London County Council ANNUAL REPORT OF THE COUNCIL, 1937 Vol. Ill (Part I) PUBLIC HEALTH (Report for the year 1937 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.VV.l, Agents for the sale of the Publications of the London County Council. 1938 No. 3380. Price 1s. Post Free 1s.1½.3 d London County Council ANNUAL REPORT OF THE COUNCIL, 1937 Vol. Ill (Part I) PUBLIC HEALTH (Report for the year 1937 of the County Medical Officer of Health) 850 (M.0. 12036) 2.11.38–01:5 CONTENTS Page Organisation of the Department 5 Vital Statistics– Population 5 Infectious diseases 10 Tuberculosis 20 Statistical tables 25 Administration– National Health Campaign 31 Housing 31 Milk and Dairies (Consolidation) Act and Tuberculosis Order 33 Venereal diseases 35 Treatment of tuberculosis 40 Mental Deficiency Acts 58 Blind Persons Act 59 Midwives Acts–Nursing homes registration–Maternity and child welfare contribution schemes 59 Examination of staff 68 Bacteriological laboratory work 69 Chemical branch 70 Statistical information 76 Sanitary officers 78 London County Council ANNUAL REPORT OF THE COUNCIL, 1937 VOL. Ill (Part I) REPORT OF THE COUNTY MEDICAL OFFICER FOR THE YEAR 1937 By Sir Frederick Menzies, K.B.E., M.D., LL.D., F.R.C.P., F.R.S.E., K.H.P., County Medical Officer of Health and School Medical Officer. Organisation of the department The medical work of 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 the domiciliary midwifery service, 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. H. W. Bruce ; and (iii) general public health administration, etc., Dr. W. A. Daley. The duties of Miss D. E. Bannon, matron.in.chief in the public health department, include the supervision and organisation of the nursing and certain other staff at hospitals and institutions, together with the superintendence of the school nursing staff. The lay administrative work of the department for which the chief clerk and establishment officer, Mr. W. J. K. Crawforth, is responsible, is organised in the following five divisions, each under the direction of a principal clerk: special hospitals (including the pathological laboratory services and the control of infectious diseases); general hospitals (including district medical work); hospital finance; staff; and general public health (including the school medical service). The ambulance service is under the direction of an officer.in.charge. Other volumes of the Council's Annual Report which deal with the work of the department are:– Vol. Ill, Part II School medical service. Vol. IV, Part I General and special hospitals (including pathological services, staff and London ambulance service). Vol. IV, Part II Hospital finance. Vol. IV, Part III Medical supplement (containing original articles by members of the medical and technical staff). This volume describes the other activities of the public health department. 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 1937 to have been 4,094,500, compared with 4,141,100 a year earlier. The corresponding estimates for metropolitan boroughs are shown in table 34, and the rates given in this annual report are calculated upon these figures. ( 5 ) 6 The age and sex.distribution of this estimated population is as follows:– Table 1 Age group Males Females Total 0 –5 years 126,500 122,800 249,300 5 –15 „ 279,700 275,300 555,000 15.25 „ 346,700 375,100 721,800 25 –35 „ 325,500 373,800 709,300 35 –45 „ 264,800 322,700 587,500 45 –55 „ 229,100 283,800 512,900 55 –65 „ 188,100 229,000 417,100 65 –75 „ 104,800 139,700 244,500 75 years and over 34,300 62,800 97,100 Total 1,909,500 2,185,000 4,094,500 Marriages The marriages registered in London during 1937 numbered approximately 44,746 or 21.9 per thousand of the population, the corrected rate for the preceding year being 21.6. Births The live births allocated to London (Juring 1937 numbered 55,011, compared with 56,273 in the preceding year. The live.birth rate was 13.4 per thousand as against 13.6 in 1936. The births in the resident population of each metropolitan borough during 1937 were as follows :– Table 2–Courtly of London–Births, 1937 Metropolitan boroughs arranged in topographical order Live.births Still.births Total Legitimate Illegitimate Legitimate Illegitimate Legitimate Illegitimate Western. Paddington 1,602 286 54 16 1,656 302 Kensington 1,893 232 59 6 1,952 238 Hammersmith 1,778 135 51 2 1,829 137 Fulham 1,798 135 59 2 1,857 137 Chelsea 553 57 13 – 566 57 Westminster, City of 876 151 33 8 909 159 Northern. St. Marylebone 749 110 29 7 778 117 Hampstead 916 99 22 8 938 107 St. Pancras 2,154 232 64 14 2,218 246 Islington 4,272 244 127 7 4,399 261 Stoke Newington 715 32 19 4 734 36 Hackney 2,753 105 99 5 2,852 110 Central. Holborn 240 40 6 4 246 44 Finsbury 771 41 28 1 799 42 City of London 46 7 3 – 49 7 Eastern. Shoreditch 1,175 47 35 5 1,210 52 Bethnal Green 1,218 40 37 – 1,255 40 Stepney 2,661 98 98 7 2,759 105 Poplar 2,071 44 60 2 2,131 46 Southern. Southwark 2,071 96 64 8 2,135 104 Bermondsey 1,389 32 43 2 1,432 34 Lambeth 3,629 244 123 10 3,752 254 Battersea 2,058 86 60 3 2,118 89 Wandsworth 3,727 204 131 10 3,858 214 Camberwell 3,029 136 94 3 3,123 139 Deptford 1,420 42 57 3 1,477 45 Greenwich 1,292 36 43 3 1,335 39 Lewisham 2,923 96 112 7 3,035 103 Woolwich 2,060 65 82 2 2,142 67 London, 1937 51,839 3,172 1,705 159 53,544 3,331 London, 1936 53,116 3,157 1,720 137 54,836 3,294 7 The deaths in the total population of London during 1937 numbered 51,277, Deaths giving a death.rate of 12.5 per thousand, compared with 12.3 in 1936. Of the total deaths 25,369, or 49.5 per cent., were among females. The distribution of deaths by ages in 1937 and recent preceding periods is shown in the following table :– Table 3 Period 0. 1. 2. 5. 10. 15. 20. 25. 35. 45. 55. 65+ All ages 1919.22 Annual average. 7,836 2,131 1,919 1,376 853 1,175 1,318 3,103 4,238 6,414 8,265 19,828 58,456 1923.26 5,546 1,611 1,453 828 637 1,013 1,220 2,479 3,659 6,080 8,456 21,004 53,986 1927.30 4,585 1,396 1,152 818 490 1,009 1,245 2,414 3,444 6,195 9,200 23,788 55,736 1931.34 3,906 915 841 669 477 809 1,182 2,320 2,891 5,554 8,968 24,756 53,288 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 1936 ... 3,691 738 661 466 309 577 964 1,930 2,473 4,932 8,720 25,681 51,142 1937 ... 3,309 457 411 379 303 584 888 1,976 2,474 5,029 8,997 26,470 51,277 During the period to which the figures in the first four lines of this table relate, sthe deaths among infants under one year of age are shown to have fallen by more than 50 per cent., the chief factor in this decline being the decrease in the birth.rate. At the other extreme of life it will be seen that the deaths have increased by about 25 per cent, after 65 years of agev Here the increase is due not to increased death. rate but to the increase in population at these ages. Street accidents There was a slight decrease in the number of fatal street accidents–from 541 in 1936 (53 weeks) to 520 in 1937 (52 weeks). A comparison of the age distribution for the two years is given in the following table:– 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 1936 (53 weeks) 18 73 73 94 113 170 541 1937 (52 weeks 12 71 93 78 125 141 520 Adjusted increase (+ ) or decrease ( –) per cent. –32.0 –0.9 + 29.9 –15.4 + 12.7 –15.5 –2.03 The death.rates from all causes and from certain specified causes in each metropolitan borough in 1937 and in London as a whole in 1937 and earlier years will be found in tables 34 and 36. The deaths from the principal causes by age and sex during 1937 in London are shown in table 35. Infant mortality /. The deaths under one year of age per thousand live.births were 60, compared with 66 in the preceding year. This is slightly above the lowest rate hitherto recorded of 58 in 1935, and a comparison of the figures in table 5 below shows that the excess in 1937 over the record year 1935 is accounted for by the increase in mortality from pneumonia, associated with the winter prevalence of influenza and from summer diarrhœa. 8 The movement of the death.rates from the principal diseases at ages below one year since 1910 are shown in the following table:– Table 5 Cause of death 1911 to 1914 1915 to 1918 1919 to 1922 1923 to 19.26 1927 to 1930 1931 to 1934 1933 1934 1935 1936 1937 Measles 3.40 3.84 1.64 2.02 2.07 1.44 0.28 2.60 0.07 2.35 0.05 Whooping.cough 3.63 4.45 2.50 2.60 3.14 2.27 2.45 1.88 1.77 2.51 2.73 Influenza 0.27 1.10 0.81 0.38 0.48 0.40 0.46 0.30 0.18 0.27 0.40 Tuberculosis 3.40 3.20 1.52 1.26 0.89 0.77 0.83 0.60 0.56 0.71 0.44 Bronchitis 6.41 6.72 4.42 2.91 2.30 2.16 1.50 2.48 1.90 2.26 1 .95 Pneumonia 12.28 14.96 12.60 11.51 12.10 11.45 8.27 13.40 9.79 11.42 10.83 Diarrhœa 24.28 16.10 12.16 9.36 8.87 10.86 10.70 12.01 10.61 13.79 11 .62 Premature birth 1816 17.42 17.00 14.74 1417 14.91 15.23 14.65 14.11 13.13 13.60 Congenital defects 14.69 14.66 11.26 8.39 7.38 7.22 6.84 7.81 6.88 6.97 6.14 Other causes 21.48 20.55 15.09 11.83 12.60 13.52 13.44 11.27 12.01 12.47 12.40 All causes 108 103 79 65 64 65 60 67 58 66 60 The death.rates from various causes shown above are stated in the following table as a proportion of the deaths from all causes in each of six successive four. yearly periods and the three.year period 1935.1937:– Table 6 Cause of death. 1911 to 1914 1915 to 1918 1919 to 1922 1923 to 1926 1927 to 1930 1931 to 1934 1935 to 1037 Measles 3.1 3.7 2.1 3.1 3.2 2.2 1.3 Whooping.cough 3.4 4.3 3.2 4.0 4.9 3.5 3.8 Influenza 0.3 1.1 1.0 0.6 0.8 0.6 0.4 Tuberculosis 3.1 3.1 1.9 1.9 1.4 1.2 0.9 Bronchitis 6.0 6.5 5.6 4.5 3.6 3.3 3.3 Pneumonia 11.3 14.5 15.9 17.7 18.9 17.6 17.3 Diarrhœa 22.5 15.6 15.4 14.4 13.9 16.7 19.7 Premature birth 16.8 16.9 21.5 22.7 22.1 23.0 22.3 Congenital defects 13.6 14.3 14.3 12.9 11.5 11.1 10.9 Other causes 19.9 20.0 19.1 18.2 19.7 20.8 20.1 All causes 100.0 100.0 100.0 100.0 100.0 100.0 100.0 The infant mortality.rate has remained remarkably uniform since 1922. In the period 1911.1922, the average annual rate was 97 per 1,000 births, but for 1923.1934 it has varied little from an average of 65, representing a decrease of nearly one.third. No doubt the rate for 1911.1922 would have been lower but for the adverse conditions of war time; but the conditions, whatever they were, which brought about the marked decline down to 1922 appear thereafter to have reached the limit of their good effect. When the changes in the proportion of deaths from various causes are considered, the percentages do not show any marked variation except in the case of tuberculosis. Thus the measles and whooping.cough deaths in the period 1911.1922 formed 6.6 per cent, of the total and 7.0 per cent, in 1923.34; respiratory diseases 19.9 and 21.9 per cent.; diarrhoea and enteritis 17.8 and 15.0 per cent.; premature birth and congenital defects together 32.5 and 34.4 per cent.; all other causes 23.2 and 21.7 per cent. Broadly, one may say that each of the diseases comprised under these headings has reacted equally to the conditions prevailing in the two periods. With regard to tuberculosis, the decrease in proportion from 2.7 to 1.5 seems to indicate some specific factor acting in addition to that which has caused the general improvement observed; in regard to this undoubtedly the notification of tuberculosis (since 1912), and the subsequent extension of the work of the tuberculosis dispensaries, must be considered; but the increasing accuracy of death certification is an unknown, and undoubtedly important, factor. 9 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 7–County of London–Infant mortality, 1937 Cause of death Age at death Total Rates perl,000 live births Under 1 day 1 to 7 days 1 to 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 Males Females Measles Leg. – – – 1 – – 2 3 3 – 11 – Illeg. – – – – – – – – – – – – Whoopingcough Leg. – 1 1 22 51 31 35 141 66 75 2.47 2.98 Illeg. – – – 1 3 3 2 9 4 5 2.42 3.30 Influenza Leg. – – 3 1 3 5 9 21 9 12 .34 .48 Illeg. – – – 1 – – – 1 1 – .60 – Tuberculosis Leg. – – – – 10 6 7 23 11 12 .41 .48 meg. – – – – 1 – – 1 1 – .60 – Bronchitis Leg. – – 4 30 41 14 6 95 62 33 2.32 1.31 Illeg. – – 3 3 4 2 – 12 7 5 4.23 3.30 Pneumonia Leg. – 12 28 116 183 106 97 542 319 223 11.95 8.87 Illeg. – 2 2 15 16 14 5 54 36 18 21.75 11.87 Diarrhoea Leg. – 1 12 107 201 160 64 545 337 208 12.62 8.27 Illeg. – – 2 29 48 10 5 94 62 32 37.46 21.09 Premature birth Leg. 296 228 85 58 7 1 – 675 404 271 15.13 10.78 Illeg. 29 22 15 7 – – – 73 40 33 24.17 21.75 Congenital defects Leg. 22 60 65 88 45 15 3 298 165 133 6.18 5.29 Illeg. 11 2 4 20 3 – – 40 20 20 12.08 13.18 Other causes Leg. 92 127 71 74 94 78 53 589 343 246 12.85 9.78 Illeg. 44 15 2 12 12 5 3 93 58 35 35.05 23.07 All Causes Leg. M. 246 238 155 323 375 227 155 2,932 1,719 1,213 64.39 48.24 F. 164 191 114 174 260 189 121 Illeg. M. 46 24 16 52 58 21 12 377 229 148 138.37 97.56 F. 38 17 12 36 29 13 3 Total, 1937 494 470 297 585 722 450 291 3,309 1,948 1,361 68.71 51.05 Total, 1936 553 467 355 607 693 610 406 3,691 2,124 1,567 73.80 57.00 1936 Leg. M. 278 266 190 322 366 301 206 3,331 1,929 1,402 70.97 54.05 f. 199 172 141 209 241 267 173 Illeg. M. 35 16 14 47 42 24 17 360 195 165 121.80 106.04 F. 41 13 10 29 44 18 10 Table 8, relating to the mortality among infants aged 1.2 years and 2.5 years, appeared in the Annual Report of the Registrar.General for 1935 (statistical report, text, p. 37). The figures for 1936 and 1937 have been added. The Registrar.General observes that the "London mortality at 1.2 years from all causes fell in 1935 to the lowest level yet recorded, 693 per 100,000 living, and the rate at 2.5 years also fell to the record low level of 248, the previous lowest rate being 415 in 1931. Whereas London death.rates at these two ages were 51 and 27 per cent, in excess of the national rates in 1934, they were 28 and 32 per cent. respectively below the corresponding national rates in 1935 Measles, whooping.cough, pneumonia, and diphtheria have been chiefly responsible for the large fluctuations in mortality during the second year of life, and when these causes together with influenza are omitted, the residual death.rates have followed a declining course with relatively slight fluctuations." 10 The death.rates for all causes at ages 1.2 and 2.5 years in 1937 are not as low as those for the record year 1935; but it will be observed that they are considerably lower than in any other previous year. Table 8–County of London–Mortality from various causes at 1.2 and aJl causes at 2.5 years of age in each year 1922.1937 Year 1.2 years 2.5 vears Death.rate per 1,000 living Death. rate per cent, of England and Wales Death.rato from all causes Diphtheria Measles Whooping cough Influenza Pneumonia Other causes All causes Per 1000 living Per cent, of England and Wales 1922 2.22 8. 08 5.16 1.25 12.81 7.25 36.77 148 12.03 155 1923 0.84 1.87 1.47 0. 09 4.51 6.47 15.25 81 5.26 93 1924 0.73 6.93 2.12 0.50 9.05 5.91 25.24 115 6.84 117 1925 0.59 1.87 3.42 0.21 5.99 5.62 17.70 82 5.30 87 1926 0.97 5.55 0.99 0.09 6.15 5.36 19.11 104 5.19 99 1927 0.71 104 2.38 0.38 6.15 5.24 15.90 81 4.81 83 1928 1.07 8.33 2. 01 0.25 5.64 5.25 22.55 139 5.71 114 1929 0.64 1.44 6.19 1.06 9.75 5.55 24.63 105 5.68 86 1930 0.95 7.55 0.61 0.05 4.35 5.02 18.53 135 4.70 101 1931 0.52 0.76 1.59 0.34 5.13 4.94 13.28 85 4.15 86 1932 0.62 6.38 1.78 0.15 3.87 5.36 18.16 128 5.62 124 1933 0.47 0.68 1.89 0.28 4.27 4.31 11.91 91 4.33 98 1934 0.88 7.13 1.75 0.09 4.93 4.50 19.29 151 5.87 127 1935 0.36 0.09 0.84 0.08 2.18 3.38 6.93 72 2.48 68 1936 0.33 4.80 1 .61 0.12 3.75 3.68 14.28 133 4.45 118 1937 0.35 0.16 1.15 0.23 3.16 3.86 8.91 92 2.85 81 Infectious diseases The notifications, attack.rates and death.rates of the principal infectious diseases in London in 1937 and earlier years are shown in tables 36 to 39, and for the constituent metropolitan boroughs in 1937 in table 34 Anthrax Three cases of anthrax were notified during the year, two of which were confirmed. The confirmed cases occurred in Bermondsey and Islington, the one in the latter borough proving fatal. The case in Bermondsey was that of a man, aged 65 years, employed as a warehouseman at a hide warehouse in the borough. The probable source of infection was horse or cow hides, the firm handling wet hides from the West Indies and Spain ; dry hides from Australia, Nigeria and Rhodesia; and hides from various farms all over England. The illness commenced some time between 23rd and 28th April, 1937, the patient first undergoing medical treatment on 27th April, 1937. The site of the disease was on the face, below and laterally to the right orbit. He was admitted to Guy's hospital on 27th April, 1937, and was discharged cured on 27th July, 1937. The case in Islington was that of a man aged 42 years, who was employed at a seed warehouse in Wandsworth. He last went to work on 16th September, 1937, when there was a history of redness and swelling of the right eye. He was taken to St. Mary Abbots hospital on 18th September, 1937, and was admitted the same day to the North.Western hospital, certified as suffering from erysipelas. He died on the 21st September, 1937, and a post.mortem examination disclosed the presence of B. anlhracis and hsemolytic streptococci. The Coroner's verdict was "Death from anthrax contracted during employment," the suspected source of infection being seeds of imported origin or sacks. The borough medical officer of health was unsuccessful in ascertaining any definite source of infection. Samples of bird seed and sacks from the warehouse were examined at the group laboratory at the Archway hospital, but no evidence of B. anlhracis was found. 11 Smallpox No case of smallpox was notified in London during the year. London has now been free from this disease since June, 1934. Cerebrospinal fever During the year 175 notifications of cerebro.spinal fever were received, but in 20 of these the diagnosis was not confirmed. Of the 155 confirmed cases, 65 proved fatal. In addition, 28 deaths were recorded by the Registrar.General of cases which had not been notified, making a total of 93 deaths for the year. Encephalitis lethargica The notifications of encephalitis lethargica numbered 8, but of these 3 were not confirmed. Of the 5 confirmed cases, none proved fatal, but 50 deaths were recorded by the Registrar.General of cases which had not been notified, and 6 of cases which had been notified in a previous year, making a total of 56 deaths for the year. Poliomyelitis and polioencephalitis Notifications of poliomyelitis and polioencephalitis numbered 108 ; the diagnosis was not confirmed in 12 of these. Of the 96 confirmed cases, 6 proved fatal. In addition, 9 deaths were recorded by the Registrar.General of cases which had not been notified, making a total of 15 deaths for the year. The following table shows the age incidence of cases of cerebro.spinal fever, encephalitis lethargica, and poliomyelitis and polioencephalitis, including confirmed notified cases and deaths among unnotified cases, but excluding the unconfirmed cases:– Table 9 Age periods Under 3 3.5 5.10 10.20 20.30 30.40 40.50 50.60 Over 60 Total Cerebro.spinal fever 82 16 13 19 25 10 6 10 2 183 Encephalitis lethargica – – – 1 14 8 8 11 13 55 Poliomyelitis and polioencephalitis 23 20 33 22 4 3 – – – 105 The following statement shows the number of cases, notified and confirmed and the number of deaths, including deaths among unnotified cases, recorded in the Registrar.General's death returns :– 1933 1934 1935 1936 1937 Cerebrospinal fever– Nos. notified and confirmed 203 124 89 99 155 Deaths in the same year among 90 62 50 52 65 cases notified and confirmed Deaths among cases notified in previous years 2 1 – – – Deaths among unnotified cases 24 15 19 24 28 Encephalitis letharaica– Nos. notified and confirmed 18 24 14 11 5 Deaths in the same year among 8 6 4 4 – cases notified and confirmed Deaths among cases notified in previous years 8 3 4 1 6 Deaths among unnotified cases 31 27 26 49 50 Poliomyelitis and polioencephalitis– Nos. notified and confirmed 60 65 82 37 96 Deaths in the same year among cases notified and confirmed 5 4 5 2 6 Deaths among cases notified in previous years – 1 2 1 – Deaths among unnotified cases 7 8 4 5 9 The number of notified cases of dysentery in 1937 was 916. ihe corresponding Dysentery figures for the previous nine years were :– 1928 39 1933 31 1929 56 1934 58 1930 40 1935 199 1931 38 1936 304 1932 79 12 An increase in the incidence of the disease during the present year was noted in the week ended 9th October (when 18 notifications were received); and, including that week, 754 cases were notified to the end of the year (giving a weekly average for the 13 weeks of 58), compared with 162 during the fist 39 weeks (a weekly average of 4.3). The highest weekly number of notified cases was 124 in the week ended 5th December. During the week ended 1st January, 1938, the number of notifications had fallen to 76. The incidence of the disease was more or less evenly distributed throughout London and no common source of infection was apparent. Food poisoning In 1937 (52 weeks) particulars of 458 cases of food poisoning notified to the borough medical officers of health under the provisions of the Public Health (London) Act, 1936, were received, compared with 382 for the year 1936. Six of the notified cases died. In some instances more than one member of a family was affected by illness, but the majority were isolated cases and may have been due to idiosyncrasies of the patients. Particulars are set out below of the groups of cases that call for special comment. On 29th May, a family of six in Islington were removed to hospital suffering from food poisoning, stated to be caused through eating pressed pork. A few days later three members of another family in the same borough were similarly affected, the food suspected being part of the same supply. Although the Bacillus certryclce (an organism of the food poisoning group) was isolated from the feces of most of the patients, none of the cases was of a serious nature. Early in July, 30 persons partook of a meal of cold boiled ham in St. Pancras. Thirteen of the participants were affected with diarrhoea and vomiting, necessitating the removal of four of them to hospital. All the cases recovered after a short period of treatment. During the last week in August, an outbreak of food poisoning, affecting 143 persons, occurred in an area including parts of Finsbury, St. Pancras and Islington. Eighteen of the patients, of whom three died, were treated in the Council's hospitals. The matter was investigated by the medical officers of health of the boroughs concerned, and the cause of the outbreak was traced to a provision shop in Finsbury which had supplied ham and corned beef. A specimen of the feces from the retail dealer who handled the food in most, if not all, of the cases was found to contain food.poisoning bacilli (Salmonella Gcerlner), although the man showed no signs of illness. The following table shows the age and sex incidence in 446 cases notified during the year ; in the remaining 12 cases the ages were not stated :– Table 10 Sex Under 5 years 5.15 years 15.25 years 25.35 years 35.45 years 45.55 years 55.65 years Over Go 1 years Total Male 9 27 42 42 22 23 16 15 196 Female 10 33 59 48 38 31 15 16 250 The causes of illness in the 458 notified cases were stated to be as follows :– Fish 65 Fruit 4 Tinned fish and paste 23 Tinned fruit 4 Meat 217 Miscellaneous 53 Tinned meat 32 Not known 60 Measles The deaths from measles in 1937 numbered 24, compared with 584 in 1936 and 19 in the last non.epidemic year, 1935. The death.rate was .01 per thousand. 13 The death.rates in London and England and Wales in recent years have been as follows:– Table 11 Area. 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 London 0.20 004 0.30 0. 05 0.23 0. 03 0.19 0. 02 0.20 0. 00 0.14 England and Wales 0.09 0.09 0.11 0.09 0.11 0.08 0. 08 0. 05 0. 09 0. 03 0. 07 Whooping. cough There were 247 deaths from whooping.cough in London during 1937 compared with 278 in 1936. The death.rate was .06 per thousand. The death.rates in London and England and Wales in recent years are shown in the following table:– Table 12 Area 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 London 0. 05 0.12 0.09 0.26 0. 03 0.07 0.08 0.07 0. 07 0. 04 0. 07 England and Wales 0.11 0.09 0.08 0. 16 0. 05 0.06 0.07 0. 06 0. 05 0.04 0.05 Scarlet fever There were 8,455 notifications of scarlet fever in 1937 (52 weeks), the corre. i sponding figure for 1936 (53lweeks) being 10,705. The attack.rate was 2.1 per thousand, compared with 2.6 for 1936. The deaths numbered 33, giving a death. rate of .01 per thousand of the population at all ages and a case.mortality of .4 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 13 Weeks of the year 1. 5. 9. 13. 17. 21. 25. 29. 33. 37. 41. 45. 49.52 624 695 690 712 604 588 735 502 470 708 763 742 622 The notifications (uncorrected for errors in diagnosis), deaths and crude case. mortality during 1937 were as follows:– Table 14 Year 1937 Age.period Total 0. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 15 + Notifications (52 weeks) 76 376 578 679 826 977 879 634 497 363 1,194 1,376 8,455 Deaths (365 days) 1 4 1 5 3 – 4 – 2 – 4 9 33 Crude case . mortality percentage 1.32 1.06 0.17 0.74 0.36 – 0.46 – 0.40 – 0.34 0.65 0.39 The death.rates in London and England and Wales in recent years are shown in the following table:– Table 15 Area 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 London 0.02 0.01 0.02 0.02 0.03 0.02 0.02 0.02 0.02 0.01 0.01 England and Wales 0.02 0.01 0.01 0.02 0.02 0.01 0.01 0.02 0.02 0.01 0.01 14 Diphtheria Notifications of diphtheria numbered 7,810 in 1937 (52 weeks), compared with 7,030 in 1936. This gives an attack.rate of 1.9 per thousand as against 1.7 in the preceding year. There were 217 deaths, giving a death.rate of .05 per thousand living. The case.mortality was 2.8 per cent., compared with 3.2 per cent, in 1936. 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 16 Weeks of the year 1- 5- 9- 13- 17- 21- 25- 29- 33- 37- 41- 46- 49-52 556 637 520 435 503 492 494 370 507 721 866 961 748 The notifications (uncorrected for errors in diagnosis), deaths and crude case. mortality during 1937 were as follows:– Table 17 Year 1937 Age.period Total 0- 1- 2- 3- 4- 5- 6- 7- 8- 9- 10- 15 + Notifications (62 weeks) 168 391 525 669 728 869 767 614 523 380 958 1,218 7,810 Deaths (365 days) 13 18 24 24 28 25 26 16 15 2 17 9 217 Crude case . mortality percentage 7.74 4.60 4.57 3.59 3.85 2.88 3.39 2.61 2.87 0.53 1.77 0.74 2.78 The death.rates in London and England and Wales in recent years are shown in the following table:– Table 18 Area 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 London 0.12 0.09 0.09 0.08 0.10 0.06 0.07 0.08 0.11 0.06 0.05 England and Wales 0.08 0.07 0.08 0.09 0.09 0.07 0.06 0.07 0.10 0.09 0.08 An analysis of the types of diphtheria diagnosed in the cases of this disease admitted to the Council's fever hospitals during the two years 1936 and 1937 shows that, although the percentage of the various types is much the same in the two years, the percentage of deaths varies considerably from the one year to the other. The figures, which omit "carrier" cases and contacts, are as follows :– Table 19–Diphtheria–Types of cases under treatment in the Council's fever hospitals durinq 1936 and 1937 Type of diphtheria Percentage of total cases Case-mortality * per cent. 1936 1937 1936 1937 Anterior nasal 17.1 20.8 0.45 0.18 Laryngeal 1.7 1.3 6.59 2.99 Faucial 73.4 69.4 3.23 2.18 Nasopharyngeal 7.5 8.0 17.09 19.48 Non.respiratory 0.3 0.5 0.00 0.00 Total 100.0 100.0 3.85 3.14 * Deaths due to diphtheria per cent, of discharges and deaths. Diarrhœa and enteritis Diarrhœa and enteritis caused 676 deaths among children under two years of age, or 12.29 per thousand live.births. The corresponding rate in 1936 was 14.47. 15 Puerperal fever and pyrexia : maternal mortality There were 228 notifications of puerperal fever and 793 notifications of puerperal pyrexia in 1937 (52 weeks) compared with 175 and 635 respectively in 1936 (53 weeks). The deaths from puerperal fever numbered 46 and from other puerperal causes 80, the deaths per thousand live.births being .84 and 1.45 respectively, giving a total maternal mortality rate of 2.29 compared with 1.98 in 1936. 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 1921 to 1930 and 1931 to 1937, together with the deaths in childbirth in 1937, are shown in the following table:– Table 20 Metropolitan boroughs arranged in topographical order Childbirth deaths* per 1,000 live.births Number of deaths in child birth 1937 1921-30 1931-37 Puerperal fever Other causes Total Puerperal fever Other causes Total Puerperal fever Other causes Total Western. Paddington 1.6 1.5 31 1.9 2.6 4.5 2 6 8 Kensington 2.2 1.5 3.7 1.5 1.6 3.1 2 5 7 Hammersmith 1.9 1.9 3.8 1.3 1.4 2.7 1 3 4 Fulham 2.1 1.5 3.6 1.3 1.9 3.2 – 6 6 Chelsea 1.9 3.1 5.0 1.1 1.8 2.9 – – – Westminster 2.1 3.2 5.3 1.7 1.9 3.6 3 3 6 Northern. St. Marylebone 2.3 2.5 4.8 2.0 2.1 4.1 2 2 4 Hampstead 1.9 2.3 4.2 1.0 1.2 2.2 1 2 3 St. Panoras 1.2 1.6 2.7 1.7 1.9 3.6 2 3 5 Islington 1.6 1.6 3.2 1.4 1.6 3.0 7 6 13 Stoke Newington 2.3 2.0 4.3 0.8 3.6 4.4 – 3 3 Hackney 1.6 1.6 3.2 0.9 1.6 2.5 1 3 4 Central. Holborn 2.4 0.9 3.3 2.7 0.9 3.6 1 – 1 Finsbury 1.3 1.2 2.5 0.7 0.7 1.4 – 1 1 City of London 3.7 0.9 4.6 4.3 – 4.3 – – – Eastern. Shoreditch 11 1.4 2.5 0.8 1.4 2.2 1 3 4 Bethnal Green 1.1 1.4 2.5 1.2 1.2 2.4 2 1 3 Stepney 1.0 1.4 2.4 0.9 1.6 2.5 2 5 7 Poplar 1.1 1.6 2.7 1.5 1.2 2.7 1 1 2 Southern. Southwark 1.3 1.3 2.6 1.1 1.9 30 1 6 7 Bermondsey 10 1.8 2.8 1.5 1.4 2.9 – – – Lambeth 1.6 1.5 3.1 1.2 1.0 2.2 5 3 8 Battersea 0.9 1.9 2.8 1.1 1.7 2.8 – 4 4 Wandsworth 1.6 1.9 3.5 1.7 1.4 3.1 7 4 11 Camberwell 1.9 1.5 3.4 1.4 1.5 2.9 3 3 6 Deptford 1.5 1.7 3.2 1.3 1.3 2.6 – 1 1 Greenwich 1.2 1.4 2.6 1.5 1.9 3.4 1 – 1 Lewisham 1.2 1.5 2.7 1.2 1.7 2.9 1 3 4 Woolwich 1.4 2.0 3.4 1.2 1.2 2.4 – 3 3 London 1.50 1.66 3.16 1.32 1.58 2.90 46 80 126 * Including deaths due to abortion except those legally determined to have resulted from criminal interference. The deaths in childbirth in 1937 are shown in the above table but not the death rates, as, owing to the smallness of the figures, the rates for a single year may be misleading. The maternal mortality rates for each metropolitan borough in 1937 and for London as a whole annually since 1924 are, however, set out in tables 34 and 36. 16 Table 21 (A)–County of London–Maternal deaths from sepsis among married women, 1931.37 Metropolitan boroughs arranged in topographical order Childbirth Miscarriage Criminal abortion Age at death Age at death Age at death 15 – 20 – 25 – 30 – 35 – 40 – 45+ Total 15 – 20 – 25 – 30 – 35 – 40 – 45+ Total 15 – 20 – 25 – 30 – 35 – 40 – 45+ Total W estern. Paddington – 3 3 1 1 – – 8 – 2 1 4 – – – 7 – – – 1 – – – 1 Kensington 1 – 2 1 2 2 1 9 – 3 3 – 4 1 – 11 – 1 1 – – – – 2 Hammersmith – 2 1 4 2 3 – 12 – – 1 2 2 – – 5 – – – 1 – – 1 2 Fulham – 1 4 3 2 2 – 12 – – – – 2 – – 2 – – – – – – – – Chelsea – – 1 2 – – – 3 – – – 1 – – – 1 – – – – – – – – Westminster, City of – – 2 1 2 – – 5 – – – 1 1 – – 2 – – – 1 1 – – 2 Northern St. Marylebone – 1 1 1 – 1 – 4 – – 1 – 2 1 – 4 – – 3 1 – – – 4 Hampstead – 1 1 – 1 – – 3 – – – 1 – – – 1 – – – – 1 – – 1 St. Pancras – – 2 5 1 2 – 10 – – 3 1 1 1 – 6 – 1 1 – 1 – – 3 Islington 1 6 12 8 3 1 1 32 – – 7 2 2 – 1 12 – – 1 2 1 – – 4 Stoke Newington – – – 1 – 1 – 2 – 1 2 – – – – 3 – – – – – – – – Hackney – 3 4 2 – 1 – 10 – – – 5 1 – – 6 – – – – – 1 – 1 Central. Holborn – – 1 – 1 – – 2 – 1 – – – – – 1 – – 1 – – – – 1 Finsbury – – 2 1 2 – – 5 – – 1 – – – – 1 – – 1 – – – – 1 City of London – – – – – – – – – – – 1 1 – – 2 – – – – – – – – Eastern. Shoreditch – 1 – 1 – – – 2 – – 1 1 – 1 – 3 – – – 1 – – – 1 Bethnal Green – 2 1 1 1 2 – 7 – – 1 2 1 1 – 5 – – – – – – – – Stepney – 1 1 2 5 – – 9 – – 3 3 3 1 – 10 – – 1 – – – – 1 Poplar – – 2 4 4 2 1 13 – 1 – 5 1 2 – 9 – – 1 1 – – – 2 Southern. Southwark – 1 4 1 2 2 1 11 – 1 – 2 2 1 – 6 – – 1 – – – – 1 Bermondsey – 3 3 3 1 – – 10 – – – 4 1 – – 5 – – – – – – – – Lambeth 1 2 9 5 3 – – 20 – 2 4 4 2 – – 12 – – – 1 3 – – 4 Battersea 1 1 2 3 1 1 – 9 – 3 1 2 – – – 6 – – – – – – – – Wandsworth – 4 11 13 2 2 – 32 – 4 2 3 2 2 – 13 – – – – – – – – Camberwell – 4 7 4 6 2 – 23 – 1 2 2 2 1 – 8 – – – 2 – – – 2 Deptford – 1 3 1 2 – – 7 – – 1 2 4 1 – 8 – – – – – – – – Greenwich 1 – 2 2 2 – – 7 – – 1 – 1 1 – 4* – – – – – – – – Lewisham – – 1 6 4 3 – 14 – – 1 2 3 1 1 8 – – – – – – – Woolwich – 3 4 3 – 1 – 11 – 1 – 1 2 – – 4 – – 1 1 – – – 2 Not known – – – – – – – – – – – – – – – – – – – – 1 – – 1 Total, married women 5 40 86 79 50 28 4 292 – 20 36 51 40 15 2 165* – 2 12 12 8 1 1 36 Total, single women 3 9 7 9 4 2 – 34 5 21 19 4 6 – – 55 1 9 6 1 5 4 1 – 26 * Including one death, age not stated, in Greenwich. 17 Table 21 (B)–County of London–Maternal deaths, from causes other than sepsis, among mirried women, 1931-1937 Metropolitan boroughs arranged in topographical order Childbirth Miscarriage Criminal abortion Age at death Age at death Age at death 15– 20– 26– 30– 35. 40– 45+ Total 15– 20. 25– 30– 35– 40– 45+ Total 15– 1 20– 25– 30– 35– 40– 45+ Total Western. Paddington – 4 7 8 7 2 – 28 – – – 1 – – – 1 Kensington – 4 8 3 4 2 1 22 – – – – – – – 1 1 2 Hammersmith – 1 6 2 4 2 – 15 – 1 – – – – – 1 – – – – – – – – Fulham 1 2 8 2 3 4 – 20 – – 1 2 2 – – 5 1 – – 1 – – 2 Chelsea – 1 3 1 – – – 5 – – – – – – – Westminster, City of – – 2 2 4 2 1 11 – – – – – – – Northern. St. Marylebone – 1 5 3 2 – – 11 – – – 1 – – – 1 – – – – – – 1 1 Hampstead 4 4 – – – – – – – – – – – – – – – – – – – 1 St. Pancras – 6 10 2 8 5 – 31 – – – – 1 1 – 2 – – – – – – – – Islington – 11 14 12 6 5 2 50 – – – 1 – – – 1 – – 2 – 1 – – 3 Stoke Newington 3 6 2 2 1 – 14 – – – – – – – – – – – – – – – – Hackney – 1 12 10 5 3 – 31 – – – – 1 – – 1 – – 1 – 1 – – 2 Central. Holborn – – – – 1 1 – 2 – – – – – – – – – – – – – – – – Finsbury – – 2 – 3 – – 5 – – – – – – – – – – – – – – – – City of London – – – – – – – – – – – – – – – – – – – – – – – – Eastern. Shoreditch – 1 4 3 2 2 – 12 – – 1 1 – – – 2 – – – – – – – – Bethnal Green – 3 3 1 – 1 2 10 – – 1 – – – – 1 – – 1 – – – – 1 Stepney – 2 10 8 6 9 – 35 – – – – 1 – – 1 – 1 – 1 – – – 2 Poplar – 2 3 5 4 1 – 15 – – – 1 1 – – 2 – – – – – – – – Southern. Southwark – 4 6 7 6 3 – 26 – – – – – 1 – 1 – – – – – – – – Bermondsey – 3 6 2 2 1 – 14 – – – 1 – – – 1 – – – – – – – – Lambeth – – 7 7 7 – 2 23 – – 1 1 1 – – 3 – – 1 1 – – – 2 Battersea 1 2 12 5 1 5 – 26 – – – 1 – – – 1 – – – – – – – – Wandsworth 2 5 10 12 4 3 1 37 – – – – – – – – – 1 – – – – – 1 Camberwell 1 4 5 8 8 2 1 29 – – 1 – – – – 1 – 1 – – – – – 1 Deptford – 3 1 2 2 3 1 12 – – – – – – – – – – – – – – – – Greenwich – 2 3 4 4 3 1 17 – – – – – – – – – – – – – – – – Lewisham – 5 10 4 9 5 – 33 – – – – – – – – – – – – – – – – Woolwich 2 2 3 3 4 1 – 15 – – 1 – – – – 1 – – – – – – – – Not known – – – – – – – – – – – – – – – – – – – 2 – – 3 Total, married women 7 76 166 122 108 66 12 557 – 1 6 10 7 2 – 26 – 6 6 2 5 – 2 21 Total, single women 6 14 12 3 5 5 – 45 – 2 2 1 – – – 5 2 6 5 3 3 1 – 20 18 Maternal mortality in relation to social condition For the purpose of showing the effect of environment on deaths in pregnancy and childbirth among married women, the figures for two groups of boroughs of contrasting conditions in respect of density of population, etc., have been abstracted :– (1) Group "A" (Hampstead, Lewisham and Wandsworth) representing the better circumstances population ; and (2) Group "B" (Bermondsey, Bethnal Green, Finsbury, Shoreditch and Stepney) representing the poorer population. The scope of comparison possible is limited by the fact that births to women according to age cannot be stated. Figures of this kind will become available under new regulations relating to the registration of births, which will come into force on 1st July, 1938 (Statutory Rules and Orders, 1938, No. 569). Some general inferences can, however, be drawn from the figures. Table 22–County of London–Deaths among married women in pregnancy and childbirth in relation to social circumstances (including criminal abortion), 1931.1937 Group (metropolitan boroughs) Cause of death Age at death All ages Deaths per 1,000 legitimate live births Under 35 35 and over Number Per cent. Number Per cent. Number Per cent. A (Hampstead, Lewisham, Wandsworth) Childbirth sepsis 37 34 12 27 49 32 .94 Other causes 56 52 22 50 78 52 1.50 Abortion sepsis 13 12 10 23 23 15 .48 Other causes 2 2 – – 2 1 Total 108 100 44 100 152 100 2.92 B (Bermondsey, Bethnal Green, Finsbury, Shore. ditch, Stepney) Childbirth sepsis 22 23 11 23 33 23 .55 Other causes 48 50 28 58 76 53 1.27 Abortion sepsis 19 20 8 17 27 19 .59 Other causes 7 7 1 2 8 5 Total 96 100 48 100 144 100 2.41 The rates per thousand births for the two age groups shown cannot, for the reasons stated above, be given, but for all ages per thousand live.births the mortality rate is 2.92 in group "A" and 2.41 in group "B." The advantage of the married women of poorer class, group "B," is marked in respect of sepsis, but the deaths from "other accidents of childbirth " are also lower in this group. It will be observed that the proportion of deaths occurring among married women under thirty.five years of age in group "A"–71 per cent, of the total at all ages– is only slightly greater than the corresponding proportion in group "B" of 67 per cent. The proportion of sepsis deaths in miscarriage and abortion among women under 35 years of age is relatively higher in group "B." Abortion In respect of miscarriage and abortion among married women, the rate can only be calculated per thousand legitimate births, instead of per thousand pregnancies, since the number of pregnancies is not available; but, so calculated, group "B" appears to have a somewhat higher mortality rate, though the figures are perhaps rather too small to give stable values. 19 The figures in the following table are based upon statements obtained from women confined in the Council's hospitals during 1936:– Table 23–Stated history of miscarriages per cent, of stated previous pregnancies among 17,931 women (married and unmarried) confined in the general hospitals of the London County Council, 1936 Number of previous pregnancies Ages of women at confinement All ages 15– 20– 25– 30– 35– 40– 45+ 1 7.2 5.3 5.3 3.6 4.5 2.0 – 4.9 2 50.0 9.5 7.3 7.3 6.4 4.4 – 7.6 3 – 9.5 8.7 7.2 6.0 5.8 – 7.5 4 – 13.6 8.9 6.7 5.9 4.0 12.5 7.0 5 – – 10.4 7.5 6.6 6.1 – 7.3 6 – – 8.3 8.5 4.8 6.5 4.2 6.5 7 – – 19.6 10.0 6.6 3.0 2.0 6.7 8 – – 31.3 17.1 5.6 2.4 18.8 6.7 9 – – – 8.6 5.8 3.7 4.4 5.2 10 and over – – – 7.5 12.4 7.5 14.6 9.6 Total 10.1 7.2 7.5 7.2 6.3 5.0 8.3 6.8 In both this and the following table the percentages are printed in italics where the figures upon which they are worked are too small to give stable rates. In 1937 there were discharged from the Council's general hospitals 3,870 women who had been under treatment for or in respect of miscarriage or abortion, and in addition 476 women were discharged pregnant after treatment for threatened abortion. The following figures give a sample tabulation of the previous miscarriages among women treated for miscarriage :– Table 24–County of London–Stated history of miscarriages per cent, of stated previous pregnancies among 635 women under treatment in the general hospitals of the London County Council for the results of miscarriage or abortion r of previous pregnancies Ages of women on admission to hospital All ages 15– 20– 25– 30– 35– 40– 45 + 1–3 – 20.8 17.8 19.1 20.9 26.9 25.0 19.5 4–6 – 34.6 23.4 23.4 18.5 10.6 – 20.2 7 and over – – 40.0 29.8 23.9 15.7 – 23.7 Total – 23.2 21.0 22.8 21.0 15.5 4.8 20.8 These figures are cumulative, e.g., the histories of women aged 30-35 rela.e to all their pregnancies up to that age. There is a tendency for the percentages to decrease with advancing age. This may be due to abortions at higher ages not being followed by a pregnancy which proceeds to term, or to a miscarriage which necessitates admission to hospital. Or, again, it may be that the incidence of abortion is smaller at advanced ages. Clinical experience does not, however, support the latter view. Enteric fevers There were 216 notifications of fevers of the enteric group in London in 1937 (52 weeks) compared with 255 in 1936 (53 weeks). The deaths in the calendar year numbered 17 as against 31 in 1936. The remarkable decrease in the mortality from enteric fever during the present century will be seen from the figures in table 36. 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 25 5- 9- 13- 17- 21- 25- 29- 33- 37- 41- 45- 49-52 8 21 27 9 12 8 13 8 31 22 22 20 15 20 In addition, there were 5 deaths recorded by the Registrar.General of cases belonging to London which had not been notified within the county. Two of these were inmates of mental institutions. During the period 29th October, 1937, to 31st December, 1937, when there was an outbreak of typhoid fever in Croydon, Surrey, 32 cases of enteric fever and 12 cases of paratyphoid fever were notified in London. One of these only was connected with the Croydon outbreak, i.e., a person whose permanent address was in Croydon, but who was notified as suffering from typhoid fever while staying temporarily in London. Another case (that of a nurse who, it was reported, had been engaged in nursing typhoid patients at a hospital in Croydon) was subsequently notified on 21st January, 1938, as suffering from enteric fever while living in London. Influenza The deaths from influenza during 1937 numbered 1,656, compared with 533 in 1936. Influenza became epidemic in London towards the end of 1936, the maximum weekly deaths, numbering 344, being recorded in the second week of 1937. During the seven major weeks of prevalence the deaths numbered 1,361. In the corresponding phase of the previous epidemic, early in 1933, there were 1,802 deaths. Rheumatic fever The deaths in London from rheumatic fever in 1937 numbered 82, of which 42 were among children under 15 years of age. The corresponding figures in 1936 were 106 and 51, respectively. Cancer There were 7,320 deaths from cancer in 1937, as against 7,362 in 1936. The death.rate per thousand was 1.79. There was a decrease of 64 in the deaths among males and an increase of 22 among females compared with the previous year. Tuberculosis The deaths from pulmonary tuberculosis in London during 1937 numbered 2,888, giving a death rate of .71 per thousand living, the corresponding figures for 1936 being 2,849 and .69 respectively, and 2,847 and .68 for 1935. There were 351 deaths from other forms of tuberculosis in 1937 as against 363 in 1936 and 359 in 1935, the death rates being .09 for each year. The annual death rates from pulmonary and non.pulmonary tuberculosis in recent years are shown in the subjoined table :– Table 26 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 1936 0.94 0.47 0.69 0.10 0.07 0.09 1937 0.93 0.50 0.71 0.10 0.08 0.09 The number of primary notifications in metropolitan boroughs during the year 1937, after correction of figures within each metropolitan borough by the exclusion of cases notified as primary but subsequently found to have been previously notified, 21 was G,469, the corresponding figure for 1936 being 6,232. The following is an analysis of the notifications in London during the year 1937 :– Table 27 Form of tuberculosis notified Sex Number of formal primary notifications of now cases of tuberculosis Total notifica tions 0– 1– 5– 10– 15– 20– 25– 35– 45–| 55– 65 + Total all ages Pulmonary tuberculosis M. 5 38 62 45 253 395 735 492 501 414 162 3,102 4,021 F. 2 28 37 63 330 551 666 304 191 113 68 2,353 3,050 Other forms of tuberculosis M. 6 63 75 68 67 56 76 32 28 18 10 499 568 F. 7 60 67 63 57 73 92 43 23 15 10 515 598 All forms of tuberculosis M. 11 101 137 113 320 451 811 524 529 432 172 3,601 4,589 F. 9 88 104 126 387 624 758 347 214 128 83 2,868 3,648 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 28 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. 3 9 11 12 25 88 164 107 84 78 50 631 F. 1 6 6 11 37 109 162 58 28 30 29 477 Other forms of tuberculosis M. 5 21 18 27 23 19 17 10 10 9 5 164 F. 7 18 20 19 19 18 15 14 7 8 6 151 All forms of tuberculosis M. 8 30 29 39 48 107 181 117 94 87 55 795 F. 8 24 26 30 56 127 177 72 35 38 35 628 The sources of information as to the unnotified cases shown in the above table were as follows :– Table 29 Source of information Number of cases Pulmonary Non.pulmonary Death returns from local registrars 166 60 transferable deaths from Registrar.General 88 44 Posthumous notifications 64 39 "Transfers" from other areas 780 169 Other sources 10 3 The returns received under the Public Health (Tuberculosis) Regulations, 1930, from the medical officers of health of the metropolitan boroughs show that there were 23,591 cases of pulmonary tuberculosis (13,492 males and 10,099 females) and 7,462 cases of other forms of tuberculosis (3,799 males and 3,663 females) on the registers of the metropolitan boroughs at the end of 1937. 22 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. Table 30 Metropolitan boroughs in topographical order Cases on notification register at beginning of 1937 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 1937 Notification Otherwise Cured, removed, etc. Deaths Total Per 1,000 of population Western. Paddington 952 262 22 201 112 923 6.7 Kensington 674 253 110 247 100 690 3.9 Hammersmith 1,063 174 64 119 114 1,068 8.4 Fulham 1,784 233 22 479 136 1,424 10.3 Chelsea 310 84 38 76 53 303 5.4 Westminster, City of 1,515 228 23 111 90 1,565 12.6 Northern. St. Marylebone 709 134 39 167 59 656 7.1 Hampstead 341 98 62 126 44 331 3.6 St. Pancras 1,050 281 110 289 172 980 5.4 Islington 2,312 574 140 760 269 1,997 6.8 Stoke Newington 280 46 36 75 38 249 5.0 Hackney 1,511 304 70 163 139 1,583 7.7 Central. Holborn 340 58 18 85 33 298 8.6 Finsbury 405 105 24 64 79 391 6.7 City of London 58 14 3 19 9 47 5.0 Eastern. Shoreditoh 1,476 140 37 102 95 1,456 17.7 Bethnal Green 1,200 130 38 107 95 1,166 12.3 Stepney 2,136 299 65 277 193 2,030 10.0 Poplar 941 193 32 148 131 887 6.5 Southern. Southwark 1,503 273 29 450 129 1,226 8.3 Bermondsey 917 178 28 107 104 912 9.2 Lambeth 2,520 458 47 524 231 2,270 8.3 Battersea 842 226 21 129 131 829 5.8 Wandsworth 2,081 433 166 291 252 2,137 6.3 Camberwell 2,048 351 62 207 211 2,043 9.1 Deptford 729 156 20 115 70 720 7.5 Greenwich 647 114 52 89 78 646 6.7 Lewisham 1,634 413 22 629 142 1,298 5.7 Woolwich 966 257 23 191 127 928 6.2 London 32,944 6,469 1,423 6,347 3.436 31,053 7.6 23 The following table shows for the past seven years the number of cases of pulmonary and of non.pulmonary tuberculosis on the notification registers per cent, of the total population in each metropolitan borough. The downward trend of the percentage is, it will be observed, general, and greater in the case of non.pulmonary than of pulmonary tuberculosis. Table 31–County of London–Cases of tuberculosis on register at the end of each year, per cent, of population, 1931-1937 Metropolitan boroughs arranged in topographical order 1931 1932 1933 1934 1935 1936 1937 Pulm. Non P. Pulm. Non P. Pulm. Non P. Pulm. Non P. Pulm. Non P. Pulm. Non P. Pulm. Non P. W estern. Paddington .53 .48 .50 .44 .51 .44 .45 .41 .39 .35 .38 .30 .39 .28 Kensington .40 .21 .36 .18 .33 .17 .36 .18 .30 .14 .28 .10 .30 .10 Hammersmith .61 .28 .57 .27 .55 .25 .57 .26 .57 .26 .56 .27 .56 .28 Fulham .70 .37 .72 .40 .74 .40 .80 .40 .81 .43 .83 .43 .70 .33 Chelsea .52 .13 .53 .13 .53 .13 .52 .11 .50 .12 .46 .09 .43 .10 Westminster, City of ... 1.03 .34 .77 .26 .78 .25 .86 .27 .90 .29 .94 .28 .97 .28 Northern. St. Marylebone .64 .17 .68 .17 .75 .18 .78 .19 .74 .19 .62 .15 .59 .12 Hampstead .47 .12 .40 .10 .38 .08 .39 .10 .38 .11 .30 .08 .30 .07 St. Pancras .66 .20 .66 .20 .65 .20 .62 .18 .47 .15 .44 .13 .43 .10 Islington .74 .25 .76 .26 .78 .27 .72 .25 .57 .20 .57 .20 .51 .17 Stoke Newington .45 .15 .46 .15 .50 .14 .49 .14 .46 .14 .44 .12 .38 .11 Hackney .56 .23 .61 .24 .61 .25 .63 .25 .64 .24 .54 .18 .58 .19 Central. Holborn .81 .19 .74 .19 .71 .19 .75 .17 .76 .16 .79 .19 .68 .18 Finsbury 1.39 .49 1.38 .49 .87 .37 .91 .41 .82 .36 .54 .12 .54 .13 City of London .62 .05 .51 .06 .56 .09 .62 .06 .61 .10 .52 .09 .42 .09 Eastern. Shoreditch 1.37 .46 1 31 .46 1.29 .46 1.30 .46 1.27 .47 1.26 .47 1.29 .48 Bethnal Green .88 .42 .84 .42 .83 .44 .85 .43 .86 .41 .84 .40 .84 .39 Stepney 1.11 .43 100 .41 .77 .34 .81 .35 .77 .24 .78 .25 .76 .24 Poplar .61 .28 .53 .25 .55 .25 .56 .24 .55 .21 .49 .19 .47 .18 Southern. Southwark .72 .31 .76 .30 .74 .28 .78 .27 .76 .25 .74 .24 .64 .20 Bermondsey .67 .27 .66 .25 .69 .25 .70 .26 .66 .25 .67 .24 .69 .23 Lambeth .68 .13 .70 .13 .73 .14 .75 .14 .76 .14 .77 .14 .71 .12 Battersea .51 .24 .50 .21 .50 .20 .49 .18 .46 .16 .44 .13 .45 .13 Wandswort h .51 .17 .48 .16 .47 .16 .46 .15 .47 .15 .47 .14 .49 .14 Camberwell .63 .22 .62 .23 .64 .24 .65 .24 .66 .24 .66 .23 .68 .23 Deptford .60 .21 .63 .21 .61 .19 .54 .19 .54 .18 .55 .19 .57 .17 Greenwich .59 .23 .58 .20 .54 .19 .51 .18 .50 .17 .51 .16 .52 .15 Lewisham .48 .14 .47 .15 .49 .15 .51 .15 .53 .16 .55 .18 .45 .12 Woolwich .64 .18 .55 .15 .57 .14 .57 .15 .55 .12 .54 .12 .52 .10 London .68 .25 .65 .24 .64 .24 .64 .23 .61 .22 .60 .20 .58 .18 24 The localisation of disease and source of notification, as stated on the weekly return of notifications of tuberculosis received from the metropolitan borough medical officers of health during the year 1937, are shown in the principal age groups in the following table:— Table 32—County of London—Age distribution of primary notifications of tuberculosis accordin to localisation of disease, 1937 (52 weeks) Age group Respiratory system Spine Hip Knee Other limbs, bones and joints Abdominal Peripheral glands Other sites Total Lungs Other 0- 1 year 6 2 - - - 2 - 1 8 19 1- 5 years 64 6 10 8 7 9 7 40 44 195 6-10 „ 83 15 13 10 11 13 10 62 23 240 10-15 „ 108 7 10 8 3 11 24 44 26 241 15-20 „ 543 33 13 10 7 11 20 29 34 700 20-25 „ 937 21 27 3 5 8 19 38 30 1,088 25-35 „ 1,388 12 25 2 15 15 24 28 51 1,560 35-45 „ 766 7 10 9 2 6 11 13 25 849 45-55 „ 711 7 10 4 3 5 6 5 18 769 55-65 „ 513 5 6 1 — 8 4 1 12 550 65 + „ 227 1 3 1 — 10 2 5 5 254 Age not stated 8 - - - - - - - - 8 All ages 5,354 116 127 56 53 98 127 266 276 6,473 Table 33—County of London—Age distribution of primary notifications of tuberculosis according to source of notification, 1937 (52 weeks) Tuberculosis of the respiratory system, 1937 (52 weeks) Age group Dispensary Hospital Private l.c.o. hospitals and institutions Total 0- 1 year 2 3 3 8 1-5 years 9 45 2 14 70 5-10 „ 18 61 5 14 98 10-15 „ 25 56 14 20 115 15-20 „ 151 145 165 115 576 20-25 „ 274 255 278 151 958 25-35 „ 394 412 371 223 1,400 35-45 „ 191 208 220 154 773 45-55 „ 163 155 225 175 718 55-65 „ 77 113 130 198 518 65 + „ 34 27 63 104 228 Age not stated 1 2 4 1 8 All ages ... 1,339 1,482 1,477 1,172 5,470 Other forms of tuberculosis, 1937 (52 weeks) 0- 1 year 6 2 3 11 1- 5 years 11 79 8 27 125 5-10 „ 22 87 5 28 142 10-15 „ 16 76 7 27 126 15-20 „ 11 57 11 45 124 20-25 „ 20 56 17 37 130 25-35 „ 25 69 23 43 160 35-45 „ 11 32 9 24 76 45-55 „ 6 28 3 14 51 55-65 „ 2 12 3 15 32 65 + „ 1 8 3 14 26 Age not stated — — — — — All ages 125 510 91 277 1,003 25 Tabi e 34— Vital statistics for the metropolitan boroughs and the County of London in the year 1937 (Rales per 1,000 of population) Metropolitan boroughs arranged in topographical order Estimated resident population 1937 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 recp dis. Cancer Maternal mortality (per 1,000 live births) Notifications of infectious disease (52 weeks) Scarlet fever Diph theria Typhoid fever Erysipelas Cerebro spinal fever Acute pneumonia Western. Paddington 138,300 13.7 13.1 66 .01 — .04 .04 .01 12.7 .07 1.08 .61 1.97 4.24 1.70 1.57 .08 .41 .04 1.31 Kensington 175,600 12.1 13.4 83 .01 .01 .02 .03 .01 19.8 .65 .96 .44 1.96 3.29 1.43 1.23 .08 .41 .02 1.24 Hammersmith 126,500 15.1 12.6 68 —- .01 .09 .07 .02 14.1 .75 l.00 .58 1.79 2.09 2.62 1.40 .02 .40 .04 .68 Fulham 138,900 13.9 13.1 56 .01 .01 .03 .05 - 15.5 .78 .75 .57 1.74 3.10 2.30 1.49 .02 .45 .09 1.23 Chelsea 56,510 10.8 14.1 59 — — .04 .04 - 13.1 .0/ .78 .67 2.28 - 1.65 1.30 .05 .30 .02 1.17 Westminster, cityot Northern. 124,300 8.3 11.6 56 .02 .03 .01 10.7 .69 .60 .64 1.92 5.84 1.77 .99 .13 .31 .05 .23 St. Marylebone 92,110 9.3 13.0 73 — — .03 .03 .02 10.5 .55 .97 .54 1.94 4.66 1.28 1.18 .08 .49 .03 .66 Hampstead 90,690 11.2 11.7 54 — .01 .04 .02 — 10.8 .33 .67 .39 1.86 2.96 2.08 1.15 .01 .28 .04 .97 St. Pancras 181,900 13.1 12.8 65 .01 .02 .08 .05 .01 21.8 .81 1.19 .53 1.85 2.88 2.01 3.98 .06 .35 .03 1.23 Islington 295,400 15.3 13.1 67 .00 .01 .07 .07 .00 13.5 .70 1.27 .83 1.79 4.02 2.45 2.11 .04 .51 .03 .73 Stoke Newington 50,250 14.9 12.6 37 — .- .02 .02 - 8.0 .66 1.09 .48 1.97 1.40 1.80 .88 .02 .00 .04 1.00 Hackney Central. 206,700 13.8 11.2 43 .01 .01 .04 .05 .00 8.0 .56 .84 .39 1.68 1.40 2.03 1.49 .03 .53 .04 .94 Holborn 34,600 8.1 11.8 79 .03 — .09 .06 — 7.1 .66 .87 .49 1.91 3.57 1.07 2.12 — .32 — 1.07 Finsbury 58,700 13.8 14.6 71 — — 03 .10 — 13.5 1.01 1.33 .66 2.21 1.23 2.20 2.43 — .43 .05 1.59 City of London (a) Eastern. 9,380 5.7 11.5 38 - - .11 - - - .75 .96 .53 1.39 - 1.28 .64 .11 .11 - .53 Shoreditch 82,240 14.9 12.5 54 .02 — .04 .09 — 9.0 .89 1.11 .69 1.62 3.27 2.62 2.06 .10 .67 .06 1.10 Bethnal Green 94,560 13.3 12.6 54 .01 — .04 .11 — 9.5 .77 1.00 .59 1.76 2.38 3.22 2. 35 .03 .76 .06 1.05 Stepney 203,100 13.6 12.2 60 — — .03 .07 .00 14.9 .75 .84 .45 1.63 2.54 1.86 3.15 .02 .58 .04 1.37 Poplar Southern. 136,800 15.5 12.6 61 .03 .01 .11 .06 .01 12.3 .79 .74 .81 1.76 .95 2.57 4.19 .09 .68 .04 2.43 South wark 147,400 14.7 14.1 65 .01 — .05 .09 — 9.7 .79 1.11 .79 1.89 3.23 2.10 2.48 .03 .37 .05 1.12 Bermondsey 98,790 14.4 12.3 59 — — .05 .07 — 16.2 .88 .80 .77 1.56 - 1.70 1.70 .05 .28 .10 .0l 1.73 Lambeth 273,800 14.1 13.2 69 .00 .01 .07 .08 .00 11.6 .76 .76 .62 1.82 2.07 1.93 1.85 .04 .41 .03 1.03 Battersea 143,500 14.9 12.9 70 .02 .01 .06 .06 .01 14.0 .77 .61 .83 1.70 1.87 1.94 2.19 .03 .58 .07 2.02 Wandsworth 341,700 11.5 12.4 64 .01 .01 .05 .07 — 11.4 .57 .64 .61 1.75 2.80 1.86 1.21 .05 .33 .03 1.39 Camberwell 224,800 14.1 12.8 58 — .01 .06 .08 .00 12.3 .79 .85 .62 1.81 1.90 1.88 1.53 .03 .35 .06 0.67 Deptford 96,580 15.1 11.8 45 .01 .01 .03 .10 — 7.5 .68 .86 .45 1.68 .68 1.78 1.65 .07 .31 .01 1.25 Greenwich 95,990 13.8 12.0 50 — .02 .04 .06 — 10.5 .79 .74 .48 1.68 .75 1.91 3.21 .11 .36 .06 1.28 Lewisham 226,000 13.4 10.9 47 — .01 .05 .05 .00 9.3 .59 .47 .56 1.68 1.32 2.61 1.26 .08 .31 .03 1.12 Woolwich 149,400 14.2 11.1 40 — — .07 .03 - 6.1 .70 .70 .45 1.64 1.41 2.68 2.15 .11 .47 .06 1.77 London, 1937 4,094,500 13.4 12.5 80 .01 .01 .05 .06 .00 12.3 .71 .86 .60 1.79 2.29 2.07 1.91 .05 .43 .04 1.18 London, 1936 4,141,100 13.6 12-3 66 .14 .01 .05 .07 .01 14.5 .69 .82 .61 1.78 1.97 2.65 1.67 .06 .43 .03 ..99 (a) Including [nner and Middle Temple. 26 Table 35—County of London—Principal causes of death by sex and age, 1937 Causes of death Sex 0— 1— 2— 5— 15— 25— 35— 45— 55— 65— 75— All Ages 1937 1936 Typhoid and paratyphoid fevers. M. 2 — — — 1 1 2 — — — 6 14 F. — — — — 2 2 1 3 1 1 1 11 17 Measles M. 3 5 4 2 — — — — — — — 14 323 F. — 3 6 1 — — — — — — — 10 261 Scarlet fever M. 2 5 5 1 1 — 14 21 F. 1 2 4 5 2 1 1 1 1 — 1 19 21 Whooping-cough M. 70 23 15 5 — — — — — — — 113 134 F. 80 36 13 5 — — — — — — — 134 144 Diphtheria M. 6 8 31 45 1 — — — 91 109 F. 7 10 45 56 3 1 1 2 — 1 — 126 117 Influenza M. 10 8 5 21 24 45 129 170 169 138 719 242 F. 12 4 2 4 27 35 54 88 153 228 330 937 291 Encephalitis Iethargica. M. — — 4 6 5 8 2 1 26 30 F. — — — — 1 9 2 7 5 3 1 28 24 Cerebro-spinal fever M. 22 4 4 1 6 I 1 1 2 — 42 40 F. 15 7 5 — 8 5 — 4 2 1 — 47 31 Tuberculosis of respiratory system. M. 2 6 3 4 209 357 298 386 358 145 17 1,785 1,810 F. 3 1 2 7 313 308 183 117 95 69 15 1,103 1,039 Other tuberculous diseases. M. 10 8 24 26 38 19 14 16 16 11 2 184 202 F. 9 14 18 28 27 22 9 12 16 10 2 167 161 Syphilis M. 9 2 2 2 14 22 47 32 4 134 113 F. 8 — — 2 1 1 12 7 10 5 4 50 54 General paralysis of the insane, tabes dorsalis. M. 1 3 2 17 39 38 34 134 145 F. — — — — — 6 7 7 20 9 2 51 52 Cancer, malignant disease. M. 2 7 12 16 65 142 442 1,070 1,238 607 3,601 3,665 F. — 2 1 6 21 55 230 606 900 1,075 823 3,719 3,697 Diabetes M. 2 2 10 5 13 60 84 49 225 216 F. 1 — — — 4 7 8 33 99 181 110 443 412 Cerebral haemorrhage M. — 1 5 19 66 178 252 286 807 792 F. — — — — 2 3 21 85 218 350 398 1,077 1,134 Heart disease M. 2 31 66 77 142 513 1,245 2,180 2,431 6,687 6,711 F. i 1 2 27 73 122 171 374 944 2,090 3,842 7,647 7,478 Aneurysm M. 1 8 14 24 63 52 17 179 175 F. i 1 — — 2 4 8 30 31 39 22 138 119 Other circulatory diseases. M. 2 ] 1 4 16 63 208 383 389 1,067 1,085 F. 1 — 1 — 1 1 19 71 174 440 608 1,316 1,239 Bronchitis M. 69 3 6 4 3 14 32 140 242 299 294 1,106 1,158 F. 38 5 1 2 I 10 11 45 92 196 458 859 888 Pneumonia (all forms) M. 355 93 38 20 34 46 107 261 420 363 243 1,980 1,906 F. 241 69 31 18 28 38 75 122 203 302 417 1,544 1,472 Other respiratory diseases. M. 3 2 4 7 8 28 47 58 48 50 255 260 F. — 4 2 4 4 8 15 22 42 39 96 236 223 Peptic ulcer M. 2 25 54 116 148 94 32 471 462 F- — 1 — — — 1 10 25 43 38 21 139 147 27 Table 35—continued Causes of death Sex 0— 1— 2— 5— 15— 25— 35— 45— 55— 65— 75- All ages. 1937 1936 Diarrhoea, etc. M. 399 26 1 — 4 4 2 4 14 7 14 475 513 F. 240 11 5 1 3 10 11 9 15 15 13 333 414 Appendicitis M. 1 9 11 16 17 15 19 36 24 8 156 164 F. — 1 6 12 15 12 12 19 30 18 9 134 127 Cirrhosis of liver ... M. 1 9 29 31 22 6 98 111 F. 1 — — — 2 1 5 14 24 17 5 69 63 Other diseases of liver, etc. M. 1 1 5 1 6 21 20 14 69 77 F. 2 — — — 2 7 4 15 32 42 29 133 154 Other digestive diseases. M. 25 4 10 10 14 20 22 53 86 95 67 406 427 F. 22 4 7 11 11 17 25 49 86 110 92 434 470 Acute and chronic nephritis. M. 1 5 26 36 37 81 156 162 140 644 718 F. 1 — — 6 23 28 40 64 133 190 182 667 721 Puerperal sepsis F. — 13 19 14 — — — 46 42 Other puerperal causes F. — — — — 15 49 16 — — — — 80 69 Congenital debility, premature birth, malformation, etc. M. 794 5 3 4 1 1 — 1 — — — 809 848 F. 571 3 2 3 3 1 1 — 1 — — 585 598 Senility M. — — — — — — — — 3 37 224 264 318 F. — — — — — — — — — 38 482 520 536 Suicide M. 2 27 65 57 78 84 62 14 389 396 F. — — — — 18 29 40 51 47 35 6 226 202 Other violence M. 48 16 21 77 152 110 78 123 116 102 140 983 1,011 F. 29 14 16 42 28 23 28 54 76 125 244 679 709 Other defined diseases M. 113 27 36 91 88 96 114 185 351 480 374 1,955 2,052 F. 77 22 16 76 74 112 150 223 280 344 269 1,643 1,750 Causes ill-defined, or unknown. M. 3 — — — — — 1 2 1 6 7 20 7 F. — 1 — — — — — — — 5 13 19 11 All causes M. 1948 241 226 366 745 1029 1290 2870 5224 6402 5567 25,908 26,255 F. 1361 216 185 316 727 947 1184 2159 3773 6006 8495 25,369 24,887 28 Table 36—Counly of London—Principal vital statistics, 1891-1937 Period Annual rate per 1,000 living Annual 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. ocf ch. birth Pulmonary Non-pulmonary 1891-95 30.8 17.3 19.8 (a) 0.53 0.13 0.24 0.02 0.52 0.59 0.41 1.83 0.80 1..45 2.45 0.48 (a) 0.80 0.07 156 23.8 2.15 2.22 1890-1900 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 0.45 017 1.58 0.57 1.46 1.41 0.26 1.31 101 0.08 139 30.4 1.64 1.52 1906-10 26.5 17.4 14.9 (a) 014 0.04 0.10 0.00 0.29 0.42 0.22 1.39 0.48 1.49 1.22 0.22 1.26 111 0.10 114 23.8 1.46 1.47 1911-15 24.0 20.0 14.8 0.02 013 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 1916-20 200 20.1 151 0.04 0.17 0.02 0.03 0.00 0.20 0.28 1.01 1.43 0.34 1.38 1.30 0.19 1.70 1.28 0.09 92 15.4 1.64 1.72 1921-25 19.9 17.9 12.3 0.01 017 0.01 0.04 0.00 0.15 0.17 0.32 101 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 1931-35 13.8 19.5 12.1 0.03 0.08 0.00 0.02 0.00 0.07 0.09 0.26 0.79 0.11 0.85 0.47 0.14 2.99 1.66 0.14 63 11.6 1.50 1.66 1925 17.9 17.2 11.9 0.01 0.11 0.01 0.02 0.00 0.19 0.07 0.24 0.95 0.17 1.04 0.90 0.16 1.77 1.44 0.09 68 10.8 1.42 1.77 1926 17.1 17.2 11.6 0.02 0.12 0.01 0.02 0.00 0.05 0.20 0.18 0.88 0.15 0.94 0.79 0.16 1.79 1.46 0.10 64 12.0 1.61 1.74 1927 16.1 18.2 12.1 0.01 0.09 0.01 0.01 0.00 0.12 0.04 0.40 0.91 0.14 1.00 0.83 0.17 2.01 1.49 0.11 59 7.6 1.31 1.60 1928 16.2 18.9 12.1 0.01 0.09 0.01 0.02 0.00 0.09 0.30 0.13 0.89 0.14 0.93 0.59 0.16 2.22 1.52 0.12 67 10.3 1.59 2.00 1929 15.8 19.1 14.2 0.02 0.08 0.01 0.02 0.00 0.26 0.05 0.71 0.96 0.13 1.33 0.97 0.20 2.93 1.55 0.13 71 11.0 1.88 1.73 1930 15.8 19.5 11.6 0.02 0.10 0.01 0.03 0.00 0.03 0.23 0.08 0.87 0.12 0.78 0.44 0.12 2.51 1.57 0.12 59 9.9 1.93 1.40 1931 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 0.01 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 0.00 0.07 0.20 0.13 0.76 0.01 0.90 0.47 0.14 3.01 1.72 0.14 67 12 8 1.34 1 46 1935 13.3 21.1 11.4 0.02 0.06 0.00 0.01 - 004 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 1936 13.6 21.5 12.3 0.02 0.05 0.01 0.01 - 0.07 0.14 013 0.69 0.09 0.82 0.49 0.12 3.43 1.78 0.15 66 14.5 0.75 1.23 1937 13.4 21.9 (b) 12.5 0.02 0.05 0.00 0.01 - 0.06 0.01 0.40 0.71 0.09 0.86 0.48 0.12 3.50 1.79 0.16 60 12.3 0.84 1.45 (a) Comparable figures are not available for this period. (b) Provisional rate. 29 Table 37—County of London—Notifiable infectious diseases—Notifications per 1,000 of population Annual rates per 1,000 living Period Anthrax Cerebro.spinal fever Continued fever Diphtheria Dysentery Encephalitis Iethargica Enteric fever Erysipelas Malaria Ophthalmia neonatorum (per 1,000 live births) Pneumonia Polioencephalitis Poliomyelitis jfuerpenii lever (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 1931-35 .00 .04 .00 2.20 .02 .01 .04 .55 .01 9.02 1.31 .00 .02 4.25 12.90 3.60 .15 — 1921 .00 .02 .00 3.62 .01 .05 .07 .47 .05 10.81 .96 .00 .01 3.55 (a) 7.27 .00 .00 1922 .00 .02 .00 3.38 .01 .01 .06 .43 .03 9.17 1.56 .00 .01 3.28 (a) 3.81 .02 .00 1923 .00 .01 .00 2.26 .00 .02 .07 .40 .02 8.33 1.04 .00 .02 3.84 (a) 2.21 .00 — 1924 .00 .02 .00 2.30 .00 .13 .09 .41 .02 8.36 1.47 .00 .02 3.43 (a) 2.50 .00 — 1925 .00 .02 .00 2.72 .00 .06 .09 .42 .01 8.58 1.18 .00 .01 3.83 (a) 2.66 .00 — 1926 .00 .02 .00 2.95 .00 .05 .07 .39 .01 8.97 1.22 .00 .02 4.24 (a) 2.68 .00 — 1927 .00 .02 .00 2.69 .01 .03 .07 .43 .01 11.11 1.49 .00 .02 3.57 12.21 2.91 00 — 1928 .00 .02 .00 2.74 .01 .02 .13 .48 .02 10.19 1.-38 .00 .01 4.09 10.67 3.45 .07 .00 1929 .00 .03 .00 2.68 .01 .02 .08 .49 .01 10.42 1.98 .00 .01 4.46 10.84 3.60 .43 — 1930 .00 .02 .00 3.01 .01 .01 .07 .54 .01 8.74 1.24 .00 .01 4.15 10.48 3.74 1.15 .00 1931 .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 — 1915 .00 .03 .00 2.23 .05 .00 .04 .45 .01 6.87 0.89 .00 .02 4.33 1172 2.62 — — 1936 — .03 .00 1.67 .07 .00 .06 .43 .01 8.10 0.99 .00 .01 3.07 11.13 2.55 — — 1937 .00 .04 .00 1.91 .22 ..00 .05 .43 .01 8.26 1.18 .00 .02 4.16 14.45 2.07 — — (a) Comparable figures are not available for this period. Table 38—County of London—Annual number of notifications of infectious disease, 1926-37 Year Anthrax Cerebro-spinal fever Continued fever Diphtheria Dysentery Encephalitis Iethargica 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 0,118 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 o 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 1936 — 113 4 7,030 304 12 255 1,815 35 462 4,141 2 36 175 635 10,705 j — 1937 3 175 6 7,810 916 8 210 1,764 42 453 4,798 13 95 228 793 8,455 | — 30 Table 39—County of London—Notifications of infectious disease during the 52 weeks ended 1st January, 1938 Metropolitan boroughs (in topographical order) Anthrax Cerebrospinal fever Continued fever Diphtheria (including membranous croup) Dysentery Encephalitis Iethargica Enteric fever Erysipelas Malaria Ophthalmia neonatorum Fneumonia .Polioencephalitis Poliomyelitis Puerporul fever Puerperal pvroxia Scarlet fever Smallpox Typhus Western— Paddington — 5 1 217 56 —- 11 57 3 16 180 1 4 23 40 234 — — Kensington — 3 _ 215 68 — 14 72 3 8 217 1 8 12 33 251 — — Hammersmith — 5 —- 176 27 — 2 50 2 13 86 — 2 9 36 331 — — Fulham — 12 — 206 29 1 3 63 1 18 171 — 3 2 26 318 — — Chelsea — 1 — 73 5 — 3 17 — 5 66 — — 1 7 93 — — Westminster, City of — 6 — 123 26 — 16 38 1 9 28 — 1 2 27 219 — — Northern— St. Marylebone _ 3 _ 108 5 _ 7 45 1 10 61 _ 2 9 19 118 — _ Hampstead — 4 — 104 11 1 1 25 1 22 88 — 2 2 19 188 — — St. Pancras — 5 1 614 61 — 10 64 1 26 223 — 8 14 27 364 — — Islington 1 10 1 623 39 1 11 150 — 34 214 — 1 16 73 723 — — Stoke Newington _ 2 _ 44 12 _ J 28 _ 2 50 — 1 11 17 90 _ _ Hackney — 9 — 308 28 1 6 110 1 27 194 — 5 22 71 419 — — Central— Holborn _ — _ 73 12 _ _ 11 3 3 37 — 1 4 2 37 _ — Finsbury — 3 _ 142 19 — 25 1 11 93 — _ 2 16 132 — — City of London — — —- 6 — — 1 1 —- — 5 — — — 1 12 — — Eastern— Shoreditch _ 5 — 169 58 1 8 55 1 15 90 — 1 3 21 215 — — Bethnal Green — 6 — 222 52 — 3 72 — 14 99 — 4 6 16 304 — — Stepney — 9 — 639 28 — 5 118 — 14 278 2 8 7 33 377 — — Poplar 1 5 2 571 30 1 12 93 3 5 331 — 5 5 31 351 — — Southern— South wark _ 8 _ 364 24 _ 5 55 29 165 _ 3 8 15 308 — — Bermondsey 1 10 — 167 43 _ 5 28 1 170 _ 1 1 13 167 — — Lambeth — 8 — 506 19 — 10 111 6 54 281 1 5 20 50 527 — — Battersea — 10 — 313 9 — 5 83 3 12 289 1 2 3 18 278 — — Wandsworth ... _ 9 _ 413 32 _ 17 111 7 25 473 4 7 5 37 634 — — Camberwell _ 14 1 344 20 _ 7 78 2 16 151 __ 3 15 24 422 — — Deptford _ 1 — 159 20 _ 7 30 _ 5 120 _ 5 4 23 171 — — Greenwich _ 6 _ 307 20 _ 11 34 _ 12 123 1 1 8 28 183 — — Lewisham — 7 — 283 87 2 18 70 2 16 252 2 8 4 46 589 — — Woolwich — 9 — 321 76 — 17 70 —- 31 263 — 4 10 24 400 — — Ages 0- 44 — 168 63 — 4 42 1 453 287 — 3 — — 76 — — „ 1- _ 43 _ 2,313 321 _ 12 44 — — 781 4 36 — — 2,459 — — „ 5- — 16 — 3,153 171 1 28 47 — — 363 7 30 — — 3,350 — — „ 10- — 5 — 958 47 2 23 59 — — 161 2 11 — 1 1,194 — — „ 15- — 17 1 389 48 —- 34 77 2 — 211 — 9 7 46 456 — — „ 20- 1 17 1 334 60 — 22 79 1 — 249 _ 3 62 230 330 — — „ 25- — 15 — 320 70 1 43 175 10 _ 486 — 2 120 417 396 — —- „ 35- 1 8 1 117 37 2 15 253 13 — 496 — 1 39 98 115 — — „ 45- — 7 2 40 36 2 23 351 9 — 560 _ — — 1 59 — _ „ 55- _ 2 1 15 34 _ 5 355 6 — 588 _ _ — _ 14 — — „ 65- 1 1 2 15 — 4 191 — — 353 — — — 5 — — „ 75 + — — — 1 14 — 3 91 — — 263 — — — - 1 — — Total, 1937 3 175 6 7,810 916 8 216 1,764 42 453 4,798 13 95 228 793 8,455 — — Total, 1936 — 113 4 7,030 304 12 255 1,815 35 462 4,141 2 36 175 635 10,705 — — 31 Administration National Health Campaign In co-operation with the Ministry of Health and the Board of Education, the Central Council for Health Education prepared a scheme for a national campaign to encourage the wider use of the health services. This campaign took place during the last quarter of 1937 and the first quarter of 1938, and was inaugurated on 30th September, 1937, by the Prime Minister, who delivered an address, which was broadcast. The first month was devoted to arousing public interest in the health services in general. The slogan " Use your health services " was the keynote. The Council assisted the Central Council during this period of the campaign by arranging for the distribution of copies of pamphlets and posters through the schools organisation, the public assistance offices and the housing estates. In addition it was decided to issue a small eight-page pamphlet for free distribution describing briefly the health services of the Council. This pamphlet was entitled " Highways to Health," and 400,000 copies were printed and distributed through the schools organisation, the Metropolitan Borough Councils and certain departments of the Council with which the public have direct contact. During the months of November and December publicity material was distributed by the Metropolitan Borough Councils and through the public assistance offices and housing estates to encourage the increased use of the services available for mothers and children at ante-natal clinics, welfare centres and all the other institutions provided by the maternity and child welfare schemes of the local authorities and voluntary organisations. Housing A full description of the Council's housing activities and the public health department's share therein is to be found in " London Housing," published in May, 1937. The programme of clearance operations adopted by the Council in 1934 embraced a period of three years ending in June, 1937. At the end of the year 1936 the position regarding the progress made in respect of the programme was reviewed, and the Council on 15th June, 1937, approved a further programme for the period 1937-40. The number of properties forming the subject of "representations" by the medical officer of health under the Housing Acts, 1930 and 1936, which have been submitted to the Housing and Public Health Committee is as follows:— Areas Houses "Other buildings" included under the terms of section 40(2) of the Housing Act, 1936, or the equivalent section of the previous Housing Act During the year 1937 Total number under the Housing Acts since 43 4,606 77 1930 240 18,917 268 In addition, notifications under section 33 of the Housing Act, 1936, of their intention to deal with certain houses as clearance areas were received during the year from Metropolitan Borough Councils in respect of 125 areas, comprising 1,948 houses ; of these, 11 areas involving 261 houses were considered to be more suitable for action by the Council. The Borough Councils concerned were therefore informed accordingly. In addition, one redevelopment area (Clarendon-street) was notified by the Paddington Borough Council under section 37 of the Housing Act, 1936. The following table shows, in respect of each metropolitan borough, (a) the number of houses during the year represented by medical officers of the Council's public health department, and (b) the number of houses included in notifications from the Borough Councils, together with (c) the number of such houses which, Clearance area operations 32 in accordance with section 33 (a) of the Housing Act, 1936, it was decided to place on the Council's own programme :— Table 40 Metropolitan borough (a) Number of houses represented to L.C.C. by its medical officers (b) Houses notified under section 33, Housing Act, 1936 (c) Number of such houses which the Council decided to place on its own programme Battersea 213 35 10 Bermondsey — 198 — Bethnal Green f794 19 11 Camberwell 825 89 42 Chelsea — *108 Deptford 90 6 — Finsbury — 107 — Fulham — — — Greenwich 365 105 60 Hackney 153 93 — Hammersmith fl31 10 — Hampstead — — — Holborn — — — Islington — 123 33 Kensington — — — Lambeth 99 — — Lewisham — 129 — Paddington — 3 — Poplar — 15 — St. Marylebone — — — St. Pancras. — 73 27 Shoreditch 1,082 — — Southwark 426 34 — Stepney 748 123 37 Stoke Xewington — — — Wandsworth — 194 21 Westminster — — — Woolwich — 484 20 Total †4,926 1,948 ‡261 * Tenements. †Includes 320 houses re-represented (193 in Punderson-gardens, Bethnal Green, and 127 in Queen-street, Hammersmith). ‡Some of these houses were represented during the year and are in consequence included in column (a). Public inquiries were held by the Ministry of Health in respect of clearance orders and compulsory purchase orders made by the Council relating to 3,028 houses in 33 areas represented as suitable for action under section 25 of the Housing Act, 1936. The Council in December, 1936, being satisfied that the conditions specified in section 13 of the Housing Act, 1935, were complied with in regard to an area of 46 acres in the borough of Bethnal Green, declared that area to be a redevelopment area under that section. Operations in connection with this area progressed throughout 1937. In June the Minister of Health fixed appointed days in respect of overcrowding in the six metropolitan boroughs referred to in the Annual Report of 1936 as those in which the fixing of the appointed day was in contemplation, namely, Hampstead, Holborn, Paddington, St. Marylebone, St. Pancras and Southward. As regards section 62 of the Housing Act, 1936, the appointed days for these boroughs is 1st July, 1937, and for the purpose of sections 6 (2), 59, 60 and 64 of the Act the appointed day is 1st January, 1938. The fixing of appointed days for the remaining seven boroughs, namely, Bermondsey, Bethnal Green, Finsbury, Islington, Poplar, Shoreditch and Stepney, is still under consideration. Redevelopment area operations Overcrowding 33 An inquiry has been made from the medical officers of health of the metropolitan boroughs as to the effect of legislation concerning underground rooms contained in section 17 (7) of the Housing, Town Planning, etc., Act, 1909 (which has been re-enacted in an amended form in subsequent legislation), in reducing the number of underground rooms used for sleeping purposes. The following are summaries of typical examples of the replies received :— In Bermondsey, in the course of carrying out the housing policy of the Borough Council, a large number of underground rooms have been swept away and the majority of those at present illegally used for sleeping purposes are in insanitary areas. Twenty-eight underground rooms were closed between 1st January, 1936, and 30th June, 1937, under the Housing Acts. In Deptford eighty-four underground rooms have been closed within recent years. In Hackney sixty underground rooms have been closed since 1909, while 273 illegal occupations of underground rooms have been dealt with otherwise than by means of Closing Order procedure, i.e., by alterations which made the rooms conform to the requirements of the regulations or by acceptance of undertakings not to permit occupation contrary to statute. In addition, ninety-nine underground rooms in clearance areas have been closed and fifty-five underground rooms exist in clearance areas now being dealt with. In Hampstead 1,683 underground rooms have been found to be illegally occupied since 1909, and of these, 1,234 have been closed, their illegal occupation discontinued or made to conform to the requirements of the Public Health Act or the Housing Act. In Islington 427 underground rooms have been closed since legislation was introduced prohibiting the use of such rooms. In Kensington, as a result of powers obtained in 1933, 1,183 underground rooms were closed during the period 1934-1936 for living and sleeping purposes. In Paddington it is estimated that approximately 600 underground rooms have been closed for sleeping purposes since the legislation came into force. In St. Pancras 170 underground rooms were dealt with during 1936 under Closing Orders, while for human habitation the use of 143 has been discontinued; 68 have been vacated by the tenants' own efforts or not used for human habitation by re-arrangement and 40 have been rendered fit for human habitation. In Southwark all underground rooms used for sleeping purposes have been closed, while 2,349 occupied for living purposes only are being dealt with. In Westminster 1,932 underground rooms, including 773 lettings, have been closed or rendered fit for human habitation since the legislation came into force. An inquiry was made during the year as to the reduction in the number of underground bakehouses in London. In 1907 the number was approximately 1,400, which by 1937 had been reduced to 776. 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 consequence of the decision arrived at in 1934 that no useful purpose would be served by sampling milk brought into London in large tanks on account of the practical impossibility of tracing the farm of origin, samples are taken only from churns known to have come direct from the producer. The result of such sampling during 1937, compared with that of 1936, is as follows :— Table 41 Quarter 1936 1937 Completed examinations Number tuberculous Percentage Completed examinations Number tuberculous Percentage 1st 514 61 11.9 490 36 7.3 2nd 478 44 9.2 519 38 7.3 3rd 465 31 6.6 446 30 6.7 4th 494 47 9.5 474 31 6.5 Total 1,951 183 9.4 1,929 135 7.0 Underground rooms Underground bakehouses Examination of milk 34 Analysis of the samples taken during the year, of which examination was completed, tabulated according to the grade of the milk shows:— Table 42 Grade Number of samples Number tuberculous Percentage Tuberculin-tested 67 1 1.5 Accredited 354 34 9.6 Ungraded 1,508 100 6.6 In regard to the sample of tuberculin-tested milk which was found to be infected, subsequent investigation failed to discover the source of infection, apart from the possibility that it lay in dried milk encrusted on the churn in which the tuberculitested milk was conveyed ; this matter was referred to the local authority concerned, and steps were taken to ensure as far as possible that there should be no recurrence of infection in this way. The fact that a larger percentage of samples of accredited milk should have proved tuberculous than of ungraded milk has been the cause of concern, as it was considered that some of this milk might not be pasteurised before consumption, and an arrangement was made with the Milk Marketing Board whereby they will be informed when a sample of milk, of any grade, is found to be tuberculous and there is no evidence that it is to be pasteurised before sale. They would then arrange for milk from the infected source to be pasteurised. It was ascertained, however, that all the milk from which positive samples were obtained during the year was to be pasteurised before distribution; no notification, therefore, was made to the Milk Marketing Board in accordance with the above arrangement. The milk subject to sampling in 1937 was received from 30 counties. Where the sample proved to be tuberculous the medical officer of the county of origin was notified and arrangements were made by him for the farm from which the milk originated to be visited and the herd examined. As a result of such consequential investigations 90 cows were dealt with under the Tuberculosis Order, 1925, as against 135 in 1936, the reduction being due to the smaller number of tuberculous samples found in 1937. The result of investigations made by the county authorities during 1937 is as follows :— Table 43 Quarter No. of positive samples Source of infection traced * Not traced Investigation still in progress 1st quarter 2nd quarter 3rd quarter 4th quarter Total 1st 36 16 7 — — 23 13 — 2nd 38 — 16 2 3 21 17 — 3rd 30 — — 5 16 21 5 4 4th 31 — — 13 13 4 14† *In some of these cases cows had been removed from the herd in the interval between sampling and result of examination. †In 5 cases investigation is being delayed by the existence of foot and mouth disease restrictions over the area in which the herds are situated. 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 :— Cows at institutions under the control of the Council 35 Table 44 Department Approximate stock at 31st December, 1937 Visits by veterinary surgeon Samples taken of which examination completed Samples found to be tuberculous Cows with tuberculosis Cows with unhealthy conditions not tuberculous Milch cows Other cows and heifers Bulls Other bovines Education 9 — — — 8 6 — — 2 Mental hospitals 961 176 20 32 62 337 9 5 101 Public assistance 34 2 2 8 14 22 2 1 6 Public health 32 19 1 — 4 4 — — 4 Total 1,036 197 23 40 88 369 11* 6 113 * Or 2.9 per cent. 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 150 visits in all. During these inspections 2,545 cows were examined of which 236 were found to be unhealthy, 4 suffering from tuberculosis, 184 from mastitis, 38 from induration of the udder and 10 with some other defect. In connection with these inspections, 30 samples of milk were taken for bacteriological examination in suspected cases; of these, 4 were tuberculous and the remainder negative. In addition to the special samples, 89 routine samples were taken, the examination of 1 of which was incomplete, while 6 were tuberculous and the remainder negative. In all, 9 tuberculous cows were discovered during 1937 in London cowsheds, either as a result of veterinary inspection or milk sampling, compared with only 2 in 1936 and 6 in 1935. These animals were slaughtered either voluntarily by the owner or under 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 30 in the year now under review. The existing premises are mostly situated in the metropolitan boroughs of Stepney and Bethnal Green. During the year the Agricultural Act, 1937, was passed, Part IV of which relates to the veterinary inspection of cattle. When this part of the Act comes into force the Council's duties under the Tuberculosis Order, 1925, and Part IV of the Milk and Dairies Order, 1926, will be transferred to the Ministry of Agriculture and Fisheries, and the Council will consequently no longer be responsible for the examination of animals in licensed sheds. 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. Licensed cowsheds 36 Hospitals 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. The general and special hospitals undertaking in-patient or out-patient treatment and other work under the scheme at the end of 1937 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; 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; Guy's hospital; West London hospital; the London County Council (Whitechapel) clinic (see page 39); and the Royal Free hospital (women). In addition, the following hospitals provide facilities for all-day intermediate treatment: Miller General; Royal Northern; St. John's (Lewisham); St. Mary's; Seamen's; University College. St. Paul's hospital was included in the scheme up to March 31st, 1937. The number of new patients attending the hospitals during the year 1937 was 25,825, of whom 2,927 were suffering from syphilis, 9,952 from gonorrhoea, and 219 from soft chancre, while 12,727 were diagnosed as not suffering from these diseases. A summary of the work done by the hospitals for each of the areas in the joint scheme during the year 1937 is shown in the following table :— Table 45 London Middlesex Essex Surrey Kent Herts. Bucks. East Ham West Ham Croydon Total "Other places " Grand total New patients— Syphilis 1,964 332 105 113 85 28 18 13 49 7 2,714 213 2,927 Soft chancre 82 4 5 6 1 1 — 2 3 1 105 114 219 Gonorrhoea 6,532 1,115 463 402 148 133 64 93 170 27 9,147 805 9,952 Not venereal 8,239 1,647 643 643 254 172 81 123 239 93 12,134 593 12,727 Total 16,817 3,098 1,216 1,164 488 334 163 231 461 128 24,100 1,725 25,825 Total attendances 728,459 99,687 54,974 31,214 13,970 8,050 3,530 13,770 24,979 3,407 982,040 18,402 1,000.442 No. of in-patient days 31,583 3,470 3,581 1,862 1,815 1,306 305 110 434 40 44,506 10,523 55,029 Pathological Examinations. For or at centres— Spirochaetes 1,935 162 117 44 11 16 9 15 46 2 2,357 161 2,518 Gonococci 100,415 16,490 11,411 6,319 2,489 1,461 753 2,315 3,573 666 145,892 4.458 150,350 Wassermann 34,060 4,241 2,773 3,058 793 469 270 460 883 268 47,275 1,754 49,029 Others 42,894 5,199 4,561 3,323 1,148 601 301 764 1,554 377 60,722 3,509 64,231 Total 179,304 26,092 18,862 12,744 4,441 2,547 1,333 3,554 6,056 1,313 256,246 9,882 266,128 For practitioners— Spirochaetes 8 — 1 — — — — — — — 9 — 9 Gonococci 4,317 126 245 117 39 115 18 2 6 1,092 6,077 10 6,087 Wassermann 11,686 673 1,338 308 216 87 134 33 25 686 18,186 432 18,618 Others 9,248 313 522 191 50 40 18 6 35 1,071 11,494 467 11,961 Total 28,259 1,112 2,106 616 305 242 170 41 66 2,849 35,766 909 36,675 37 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 46 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 <925 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 1936 1,866 1,055 75 21 7,724 2,319 9,865 3,395 1937 1,783 1,144 211 8 7,636 2,316 9,630 3,468 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 1937, and also as to the number of patients suffering from congenital syphilis. The returns received from the treatment centres showed that, as regards syphilis, in approximately 40 per cent, of the new patients the disease was in either a primary or secondary stage, and, in the case of gonorrhoea, in 92 per cent, the infection had taken place within a year. Patients suffering from congenital syphilis not known to have received previous treatment numbered 284, compared with 265 in 1936; the age and sex distribution was as follows :— Table 47 Under 1 year 1 and under 6 years 5 and under 15 years 15 years and over Total M. F. M. F. M. F. M. F. M. F. 16 16 14 15 26 30 53 114 109 175 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. The provision of facilities for intermediate treatment of gonorrhoea at times other than during the hours when the medical officer attends is meeting with considerable success. A number of patients still fail to complete the full course of treatment because of the false impression that a cure has been effected on the disappearance of outward signs of the disease. 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 1937 the total attendances of V.D. patients was 907,380, and the ratio of attendances of V.D. patients to new V.D. cases was 69, compared with 59 in 1933, 66 in 1934, 69 in 1935 and 67 in 1936. Attendances 38 Comparative figures for the twenty-one years during which the scheme has been in force are shown in the following table :— Table 48 Year New oases Total attendances (venereal and non-venereal) I 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 25,650 555,509 106,662 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 1936 13,260 12,817 26,077 1,102,378 57,342 1937 13,098 12,727 25,825 1,0(10,442 55,029 Defaulting The number of non-venereal patients who present themselves for examination remains large and indicates that many of the general public understand the serious nature of the venereal diseases and seek advice after risk of infection has been taken. The question of defaulting is one to which attention is frequently drawn. Analysis of the returns for 1937 shows that, as regards syphilis, 2,312 patients failed to continue treatment until discharged. Of these, 416 ceased to attend before completing one course of treatment; 1,378 before completing treatment; and 518 after completion of treatment but before final tests for cure. Of the 416 who ceased before completing one course of treatment, 100 (compared with 122 in 1936) were in the primary stage of the disease when, not only is the danger of transference of the disease greatest, but when also the greatest benefit can accrue to the patient by continuing treatment. Pathology and bacteriology In the case ol gonorrhoea, 4,do0 patients tailed to continue treatment until discharged. Of these, 3,161 ceased to attend before completing treatment and 1,169 after completion of treatment but before final tests for cure ; the corresponding numbers for 1936 were 3,840 and 1,347 respectively. Much time is spent in the almoner's department of the various clinics in "following up" defaulters. Many letters are despatched to patients and, where considered practicable, home visiting is undertaken. In cases where default is due to inability to attend through lack of means, bus or tram fares are paid. Another point worthy of note is the total number of examinations made of pathological specimens. Comparative figures for the twenty-one 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 1928 107,410 29,785 1918 25,973 6,380 1929 114,840 32,605 1919 51,554 10,464 1930 125,177 33,309 1920 58,920 14,027 1931 161,092 35,498 1921 66,134 18,472 1932 196.357 40,626 1922 74,022 19,836 1933 219,852 39,649 1923 69,784 24,403 1934 261,116 37,286 1924 79,005 24,797 1935 255,403 38,354 1925 106,064 26,346 1936 263,050 37,748 1926 100,543 27,565 1937 266,128 36,674 1927 107,512 27,046 39 Considerable use is made by medical practitioners of the facilities for the examination of pathological specimens. 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 or hospital patients. The number of medical practitioners within the county availing themselves of this service is now 566, compared with 108 at the end of 1917, the first year of the operation of the scheme. From the outset the necessity was recognised for accommodation where young women under treatment could be lodged during the period of infectivity, and where various interests and occupations could be provided. Certain hostels managed by, or independently of, hospitals have received grants-in-aid for this purpose, and experience has proved the value of these hostels for the more efficient treatment of certain cases and for preventing the spread of disease. During the year 1937 the number of patients dealt with at these institutions from the areas in the scheme was 237, the aggregate number of days in residence being 28,075. Comparative figures for 1936 were 229 and 23,496. The liostels undertaking work in connection with the scheme for the year 1937 were as follows :— 20-22, Highbury-quadrant, N. (Royal Free Hostels Committee); 148, Lambethroad, S.E. (St. Thomas's hospital); 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. Venereal disease ; hostel accommodation Two girls were provided with accommodation in rescue homes in accordance with the arrangements described in the report for 1936. Rescue homes During the year 1937 the number of new patients attending the London County Council (Whitechapel) clinic, which is administered direct by the Council, was 3,665 and attendances totalled 257,581. Of the new patients 84 per cent, of the male and 74 per cent, of the female venereal cases were infections of less than one year's duration. The London County Council (Whitechapel) clinic The number of pathological examinations made at the clinic during the year was 69,211 ; of these 9,446 were made for private practitioners. All these figures are included in the figures for the scheme as a whole. As at other clinics in the scheme, facilities for the study of venereal diseases are available for midwives, medical students and post-graduates. In addition a special course of instruction for post-graduates is held twice a year. Facilities for the treatment of venereal diseases are also provided within the Council's municipal hospitals service. Special wards are provided for both male and female patients and provision is also made for maternity cases. In addition, children suffering from vulvo-vaginitis or from congenital syphilis are accommodated in special units. Further details are contained in Vol. IV, Part I, of the Annual Report. Under present arrangements, the British Social Hygiene Council exercises certain of the Council's powers relating to propaganda work, and is assisted in this work by local propaganda committees which work in close co-operation with the public health committees of the Metropolitan Borough Councils. During the year ended 31st March, 1937, some 456 addresses and lectures, several illustrated by film exhibitions, were given in the London area, the total estimated attendance thereat being 41,195. A grant of £2,405 10s. lOd. was made by the Council to the British Social Hygiene Council for this work during this period. Publicity and propaganda The decline in the number of new cases of syphilitic infection attending the approved centres in the London and Home Counties Scheme was fully commented upon in the Annual Report for the year 1936. There has been no further decline during 1937, the returns received from the centres for the year showing a small increase of 6 cases over the total for the preceding year. Analysis shows a reduction of cases in males and an increase in females. Apparent decline in the incidence of syphilis 40 Gonorrhœa The new patients suffering from gonorrhoea were in 1937 fewer in the case of men, than in any year since the scheme came into full operation and, in the case of women since 1921, except for 1931. This, however, may not be entirely a matter for congratulation as the opinion is generally held that many persons infected with gonorrhoea do not seek treatment at the clinics. Efforts are, however, being made by various methods of publicity to induce those who are infected to attend the clinics. Prevention of venereal diseases It is proposed, during the year 1938, to obtain from the medical directors ot the various clinics their views on the working of the scheme, more particularly from the point of view of preventive medicine. It is hoped to deal with this matter more fully in my annual report for next year. Treatment of tuberculosis The Council is under statutory obligation to make, for the administrative county of London, adequate arrangements for the treatment of tuberculosis at or in dispensaries, sanatoria or other institutions approved by the Minister of Health, and also has power to make such arrangements as it may think desirable for the after-care of persons who have suffered from tuberculosis. The arrangements made by the Council in compliance with the foregoing obligation and authority are published in detail in document No. 3194 (price 4d.), obtainable from P. S. King & Son, Limited, 14, Great Smith Street, S.W.I. 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 Council. 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 hospitals which serve their areas. The dispensaries are linked with hospitals for special services, such as provision for X-ray examinations and artificial pneumothorax refills. 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. 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 arrangements for residential treatment include the provision of observation beds (a) for the purpose of diagnosis, and (b) to determine disposal for treatment of definitely diagnosed cases which present difficulty of decision. These " observation " beds are provided principally at Brompton hospital, St. George's home, Chelsea, and in the Council's general hospitals. The last mentioned are also used for acute and emergency cases and for patients with advanced disease who are mainly confined to bed. 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, 41 which provides for youths between 14 and 18 years of age and, during treatment, trains them for clerical employment or for gardening work. A feature of the scheme is the facility with which it is possible to interchange patients between various types of institution. Thus patients who deteriorate while under sanatorium treatment or develop complications are returned to general or special hospitals ; the constant outflow of patients from general hospitals to institutions in the country is a considerable asset in creating an atmosphere of hopefulness among the bedridden patients. Further features worthy of note concerning the general hospitals are (1) the liaisoD between Grove Park tuberculosis hospital and Lewisham general hospital as regards pregnant women, and (2) the unit at St. Mary Abbots hospital, Kensington, for thoracic surgery. As regards the former, pregnant women are sent to Grove Park hospital for treatment of tuberculosis and while there attend the ante-natal clinic at Lewisham hospital situated nearby, to which they are admitted for the confinement. They can afterwards, if necessary, resume treatment for tuberculosis at Grove Park hospital or elsewhere. The auxiliary services provided by the Council are as set out in the report for 1936. During the year there has been a pronounced rise compared with 1936 in the number of notifications of pulmonary tuberculosis. This has reacted upon the number of applications for residential treatment under the scheme. The rise in the number of applications has been most marked in regard to females, the increase being 27 males and 225 females over the number of applications for the previous year. The increase in applications for residential treatment, the more extensive use of artificial pneumothorax and other surgical methods of treatment combined with the additional use of settlement sanatoria, and larger provision for destitute ambulant patients has necessitated additional provision for residential accommodation. Applications for residential treatment The increased accommodation has been obtained in voluntary establishments in various parts of the country. The Council has been able to satisfy the demands "made upon it without materially increasing the period of waiting for vacancies. Another marked feature of the year under review has been the increased use made of tuberculosis wards in the Council's general hospitals. Throughout the year the pressure on beds in general hospitals has been constant. The following pages indicate the operation of the tuberculosis scheme durin] the year 1937, and in certain particulars during previous years. Table 49—Beds occupied at end of year Year Adults Children Total Year Adults Children Total 1914 722 90 812 1926 1,841 880 2,721 1915 544 241 785 1927 1,946 884 2,830 1916 481 320 801 1928 1,920 855 2,775 1917 526 375 901 1929 2,083 858 2,941 1918 816 376 1,192 1930 2,017 890 2,907 1919 1,308 557 1,865 1931 † 2,255 898 3,153 1920 1,636 704 2.340 1932 † 2,368 811 3,179 1921 1,382 669 2,051 1933† 3,216 787 4,003 1922 1,370 655 2,025 1934 3,574 781 4,355 1923 1,458 707 2,165 1935 3,673 813 4,486 1924 1,612 746 2,358 1936 3,217 728 3,945 1925 1,668 792 2,460 1937 3,462 758 4,220 Operation of tuberculosis scheme during 1937 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 since 1st April, 1933, have all been regarded as tuberculosis scheme patients. 42 The numbers of applications for residential treatment during each of the last five years were as follows :— Table 50 Year For first period ol treatment For further treatment Total Exservice Civilian adults Children Exservice Civilian adults Children Male Female Male Female 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 1936 9 2,621 1,890 812 70 1,645 1,187 218 8,452 1937 11 2,636 2,080 760 70 1,655 1,222 201 8,635 Patients recommended for treatment during 1937 were dealt with (the corresponding figures for 1936 being shown in brackets):— as follows Adults Children (a) Admitted to " observation " beds to determine diagnosis or suitability for sanatorium treatment ... 1,392 (1,450) 220 (241) (6) Passed for admission direct to sanatoria or hospitals 6,189 (5,846) 691 (742) (c) Not accepted for residential treatment ... 52 (73) 25 (26) (d) Withdrawn after application but before decision was reached 41 (53) 25 (21) Total 7,674 (7,422) 961 (1,030) N.B.—The treatment offered was refused in the cases of 148 adults and 15 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 observation and treatment is shown below :— Table 51 Classification In institutions on 1st January, 1937 Admitted during the year Discharged during the year Died in institutions In institutions on 31st December, 1937 Number of doubtfully tuberculous cases admitted for observation. Adult males 37 230 208 7 52 Adult females 49 179 176 1 51 Children 17 217 222 — 12 Total 103 G26 6C6 8 115 Number of patients suffering from pulmonary tuberculosis. Adult males 1,700 4,182 3,035 1,121 1,726 Adult females 1,072 2,961 2,164 652 1,217 Children 287 233 209 15 296 Total 3,059 7,376 5,408 1,788 3,239 Number of patients suffering from nonpulmonary tuberculosis. Adult males 183 318 244 37 220 Adult females 176 307 253 34 196 Children 424 350 296 28 450 Total 783 975 793 99 866 Grand total 3,945 8,977 6,807 1,8S5 4,220 The distribution of patients in institutions on 31st December, 1937, is shown below, the figures for 1936 being given in brackets :— Table 52 Hospitals and institutions Ex-service men Civilian adults Children under 16 years Total London County Council special hospitals 5 (3) 1,268(1,255) 670 (648) 1,943(1,906) London County Council general hospitals 12 (4) 1,C02 (979) 20 (19) 1,034(1,002) Voluntary institutions 19 (15) 1,156 (961) 68 (61) 1,243(1,037) Total 36 (22) 3,426 (3,195) 758 (728) 4,220 (3,945) 43 The following table shows the results of observation of doubtfully tuberculous patients discharged from observation hospitals:— Table 53 Dagnosis 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 41 30 16 32 34 10 2 1 3 73 66 30 Non-tuberculous 67 68 24 67 33 77 — 2 12 8 8 79 142 111 192 Total 108 93 40 99 67 87 — 4 13 8 8 82 215 177 222 The immediate results of the treatment of patients discharged during 1937 and the two preceding year3 are indicated in the subjoined tables. The figures given in the second line under each classification group represent the percentage of the total number of cases falling within each classification group. For example, in 1937 there were 765 "A," 310 "B1," 2,834 "B2" and 1,544 "B 3" cases discharged during the year. Of these numbers, 297 or 38.8 per cent, group "A," 87 or 28.1 per cent, group " B1," 164 or 5.8 per cent, group "B2" and 2 or 0.1 per cent, group " B 3 " cases were discharged as quiescent, totalling 550 quiescent cases, or 10.1 per cent, of the total number (5,453) of pulmonary cases discharged during 1937. Table 54—Immediate results of treatment Adults Classification Quiescent Not quiescent Died in institution Total Years Years Years Years 1935 193g 1937 1935 1936 1937 1935 1936 1937 1935 1936 1937 a. Number 328 335 297 364 343 422 25 23 46 717 701 765 Percentage 45.7 47.8 38.8 50.8 48.9 55.2 3.5 3.3 6.0 100 100 100 bl. Number 103 135 87 183 201 216 2 7 288 336 310 Percentage 35.8 40.2 281 63 o 59.8 69.7 0.7 — 2.2 100 100 100 b2. Number 179 174 161 2,601 2,716 2.519 63 114 151 2,843 3,004 2,834 Percentage 6.3 5.8 5.8 91 .5 90.4 88.9 2.2 3.8 5.3 100 100 100 b3. Number 4 2 593 605 621 943 909 921 1,536 1,518 1,544 Percentage — 0.3 0. 1 38.6 39.8 40.2 61.4 59..9 59.7 100 100 100 Total pulmonary 610 648 550 3,741 3,865 3,778 1,033 1,046 l,12.1 5,384 5,559 5,453 Percentage 11.3 11.7 10.1 69.5 69.5 69.3 19.2 18.8 20.6 100 100 100 Non.pulmonary 181 210 210 252 259 233 43 47 44 476 516 487 Percentage 38.1 40.7 43 .1 52.9 50.2 47.9 9.0 9.1 9.0 100 100 100 Grand total 791 858 760 3.993 4,124 4.011 1,076 1,093 1,169 5,860 6,075 5,940 Percentage 13.5 141 12.8 68.2 67.9 07.5 18.3 18.0 19.7 100 100 100 44 Children Classification Quiescent Not quiescent Died in institution Total Years Y ears Years Years 1935 1936 1937 1935 1936 1937 1935 1936 1937 1935 1936 1937 A. Number 159 102 136 26 19 30 3 5 4 188 126 170 Percentage 84.6 81.0 80.0 13.8 15.1 17.6 1.6 3.9 2.4 100 100 100 bl. Number 10 15 9 8 7 4 1 19 22 13 Percentage 52.6 68.2 69.2 421 31.8 30.8 5.3 — — 100 100 100 b2. Number 4 3 2 7 4 7 — 1 — 11 8 9 Percentage 36.4 37.5 22. 2 63.6 50.0 77.8 — 12.5 — 100 100 100 b3. Number 3 3 2 17 8 5 20 11 7 Percentage — — — 150 27.3 28.6 850 72.7 71.4 100 100 100 Total pulmonary 173 120 147 44 33 43 21 14 9 238 167 199 Percentage 72.7 71.8 73.9 18.5 19.8 21.6 8.8 8.4 4.5 100 100 100 Non.pulmonary 354 285 213 52 48 67 13 6 6 419 339 286 Percentage 84.5 84 1 74.5 12.4 141 23.4 3.1 1.8 2.1 100 100 100 Grand total 527 405 360 96 81 110 34 20 15 657 506 485 Percentage 80.2 800 74.2 14.6 160 22 . 7 5. 2 4.0 31 100 100 100 Papworth and Preston Hall village settlements Patients sent to the Papworth village settlement, Cambridge, and Preston Hall colony, Aylesford, Kent, are carefully selected, having regard to fitness to benefit from the special facilities afforded at these institutions for the employment of patients in the industries, and possible settlement. lhe average numbers of patients under the scheme at Papworth and rrestor Hall, respectively, during each of the past ten years are shown below :— Table 55 1928 1929 1330 1931 1932 1933 1934 1935 1936 1937 Papworth 9 16 33 61 90 109 118 140 136 145 Preston Hall 13 13 10 53 84 89 113 150 173 107* Douglas House 69 * Exclusive of patients at the Douglas House annexe of Preston Hall. Burrow Hill colony 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. The course of instruction is approved both by the Ministry of Agriculture and the Board of Education. The instruction given permits the youths to continue their general education during their period of residence. A high standard of success has been attained by students who have studied for the examinations of the Royal Horticultural Society. Those entering for the clerical course have obtained distinctions in examinations in shorthand, typewriting, bookkeeping and business methods set by Pitman's Institute and the Royal Society of Arts. During 1937, 20 youths were discharged from the colony. Of this number 4 completed a two years' course of training. In conjunction with this scheme, there is an arrangement whereby selected youths who have taken the gardening course are offered employment in the parks department of the Council as "improvers." Since 1931, 30 youths have been accepted for employment and only one left the service on health grounds, which result is undoubtedly very gratifiying. Four are now on the permanent adult staff and six others are eligible, but failed to pass the medical examination for entrance; they will be re.examined in due course. The youths have done well in the Council's horticultural examination, the passing of which is a condition of appointment. Eighteen have qualified including one first place in the examination. Satisfactory reports continue to be received with regard to the work of these employees. The youths are evidently keen to do well and are rendering the Council good value in their work. Time lost owing to sickness has been approximately 2'04 per cent., which is considered very satisfactory. 45 Reference was made in the Annual Reports of 1934 (pp. 51.3), 1935 (pp. 57.8) and 1936 (p. 42) 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 previous case of the disease. This enquiry has been continued and information is now available in respect of 6,933 patients who have undergone residential treatment under the Council's scheme. Of these, it was noted that in 4,766 patients there was " no known contact" with a previous case of the disease, leaving 2,167 patients or approximately 313 per cent, exhibiting contact of some kind. It is of interest to note that in 350 instances there was more than one such contact. Contact investigation The total figures now available in regard to the class T.B. plus cases are shown in the subjoined tables. Table 56—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 10 22 3 3 38 Pulm. tub. class T.B. —, living — 1 3 1 — 1 6 — Pulm. tub. (condition of sputum unknown), living 3 2 5 Non-pulm. tub., living — — — — 2 1 3 Non-pulm. tub., dead within last 5 years 1 1 2 Pulm. tub., dead within last 5 years I 11 15 7 6 2 42 — Total I 23 43 14 11 4 96 20-6 Wife Pulm. tub. class T.B. +, living — — — 3 7 12 22 Pulm. tub. class T.B. —, living — — 1 — 1 1 Non-pulm. tub., living — — — — 1 — 1 Non-pulm. tub., dead within last 5 years 3 3 Pulm. tub., dead within last 5 years — — — 2 11 10 23 — Total — 1 5 20 26 52 11-2 Child Pulm. tub., class T.B., +, living — 1 2 18 21 Pulm. tub. class T.B. —, living — — — — 3 10 13 — Pulm. tub. (condition of sputum unknown), living 1 6 7 Non-pulm. tub., living — 4 5 9 Non-pulm. tub., dead within last 5 years 2 1 3 3 9 Pulm. tub., dead within last 5 years — — — 1 2 5 8 — Totsl — — 3 2 15 47 67 14.4 Brother or sister Pulm. tub. class T.B. +, living 18 43 23 18 12 114 Pulm. tub. class T.B. —, living — 3 6 6 2 1 18 Pulm tub. (condition of sputum unknown), living 1 4 6 5 16 Non-pulm. tub., living — 3 4 6 1 3 17 — Non-pulm. tub., dead within last 5 years 4 4 1 1 10 Pulm. tub., dead within last 5 years 2 9 24 9 15 16 75 — Total 2 37 82 49 43 37 250 53.8 Total relatives as above Pulm. tub. class T.B. +, living 28 66 29 30 42 195 41.9 Pulm. tub. class T.B. —, living — 4 10 7 6 13 40 8.6 Pulm. tub. (condition of sputum unknown), living 4 6 7 11 28 6.0 Non-pulm. tub., living — 3 4 0 6 9 30 6.5 Non-pulm. tub., dead within last 5 years 5 6 3 4 6 24 5.2 Pulm. tub., dead within last 5 years 3 20 39 19 34 33 148 31.8 Total 3 60 129 70 89 114 465 100.0 Other contacts 3 17 46 37 77 122 302 - No known contacts 5 201 367 291 537 853 2254 — Total number investigated 11 278 542 398 703 1089 3021 — Percentage showing important contact 27.3 21.6 23.8 17.6 12.7 10.5 — 15.4 Percentage showing any contact 54.5 27.7 32.3 26.9 23.6 21.7 — 25.4 46 Table 57—Females—Class T.B. plus Previously known case Age group of new cases Total Relationship Clinical classification 0-15 16-20 21-25 26-30 31-40 Ovei 40 No. Percent age Parent Pulm. tub. class T.B. +, living £ 12 2C 4 3 - 44 — Pulm. tub class T.B. — , living 2 : — — - 6 — Pulm. tub. (condition of sputum unknown), living 1 l — — 1 3 Non-pulm. tub., living 1 2 — — - 3 1 — Pulm. tub., dead within last 5 years 3 1 27 32 4 8 3 75 — Total 7 43 58 8 11 4 131 27-5 Husband Pulm. tub. class T.B. +, living — — 2 8 7 5 22 — Pulm. tub. class T.B. —, living — — — — — 1 1 — Pulm. tub. (condition of sputum unknown), living — — — 1 — — 1 — Non-pulm. tub., living — — 1 — — — 1 — Non-pulm. tub., dead within last 5 years — — — 1 1 — 2 — Pulm. tub., dead within last 5 years — — — 8 6 6 20 — Total — — 3 18 14 12 47 9.9 Child Pulm. tub. class T.B. +, living — 1 — 3 10 14 — Pulm. tub. class T.B —, living — — — 1 5 6 — Pulm. tub. (condition of sputum un- — — — — 1 1 2 — Non-pulm. tub., living — — 1 3 3 2 9 Non-pulm. tub . dead within last 5 years — — — 2 — 2 — Pulm. tub., dead within last 5 years — 1 1 2 2 6 12 — Total — 1 3 5 12 24 45 9.5 Brother or Pulm. tub. class T.B. +, living 2 18 31 21 13 3 88 — sister Pulm. tub. class T.B. —, living — 6 6 7 2 2 23 — Pulm. tub. (condition of sputum unknown), living — 9 6 5 4 24 — Non-pulm. tub., living — 5 6 8 3 — 22 — Non-pulm. tub., dead within last 5 years — — 3 — 1 — 4 — Pulm. tub., dead within last 5 years 2 21 24 23 18 3 91 — Tota1 4 50 79 65 42 12 252 53.1 Total Pulin. tub. class T.B. +, living 7 30 54 33 26 18 168 35.4 relatives Pulm. tub. class T.B. —, living 1 8 9 7 3 8 36 7.5 as above Pulm. tub. (condition of sputum unknown), living 1 10 7 6 6 30 6.3 Non-pulm. tub., living — 6 10 11 6 2 35 7.4 Non-pulm. tub., dead within last 5 years — — 3 1 4 — 8 1.7 Pulm. tub., dead within last 5 years 3 49 57 37 34 18 198 41.7 Total 11 94 143 96 79 52 475 1000 Other contacts 2 38 45 44 66 54 249 — No known contact 22 229 387 301 296 199 1434 — Total number investigated 35 361 575 441 441 305 2158 — Percentage showing important contact 31.4 26.0 24.9 21.8 17.9 17.0 220 Percentage showing any contact 37.1 36.6 32.7 31.7 32.9 34.8 - 33.5 It will be seen that details are now available in respect of 3,021 males and 2,158 females, whose sputum contained tubercle bacilli. Study of the details in the various age groups as regards previous contact with other cases of the disease confirms the original findings. Thus the frequency with which contact with a previous case is noted is seen to diminish with increasing age; for instance, while 15.4 per cent. 47 of all males with positive sputum show previous important contact with the disease in the intimate family circle, the percentage ranges from 21"6 and 23'8 per cent, in the 16-20 and 21-25 year groups, respectively, down to 10'5 per cent, in those over 40 years of age. As age advances a similar diminution in the importance of contact with a previous case is seen in females. Females throughout, however, show a higher incidence of contact with previously known cases. Thus, at all ages, 22 per cent, have been in important contact with a previous case in the intimate family circle, while the percentage ranges from 31.4 per cent, in the 0.15 year group down to 17 per cent, in those over 40 years of age. The greater incidence of contact as a factor in the causation of the disease in females, as compared with males, may be due to the wider opportunities of exposure to infection in the family by reason of domestic and nursing duties. Kissing also may be a factor. As regards the relationship of what may be called the " infecting " case, it is seen that the original cases were in parents in 20'6 per cent, in males, compared with 27'5 per cent, in females. A tuberculous parent would seem to be a greater danger to a daughter than to a son. Here again the reason may be the special position of women in the household in regard to nursing and domestic duties and the like. During the last two years previous cases in parents have been subdivided into the sexes and previous cases occurring in brothers and sisters have also been separately recorded. Thus in 1,241 new male T.B. plus patients there was recorded a previous case in 60 instances amongst brothers, and in 36 instances amongst sisters. In 931 new female T.B. plus patients there was recorded a previous case in 50 instances among brothers and in 60 instances among sisters. It will be noted that the sexes more frequently show contact with a previous case in the same sex than in the opposite, and that this is more marked among males. Daily association and proximity in sleeping probably account largely for this, the smaller diiference in females possibly being due to their special position in the household as to nursing and domestic duties with consequent increased risk of infection. Thus a daughter in a household, while less in touch ordinarily with her brothers than with her sisters, may have to help and come into close contact with a brother also, in the event of sickness. Similar considerations seem to hold good concerning previously known cases occurring in the parents. In the 1,241 new male T.B. plus patients referred to above, there were 41 instances of a previous case in a parent, and of these no less than 31 were cases among fathers. Turning to the 931 new female T.B. plus patients in which this factor has been investigated, it is found that in 54 instances a parent had previously been affected, and of these 28 instances were among fathers and 26 instances were among mothers. Considering the clinical classification of the disease in the original case, it will be seen from tables 56 and 57 that approximately three quarters of the " infecting " cases are either living cases of pulmonary tuberculosis with positive sputum or cases which have succumbed to pulmonary tuberculosis within the immediately preceding five years. Investigation has been made, in regard to the last two years' patients, into the interval between the onset of a new patient suffering from positive sputum tuberculosis and the death of a previous case of pulmonary tuberculosis within the intimate family circle during the preceding five years. Data are available in respect of 57 such instances among males. In 40 of these (70'2 per cent.) the previous case in the family had died within the preceding two years. Among females this information is available in 89 instances. In 48 (53.8 per cent.) the death in the family had taken place within the preceding two years. The importance of continued supervision of contacts (particularly for the first two years) following the death in the family of a case of pulmonary tuberculosis is hereby demonstrated. 48 A sufficient number of non-pulmonary cases has now been investigated to justify publication of a separate table, which is subjoined. Table 58—Males and females—Non-pulmonary Previously known case Age group of new cases Total Relationship Clinical classification 0-15 16-20 21-25 26-30 31-40 Over 40 No. Percent age Parent Pulm. tub. class T.B. +, living 21 — 1 — — 1 23 — Pulm. tub. class T.B. —, living 10 — 10 Pulm. tub. (condition of sputum unknown), living 2 — — — — — 2 — Non-pulm. tub., living 4 1 1 6 Non-pulm. tub., dead within last 5 years 1 — — — — — 1 — Pulm. tub., dead within last 5 years Total 13 — 2 1 — — 16 — 51 1 3 1 1 1 58 59.2 Husband or wife Pulm. tub. class T.B. +, living Total — 1 — 1 — — 0 — — 1 — 1 — — 0 2.0 Child Non-pulm. tub., living — 1 — — — i Pulm. tub., dead within last 5 years Total 1 — 1 — — 2 — 1 1 1 — — — 3 30 Brother or Pulm. tub. class T.B. +, living 8 — 1 1 — 10 sister Pulm. tub. class T.B. —, living 2 2 — — — 4 — Non-pulm. tub., living 14 — 1 — — — 15 Pulm. tub., dead within last 5 years Total 1 2 2 — — 1 6 — 25 4 4 1 — 1 35 35.8 Total Pulm. tub. class T.B. +, living 29 1 2 2 — 1 35 35.8 relatives Pulm. tub. class T.B. — , living 12 2 — — — — 14 14.3 as above Pulm. tub. (condition of sputum unknown) living Non-pulm. tub., living 2 18 2 1 — 1 — — 2 22 20 22.4 Non-pulm. tub., dead within last 5 vears 1 — — — — — 1 1.0 Pulm. tub., dead within last 5 years 15 2 5 1 — 1 24 24.5 Total 77 7 8 3 1 2 98 1000 Other contacts No known contact 17 134 5 28 2 37 6 20 3 30 2 24 35 273 — Total number investigated 228 40 47 29 34 28 406 Percentage showing important contacts 33.8 17.5 17.9 10.3 2.9 7.1 24.1 Percentage showing any contact 41.2 30.0 21.3 31.0 11.8 14.3 — 32.8 It will be seen that 406 non-pulmonary cases have now been investigated and that approximately one-quarter show contact with a previously known case of tuberculosis in the intimate family circle, while almost one-third show contact of some sort thought worthy of record. The highest incidence of a previously known case is seen to be among the children under 15 years, 338 per cent, showing important contact. In 51 out of these 77 instances in which a child suffering from nonpulmonary tuberculosis was noted as having been in contact with a previous tuberculous case in the family, the original case was a parent. Moreover, all but 5 of these 51 cases of tuberculosis in parents were suffering from pulmonary tuberculosis. This would seem to confirm bacteriological experience that a substantial proportion of non-pulmonary lesions in childhood is due to infection with human tubercle bacilli from pulmonary sources. Efforts to prevent non-pulmonary tuberculosis of the bovine type, while very important, cannot be expected to influence the infection due to human bacilli. 49 The following are summarised conclusions relating to human infections :— (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, 21 per cent of new male positive sputum cases and 24 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 or were 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 59—on-pulmonary tuberculosis in London—Notifications Classification 1913 1922 1925 1936 1937 Percent age decrease on 1925 Total notifications 6,436 2,158 2,107 1,056 1,014 51.9 Rate per 10,000 population 15.7 4.8 4.6 2.6 2.5 — Notifications of children — 1,307 1,307 437 409 68.7 Notifications of adults 851 800 619 605 24.4 Bone and joint notifications in children — 427 147 115 73.1 Bone and joint notifications in adults — — 214 180 219 — Non- pulmonary tuberculosis It will be seen from the above table that there has been a steady and continuous decline in the number of notifications of non-pulmonary tuberculosis in London since 1913. Since 1925 the decrease has been more marked in children, particularly in respect of bone and joint affections. The first occasion on which non-pulmonary tuberculosis in adults exceeded that in children occurred in the annual return of notifications for 1933. It is not possible to say whether or not this feature will be permanent. Table 60—Non-pulmonary tuberculosis in London—Total (all ages) notifications and applications for residential treatment Year Children Adults Total Notifications Applications Percentage Notifications Applications Percentage Notifications Applications 1927 1,122 624 55.6 795 378 47.6 1,917 1,002 1928 1,066 497 46.6 756 359 47.5 1,822 856 1929 884 526 59.5 753 461 61.2 1,637 977 1930 793 582 73.4 717 431 60.1 1,510 1,013 1931 731 617 84.4 671 412 61.4 1,402 1,029 1932 696 538 77.3 679 474 69.8 1,375 1,012 1933 544 412 75.7 698 478 68.5 1,242 890 1934 552 394 71.4 606 339 55.9 1,158 733 1935 535 378 70.7 610 344 56.4 1,145 722 1936 437 301 68.8 619 344 55.5 1,056 645 1937 409 297 72.6 605 320 52.9 1,014 617 Table 61—Deaths from non-pulmonary tuberculosis in London Classification 1913 1922 1936 1937 Total 1611 936 363 351 Rate per 1,000 population .356 .207 .087 .086 Children — 590 143 137 Adults — 346 220 214 50 This table indicates that there has been a similar satisfactory record as regards decline in the number of deaths from non-pulmonary tuberculosis as is shown in table 59 concerning notifications. Here again the position is less favourable as regards adults than in respect of children. The problem, therefore, in London, is now more difficult as regards adults than children. It will be seen from table 60 that the percentage of applications for residential treatment in relation to notifications is lower for adults than children, except during periods of industrial depression. It is difficult to say how far the higher mortality in adults is due to the reluctance to undergo residential treatment or to reduced natural resistance to tuberculous infection in adult life. The economic factor certainly has an influence on willingness to undergo the prolonged treatment necessary in these cases. Following-up of discharged patients Adults.—During the year investigations were made concerning the adult patients discharged from hospitals or sanatoria in 1931 : the number investigated was 3,470. including 257 non-pulmonary. The following table shows the result of the inquiry and also (in brackets) the corresponding figures ascertained from last year's inquiry into the 1930 discharges :— Table 62 Classification Total Percentage alive five years after discharge Percentage dead A 517 (481) 77.2 (74.8) 22.8 (25.2) B 1 162 (126) 77.8 (71.4) 22.2 (28.6) B 2 1,704(1,866) 41.1(34.7) 58.9 (65.3) B 3 830 (889) 7.8 ( 6.7) 92.2 (93.3) Non-pulmonary 257 (272) 74.1 (76.8) 25.9 (23.2) Particulars obtained in 1936 as to the fitness for work of the 1,479 surviving adult patients who were discharged from treatment in 1931 show that out of a total of 525 classified A and B1 68'4 per cent, were at work. The corresponding percentage for those classified A and B1 in the 1930 group was 70.2. The percentages at work in the other categories and also the corresponding figures for the 1930 group (shown in brackets) are as follows : B2 54.1 (47.6) per cent.; B3 40.0 (21.6) per cent.; and surgical 61.9 (62.6) per cent. Of the total number of 1,479 in all categories 59.5 (56.3) per cent, were at work, 5.0 (5.6) per cent, were fit for work but were unemployed, 28.1 (31.2) per cent, were unable to work (including patients receiving further residential treatment). Children.—The particulars obtained as to the after-histories of children discharged under 16 years of age in 1931 relate to 595, of whom 170 are pulmonary and 425 non-pulmonary. The mortality records are as follows, the figures in brackets referring to last year's enquiry into the 1930 discharges :— Table 63 Classification Total patients Percentage alive five years after discharge ntage dead A 117 (153) 90.6 (91.5) 9.4 (8.5) B 1 9 (6) 77.8 (66.7) 22.2 (33.3) B 2 16 (27) 37.5 (33.3) 62.5 (66.7) B 3 28 (20) - (-) 100.0 (100.0) Non-pulmonary 425 (435) 91.5 (90.8) 8.5 (9.2) 51 The mortality rates of the non-pulmonary patients classified according to the location of the disease are as follows :— Table 64 Location of disease Total Percentage alive five years after discharge Percentage dead Hip 51 (42) 94.1 (92.9) 5.9 (7.1) Spine 62 (52) 79.0 (73.1) 21.0 (26.9) Other bones 89 (88) 93.3(94.3) 6.7 (5.7) Glands 186 (231) 95.2 (93.1) 4.8 (6.9) Other parts 37 (22) 86.5 (90.9) 13.5 (9.1) Of the 389 surviving non-pulmonary patients, 158 were at school and 144 at work. The pulmonary class A (i.e., T.B. minus) patients have again been the subject of inquiry in some detail by Dr. F. J. Bentley, divisional medical officer. During 1932, 136 T.B. minus children were discharged from residential treatment. In seven instances the diagnosis was not confirmed during subsequent supervision and these are omitted. Of the remaining 129, the following results are noted five years later:— No. Percentage Alive 106 82.2 Dead 10 7.7 Untraced 13 10.1 Total 129 100.0 As regards the 10 children who were ascertained to have died by the end of the 5 year period, detailed inquiry has again confirmed the opinion that the commonly encountered childhood type of pulmonary tuberculosis fares favourably, and that children who die within five years from the date of receiving treatment for pulmonary tuberculosis are either acutely ill when under residential treatment or suffer from the adult type of the disease with definite lesions of the lung substance, or that they succumb to some other illness. The following are short notes relating to the 10 patients who died from pulmonary tuberculosis, indicating the condition found whilst under residential treatment:— (1) Infiltration middle zone ; haemoptysis ; treated as adult with positive sputum 4 months later. (2) Acute bilateral caseating tuberculosis. (3) Widespread disease with cavitation. (4) Involvement of two lobes of left lung and one lobe of right. (5) Deposits upper part of right lung. (6) Deposits upper parts of both lungs ; T.B. plus a few months later. (7) Infiltration in two lobes. (8) Both upper lobes involved ; T.B. plus in following year. (9) Left apical striation and diminished translucence. (10) High fever ; acute, advanced pulmonary disease. It will be seen that with the exception of case no. 9, no child died of pulmonary tuberculosis who was not at the outset either seriously ill or found to be suffering from gross pulmonary involvement. Of the 106 traced survivors, as many as 100 (94 3 per cent.) are well and at full work or school, while 56 have already been removed from the tuberculosis registers as " recovered." The subsequent history of the children who suffered with pleural effusion is of interest. During 1931, 39 children were discharged after treatment for this condition. Patients recorded as " pleurisy " and " thickened pleura " are not included. Of these 39 patients, only 8 were females. Five years later one child could not be traced, but this child was well and at work a year previously. Of the remaining 38, no less than 23 were already (at the fifth anniversary from discharge) marked off the tuberculosis registers as " recovered," thus signifying uninterrupted quiescence since discharge. Of the remaining 15, 8 were arrested, 4 were quiescent, two were not attending the dispensary, while one was under residential treatment for debility. This last child is marked " arrested " in 1938, and is in full work as a shop assistant. Only one other child besides the one just referred to underwent a further spell of residential treatment for tuberculosis after discharge in 1931. Out of the total 39 patients who suffered from pleurisy with effusion, 38 were well and at full work or school at the end of five years. These results demonstrate that the prognosis in cases of children who are treated for pleurisy with effusion in the absence of any other sign of lung involvement is extremely favourable. 52 Tuberculosis dispensary service 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 and aided by grants from the Council. Prior to April, 1933, an annual grant, based on actual expenditure approved by the Council for the year, was made by the Council to the Metropolitan Borough Councils, subject to the dispensary service being carried out to the satisfaction of the Council. Since 1st April, 1933, the Council has substituted, for annual percentage grants based on actual expenditure, a system of fixed block grants in the form of annual payments of fixed amounts operating for periods of three years, based on examination of audited statements of actual expenditure during the triennium immediately preceding the commencement of each block grant period, together with a further statement of the amount of the probable expenditure by the Metropolitan Borough Councils during the ensuing grant period, and reasons for variations from previous expenditure. This arrangement does not include the City of London, which maintains its own dispensary at St. Bartholomew's hospital. There are now 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 and one is 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. In order to encourage the closer association of the municipal dispensaries with the Council's general hospitals, special facilities have been made available enabling the Borough Councils' tuberculosis officers to utilise the hospital X-ray installation for their patients and also to provide their patients with artificial pneumothorax refills at the hospitals. This has resulted in an increased number of boroughs arranging for the whole or part of their work in this connection being carried out at the Council's general hospitals. No charge, beyond 2s. 6d., the cost of any film exposed, is made by the Council to the Borough Councils for X-ray examinations of tuberculosis dispensary patients. The increased recognition of the value of X-rays as an aid to diagnosis and treatment has resulted in their more frequent use by tuberculosis officers. The Council has, therefore, concurred on certain conditions in the provision by Borough Councils of X-ray apparatus of simple type for the routine examinations in tuberculosis dispensaries of straightforward cases. Patients whose conditions present difficulty can still be referred to hospitals specially equipped and possessing specialist staff. 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 53 to 55. 53 Table 65—Tuberculosis Dispensaries Analysis of Returns, January-December, 1937 Metropolitan borough On dispensary register. 1-1-37 Transferred during 1937 from other areas and cases returned after discharge Examined for first time during 1937 (a) New cases excluding contacts (b) Contacts (printed in italics) Total number (including contacts) under dispensary supervision during 1937 Removed from dispensary register during 1937 On dispensary register 3l-12-37 Total attendances Visits to home for dispensary purposes by No, of specimens of sputum examined No. of X ray ex amina tiors Number of T.B. † case on dispensary register Definitely tuberculous Diagnosis not confirmed Pulmonary Nonpulmonary Diagnosis not confirmed Nontuberculous Total (a) liecovered (b) Non tuberculous (printed in italics) (a) Transferred to other areas or lost sight of (b) Died (printed in italics) Definitely tuberculous Diagnosis not completed Tuberculosis officers Nurses or health visitors Adults Children Adults Children Adults Children Adults Children Adults Children Battersea 724 15 37 120 8 17 6 14 312 96 463 110 1,617 35 84 709 15 4,837 362 3,884 586 921 375 2 1 128 137 131 137 685 89 724 Bermondsey *797 20 16 96 3 12 4 9 380 68 497 75 1,897 48 49 775 9 4,143 914 2,832 1,109 1,123 329 16 224 252 240 252 939 77 784 Bethnal Green 647 17 32 90 3 13 9 12 4 192 107 307 123 1,483 12 55 666 18 3,701 144 3,571 328 525 262 5 3 2 183 164 191 166 660 72 684 Cambernell 1,626 29 58 135 4 19 9 3 407 101 564 114 3,103 25 162 1.568 8 5,620 667 8,967 1,069 751 662 36 3 2 3 347 321 385 327 1,213 127 1,576 Chelsea 279 4 36 65 4 13 1 7 182 80 267 85 787 22 61 280 7 1,733 32 2,982 314 573 133 5 2 1 61 47 67 49 378 30 287 Deptford 475 27 41 79 4 11 4 8 3 163 47 261 58 1,050 27 98 * 448 19 2,336 196 2,856 634 263 251 6 8 3 7 82 82 91 97 395 63 467 Finsbury 399 5 18 74 6 6 5 10 1 71 21 161 33 710 22 40 376 13 1,275 101 1,938 111 319 181 3 2 1 37 51 40 54 190 69 389 Fulham 703 22 57 155 5 14 8 3 3 280 300 452 316 1,778 78 104 655 7 5,201 466 3,359 910 421 331 1 2 129 96 130 98 830 104 Greenwich 513 28 46 90 4 2 3 17 1 194 93 303 101 1,145 32 69 498 19 2,683 140 3,287 272 618 258 2 3 1 78 70 80 74 463 64 517 * Adjustment from 1936. 54 55 Table 65—continued Metropolitan borough on dispensary register, 1-1-37 Transferred during 1937 from other areas and cases returned after discharge Examined for first time during 1937 (a) New cases excluding contacts (b) Contacts (printed in italics) Total number (including contacts) under dispensary supervision during 1037 Removed from dispensary register during 1937 On dispensary register 31-12-37 Total attendances Visits to home for dispensary purposes bv No. of specimens of sputum examined No. of X-ray examina tions N umber of T.B. + cases on dispensary register Definitely tuberculous Diagnosis not confirmed Pulmonary Nonpulmonary Diagnosis 1 not confirmed Nontuberculous Total (a) Hecovered (b) Nontuber culous (printed in italics) (a) Transferred to other areas or lost sight of (b) Died (printed in italics) Definitely tuberculous Diagnosis not completed Tuberculosis officers Nurses or health visitors Adults Children Adults Children Adults Children Adults Children Adults Children Hackney 1,150 16 67 183 1 25 12 25 2 442 115 675 130 2,467 44 138 1,201 19 5,502 289 3,454 961 810 550 3 2 1 2 242 179 246 183 985 80 1,220 Hammersmith 833 1 74 107 4 12 11 — — 182 41 301 56 1,612 31 116 824 2,503 237 3,837 491 303 382 14 1 1 174 157 188 159 555 86 824 Hampstead 218 8 37 54 — 3 2 — 1 95 21 152 24 516 14 54 229 3 1,687 153 1,232 186 371 130 1 2 43 31 44 33 198 18 232 Holborn 238 1 10 23 1 2 2 — — 15 4 40 7 350 3 30 239 1 921 30 985 121 135 114 5 1 1 24 23 29 25 66 11 240 Islington 1,366 8 144 222 4 29 19 4 - 438 80 693 103 2,884 36 243 1,395 4 9,555 534 6,466 906 731 719 31 3 8 280 248 311 259 1,053 153 1,399 Kensington 537 16 75 155 11 19 30 5 — 250 78 429 119 1,454 38 110 588 1 5 3,027 78 3,355 710 768 306 6 1 146 125 152 126 632 81 593 Lambeth 1,345 105 51 239 3 29 14 88 12 387 70 743 99 3,166 21 207 1.418 143 6,604 903 4,397 1,286 1,403 665 38 10 3 69 39 407 257 514 309 1,157 220 1,561 Lewisham 987 3 105 163 5 14 11 6 — 190 55 373 71 1,854 48 120 1,054 1 3,439 307 4,758 412 121 611 9 2 123 181 132 183 554 77 1,055 Paddington 852 11 38 100 5 15 5 3 13 320 299 438 322 1,853 35 121 810 7 6,734 511 5,137 396 443 260 7 2 103 80 110 82 822 58 817 Poplar 741 29 28 127 4 11 9 14 1 291 176 443 190 1,711 45 80 700 16 5,321 610 7,128 616 361 402 4 1 1 169 105 174 106 776 94 716 St. Marylebone 375 10 43 80 3 12 4 6 1 114 17 212 25 769 24 109 347 9 2,141 298 2,818 213 370 182 2 2 1 63 36 66 38 243 37 356 St. Pancras 754 42 111 206 10 16 20 11 — 201 46 434 76 1,724 47 180 779 18 3,641 118 4,083 564 363 438 2 2 2 174 127 178 129 579 121 797 Shoreditch 591 19 41 78 7 11 8 10 7 209 122 308 144 1,303 33 62 572 | 23 3,737 123 2,986 803 378 259 5 3 3 105 84 113 87 540 73 595 South wark 557 56 49 117 7 16 10 58 21 180 14 371 52 1,391 52 155 526 108 4,782 198 3,777 510 1,693 303 6 3 1 21 8 143 124 170 136 468 82 634 Stepney 1,676 22 239 224 1 22 17 14 5 209 66 469 95 3,201 144 486 1,395 19 5,685 514 5,284 844 796 695 2 254 444 256 444 994 163 1,414 Stoke Newington 213 5 25 27 3 3 1 5 — 87 13 122 17 489 21 49 184 5 1,132 106 1,282 307 69 94 1 39 67 40 67 206 24 189 Wandsworth 1,379 19 113 208 8 30 16 33 4 346 283 617 311 2,875 59 171 1,406 | 49 4,870 598 5,644 1,523 258 807 34 1 2 12 202 185 248 188 1,035 155 1,455 Westminster 646 — 26 229 4 23 11 1 — 56 33 309 48 1,143 — 176 685 | 1 2,141 95 2,915 162 123 233 5 2 3 29 75 34 80 206 75 686 Woolwich 877 8 219 8 23 12 1 1 401 178 644 199 2,277 97 83 873 | 6 5,751 397 4,000 506 1,050 337 16 9 1 290 230 307 242 1,119 99 879 Total 21,498 538 1,625 3,665 136 422 263 367 80 6,594 2,024 11,048 3,103 46,609 1,003 3,412 21,200 | 552 110702 9,121 107214 16,850 16,060 10,269 267 60 20 121 72 4,279 3,978 4,667 4,130 17,941 2,411 21,752 56 The following is a summary, for purposes of comparison, of certain sections of the foregoing table :— Table 66 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 with medical practitioners per case on register Nurses' visits per case on register X-ray examinations Actual Per 1,000 inhabitants Definitely tuberculous personson dfspensary register. T.B. + cases on dispensary register Examinations per 100 new cases and contacts per 100 new cases New cases Contacts Adults Children Battersea 123 •86 •87 576 305 466 107 111 6•7 •50 •56 5•4 109•5 160•7 Bermondsey 92 •93 •86 842 358 622 261 274 5•3 1•17 •45 3•6 105•5 196•3 Bethnal Green 80 •85 •59 833 328 538 239 208 5•4 •21 •43 5•2 66•7 122•1 Camberwell 206 •92 •77 761 321 329 187 159 3•6 •42 •47 5•7 54•0 110•8 Chelsea 48 •85 •95 583 277 733 140 102 60 •11 •37 10•4 122•4 162•8 Deptford 75 •78 •65 597 335 425 121 129 5•0 •42 •37 6•1 51•9 82•4 Finsbury 62 1•06 •99 606 292 313 65 87 3•3 •26 •67 5•0 110•8 164•4 Ful ham 118 •85 •46 555 281 651 110 83 7•9 •70 1•77 5•1 42•3 54•8 Greenwich 81 •84 •80 615 319 499 99 91 5•2 •27 •67 6•4 110•8 153•0 Hackney 130 •63 •77 924 423 619 189 141 4•5 •24 •89 2•8 65•6 100•6 Hammersmith 106 •84 •77 777 360 337 177 150 30 •29 •78 4•7 43•0 84•9 Hampstead 36 •40 •70 636 361 489 122 92 7•3 •66 1 •24 5•3 146•6 210•8 Holborn 27 •78 •81 885 422 174 107 93 3•8 •13 •49 4•1 133•7 287•2 Islington 228 •77 •70 612 315 349 136 114 6•8 •38 •63 4•6 53•5 91•8 Kensington 130 •74 •86 452 235 422 117 97 51 •13 •64 5•7 93•0 140•1 Lambeth 239 •87 •69 593 278 352 215 129 4•2 •58 1•58 2•8 84•3 166•6 Lewisham 147 •65 •81 717 416 302 90 124 3.3 •29 •36 4•5 15•9 27•3 Paddington 109 •79 •89 743 239 697 101 75 8•2 •63 •52 6•3 46•5 58•3 Poplar 119 •87 •81 588 338 532 146 89 7•4 •85 •42 10•0 39•5 57•0 St. Marylebone 54 •59 •54 643 337 439 122 70 6•0 •84 •53 7•9 108•5 156•1 St. Pancras 162 •89 •81 481 270 315 110 80 4•6 •15 •36 5•1 44•4 71•2 Shoreditch 86 1•05 •41 665 301 526 131 101 6•3 •21 •29 5•0 58•0 83•6 South wark 129 •88 •52 408 235 328 132 105 7•5 •31 •58 6•0 232•2 400•2 Stepney 170 •84 •70 821 409 332 151 261 4•0 •36 •57 3•7 63•0 141 • 1 Stoke Newington 35 •70 •76 526 269 397 114 191 6•0 •56 1•85 6•8 28•0 49• 6 Wandsworth 224 •66 •68 628 360 414 111 84 3•3 •41 1•45 3•9 18•9 27•8 Westminster 97 •78 •44 706 240 368 35 82 3•1 • 14 • 60 4.2 26.1 34.5 Woolwich 119 •80 •95 734 283 708 258 203 6•5 •45 1•27 4•6 75•4 124.6 London (excluding City) 3,232 •79 •70 656 318 438 144 128 51 •42 •76 4•9 70•0 113•5 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 parent or parents 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 1937 with the co-operation of the Association. There were 178 applications during 1937, concerning 310 children, of whom 253 were accepted, the remaining 57 being withdrawn or regarded as unsuitable. At the end of the year 130 children were being maintained under this scheme. The total number of children dealt with (253) is a decrease from that for the previous year (264). The number still being cared for at the end of the year (130) was 16 more than the previous year's figure. 57 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 32 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 longeT made as, since 1st April, 1925, the contributions towards the cost of residential treatment of patients have been paid into the County Fund until August, 1934, on the basis of assessment on parents according to means and, since that date, only on a purely voluntary basis. The balance of the Tuberculosis Contributions Fund is, however, being applied as indicated above. 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 602) suffering from pulmonary tuberculosis or from tuberculous glands with no open wounds, who do not require treatment in residential institutions and 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. Ill, Part II, p. 52). In each metropolitan borough there is a tuberculosis care committee, or some other provision for social service, in connection with the care of tuberculous patients and their families, working in association with the dispensaries. This work has been carried on with increasing activity owing to the greater scope afforded by the increase of voluntary funds. Nearly all care committees have participated in the Christmas Seal sales inaugurated by the National Association for the Prevention of Tuberculosis and have thus substantially increased their incomes. Moreover, since the Council abolished the assessments for residential treatment more time has been available to care committees for purely " care " work. In 1937 one new handicraft class was formed to serve two boroughs, and there are now 14 handicraft classes serving 16 boroughs. There are also two glovemaking classes conducted by the Central Fund for the Industrial Welfare of Tuberculous Persons, and two cookery classes. One borough has also started a weekly dressmaking class and a class on current literature, both of which are proving popular. One other borough tuberculosis care committee, which abandoned its handicraft class some years ago as being unsuited to the type of district it served, started in its place a sewing class, which is successful and well attended. The object of the cookery classes and the dressmaking classes is to raise the economic standard and self-reliance of households impoverished by tuberculosis. The type of work done in the dressmaking and sewing classes is the repairing of clothes, the making of underclothing and pyjamas for patients' needs while undergoing residential treatment, the altering of all kinds of garments, e.g., remaking discarded adult clothing into clothes for children. The experiment appears to be proving successful and affords occupation and instruction of definite economic value to many women whose physical condition prevents them from entering the ordinary labour market. The cookery classes are open to contacts as well as to ex-patients. It is hoped thereby to raise the standard of nourishment in households where there is a tuberculous patient. The Central Fund for the Industrial Welfare of Tuberculous Persons conducts workshops in which are carried out the manufacture of wooden toys and leather goods and the preparation of firewood. The woodwork and toy factory employs between 30 and 40 men, and the leather workshop between 15 and 20. The employees are all tuberculous patients. The goods produced by the workers are sold in the best markets available, but the income from the sale of goods is insufficient to enable the Central Fund to work without a loss. To assist the Central Fund Committee in its valuable work the Council has made a grant of £500 for each of the past three years. Supply of surgical appliances Open-air schools Tuberculosis care committee work Handicraft classes Workshops for the tuberculous 58 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 ; Princess Mary's hospital, Margate (now closed); and Heatherwood hospital, Ascot, for children. The total number of attendances at the three clinics was 1,606 (St. Luke's hospital, Lowestoft, 493 ; Princess Mary's hospital, 765 ; Heatherwood hospital, 348). The clinic for adults (ex-patients of St. Luke's hospital, Lowestoft) is held once a month, the average attendance being 41. The clinic conducted by the former medical superintendent of Princess Mary's hospital is held every Monday, the average attendance per session being 17. The clinic conducted by the medical superintendent of Heatherwood hospital is held twice a month, the average attendance per session being 15. 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. 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 patient suffering from 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 1937 approximately 260 families were rehoused under this scheme, compared with 217 in 1936. After-care clinics for surgical tuberculosis Housing of tuberculous persons Cases dealt with by the Council Mental Deficiency Acts, 1913-27 On 31st December, 1937, 11,297 cases were being dealt with by the Council under the provisions of the Mental Deficiency Acts, 1913-27. Of these, 7,017 were in institutions, 407 under guardianship, 3,847 under supervision and 26 in places of safety awaiting action. During the year 1,190 cases were examined with the following results :— Table 67 Sex Source of notification Feebleminded Imbecile Idiot Morally defective Not defective Total Children Adults Children Adults Children Adults Children Adults Children Adults Children Adults Male Mental hospitals department, etc. 67 28 72 2 6 1 — — 7 3 152 31 Special school leavers 307 — — — — — — — — — 307 — Public assistance 3 9 1 1 — — 3 6 6 17 General hospitals 8 7 2 1 1 — — 7 5 16 15 Sections 8 & 9 of M.D. Acts 17 41 — 1 — — — — 1 4 18 46 Female Mental hospitals department, etc. 57 62 65 7 6 1 — — 7 29 135 09 Special school leavers 226 — — — — — — 2 — 228 — Public assistance 3 29 4 — 1 — — 2 10 5 44 General hospitals 10 20 1 1 — 2 9 13 30 Sections 8 & 9 of M.D. Acts — 23 — — — — — 1 — 1 — 25 Total 698 219 138 17 13 6 — 1 31 67 880 310 917 155 19 1 98 1,1 80 Total for 1936 793 210 114 24 15 2 - 2 21 98 943 336 1,003 138 17 2 119 1,279 59 Blind Persons Act, 1920 The following table contains particulars for 1937 of applicants for registration or training under the provisions of the Blind Persons Act, 1920 :— Table 68 Description Registration of the blind Training of the blind Total m. f. m. F. (1) Applicants who were examined and were certified as blind 376 533 36 22 967 (2) Acceptance of certificates issued by hospital and private doctors 43 42 — — 85 (3) Acceptance of certificates issued by hospital and private doctors stating applicants were not certifiable as blind — 3 — — 3 (4) Applicants who were examined and not certified as blind 216 302 24 1 £6 (5) Found blind but unfit for training — — 3* 1* 4* (6) Previously certified as blind and found fit for training — — 21 11 32 (7) Previously certified as blind and found unfit for training — — 3 7 10 Total 635 880 87 55 1,657 Total for 1936 681 1,042 74 43 1,840 Blind persons * Included in (1) above. Midwives Acts, 1902 to 1936, Nursing Homes Registration and Maternity and Child Welfare Contribution Schemes The Midwives Acts, 1902-1936, and the Rules of the Central Midwives Board 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 of 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 the Central Midwives Board. (g) Appointment of midwives under the Act of 1936. (h) Arrangements with voluntary organisations for the employment by them of domiciliary midwives. (i) Fixation of fees to be paid by patients for attendance of midwives employed by local authorities under the Act of 1936. (j) Compensation to midwives ceasing or required to cease practice. (k) Prohibition of unqualified persons acting as maternity nurses for gain. Section I of the Midwives Act, 1936, lays upon the local supervisory authorities under the Midwives Act, 1902, the duty of providing a domiciliary service of midwives. In London this duty devolves upon the Council. Midwives Acts Domiciliary service of midwives 60 The material provisions of the section are as follows :— (1) It shall be the duty of every local supervising authority within the meaning of the principal Act (in this Act referred to as an " authority ") to secure, whether by making arrangements with welfare councils or voluntary organisations for the employment, by those councils or organisations, of certified midwives as whole-time servants or by itself employing such midwives, that the number of certified midwives so employed who are available in its area for attendance on women in their own homes as midwives, or as maternity nurses during childbirth and from time to time thereafter during a period not less than the lying-in period, is adequate for the needs of the area. In this sub-section the expression " lying-in period " means the period defined as the lying-in period by any rule for the time being in force under section three of the principal Act. [Under recent rules of the Central Midwives Board the lying-in period has been extended from 10 to 14 days.] (2) Within the period of six months from the commencement of this Act, or such longer period as the Minister may in any particular case allow, every authority shall submit to the Minister its proposals for carrying out its duties under this section, after consultation :— (a) in the case of every authority— (i) with all the voluntary organisations which, to the knowledge of the authority, employ or are willing to employ domiciliary midwives in the area of the authority; and (ii) with such local organisation (if any) of registered medical practitioners as appears to the authority effectively to represent the opinions of such practitioners practising in that area on the questions to be considered in formulating the proposals ; and (iii) with such local organisation (if any) of midwives as appears to the authority effectively to represent the opinions of midwives practising in that area on the questions aforesaid ; and (c) in the case of the London County Council, with any association or committee which appears to that Council to be representative of the Metropolitan Borough Councils. Careful and prolonged consideration was given to the preparation of proposals for recommendation to the Council and submission to the Minister of Health for carrying out the Council's duties under the Act. The problem in London was a complex and difficult one, owing to the large area and population affected, and to the number of voluntary hospitals, maternity homes and district nursing associations which already provided domiciliary midwifery services. There was also the circumstance that the City Corporation and the Metropolitan Borough Councils, who are the authorities in London under the Maternity and Child Welfare Act, 1918 (these provisions are now incorporated in the Public Health (London) Act, 1936), had in three cases exercised their power to appoint each a whole-time midwife, and in about 15 cases had made contributions in respect of domiciliary midwifery services provided by voluntary agents. There was the further point that the Council itself, under the Maternity and Child Welfare Contributions (London) Scheme of the Minister of Health under the Local Government Act, 1929, makes substantial payments (replacing former grants by the Minister) to hospitals and nursing associations in respect of domiciliary midwifery services. The consultations prescribed in Section I (2) began immediately the Act came into operation in July, 1936, and were continued during the early part of 1937. In the course of the discussions, it became apparent that proposals for utilising existing midwifery services in London could not, if they were to be capable of efficient application in practice, be related to the county as a whole, which would be too large an area, or to the metropolitan boroughs singly, as the activities of the 61 voluntary organisations were quite independent of borough boundaries and in most cases covered parts of the areas of several boroughs. A solution of these difficulties was found by adopting an " area " basis, and the proposals approved by the Council for submission to the Minister of Health provided that London should be divided for the purposes of the Act into five areas, three north and two south of the Thames, each composed of a convenient number of boroughs. The following is a list of the areas :— Area A, comprising the metropolitan boroughs of Bethnal Green, Hackney, Poplar, Shoreditch, Stepney and Stoke Newington. Area B, comprising the City of London and the metropolitan boroughs of Finsbury, Holborn, Islington and St. Pancras. Area C, comprising the metropolitan boroughs of Chelsea, Fulham, Hammersmith, Hampstead, Paddington, and St. Marylebone, the Royal borough of Kensington and the City of Westminster. Area D, comprising the metropolitan boroughs of Battersea, Bermondsey, Lambeth, Southwark and Wandsworth. Area E, comprising the metropolitan boroughs of Camberwell, Deptford, Greenwich, Lewisham and Woolwich. The proposals which were submitted to the Minister of Health provided (a) for the employment by the Council of 42 municipal midwive3 ; and (b) for the employment by 39 voluntary organisations of 124 midwives under arrangements with the Council. It was also proposed that, under certain conditions, the three municipal midwives employed by Metropolitan Borough Councils should, while remaining employees of those Councils, be included in the County Council's arrangements for performing its duty under the Act. In regard to the London County Council municipal midwives, it was proposed that " relief " should be provided by the appointment of additional midwives and/or by utilising for the purpose the services of midwives employed by voluntary organisations with which the Council had arrangements. It was estimated that the relief services required would be equivalent to the whole-time services of six midwives. The Minister of Health expressed the hope that every effort would be made to carry the Council's proposals into effect at the earliest possible date, and in any event not later than 1st January, 1938. Arrangements were accordingly made for the scheme to be brought into operation on 1st January, 1938. It became necessary to make certain minor modifications in the proposals originally submitted to the Minister of Health. Of the voluntary organisations with which arrangements under the Act were contemplated, one decided not to enter into agreement w th the Council and two decided to discontinue their domiciliary midwifery service. One municipal midwife employed by a Borough Council (Bethnal Green) surrendered her certificate and the Borough Council did not fill her position. In the case of one of the other two boroughs (Battersea), the Borough Council decided to continue outside the Council's scheme and in the other (Shoreditch) negotiations were still pending at the close of the year. These changes necessitated an increase by three in the number of midwives to be directly appointed by the Council, and it was also decided to draw upon the provision which had been sanctioned for " relief" purposes, by appointing two additional midwives to act as " reliefs," making a total of 47 municipal midwives required. Steps were taken in accordance with the procedure laid down in the Act for the appointment, following public advertisement, of this number of midwives, all to commence work on 1st January, 1938. The Minister, in Circular 1569, drew attention to the importance of absorbing into the new service as many as possible of the independent midwives at present in practice, and in making appointments preference was given to thoroughly competent independent midwives already practising in the administrative area. It was also decided at the outset not to differentiate between Municipal midwives 62 fully-trained nurses and midwives holding only the certificate of the Central Midwives Board, nor to exclude married women from appointment provided they were able to undertake whole-time employment. It was decided also, with regard to any further appointments which may be necessary in the near future, that midwives who were married on a date earlier than 1st January, 1938, are to be eligible to apply for any appointments made before 30th July, 1939, when the position is to be reviewed, and any unmarried midwives who may be appointed before 30th July, 1939, are to be allowed to retain their appointments if they marry before that date. It was also decided that, for the first appointments and for the filling of vacancies occurring up to 30th July, 1939, independent midwives practising in London, who had not reached 60 years of age, should be regarded as eligible for employment. The salary fixed for the midwives was £200 a year rising by annual increments of £12 10s. to £250 a year and, after a further period of four years, by similar annual increments to £300 a year. They receive in addition annual allowances of £12 for laundry and £10 for travelling expenses, and are also supplied with their telephone free of cost. Uniform, nursing equipment, and necessary drugs are supplied by the Council. Those appointed are required to reside in a locality and in premises approved by the Council, and the Council may require removal to other premises if it so desires. The annual leave allowance has been fixed at four weeks, and periodical leave is granted, subject to the exigencies of the service, at the rate of 24 hours each week and two days and three nights each calendar month, this monthly leave to include the weekly 24 hours' leave falling due in the week in which such monthly leave is taken. The 36 voluntary organisations with which the Council is entering into agreement include 9 teaching hospitals (employing 40 midwives under their agreements with the Council), 7 maternity hospitals (including Royal Northern hospital, whose district work is centred in Myddelton Square Maternity Nursing Association) (43 midwives), and 20 nursing organisations (37 midwives); the total number of midwives employed by voluntary organisations under the scheme is 120. The midwives employed by the teaching hospitals and maternity hospitals are accompanied by medical students or pupil midwives. The nursing associations fall into three groups :— (i) Those which undertake maternity nursing only ; (ii) Those which undertake midwifery as well as maternity nursing ; (iii) Certain nursing associations which will undertake both midwifery and maternity nursing and are also concerned in the training of pupil midwives. The midwives employed by the voluntary organisations are subject to the approval of the Council. They must be whole-time servants of the organisations, although not necessarily devoting the whole of their time to midwifery or maternity work. The agreements with the voluntary organisations provide for the keeping of the necessary records and accounts, and for the inspection by duly authorised officers of the Council of the places of residence of the midwives and the provision made for carrying on domiciliary midwifery service. Payment will be made by the Council to voluntary organisations on the basis of the number of cases attended, and on the conditions laid down in the agreements. (а) Voluntary hospitals and maternity homes— £2 6s. lOd. for every case attended by a midwife acting alone or when a medical student is also present. £1 17s. 6d. for every case attended by a midwife associated with a pupil midwife. (б) Nursing associations—■ £2 14s. per case for every case attended. Voluntary organisations 63 Payment to nursing associations for relief of the Council's midwives is to be based on time given, calculated as follows :— For any period not exceeding 12 hours 10s. For any period exceeding 12 hours but not exceeding 24 hours 15s. For any period exceeding 24 hours— In respect of each complete day of 24 hours 15s. In respect of part of a day not exceeding 12 hours 10s. In respect of part of a day exceeding 12 hours 15s. From these payments will be deducted (a) contributions received from parents or liable relatives ; (b) grants made by the Council under the Maternity and Child Welfare Contributions (London) Scheme in respect of district midwifery and maternity nursing, and (c) grants or payments made by the City Corporation or Metropolitan Borough Council in respect of domiciliary midwifery and maternity nursing. Following the acceptance by the Minister of Health of the Council's proposals it was possible, through the courtesy of the City Corporation and the Metropolitan Borough Councils, to arrange conferences with the medical officers of health of each of the five areas as a result of which a scheme was evolved for co-ordinating the domiciliary midwifery service with the ante-natal, post-natal and social services provided by the City Corporation and the Metropolitan Borough Councils. The Metropolitan Counties Branch of the British Medical Association have supplied to the midwives a list of practitioners who are prepared to render " medical aid if called upon. Where a midwife's case receives ante-natal care from a practitioner, arrangements have been made for a report on the ante-natal examination to be furnished to the midwife. Section 3 of the Act requires every authority employing midwives to fix a scale of fees payable for their attendance as midwives and a scale of fees payable for their attendance as maternity nurses. It also provides for the remission of part or the whole of the fee in suitable cases. The fees approved by the Council are as follows :— For a first confinement £2. For a subsequent confinement £1 10s. For maternity nursing £1 10s. For the purpose of deciding whether any part of the fee shall be in any case remitted having regard to the circumstances of the patient or liable relatives, standard rules for assessment have been approved. All the voluntary organisations within the scheme have agreed to adopt the same charges and rules of assessment as operate in the case of patients attended by a directly-appointed municipal midwife. Considerable publicity was given in the press to the Council's arrangements. In addition, posters were displayed widely throughout London at the Council's hospitals and other establishments and also, through the courtesy of the City Corporation and Metropolitan Borough Councils, at the town halls, maternity and child welfare centres, etc. Persons desiring further information were invited to obtain a leaflet giving detailed particulars of the service provided in each area by applying at any of the Council's hospitals or at the Borough Council establishments. A synopsis of the scheme was also furnished to all general practitioners in London and their attention was drawn to the facilities available under the scheme for obtaining the services of maternity nurses. Under the Act, practising midwives are given the option of relinquishing their practice and, subject to certain conditions, are entitled to receive compensation. This provision remains in force until 31st July, 1939. Up to 31st December, 1937, compensation was authorised to 27 midwives who had voluntarily surrendered their certificate of enrolment by the Central Midwives' Board and during the same period 16 were called upon by the Council to cease practising as they were deemed to be incapable of efficiently performing their duties by reason of age or infirmity of mind or body. Compensation amounting to £12,102 4s. has been authorised for payment to the 43 midwives concerned. Co-ordination with maternity and child welfare services Medical practitioners Fees Inauguration of the scheme 64 Births in London in 1937 The following statement shows the number of confinements which occurred in London in 1937, classified under the various forms of attendance. The figures have been arrived at as a result of an examination of statistics furnished from various sources. The total number of confinements in London in 1937 was 66,029. Institutional confinements Voluntary hospitals *20.579 Borough maternity homes 2,409 L C.C hospitals 19.843 Private nursnm homes 3.440 Total 46 271 Domiciliary confinements Borough midwives 176 Voluntary hospitals and organisations 7,585 Independent midwives *6.858 Private doctors *5,139 Total 19.758 * Estimated. Midwives The number of births used by the Registrar-General in calculating the birthrate of London was 55,011. The substantial difference between this figure and the 66,029 notified births indicates that a large number of women whose normal place of residence is outside London come to London for their confinement. Certified midwives to the number of 1,045 gave notice of intention to practise within the county during the year, compared with 956 in 1936. These 1,045 midwives fall into the following categories :— In private practice 224 Out-county 54 Nursing homes 129 Municipal 4 L.C.C. hospitals 197 Voluntary maternity hospitals (district) 180 Voluntary general and special hospitals 86 Borough maternity homes 59 Voluntary nursing associations 95 Holiday relief only 11 Specific occasions 6 Total 1,045 The following is a summary of returns which have been made voluntarily by the 224 midwives in private practice in London as to the number of cases attended by them during 1937 :— Number of midwives who attended under 25 cases *121 „ „ 25 to 50 48 „ „ 50 to 75 „ 25 75 to 100 „ 16 ,, ,, ,, over 100 „ 14 Total .. 224 Of whom 51 took no patients. 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; 3,160 visits were paid this year compared with 2,978 in 1936. 65 Infringements of the Rules of the Central Midwives Board to the number of 15 were reported during the year, compared with 28 in 1936. Of these, 12 were slight and an oral caution by the inspector was deemed to be sufficient; 3 cases of a more serious nature were dealt with by a written caution. 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 14 claimed and received compensation. The Midwives Act, 1926, amended section 1 (2) of the Midwives Act, 1902, sc as to make it an offence for any uncertified person to attend women in childbirth except under the direction and personal supervision of a registered medical practitioner, unless the case was one of sudden or urgent necessity. During the year enquiry was made into one case of alleged contravention of the Act, compared with 5 such enquiries made in 1936. In this case no further action was considered necessary. During the year there were 237 still-births reported to the Council by midwives in their practice, compared with 211 in 1936. Of the cases reported this year 114 were male, 122 female, and one sex not stated ; 117 were reported as macerated, and 120 not macerated. During the year 240 cases of notified puerperal fever were investigated, compared with 170 in 1936. Of these cases 18 proved fatal, compared with 11 in 1936, a case mortality of 7.5 per cent., compared with 6.47 per cent, in 1936. The case mortality in 1935 was 9.5. The distribution of notified cases, with the mode of delivery, was as follows, deaths being shown in brackets : medical practitioners 63 (4); certified midwives 34 (3); hospitals 122 (8); medical students 4 (0); cases of miscarriage or abortion where no attendant was engaged 17 (3)—total 240 (18). The number of notifications of puerperal pyrexia investigated during 1937 was 859, compared with 681 in 1936. The cases were distributed as follows, the deaths being shown in brackets : medical practitioners 108 (3); certified midwives 85 (2); hospitals 636 (8); medical students 10 (0); cases of miscarriage or abortion where no attendant was engaged 20 (1)—total 859 (14). Fourteen of the cases, of whom none died, 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 call in a medical practitioner. A notice in the approved form is sent to the doctor, and to the Council. In the year now under review 4,269 such notices were received, compared with 4,726 in 1936. 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 17,800. This appears to indicate that medical aid was necessary in about 24 per cent, of the cases, compared with 27 per cent, during 1936. The number of claims from medical practitioners for attending cases of eye affection of newly-born children during the year was 547 and the amount paid in respect of the cases was £544, compared with £516 in 1936. During the year, 830 notices were received from midwives indicating that medical aid had been summoned for inflammation of the eyes of infants, compared with 782 in 1936 ; 9 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 the total 839 cases, 144 proved to be ophthalmia neonatorum (.8 per cent, of the 17,800 patients attended by midwives), compared with 158 in 1936 ; 310 other cases that did not occur in midwives' practices were also notified, making a total of 452 cases during the year, the percentage occurring in the practice of midwives being 31.42 per cent, of all cases of ophthalmia neonatorum, compared with 33.97 per cent, in 1936. Suspension of midwives Uncertified persons Still-births Puerperal fever Puerperal pyrexia Medical aid Ophthalmia neonatorum Inflammation of the eyes— notices 66 All the midwives' cases were investigated, and it was found that 136 were completely cured ; three children were found to be still under treatment at the end of the year ; two children had removed from London and the condition of the eyes after completion of treatment has not been ascertained ; in one child the right eye was found to be blind and the left eye impaired ; two children died from causes other than ophthalmia. Twenty-nine cases became in-patients at St. Margaret's hospital, compared with 35 during 1936. Pemphigus neonatorum During the year 44 cases of pemphigus neonatorum occurred in the practice of midwives, compared with 53 during the previous year. Instruction of midwives As in past years, courses of demonstrations and lectures at convenient centres were provided for the post-certificate instruction of midwives practising in London, Middlesex, Ealing, Hendon, Isleworth, Tottenham and Willesden, the cost being shared by the local supervising authorities in proportion to the numbers of their midwives attending. Two lectures are given four times a year by medical officers of the Council for the instruction of pupil midwives in public health matters and the rules of the Board before each examination of the Central Midwives Board. Pupils attending during the year numbered 768, compared with 751 in 1936. 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 and the Minister of Health has laid down a scale of fees to which local authorities must adhere. The patient is required to reimburse the Council according to her means, but, in cases of inflammation of the eyes, as already mentioned, the Council has decided to forego any claim to a fee.* Claims for fees accepted during the year numbered 2,641, compared with 2,854 in 1936, the total amount involved being £3,342, compared with £3,386 in 1936. 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, 28 claims amounting to £28 8s. Od. were refused during 1937. Registration of nursing homes The provisions with regard to the registration of nursing homes in London are contained in Part XI of the Public Health (London) Act, 1936, which repealed, inter alia, the Nursing Homes Registration Act, 1927, so far as London is concerned. The Annual Report for 1928 (Vol. Ill, pp. 53-54) indicates fully the powers of the Council under the latter Act. The number of nursing homes on the register on 1st January, 1937, was 186. During the year 1937, 11 homes were added, of which 6 had applied during 1936, while 27 were removed on cancellation of the registration, leaving 170 on the register on 31st December, 1937. In 26 cases cancellations were made at the request of the persons registered and/or upon change of ownership. The remaining cancellation was made on account of the death of the person registered. During the year proceedings were instituted against one person for conducting premises as a nursing home without being duly registered in respect thereof— lefendant fined £5 and ordered to pay 2 guineas costs. There were 12 applications for registration during the year, of which, at the end of the year, 3 had been withdrawn, 1 refused, and 4 granted, 4 being still under consideration. * The appropriate Committee decided that, as from 1st January, 1938, no further action should be taken under the Council's resolution of 26th April, 1921, which provided for arrangements to bo made for the recovery of fees paid to medical practitioners called in by midwives in emergency. 67 The general considerations taken into account by the Council in connection with registration of nursing homes are fully described in the Annual Report for 1930 (Vol. III, Part I, pp. 53-54). In 1937 the Council granted 113 exemptions from the provisions of Part XI of the Public Health (London) Act, 1936, in respect of premises not conducted for profit. These exemptions are for a period due to expire on 30th June, 1938 ; 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. The following information concerning midwifery and maternity work undertaken in registered nursing homes was obtained :— 1934 1935 1936 1937 Number of registered nursing homes with maternity beds 150 150 132 117 Number of beds provided lor maternity patients in such nursing homes 1,299 1,310 1,234 1,146 Number of births in such nursing homes :— Births with doctor engaged to attend 2,797 2,954 3,020 2,870 with State certified midwife (no doctor being in attendance) 899 1,174 848 446 with State certified midwife and doctor summoned in emergency by the midwife 99 98 86 124 Total 3,795 4,226 3,954 3,440 Midwifery in registered nursing homes The Maternity and Child Welfare Contributions (London) Scheme, 1937, for the five years from 1st April, 1937, to 31st March, 1942, provides for payment by the Council of grants in each of the financial years 1937-38, 1938-39, 1939-40, 1940-41, 1941-42, to 49 voluntary associations. The scheme provides for payment by the Council of grants amounting to £31,486 in the year 1937-38. Maternity and child welfare work by voluntary associations 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 time by the Council's officers. This work is performed by the medical staff engaged on work in connection with the registration of nursing homes, while it also involves the employment of a sanitary inspector, who is detailed by the chief inspector from among his staff. In the course of the year one mother and baby home was closed on account of the expiration of the lease and for financial reasons. Another home was closed but the mother and baby home service was transferred to other premises. An increase for one year only in the amount of grant to one baby home was authorised. 68 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. The following table indicates the nature of the services which are aided by the Council for the year ended 31st March, 1938 :— Table 69 Number of associations Description of service Total of beds Grant paid by the Council £ 6 Maternity hospitals or maternity wards 303 10,425 11 District midwifery and maternity nursing — 3,175 2 Infant welfare centres — 631 1 Children's wards 20 398 1 Ante-natal and post-natal clinics — 136 26 Mother and baby homes ... 418 for mothers 351 11,191 10 Babies' homes for babies 325 5,530 * 45 associations provide a single service and 4 associations provide more than one type of service. Examination of staff During the year 13,912 candidates and employees were referred to the department for medical examination or investigation by the medical staff at County Hall. These may be classified as follows (the comparable figures for the previous year being also shown):— Examinations of:— 1937 1936 Entrants 2,681 2,505 Sick staff 8,214 7,463 Casualties, illness, etc., at County Hall 538 548 Visits to staff in their homes or in hospitals 136 178 Recommendations based on investigations by telephone and correspondence 2,343 2,057 Total 13,912 12,751 Two-hundred-and-one applicants for appointment to the permanent service failed to pass the medical examination for the following reasons :— Males Females Total Defective hearing and ear disease 1 3 4 Defective vision and eye disease 8 18 26 Poor physique and deformities 7 23 30 Cardio-vascular disease 6 26 32 Varicose veins 4 8 12 Rheumatism 1 5 6 Genito-urinary disease 2 6 8 Tuberculosis and lung disease 8 37 45 Nervous disorders 4 11 15 Diseases of bones and joints 2 4 6 Miscellaneous 2 15 17 Total 45 156 201 69 As a result of the examinations of the staff, 377 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 44 45 89 Diseases ot the bones and joints 13 32 45 Disability following trauma 9 4 13 Pulmonary tuberculosis 19 15 34 Diseases of the lungs other than pulmonary tuberculosis 26 7 33 Malignant disease 5 8 13 Gastro intestinal disorder 4 3 7 Renal disease 1 2 3 Functional nervous disorder 25 30 55 Organic nervous disorder 10 3 13 Senile decay 4 2 6 Post-operative disability 4 1 5 Sight or hearing defect 6 5 11 Endocrine disorder 3 5 8 Varicose veins and ulceration 2 5 7 Rheumatism 2 15 17 Skin disease 2 2 4 Miscellaneous 2 12 14 Total 181 196 377 Under the Council's scheme for providing pensions to spouses and dependants of contributors to the superannuation and provident fund, sixteen applicants for admission to the scheme were examined during the year, and, of these, two were rejected on the ground that their expectation of life was deemed to be less than normal for their age and sex. Work done in the bacteriological laboratory at County Hall The work undertaken in the laboratory is chiefly associated with the control of infectious diseases in the Council's day and residential schools. 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 and on sundry material, e.g., sputum and urine, sent for report by the Council's examining medical officer in connection with the medical examination of employees of the Council, school children and others. The investigations carried out during the year 1937 are summarised below under the various headings :— Diphtheria investigations.—Including 155 reswabs, a total of 4,466 swab cultures (4,431 from throat and nose, 34 from ears and 1 from eyes) were examined and yielded 4,093 negative results (including 7 from persons whose direct smear preparations from the throat showed spirilla and B.fusiformis, organisms associated with Vincent's angina) and 373 (8.35 per cent.) in which bacilli morphologically resembling diphtheria were reported. Of the latter cultures 285 were submitted for animal test for virulence, 246 (86.3 per cent.) proving virulent and 39 non-virulent. Among the 4,311 primary swabs, 299 (6.9 per cent.) proved positive, including 12 positive out of 34 swabs from ears. In the single instance of culture from the eyes (of a child suffering from conjunctivitis), bacilli morphologically resembling diphtheria were isolated but proved to be non-virulent. Ringworm and favus.—Specimens of hair from 431 children were examined on account of suspected ringworm. In 114 cases fungus was identified, 90 being of the small spore and 23 of the large spore variety of ringworm and 1 of favus. 70 Skin scrapings from the wrist of an adult yielded pure culture of trichophyton of body ringworm. Sputum.—Specimens from 17 adult employees of the Council were examined for tubercle bacilli, with positive results in 5 instances. Miscellaneous.—(1) Slide preparations from the vagina or urethra of 21 persons were examined for the presence of gonococci; 3 were regarded as positive, and in 18 the gonococcus was not identified. (2) Five throat and nose swabs from 4 persons were examined for the hsemolytic streptococcus. Each of 2 examinations from one individual yielded a positive result while the other 3 proved negative. (3) Cultures from 5 children with ear discharges showed the presence of pneumococcus, streptococcus (non-hsemolytic), B. proteus and diptheroids, but no diphtheria bacilli. (4) Urine from 2 cases of renal fibrosis showed the presence of albumin, low urea content and some granular casts. (5) An instance of verminous infestation occurred in a room at the County Hall, which involved the occupants of the room. Entomological specimens from the window-sill and adjacent woodwork and a table were identified as the mite Dermanyssus gallince, a parasite commonly infesting poultry and pigeons. It transpired that pigeons had nested near the window ledges of the affected room. Examples of this form of infestation are recorded in the appendix to the annual report for 1931 of the medical officer of health, metropolitan borough of Lambeth. Milk.—Four samples from the milk supplied to two establishments were examined bacteriologically. One was reported as satisfactory and one as unsatisfactory. Water examinations.—Examinations were made of 433 samples from 32 establishments. The preparation during the year of culture media for use in the County Hall laboratory included 8,000 tubes or screw-capped bottles of Loeflier's serum and 45 litres of other media. 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 foods, air in tunnels, 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 Stuff's Act, 1926. A systematic determination is made of the amounts of sulphur in air both in London and in other 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. 71 The total number of samples examined in 1937 amounted to 23,667. The following table shows their classification :— Air (tunnel) 257 Greases 14 Air (various special examinations) 32 Gum, paste and glue 25 Asphalt 88 Ink 13 Building materials 60 Insecticides 13 Cable (tinning test) 91 Meals 107 Coal, coke and ash 127 Metals— Cement and lime 144 Solder 13 65 Chemicals 57 Various 52 Chemical apparatus 126 Milk, condensed 9 Disinfectants 14 ,, schools and institutions 179 Driers 9 „ (cream) 14 Drugs and medical stores 905 Motor spirit 54 Dust (atmospheric pollution) 21 Oils- Enamelware 171 Fuel 8 167 Fertilisers and feeding stuffs 164 Lighting 23 Moor oils and polishes 41 Lubricating 107 Foods— Painting 9 Baking and egg substitute powders 21 Miscellaneous 20 Beef extracts 80 Oilman's sundries 34 Butter 3 Paints, stains 950 Cakes, biscuits, bread 1 Petroleum (Petroleum Act, 1928 92 Cheese 4 Rainwater, etc. (atmospheric pollution) 134 Cocoa 17 Rubber 25 Flavouring essences 27 Sewage 2,020 Fish 2 Sludge 7,266 Fish, tinned 3 Soap and soap powders 57 Flour 3 Soil 16 Fruit and fruit juices 9 Sulphur determinations (air) 1,930 Jam 4 Turpentine and turpentine substitute 22 Margarine 16 Urine 2,657 Miscellaneous foodstuffs 24 Varnish 8 Mustard 9 Water, boiler 985 Sugar and syrup 7 „ chlorine tests 312 Vinegar 6 „ river 3,368 — 236 „ drinking (from wells) 206 Gas—dry cleaners 22 ,, and deposit (in leakage ) 2 Gas—flue 134 ,, various 74 Gas—from fire extinguishers 36 Waxes 4 Gas liquor 47 Miscellaneous 63 Eamination of samples In addition to the work entailed by the examination of these samples the services of the branch have been freely utilised by other departments in an advisory or consultative capacity. The time occupied in this manner has increased very much in the last few years, particularly in the year under review, and it shows that the usefulness of the science of chemistry in the various ramifications of the local government service is being increasingly appreciated. Examples of particular instances in which advice has been sought during the year 1937 are : (a) inspection of the premises and plant of a degreasing firm after a serious explosion had occurred, with a view to ascertaining the probable cause, (b) visits and advice as to the installation of a methyl chloride operated air conditioning plant at a restaurant, (c) investigations into the efficiency of the ventilation plants of certain theatres, halls and cinemas. The following table shows the results of the analyses of paints, colours and Paints stains :— Satisfactory 861 Not complying with the specification 42 Not suitable for the Council's requirements 40 Unsatisfactory 7 Observations on the effect of the London atmosphere on paint films of different composition have been made during the last four years, and information has been obtained which will prove valuable in assessing the suitability of paints submitted for use in the Council's service. 72 Oils The following table shows the classification and the results of the analyses of oils :— Satisfactory Unsatisfactory Fuel 8 0 Lighting 21 2 Lubricating 91 16* Painting 9 0 Miscellaneous 17 3 * Either unsatisfactory or not suitable for the Council's requirements. Foodstuffs During the year 236 samples of the foodstuffs supplied to the Council s various institutions and hospitals were examined and, except in a few instances where minor defects were observed, these were found to be of a satisfactory quality. School meals In connection with the provision of meals tor necessitous children, 107 samples were examined during the year. Included in this total were samples taken from 51 complete two-course meals. The standard adopted is that each meal shall contain not less than 25 grammes protein and have a heat value of not less than 750 calories. The average of the samples examined was 28.6 grammes protein and 732 calories. In cases where the requirements were not fulfilled, suggestions were made as to the steps which should have been taken to avoid the deficiencies. Milk The total number of milk samples examined during the year in the laboratory at County Hall was 179. Of this number 67 were of milk supplied to children in residential schools and educational institutions, while 112 were from supplies to general, special and mental hospitals and public assistance institutions, under contracts which require a minimum of 3.25 per cent, of fat and 8.5 per cent, of other solids, except during the months of March and April, when the fat must not be less than 3 per cent. The quality of the supplies generally has been much less satisfactory than in recent years, 33 samples being deficient in fat and one giving presumptive evidence of added water. The condition of the supplies in respect of extraneous matter was also not satisfactory, for of the samples examined, 13 (7.3 per cent.) were unsatisfactory in this respect. The arrangement made for the co-operation of the borough 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 601 samples, of which 10 were deficient in fat and 2 contained added water. In addition to the above, results have been received from borough medical officers of the bacteriological examination of 255 samples of pasteurised milk, of which 18 failed to comply with the standard laid down in the Milk (Special Designations) Order, 1936. The results of all examinations are forwarded to the chief officer of supplies for his information and he takes any action that he may consider necessary. Drugs During the year 905 samples of drugs and medical supplies were examined, and of these 70 (or 7.7 per cent.) were found to be either definitely unsatisfactory for use or below standard strength or quality. In the large majority of cases the latter description applied, and in general the deficiency was small. Satisfactory 835 Unsatisfactory or below standard— Deficient in active constituent 25 Specific impurities found 16 Dirty or badly made 13 General deficiency 15 Misdescribed 1 — 70 Total 905 The percentage of samples reported upon adversely during the previous year was 7.9, which is not very different from this year's figure. 73 Two samples supplied as mistura alba (duplex) were found to be of only half the required strength, and two samples of sennæ fructus were rejected as being of inferior size and quality. A sample of tablets alleged to be tabs, calcii acetylsalicylatis was found to consist of sodium acid phosphate. In accordance with an arrangement whereby, in any case of post-operative convulsions, a sample of the ether used is sent for examination, three samples were analysed during the year. In each case the ether was of satisfactory quality and there was no apparent reason why its use should have caused any abnormal reaction. In connection with the provisions of the Fertilisers and Feeding Stuffs Act, 1926, 164 samples have been examined during the year under the supervision of the chemist-in-chief who is the official agricultural analyst for those parts of the county which do not come within the purview of the City Corporation or Port Sanitary Authority. Fertilisers and feeding ■tuffs The results of the analyses were :— Samples of feeding stuffs Complied with guarantee 62 Deficient 15 Constituents in excess of guarantee 22 Guarantee incorrect in form or no guarantee 3 Composition not of the nature of definition stated 12 Contained deleterious substances 2 Total 116 Samples of fertilisers Complied with guarantee 17 Deficient 11 Constituents in excess of guarantee 11 Guarantee incorrect in form or no guarantee 4 Composition not of the nature of definition stated 5 Total 48 Three samples which were described as feeding oatmeal were found to contain fibre to the extent of 21 per cent, or more. Such an article should be classed as an oat offal or oat bran, and not as oatmeal. Four samples, described as feeding meat and bone meal, were found to contain less than 40 per cent, albuminoids (protein), which is the minimum figure to qualify a preparation of this nature for being sold under this designation. Two samples of meat meal contained salt largely in excess of the 4 per cent, limit imposed by the Act on commodities of this description. The application of the term " bone-meal" to samples containing large amounts of acid insoluble matter was objected to in several cases during the previous year as pointed out in the report for 1936. Similar instances have occurred during the present year, and the samples in question have been reported as not complying with the definition given. 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 206 samples have been analysed chemically, and 440 samples have been examined bacteriologically in the bacteriological laboratory at County Hall. In addition, 312 chlorine tests have been made to check the dosage being applied at those institutions at which it has been deemed advisable to chlorinate the supply. Two additional wells have been found during the year to yield water which at times was not of quite such a high standard of purity as could be desired, and chloramine treatment plants have been installed in both instances. At the end of 1937 there were in use for drinking purposes in the Council's institutions only two private wells where the water was not chlorinated. Where chlorinating plants are in use, periodical tests have, at the request of the chief engineer, been made on the premises to ensure that an adequate dose of chlorine was being applied, these tests being additional to the daily ones made as a routine by the resident engineer of the institution. In several instances a recommendation was Drinking water supply 74 made that the dosage should be increased to ensure a sufficient margin of safety. As the results of slight deteriorations found in the quality of the water drawn from service taps, the chief engineer was advised during the year that the tanks or reservoirs at eight institutions should be cleaned and chlorinated, and after this treatment the quality of the water again became of the highest class. Sewage treatment The addition of ferric chloride to the sewage has been continued with advantage. Chlorination in the sewers has been found to improve the condition of the sewage and is being continued. Three of the five activated sludge units under construction have been brought into use with satisfactory results, and it is hoped that still further improvement will ensue when the others commence work and will tend to restore the balance between oxygen absorption and re-absorption at the critical times of low flow of river water and high temperature. The dry matter in individual cargoes of sewage sludge sent to sea from the northern outfall varied from 539 per cent, to 7 88 per cent., the average being 6.91 per cent. In regard to the cargoes from the southern outfall, the variations were from 4.7 to l0.1 per cent., with an average of 7.2 per cent., which are rather higher than those of last year. Vehicular tunnels The systematic investigations, commenced in 1928, as to the condition of the air in Blackwall and Rotherhithe tunnels, were continued during 1937, 101 and 104 samples of air, respectively, from these tunnels having been examined for the carbon monoxide content and 26 from each for black suspended matter. The increase in motor traffic using the tunnels has continued at the same considerable rate at which it has been occurring since this work was started. However, on the whole the atmospheric conditions can be said to have been no worse than in the previous year. The chief engineer, at present, has in hand works which will effect a large increase in the ventilating capacity of the plant at Blackwall tunnel. Atmospheric pollution The work on atmospheric pollution, which has been carried on systematically for some years, has been continued. The methods of examination and number and location of the observation stations remained as detailed in the report for last year, and the results of much of the work have, as in the past, been communicated to the Department of Scientific and Industrial Research ot' His Majesty's Government for inclusion in its comprehensive annual report on this subject. Cod-liver oil In addition to its use in various preparations in the Council's hospitals, cod-liver oil in conjunction with malt is largely used in the form of " cod-liver oil and malt meals " for additional feeding of school children. In order that the assay of the vitamin A content (this being the most important constituent) may be made by the most accurate method, a quartz spectrograph has been added to the equipment of the laboratory during the year, and a number of samples examined by means of it. The results of all the tests have shown the supplies to be of satisfactory quality, in fact considerably above the minimum standard required by the British pharmacopoeia. Fire extinguishers At the request of the chief officer London Fire Brigade, an investigation was carried out as to the relative toxicity of the products from the use of fire extinguishers of the carbon dioxide, carbon tetrachloride, and methyl bromide types. A " standard " fire was generated in a small room by the ignition of wood wool and high tension cable. The fire was then extinguished by the use of one of the extinguishers and samples of the atmosphere in the room at different levels collected at once, and after an interval, by aspiration through glass gas tubes. The contents of the tubes were then analysed to determine the proportion of various toxic gases present, such as carbon monoxide, carbon dioxide, chlorine, bromine, hydrochloric acid, hydrobromic acid, carbonyl chloride and carbonyl bromide. Taking into consideration the results of the analyses and information gained from a research into the available scientific literature on the toxicity of these substances, it was concluded that methyl 75 bromide and carbon tetrachloride under the conditions of test can produce acid vapours of such a concentration as would be dangerous in an enclosed space unless a mask were worn. Although carbonyl chloride (phosgene) and carbonyl bromide were not found in appreciable quantity, the possibility of their formation under special circumstances must be borne in mind. In order to extinguish a fire with carbon dioxide it appears that a concentration of this gas is required which must be regarded as a possible danger in a confined space unless a mask is worn : the time required to extinguish a fire by this means is also longer than when using methyl bromide. The final opinion expressed was that there is no more risk involved in the use of methyl bromide and carbon tetrachloride extinguishers than when carbon dioxide alone is used. In each case it would be necessary to use a mask if the fire were in a confined space. During the year, 92 samples, taken under the Petroleum (Consolidated) Act, 1928, and London County Council (General Powers) Act, 1912, were examined. Of these, 22 samples were petroleum spirit as defined by the Act; 49 samples contained petroleum spirit and came under the provisions of the Act; and 21 samples were not, or did not contain, petroleum. Petroleum Act A sample of a white cotton material was submitted which showed irregularly distributed thin patches and holes. An examination of the article showed that although the material was quite strong generally, the fibres were badly damaged in places, and there was evidence that borates had been used in the process of washing. It seemed probable that a washing powder containing sodium perborate had been used in a manner resulting in an uneven distribution in the washing machines. Recent work has shown that unless these bleaching materials are used under proper conditions, serious damage to fabrics is likely to be caused. Laundry work Much discussion has taken place in professional circles, and many papers have been published on the question of the effect of sulphates in water or subsoil, on Port land-cement concrete. The matter has been investigated during the year, and work is still being continued in connection with one of the Council's housing estates where the clay has been found to contain a small amount of sulphuric anhydride present as soluble sulphates, and also appreciable quantities of pyritic matter and selenite which may cause damage to Portland-cement concrete especially in the presence of water. A sample of water from this site was found to contain soluble sulphate considerably in excess of that found in normal surface water. Concrete In accordance with an order of the Entertainments Committee, arrangements were made for the examination of the atmosphere in several places of public entertainment, and a report was submitted thereon from the hygienic point of view. The conclusion was that the average "cinema" without mechanical aids to reasonable ventilation, was not well ventilated, and that "theatres" without mechanical yentilation, were definitely unsatisfactory from this point of view. One particular hall, in which alterations to the ventilating system were subsequently made, was re-examined later in the year. Considerable improvement was evident and the atmospheric conditions were then described as satisfactory. i Places of entertainment : ventilation In addition to the applied research which has been necessary to elucidate many of the problems submitted by other departments during the year, it has been found possible to carry out several pieces of what may be termed "pure" research work. These have been found necessary in connection with the critical examinations of 'analytical processes available for the testing of products used by the Council, and include the determination of small quantities of strychnine in the presence of caffeine, the colorimetric determination of morphine, and the determination of the best method for estimating cod-liver oil in preparations of this substance. By the aid of the quartz spectrograph mentioned above, an investigation has been begun as to the possible loss in course of manufacture or storage of the vitamin A content of cod-liver oil in extract of malt and oil. Research 76 Table 70 County of London—Statistics of the administrative work carried out by the Metropolitan Borough Councils during the year 1937 Sanitary authority Cowsheds Slaughterhouses Offensive trades Smoke nuisances Common lodging houses Cleansing of persons and rooms Water supply Milkshops ice cream premises Restaurants am 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 Persons Rooms or premises Tenement houses extra supply No. on register No. of inspections No. on register No. of inspections No. of places No. of inspections Adults Children After infectious diseases For vermin City of London — — — — — — 462 — 21 — 1 3 123 1,031 32 31 81 127 57 64 1,029 571 Battersea — — 1 99 3 8 173 9 12 4 2 44 389 4,256 1,696 544 25 120 522 231 330 130 343 Bermondsey — — — — 14 373 69 2 6 2 3 45 131 3,214 751 1,091 25 260 674 148 379 131 117 Bethnal Green 7 60 2 16 9 275 29 1 29 — 4 34 348 50 165 1,650 — 367 807 179 331 97 399 Camberwell 1 7 2 76 9 29 81 4 22 — 1 60 103 5,579 1,951 1,320 18 562 1,158 406 681 202 582 Chelsea — 1 7 — — 6 3 — 2 12 27 515 280 369 1 75 170 44 50 65 70 Deptford — — 2 233 7 10 12 — — — 5 49 81 2,580 595 159 — 226 328 149 171 45 390 Finsbury — — 1 110 3 605 179 5 20 3 2 112 35 5 937 309 155 171 632 135 222 341 26 Fulham — — — — — — 37 1 5 — 1 4 39 5 830 385 — 106 485 232 94 122 110 Greenwich — — 3 304 1 9 45 3 16 — 1 3 5 1,745 562 220 24 194 350 143 209 98 417 Hackney 2 65 8 563 10 40 1298 29 50 11 2 26 619 3,751 1,774 832 10 125 1,184 340 495 211 198 Hammersmith — — 3 80 — — 59 7 4 — 1 13 292 2,935 727 62 30 178 800 169 246 195 497 Hampstead — — — — 20 5 8 — — — 78 605 1,429 75 11 107 143 111 44 110 42 Holborn — — 1 3 — — 215 I 9 3 16 102 — 434 140 — 159 336 70 74 521 1,072 Islington — — 8 305 12 135 - 69 22 33 2 17 425 55 6,237 2,173 173 289 240 878 480 701 544 889 Kensington — — 1 22 — 19 8 — 3 146 304 4,983 1,451 1,178 86 137 462 300 372 183 594 Lambeth — — 3 112 3 51 81 43 43 — 3 175 318 — 1,873 1,858 19 504 1,131 407 1,222 227 460 Lewisham 1 4 5 335 — — 248 18 29 1 — — — 1,222 1,246 130 27 131 176 364 402 123 254 Paddington — — 1 322 — — 14 2 g 1 3 124 95 14 121 156 139 588 198 316 163 460 Poplar l 19 7 32 4 83 38 4 19 1 4 132 150 4,120 1,543 1,883 18 85 355 212 267 1,098 1,691 St. Marylebone — — 1 12 1 14 186 4 27 — 2 34 — — 537 278 21 182 250 105 125 386 442 St. Puncras — — 3 144 2 75 262 5 6 2 1 6 2,197 5,923 989 212 68 426 1,246 341 557 306 1,078 Shoreditch 1 11 — — 1 7 58 6 4 — 4 29 44 13 834 155 123 288 729 185 287 231 417 Southwark — — 4 229 3 10 221 1 14 — 13 149 2,203 5,547 809 955 30 394 1,540 222 310 342 386 Stepney 17 128 — — 51 338 438 66 72 1 16 258 165 — 1,147 1,040 17 617 1,273 366 563 385 567 Stoke Newington — — 3 7 — 17 3 3 — — — — 2,540 321 95 13 101 283 83 85 33 107 Wandsworth 1 6 5 1184 2 6 209 24 30 2 — — 317 57 2,076 200 4 199 510 683 915 533 638 Westminster — — — — — — 522 24 36 2 5 166 411 645 613 120 3 229 439 132 181 1,447 1,601 Woolwich 5 46 4 16 2 5 18 — 10 1 9 65 26 2,707 1,042 1,377 — 71 310 247 250 172 041 Note.—In the columns above a dash signifies a nil return. Seamen's lodging houses, 15—Bermondsey, 3 (8 inspections) ; Poplar, 2 (79 inspections); Stepney, 10 (108 inspections). Prosecutions.— Ice cream—Stepney, 2. Milkshops—Bethnal Green, 1 ; Hackney, 2; Islington, 3; Stepney, 14. Smoke nuisances—Islington, 1. Restaurants—Westminster, 1. Water supply—Paddington, 2; Poplar, 1; St. Pancras, 1. 77 Table 71 Borough No. of houses in borough Public Health Act No. of houses inspected Section 25 Sections 9 & 10 Housing Acts, 1936 No. of houses inspectedon account of complaints or illness No. of statutory notices served No. of houses repaired Number of houses demolished Closing Orders Overcrowding No. of houses for working classes erected during the year Underground rooms Houses let in lodgings No. of houses represented No. of houses demolished No. of houses repaired No. of families overcrowded No. of families alternative accom. obtained No. occupied but unfit No. closed or modified occupation approved No. in borough No. of inspections No. of prosecutions No. of complaints remedied By owners By L.A. Section 11 Voluntarily No. made No. deter j mined City of London 2,196 35 3 28 54 — — — — — — 11 2 20 — 36 91 — 6 Battersea 28,440 4,872 1,537 2,593 1,128 35 12 455 — 2 3 3 — 432 940 18 2,545 2 65 331 — — Bermondsey 19,606 3,890 1,811 4,305 3,354 296 302 1,152 — 9 5 — — 3,022 449 448 2,249 41 1,102 3,256 14 Bethnal Green 18,156 1,732 2,429 5,900 576 13 31 — — 1 1 — — 179 784 35 * 1 270 1,473 — — Camberwell 41,179 6,342 2,146 4,508 1,123 47 155 247 5 5 . 1 - — 38 232 — 520 7 245 112 — — Chelsea 13,016 547 23 276 170 108 47 — — — 87 — — 10 70 38 — — 605 32 — — Deptford 18,250 2,146 805 2,997 1,646 8 13 1 359 155 — — 65 695 — — — Finsbury ‡10,500 1,620 768 1,926 748 — — — — — — — 2,442 46 — ‡1,500 7 758 1,792 — — Fulham 26,964 4,763 564 2,817 273 — 44 150 3 2 — 4 — 413 873 70 16 67 746 — — — Greenwich 21,630 2,512 187 1,858 191 165 95 23 — 6 1 21 — 751 340 76 29 21 97 96 — — Hackney 37,859 6,136 1,119 4,852 834 93 46 46 — — 351 — — 504 793 91 69 16 475 558 3 91 Hammersmith 23,959 6,738 1,429 2,660 18 10 34 — — — — — — 1,687 267 — * 27 1,773 — — — Hampstead 16,997 1,236 873 1,176 40 — 4 — — — — — — 16 25 — 620 57 1,564 588 — 258 Holborn 6,462 224 46 191 135 — — — — 5 — 9 1 384 276 — 669 77 394 871 — 183 Islington ‡46,296 6,159 583 5,215 1,489 14 122 95 — 9 130 19 — 6,652 193 159 * 260 983 6,009 3 491 Kensington 29,653 2,608 168 1,254 857 16 37 136 11 — 4 1 — 2,034 450 — 38 378 3,161 2,815 1 539 Lambeth 48,873 10,490 326 4,364 19 — 3 56 1 2 — 7 14 3,162 881 — — 141 — — — — Lcwisham ‡60,000 2,605 248 1,170 384 88 60 — — — — — — 112 434 — 33 17 63 278 — — Paddington 21,592 2,295 698 2,037 — — 4 226 — — — 73 2 76 83 8 * 178 2,031 8,025 14 5,885 Poplar 23,977 5,478 1,657 4,081 — 10 13 — — 38 12 — — 190 338 36 64 55 347 2176 6 83 St. Marylebone 19,974 2,610 37 1,273 600 — — — — 2 2 8 7 1,619 550 — 658 132 852 6,164 — 7 St Pancras 25,670 4,567 1,239 2,592 724 47 41 208 — — — 1 — 275 121 53 * 141 4,985 1,040 4 323 Shoreditch 13,859 12,606 874 4,474 568 — 43 57 — 3 140 — — 279 269 — 221 106 378 208 — — Southwark 29,166 1,706 1,245 2,697 1,965 104 85 132 2 — 16 7 4 2,769 1,424 50 3,471 76 See footnote Stepney 37,206 4,002 2,896 10,483 595 68 — — — 3 — — 1 6,738 639 354 5,949 185 3,356 1,838 7 85 Stoke Newington 8,813 729 63 636 179 _ 9 11 — — 2 1 — 410 164 96 7 100 43 — — Wandsworth 80,163 7,593 1,462 4,449 2,034 198 98 — — 4 182 8 — 1,346 454 126 17 74 340 479 — 5 WestminsterCity of 22,536 1,887 31 820 2,449 64 15 — — 2 17 251 82 98 403 74 2,241 269 3,350 4,841 — 94 Woolwich 37,232 4,603 358 1,583 47 188 128 1 — 5 257 2 — 390 184 266 4 4 * 231 — — * Information not available. ‡ Estimated. The question of "houses let in lodgings " in the case of Southwark is the subject of a special report by the borough medical officer to his Council, which will be included in his annual report. 78 Table 72—Sanitauy Inspectors, 1937 Sanitary authority tion (Census) 1931 Male Female Health visitors Whole time Part time Whole time Part time Whole time Part time City of London 10,999 24 1 2 Batteraea 159,552 11 — — 2* 12 2* Bermondsey 111,542 14 — — — 13 — Bethnal Green 108,194 11 — — — 13 — Camberwell 251,294 16 — 1 — 12 3 Chelsea 59,031 4 — — 1* — 1* Deptford 106,891 8 — — — 8 1 Finsbury g9.888 8 — 1 — 7 — Fulham 150,928 15 — 1 — 12 — Greenwich 100,924 8 — 1 — 7 — Hackney 215,333 23 — — — 18 — Hammersmith 135,523 9 2 1 — 7 — Hampstead 88,947 8 — — 1 4 1 Holborn 38,860 4 — — 1 2 1 Islington 321,795 24 — 2 — 8 — Kensington 180,677 15 — 9 — 5 — Lambeth 296,147 16 — 2 — 4 — Lewisham 219,953 12 — 1 — 16 — Paddington 144,923 18 — 2 — 13 — Poplar 155 089 16 — 1 — 13 — St. Marylebone 97,627 10 — 1 1 6 4 St. Pancras 198,133 15 — 1 — 14 3 Shoreditch 97,042 12 — 1 — 10 4 Southwark 171,695 18 — 1 — 14 — Stepney 225,238 22 — 1 — 10 — Stoke Newington 51,208 4 — — — 4 — Wandsworth 353,110 18 — — — 16 — Westminster, City of 129,579 17 — 1 — 9 — Woolwich 146,881 13 — 1 2* 10 2* Total, County of London 4,397,003 393 2 30 8 269 22 * Act both as sanitary inspectors and health visitors. 79 INDEX Subject Page Abortion 18 Anthrax 10 Atmospheric pollution 74 Bacteriological laboratory 69 Births 6, 64 Blind Persons Act 59 Cancer 20 Cerebro-spinal fever 11 Chemical branch 70 Cod-liver oil, Testing of 74 Concrete, Effect of water on 75 Cowsheds 35 Deaths 7 Diarrhoea 14 Diphtheria 14 Drugs, Testing of 72 Dysentery 11 Encephalitis lethargica 11 Enteric fevers 19 Fertilisers and feeding stuffs 73 Fire extinguishers 74 Food poisoning 12 Foodstuffs, Sampling of 72 Housing 31 Housing Acts (statistics) 77 Infant mortality 7 Infectious diseases 10 Influenza 20 Laundry work materials 75 Marriages 6 Maternal mortality 15,66 Maternity and child welfare 67 Measles 12 Medical examination of staff 68 Mental deficiency 58 Subject Page Midwives Acts 59 Milk examination 33, 70 Milk sampling 72 National Health Campaign 31 Nursing homes 66 Oils, Sampling of 72 Ophthalmia neonatorum 65 Overcrowding 32 Paints, Sampling of 71 Petroleum Act 75 Polioencephalitis 11 Poliomyelitis 11 Population 5 Puerperal fever 15, 65 Puerperal pyrexia 15,65 Research work 75 Rheumatic fever 20 Sanitary officers 78 Scarlet fever 13 School meals, Sampling of 72 Sewage treatment 74 Smallpox 11 Street accidents 7 Tuberculosis (care committee work) 57 Tuberculosis (contact scheme) 56 Tuberculosis (notifications) 20 Tuberculosis (residential treatment) 40 Tuberculosis (dispensary service) 52 Underground rooms 33 Vehicular tunnels 74 Venereal diseases 35 Ventilation of places of entertainment 75 Vital statistics 5 Water examination 70, 73 Whooping-cough 13 PUBLICATIONS OF THE LONDON COUNTY COUNCIL The undermentioned publications, issued by the Council, may be. purchased through any bookseller, or from the Council's Agents, P. S. KING & SON, LIMITED, 14, GREAT SMITH STREET, WESTMINSTER, S.W.I, from whom a complete list of the Publications of the Council may be obtained post free. Annual Report of the Council for 1930:— Vol. I (Part I).—Powers and duties— Flections — Finance — Rating and Taxation—Public Protection—Traffic— Public Amenities—Domestic and Miscellaneous Services. Is. 6d. (Ready shortly). Vol. I (Parts II and III).—Public Assistance. 1s. No. 3306. Vol. II—Public Health, General matters as to public health, Main Drainage and Housing. Is. No. 3374. Vol. Ill (Part I).—Public Health, Report of County Medical Officer of Health. Is. No. 3292. Vol. Ill (Part II).—Public Health, Report of School Medical Officer. Is. 6d. No. 3125. Vol. IV (Part I).—General and Special Hospitals. 2s. 6d. No. 3308. Vol. IV (Part II).—Hospital Finance. Is. No. 3311. Vol. IV (Part III).—Medical Supplement, 5s. No. 3320. Vol. V —Education. Is. No. 3347. Vol. VI.—Mental Health Services. Is.No. 3309. 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(3) CONTENTS page Introduction 5 Staff 6 School buildings and equipment 6 Medical inspection 8 The nutritional state of London school children 18 Following-up 27 Medical and dental treatment 29 Co-operation of voluntary bodies 37 Stammering children 38 Rheumatism scheme 38 Personal hygiene scheme 42 Chronic invalidity 44 Infectious diseases in schools 45 Open-air education 52 Convalescence 55 School journeys 55 Physical education 56 Provision of meals 57 Defective children 60 Stamford House remand home 65 Child guidance 72 Nursery schools and nursery classes 75 Medical inspection and treatment—Day continuation schools, evening institutes and junior instruction centres 79 Medical inspection at secondary and trade schools 80 Sight-saving classes in central and secondary schools 82 Residential schools and children's homes 82 Hospital schools 83 Special inquiries and reports 84 Wage-earning employment of school children 84 Examination of candidates for the education service and scholars 86 Statistical Tables.— I. Medical inspections 87 II. Defects 88 III. Exceptional children 89 IV. Treatment of minor ailments 90 V. Medical inspection—Number of children examined 91 VI. Medical treatment—Number of cases treated 92 VII. Medical inspection of students in higher education institutions 92 Index 93 / (5) London County Council ANNUAL REPORT OF THE COUNCIL, 1937 VOL. Ill (Part II) REPORT OF THE SCHOOL MEDICAL OFFICER FOR THE YEAR 1937. By Sir Frederick Menzies, K.B.E., M.D., LL.D., F.R.C.P., F.R.S.E., K.H.P., County Medical Officer of Health and School Medical Officer. Introduction Since 1902, when the school medical service in London began its work under the leadership of Dr. James Kerr, great strides have been made in improving the health and physical condition of the children. The death-rate of children of school age has been much more than halved, diseases rife in the schools before its establishment have completely disappeared. Among these may be mentioned favus, a particularly repulsive scalp disease, for which in the early days of the service it was necessary to establish a special school in east London; chlorosis, the green sickness, from which many older girls suffered; and severe forms of ophthalmia, such as trachoma. The aim of the service is preventive, only a small proportion of its time and energy is devoted to the provision of crutches for "lame ducks"; its main business is the prevention of lameness. Blindness and deafness among children have greatly diminished, as has also crippling from tuberculosis ; and in every way the condition of the school children is better, healthier and happier. Great efforts are still necessary, particularly in regard to dental work; more than one-third of the parents remain apathetic to the need of care and attention to their children's teeth. The provision of better premises for medical and dental treatment is being pushed forward with energy, and reference may be made to two replacement centres opened during the year, which are models of construction and equipment. These are the Marylebone health centre, No. 2, provided by the Marylebone Borough Council and in which the "Lissonia" school treatment centre is now housed, and the Hoxton treatment centre in Sarah-street, Shoreditch, built by the Council itself but rented to a local centre committee. A great deal of the success obtained by the service has been due to the children's care organisation, with its voluntary workers numbering over 5,000 members, and to the generous support of the teaching staff. Among the many extensions and improvements in the service recently made to which reference is made in the pages of this report, are:— (i) Close attention to the nutritional state of the children, the introduction of continuous height and weight charts for all, and the establishment of " nutrition centres " where special research is carried out and where parents are instructed in dietetic methods. (ii) The extension of annual dental inspection in the schools to all children, and improvement generally of the dental services, including the development of an " orthodontic " service for the regulation of badly placed teeth and ill-shaped jaws. (iii) The large extension of audiometric testing, whereby loss of hearing is rapidly detected at its earliest appearance, and the introduction of special methods of treatment to restore hearing or to arrest the progress of the condition. (iv) The treatment of squint in young children by methods of re-education. (v) The establishment of nursery schools and nursery classes for the care of children under five years of age. 6 Staff The administrative work of the public health department in connection with the school medical service falls mainly within the general public health division, which is directed by a principal medical officer (Dr. W. A. Daley), though matters in regard to infectious disease in school are dealt with by the principal medical officer of the special hospitals division (Dr. J. A. H. Brincker), who has the assistance of a principal assistant medical officer for these duties. The work is organised in two main sections. One of these, 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, each under a divisional medical officer, viz.: north-west, north, north-east, south-east and south-west. The remaining staff in this branch of the school medical work includes one principal assistant medical officer for aural work; 9 part-time assistant aurists; one part-time principal assistant medical officer; one divisional medical officer for ophthalmic work, nursery schools, etc.; *21 whole-time assistant medical officers; 5 assistant medical officers giving six sessions a week; 56 assistant medical officers giving three sessions a week ; additional temporary medical assistance for 120 sessions a week ; 9 medical officers (part-time) at open-air schools ; and 77 part-time inspecting dental surgeons. There are 251 part-time doctors, surgeons and anaesthetists, and 112 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, each individual appointment being subject to the approval of the Council, with the exception that at Lissonia treatment centre, established in the Marylebone Health Centre, No. 2, and the South Hammersmith centre, which were opened during the year, the medical and dental staff is now appointed directly by the Council. 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, together with a principal assistant medical officer, the medical examination of the Council's staff. In this section for school purposes are included the services (part-time) of the Council's consulting orthopaedic surgeon; a part-time ophthalmologist; two divisional medical officers, and a part-time medico-psychologist at the Council's remand home. The duties of consulting surgeon for aural disease in this section are performed by a principal assistant medical officer attached to Dr. Thomas' section, while a divisional medical officer in the same section carries out the medical supervision of schools for the partially sighted. The oversight of the school dental service is performed by the whole-time consulting dental surgeon to the Council. His duties are concerned with the development of dental services in all the Council's institutions and hospitals, and are thus not confined to the school medical service. The duties of the matron-in-chief in the public health department, include the superintendence of the school nursing staff. A principal matron supervises the school nursing service, which comprises at present, 5 assistant superintendents, 57 nursing sisters and 365 nurses. School buildings and equipment The three years' programme of development adopted for the years 1935-38, included 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 * Not including two officers temporarily seconded for work under the Housing Acts (equivalent substitutes authorised). 7 feature of the programme was 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. At the end of the year 1937, the following progress has been made. Ten new schools or enlargements have been completed, and the schools opened. Preliminary plans in 5 more cases are in preparation, in 4 are awaiting the approval of the Board of Education, and in 2 others have been approved and working drawings are being prepared ; while in a further 9 cases, the accommodation and organisation are under consideration. Of the 40 rebuilding or modernising cases, in 8 the work has been completed ; it is in progress in 6; working drawings have been approved by the Board of Education in 2; preliminary plans have been approved by the Board of Education and working drawings are in preparation in 14; preliminary plans are awaiting the Board's approval in 3, and are in preparation in 6 more. In the remaining case, the accommodation and organisation are under consideration. The three years' programme provided for a number of schools to be reconditioned in 1936-37. In 43 of these, building work has been completed and has been nearly completed in one more. Heating work has been completed in 39, and minor alterations remain to be completed in 6 further cases. Electric lighting installations have been completed in 9 schools, and are practically completed in one more. The programme provided for about 50 schools to be reconditioned in 1937-38. In 46 of these work has been commenced, and, indeed, in 31 has already been completed. A sum of £40,000 is provided in each of the three years of the programme for the acquisition of playing fields, and there are further sums for the adaptation and laying-out of the grounds required. Playing fields An area at Friern Barnet has been acquired. Classrooms, etc., have been erected thereon, and a scheme involving daily visits to the ground of 160 children from schools in north London has been in operation since May. Kidbrooke playing-field is in full use. The acquisition of a playing-field at Becontree has been approved and detailed plans of a classroom scheme on the site have been approved by the Board of Education. Schemes for the acquisition of a large playing-field in south London, and two large playing-fields in east London have also received the approval of the Council. Further large areas are under consideration. In response to a request from the education officer as to the colour of school furniture, in relation to school hygiene, the following advice was given:— There are practically no schoolrooms in which the optimum amount of light is always available, and there are many in which it is never obtained. It is therefore desirable that the objects inside a classroom should be light in colour in order to minimise the amount of light lost by absorntion. Surface and colour of school furniture Owing to the loss of light through absorption by blackboards, it was at one time suggested that all blackboards should be green, and such " greenboards " were in fact experimentally tried in London. It was found, however, that the contrast between the chalk and the green background was insufficient and greater eyestrain resulted. It was therefore reluctantly concluded that the boards must be black. It has recently, however, been suggested that blue and yellow gives even better contrast than black and white. With regard to other articles of furniture, it is desirable that they should be as little absorptive of light as possible. Cream-coloured furniture is apt to get dingy in a short time, and contact with children's footwear produces unsightly marks on legs and pedestals. In some open-air classrooms furniture of a light green colour gives a harmonious and restful effect. In no classroom conditions is it at all likely that the light will need to be toned down by the introduction of dark objects, as even in " suntrap " schools the number of dull days and the failing afternoon light, especially through the long English winter, make it desirable that they should be kept as light as possible. As a rule, desks and furniture should therefore have light natural staining with a dull surface to eliminate glare. Woodwork above the level of 3 ft. should tone with the rest of the wall decorations and should have a reflection value of about 60 per cent. It also should have a dull finish. Furniture should be of an unobtrusive though light colour with reflection value of 50 per cent, or more. Furniture with painted surfaces soon becomes shabby and staining is therefore advised. 8 Washing facilities Among the amenities which are being introduced under the new standard planning in schools for older children are gymnasia completely equipped and provided with changing rooms supplied with shower baths. This provision brings in train a greater amount of ablution. It necessarily follows that additional provision of towels is required. In the course of a survey reported in the Annual Report for 1936 (Vol. III, Part II, p. 8), I referred to the experimental use in course of trial of paper towelling in schools. Thirty-two head teachers have made this experiment and their opinion of the suitability of paper towelling for general use in school is practically evenly divided for and against. Paper towels are far more hygienic than are the roller towels hitherto in general use. There are, however, disadvantages in their use: (i) high cost, in spite of saving on laundry expenses; (ii) difficulty of storage; (iii) difficulty of disposal of used towels ; (iv) interference with drainage of basics by accumulation of wet pulp; and (v) especially in cold weather, the difficulty of drying the skin thoroughly. Although paper towels are not very suitable on the above grounds for universal use, it should be possible for them to be requisitioned for occasional purposes such as use by the visiting staff of the school medical service. Another experiment is being made at some schools with small linen towels prepared for the use of individual children. The towelling, 18 inches wide, is supplied in long lengths, and the head teachers obtain the co-operation of the children's mothers in making the towels, and in having each towel washed weekly. At one school where this is being done, the school doctor reports:— The scheme for supplying each child with an individual towel is working well. The parents readily co-operate in washing the towels, and the majority are presented cleanly washed every Monday morning, apart from a few stragglers who bring their towels on Tuesday. The children are very enthusiastic and the general standard of hand cleanliness has been raised considerably. It is considered that the provision of individual towels, with the co-operation of parents in making and washing them, gives the best promise of a solution of the towel difficulty. It has been decided that paper towels for occasional use, such as by school doctors, dentists and nurses, should be added to the school requisition list, and that as an experiment for one year towelling for individual towels, soap, and hooks for hanging individual towels should be supplied to the public elementary schools. Paper handkerchiefs An experimental issue of paper handkerchiefs was made to six infants' schools. The head teachers reported that the result was successful. The school doctors also carefully watched the experiment and their reports were uniformly favourable. The disposal of used handkerchiefs, which threatened to be difficult, was solved by the issue of large paper bags in which the soiled handkerchiefs were placed, container and contents being burned by the schoolkeeper at the end of each session or day. A fear that the issue of paper handkerchiefs would deter pupils from bringing their own proved to be unfounded; one head teacher reported that it proved an incentive rather than a deterrent. The Education Committee has, as a result of this experience, approved in principle the inclusion of paper handkerchiefs and container bags in the requisition list. Medical inspection The foundation of the medical work in the schools continues to be the periodical examination of the children in certain age groups prescribed by the Board of Education. By agreement with the Board, so far as London is concerned, the age groups selected are four. These are (1) all children on first entrance to school, (2) all children in their eighth year, (3) all children in their twelfth year, and (4) all children in the term before that in which they normally leave school. Elsewhere in the country generally the age groups, as prescribed by the Board, are three, viz., entrants, children aged 8 and children aged 12. 9 The additional age group in London is that of the leavers. Great importance is attached to the examination of this group. It not only affords an opportunity for a final survey of the results of the child-care activities in school, but gives a last opportunity for pressing attention to defects which have been ignored or have developed late, and, perhaps most important of all, provides for advice upon the choice of occupation in relation to physical condition and needs. The arrangement whereby the two intermediate medical surveys are made at ages 7 and 11 brings the system of medical inspection into close relation with the modern educational ladder and provides for examination at the most important moments of school life—the promotion of children from infant to junior school at age 7, and from junior to senior school at age 11. The examination at age 7 provides an earlier examination of the vision of the school children at the best possible moment, since such examination is not possible in the case of entrants to school. The change in London from the usual age groups to those specified above, took place in 1933. During that and the following two years, there was a departure from normal procedure in carrying out the routine examinations necessitated by the gradual change over from eight to seven years in the intermediate group. This was completed by the end of 1936, and in 1937 normal conditions were re-established. The routine inspection of the children is one of the foundations upon which is built a complete system of care in which reference of children is made for special modifications of education, for convalescence, to supervisory centres for rheumatism, or for nutritional observation, or to treatment centres or hospitals for defects of all kinds. Many children detected at primary examinations to have defects are kept under continuous observation by systematic re-inspection until the school doctor is satisfied with their condition, and, apart from routine inspections, increasing numbers of children not falling within the age groups are examined by the school doctors as special cases at the instance of teacher, care worker, parent, or attendance officer. The average roll of children in London elementary schools for the year 1936-37 was 479,974, and the average attendance 417,028. The number of elementary school children examined in the three statutory age groups (entrants, children aged 7 and children aged 11) during the year 1937, was 131,841. These were made up of 48,689 entrants, 40,017 children aged 7, and 43,135 children aged 11. In addition 48,224 children were examined in detail in the term prior to that in which they were due to leave school, and 1,044 children in special schools were examined on reaching their respective age groups. Apart from the routine groups, children referred by nurses, school teachers, care committee workers, divisional officers, etc., for examination for special reasons numbered 133,850, and 24,027 were examined in connection with outbreaks of infectious disease. The total inspections amounted to 338,986. To these must be added the children, 114,015 in number, who were re-inspected because of some previously noted defect. As inspections of all kinds and re-inspections totalled no less than 453,001, 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. Parents are invited to be present at all routine inspections, and attended in 77.3 per cent. of the examinations in the three prescribed age groups, compared with 76.9 per cent. in 1936 and 78.5 per cent in 1935. At the inspection of entrants, the proportion was 90.8 per cent., and in the "leaver" group 39.7 per cent. 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. Co-operation of parents 10 Particularly important is the presence of the parent at the entrant examination, and that this is recognised by the parents themselves is shown by the fact that no less than 90. 8 per cent. of parents attended at this time. Least satisfactory attendances by parents are at the leaving examinations of boys, when only 31.5 per cent. were present, although 47.9 per cent, attended in the case of girls. The hatred of boys of this age of being thought to be still attached to their mothers' apron-strings is well known, and the mothers are, no doubt, sternly warned off by their adolescent male offspring. Refusals of parents to submit children for medical inspection are so few in number as to be almost negligible. During the year 1937, the parents of 41 children (18 boys, 23 girls), being 17 less than in 1936, refused to allow them to be examined by one of the Council's assistant medical officers. Six objections were subsequently withdrawn, and in 9 instances medical record cards were completed by a private medical practitioner. Children referred for treatment The number of children in the three prescribed age groups who were referred for treatment for defects other than malnutrition, uncleanliness and dental disease was 20,119, or 15.3 per cent. This number does not include those who were at the time of inspection undergoing treatment. For the convenience of workers engaged in following-up the children found defective, an easily recognisable sign was originally used to indicate those who were in need of treatment and were not getting it. It was a signal for action. When the Board of Education asked that children suffering from defects requiring treatment should be separately stated, the fact that all records of children referred for treatment were already so marked seemed to give a ready means of complying with the Board's desire. The Board has, however, now intimated that they desired that all children under treatment should be included with those referred for treatment, since that is the practice of other authorities, and this will in future be done. Consequently, the percentage of 15.3 which has been almost a constant for some years, may be exceeded in future returns. The analysis immediately following in accordance with the practice of preceding years is confined to the three "statutory" age groups, viz.: entrants, intermediates (age 7), and children aged 11. The health of the leaving children will be separately considered afterwards. The state of nutrition of the children The nutritional state of the children has been well maintained. The returns made from reports of school medical inspections show no significant alteration from those of the previous year. In view of the importance now attached to nutritional surveys, the figures will be set out and discussed in a later section of this report devoted wholly to a consideration of this and cognate conditions (p. 18). Cleanliness Personal hygiene is the second of three great indices—nutrition, cleanliness, clothing—by which social conditions and their improvement can be assessed. In 1937 the percentage of children in the three prescribed age groups found free from traces of nits or pediculi in the hair at routine medical inspection was 97.4, being identical with that in the previous-year, and compared with 97.0 in 1935. 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. 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. This percentage was raised to 95.1 in 1935, 95.7 in 1936; and 96.1 in 1937, thus establishing a new high record. 11 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 have responded so well 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 72 children were found in the statutory age groups to be affected by body vermin in 1937, out of 131,841 examined. 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 1936 and 1937 are given below. Clothing and footwear Table 1.—Clothing and footgear—Percentages Age group 1936 1937 Good Fair Bad Good Fair Bad Entrant boys 57.0 42-6 0-4 57.4 42.2 0.4 Entrant girls 58.6 41.0 0.4 58.9 40.8 0.3 Seven-year.old boys 55.1 44.5 0.4 55.4 44.2 0.4 Seven-year.old girls 56.8 42.9 0.3 56.6 43.2 0.2 Eleven-year.old boys 55.2 44.3 0.5 52.8 46.8 0.4 Eleven-year.old girls 57.5 42.2 0.3 55.7 44.0 0.3 Leaver boys 53.0 46.5 0.5 51.3 48.2 0.5 Leaver girls 57.9 42.0 0.1 56.4 43.4 0.2 In earlier years the percentages of children with insufficient clothing and inadequate footgear were much higher. In 1937, the percentage of children found by the school doctors in the statutory age groups with sound teeth was 68.3 compared with 68.5 in 1936, and 66.6 in 1935. A comparison with former years is shown in the following table:— Dental decay Table 2 Age group 1924 1927 1935 1936 1937 Sound Serious decay' Sound Serious decay Sound Serious decay Sound Serious decay Sound Serious decay Entrant boys 59.0 12.5 51.7 15.3 56.8 9.7 58.1 8.2 58.7 8.2 Entranc girls 58.4 12.4 50.7 15.2 54.8 10.0 56.6 8.1 57.1 8.4 7 or 8-year-old boys 58.5 100 61 .1 81 70.1 3.6 72.1 3.2 71.1 3.5 7 or 8-year-old girls 58.0 10.2 60.9 8.3 69.4 3.7 71.0 3.4 69.7 3.7 11 or 12-year-old boys 68.0 3.4 70.6 2.7 76.1 1.4 77.1 1.0 77.7 1.0 11 or 12.year.old girls 70.5 2.6 72.3 2.3 77.3 1.0 78.7 0.8 78.7 0.9 All above age groups 62.1 8.5 60.3 9.3 66.6 5.3 68.5 4.3 68.3 4.5 N.B.—Serious decay means four or more carious teeth requiring treatment. It must be remembered that these figures represent only the impressions recorded by the school doctors, and do not correspond with the findings of the school dentists making special inspections with mirror and probe. Nevertheless, the improvement over former years, especially as regards the diminution of oral sepsis, is noteworthy, although it is not possible to record any improvement in dental conditions in 1937 compared with 1936. 12 The subjoined table gives figures for the past eleven years for entrants:— Table 3 Boys Girls Year Number inspected Percentage with sound teeth Percentage with serious decay Number inspected Percentage with sound teeth Percentage with serious decay 1927 39,199 51.7 15.3 38,790 50.7 15.2 1928 37,222 53.0 15.2 37,105 52 0 15.3 1929 38,347 53.3 15.9 37,677 52.3 15.6 1930 32,455 53.0 14.7 32,177 52.2 14.9 1931 34,250 54.2 13.2 34,033 53.6 13.5 1932 29,183 55.6 12.2 29,162 54.7 12.1 1933 28,086 56.1 11.6 27,575 55.3 11.7 1934 29,576 54.3 11.3 29,062 54.3 11.4 1935 28,485 56.8 9.7 27,106 54.8 10.0 1936 25,439 58.1 8.2 25,069 56.6 8.1 1937 24,637 58.7 8.2 24,052 571 8.4 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 1936 and 1937 are given in the table below in percentages:— Table 4 Age group Visual acuity (percentages) Normal Slight defect More serious defect 1936 1937 1936 1937 1936 1937 Seven-year-old bovs 63.5 64.1 25.1 24.7 11.4 11.2 Seven-year-old girls 63.0 63.6 25.6 25.2 11.4 11.2 Eleven-year-old boys 68.1 70.1 16.9 16.5 15.0 13.4 Eleven-year-old girls 66.1 67.8 18.7 17.8 15.2 14.4 Leaver bovs 68.3 70.8 15.5 14.7 16.2 14.5 Leaver girls 66.6 68.2 17.0 16.7 16.4 15.1 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 had given his consent after examination of the lighting. The figures for 1937 show that there is again a heavier incidence upon older girls, although the excess of visual defect in girls is much less than in former years, and generally the figures for visual acuity in 1937 show a welcome improvement, particularly at the higher ages. Enlarged tonsils and adenoid growths In the prescribed age groups, 7,186 children were referred for some form of treatment of enlarged tonsils or adenoid growths; this is 5.4 per cent. of the children examined, compared with 5.0 per cent. in 1936, 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 were: entrant boys 9.0, girls 8.2; 7-year-old boys 5.1, girls 5.3; 11-year-old boys 1.8, girls 2.4. There has been a fall in recent years in the percentage of children referred for treatment for enlarged tonsils and adenoid growths, though 1937 shows a slight upward tendency. The older the children the fewer there are that suffer from ear, nose and throat defects. 13 Many children 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 45.8 per cent., compared with 44.4 in 1936, 38 per cent. in 1933 and 1934, and 43 per cent. in 1932. Of the 7,186 children referred for treatment for these defects, 4,739 were referred for enlarged tonsils only, 460 for adenoid growths only, and 1,987 for both enlarged tonsils and adenoid growths. Otorrhœa was noted in 877 children, or .7 per cent. of those examined in the prescribed age groups, the same percentage as in 1936, compared with .8 per cent. in 1935, .9 per cent. in 1934, .8 per cent. in 1933 and in 1932, and with 1 per cent. in 1931 and 1930. 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 among entrants and diminishes during school life year by year. Hardness of hearing was found in 262 children, or only .2 per cent. of those examined, being the same percentage as in 1936. 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 materially 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. Otorrhoea and hardness of hearing Heart defect (functional or organic) was reported in 1,795 children in the prescribed groups or 1.4 per cent., compared with 1.5 per cent. in 1936, 1.7 in 1935, 1.9 in 1934 and 2 per cent in 1930. As usual, older girls presented a percentage (1.5) in excess of older boys (1.2). 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. The continuous reduction in the percentage of children found with heart disease of late years corresponds with the increase in preventive measures described in the account of the rheumatism scheme (p. 38). Heart defect Anæmia was recorded in 654 children, or .5 per cent., compared with .6 per cent. in 1936, .7 in 1935, 1.0 in 1934, 1.1 in the years 1931 and 1932, and 1.2 per cent in 1930. In this respect also the children's health shows steady improvement. Anaemia Lung defects were noted in 2,381 children in the prescribed age groups (or 1.8 per cent.), showing a decided improvement over 1936 and 1935, in both of which years the percentage was 2 .1. Lung defects The bulk of the cases is provided by the entrants (3.1 per cent. boys and 2.9 per cent, girls). This is due largely to bronchial catarrh, which is especially prevalent among entrant infants. There were 56 children in the three age groups reported to have symptoms indicative of pulmonary tuberculosis, compared with 66 in the previous year. In addition, 24 children were found with other forms of tuberculosis, compared with 30 in 1936. The incidence of tuberculosis in any form found at routine inspections was .6 per thousand. For many years the amount of tuberculosis among school children has been very small. Tuberculosis Epilepsy was noted in 45 children, compared with 30 in 1936, 28 in 1935, 52 in 1932, 65 in 1931, and 73 in 1929 ; chorea in 76 children, compared with 101 in 1936, 104 in 1935, 158 in 1932, and 170 in 1931 ; paralysis in 61 children, compared with 41 in 1936, 45 in 1935, 55 in 1934, 63 in 1932, and 81 in 1931. Nervous diseases B 14 Although the number of epileptics and paralytics increased in 1937, the number of children found with chorea fell considerably; this may be connected with the general measures now taken to combat rheumatic disease, and may be compared with the general reduction in the proportion of children found suffering from heart disease. Rickets Signs of rickets or the effects of early rickets were noted in 601 children in the prescribed groups. This is .5 per cent., the same percentage as in 1936, compared with .4 in 1935, .5 in 1934, .3 in 1932, and .4 per cent. in 1931 and 1930. Infant boys had an incidence of 1.0 per cent., compared with 1.1 in 1936, 1.0 in 1935 and 1934, .7 in 1933, and .9 per cent. in 1932, and infant girls .5 per cent., as in 1936 and 1935, compared with .3 in 1933, and .4 per cent. in 1932. The stigmata of early rickets tend to disappear as growth proceeds, and only .2 per cent. of the 11.year.old group are noted with remains of the disease. Deformities Among deformities, spinal curvature accounted, in the prescribed age groups, for 371 children, or .3 per cent. as in 1936, compared with .4 per cent. in 1935. Of these, 147 were among the 11.year.old girls, and 96 among the 11.year.old boys. Other deformities, mainly flat foot, were present in 1,132 children (.9 per cent., the same as in 1936, compared with 1.0 in 1935 and 1934). The health of the leaving child The results of the examination which takes place in the term prior to that in which the children are due to leave school 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 attent ion received since the children entered school. This year's "leaver" group comprised 24,029 boys and 24,195 girls. In nutrition they were found to be better than the younger groups, only 4.2 per cent. of the boys and 3.8 per cent. girls being classed as subnormal, whereas in the three prescribed ages, 6.9 per cent. were considered subnormal. They compared with 4.1 per cent. boys, and 3.4 per cent. girls in the previous year. In personal cleanliness, this group also shows an improvement on the 11.year.old group, 98.8 per cent. boys and 96.9 per cent. girls having perfectly clean heads. The dental condition of this group was found to be slightly inferior to that of the 11.year. old group, for both boys and girls, the percentage with satisfactory mouths being 75.7 in the case of boys, and 74.9 in the case of girls, compared with 77.7 and 78.7 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. compared with .7 per cent. at age 11; on the other hand, heart defect in the "leaver" girls was 1.5 per cent., the same percentage as in the 11.year.old group. The older girls invariably present more cases of spinal curvature and heart defect than do the older boys. The percentage of spinal defect in "leaver" boys was .4 per cent. and of heart defect 1.3 per cent. 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, until the latter part of 1937, skilled inspection of the teeth by the inspecting dental surgeons had not extended in all cases to the children aged 12 and 13 years, but had ceased at the age of 11 in many schools. The reorganisation of the tops of schools has also caused difficulty in the way of following up the older children. "Choice of employment" slips are supplied to school doctors, to be made out for every leaver who possesses some disability which affects choice of employment. These slips show the following occupational conditions for which a child might be unsuitable, and are 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. 15 The school doctor indicates any of these occupational groups for which a child is physically unsuitable. Some criticism was expressed during 1936, with regard to the results of this procedure, and cases were reported in which children stated to be "fit" by the school doctor had subsequently been rejected as "unfit" by the factory surgeon. The plan, however, had not then been in operation long. During 1937, there have been no further complaints, and the scheme appears to be giving satisfactory results. Vaccination. 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, 45.3; 7.year.olds, 47.2; 11.year.olds, 47.9; and "leavers" (13½), 54.6; compared with, in 1936, entrants, 44.9; 7.year.olds, 45.5; 11.year.olds, 49.3; and "leavers" (13½), 49.2. These figures show that the percentage of children with obvious vaccination marks is greater than last year at all ages except in the 11.year.old group. This is the first time since these figures began to be kept that an improvement in the proportion of children found to have been vaccinated has been recorded. Special examinations The number of children, not in the age groups for routine examinations, submitted to the school doctors as special cases was 133,850, equivalent to nearly three additional age groups, and this figure does not include another 24,027 who came under inspection in the course of enquiries into outbreaks of infectious diseases. The number of special examinations in 1936 was 122,963, in 1935, 125,199, and in 1934, 91,880. The increase in the number of special examinations in the past three years 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 since 1934 is equivalent to that of four whole.time school doctors, and explains why considerable strain has been felt. It could not have been carried out had it not been that the routine age groups were smaller. 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 some diseases the actual numbers found to be suffering therefrom in the former exceeded those in the latter. Thus 3,553 children with scabies were referred for treatment at special inspections, compared with 220 only at routine inspections. In regard to children with chorea, 129 were seen at special inspections, compared with 40 at routine examinations. This is evidence that full advantage is being taken of the doctors' visits to the schools promptly to present to them really ailing children. The number of children among the special cases who were submitted to the school doctors on account of real or supposed nutritional defect was 87,567, compared with 78,706 in 1936 and 53,066 in 1935. At the resulting medical examinations, the nutritional classification, on the Board's scale, of the children was as follows:— Table 5 Sex Number Nutritional classification 1 2 3 4 Boys 42,279 1,344 22,470 18,294 171 Girls 45,288 1,502 24,784 18,723 279 Total 1937 87,567 2,846 47,254 37,017 450 Total 1936 78,706 2,130 39,536 36,547 493 Total 1935 53,066 1,038 24,876 26,329 827 16 The very large increase in the numbers submitted for nutritional classification should be noted, as it is due to the anxiety that the children needing milk in school or other help should not be missed. Although more children were considered than in previous years, the number found to be seriously ill.nourished was fewer, being 450 compared with 493 in 1936, and 827 in 1935. 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 of the county in November, 1934, a second unit in the south.east division in May, 1935, and a third unit in 1936 in the south.western division thus completing the development foreshadowed in the three.year programme. 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; and an otologist, who conducts one clinical examination and one treatment session each week. The work is under the direction of Mr. A. G. Wells, F.R.C.S., who has submitted the following report:— Audiometric work The number of children tested by the gramophone audiometer during the year was 60,440, and the total number of individual tests was 69,759. Particulars of children who failed are shown in the following table:— Table 6.—Routine audiometer tests School Total number tested Total number of children failed Number failed in Percentage of failures (either ear) One ear Both ears Bovs 31.076 2,239 1,432 807 7.20 Girls 29.364 2,137 1,389 748 7.27 Total 60,440 4,376 2,821 1,555 7.24 The subjoined table gives the total number of ears tested in 1937 and 1936, 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 = severer degree of hearing loss. (The audiometer records are graded in steps of three decibels.) Table 7 Year Total ears Number of ears showing level of recording in decibels —3 to 6 9 12 to 18 21 to 30 1937 120,880 114,949 1,442 3,162 1,327 Percentage 95.09 1.19 2.61 1.09 1936 91,158 85,962 1,564 2,244 1,388 Percentage 94.3 1.7 2.4 1.5 Fig. 1 is a differential analysis of failed children, and shows the hearing in the better ear before and after treatment. The amount of educational handicap is shown in this graph. Fig. 2 shows the differential analysis of all ears before and after treatment. Both graphs show clearly the improvement in hearing as the result of treatment. 17 Fig. 1 Fig. 2 Defects found in failed children The clinical examination of the failed children conducted by the assistant otologists revealed the following defects, which were partly or wholly responsible for their loss of hearing:— Catarrhal condition of middle ear 2,019 Old mastoid operation 2,232 Wax 1,172 Polypus 1 Rhinitis 912 Nerve deafness 6 Deflected septum 91) Foreign body 7 Otorrhoea 518 Congenital malformations 7 Sclerosis 1,373 Sinusitus 3 External otitis 1 Stenosis of meatus 1 Tonsils and adenoids 259 Nothing abnormal found 69 18 Among 4,376 children who failed, 823 were treated by diastolisation treatment, and 400 of these benefited sufficiently to enable them to pass their final test, after the completion of their treatment. The results of 98 were unknown owing to their either having left school or lapsed from treatment. Among the 60,440 children tested by the gramophone audiometer, there were 80 who gave no better response than the 18 decibel level or worse in the better ear at their final test, and who consequently were potential cases for special educational facilities. All these were invited to County Hall and were given a complete test, with the result that 49 were found to be suitable for ordinary school, and these should be known as grade I children. Twenty were able to benefit educationally in the ordinary school with special facilities such as favourable position in class; these should be known as grade IIa children. Eleven needed education in a partially deaf school; these should be known as grade IIb children. The nutritional stale of the London school children Between the sunshine of robust health and the night of disease there is a twilight of unease. School medical officers, in virtue of their approach from the point of view of health, have long been aware of this; practising physicians, on the other hand, have been tardy in their recognition of the intermediate state. They have inclined to be rather critical of the fussiness of the school doctors, and often met the patients referred to them with assurances that there was nothing wrong or nothing to worry about. Many a complaint has been, and still is, heard from parents on this score. The complaints are more usually directed at the official doctor whose "officiousness" they deplore, and whom they blame for the trouble and anxiety caused for, supposedly, no reason. Lately, the state in which children, though not ill are not yet perfectly fit, has received wider recognition, and is being explored by the help of the biochemist. The idea has emerged of latent conditions which interfere with full health, although they may never pass over into disease. New methods of investigation are being perfected whereby the degree of saturation or deficiency of substances necessary for steady growth and maintenance of health can be assessed. The children so often in the past brought to the school medical officer by anxious parents because they exhibited excessive bruising as the result of minor injury, now turn out to be sufferers from hypovitaminosis C. The bruising was not a sign of ferocity on the part of the teacher or playmates, but of unwise feeding on the part of the parent, and the degree of this deficiency is now assessed by the resistance which the superficial blood vessels make to rupture by pressure. Other children suffer from hypovitaminosis A, and the attempt is made to measure this deficiency by the lag in regeneration of their visual purple under tests for night blindness. Such states, hitherto so difficult to recognise or even to define, appear to be widespread in all countries. For twenty.eight years in London, the school doctors have sought to improve these conditions by the administration of milk, malt and cod.liver oil in school. Perhaps to these must shortly be added other remedies as Dr. Wilfrid Oakley suggests (pp 25.6). Miss Kate Hogan*, writing on changes in infant schools in 50 years, says:— Thanks to the introduction of nurses into the schools, we were able to get the children's heads cleaner. The mothers disliked their children having to go to the cleansing station and having their hair cut. Later came medical inspection and with it a host of hygienic benefits, such as free feeding, the abolition of needlework in infant schools, and a wonderful improvement in the underclothing and personal hygiene of the children. In fact, the old nightmare of malnutrition and general neglect had become a thing of the past. Of serious malnutrition, it is true, there is now very little, but of slighter degrees of subnutrition there may be much, although their full significance is still in doubt. * The London Teacher (No. 1,000), 25th February, 1938. 19 Children in northern latitudes appear widely to undergo vitamin shortage, especially during the winter months. This can be no new thing, yet the inhabitants of these very countries have proved in the past to be the most virile of human races. Perhaps periods of alternating saturation and unsaturation are stimulant. Of this there is no certain knowledge. Here is a field for exploration and discovery. The time may be near when new methods of examination and diagnosis must be installed in schools and treatment centres. Meanwhile, it is not surprising that clinical assessments differ in this shadowy state between definite health and definite disease. 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. Bearing in mind the above considerations in regard to the limitations of the clinical assessment of nutrition, the figures for London give astonishingly consistent results. From year to year the fluctuations are minute, and each year each age group preserves its own distinctive features. Thus the 7.vear.old boys always present the greatest proportion of subnormal cases, which is in accordance with physiological expectation. Leaver children always present the lowest proportion of subnormality, and girls are always better nourished than boys in each age group. While the groups differ in their characteristics, fluctuations from year to year in each group are, like the total figures, exceedingly small (see percentages in table 10). These facts give grounds for placing reliance upon the returns for the purpose of assessing nutritional state and for comparison from year to year. The analysis with regard to nutrition, of the results of routine medical inspection in the elementary schools during 1937 is shown in the following table:— Table 8.—Assessment of nutrition, 1937 Group Numbers examined Nutrition Excellent 1 Normal 2 Subnormal 3 Bad 4 Entrant boys 24,637 3,472 19,463 1,679 23 Entrant girls 24,052 3,970 18,741 1,321 20 Seven.year.old boys 20,029 2,416 15,821 1,778 14 Seven.year.old girls 19,988 3,091 15,396 1,482 19 Eleven.year.old boys 21,430 2,915 17,090 1,418 7 Eleven.year.old girls 21,705 3,928 16,482 1,283 12 Leaver boys 24,029 4,381 18,628 1,013 7 Leaver girls 24,195 5,616 17,668 906 5 Total 180,065 29,789 139,289 10,880 107 Percentage 16.54 77.36 6.04 .06 Corresponding figures for the previous year are shown in the following table:— Table 9.—Assessment of nutrition, 1936 Group Numbers examined Nutrition Excellent 1 Normal 2 Subnormal 3 Bad 4 Entrant boys 25,439 3,633 20,100 1,675 31 Entrant girls 25,069 3,985 19,625 1,448 11 Seven.year.old boys 18,802 2,305 14,798 1,689 10 Seven.year.old girls 18,462 2,978 14,170 1,302 12 Eleven.year.old boys 24,222 3,353 19,248 1,602 19 Eleven.year.old girls 23,844 4,365 18,061 1.390 28 Leaver boys 24,393 4,539 18,848 1,003 3 Leaver girls 24,502 5,614 18,054 826 8 Total 184,733 30,772 142,904 10,935 122 Percentage 16.66 77.35 5.92 .07 20 Table 10.—Assessment of nutrition in percentages 1936 and 1937 Group Nutrition Excellent 1 Normal 2 Sub.normal 3 1936 1937 1936 1937 1936 1937 Entrant boys 14.3 14.1 79.0 79.0 6.7 6.9 Entrant girls 15.9 16.5 78.3 77.9 5.8 5.6 Seven.year.old boys 12.3 12.0 78.7 79.0 9.0 9.0 Seven.year.old girls 16.1 15.5 76.8 77.0 7.1 7.5 Eleven.year.old boys 13.8 13.6 79.5 79.7 6.7 6.7 Eleven.year.old girls 18.3 18.1 75.8 75.9 5.9 6.0 Leaver boys 18.6 18.2 77.3 77.6 4.1 4.2 Leaver girls 22.9 23.2 73.7 73.0 3.4 3.8 The percentage of children examined who were assessed as below normal in nutrition was, therefore, 6.10 in 1937, and 5.99 in 1936, a quite remarkably close result in the two years. The number of children who were found to be seriously ill. nourished was 107 in 1937, or 5.9 per ten thousand, while in 1936 it was 122, or 6.6 per ten thousand. It is not astonishing that the number of children found to be seriously ill. nourished at routine inspections is so small and diminishing each year, for, with the general condition of the children so good, it is most unlikely that such a child should remain in school for any length of time unnoticed; and, if noticed, it is almost unthinkable that, with the present opportunities for medical examination and amelioration, he should remain unrelieved. It should be noted that, while in the routine age groups in 1937, only 107 seriously ill.nourished children were found, yet at special inspections there were 406. The following are the measures by which it is sought in London to observe and control the nutritional state of the children:— (1) The general continuous oversight of the children in school by teachers, school doctors, school nurses, and care committee workers. (2) The weighing and measuring of all children at six.monthly intervals. This is carried out by the school nurses, who bring before the school doctor all children who do not progress normally. (3) The feeding of necessitous children; including the giving of milk twice a day, or cod. liver oil on the advice of the school doctors. (4) The carrying out of special enquiries at certain schools. (5) The reference for expert investigation at "nutrition centres" of every child whose condition does not improve by ordinary school measures. (6) The provision, for children who are under.nourished, of convalescence at country or seaside open.air residential schools or convalescent homes. (7) The investigation of home conditions by care committee workers, and their improvement so far as possible by advice and help. (8) The steady improvement of housing conditions intensively followed by the Council's housing committee. Nutrition centres The work of the five main and seven subsidiary nutrition centres has continued throughout the year. Particulars of attendances at nutrition centres during 1937 are shown below:— Number of appointments made for new cases 725 Attendances: new cases 578 old cases 2,291 —— 2,869 Number discharged: no longer needing supervision 127 leaving school 85 — 212 Number of sessions 379 These centres, which were first established in May, 1935, have continued to perform an important function. They are essentially "further inspection" centres, conducted by experienced physicians, to which school doctors refer children for more detailed investigation than is possible at the routine inspections in the schools. 21 They have attracted much interest and have won general approval. Originally they served for investigation only, but they have now become centres for treatment also. Vitamin concentrates and other remedies are now supplied, so that specific deficiencies can be corrected by appropriate supplements. Their influence as centres of research is extending into the surrounding schools, and short accounts of investigations in schools carried out by physicians attached to the centres are given later in this section. An interesting offshoot of the work at the Hoxton nutrition centre is described by the divisional treatment organiser:— A meeting of voluntary workers in the Hoxton area was held before Christmas and was addressed by Dr. Gourlay, of the Hoxton nutrition centre. The suggestion was made that a cookery class should be started for the mothers attending the nutrition department where instruction could be given on very simple lines for the preparation of suitable meals for a family income of about 5s. per person per week. The assistance of an evening institute was sought and as a result a meeting of officials and parents was held at Hoxton House on 22nd February. There were enough parents present, together with promises of co.operation from others, to warrant the starting of a cookery class. At the meeting, which was attended by the head of the evening institute, the care committee secretary, two teachers from a neighbouring school, Dr. Gourlay and the assistant organiser from the nutrition centre, the parents decided what sort of things they would like to learn, and they were promised that the course would be one which would be suitable to their modest incomes. It is proposed to cook things which can be taken home for the family supper, or which can be used for the next day's dinner. Dr. Gourlay is to co.operate with the cookery mistress with a view to seeing that the meals are well.balanced from a dietetic point of view. Valuable detailed reports have been received from the medical officers in charge of the centres, extracts from which are appended. It is impossible not to be impressed with the complexity of the conditions which are being studied. In the poorer areas, like Poplar and Hoxton, economic questions predominate, but in other areas it is clear that there are "problem" children physically as there are "problem" children psychologically speaking, and that the two problem complexes are often intertwined. All the medical officers speak in the highest terms of the help of the nurses and care committee workers, and, above all, of the children's care organisers, who spare no pains over the following.up of the cases and to whose efforts much of the successful work is attributable. Two hundred and eighty.eight children attending the centres were sent for a period of convalescence in the country or at the seaside, and 54 additional children were sent for a country holiday. The following report has been received from Dr. Batten, of the Paddington centre:— During the year 52 new cases were seen and 65 old cases kept under observation. Thirty.two children were discharged after periods of observation long enough to ensure that their progress was satisfactory, and one was discharged on account of the parents' refusal to accept every suggestion made for assistance or treatment. Recommendations and help given were:— Supplements to diet (supplied at clinic)— Pil. ferri 6 Malt and halibut oil 22 Recommended for extra food or school dinners (1 refused dinners.) 10 Recommended for holidays (5 failed for various reasons.) 9 Recommended for residential open.air school (17 arranged, 2 pending, 2 refused.) 21 Recommended for day open.air school (10 arranged, 1 pending, 3 refused.) 14 Recommended for convale cence (9 arranged, 5 failed.) 14 Referred for treatment or investigation— Orthodontic, dental, aural (3 refused.) 8 Rheumatic clinic 1 "Child guidance" 1 Hospital 7 22 The children who come have been recommended by school doctors, and have been chosen chiefly because the reason for their "not getting on" or departing from accepted standards was obscure. The problems raised are individual and clinical rather than collective and economic. Perhaps the most significant feature of the children as a group is their diversity. Except that they are London children, they have almost no quality in common. Most, though not all, are thinner than the child whose image is carried in the mind as a standard of health ; most, but not all, depart in some direction from the recorded average in stature or weight, or both ; most show some degree of pallor or do not look in really good health, but some have none of these qualities and few have all. It is not difficult to come to a conclusion supported by evidence as to the main factors responsible for each child's condition or appearance, but these factors are numerous in the aggregate and almost always multiple in any one case. The question of anaemia, a condition with which a large number of the children were credited before being sent to the clinic, has also been further investigated. The estimation of haemoglobin has been considered to be part of the routine examination of the children sent. The blood is obtained by needle puncture from the lobe of the ear, and the haemoglobin estimated by the Sahli method. The results for 71 children are as follows:— Table 11.—Hœmoglobin per cent. Below 70 71.80 81.90 91.100 101.110 111.120 Number of cases 1 10 19 20 16 5 Approximate percentage 1.5 14.0 27.0 28.5 22.0 7.0 The single case with hæmoblobin below 70 per cent. was a boy with hypochromic anaemia of obscure origin. The groups with haemoglobin between 70 and 100 per cent. do not seem to call for special comment, except to say that there was nothing distinctive in the colour or appearance of the 71.80 group, and that, in some cases at least, the administration of iron made no difference to the haemoglobin level. The group 101.120 per cent. have perhaps more in common and seem to merit further study. Of these 21 children, I placed 9 in nutritional category "3" and 2 in "4" and the group contained some of the palest children sent up. These pale children with high hæmoglobin have much in common. They are, typically, thin, lacking in signs of vitality, the very reverse of "sanguine" in appearance. A dark, "thick.looking" drop of blood flows sluggishly from the ear when pricked, and the high hæmoglobin can be confidently guessed before it is measured. That the condition is not one of good health is, I think, beyond dispute; what are its concomitants and significance, if there is in fact a general hyperhæmoglobinaemia, I cannot ascertain in the course of the ordinary work of the clinic. I can at present record my belief only that a small group of similar children exists who characteristically show this phenomenon; and, so far as I know, it has not been clinically recognised. Dr. Elman's report on the Poplar centre and the two sub.centres at Kingsland (Hackney) and Wapping is summarised below:— The total number of attendances was 705, made by 128 old and 93 new cases. Progress was very satisfactory in 72 old and in 30 new cases. Out of 221 children, 14 are recorded as having made no progress. These were, however, chiefly in those seen in the latter part of the year. Thirty.three children were discharged. Economic conditions played a considerable part in the causation of malnutrition. Among the new cases the amounts available for food per head per week were obtained in 81. They were as follows:—Less than 4s., 15; 4s..6s., 36; 6s..8s., 19; 8s..10s., 7; over 10s., 4. Housing conditions were classified in the 93 new cases as:—Very bad, 16; bad, 29; moderate, 36; good, 12. Among the "very bad" cases there were two families sleeping five in a bed, and one family sleeping seven in a room; and among the "bad" there were three families sleeping six in a room. One family of five is said to have slept in one room with six cats. In 28 children the main cause was considered to be other than economic. In 18 children, physical causes alone (e.g., infectious and other illnesses) were assigned, and in ten there were psychological causes; this was also probably a contributory cause in others. The methods of treatment available included advice as to house management and diets, extra nourishment, milk and school dinners, convalescence, admission to open.air school, and prescription of iron, malt and oil. The question of sleep is intricately bound up with that of housing, and it must be obvious that in overcrowded dwellings the entry of older children and adults into the bedroom of the younger children must cause great disturbance of sleep. The general progress of the children appears satisfactory, although the economic status and the unwholesome surroundings of many make improvement a slow process. 23 Dr. Cicely Peake reports as follows in regard to the south.western division:— Clinics are held about eight times a month. They are spread over three area.centres at (a) Stoekwell.gardens, (b) St. George's dispensary, Blackfriars, and (c) Shillington.street school, Battersea. This arrangement avoids as much journeying as possible for mothers and children, saves their money and time, and enables them to attend a place that is probably already known to them, and not therefore too formidable. In the earlier groups of malnourished children referred to the centres, "problem cases" predominated over those due to poverty, but among the later cases it has been found that the underlying cause is more often an economic one. Incidentally, almost every sort of problem arises among them. Many of the children have relatives who have been, or are, of a "thin kind"; and a history of anxiety, over.work, poor feeding and ill.health during the mother's pregnancy is common; twin pregnancies, prematurity and small birth.weight are also factors. Children at the end of large families tend to malnutrition. It is very conducive to bad nutrition to be the youngest child of a large poor family with the eldest under fourteen years of age. A large proportion of income goes on food, and clothes have to be found. The money left for rent will not pay for suitable accommodation. The children go to swell the numbers in one or two rooms of a full house, and may have to live in a basement. There is then lack of daylight, fresh air and the quiet that they need even more than the better.off. It is also unfortunate to be the youngest of a family where money is earned by the older children and the family circumstances are flourishing. The problem of the only child is then seen in the youngest, who becomes a malnutrition case through too much spoiling and too many halfpennies for sweets. Loss or ill.health of one or both parents and absence from home of the mother are all important. Irregularity of the father's employment, whether in a building trade, road.making, dock labour or street selling, means that there will be periods of absence or loss of income. The family has to live on credit and buy at top prices. Nearly all the mothers are making an effort to do well by their children. They are grateful for advice, very interested in nutrition and willing to co.operate. They need education. They believe that meat is bad for children, and that a little flavouring of it in a stew is what they need. Milk, in their view, is only a pleasant drink, good for infants and not necessary for children who can eat with the family. Plain Empire or Dutch cheese by the pound is not so good a bargain, they think, as an expensive kind in silver paper wrappings. There is a very common notion that a little of the water in which greens have been boiled is a good substitute for the greens themselves. They believe that fruit and vegetables are not necessary if the bowels are regular, but insist that a weekly purge should always be given. There is a strange prejudice against the white of an egg, and a child who asks for the yolk to be cooked solid must be refused. Mothers are willing to agree that the children's lack of appetite for breakfast may be due to their own example, and they promise to co.operate about this, as well as in trying to make meals as regular and attractive as possible. A reasonable bedtime is impossible to arrange for badly overcrowded families, and nearly always difficult for any poor family in a crowded district. Noises and lights and other children playing outside keep the younger ones awake. The word "nutrition" still raises animosity in the minds of some parents. They think it suggests that they starve the children. There is trouble with a superior type of parent, having a superior and "linear" type of child, who is too tall for his or her weight though otherwise in very good health. Usually the child is growing very rapidly. It is wise to watch such children and keep up their intake of protective foods, for it is among them that active rickets, causing changes in the chest wall, has been seen to develop in five cases (girls) this winter after they had begun attending the centre. The provision of milk for school children is a great help towards satisfactory nutrition. But if the child is sick once after its milk—and nearly all children are sick occasionally—or if it once finds its milk unattractive, the arrangement for milk in school is quietly stopped "because it doesn't suit him." The loss of milk meals when the children are absent from school is unfortunate. Official milk schemes have helped in a few cases and outside agencies have also been useful, e.g., one child was allowed to go and drink its milk daily at a local Invalid Children's Aid Association office and charitable funds provided holiday milk that was delivered daily for certain children as ordered from a local shop. It will be a great boon when official schemes cover all cases and milk is available in the holidays, etc., for all who are ordered official milk.* Convalescence, residential open.air day schools and open.air classes are all exceedingly useful for children attending nutrition centres. Hopping or visits to relations are not as a rule satisfactory. It is the regular routine and feeding and the atmosphere of quiet security that the children need. They often gain four or five pounds in weight in a stay of as many weeks. The progress of the children is greatly dependent on the nurse.in.charge and the care organiser who initiates and maintains contact. It is impossible to over.emphasise the value of their work. * An account of the experimental arrangement for giving milk in the holidays is given on p. 59 24 Dr. Gourlav's report on the Hoxton nutrition centre and the Starcross.street sub.centre is summarised below:— During the year 68 new cases were admitted to the Hoxton centre; 44 children were found to be suffering from one or more physical defects, of which 17 were respiratory, 12 circulatory, 8 nervous, 3 orthopaedic and 24 miscellaneous. Ten of the above suffered from bronchial catarrh, of whom 5 showed signs of infantile rickets. The dental condition of the children was surprisingly good. Anaemia was not common. As is usual at all the nutrition centres, haemoglobin estimations were made in all cases. Investigation of the incomes of 58 families was made, with the following result:— Table 12 Classification Number of families Amount available for food per " man " 7s. and upwards 5s. 10½d. to 7s. Less than 5s. 10½d. Children of employed men 33 8 9 16 Children of unemployed men 18 1 1 16 Children of widows and separated parents 7 3 — 4 Of the 68 children, 49 were already having milk in school when they were admitted. In many cases where the family income indicated that the children could not be having adequate meals at home, school dinners were refused by the parents. At the Starcross.street sub.centre, 37 new cases were admitted. Assessment of family incomes showed that they came from homes distinctly better off than those of the Hoxton children. Fifty per cent. of the children came from homes where the income per "man" was over 10s. a week. As in the Paddington and other centres, here the picture was often of highly.strung problem children. Physical defects were observed in 27 children, including respiratory, 5; circulatory, 2; nervous, 6; orthopaedic, 3; miscellaneous, 7; rickety, 4. It is remarkable to find the children here, coming from better homes, were generally much more anaemic than the poorer Hoxton children. The haemoglobin estimations at Hoxton and at Starcross.street compared with accepted standards, were as shown in the following table:— Table 13 Age group Hoxton Starcross. street * Osgood & Baker † Davidson & Fullerton 13 91.0 84.4 93.5 12 93.9 86.8 87.9 — 11 90.5 80.6 87.5 93.0 10 90.4 80.0 90.0 92.0 9 89.5 84.1 83.5 91.4 8 89.1 71.5 85.8 88.0 7 90.8 82.6 85.0 90.2 6 94.9 85.6 84.7 87.4 5 88.1 90.0 82.8 86.0 4 95.0 — 84.6 83.1 * American Journal of Diseases of Children, August, 1935. † British Medical Journal, 3rd August, 1935. These results are very perplexing, as is also the failure to bring about any improvement in some of the anaemic cases by giving iron in the doses ordinarily prescribed. In some of these cases a holiday has brought about a cure, but in others even prolonged convalescence has failed. Finally, the help of Dr. Lucy Wills, of the biochemical department of the Royal Free hospital, was enlisted. Complete blood counts were carried out and greater success in removing the anaemia was attained by special medical measures, including the administration of heroic quantities of iron. Particulars of the remedial measures taken at the Starcross.street sub.centre were as follows: Convalescence, 25; country holiday, 8; additional nourishment, 15; housing improvement, 6; sun.ray treatment, 2; open.air school, 1; treatment of dental or other conditions, 28. Co.operation in carrying out the treatment was good on the whole, except for dental conditions. During holidays, in addition to meals and allowances from the Unemployment Assistance Board, cod.liver oil, malt and halibyn were supplied from the centre in several cases and others had milk in the parks and schools. 25 Dr. Florence Louis reports as follows on the Forster sub.centre:— Fifty.three children attended during 1937. They may be classified in three groups. Group I, consisting of 24 children, contained those whose home diet was inadequate, being without exception deficient in protein and fat and excessive in starch. Signs of old rickets were present in eight, and anaemia (haemoglobin level below 80 per cent.) in six. All the children in this group had been receiving daily two.thirds of a pint of milk in school, and half of them were on malt and oil in school as well. When large doses of halibut.liver oil were given, there was a consistent gain in weight and rise in haemoglobin. Disappointing results were obtained by iron therapy, but it was doubtful whether the medicines were taken with regularity. Periods of stay in a convalescent home resulted in a rapid gain in weight. Group II included 10 children. In these there was no marked financial necessity at home, but there were gross ignorance and mismanagement. Five out of 10 showed signs of old rickets. Improvement was obtained by advice on diet, and the addition of vitamins A and D. Group III contained 19 children. These children were well cared for and came from good and prosperous homes. They suffered from psychological maladjustments, nervous vomiting and indigestion, etc. Appropriate advice secured improvement in most cases. In the south.eastern division, Dr. G. D. Morgan reports:— During the year 75 children attended the Peckham centre, in 35 (46 per cent.) of whom environmental conditions were considered the cause of failure in growth. These included: poverty, 23; ill.adjusted diet, 2; housing and sleeping defect, 6; inadequate parental care, 4. In 8 there was debility following acute illness or prolonged ill.health. In 25 the cause was physiological or pyschological instability. Treatment is mainly through environmental modification, although vitamin concentrates, glucose, calcium and iron are given in appropriate cases. The children presenting the greatest problem are those whose parents are not co.operative. The most successful means of treatment placed in order of potency have been found to be: (i) convalescence in the country; (ii) residential open.air schools; (iii) day open.air school; (iv) school dinners; (v) cod.liver oil and milk in school; (vi) modifications in home environment. A tribute should be paid to the King's Canadian open.air school, a period of six weeks at which has produced great improvement not only in physique and stamina, but also in mental outlook. Particulars follow of three special enquiries carried out during 1937. Dr. G. D. Morgan made a special investigation into the nutritional standard of ten.year.old children attending a neighbouring elementary school. In assessing the condition of the children, physical measurements were undertaken, in addition to careful clinical examination. The latter included assessment of the condition of the skin and subcutaneous tissue, pallor and conjunctival appearance, body shape, size of the abdomen, etc. At the same time records were taken of the size of the family, health of family, and the health of the child under observation. Particular note was also taken of the child's previous illnesses. Other children in the family attending school were also examined. In all, 152 children were examined. The nutritional assessment according to the Board of Education scale was:— Grade of nutrition Number Percentage 1 25 16.5 2 108 71.0 3 & 4 19 12.5 The previous health of the children was expressed as the number of illnesses of which a history was obtained, serious illnesses being separately entered. The average number of illnesses recorded did not vary in the three groups, but serious illnesses were much more frequently recorded in the subnormal group, the percentages being: grade 1, 14.3; grade 2, 10.2; grades 3 and 4, 45.4. The hours of sleep averaged 11.3 per night and did not vary in the three groups. Size of family varied inversely with nutritional states, viz.: average number of children, grade 1, 2.8; grade 2, 3.2; grades 3 and 4, 5.8. The more seriously affected children were referred to the nutrition centre for more detailed investigation. Dr. Wilfrid Oakley, who is temporarily in charge of the Forster nutrition sub. centre, investigated the home diets of 230 boys from a central school. Examination of the diets showed, with regard to protective foods, 59.1 per cent. were satisfactory, 16.5 per cent. deficient in fresh fruit, 14.4 per cent. deficient in green vegetables, and 10 per cent. in both fruit and vegetables. Twelve of the 230 diets, or 5.2 per cent., 2G were found to be deficient in protein content. Ten per cent. of the diets were therefore, certainly deficient in vitamin C, and 16.5 per cent. were probably low in this vitamin. The ease with which this defect can be remedied by ascorbic acid preparations raises the question whether vitamin C in this form should not be available for school children in the same way as vitamin D is available on the school doctors' advice in the form of cod.liver oil. As regards protein, there was no evidence of widespread deficiency; diets of boys taking milk regularly showed no sign of deficiency in this respect. Dr. Leslie Harris of the Dunn nutritional laboratory, Cambridge, carried out an investigation in connection with the Poplar nutrition centre, first of child patients attending the centre, and later of unselected boys attending a Council school in east London. The investigation consisted in the estimation by photometric methods of the activity of the visual purple in the retina. When the eye is exposed for a few minutes to a bright light a proportion of the visual purple is destroyed by bleaching, and the ability to see a dimly.lit object in the dark is lessened. The extent to which the sight returns to normal will depend on the amount of visual purple which can be regenerated in a given time. In vitamin A deficiency there is a diminished degree of recovery in the dark. The following tables have been taken from an article giving the results of the investigation published by Drs. Maitra and Harris in the Lancet, 30th October, 1937. Table 14.—Incidence of hypovitaminosis among various groups of subjects Description Age Number examined Percentage found Normal Slightly below. normal Definitely subnormal Boys and girls. School treatment centre in east London. 8.12 31 45 19 36 Council school in east London 11.14 92 40 38 22 Council school clinic, Cambridge 8.13 70 44 25 31 Boys, public school, east of England 13.14 30 90 10 0 Mothers, Council school, Cambridge. 25.35 38 50 50 0 Undergraduates, research workers, medical men and dentists, Cambridge. 20.50 22 81 14 5 Table 15.—Incidence of hypovitaminosis among boys and girls at an elementary school in east London Group Cases examined Number and percentage found Normal Slightly below normal Definitely sub. normal Boys—11.12 years 25 9 (36) 8 (32) 8(32) „ 13.14 26 11 (42) 9 (35) 6(23) Total boys 51 20 (39) 17 (33) 14 (28) Girls—11.12 years 19 6 (32) 8 (42) 5 (26) „ 13.14 22 11 (50) 10 (45) 1 (5) Total girls 41 17(41) 18 (44) 6(15) Grand total 92 37 (40) 35 (38) 20 (22) Note.—Figures in brackets express percentages. 27 Table 16.—He.examination of children found "definitely subnormal" or "slightly below normal" at the first test Group Interval after which re.examined Dosage of vitamin A administered Cases examined Number and percentage Became normal Improved No improvement Children, Council school, east London. 2 weeks Halibut. liver oil 15 drops daily 40 25 (63) 8(20) 7(17) 4 „ 30 (75) 9(22.5) 1 (2.5) Negative controls 2 „ Nil 20 0 2(10) 18 (90) Of 92 unselected school children aged 11.14, 20 were found by this method to be definitely subnormal, and 35 slightly subnormal. After heavy dosage in school with halibut.liver oil for four weeks, 30 out of 40 subnormal children became normal and nine improved. Opportunity was taken by me to correlate the result of Dr. Harris' research with the administration of milk in school to the children. The results of this correlation are given below:— No. of children, 88; No. found normal by Dr. Harris, 38 (43.2 per cent.); No. slightly subnormal, 30 (34.1 per cent.); No. below normal, 20 (22.7 per cent.). No. of normal children, 38; No. on doctor's milk, 12 (31.6 per cent.); No. on voluntary milk (regular), 8 (21 per cent.); No. on voluntary milk (occasional), 10 (26.4 per cent.); No. not on milk, 8 (21 per cent.). No. of children slightly subnormal, 30 ; No. on doctor's milk, 3 (10 per cent.); No. on voluntary milk (regular), 8 (26.6 per cent.); No. on voluntary milk (occasional), 10 (33.3 per cent.); No. not on milk, 9 (30 per cent.). No. of children subnormal, 20; No. on doctor's milk, 3 (15 per cent.); No. on voluntary milk (regular), 5 (25 per cent.); No. on voluntary milk (occasional), 6 (30 per cent.); No. not on milk, 6 (30 per cent.). Of those children on doctor's milk, 66.6 per cent. were found by Dr. Leslie Harris to be normal, while of those not on doctor's milk, only 37.1 per cent. were found normal. Children on doctor's milk are those found by the doctor on clinical examination to be poorly nourished, who receive two bottles (⅔ pint) of milk a day in school. Children receiving voluntary milk have only one bottle (⅓ pint) a day. Considering that those upon doctor's milk were clinically found originally to be the least well. nourished, it may be deduced from these figures that the administration of two. thirds of a pint of milk in school goes far to protect the children, and the results justify the practice which the school medical officer has always insisted upon, that children appearing ill.nourished should have daily two bottles and not one only. Children's care committees Following.up 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. 28 Re.inspections 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 1937, 114,015 re.inspections were made. At the first re.inspection, which takes place in the next term but one after primary inspection, 70,039 cases of defects requiring treatment (some children having more than one defect) were reviewed. At the second re.inspection, which takes place after the lapse of a clear term after the first re.inspection, 43,976 cases not cleared up at a first re.inspection were again reviewed. By combining the results of both re.inspections it is found that 82 per cent. of the children re.inspected were treated or discharged as no longer requiring treatment. This figure compares with 83.9 per cent. in 1936, 82.3 in 1935, and 75.1 in 1934. It is the dental cases, which contribute more than half of those to be followed.up, that cause the most difficulty. If these be eliminated the cases of defect satisfactorily dealt with at the time of the second re.inspection, reached the proportion of 84.4 per cent. in 1937. The relatively poor result in 1934 was almost entirely due to failure to obtain dental treatment. The better results in this respect in the years 1935 to 1937 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. Table 17 First re.inspections, 1937 (Percentages are given in italic type) Defect treated No. of defects Treated Untreated By private doctor or dentist Under Council's scheme At other hospitals Discharg'd Improved. For observation only Still needing treatment Discharg'd Not discharg'd Discharg'd Not discharg'd Discharg'd Not dis. oharg'd Refraction 11,590 95 43 2,695 1,713 245 129 931 2,560 3,179 0.8 0.4 23.3 14.8 2.1 1.1 8.0 22.1 27.4 Minor ailments 4,735 119 23 1,107 366 271 101 1,380 650 718 2.5 0.5 23.4 7.7 5.7 2.1 29.2 13.7 15.2 Nose and throat 9,931 31 6 3,146 273 573 73 1,195 1,231 3,403 0.3 0.1 31.6 2.7 5.8 0.7 12.2 12.4 34.2 Teeth 36,323 981 257 13,673 798 1,413 102 2,415 919 15,765 2.7 0.7 37.6 2.2 3.9 0.3 6.7 2.5 43.4 Other ailments 7,460 136 71 592 666 611 478 1,788 2,068 1,050 1.8 1.0 7.9 8.9 8.2 6.4 24.0 27.7 14.1 Total 70,039 1,362 400 21,213 3,816 3,113 883 7,709 7,428 24,115 1.9 0.6 30.3 5.4 4.4 1.3 11.0 10.6 34.5 Second re.inspections, 1937 Refraction 10,480 48 31 1,635 1,664 175 123 827 2,792 3,185 0.5 0.3 15.6 15.9 1.7 1.2 7.9 26.6 30.3 Minor ailments 2,718 31 11 461 282 91 77 741 456 568 1.1 0.4 17.0 10.4 3.3 2.8 27.3 16.8 20.9 Nose and throat 6,419 13 12 1,611 152 371 36 943 1,025 2,256 0.2 0.2 25.1 2.4 5.8 0.5 14.7 16.0 35.1 Teeth 19,028 525 155 6,728 409 782 66 1,539 511 8,313 2.8 0.8 35.4 2.1 4.1 0.3 8.1 2.7 43.7 Other ailments 5,331 35 38 328 572 279 338 1,124 1,817 800 0.7 0.7 6.2 10.7 5.2 6.3 21.1 34.1 15.0 Total 43,976 652 247 10.763 3,079 1,698 640 5,174 6,601 15,122 1.5 0.6 24.5 7.0 3.9 1.4 11.7 15.0 34.4 29 Cases referred to the N.S.P.C.C. During 1937, 416 children, involving 508 defects, were reported to the National Society for the Prevention of Cruelty to Children; these included 266 dental defects, 98 vision cases, 53 nose and throat affections and 9 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. 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 borough 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 children reported was 452, of whom 11 were referred to Borough Councils or other local authorities. Of the children followed up at school, 29 were found on the first examination to have otorrhœa, and of those seen at second examinations the condition was found in 20 children. Spectacles Spectacles for children in the elementary schools are not provided from the rates, but parents are assisted by the voluntary London Central Spectacles Committee. In 1937, 26,263 children were prescribed spectacles at the treatment centres and hospitals, and of these 24,958 or 95 per cent. obtained them. History Medical and dental treatment The Council's arrangements for the medical treatment of school children began in January, 1910, when arrangements were made with 7 hospitals for the treatment of some 12,700 children, and the hospital authorities accepted responsiblity for the treatment undertaken. The first school treatment centre under the aegis of a local committee of medical practitioners, was opened in July, 1910, at Hampstead, on the premises of the Kilburn provident medical institute. This was followed by a second at Norwood iu September of that year, and a third in Wandsworth in January, 1911. In 1912, the first of the centres to be organised by local voluntary committees was opened, and during that year 9 such centres were opened, the total number of children treated during the year being 37,446. In 1913 there were 12 hospitals and 17 centres providing for the treatment of 73,000 children a year. Despite the difficulties created by reason of the Great War, 1914.1918, the scheme continued to be developed; and by the year 1919, there were 11 hospitals and 43 centres in operation. During that year the actual number of children treated was 169,200. By the end of 1925, there were 13 hospitals and 60 centres in addition to the dental centre established at the King's Canadian open. air school at Bushy Park, providing, in all, facilities for the treatment of 231,352 children a year. From this time steady progress in the provision of centres has been made, as shown in the following table:— Table 18 Year No. of hospitals No. of centres No. treated 1926 12 64 258,638 1927 12 68 283,871 1928 17 68 288,835 1929 16 71 289,979 1930 16 72 303,275 1931 17 73 306,771 1932 17 73 296,804 1933 17 74 299,192 1934 17 74 306,050 1935 17 74 313,859 1936 17 78 319,570 1937 18 81 315,117 c 30 During the past year, in place of working through local voluntary committees, the Council has decided in four instances to assume sole responsibility for the administration of centres, two in St. Marylebone, one in Old Ford, and one in south Hammersmith. In each of these instances special circumstances arose which led the Council to vary its long.standing policy. In three cases the centres have been or will be transferred to new buildings erected by the Borough Councils, providing accommodation for maternity and child welfare centres organised by the Borough Councils, on the ground floor, and for school treatment centres on the first floor, and in the fourth case the treatment centre concerned is accommodated in vacant rooms of a Council school. So far, the new arrangements have worked very well. So far as the general arrangements for treatment during the year 1937 are concerned, the work at the hospitals and centres has been well maintained, and the attendances of the children have been extremely good. There has always been a proportion of parents who were unwilling to take advantage of the facilities provided for the treatment of their ailing children. With the increasing effect of education, this proportion has become progressively less, but it is still remains higher than it should be. During the past year there has been an intensification of educational effort in health propaganda, particularly the "National Health Campaign," and there is evidence that this is already having a salutary effect. It is hoped that this will increase in the future, with a resultant increase in the proportion of parents seeking treatment for their children. Developments in 1937 At the end of 1937, the scheme comprised 18 hospitals and 81 centres, including the King's Canadian open.air school centre (Bushy Park), and the Cyril Henry centre. Three new centres were opened during the year, and 1 additional voluntary hospital (Guy's) was included in the scheme. The three centres were the Charlton (minor ailments) centre, Eltham sub.centre (minor ailments) and South Hammersmith centre (dental). The Lissonia treatment centre was transferred from 12, Salisbury.street, Church.street, Edgware.road, to the new building erected by the St. Marylebone Borough Council at 217, Lisson.grove, as a combined maternity and child welfare and school treatment centre, which was opened on 26th August, 1937. The number of children treated at all the hospitals and centres under the scheme during 1937 compared with 1936 were:— Ailment 1936 1937 Vision 39,570 37,341 Ear, nose and throat 13,190 13,592 Ringworm 89 78 Minor ailments 122,305 125,669 Teeth 144,416 138,437 Total 319,570 315,117 Eye defects The number of eye defects dealt with in the eye departments of the centres and hospitals during the year was 37,341, compared with 39,570 during 1936. The arrangements at certain of the hospitals, in addition to refraction work, include the treatment of children suffering from diseases of the eye. It is estimated that of the total number dealt with (37,341) about 2,000 were cases of this nature. Children suffering from eye diseases, e.g., blepharitis, keratitis, and conjunctivitis, which need daily attention by a nurse, are, for the most part, dealt with in the minor ailments departments of the centres. Acute cases, including those of trachoma, can be referred speedily to the Council's residential special hospital at White Oak, Swanley, where the children receive treatment, and, at the same time, are able to attend the hospital school. Special facilities for dealing with squint are provided in various districts of London. Separate sessions for these cases are set apart at Belgrave, Central London Ophthalmic, Guy's, King's College, Lewisham (L.C.C.), Royal Eye and St Mary's hospitals, and at the Paddington, Streatham and Whitechapel centres. 31 During the past two or three years, orthoptic training in the treatment of squint has made progress. The ophthalmic surgeons take full responsibility for the treatment, and, after examining the children to ascertain the visual acuity, the angle of squint, the presence of fusion and its degree, and the presence of stereoscopic vision, prescribe the exercises most suitable for the individual children. These exercises are then undertaken under the supervision of trained orthoptists. As a general rule, it is necessary to devote at least 20 minutes to each child twice a week. Such training by orthoptists is undertaken at Central London Ophthalmic, Guy's and King's College hospitals, and at the Streatham and Whitechapel centres. During 1937, the number of squint cases treated at the various hospitals and centres was 243. The following particulars relating to the orthoptic treatment of squint at the Streatham centre has been received from Mr. P. M. Moffatt, M.D., D.P.H., D.O.M.S., the ophthalmic surgeon in charge of the work:— The clinic was opened in April, 1936, and held two sessions a week until April, 1937, when the number of sessions was increased to three a week. The figures in this report cover the period from the commencement of the clinic to the end of December, 1937. The total number of children examined was 65. If from this figure is deducted 10 on waiting list, 16 being at present treated, 4 "apparent" cases, 3 failed to attend, and 6 unsuitable for treatment by orthoptist, i.e., a total of 39, it will be seen that 26 children were treated to completion. These may be analysed as follows:—12 cured by orthoptic exercises alone; 3 cured by orthoptic exercises and operation; 3 cosmetically straight in glasses, but fusion not complete; 3 improved; 5 not improved, or so little that treatment was stopped after 12 treatments on the ground that more suitable cases would benefit. Ear, nose and throat During the year, the number of children suffering from ear, nose and throat diseases dealt with was 13,592, for whom 9,251 operations were performed for enlarged tonsils and adenoids, compared with 13,190 and 9,116, respectively, during the preceding year. Of the operations, 8,004 were for both enlarged tonsils and adenoids, 862 for enlarged tonsils only, and 381 for adenoid growth only. The remaining 4 were operations in which cauterisation was used. There are 6 hospitals, viz., Belgrave, Royal Free, Princess Louise, St. Mary's, South.Eastern, and Victoria hospitals, and 7 centres, viz., Cyril Henry, Hammersmith, Highgate New Town, Poplar, Hanover Park, St. Georges dispensary and the Wick, where operative treatment is undertaken. In all cases, the children are dealt with as in.patients, and as a general rule they remain at the hospital or centre for two nights after the operation. Those cases in which the operation is performed on Friday are normally kept in for one night only, but arrangements have been made to convev them to their homes by ambulance. Ringworm Although the incidence of ringworm of the scalp among school children is now happily of rare occurrence, it has been thought desirable to retain centres in different districts of London in order that such cases as may arise may be speedily dealt with. One centre was, however, closed in Woolwich during the year, as the apparatus, which had been in use for over 20 years, was worn out. There are so few cases forthcoming in the district that it was deemed undesirable, on the score of expense to renew the apparatus. Such cases as may arise can be dealt with at one of the hospitals in central London without difficulty. There remain 5 hospitals and 3 centres where suitable treatment by X.rays is available. At two hospitals (Charing Cross and the London) payment is made on a capitation basis (25s.), at three hospitals (Princess Louise, Queen's and St. Mary's) payment for such cases as may arise is included in the block grants, and at three centres (Fulham, Islington and St. George's dispensary) the salaries of the surgeons are paid on a sessional basis as required. During the year, the number of children dealt with was 78, of whom 69 were treated by X.rays, compared with 89 cases (80 X.rays) during the year 1936. Minor ailments The nominal provision in London for the treatment of minor ailments is at present 87,450 cases a year. The number of children actually dealt with during 1937 was 125,669, including 19,304 seen by the nurses only, compared with 122,305, including 16,548 nurses' cases, during the year 1936. In addition, a number of children suffering 32 from scabies and impetigo were treated at the bathing centres apart from the medical treatment scheme, and these are included under the heading of minor ailments in table IV at the end of this report, which brings the total number of children treated for minor ailments to 136,707. The minor ailments sessions are always well attended. The original basis of calculating the numbers in connection with the provision for treatment was 15 new cases to each doctor's session. This on an average is greatly exceeded in practice, thus the total number treated is always higher than the nominal provision. During the year, two additional minor ailments centres were opened, viz., the Charlton centre at Sherington Road school and the Eltham sub.centre at Middle Park school. In each of these, advantage has been taken of the new medical inspection rooms which are now provided as a standard feature of all new and reconditioned schools. The rooms are fitted with sinks, basins and hot.plates for heating the sterilisers. The provision of minor ailments centres on school premises is of very great advantage both to the schools and to the parents. The total number of minor ailments centres is 76 including the two new centres mentioned above. In addition, the Council subsidised minor ailments treatment at the Bloomsbury dispensary, the Public Dispensary, Drury.lane, and St. Martin's Northern school. Daily nursing treatment is also provided at 13 outlying schools where difficulty is experienced in arranging for the attendance of the children at the centres. Dental treatment The total number of dental treatment centres at the end of 1937 was 71, including Berkshire Road school centre and the Eastman clinic. Two new centres were opened during the year at Honor Oak (Brockley Road school), and south Hammersmith (Waterloo Street school). As previously mentioned, the Lissonia centre was transferred in August, 1937, from Salisbury.street, Edgware.road, to the new health centre No. 2, at 217, Lisson.grove, W.1. The Hoxton school treatment centre was also transferred in November, 1937, from temporary premises at the former St. John's Road (M.D.) school to a new building specially built for the purpose by the Council on a site in Sarah.street, adjoining the new Drysdale Street housing estate, Hoxton, N.l. The dental inspection of the children has been undertaken by 75 part.time inspecting dental surgeons, of whom 15 are women, and 2,974 half days were devoted to the work during the year. Prior to 1st April, 1935, it was the practice to exclude from the dental inspections held by the dental surgeons the children in the four age groups medically inspected by the school doctors. About that time, it was decided in principle that all children in the schools should be inspected by the inspecting dental surgeons and it was arranged that, as from that date, one age group should be added to the dental inpections in each of the three succeeding years. During 1935, the age group 7.8 years was included; in 1936, the age group 11 years was added, and from 1st April, 1937, the entrant and leaver groups were included. Thus provision was made for the dental inspection of all school children at least once a year. The number of children inspected during the year was 315,016, and of these 215,243 were found to require treatment, a percentage of 68.32. Prior to 1932, the percentage of children noted as requiring treatment was progressively reduced from 81.94 in 1914 to 63.86 in 1932, and during that period the former apathy of the parents to dental treatment had been to some extent overcome. It will be noted that, although provision is now made for the dental inspection annually of all children in the schools, only 315,016 children were, in fact, inspected, out of an average attendance of 417,028. This is due to the facts that provision for the dental inspection of entrants and leavers was only made during part of the year 1937, and that there is always some leakage in dental inspections owing to absences from their usual classes of children on the dates of the visits of the dental inspector. In addition to absences for illness, there are many withdrawals by parents of their children from dental inspection, and there are also absences, especially of the older children, through educational visits, attendance at special classes for manual training, housewifery, etc. 33 The subjoined table shows the number of children dentally inspected, and the number found to require treatment:— Table 19 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 1936 306,969 193,990 63.39 1937 315,016 215,243 68.32 With regard to treatment, the number of children dealt with at the hospitals and centres in the Council's scheme during the year was 138,437 compared with 144,416 during the year 1936. Details of the work undertaken will be found in table IV, group IV, at the end of this report. It will be seen that while the total number of children treated was less than during the year 1936, the figures for the conservation of teeth, both in the permanent and temporary dentition, were greater, as is evidenced by the number of fillings (132,532 in permanent teeth and 21,324 in temporary teeth) undertaken during the year, compared with 124,881 and 19,539 during the year 1936, an increase of 9,436 fillings. At the same time, the number of extractions has been reduced from 60,377 permanent teeth and 257,103 temporary teeth in 1936 to 57,252 permanent and 226,921 temporary teeth during the year 1937, a total reduction of 33,307 extractions. This is a tribute to the increased attention being paid by parents and dentists alike to the conservation of teeth as distinct from extractions. It, however, takes much more time to conserve than to extract, and it has been necessary to authorise many extra sessions at the centres in order to deal with the increased amount of conservative treatment undertaken. Sound conservative treatment is the essence of good dental service, and every effort is being made to improve still further the standard of work undertaken at the centres. The special dental centre established by the Manor Charitable Trust at Berkshire Road school in 1933, enlarged its activities in the past year to include children from Gainsborough Road school to which the older children from Berkshire Road are drafted under the Hadow re.organisation scheme. The number of children inspected was 1,613, and of these, 1,189 (73.7 per cent.) were found in need of treatment. The number of children treated was 654. Orthodontics Following the original orthodontic scheme at the Battersea, Deptford, Hammersmith, Prunella and St. Mary Newington centres, which was held in abeyance in 34 1936 after two years' working owing to the inability of the dental laboratory at St. James' hospital, Balham, to provide the necessary appliances, an experimental scheme was commenced by Miss E. M. Still, L.D.S., of the Bermondsey Medical Mission hospital dental centre, who undertook the treatment of orthodontic defects mainly by means of fixed appliances, most of which she was able to make in her own laboratory. This method proved most successful, and as a result the Council decided to extend the work, and to appoint Miss Still and Miss L. M. Clinch, L.D.S., as orthodontists in the public health department each on 5 half days a week, as from 1st April, 1937. Eight centres were equipped for the work, including the one already in operation at Bermondsey Medical Mission hospital, 4 south of the river, and 4 on the north. Miss Still undertakes the work at the former, and Miss Clinch at the latter centres. A central workshop was also equipped at 123, Peckham-road, S.E., where the orthodontists attend each on one session a week to deal with the construction of the appliances, which are mainly made of stainless steel. The eight centres referred to are at Bermondsey Medical Mission hospital, Deptford, St. Christopher (Battersea), and Stockwell on the south side and Hackney, Hammersmith, Paddington and Whitechapel on the north. A specially trained nurse assists each orthodontist at the centres and at the workshop, and she helps in the making of the plaster models, etc. In certain instances, where removable appliances are necessary, the models are forwarded to the central dental laboratory where it is now possible for the mechanics to construct a limited number of orthodontic appliances in addition to their normal denture work in connection with the general hospitals. The scheme is proceeding satisfactorily and the attendances of the children have been excellent. In fact, almost every instance of failure to attend was due to illness. From 1st April to the 31st December, 1937, the number of new cases seen at the 8 centres was 657 and 2,929 attendances were made. Fixed appliances were made for 353 of the children, and for 44, removable appliances were provided. The number in which treatment was completed and the children discharged was 126, and 56 were found to be unsuitable for treatment. The remaining 475 children were still under treatment at the end of the year. Where it is necessary for X-ray photographs to be available in order to ascertain the position of unerupted teeth, the children are referred to one or other of the Council's general hospitals for the films to be taken. Plaster models are made in all cases under treatment and observation, and these are retained for reference at each centre. Before children are finally discharged their mouths are again examined; and, if conservative treatment has become necessary, they are referred back to their local centres for treatment. Special aural centres The Council maintains 15 special aural clinics which are under the direction of Mr. A. G. Wells, F.R.C.S., who is assisted by nine assistant aurists giving parttime services. One special ear, nose and throat session was transferred during the year from St. Mary Newington, Penrose.street, S.E., to Elizabeth Bullock centre, Wandsworthroad, S.W., to meet the needs of the district. Table 20 gives a record for 1937 of the ear, nose and throat cases from the centres, exclusive of those referred for deafness. Table 21 gives particulars of the deaf cases. Table 20.—Ear, nose and throat, excluding after.care clinic and deaf cases Classification Patients Ears Total number of examinations made 15,207 18,936 New cases 1,597 2,020 Cases carried over from 1936 764 950 Old cases returned 834 976 35 Table 21.—Deaf cases—organisers' returns from special ear, nose and throat clinics Classification Patients ###] Total number of examinations made 5,563 8,558 New cases 1,925 2,846 Cases carried over from 1936 254 414 Old cases returned 68 111 Cases cured 1,207 1,784 Cases partially relieved 195 290 Cases unrelieved 88 122 On current file, lapsed, etc. 757 1,175 In addition to the above there were:— Throat cases 68 Nasal cases—New 199 ,, Carried over from 1936 30 „ Old cases returned 139 Analysis of otorrhœa cases from ear, nose and throat clinics The subjoined table gives a detailed analysis of all cases of otorrhœa 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, 1937. This table includes otorrhœa cases among children from residential schools. Table 22.—Special ear clinics—totals for all clinics Cause of suppuration Total ears Cured Referred for mastoid operation Lapsed Still under treatment Acute otitis media suppurativa 325 265 19 9 32 Chronic otitis media suppurativa due to (I) Tympanic Conditions (a) Tympanic sepsis (T.S.) 1,307 952 — 63 292 (b) T.S. + granulations 198 112 21 8 57 (c) T.S. + polypi 20 13 4 — 3 (d) T.S. + caries 3 — 1 — 2 (e) T.S. + other conditions 6 5 — I — (II) Tympanic Conditions + (a) Tonsils and adenoids 258 174 1 15 68 (b) Nose conditions 456 294 — 16 146 (c) Mouth conditions — — — — — (III) Tympanic Conditions + (a) Attic disease 25 5 8 3 9 (b) Mastoid disease (no operation yet done) 140 — 128 6 6 (c) Mastoid disease (operation already done) 536 282 36 33 185 (IV) Tympanic Conditions + (a) External otitis 81 57 — 3 21 (b) Stricture of meatus 2 2 — — — External otitis 103 85 — 6 12 Total 3,460 2,246 218 163 833 From these figures it will be seen that the percentage of "cases cured" is 68.1 per cent. 36 After-care clinic, St. George's dispensary At the St. George's dispensary, Southwark, a special aural centre is maintained where children suffering from otorrhœa from the Council's residential schools 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 214, and the percentage of cure 73.7. The number of children under supervision at the centre who had been discharged from the Downs hospital was 213, including 53 children discharged in 1936. The total number of children attending, including after-care cases, was 819, and the number of attendances made was 8,108. Orthopædic treatment The provision for orthopædic treatment in London is generally adequate. As local education authority, the Council has established 30 day schools for the physically defective with accommodation for 3,417 children. These schools are regularly visited by an orthopaedic surgeon. The care and education of cripples are continued at these schools until they reach the age of 16, and a scheme of after-care of all children subsequent to their leaving has long been in existence. There are 11 visiting orthopædic surgeons employed in connection with the Council's general and special hospitals. There are two special children's hospitals maintained by the Council to which children suffering from orthopædic defects are admitted; one of these is Queen Mary's hospital, Carshalton, at which there are 1,284 beds and where special facilities are provided for the treatment of orthopædic patients. There is no difficulty in finding accommodation immediately for all orthopædic cases. These special hospitals are now recognised as hospital schools. The number of children suffering from orthopaedic defects discharged after treatment as in-patients in the Council's hospital schools during 1936 was 698, of whom 342 were non-tuberculous and 356 tuberculous. London is a great centre for medical education and there are many voluntary hospitals, which maintain orthopædic departments, engaged in the teaching of medical students. These are all eager to undertake the orthopædic care of children. There are also special voluntary orthopædic hospitals at which orthopædic surgeons of the highest repute hold appointments. At some of these hospitals the Council's organisers of children's care work attend in the orthopædic departments as liaison officers. These include the orthopædic departments at Guy's, the Miller, St. George's, the Metropolitan and the Queen's hospitals. The Woolwich area stands in a category by itself owing to the lack of local orthopædic out-patient provision, and the distance parents must travel with their crippled children for advice. In this area the Council subsidises the remedial clinic which is provided by the Invalid Children's Aid Association. The number of children treated at this centre in 1937 was 279. 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 children 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, on behalf of whom the Council provides institutional treatment whenever required. Charges made to parents for medical and dental treatment The Education Act directs that a charge to the parents must be made for medical treatment. The following flat rates are charged to parents in London:— Minor ailments First fortnight free; then 1s. for each succeeding 6 months. Dental Slight, 1s.; Ordinary, 2s.; Extensive, 3s. (mainly gas). Nose and throat In-patient treatment for operation, 5s. All other 2s. 37 The number of "slight treatments" for dental conditions in 1937 was 12,827. Parents are invited by notices in the treatment centres to pay the full cost of treatment to the Council if they can afford it. For refraction of the eyes no charge is made as the Board of Education has indicated that refraction is "further inspection." The cost of spectacles, however, is borne bv the parents assisted, if necessarv, from voluntary funds. The average cost per case to the Council for the year ending 31st March, 1938, for treatment was:— s. d. Refraction 6 8 Operative treatment of enlarged tonsils and adenoids 17 10 Minor ailments 7 9 Dental treatment 7 3 Ringworm (X-ray treatment) 27 4 Where parents are too poor to pay anything, treatment is given and the charges are remitted after reference to the school care committees. The amount recovered from parents in 1937 was £14,072. Voluntary hospitals Co-operation of voluntary bodies A very valuable arrangement exists whereby one of the Council's organisers attends at many voluntary hospitals which are not included in the Council's scheme of medical treatment. These include the children's departments of the following hospitals: the Belgrade, Charing Cross, Guy's, the London, the Miller, the Queen's, West London, and Poplar. Organisers are also attached to the aural, eye and skin departments of Guy's hospital. Guy's hospital As an example of the work carried out under this provision, is given the following report of the divisional treatment organiser, who has assistant organisers working in the aural, eye, orthopædic and skin departments of Guy's hospital, and in the diphtheria carrier clinic:— The organisers form a link between the hospital physicians and surgeons and the school authorities. Reports are sent to the care committees on children attending the hospital, and the care committees send reports for the information of the physicians and surgeons. The almoner is very helpful in obtaining reports on children attending departments where there is no organiser. One of the children's physicians asked to have an organiser to work in the children's department in order to ensure closer co-operation with the schools. Accordingly, on 1st September, 1937, an organiser began work in that department and attends three mornings a week. The number of new children seen in the aural department during the year was 1,132, of whom 583 were discharged cured and an additional 24 were reported well by the care committees. There were 45 operations for removal of tonsils and adenoids. In the eye department, 652 new patients were seen during the year. Glasses were prescribed for 454 children and 428 obtained their glasses, 150 children were retested and found not to need a change of glasses and 47 children required no glasses. The number of new children seen in the orthopædic department during the year was 189, and 37 were discharged cured. Two children were found not to need treatment and 144 left school, left London, lapsed attendance or were treated elsewhere. There were 15 operations performed in the out-patient department, and 641 children attend periodically for supervision. Many children from this department are referred to the massage department for treatment. The organiser checks their attendances and reports to the care committee if they do not attend regularly. In the skin department, 545 new children attended during the year. Of that number 3 were cases of ringworm of the head and 76 were cases of scabies. The ringworm cases were referred to the light department of the hospital, and most of the scabies cases were referred to the school bathing centres for treatment. The number of new children seen in the children's department since 1st September, 1937, was 364. In the diphtheria carrier clinic, 54 new cases were treated, with a total of 195 attendances. Most of the children who attended in the aural, eye and skin departments are treated at home, but, for some, the surgeon recommends daily nursing treatment and the organiser arranges for such children to attend for daily treatment at the school treatment centres. The numbers of children referred to the school medical officer for special examination were as follows: for schools for the physically defective, 2; for elementary schools from schools for the physically defective, 4; for schools for the partially sighted, 1; for easy treatment (myopes), 2; for schools for the deaf, 4. 38 Pre-school children: co-operation with Borough Councils In order to effect improvement in the pre-school care of children, particularly of those between one and five years of age who are not under supervision by officers of a public authority, the Ministry of Health issued Circular 1550 in May, 1936. This circular advised maternity and child welfare authorities to make, wherever possible, arrangements with local education authorities for children of pre.school age to attend for the treatment of minor ailments and dental defects at the school treatment centres. Seven Borough Councils in London have made such arrangements with the Council. These are Battersea, Camberwell, Finsbury, Lewisham, St. Pancras, Wandsworth and Westminster. Stammering children At the ten centres for the treatment of stammerers from elementary schools a total of 405 children attended during the year; of these, 134 were discharged as cured, while 44, 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) three groups are dealt with by the same speech therapist on each half day. The two centres for secondary school pupils at the Henry Thornton school (south London) and the North.Western polytechnic (north London) were continued; 60 pupils attended, of whom 15 were discharged cured and 9 left. At Salter's Hill school, 51 children from residential schools of the Council attended a special centre. Of these, 15 were cured and 3 left. In 1934, the speech therapists began meeting regularly once a month to exchange views and ideas. The meetings were found to be so helpful that they have been continued ever since. Discussions take place regarding treatment, organisation and research; problems and experience are pooled and the meetings have proved of great value to the individual therapists, and to the work as a whole. In June, 1937, the meeting was thrown open to speech therapists outside London, and this extension was so successful that these larger meetings are now a quarterly institution. They are held on Saturday afternoons and are very well attended, not only by those who live near London, but by many from the Midlands and the north, who are thus able to discuss their problems and keep in touch with the work and each other. Nominations for treatment Rheumatism scheme Dr. C. E. Thornton, who supervises the rheumatism work, under the direction of Dr. C. J. Thomas, has prepared the following report:— During the year, 2,367 children were nominated for institutional treatment under the Council's rheumatism scheme, this figure being 30 fewer than the number of nominations received during the preceding year. For various reasons 69 of these nominations were subsequently withdrawn. Of the remaining 2,298, 113 were found on medical examination to be unsuitable for treatment under the scheme, either because of an error in diagnosis, or because they were cardiac cripples in a stage too far advanced to derive any benefit from treatment. Those accepted numbered 2,173, but in 114 instances the parents refused to allow the child to be sent away. It is gratifying to note that such refusals were approximately half those in 1936. During the year, 2,018 children were admitted to the units, and 69 were still awaiting admission at the end of the year. Accommodation in rheumatism units The nominal accommodation provided in the units was, at the end of the year, 900 beds, but the actual accommodation available tends to fluctuate considerably. This is due partly to the closure of wards for structural alterations or quarantine, and partly to the necessity at times of using the beds for other purposes. The number of children actually under treatment in the units on 31st December, was 774. All the available beds were occupied, and there were 69 children awaiting admission. 39 At the end of the year, 7,690 children were being supervised, either by school doctors or at the rheumatism supervisory centres. Care committee workers visited and made detailed reports on the home conditions of a large proportion of the children admitted to the rheumatism units during 1937. Altogether 1,448 such reports were received, and in 335 instances revealed defective housing conditions. These were reported to the borough medical officer of health in order that further investigations might be made and such remedial action taken as was possible. The principal defects found were dampness and overcrowding, but in not a few instances premises were reported to be verminous. Table 23 sets out in detail the facts which have been briefly summarised above. The factors associated with the occurrence of juvenile rheumatism all suggest that it is essentially an infective disease. Its seasonal incidence and social distribution are both consonant with this view, and its association with tonsillar infections even tends to implicate a specific organism—the hemolytic streptococcus. The seasonal prevalence is shown by the accompanying graph (fig. 3), which was constructed from an analysis of 1,500 cases admitted to the rheumatism units. The greater proportion of cases occur during the period October to February, and a definite relationship would seem to exist between the prevalence of the disease and the amount of sunshine, the mean air temperature and the percentage of atmospheric humidity. A low mean air temperature, a small amount of sunshine and high percentage atmospheric humidity when occurring simultaneously, seem to be associated with a high incidence of juvenile rheumatism, and these are also conditions which favour the lowering of the resistance of the body to infection. The distribution of juvenile rheumatism among the various London boroughs may be gauged by the number of nominations for treatment per 1,000 elementary school children in each borough. As thus arrived at, the incidence seems to coincide closely with the density of population and is therefore, in the main, heaviest in the poorer and more over-crowded boroughs. A comparison of the incidence of rheumatism in secondary school children with its incidence amongst elementary school children also suggests that children of less prosperous parents suffer more frequently. Figures from the secondary schools showed an incidence of rheumatism equal to approximately .5 per cent. of the secondary school population, whereas for elementary schools the percentage incidence was about 2.6. Also rheumatism was found more frequently in "scholarship" children in attendance at secondary schools than in the fee-paying pupils. It seems clear that, until more precise knowledge of the infecting agent is available and it can be attacked directly, the chief efforts, in so far as prevention is concerned, must take the form of an endeavour to increase the child's resistance to infection. This can best be accomplished by ensuring a healthy home environment, coupled with an adequate and well-balanced dietary. It is at present lamentably obvious, judging from reports received of the home conditions of rheumatic children, that much still remains to be done in the matter of improved housing conditions, although great progress has, of course, been made. With regard to an adequate dietary, it can be confidently expected that the recently established nutrition centres will be of much indirect assistance in the campaign against juvenile rheumatism. An analysis of the admissions to and discharges from the rheumatism units during 1937, is given in tables 24 and 25, respectively. It is to be noted that approximately 43 per cent. of the children admitted showed signs of cardiac involvement, but, as has been pointed out in previous reports, in about 25 per cent. of such cases the carditis subsides, no permanent cardiac damage being sustained. Even in the group of cases where the heart has been permanently damaged, the lesion is not necessarily of the severe progressive type. A special analysis of 1,000 cases admitted to the units revealed the fact that, when the attack of rheumatism was ushered in by an acute tonsillitis, the prognosis, so far as the heart was concerned, was particularly grave. In no fewer Supervision Home conditions Infective nature of juvenile rheumatism Seasonal prevalence Distribution of juvenile rheumatism in London Prevention Tonsillitis and cardiac damage 40 than 70 per cent. of such cases gross and permanent cardiac damage resulted. Fortunately this type of onset is not very common, only 53 cases occurring in this series of 1,000. Even where there is no definite history of tonsillar infection, there is some evidence that, when the tonsils have been removed prior to the first attack of rheumatism, there is slightly less risk of severe cardiac involvement occurring. An analysis of 1,500 cases admitted to the rheumatism units showed that, of those children whose torsils had not been removed before the onset of the first attack, 24.6 per cent. suffered definite and somewhat severe permanent cardiac damage. On the other hand, in those children whose tonsils had been removed, the heart was permanently and severely damaged in only 18.9 per cent. of cases. 41 It is hoped that it will be possible to investigate this point more fully during the ensuing year. From table 25. which deals with discharges from the units, it will be seen that 76.3 per cent. of the children on discharge were regarded as fit for ordinary education or any type of employment; 3.5 per cent. could only be described as "permanently unfit" for any type of school or work; 20 per cent. were regarded as fit to attend schools for the physically defective or able to undertake light work. Although a somewhat high percentage of children discharged must be classed as more or less "invalid," it must be remembered that many of them are long-standing cases of rheumatic cardiac disease who have been admitted for a period of cardiac rest. Actually the percentage of school children suffering from acquired heart disease has shown a steady diminution since 1926. In that year, the percentage was 2.0; in 1936 it had decreased to .8 per cent. While it might be claiming too much to attribute the whole of this decrease to the operation of the Council's rheumatism scheme, it is unreasonable to believe that the two are in no way associated. Fitness of children discharged from units Table 23 Particulars 1935 1936 1937[.###] Nominations for institutional treatment under the, scheme— Number received from the Council's hospitals 256 678 761 „ „ „ voluntary hospitals 750 619 548 „ „ „ rheumatism supervisory centres 526 576 565 „ „ „ school doctors 214 303 348 „ „ „ other sources (chiefly private practitioners and welfare organisations) 213 221 145 Total number received 1,959 2,397 2,367 Subsequently withdrawn No record 55 69 Final total 1,959 2,342 2,298 Examinations by medical referees— Examined and accepted with concurrence of parents Not recorded 2,013 2,059 „ „ „ but treatment refused 210 114 Examined and found unsuitable for institutional treatment 117 113 Awaiting examination, 31st December 2 12 Total — 2,342 2,298 Treatment— Outstanding cases awaiting admission from previous year Not recorded 72 33 Number accepted during current year 2,013 2,059 Total — 2,085 2,092 Admitted to rheumatism units 1,639 2,039 2,018 Died before admission was arranged — 1 5 Awaiting admission, 31st December 72 45 69 Total 1,711 2,085 2.092 Supervision— Number of children under supervision (31st December) by school doctors. 2,129 2,596 2,526 Number of children under supervision (31st December) at supervisory centres Not re corded 5,164 Total — — 7,690 Number of supervisory centres 20 20 20 Number of sessions at supervisory centres 1,067 1,088 1,073 Number of children attending for first time 2,047 1,921 1,920 Total number of attendances at centres 15,420 15,913 15,552 Reports by care committees on home conditions 1,365 1,664 1,448 Number of premises reported to borough medical officers of health re dampness or to valuer re obtaining of better accommodation 225 442 335 Rheumatism Units— Nominal accommodation (i.e., number of beds) 830 930 900 Average number of beds available 826 889 856 Average number of beds occupied 730 803 798 42 Table 24.—Admissions to rheumatism units, 1937 Sex Rheumatism and/or chorea with cardiac involvement Rheumatism and/or chorea with no cardiac involvement Total Number | Percentage Number Percentage Boys 387 43.4 504 56.6 891 Girls 481 42.7 646 57.3 1,127 Total 868 431 1,150 56.9 2,018 Table 25.—Discharges from rheumatism units, 1937 Sex Fit for elementaryschool or any employment Fit for P.D. school or light work Permanently unfit Total Number Percentage Number Percentage Number Percentage Boys 634 74.3 188 22.0 31 3.7 853 Girls 839 78.3 197 18.4 36 3.3 1,072 Total 1,473 76.3 385 20.2 67 3.5 1,925 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 in accordance with 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 1937, 1,556,682 examinations of children were made at these rota visits. In 123,663 cases the child was noted as verminous, i.e., in 7.9 per cent. of the examinations, compared with 8.1 for 1936 and 8.6 for 1935. 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 82,357 (compared with 85,300 in 1936, and 79,557 in 1935), figures which represent all those children who were noted to be infested with live vermin or their ova. About 48 per cent. of the cases in which verminous conditions were recorded at the rota visits were stated to be infested, at the time of examination, with nits only. There are 10 Council centres for cleansing, 21 Borough Council centres, and 9 centres organised by voluntary committees; but, as the last named are limited to head cleansing, these are not equipped with sterilisers or baths. An additional Borough Council centre. Holborn, was opened in April. The following particulars for 1936 and 1937 are in respect of the cleansing scheme operated from the Council's and Borough Councils' centres (as distinct from the "head" cleansing centres):— 1936 1937 Number of advice cards issued to parents from bathing centres 84,116 82,357 Number of children attending voluntarily at bathing centres after advice cards 44,583 42,899 Number of statutory notices served in accordance with section 87 of the Education Act, 1921 20,716 22,604 Number attending bathing centres after statutory notices:— (a) voluntarily 4,726 4,279 (b) compulsonly 15,641 16,514 Number of cases in which police court proceedings were taken 300 250 43 At the head cleansing centres, 20,362 children attended during the year compared with 22,138 in 1936. 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 1937 a total of 63,451 children attended the bathing and head-cleansing centres, compared with 66,464 in 1936 and 75,023 in 1935. Not all these children were, however, referred under various stages of the cleansing scheme, but a certain number attended voluntarily before their departure for 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, taken by ambulances. In 1937, 12,510 children were conveyed in the ambulances. Children suffering from scabies and impetigo are treated at the bathing centres. The total of such cases was 10,962 for the year, a considerable increase on the number for the previous year (8,389). Co-operation with the medical officers of the City of London and the metropolitan boroughs in remedying verminous conditions in the homes of children has been continued. The high incidence of scabies which shows still further increase 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 re-infection is frequent. In the early part of 1937, consideration was given to the measures which could usefully be taken with a view to reducing the incidence of impetigo and scabies. It was decided to adopt the following measures:— (1) The education officer to arrange for school attendance officers to forward to the divisional medical officers information concerning children suffering, or suspected to be suffering, from scabies or impetigo. (2) Head teachers to be asked to co-operate by drawing the attention of the assistant medical officers or the school nurses to children with sores, scabs, or other abnormal conditions of the skin, and to report on the appropriate form to the officers concerned information regarding children absent or excluded from school suffering from scabies, impetigo, or abnormal skin conditions. (3) A letter, indicating the facilities for treatment provided at the Council's bathing centres, to be circulated to the voluntary hospitals and private medical practitioners. The medical officers of health of the metropolitan boroughs very kindly arranged for the distribution of this letter to the hospitals and practitioners in their respective areas. (4) School nurses to be invited to attend a "refresher" lecture and demonstration dealing with scabies, impetigo and allied skin complaints in school children, to be conducted by members of the Council's medical staff at the group laboratory at the North-Western hospital. The co-operation of the sanitary departments of the Borough Councils in respect of simultaneous disinfection of homes is gratefully acknowledged. 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 1937 was 25,031, compared with 30,263 in 1936. Scabies and impetigo Warm baths 44 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. Table 26 shows the number of children reported to have been out of school for more than three months in November, 1937, and comparative figures for the three preceding years. The number of children (114) absent on account of rheumatism, chorea and heart disease still forms a very high proportion (22 per cent.) 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, and the number not receiving education is now 114, compared with 320 in 1934. Nervous disorders (including 18 cases of epilepsy, 4 of infantile paralysis, and 2 of encephalitis lethargica) accounted for 36 children. Ringworm, formerly a chief cause of prolonged absence from school, accounted for only 6 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 22 cases. Among other ailments, respiratory diseases, other than tuberculosis, accounted for 54 cases, and ear disease for 27. The total invalidity among girls was greater during 1937 than among boys (272 to 240). There were 2 boy cripples and 4 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." Among the "other defects" are also certain numbers of deaf, blind and mentally defective children, who, after ascertainment, at the moment of taking the census had not been placed in special schools. Table 26.—Census of chronic invalids, November, 1937, and preceding years Ailment Cases Percentage of total 1934 1935 1936 1937 1934 1935 1936 1937 Rheumatism, heart disease and chorea 320 232 153 114 36.00 30.9 26.7 22.3 Nervous disorders 59 61 58 36 6.64 8.1 10.0 7.0 Tuberculosis (all forms) 79 67 39 22 8.90 8.9 6.8 4.3 Anaemia and debility 40 41 37 30 4.53 5.5 6.4 5.9 Ringworm 5 2 2 6 0.56 0.3 0.3 1.2 Skin complaints (excluding ringworm) 25 35 24 29 2.82 4.7 4.2 5.6 Eye disease 8 9 12 10 0.91 1.2 2.1 2.0 Infectious diseases 45 35 23 29 5.07 4.7 4.0 5.6 Other defects 307 268 225 236 34.57 35.7 39.5 46.1 Total 888 750 573 512 100 100 100 100.0 45 Infectious diseases in schools Elementary 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 1937, compared with similar figures reported during the preceding six years, are shown below:— Table 27 Year Diphtheria Scarlet fever Measles and German measles Whoopingcough Chickenpox Mumps Ophthalmia 1931 3,202 5,626 3,811 9,019 13,598 5,685 889 1932 3,338 6,832 34.922 7,624 11,440 8,016 649 1933 4,446 11,357 14,130 8,373 10,863 9,591 427 1934 5,439 8,850 37,701 5,029 10,283 6,354 554 1935 4,337 5,078 3,079 7,500 10,146 12,199 354 1930 3,268 4,852 32,089 7,303 8,659 7,844 473 1937 3,656 3,903 5,536 6,320 10,032 8,788 274 The figures for ringworm are given later in this section of the report (page 48). A reference to the numbers of cases of scabies and impetigo, the treatment of these diseases, and the special measures taken during 1937 with a view to reducing their incidence, is made on page 43. No case of smallpox was 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 28 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. 28 24 3,226 18 14 2,074 N. 45 32 4,159 25 21 2,593 N.W 14 12 911 30 24 2,208 S.W. 31 26 2,698 15 15 1,429 S.E. 33 25 2,185 37 28 2,415 Total 151 119 13,179 125 102 10,719 Children in certain schools were examined from time to time tor the reasons stated, viz., one on account of ophthalmia; one on account of dysentery, and one on account of a skin condition which subsequently proved to be chickenpox. 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 and diphtheria, as well as in the special visitation of schools where there were outbreaks of whooping-cough, chickenpox, mumps, measles, scabies and ophthalmia. In the course of 151 visits paid by the school medical staff to 119 departments in elementary schools, 13,179 children were inspected and swabbings from the throat and nose of 3,631 selected children (including a number seen at clinics or treatment centres) were taken for bacteriological examination; 3,362 proved negative. In 269 (7.4 per cent.) bacilli morphologically resembling diphtheria were found in culture, and 237 of the cases were isolated for virulence testing, 216 (91 per cent.) proving virulent and 21 non-virulent. In addition to the above, swabs were taken from discharging ears of 32 children (21 proving negative and 11 yielding diphtheria bacilli), and from the eyes in one case of conjunctivitis, which showed diphtheria bacilli. Diphtheria D 46 Virulence tests were applied in six of the eleven positive cultures from the ears, three proving virulent and three non-virulent, while the single case of conjunctivitis (diphtheria bacilli) proved non-virulent. As a precautionary measure cultures from throat and nose were taken from 482 children prior to entry to convalescent homes, holiday camps, etc. In 7 (1.45 per cent.) bacilli morphologically resembling diphtheria were found in culture; 4 proved virulent and 3 non-virulent. The arrangements made with Guy's hospital, St. Mary's, Paddington, hospital, and the Hospital for Sick Children, Great Ormond-street, for the treatment of diphtheria "carriers" at special out-patient clinics, to which reference has been made in previous annual reports, were continued throughout 1937. During the year, 66 children from the Council's schools, who were found to be harbouring virulent diphtheria bacilli, were sent to these clinics. The medical officers in charge of the clinics have furnished reports on the methods of treatment employed and the results obtained. Some of the cases were found to have lost their "carrying" propensity by the time they reached the clinics. The persistent "carriers" all cleared up after intensive treatment. In one case, it was found necessary to remove unhealthy tonsils and adenoids before the "carrier" condition cleared up. As stated in the annual report for 1936, arrangements for immunisation against diphtheria are now made by the Corporation of London and the Metropolitan Borough Councils, the work being carried out at infant welfare or special centres, or by arrangement with medical practitioners or voluntary hospitals. 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 Councils providing the facilities. The following review of the incidence of diphtheria, and the mortality amongst the child population of London for the ten-year period 1926-1935, and of the measures of prevention by immunisation, will be of interest:— The mean of the total child (0—15 years) population (1,000,100) for the period of the review shows annual averages of 9,047 notified cases (9-01 per 1,000); 367 deaths (3-05 per 10,000) and a case mortality of 4 per cent. Immunisation against diphtheria by the Metropolitan Borough Councils was commenced in 1922 in the metropolitan borough of Holborn, and by the beginning of 1927 two other authorities adopted preventive inoculation, yielding in all at that date a total of under 1,000 Schick-tested and fewer than 500 immunised. Five years later, at the end of 1932, marked progress had been made, as, by that time, fourteen local sanitary authorities were affording facilities, and not far short of 16,000 individuals had been tested or inoculated, including over 9,000 actively immunised. During the next three years, 1933-35, provision was made by ten additional local sanitary authorities, either by the establishment of immunisation clinics or through cooperation with general medical practitioners who undertook the inoculation of their private patients, so that by the end of 1935 it was possible to record that 14,000 further individuals had been immunised, and that a total of over 38,000 were Schick negative or had been inoculated, i.e., more than double the number dealt with at the close of 1932. During 1936, four more local sanitary authorities, which had not, up till then, adopted preventive measures, decided to open immunisation clinics at treatment centres. During the period under review, 6,498 children were found to be Schick negative at the primary test. A course of diphtheria prophylactic treatment was given to 31,573 positive cases, and of these 23,118 were subsequently found to be Schick negative. The total number of clinical cases of diphtheria reported among the 23,118 immunised children was 41, but in the majority the symptoms of the disease were mild in character. There was no death. The attack rate was 1.77 per 1,000. Additional reported cases occurring among those who had received prophylactic inoculation, but who had not been subsequently Schick-tested, are not included in the 41 cases mentioned above. Those known or presumed to be protected, including primary Schick negatives (i.e., naturally immune) and those immunised (i.e., found negative after inoculation) numbered, at the end of 1935, 29,616—a proportion of 2.96 per cent, of all children under 15 years of age. By taking into account those children who received the full prophylactic course, but who were not proved immune by subsequent Schick negative test, a total of 38,071 potentially protected individuals was reached at the end of 1935. If the child population of the five boroughs in which there is no record of immunisation up to 1935 is discounted, the following percentages would be obtained: known or presumed to be protected 3.87; potentially protected 4.97. A diphtheria protection rate of approximately 3 per cent. for the whole of London will leave the general incidence and mortality practically unaffected, as, to produce any material effect, the immunisation of between fifty or sixty per cent. of the child population, including the pre-school age group, should be secured and maintained. There is, however, substantial benefit to the individuals who have been immunised. Diphtheria "carriers" out-patient clinics Active immunisation against diphtheria 47 The immunising agent in most common use is toxoid antitoxin mixture (T.A.M.). This agent was used in twenty-three of the twenty-four areas in which immunisation had been adopted up to the end of 1935. Eight of the areas in which there have been facilities for immunisation for the longest periods have continuously adhered to its sole use. In one borough, the use of T.A.M. has been restricted to the cases of younger children, toxoid antitoxin floccules (T.A.F.) having been reserved for older children and adults. In fourteen areas T.A.M. has been supplemented or replaced by other prophylactics of later production, e.g., toxoid antitoxin floccules in nine areas ; alum precipitated toxoid (A.P.T.) in seven areas ; toxoid antitoxin (goat) in two areas. A reference to the active immunisation against diphtheria of children in the Council's residential schools and homes appears later in this section of the report. The incidence of scarlet fever among the children on the school rolls was again unusually low, 3,903 cases being reported, compared with 4,852 cases during 1936, and an average of 7,100 for the years 1931-1936 inclusive. There was an even distribution of the cases throughout the year. A reference to immunisation against scarlet fever, which is being carried out in three of the residential establishments for children, appears later in this report. References have been made in previous annual reports to the practice which has been carried out at the Cyril Henry treatment centre, Woolwich, since 1933, and at the Hanover Park centre, Peckham, since October, 1936, 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. Parental consent is obtained in each case The following arc particulars which have been received from Dr. H. R. Kidner, divisional medical officer:- Cyril Henry treatment centre Hanover Park treatment centre Children attended . 1,530 1,312 Operation deferred 329 201 Scrum given ... 1,052 689 Serum not given because of— Recent attack of scarlet fever or diphtheria 30 176 Recent immunisation — Recent asthma 2 Parents refused consent 108 225 Consent, forms not completed bv parents 21 As noted in previous reports, no case of scarlet fever or diphtheria occurred at either centre amongst those injected. Two cases of scarlet fever occurred at the Hanover Park treatment centre amongst those not immunised. No serious aftereffects of the injection occurred amongst the children. The biennial epidemic of measles was due to begin in the autumn of 1937, and, from information furnished by the head teachers, it was evident that it had commenced in certain parts of London towards the middle of November, 75 cases being reported during the week ended the 13th of that month. The average number of cases reported weekly during the preceding eight weeks was 46. The following statement shows the number of cases of measles reported from the schools during the first stages of this, and of the three preceding epidemics:— 1931-32 1933-34 1935-36 1937-38 Nine school weeks preceding Christmas holidays 1,568 1,899 1,032 1,553 First six weeks of spring term 4,809 7,065 3,928 6,425 It is evident that the present epidemic developed rather more rapidly than the last epidemic and approximated, in this connection, to the epidemic of 1933-34. The special scheme of co-operation between the school nurses, teachers, school attendance officers, and borough medical officers of health (through their health visitors), to which reference has been made in previous annual reports, has again been put into operation during the present epidemic. 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, so that consideration may be given to the question of providing home nursing facilities through the borough health services or of arranging for the admission of cases of the disease to the Council's hos2)itals. In January and February, 1938, the scheme was applied to 210 schools, and leaflets containing advice to parents, issued by the borough medical officers, were distributed in the schools concerned. According to past experience, the epidemic is likely to last until July, 1938. Scarlet fever Passive immunisation against scarlet fever and diphtheria at treatment centres Measles 48 Ringworm Cases of ringworm of the scalp occurring among children in the Council's schools are followed up by the school nurses, and, if any difficulty is experienced in treatment by ointments and lotions, the parents are offered X-ray treatment under agreements made by the Council with certain voluntary hospitals and treatment centres. The following table shows the number of cases of ringworm of the scalp among the children in the Council's schools reported during 1937 compared with previous years:— Table 29 Year New cases Cured cases Cases outstanding at the end of the year Percentage of cures effected by X-ray treatment 1926 1,029 1,141 228 76 1931 419 420 107 62 1934 265 281 65 73 1935 196 211 43 77 1936 190 187 44 67 1937 181 164 61 66 During the year, 409 specimens of hair from school children were examined for ringworm at the laboratory at the County Hall. Ringworm fungus was found in 107 of these (84 small spore and 23 large spore). One case of favus was discovered after microscopical examination. 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. Special arrangements for the medical examination of children before departure for school journeys were continued. Particulars of the general arrangements made for school journeys during 1937 are set out on page 55. The measures taken in co-operation with the public health authorities in the home counties with a view to preventing the introduction of infectious diseases among workers in the hop-fields, which have been described in previous annual reports, were continued in 1937. Residential establishments for children In the annual report for 1936, reference was made to cases of body ringworm which occurred among boys at Ardale and Mayford approved schools. The outbreaks subsided in the early part of 1937. Apart from an outbreak of tinea (feet) and a few cases of otitis media at Mile Oak school, in connection with which appropriate steps were taken, the few cases of infectious diseases in the approved schools do not call for comment. A small number of cases of scarlet fever occurred during the year at Stamford House remand home and some cases of diphtheria developed there. The inmates were kept under careful observation and swabbed where necessary. References to the occurrence of cases of vulvo-vaginitis at this home are made later in this report. Active immunisation against diphtheria was continued during 1937 at all five of the approved schools, as was also active immunisation against scarlet fever at the Mayford school. The few cases of infectious illness which occurred among the children at the residential special and open-air schools do not call for any special comment. The infectious diseases which occurred in any appreciable numbers in the residential schools, children's homes and children's receiving homes were : measles at two schools, German measles at one, whooping-cough at two, chickenpox at four schools and one receiving home, mumps at three schools, ringworm (head) at one and influenza at one. All practicable steps were taken to control the spread of infection in the establishments, including the removal of patients to one or other of the Council's hospitals. Favus Play centres School journeys Hop picking —infectious disease Approved schools and remand home Residential special and open-air schools Residential schools, children's homes, and children's receiving homes 49 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, 295 children were admitted to the "contact" block at Earlsfield House, and of these, 30 children developed the, disease to which it was stated they had been exposed, and 16 developed other diseases. References have been made in previous annual reports to the scheme for active immunisation against diphtheria in the Council's residential establishments for children. In the report for 1936 it was mentioned that this preventive measure was first systematically applied in 1931 at the establishments under the control of the Council where children are permanently in residence, including the residential special schools and the approved schools, but that immunisation had not been put into operation in the 2 receiving homes, the 3 residential open-air schools and the remand home, as the children at these establishments do not remain there for a sufficient length of time. The materials employed for this prophylactic work, i.e., the diphtheria toxin for Schick-testing and the formol toxoid used as immunising agent, are prepared at the Council's antitoxin establishment at Belmont, Surrey, under the supervision of Dr. R. G. White, the director. In the annual report for 1936 an analysis was made of the numbers of children Schick-tested and immunised during the period 1932-1935. During the year 1936, 1,598 children were Schick-tested, viz., 1,095 boys and 503 girls, of whom 693 boys (63.3 per cent.) and 258 girls (51.3 per cent.) proved to be Schick negative or naturally immune from diphtheria, whilst 402 boys (36.7 per cent.) and 245 girls (48.7 per cent.) were found to be Schick positive, or susceptible to diphtheria. The percentage proportion in each year of age of Schick negative and positive cases, tabulated according to sex, was found to be as follows Table 30 Age Total tested Percentage Male Female Schick negative Schick positive Male Female Male Female 2 years 52 45 19.2 20.0 80.8 80.0 3 „ 72 52 34.7 32.7 65.3 67.3 4 „ 64 45 32.8 40 0 67.2 60.0 5 „ 36 39 66.7 43.6 33.3 56.4 6 „ 35 41 57.1 34.1 42.9 65.9 7 „ 35 35 57.1 54.3 42.9 45.7 8 „ 42 36 47.6 66.7 52.4 33.3 9 „ 39 35 61.5 62.9 38.5 37.1 10 „ 37 26 73 0 53.8. 27.0 46.2 11 ,, 51 30 76.5 80.0 23.5 20 0 12 „ 96 22 67.7 81.8 32.3 18.2 13 „ 112 34 70.5 58.8 29.5 41.2 14 „ 129 20 65.9 80.0 34.1 20.0 15 „ 130 18 80.0 66.7 20.0 33.3 10 „ 165 24 78.8 58.3 21.2 41.7 1095 502 63.3 51.3 36.7 48.7 Age groups of children in above table 2-5 years 224 181 35.7 33.7 64.3 66.3 6-10 „ 188 173 59.0 53.8 41.0 46.2 11-16 „ 683 148 73.5 70.3 26.5 29.7 No date of birth — 1* — — — — 1095 503 63.3 51.3 36.7 48.7 * Schick positive. Active immunisation against diphtheria 50 Of the total of G47 Schick positive cases 508 (78.5 per cent.) proved to be negative after three immunising injections. Of those remaining Schick positive and therefore not protected, 14 were found to have become immune after receiving further injections of formol toxoid, yielding a total of 522 immunised. The remaining 125 children left school before immunisation could be completed. The following is a summary of the progress of immunisation during 1937 :— Table 31 Classification Residential schools and children's homes Residential special schools Approved schools Uncompleted cases brought forward from 1930 177 20 58 Number tested for susceptibility 648 112 330 Number found to be immune 322 72 212 Number found to be susceptible 320 40 118 Completed full immunising course and gave negative reactions on re-test 316 35 104 Loft school before course of immunising injections had been completed 90 4 22 Outstanding on 31st December, 1937, to be completed in 1938 91 21 50 During the year, 17 children were removed to hospital from the residential institutions where immunisation against diphtheria is carried out, suffering or suspected to be suffering from diphtheria. As a result of subsequent findings, 1(5.9 per cent.) proved to be not diphtheria, 1 (5.9 per cent.) yielded bacteriological but no clinical evidence of diphtheria, and 15 (88.2 per cent.) were found to be suffering from clinical diphtheria. The following is an analysis of the 15 clinical cases:— Classification Diagnosis Schick negative on preliminary test Mild faucial 1 2* Mild clinical and morphological 1 Schick negative after course of prophylactic injections Laryngeal and faucial 1 2t Mild clinical 1 Course of prophylactic injections not completed Mild faucial 1 3** Mild anterior nasal 1 Moderate faucial 1 Not Schick-tested Moderate clinical 2 8 Mild faucial 1 Moderate faucial 1 Laryngeal 1 Mild anterior nasal 1 Moderately severe nasal 1 Diphtheritic stomatitis 1 There was a general consensus of opinion amongst the medical officers of the establishments concerned that the results of immunisation had been satisfactory ; that reactions following inoculation had been negligible ; and that there had been no administrative difficulties. Active immunisation against scarlet fever was continued during 1937 at Mayford approved school and at Shirley and Ongar residential schools, and was commenced at Hutton residential school in January, 1937. Active immunisation against scarlet fever *—1—19 months after Schick negative result. 1— 5 years „ „ „ „ †—1— 2 years ,, ,, „ ,, 1— 3 years ,, „ ,, ,, **—1—3 clays after first injection of diphtheria prophylactic. 1— 9 days „ second „ „ ,, 1— 4 days „ third „ „ „ 51 The following is an analysis of the number of children Dick-tested and immunised at Mayford approved school and Shirley and Ongar residential schools during 1936:— Table 32 Age Total tested Percentage Male Female Dick negative Dick positive Male Female Male Female[/##] 2 years 25 16 20.0 37.5 80.0 62.5 3 „ 15 9 13.3 22.2 86.7 77.8 4 „ 5 2 40.0 50.0 60.0 50.0 5 „ 5 5 100.0 80.0 — 20.0 6 „ 1 7 100.0 71.4 — 28.6 7 „ 6 6 66.7 66.7 33.3 33.3 8 „ 12 6 91.7 66.7 8.3 33.3 9 „ 18 6 83.3 83.3 16.7 16.7 10 „ 11 5 90.9 80.0 9.1 20.0 11 2 — 100.0 — — — 12 „ 8 5 12.5 40.0 87.5 60.0 13 „ 33 5 66.7 80.0 33.3 20.0 14 „ 44 5 68.2 100.0 31.8 — 15 „ 21 3 52.4 100.0 47.6 — 1C „ 1 — 100.0 — — — 207 80 58.9 61.2 41.1 38.8 Age groups of children in above table 2- 5 years 50 32 28.0 40.6 72.0 59.4 0-10 „ 48 30 85.4 73.3 14.6 20.7 11-16 „ 109 18 61.5 77.8 38.5 22.2 207 80 58.9 61.2 41.1 38.8 Of the total of 11G Dick positive cases, 90 (77.6 per cent.) proved to be negative after the usual course of immunising injections. Of those remaining Dick positive, and therefore not protected, 6 were found to have become immune after further injections, yielding a total of 96 immunised. The remaining 20 children left school before immunisation could be completed. The following is a summary of the progress of immunisation during 1937 at the three residential schools (Shirley, Hutton and Ongar) and at Mayford approved school:— Uncompleted cases brought forward from 1936 62 Tested for susceptibility 863 Found to be immune 625 Found to be susceptible 238 Completed full immunising course and gave negative reactions on re-test 211 Left school before course of injections had been completed 39 Outstanding on 31st December, 1937, to be completed in 1938 50 During the year, 8 children were removed to hospital from the above-named schools suffering from scarlet fever. Six of these children had not been Dick-tested; one (who had proved to be Dick positive) contracted scarlet fever 6 days later before immunisation had been commenced; and one (who had been Dick negative in 1935) contracted scarlet fever on the 22nd October, 1937—28 months after the Dick negative result. During the year 29 cases of vulvo-vaginitis were reported among the girls in the residential establishments (excluding the remand home). Of the 29 cases, 2 only were found to be positive for gonococcal infection: one from an approved school, and one, in which no evidence of gonorrhoea was found either clinically or pathologically, after admission to hospital. Vulvovaginitis 52 There were 65 cases of vulvo-vaginitis reported from the Stamford House remand home, all of which were removed to hospital. Bacteriological or clinical examination revealed evidence of gonococcal infection in 27 of these cases. Open-air education Provision for education in the open air includes nine day open-air schools (non-tuberculosis) with accommodation for 1,400 children, and six day open-air schools (tuberculosis) accommodating 515 children. There are also seven country and seaside convalescent camp schools, accommodating 520 children for periods varying from one to three months, through which 3,479 children passed last year, and 225 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. The following table gives the roll of these schools in December, 1937:— Boys Girls Total Aspen House 77 53 130 Bow Road 105 77 182 Brent Knoll 91 53 144 Charlton Park 94 56 150 Downham 89 54 143 Holly Court 189 98 287 Stowey House 176 114 290 Upton House 90 62 152 Wood Lane 91 63 154 Total 1,002 630 1,632* *Note—The roll of an open-air school may be 20 per cent. above the nominal accommodation. Plans have been approved for the rebuilding of Bow-road school. In addition to the provision of treatment for tuberculous children in residential institutions, the Council has provided six open-air schools (type T) specifically for children with quiescent tuberculosis, contacts of cases of 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. The six schools—Elizabethan (Fulham), Geere House (Stepney), Kensal House (Paddington), Springwell House (Battersea), Stormont House (Hackney), and Nightingale House (Bermondsey)—have a total nominal roll of 602. The number on the roll on 31st December, 1937, was 563, and the average attendance for the year was 472. 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 1937, 165 children were admitted and 156 discharged. Of the latter, 47 were transferred as fit to attend elementary schools, 51 were fit for work on attaining school-leaving age, 36 moved away, 12 were transferred to other special schools, and 10 were discharged for other reasons (e.g., the distance was found to be too great for the children). During the year, 68 children were also transferred to institutions for residential treatment for tuberculosis or admitted to hospitals for various reasons. Efforts were made to secure that, during 1937, 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. Provision Open-air schools for non-tuberculous children Open-air sohools for tuberculous children 53 The following school journeys were made during the year, through the ordinary school journey organisation:— Table 33 School Period Place visited No. of children From To Elizabethan 21.5.37 4.6.37 Shanklin 35 Geere House 11.6.37 25.6.37 Ewhurst 30 Geere House 6.7.37 20.7.37 Kimpton 20 Kensal House 2.7.37 16.7.37 Hroadstairs 44 Kensal House 26.8.37 9.9.37 Broadstairs 44 Nightingale House 2.7.37 16.7.37 Weymouth 38 Springwell House 27.8.37 10.9.37 Tankerton 30 Springwell House 10.9.37 24.9.37 Broadstairs 30 Springwell House 10.9.37 24.9.37 Tankerton 30 In addition, provision was made for a further 129 children in accommodation specially set aside for the purpose at the Council's Millfield convalescent hospital, Rustington. They went in parties for a fortnight each, and 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 or private arrangements for holiday failing to materialise. The advantages of open-air education, especially for the debilitated town child who has few or no opportunities at home to enjoy fresh air, sunshine and play, are now so well proven that they hardly require further demonstration. The following annual report by Dr. Louisa Adam on the open-air school at Aspen House school, Brixton, serves as an example:— The school was visited weekly throughout the year, the children being kept under strict medical supervision and weighed and measured monthly. Of the various types of child submitted for admission, a few only were found to be unsuitable, e.g., sufferers from bronchitis, and those giving a rheumatic history. Cases of fibroid lung, not exhibiting marked symptoms, and sufferers from mild and infrequent asthma, were found usually to do well and derive benefit. The many children suffering from general debility, and also those suffering from anæmia, made good progress and showed an all-round improvement. Certain cases of old tuberculous peritonitis and cervical adenitis, also tuberculosis contacts referred by the tuberculosis officer, were admitted and made satisfactory progress. The incidence of infectious disease during the year was very small. Four children attended St. Thomas' hospital for remedial exercises; 67 received dental treatment, 2 children were treated for enlarged tonsils and 7 for vision. An average of about 20 children attended daily for treatment for minor ailments. It is obvious that the life at the open-air school, with its combination of work, rest and exercise, regulated as it is to suit the type of child in attendance, has a most beneficial effect on the health of the children, who give the impression of happiness and contentment. The average increase in height for the whole school was 5.89 cm., and in weight 3.82 kg. The average increase in height in children over 11 years of age was: boys, 5.25 cm.; girls, 5.75 cm.; and in weight: boys, 3.22 kg.; girls, 3.87 kg. The average gain in height in children under 11 years of age was: boys, 5 cm.; girls, 6 cm.; and in weight: boys, 3.22 kg.; girls, 2.53 kg. In respect of the Charlton Park open-air school, Greenwich (from the neighbourhood of which an open-air school (T) is not readily accessible), the following extract from the report of the medical officer of health of he borough of Greenwich is of interest:— Many children were recommended for admission to the open-air school during 1936. Some 50 children are on the roll, and they are seen at intervals by the tuberculosis officer. Once again, special mention must be made of the remarkable improvement seen in these sub-normal or "contact" children after a period at the school. It is a tribute to the care and attention bestowed on them. The numbers of children spending a period of stay at the residential convalescent camp schools during 1937 were: boys, 1,861; girls, 1,618; total, 3,479. Reports on open-air schools Convalescent camp schools 54 In detail the numbers were:— Provided schools:— Boys Girls King's Canadian school, Bushy Park 1,749 — George Rainey, St. Leonards — 513 Wanstead House, Margate — 633 Total 1,749 1,140 Non-provided schools:— Boys Girls Fairfield House, Broadstairs — 78 Russell Cotes school, Bournemouth — 230 St. Vincent's, Hastings — 109 Sandon home, Chelmsford 112 55 Total 112 472 The actual number of children away at these schools at one time in 1937 was: Rushy Park, 248; St. Leonards, 62; Margate, 94; Broadstairs, 20; Bournemouth, 31; Hastings, 7; Sandon, 19. Total, 481 children, of whom 214 were girls and 267 boys. The small home at Sandon accommodates the children needing a country holiday from the various types of special schools. The length of stay of boys at the King's Canadian camp school, which was formerly limited during the summer months to four weeks, was increased to six weeks throughout the year. This resulted in reducing the number of boys sent during the year, but gave more lasting benefit. The six Weeks' stay is now the rule for all these schools. The headmaster of the school refers to the alteration in organisation consequent upon the increase in length of stay of the boys from four to six weeks. Additional facilities for physical education have been provided. Extension of stay beyond six weeks was granted to 141 boys on medical advice. Nine hundred and fifty boys received dental treatment, and there were 22,812 separate treatments by the resident nursing staff for minor ailments. The number of open-air classes held in connection with the elementary schools in 1937 was 225. Of these, 7 were of type A (children selected on medical grounds from a group of schools); 110 were of type B (children selected on medical grounds from the various classes of a single school); 20 were of type C (consisting of a single class from one school, educated continuously at one open-air station); and 74 of type D (consisting in a rotation of classes from one school occupying one open-air station). Fourteen classes are permanent, that is to say they are outside the yearly programme and do not need re-authorisation each year. In addition, 114 of the 225 classes were continued throughout the winter, where the suitability of the sites had been approved by the school medical officer. Of the 225 classes, 79 were held in parks, gardens, playing-fields and other open sites, while 146 were held in school playgrounds, of which 39 were roof playgrounds. Very noteworthy is the great increase in the proportion of the classes which are carried on all through the year. As in the case of the open-air school, timidity in regard to the open-air regime has more and more given way to frank appreciation of its benefits and boldness in carrying its tenets to their logical conclusion. A very large number of detailed reports are received upon the classes, which testify to the devoted work which is carried out by the teachers, school nurses and school doctors at the open-air classes, but this work is in almost every instance amply repaid by the results shown in the improved health and progress of the children. Open-air classes in parks and playgrounds 55 The following report by Dr. M. W. Geffen on an open-air class, type B, at the Wandle (infants') school, may be taken as an example:— This class was visited early in March, on 6th July and on 28th September. The number of children in the class on 28th September, 1937, was 22. Of these 18 were examined, 4 being absent. The average period of attendance was six months. All the children had increased in height, the average increase being 2.69 em. Fifteen had increased in weight, the average increase being 1.3 kg.; in one there was no change; while 2 showed a slight decrease in weight (.2 kg.). Improved nutrition was shown in 14 children. About half the children seen showed improved colour, and several were mentally much more alert. Of tho four whose nutrition had not improved, three had recently had whooping-eough. In two instances the improvement was so marked that no trace of debility remained in children who were formerly emaciated and sickly, and they exceeded the normal standard. 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 immensely increased. In the year 1937, 5,972 children were discharged from convalescence at the undermentioned hospitals. Institution No. of children discharged from convalescence St. Anne's home 1,328 Goldie Leigh hospital 194 Downs hospital for children 415 Lower Southern hospital 3,637 Millfield convalescent hospital 398 Total 5,972 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. Lower Southern hospital is primarily an infectious diseases hospital, and the continuance of convalescent arrangements here cannot be counted upon all the year round. The opening-out of this provision for convalescence has indeed been a boon to London children, and it has greatly mitigated the sense of frustration which afflicted social workers and officers alike when faced with the long delays and checks, which formerly so frequently occurred and so hampered the work of children's care. 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, and in 1937 grants in respect of a maximum period of eight weeks' convalescence were authorised for each of 1,110 children. 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 1937, 390 school journeys were arranged. The children taking part were medically examined in all cases before departure. In all, 13,102 children were examined, and of these 65 were excluded as unfit to take part in the journeys for the following reasons: heart disease, 2; tonsillitis, 12; otorrhœa, 9 ; conjunctivitis, 6; 56 enlarged glands, 1; skin disease, 17; fracture, 1; rheumatism, 1; raised temperature, 5; dental trouble, 3; infectious disease, 2; other conditions, 6. Several children were provisionally rejected on grounds connected with personal hygiene, but were subsequently passed after visiting a bathing centre. Physical education The next report of the organisers of physical education will not be available until September, 1938, but the following brief resume of the activities and developments of the past twelve months has been kindly supplied by Mr. A. H. Gem and Miss Grant Clark:— The year 1937 is one which will stand as a landmark in the world of physical education. The publication by the Board of Education of circulars 1445 and 1450, the pioneer work of the Central Council of Recreative Physical Training, and the establishment of the National Fitness Council have all focussed attention very closely on present problems and future developments. In this short review it is proposed to consider only the issues raised in the two publications already referred to, and to touch briefly on the contribution which the Council can make towards the National Fitness Campaign. While already progress has been made in infant, junior and unreorganised schools, attention has largely been concentrated on the reorganisation of the work in the senior departments. In the past the training in these departments has, in the main, been confined to free standing exercises, agilities, activities and games, but during the past year a start has been made on the introduction of a range of work which necessitates the use of portable apparatus. The standard of equipment for each department will be: 6 gymnastic bcnches, 4 stools, 1 vaulting box, 1 vaulting buck and/or vaulting horse, 1 beating board, 4 gymnastic mats, 1 pair jumping stands and rope, and 10 climbing ropes. The introduction of this apparatus must of necessity be gradual, as it is necessary to ensure that the training of teachers skilled in this work keeps pace with the issue of the equipment. With this end in view a series of special six-week half-time courses has been established at the Council's College of Physical Education, and at these courses selected teachers, who show an aptitude for this branch of work, will be trained. It is anticipated that this reorganisation will be completed in 1940—41. Given suitably trained teachers and an adequate supply of apparatus, there still remains the problem of providing suitable accommodation for this work. In recent times considerable progress has been made with the improvement of facilities. New senior schools have been built, and in each case a gymnasium has been provided, together with changing rooms fitted with shower baths and drying space. But the London problem can never be dealt with by the provision of new schools. Old schools abound and for many years to come (probably for several generations) these buildings will be used. Owing to the fall in the child population and the consequent surplus school accommodation, an extensive programme of reconditioning has been introduced, and by this means improved facilities can be obtained for many schools, which include changing rooms and shower baths and the adaptation of the school hall as a gymnasium. Much of the benefit which should be derived from physical training is inevitably lost unless the students change into suitable costume and wear rubber-soled shoes, and negotiations are taking place with the Board of Education as to the grant payable for expenditure in this connection which the Council may be required to incur. It is hoped that an early agreement may be reached, as there can be little doubt that the progress of the work is being retarded owing to the lack of suitable clothing and footwear. It is probable that the wholesale adoption of the principle of a daily period of organised physical activity may never be achieved. Limitations imposed by playgrounds and buildings and the lack of suitable staff will in a few cases inevitably limit the amount of time which can profitably be devoted to physical education. In the main, however, children do now enjoy a daily period of physical activity and the position in this respect has improved considerably in recent years. The difficulty of providing adequate facilities for playing games under conditions suitable for children in congested areas led the Council to adopt the scheme of sending groups of children for a whole day to fields equipped with playing pitches and classroom accommodation. The first site of this type was opened in 1931, and since then the scheme has grown until now there are eight sites in use with a total of 31 classrooms, allowing for a weekly attendance of some 0,000 children. The experience gained on the early fields has resulted in successive improvements and will be invaluable in showing what will be required for the large new areas which the Council has acquired, and intends to go on acquiring, until it has sufficient space for every child over ten years of age to have a game on a playing field one day a week. The past year has shown a marked increase in the provision of suitable facilities for physical education in secondary and technical schools. New gymnasia, changing rooms and shower baths have either been scheduled or actually completed, while a considerable expansion of playingfields has taken place. Among the more interesting of the new developments is the provision Elementary education Playing-fields with classroom accommodation Secondary and technical schools 57 of several modern pavilions fitted with changing rooms, trough and shower baths and facilities for refreshments, those situated at Morden and Middle Park being admirable illustrations of modern practice. In circular 1445 the Board of Education recommended that three periods a week should be devoted to gymnastic training and that this time should be in addition to that devoted to games and swimming. While it must be many years before this ideal is reached, nevertheless a decided advance has been made in recent times. Physical education is now far more widely accepted as a fundamental of education than was formerly the case, and progressive schools now give each form at least two lessons a week in addition to games and swimming. The Council has for many years past made generous provision for the continued education of the citizens of London, and gymnastics, dancing and boxing have always held a prominent place in the curriculum of the various institutes. These activities have in the past attracted many keen students and it is of interest to note the steady growth of classes of this type. Since the formation of the Central Council of Recreative Physical Training, the education of public opinion on the necessity of keeping fit has been intensified, and the recent formation of the National Fitness Council has given further impetus to this movement. The County Council, through the medium of the evening classes, is peculiarly well placed to assist this campaign, as not only can students be recruited to the existing classes, but the number of classcs can be very considerably increased. During the past year the range of physical activities which a student may take has been widened, and a boy or man now has the choice of gymnastics (with or with out apparatus), boxing, fencing, wrestling, swimming and folk dancing. The aim is to offer such a wide variety of physical activities that each may choose his own method of keeping lit. There is little demand on the part of the men for the more simple "keep-fit" type of class, and the lessons which necessitate the use of apparatus make a greater appeal. The newer types of activity have made a promising start, and there are already twelve fencing classes and seven wrestling classes. Gymnastics and boxing draw the greatest number of students, and there are several hundred of such classes. A girl or woman can take gymnastics (with or without apparatus), fencing, swimming, eurhythmies and dancing of various types. There was a very heavy enrolment for women's classes in physical education in one or other of its branches at the beginning of the current session. It will be appreciated that an enrolment figure in any subject is always considerably higher than the attendance figure, but the latter is not yet available. Frequently the student attends two or more classes in the week, so the number given does not represent individuals, although it gives some gauge of the popularity of the subject. Quite a wide range of physical activities is available, and while all branches of the subject have their adherents, the "keep-fit" classes have claimed the largest numbers. The outstanding feature of the present session is the growth of interest amongst the older women, for whom classes have been formed, both in the afternoon and the evening. For these women the "keep-fit" type of lesson, consisting mainly of simple exercises performed to music and easy dances is particularly suited. The women look forward to their classcs and all testify to the value of the exercise. When refresher courses for teachers arc held, the special points to bear in mind when dealing with these older women are always stressed. There is clear evidence that the suspicion with which classes sponsored by a local education authority were at one time treated is decreasing, and students are enrolling in such classes in increasing numbers. One feature of considerable interest is the growing tendency of firms to seek facilities for their employees to join " keep-fit " classes during working hours, and the Council is able to do much to foster this enterprise. 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. Since the commencement of 1936 all children receiving dinners free or on partpayment have been brought before the school doctor at the earliest opportunity, and thereafter kept under observation by examination at 3-monthly intervals. Children are given milk and/or oil and malt on the recommendation of the school doctor. Those on the milk list receive two bottles of milk daily, and they are kept under observation by the school doctor regularly. In addition to those shown in the following table as receiving milk free, on the doctors' advice, there are a number recommended by the doctors to have milk, whose parents are able to pay for it. These, too, receive two bottles daily. Evening education 58 The numbers of individual children on free " meals " in December in the years 1934 to 1937, inclusive, were as follows:— Table 34 Meal 1934 1935 1936 1937 Dinners 5,725 5,245 5,596 6,251 Milk 15,091 20,300 24,120 28,800 Some 2,000-3,000 children received cod-liver oil and malt in school on the doctor's advice. In addition to the children receiving milk in school on the school doctors' advice, a large number of children are taking advantage of the Milk Marketing Board's scheme through voluntary school milk clubs organised by the head teachers. In January, 1938, it was reported that the total number of children receiving milk in the London schools was estimated to be 374,000, about 322,000 of whom were having one bottle, and 52,000 were having two bottles a day. The scheme of the Milk Marketing Board provided originally that only one bottle should be allowed daily at the reduced price to children other than those who were certified by the school doctors to require milk on medical grounds. At the instance of the representative groups of teachers, however, it was agreed in October, 1936, by the Milk Marketing Board that all children in the London schools who desired it might have two bottles daily at the reduced price. All milk given in the London schools is pasteurised. Many practical points have arisen from time to time in connection with the scheme. (1) The amount.—The medical officer has always insisted that the "medical" cases should have two bottles, each containing one-third of a pint, of milk a day. Further experience has emphasised the importance of this and leads to the opinion that all children, whether medical cases or not, should have the opportunity of having two bottles of milk daily. (2) Warming.—The question of warming the milk during cold weather is frequently raised. The medical officer has always discountenanced any form of irregular heating of the milk delivered to the schools. Keeping the milk for a period before consumption in the class room, probably near a radiator, so that at the time of consumption the chill is taken off, and the milk is consumed at room temperature appears to be quite satisfactory. (3) Straws.—Natural straws proved unsatisfactory, as there was never any guarantee that they were clean. In some consignments live maggots were found. After conference with the trade, English manufactured artificial straws were introduced, and these have proved quite satisfactory. (4) Problems connected with the covering of the bottles, their cleaning, and the presence of spicules of glass.—In the earlier months of the scheme, there were frequent complaints of the danger from spicules of glass found in the bottles. The presence of such spicules, it was thought, was promoted by the method of cover of the bottles used. A shallow cavity existed above the level of the cardboard discs used as covers; in this cavity water of condensation (as well as dust) collected; and in cold weather, ice was apt to form, which by its expansion, split off spicules from the glass rims. The substitution of bottles with metal caps has led to diminution in the complaints of the presence of glass spicules, thus lending some support to the above explanation of their formation. The metal caps are much more cleanly, and are altogether to be preferred. Another objection to the use of cardboard discs was that accumulations of these in or about the school with adherent milk or cream attracted mice. Milk Marketing Board's scheme, voluntary milk clubs 59 (5) Time at which the milk should be consumed.—It is advisable that the milk should be given at a point as far as possible equidistant between meals. Where two bottles are consumed a day, one should be taken in the morning and one in the afternoon. The play intervals, both morning and afternoon, appear to be the most appropriate times. Trouble has occurred when the milk is given too soon after meals, and this particularly in the afternoon, when milk was given sometimes before lessons began (i.e., at 2 o'clock). (6) Propaganda.—There appears still to be need for further efforts to convince the parents (and, in a small minority of cases, the teachers) of the value of the scheme. One parent whose child was seen recently at the County Hall, and appeared to be in need of additional nourishment, was asked why she did not take advantage of the scheme. She replied that she would not dream of letting her child have school milk, as it stood to reason that it must be stale and inferior milk which could not be got rid of otherwise, or else it would not be sold at half price ! The beneficial results of the milk-in-schools scheme has naturally suggested the desirableness of making some provision for its continuance throughout the school holidays. The Education Committee therefore arranged, with the consent of the Board of Education, for an experimental distribution of milk in the summer and Christmas holidays of 1937 to some of the children who were receiving milk in school on the recommendation of the school doctors. In the summer holiday the experiment took place at six different centres, the distribution being generally in the children's gymnasia in the parks, between 10 a.m. and 12 noon. One bottle of milk daily was distributed to children who received two in termtime, free or at half the normal charge, on the recommendation of the school doctors. At Battersea park, children who received milk in school on the doctor's recommendation, but paid the full charge, were also enabled to purchase a bottle daily. The arrangements made worked smoothly, and no serious difficulties were experienced. In the parks, the children were dealt with by the parks staff, and their efficient co-operation contributed very greatly to the success of the scheme. Comment was made on the good behaviour of the children. They were tidy and left no litter. The caps and straws from the bottles were carefully placed in the receptacles provided. At Battersea park it was stated that the scheme brought increased numbers of children to the park, and that they remained in the park for the whole day. The attendances on the first day were, at each centre, the highest recorded, and thereafter the numbers, although fluctuating slightly, generally speaking, declined progressively. During the first seven days, attendances ranged from 57 per cent. to 76 per cent. of those who had intimated their intention to attend, only one being under 64 per cent. After the first seven days attendances fell, particularly during the last days of the holiday, and the attendance for the whole period at all the centres was 49.9 per cent. The decline cannot be attributed to the weather, which was generally fine, or to the operations of the Children's Country Holidays Fund, because large parties of children were taken away at the very beginning of the holidays. The general decline in the number of "doctors' cases" at the centres as the holidays progressed was somewhat disappointing. The attendances of the "paying" children at Battersea park, although affected by Bank holiday and two wet days in the same way as the figures for the "free" children, did not decline progressively, but actually increased as the holiday went on. Ignoring the three exceptional days referred to, the average attendance was 73 per cent. in the first half of the holiday, and 80 per cent. in the last half, and the average attendance for the whole period was 67.9 per cent.. compared with 49.9 per cent, for the free cases. Experimental distribution of milk during the holidays 60 In the Christmas holiday, a more extended experiment was conducted, and milk was distributed at 36 centres to children who receive it during term time on the recommendation of the school doctors. Three schools in each of the twelve educational administrative districts were used as distributing centres. The centres were open from 10 a.m. to 12 noon, except on Saturdays and Sundays. One bottle was given daily. In issuing the invitations, preference was given to the free or part-paying cases, but full-payment cases were invited at three centres, where it was found, in working out the arrangements, that their attendance would not prejudice the attendance of the free and part-paying cases. In addition, permission was given to the managers of two non-provided schools to open distributing centres in their schools. The following statement shows the number of invitations issued, the number of acceptances, and the average attendances for all the 38 centres. The figures in parentheses are those for the previous summer holiday experiment:— No. of invitations issued No. of acceptances Percentage of acceptances Average attendance Percentage of average attendance, to acceptances Free and part-paying cases—37 centres (G centres) 14,528 (3,124) 11,823 (2,517) 81.4 (80-0) 7,298 (1,257) 61.7 (49.9) Full-pairing cases—3 centres (1 centre) 511 (259) 197 (106) 38.5 (41) 113 (72) 57.3 (67.9) The managers of one non-provided school, who arranged for milk to be sold to children paying the full charge, did not record the number of invitations issued, but the other figures are as follows:— Acceptances Average attendance Percentage of average attendance to acceptances 83 38 45.8 The percentage of acceptances for the free cases was 1.9 higher than during the summer holidays, and the percentage of average attendances was 11.8 higher. For the full-paying cases, both percentages were lower than in the summer, that for average attendance being considerably so. With the exception of five centres, the attendance on the first day was lower than the average for all days, and, with only three exceptions, the attendances on the last day were lower than on the preceding day. The percentages of attendances on the first, second and last days were respectively 51.4, 63.7 and 55.6. In the summer holiday experiment the percentage of attendances declined progressively from 61.4 on the first day to 30.2 on the last day. Generally speaking, the daily attendances were maintained much more steadily during the Christmas holidays, they were not affected, as during the summer holidays, by the operation of the Children's Country Holiday Fund and similar agencies. On the whole, weather was not unfavourable. It is gratifying that, for the free-cases, figures, both for acceptances and attendances, showed an increase on the summer experiment. If the percentage had proved to be the same for acceptances and attendances, the average attendance would only have been 5,800 compared with the actual figure of 7,297, which represented about 21.4 per cent. of the free and part-paying doctors' cases in term time at ordinary schools, central schools and day special schools. Defective children Examinations with a view to the admission of children to special schools, were made in 4,295 cases. The following table shows the number of children nominated for examination and the recommendations made:— 61 Table 35 Defect Number nominated Suitable for admission to Returned to elementary school Invalided as for the time unfit for any school Notified under M.D. Acts Ocular Boys Girls Blind school Partially sighted Swanley Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls 548 847 5 4 80 119 192 226 265 490 6 8 — — Aural 195 167 Deaf school Partially deaf school 141 124 — 2 — — Boys Girls Boys Girls 31 17 23 24 Physically defective 684 561 P.D. school Day open-air school Residential P.D. and hospital 8ohool 109 110 30 29 — — Boys Girls Boys Girls Boys Girls 409 346 45 27 91 49 Mentally defective 724 442 M.D. school 341 204 41 26 *43 *39 Boys Girls 299 173 Epileptic 63 64 Epileptic colony 30 33 16 16 — — Boys Girls 17 15 Total 2,214 2,081 1,192 1,000 886 961 93 81 43 39 4,295 2,192 1,847 174 82 *Of these 23 boys and 29 girls were imbeciles; 6 boys and 3 girls were idiots; and 14 boys and 7 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 36 Morbid conditions Boys Girls Total Infantile paralysis 33 25 58 Cerebral paralysis 14 9 23 Various paralyses 13 5 18 Tuberculosis of bones and joints 47 35 82 Osteomyelitis 39 23 62 Rickets and resulting deformities 13 5 18 Congenital deformities (including dwarfism) 13 23 36 Spinal deformities (including scoliosis) 1 8 9 Traumata and amputations 10 7 17 Non-tuberculous arthritis and synovitis 21 9 30 Rheumatism and chorea 13 20 33 Various chest conditions—fibrosis, bronchitis, asthma 80 33 113 Heart diseases— Congenital 29 22 51 Acquired valvular with history of rheumatism 117 127 244 without history of rheumatism 7 11 18 Non-valvular with history of rheumatism 7 5 12 without history of rheumatism — — — Anæmia 20 14 34 Pseudo-hypertrophic muscular dystrophy 7 1 8 Various nervous conditions, ataxia, etc. 5 2 7 Other diseases—chiefly medical 11 11 22 Total 500 395 895 • Including 3 girls suffering from fragilitas ossium and 5 boys suffering from hæmophilia. E 62 The following statement gives an analysis of the 278 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 37 Morbid conditions Elementary school Invalided Infantile paralysis 6 3 Cerebral paralysis 2 3 Various paralyses 1 2 Tuberculosis of bones and joints 6 1 Osteomyelitis 10 5 Rickets and resulting deformities — — Congenital deformities (including dwarfism) 14 4 Spinal deformities (including scoliosis) 5 1 Traumata and amputations 8 3 Non-tuberculous arthritis and synovitis 1 1 Rheumatism and chorea 21 2 Various chest conditions—fibrosis, bronchitis, asthma 41 7 Heart diseases— Congenital 16 3 Acquired valvular— with history of rheumatism 34 9 without history of rheumatism 1 — Non-valvular— with history of rheumatism 1 — without history of rheumatism 1 — Anaemia 13 — Pseudo-hypertrophic muscular dystrophy — 2 Various nervous conditions, ataxia, etc 3 — Other diseases—chiefly medical 35 13 Total 219 59 Children returned to elementary schools or invalided Rota visits to the schools The special schools were visited at least once a quarter, and every child present was examined at least once during the year. The total number of examinations made was 14,159, and in addition 694 special examinations were made of children already on the rolls of special schools in connection with applications for non-enforcement of attendance and for similar reasons. As a result of the rota examinations the following re-classifications took place:— Table 38 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 eye hospital Physically defective — 8 1 — — — 5 — 1 Mentally defective — — — — 1 — — — 7 Partially sighted 1 2 — 14 — — 3 — 2 Blind — — 1 — — — — — — Deaf — — — — — — — — — Partially deaf — — — — — — — — — After trial in a special school, 85 children were excluded (28 as imbecile, 33 as feeble-minded ineducable, 1 as "special circumstances," and 2 as feeble-minded "detrimental," and 21 invalided on medical grounds). 63 There were also 395 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 39 Action taken Special school classification P.D. M.D. Blind Partially sighted Deaf Partially deaf Total Returned, on improvement, to elementary schools 101 10 — 3 — — 114 Over 14 years of age and excluded as no longer certifiable 148 39 — 94 — — 281 Total 249 49 97 — — 395 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 40 Morbid conditions Cases deemed no longer certifiable Cases deemed fit to return to elementary schools Infantile paralysis 11 2 Cerebral paralysis — — Various paralyses 1 2 Tuberculosis of bones and joints 21 17 Osteomyelitis 11 13 Rickets and resulting deformities 3 5 Congenital deformities 2 7 Scoliosis — 1 Traumata and amputations 5 6 Non-tuberculous arthritis and synovitis 1 2 Rheumatism and chorea 29 17 Various chest conditions—fibrosis, bronchitis, asthma — 2 Heart diseases— Congenital 4 2 Acquired valvular with history of rheumatism 51 22 without history of rheumatism 1 — Non-valvular with history of rheumatism 3 2 without history of rheumatism 1 — Anaemia 1 — Various nervous conditions—ataxia, etc. — — Other diseases—chiefly medical 3 1 Total 148 101 During the year Mr. Wells examined 362 children with defective hearing, the Deaf decisions regarding whom are set out on page 61, and an analysis of the hearing children defects and grading is given below. Grade I includes children who can benefit educationally at an ordinary school without any form of special facility; grade Ila includes those children who can benefit educationally at an ordinary school, but require special facilities such as favourable position in class, mechanical hearing aid, etc.; grade IIb includes children who need educational training in a partially deaf class; and grade III includes those children who can only benefit by education provided in a school for the deaf. Decertification of physically defective children 64 Acquired cases.—Hearing defect due to :— Post-suppurative otitis media Grade I 38 64 ,, Ila 19 ,, lib 6 ,, III 1 — Suppurative otitis media (unknown origin) I 23 41 ,, Ila 8 lib 8 ,, III 2 — Suppurative otitis media (due to infectious disease) ,, I 15 30 ,, Ila 4 ,, lib 8 ,, III 3 — Suppurative otitis media (due to other conditions) ,, I 7 16 ,, Ila 5 ,, lib 4 ,, — Middle ear catarrh (due to various causes) ,, I 71 ,, ,, Ila 15 lib 13 — Suppurative otitis media and middle-ear catarrh ... ,, I 13 22 ,, Ila 7 ,, lib 2 Otosclerosis ,, I 1 Wax I 4 Meningitis ,, III 2 Nerve deafness due to injury ,, lib 2 7 ,, III 5 Nerve deafness due to infectious fevers ,, I 1 ,, lib 6 ,, III 8 — 15 Nerve deafness (unknown cause) v lib 1 Mixed deafness due to infectious disease ,,, Ila 1 2 ,, III 1 Congenital cases. True hereditary deafness ,, lib 1 9 ,, III 8 Sporadic deaf birth ,, III 30 Uncertain origin ,, I 7 19 ,, lib 8 ,, III 4 Mental Deficiency Acts : cases notified to the local authority There are 428 children in schools for the deaf, and 137 in those for the partially deaf. During the vear Mr. Wells made 739 examinations at these schools. The following table shows the number of children 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 1937 (the figures in brackets being those for the previous year):— (a) Feeble-minded— Boys Girls (1) Leavers 269 (295) 210 (268) (2) Detrimental 1 (5) 4 (-) (3) Special circumstances 1 (-) 3 (5) (4) Ineducable 27 (22) 23 (14) (b) Imbeciles 51 (47) 49 (28) (cj Idiots 5 (2) 4 (5) (d) In addition to being mentally defective, were blind or deaf 2 (1) (2) 356 (372) 293 (322) Total 649 (694) 65 After-careers The chief officer of the mental hospitals department has furnished the following return for the year 1937 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 41 Classification Male Female Total Grand total under headings (1) Number not exceeding 18 years of age who have left special schools and who were on the books of the supervision section on 31st December, 1937 638 492 1,130 1,130 (2) Number who after trial have proved themselves to be incapable by reason of mental or physical defect of undertaking remunerative employment 28 43 71 71 (3) Number employed as under :— (a) Industrial or manual occupations (i.e., factory work, trade or any part of a trade) 417 357 774 (6) Agricultural or rural occupations 2 — 2 (c) Domestic occupations— M. F. Total (1) Receiving remuneration 8 27 35 (2) Required for work at home 2 30 32 10 57 67 (d) Commercial, shop assistant, or selling behind a counter, office boys or girls 14 14 (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) 114 2 116 973 (4) Number judged to be employable but out of work 32 12 44 44 (5) Number whose careers have not been traced :— (a) Not visited and not seen at bureaux 8 14 22 (6) Visited but no information obtainable 13 7 20 42 (6) Cases dealt with in addition to above including those who have since :— (a) died — 1 1 (6) attained the age of 18 years 268 216 484 (e) been dealt with under M.D. Acts 52 30 82 (d) been lost sight of, or have left London 28 24 52 619 Stamford House remand home The report set out below has been received from Dr. John D. W. Pearce, parttime medico-psychologist at Stamford House remand home. Provision has been made to deal with cases of illness occurring during the absence of the medico-psychologist from the home by the appointment of a local (male) general practitioner, who is paid for his services at a per capita rate, which varies according to the hours of the day or night when his services are called for. The number of emergency calls during the year was six. The services of a woman doctor to examine girls who were alleged to have been criminally assaulted have been available since 1927. The girls were, until 30th June, 1937, examined at the surgery of the doctor, but in view of the inconvenience of this procedure, the Council decided to appoint a local woman medical practitioner to visit the remand home to examine these girls, and in addition, when requested by the medico-psychologist, to examine contacts of girls suffering from vulvovaginitis. The number of girls alleged to have been assaulted, who were examined during the year, was 51. 66 During the year, 2,331 children and young persons were admitted, of whom 1,872 were boys, and 459 were girls. There was a decrease of 277 in the admission rate compared with 1936. This fall is more than accounted for by the opening of remand homes in Essex and Middlesex. The admission rate from the London area increased by 104 in 1937, compared with 1936. Ihe variation in admission rate is shown below :— 1930 1935 1936 1937 Admissions from all areas 785 2,420 2,608 2,331 „ „ London area 695 1,436 1,881 1,985 ,, ,, out-county areas 90 984 727 346 In view of the increased attention focussed on problems of delinquency, the data provided by the 2,331 admissions are presented in detail below. The aetiology of delinquency is very complex, and caution is advised in interpreting the particulars submitted. Below is shown in a condensed form, the distribution of cases admitted according to the Courts from which they were received. The corresponding figures for the two preceding years, and for 1930, are given for comparison. The decline of 381 in admission rate from out-county areas has already been explained. The other minor variations are of little significance. Name of Court Number dealt with 1930 1935 1936 1937 Caxton Hall 40 129 169 157 Toynbee Hall 154 303 334 307 Stamford House 94 248 308 303 Islington 118 141 341 342 Hampstead — 6 10 21 Springfield Hall 83 252 295 325 Southwark 102 214 255 325 Adult courts 55 80 117 132 City of London 9 39 21 32 Education Act cases 40 24 31 41 Out-county cases . 90 984 727 346 Total 785 2,420 2,608 2,331 The distribution of admissions month by month, together with the corresponding monthly totals for 1936, are given below. There is but little correlation in the seasonal fluctuations. As an index of the incidence of delinquency, these figures are of no significance unless they are a true index of all cases dealt with by the Juvenile Courts. A temporary change in the personnel of the Bench, as in holiday time, may modify the extent to which use is made of a remand home. 1937 1936 1937 1936 January 180 266 August 173 191 February 194 234 September 165 221 March 231 248 October 194 235 April 247 177 November 171 166 May 194 240 December 168 163 June 229 236 July 185 231 Total2331 2608 The incidence of various charges is shown in the subjoined statement. As in previous years, the great majority consist of offences against property. It will be seen that 26 sexual offences are recorded, but actually many more such cases have occurred, and appear as cases requiring care or protection. Sexual delinquency in remand home cases is much more common among girls than boys. Offences 1937 Breaking, entering and stealing 116 Breaking and entering 117 Larceny 1,106 Burglary 2 Carrying firearms 4 Sacrilege 1 Embezzlement 23 Forgery 6 Demanding money by menaces 2 False pretences 7 Travelling without ticket 9 Suspected person 54 Desertion from army 1 Begging 2 Insulting conduct 9 Wilful damage 7 Assault 6 Malicious wounding 6 Murder 1 Offences 1937 Attempted suicide 1 Sex offences 26 Arson 2 Absconding from approved school 7 Robbery with violence 1 Breach of recognisances 119 Beyond control 212 "Care or protection" cases 311 Education Act cases 44 " Place of safety " and " lodgers " 52 Motor offences 68 Gambling 1 Drunk and incapable 4 Stowaway 3 Coining 1 Total 2,331 67 The subjoined statement deals with 2,000 consecutive admissions in 1937 according to sex and age group. It will be observed that there was a steady increase in admission rate in succeeding age groups in females, but in males there was a sharp decline in the 15th year. While there is no single explanation for this, it is thought that one factor is the fresh interest in, and the new outlets of, the life which begins on leaving school. The boy has not yet become dissatisfied, discouraged or apathetic. The uniform increase in succeeding female age groups is accounted for by the large number of female offences associated with puberty. Age Males Females Less than 8 years 20 6 8 - 9 „ 22 6 9 - 10 „ 50 2 10 - 11 „ 110 11 11 - 12 „ 140 12 12 - 13 „ 182 14 13 - 14 „ 251 33 14 - 15 „ 170 58 15 - 16 „ 274 97 Over 16 „ 397 145 With but few exceptions, every case was examined physically in considerable detail. The aim of this examination was threefold. The state of health was determined in order to exclude the introduction into, and spread of infection in, the remand home, and to increase the personal welfare of the individual examined. A decision was reached as to fitness for approved schools, and (in the case of males) for training in a nautical school. The influence, if any, of the physical state as a factor in the disordered conduct was assessed. The physical anomalies and chronic diseases which were diagnosed are shown below:— Condition Number of cases Condition Number of cases Dental caries 839 Epilepsy 16 Defects of vision 516 Former tuberculosis 12 Knock-knee 169 Hypospadias 3 Other sequelae of rickets 139 Hydrocele 2 Colour blindness 128 Congenital syphilis 2 Flat-foot 109 Phimosis 1 Incontinence of urine 99 Lymphadenoma 1 Deformities of the feet and toes (other than flat-foot) 66 Haemophilia Asthma 1 1 Impaired hearing 42 Torticollis 1 Enlarged tonsils 40 Kyphosis 1 Varicocele 37 Hydrocephalus 1 Deformities of the limbs 33 Tuberculous glands 1 Varicose veins 32 Encephalitis lethargica 1 Minor anomalies 30 Endocrine gland dystrophies :— Undescended testicle 29 Thyroid (simple goitre) 2 Heart disease 28 „ (hypothyroidism) 1 Stammer and allied defects of speech 27 „ (hyperthyroidism) 4 Well-defined postural spinal curvature 21 Pituitary 15 Adrenal 1 Hernia 16 Gonodal 9 The group of disorders of the endocrine glands, though small in number, is of interest, in that in several cases the condition was a factor, direct or indirect, in the aetiology of delinquency. During the year, 1257 cases of illness or injury were treated. Details of these are given below:— Condition Number of cases Condition Number of cases Infectious and contagious maladies Non-infective skin disease 217 Scarlet fever 19 Diseases of the ear 67 Influenza 8 lungs 11 Diphtheria 2 „ „ nervous system 16 Chickenpox 2 „ „ alimentary system 24 Measles 1 Vaginal discharge 65 Mumps 1 Accidents 139 Trachoma 1 Injuries existing on admission 69 Tonsillitis 160 Rheumatic infection 7 Pharyngitis 50 Anaemia and debility 69 Laryngitis 1 Toothache 63 Coryza 33 Pyorrhoea 5 Scabies 42 Minor septic lesions 94 Impetigo 17 Other minor maladies 62 Pubic lice 6 Total Body ringworm 4 1,257 Conjunctivitis 1 Balanitis 1 68 Many of the conditions treated, such as infections of the skin and ear, were found on admission. The incidence of vaginal discharge should be noted. Out of 65 cases discovered during 1937, 27, that is over 41 per cent., were found to be suffering from gonorrhoea; 7-3 per cent, of all females admitted when over 14 years of age were therefore found to have gonorrhoea. Two deaths occured in 1937. A boy aged 10 years died in Dulwich hospital on 6th April, 1937, from acute appendicitis and pericarditis. He had been in Dulwich hospital since 21st November, 1936: A 6-months old infant (female) died from gastro-enteritis in Grove hospital on 9th December, 1937. She was admitted, with others of her family, to the remand home, as a place of safety, on 23rd November, and transferred the same day to St. Alfege's institution and thence to Grove hospital. Investigation of the psychological state of the young offender has been regarded as an integral part of a general examination. Delinquency is considered as a disturbance of health. Health is regarded as divisible into the 4 categories, suggested by Dr. I. S. Wile of New York. These are physical, mental (in the sense of intelligence capacity), emotional and social. This division is quite arbitrary, but is useful as a practical formulation. Though all four groups of factors are to be assessed in each case, one or other tends to predominate in the aetiology of the delinquent behaviour. The psychological classification adopted below is to be considered in conjunction with this method of approach. It is well to bear in mind that the responsibility for disposal rests entirely with the Court, and that the purpose of these examinations is to furnish the magistrates with further information which may assist them in disposing of the case. In the great majority of cases, recommendations made following a request for a special report have been adopted. The 2,331 children admitted in 1937 fall into 5 groups :— (а) 387 were not examined psychologically. The majority of these were in the remand home for only a few days pending hearing at Court. Others were lodgers. These included absconders from approved schools who were admitted to the remand home until arrangements could be made for them to be taken back to school, children admitted as to a " place of safety " pending the presentation of petitions under the Mental Deficiency Acts, and similar cases. 1 (б) 36 were not examined for various reasons ; in a few, the examination has still to be made. (c) 223 in which the school report furnished by the child's headmaster stated that the mental ability, having regard to age, was normal, were submitted only to a short examination in the nature of a discussion. (d) 1,198 were mentally tested, using the Binet-Stanford scale (London revision) and a short psychiatric examination was made in each case. (e) 487 were examined in considerable detail at the request of the Courts. A valid diagnosis of the causes underlying delinquency can but rarely be based solely on a clinical psychiatric examination. Ideally the medico-psychologist should have at his disposal an adequate history of the child's life from the earliest years and of the environmental influences to which he has been subjected, including school and home conditions, outside interests and associates, etc. The following is an analysis of the 223 cases included in group (c):— Temperamental character-trait 10 Temperamental and environmental character-traits 15 Environmental character-trait 23 Simple character-trait not classified 53 Reaction character-trait 13 Psychopathic personality 2 Normal 11 Not diagnosed 96 In groups (c) and (d), a school report recorded the headmaster's impression of the child, and a brief record in very general terms was furnished by the special officer, who is a school attendance officer specially appointed for the purpose, with regard to the home and environment. The school medical cards were submitted for many of the children. Of necessity, the time spent on the cases in groups (c) and (d) was very short, and the diagnostic classification in tables 42 and 43 is to be regarded only as impressionistic, and not entirely accurate or reliable. Further investigation of these cases would probably have resulted in a shift downwards from the group of simple temperamental character-traits. In table 43 a diagnostic survey is made of 470 of the cases in which a special report was asked for by the Court. The examinations were careful and detailed, supplemented in 17 cases by a complete investigation by a child guidance clinic team. The special officers have helped considerably in furnishing detailed reports on the history background and environment, and in obtaining school reports, medical record cards and care committee files. Where cases were known to the probation officers, useful reports have been furnished by them. Hospitals and clinics provide what information they may have. Occasionally a parent is interviewed at the remand home. The organisation and efficiency of this service of information has improved considerably during 1937. 69 There has been a tendency recently in current opinion to disregard the significance of the intelligence quotient (I.Q.) in delinquency, but, though admittedly only one factor, it is, nevertheless, an important constitutional feature. The mean I.Q. of these 470 cases was 87 -5. In 279 cases, the I.Q. was between 70 and 95, while only 55 cases had an I.Q. greater than 105. It is significant that the I.Q. in 93 cases lay between "0 and 79. Admittedly this group of 470 cases is a selected one. In any individual, a mental capacity less than the average definitely constitutes a handicap in life. Perhaps an even more important factor than I.Q. is abnormality in temperamental charactertraits, which is the principal serological factor in a large group of delinquents. Such individuals suffer from defects of temperament which are inborn. A careful study of the heredity in such cases would yield valuable information. Where the principal serological factor is an environmental character-trait, there is good scope for successful treatment through the environment. The group characterised by reaction charactertraits are, for the most part, children who should respond well to improvement in environmental circumstances ; but, in some cases, psychotherapy is necessary to enable the child to understand the manner in which his delinquent conduct is a reaction to difficulties not outside but within himself. Psychoneurotic cases require psychotherapy for their adequate correction. In psychotic cases, the delinquency is only a part of a general psychosis requiring specialised management and treatment. Psychopathic personalities can be dealt with only by supervision and control. The groups overlap and are not sharply defined entities. There are exceptions to the generalisations, and most cases are mixed. In order that tables 42 and 43 may be more fully appreciated it is considered advisable to define shortly and precisely some of the groups, as follows :— A temperamental character-trait is an inherent quality of the mental constitution, closely linked to, and dependent on, the physiological endowment of the individual. An environmental character-trait is a mental attitude acquired in response to the direct influence of the environment. The environment comprises everything outside the individual. A temperamental character-trait may combine with an environmental character-trait in delinquency. For example, an unusually suggestible type of boy is more prone to join a gang of thieves than is a less suggestible boy. An exaggerated character-trait is due to the over-stimulation of a native tendency; for example, excessive aggressiveness overdeveloped by parental example. A reaction character-trait is a mental attitude which serves to repress the opposite tendency ; i.e., it is a reaction to a difficulty in onesslf and not in environment. For example, a child deprived of love may repress the need for love by becoming aggressive and independent, and he must continue thus lest the yearning for love emerges. Treatment by analysis or environmental methods aims at a healthier way of dealing with the frustrated need, and so achieving harmony of the whole personality. A psychoneurotic character-trait is the emergence of a repressed tendency. It is always contrary to the character of the individual; e.g., the model pupil who steals. A psychotic character-trait is part of a state of insanity. It is a pleasure to acknowledge the unvarying assistance and help of Mr. M. S. T. Jones and also of Mr. A. M. Murray. 70 Table 42 — Analysis of 1,198 cases on remand Classification Under 5 years 5—6 years 6—7 years 7—8 years 8—9 years 9—10 years 10—11 years 11—12 years 12—13 years 13—14 years 14—15 years 15—16 years Over 16 years Total M F M F M F M F M F M F M F M F M F M F M F M F M F M F Borderline — — — — — — — — — — — — 1 — 3 — 2 — 6 — 11 — 1 4 6 — 30 4 Mentally defective — — — — — — — — — — 2 — — 1 1 1 — 4 1 1 — 6 1 7 2 22 5 Temperamental character—trait — — — — — — — — — — 2 — 7 — 7 1 15 — 22 2 31 5 32 16 54 12 170 36 Temperamental and environmental character— traits 1 — — — — — — — 1 — 9 — 20 — 24 1 41 2 52 3 25 3 59 4 73 8 311 21 Environmental character—trait — — — — — — — — 1 — 7 2 7 1 12 1 12 2 19 — 12 4 11 2 21 8 102 20 Exaggerated character—trait — — — — — — — — — — — — — — 1 — — — — 1 — 2 — — — 4 — Reaction character—trait — — — — — — — — 2 — 4 — — — 3 — 3 1 4 — 8 — 5 1 11 2 40 4 Psychoneurotic character—trait — — — — — — — — — — 1 — 1 — 1 — — — 3 — 1 1 1 — — — 8 1 Psychotic character—trait — — — — — — — — — — — — 1 — 1 — 1 — — — — — — — 4 — 7 — Psychopathic personality — — — — — — — — — — — — — — — — 1 — — — — 1 4 — 1 — 6 1 Epilepsy — — — — — — — — — — 1 — — — — — — — 1 — — 1 — 1 — — 2 2 Normal — — 1 — 1 — 1 2 — — 1 1 2 1 1 2 — — 1 2 1 1 3 1 6 3 18 13 Not diagnosed 1 — — — — — 1 1 3 1 15 — 23 2 30 2 35 5 42 7 30 11 43 13 81 25 304 67 Total 2 — 1 — 1 — 2 3 7 1 42 3 68 5 84 7 111 10 154 15 121 27 167 43 264 60 1024 174 71 Table 43 — Analysis of 470 cases in which special reports were submitted Classification 4—5 years 5—6 years 6—7 years 7—8 years 8—9 years 9—10 years 10—11 years 11—12 years 12—13 years 13—14 years 14—15 years 15—16 years Over 16 years Total M F M F M F M F M F M F M F M F M F M F M F M F M F M F Borderline — — — — — — — — — — 1 — — — 2 — 2 — 3 — 3 1 1 2 1 1 13 4 Mentally defective — — — — — — — — — — — — — — 1 1 6 — 6 — 6 3 8 2 7 5 34 11 Temperamental character—trait — — — — — — — — — — — — 4 — 3 — 7 1 14 — 16 2 17 8 16 17 77 28 Temperamental and environmental character— traits — — — — — — — — 3 2 — 6 1 5 1 8 — 2 — 4 2 16 7 9 5 55 16 Environmental character—trait 1 — — — — — 4 — 4 4 1 2 1 5 2 4 1 7 — 5 3 13 2 7 3 56 13 Exaggerated character—trait — — — — — — — — — — — 1 — — — _ — — — 1 1 — 1 _ 1 — 3 2 Reaction character—trait — — 2 — — — 1 — 2 — 3 — 4 2 9 1 7 — 13 1 5 3 7 4 14 4 67 15 Psychoneurotic character—trait — — — — — — — — — 3 — 2 — 2 — — 1 2 2 3 1 3 — 5 — 20 4 Psychotic character—trait — — — — — — — — — 1 2 — — — — — 1 — 1 — 1 — 3 — 3 1 11 2 Psychopathic personality — — — — — — — — — — — — — — — — — — 1 — — 2 3 3 4 — 8 5 Epilepsy — — — — — — — — — — 1 — — — 1 — — — 1 — — — 1 — 1 — 5 — Encephalitis lethargica — — — — — — — — — — — — — — — — — — — — — — 1 — — — 1 — Congenital general paralysis of the insane — — — — — — — — — — — — — — — — — — — — — — — 1 — — — —1 Normal 1 — — — — — — — — — — — — — — — — — — 1 — _ 4 _ 6 — Not diagnosed — — — — — — — — — — 1 — — — 4 — 1 — 1 1 2 — 1 1 — 1 10 3 Total 2 — 2 — — — 5 — 9 1 17 2 18 4 32 5 36 3 51 5 47 17 75 30 72 37 366 104 72 Child guidance The Council, as education authority, co-operates with several voluntary organisations providing facilities for child guidance, by placing at their disposal information regarding school children both from the educational and medical standpoints. Arrangements have also been made, with the consent of the Board of Education, for the attendances of school children at certain clinics to be recognised as equivalent to attendance at school. In one instance, viz., the London child guidance clinic, where special circumstances obtain, a grant is made by the Council. There are at present 8 child guidance clinics " recognised " by the Council. They are the Maudsley hospital clinic, London child guidance clinic, East London child guidance clinic, Guy's hospital clinic, Institute of Child Psychology, Institute of Medical Psychology (Tavistock clinic), North-Western child guidance clinic, and the West End hospital for nervous diseases. Maudsley hospital child guidance clinic The following information and observations as to the work undertaken at these clinics during the year 1937 has been supplied by them. At the Maudsley hospital child guidance clinic, the general methods of treatment under the direction of Dr. Mapother have been continued during the year. On two half-days a week, selected cases are given individual treatment, and certain special groups for coaching on account of educational retardation have been formed. Special attention is given to playroom work and observation. Groups of students from the occupational therapy department of the hospital and from Goldsmith's college take part in the supervision of this work, and, besides giving valuable assistance to the clinic, the students are able to gain some understanding of the type of child referred for behaviour problems. A great deal of the time of the clinic is devoted to children requiring diagnosis or opinion only. A considerable number of the children, from the first, are not regarded as suitable for treatment, although in every case an attempt is made to suggest suitable care in the future. Nevertheless, while intensive treatment is not sought for every child, nor indeed would be suitable, there still remains a large field for further exploration from the point of view both of research and individual therapy. The number of school children referred to the clinic during the year was 325, of which number 203 were boys and 122 girls. The age distribution was : 4 to 8 years, 110 ; 9 to 11 years, 111 ; 12 to 14 years, 104. The sources of reference of the cases were : hospitals, 107 ; spontaneous, 43 ; school doctors, 42 ; care committees, 37 ; private doctors, 31 ; head teachers, 22 ; education officer, 14 ; probation officer, 9 ; other agencies, 20. The reasons for reference were : difficult and unmanageable, 53 ; backwardness, 43 ; nervousness, 43 ; stealing, 30 ; intelligence test, 26 ; enuresis, 18 ; nervous movements, 17 ; temper, 13 ; night terrors and fears, 13 ; truancy and unwilling to attend school, 12 ; speech difficulty, 10 ; fits, 8 ; other reasons, 39. London child guidance clinic The results obtained were : satisfactorily adjusted, 14 ; partially adjusted, 44 ; unadjusted or unsuitable, 91; psychological test only, 26 ; still under treatment, 150. The work at the London child guidance clinic during the year 1937 has continued under the direction of Dr. William Moodie on the usual lines, and close contact has been maintained between the clinic and the education and school medical services of the Council. The number of London school children dealt with during the year was 205, of whom 134 were boys and 71 girls. The age distribution was : under 5 years, 11 ; 5 to 8 years, 74 ; 9 to 11 years, 64 ; 12 to 14 years, 50 ; over 14 years, 6. The sources of reference were : district organisers and care c ommittees, 86 head teachers, 19; hospitals and clinics, 31 ; parents, relatives and friends, 21 ; remand home,* 14 ; probation officers, 13 ; social agencies, 10 ; school doctors, 6 ; private physicians, 5. The reasons for reference were : stealing, 33 ; behaviour difficulties, 27 ; enuresis, 23 ; school difficulties, 17 ; nervousness and fears, 12 ; * Reference to the diagnostic work undertaken at the clinic in connection with children from the Council's remand home is made in the section of thi^ report dealing With the remand home (page 65.) 73 sex difficulties, 11 ; temper and screaming fits, 9 ; truancy and wandering, 8 ; feeding difficulties, 8; incontinence and soiling, 6 ; advice as to placement, 5 ; vocational guidance, 5; night terrors, 5; other reasons, 38. The results of treatment were : very much improved, 3 ; improved, 17 ; unimproved, 2 ; special service, 6 ; transferred for treatment, 4 ; placed in homes, etc., 5 ; withdrawn, 7 ; incomplete (parents unwilling, etc.), 6 ; diagnosis only (no treatment), 39 ; still under treatment, 116. East London child guidance clinic The East London clinic established by the Jewish Health Organisation of Great Britain is held at the Jews' Free school, Whitechapel, under the direction of Dr. Emanuel Miller. The clinic is entirely undenominational and does not confine its activities to the immediate neighbourhood, although the majority of the children are drawn from the districts of Stepney, Bethnal Green and Poplar. The number of London school children dealt with during the year was 219, of whom 141 were boys, and 78 girls. The age distribution was : under 5 years, 6 ; 5 to 7 years, 63 ; 8 to 10 years, 69 ; 11 to 13 years, 64 ; 14 years and over, 17. The sources of reference were : school doctors, 87 ; hospitals and clinics, 30 ; head teachers, 23 ; school care committees, 20 ; probation officers and children's courts, 18 ; parents, friends, etc., 15 ; private doctors, 10 ; other agencies, 16. The reasons for reference were : backwardness, 31 ; difficult or beyond control at home, 29 ; nervousness, restlessness and excitability, 28 ; theft, pilfering, 26 ; enuresis, 25 ; night terrors, sleepwalking, 12 ; reading disability, 11 ; unmanageable at school, 10 ; stammering, 4 ; other speech defects, 10 ; aggressive, spiteful, destructive, 8 ; habit spasm, 5 ; other reasons, 20. The results obtained were : satisfactorily adjusted, 18 ; partially adjusted, 16 ; unsuitable or unadjusted, 36 ; placement, 17 ; failed to attend, 17 ; advice only, 12 ; progressing satisfactorily, 53; no change, 2 ; too early to report, 18 ; awaiting appointments, 30. Guy's hospital child guidance clinic The child guidance clinic at Guy's hospital is attached to the department of psychological medicine, but is a separate unit under the direction of Dr. R. D. Gillespie. The number of school children referred to the clinic during the year was 376, of whom 234 were boys and 142 girls. The age distribution was : under 5 years, 28; 5 to 8 years, 132 ; 9 to 11 years, 111 ; 12 to 14 years, 92 ; over 14 years, 13. Of these children, 181 were referred through the Council as education authority. Other sources of reference were : other departments of the hospital, private doctors, other hospitals or clinics, private persons, police courts, employment exchange, public health departments, the Invalid Children's Aid Association, and public assistance committees. The clinic authorities give information and advice to head teachers, care committees, etc., as to suitable treatment for particular children, and, although a child may not need to continue attendance at the clinic, the treatment is carried on in the school or home. The clinic has instituted a careful system of following-up the children after a period of about 2 years, and, therefore, does not assess the results of treatment each year. It is, however, understood that the work undertaken is comparable with that at other similar clinics in London. Institute of Child Psychology The work at the Institute of Child Psychology, 26, Warwick-avenue, W.9, has continued during the year under the direction of Dr. Margaret Lowenfeld. Close contact has been maintained with the school authorities and care committees/ and the interchange of information has been very helpful both in the diagnosis of the cases and the carrying out of the treatment recommended. The number of school children from the county of London referred to the clinic during the year was 83, of whom 47 were boys and 36 girls. The age distribution was : 5 years and under, 14 ; 6 to 8 years, 18 ; 9 to 11 years, 30 ; 12 to 14 years, 16 ; over 14 years, 5. The sources of reference were : care committees, 31 ; social agencies, 10 ; private individuals, 10 ; medical practitioners, 9 ; head teachers, 8 ; parents and guardians, 8; medical officer of health and general hospitals, 7. The reasons for reference were : anti-social behaviour, 36 ; neurosis, 33 ; educational difficulties, 74 Institute of Medical Psychology 8 ; basic factor physical, 6. The results obtained were : satisfactorily adjusted, 15; partially adjusted, 7 ; no change, 6 ; consultations only, 8; unsuitable, failed to attend, etc., 9 ; still under treatment, 20 ; awaiting appointments, 18. The number of London school children dealt with, under the direction of Dr. J. R. Rees, at the Institute of Medical Psychology (Tavistock clinic) during the year was 75, of whom 47 were boys and 28 girls. The age distribution was : 4 to 6 years, 11 ; 7 to 9 years, 27 ; 10 to 13 years, 29 ; 14 years and over, 8. The sources of reference were : care committees, 16 ; parents and friends, 15 ; head teachers, 10 ; hospitals and clinics, 10 ; medical officers of health, 10 ; general practitioners, 9; children's special workers, 3 ; welfare workers, 2. The reasons for reference were : behaviour difficulties, 17 ; fears, 17 ; backwardness, 9 ; stealing, lying and truancy, 9 ; enuresis, 7 ; sex difficulties, 5 ; speech difficulties, 3 ; depressive state, 3 ; nail biting, 2 ; endocrine disorder, 1 ; habit spasm, 1 ; lack of concentration, 1. The results obtained were : improved, 7 ; some improvement, 3 ; unsuitable or not co-operative, 17 ; consultations only, 10 ; placement, 1 ; still under treatment, 37. North Western child guidance clinic The North-Western child guidance clinic is situated at Sheldon Lodge, Cricklewood, and is able to deal with difficult cases which arise in the Hampstead and northern districts of London. The work is under the direction of Dr. W. Paterson Brown. During the year the number of school children dealt with was 11, of whom 8 were boys and 3 girls. The age distribution was : 4 to 8 years, 6 ; 9 to 15 years, 5. The sources of reference were : care committees, 6 ; head teachers, 4 ; welfare clinic, 1. The reasons for reference were : unmanageable, 2 ; backwardness, 2 ; enuresis, 2 ; uncontrollable and violent, 1 ; petty theft, 1 ; desire for independence and freedom, 1 ; loss of weight, 1 ; excitability, 1. The results obtained were : satisfactorily adjusted, 4 ; partially adjusted, 2 ; still under treatment, 5. West End hospital for nervous diseases The work at the West End hospital for nervous diseases, 73, Welbeck-street, W.l, under the direction of Dr. Emanuel Miller, has continued during the year. The number of Council school children dealt with was 41, of whom 26 were boys and 15 girls. The age distribution was : 5 to 8 years, 12 ; 9 to 11 years, 14 ; 12 to 14 years, 14 ; over 14 years, 1. The sources of reference were : other departments of West End hospital, 21 ; care committees, 10 ; school doctors, 3 ; other hospitals, 3 ; parents, 2 ; Invalid Children's Aid Association, 1; head teacher, 1. The reasons for reference were : tics and jerky movements, 9 ; backwardness, 6 ; unmanageable, 5 ; enuresis, 4 ; intelligence tests, 4 ; stealing, 3 ; anxieties, 3 ; hysterical ailments, 2 ; truanting, 1 ; obsessional behaviour, 1 ; sleepwalking, 1; insomnia, 1 ; speech defect, 1. The results obtained (including children still under treatment at commencement of year) were : adjusted, 12 ; improved, 7 ; unadjusted, 3 ; unsuitable, 3 ; parents refused to co-operate, 8 ; transferred to other institutions, 2 ; left district, 2 ; consultations only, 10 ; still under treatment, 35. Summary During the year, 959 London school children, of whom 606 were boys and 353 girls, were dealt with at the above-mentioned clinics, with the exception of Guy's hospital clinic, the work of which is set out in a different form. The following statement gives details of the cases :— Source of reference Hospitals 209 Care committees 206 School doctors 148 Parents and friends 124 Head teachers 87 Private doctors 64 Probation officers 40 Other agencies 81 Total 959 Reasons jor reference Behaviour difficulties 180 Nervousness 142 Backwardness 116 Stealing 102 Enuresis 79 Night terrors and fears 47 Intelligence tests 30 Speech difficulties 28 Temper 22 Truancy 21 Sex difficulties 16 Fits 8 Other reasons 168 Total 959 75 Results obtained Adjusted 60 Improved 103 Not improved 87 Unsuitable or not co-operative 120 Placement 23 Consultations only 111 Transferred 6 Still under treatment 449 Total 959 Nursery Bchools Nursery schools and nursery classes The nursery schools provided and aided by the Council now number twenty-two. The medical oversight of the schools is carried out by Dr. E. M. McVail. During the year alterations have been made in some of the nursery schools maintained by the Council. An extension of Old Church Road nursery school, providing 80 places, and bringing the total to 200 places, was opened on 1st September, 1937. Plans have been passed for two new nursery schools, one at Kintore-street in Bermondsey, and the other on the new building estate at Honor Oak in Lewisham. Each school is planned for 120 places. Certain playrooms at the Rachel McMillan nursery school, Greenwich, were found to provide less than the desired minimum of 15 square feet per child, and, in consequence, the nominal accommodation of the school was reduced from 260 to 243 places. Rebuilding of two of the playrooms is, however, now in process, and when this has been completed the total number of places in the school will be 255. Four additional voluntary nursery schools, with a total of 180 places, were recognised during the year, 1937, viz., Kensal House, North Kensington ; St. Agnes Place, Kennington ; the Sherborne, Kentish Town; and Balham nursery school, Endlesham-Road, Balham. The nursery schools maintained and aided by the Council at the end of the year, 1937. were :— Provided by the London County Council Accommodation 1. Columbia Market, Hackney-road, E.2 120 2. Rachel McMillan, Deptford, S.E.8 243 3. Old Church Road, Commercial-road East, E.l 200 Total 563 Aided by the London County Council 1. Balham, Endlesham-road, S.W.12 40 2. Buck Street, Kentish Town, N.W.I 40 *3. Children's House, Bow, E.3 35 4. Dalgarno Gardens, W.10 80 5. Goldsmith's college, New Cross, S.E.14 35 *6. Jellicoe, Rochford-street, Kentish Town, N.W.5 54 7. Kensal House, Ladbroke-grove, W.10 60 8. Mary Ward, Tavistock-place, W.C.I 30 9. North Islington, Tollington-park, N.4 45 *10. North Kensington, 325, Kensal-road, W.10 60 *11. Notting Hill, Darnley-road, W.ll 80 12. Rommany, West Norwood, S.E.27 40 13. St. Agnes'-place, Kennington, S.E.I 40 14. St. Christopher's, Bridgeway-street, N.W.I 40 15. St. Leonard's (St. Andrew's), 93, Guilford-atreet, W.C.I 60 *16. Sherborne, Litcham-street, N.W.5 40 *17. Somers Town, Crowndale-road, N.W.I 40 18. Stafford Street settlement, Peckham, S.E.15 40 19. Women's university settlement, Blackfriars-road, S.E.I 35 Total 894 76 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, where other arrangements of a satisfactory character are made. The following is a statistical summary of medical examinations and treatment at the 19 nursery schools which were open throughout the year, 1937 :— Total average roll 1,346 Total average attendance 1,136 Total number of visits made by medical officers 245 Total number of examinations of children 3,902 Total number of individual children seen 1,942 Total number of individual children with defects 1,097 Table 44 † Defects For observation Referred for treatment Treated Percentage treated of those referred Rickets 51 55 47 85 Nose and throat 191 201 158 79 Eyes and eyelids 3 30 30 100 Vision and squint 8 39 37 95 Ears 11 67 64 96 Lungs 27 60 55 92 Heart 60 7 5 71 Skin 9 110 108 98 Teeth 17 562 409 73 Other defects 89 173 169 98 Total 466 1,304 1,082 83 † Many cases of minor ailments arising between medical inspections were treated by the school nurses. Average number of medical examinations per child 2.01 Average number of defects per child 1.61 Percentage of children examined found to be suffering from one or more defect 56.5 Nursery classes The three-year programme 1935-38 provided for the establishment of experimental " nursery classes " in connection with infants' departments. The first nursery class under this provision was opened in June, 1936. at Senior-street school, Paddington, to accommodate 40 children, and two similar classes were started at the Raleigh school at Stepney later in the year. A further nursery class was established during 1937 at Crondall-street school, Hoxton. The nursery classrooms face south and have french windows opening on to the playgrounds. There is indoor sanitation and provision for bathing. Milk, apples and rusks are provided. Cod-liver oil was also available for the children. The babies are attended to by the school nurse daily, and all are medically examined once a term. A study was conducted whereby, at Senior Street school the physical progress of the infants attending the nursery class was compared with that of the infants of corresponding age attending an ordinary babies' class at the school. A similar comparison was carried out between the children attending the nursery classes at the Raleigh school and those of the same age attending the neighbouring Old Church Road nursery school. Senior Street nursery class A school nurse attends daily and the following is an account of her work:— The average time spent daily was one hour, from 9.0 to 10.0 a.m. The daily routine was as follows: (1) Distributed cod-liver oil to each child; (2) General inspection of each child, i.e. (a) ears, eyes and nose, (b) tongue, (c) glands of neck, (d) fingers and limbs for blemishes, (e) general appearance (in doing so, it was necessary to gain their confidence and, therefore, their readiness to impart information of any ailments unseen, or additional to previous ones); (3) After the general inspection, attending to any minor ailments. 77 Inspection of heads was carried out once a week. I found the parents of the unsatisfactory cases not averse from advice, and had not to complain a second time to any parent. Weighing and measuring took place every 28th day, as nearly as possible. Medical inspections were carried out twice a term. Individual parents awaited me at 9.0 a.m. each day, if previously summoned by me, for advice about their child, or children, as to glands, discharging ears, bad sores, or anything upon which I thought medical advice was needed, or any defective hygiene. The parents almost always acted upon advice, and often many consulted me voluntarily on diet, aperients, health and hygiene, and the general well-being of their offspring at the "At Home," given each month to parents by the head mistress. I attended when possible, and answered any questions the parents cared to ask me, advising them of the best for their children's welfare. The following is an abstract of a report made by Dr. A. B. Francklyn, who undertook the medical supervision of the class :— It was arranged that the children entering the class should be medically examined on admission, and at further three-monthly intervals for a period of a year. A " control " group of children, selected in the same department of the school was medically examined at the beginning and at the end of the experimental year. The standards chosen as being applicable for purposes of comparison were : (a) gains in height and weight, (6) incidence of dental decay, (c) incidence of infectious illness. The nursery class was run by a specially trained nursery class teacher with the aid of a young untrained helper. The control class was in the charge of an infants' certificated teacher. The classrooms used for the experiment were adjacent, both facing south. They differed somewhat in size and brightness, the nursery class being both lighter and larger than the control class. Both classrooms opened directly on to the playground, which was extensively used in fine weather for outdoor activities by nursery and control class children alike. The equipment provided was very similar for both classes, most of the teaching material being Montessori apparatus, supplemented by an ample supply of games and toys. The furniture in use was of the " infant room " type, that of the nursery class having the advantage of being enamelled, which enabled it to be washed several times a week. The nursery class had the added advantage of a cloakroom specially adapted for its use. Besides the usual facilities, it contained five porcelain hand-basins and a bath fitted with hot and cold water. Satisfactory arrangements were made for the separation of individual washing implements. Two sanitary conveniences of infant size were provided next door to the cloakroom. Certain special health measures were current in the nursery class only. They were the following (а) Daily examination and treatment of minor ailments by the school nurse. (б) Daily toilet drill. The children were all provided with face cloths, towels, toothbrushes and mugs and were taught how to use them. (c) Daily lavatory drill. A record was kept of bowel actions. (d) " Meals." These were provided at the cost of 7Jd. a week, and consisted of a midmorning meal of J-pint of milk, milk rusk and 1 teaspoonful of cod-liver oil. In the afternoon, each child received an apple and a further J-pint of milk. Those children whose parents were unable to defray the cost received these meals free. (It should be specially noted that nearly «all the children in the control class took advantage of the " milk scheme," many having §-pint of milk a day, while some on medical grounds received a daily teaspoonful of cod-liver oil.) (e) Provision of individual clean overalls twice weekly and of individual blankets for the afternoon rest hour. (/) Facilities for a weekly bath. A rota of mothers was arranged, and a large number availed themselves of these facilities, coming on the day and at the time allocated to them to bathe their children. (g) Hygiene instruction to parents. A monthly social and educational meeting was organised by the teaching staff. This was held in the evening at the school. The attendance was invariably good. After a cup of tea and some form of light entertainment, a short talk was given, either by the care committee worker, nurse or doctor, on one of the many problems of child health. The composition of the two groups of children varied to a certain extent with regard to sex, age, nutrition, home environment and in other unidentifiable respects. An attempt to evaluate some of these factors follows. The boys predominated in both classes, figures being 59 per cent, in the nursery class and 69 per cent, in the control class. A slight difference in the age incidence was noted, the average age for the nursery class being 3 years and 8 months and that for the control class 3 years and 10 months. The weight and height ratio of all entrants was compared with the London averages and any deviation noted. It was found by this method that the children admitted to the nursery class were, on an average, .94 kg. below the London average standard weights, whereas entrants to the control class averaged .4 kg. below the same scale. The general nutritional level of the nursery class was, therefore, less satisfactory than that of the control class at the beginning of the experiment. F 78 Adequate rest and sleep, well balanced diet, cleanliness and competent handling are all indispensable to the child's well-being. As the varying home circumstances of the children in the nursery and control classes inevitably modified the results obtained during the experimental year, it has been attempted to group them into three classes : " good homes," " average homes," " unsatisfactory homes." This was possible with the help of the care committee secretary, who knew all the home circumstances intimately. Twenty per cent, of both classes had "good homes," 37 per cent, of the nursery and 47 per cent, of the control class had " average homes," whilst 43 per cent, of the nursery and 33 per cent, of the control class had " unsatisfactory homes." Here it is again apparent that the nursery class had a more unfavourable composition than the control class. The children in both classes were weighed and measured every four weeks during the experimental year. There was a general steady gain in height and weight. The results in both classes are so close as to make any discrimination of superiority of little value. The average gains in weight, from June 1936, to June, 1937, were : nursery class, 2.86 kg.; control class, 2.60 kg. The average gains in height, for the same period, were: nursery class, 5.94 cm.; control class, 6.15 cm. The weight average for the nursery class rose from .94 kg. below to .12 kg. above the London average standard. The control class average weight rose to a lesser extent from .4 kg. below to .19 kg. above the standard. The children in the nursery class all received one teaspoonful of cod-liver oil and ⅔-pint of milk daily, a daily apple and a rusk supplied the incentive for healthy mechanical action of the jaws, and, in addition, daily cleansing of teeth at school was the rule. With these advantages, the nursery class might be expected to show a superiority over the control class children as regards incidence and spread of dental decay. This was, however, not the case, and the occurrence of decay was approximately the same in both classes. The cause for this failure must be looked for in the many factors which play a part in the onset and prevalence of the condition, such as : previous illness, home feeding, heredity, vitamin D intake, etc. In spite of these negative results, it may be surmised that the calcification of the permanent (unerupted) teeth will be improved, a possibility which, however, would only become apparent later. A daily return of absences and causes of absence was kept by each class mistress, and in this way a complete list of all illnesses occurring during the experimental year was obtained. The control class suffered heavier casualties than the nursery class, the number of cases of infectious illness in the two classes beine as follows :— Nursery class Control class Upper respiratory infection (i.e., colds and sore throats) 24 51 Mumps 5 3 Whooping-cough 1 10 Chickenpox 1 2 Infantile paralysis 1 0 Diphtheria 0 1 The above figures relate to all the children attending the two classes and not to the 16 children in each class used for comparative investigation in the rest of the report. The marked superiority of the nursery class as regards low incidence of infection may fairly be ascribed to the special care exercised in the nursery class, particularly the daily visit of the trained nurse. In conclusion, two facts stand out: the marked improvement in nutrition of the nursery class group, and their satisfactory health record for the year. The Raleigh nursery classes In connection with the two nursery classes for 80 children opened towards the end of 1936 at the Raleigh school, Mile End, it was arranged to make a comparison between the work of the classes and that of similar groups of children at the Old Church Road nursery school. The experiment was conducted over a period of one year from January, 1937. The work of the visiting school nurse is shown in the following report:— The average time spent daily was one hour, from 9.0 to 10.0 a.m. On an average, there were 71 children on the roll, and the attendance was 56. The daily routine was as follows : (1) Interviewing and advising mothers. (2) General inspection of children in classrooms. (3) Attention to minor ailments (average 15 daily)—eyes, ears, skin, sores, etc. Personal hygiene received attention once a week and made very satisfactory progress. Weighing and measuring took place once a month. Each child was medically examined in detail once a term, and frequently re-inspected. Parents attended the first inspection, and at any of the following, if necessary, or if they wished to see the doctor. The following treatments were given during the year: tonsils and adenoids (operative), 9 ; teeth, 20 ; squints, 4 ; warts, 1 ; ringworm of neck, 1 ; scabies, 4. 79 The children, both at the nursery classes and at the nursery school, were watched by Dr. Nora Cotter, from whose report the following account is taken :— To carry out this experiment, forty-six children corresponding in age and sex were selected from the Raleigh nursery classes and the Old Church Road nursery school. The children in each group were examined at the beginning and end of the experiment, and at least once each term. The conditions under which the experiment was carried out made estimates of the comparative value of the nursery classes and the nursery school difficult. The latter group had already spent 1½ to 2 years in the congenial and beneficial environment of the nursery school. The irregular attendance and the removal from the register of children in the nursery class group made records of many children valueless. The attendance of the nursery school group was very regular. The records of all the selected children were available at the end of the year, with the exception of three children who had left the district for better housing conditions on the Council's estates. For purposes of comparison, it was possible to use the records of 72 children, 36 in each group. Each group consisted of children born in 1933, i.e., 12 boys and 8 girls; children born in 1932, i.e., 8 boys and 8 girls. The special health measures carried out in the nursery classes were similar to those described above at Senior-street. The nursery class group were in two rooms on the ground floor, opening directly on the playground. The rooms, suitably decorated and furnished, were provided with adequate lavatory, sanitary and cloakroom arrangements. Every effort was made to obtain the maximum benefit from nursery class amenities. The nursery school group enjoyed the special conditions of a first class open-air nursery school—unlimited space and fresh air, good food, adequate mid-day sleep and suitable companionship from 8.30 a.m. to 4.30 p.m. In addition, 82 per cent, of this group had the advantage of three weeks' summer holiday at the sea or in the country, living under ideal conditions. For purposes of comparison the following points were specially noted and recorded: (a) Nutritional level and gains in weight and height. (6) Incidence of dental caries, (c) Incidence of infectious disease. (а) In comparing the average weights of the two groups at the beginning and end of the experimental year with the standard London table of averages, as would be expected the nutritional standard of the children of the nursery school was higher than that of the nursery class group, both at the beginning and end of the year. The average gains in weight during the year were : nursery class, 1.98 kg.; nursery school, 2.53 kg. The average gains in height were : nursery class, 6.13 cm. ; nursery school, 6.42 cm. (b) Of the children in the nursery class group, 52 per cent, were suffering from dental caries. Advantage had not been taken of the facilities offered at the child welfare centres for dental treatment before entering school. Dental treatment was obtained during the year in 56 per cent. The children in the nursery school group having had medical and dental supervision for two years were all free from dental decay. During the year many of the nursery school group attended the dental centre for conservative dental treatment. In these circumstances a comparison between the two croups as to the spread and incidence of dental decay is impossible. (c) The number of cases of infectious disease was as follows :— Disease Nursery class Nursery school Whooping-cough 4 3 Chickenpox _ 1 Mumps 1 _ Upper respiratory infections (colds and sore throats) 17 8 Ihe daily visit of the school nurse, with the consequent early detection of illness, contributed to the low incidence of infection in both groups. From information obtained from the care committee secretaries and health visitors, and from personal experience as medical officer of child welfare centres in Stepney, it was known that 50 per cent, of the children in the nursery class group and all the children in the nursery school group were living under conditions unsuitable for the proper mental and physical development of a child from 2 to 5 years. Studying the individual records of the nursery class group, it was found that the children who derived most benefit from the scheme were those who were free from physical defects and receiving good food and adequate rest at home. The nursery class conditions do not wholly meet the needs of the children who, through home circumstances, are unable to have the rest, food, and scope for childish activity which are so essential. Medical inspection and treatment—Day continuation schools, evening institutes and junior instruction centres With a view to closing to some extent the " gap " which exists between the medical care of children in school and the operation of the health service of the National Health Insurance scheme, the Council authorised in 1934 as an experiment the voluntary medical inspection of pupils aged 14 to 16 attending day continuation schools and certain selected evening institutes. These arrangements have been continued in 1937. G 80 In addition, in order that juveniles attending junior instruction centres could when so certified, be able to obtain milk as medical treatment, a weekly visit of one of the Council's medical officers to these centres was made, and this was continued until the closure of the centres in May, 1937, owing to the substantial reduction in juvenile unemployment. During the year, at the twelve day continuation schools, 746 pupils submitted themselves to medical inspection out of 5,138 eligible ; 21 pupils were found subnormal in nutrition, in 1 pediculi were found, 583 had sound teeth, 174 had subnormal vision (121 were wearing glasses), and 158 various defects were found, including : nose and throat ailments, 16 ; circulatory troubles, 25 ; flat foot, 18 ; and postural deformities, 27. In all, 207 were advised to obtain treatment. At two selected evening institutes, 97 pupils desired medical inspection. Of these, 11 were subnormal in nutrition, in 2 pediculi were present, 60 had sound teeth, 26 had subnormal vision (3 were wearing spectacles), and 50 were found to be needing observation or treatment for various other ailments, including: nose and throat disease, 16 ; enlarged glands, 5 ; ear disease, 2 ; defective hearing, 1 ; defective speech, 1 ; eye disease, 4 ; defects of heart and circulation, 4 ; ana;mia and debility, 3 ; defects of lungs, 2 ; spinal deformities, 2 ; flat foot, 3 ; other defects, 7. In all, 21 were referred for treatment. At junior instruction centres, prior to their closure in May, 1937, 44 juveniles were examined by the doctors. Of this number, 13 were subnormal in nutrition, none was verminous, 23 had carious teeth, 34 failed to pass the vision test (8 were wearing glasses), and 32 other defects were discovered. Medical treatment at the school treatment centres was available for juveniles under 16 years or those who, being over 16 years of age, were not entitled to medical benefit under the National Health Insurance scheme. Medical inspection at secondary and trade schools In the maintained secondary and trade schools mcdical inspection has been carried out by the school medical staff over a very long period of years. The pupils are, in accordance with the instructions of the Board of Education, inspected in detail on entrance, again at the age of 12, and at the age of 15 ; in 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 23 schools. At 22 other aided 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. Excluding students in training colleges, 15,788 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 3,292 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. In no instance was the clothing found to be poor, but in 2 cases (both boys) infestation with vermin was noted. 81 Dental condition The percentage of children, aged 12, with sound teeth was : boys, 87.1 ; girls, 82.7 ; but at the age of 15 this percentage had decreased to 81.8 per cent, among boys and to 78.3 per cent, among girls. Of cases of widespread dental decay where 4 or more teetn were affected, the percentage among boys and girls of 12 years old was 1.8 and 1.1, respectively, compared with .9 in boys and .9 in girls leaving elementary schools. Vision At the age of 12, 81.4 per cent, of the boys and 74.2 per cent, of the girls were able to pass the vision test, compared with 70.8 and 68.2 in elementary school leavers. In secondary schools, 16.0 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 19.6 boys and 23.0 girls. In spite of the greater percentage wearing glasses at the age of 15, the percentage of pupils passing the vision test was less, viz., 77.1 per cent, among boys and 71.8 per cent, among girls, suggesting that the more serious strain in reading has a detrimental effect upon the eyesight. Better eyesight among boys than girls is still a noteworthy feature of the results of school medical inspection. The deterioration in visual acuity which takes place during school life is emphasised by the figures for more serious defect (6.12 or worse) which rises between 12 and 15 from 8.8 to 11.9 per cent, in secondary school boys, and from 13.9 to 15.4 per cent, in girls. Nutrition The nutritional state of the pupils in the secondary schools, as returned by the school doctors, is very similar to that of the leavers in elementary schools, 5.0 per cent, being returned as subnormal. Defects During the year, 3,490 pupils (22.1 per cent.) were referred for treatment for various defects. Heart defect was noted in 2.2 per cent, boys and 3.0 per cent, girls ; defects of nose and throat in 2 .1 per cent, boys and 5.2 per cent, girls ; ear disease in .4 per cent, boys and .3 per cent, girls ; anasmia and debility in 1.2 per cent, boys and 1 .8 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. Such postural defect of the spine was noted in .9 per cent, of boys at 12 and 1.7 per cent, at 15, but in girls the amount of this defect was much greater, viz., 10.1 per cent, at 12 and 9.0 at 15. The increase, between ages 12 and 15 in institutions of higher education, of defect of vision and dental caries is disturbing. Re. inspection The re.inspection of 3,247 pupils in higher education institutions was carried out; 1,640 defects had been satisfactorily treated, 467 were under, treatment, 753 had had treatment but needed further treatment, and in 616 cases no treatment had been obtained. The following.up of defects discovered at secondary schools is undertaken by 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. 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, provided that they are entitled to either partial or full remission of educational fees. 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 1,057 students examined in training colleges, 3 were found to be suffering from extensive dental caries; 78.5 per cent of the men and 81.4 of the women passed the vision test, but 33 . 6 per cent, of the men and 36 . 5 per cent, of the women were wearing glasses. While none of the men was classified as below normal innutrition, no less than 7 . 2 per cent, of the women were placed in the subnormal class. 82 Sight-saving classes in central and 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. Three central schools, Regent's Park, the Hugh Myddelton and the Ensham also provide special education for the partially-sighted. These schools do excellent work and many scholastic successes have been scored by the pupils. Central schools The following reports have been made during 1937 by Dr. E. M. McVail:— Three central schools, Regent's Park, Hugh Myddelton and the Ensham, now provide special education for partially-sighted children. Regent's Park central school.—The partially-sighted children were first admitted to this school in January, 1936. Of 14 on the roll, 6 came from ordinary partially-sighted schools, their educational progress at their schools having justified their higher education. Although some have been admitted with ocular conditions more serious than originally allowed for ccntral schools, the children are all doing well, both from the educational and medical standpoints. It is reported that six are working with " remove " classes, and that their examination results have justified their classification. Several of the partially-sighted have gained first place in one or other subject. Where desirable, boys are given extra periods at handicraft and girls at housewifery and confectionery. No case of myopia has shown any marked increase during the year, and most have remained stationary. Three or four children are non-myopes with defective vision from such causes as congenital cataract and choroidal degeneration. Hugh Myddelton central school.—The number of partially-sighted children is 21, all of whom are myopes. One was admitted from an ordinary, partially-sighted school. Four have a mean of 5 dioptres of myopia, 8 have 6 dioptres, 5 have 7 dioptres, one has 8 dioptres, and 3 have 9 dioptres. In 15 who have been examined at the central school over a year or more, the mean increase per eye per year has averaged rather less than -3 dioptre, and the greatest increase in any child has been • 53 dioptre. The partially-sighted share fully in the ordinary life of the school; one has been house captain, six have been prefects and several have been members of the school orchestra. One boy gained the geography prize in the Chamber of Commerce examination and three children have passed the first part of the Junior Supplementary Scholarship examination. The head master writes, " Some of the most reliable and useful boys and girls I have had in the school have been from this class." Ensham central school.—The number of partially-sighted children is 24, of whom 21 arc myopes. The remaining three have nystagmus and partial albinism with vision of 6-36 or 6-24. Eight of the 24, including the three non-myopes, were admitted from ordinary partially-sighted schools. Of the 21 myopes, 3 have a mean of 4 dioptres, 3 have 5 dioptres, 4 have 6 dioptres, 5 have 7 dioptres, 4 have 8 dioptres, and 2 have 10 dioptres. In 15 who have been examined at the central school over a year or more, the mean increase per eye per year has averaged approximately-42 dioptre. Four have had an average increase of more than -5 dioptre per eye per year, the highest increase having been at the rate of 1 06 dioptre. Seven partially-sighted scholars have, since January, 1933, taken the Oxford school-leaving certificate, each with 5 or 6 credits. Many have taken London Chamber of Commerce examinations with distinctions. Special care is exercised by the staff in the selection of after-school occupations, and nearly all who have left are very satisfactorily placed. The partially-sighted share fully in the life of the school. Secondary school Honor Oak secondary school was visited on 13th December, 1937. The total roll was approximately 450, the number of partially-sighted children being 27 ; while 9 children were on easy treatment and under special observation at school. The methods of work described in the Annual Report for 1933, vol. Ill, part II (p. 89), are practically unaltered. The head mistress states that nearly all the partially-sighted children enter for the leaving examinations. Two girls have been passed for the Civil Service. The head mistress has now come to an arrangement whereby scholarship holders can be transferred from Honor Oak to Clapham trade school for tea-room cookery, or to the SouthEast London technical institute for home training at any age from 13J years upwards. Touch-typewriting on Bulletin typewriters is much used for essay work, but scholars still prefer to write at examinations. Residential schools and children's homes The ten children's homes formerly belonging to the metropolitan boards of guardians, the use of which was continued for this purpose by the Council, viz., 83 Anerley, Ashford, Banstead, Grays, Hornchurch, Hutton, Lamorbey, Norwood, Ongar and Shirley, have been visited regularly by Dr. Mabel Russell, who has reported as follows:— During the year, 33 visits have been paid to residential schools and homes, and 11 visits to receiving homes. A survey of the dormitory accommodation in each of the residential schools and receiving homes was made and, where it was considered necessary, modification of the existing accommodation was advised. All the school infirmaries have been inspected and reported upon. In every infirmary, with the exception of that at one school, there is some isolation accommodation. At that infirmary the provision of suitable accommodation is under consideration. Twenty-three cases of suspected vulvo-vaginitis were reported, 6 children were transferred to hospital, but in every case the pathological report stated no gonococci seen." Following on two of the cases, which were at first doubtful, visits were paid to the schools, and all the female child contacts were examined and 12 were isolated and treated in the school infirmary. During the latter part of the year, there was an outbreak of gastro-enteritis in the Shirley nursery. Fortunately it was confined to one cottage, which houses the small babies. Many visits to Shirley have been paid in connection with the outbreak, and a nurse who has been in the enteritis unit at the Grove hospital was lent to the homo. Her help was invaluable. Anerley residential school and Grays homes were closed during the year owing to a reduction in the need for residential schools. Hospital schools Reference has been made in various sections of this report to the manifold benefits conferred upon the general school population of London by the appropriation of the special children's hospitals previously maintained by the former poorlaw authorities, in particular the Metropolitan Asylums Board. These hospitals are under the direction of the Hospitals and Medical Services Committee, and full details of the year's work will be found in Vol. IV, Part I, of the Annual Report of the Council. The special children's hospitals are, however, now recognised by the Board of Education as hospital schools. The following is a list of the hospitals at which schools are conducted, with their classification and nominal school accommodation :— Table 45 Hospital School Classification Nominal accommodation Num ber of children In hospital 31-12-37* On school roll at eni of winter term* Downs, Sutton Mastoiditis, otitis media, rheumatism and convalescence 360 349 248 Goldie Leigh, Abbey Wood Skin diseases and convalescence... 248 179 155 Heatherwood, Ascot Surgical tuberculosis 244 201 168 High Wood, Brentwood Pulmonary tuberculosis, rheumatism 482 417 349 Millfield, Littlehampton Convalescent tuberculosis and other convalescents 98 93 95 Northern, Winchmore Hill Post-encephalitis lethargica 38 19 18 Norwood children's Severe crippling, rheumatism 50 152 53 Queen Mary's, Carshalton Rheumatism, tuberculosis (nonpulmonary), poliomyelitis, osteomyelitis and congenital malformations 900 1,050 683 St. Anne's home, Heme Bay Convalescence 140 140 109 St. Faith's, Brentwood Epilepsy 30 22 23 White Oak, Swanley Trachoma, interstitial keratitis, and other acute eye diseases 360 200 171 * The above dates are not identical 84 Of the 2,803 children who were in.patients at the hospital schools at the end of the year, 690 were suffering from tuberculosis. Special inquiries and reports Abstracts of special inquiries and reports will be found in their appropriate sections. Attention may be directed to the reports by Mr. A. G. Wells on the audiometer (p. 16), and the aural work (p. 63); by Dr. E. M. McVail on sight.saving classes in central and secondary schools (p. 82); by Dr. C. E. Thornton on rheumatism (p. 38); by Dr. J. W. D. Pearce on juvenile delinquency (p. 65); by Dr. Agnes Francklyn on a comparison between children in a nursery class and those in an ordinary infants' class (p. 77); by Dr. Nora Cotter on a comparison between children in nursery classes and in a nursery school (p. 79); by Dr. G. D. Morgan on the nutritional standard of ten.year.old children in a Council school (p. 25); by Dr. Wilfred Oakley on an investigation of home diets of boys at a Council school (p. 25); and by Dr. Leslie Harris on an investigation of hypovitaminosis A (p. 26). During the past three years a special inquiry into the incidence of certain rare congenital conditions has been carried on in London by the school medical staff at the request of the Medical Research Council. Foot inspection An important investigation into the condition of the feet of 608 unselected children in two west London schools was made by Miss E. H. Jebens, F.R.C.S., whose report will be printed in full in the medical supplement (Vol. IV, Part III). In the course of a complete and detailed survey of all the pathological and physiological variations found, Miss Jebens classified the feet according to the height of the arches as high, medium and low. The great majority (75.4 per cent.) were of the medium.arch type, 10.5 per cent, were of the high.arch type, and only 5.4 per cent, were of the low.arch type. These last were more frequent among the youngest children, and are looked upon as transitional from the flat foot, which is normal in the infant, to the medium arch of the adult. In the whole series there was no child with completely flat foot. Wage.earning employment of school children In the year 1937, 4,212 applications (4,183 boys and 29 girls) were dealt with under the by.laws for medical certificates in connection with the employment of school children out of school hours. In the subjoined statement the numbers first given are in respect of boys, the figures for girls being given in brackets. Certificates were granted unconditionally in the following cases : delivery of milk, 311 (—); delivery of newspapers, 2,242 (12); carrying or delivery of goods or parcels, 781 (5); in, or in connection with, a shop, 359 (8); in a coal yard, 5 (—); industrial work at home, 2 (—); house work away from home, 13 (2); as a messenger, 14 (—); miscellaneous, 6 (—). In 321 other cases (320 boys and 1 girl) the certificates were granted subject to medical treatment being obtained, or special conditions being observed. Certificates on medical or other grounds were refused to 130 boys and 2 girls for the following reasons: rheumatism, 8 (—); dental condition, 4 (—); defective vision, 4 (—); heart condition, 4 (1); scoliosis, 2 (—); poor general condition, 7 (—); otorrhcea, 1 (—); personal hygiene, 2 (—); fatigue signs, 3 (—); enuresis, 1 (—); epilepsy, 2 (—); anaemia and malnutrition, 9 (—); and for non.medical reasons such as " withdrawn," illegal hours, failed to attend, work unsuitable, under or over age, etc., 85 (1). Employment of children in entertainments During the year, 707 children were medically examined at the County Hall in connection with employment under licence in entertainments, comprising 605 girls and 102 boys. Of these, 146 were referred for treatment, including : refraction error, 14 ; dental decay, 110 ; throat affections, 1 ; skin disease, 7 ; personal hygiene, 8 ; discharging ears, 1 ; catarrh, 2 ; scoliosis, 3. Four were refused certificates on account of the presence of the following conditions : heart disease, 3 ; high myopia, 1. 85 In consequence of the consideration, in April, 1937, by the General Purposes Sub-Committee of the Education Committee of resolutions submitted by the Central Consultative Committee of Head Mistresses of Girls' schools, the school medical officer was requested to arrange for the re-examination of all children taking part in entertainments under licence for continual periods of not less than four weeks immediately on the completion of their engagements. During the last eight months of 1937 this was carried out. There are now medical histories of 162 children who have been medically examined under this requirement, 150 of whom are girls and 12 boys. The girls fall into two groups : a group numbering 102 engaged in Christmas pantomimes and shows under conditions which were fairly uniform; and a miscellaneous group of 48 girls seen during a period spread over the year who had been employed for varying times and under variable conditions. Girls in the first group had been employed for a period of about five weeks. Of the 102 girls 91, immediately at the end of their engagements, were in perfect health, with improved physical fitness and presenting no signs of fatigue. They averaged about thirteen years of age, and at their original examination for licence their average weight was 5 stone 9 lb. The average period between examination and re-examination at the end of their engagements was seven weeks, and during that time they had increased in weight on an average just over three pounds. The average weight of London elementary school children at the age of thirteen is 5 stone 8 lb., and the normal rate of increase in weight at this age is 1 -2 lb. in seven weeks. The condition of eleven of the girls at re-inspection called for special scrutiny owing to signs of fatigue, loss of weight, or disturbance of health. The analysis of these eleven cases suggests that in three there was a loss of weight in children who were previously over-weight and who did not suffer in any way in health ; in three children there was fatigue or loss of weight connected with intercurrent ailments that were contracted during employment; in three children there was fatigue due to the employment combined with constitutional defect of heart, and in two there was fatigue or physical deterioration for which no other cause was apparent except the strain of employment. In the three children with functional disorder of the heart who showed signs of fatigue on re-examination, the condition of the heart was noted at the original examination. It may be asked, perhaps, why in their cases a certificate of fitness was issued. The reply is that, while every child who was ascertained to have organic disease was rejected, the condition of these children was very carefully considered and only after obtaining a second opinion were they passed. In each case there had to be balanced against possible injury the psychological effect of rejection. The children love the work so greatly that the possibility of rejection arouses intense emotional disturbance which can easily have such a serious effect on them that it would outweigh the risk of injury due to employment. The second group of girls, numbering 48, were re-examined at the conclusion of their engagements, which in general were longer than those of the girls in the group already considered. Of the 48 children, 44 were found on re-examination to be in excellent physical condition, showing no signs of fatigue and to have made good physical progress. The condition of four girls was, however, unsatisfactory. In one of these, although the appearance of the child on the stage was for only 15 minutes nightly, there had been continuous employment for a long period and there was evidence of strain combined with failure to make normal progress. Of the twelve boys, all but one at re-inspection were found with improved physique and in perfect health with no signs of fatigue. The one boy whose condition was not so good on re-inspection had lost two pounds in weight between May and July, 1937. He had been employed for about a year, appearing twice at the theatre each evening for 10 minutes on each occasion. 86 In about eight per cent, of the children, their condition called for close scrutiny at the re-inspection, but, in several, there were intercurrent causes for the conditions found, not directly connected with the employment. In five children (three per cent.) no other reason than the employment was found to account for deterioration. It was noted that constant and prolonged employment, even though the actual daily appearances on the stage were short, were more harmful than short terms of employment which necessitated longer hours. In robust children a short period of about five weeks appears to produce no ill-effect, and even the contrary, but in children who are not robust this is too great a strain. Examination of candidates for the education service and scholars The total number of examinations in 1937 was 12,044, compared with 12,252 in 1936 and 10,547 in 1935. During 1937, 9,436 entrants to the education service, and candidates for teaching awards, scholarships, and local special places, presented themselves for examination ; of these, 48 had been referred from 1936. The following table indicates the numbers of candidates and the results of the examinations :— Table 46 Category Number examined Number fit Number rejected Number who withdrew after being referred for remediable defects or were not due for reexamination until 1938 Male Fomale Male Female Male Female Male Female Education service 211 369 199 356 3 9 9 4 Teaching awards 143 468 135 433 4 9 4 26 Scholarships 4,163 4,082 4,017 3,947 31 26 115 109 4,517 4,919 4,351 4,736 38 44 128 139 Total 9,436 9,087 t82 267 t The causes of rejection were mainly defects of vision, unsatisfactory general health and morbid conditions of the heart. In addition to the examinations referred to above, 254 scholars were examined (98 males, 156 females) with a view to determining their fitness to continue to hold awards, and of these 12 (8 males, 4 females) were found to be unfit. Re-examinations totalling 2,354 were made of entrants, scholars, etc., who were referred at the first examination for treatment for one or more remediable defects. Cases specially referred There were also referred to the public health department 3,416 special cases in which medical advice was required. This figure includes 2,828 teachers (638 men, 2,190 women) and 588 schoolkeepers, cleaners, etc. (112 men, 476 women). In regard to recommendations governing sick leave to teachers, 2,035 or 71-92 per cent, were in respect of teachers over 40 years of age. Teachers of physical education During the year, 297 applicants for admission to the Council's course of physical education were examined. Of these, 29 were deemed to be either temporarily or permanently unfit to undergo the training on the following grounds : poor general condition, 3 ; varicose veins, 6 ; injury, 1 ; heart condition, 10 ; renal calculi, 1 ; diseases of bones and joints, 7 ; myopia, 1. Medical inspection of scholarship holders During the year, 931 scholars were medically inspected at County Hall, comprising 275 girls and 656 boys. Re-inspection of scholars referred for treatment was carried out in respect of 55 girls and 60 boys. 87 STATISTICAL TABLES Table I —Medical inspection, 1937 (a) Routine inspections Group Boys Girls Total Entrants 24,037 24,052 48,689 Age 7 20,029 19,988 40,017 Age 11 21,430 21,705 43,135 Leavers 24,029 24,195 48,224 Total elementary schools 90,125 89,940 180,065 „ special schools 579 465 1,044 (b) Other inspections Special inspections 66,173 67,677 133,850 Infectious disease enquiries — — 24,027 Re-inspections — — 114,015 88 Table II (a) (1) Defects found at medical inspections of all children in elementary and special schools Disease or defect Routine inspectionsDefects Special inspections— Defects Requiring treatment Requiring observation. Requiring treatment Requiring observation Elementary schools Special schools Elementary schools Special schools Malnutrition 1,719 11 829 7 406 1 Skin—Ringworm, head 2 — — — 27 3 „ „ body 26 1 — — 10 1 Scabies 220 2 — — 3,553 18 Impetigo 109 — 3 — 770 14 Other disease (non-tubercular) 723 5 71 — 728 68 Eye— Blepharitis 560 5 49 1 233 20 Conjunctivitis 136 — 7 — 134 4 Keratitis 1 1 — — 3 10 Corneal opacities 7 1 3 — 13 1 Defective vision, excluding squint 11,626 77 5,373 70 2,908 494 Squint 881 1 306 1 374 32 Other conditions 132 — 34 — 202 33 Ear— Defective hearing 144 6 102 — 151 40 Otitis media 656 3 190 — 430 107 Other ear disease or defect 327 4 69 — 253 53 Nose and throat— Chronic tonsillitis 5,188 3 5,078 5 1,345 323 Adenoids 485 2 193 — 184 22 Chronic tonsillitis and adenoids 2,081 2 590 — 641 45 Other conditions 553 6 174 2 432 65 Enlarged cervical glands 235 — 764 3 145 130 Defective speech 94 — 138 2 95 48 Teeth—Dental disease or defect 50,766 206 952 1 4,517 95 Heart and circulation, heart disease— Organic 24 — 51 1 — — Functional 23 — 116 — 7 11 Not stated 207 1 1,393 13 204 537 Anaemia 348 — 222 1 258 109 Lungs—Bronchitis 763 4 560 — 152 56 Other non-tubercular 203 2 339 1 174 117 Tuberculosis— Pulmonary definite 2 1 — — 1 2 „ suspectcd 9 — 45 — 10 41 Glands 2 — 6 — 3 1 Spine 1 — 1 — — — Hip — — — — 2 — Bones and joints — — 3 — 1 1 Skin — — — — — — Other forms 3 — 2 — 2 2 Nervous—Epilepsy 27 — 15 43 15 Chorea 40 — 35 — 129 55 Other conditions 142 — 148 1 116 54 Deformities— Rickets 56 — 26 1 14 4 Spinal curvature 389 7 134 1 46 38 Other 645 6 328 1 202 57 Other conditions 2 158 13 789 5 2 864 1006 Total 81,713 370 19,138 117 21,782 3,733 89 Table II (continued) (6) 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 subnormal) D (Bad.) No. Percentage No. Percentage No. Percentage No. Percentage Entrants 48,089 7,442 15.28 38,204 78.47 3,000 6.16 43 0.09 Age 7 years 40,017 5,507 13.76 31,217 78.01 3,260 8.15 33 0.08 „ 11 43,135 6,843 15.86 33,572 77.83 2,701 6.26 19 0.05 „ 13¾ (leavers) 48,224 9,997 20.73 36,296 75.27 1,919 3.98 12 0.02 Total, elementary 180,065 29,789 16.54 139,289 77.36 10,880 6.04 107 0.06 „ special sch. 1,044 153 14.66 779 74.61 109 10.44 3 0.29 Table III (a) Exceptional children in London in 1937 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 527 24 32 — 583 Deaf children 476 — 2 3‡ 481 Partially deaf children 137 4 5 — 146 Mentally defective children— Feeble-minded children 3,009 3§ 20 8** 3,040 Epileptic children— Children suffering from severe epilepsy 94 — 6 100 Physically defective children— Tuberculous children— Pulmonary 372 — 20 — 392 Non-pulmonary 640 — 18 — 658 Delicate children 2,605 5,857|| 16 — 8,478 Crippled children 1,699†† — 22 — 1,721 Children with heart disease 2,010 — 39 — 2,049 * 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. †† Includes 17 children at Northern hospital (post-encephalitis lethargica) and also non-cardiac cases of chorea, rheumatism, etc. || Of these 40 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. ** Three under instruction at home and five under enforceable age. 90 Table III (continued.) (6) Return of children suffering from more than one defect, 1937 Defect Type of School Day M.D. Residential P.D. Day deal Residential deaf Epileptic colony Day P.D. Certified hospital schls. Total M.D. and deaf 7 _ _ 20 _ _ _ 27 M.D. and crippled 31 1 _ _ _ 3 6 41 M.D. and heart 11 _ _ _ _ 3 1 15 M.D. and epileptic 17 _ _ _ 28 _ _ 45 M.D. and T.B. _ — _ _ _ _ 1 1 M.D., crippled and deaf _ _ _ 6 _ _ _ 6 M.D. epileptic and crippled 1 _ _ _ _ _ _ 1 M.D. crippled and heart _ _ _ _ _ 1 _ 1 Deaf and crippled _ _ 1 2 _ _ _ 3 Deaf and heart _ _ _ 1 _ — _ 1 Epileptic and crippled _ _ _ _ 1 1 1 3 Epileptic and heart _ _ _ _ 1 _ 1 2 Heart and crippled _ 1 _ _ _ 20 — 21 Total 67 2 1 29 30 28 10 167 Table IV Treatment table (a) Group I.—Minor ailments, excluding uncleanliness, for which see group V Disease or defect Defects treated or under treatment Under Council's scheme Otherwise Total Skin— Scabies 6,720 _ 6.720 Impetigo 4,240 _ 4,240 Ringworm, head 78* 147 225t „ body 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.) 125,669 724 126,393 136,707 871 137,578 * 69 by X-ray. † 152 by X-ray. (6) Group II.—Defective vision and squint (excluding eye defects treated as minor ailments, for which see group I) Disease or defect Defects dealt with Under Council's scheme Otherwise Total Errors of refraction (including squint, but excluding operations for squint) 35,341 889 38,230 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, 26,263; otherwise 661 (estimated). Children who obtained or received glasses—under the Council's scheme, 24,958 = 95 03 per cent.; otherwise 563. * Included in group I minor ailments. 91 Table IV (continued) (c) Group III.—Treatment of defects of the throat and nose—number of defects Defect Received operative treatment Total Received other forms of treatment Total number treated Under Council's scheme Private practitioner or hospital Tonsils 862 571 1,433 4,341 14,707 Adenoids 381 53 434 Tonsils and adenoids 8,004 327 8,331 Other 4 164 168 Total 9,251 1,115 10,366 4,341 14,707 (d) Group IV.—Dental defects 1. Number of children who were :— (a) Inspected by the dentist—Age groups 5 years and under 26,907 \6 „ 29,304 7 „ 32,242 8 „ 32,637 9 „ 10 „ 34,993 35,418 315,016 11 „ 33,452 12 „ 33,507 13 „ 33,306 14 ,, and over 23,250 (6) Found to require treatment 215,243 (e) Actually treated 138,437 2. Half-days devoted to inspection ,, ,, „ treatment 2,9741 20,704 23,678 3. Attendances by children for treatment 243,102 4. Fillings—permanent teeth „ temporary teeth 132,532 21,324 153,856 5. Extractions—permanent teeth ,, temporary teeth 57,252 226,921 284,173 6. Administration of general anaesthetics for extractions 64,102 7. Other operations—permanent teeth „ ,, temporary teeth 25,728 (e) Group V.—Uncleanliness and verminous conditions (a) Average number of visits per school made by school nurse during the year 1937 6 (b) Examinations of children in the schools by school nurses 1,556,682 (c) Number of verminous children noted 74,636 (d) Children cleansed under Council's arrangements *63,451 (e) Cases in which legal proceedings were taken under the Education Act, (section 87) 1921 250 * Includes 13,792 compulsory cleansings. Table V Medical inspection—number of children examined, 1927-1937 Year Routine examinations Special examinations Reinspections Examinations at special enquiries into outbreaks of infectious disease Special ear inspection centre attendances Rheumatism supervisory centre attendances 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 1936 196,217 122,963 129,867 30,535 28,387* 15,913 1937 181,109 133,850 114,015 24,027 29,314* 15,552 * Includes after-care clinic attendances: 1936—8,317; 1937—8,108. 92 Table VI Medical treatment—number of cases treated under the Council's scheme and by other agencies, 1927-1937 Minor ailmenta† Vision Nose and throat Dental Year Under the Council's scheme Otherwise Under the Council's scheme Otherwise Under the Council's scheme Otherwise Under the Council's scheme Otherwise* 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 1936 ||122.305 801 39,570 1,006 13,190 966 144,416 5,862 1937 ¶125,669 724 37,341 889 13,592 1,115 138,437 4,281 * It is not possible to give complete figures, but those given are the result of following up of medical inspections. Other children receive dental treatment outside the Council's scheme as a result of dental inspection. ‡ Includes skin and head ringworm cases. § Includes 14.537 “nurses’ cases.” ‡ Includes 13,087 “nurses’ cases.” || Includes 16,548 “nurses’ cases.” ¶ Includes 19,304 “nurses’ cases.” Table VII Medical inspection of students in higher education institutions, 1937 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 11 18 16 1 4 45 47 I. Routine detailed examination at— (1) age 12 881 953 1,374 539 124 107 — — 2,379 1,599 (2) age 15 949 864 1,065 454 922 931 — — 2,936 2,249 II. Examination (not necessarily detailed) at other ages (i.e., specials) 1,531 1,410 1,689 764 757 474 149 908 4,126 3,556 III. Reviewals 323 1,661 533 515 121 139 — 34 977 2,349 IV. Re-inspections 520 1,145 280 542 345 415 — 20 1,145 2,122 93 INDEX page After-care clinic 36 After careers 65 Anaemia 13 Approved schools 48 Audiometer 16 Candidates, Examination of 86 Child guidance 72 Children's care committees 27 Cleanliness 10 Clothing and footwear 11 Convalescence 53, 55 Co-operation of parents 9 Co-operation of voluntary bodies 37 Day continuation schools 79 Deaf children 63 Defective children 60 Deformities 14 Delinquency, Juvenile 66 Diphtheria 45, 49 Ears 13, 16, 29, 34 Employment of school children 84 Entertainments, Employment of children in 84 Evening institutes 57, 79 Eyes 12, 30, 81, 82 Favus 48 Foot inspection 84 Furniture, School 7 Handkerchiefs, Paper 8 Heart 13 Hop picking 48 Hospital schools 83 Hygiene, Personal 10, 42 Impetigo 43 Infectious diseases 45 Invalidity, Chronic 44 Junior instruction centres 79 Lungs 13 Measles 47 page Medical inspection 8, 79, 80 Medical treatment 29, 79 Mental deficiency 64 Milk distribution during holidays 59 Minor ailments 31 Nervous diseases 13 Nursery schools and classes 75 Nutrition 10, 15, 18, 57, 81 Open-air education 52 Orthodontics 33 Orthopædic treatment 36 Otorrhoea 13, 35 Personal hygiene 10, 42 Physical education 56 Play centres 48 Playing-fields 7, 56 Remand home 48, 65 Residential schools and children's homes 48, 82 Rheumatism 38 Rickets 14 Ringworm 31, 48 Scabies 43 Scarlet fever 47, 50 Scholars, Examination of 86 School buildings and equipment 6 School journeys 48, 55 Secondary and trade schools 80 Sight-saving classes 82 Spectacles 29 Staff 6 Stammering 38 Teeth 11, 32, 81 Tonsils and adenoids 12, 31 Towels 8 Tuberculosis 13, 52 Vaccination 15 Vulvo-vaginitis 51 Washing facilities 8 PUBLICATIONS OF THE LONDON COUNTY COUNCIL The undermentioned publications, issued by the Council, may be purchased through any bookseller. or from the Council's Agents, P. S. KING & SON, LIMITED, 14, GREAT SMITH STREET, WESTMINSTER, S.W.I, from whom a complete list of the Publications of the Council may be obtained post free. Annual Report of the Council for 1935:— Vol. I (Part I). Powers and duties— Elections— Finance— Rating and Taxation—Public Protection—Traffic— Public Amenities—Domestic and Miscellaneous Services. Is. 6d. No. 3274. Vol. I (Part II).—Public Assistance. 1s. No. 3240. Vol. II.—Public Health, General matters as to public health, Main Drainage and Housing. Is. No. 3287. Vol. III (Part I).—Public Health, Report of County Medical Officer of Health. 1s. No. 3212. Vol. III (Part II).—Public Health. Report of School Medical Officer. 1s. 6d. Xo. 3196. Vol. IV (Part I).—General and Special Hospitals. 2s. 6d. No. 3213. Vol. IV (Part II).—Hospital Finance. Is. No. 3237. Vol. IV (Part III).—Medical Supplement. 5s. No. 3254. Vol. V.—Education. Is. No. 3255. Vol. VI.—Mental Hospitals. 1s. No. 3234. Vol. VII.—Abstract of Accounts and Index. 6d. No. 3307. Report for 1936 :— Vol. I (Parts II and III).—No. 3306. Vol. Ill (Part I).—No. 3292. Vol. III (Part II).—No. 3125. Vol. IV (Part I).—No. 3308. Vol. IV (Part II).—No. 3311. Vol. IV (Part III). No. 3320. Vol No. 3347. Vol. VI—No. 3309. Archives of Neurology and Psychiatry from the Pathological Laboratory' of the London County Mental Hospitals. Cloth:—Vol. 1 (out of print) ; Vol. II, 1903, No. 680, 17s. fed.; 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.; Vol. XII, No. 3190, 1936, 15s.; Vol. XIII, No. 3295, 1937, 15s. Accounts in Abstract.—Accounts of the Income and Expenditure of the Council from 1st April to 31st March. 1s. Issued annually. 1936-37. No. 3361. London Statistics.—Statistics relating to London and the public services therein, with certain statistics of the adjacent districts. Issued annually. Vol. XL, 1935-37. 15s. No. 3323. Statistical Abstract for London.—Comparative statistics for 10 years relating to parishes, metropolitan boroughs, poor law areas, electoral areas. Administrative County of London, Greater London, etc.—Education, rateable value, mental disorder, poor relief, fires, finance, population, rates, locomotion, etc. Vol. XXIX, 1927-37, 2s. 6d. No. 3341. 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 Issued annually, 1d., 1936-37. No. 3296. Census, 1921. Report upon the statistics relating to Greater London contained in the various volumes of the Census of England and Wales. 1921. 1s. No. 2550. —1931. Report to the Housing and Public Health Committee by the Valuer to the Council. 1s. 9d. No. 3134. Municipal Map of London, 1931. In 28 sheets, scale 6 inches to a mile, 1s. 6d. a sheet; complete sets, with key sheet, 35s. Street Index, 5s, THE LONDON COUNTY COUNCIL GAZETTE Issued fortnightly. Containing full particulars of official notices, appointments, contracts, etc. Price 2d. Annual subscription, payable in advance, 6s. 6d. post free. The Survey of London (a series of volumes dealing both historically and architecturally with a number of London parishes), fully illustrated :— Bromley-by-Bow—Vol. I (out of print) ; Chelsea—(Part I) Vol. II (out of print), (Part II). 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