr. Batten thinks as a result of his experience that " it is hard to believe that a new light will be thrown on the nature and cause of ' malnutrition ' by the clinical examination of any number of subnormal children. On the other hand the clinic can perform a useful function if it be regarded as a place where the individual subnormal child can be examined, watched and helped according to its needs." Dr. Morgan finds at the south-eastern centre that the most striking results are obtained from convalescence which in almost every case has produced marked improvement in the child's general condition, and a jump up in weight. There are also many clinical evidences of good results. Many children come up fatter, happier and with good home and school reports. Dr. Elman finds that out of 38 cases in the north-eastern division on whom it has been possible to make an assessment of the results, improvement ranging from slight to very good took place in 28. Several of the observers discuss the future place and continuance of the nutrition centres. Dr. Hogarth remarks " whether the school population as a whole would derive greater benefits from the multiplication of nutrition centres depends very much upon how great a benefit to the individual child such nutrition centres constitute. In no case were children attending the nutrition centre offered facilities for medical treatment which were not available for every school in London." Dr. Morgan thinks the results of the work show that a clinic concerned purely with nutrition can never exist because many other problems necessarily come within its purview ; but as a welfare centre for school children which it has become it has before it a highly important field for investigation and later of social service ; it may well be said to represent one of the most important modern lines of development of the social services. Dr. Simpson considers that the functions of the nutrition centres should as a result of the present experience be better defined. Up to the present there has been confusion between the scientific and research aspect of the centres and the social or remedial aims. He doubts the value of the attempt to evaluate tests which will facilitate and give added precision to the diagnosis of potential malnutrition, which must, in his opinion, remain a vague entity. By giving up this side of the work it will be possible to concentrate upon the practical problem of helping the parents and children, and it would be possible to deal with larger numbers. The simplification 26 which he advocates would make the work merely an extension of that at a medical inspection with the advantages of ample time for the examination and for the discussion of problems with parents, and of conveniences which do not exist in all schools. This, he admits, weakens the case for ad hoc clinics. He points out that the facilities for treatment are available equally to the doctor in the centre and the doctor in the school, that in the school there is the definite advantage of personal contact with teachers and with care committee secretaries, and that geographical considerations limit the scope of the centres unless their number is multiplied considerably. Dr. Batten in dealing with this question says : " It is quite possible that this work could be as well or better done at special sessions in the schools, but there is no doubt in my mind that it cannot be done adequately in the course of routine medical inspections." Extracts from the reports may well conclude with one from that of Miss Owen, divisional treatment organiser (south-eastern division) which will reflect the opinion of the social workers as distinct from that of the medical officers :— One, if not the most important, factor in the work being done is in the education of the parents. This is found to be possible as not more than 5 to 8 children are seen each session, and by this means adequate time can be given to each child. There is no doubt that the absence of hurry has reacted very favourably on the parents and in many cases where it was thought that the parent had appeared to be on the defensive on arrival, he or she always left with no trace of such an attitude and only with the apparent intention of carrying out the advice received, of doing his or her share in making the necessary adjustments in the home life. It might be argued that all the recommendations made come within the scope of the existing scheme of school medical services, but the fact remains that they had not already been made, and in spite of the existing scheme the condition of these 46 children was found to be such that the school doctors considered they required further supervision. It is obvious, also, that there is not sufficient time at a routine medical inspection for the examining doctor to deal with each (subnormal) child in sufficient detail and it would seem therefore necessary to have some other place where such detailed examination can be made in these cases who, in spite of existing services, are still sub-standard physically. The nutrition centre has in my opinion fulfilled this function and in doing so is most valuable, and I feel strongly that it should be continued. In saying this I feel sure that those care committees who have had contact with the centre would agree. 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 1935, 158,686 children were re-inspected, an increase of 12,066 on the number for 1934. At the first re-inspection 102,883 cases of defects requiring treatment (some children having more than one defect) were reviewed. At the second re-inspection 47,975 cases not cleared up at a first re-inspection were again reviewed. By combining the results of both reinspections it is found that 82 • 3 per cent. of the children re-inspected were treated or discharged as no longer requiring treatment. This figure is a great improvement over that of the previous year when only 75.1 per cent. were found by the time the second inspection was reached to have been satisfactorily dealt with. The result in 1935 is the best ever attained in London. It is the dental cases, which contribute 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 85 .5 per cent. The relatively poor result in 1934 was almost entirely due to failure to obtain dental treatment. The better results in this respect in 1935 correspond with the better condition of the teeth found at inspections, and reinforce the impression of redoubled efforts on the part of social workers in response to the statements contained in my recent reports. 27 Table 11 First Re-inspections, 1935. (Percentages are given in italic type.) Defect treated. No. of defects. 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 dis- charg'd Diacharg'd Not discharg'd Refraction 18,145 100 48 4,738 2,374 436 194 1,393 3,882 4,980 .5 .3 26.1 13.1 2.4 1.1 7.7 21.4 27.4 Minor ailments 6,028 137 18 1,405 362 359 142 1,844 842 919 2.3 .3 23.3 60 6.0 2.3 30.6 14.0 15.2 Nose and throat 11,949 31 3 3,661 169 690 49 1,530 1,842 3,974 .3 .0 30.6 1.4 5.8 .4 12.8 15.4 33.3 Teeth 55,325 1,442 318 20,906 986 2,492 121 4,326 1,320 23,414 26 .6 37.8 1.8 4.5 .2 7.8 2.4 42.3 Other ailments 11,436 166 77 661 793 1,079 803 2,760 3,301 1,796 1.5 .7 5.8 6.9 9.5 7.0 24.1 28.8 15.7 Total 102,883 1,876 1.8 464 .5 31,371 30.5 4,684 4.5 5,056 4.9 1,309 13 11,853 11.5 11,187 10.9 35,083 341 Second Re-inspections, 1935. Refraction 11,232 49 20 2,088 1,341 259 111 1,147 3,048 3,169 .4 .2 18.6 11.9 2.3 1. 10.2 27.2 28.2 Minor ailments 2,412 35 10 341 156 120 61 807 425 457 1.5 .4 141 6.4 50 2.6 33.5 17.6 19. Nose and throat 6,230 17 4 1,345 66 284 16 1,157 1,156 2,185 .3 •0 21.6 11 4.6 .3 18.6 18.5 35.0 Teeth 22,098 643 141 7,137 303 936 56 2,334 636 9,912 2.9 .6 32.3 1.4 4.2 .3 10.6 2.9 44.8 Other ailments 6,003 41 30 234 446 382 367 1,536 2,067 900 .7 .5 74 6.4 61 25.6 34.4 150 Total 47,975 785 205 11,145 2,312 1,981 611 6,9*1 7,332 16,623 1.6 •4 23.3 4.8 41 1.3 14.6 15.3 34.6 Children's care committees. 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, or illness, 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. Cases referred to the N.S.P.C.C. During 1935, 437 cases, involving 542 defects, were reported to the National Society for the Prevention of Cruelty to Children : these included 281 dental defects, 122 vision cases, 55 nose and throat affections and 4 cases of ear disease or deafness. Aural disease and the acute infections. 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. 28 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 403, of which 132 were forwarded to Borough Councils or other local authorities. Of the cases followed up at school, 22 were found on the first examination to have otorrhoea, and of the cases seen at second examinations the condition persisted in eighteen. 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 in 1934 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. During 1935 still fuller co-ordination has been effected with the isolation hospitals whose superintendents, from 1st January, 1936, will forward to the school medical officer particulars on discharge of all school children, who have been admitted, not merely those who suffer from discharging ears. Medical and dental treatment. The Council's scheme for the medical and dental treatment of children attending public elementary schools, scholars and pupils attending secondary, trade and day continuation schools, and pupils at certain evening institutes, has proceeded on the usual lines, and the attendance of patients has been satisfactory. It is to be noted that the total number of children treated has increased compared with the year 1934, in spite of the fall in the school roll and the additional school holidays during the festivities associated with the late King's Jubilee. This is due in the main to intensified following-up. The following table shows the number of school children treated each year under the scheme from 1924 to 1935 :— Table 12. Year. Vision. Nose and throat. Minor ailments. Dental. 1924 32,747 12,980 83,751 99,045 1925 36,356 15,066 91,691 112,964 1926 37,985 15,168 92,683 113,932 1927 40,293 18,176 103,019 124,992 1928 40,984 20,162 101,254 129,255 1929 41,620 19,903 101,666 129,952 1930 43,579 19,760 105,118 138,280 1931 44,686 20,703 106,072 139,723 1932 44,172 17,364 105,624 134,769 1933 40,434 14,145 *116,089 133,835 1934 40,284 12,622 †l 20,549 138,140 1935 39,450 12,766 †123,695 144,383 *Includes 11,876 "nurses" cases. t Includes 13,087 "nurses" cases. {Includes 14.537 " nurses " cases. Prior to 1933 " nurses " cases were not included in the return. The number of hospitals and centres under the scheme remains at 17 hospitals and 74 centres. At these hospitals and centres the work is undertaken by the hospital committees and local centre committees under agreement or arrangement with the Council. In addition, there are two centres which are organised and managed directly by the Council, viz., the special in-patient centre at the Cyril Henry centre, Woolwich, and the dental centre for the resident children at the King's Canadian camo school, Bushy park. Eye defects. The large majority of cases dealt with in the eye departments are those needing correction for errors of refraction. At certain of the hospitals special provision has been made for dealing with external diseases of the eye, whilst at most of the 29 treatment centres such ailments are more conveniently dealt with in the minor ailment departments. The number of cases dealt with in the eye departments during the year was 39,450, including a number of eye diseases cases estimated at about 2,000. The number of cases in which spectacles were prescribed was 28,827, and spectacles were obtained in 26,569 cases, a percentage of 92 • 2. Increased provision for the training of children suffering from strabismus has been made during the year. Prior to 1935 special attention was given to squint cases at the Belgrave hospital, Royal Eye hospital, and at the Paddington centre. During the year three additional centres were arranged at St. Mary's hospital and at the Lewisham and Whitechapel centres. The training of children to obtain single binocular vision with proper fusion is very often a long process, and requires the regular attendance of the children with persistence in endeavour. Dr. Victoria Brander, who is in charge of the squint training at the Whitechapel centre, reports that with the use of the synoptophore and variable prism stereoscope very satisfactory results are being obtained, the children have maintained their interest and the parents are co-operating well in the training. Ear, nose and throat. The number of ear, nose and throat cases treated during the year has increased slightly on the number dealt with during 1934. During 1935, 12,766 cases were seen and 9,037 operations were performed compared with 12,622 and 8,860 respectively during the year 1934. Of the 9,037 operation cases, 7,940 were for both tonsils and adenoids, 649 for enlarged tonsils only, and 422 for adenoid growth only. The remaining 26 cases were mainly operations in which cauterisation was necessary. Ringworm. The incidence of ringworm of the head amongst the school children is now of comparatively rare occurrence. During the year, 120 cases were dealt with, of which 110 were treated by X-rays, compared with 195 cases (118 X-rays) during the year 1934. A skeleton service is maintained at 5 hospitals and 5 centres in various districts of London, so that cases may be dealt with expeditiously when they arise. Minor ailments. The number of minor ailments cases dealt with at the treatment centres during the year was 117,140, including 14,537 cases seen by the nurses only, compared with 114,809 and 13,087 during the year 1934. The total number of attendances made was 1,370,022. These figures do not include children treated for scabies and ringworm, who appear, however, in the total given under " minor ailments " in table 12. Special consideration has been given during the year to the question of the provision of nutritives and tonics to children treated in the minor ailments departments. Children attending these departments mainly suffer from minor complaints of the eyes, ears and skin, etc., which require the daily attention of a trained nurse, and many of them, especially those excluded from school, need nutritives and tonics such as cod liver oil, malt and iron salts to correct deficiencies in diet, which so often promote chronicity of skin eruptions and external eye diseases. Arrangements have, therefore, been made at the centres for suitable nutritives and tonics to be supplied at the discretion of the minor ailments doctors, free of charge to the children. Dental treatment. There are 69 dental centres included in the Council's scheme, as well as the experimental centre at the Berkshire Road school (undertaken without cost to the Council by the Manor Charitable Trust for the special benefit of the children attending the school). Dental inspections are held in the schools by the 70 part-time inspecting dental surgeons, of whom 14 are women, and 2,641 sessions were devoted to the wort during the year. Prior to 1st April, 1935, it was the general practice to except from dental inspection those children of the three age groups medically inspected by the school doctors. It has been decided in principle that children of all ages in the schools should be subject to inspection by the inspecting dentists, but it was found that the administrative difficulty and cost of including the children of the age groups 7-8 years, 11 years, and entrants and leavers at the same time would be considerable, so it was decided to implement the arrangement gradually. It was 30 therefore arranged that, as from 1st April, 1935, the age group 7-8 years should be included, that the age group 11 years should be added during the year commencing 1st April, 1936, and that in the succeeding year the entrants and leavers group should be included, so that, at the end of the year 1937, children of all ages in the schools will be inspected annually by the inspecting dentists. The number of children inspected by the school dentists during the year 1935 was 290,021, compared with 273,672 during 1934. The number found to require treatment was 183,035, or 63.11 per cent. The following table shows the steady improvement in the condition of the teeth of the children in London as the result of 22 years continuous effort in propaganda, treatment and following-up. Whilst the position leaves much to be desired, there is reason to believe that to a considerable extent both parents and children are now realising the importance and value of dentistry. The greatest difficulty is still to be found in persuading parents to accept early treatment, especially when children are apparently suffering no inconvenience. Table 13. Year. Number of children inspected. Number found to require treatment. Percentage. 1914 56,491 46,290 81.94 1915 69,516 56,864 81.79 1916 81,794 66,624 81.45 1917 89,962 71,447 79.42 1918 106,586 83,068 77.99 1919 144,456 112,227 77.68 1920 154,347 115,619 74.91 1921 151,395 111,250 73.48 1922 192,730 137,487 71.33 1923 236,658 166,454 70.33 1924 256,542 178,802 69.69 1925 262,482 182,524 69.53 1926 237,022 163,422 68.94 1927 224,553 157,537 70.15 1928 226,279 156,001 68.94 1929 240,040 163,114 67.95 1930 251,251 165,616 65.91 1931 268,545 173,180 64.48 1932 273,737 174,089 63.86 1933 275,213 175,559 63.79 1934 273,672 176,509 64.49 1935 290,021 183,035 63.11 The total number of children treated was 144,383, compared with 138,140 during the year 1934, an increase of 6,243. Included in the total is the number of children (3,774) from the 16 elementary schools allocated to the Eastman clinic, who were treated at the clinic, and 33 scholarship cases, as well as 511 cases dealt with at Berkshire Road school. In addition to the numbers given above, there were 8,542 children from schools not allocated to the Eastman clinic, who voluntarily presented themselves and were treated at the clinic. • The number of treatment sessions, including 3,296 general anaesthetic sessions, held during the year was 18,436 compared with 18,211 during 1934. An analysis of the work undertaken is set out in table IV, group IV. The quality of the work has been maintained, and the centres have been well attended. The addition of the 7-8 year old group has caused congestion at certain of the centres, and extra sessions have been arranged where required. Orthodontics. The question of providing orthodontic treatment in connection with school dentistry has not in the past generally been seriously considered by local authorities owing to the greater demands for a dental service primarily needed to deal with the vast amount of dental caries which was evident among the school children. As time elapses and the general condition of the mouths of the children improves, it is possible to extend the operation of the scheme to include the treatment of orthodontic cases. For example, a successful scheme has been described by the 31 school medical officer of the borough of Heston and Isleworth. Apart from the aesthetic standpoint, dental irregularities, crowded teeth and malocclusion have a definite bearing upon the general health of the child, and should, therefore, be attended to. Suitable treatment of the simpler type can conveniently be provided at the ordinary dental centres under the guidance of a visiting orthodontist. An experimental scheme has been put into operation in London during the past year. At the outset, three centres at Deptford, Hammersmith and Prunella (St. George's-in-theEast) were selected, and later two centres at Battersea and St. Mary Newington were added. Special sessions are set apart at these centres for the preliminary examination of a number of cases, and Mr. Bertram Samuel, the Council's consulting dental surgeon, visited the centres on these sessions to consult with the dental surgeons engaged at the centres, as to the treatment desirable in each case. This is charted on separate cards, and the children are instructed to attend subsequently one or two at a time at the ordinary dental treatment sessions, when the necessary treatment is commenced. In some cases it is found that judicious extraction is all that is required, whilst, in cases needing appliances, impressions are taken. These are forwarded to the Council's dental laboratory attached to St. James' hospital, Balham, where the necessary appliances are made and returned by post to the various centres. The centre dentist undertakes the fitting, and the chiidren are seen at varying intervals for adjustment of the appliances, notes being taken of the progress. In obscure cases X-ray photographs of the jaw or parts of the jaw, showing the position of unerupted teeth, are needed in order to enable a correct estimate to be made of the treatment desirable. Arrangements have, therefore, been made for these to be obtained at certain of the Council's general hospitals during the year. By these means 391 children have been treated or have commenced treatment at the five centres. There is evidence that these special facilities are greatly appreciated by the parents, and the attendances of the children have been maintained. Aural centres. The Council maintains 15 special aural clinics which are under the dir of Mr. A. G. Wells. Particulars of the work carried on at these centres are in tables 14 and 15. Table 14.—Ear, nose and throat, excluding pure hardness of hearing. Classification. Patients. Ears. Total number of examinations made 15,668 19,254 New cases 1,507 1,927 Cases carried over from 1934 710 860 Old cases returned 1,002 1,177 Cases examined but no treatment required 252 392 Cases cured 1,752 2,086 Lost sight of 258 308 Table 15.—Hard of hearing cases. Organisers' returns from special ear, nose and throat clinics. Classification. Patients. Ears. Total number of examinations made 2,383 3,736 New cases 621 953 Cases carried over from 1934 62 129 Old cases returned 21 40 Cases cured 182 286 Cases partially relieved 121 182 Cases unrelieved . 40 64 Cases requiring no treatment 45 70 Lost sight of 53 83 In addition to the above there were:— Throat cases 15 Nasal cases—New 178 „ Carried over from 1934 49 „ Old cases returned 38 c1 32 The subjoined table gives a detailed analysis of all cases of otorrhcea treated, showing number of acute conditions, cause of the persistence of discharge in chronic cases, the number cured, the number referred for operation, those lost sight of and the numbers still under treatment on 31st December, 1935. This table includes otorrhcea cases among children from residential schools. Table 16—Special ear clinics—totals for all clinics. Cause of suppuration. Total ears. Cured. Referred for mastoid operation. Lapsed. Stilt under treatment. Acute otitis media suppurativa 200 158 8 6 28 Chronic otitis media suppurativa due to (I) Tympanic Conditions (a) Tympanic sepsis (T.S.) 1,823 1,319 9 107 388 (6) T.S. + granulations 251 139 11 20 81 (c) T.S. + polypi 33 11 8 1 13 (<2) T.S. + caries 16 5 2 — 9 (e) T.S. + other conditions 17 16 — — 1 (II) Tympanic Conditions + (a) Tonsils and adenoids 170 110 5 9 46 (b) Nose conditions 272 180 — 17 75 (e) Mouth conditions 1 1 — — — (III) Tympanic Conditions + (a) Attic disease 80 18 42 2 18 (6) Mastoid disease (no operation yet done) 106 1 100 5 (c) Mastoid disease (operation already done) 743 396 38 57 252 (IV) Tympanic Conditions + (a) External otitis 30 26 — — 4 (6) Stricture of meatus — — — — — External otitis 91 80 — 1 10 Cause undetermined 1 1 — — — Total 3,834 2,461 223 220 930 From these fierures it will be seen that the percentage of " cases cured " is 68. After-care clinic. St. George's dispensary. At the St. George's dispensary a special aural centre is maintained where children suffering from otorrhcea from the Council's residential school are treated, and where also the after-care of children who have returned home from the Downs hospital after mastoid operations is carried out. The number of " ears " dealt with in children from the residential schools was 196, and the percentage of cure 80 • 8. The number of children attending as " after care " cases was 632. 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. 33 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. 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. The calculated full cost during 1936-37 for each class of ailment treated is :— Enlarged tonsils and adenoids, 17s. 8d. ; Minor ailments, 7s. 7d. ; Dental treatment, 7s. 2d. ; X-ray treatment for ringworm, 26s. 10d. 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, but 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 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 1935, 15,095. 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 : a percentage of above 92 was repeated in 1934 and 1935. 34 Table 17. Year. No. of spectacles ordered. No. of spectacles obtained. Percentage. 1925 25,555 22,757 89.8 1926 26,718 23,593 88.3 1927 28,726 26,086 91.0 1928 28,977 25,887 89.3 1929 29,212 26,993 92.4 1930 29,846 27,264 91.3 1931 30,151 27,939 92.6 1932 29,548 26,200 88.6 1933 29,382 27,292 92.9 1934 29,599 27,997 92.8 1935 28,827 26,569 92.2 Orthopaedic treatment. The provision for orthopaedic treatment in London is extensive and adequate. As local education authority, the Council has established 32 day schools for the physically defective with accommodation for 3,537 children. These schools are regularly visited by an orthopaedic surgeon and the care and education of cripples are maintained at these schools until they reach the age of 16, and a scheme of aftercare of all children subsequent to their leaving has long been in existence. There are 10 visiting orthopaedic surgeons, employed by the Council in connection with the Council's general hospitals, and there are 3 special children's hospitals maintained by the Council to which children suffering from orthopaedic defects are admitted; these include Queen Mary's hospital, Carshalton, at which there are 1,284 beds and where special facilities are provided for the treatment of orthopaedic cases. There is no difficulty in finding accommodation immediately for all orthopaedic cases. These special hospitals are now recognised as hospital schools. There are 19 residential special schools for physically defective children, other than those above, maintained by voluntary bodies with which the Council, as local education authority, has agreements, and 70 children, for whom the Council is responsible, are at present in residence at 12 of these institutions. London is a great centre for medical education and there are many voluntary hospitals, which maintain orthopaedic departments, engaged in the teaching of medical students. These are all eager to undertake the orthopaedic care of children. There are also special voluntary orthopaedic hospitals at which orthopaedic surgeons of the highest repute hold appointments. At some of these hospitals Council's organisers of children's care work attend in the orthopaedic departments as liaison officers. The three main causes of crippling in London are tuberculosis, infantile paralysis and congenital malformation. The first two conditions are notifiable, and schemes are in operation on the general public health side of the Council's activities for dealing with cases under both these headings. A special unit for the treatment of congenital malformation has been established at Queen Mary's hospital, Carshalton. The principal causes of crippling operate before school life begins, at which period of their lives the children in London are under the care of the public health departments of the Borough Councils, for whose cases the Council provides institutional treatment whenever required. Stammering children. At the ten centres for the treatment of stammerers from elementary schools a total of 432 children attended during the year ; of these, 124 were discharged as cured, while 55, 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 speech therapist on each half day. 35 In June two new centres for stammerers from elementary schools were established at, the Kennington-road and Tottenham-road schools, and in November the facilities already provided for elementary school stammerers were extended to pupils from secondary schools by the opening of centres at the North Western polytechnic (for north London) and the " Henry Thornton " school (for south London). These centres meet on Saturday mornings only, in order that the secondary school curriculum may not be unduly interrupted. Thirty-four pupils have been enrolled at the two last named centres since their inception. In November, another new centre at the Salters-hill school was opened. This centre deals entirely with stammerers and speech defect cases found among the children in the Council's residential schools and homes. Treatment by relaxation makes further progress every year and its effects become more noticeable. During the past year for example a boy of twelve was completely cured in the space of six weeks. At another centre a training-ship boy of 15£ who stammered after falling overboard was re-adjusted and cured, and has now been passed for the Royal Navy. Relaxation has also had notable results in children working for scholarships. In order to help the children to practise regularly at home, books in which each child could keep his own record were instituted at several of the centres. In a certain number of cases books were mislaid, but the majority of the children have kept a faithful and regular record of the practice carried out at home. These records are in no sense competitive but enable each child to watch his own progress and the maintenance of a good record becomes an incentive to practice. In one or two instances a child has been so inspired by the effects in himself of his own relaxation as to bring a stammering friend to the centre with the request " will you please cure my pal, too ! " At one centre one of the boys was found to have conjuring abilities. A " show " was therefore staged at the end of the term which was attended by all three groups and several outside visitors. The self-confidence acquired by this boy enabled him to maintain his " patter " throughout without a trace of stammer. Dr. Boome, the supervising medical officer of the day centres, has also visited the centres for adult stammerers held in connection with the " Hugh Myddelton " and Pages Walk evening institutes, where some of the pupils, whose cure was not completed before leaving day school, were continuing their treatment. Rheumatism scheme. During 1935 certain changes were introduced in the organisation of the rheumatism scheme, the general effect of which has been to ensure that the majority of London children suffering from rheumatism may now be brought at the earliest possible moment within the ambit of the scheme. This result has been obtained partly by the provision of a larger number of beds in the rheumatism units (there are now 630 beds for acute and sub-acute cases, and about 200 beds for convalescent cases) and partly by the organisation of arrangements whereby children admitted to the Council's general hospitals on account of rheumatism have been brought within the general framework of the scheme and their transfer to an appropriate type of rheumatism unit thus expedited. To this latter administrative change must be attributed the greater proportion of the sudden increase in the number of nominations for treatment under the scheme received during 1935 over the number recorded for 1934. The actual number of nominations received from the medical superintendents of the Council's general hospitals was 256, and since the new arrangements have only been in force for six months it is to be expected that in a complete year the rheumatism section will have to deal with from 500 to 600 additional nominations from this source, and it may well be that even the present number of beds allocated to the rheumatism scheme may have to be increased. Of the 1,959 nominations received this year (see table 18) the voluntary hospitals and the rheumatism supervisory centres were responsible for over 1,200. The 36 remainder (approximately 700) came in about equal proportions from the Council's general hospitals, the school medical inspections and from outside sources. During the year, 1,639 children were actually admitted to the units for treatment, this representing 83 per cent. of the number nominated. In addition 115 children were found by the medical referees to be unsuitable for treatment under the scheme and these, together with the 126 whose parents refused to allow the children to go away, account for the greater part of the discrepancy between the number of nominations and that of admissions. Table 19 giving the figures of admissions to the various units and showing the numbers of the cases in which the heart had been definitely affected before admission shows that the clinical picture as a whole has changed little from that which last year's figures indicated. Boys formed a slightly larger proportion than usual of the total number of admissions, the proportion of girls to boys being usually about three to two, whereas this year's figures show the proportion to be about six to five. Approximately 40 per cent. of those admitted had evidence of definite cardiac damage, and as usual boys suffered to a slightly greater degree than girls (boys, 41 per cent.; girls, 39 per cent.). It is a possibility that the somewhat greater physical activity which boys exhibit, and their disinclination to accept the role of invalid until compelled to do so, may be related to this. In rheumatism the final condition of the heart is a trustworthy indication of the success or failure of the end results of treatment. Measured by this standard, table 20 shows that in approximately 2 per cent. of cases treatment must be regarded as having failed since the children were discharged as unfit for any form of activity. But there is, nevertheless, legitimate ground for satisfaction when it is noted that 84.5 per cent. of the children discharged were regarded as fit to resume normal life, and the number of those who were partially incapacitated by reason of cardiac involvement was only 13.5 per cent. of the total, against 16 per cent. during the preceding year. There is excellent hope that this number will be reduced still further as it becomes more and more realised by all those who have anything to do with children that rheumatic infection of the heart is of all diseases the most treacherous, producing its effects with few or none of those signs which the general public are accustomed to associate with heart disease. One of the greatest difficulties experienced by the physician in the treatment of rheumatic infection is to secure the whole-hearted co-operation of the parents who feel that his attitude is somewhat " grandmotherly " when he insists that a child who does not complain needs prolonged rest in bed. The statistics relating to the work of the supervisory centres are shown in tables 18 and 21. Somewhat fewer new cases were seen than during the preceding year, but the decline was trifling. Additional centres were opened at the Hampstead general hospital, at Poplar, and at Deptford. An increase of 733 in the total number of children attending the centres, i.e., including old cases, is registered, and a very considerable increase in the number nominated by the centre doctors for institutional treatment (526, as against 313 for 1934). Gratitude must again be expressed for the great help obtained from the care committee organisation in connection with the reports on the home conditions of the children. As a result of these reports borough medical officers of health were notified in 225 instances of defective housing conditions. In addition the care committee visitors have provided valuable reports on individual cases of children absent owing to recurrence of rheumatic infection. 37 Table 18. Particulars. 1933 1934 1935 Total number of nominations 1,845 1,571 1,959 Nominations received from voluntary hospitals 1,017 804 750 „ „ ,, rheumatism supervisory centres 352 313 526 „ „ „ school doctors 293 320 214 „ „ ,, general hospitals since 1-7-35 — — 256 „ ,, „ other sources 183 134 213 Number of children admitted to special hospitals 1,447 1,096 1,639 Cases seen by medical referee in voluntary hospitals 244 348 315 „ „ „ „ „ in general hospitals since 1-7-35 — — 248 „ „ „ „ „ in their homes 720 561 541 „ „ „ ,, „ at rheumatism supervisory centres 394 329 534 „ „ „ „ ,, at County Hall 357 248 256 Cases transferred direct from special hospital or residential school — — 9 Number of cases under supervision by school doctors 1,481 1,803 2,129 Reports made by care committees on home conditions 1,147 995 1,365 Number of rheumatism supervisory centres 16 17 20 Number of sessions at rheumatism supervisory centres 999 1,051 1,067 Number of children attending rheumatism supervisory centres for first time 1,973 2,187 2,047 Total number of attendances at supervisory centres 14,880 15,340 15,420 Number of cases reported to medical officers of health re dampness, etc., or to valuer for better accommodation 230 150 225 Table 19.—Admissions to special hospitals and convalescent homes during 1935. Boys. Girls. Hospital or home. 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 115 173 128 184 600 High Wood hospital 18 36 53 46 153 Downs hospital 128 53 157 63 401 Lower Southern hospital 160 35 198 52 445 Norwood children's hospital from 1-7-35. 8 9 10 13 40 Total 429 306 546 358 1,639 Table 20.—Recommendations on discharge as to future education. Hospital. p.d. school. Elementary school. Totally unfit. Under or over school age. Transfers. Total. Queen Mary's, Carshalton. Hoys. Girls. Boys. Girls. Boys. Girls. Boys. Girls. Boys. Girls. Boys. Girls. 48 29 159 217 7 6 27 43 1 1 242 296 High Wood 4 21 22 62 2 4 2 19 5 3 35 109 Downs 19 26 116 142 5 2 8 17 2 — 150 187 Lower Southern 10 12 157 210 — — 6 11 2 3 175 236 Norwood children's 2 2 8 7 1 — o — 1 11 12 83 90 462 638 15 12 13 92 10 8 613 840 Total 173 1,100 27 135 18 1,453 38 Table 21.—Rheumatism supervisory centres. Name of rheumatism supervisory centre. Number of children attending during 1935. 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 367 168 476 644 14.6 43 eptford 121 120 138 258 9.2 34 Downham 380 101 581 682 14.2 37 "Elizabeth Bullock" 261 115 412 527 12.8 32 Eltham 237 76 415 491 12.3 31 Hammersmith 414 95 640 735 17.5 20 Hampstead 56 56 165 221 7.1 9 Hospital for Sick Children (Great Ormond-street) 319 104 1,021 1,125 5.6 18 King's College hospital 499 155 934 1,089 18.2 38 Lewisham 380 104 480 584 14.7 40 Poplar 69 69 150 219 7.1 13 Princess Elizabeth of York hospital (Shadwell) 462 130 942 1,072 23.6 45 Putney 145 59 251 310 14 13 Queen's hospital 608 147 1,388 1,535 18 59 Royal Free hospital 394 109 1,586 1,695 28.6 31 Royal Waterloo hospital St. George's 665 161 2,247 2,408 28 35 tal 203 55 272 327 7.8 — St. Marylebone dispensary 97 34 382 416 9.9 1 Stoke Newington 213 89 553 642 12.6 12 Woolwich 309 100 340 440 10 8 Total, 1935 6,199 2,047 13,373 15,420 14.3 519 Total, 1934 5,466 2,187 13,153 15,340 14.6 241 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 1935, 1,629,068 examinations of children were made at these rota visits. In 140,755 cases the child was noted as verminous, i.e., in 8.6 per cent. of the examinations, compared with precisely the same percentage of 8.6 for 1934 and 9.0 for 1933. In accordance with the desire of the Board of Education, arrangements were made in 1933 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 79,557 (compared with 83,207 in 1934, and 91,629 in 1933), figures which represent all those children who were noted to be infested with live vermin or their ova. About 52 per cent. of the cases in which verminous conditions were recorded at the rota visits are stated to be infested with nits only. 39 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 for cleansing, 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 and 1935 are in respect of the cleansing scheme operated from the Council's and Borough Councils' centres (as distinct from the " head " cleansing centres):— 1934 1935 Number of advice cards issued to parents 80,260 80,682 Number of children attending voluntarily at bathing centres after advice cards 40,079 41,603 Number of statutory notices served in accordance with section 87 of the Education Act, 1921 22,302 20,513 Number attending bathing centres after statutory notices— (а) voluntarily 4,749 4,565 (b) Compulsorily 14,016 14,661 Number of cases in which police court proceedings were taken 465 321 At the head cleansing centres 24,390 cases attended during the year compared with 23,171 in 1934. 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 1935 a total of 75,023 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. 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 1935, 11,891 children were conveyed in the ambulances. Children suffering from scabies and impetigo are treated at the bathing centres. The total of such cases was 6,435 for the year, a considerable increase on the number for the previous year (5,545). 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. 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. Warm baths. A scheme by which children attend certain public baths of the Borough Councils for warm baths has existed for several years. Parties are formed with the consent of the parents and are accompanied by the school nurse, who excludes any suffering from contagious disease. The number of children attending for warm baths during school hours in 1935 was 32,007, compared with 31,742 in 1934. 40 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 of&ces, where action could be more quickly taken in appropriate cases. The subjoined table shows the number of children reported to have been out of school for more than three months in November, 1935, and comparative figures for the four preceding years. The reduction in the numbers between 1933 and 1934 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 number of children (232) 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 half as many cases again compared with boys. These include children who are being nursed at home, are in voluntary hospitals or institutions and in the Council's general hospitals. Since July, 1935, steps have been taken to expedite the removal of such children as were in the Council's general hospitals, where education is not provided, into the hospital schools. Nervous disorders (including 18 cases of epilepsy and 6 of encephalitis lethargica) accounted for 61 children. Ringworm, formerly a chief cause of prolonged absence from school, accounts for only 2 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. Tuberculosis was the cause in 67 cases. Among other ailments, respiratory diseases, other than tuberculosis, accounted for 41 cases, and ear disease for 25. In spite of the greater incidence of the rheumatic diseases upon girls (134 as against 98 in boys), the total invalidity amongst girls is less during 1935 than that amongst boys (369 to 381). There were 17 boy cripples and 11 girl cripples. These are children with spinal or lower limb disease who are either unable to walk or require assistance in walking, and are returned by the attendance officers simply as "cripples." Table 22.—Census of chronic invalids, November, 1935, and the four preceding years. Ailment. Cases. Percentage of total. 1931. 1932. 1933. 1934. 1935. 1931. 1932. 1933. 1934. 1935. Rheumatism, heart ease and chorea 546 550 608 320 232 33.67 31.87 33.40 36.00 30.9 Nervous disorders 93 65 95 59 61 5.74 3.76 5.20 6.64 8.1 Tuberculosis (all forms) 212 219 209 79 67 13.07 12.68 11.50 8.90 8.9 Anaemia and debility 52 77 75 40 41 3.21 4.46 4.10 4.53 5.5 Ringworm 9 5 4 5 2 0.55 0.29 0.22 0.56 0.3 Skin complaints (excluding ringworm) 38 45 51 25 35 2.34 2.61 2.80 2.82 4.7 Eye disease 70 63 76 8 9 4.31 3.65 4.10 0.91 1.2 Infectious diseases 34 90 70 45 35 2.10 5.22 3.80 5.07 4.7 Other defects 568 612 632 307 268 35.01 35.46 34.88 34.57 35.7 Total 1,622 1,726 1,820 888 750 100 100 100 100 100 41 Infectious diseases in schools. The numbers of cases of infectious illness reported by head teachers as occurring among children on the rolls of the day elementary schools during 1935, compared with similar figures reported during the preceding six years, are shown below:— Table 23. Year. Diphtheria. Scarlet fever. Measles and German measles. Whoopingcough. Chickenpox. Mumps. Scabies. Ophthalmia. 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 1935 4,337 5,078 3,079 7,500 10,146 12,199 1,133 354 Day- elementary schools. The figures for ringworm are given later in this section of the report (page 45). No cases of smallpox were notified in London during the year. The last confirmed case occurred in June, 1934. 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 24. Division. Diphtheria. Scarlet fever. Number of visits. Number of depts. visited. Number of children examined. Number of visits. Number of depts. visited. Number of children examined. N.E. 44 39 4,401 14 14 1,868 N. 29 28 1,721 16 15 1,154 N.W. 35 29 2,218 14 14 1,210 S.W. 20 19 1,580 19 19 1,230 S.E. 27 22 2,473 35 31 3,858 Total 155 137 12,393 98 93 9,320 The children in one school were 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 and ophthalmia, as well as in the special visitation of the schools where there were outbreaks of whoopingcough and chickenpox, mumps, measles, scabies and influenza. Diphtheria. In the course of 155 visits paid to the schools by medical officers for special investigation of diphtheria, a total of 2,946 children in affected classrooms were swabbed, yielding 2,843 negative and 103 positive results or a percentage of 3.5 children with diphtheria bacilli in the throat or nose or both, or, in a few instances, the ear. Virulence tests were applied to 90 isolated subcultures of the diphtheria bacillus from the 103 positive swabbings, yielding 76 virulent (84.4 per cent.) and 14 non-virulent. In two of the 8 cases of ear discharge, diphtheria bacilli were isolated, one case proving virulent and the other non-virulent. In addition, 387 children were swabbed as a precautionary measure, previous to going to convalescent homes, holiday camps or on school journeys. Among them were seven who showed the presence of diphtheria bacilli (1.8 per cent.). Of 6 of the subcultures tested for virulence, two proved virulent and four non-virulent. Also 183 boys and girls were swabbed in various residential establishments for children (apart from the Council's residential schools and children's homes); 12 of them proved positive (6.5 per cent.), 10 being tested for virulence (5 virulent and 5 non-virulent). 42 In addition to the above groups, a total of 723 individual children were selected for swabbing either at treatment centres or at schools on account of suspicious conditions of the throat or nose, or as known home contacts of diphtheria. Among them, 96 or 13.2 per cent. were found to yield diphtheria bacilli. Out of the 96 positive cultures 85 subcultures were tested for virulence, and 70 (82.3 per cent.) proved virulent and 15 non-virulent. These four groups may be classified in order of proportionate presence of of diphtheria bacilli as follows:— Table 25. Group. Number. Diphtheria bacilli present in Percentage positive Percentage virulent Selected children (at treatment centres and schools) 723 96 13.2 10.9 Children in residential establishments (except the Council's residential schools and children's homes) 183 12 6.5 3.3 Elementary school children 2,946 103 3.5 2.9 Unselected children 387 7 1.8 0.6 Total 4,239 218 5.1 4.4 Diphtheria " carrier " clinics. With these results may be compared those obtained in the residential schools and children's homes, recorded elsewhere : 15.4 per cent. positive and 13.1 per cent. virulent. In 70 re.examinations (at varying intervals) of children previously swabbed (the majority positive at the first swabbing) 27 (or 38.5 per cent.) were still found to show the presence of diphtheria bacilli, and 43 proved negative. On arrival 11 cases were found to be positive and 12 negative. The following is an analysis of these cases:— Table 26. Result. Positive on arrival. (8 operations.) Negative on arrival. Total. Discharged cured 9 11 20 Ceased to attend 1 1 2 Current cases 1 — 1 Total 11 12 23 Dr. H. G. Close has furnished the following statement regarding the work carried out at the special clinic at Guy's hospital:— Number of new patients treated 34 Ages—Under 5 years 5 Between 5 and 14 years 24 Over 14 years 5 Sex—Male 17 Female 17 The arrangements made with three voluntary hospitals, viz., London, Guy's, and St. Mary's, Paddington, for the treatment of diphtheria carriers at special outpatient clinics, were continued during 1935. 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 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 summarv of cases for 1935:— 43 The carrier condition was originally detected in swabs taken in the following circumstances:— Routine examination before going to a convalescent home 13 Diphtheria contact at school 7 Recent diphtheria 5 Diphtheria contact at home 4 Nasal discharge 4 Tonsilitis 1 After arrival at the clinic the following results were obtained:— In 14 cases (41 per cent.) three consecutive swabs of nose and throat taken at weekly intervals failed to show the presence of K.L.B. In 3 cases the K.L.B. found was shown to be of a non-virulent variety. In 17 cases (50 per cent.) the K.L.B. present was virulent and the distribution of cases according to the site of the K.L.B. was as follows:— Tonsils and nose 4 Tonsils only 6 Nose only 7 With the exception of one carrier (non-virulent K.L.B.), all cases yielded to the appropriate treatment and were discharged after three consecutive swabbings had failed to show the presence of the diphtheria bacillus. During the above investigations and treatment the following bacteriological examinations were found necessary:—244 swabs taken and cultured; 23 virulence tests. Dr. A. B. Porteous, who is in charge of the clinic at St. Mary's hospital, Paddington, has submitted the following report:— During the year, 28 cases were referred to St. Mary's hospital diphtheria carrier clinic, compared with 36 in the previous year. Of these, 2 were adults and the remainder were children of ages ranging from 13 months to 13 years. Only 3 of these cases had previously had diphtheria, and 2 were contacts of diphtheria; the rest were so-called carriers, found whilst being swabbed previous to going to convalescent homes, or detected in schools. At the outset I should state that 18 of these cases were found consistently negative from the first examination. This means probably that the so-called K.L.B. reported was only present for a very short time, or else the diagnosis of K.L.B. was made too readily. In this regard it should be also stated that all these 18 cases had been reported as carrying the germ in the nose only. The technique at the clinic has been to plant the swabs directly from the patient on to inspissated serum. Where so-called positives are obtained, these are subcultured on to tellurite plates in order to obtain pure cultures, thence they are again planted on serum and made into vaccines, or used for virulence tests. It has been found necessary to perform virulence tests in respect of only 5 of the cases, and all of these were negative. Active immunisation against diphtheria. Facilities for Schick-testing and immunisation against diphtheria were provided by four more metropolitan boroughs during the year, making a total of 22 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 later in this section of the report. Passive immunisation against scarlet fever and diphtheria. Cyril Henry treatment centre. Reference has been made in previous annual reports to the practice which has been adopted at the Cyril Henry treatment centre of passively immunising children against scarlet fever and diphtheria with a combined antitoxin consisting of streptococcus and diphtheria antitoxins before tonsil and adenoid operations, with a view to the prevention of the occurrence of those diseases after the operations are performed. The practice was continued during 1935. Parental consent is obtained in each case. During the year the following modifications were introduced : (a) if a further operation became necessary after the lapse of an interval of 3 weeks the antitoxin was again administered; (b) the antitoxin was given in cases in which there was a previous history of scarlet fever or diphtheria attack. The following report on the results of the scheme has been received from Dr. H. R. Kidner, divisional medical officer:— The surgeons concerned agreed to inject even when there was a previous history of an attack of scarlet fever or diphtheria or a previous pre-operation injection. 44 The surgeons were asked to have adrenalin at hand for immediate injection in such cases if it appeared advisable. One surgeon decided to give an intra-muscular injection of adrenalin before the antitoxin and reported that there had been no signs of any ill effects even with a history of diphtheria only two months before. The sister in charge has provided the following statistics for the two periods of the year:— 1st January to 30th April. (No injection if child had previously had scarlet fever or diphtheria.) 509 children attended. 75 operations deferred as child unfit. 280 children given combined serum. 86 children were not injected because they had had previous attacks of scarlet fever or diphtheria. 68 parents refused. 1st May to 31 si December. 1,152 children attended. 158 operations deferred as child unfit. 892 children given combined serum. 9 children not given serum because of recent immunisation. 4 children not given serum because of history of recent asthma. 89 parents refused. Six children had a slight serum rash during their stay at the centre and 377 others were reported by nurses visiting after the operation to have suffered from serum reaction, but none was seriously ill. During the year three children were diagnosed as suffering from scarlet fever after operation at the centre:— Case 1.—Operation 30th January, 1935; scarlet fever 4th February, 1935. Antitoxin not administered owing to parental refusal. Case 2.—Operation 13th March, 1935; scarlet fever 19th March, 1935. Antitoxin not administered as child had previously suffered from diphtheria. Case 3.—Operation 19th March, 1935; scarlet fever 23rd March, 1935. Antitoxin not administered as child had had injection before a previous operation. Measles. The completion of the report on the measles epidemic in London of 1933-34, to which reference was made in the last annual report, was unavoidably delayed. It was published in April, 1936.* References were made in this report to various aspects of the epidemic, including incidence, mortality, hospital provision and treatment, and home nursing, and a special section was included dealing with the use of serum in measles prophylaxis. The biennial epidemic was due to begin in the autumn of 1935, and, from the information furnished by the daily reports of the head teachers, it was evident that it had commenced in certain parts of London towards the end of October, 78 cases being reported during the fourth week of that month. The average number of cases reported weekly during the preceding eight weeks had been 31. The following statement shows the numbers of cases of measles reported from the schools during the first stages of this and of the two preceding epidemics:— 1931-32. 1933-34. 1935-36. Nine school weeks preceding Christmas holidays 1,568 1,899 1,032 First six weeks of spring term 4,809 7,065 3,928 It is evident that the present epidemic was unusually slow in developing. The special scheme of co-operation between the school nurses, teachers, school attendance officers and borough medical officers of health (through their health visitors) was reviewed in consultation with the borough medical officers of health and the education officer during the summer months, and a few minor alterations were made as a result of experience gained in previous epidemics. The object of the scheme is to bring to the notice of the borough medical officers of health cases of measles in their earliest stages, in order that consideration may be given to the question of providing home nursing facilities through the borough health services or arranging for the admission of cases of the disease to the Council's hospitals. During November and December the scheme was put into operation in 23 schools. Leaflets containing advice to parents, which are issued by the borough medical officers, were distributed in affected schools. * Report of the Medical Officer of Health and School Medical Officer on the Measles Epidemic, 1933-34. No. 3180. Price 1s. 45 Whoopingcough. Judging from past experience the epidemic will last until July, 1936. During the year the school nursing staff kept under daily observation the children in 141 schools where whooping-cough was prevalent. At the request of Dr. A. Ferguson, medical officer of health of the borough of Stepney, who desired to " follow up " cases of whooping-cough in their homes, arrangements were made early in the year for the close co-operation of the teachers, school nurses and school attendance officers in drawing immediate attention to cases or suspected cases of the disease occurring amongst children on the rolls of the schools in the borough and also amongst those of pre-school age in the families concerned. Dr. Ferguson has stated that the scheme has been of definite value and it is being continued. Chickenpox. Arrangements were made during the year for the school nurses to pay daily visits for varying periods to 195 schools owing to the incidence of chickenpox amongst children on the school rolls. Mumps. The incidence of mumps amongst children on the school rolls was high during 1 the first half of the year, the north-eastern and south-western areas being first affected. The disease spread later to other districts. During the twelve months under review 12,199 cases were reported by the head teachers, compared with a yearly average of 7,817 during the previous 5 years. The school nurses visited daily 251 schools for the purpose of keeping the children under observation and advising as to the exclusion or readmission of cases and suspects. 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 cases of the disease amongst the children Ringworm. The following table shows the number of cases of ringworm of the scalp among the children in the Council's schools dealt with during 1935 compared with the ten preceding years:— Table 27. 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 1935 196 211 43 77 During the year, 474 specimens of hair from school children were examined for ringworm at the laboratory at the County Hall. Ringworm fungus was found in 128 of these (103 small spore and 25 large spore). Favus. Play centres. 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. School journeys. 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 1935 are set out on page 58. Hop picking —infectious disease. The Council continued the co-operation with the public health authorities in the home counties in measures to lessen the spread of infectious disease in the hop D 46 fields. Following the practice which was inaugurated in 1933, a leaflet giving advice on the subject to intending hop pickers was distributed to those concerned through the health services of the various Borough Councils, the officers of the Council's public assistance department, and the school organisation. It may be of interest to reproduce a copy of the leaflet which was drawn up in collaboration with the medical officers of health of the Kent County Council and of certain of the local authorities in that county as well as the medical officers of the metropolitan boroughs:— HOP PICKING. Help is asked of all those who will go hopping this year to lessen the risks of spreading infectious disease among London hop pickers. 1. You can help by preventing actual cases of infectious disease, or contacts of cases of infectious disease, from entering the hop fields. It is unlawful for any one suffering from an infectious disease to travel in a public conveyance, the penalty being a fine not exceeding £10. Apart from this there is great danger of spreading disease to other families in the hop fields. Anyone who has been in contact with infectious disease is strongly urged not to go hopping during the three weeks following contact. People who have been in contact with infectious disease and who go to the hop fields against advice are sent back by the farmers. 2. You can help by preventing cases of tuberculosis from entering the hop fields. No one suffering from consumption or tuberculosis should go hopping, as there is a grave risk to other people sleeping in the huts which are invariably overcrowded at week-ends. 3. You can help by making sure that only pickers booked by the growers go to the farms. No one should go hopping who has not actually been engaged by the farmers to pick, as the accommodation is limited. Unauthorised visitors may be turned off the farms. Overcrowding will cause great discomfort in the huts, the sanitary provision will not be adequate, and the risk of an outbreak of infectious disease will be increased. The medical officer of health of the South-West Kent United Health Area has stated that, since the leaflets were first distributed, fewer contacts of cases of infectious disease have come to the hop fields. Approved schools and remand home During the year, fifteen children were admitted to the Council's infectious hospitals from the Ponton-road remand home as cases of diphtheria or as carriers. The inmates were kept under careful observation, and swabbed where necessary. Two cases of diphtheria occurred at Mayford school. References to the progress of active immunisation against scarlet fever at the Mayford school, and of active immunisation against diphtheria at Mile Oak, Ardale and Cumberlow Lodge schools appear later in this section of the report. A few cases of other infectious illnesses were reported during the year from these establishments. Residential open-air schools. A few sporadic cases of infectious illness were reported during the year from the residential open-air schools. Residential special schools. Apart from some cases of chickenpox that occurred amongst the children at one of the residential special schools, the incidence of infectious illness during the year amongst the children in these schools does not call for any comment. Reference to active immunisation against diphtheria in these schools appears later in this section of the report. 47 Residential schools, children's homes, and children's receiving homes. The arrangements described in previous annual reports for sending infectious disease "contacts" to Earlsfield House children's receiving home have been continued. During the year, 151 children were admitted to the "contact" block at Earlsfield House. Of these, 36 developed the disease to which they had been stated to have been exposed, and 2 developed other diseases. A brief summary of the incidence of infectious illnesses in the residential schools, children's homes, and children's receiving homes during 1935 is set out below. The cases of infectious illness (except scabies, impetigo, and some of the cases of body ringworm) were removed to one or other of the Council's hospitals. All practicable steps were taken in close co-operation with the officers of the schools and homes with a view to preventing the spread of infection. Diphtheria.—A group of cases of diphtheria occurred in one school from which 11 children were removed to hospital, 7 of these were confirmed as mild clinical cases and 4 were found to be carriers. Of the 7 clinical cases, 3 had not been Schick-tested owing to parental refusal or other reasons, 2 had been reported as Schick negative and 2 had received courses of prophylactic treatment. Twenty-six children were transferred to hospital from one of the receiving homes, a diagnosis of diphtheria being confirmed in 22 (4 were carriers). In another receiving home 15 cases of diphtheria were confirmed after removal to hospital, and there were also 4 carriers. The cases were mainly sporadic and most of the children concerned were incubating the disease on admission. All the cases were mild. Owing to the short length of stay of children in the receiving homes, active immunisation against diphtheria has not been undertaken in these homes. In 15 of the residential schools, throat and nose swabbings of 318 children yielded a total of 49 (or 15.4 per cent.) showing the presence of diphtheria bacilli, 269 proving negative. Of 34 subcultures tested for virulence, 29 proved virulent and 5 non-virulent; one of the latter in subsequent testing of a further subculture, was, however, found to be virulent. Of 7 children with ear discharge, 2 yielded virulent diphtheria, the remaining 5 being negative. In 9 re-examinations of children already found positive, diphtheria bacilli were still present in 6. Among 16 adults, employed in the residential schools, who were swabbed, 15 yielded negative results, and 1 showed the presence of virulent diphtheria in the throat. Scarlet fever.—Sporadic cases of scarlet fever occurred in some of the schools and homes. Measles.—A few cases of measles were reported during the year. Gentian measles.—A group of cases of German measles occurred in one school, and some sporadic cases were reported from some of the other establishments. Whooping-cough.—Several cases of whooping-cough were reported from one school, and a few cases from other schools and homes. Chickenpox.—Groups of cases of chickenpox occurred in three of the schools, and there were a few cases in some of the others. Mumps.—Outbreaks of mumps occurred in six of the schools as well as in one of the receiving homes. A few cases were reported elsewhere. Scabies.—Cases of scabies were reported from four schools. Impetigo.—Cases of impetigo were reported from four schools. Ringworm.—A few cases of scalp ringworm were reported. Specimens of hair stumps taken from suspected cases were microscopically examined in the laboratory at the County Hall. Out of 26 specimens examined, ringworm fungus (small spore) was found to be present in 6. Some cases of body ringworm were reported from one school during the autumn, particularly amongst some of the girls, and the children in the nursery. The cases cleared up satisfactorily after treatment at the school. Special measures were taken with regard to the washing and disinfection of the towels. In consequence of the occurrence of some cases of body ringworm amongst the boys on the T.S. "Exmouth," visits were paid to the ship by the consulting physician for skin diseases (Dr. J. M. H. MacLeod), who reported as follows D1 48 The cases were found to be due to the epidermophyton inguinale, the most common fungus of body ringworm in this country. The parts specially affected by it are the crutch, armpits, and between the toes, with occasional small satellite patches present elsewhere. This fungus never affects the hairs. The possible causes of the spread of this type of infection are latrines, underclothes, towels, insufficient washing and lack of care in drying the toes. In addition to a special examination of the boys twice a day after washing, various measures were taken in accordance with Dr. MacLeod's recommendations, including the remodelling of the W.C. seats, the replacement of the woollen pants worn by the boys by cotton cellular trunks, the provision of thin cotton undervests which could be easily washed and sterilised; the prevention of cracking and scaling of the skin between the toes by strict supervision of bathing parades, and the proper disposal and drying of towels after use. Acting on instructions issued in a circular sent to medical officers of residential schools and homes where there are girls, 20 cases of vaginal discharge were reported during the period July to December (apart from the remand home); 15 of these were transferred to hospital for observation. No evidence of gonococcal infection was found in any of these cases. Thirteen cases of vulvo-vaginitis were transferred from the remand home to hospital. As a result of bacteriological examination, gonococcal infection was found to be present in 5 of them, and they were retained in hospital for appropriate treatment. The remaining 8 cases were negative. In connection with these instructions, the matrons and women superintendents of the schools and homes concerned were invited to County Hall, and the methods of detection and of dealing with cases of suspected vulvo-vaginitis were explained fully by one of the Council's women medical officers. The arrangements for the Schick-testing and active immunisation against diphtheria of the children in the residential schools, children's homes, residential special schools and approved schools have been described in previous annual reports. Vulvovaginitis. Active immunisation against diphtheria in residential establishments for children. The following is a summary of the progress of the work during 1935 :— Table 28. Classification. Residential schools and children's homes. Residential special schools. Approved schools. Number tested for susceptibility to diphtheria 842 136 35 Number found to be immune 486 77 28 Number found to be susceptible 356 59 7 Number who completed the full immunising course and gave negative reactions on re-test 210 33 - Number who left the schools before course of injections had been completed 33 3 - Number outstanding on 31st December, 1935, who had received one or more injections and whose course of immunisation was to be completed in 1936 113 23 7 The medical officers of the schools reiterate the opinions expressed last year that there has been little or no local or general reaction to the prophylactic agent (formol toxoid) and that the process of immunisation has not interfered with the ordinary routine of the children in the schools and homes. The following report from Dr. R. D. Milford, medical officer of Hornchurch children's home, is worthy of note:— I think it is of interest that, during a severe epidemic of diphtheria in this district occurring in the summer and autumn of 1934 and the spring of 1935, although all the outside schools which are attended by our children were involved quite heavily, yet no single case occurred among the children of this institution. I think this can be taken as evidence of the effectiveness of the measures taken against diphtheria. Actually about 85 per cent. of our children have been Schick-tested and either found negative or rendered negative by toxoid administration. On 20th November, 1935, the Education Committee approved the introduction of active immunisation against diphtheria at Ardale approved school and on 4th December, 1935, a similar scheme was sanctioned for Cumberlow Lodge approved school. The work at these two schools was begun early in 1936. 49 The Council, in November, 1935, decided that the members of the staffs employed at the residential establishments for children should be given the opportunity of being immunised against diphtheria if they so desired. The officers and employees concerned are being asked whether they wish to be immunised. Active immunisation against scarlet fever. Active immunisation against scarlet fever is being carried out at two of the Council's residential schools—Mayford approved school and Shirley residential school. The position in each of these schools since active immunisation commenced is set out in the following tables:— Table 29.—(a) Mayford approved school. Accommodation, 150. Ages 9-15 (males). Year 1933. 1934. 1935. Average number in residence 143 146 145 Tested for susceptibility Whole school 41* 53* Refusals 10 1* 1* Number (and percentage) of susceptibles found 8 out of 51† (15.7 per cent.) 11 (26.8 per cent.) 7 (13.2 per cent.) Negative after 5 injections 6 8† 10 11 5 7 Negative after further injection(s) 2 1 2 Cases of scarlet fever occurring in the school 2 (not tested) 0 0 * Represents new admissions. † These figures relate to 8 susceptibles out of 51 tested for whom complete records were kept. Complete records were not kept of the remaining 92 children tested in 1933. (b) Shirley residential school. Accommodation, 600. Ages, 2-16 (males and females). Year 1934. 1935. Average number in residence 520 530 Tested for susceptibility 442 159 Refusals 9 13 Number (and percentage) of susceptibles found 63 (14.3 per cent.) 27 (17 per cent.). Negative after 5 injections 37 63 8 27 Negative after further injection(s) 18 14 Left before completion of course 8 5 Cases of scarlet fever— (a) Among those not tested or immunised* 4 6 (6) Among those in the scheme : (i) Before completion of course of injections 1 0 (ii) After completion of course of injections 0 1 (11 months later) (iii) Negative after preliminary test 1 0 * Including parental refusals and those for whom parental consent had not been received. In both schools immunisation began at a time when scarlet fever was prevalent. A comparison of the incidence of the disease before and after immunisation is provided by the following figures:— Table 30. Year. Mayford. Year. Shirley. 1932 3 1932 35 1933 Jan. to April 9 1933 41 1934 January ... 2 Immunisation began— Immunisation began— 23rd May: 1st February: 2 (not immunised) 6 (one "immune" after preliminary test). 1934 0 1935 0 1935 7 (one returned as "immune" after completion of course of injections). 50 Table 31.—Shirley residential school. Months. 0- 1- 2- 3- 4- 5- 6- 7- 8- 9- 10- 11- 12+ 1935—Period for which susceptibles were in the school before coming under the immunisation scheme. Numbers of susceptibles — — — 5 4 2 1 2 5 3 3 — 2 1934-5—Time after joining school that cases of scarlet fever appeared. Numbers not immune 4 — — — 1 1 — 1 1 1 — 1 — 2 Numbers immune — — — — — — — — — 1 1 Mr. W. T. Russell, F.S.S. (Medical Research Council), assistant in the division of epidemiology and vital statistics, University of London, has very kindly examined these statistics, and his comments are as follows:— Comparing the experience at Shirley school (the larger series) during 1932-33 with that during 1934-35, it would appear that the second course suggests success with immunisation. But it will be noted that there were 379 children out of a total of 520 who had an acquired or natural immunity in 1934 (there were 442 tested of which 63 were positive and hence 379 immunes). This high proportion of immunes, nearly 80 per cent. would accrue as an inevitable result of the severe infection in 1932 and 1933, when there were 35 and 41 cases of scarlet fever. Hence, with such a high percentage of immune children in the population in 1934 one would scarcely expect much scarlet fever in 1934 and 1935. Furthermore, there is the additional difficulty of delayed parental consent to immunisation. In the circumstances no conclusions can be drawn from the present data. Disinfection of water in swimming baths at residential schools. During the year experiments were carried out by Dr. J. E. McCartney, director of research and pathological services, to ascertain the best method to be adopted for the sterilisation of the water in the swimming baths at the Council's residential schools, and a simple procedure was devised for testing the sterility of the water, and for carrying out any necessary treatment. The chloramine method was employed, using ammonium sulphate followed by "chloros." Three parts of chlorine per million can be used without affecting the taste or smell of the water. In order to ensure thorough mixing, so essential for the proper working of the method, a weighted board was devised, which was towed the length of the bath several times. The water was tested for the presence of chlorine by an orthotolidine reagent. When the chlorine content was below .2 parts per million, the bath was re-treated with ammonium sulphate and chloros. The chemicals are supplied direct from the Southern group laboratory in amounts calculated for the size of each individual swimming bath. Detailed instructions were sent to the schools and a demonstration was given to the officers concerned. The method has resulted in keeping the baths free from micro-organisms, and has prolonged the time between renewals of the water. Open-air education. The first open-air school in this country was established by the London County Council in Bostall Woods in the year 1907. Throughout the nineteenth century tuberculosis, which was rife, was considered an incurable disease. In 1815, Sir Thomas Young, one of the leading English physicians said: "Even with the utmost powers of art perhaps not more than one case in one hundred will be found curable." The art to which Sir Thomas Young referred universally consisted in wrapping up in heavy clothes every tuberculous individual as well as those regarded as likely to become tuberculous, in keeping them in a confined and heated atmosphere and in guarding them against exposure to the fresh air as carefully as against the Evil One. Under this treatment the threatened attack usually supervened and was taken to prove how prescient and wise was the medical attendant who feared and prophesied it. 51 As art proved unavailing it is not surprising that a voice here and there was raised in favour of Nature, but these voices, such is the strength of use and custom, cried in the wilderness or fell upon deaf ears. One of these voices was that of Dr. George Bodington who opened what would now be called a sanatorium, the first of its kind, at Sutton Cold field, where he practised the principles of the necessity of a continuous supply of fresh unheated air, keeping the rooms so open that the air should be indistinguishable from the pure air outside. He expressed the opinion that "cold is never too intense for a consumptive patient." Convinced by his experience of the truth of his observations he published in 1840 an essay on "the cure of pulmonary consumption on principles, natural, national and successful," in which he advocated a generous diet, fresh air day and night, together with systematic arrangements with regard to exercise. Bodington was thereupon attacked with the utmost venom by press and populace, including his medical brethren, and received the most bitter and contemptuous treatment. He was before his time. He was regarded as a lunatic; his patients were driven from his institution. Bodington's revenge was to turn his sanatorium into an asylum for the insane. Thus, while the seeds of open-air therapy were first sown in England, they fell on barren ground. Later the light began to break through in foreign countries, and it was only after general acceptance of the principles was achieved abroad that the truth at last prevailed in this country. Sanatorium treatment for consumptives began in Germany in 1859 where Brehmer founded a sanatorium. Like Bodington and other pioneers in England, he suffered fierce opposition and ofttimes abuse, but he persisted with his efforts and after long fighting he convinced the world of the soundness and importance of his principles and practice. Brehmer had noted that people forced by their occupation to follow an open-air life did not succumb to tuberculosis in spite of the fact that their relatives who followed indoor occupations were not immune. His experience was amongst peasants living at a high altitude. He reasoned that " anything that protects one man from falling ill must be able, if properly employed, to cure another of the same disease." He evolved a regime which included seven principles:— (i) A life in the open air. (ii) A high altitude. (iii) Complete freedom from debilitating circumstances. (iv) Methodical hill climbing. (v) Constant medical supervision. (vi) Abundant supply of food in which milk, fatty food and vegetables occupy the chief place. (vii) Hydrotherapy. In these principles of Brehmer are to be found almost all that is still thought of importance in regard to health in the open-air school. Only one of Brehmer's principles has proved in universal experience in every country not to be essential and that is the principle of altitude. Naturally coming from such an authority, whose teaching was at long last accepted, the idea that a high altitude was necessary persisted long, and at the end of the last century it was still generally held in England that every consumptive must go to Switzerland to have any chance of cure. Gradually, however, it was found that by following Brehmer's principles of treatment consumptives could be cured in low-lying and humid countries, and that expensive journeys to central Europe were not essential. The great objection to Brehmer's views raised by medical men and others in England was that patients, especially delicate people, could not stand the necessary exposure, but on submission to the test of practice it was shown that no amount of exposure to wet conditions or variation of temperature in the open air causes the most 52 delicate patient to contract what is termed a chill or suffer any harm as long as a strict open-air life is led and exposure is constant. If patients are well fed, sufficiently clothed and sheltered from the wind, any degree of cold may be defied. One of the greatest advantages of the open-air life is the comparative freedom from colds which are suffered almost universally and repeatedly by those living under the usual conditions of confined and heated rooms with greatly debilitating effect. The principles of Brehmer were derived from observation of the healthy and applied to the sick for curative purposes. The opening of the open-air or forest school in the Griinewald of Berlin in 1904 was a re-application of the principles to the day school for preventive purposes. With commendable promptitude the Griinewald idea was transplanted to England by the London County Council and the Bostall Woods open-air school was formed. No attempt was made to modify the arrangements which had already been worked out and the continental siesta which was part of the Griinewald regime was included. This was the first application of the principle of organised rest into English day schools. It has proved to be an important and necessary part of the open-air system. In the Council's schools the principles of Brehmer are seen carried out almost in their entirety; life complete in the open air, the absence of heating or impeding buildings, shelters open on all sides, abundant food, rest, organised but free exercise and hydrotherapy. Perhaps the least developed has been hydrotherapy, although that has by no means been altogether neglected and regular bathing occupies a place in the curriculum. Adapting the words of an American writer, what is received in the curriculum of the open-air schools is unlimited rations of pure air, double rations of food, double rations of exercise, double rations of rest and one-third rations of sedentary work. Too often the word "school" is used when merely the word "school-building" is meant. In the open-air school the spirit, the relation of teacher and pupils, the activities are all important as they should be, but when visiting the site when teachers and pupils are absent there is no "school" to see. Since Brehmer's time there has been one new physical principle discovered and that is the healing power of sunlight. No doubt the success of open-air treatment has always depended to some degree upon this, and, as the ultra-violet rays are more abundant in the high and clear atmosphere of the heights, some light is thrown by this upon Brehmer's doctrine of altitude. Systematised knowledge of the value of ultra-violet rays is a product of the intense study of nutritional problems which the war made necessary. A man was always congratulated on his bronzed appearance when he returned from an open-air holiday. It was thought, however, that it was a mere concomitant of his restoration to health and there was no idea that the bronzing was a specific part of the process of health renewal until the studies which resulted in the discovery of the part that vitamins play in the preservation of health were carried out some 15 years ago or so. It was then found that sunlight, or rather that ultra-violet rays, which do not pass through ordinary glass, enable the skin to transform inert substances into health-giving vitamin. Although in the London atmosphere, even in the suburbs, there is insufficient ultra-violet light to produce an effect through most of the year, every open-air school should make arrangements to utilise this aid to health by organised sunbathing between the middle of May and the middle of September. The children selected for the non-tuberculous day open-air schools are those who were called pretuberculous in the old days. The term has now gone out of fashion, but the children are those who are unable to thrive under the confined conditions which exist in ordinary school life, many of whom indeed fall ill immediately they attempt to attend under usual conditions and are, in consequence, backward through repeated or continuous absence. 53 The aim is to restore them to health and preserve them in health while giving them necessary education, the chief result of their education being, however, a love of open-air conditions, a hatred of confinement and a technique of life which will stand them in good stead after their departure from school in preserving them from the dangers which are undergone by those who do not appreciate the value or importance of fresh air. The almost immediate results of the entry of the debilitated child to an open-air school are an increased rate of metabolism with improved appetite, an increased rate of growth, improved circulation and respiratory capacity, relative freedom from colds and catarrh, and consequent freedom from obstruction of the respiratory passages, increased percentage of haemoglobin in the blood, improved carriage and posture, the replacement of poor spirits by a feeling of the joy of life (partly dependent upon the heightening of the blood pressure) and as a result of this an improvement in alertness and in mental capacity. The teachers of the open-air schools have made many reports and observations of the greatest value. Thus at Bow-road careful records kept over a period of five years all the year round showed that lessons were taken entirely outside the shelters on 1,008 days, partly in and partly out on 95 days, and inside the shelters only on 125 days; thus the shelters are unnecessary for 85 per cent. of the time during which school is held. At the beginning of the open-air work in London prejudice was too strong to allow of the school being maintained open in the winter months, but experience soon, not only dispelled the qualms which even the hardy might have felt, but convinced even the timorous that this was quite feasible. From Upton House records were compiled showing the attendances of children at school for corresponding winter months before and after admission, which showed that children who had been absent for long periods before admittance, made attendances from 70 upwards after admission and in many cases indeed of 100 per cent. Provision. Provision for education in the open air now includes nine day open-air schools (non-tuberculosis) with accommodation for 1,460 children, and six day open-air schools (tuberculosis) accommodating 618 children. There are also seven country and seaside convalescent camp schools, accommodating 520 children for periods varying from one to three months, through which 4,337 children pass annually; and 224 open-air classes in playgrounds and parks providing for upwards of 6,000 children. The nine day open-air schools for non-tuberculous children maintained by the Council have continued their excellent work. Open-air schools for non-tufcerculous children. Council have continued their excellent work. The following table gives the roll of these schools in December, 1935:— Boys. Girls. Total. Aspen House 96 55 151 Bow Road 107 83 190 Brent Knoll 84 49 133 Charlton Park 93 54 147 Downham 96 51 147 Holly Court 178 119 297 Stowey House 167 118 285 Upton House 93 57 150 Wood Lane 86 63 149 Total 1,000 649 1,649* *Note—The roll of an open-air school may be 20 per cent. above the nominal accommodation. In addition to the provision of treatment for tuberculous children in residential Open-air institutions, the Council continued the use of the open-air schools (type T) specifically schools for for children with quiescent tuberculosis and for those suspected to be suffering from chiidren°US 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. 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. 54 The six schools—Elizabethan (Fulham), Geere House (Stepney), Kensal House (Paddington), Springwell House (Battersea), Stormont House (Hackney), and Nightingale House (Bermondsev) have a total nominal roll of 618. The number on the roll on 31st December, 1935, was 564, and the average attendance for the year was 492. 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 1935, 188 children were admitted and 194 discharged. Of the latter, 45 were transferred as fit to attend elementary schools, 94 were fit for work, 16 were transferred to institutions for residential treatment for tuberculosis or admitted to hospitals for various reasons, 25 moved away, 11 were transferred to special schools, and 3 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 1935, every child in attendance at these schools should have a holiday out of London either by means of private arrangements or through the school journey organisation. The following school journeys were made during the year, through the ordinary school journey organisation:— Table 32. School. Period. Place visited. No. of children. From To Elizabethan open-air school 1.6.35 15.6.35 Broadstairs 50 Geere House 7.5.35 21.5.35 „ 55 Kensal House 12.7.35 26.7.35 Whits table 25 Nightingale House (Boys) 24.5.35 7.6.35 St. Leonards 35 „ „ (Girls) 9.7.35 23.7.35 Bognor 35 „ „ (Mixed) 14.9.35 28.9.35 „ 35 Springwell House (Girls) 25.6.35 9.7.35 ,, 40 „ (Senior Boys) 24.5.35 7.6.35 Tankerton 20 „ (Junior „ ) 12.6.35 26.7.35 „ 20 Stormont House (Boys) 10.5.35 24.5.35 Broadstairs 30 „ „ (Girls) 7.6.35 21.6.35 30 In addition, provision was made for a further 36 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 2nd to 16th and 16th to 30th September. 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. Convalescent camp schools. The numbers of children passing through the residential convalescent camp schools during 1935 were : boys, 2,833; girls, 1,504; total, 4,337. In detail the numbers were:— Provided, schools:— Boys. Girls. King's Canadian school. Bushy Park 2,813 George Rainey, St. Leonards — 522 VVanstead House. Margate — 535 Total 2,813 1,057 Non.proiided schools:— Boys Girls Fairfield House, Broadstairs 92 Russell Cotes school, Bournemouth 236 St. Vincent's, Hastings 99 Sandon Home, Chelmsford 20 20 Total 20 447 55 The actual number of children away at these schools at one time in 1935, was : Bushy Park, 280; Margate, 60; St. Leonards, 63; Bournemouth, 30; Broadstairs, 20; Hastings, 12; Sandon, 20. Total, 485 children, of whom 205 were girls and 280 boys. The experimental camp school for mentally defective children at Loughton was initiated owing to the desire to give the children in the special schools the same advantages as those enjoyed by the children of the ordinary elementary schools. With the assistance of the Shaftesbury Society, arrangements have been made upon a permanent basis to conduct a residential open-air school at the Society's premises at Sandon Home, Chelmsford. It is intended that the benefits of this home shall not be confined to children from the schools for the mentally defective only, but shall be extended to other classes of special school children, including the physically defective and the partially deaf. The accommodation is for 20 children, and it is proposed to send from 120 to 200 children a year. The home was opened for the purpose on 26th October, 1935, when 20 mentally defective girls went for a stay of four weeks. The head master of the King's Canadian residential open-air school has submitted the following account of the physical activities:— The school roll for the year was 2,813 boys, all of whom received the usual type of physical training in accordance with an approved syllabus. In addition to this normal class-work, 1,480 of the number came under the special care of the two physical training specialists for strengthening exercises and a further 402 boys received treatment in the following groups:—kyphosis, 182; lordosis, 40; scoliosis, 37; flat feet, 118; mouth breathers, 25. Much benefit accrued from the exercises taught and many of the old boys who have visited after leaving school show that improvement has been continuous. The other activities of the school, walks, gardening, hygiene, health talks and social life, have all helped in this work. It has been noted that many boys are handicapped by wearing too many and too tight garments, both in summer and winter. Breathing is restricted by the use of waistcoats, which may also encourage a stooping carriage. The figures concerning dental and nursing treatment are again most interesting:— Dental treatment— Cases treated 1,163 Attendances 1,486 Extractions—temporary teeth 294 permanent teeth 344 Anaesthetics—nitrous oxide 228 E.C. spray 103 Fillings 1,073 Gum treatment 153 Scalings, etc. 508 Nursing treatment— Treatments for minor ailments 18,462 Infectious cases sent to hospital 10 Other illness cases sent to hospital 3 Stammerers whose treatment was continued 9 Illness cases nursed in sick ward 11 Sent home with scabies (recurrences) 2 The length of stay at residential open-air schools was raised on the presentation of a report by Mr. G. H. Leslie, district inspector, and Col. E. Eton, special services branch of the education officer's department, on their visit to the residential open-air school at Knocke, Belgium. The Special Services Sub-Committee instructed the chief inspector to report upon the length of stay at residential schools. At Knocke the stay is 12 weeks, while at the Council's open-air residential schools the stay varies from four to six weeks. The system of admission is also different in that at Knocke, at the end of the 12 weeks' period, all the children are discharged and replaced by an entirely new complement. The chief inspector set up an inter-departmental committee to consider the question, and their report is now under consideration. The present position in regard to length of stay is : Council's schools—King's Canadian (Bushy Park), 4 weeks in summer, 6 weeks in winter; George Rainey (St. Leonards), 6 weeks; Wanstead House (Margate), 6 weeks. Non-Council schools—Fairfield House (Broadstairs), 12 weeks; Russell Cotes (Bournemouth), 56 6 weeks; St. Vincent's R.C. (Hastings), 4 weeks. At all these schools the stay can be extended upon the advice of the school doctor, while, at Fairfield House, children are sent home if they have completely recovered at an earlier date than 12 weeks. The excellent results at the open-air residential schools are illustrated in fig. 2, which has been prepared for the inter-departmental committee from records which have been supplied by the superintendent of Fairfield House, to whom my thanks are due. Fig. 2.—Average increase in weight of girls at Fairfield House as shown by the fortnightly weighings. A, D and H represent the average increase for the whole party. B, E and G „ „ „ „ „ girls newly admitted. C, F and K >. „ „ „ „ second-term girls. The dotted line shows the average increase for normal elementary school children. The remarkable increase of weight which open-air life immediately promotes is once more shown in these charts which also show the average increase for elementary school children. It is to be noted that especially large increases are made in the first six weeks, after which the rate of increase slackens considerably, although it is still greater than that of average children living at home. Observations made upon children returning to London after a stay of six weeks show that the impetus to growth is not lost but lasts for some time after return from the open-air holidav. Barham House— weights. For instance, Dr. McVail reports that at Barham House for five weeks the average increase in weight of 25 girls was 3.55 lbs. per child, or .71 lbs. per child per week, an increase about four times as great as the average for normal elementary school children during the same period. In the following 8 weeks, the average increase per child for the same 25 girls was 3 lbs., or .34 lbs. per child per week, an increase about twice as great as the average for elementary school children. Open-air classes in parks and playgrounds. The number of open-air classes held in connection with the elementary schools in 1935 was 215. Of these, 9 were of type A (children selected on medical grounds from a group of schools); 90 were of type B (children selected on medical grounds 57 from the various classes of a single school); 30 were of type C (consisting of a single class from one school, educated continuously at one open-air station); and 86 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, 81 of the 215 classes were continued throughout the winter, where the suitability of the sites had been approved by the school medical officer. Of the 215 classes, 69 were held in parks, gardens, playing-fields and other open sites, while 146 were held in school playgrounds, of which 35 were roof-playgrounds. Children in classes of the types A and B are kept under special observation by the school doctors, and 51 detailed reports upon the results of these have been received. The physical progress of the children is carefully watched, and regular charting of height and weight is carried out. Perusal of the reports leaves no doubt of the great benefit delicate or debilitated children derive from well organised openair schooling. Typical extracts from the reports follow:— "The general improvement in tone, liveliness, colour and response of the children attending the class is definitely noticeable." "Several nervous children have improved; other children who were dull are more alert. Parents who attended were all satisfied that the children had improved, and reported increased appetite and better sleeping at night." "There has been no case of infectious disease and very little absence on account of colds. The children all like being in the class, and appear brighter and more mentally alert." "Two children who were subject to frequent bronchitis are now in regular attendance and the bronchitis has disappeared." "All children reported by parents to have a better appetite, to be better in general health and to sleep better." Convalescence. In addition to the provision for children at residential open-air schools, there is now a large provision for convalescence in institutions of the Council's special hospitals service. This is one of the benefits of inestimable value which the Local Government Act, 1929, has bestowed upon the school children of London. The institutions were formerly maintained by the Metropolitan Asylums Board and were restricted in their use. Now they are open to children referred through the school medical service. Full advantage is being taken of them by the elementary school children, and the resources of the service for promoting the welfare of the school population are thus immenselv increased. are thus immensely increased. In the year ending September, 1935, 5,998 children were sent for convalescence. Institution. No. of beds. No. of children convalescent during the year ended September, 1935. St. Anne's home 127 1,037 Goldie Leigh hospital 50 163 Downs hospital for children 100 *1,351 Lower Southern hospital 660 2,852 Princess Mary's hospital for children 50 202 (when available) †Millfield convalescent hospital 98 385 ‡ Holy Cross convents (Broadstairs and Margate) — 8 5,998 * The total number of admissions is given as there is no separate convalescent unit. All cases sent require medical and nursing attention. † Admission is from special hospitals only; the number of children is therefore not included in the total number of applications. ‡ A voluntary institution. Except at the Lower Southern hospital, education is provided for the convalescent children and the institutions are recognised by the Board of Education as hospital schools. 58 In addition to the provision detailed above, the Council has agreed to pay grants to the Invalid Children's Aid Association on account of certain children convalesced by the Association. This provision came into operation in May, 1935, and by the end of the year the Council had paid grants to the Association in respect of a maximum period of eight week's convalescence for each of 566 children. Lower Southern hospital is primarily an infectious diseases hospital, and the continuance of convalescent arrangements here cannot be counted upon all the year round. School journeys. The teachers in many schools voluntarily organise arrangements by which children are taken during term time to hostels and camps in the country or by the seaside, for periods generally of two or three weeks. The Council has directed that the school medical service shall assist so far as is possible with this excellent work. In 1935, 429 school journeys were made (compared with 407 in 1934), and the children taking part were medically examined in all cases before departure. In all 14,310 children were examined (the corresponding figure for 1934 being 13,569); and of these 49 were excluded as unfit to take part in the journeys on various grounds, including the following (the figures in parenthesis refer to the year 1934):—otorrhcea, 8 (7); infectious disease or contacts, 4 (4); tonsillitis and kindred ailments, 11 (12); temperature, 5 (11); personal hygiene, 0 (2); skin diseases, 10 (14); heart, 4 (0). 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 54 respecting the school journeys from open-air schools for tuberculous children. 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, the required standard being that each complete meal should contain 25 grammes protein and have a heat value of 750 calories. The menus of dinner meals have been revised during 1935. As the result the subjoined general instructions were issued for the guidance of domestic subjects instructresses. Quantities and ingredients to be allowed for each child in preparing meals of various types:— 1. Meat meals. Meat (uncooked), 3½ ozs. with bone; 2½ ozs. without bone. Potatoes, J lb. Root vegetables, ½ lb., or green vegetables, 1/4 lb. Second course.—A selection of one of the types of pudding set out below. 2. Soup meals. Stock, ½ pt. Pulse vegetable, 2 ozs. Cereal, ½ oz. Potatoes, ½ 1b. Dripping, ½ oz. Seasoning. Minced meat or liver can be added to this with advantage. Fresh vegetables in season to be included for variety. Second course.—This must always consist of some form of suet pudding. 3. Meat puddings and pies. Meat (without bone), 2} ozs. Flour, 2 ozs. Suet, 2/3 oz., or dripping and/or lard. Potatoes, 1/3 lb. Root vegetables, 1/5 lb., or green vegetables, 1/4 lb. Seasoning. Second course.—Either of puddings (c), (d), (e), (f), (g). 59 4. Fish meals. Fish, 1/4 1b. Potatoes. ½ lb. Root vegetables, 1/5 lb., or green vegetables, 1/4 lb. Sauce must be served with (not over) all fish meals. Herrings may be served without sauce if wished. Sauce. 1/8 pt. milk and water. ½ oz. flour. ½ oz. fat. Seasoning and flavouring as desired. Second, course.—Either of puddings (a), (6), (c), (d). 5. Puddings suitable fob inclusion in meals. (a) Boiled suet pudding. Flour, 2 ozs. Dried fruit, ½ oz., or Suet, 2/3 oz. with Syrup or jam, 3/4 oz., or Sugar, 1/4 oz. Fresh fruit, 21/2 ozs., and sugar, ½ oz. (b) Baked pastry. Flour, 2 ozs. Dripping, 2/3 oz. with Jam or syrup, 3/4 oz., or Baking powder—a pinch. Fresh fruit, 21/2 ozs., and sugar, 1/2 oz. (c) Milk puddings.—1/3 pint of pudding per child. The pudding should contain the following proportions:— Cereal, 2 ozs., viz., rice, sago, tapioca, barley. Milk, 3/4 pt. Water, 1/4 pt. Sugar, 2 oz. Suet, 1 oz., chopped finely. (d) Baiter pudding. Flour, 1 oz. Egg, 1/4. Milk, 1/4 gill. with Syrup or sugar or jam 3/4 oz., or Water, 1/4 gill. Fresh fruit, 1½ ozs., and sugar, ½ oz. Salt. (e) Orange pudding. Orange, 1, cut in slices. Sugar, ½ oz. Milk custard, ½ gill. (/) Fruit and custard. Uncooked fruit, 3 ozs. or Dried fruit, 1½ ozs. (before soaking). Sugar, ½ oz. (approx.). Sugar, 1/8 oz. Custard.—1/4 pt. milk custard per child. (gr) Fresh fruit.—One medium-sized apple or orange or 1/5 1b. of plums. (h) Any other pudding of equal food value may be served. General rules. Meat must be served three or four times a week. Soup must only be served once a week. Fish may be served once a week in lieu of meat. Cheese, pie or pudding may be served occasionally instead of soup. Haricot beans may be served once a week in place of root or green vegetables. Fresh fruit should be used in the making of puddings and pies when it is cheap. Potatoes baked in dripping should be served at least once a week. An endeavour should be made to vary the meals as much as possible. Hitherto, as was explained in the last annual report, children placed upon the free dinner list have not necessarily come under the school doctors' notice, whereas children were placed upon the free milk list solely upon the doctor's recommendation, and these were kept under continuous medical observation and weighed at regular intervals. The situation with regard to the provision of free meals has been clarified by the issue by the Board of Education in December, 1935, of Circular No. 1443. Under the terms of this circular the Board consider that provision may properly be made for any child who shows any symptoms, whether educational or physical, however slight. Local education authorities should take steps to ascertain the needy children by inviting reports from school doctors, teachers, school nurses, attendance officers and others in regular contact with the children. Interim arrangements should be made for the immediate feeding of the children, however ascertained, but all children selected for feeding should be seen as soon as possible by the school doctor, who should keep under review their condition and progress. The Council has considered the circular and has arranged that in future the practice set out in the paragraphs above should be followed. 60 The free provision of meals and of milk in London schools will in future be carried out in the same way. Teachers are now empowered to place children who appear to need feeding on the dinners or milk list as an interim measure, pending the investigation and decision of the school care committee, and the children concerned will all be placed under medical supervision as soon as possible. The number of individual children on free meals in December in the years 1933, 1934 and 1935 were as follows:— Table 33. Meal. 1933. 1934. 1935. Dinners 7,190 5,725 5,245 Milk 12,775 15,691 20,300 Cod-liver oil and malt 2,094 2,190 No return. The making of returns in relation to meals in school imposes such labour upon the teachers that since April, 1935, they were relieved of the duty of returning the numbers of children having milk in school for payment and of those having codliver oil free or for payment. The great enthusiasm with which the scheme of the Milk Marketing Board, made under the Milk Act, 1934, was taken up in London was described in the last annual report. In October, 1934, within a fortnight of the scheme coming into force, there were no fewer than 364,157 children obtaining milk in school at the new cheap rates. There occurred a considerable drop in the total number of children on the rolls of public elementary schools in London between October, 1934, and October, 1935. According to returns made on form 208M to the Board of Education, there were in March, 1935, 344,604 children in public elementary schools in London receiving milk under the " milk in schools scheme," and 322,597 children in October, 1935. The number of children on the registers on 29th March, 1935, was 521,532 and on 1st October, 1935, was 507,066. Under the scheme of the Board, payment for milk supplied to schools under its provisions is only made to those dealers who are approved by the school medical officer in consultation with the local medical officer of health. In 1935 two sources were found to be unsuitable, either on account of the cleanliness or quality of the milk supplied, and my approval was formally withdrawn. A series of complaints that spicules of glass were found in the milk bottles supplied made an enquiry into this trouble necessary. It appears that the presence of the spicules was connected with the use of wide-mouthed bottles sealed with cardboard discs. The dealers are meeting this difficulty by the provision of a narrower-necked bottle sealed with caps of tinfoil and improved carriers. From a return made by the nurses visiting the schools, it appeared that spicules of glass had been noted in bottles delivered under 152 contracts, and several reports suggested that none had been found since the introduction of the narrower-necked bottles. The progress by the end of July, 1935, in replacing the wide-mouthed by narrownecked bottles sealed with tin-foil caps is shown by the figures given in the returns made by the nurses. At that time deliveries were made as follows:— In glass bottles with cardboard discs 968 In glass bottles with metal caps 296 In cartons 14 Total 1,278 Defective children. Examinations with a view to the admission of children to special schools, other than hospital schools, were made in 4,061 cases. The following table shows the number of children nominated for examination and the recommendations made:— 61 Table 34. 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. Ocular Boys. Girls. Blind school. Partially sighted. Swanley. Boys. Girls. Boys Girls- Boys. Girls. Boys. Girls. Boys Girls. Boys. Girls. 467 660 9 5 58 61 114 147 278 440 8 7 — — Aural Deaf school. Partially deaf school. 82 70 1 1 — Boys. Girls. Boys. Girls. 118 89 23 11 12 7 Physically defective P.D. school. Day open-air school. Residential P.D. school. Boys. Girls. Boys. Girla. Boys. Girls. 655 611 424 423 26 15 64 31 110 110 31 | 32 — Mentally defective 802 526 M.D. school. 391 243 42 36 *43 *41 Boys. Girls. 326 206 Epileptio 68 65 Epileptic colony. 32 35 18 22 Boys. Girls. 18 8 Total cases 2,110 1,951 1,074 914 893 898 100 98 43 41 4,061 1,988 1,791 198 84 *Of these 30 boys and 26 girls were imbeciles; 1 boy and 4 girls were idiots; and 12 boys and 11 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 35. Morbid conditions. Boys. Girls. Total. Infantile paralysis 28 29 57 Cerebral paralysis 23 11 34 Various paralyses 16 12 28 Tuberculosis of bones and joints 61 57 118 Osteomyelitis 29 9 38 Rickets and resulting deformities 4 4 8 Congenital deformities 23 21 44 Scoliosis 3 4 7 Traumata and amputations 25 6 31 Non-tuberculous arthritis and synovitis 13 6 19 Rheumatism and chorea 19 19 38 Various chest conditions—fibrosis, bronchitis, asthma 77 42 119 Heart diseases— Congenital 22 18 40 Acquired valvular Rheumatic 84 117 20] Non-rheumatic 41 69 110 Non-valvular Rheumatic 5 10 15 Non-rheumatic 2 10 12 Anaemia 2 3 5 Pseudo-hypertrophic muscular dystrophy 2 1 3 Various nervous conditions, ataxia, etc. 1 - 1 Other diseases—chiefly medical 8 6 14 Total 488 454 942 E 62 Children returned to elementary schools or invalided. The following statement gives an analysis of the 283 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 36. Morbid conditions. Elementary school. Invalided Infantile paralysis 5 2 Cerebral paralysis 5 2 Various paralyses 5 5 Tuberculosis of bones and joints 16 4 Osteomyelitis 6 3 Rickets and resulting deformities 2 Congenital deformities 9 4 Scoliosis 4 1 Traumata and amputations 3 2 Non-tuberculous arthritis and synovitis 6 — Rheumatism and chorea 20 4 Various chest conditions—fibrosis, bronchitis, asthma 25 4 Heart diseases— Congenital 11 4 Acquired valvular-— Rheumatic 25 6 Non-rheumatic 27 8 Non-valvular— Rheumatic 2 — Non-rheumatic 12 3 Anaemia 8 1 Pseudo-hypertrophic muscular dystrophy 3 1 Various nervous conditions, ataxia, etc 3 1 Other diseases—chiefly medical 23 8 • Total 220 63 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 16,216, and in addition 537 special examinations were made of children already on the rolls of special schools in connection with applications for non-enforcement of attendance and for similar reasons. attendance and for similar reasons. As a result of the rota examinations the following re-classifications took place:— Table 37. 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. Swanley. Physically defective 13 2 _ _ 1 5 4 2 Mentally defective 2 - - 1 - 1 - 2 - Partially sighted - - 7 - - - - 2 Blind — _ 2 — — - - - - Deaf — - — - - 4 - — 1 Partially deaf - - - - 7 - - - - After trial in a special school, 85 children were excluded (35 as imbecile, 1 as idiot, 13 as feeble-minded ineducable, 1 as "special circumstances" and 7 as feeble-minded "detrimental," and 28 invalided on medical grounds). 63 There were also 617 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 38. Action taken. Special school classification. P.D. M.D. Blind. Partially sighted. Deaf. Partially deaf. Total. Returned, on improvement, to elementary schools 176 22 1 7 1 - 207 Over 14 years of age and excluded as no longer certifiable 277 47 _ 86 — _ 410 Total 453 69 1 93 1 - 617 Decertification of phvsically defective children. The following table classifies the children who improved to such an extent that they were able to return from the schools for physically defective children to the ordinary elementary schools, or were " no longer certifiable " as defective between the ages of 14 and 16 years:— Table 39. Morbid conditions. Cases deemed no longer certifiable. Cases deemed fit to return to elementary schools. Infantile paralysis 15 10 Cerebral paralysis 2 — Various paralyses 6 1 Tuberculosis of bones and joints 30 24 Osteomyelitis 11 9 Rickets and resulting deformities 6 7 Congenital deformities 7 15 Scoliosis — 1 Traumata and amputations 11 16 Non-tuberculous arthritis and synovitis 5 4 Rheumatism and chorea 18 24 Various chest conditions—fibrosis, bronchitis, asthma 3 2 Heart diseases— Congenital 13 7 Acquired valvular 117 41 Non-valvular 22 3 Anaemia 2 3 Various nervous conditions—ataxia, etc. Other diseases—chiefly medical 9 9 Total 277 176 Deaf children. During the year Mr. Wells examined 207 children with defective hearing, the decisions regarding whom are set out on page 61. The cause of deafness in the partially deaf, deaf and defective, and deaf, seen for the first time during the year, was found in 21 cases to be congenital, and in 163 cases acquired, while in 21 the cause was uncertain and there were two cases of aphasia. The congenital cases were classified as follows:— Cause of deafness. True hereditary deafness 5 Sporadic deaf birth 16 Total 21 The acquired cases were classified as:— Cause of deafness. Disease of the nervous system 4 Infective conditions 9 Other infectious disease 10 Nasal obstruction 24 Ear disease 112 Injury 4 Total 163 EI 64 Mental Deficiency Acts. Cases notified to the local authority. Mr Wells also visited the schools for the deaf and partially deaf and examined all the children. As a result, 1 child in a school for the deaf was returned to elementary school as having improved. Table 37 on page 62 gives particulars of the re-allocation of children already in attendance at special schools. 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 1935 (the figures in brackets being those for the previous year):— (a) Feeble-minded— Boys. Girls. (1) Leavers 126 (148) 149 (143) (2) Detrimental 3 (2) 5 (3) (3) Special circumstances 2 (2) - (2) (4) Ineducable 10 (8) 12 (11) (b) Imbeciles 55 (55) 48 (43) (c) Idiots 3 (7) 4 (4) (d) In addition to being mentally defective, were blind and deaf 1 (-) 1 (-) 200 (222) 219 (206) Total 419 (428) After-careers. The chief officer of the mental hospitals department has furnished the following return for the year 1935 on after-care of children formerly attending special schools for the mentally defective, but whose names were not notified to the Mental Hospitals Committee as being cases in which the Education Committee were of opinion that further aid in the form of supervision, guardianship or institutional care under the Mental Deficiency Acts was necessary :— Table 40. Classification. Male. Female. Total. Grand total under headings. (1) Number of children born in or subsequent to 1917 who have left special schools and who were on the books of the supervision section on 31st December, 1935 382 189 571 571 (2) Number who after trial have proved themselves to be incapable by reason of mental or physical defect of undertaking remunerative employment 5 2 7 7 (3) Number employed as under :— (a) Industrial or manual occupations (i.e., factory work, trade or any part of a trade) 252 144 396 (6) Agricultural or rural occupations — — — (c) Domestic occupations— M. F. Total (1) Receiving remuneration 3 23 26 (2) Required for work at home 16 7 4 29 33 (d) Commercial, shop assistant, or selling behind a counter, office boys or girls 12 1 13 (e) Gone into army, navy or merchant service — — — (/) Blind alley or other precarious occupations (i.e., vanboys, newsboys, errand boys and girls, selling from a barrow) 76 2 78 520 (4) Number judged to be employable but out of work 18 4 22 22 (5) Number whose careers have not been traced :— (a) Not visited and not seen at bureaux 8 4 12 (6) Visited but no information obtainable 7 3 10 22 (6) Cases dealt with in addition to above including those who have since :— (a) died 1 1 (6) attained the age of 18 years 138 88 226 (e) been dealt with under M.D. Act ... 12 17 29 (d) been lost sight of, or have left London 13 8 21 277 N.B.—In addition to the 571 after-care cases shown in the above return there were 443 boys and girls between 16 and 18 years of age who had left special schools and were under statutory supervision on 31st December, 1935. These also were on the books of the supervision section for placing in employment. 65 Portion Road remand home. The medical supervision of Ponton Road remand home has been carried out by Dr. Ingham, one of the Council's whole-time assistant medical officers. During the year the total number of admissions was 2,420 (2,056 boys, 364 girls). The courts from which children or young persons were received are shown below. The annual increase in numbers since 1930 is shown by the following statement of the numbers admitted in each year :— 1930. 1931. 1932. 1933. 1934. 1935. 785 1,065 1,157 1,504 2,184 2,420 Thus the number of admissions has steadily increased at the approximate rate of 200 a year up to 1932, and since then at roughly 400 a year. The following statement shows the numbers dealt with by each court during the year; together with the corresponding total number dealt with by the court in 1930 Name of court. Number dealt with. Name of court. Number dealt with. 1935. 1930. 1935. 1930. Caxton Hall 129 40 Hertfordshire 36 — Toynbee Hall 303 154 Kent 47 — Lindsey Hall 248 94 Middlesex 468 79 Stamford House Surrey 22 — Deptford 214 102 East Ham 57 — Lambeth 252 83 West Ham 87 — Islington 141 118 Southend-on-Sea 33 — Hampstead 6 — Lodgers, etc 35 11 Various adult courts 80 55 Education Act, petty sessions 24 40 City of London 39 9 Total 2,420 785 Essex 199 — It will be seen that since 1930 seven additional local authorities are now sending their juvenile cases to the London remand home. These additional sources of supply account for 481 cases in 1935. In 1933 the age limit of the juvenile courts jurisdiction was raised from 16 to 17 years. This, no doubt, accounts in some degree for the increased number of admissions in the years 1933-4. The increase in the number of cases received from the various Middlesex courts is striking, and the large numbers remitted from Lindsey Hall (now Stamford House) and Lambeth juvenile courts are also noteworthy. On the other hand, the numbers admitted from Islington juvenile court show a comparatively small increase. Of the total number of cases admitted (2,420) 949 were from outside authorities. Middlesex accounting for 468 and Essex for 199. The following statement shows the charges in detail and the totals under each heading, together with the corresponding total for 1930 :— Offences. 1935. 1930. Offences. 1935. 1930. Larceny, including unlawful possession, etc. 1,566 440 Travelling on railway without paying fare 9 2 Burglary and possessing firearms 5 Arson Wilful damage 2 32 1 10 Armed robbery 6 — Care and protection cases 286 84 Robbery with violence 3 1 Beyond control cases 196 95 Suspected persons 109 14 Begging 13 3 Embezzlement 16 14 Aliens order 1 — Breach of recognisances 09 51 Education Act cases 24 40 Assault with intent to rob 1 — Escaping from approved schools and casual wards 3 1 Common assault 6 6 Sex offences 32 12 Lodgers, place of safety cases, Attempted suicide 2 — etc 35 11 Causing grievous bodily harm 3 — Total 2,420 785 Loitering for purpose of betting 1 — The admissions remain more or less constant for each month with the exception of a distinct drop in December and a lesser drop in August and September. 66 Larceny and allied delinquencies remain by far the most prevalent type of juvenile crime, and account for over one half of the total amount of charges. The number of juveniles charged with " being suspected persons " shows a great increase on the 1930 figure. This charge is noted chiefly amongst boys over 15 and shows an increase since the age of court jurisdiction was raised. The number of " care and protection " cases also shows an increase and accounts for a large percentage of the girl admissions. Physical examination. Crimes of violence and the carrying of firearms appear to show a definite increase. In 1930 and 1933 no cases were reported. In 1931, one case was reported, but in 1935 the number of cases had risen to 14. This number is still small, but the appearance and growth of such crime amongst juveniles must be viewed with some uneasiness. A detailed physical examination was carried out in almost every case. The detailed results are shown below :— Physical condition. 1 = Good, 2 = Fair, 3 = Bad. Condition. Percentage Defects. Percentage Nutrition 1 13.3 Nose and throat Heart. 8.2 2 77.7 3 90 Rheumatism V.D.H. 1.3 Physique 1 11.8 Congenital morbis cordis 0.5 2 74.2 Functional abnormalities 0.9 3 14.0 Circulatory system (anaemia) 2.4 Cleanliness of head 1 81.4 Diseases of lungs 3.0 2 14.0 Diseases of alimentary system 0.9 3 4.6 Central nervous system— Cleanliness of body 1 91.0 Epilepsy (including history) 0.9 2 7.1 Paralysis 0.5 3 1.9 Functional 19.6 Defects. Diseases of skin— Enuresis 0.9 Speech defective 1.8 Scabies 0.6 Genito.urinary disease and deformities . 3.6 Impetigo 0.2 Non.infectious 1.7 Rickets 4.2 Teeth defective 31.8 Endocrine disturbances 0.7 Vision defects (6/9 either eye or worse) 24.0 Rheumatism (including chorea— history and actual) 6.2 Diseases of eyes 4.7 Congenital syphilis stigmata 0.1 Diseases of ear 2.4 Deformities (flat foot, etc.) 21.5 Hearing defective 2.2 As regards nutrition, 9 per cent, were noted to be " poorly nourished." This compares favourably with the 22 per cent, of the 1930 admissions. Personal cleanliness also shows a very decided improvement on the 1930 figures. Skin disease was noted in 4.6 per cent. of cases. This shows a very satisfactory reduction if compared with the corresponding percentage of 16.2, recorded in 1930. Evidence of early rickets shows a comparatively high percentage (4.2). This is as observed in previous reports, and would appear to offer practical evidence of faulty home environment. A very careful watch was kept on all cases for signs of stigmata of congenital syphilis, but out of 2,420 cases only 3 (.1 per cent.) presented any signs. Under the heading of minor deformities, flat feet (15 per cent.), knock.knees (4.9 per cent.), and bow-legs (1.3 per cent.), were responsible for most of the cases noted. The majority of cases, however, were slight, causing no inconvenience in ordinary life, and were of interest only when the question of a sea.faring life was considered. There were 21 cases (.86 per cent.) of enuresis. Under the heading of functional nervous diseases are included not only all cases that showed definite physical manifestation of nervous abnormality (e.g., hysteria, various muscular spasms and tics), but also those that presented marked nervous tension or a high degree of instability. This rather wide interpretation of the heading accounts for the high number of cases recorded (472, or 19.6 per cent.). Behind such 67 charges as " beyond control," and " care and protection," there often lies a history of serious domestic maladjustment and consequent nervous strain. Added factors are the imminence of court proceedings and the attendant investigations, so that when the child comes under the notice of the examiner the nervous tension is at its highest. The general result of the routine physical examination would tend to confirm the observation that the delinquent child is of inferior physical make-up when compared with the average child of similar age. The percentage improvement, compared with five years ago, noted in the physical condition may be due to the larger numbers admitted from the less crowded and more airy environment of the home counties. The physical condition of the children admitted to the remand home shows an improvement, and the numbers admitted (allowing for the wider source of origin and the increase of age) show a great increase. The facts show that physical disability is not a factor of anv importance in child delinquency. Illness and accidents. During the year, 1,206 cases of illness and accident were seen and treated. Of these 319 were serious enough to require hospital treatment. Tonsillitis was still very prevalent, there being 118 cases. The following cases of infectious illness occurred : diphtheria, 14 ; scarlet fever, 2 ; rubella, 3. Two deaths occurred during the year of children under remand in the home. Case 1.—Tubercular meningitis. Admitted to remand home 11.7.35. Transferred to St. James's hospital 22.7.35. Died in St. James's hospital 24.9.35. Case 2.—Cardiac failure (old rheumatic V.D.H.). Admitted to remand home 19.6.35, Transferred to Lambeth hospital 16.7.35. Died in Lambeth hospital 20.11.35. Mental examination. Mental examination was carried out in 89 cases. As a result, 32 cases were found to be mentally defective and certifiable under the Mental Deficiency Acts ; feebleminded, 31 ; imbecile, 1. One case showed definite symptoms of dementia præcox. Of the total number of cases of mental deficiency, 24 were known to be defective on admission, and 8 were unsuspected until examined in the remand home. Acknowledgment must be made to the superintendent of the remand home, Mr. M. J. T. Jones, for his constant help throughout the year, and for his assistance in compiling the records necessary for making the report given above. Child guidance. The question of dealing effectively with the maladjusted or " difficult" child has always been a problem which has caused anxiety to parents, school authorities and the social services alike. In the early days such cases were considered to be merely " naughty," and were very often dealt with as disciplinary cases with negative or unfortunate results. It is now universally recognised that underlying the manifestation of abnormal behaviour is, in many cases, a hidden neurosis, which eventually finds expression in rebellion against the accredited rules and tenets of society, and that such cases must be treated with consideration and care as patients and not as delinquents. After considerable study of the problem over many years, the methods of the child guidance clinics in America were introduced into England about seven years ago. Under these methods each case is considered individually with a view to discovering the underlying factor responsible for the abnormality, and to devising treatment or suitable outlets to enable the child to make the proper adjustment. For this purpose it is necessary that the psychiatrist, psychologist, pedagogue and social worker should work hand in hand in order that a complete picture may be obtained of the past history of the child and his relations, both from a medical and social standpoint, his standard of intelligence and of attainment, his physical condition and his reactions during play. The assistance of the school authorities— teachers, care committee workers and school attendance officers, and the school medical service (school doctors, nurses, medical treatment centres and organising staff)—is essential to the child guidance clinic in order to obtain a proper perspective and also to assist in many cases in the treatment recommended by the clinic. Although the Council as educational authority does not itself accept responsibility for the organisation of child guidance clinics as a part of the school medical service for London, nor is any financial assistance given, every facility available is 68 placed at the disposal of the authorities of the clinics recognised by the Board of Education, so that reports both educational and medical may be exchanged and case conferences attended by teachers, care committee members, and others. Moreover, the attendances of school children at those clinics recognised by the Board of Education are allowed to count as equivalent to attendance at school under section 80 of the Education Act, 1921. - There are at present six clinics thus recognised, viz., (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) Institute of Medical Psychology (Tavistock clinic), Malet-place, W.C.I, (5) North Western child guidance clinic, 32, Lichfield-road, Cricklewood, N.W.2, and (6) The West End hospital for nervous diseases, 73, Welbeck-street, W.l. Maudsley hospital guidance clinic. The information set out below in regard to the work of the clinics has been supplied by the authorities of the clinics concerned. The work at the Maudsley hospital guidance clinic has been continued by the special staff at the hospital, and co-operation has been maintained with the school medical service. During the year the number of school children dealt with was 348. Of these 200 were boys and 148 girls. The age distribution was : age 5 and under. 42 ; 6 to 8 vears. 94; 9 to 11 years. 98 ; 12 to 14 years. 107 ; over 14 years. 7. The following statement shows the sources of reference of the cases, and the reasons for reference :— Source of reference. Reasons for reference. Care committees 110 Difficult and unmanageable 62 Hospitals 97 Backwardness 47 Spontaneous 45 Nervousness 46 Private doctors 29 Enuresis 30 Education authorities 27 Stealing 29 Probation officers 8 Nervous movements 24 Other agencies 32 Intelligence test 20 Total 348 Night terrors and fears 20 Temper 18 Truancy and unwillingness to attend school 12 Sex difficulties 11 Fits 10 Speech difficulties 5 Chorea 3 Faecal incontinence 2 Wandering from home 1 Reading difficulty 1 Schizophrenia 1 Confusional state 1 Sleeping attacks 1 Obsessions 1 Headaches 1 Hysteria 1 Pyknolepsy 1 Total 348 The results obtained were as follows:— Cases closed— Recovered 9 Improved 59 Not improved 20 Seen—not treated (including unsuitable) 42 Failed to attend 24 Psychological test only 20 174 Cases still under treatment 174 Total 348 69 London child guidance clinic. Dr. William Moodie, the medical director of the London child guidance clinic, Canonbury, reports that a general survey of the clinic shows that the work is steadily increasing, that the results of treatment are at a constant high level, and that, by means of certain economies of administration, recording and general management, the labour involved and the time expended in the treatment of cases are gradually but steadily decreasing. With the experience of the past seven years the staff have now that confidence in their own powers of dealing with cases which enables the work to be approached in a more definite way, and it is now possible to predict with greater exactitude the course which a particular case is likely to take, and so to concentrate effective effort in the direction most suitable. Fewer home visits are undertaken by the social workers, but the parents are encouraged to attend more frequently at the clinic for interview, as it is shown that the visits to the centre are taken much more seriously and the parents are able to look upon their troubles in a more detached way. Play activities have continued to prove of great value in diagnosis and treatment. Special attention has been given to individual instruction in cases of educational backwardness where the children have been psychologically able to profit from definite teaching in the fundamentals of school work, and the results indicate the value of assessing the causative factors underlying such backwardness, and of giving the appropriate help in the light of this knowledge. The co-operation of the teachers in this work has been most helpful, and in many cases it has been possible for the clinical work to be supplemented by special programmes of instruction in school. Very great assistance has also been given to the work of the clinic by the unfailing co-operation of district organisers and care committee workers in the interchange of information and following-up of the cases. So far as the treatment of cases during the year is concerned, the largest number of boys dealt with fall within the age group 5 to 11 years, and girls in the age groups 11 to 13 years. Every child is submitted to an intelligence test, and the estimate of his capabilities balanced against his actual educational attainments. Discrepancies between these are very frequently associated with disturbances of behaviour and often form an important feature in their production. The extent of these discrepancies are seldom recognised before clinical examinations. During the year, 206 children attending the Council's elementary and secondary schools were dealt with at the clinic. Of these, 125 were boys and 81 girls. The age distribution was : under 5 years, 11 ; 5 to 8 years, 74 ; 9 to 11 years, 66 ; 12 to 14 vears, 48 ; over 14 years, 7. The following statement shows the sources of reference of the cases and the reasons for reference :— Source of reference. Reasons for reference. School care committees and district organisers 107 Unmanageable 39 Nervousness 33 Parents, relatives, etc. 26 Stealing and lying 28 Head teachers 17 Backwardness 24 Hospitals 14 Enuresis 19 Juvenile courts 8 Truanting and wandering 9 Private doctors 5 Educational difficulties 8 School medical officers 4 Temper tantrums 8 Royal Soldiers' Daughters' homes 4 Sex difficulties 5 Montefiore House 3 Sleep difficulties 5 Jewish Association 3 Habit spasms and tics 4 Charity Organisation Society 2 Stammer 4 Bermondsey medical mission 2 Speech difficulties 4 Parents' employers 2 Sleep-walking 3 Children's special workers 2 Behaviour difficulties 3 Invalid Children's Aid Association 1 Vocational guidance 2 Orphanages 1 Night terrors 2 Juvenile employment exchange 1 Attention-getting behaviour 2 Tiny Tots Brigade 1 Incontinence 2 Aberdare Home 1 Advice re placement 1 Medical officer of health 1 Abdominal pain 1 Clergyman 1 Total 206 Total 206 70 The results of treatment were as follows :— Cases closed — Adjusted 15 Advisory service 35 Partially adjusted 13 Placement 11 Unadjusted or unsuitable 17 Parents not co-operative 10 Treatment interrupted 3 No problem 1 105 Cases still under treatment 101 Total 206 Northwestern child guidance clinic. The North-Western child guidance clinic commenced operations towards the end of 1934, after 18 months preliminary work in close touch with the Child Guidance Council. The methods adopted are closely related to those in operation at the London child guidance clinic, i.e., the team work of the psychiatrist, psychologist and social worker. The clinic is situated on the border of the county and serves the districts of Hampstead and parts of Marylebone and Paddington. Co-operation has been established with the school organisation and the school medical service, and the Council has obtained the Board of Education's recognition of the clinic under Section 80 of the Education Act, 1921, in order that the attendance of school children at the clinic may be regarded as equivalent to attendance at school. During 1935 the number of school children dealt with was 13, of whom 8 were boys and 5 girls. The ages of the children were : 5 years and under, 3 ; 6 to 8 years, 4 ; 9 to 11 years, 4 ; 12 to 14 years, 2. The sources of reierence and reasons for reference were as follows :— Source of reference. Reasons for reference. Care committee or head teacher 7 Nervousness 5 Hampstead Council of Social Welfare 2 Behaviour problems 5 Private doctors 2 Learning difficulties 3 Parents 2 Total 13 Total 13 The results obtained were as follows:— Cases dosed— Satisfactorily adjusted 2 Partially adjusted 1 Placement recommended 2 Cases still under treatment 5 8 Total 13 Institute of Medical Psychology. During the year 1935 the number of children from the Council's schools dealt with at the Institute of Medical Psychology (Tavistock clinic) was 68, of which number 40 were boys and 28 girls. The age distribution was : from 4 to 7 years, 12 ; 7 to 10 years, 25 ; 10 to 14 years, 22 ; 14 years and over, 9. [####]Source of reference. Reasons for reference. Care committees 18 Nervousness 14 Parents and friends 13 Behaviour difficulties 14 General practitioners 10 Backwardness 13 Hospitals 10 Delinquency 7 Head teachers 9 Enuresis 6 Children's special worker 5 Stammering 4 Medical officer of health 2 Sex difficulties 4 Probation officer 1 Truancy 2 Total 68 Lack of concentration 2 Asthma 1 Fits 1 Total 68 The results obtained were as follows:— Improved 11 Partial improvement 8 Not improved 3 Unsuitable or parents not co-operative 5 Placement 3 Consultation only 4 Still under treatment 31 Removed out of London 2 Transferred to hospital 1 Total 68 West-End hospital for nervous diseases. The work of the child guidance unit of the West End hospital for nervous diseases is under the direction of Dr. Emmanuel Miller, and the methods adopted are closely allied to those of the London child guidance clinic, Canonbury, and the East London clinic, Whitechapel. Such neurotic and behaviour disorders as are not treated by social re-adjustment are observed in the playroom, where trained observers keep detailed notes of each child's behaviour. These records are of great assistance to the psychiatrists in diagnosis. In addition, the release of nervous tension and the increase in social adaptability which the playroom affords can be regarded as an actual therapeutic measure in this work. Special individual tuition is given in cases where educational disabilities are found to give rise to anxiety states. During the year 108 new cases were registered, 73 cases were carried over from the preceding year, and 6 cases which had previously been closed were re-opened during the year, making a total of 187. Of the 108 new cases, 72 were boys and 36 girls. The age distribution was: from 4 to 8 years, 40 ; 9 to 11 years, 37 ; 12 to 14 years, 29 ; over 14 years, 2. The following statement shows the source of reference of the cases, and the reasons for reference :— Source of reference. Reasons for reference. Other departments of West End hospital 42 Backwardness 17 Stealing 12 Care committees 37 Intelligence tests only 12 Parents and friends 9 Unmanageableness 10 Juvenile courts 6 Tics and jerky movements 9 School doctors 5 Enuresis 8 Other hospitals 3 Anxieties 7 Other child guidance clinics 2 Temper 6 Head teachers 2 Stammer or speech defect 5 Child Guidance Council 1 Truanting 4 Health visitor 1 Night terrors 4 Total 108 Hysterical illnesses 3 Spitefulness 2 Somnambulism 2 Screaming 2 Masturbation 2 Solitariness 1 Destructiveness 1 Erratic behaviour 1 Total 108 The results obtained were as follows :— Cases closed— Adjusted 39 Improved 19 Unadjusted 5 Parents refused further treatment 14 Unsuitable for treatment 9 Transferred to other clinics 7 Consultation only 25 Parents removed from district 4 122 Cases still under treatment 65 Total 187 72 East London child guidance clinic. The East London child guidance clinic is organised by the Jewish Health Organisation of Great Britain and is held at the Jews' free school, Whitechapel. The director of the clinic, Dr. Emanuel Miller, reports that the clinic continues to provide a steadily increased service on progressive lines. The work has expanded both in the number of cases dealt with and in the field from which they are drawn. Among recent developments, special attention has been given to remedial work for children whose disabilities are educational, and in the speech clinic, which has been re-started, the children are treated individually. The playroom technique continues to produce good results, and not only affords an opportunity for studying the social behaviour of children, but provides the solution for many individual neurotic problems through the freedom for expression during play. Much assistance has been given by the school teachers, and an extraordinary degree of co-operation has been shown by parents and patients in spite of grave economic difficulties. Although many cases have obviously been weighed down by the burden of poverty resulting from unemployment, the reaction to treatment has been surprisingly good. During 1935, the clinic dealt with 326 cases from the Council's schools. Of these, 201 were boys and 125 girls. The age distribution was : under 5 years, 14 ; from 5 to 8 years, 92 ; 8 to 11 years, 93 ; 11 to 14 years, 96 ; 14 years and over, 31. The following statement shows the source of reference of the cases and the reasons for reference :— Source of reference. Reasons for reference. School doctors 143 Nervousness, excitability, restlessness... 90 Care committees 43 Beyond control 36 Hospitals and clinics 36 Theft, pilfering 30 Probation officers and children's courts 30 Enuresis 30 Parents, friends, etc. 27 Backwardness 28 Head teachers 23 Night terror, sleepwalking 19 Private doctors 2 Unmanageable at school 14 Miscellaneous agencies 22 Reading disability 14 Total 326 Habit spasm 12 Stammer 4 Other speech defects 8 Temper tantrums 7 Aggressiveness, spitefulness, destructiveness 7 Wandering 6 Depression 6 Masturbation, sex difficulties 4 Truanting 3 Lack of appetite 3 Advice re employment 2 Solitariness 1 Faecal incontinence 1 Inability to keep job 1 Total 326 The results obtained are as follows:— Cases discharged— Satisfactorily adjusted 73 Partially adjusted 32 Unsuitable or unadjusted 49 Other reasons 19 173 Cases still under treatment— Progressing satisfactorily 36 No change 4 Too early to report 21 61 Cases failed to attend 48 Number of cases on waiting list 44 Total 326 73 Nursery schools. The nursery schools maintained and aided by the Council at the end of the year, 1935, were:— Provided by the London County Council. Accommodation. 1. Columbia Market, Hackney-road, E.2 120 2. Rachel McMillan, Deptford, S.E.8 260 3. Old Church Road, Commercial-road East, E.l 120 Total 500 Aided by the London County Council. *1. Children's House, Bow, E.3 35 2. Goldsmith's College, New Cross, S.E.14 35 3. North Islington, Tollington-park, N.4 40 *4. North Kensington, 325, Kensal-road, W.10 60 *5. Notting Hill, Darnley-road, W.ll 80 6. Rommany, West Norwood, S.E.27 40 *7. Jellicoe, Rochford-street, Kentish Town 54 8. Mary Ward, Tavistock-place, W.C.I 30 (increased from 25 as from 23.10.35). 9. St. Christopher's, Bridge water-street, N.W.I 40 10. St. Leonard's (St. Andrew's), old Foundling site 60 *11. Somers Town, Crowndale-road, N.W.I 40 *12. Women's University Settlement, Blackfriars-road, S.E.I 35 13. Stafford Street Settlement, Peckham, S.E.15 40 (opened 2.9.35). 14. Buck Street, Kentish Town, N.W.I 40 (recognised as from 14.10.35). Total 629 N.B.—The above list excludes the Dalgarno Gardens (N. Kensington) nursery school for 40 children opened on 7th January, 1936. The medical oversight of the nursery schools is under the direction of Dr. E. M. McVail, divisional medical officer. One of the Council's medical officers visits all the schools, except those marked with an asterisk in the above list which provide their own medical officer. School nurses visit daily all the schools except that of the Women's University Settlement, Blackfriars. Accommodation in aided nursery schools was increased by 85 places during the year 1935. Stafford Street and Buck Street nursery schools, each with 40 places, were recognised in the autumn of 1935, and accommodation at the Mary Ward nursery school was increased by 5 places. The following is a statistical summary of medical examinations and treatment at the 15 nursery schools which were open throughout the year 1935 :— Total average roll (all schools) 1,133 Total average attendance (all schools) 946 Total number of visits made by medical officers 185 Total number of examinations of children 2,935 Total number of individual children seen 1,480 Total number of individual children with defects 933 74 Table 41. Defects. For observation. Referred for treatment. *Treated. Percentage treated of those referred. Rickets 80 43 36 84 Nose and throat 237 155 101 65 Eyes and eyelids 10 32 30 94 Vision and squint 7 27 19 70 Ears 7 48 45 94 Lungs 48 49 32 66 Heart 49 3 2 67 Skin 10 94 94 100 Teeth 25 373 260 69 Other defects 93 77 69 90 Total 566 901 688 76 * i.e., known to have had treatment. A number of cases were awaiting appointments. Average number of medical examinations per child 1.98 Average number of defects per child ... 1.57 Percentage of children examined found to be suffering from one or more defect 63 Nursery classes. It is noted that experience is showing the value of increased floor space in the training of young children, for whom older standards prescribed very restricted space. This has been recognised in the Council's new standard planning for all infants' departments. At recently established nursery schools more space than the minimum 15 square feet per child has been provided. The education programme, 1935-38, provided for one additional Council nursery school in each of the three years, and an increase in the grants in respect of voluntary nursery schools. The programme has been modified so that an enlargement of the Old Church-road nursery school will take the place of one of the three additional schools, leaving two new schools still to be provided. For one of these a site has been secured in Kintore-street, Bermondsey, and plans have been prepared. Additional proposals for the establishment by voluntary associations of aided nursery schools are under consideration. It has always been the practice of the London local education authority to admit children from the age of three to five years, and babies' rooms are provided in all infants' schools. All the new infants' departments have specially planned accommodation on nursery class lines, and under the re-conditioning scheme adopted as part of the three-year programme the accommodation of babies' rooms in ordinary schools will, as far as possible, be brought up to the modern standard. Beds are provided for all babies' rooms and no less than 60,000 are in use in London schools. Large toys such as dolls' houses, push carts and other wheeled toys are provided. The three-year programme, 1935-38, provides for experimental nursery classes in connection with infants' departments, two in each year. Proposals have been approved by the appropriate sub-committees for making part of this projected provision. Equipment on the lines suggested will be provided, and in each case a girl helper will be appointed to assist the teacher in the care of the children. It has been decided to establish the first nursery class during the coming year at Senior Street school, Paddington, to accommodate 40 children. Whether future development will be in the direction of detached nursery schools or nursery wings will depend upon the results of the present experiments. Medical inspection and treatment—Day continuation schools, evening institutes and junior instruction centres. The Council in April, 1935, decided that the experiment for the voluntary medical inspection and treatment of pupils attending day continuation schools and three selected evening institutes, which was put into operation on 1st April, 1934, and described in the annual report for that year, should be continued for a further 75 year as from 1st April, 1935. It was also decided that the experiment should be extended to include a fourth evening institute, and that the arrangements should apply to all students under 16 years of age. In addition the Council decided that, as from 1st April, 1935, the medical officer should, as a rule, visit weekly each group (boys and girls) of juveniles attending junior instruction centres for the purpose of conducting a medical inspection of such juveniles as are willing to undergo inspection; but that a juvenile should not be presented to a medical officer until he (or she) had been in attendance for at least one week, subject to any juvenile in regard to whom advice is required being inspected at any time. Day continuation schools and evening institutes. The following are the statistical returns relating to the experiment lor the calendar year 1935 :— Table 42.—Medical inspection. Sex. Number examined. Nutritional state. Condition of clothing and footwear. Cleanliness of skin and hair. Teeth. Vision. Number wearing glasses. Various other defects found. Number advised to have treatment. Excellent. Normal. Subnormal. Bad. Good. Fair. Bad. Clean. Dirty. Pediculi present. Sound. Less than four decayed. More than four decayed. Normal. Slightly subnormal. Treatment required. Day continuation schools. (Number of schools—11.) Boys 508 155 345 8 - 490 18 - 500 8 - 376 124 8 410 51 47 67 *59 183 Girls 288 129 151 7 1 285 3 - 283 5 - 213 | 62 13 193 41 54 62 †67 80 Evening institutes. (Number of institutes—3.) Boys†† 129 27 85 17 - 90 38 1 128 1 - 97 29 3 59 23 19 11 $54 31 Girls†† 153 39 109 2 3 128 25 - 140 11 2 100 39 14 90 34 16 9 ‡127 84 *Nose and throat 5, ear disease 3, defective speech 3, eye disease 3, heart and circulation 3, anaemia and debility 2, lungs 3, nervous system 3, digestive system 1, spinal deformities 4, defects of U.G. system 2, flatfoot 5, other defects 22. †Nose and throat 4, glands 3, ear disease 2, defective hearing 2, eye disease 1, heart and circulation 7, anaemia and debility 7, lungs 1, spinal deformities 15, defects of U.G. system 5, flatfoot 11, other defects 9. §Nose and throat 7, glands 2, ear disease 2, defective speech 5, eye disease 5, heart and circulation 7, lungs 3, digestive system 3, spinal deformities 2, defects of U.G. system 3, flat foot 8, other defects 7. ‡Nose and throat 8, glands 8, ear disease 3, defective speech 1, eye disease 9, heart and circulation 25, anaemia and debility 15, lungs 7, nervous system 5, digestive system 4, spinal deformities 13, defects of U.G. system 2, flat foot 2, other defects 25. ††28 boys and 13 girls not inspected for vision pending availability of suitable room. Table 43.—Re-inspection. Defect. Satisfactorily treated. Under treatment. Further treatment required. Not treated. Day continuation schools. (Number of pupils re-inspected 89.) Dental 25 1 7 17 Vision 23 1 1 7 Nose and throat — — 1 — Eye, ear and minor ailments 1 — — — Other defects 3 9 — 2 Evening institutes. (Nutnber of pupils re-inspected 60.) Dental 22 2 6 2 Vision 15 6 1 3 Nose and throat 1 3 — — Other defects 34 33 2 — 76 The foregoing figures do not include the fourth evening institute as, up to the end of 1935, no medical inspections could be arranged. Medical treatment under the Council's treatment arrangements was asked for in 26 vision and 39 dental cases. In 14 of the dental cases the normal full cost charges were reduced by order of the Special Services Sub-Committee in view of necessitous circumstances. Where the treatment recommended is not available at the school treatment centres, the pupils are advised to make their own arrangements with hospitals, private practitioners, etc., and in some instances the inspecting medical officers have used their personal influence in this direction. In this connection the following is an extract from a report of the inspecting medical officer to one of the girls' evening institutes:— All children we are examining are in full-time work, so I spent some time looking out for facilities for evening treatment of any defects that might be found. I find that almost any ailment can be treated at the voluntary hospitals in the evening. The following is a list of some of the facilities available :— Eyes.—Cases of defective vision can be sent to the Central London Eye hospital, Tuesdays and Fridays, 6.30 p.m. Examination is free. Glasses are obtainable for 3s. with ordinary lenses, with astigmatic lens 5s., gold or horn-rimmed framed are 7s. extra. Tonsils and adenoids, otorrhoea and deafness.—These can be treated on Saturday afternoon at 3 o'clock or Tuesday at 6.30 p.m. at the Central London Ear, Nose and Throat hospital. Orthodontic treatment and dental extraction.—This is most excellently catered for at the Shoreditch Dental hospital every night from 6-8 p.m., maximum charge 2s. 6d., which can be reduced to nothing in necessitous cases. Rheumatism.—This is dealt with at the Peto Place rheumatism clinic, Regent's Park, on Tuesday at 6 p.m., when a specialist doctor attends. Remedial Exercises.—These can be given at the drill instruction classes at Gopsall-street institute. Menstrual troubles.—There is a clinic in charge of a woman doctor at the Royal Free hospital in the evenings. Maladjustment to factory life and nervous troubles.—These can be treated at Malet Place psychological clinic any evening of the week. With every child recommended for treatment I send a personal note to the appropriate hosnital or clinic. Junior instruction centres. The medical inspections at the junior instruction centres began on 31st December, 1934. The visiting medical officers were advised to interview all the juveniles and to recommend milk for all those obviously requiring it, at the same time noting those juveniles for a detailed medical inspection for whom it appeared especially desirable. During 1935, the number of juveniles interviewed was 3,988, the number recommended for milk was 2,099, and the number referred for detailed examination was 1,143. The following table gives particulars of 851 boys and 287 girls examined in detail :— Table 44. Sex. Number examined in detail. Nutrition. Clothing. Skin and hair. Teeth. Vision. Number wearing glasses. Various other defects found. Excellent. Normal. Below normal. Bad {i.e., malnutrition.) Good. Fair. Poor. Clean. Dirty. Pediculi present. Sound. Less than four decayed. Four or more decayed. Normal. Slightly subnormal. Treatment required. Boys 851 110 506 230 5 672 160 19 800 48 3 562 244 45 543 191 83 66 *896 Girls 287 10 244 33 - 174 111 2 235 51 1 176 93 18 149 28 28 18 †148 *Nose and throat 39, glands 230, ear disease 7, defective hearing 4, defective speech 22, eye disease 21, heart and circulation 21, anaemia and debility 366, lungs 21, nervous system 30, digestive system 22, spinal deformities 3, defects of U.G. system 3, flat foot 2, other defects 105. †Nose and throat 8, glands 2, ear disease 10, defective hearing 6, defective speech 2, eye disease 4, heart and circulation 18, anaemia and debility 55, lungs 18, nervous system 2, digestive system 5, spinal deformities 4, other defects 14. 77 The numbers of medical officers' sessions given to this service from 31st December, 1934, to 31st March, 1935, was 121, but, in view of the decision of the Council quoted above that a juvenile should not be presented to a medical officer until he (or she) had been in attendance for at least a week, it was found that a considerable reduction of numbers for interview occurred. Whilst preserving the principle of a weekly visit to each group of juveniles, insufficient numbers were available at each such visit for a full session's work. With regard to medical treatment, the Council agreed that juveniles, who are less than 16 years of age or are not entitled to medical benefit under the National Health Insurance scheme, should be permitted to avail themselves of the arrangements for medical treatment at school treatment centres on the same terms as are generally applicable to pupils at day continuation schools and evening institutes. The Ministry of Labour's approval to this arrangement has now been received. Medical inspection at secondary and trade schools. In the maintained secondary and trade schools medical inspection has been carried out by the school medical stall 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 all other years the records of all pupils are reviewed, but a detailed examination is only carried out when there is some special indication or request. So far as the aided schools are concerned, medical inspection of all the pupils by members of the Council's medical staff is carried out at 22 schools. Also at 22 other such schools these inspections are conducted by doctors appointed by the respective governors. The holders of Council's scholarships at 8 aided schools are seen by the Council's staff at County Hall, the governors' doctors in those schools confining themselves in the main to fee-payers, trust-fund scholars, etc. In one non-aided school, the medical inspection of pupils is carried out by one of the Council's medical officers at the request of the governors. 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 those aided schools at which the pupils are examined by the doctor appointed by the governors, but the record cards of all the Council's scholarship children examined are sent for the school medical officer's information at the end of each term. Including students in training colleges, 15,063 pupils were examined during the year by the Council's medical officers. 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 3,572 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 freedom from physical defect over children in the elementary schools, but in 15 instances the clothing was found to be poor and in 15 infestation with vermin was noted. Dental condition. The percentage of children, aged 12, with sound teeth was : boys, 83.9 ; girls, 81.3 ; but at the age of 15 this percentage had decreased by 2.2 per cent, among boys and increased by 3.9 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 1.5 and 1.4, respectively, compared with 1.1 in boys and girls leaving elementary schools. Vision. At the age of 12, 79.8 per cent.of the boys and 73.6 per cent. of the girls were able to pass the vision test, compared with 69.5 and 66.7 in elementary school leavers. In secondary schools 17.2 per cent. of the boys and 18.2 per cent. of girls were wearing glasses at the age of 12, but at the age of 15 the percentages were 19.8 boys and 22.7 girls. In spite of the greater percentage wearing glasses at the age of 15, the percentage of pupils passing the vision test was considerably less, viz., 73.5 per cent. among boys and 69.5 per cent. among girls, suggesting that the more serious strain in reading has a detrimental effect upon the eyesight. F 78 Care of eyesight in secondary schools. 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. Nutrition. 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 4.1 per cent. of the boys are reported as subnormal, amongst girls, 5 .8 per cent. are so returned. Apart from the reversal in sex incidence, the figures for nutrition are very close to those of the elementarv school children. Defects. During the year, 3,135 pupils (20.8 per cent.) were referred for treatment for various defects. Heart defect was noted in 2.2 per cent. boys and 2.9 per cent. girls ; defects of nose and throat in 1.7 per cent. boys and 4.7 per cent. girls ; ear disease in .7 per cent. boys and .3 per cent. girls ; anaemia and debility in 1.4 per cent. boys and 2 .2 per cent. girls. In the secondary schools there are more cases than in the elementary schools of postural defects, especially in girls, 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. Such postural defect of the spine was noted in 1.1 per cent. of boys at 12 and 1.6 per cent, at 15, but in girls the amount of this defect was much greater, viz., 8.1 per cent, at 12 and 10.6 at 15. The increase, between ages 12 and 15 in institutions of higher education, of defect of vision, dental caries and postural defect is disturbing. Re- inspection The re-inspection of 3,577 pupils in higher education institutions was carried out; 1,691 defects had been satisfactorily treated, 406 were under treatment, 554 had had treatment but needed further treatment, and in 611 cases no treatment had been obtained. 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. Training colleges. Of the 846 students examined in training colleges, none was found to be suffering from extensive dental caries ; 92.5 per cent. of the men and 80.7 of the women passed the vision test, but 34.3 per cent. of the men and 32.7 per cent. of the women were wearing glasses. Residential schools and children's homes. During the year all the residential schools and children's homes have been visited and reported upon by Dr. Mabel Russell. The general health of the children has been good and the average number of children in most of the infirmaries is under 10, although, in the case of some of the schools which have small children under 3 in the nurseries, this number is considerably higher during the winter months owing to the incidence of " colds." Reference has been made on page 48 to the action taken in connection with the occurrence of cases of vaginal discharge. During the year a survey of the bathing and sanitary accommodation in the schools has been made. At the end of March, Stepney Jewish children's homes were closed and the children transferred to Lamorbey, and, in May, Cumberlow Lodge and Stifford were 79 taken over as Home Office schools. Grays scattered homes (which formerly were incorporated with Stifford) became a separate unit with a resident superintendent and this has necessitated the provision of a small infirmary unit in Whitehall Lodge and some alterations and additions to the existing bathing and sanitary accommodation were recommended. During the late summer at the request of the education officer, a visit was paid by two of the Council's medical officers to Walton camp, while the children were in residence, and both medical officers were very favourably impressed. Arrangements are in hand for the formation of a permanent camp on the site. Instruction in sex hygiene. Attention was directed early in the year to the question of instruction in sex hygiene. Dr. Russell made an enquiry into what was being done to provide such instruction in the residential schools and homes; she found that usually every child leaving the school to take up work was given some instruction in sex hygiene, the boys by the superintendent or sports master and the girls by the matron or responsible woman officer. The instruction takes the form of an informal talk to the boy or girl concerned. There was one exception, and in that school no instruction is given to the boys. The head master stated that, during the 12 years he had been at the school, he has never heard of harm which had come to the boys through lack of such instruction. It was also found that without exception, the superintendents were not in favour of class teaching of sex hygiene, and no instruction was given in this subject in the elementary schools attended by the children. Dr. Russell's opinion was that the most important thing in this connection is character training and, for this, careful selection of house mothers should be aimed at. Later an inter-departmental committee examined the question " with a view to co-ordinating the varied information on the subject." The public health department was represented on this committee by the late Dr. Shrubsall and Dr. Russell. Oral evidence was taken by this committee from representatives of important societies and from prominent medical men and other persons of experience in the problems of adolescence. At the conclusion of a valuable report made by this committee the following were the chief recommendations :— (а) That there should be no class instruction in sex education in the residential schools. (b) That appropriate instruction of the type indicated in the report should be given to girls and boys (i) at or immediately before puberty, (ii) during early adolescence, and (iii) on leaving for employment. This instruction should be given to individuals or to small groups. (c) That school courses in elementary science should include some biological teaching, and that this should form the basis upon which the sex instruction should rest. (d) That those in charge of physical education in the residential schools should seize suitable opportunities for talks on personal hygiene and the care of the body. (e) That the training of girls for domestic service should include talks on infant care and management, personal hygiene and physiology. (f) That no girl or boy should leave school for employment without a talk, either individually or in small groups, from a senior officer. The talk should be designed to help the leaver to adjust herself (himself) to adult life. That girls and boys should not be supplied with books or pamphlets on sex subjects, and that films on sex instruction should not be shown. (g) That adequate activities in the nature of games and recreations should be organised for all girls and boys ; that greater freedom and increased opportunities for meeting together should be given to the girls and boys and that 11 these should extend to people and experiences outside the school walls ; and that sex education should be looked upon as a part of the general question of character training. (h) That officers in charge of children should be trained in the inculcation of good habits, in the proper way of answering children's questions, and in the giving of simple sex instruction. Anerley residential school— Enuresis unit. (i) That a course or courses of lectures on sex instruction for children should be arranged for the staffs of residential schools. The problem of nocturnal enuresis continues to vex the administration of the residential schools. None of the schools is free from it, but some suffer far more than others. The objectionable and disabling habit is especially troublesome in the case of boys who have arrived at the age of 16 and who are sent out into the world under a system of " after-care." In order to study the question of the prevention and cure of this condition in a scientific way, a special unit has been organised at the Anerley residential school to which 20 boys selected from various schools were admitted in September, 1935. The unit was placed under the observation of Dr. W. A. Scott. The ages of the boys ranged from 10 to 15 years. Dr. Scott, from whose report the subjoined sentences are derived, points out that many of these boys had previously had hospital treatment for the complaint with only temporary relief. During their stay in the unit the boys follow a normal school life, but sleep in a dormitory where special facilities are available. The nursing staff were instructed in the objects of the unit and an effort was made to secure the confidence and co-operation of each boy. The physical and mental build of the boys was observed and an estimate of the intelligence quotient was made. All causes of local irritation in the excretory organs and the urine were, as far as possible, eliminated. An investigation was made of the relationship of fluid intake to the occurrence of enuresis, the most frequent time at which each boy wetted his bed during the night was determined, and the importance of waking the sufferers at stated periods during the night was evaluated. The effect of treatment by various drugs was also noted. While there was no physical type found which could be said to be typical, intelligence testing made it possible to divide the boys into three types : (a) highly sensitive boys of superior intelligence ; (6) boys of average intelligence ; (c) very dull boys on the border of mental defect or even beyond it. In group (a) the results of treatment were found to be especially good, although one boy with an I.Q. of 110 has not responded well. In group (6) the results, though not as good as in the (a) group, were satisfactory. In group (c) no permanent improvement has as yet been effected. Taking all together, the frequency of wet beds has fallen to about one-third, while treatment has been continued, but, in the main, cessation of treatment brought about some relapse. Six boys have been discharged from the unit and returned to their own schools. Two have remained without any recurrences, two have had recurrences but greatly diminished in frequency, two have relapsed into their former condition. The last two were very difficult cases in which there were moral deficiencies and lack of co-operation on the part of the boys. During the last two weeks of February, 1936, the number of wet beds in the unit has been 75 for 18 boys, this is 30 per cent. The percentage expected from their old history, if no improvement had been obtained, would have been 83. The failures are largely made up of boys whose mentality is low and in whom co-operation with the doctor and staff is almost impossible to obtain. With regard to local irritation the question of circumcision appeared to have no effect, but attention to constipation was of definite importance. Self-abuse does not appear to be specially connected with bed-wetting. In order to ascertain the relation between fluid intake and bed-wetting, the boys were divided into two sets in which the incidence of wet beds was approximately the same. Both sections were wakened at 10 p.m. and at this time one set was given 1/3 pint of milk, observation over ten days showed no appreciable change in frequency of wet beds. Dr. Scott is of opinion that it is the total fluid intake for the day that affects the question rather than the amount taken about bed time. The old instruction " nothing to drink after 5 p.m." is of little importance unless combined with a limited total fluid intake in the 24 hours. Careful records are kept by the staff and Dr. Scott finds no evidence that there is a constant time at which a particular boy wets the bed. Sedative drugs (including belladonna) proved on the whole disappointing. Of all the drugs tried ephedrine proved the most useful. The Anerley results, it is true, do not justify any claim that this drug is a specific for the condition. It was found that the boys are very tolerant of this drug, and it was gradually increased beyond the normal dosage. At first it was administered daily in J grain doses ; in the absence of result in particular cases the amount was gradually 80 81 increased and there were cases that did not respond until 4 grains daily were given. The beneficial results of ephedrine were aided by adopting subsidiary methods of treatment. The aim during the experimental period was to obtain three weeks complete cessation of the habit under treatment; at the end of this time the dose was reduced until the patient remained dry for three weeks without administration of any drug. When these conditions were fulfilled it was considered a boy was fit to return to his own school. It is now thought that the three weeks' freedom can be reduced to two. In order to estimate the psychological effect of the administration or withholding of the drug, it was arranged that the administration of ephedrine should be stopped in all cases for four nights, but calcium lactate tablets were substituted so that the boys were unaware of any alteration. From the first night of this experiment a great increase in the amount of bed-wetting took place. Under ephedrine the average wet beds for nineteen boys was 4.5 nightly, under calcium lactate this average rose to 12.1. Waking at night is a most valuable manoeuvre in the treatment. In some cases this alone will be sufficient to effect a cure. At Anerley it is customary to wake the boys in the unit at 10 p.m. If any boy was found to be wet in the morning, he was placed on the list of those to be wakened at 5.30 a.m. If this did not secure dry beds he was aroused also at 3.30 a.m. The actual wakening disturbs the boys but little. They go to sleep again almost immediately upon return to bed. Summing up the results of the experiment, Dr. Scott concludes that there is at present no specific cure for nocturnal enuresis, nor can any one line of routine be laid down for the satisfactory treatment of cases. Each case has to be individually studied and the procedure must be modified by the physician as each case demands. The condition is not a disease but an infantile habit, which has been carried on into school life through the failure of appropriate training at the proper time. The reason why so many boys in the residential schools are found to be sufferers is that proper care and training was lacking at the appropriate age. So far as the Anerley experience has yet gone, the following suggestions appear to be the best which at present can be made for old standing cases :— (1) Provide facilities for close observation and attention nightly, the general arrangement being directed by an experienced physician. (2) Deal with local predisposing causes. (3) Limit total fluid intake. (4) Administer ephedrine gr. 1½ nightly and increase if necessary. (5) Arouse patient at 10 p.m., and if this does not assist then at 5.30 a.m. and if necessary also at 3.30 a.m. (6) Endeavour by the combination of the above measures to secure two weeks complete freedom from the habit, and then gradually reduce the treatment until the boy is not having drugs, is taking an average amount of fluid in the day and is being aroused only at 10 p.m. Special inquiries and reports. Certain special reports have been included in their appropriate sections. They include Mr. A. G. Wells' report upon the audiometer (p. 17), and Dr. W. A. Scott's report upon the enuresis unit (p. 80). Special attention has been given to questions of nutrition and physique. Reference is made to the reports of the medical officers in charge of the nutrition centres on pases 20-26. The boys covered four age groups :— Age. Athletes. Non-athletes 11—12 years 63 63 12—13 81 81 13—14 88 88 14—15 48 48 Comparison of the physique of athletic and non-athletic boys. Dr. W. A. Scott undertook an investigation into the physique of athletic boys in elementary schools compared with that of their non-athletic class-mates. It was desired to ascertain how those boys who were in training and in a condition of fitness, which permitted them to excel in sport, compared with non-selected boys who were undistinguished in games, and thus obtain a criterion as to the validity of " using the average as a norm." Several elementary schools were visited, and the head masters brought forward the best athletes—those who represented the school in competitive contests in football, boxing, swimming and other athletic games. The measurements were taken of 280 such boys, and for each athletic boy a classmate of the same age, undistinguished in sport, was taken at random. 82 The average heights and weights were taken of all the boys with the following results :— Table 45. Age. Athletic boys. Non-athletic boys. Kilos. Centimetres. Kilos. Centimetres 11—12 years 34.0 129.6 34.2 127.1 12—13 „ 37.7 143.5 36.0 140.1 13—14 „ 40.9 146.5 39.9 148.7 14—15 „ 46.5 158.0 47.5 157.1 It is clear that there is no significant difference between the two groups from the point of view of physical measurements. This is clearly shown in fig. 3, which gives the height.weight ratios of the two groups. It was thought that it might be of interest to compare the physique of boys who excelled in different types of sport. Some surprising results emerged. It was found that the type of physique which supplied the best talent in boxing, football and swimming was, in each, distinct and different from that of the others. Boxers were short and heavy, footballers corresponded to the average, while swimmers were very tall but with a normal weight for their height. The results are shown graphically in fig. 4. Table 46. Classification. 11—12 years. 12—13 years. 13—14 years. 14—15 years. Kilos. Cms. Kilos. Cms. Kilos. Cms. Kilos. Cms. Boxers 33.2 113.7 36.7 133.0 40.8 140.1 42.3 155.1 Footballers 33.8 136.7 37.2 145.2 40.3 146.9 42.7 152.0 Swimmers 39.9 146.7 39.8 144.6 42.6 153.4 50.7 161.2 Non.athletes 34.2 127.1 36.0 140.1 39.9 148.7 47.5 157.1 Physique in children at residential schools. The managing committee of the Leytonstone children's home drew attention to the fact that of 36 boys of appropriate age only 20 satisfied the physical requirements for transfer to the Exmouth training ship, if they desired to be trained for sea life. I was instructed to report upon the question, showing how the Leytonstone boys compare with boys in other residential schools, and also in elementary (including central) schools, especially those in the East End. 83 84 There is evidence, which Dr. Sheldon's enquiry has shown, that the care given to children in the residential schools improves them greatly and they gain in height under the present dietary year by year more than the average gain expected from consideration of the gains in the general population. Thus, at 12—13 the average gain in height in 1932-33 of 12-year-old boys was 3 inches (as against expected gain of 2.12 inches) and of 13-year-old boys 2.5 inches (as against an expected gain of 2.12 inches). The chest measurements of unselected groups of boys at the ages 13—15 are on an average 45 per cent. of the height. The Exmouth demands at the 14th birthday, boys of 57 inches in height with a chest measurement 48 per cent. of height, i.e., boys much more sturdy and of better physique than the average, because they are going in for a hard life. The average height for London boys of 14 (i.e., of an average age of 14½ years) in the general population is 58 inches, so that an average London boy would qualify in height for the Exmouth. As 50 per cent. of the boys are above the average and 50 per cent. below, it may be assumed that some 50 per cent. would qualify in height, but some of them undoubtedly would fail to qualify in chest measurement; so that it could very fairly be assumed that a similar proportion of London boys as a whole might fail as from Leytonstone. Sir George Newman, in a recent report, stated that, because boys have not the physique for the services, it is not to be deduced that they are not fully able to cope with civilian life adequately. There is another way of looking at the question. The population is made up of a number of physical " types ". These types are congenital and fixed, and no amount of feeding or physical exercises will change one of these types into another. There are, for instance, the brevilinear type with heavy physique and broad chests, the longilinear type with lanky physique and narrow chests, and the normosphlanchnic type which lies between these. The method of the services (and the Exmouth) in demanding average height with more than average chest girth selects only one type of the population, viz., the brevilinear (which no doubt experience has shown is best fitted for a seafaring life) and excludes the others ; as, however, these others are congenitally fixed and cannot be altered, a high proportion of the population must fail to qualify naturally for the Exmouth. That these considerations are well founded is shown by the results of the examination with regard to fitness for the Exmouth of boys in east end schools. An examination has been made of 200 unselected boys in east London central schools and 200 unselected boys in senior boys' departments of east London elementary schools for their ability to pass the Exmouth test, with the following results:— Type of school. Percentage failing to reach the Exmouth standard Leytonstone children's homes 44.4 East London central schools 40.6 East London elementary schools 43.0 The boys at Leytonstone, however, are not unselected. The children under public assistance generally come from the poorest stocks and start out with a congenitally poor physique; they are also frequently stunted by rickets and neglect in infancy before the Council receives them. In May, 1935, the heights and weights of boys aged 12 to 14½ were taken in four of the Council's residential schools, including Leytonstone. The results are given below. The boys in all the schools are on the standard diet. A consideration of the figures shows that there is no constant or significant difference between the measurements of boys at Leytonstone and those at the other schools. There is the usual variation which is always found when small groups are being compared. 85 Age. group. Anerley. Number of boys. Leytonstone. Anerley. Height (without boots). Leytonstone. Ashford. Hutton. Ashford. Hutton. ft. ins. ft. ins. ft. ins. ft- ins. 12—13 30 43 47 13 4 7 4 8 4 7½ 4 6½ 13—13½ 12 20 43 10 4 7 4 10 4 8¾ 4 10½ 13½-14 11 21 21 8 4 9¾ 4 10 4 9 4 l0½ 14—14½ 11 14 16 5 4 11 4 11½ 5 0¼ 5 0½ Age group. Anerley. Number of boys. Leytonstone. Weight (with ordinary indoor clothing without boots). Ashford. Hutton. Anerley. Ashford. Hutton. Leytonstone. st. lbs. oz. St. lbs. St. lbs. St. lbs. oz. 12—13 30 43 47 13 5 7 7 5 8 5 9 5 2 4 13—13½ 12 20 43 10 5 10 2 6 3 5 10 5 13 6 13J-14 11 21 21 8 6 4 13 6 3 6 2 5 11 0 14r—14½ 11 14 16 5 6 11 5 6 6 6 13 6 13 0 Physique of secondary school children— Fee-paying and scholarship—11 to 15 years. The following is the summary of an investigation which was undertaken to find out how the physique of London " scholarship " children compares with that of " fee-paying " children of the same age. Material was collected from schools in different areas of London. Scholarship children are those whose financial resources are inadequate to provide higher education. The investigation included 3,244 secondary school children, as follows :— Fee payers. Scholars. Boy 699 695 Girls ... ... 891 959 The average heights and weights were:— Table 47. Age. Boys. Girls. Scholars. Fee-payers. Scholars. Fee-payers. Height. Weight. Height. Weight. Height. Weight. Height. Weight. 11—12 years 138.2 31.8 139.3 31.8 145.2 38.7 145.0 38.6 12—13 140.9 33.7 140.2 33.8 148.2 41.0 150.3 40.8 13—14 „ 145.5 37.8 149.2 38.6 152.4 47.5 156.2 48.0 14—15 „ 150.1 40.7 151.4 40.9 157.0 49.8 160.0 51.0 15+ 154.8 43.8 154.6 44.0 160.9 55 0 161.4 54.3 There is no material difference between the average physique of scholarship and fee-paying children at 11 and 12 years. At 13 the physique of the fee-payers is superior. This superiority appears in both boys and girls. In the 15th year the scholars pull up considerably, and in the 16th year there is again no material difference in physique. Dr. E. J. Boome in a comparison of fee-payers and scholarship children at Putney girls' secondary school makes the following observation : " the progress between the ages of 13 and 15 in both groups is roughly the same. The marked progress is in the year between 14 and 15 in the case of scholars and 13 and 14 in the case of feepayers, i.e., a year earlier than the scholars. It appears from this that the scholars mature one year later." Dr. H. R. Kidner took the heights and weights of scholars and fee-payers in the age groups examined by him at the Brockley county school throughout the year. These measurements also bore out the general conclusion that there is no significant difference between the physique of scholarship holders and fee-payers in the Council's secondary schools. Conferences of school medical staff. On the opening session of each term a conference is held at the County Hall of the medical members of the school medical staff. The first such conference in the year 1935 was held on 8th January. On behalf of the Medical Research Council the conference was addressed by Dr. E. A. Cockayne, 86 F.R.C.P., who explained the Research Council's enquiry into rare congenital defects. The school medical service in London undertook throughout the year to report to the Medical Research Council certain specified congenital defects and malformations discovered in the course of the medical inspections. The conference was subsequently addressed by Dr. L. W. Batten on the care of rheumatism in children. The conference at the commencement of the summer term was held on 30th April when a discussion took place on Dr. Batten's address previously delivered. The final conference was held on 27th August when a discussion was introduced by Mr. T. A. Rogers, M.A., of the National Institute of Industrial Psychology and by Mr. G. E. Wear of the Ministry of Labour on vocational guidance with special reference to the medical reports made at the medical examinations of children leaving school. Recent reports on special subjects. The following is an index of articles on special aspects of subjects in recent annual reports of the school medical officer :— Subject matter. Page number of report for the year. 1920. 1930. 1931. 1932. 1933. 1934. Arachnodactyly or " spider limbs " — 53 — — — — Aural disease, audiometer, etc. 23 17 22 — 36 29 Basements: Condition of children in 53 — __ — — Canal-boat children (barge class) 12 — — — — Cardiac disease, Children suffering from — — 77 — Care committees, Reports of 19 — 12 — Child guidance — 63 59 45 85 73 Condition of entrants in relation to infant feeding 48 — — — Delinquents : Mental and physical attainments — 78 — — Dental conditions : Improvement — 20 — — — — Dental hygienists — 22 — — — Dental investigation of " school leavers " 27 — — — — — Dental propaganda by travelling exhibit — — 40 — 32 Dietaries in residential schools — 16 18 68 Diphtheria " carrier " clinics 88 84 58 48 41 Diphtheria active immunisation : Facilities in London 88 — — — — — Diphtheria active immunisation, residential schools — 94 65 55 47 Enuresis 18 19 — — Hearing tests 52 Hygiene, Teaching of — — 39 — Incapacitated children: Use of special hospitals — — — — — 67 Jewish children, Health of 13 — — Kyphosis — 82 Left-handedness in children 29 32 M.D. acts : Relation between parents and children 75 79 — M.D. acts: Sex distribution in defective children 65 M.D. schools: Numbers admitted in recent years 72 — Measles (1) serum 90 — — — (2) sequela; 8 — — Measles, Control of 90 — — — Medical inspection : Alteration in age groups 10 9 Medical inspection : Arrangements in schools — — — — 10 Medical inspection : Day continuation schools and evening institutes — — — — — 78 Medical inspection: Numbers inspected per session — 11 Medical inspection : " Preliminary " (cursory) examinations — — — — — 16 Medical inspection : Equipment of rooms _ 8 — Medical treatment: Institution of block grant payments — — — — 26 — Milk meals : Inception of provision — — __ 54 Milk meals: Milk Marketing Board's scheme for cheap supply — — — — — 58 87 Subject matter. Page number of report for the year. 1929. 1930. 1931. 1932. 1933. 1934. Milk meals : Report as to condition of children — — — — — 55 Myope classes in secondary and central schools 52 — — 34 89 — Myopes: Gentiles and Jews 47 — — — — — Nutrition centres — — — — — 60 Nutrition : Comparison of various schools — — — — 12 — Open-air education : Photographs 56 — — — — — Ophthalmia in residential institutions — 48 — — — — Orthodontics — — — — — 22 Otorrhcea, Control of — — — — — 24 Partially-sighted schools — — — — — 69 P.D. children : Absentees — — — — 76 — Plantar warts — — — — — 17 " Poor-law " schools : Medical arrangements — 12 15 — — — Postural defects : Secondary and trade schools 50 — — — — — Preventive and curative treatment of children 14-16 years of age — — — — 45 78 Provision of meals : Comparison of numbers in provided and non-provided schools — — — 37 — — Residential schools: Control of infectious diseases — — 92 — — — Residential schools for defective children — — — 38 — — Rheumatism : Review of scheme — 35 — — — — „ Symptoms 43 — — — — — Rickets and dental disease in relation to tonsils and adenoids 7 — — — — Ringworm: Outbreak on T.S. " Exmouth " — — — — 55 46 Sandpits — — — 45 — — Scarlet fever : Active immunisation — — — — — 48 Scarlet fever immunisation: Cyril Henry treatment centre — — — — 50 43 School buildings : New planning 3 — — — — 7 School feeding : Policy of Council — — — — — 54 School medical service : Outline of activities — — — 2 — — School medical service : Progress during 25 years — — — — — 5 Secondary and trade schools, Overpressure in 15 — — — — — Secondary and trade schools : Unification of medical service — — 9 — — — Secondary and trade schools : Nutrition — — — — 90 — Smallpox among school children 91 90 86 — — — Special schools : Ages of children — — 76 — — — Special schools : Children from poor-law schools — 68 — — — — Squint: Treatment at Paddington treatment centre — — — 34 — Stammering: Causes and treatment — 27 35 1 — — — Vaccination, Recording of — 6 — — — — Voluntary bodies, Co-operation with — — — — 72 — Wick special dental centre and special report — — 28 27 — — Wage-earning employment of school children. In the year 1935, 3,460 applications (3,429 boys and 31 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 unconditionally is shown below ; the first numbers are in respect of boys, the figures for girls being given in brackets : delivery of milk, 273 (—); delivery of newspapers, 1,774 (11); carrying or delivery of goods or parcels, 645 (6); in or in connection with a shop, 271 (5); in a coal yard, 7 (—); industrial work at home, 1 (1); house work away from home, 12 (5); as a messenger, 48 (—); miscellaneous 5 (—). In 282 other cases the certificates were granted subject to medical treatment being obtained, or special conditions being observed. Certificates on medical or other grounds were refused to 113 boys and 1 girl for the following reasons : rheumatism, 2 ; dental condition, 3 , defective vision, 9 ; heart condition, 5 : scoliosis, 1 ; poor general condition, 10 ; nervous condition, 1 ; broken arm, 1; stunted growth, 83 Employment of children in entertainments. 1 ; psoriasis, 1 ; non-medical reasons such as " withdrawn," illegal hours, under or over age, etc., 79 (1). The number of medical examinations of children under the regulations governing the employment of children in entertainments was 699 (59 boys, 640 girls). Two children, girls, were rejected owing to heart disease. One hundred and eighteen 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 85, visual defect 19, throat condition 4, skin affection 2, personal hygiene 3, heart 1, infectious disease 1, ear affection 2, and flat-feet 1. Examination of employees in the education service and scholars. In the year 8,589 entrants to the permanent education service, and candidates for teaching awards, scholarships, and local special places, presented themselves for examination. The following table indicates the numbers submitted for each grade and the results of the examinations :— Table 48. 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 Fomale Male Female Male Female Male Female Permanent service 198 342 189 330 5 8 4 4 Teaching awards 132 462 128 431 3 14 1 17 Scholarships Total 3,780 3,709 3,615 3,610 28 9 137 90 4,110 4,513 3,932 4,371 36 31 142 111 *8,623 8,303 t67 253 * Including 13 permanent service cases (8 male, 5 female), 6 teaching awards (female) and 15 scholarships (8 male, 7 female) referred from 1934. † The causes of rejection were mainly defects of vision, unsatisfactory general health and morbid conditions of the heart. In addition to the above, 123 examinations were made of scholars (52 male, 71 female) with a view to determining their fitness to continue to hold awards, and of these 10 (3 male, 7 female) were found to be unfit. Re-examinations totalling 1,801, 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 10,547, an increase of 1,316 on the total for 1934. Cases specially referred. There were also referred to the public health department 3,629 special cases in which medical advice was required. This figure includes 3,137 teachers (614 men, 2,523 women) and 492 schoolkeepers, cleaners, etc. (124 men, 368 women). In regard to recommendations governing sick leave to teachers, 2,133 or 72.5 per cent. of the teachers concerned were over 40 years of age ; this shows an increase of 1.5 per cent. on that of the previous year. Teachers of physical education. In connection with these cases, 15 home visits were paid during the year. During the year 274 applicants for admission to the Council's course of physical education were examined. Of these 22 were deemed to be either temporarily or permanently unfit to undergo the training on the following grounds : poor general condition, 7; varicose veins, 7 ; recent injury, 1 ; hernia, 1 ; heart trouble, 3 ; myopia, 1; gastric condition, 2. 89 STATISTICAL TABLES. Table I.—Medical Inspection, 1935. (a) Routine Inspections. Group. Boys. Girls. Total. Entrants 28,485 27,106 55,591 Age 7 15,869 16,096 31,965 Age 8 (preliminary survey only) 7,912 7,398 15,310 Age 8 (detailed examination) 1,091 1,094 2,185 Age 11 24,486 23,952 48,438 Leavers 26,739 26,470 53,209 Total elementary schools 104,582 102,116 206,698 „ special schools 799 580 1,379 (b) Other Inspections. Special inspections 63,068 62,131 125,199 Infectious disease enquiries — — 21,713 Re-inspections — — 158,686 (c) 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 55,591 7,672 13.8 Age 7 31,965 5,403 16.9 Age 8 (preliminary examination only) 15,310 2,398 15.7 Age 8 (in detail) 2,185 444 20.3 Age 11 48,438 8,424 17.4 Leavers—age 13¾ 53,209 7,977 15.0 Total, elementary schools 206,698 32,318 15.6 „ special schools 1,379 202 14.6 90 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 1,684 5 808 4 — — Skin—Ringworm, head 2 — — — 18 2 „ „ body 36 — — — 15 1 Scabies 120 1 — — 1,909 8 Impetigo 151 4 3 — 414 13 Other disease (non-tubercular) 842 9 97 1 659 84 Eye— Blepharitis 570 5 73 — 198 11 Conjunctivitis 144 — 6 — 140 10 Keratitis 2 — 1 — 2 — Corneal opacities 5 1 — — 16 3 Defective vision, excluding squint 12,335 101 5,195 49 3,189 373 Squint 1,059 5 370 1 416 27 Other conditions 140 — 39 — 154 20 Ear— Defective hearing 129 2 97 — 150 44 Otitis media 775 5 274 2 406 88 Other ear disease or defect 352 4 72 — 184 36 Nose and throat— Chronic tonsillitis 4,696 8 5,544 5 1,217 263 Adenoids 502 1 259 1 197 30 Chronic tonsillitis and adenoids 1,627 2 488 1 500 34 Other conditions 613 2 220 1 438 89 Enlarged cervical glands 324 1 871 — 157 152 Defective speech 107 1 149 — 102 42 Teeth—Dental disease or defect 54,142 274 1,324 2 4,235 84 Heart and circulation, heart disease— Organic 29 — 73 — 2 — Functional 19 — 134 1 11 14 Not stated 204 1 1,894 9 218 585 Anaemia 506 3 273 — 309 128 Lungs—Bronchitis 752 1 735 2 107 52 Other non-tubercular 261 — 478 2 119 156 Tuberculosis— Pulmonary definite 2 — 1 — — — „ suspected 9 — 58 — 8 17 Glands 3 — 4 — 7 3 Spine — — — — — — Hip — — 3 — — — Bones and joints 1 — 1 — — 1 Skin — — 1 — — — Other forms 1 — — — — — Nervous—Epilepsy 20 — 12 1 47 30 Chorea 55 — 58 — 120 74 Other conditions 156 1 225 1 124 82 Deformities— Rickets 63 1 35 — 11 12 Spinal curvature 460 7 186 1 74 36 Other 642 3 447 2 173 77 Other conditions 2,356 11 1,069 2 3,273 1,240 Total 85,896 459 21,577 88 19,319 3,921 91 (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 41 — 20 — Skin—Ringworm, head — — — — body — — — — Scabies 3 — — — Impetigo — — — — Other disease (non-tubercular) 14 — 3 — Eye—Blepharitis 9 — 2 — Conjunctivitis 4 — — — Keratitis — — — — Corneal opacities — — — — Defective vision, excluding squint 206 5 144 3 Squint 9 — — — Other conditions 1 — — — Ear— Defective hearing — — 2 — Otitis media 13 1 7 — Other ear disease or defect 3 — 1 — Nose and throat— Chronic tonsillitis 83 1 74 1 Adenoids 8 — 2 — Chronic tonsillitis and adenoids 14 — 8 — Other conditions 4 — 2 — Enlarged cervical glands 3 — 23 — Defective speech 3 — 5 — Teeth—Dental disease or defect 685 6 24 — Heart and circulation, heart disease— Organic 1 — 2 — Functional — — 1 — Not stated 4 — 66 1 Anaemia 8 — 11 — Lungs—Bronchitis 13 — 9 — Other non-tubercular 3 — 12 — Tuberculosis— Pulmonary definite — — — — „ suspected — — 3 — Glands — — — — Spine — — — — Hip — — — — Bones and joints — — — — Skin — — — — Other forms — — — — Nervous—Epilepsy — — — — Chorea 2 — 5 — Other conditions 7 — 5 — Deformities— Rickets — — — — Spinal curvature 9 1 — — Other 6 — 7 — Other conditions 45 — 29 — Total 1,201 14 467 5 92 Table II (cont.). (a) Classification of the nutrition of children inspected during the year in the routine age groups. Age Group. Number of children inspected. A (Excellent). b (Normal). C (Slightly Sub-normal). D (Bad.) No. Percentage No. Percentage No. Percentage No. Percentage Entrants 55,591 9,143 16.44 43,304 77.90 3,096 5.57 48 0.09 Age 7 years 31,965 4,609 14.42 24,970 78.12 2,346 7.34 40 0.12 „ 8 (prelim.) - - - - - - - - - ,, 8 (detailed) 2,185 292 13.36 1,682 76.98 203 9.29 8 0.37 „ 11 48,438 7,862 16.23 37,482 77.38 3,053 6.30 41 0.09 „ 13¾ (leavers) 53,209 11,310 21.25 39,725 74.65 2,151 4.06 23 0.04 Total, elementary 191,388 33,216 17.36 147,163 76.89 10,849 5.67 160 0.08 „ special sch. 1,243 135 10.86 1,031 82.94 77 6.20 - - Table III. (a) Exceptional children in London in 1935. Classification. At certified special schools. At public elementary schools. At other institutions* At no school or institution Total. Blind children 109 — 2† 4 115 Partially sighted children 607 15 46 — 668 Deaf children 497 — 2 9‡ 508 Partially deaf children 135 6 4 145 Mentally defective children— Feeble-minded children 3,730 7§ 15 15§ 3,767 Epileptic children— Children suffering from severe epilepsy 117 — 32 13¶ 162 Physically defective children— Tuberculous children— Pulmonary 357 — 28 — 385 Non-pulmonary 760 — 9 — 769 Delicate children 2,732 6,235|| 7 — 8,974 Crippled children 1,940†† — 6 — 1,946 Children with heart disease 1,990 — 39 — 2,029 * 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 24 children at Northern hospital (post encephalitis lethargica). || Of these 23 children were suitable for admission to open-air schools (O) but their parents refused to allow their transfer to such schools or the children were awaiting admission. The remainder could not be certified as incapable by reason of physical defect of receiving proper benefit from instruction in the ordinary public elementary schools, but they might have benefited from a period of open-air treatment. 93 (6) Return of children suffering from more than one defect, 1935. 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 1 - - - 14 - - - - - 15 M.D. and crippled 27 2 - - - - 3 8 1 - 41 M.D. and heart 30 - - - - - 1 1 - - 32 M.D. and epileptic 17 - - - - 21 - 1 - - 39 M.D. and T.B. - - - - - - - 4 1 - 5 M.D., cripple and heart 2 - - - - - - - - - 2 M.D., crippled and deaf - - - - 6 - - - - - 6 Blind and epileptic - - 2 - - - - - - - 2 Blind and M.D. - - 1 - - - - - - - 1 Deaf and crippled - - - - 2 - - 1 - - 3 Deaf and heart - - - - 1 - - - - - 1 Epileptic and crippled - - - - - - 4 2 - - 6 Epileptic and heart - - - - - 3 - - - - 3 Epileptic heart and M.D. - - - - - 1 - - - - 1 Heart and crippled - - - - - - 25 - - - 25 T.B. and blind - - - - - - - 1 - - 1 M.D., blind and crippled - - - - - - - - 1 - 1 M.D., blind and deaf - - - - - - - 1 - - 1 T.B., and deaf - - - - - - - 1 - - 1 77 2 3 - 23 25 33 20 3 - 186 Table IV. Treatment table. (a) Group I.—Minor ailments, excluding uncleanliness, for which set group V. Disease or defect. Defects treated or under treatment. Under Council's scheme. Otherwise. Total. Skin— Scabies 4,037 — 6,435 Impetigo 2,398 Ringworm, head 120* 134 254† body 117,140 882 118,022 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.) 123,695 1,016 124,711 * 110 by X-ray. † 191 by X-ray. (6) Group II.—Dejeclive 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) 37,450 1,217 40,667 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, 28,827; otherwise 937 (estimated). Children who obtained or received glasses—under the Council's scheme, 26,569 =92.2 per cent.; otherwise 844. * Included in group I minor ailments. G 94 (c) Group III.—Treatment of defects of the throat and nose. Number of defects. Defect. Received operative treatment. Total. Received other forma of treatment. Total number treated. Under Council's scheme. Private practitioner or hospital. Tonsils 649 623 1,272 3,729 13,860 Adenoids 422 80 502 Tonsils and adenoids 7,940 245 8,185 Other 26 146 172 Total 9,037 1,094 10,131 (d) Gboup IV.—Dental defects. 1. Number of children who wore:— (a) Inspected by the dentist-—Age groups 5 years and under 22,343 290,021 6 „ 32,162 7 „ 31,345 8 „ 28,613 9 „ 36,221 10 „ 37,137 11 „ 20,894 12 „ 34,681 13 „ 32,029 14 „ and over 14,596 (6) Found to require treatment 183,035 (c) Actually treated 144,383 2. Half days devoted to inspection 2.6411 21,183 „ „ „ treatment 18,542 3. Attendances by children for treatment 243,593 4. Fillings—permanent teeth 117,880 138,507 „ temporary teeth 20,627 5. Extractions—permanent teeth 57,672 328,937 „ temporary teeth 271,265 6. Administration of general anaesthetics for extractions 69,428 7. Other operations—permanent teeth ... 25,287 ,, „ 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 1,629,068 (c) Number of verminous children noted 79,557 (d) Children cleansed under Council's arrangements 75,023 (e) Cases in which legal proceedings were taken under the Education Act, 1921 (section 87) 321 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. 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 1935 208,077 125,199 158,686 21,713 18,051 15,420 95 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. Other wise. * 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 1935 §123,695 882 39,450 1,217 12,766 1,094 144,383 5,149 * It is not possible to give complete figures, but those given are the result of following up of medical inspections. Other children rereive dental treatment outride the Council's scheme as a result of dental inspection. † Includes skin and head ringworm cases. ‡ Includes 13,087 "nurses' cases." § Includes 14,537 "nurses' cases." Table VII. Mtdical 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 12 781 843 1,085 482 111 36 — — 1,977 1,361 (2) age 15 938 964 1,356 547 991 833 — — 3,285 2,344 11. Examination (not necessarily detailed) at other ages (i.e., specials) 1,234 1,516 1,312 569 770 695 67 779 3,383 3,559 III. Reviewals 451 1,934 1,002 275 90 226 — 10 1,543 2,445 IV. Re-inspections 551 1,006 423 1,072 171 354 — 61 1,145 2,493 96 INDEX page After-care clinic 32 After careers 64 Anaemia 14 Approved schools 46 Audiometer 16 Chickenpox 45, 47 Child guidance 67 Children's care committees 27 Cleanliness 11 Clothing and footgear 12 Conferences of school medical staff 85 Convalescence 54, 57 Co-operation with juvenile advisory committees 16 Day continuation schools 75 Deaf children 63 Defective children 60 Deformities 14 Diphtheria 41,47,48 Ears 13, 16, 27, 29, 31 Employees, Examination of 88 Employment of school children 87 Enuresis 80 Evening institutes 75 Eyes 12, 28,77 Favus 45 Heart 14 Hop picking 45 Hygiene, Personal 38 Infectious diseases 41 Invalidity, Chronic 40 Junior instruction centres 76 Lungs 14 Measles 44, 47 Medical inspection 7, 26, 74, 77 Medical treatment 28, 74 Mental deficiency 64 page Milk scheme 10, 60 Mumps 45,47 Nervous diseases 14 Nursery schools 73 Nutrition 9, 20,58, 78 Open-air education 50 Orthodontics 30 Orthopaedic treatment 34 Otorrhoea 13 Personal hygiene 38 Physical deficiency 62, 63 Physique of athletic and non-athletic boys 81 Physique of children in residential schools 82 Physique of secondary school children 85 Play centres 45 Remand home 46, 65 Residential schools 46, 78 Rheumatism 35 Rickets 14 Ringworm 29,45,47 Scabies 39,45,47 Scarlet fever 43,47,49 School buildings and equipment 6 School journeys 45, 58 Secondary and trade schools 77 Sex hygiene 79 Spectacles 33 Staff 5 Stammering 34 Swimming baths 50 Teeth 12, 29, 77 Tonsils and adenoids 13 Tuberculosis 14. 53 Vaccination 16 Vulvo-vaginitis 48 Whooping-cough 45,47 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.1, from whom a complete list of the Publications of the Council may be obtained post free. Annual Report of the Council for 1934:— Vol. I (Part I). Powers and duties— Elections — Finance — Rating and Taxation—Public Protection—Traffic— Public Amenities—Domestic and Miscellaneous Services. Is. 6d. No. 3197. Vol. I (Part II).—Public Assistance. 1s. No. 3169. Vol. II.—Public Health, General matters as to public health, Main Drainage and Housing. Is. No. 3176. Vol. Ill (Part I).—Public Health, Report of County Medical Officer of Health. Is. No. 3131. Vol. Ill (Part II).—Public Health. Report of School Medical Officer. 1s. 6d. No. 3125. Vol. IV (Part I).—General and Special Hospitals. 2s. 6d. No. 3141. Vol. IV (Part II).—Hospital Finance. 1s. No. 3163. Vol. IV (Part III).—Medical Supplement. 5s. No. 3156. Vol. V.—Education. Is. No. 3158. Vol. VI.—Mental Hospitals. Is. No. 3148 Vol. VII.—Abstract of Accounts and Index. (In, preparation.) Archives of Neurology and Psychiatry from the Pathological Laboratory of the London County Mental Hospitals. Cloth :—Vol. I (out of print) ; Vol. II, 1903, No. 680, 17s. 6d.; Vol. III. 1907, No. 715, 17s. 6d.; Vol. IV, 1909, No. 152. 10s. 6d.; Vol. V. 1911, No. 1459, 10s. 6d.; Vol. VI, 1914, No. 1677, 10s. 6d.; Vol. IX, No. 2501, 1927, 15s.; Vol. X. No. 2823, 1931, 15s.; Vol. XI. No. 3044, 1934, 15s. Accounts in Abstract. Accounts of the Income and Expenditure of the Council from 1st April to 31st March. Is. Issued annually. 1934 35. No. 3174. London Statistics. Statistics relating to London and the public services therein, with certain statistics of the adjacent districts. Issued annually. Vol. XXXVIII, 1933-34. 15s. No. 3133. Statistical Abstract for London. Comparative statistics for 10 years relating to parishes, metropolitan boroughs, public assistance areas, electoral areas. Administrative County of London, Greater London, etc.—Education, rateable value, mental disorder, public assistance, fires, finance, population, rates, locomotion, etc. Vol. XXVII, 1924 34, 2s. 6d. No. 3155. Statistics of Metropolitan Boroughs.— Population, vital statistics, electors, finance and rates, etc., for each borough.— Prepared and published by the London County Council on behalf of the Metropolitan borough councils, and designed as a common appendix to their reports. Id. 1934-35. No. 3142. Census, 1921. Report upon the statistics relating to Greater London contained in the various volumes of the Census of England and Wales. 1921. Is. No. 2550. 1931. Report to the Housing and Public Health Committee by the Valuer to the Council. Is. 9d. No. 3134. Municipal Map of London, 1931. In 28 sheets, scale 6 inches to a mile, Is. 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