LCC 47 LONDON COUNTY COUNCIL Report of the County Medical Officer of Health for the year 1938 CONTENTS Page Vital Statistics— Population 3 Infectious diseases 6 Tuberculosis 11 Statistical tables 14 Administration— Housing 21 Milk and Dairies (Consolidation) Act and Tuberculosis Order 21 Venereal diseases 22 Treatment of tuberculosis 25 Mental Deficiency Acts 28 Blind Persons Act 28 Midwives Acts, nursing homes registration and maternity and child welfare contribution schemes 29 Medical examination of staff 33 Bacteriological laboratory work 34 Chemical branch 34 Hospitals and Ancillary Services— General Hospitals— Appropriation of institutions 34 Planning and development 34 Maternity 35 Dental service 36 District medical service 37 District nursing 37 Oxygen therapy 37 British Empire Cancer Campaign 37 Statistics 38 Special Hospitals— Statistical table 41 Planning and development 41 Infectious diseases hospitals 42 Children's hospitals 43 Tuberculosis hospitals 44 Pathological Laboratory Services 44 London Ambulance Service 45 Index 47 London County Council ANNUAL REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH FOR THE YEAR 1938 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. Lateness of publication This report was almost ready for publication at the outbreak of war. For some considerable time afterwards, no staff was available except for the most pressing duties. The report is much smaller than in recent years and much sub-editing has been necessary. Apart from the annual report of the school medical officer, which was published on 3rd November, 1939, this is the only volume which will be issued dealing with the activities of the public health department during 1938. Organisation of the department There was no change in the organisation of the department as outlined in the report for 1937. VITAL STATISTICS The Registrar-General estimates the resident population of the county in the Population middle of 1938 to have been 4,062,800, compared with 4,094,500 a year earlier. The corresponding estimates for metropolitan boroughs are shown in table 27, and the rates given in this annual report are calculated upon these figures. The age and sex-distribution of this estimated population is as follows :— Table 1 Age group Males Females  0- 5 years 126,600 122,700 249,300 7879 5-15 „ 271,000 267,600 538,600 15-25 „ 341,700 368,000 709,700 19609 25-35 „ 331,600 368,600 700,200 35-45 „ 268,200 322,800 591,000 45-55 „ 227,400 282,700 510,100 9273 55-65 „ 187,200 230,000 417,200 65-75 „ 106,200 141,500 247,700 1467 75 years and over 35,000 64,000 99,000 Total 1,894,900 2,167,900 4,062,800 The marriages registered in London during 1938 numbered approximately Marriages 44,565 or 21.9 per thousand of the population, the corrected rate for the preceding year being also 21.9. The live births allocated to London during 1938 numbered 54,495, compared Births with 55,011 in the preceding year. The live-birth rate was 13.4 per thousand, the same rate as in 1937. (3) 4 The births in the resident population of each metropolitan borough during 1938 were as follows Table 2—County of London—Births, 1938 Metropolitan boroughs arranged in topographical order Live-births Still-births Total Legitimate Illegitimate Legitimate Illegitimate Legitimate Illegitimate Western. Paddington 1,620 268 62 12 1,682 280 Kensington 2,009 227 52 10 2,061 237 Hammersmith 1,715 159 54 5 1,769 164 Fulham 1,821 137 61 6 1,882 143 Chelsea 519 55 10 2 529 57 Westminster, City of 894 152 24 5 918 157 Northern. St. Marylebone 705 97 22 7 727 104 Hampstead 932 127 30 4 962 131 St. Pancras 2,157 286 66 17 2,223 303 Islington 4,209 278 116 11 4,325 289 Stoke Newington 659 36 22 — 681 36 Hackney 2,631 114 85 11 2,716 125 Central. Holborn 213 37 13 3 226 40 Finsbury 702 39 35 3 737 42 City of London 54 9 — 1 54 10 Eastern. Shoreditch 1,129 52 30 7 1,159 59 Bethnal Green 1,271 45 40 3 1,311 48 Stepney 2,502 117 76 6 2,578 123 Poplar 1,959 42 61 5 2,020 47 Southern. Southwark 1,924 106 60 7 1,984 113 Bermondsey 1,404 35 36 1,440 35 Lambeth 3,581 265 112 8 3,693 273 Battersea 2,026 88 54 2 2,080 90 Wandsworth 3,822 231 116 6 3,938 237 Camberwell 2,975 131 100 3 3,075 134 Deptford 1,330 49 41 2 1,371 51 Greenwich 1,253 50 38 2 1,291 52 Lewisham 3,073 115 82 5 3,155 120 Woolwich 1,987 72 58 2 2,045 74 London, 1938 51,076 3,419 1,556 155 52,632 3,574 London, 1937 51,839 3,172 1,705 159 53,544 3,331 Deaths The deaths in the total population of London during 1938 numbered 46,456, giving a death-rate of 11.4 per thousand, compared with 12.5 in 1937. Of the total deaths 22,351, or 48.1 per cent., were among females. The distribution of deaths by ages in 1938 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 1935-38 3,340 501 481 422 320 565 900 1,904 2,400 4,757 8,571 25,020 49,181 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 1938 ... 3,130 444 416 377 282 532 760 1,724 2,239 4,345 8,166 24,041 46,456 5 During the period to which the figures in the first five lines of this table relate, the deaths among infants under one year of age are shown to have fallen by more than 57 per cent., the chief factor in this decline being the decrease in the birth-rate. Over the same period the number of live births declined by 44 per cent. At the other extreme of life it will be seen that the deaths have increased by about 26 per cent. after 65 years of age. Here the increase is due not to increased death-rate but to the increase in population at these ages. There was a substantial decrease in the number of fatal street accidents—from 520 in 1937 to 363 in 1938. 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 0-6 5-15 15-25 25-45 45-65 65+ All ages 1937 12 71 93 78 125 141 520 1938 12 40 57 49 90 115 363 Decrease per cent. — 43.7 38.7 37.2 28.0 18.4 30.2 Street accidents The death-rates from all causes and from certain specified causes in each metropolitan borough in 1938 and in London as a whole in 1938 and earlier years will be found in tables 27 and 29. The deaths from the principal causes by age and sex during 1938 in London are shown in table 28. The deaths under one year of age per thousand live-births were 57, compared with 60 in the preceding year. This constitutes a new low record, being below the record low rate of 1935. The general improvement in infant mortality would have been more strikingly reflected in this rate had it not been for the effect of the epidemic of measles during the year. Infant mortality 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 1926 1927 to 1930 1931 to 1934 1935 to 1938 1935 1936 1937 1938 Measles 3.40 3.84 1.64 2.02 2.07 1.44 0.95 0.07 2.35 0.05 1.32 Whoopi ng.cough 3.63 4.45 2.50 2.60 3.14 2.27 2.01 1.77 2.51 2.73 1.03 Influenza 0.27 1.10 0.81 0.38 0.48 0.40 0.24 0.18 0.27 0.40 011 Tuberculosis 3.40 3.20 1.52 1.26 0.89 0.77 0.56 0.56 0.71 0.44 0.55 Bronchitis 6.41 6.72 4.42 2.91 2.30 2.16 1.97 1.90 2.26 1 .95 1.76 Pneumonia 12.28 14.96 12.60 11.51 12.10 11.45 10.39 9.79 11.42 10 83 9.80 Diarrhœa 24.28 16.10 12.16 9.36 8.87 10.86 12.10 10.61 13.79 11 62 12.37 Premature birth 18.16 17.42 17.00 14.74 14.17 14.91 13.41 14.11 13.13 13.60 12.77 Congenital defects 14.69 14.66 11.26 8.39 7.38 7.22 6.35 6.88 6.97 6.14 5.91 Other causes 21.48 20.55 15.09 11.83 12.60 13.52 12.30 12.01 12.47 12.40 11.82 All causes 108 103 79 65 64 65 60 58 66 60 57 6 The deaths among infants under one year of age in age groups from the causes included in the above table are shown by sex and according to legitimacy in the following table:- Table 6—County of London—Infant mortality, 1938 Cause of death Age at death Total Rates per 1,000 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. — — — — 9 20 39 68 33 35 1.26 1.41 Illeg. — — — — — 1 3 4 4 — 2.22 — Whooping. cough Leg. — — — 10 18 12 14 54 28 26 1.07 1.05 Illeg — — — — — 7 1 2 1 1 .55 .62 Influenza ... Leg. — — — 1 2 2 1 6 5 1 .19 .04 Illeg. Tuberculosis Leg. — 1 — 1 8 8 12 30 15 15 .57 .60 Illeg. — — — — — — — — — — — — Bronchitis ... Leg. — — 4 28 26 17 7 82 52 30 1.98 1.21 Illeg. — — — 2 7 5 — 14 10 4 5.55 2.47 Pneumonia Leg. — 9 36 104 151 111 75 486 265 221 10.11 8.89 Illeg. — 1 2 13 13 11 8 48 28 20 15.54 12.37 Diarrhoea ... Leg. — — 14 111 246 141 74 586 365 221 13.93 8.89 Illeg. — — 2 26 38 13 9 88 49 39 27.19 24.12 Premature birth Leg. 306 203 75 40 5 1 1 631 343 288 13.09 11.58 Illeg. 28 10 12 13 1 1 — 65 37 28 20.53 17.32 Congenital defects ... Leg. 33 65 72 72 33 10 7 292 166 126 6.33 5.07 Illeg. 13 6 3 5 3 — — 30 18 12 9.99 7.42 Other causes Leg. 100 128 71 68 77 54 52 550 328 222 12.52 8.93 Illeg. 40 12 7 9 15 9 2 94 62 32 34.41 19.79 All Causes Leg M. 259 221 156 257 347 197 163 12785 1,600 1,185 61.05 47.65 F. 180 185 116 178 228 179 119 Illeg M. 46 20 21 43 47 22 10 345 209 136 115.98 84.11 F. 35 9 5 25 30 19 13 Total, 1938 ... 520 435 298 503 652 417 305 3,130 1,809 1,321 64.58 49.88 Total, 1937 ... 494 470 297 585 722 450 291 3,309 1,948 1,361 68.71 51.05 1937 Leg. M. 246 238 155 323 375 227 155 2932 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 Infectious diseases The notifications, attack.rates and death.rates of the principal infectious diseases in London during 1938 and earlier years are shown in tables 29 to 32, and for the constituent metropolitan boroughs in 1938 in table 27. Anthrax Five cases of anthrax were notified during the year, all of which were confirmed. Particulars are as follows:— Table 7 Metropolitan borough Age] Occupation Probable source of infection Outcome Wandsworth 65 Locomotive inspector Canadian furs Recovered Lewisham 47 Tram conductor Not known Died Bermondsey 42 Checker at a wharf Pickled lambs' skins from Alexandria Died Southwark 57 Brushmaker Horsehair from Manchuria Recovered Stepney 36 Dock labourer Wool hides from Irak or Australia, or rabbit skins from New Zealand. Recovered 7 No case of smallpox was notified in London during the year. London has now been free from this disease since June, 1934. Smallpox During the year 146 cases of enteric fever and 45 cases of paratyphoid fever were notified. Typhoid fever During the year 182 notifications of cerebro-spinal fever were received, but in 25 of these the diagnosis was not confirmed. Of the 157 confirmed cases, 47 proved fatal. In addition 17 deaths were recorded by the Registrar-General of cases which had not been notified, making a total of 64 deaths for the vear. Cerebrospinal fever Five notifications of encephalitis lethargica were received during the year. Two of these were not confirmed, and of the 3 confirmed cases, 2 proved fatal. In addition, the Registrar-General informed the Council of 46 deaths occurring in that vear, making a total of 48 deaths for the vear. Encephalitis lethargica During the year, 134 notifications of poliomyelitis or polioencephalitis were received, but in 25 the diagnosis was not confirmed. Of the 109 confirmed cases, 12 proved fatal. In addition, 3 deaths were recorded by the Register-General of cases which had not been notified, making a total of 15 deaths for the year. Poliomyelitis and polio. encephalitis 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:— Table 8 Age periods Under 3 3-5 5-10 10-20 20-30 30-40 40-50 50-60 Over 60 Total[/##] Cerebro-spinal fever 53 11 21 30 32 10 8 7 2 174 Encephalitis lethargica 1 — — — 7 12 7 7 15 49 Poliomyelitis and polioencephalitis 22 26 31 23 7 2 1 — — 112 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 :— 1934 1935 1936 1937 1938[/##] Cerebrospinal fever— No8. notified and confirmed 124 89 99 155 157 Deaths among cases notified and confirmed 62 50 52 65 47 Deaths among cases notified in previous years 1 — — — — Deaths among unnotified cases 15 19 24 28 17 Encephalitis lethargica— Nos. notified and confirmed 24 14 11 5 3 Deaths among cases notified and confirmed 6 4 4 — 2 Deaths among cases notified in previous years 3 4 1 6 3 Deaths among unnotified cases 27 26 49 50 43 Poliomyelitis and polioencephalitis— Nos. notified and confirmed 65 82 37 97 109 Deaths among cases notified and confirmed 4 5 2 6 12 Deaths among cases notified in previous years 1 2 1 — — Deaths among unnotified cases 8 4 5 9 3 In 1938 particulars were received of 270 cases of food poisoning notified to the borough medical officers of health under the provisions of the Public Health (London) Act, 1936. The number for the year 1937 was 458. Three of the notified cases died, one as the result of tyhoid infection. Food poisoning 8 In some instances more than one member of a family were affected by illness, but the majority were isolated cases and may have been due to idiosyncrasies of the patients. The following table shows the age and sex incidence in 259 of the 270 cases notified during the year; in the remaining 11 cases the ages were not stated:— Table 9 Sex Under 5 years 5-16 years 15-25 years 25-35 years 35-45 years 45-55 years 55-65 years Over 65 years Total Male 5 9 22 23 22 17 8 3 109 Female 9 17 36 41 19 16 6 6 150 The causes of illness in the 270 notified cases were stated to be as follows:— Fish 53 Fruit 3 Tinned fish and paste 32 Tinned fruit or vegetables 12 Meat 94 Miscellaneous 27 Tinned meat and paste 2 Not known 47 Measles The deaths from measles in 1938 numbered 235, compared with 24 in 1937 and 584 in the last epidemic year, 1936. The death-rate was -06 per thousand. The death-rates m London and England and Wales in recent years have been as follows:— Table 10 Area. 1927 1928 1929 1930 1931 1932 1933 1034 1035 1936 1937 London 0.04 0.30 0.05 0.23 0. 03 0.19 0.02 0.20 0.00 0.14 0.01 England and Wales 0.09 0.11 0.09 0.11 0.08 0.08 0.05 0.09 0.03 0.07 0.03 Whoopingcongh There were 102 deaths from whooping-cough in London during 1938, compared with 247 in 1937. The death-rate was -03 per thousand. The death-rates in London and England and Wales in recent years are shown in the following table:— Table 11 Area 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 London 0.12 0.09 0.26 0.03 0.07 0.08 0 .07 0. 07 0. 04 0.07 0.06 England and Wales 0.09 0.08 0.16 0.05 0.06 0 .07 0. 06 0.05 0.04 005 0.04 Scarlet fever There were 8,093 notifications of scarlet fever in 1938, the corresponding figure for 1937 being 8,455. The attack-rate was 2.0 per thousand, compared with 2.1 for 1937. The deaths numbered 27, giving a death-rate of .01 per thousand of the population at all ages and a case-mortality of .3 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 12 Weeks of the year 1- 5- 9- 13- 17- 21- 25- 29- 33- 37- 41- 45- 49-52 593 658 719 689 708 696 637 525 374 620 695 672 507 9 The notifications (uncorrected for errors in diagnosis), deaths and crude case mortality during 1938 were as follows:— Table 13 Year 1938 Age-period Total 0- 1- 2- 3- 4- 5- 6- 7- 8- 9- 10- 15 + Notifications (52 weeks) 64 370 536 737 859 987 764 667 518 360 1,056 1,175 8,093 Deaths (365 days) — 3 3 1 3 2 2 1 1 — 2 9 27 Crude case - mortality percentage — 0.81 0.56 0.14 0.35 0.20 0.26 0.15 0.19 — 0.19 0.77 0.33 The death-rates in London and England and Wales in recent years are shown in the following table:— Table 14 Area 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 London 0.01 0.02 0.02 0.03 0.02 0.02 0.02 0.02 0.01 0.01 0.01 England and Wales 0.01 0.01 0.02 0.02 0.01 0.01 0.02 0.02 0.01 0.01 0.01 Notifications of diphtheria numbered 7,611 in 1938, compared with 7,810 in 1937. This gives an attack-rate of 1.9 per thousand, a similar rate to that for the preceding year. There were 205 deaths, giving a death-rate of .05 per thousand living. The case-mortality was 2.7 per cent., compared with 2.8 per cent. in 1937. Diphtheria 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 15 Weeks of the year 1- 5- 9- 13- 17- 21- 25- 29- 33- 37- 41- 46- 49-62 703 723 639 581 525 487 549 521 511 560 602 632 578 The notifications (uncorrected for errors in diagnosis), deaths and crude casemortality during 1938 were as follows:— Table 16 Year 1938 Age-period Total/###] 0- 1- 2- 3- 4- 5- 6- 7- 8- 9- 10- 15 + Notifications (52 weeks) 146 348 552 647 752 841 756 600 483 373 933 1,180 7,611 Deaths (365 days) 11 7 15 27 30 29 26 22 13 4 14 7 205 Crude case-mortality percentage 7.54 2.01 2.72 4.17 3.99 3.45 3.44 3.67 2.69 1.07 1.50 0.59 2.69 The death-rates in London and England and Wales in recent years are shown in the following table:— Table 17 Area 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 London 0.09 0.09 0.08 0.10 0.06 0.07 0.08 0.11 0.06 0.05 0.05 England and Wales 0.07 0.08 0.09 0.09 0.07 0.06 0.07 0.10 0.09 0.08 0.07 Diarrhoea and enteritis caused 721 deaths among children under two years of age, or 13.23 per thousand live-births. The corresponding rate in 1937 was 12.29. Diarrhœa and enteritis 10 The death-rates per 1,000 live births in London and England and Wales in recent years are shown in the following table:— Table 18 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 London 7.59 10.32 10.96 9.89 9.71 12.55 11.74 12.80 11.31 14.47 12.29 13.23 England and Wales 6.69 7.22 8.26 6.15 5.90 6.60 6.98 5.36 5.56 5.75 5.54 5.30 Puerperal fever and pyrexia : maternal mortality There were 199 notifications of puerperal fever and 853 notifications of puerperal pyrexia in 1938, compared with 228 and 793 respectively in 1937. The deaths from puerperal fever numbered 43 and from other puerperal causes 61, the deaths per thousand live-births being .79 and 1.12 respectively, giving a total maternal mortality rate of 1.91, compared with 2.29 in 1937. The deaths from puerperal fever and other puerperal causes per thousand livebirths in each metropolitan borough and in the county of London in the periods 1921 to 1930 and 1931 to 1938, together with the deaths in childbirth in 1938, are shown in the following table:— Table 19 Metropolitan boroughs arranged in topographical order Childbirth deaths* per 1,000 live-births Number of deaths in ohildbirth 1938 1921-30 1931-38 Puerperal fever Other causes Total Puerperal fever Other causes Total Puerperal fever Other causes Total Western. Paddington 1.6 1.5 3.1 1.7 2.4 4.1 1 2 3 Kensington 2.2 1.5 3.7 1.4 1.6 3.0 2 3 5 Hammersmith 1.9 1.9 3.8 1.2 1.4 2.6 — 2 2 Fulham 2.1 1.5 3.6 1.2 1.7 2.9 1 — 1 Chelsea 1.9 3.1 5.0 1.4 1.7 3.1 2 1 3 Westminster 2.1 3.2 5.3 2.1 1.7 3.8 6 — 6 Northern. St. Marylebone 2.3 2.5 4.8 1.8 2.2 4.0 — 2 2 Hampstead 1.9 2.3 4.2 0.9 1.1 2.0 — 1 1 St. Pancras 1.2 1.5 2.7 1.5 1.8 3.3 — 2 2 Islington 1.6 1.6 3.2 1.3 1.6 2.9 3 7 10 Stoke Newington 2.3 2.0 4.3 0.7 3.3 4.0 — 1 1 Hackney 1.6 1.6 3.2 0.9 1.4 2.3 1 — 1 Central. Holborn 2.4 0.9 3.3 2.5 1.2 3.7 — 1 1 Finsbury 1.3 1.2 2.5 0.6 0.8 1.4 — 1 1 City of London 3.7 0.9 4.6 3.8 — 3.8 — — — Eastern. Shoreditch 1.1 14 2.5 0.8 1.4 2.2 1 2 3 Bethnal Green 1.1 1.4 2.5 1.2 1.1 2.3 1 1 2 Stepney 1.0 1.4 2.4 0.9 1.6 2.5 3 3 6 Poplar 1.1 1.0 2.7 1.5 1.1 2.6 3 2 5 Southern. South wark 1.3 1.3 2.6 1.0 1.8 2.8 — 2 2 Bermondsey 10 1.8 2.8 1.5 1.4 2.9 2 2 4 Lambeth 1.6 1.6 3.1 1.1 1.1 2.2 2 5 7 Battersea 0.9 1.9 2.8 1.2 1.6 2.8 5 1 6 Wandsworth 1.6 1.9 3.5 1.6 1.4 3.0 4 6 10 Camberwell 1.9 1.5 3.4 1.3 1.6 2.9 1 7 8 Deptford 1.5 1.7 3.2 1.1 1.3 2.4 — 2 2 Greenwich 1.2 1.4 2.6 1.3 1.8 3.1 — 2 2 Lewisham 1.2 1.5 2.7 1.2 1.6 2.8 5 2 7 Woolwich 1.4 2.0 3.4 1.0 1.1 2.1 — 1 1 London 1.5 1.66 3.16 1.3 1.5 2.8 43 61 104 *Including deaths due to abortion except those legally determined to have resulted from criminal interference. 11 The deaths in childbirth in 1938 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 in any metropolitan borough may be misleading. The maternal mortality rates for each metropolitan borough in 1938 and for London as a whole annually since 1924 are, however, set out in tables 27 and 29. The death-rates per 1,000 live births in London and England and Wales in recent years are shown in the following table:— Table 20 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 Puerperal fever, London 1.31 1.59 1.88 1.93 2.01 1.33 1.69 1 34 1.15 0.75 0.84 0.79 England and Wales 1.57 1.79 1.80 1.92 1.66 1.61 1.83 2.03 1.68 1.39 0.98 0.89 Other causes, London 1.50 2.00 1.73 1.40 1.80 1.66 1.97 1.46 1.43 1.23 1.45 1.12 England and Wales 2.54 2.63 2.53 2.48 2.45 2.60 2.68 2.57 2.42 2.41 2.28 2.19 7 line Birth not total There were 191 notifications of fevers of the enteric group in London in 1938 compared with 216 in 1937. The deaths numbered 12 as against 17 in 1937. The mortality from enteric fever has thus been maintained at the low level to which it has been reduced during the present century. Enteric fevers 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 21 1- 5- 9- 13- 17- 21- 25- 29- 33- 37- 41- 45- 49-62 24 8 3 5 4 12 11 10 17 12 27 43 15 In addition, there were 2 deaths recorded by the Registrar-General of cases belonging to London which had not been notified within the county. One of these was an inmate of a mental institution. The deaths from influenza during 1938 numbered 271, compared with 1,656 in 1937. Influenza The deaths in London from rheumatic fever in 1938 numbered 103, of which 44 were among children under 15 years of age. The corresponding figures in 1937 were 82 and 42, respectively. Rheumatic fever There were 7,280 deaths from cancer in 1938, as against 7,320 in 1937. The death-rate per thousand was 1.79. There was an increase of 12 in the deaths among males and a decrease of 52 among females compared with the previous year. Cancer Tuberculosis The deaths from pulmonary tuberculosis in London during 1938 numbered 2,590, giving a death-rate of .64 per thousand living, in both cases a new low record, the corresponding figures for 1937 being 2,888 and .71 respectively, and 2,849 and .69 for 1936. There were 347 deaths from other forms of tuberculosis in 1938 as against 351 in 1937 and 363 in 1936, the death rates being .09 for each year. In England and Wales as a whole the corresponding death-rates for pulmonary and non-pulmonary tuberculosis, respectively, were .53 and .1 for 1938, and .58 and .11 for both 1937 and 1936. 12 The annual death-rates per 1,000 population in London from pulmonary and non-pulmonary tuberculosis in recent years are shown in the subjoined table:— Table 22 Period Pulmonary tuberculosis death-rates Non-pulmonary tuberculosis death-ratee 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 113 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 1938 0.85 0.45 0.64 0.10 0.07 0.09 The number of primary notifications in metropolitan boroughs during the year 1938, after correction of figures within each metropolitan borough by the exclusion of cases notified as primary but subsequently found to have been previously notified, was 6,182, the corresponding figure for 1937 being 6,469. The following is an analysis of the notifications in London during the year 1938:— Table 23 Form of tuberculosis notified Sex Number of formal primary notifications of new cases of tuberculosis Total notifica tions - 1- 5- 10- 15- 20- 25- 35- 45- 65- 65+ Total all ages Pulmonary tuberculosis M. 6 43 54 00 287 382 670 530 483 409 130 3,060 3,956 F. 12 30 39 64 348 469 599 200 143 100 64 2,140 2,825 Other forms of tuberculosis M. 8 51 83 67 74 62 79 33 14 14 13 498 580 F. 8 45 51 49 63 66 89 42 31 15 25 484 561 All forms of tuberculosis M. 14 94 137 127 361 444 749 503 497 423 149 3,558 4,536 F. 20 81 90 113 411 535 088 308 174 115 89 2,024 3,386 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 24 Form of tuberculosis notified Sex New cases of tuberculosis coming to knowledge otherwise than by formal notification 0- 1- 5- 10- 16- 20- 25- 35- 45- 55- 65+ Total Pulmonary tuberculosis M. 5 11 9 10 21 71 134 124 84 65 38 572 F. 2 10 8 9 42 102 179 66 36 24 21 499 Other forms of tuberculosis M. 3 23 16 21 17 9 30 8 8 5 6 146 F. 2 21 17 15 18 15 32 14 6 7 6 153 All forms of tuberculosis M. 8 34 25 31 38 80 164 132 92 70 44 718 F. 4 31 25 24 60 117 211 80 42 31 27 652 13 The sources of information as to the unnotified cases shown in the above table were as follows :— Table 25 Source of information Number of cases Pulmonary Non-pulmonary Death returns from local registrars 145 45 transferable deaths from Registrar-General 83 41 Posthumous notifications 50 37 "Transfers" from other areas 783 173 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 23,201 cases of pulmonary tuberculosis (13,340 males and 9,861 females) and 6,890 cases of other forms of tuberculosis (3,501 males and 3,389 females) on the registers of the metropolitan boroughs at the end of 1938. The following statement shows the changes in the numbers on the registers, for the whole county, during 1938 and also during the previous year. County of London—Notification registers 1937 1938 Cases on notification register at beginning of the year 32,944 31,053 Cases added to register during the registration year, by— notification 6,469 6,182 otherwise 1,423 1,370 Cases removed from register during the registration year— Cured, removed, etc. 6,347 5,396 Deaths 3,436 3,118 Cases on the register at the end of the year— Pulmonary— Males 13,492 13,340 Females 10,099 9,861 Other forms— Males 3,799 3,501 Females 3,663 3,389 Total 31,053 30,091 No. per 1,000 of population 7.6 7.4 14 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 26—County of London—Cases of tuberculosis on register at the end of each year, per cent, of population, 1932-1938 Metropolitan boroughs arranged in topographical order 1932 1933 1934 1935 1936 1937 1938 Pulm. Non P. Pulm. Non P. Pulm. Non P. Pulm. Non P. Pulm. Non P. Pulm. Non P. Pulm. Non P. Western. Paddington .50 .44 .51 .44 .45 .41 .39 .35 .38 .30 .39 .28 .40 .25 Kensington .36 .18 .33 .17 .36 .18 .30 .14 .28 .10 .30 .10 .28 .08 Hammersmith .57 .27 .55 .25 .57 .26 .57 .26 .56 .27 .56 .28 .49 .19 Fulham .72 .40 .74 .40 .80 .40 .81 .43 .83 .43 .70 .33 .70 .31 Chelsea .53 .13 .53 .13 .52 .11 .50 .12 .46 .09 .43 .10 .38 .07 Westminster, City of .77 .26 .78 .25 .86 .27 .90 .29 .94 .28 .97 .28 1.04 .31 Northern. St. Marylebone .68 .17 .75 .18 .78 .19 .74 .19 .62 .15 .59 .12 .53 .08 Hampstead .40 .10 .38 .08 .39 .10 .38 .11 .30 .08 .30 .07 .31 .06 St. Pancras .66 .20 .65 .20 .62 .18 .47 .15 .44 .13 .43 .10 .44 .10 Islington .76 .26 .78 .27 .72 .25 .57 .20 .57 .20 .51 .17 .54 .16 Stoke Newington .46 .15 .50 .14 .49 .14 .46 .14 .44 .12 .38 .11 .40 .10 Hackney .61 .24 .61 .25 .63 .25 .64 .24 .54 .18 .58 .19 .57 .18 Central. Holborn .74 .19 .71 .19 .75 .17 .76 .16 .79 .19 .68 .18 .74 .19 Finsbury 1.38 .49 .87 .37 .91 .41 .82 .36 .54 .12 .54 .13 .59 .15 City of London .51 .06 .56 .09 .62 .06 .61 .10 .52 .09 .42 .09 .60 .08 Eastern. Shoreditch 1.31 .46 1.29 .46 1.30 .46 1.27 .47 1.26 .47 1.29 .48 1.05 .38 Bethnal Green .84 .42 .83 .44 .85 .43 .86 .41 .84 .40 .84 .39 .84 .38 Stepney 1.00 .41 .77 .34 .81 .35 .77 .24 .78 .25 .76 .24 .74 .23 Poplar .53 .25 .55 .25 .56 .24 .55 .21 .49 .19 .47 .18 .45 .16 Southern. Southwark .76 .30 .74 .28 .78 .27 .76 .25 .74 .24 .64 .20 .59 .18 Bermondsey .66 .25 .69 .25 .70 .26 .66 .25 .67 .24 .69 .23 .67 .19 Lambeth .70 .13 .73 .14 .75 .14 .76 .14 .77 .14 .71 .12 .72 .11 Battersea .50 .21 .50 .20 .49 .18 .46 .16 .44 .13 .45 .13 .48 .12 Wandsworth .48 .16 .47 .16 .46 .15 .47 .15 .47 .14 .49 .14 .48 .13 Camberwell .62 .23 .64 .24 .65 .24 .66 .24 .66 .23 .68 .23 .71 .22 Deptford .63 .21 .61 .19 .54 .19 .54 .18 .55 .19 .57 .17 .60 .18 Greenwich .58 .20 .54 .19 .51 .18 .50 .17 .51 .16 .52 .15 .57 .16 Lewisham .47 .15 .49 .15 .51 .15 .53 .16 .55 .18 .45 .12 .44 .13 Woolwich .55 .15 .57 .14 .57 .15 .55 .12 .54 .12 .52 .10 .50 .10 London .65 .24 .64 .24 .64 .23 .61 .22 .60 20 .58 .18 .57 .17 15 Table 27— Vital statistics for the metropolitan boroughs and the County of London in the year 1938 (Rates per 1,000 of population) Metropolitan boroughs arranged in topographical order Estimated resident population 1938 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 respdis. 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 137,400 13.7 11.3 66 .08 — .06 .02 — 13.8 .51 .81 .36 1.96 1.59 1.44 1.67 .04 .39 .05 .93 Kensington 174,100 12.8 11.8 78 .07 — .05 .03 .01 24.6 .53 .82 .40 1.80 2.24 1.42 1.02 .09 .30 .04 .56 Hammersmith 125,100 15.0 11.3 62 .04 — .04 .03 — 13.9 .58 .75 .51 1.87 1.07 2.30 1.54 .02 .42 .06 .93 Fulham 137,700 14.2 11.6 51 .04 .01 .03 .04 — 10.7 .78 .69 .39 2.00 .51 1.92 1.54 .03 .50 .04 .96 Chelsea 56,050 10.2 13.5 80 .05 .02 .07 .02 — 19.2 .70 .66 .52 2.12 5.23 1.54 2.92 .16 .48 .05 1.14 Westminster, City of 124,400 8.4 10.5 57 .03 — .01 — .01 10.5 .48 .56 .32 1.83 5.74 .79 1.19 .08 .26 .05 .18 Northern. St. Marylebone 90,680 8.8 11.1 60 .01 .02 .02 .01 — 12.5 .37 .77 .35 1.99 2.49 .96 .96 .10 .36 .04 .27 Hampstead 90,480 11.7 11.4 57 .02 — — — .01 7.6 .38 .70 .23 2 03 .94 1.81 .95 .09 .33 .07 1.02 St. Pancras 179,400 13.6 11.5 64 .07 — .04 .02 .01 17.2 .67 .84 .38 1.92 .82 1.84 2.10 .04 .48 .06 1.13 Islington 292,300 15.4 11.9 65 .08 .01 .08 .05 — 20.1 .73 .92 .47 1 .81 2.23 2.40 2. 05 .03 .54 .04 .64 Stoke Newington 50,480 13.8 110 43 .12 — .04 .02 — 5.8 .48 .55 .55 1.49 1.44 1.95 1.01 — .50 .04 .70 Hackney 205,200 13.4 10.7 56 .03 .00 .02 .02 — 12.4 .56 .79 .36 1.60 .36 1.80 1.13 .02 .51 .04 .90 Central. Holborn 34,350 7.3 10.5 84 .03 — —. — — 24.0 .87 .55 .49 1.78 4.00 1.69 1.31 — .41 .03 .67 Finsbury 56,960 13.0 12.9 73 .02 — .05 .12 — 21.6 .61 .81 .56 1.98 1.35 2.71 2.45 — .60 .02 1.09 City of London (a) 9,180 6.9 10.9 63 — — — .87 .33 — 1.31 — .98 1.31 .11 .22 .11 .33 Eastern. Shoreditch 80,360 14.7 11.4 64 .07 .01 .05 .06 .05 25.4 .58 .90 .32 1.70 2.54 2.65 2.52 .41 .45 .11 1.02 Bethnal Green 92,910 14.2 11.3 59 .06 .02 .05 .02 — 22.0 .73 .84 .33 1.70 1.52 3.73 2.53 .02 .79 .02 1.40 Stepney 200,500 13.1 11.1 63 .08 .01 .04 .06 — 17.6 .60 .86 .34 1.71 2.29 1.83 2 03 .06 .64 .04 1.19 Poplar 134,400 14.9 11.4 60 .10 .01 .07 .02 — 8.5 .73 .73 .53 1.82 2.50 2.48 4.04 .04 .49 .07 2.23 Southern. South wark 145,300 14.0 12.5 57 .08 .01 .06 .01 — 14.8 .84 .89 .42 1.64 .99 2.34 2.49 .02 .50 .05 .97 Bermondsey 97,420 14.8 11.1 45 .11 .01 .04 .04 — 9.0 .69 .66 .68 1.85 2.78 2.06 1.92 .02 .59 .03 1.15 Lambeth 272,800 141 11.9 51 .07 .00 .04 .01 — 10.9 .68 .77 .38 1.85 1.82 1.69 2.23 .03 .40 .07 .82 Battersea 141,700 14.9 11.8 53 .08 — .05 .02 — 14.7 .62 .54 .59 1.93 2.84 2.28 1.95 .05 .37 .01 1.69 Wandsworth 340,100 11.9 11.2 46 .04 .01 .04 .01 .00 10.6 .60 .50 .41 1.81 2.47 1.67 1.47 .04 .33 .05 .96 Camberwell 222,400 14.0 12.3 61 .05 .00 .09 .03 — 11.3 .68 .81 .49 1.67 2.58 2.54 1.96 .02 .47 .03 .68 Deptford 95,460 14.4 11.8 54 .02 .01 .05 .01 .01 5.1 .57 .79 .40 1 . 73 1.45 2.35 1.82 .02 .41 .02 .97 Greenwich 95,770 13.6 10.9 42 .04 .01 .01 .02 — 2.3 .63 .72 .30 1.60 1.53 1.64 2.65 .03 .50 .01 .96 Lewisham 229,000 13.9 10.5 47 .06 .00 .10 .01 — 5.0 .67 .60 .39 1.69 2.20 2.06 1.73 .03 .31 .03 1.22 Woolwich 150,900 13.6 10.4 50 .03 .03 .05 .01 .01 9.2 .78 .64 .40 1.02 .49 2.58 1.97 .04 .61 .05 1.23 London, 1938 4,062,800 13.4 11.4 57 .06 .01 .05 .03 .00 13.2 .64 .74 .42 1.79 1.91 2.00 1.88 .05 .45 .04 .98 London, 1931 4,094,500 13.4 12.5 60 .01 .01 .05 .06 .00 12.3 .71 .86 .60 1.79 2.29 2.07 1.91 .05 .43 .04 1.18 (a) Including Inner and Middle Temple. 16 Table 28—County of London—Principal causes of death by sex and age, 1938 Causes of death Sex 0— 2— 5— 15— 25— 35— 45— 55— 65— 75— All Ages 1938 1937 Typhoid and paratyphoid fevers M. — — — 1 1 2 — 1 1 — — 6 6 F. — — — 1 1 — 2 1 — 1 — 6 11 Measles M. 37 51 29 8 1 — — — — — — 126 14 F. 35 35 30 8 — — — — — — 1 109 10 Scarlet fever M. — 1 5 4 1 — 1 2 — — — 14 14 F. — 2 2 4 1 — 3 1 — — — 13 19 Whooping-cough M. 29 15 3 1 — — — — — — — 48 113 F. 27 18 9 — — — — — — — — 54 134 Diphtheria M. 7 4 31 52 2 — — — 1 — — 97 91 F. 4 3 41 56 2 1 1 — — — — 108 126 Influenza M. 5 4 1 3 2 4 8 23 34 29 29 142 719 F. 1 4 1 2 1 3 5 15 29 31 37 129 937 Encephalitis lethargica M. — — — — 5 8 2 2 2 1 — 20 26 F. — 1 — — — 2 4 7 1 6 — 21 28 Cerebro-spinal fever M. 12 2 4 2 5 2 4 3 1 — — 35 42 F. 7 4 3 4 2 4 — — 1 1 — 26 47 Tuberculosis of respiratory system M. 3 5 5 15 206 273 275 350 337 125 20 1,614 1,785 F. 6 4 7 10 253 295 143 104 86 51 17 976 1,103 Other tuberculous diseases M. 12 17 17 27 40 27 13 13 14 9 2 191 184 F. 9 8 25 32 26 19 12 6 9 2 8 156 167 Syphilis M. 10 1 — — 1 3 9 42 46 31 9 152 134 F. 11 — — 1 — 2 14 13 8 4 2 55 50 General paralysis of the insane, tabes dorsalis M. — — — 1 1 4 21 36 49 48 7 167 134 F. — — — — — 7 15 6 12 2 1 43 51 Cancer, malignant disease M. — 2 1 5 19 48 153 459 1,111 1,227 588 3,613 3,601 F. — 1 — 6 11 64 230 567 945 1,044 799 3,667 3,719 Diabetes M. — — — 2 1 3 5 23 59 92 50 235 225 F. — 1 1 2 2 — 8 35 98 167 100 414 443 Cerebral hæmorrhage M. — — — 1 1 4 13 60 161 294 216 750 807 F. 1 — — — 1 7 15 72 207 314 377 994 1,077 Heart disease M. — — 3 22 66 91 139 457 1,232 2,112 2,422 6,544 6,687 F. — 1 3 23 59 107 143 298 798 1,905 3,610 6,947 7,647 Aneurysm M. 1 — — 3 3 6 10 22 61 45 20 171 179 F. — — — — 1 5 8 20 38 33 18 123 138 Other circulatory diseases M. 2 1 1 — — — 12 51 221 379 422 1,089 1,067 F. 1 — — — — 2 14 59 217 385 565 1,243 1,316 Bronchitis M. 62 10 1 2 8 10 20 108 169 213 218 821 1,106 F. 34 1 1 1 8 4 11 33 54 136 259 542 859 Pneumonia (all forms) M. 293 78 32 27 44 49 109 211 321 346 224 1,734 1,980 F. 241 43 33 18 26 26 65 95 152 229 327 1,255 1,544 Other respiratory diseases M. 5 1 3 — 6 7 16 26 41 31 38 174 255 F. 4 1 — 4 11 12 9 11 25 33 47 157 236 Peptic ulcer M. — — — — 2 18 57 111 154 84 36 462 471 F. — — — — 1 3 8 18 24 37 35 126 139 17 Table 28—continued Causes of death Sex 0— 1— 2— 5— 15— 25— 35— 45- 55— 65— 75— All Ages 1938 1937 Diarrhoea, etc. M. 414 28 2 1 3 5 6 5 14 8 12 498 475 F. 260 19 1 4 3 8 8 7 9 19 11 349 333 Appendicitis M. 2 — 8 21 23 10 12 23 20 19 9 147 156 P. — 1 9 9 7 9 6 19 26 19 11 116 134 Cirrhosis of liver M. — — 1 — — 1 5 17 30 16 5 75 98 F. — — — — 2 — 10 11 20 12 7 62 69 Other diseases of liver, etc. M. 2 — — 1 — 3 2 7 12 16 16 59 69 F. 1 — — — 1 1 11 12 26 48 39 139 133 Other digestive diseases M. 24 7 7 8 11 23 29 44 80 89 68 390 406 F. 15 1 3 18 5 20 26 47 69 97 93 394 434 Acute and chronic nephritis M. 4 — 4 11 24 30 40 80 127 151 115 586 644 F. 1 1 2 6 17 30 28 69 115 169 132 570 667 Puerperal sepsis Other puerperal causes F. — — — — 7 17 19 — — — — 43 46 F. — — — — 9 28 23 1 — — — 61 80 Congenital debility, premature birth, malformation, etc. M. 750 6 3 6 1 2 — 1 2 1 — 772 809 F. 550 3 3 4 1 2 — — — 1 — 564 585 Senility M. — — — — — — — — 1 22 183 206 264 F. — — — — — — — — 2 41 407 450 520 Suicide M. — — — 1 23 47 55 89 96 62 25 398 389 F. — — — — 9 27 39 47 45 21 12 200 226 Other violence M. 36 11 23 60 121 95 71 80 115 111 141 864 983 F. 28 5 7 20 26 38 23 39 57 130 271 644 679 Other defined diseases M. 99 21 25 73 106 113 109 178 317 453 410 1,904 1,955 F. 85 21 26 68 72 92 140 207 263 314 285 1,573 1,643 Causes ill-defined, or unknown M. — — — — — — — — — 1 — 1 20 F. — 1 — — — 1 — 1 1 8 10 22 19 All causes M. 1809 265 209 358 727 888 1196 2524 4829 6015 5285 24,105 25,908 F. 1321 197 207 301 565 836 1043 1821 3337 5260 7481 22,351 25,369 18 Table 29—County of London—Principal vital statistics, 1891-1938 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 Whoopingcough Measles Influenza Tuberculosis Pneumonia (all forms) Bronchitis Other resp- diseases Heart disease Cancer Diabetes Infants 0—1 Diarrhoea and enteritis 0—2 Puerperal fever Other acc. of ch. birth Pulmonary Non -pulmonary 1891-95 30.8 17.3 19.8 (a) 0.53 0.13 0.24 0.02 0.52 0.59 0.41 1.83 0.80 1.45 2.45 0.48 (a) 0.80 0.07 156 23.8 2.15 2.22 1896-1900 29.7 18.4 18.5 (a) 0.45 0.14 0.14 0.00 0.47 0.57 0.27 1.75 0.69 1.32 1.80 0.35 (a) 0.92 0.07 162 41.3 1.70 1.74 1901-05 28.6 17.7 16.4 (a) 0.20 0.08 0.11 0.07 0.36 0.45 0.17 1.58 0.57 1.46 1.41 0.26 1.31 1.01 0.08 139 30.4 1.64 1.52 1906-10 26.5 17.4 14.9 (a) 0.14 0.04 0.10 0.00 0.29 0.42 0.22 1.39 0.48 1.49 1.22 0.22 1.26 1.11 0.10 114 23.8 1.46 1.47 1911-15 24.0 20.0 14.8 0.02 0.13 0.03 0.05 0.00 0.22 0.43 0.16 1.39 0.39 1.33 1.29 0.21 1.54 1.16 0.11 108 28.0 1.40 1.57 1916-20 20.0 20.1 15.1 0.04 0.17 0.02 0.03 0.00 0.20 0.28 1.01 1.43 0.34 1.38 1.30 0.19 1.78 1.28 0.09 92 15.4 1.64 1.72 1921-25 19.9 17.9 12.3 0.01 0.17 0.01 0.04 0.00 0.15 0.17 0.32 1.01 0.19 1.14 0.97 0.16 1.66 1.38 0.10 71 11.7 1.36 1.63 1926-30 16.2 18.6 12.3 0.02 0.10 0.01 0.02 0.00 0.11 0.16 0.30 0.90 0.14 1.00 0.72 0.16 2.29 1.52 0.12 64 10.2 1.66 1.69 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 1936 13.6 21.5 12.3 0.02 0.05 0.01 0.01 — 0.07 0.14 0.13 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 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 1938 13.4 21.9 (b) 11.4 0.02 0.05 0.00 0.01 — 0.03 0.06 0.07 0.64 0.09 0.74 0.34 0.08 3.32 1.79 0.16 57 13.2 0.79 1.12 (a) Comparable figures are not available for this period. (b) Provisional rate. 19 Table 30—County of London—Notifiable infectious diseases—Notifications per 1,000 of population Period Annual rates per 1,000 living Anthrax Cerebrospinal fever Continued fever Diphtheria Dysentery Encephalitis lethargica Enteric fevers Erysipelas Malaria Ophthalmia neonatorum (per 1,000 live births) Acute primary and influenzal pneumonia Polio. encephalitis Poliomyelitis Puerperal fever (per 1,000 live births) Puerperal pyrexia (per 1,000 live births) Scarlet fever Smallpox Typhus 1891-95 (a) (a) .00 2.4 (a) (a) .78 1.54 (a) (a) (a) (a) (a) 2.17 (a) 5.3 .26 .00 1896-1900 (a) (a) .00 2.9 (a) (a) .82 1.24 (a) (a) (a) (a) (a) 2.03 (a) 4.4 .02 .00 1901-05 (a) (a) .00 1.9 (a) (a) .52 1-08 (a) (a) (a) (a) (a) 2.10 (a) 3.6 .46 .00 1906-10 (a) (a) .00 1.6 (a) (a) .28 .97 (a) (a) (a) (a) (a) 2.27 (a) 4.2 .00 .00 1911-15 .00 .05 .00 1.8 (a) (a) .17 .98 (a) (a) (a) (a) (a) 3.11 (a) 3.6 .00 .00 1916-20 .00 .07 .00 2.3 (a) (a) .09 .60 (a) 8.95 (a) (a) .02 3.00 (a) 2.7 .00 .00 1921-25 .00 .02 .00 2.86 .00 .05 .08 .43 .03 9.05 1.24 .00 .01 3.59 (a) 3.69 .00 .00 1926-30 .00 .02 .00 2.81 .01 .03 .08 .47 .01 9.89 1.46 .00 .01 4.10 (a) 3.28 .33 .00 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 — 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 — — 1938 .00 .04 .00 1.88 .26 .00 .05 .45 .00 9.00 0.98 .00 .03 3.66 15.70 2.00 — — (a) Comparable figures are not available for this period. Measles and whooping-cough were made notifiable in the administrative County of London from 1st October, 1938. The equivalent annual notification rates per 1,000 of the population based on the last quarter of 1938 were: measles 0.28 and whooping-cough 1.87. Table 31—County of London—Annual number of notifications of infectious disease, 1929-38 Year (52 or 53 weeks) Anthrax Cerebro-spinal fever Continued fever Diphtheria Dysentery Encephalitis lethargica Enteric fevers Erysipelas Malaria Ophthalmia neonatorum Acute primary and influenzal pneumonia Polioencephalitis Poliomyelitis Puerperal fever Puerperal pyrexia Scarlet fever Smallpox Typhus 1929 5 121 8 11,788 56 92 351 2,158 38 728 8,717 4 62 312 758 15,855 1,908 — 1930* 1 88 6 13,411 40 60 291 2,387 29 617 5,531 8 29 293 740 16,699 5,149 2 1931 2 175 3 8,384 58 40 186 2,294 32 629 6,880 5 51 291 828 12,025 1,452 — 1932 3 247 4 8,087 79 47 195 2,230 41 687 5,673 10 79 218 741 14,119 1,131 — 1933 3 216 5 9,557 31 22 164 2,766 21 527 6,299 6 60 255 838 21,911 531 — 1934 3 137 4 11,782 58 29 109 2,586 30 467 5,569 8 66 254 758 18,238 144 — 1935 2 105 3 9,294 199 15 187 1,868 37 382 3,707 4 81 241 652 10,954 — — 1936* — 113 4 7,030 304 12 255 1,815 35 462 4,141 2 36 175 635 10,705 — — 1937 3 175 6 7,810 916 8 216 1,764 42 453 4,798 13 95 228 793 8,455 — — 1938 4 182 1 7,611 1,049 5 191 1,829 16 489 3,962 12 122 199 853 8,093 — — * 53 weeks. The number of notifications of measles from 1st October, 1938, was 282, and of whooping-cough 1,891. 20 Table 32—County of London—Notifications of infectious disease during the 52 weeks ended 31st December, 1938 Metropolitan boroughs (in topographical order) Anthrax Cerebrospinal fever Continued fever Diphtheria (including membranous croup) Dysentery Encephalitis lethargica Enteric fever Erysipelas Malaria *Measles Ophthalmia neonatorum Acute primary and influenzal Pneumonia Polio- encephalitis Poliomyelitis Puerperal fever Puerperal pyrexia Scarlet fever Whoopingcough Western— Paddington — 7 1 229 32 — 5 54 2 6 13 128 1 1 21 44 197 106 Kensington — 7 — 177 84 — 15 52 — 5 11 98 — 8 6 36 247 115 Hammersmith — 8 — 192 41 1 2 52 — 8 7 116 1 4 10 17 287 52 Fulham — 6 — 212 29 — 4 68 — 10 18 132 2 4 5 35 264 17 Chelsea — 3 — 163 43 — 9 27 _ 1 3 64 — 3 1 7 86 24 Westminster, City of — 6 — 148 27 — 10 32 2 4 7 22 — 2 6 18 98 16 Northern— St. Marylebone — 4 — 87 16 — 9 33 1 3 4 24 — 2 3 17 87 19 Hampstead — 6 — 86 10 — 8 30 — 3 15 92 — 1 4 20 163 20 St. Pancras — 11 — 376 59 — 8 86 2 14 22 203 — 5 7 37 329 113 Islington — 13 — 599 98 — 8 157 1 13 38 188 — 4 19 70 699 111 Stoke Newington — 2 — 51 6 — — 25 — 2 6 35 — 1 11 22 98 10 Hackney — 8 — 232 18 1 5 105 — 7 23 185 — 3 21 67 368 202 Central— Holborn — 1 — 45 11 — — 14 — 2 6 23 — — — 2 58 10 Finsbury — 1 — 139 20 — — 34 — 10 13 62 — 1 5 9 154 49 City of London — 1 — 12 5 1 1 2 — — 2 3 — — — — 9 1 Eastern— Shoreditch — 9 — 202 80 1 33 36 1 8 13 82 — 1 2 17 212 59 Bethnal Green — 2 — 234 22 — 2 73 — 7 15 130 — 2 2 18 346 43 Stepney 1 8 — 405 41 1 11 128 1 24 10 238 1 3 8 41 366 102 Poplar — 9 — 542 17 — 5 66 — 11 9 299 — 4 4 48 333 80 Southern— South wark — 7 — 361 25 — 3 72 3 18 27 141 — 5 — 26 339 125 Bermondsey 1 3 — 187 26 — 2 57 — 8 10 112 — 1 1 10 200 67 Lambeth — 19 — 607 18 — 8 108 — 41 50 222 1 4 20 44 459 91 Battersea — 2 — 276 17 — 7 52 — 18 30 239 2 12 9 22 322 106 Wandsworth 1 17 — 498 179 — 14 113 — 9 32 327 — 13 8 45 568 148 Camberwell — 6 — 435 22 — 4 104 2 12 22 150 — 5 13 45 563 37 Deptford — 2 — 173 12 — 2 39 1 15 14 92 — 10 1 25 224 51 Greenwich — 1 — 253 23 — 3 48 — 10 15 92 — 6 2 36 157 34 Lewisham 1 6 — 394 19 — 7 70 — 8 22 278 4 12 2 39 471 64 Woolwich — 7 — 296 49 — 6 92 — 5 32 185 — 5 8 36 389 19 Ages 0- — 23 — 146 78 — — 26 — 59 489 215 — 3 — — 64 231 „ 1- — 45 — 2,299 335 1 7 55 — 139 — 741 4 51 — — 2,502 1,149 „ 5- — 22 — 3,053 164 — 19 44 — 51 — 448 5 35 — — 3,296 490 „ 10- — 7 — 933 43 1 16 55 — 15 — 137 1 13 1 — 1,056 8 „ 15- — 22 — 409 28 — 17 95 — 6 — 211 1 10 10 54 450 2 „ 20- — 15 — 272 39 — 26 96 1 4 — 177 — 5 49 239 226 — „ 25- — 25 — 327 69 2 41 229 2 6 — 408 — 5 100 429 313 6 „ 35- 2 9 — 106 42 — 29 277 6 1 — 421 — — 37 129 114 1 „ 45- 1 7 — 35 36 — 17 318 5 — — 420 1 — 2 2 49 2 „ 55- — 7 1 16 42 — 8 322 2 — — 402 — — — — 15 2 „ 65- 1 — — 12 55 1 10 210 — 1 — 270 — — — — 5 — „ 75 + — — — 3 118 — 1 102 — — — 112 —- — — — 3 — Total, 1938 4 182 1 7,611 1,049 5 191 1,829 16 282 489 3,962 12 122 199 853 8,093 1,891 Total, 1937 3 175 6 7,810 916 8 216 1,764 42 — 453 4,798 13 95 228 793 8,455 — *Measles and whooping-cough were made notifiable in London from 1st October, 1938. There were no notifications of smallpox or typhus fever during the year. 21 ADMINISTRATION 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. Clearance area operations 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 1938 34 3,228 125 Total number under the Housing Acts since 1930 274 22,145 393 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 81 areas, comprising 1,538 houses ; of these, 4 areas involving 196 houses were considered to be more suitable for action by the Council. At the end of the year a further 7 areas, involving 141 houses, were still under consideration as to whether the Council should itself deal with them. The Borough Councils concerned were therefore informed accordingly. During the year, 3,661 houses were represented by the Council's medical officers (including 433 re-represented), 1,568 were included in notifications from the Borough Councils, and of these it was decided to include 196 houses (some of which are included above) in the Council's own programme. Public inquiries were held by the Ministry of Health in respect of clearance orders and compulsory purchase orders made by the Council relating to 3,521 houses in 37 areas represented as suitable for action under section 25 of the Housing Act, 1936. Overcrowding In March the Minister of Health fixed appointed days in respect of overcrowding in the seven metropolitan boroughs referred to in the annual report of 1937 as those in which the fixing of the appointed day was still under consideration. Preferential housing During the year nearly 1,000 applications were received tor preferential consideration for rehousing on the Council's estates on the grounds of ill-health of a member of the family. If the applicants were living under conditions considered to be dangerous or injurious to the health of the occupants, recommendations were forwarded to the valuer with a request that priority should be granted. Over 400 families, who were placed on the preferential waiting list as a result of these recommendations, were rehoused during the year. The above figures do not include applications on the grounds of tuberculosis, to which reference is made elsewhere in this report (p. 28). New legislation— Agriculture Act, 1937 Milk and Dairies (Consolidation) Act, 1915, and Tuberculosis Order, 1925 On 1st April, 1938, Part IV of the Agriculture Act, 1937, which relates to the veterinary inspection of cattle, came into force, and the Council's duties under the Tuberculosis Order, 1925, and Part IV of the Milk and Dairies Order, 1926, were transferred to the Ministry of Agriculture and Fisheries; the Council are consequently no longer responsible since that date for the examination of animals in licensed sheds. Examination of milk This new legislation did not, however, affect the Council's duties concerning the sampling of milk arriving in London by road or rail from the provinces for ascertaining the presence of tubercle bacilli; and this practice, as described in previous annual reports, has been continued in 1938. The result of such sampling during 1938, compared with that of 1937, is as follows (the figures for 1937 being given in brackets): completed examinations, 2,112 (1,929); number tuberculous, 158 (135); percentage, 7.5 (7.0). 22 Analysis of the samples taken during the year, of which examination was completed, tabulated according to the grade of the milk shows:— Table 33 Grade Number of samples Number tuberculous Percentage tuberculous Tuberculin-tested 107 (67) - (1) - (1.5) Accredited 386 (354) 45 (35) 11.7 (9.6) Ungraded 1,619 (1,508) 113 (100) 7.0 (6.6) The figures in brackets are for the year 1937. The policy of referring to the Milk Marketing Board particulars of infected milk of any grade concerning which there is no evidence that it would be pasteurised before consumption has been continued. Action was taken during the year in respect of three such samples, and an assurance was given by the company concerned that the milk from the infected sources would be pasteurised. During the year milk from 26 counties was sampled, and when found to be tuberculous the medical officers of health of the counties concerned were notified, with the result that 91 cows were dealt with under the Tuberculosis Orders, 1925 and 1938, as against 90 in 1937. During 1938 there were 158 positive samples. The source of infection of 99 was traced, and of 46 not traced. Of 18 positive samples discovered in 1937, in respect of which examination was in progress at the beginning of 1938, the source of infection of 9 was traced and of 9 not traced. Inquiry in regard to the remaining 13 discovered in 1938 is still in progress. Cows at institutions under the control of the Council Samples of milk from cows kept at institutions under the control of the Council, other than those in tuberculin-tested herds, have been taken at least twice during the year. The results of such sampling showed that, of 212 samples, the examination of which was completed, 7 (or 3.3 per cent.) were tuberculous, and 5 cows were found to be suffering from tuberculosis. Cows at these institutions are sampled in groups; the Minister of Agriculture and Fisheries is informed of any sample proving to be tuberculous and arranges for the necessary steps to be taken to discover individual cows affected. Licensed cowsheds During the first three months of the year, before the Agriculture Act, 1937, came into operation, the cows in the London licensed sheds were inspected under the provisions of Part IV of the Milk and Dairies Order, 1926. The veterinary surgeons inspected the cows in all such sheds, making 32 visits in all. During these inspections, 514 cows were examined, of which 32 were found to be unhealthy, 2 suffering from tuberculosis, 22 from mastitis, 6 from induration of the udder and 2 from some other defect. In connection with these inspections, 6 samples of milk were taken for bacteriological examination in suspected cases ; of these, 2 were tuberculous, 1 was incomplete and the remainder negative. In addition to the special samples, 60 routine samples were taken, the examination of 3 of which was incomplete, while 4 were tuberculous and the remainder negative. Venereal diseases In the annual report for the year 1916 particulars were given of a scheme for the provision of the necessary facilities for the diagnosis and treatment of venereal disease which had been formulated as a result of conferences between representatives of the counties of London, Buckingham, Essex, Hertford, Kent, Middlesex and Surrey, and of the county boroughs of Croydon, East Ham and West Ham. The Local Government Board, in due course, signified its approval of the scheme, which came into operation on 1st January, 1917, and is known as the London and Home Counties Scheme. Hospitals Fifteen general and four special hospitals were undertaking in-patient or outpatient treatment and other work under the scheme at the end of 1938. 23 Clinics with all-day medical and intermediate treatment have been provided at four hospitals, and at the London County Council (Whitechapel) clinic (see page 24). In addition, eight hospitals provide facilities for all-day intermediate treatment. The number of new patients attending the hospitals during the year 1938 was 25,897, of whom 2,864 were suffering from syphilis, 9,271 from gonorrhoea, and 244 from soft chancre, while 13,518 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 1938 is shown in the following table:— Table 34 London Middlesex Essex Surrey Kent Herts. Bucks. East Ham West Ham Croydon Total "Other places" Grand total New patients— Syphilis 1,929 322 87 104 67 50 17 18 31 19 2,644 220 2,864 Soft chancre 90 5 7 5 8 - - 2 - - 117 127 244 Gonorrhœa 5,976 1,096 454 365 155 149 58 84 193 33 8,563 708 9,271 Not venereal 8,480 1,759 733 716 351 190 106 136 288 82 12,841 677 13,518 Total 16,475 3,182 1,281 1,190 581 389 181 240 512 134 24,165 1,732 25,897 Total attendances 608,247 90,699 44,418 33,818 16,023 8,031 3,574 11,020 18,298 3,299 837,427 15,296 852,723 No. of in-patient days 27,763 4,367 3,672 2,187 2,145 500 236 182 452 352 41,856 11,055 52,911 Pathological examinations For or at centres— Spirochaetes 2,041 197 127 51 21 58 6 43 47 6 2,597 174 2,771 Gonococci 94,103 16,894 11,262 5,731 2,267 1,686 962 2,037 3,928 549 139,419 5,258 144,677 Wassermann 33,175 4,937 2,352 2,310 919 608 317 464 868 268 46,218 1,737 47,955 Others 45,409 6,233 4,847 3,202 1,351 815 393 992 1,844 349 65,435 2,872 68,307 Total 174,728 28,261 18,588 11,294 4,558 3,167 1,678 3,536 6,687 1,172 253,669 10,041 263,710 For practitioners— Spirochaetes 5 — 1 2 — — — — — 4 12 — 12 Gonococci 6,538 237 508 568 50 39 20 2 22 1,401 9,385 7 9,392 Wassermann 16,632 735 2,198 1,465 228 154 158 40 6 855 22,471 383 22,854 Others 11,760 384 1,458 1,011 124 80 19 21 5 1,348 16,210 295 16,505 Total 34,935 1,356 4,165 3,046 402 273 197 63 33 3,608 48,078 685 48,763 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 35 Year New cases Total venereal cases Syphilis Soft chancre Gonorrhoea M. F. M. F. M. F. M. F. 1918-22 (average) 5,288 3,134 422 16 8,552 2,269 14,262 5,419 1923-27 (average) 3,968 2,330 277 6 8,907 2,776 13,152 5,112 1928-32 (average) 3,281 1,699 270 10 8,284 2,514 11,835 4,223 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 1938 1,799 1,065 235 9 7,120 2,151 9,154 3,225 Attendances For the year 1938 the total attendances of V.D. patients was 767,765, and the ratio of attendances of V.D. patients to new V.D. cases was 62, compared with 69 in 1937. The drop in the number of attendances, is attributable very largely to the use of drugs of the sulphanilamide group which considerably reduces the number of attendances reouired. 24 Comparative figures are shown in the following table:— Table 36 Year New cases Total attendances (venereal and non-venereal) In-patients days Venereal Non-venereal Total 1918-22 (average) 19,682 5,281 24,963 393,290 82,635 1923-27 (average) 18,263 8,354 26,617 648,999 105,144 1928-32 (average) 16,057 10,253 26,310 856,579 55,681 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 1,000,442 55,029 1938 12,379 13,518 25,897 852,723 52,911 Defaulting The question of defaulting is one to which attention is frequently drawn. Analysis of the returns for 1938 shows that, as regards syphilis, 789 patients were discharged after completion of treatment and final tests of cure, but that 2,841 patients failed to continue treatment until discharged. Of these, 449 ceased to attend before completing one course of treatment; 1,970 after completing one course of treatment but before completing treatment; and 422 after completion of treatment but before final tests for cure. Of the 449 who ceased before completing one course of treatment, 111 (compared with 100 in 1937) 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. In the case of gonorrhoea, 5,617 patients were discharged after completion of treatment and final tests of cure, 4,783 patients failed to continue treatment until discharged. Of these, 3,218 ceased to attend before completing treatment and 1,565 after completion of treatment but before final tests for cure; the corresponding numbers for 1937 were 3,161 and 1,169, respectively. Much time is spent by almoners and other officers 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. Pathology and bacteriology Another point worthy of note is the total number of examinations made of pathological specimens. These have increased from 13,988 from treatment centres and 3,649 from medical practitioners in 1917 to 263,710 and 48,763, respectively, in 1938. Venereal disease; hostel accommodation During the year 1938 the number of patients dealt with at venereal disease hostels from the areas in the scheme was 223, the aggregate number of days in residence being 24,472. Comparative figures for 1937 were 237 and 28,075. The London County Council (Whitechapel) clinic During the year 1938 the number of new patients attending the London County Council (Whitechapel) clinic, which is administered direct by the Council, was 3,673, and attendances totalled 203,306. Of the new patients 84 per cent. of the male and 67 per cent. of the female venereal cases were infections of less than one year's duration. The number of pathological examinations made at the clinic during the year was 75,814; of these 11,937 were made for private practitioners. All these figures are included in the figures for the scheme as a whole. Publicity and propaganda 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, 1938, some 405 addresses and lectures, several illustrated by film exhibitions, were given in the London area, the total estimated attendance thereat being 51,627. A grant of £2,380 16s. 7d. was made by the Council to the British Social Hygiene Council for this work during this period. 25 Treatment of tuberculosis The dispensary services of the Metropolitan Borough Councils continued as Dispensary before and the following is a summary of certain aspects of their work:— services Table 37 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 persons on dispensary register T.B. + cases on dispensary register Examinations per 100 new cases and contacts per 100 new cases New cases Contacts Adults Children Battersea 101 .71 .88 739 410 608 119 122 7.0 .46 .61 5.0 235.7 329.0 Bermondsey 76 .78 .92 1,018 441 684 318 317 4.8 1.28 .50 3.2 115.5 222.7 Bethnal Green 80 .86 .58 815 305 616 179 114 5.3 .21 .41 6.5 77.3 114.0 Camberwell 179 .81 .78 894 363 541 86 90 3.9 .57 1.01 4.6 98.2 130.2 Chelsea 44 .79 .93 523 273 823 184 102 7.7 .12 .50 13.0 120.9 163.0 Deptford 64 .67 .63 691 402 627 139 119 5.4 .40 .54 7.1 56.0 78.8 Finsbury 38 .67 .98 1,042 479 526 79 100 3.2 .09 .62 3.9 119.0 159.5 Fulham 121 .88 .46 517 268 656 136 89 7.5 .74 2.19 5.5 47.4 63.6 Greenwich 74 .77 .77 703 361 586 123 120 4.9 .20 .67 5.2 125.1 177.0 Hackney 127 .62 .79 946 443 624 179 154 4.7 .23 1.17 3.6 71.7 110.0 Hammersmith 87 .70 .98 972 451 453 149 130 3.3 .37 .84 4.6 43.2 69.8 Hampstead 37 .41 .73 646 346 484 132 157 9.1 .88 1.98 2.8 91.3 145.8 Hoi born 31 .91 .80 816 394 277 100 74 3.9 .08 .47 3.7 163.6 266.3 Islington 235 .80 .69 595 391 349 134 100 6.9 .33 .56 4.4 57.4 95.9 Kensington 106 .61 .88 510 265 498 132 108 5.4 .44 .86 6.5 82.8 122.7 Lambeth 209 .77 .68 676 311 405 261 147 4.4 .59 1.34 3.0 85.2 171.1 Lewisham 175 .76 .89 664 345 343 74 82 3.3 .23 .38 4.5 25.4 36.9 Paddington 81 .59 .84 922 327 891 137 135 8.9 .66 .56 6.5 58.3 76.0 Poplar 109 .81 .80 583 327 477 183 138 7.7 .85 .47 9.9 64.7 107.9 St. Marylebone 44 .48 .65 777 393 573 232 155 6.4 .43 .65 5.8 96.9 162.3 St. Pancras 133 .74 .84 597 322 378 119 97 4.3 .09 .34 4.5 47.7 75.0 Shoreditch 57 .71 .48 939 453 740 158 84 7.0 .19 .27 6.0 70.0 92.9 Southwark 134 .92 .65 467 242 458 125 113 7.9 .16 .79 3.8 229.4 348.5 Stepney 131 .65 .74 1,073 529 397 211 359 3.7 .39 .67 3.6 36.2 88.3 Stoke Newington 26 .52 .82 758 373 600 392 173 5.5 .47 1.78 8.2 37.3 72.4 Wandsworth 233 .69 .68 590 337 413 121 91 3.4 .29 2.17 4.0 17.0 25.7 Westminster 69 .56 .35 846 290 442 72 120 3.5 .17 .65 4.7 37.4 53.8 Woolwich 128 .85 .97 679 241 626 234 166 6.2 .33 1.26 5.2 88.0 144.3 London (excluding City) 2,937 .72 .72 720 352 504 154 131 5.2 .41 .90 4.8 81.2 127.0 Tuberculosis care committees Tuberculosis care committees functioned in 22 of the 28 metropolitan boroughs. In the remaining boroughs care work is undertaken by social workers in connection with the dispensary service. In order to extend the scope of voluntary "care" and "after.care" efforts, funds have been raised chiefly by means of sales of the Christmas stamps of the National Association for the Prevention of Tuberculosis. The object of the work remains the same, namely, to deal with each case of tuberculosis as an individual problem, particularly as it affects the larger economic group of the family, to render assistance in the most appropriate form towards mitigating any adverse social and economic results, and to endeavour to help patients towards rehabilitation in ordinary life on discharge from sanatoria. Owing to the long and often permanent disability which is a frequent characteristic of the disease, much effort and expenditure of money has perforce to be palliative rather than constructive. Handicraft, glove-making, dressmaking and cooking classes have been carried on as before, and to these have been added classes in book-binding and literature with a view to relieving the tedium of enforced idleness, and, to a very limited extent, to enabling patients to earn some pocket money as well as to develop a practical hobby. Metropolitan Borough Councils as public health authorities provide extra nourishment for certain tuberculous patients. Workshops for the tuberculous The Central Fund for the Industrial Welfare of Tuberculous Persons provides workshops in which are carried out the manufacture of leather goods, furniture, wooden toys and the preparation of firewood. The furniture and woodwork factory employs 26 between 35 and 40 men, and the leather workshop approximately 23 men. The employees are 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. Residential treatment No essential change in the Council's scheme for the residential treatment of tuberculosis, as described in previous reports, has taken place during 1938. The following pages indicate the operation of the scheme during the year, and in certain particulars during previous years. At the end of 1938 there were 4,174 beds occupied—3,443 by adults and 731 by children. Table 38—Applications for residential treatment Year For first period of 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 1938 2 2,610 1,960 796 52 1,671 1,160 199 8,450 Patients recommended for treatment during 1938 were dealt with as follows (the corresponding figures for 1937 being shown in brackets):— Adults Children (a) Admitted to "observation" beds to determine diagnosis or suitability for sanatorium treatment 1,338 (1,392) 202 (220) (6) Passed for admission direct to sanatoria or hospitals 5,963 (6,189) 749 (691) (c) Not accepted for residential treatment ... 106 (52) 23 (25) (d) Withdrawn after application but before decision was reached 48 (41) 21 (25) Total 7,455 (7,674) 995 (961) N.B.—The treatment offered was refused in respect of 127 adults and 24 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. Table 39—Extent of residential observation and treatment Classification In institutions on 1st January, 1938 Admitted during the year Discharged during the year Died in institutions In institutions on 31st December 1938 Number of doubtfully tuberculous cases admitted for observation. Adult males 52 198 194 7 49 Adult females 51 171 171 2 49 Children 12 272 263 - 21 Total 115 641 628 9 119 Number of patients suffering from pulmonary tuberculosis. Adult males 1,726 4,164 3,092 1,000 1,789 Adult females 1,217 2,688 2,158 547 1,200 Children 296 248 233 31 280 Total 3,239 7,100 5,483 1,587 3,269 Number of patients suffering from nonpulmonary tuberculosis. Adult males 220 267 266 41 180 Adult females 196 316 305 31 176 Children 450 311 293 38 430 Total 866 894 864 110 786 Grand total 4,220 8,635 6,975 1,706 4,174 27 Table 40—Distribution of patients in institutions on 31st December, 1938 (figures for 1937 in brackets) Hospitals and institutions Ex-service men Civilian adults Children under 16 years Total London County Council special hospitals 1 (5) 1,298 (1,268) 658 (670) 1,957 (1,943) London County Council general hospitals 6(12) 1,004 (1,002) 13 (20) 1,023 (1,034) Voluntary institutions 16(19) 1.118 (1,156) 60 (68) 1,194 (1,243) Total 23 (36) 3,420 (3,426) 731 (758) 4,174 (4,220) Table 41—Average number of patients under the scheme at Papworth and Preston Hall, respectively, during each of the past ten years 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 Papworth 16 33 61 90 109 118 140 136 145 150 Preston Hall 13 10 53 84 89 113 150 173 107* 100* Douglas House — — — — — — — — 69 75 * Exclusive of patients at the Douglas House annexe of Preston Hall. An average of 42 youths were treated during 1938 at the Burrow Hill Sanatorium Colony. Since 1931, 35 youths, trained in horticulture at the colony, have been accepted for employment as "improvers" in the parks department of the Council. Seven are now on the permanent adult staff and four others are eligible but failed to pass the medical examination for entrance ; they will be re-examined in due course. One left the service on health grounds. Time lost owing to sickness has been approximately 5 • 3 per dent. Afterhistories of discharged patients The following table shows the number of adult patients discharged from residential treatment in 1932 who were living at the end of five years after discharge, with comparative figures (given in brackets) relating to patients who were discharged in 1927:— Table 42—Adults Classification Number discharged Number lost sight of Total followed up Living at end of 5 years Number Percentage A 544 (620) 64 (115) 480 (505) 365 (371) 76.0 (73.5) B 1 181 (250) 12 (44) 169 (206) 137 (140) 81.0 (68.0) B 2 1,914 (2,155) 111 (173) 1,803 (1,982) 743 (670) 41.2 (33.8) B 3 632 (998) 13 (26) 619 (972) 49 (60) 7.9 (6.2) Total pulmonary 3,271 (4,023) 200 (358) 3,071 (3,665) 1,294 (1,241) 42 1 (33 9) Non-pulmonary 351 (317) 48 (71) 303 (246) 226 (182) 74.6 (74.0) Grand total 3,622 (4,340) 248 (429) 3,374 (3,911) 1,520 (1,423) 45.1 (36.4) The proportion of patients suffering from pulmonary tuberculosis who were followed up and found to be alive five years after completion of treatment, which was 33.9 per cent. in respect of those discharged in 1927, improved to 421 per cent. in respect of patients discharged in 1932. The smaller number of patients "lost sight of" in the 1932 group is, however, a factor to be considered. Experience shows that those patients who discontinue dispensary attendance or who leave London without notifying change of address are mainly those who feel well and are not so heavily infected. On the other hand, the fact of the death of a patient immediately comes to the notice of the appropriate authorities. Assuming, however, that all the patients lost sight of were alive at the end of the five-year period the percentage of survivors would still show an improvement of more than 6 per cent. 28 Longer periods of residential treatment may have played some part in this. While, in 1927, 22.9 per cent. of patients received more than six months' residential treatment, in 1932 the percentage receiving similar lengthy periods of treatment had risen to 34.2 per cent. It is of interest to note in passing that the most recently available comparable figure is 38.2 per cent. for 1938. Collapse therapy also must account for a substantial degree of the improvement in ultimate results that is seen to have taken place. subjoined are particulars ot the survival five years later ot children discharged from residential treatment in 1932, the figures for 1927 being given in brackets:— Table 43—Children Classification Number discharged Number lost sight of Total Number living at followed up end of 5 years A 166 (166) 13 (23) 153 (143) 139 (131) B1 8 (2) - (-) 8 (2) 6 (1) B 2 19 (20) - (2) 19 (18) 10 (6) B 3 21 (26) - (1) 21 (25) - (-) Total pulmonary 214 (214) 13 (26) 201 (188) 155 (138) Non-pulmonary 476 (609) 48 (88) 428 (521) 396 (492) Grand total 690 (823) 61 (114) 629 (709) 551 (630) Boarding-out scheme During 1938, 267 children were boarded out and, at the end of the year, 143 children were still being maintained under this scheme. The corresponding figures for 1937 were 253 boarded out and 143 still away at the end of the year. Supply of surgical appliances Tuberculosis patients attending the Council's after-care clinics are provided with surgical appliances free of charge. The Invalid Children's Aid Association assisted, in 35 instances, in providing children who do not attend the above-mentioned aftercare clinics with surgical appliances after discharge from residential treatment. The amounts paid in this connection were met from 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. After-care clinics for non- pulmonary tuberculosis Clinics for the after-care of ex-patients are held at County Hall by the medical superintendents of three of the Council's tuberculosis hospitals, viz., St. Luke's hospital, Lowestoft, for adults; the former Princess Mary's hospital, Margate; and Heatherwood hospital, Ascot, for children. There is also an after-care department at Queen Mary's Hospital for Children, Carshalton, for ex-patients of that hospital. The number of attendances at the clinics during the year was 1,560. Housing of tuberculous persons As part of the Council s arrangements tor the care ot tuberculous persons, special consideration is given to housing applications from families in which there is a member suffering from tuberculosis. Where justified by the existing home conditions, the Council's valuer is asked to give preference to such applications in the allotment of vacancies on the Council's housing estates. During the year 1938 approximately 310 of the families who were given preferential consideration were rehoused, compared with 261 in 1937. Cases dealt with by the Council Mental Deficiency Acts, 1913-38 On 31st December, 1938, 11,771 cases were being dealt with by the Council under the provisions of the Mental Deficiency Acts, 1913-38. Of these, 7,215 were in institutions, 450 under guardianship, 3,914 under supervision, 20 in places of safety awaiting action, 68 awaiting institutional care and 104 under consideration. During the year 1,151 cases were examined with the following results: feeble minded, 879; imbecile, 152; idiot, 14; morally defective, 2; not defective, 104. Blind Persons Acts, 1920 and 1938 Blind persons During the year, 1,663 applicants for registration or training under the provisions of the Blind Persons Acts, 1920 and 1938, were examined by the Council's ophthalmologists. Of these, 987 (450 male and 537 female) were certified as blind and 676 (292 male and 384 female) were found not to be blind. 29 In addition 27 certificates (14 male and 13 female) were accepted as evidence of blindness in respect of persons transferred to London from other authorities, and 4 certificates (1 male and 3 female) in respect of persons privately examined. Eighty-two blind persons were examined as to suitability for training and 69 (55 male and 14 female) were found suitable. Midwives Acts, 1902 to 1936, Nursing Homes Registration and Maternity and Child Welfare Contribution Schemes Domiciliary midwifery service In the annual report tor the year 1907, particulars were given of the scheme, which was approved by the Council and by the Minister of Health, for implementing Section (1) of the Midwives Act, 1936, so far as London was concerned. The scheme came into operation on 1st January, 1938. The scheme has been a marked success, and this was attributable very largely to the careful planning, in advance, of co-ordinated effort by the Council, by the Borough Councils, and by the participating voluntary organisations. L.C.C. midwives When the scheme started, 47 Council midwives were appointed. Experience has shown that, in some parts of the county, provision was adequate, but in certain districts, especially in those in which independent midwives took advantage of the opportunity of obtaining compensation by surrendering their certificates under Section 5 of the Act (see p. 30), bookings became heavier and it became necessary, from time to time, to strengthen the staff. The total number of Council midwives employed at the end of the vear was 53. Liason between hospital and domiciliary service In view of the large demand for accommodation in the maternity wards of the Council's hospitals, arrangements were made to advise applicants for admission thereto, who, after medical examination, were considered suitable for confinement at home, to apply to one of the Council's domiciliary midwives. During the year 389 such patients were booked by Council midwives. Voluntary organisations In last year s report it was stated that 36 voluntary organisations were entering into agreements with the Council to provide for the employment of 120 midwives on domiciliary midwifery. Towards the end of 1938, the Council decided, after consultation with the London Maternity Services Joint Committee, the representative body with which the preliminary negotiations with regard to the scheme were conducted, that the present scheme should be allowed to continue for a further year, subject to certain minor amendments. The Women's Public Health Officers' Association, the Midwives' Institute and the Metropolitan Counties Branch of the British Medical Association expressed the opinion that the scheme as a whole had worked satisfactorily. Meetings with obstetric consultants, health visitors, etc., have been held to ensure the smooth working of the scheme. Statistics The number of midwifery and maternity nursing cases undertaken in 1938 by the domiciliary midwifery service was as follows :— Midwifery Maternity Organisation cases nursing cases Total L.C.C. midwives 2,924 449 3,373 Maternity hospitals 6,642 857 7,499 Teaching hospitals Other organisations Grand total 9,566 1,306 10,872 The ante-natal care of the midwifery patients (booked cases only) was undertaken by the under-mentioned agencies:— Midwife only 807 Private doctor 241 Hospital 5,049 Borough ante-natal clinic 3,097 Private doctor and hospital 10 Private doctor and borough ante-natal clinic 39 Hospital and borough ante-natal clinic 80 Private doctor, hospital and borough ante-natal clinic 3 Voluntary organisations 47 Total 9,373 30 Maternal deaths Among those booked with the service or attended in emergency by midwives working under the scheme, there were nine deaths due to pregnancy and confinement and two deaths associated with pregnancy and confinement. Five of the patients were booked by the Council's midwives, four by midwives of voluntary organisations and two were emergency cases. Each case was investigated fully. Non-medical supervisors During the year two positions of non-medical supervisor of midwives were authorised in place of two assistant medical officers and the new positions were filled in January, 1939. Refresher courses Section 7 (i) of the Midwives Act, 1936, provides that the Central Midwives Board shall have power to frame rules requiring midwives to attend a course of instruction, and clause (ii) of Section 7 of the Act directs that every supervising authority shall provide or arrange for the provision of such courses of instruction for midwives practising in its area. The rules of the Board have been formulated and prescribe a four weeks' residential course, normally every seven years. During the year the Council made arrangements with the St. John's Post-Certificate School for the reservation of 30 places during the year 1939 for practising midwives working in London. Compensation Under the Midwives Act, 1936, practising midwives were given the option of relinquishing their practice and, subject to certain conditions, became entitled to receive compensation. This provision remained in force until 30th July, 1939. During the year compensation was authorised to 30 midwives who had voluntarily surrendered their certificate of enrolment by the Central Midwives Board and during the same period one was called upon to cease practising as she was deemed to be incapable of performing her duties efficiently by reason of age. Compensation amounting to £8,959 13s. 8d. was authorised for payment to the 31 midwives concerned. One case was referred to the Minister of Health for decision. Number of confinements The following statement shows the number of confinements which occurred in London in 1938, 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 1938 was 66,318. Institutional confinements Voluntary hospitals *18,707 Borough maternity homes 2,556 L.C.C. hospitals 21,037 Private nursing homes 3,261 Total ... 45,561 Domiciliary confinements L.C.C. midwives 3,373 Borough midwives 340 Voluntary hospitals and organisations 7,499 Independent midwives *3,892 Private doctors 5,653 Total 20,757 * Estimated. The number of births used by the Registrar-General in calculating the birthrate of London was 54,495. The substantial difference between this figure and the 66,318 notified births indicates that a large number of women whose normal place of residence is outside London come to London for their confinement. Midwives Certified midwives to the number ot 1,050 gave notice of intention to practise within the county during the year, compared with 1,045 in 1937. These 1,050 midwives fall into the following categories:— L.C.C. domiciliary midwives 55 In private practice 139 Out-county 50 Nursing homes 95 Municipal (Borough Council) 10 31 L.C.C. hospitals 196 Voluntary maternity hospitals (district) 210 Voluntary general and special hospitals 107 Borough maternity homes 59 Voluntary nursing associations 129 Total 1,050 The following is a summary of returns wh1ich have been made voluntarily by the 139 midwives in private practice in London as to the number of patients attended by them during 1938:— Number of midwives who attended under 25 cases*90 25 to 50 „ 20 50 to 75 11 75 to 100 11 „ „ „ over 100 7 Total 139 * Of whom 44 took no patients. Infringements of the Rules of the Central Midwives Board to the number of 14 were reported during the year, compared with 15 in 1937. Eight midwives received a written caution and four received an oral caution. Of the remaining two cases, which were of a more serious nature, one was cautioned by the appropriate Committee of the Council and one by the Central Midwives Board. The County of London (MidwiferyProhibition of Unqualified Persons) Order, 1938. The County of London (Midwifery—Prohibition of Unqualified Persons) Order, 1938, came into operation on 1st November, 1938. With certain exceptions, an unqualified person is prohibited from attending patients for gain in the capacity of a maternity nurse. Up to the end of the year, four persons received either written or oral cautions. Still-births During the year there were 203 still-births reported to the Council by midwives in their practice, compared with 237 in 1937. Of the cases reported this year 101 were male, 102 female; 104 were reported as macerated, and 98 not macerated, and in one the condition was not stated. Puerperal fever During the year 201 cases of notified puerperal fever were investigated, compared with 240 in 1937. Of these cases 7 proved fatal, compared with 18 in 1937, a case mortality of 3.46 per cent., compared with 7.5 per cent. in 1937. The case mortality in 1936 was 6.47. The distribution of notified cases, with the mode of delivery, was as follows, deaths being shown in brackets: medical practitioners 43(1); certified midwives 32 (3); hospitals 102 (2); cases of miscarriage or abortion where no attendant was engaged 24 (1)—total 201 (7). Puerperal pyrexia The number of notifications of puerperal pyrexia investigated during 1938 was 930, compared with 859 in 1937. The cases were distributed as follows, the deaths being shown in brackets: medical practitioners 103 (1); certified midwives 111 (3); hospitals 677 (8); cases of miscarriage or abortion where no attendant was engaged 39 (0)—total 930 (12). Six of the cases, of whom none died, were subsequently notified as puerperal fever, and are therefore shown in both tables. Medical aid The Rules of the Central Midwives Board indicate the emergencies for which a midwife must 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 5,410 such notices were received, compared with 4,269 in 1937. 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 17,850. Thi,s appears to indicate that medical aid was necessary in about 30'3 per cent. of the cases, compared with 24 per cent. during 1937. Inflammation of the eyes— notices During the year, 845 notices were received from midwives indicating that medical aid had been summoned for inflammation of the eyes of infants, compared with 830 in 1937; 11 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 32 856 cases, 178 proved to be ophthalmia neonatorum (1 per cent. of the 17,850 patients attended by midwives), compared with 144 in 1937; 334 other cases that did not occur in midwives' practices were also notified, making a total of 512 cases during the year, the percentage occurring in the practice of midwives being 34.77 per cent. of all cases of ophthalmia neonatorum, compared with 31.42 per cent. in 1937. All the midwives' cases were investigated, and it was found that 165 were completely cured; one child was found to be still under treatment at the end of the year; eight children had removed from London and the condition of the eyes after completion of treatment has not been ascertained; in one child the vision of the left eye was found to be impaired; three children died from causes other than opthalmia. Thirty-eight became in-patients at St. Margaret's Hospital, compared with 29 during 1937. There was no case of bhndness. Pemphigus neonatorum During the year 59 cases of pemphigus neonatorum occurred in the practice of midwives, compared with 44 during the previous 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 Council decided that, from 1st January, 1938, it would forego its claim on patients for reimbursement of the medical fee. Claims for fees accepted during the year numbered 3,189, compared with 2,641 in 1937, the total amount involved being £3,700, compared with £3,242 in 1937. The Midwives Act, 1926, fixed a period of two months from the date of the first visit, within which a medical practitioner must submit his claim. In pursuance of this provision, 39 claims amounting to £48 7s. 6d. were disallowed during 1938. Registration of nursing homes The provisions with regard to the registration ot 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 was concerned. The number of nursing homes on the register on 1st January, 1938, was 170. During the year five homes were added, of which one had applied during 1937, while 18 were removed on cancellation of the registration, leaving 157 on the register on 31st December, 1938. In 15 cases cancellations were made at the request of the persons registered and/or upon change of ownership. The remaining cancellations were made by order of the appropriate committee, or on vacation of premises. During the year proceedings were instituted against two persons for conducting premises as a nursing home without being duly registered in respect thereof. Both cases were dismissed, but one defendant was ordered to pay two guineas and the other ten guineas costs. There were 12 applications for registration during the year, of which, at the end of the year, four had been withdrawn, four granted, and three were still under consideration. One application was superseded by an application for exemption, which was granted. In 1938 the Council granted 109 exemptions from the provisions of Part XI of the Public Health (London) Act, 1936, in respect of premises not conducted for profit. These exemptions were for a period due to expire on 30th June, 1939; the exemption may be renewed at the discretion of the Council from year to year. Midwifery in registered nursing homes The following imormation concerning midwifery and maternity work undertaken in registered nursing homes was obtained:— 1935 1936 1937 1938 Number of registered nursing homes with maternity beds 150 132 117 111 Number of beds provided for maternity patients in such nursing homes 1,310 1,234 1,146 1,083 Number of births in such nursing homes:— Births with doctor engaged to attend 2,954 3,020 2,870 2,744 with State certified midwife (no doctor being in attendance) 1,174 848 446 418 with State certified midwife and doctor summoned in emergency by the midwife 98 86 124 99 Total 4,226 3,954 3,440 3,261 33 Maternity and child welfare work by voluntary associations 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 from 1937-38 to 1941-42, to 48 voluntary associations. The scheme, as amended, provides for payment by the Council of grants amounting to £31,433 6s. 8d. in the year 1938-39. In the course of the year one baby home was closed on account of the expiration of the lease and for financial reasons. An additional baby home was included in the scheme. An increase in the amount of grant to one mother and baby home was authorised. The following table indicates the nature of the services which are aided by the Council for the year ended 31st March, 1939:— Table 44 Number of associations at end of year Description of service Total of beds Grant paid by the Council 6 Maternity hospitals or maternity wards 302 £ 10,359 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 25 Mother and baby homes 421 for mothers 336 for babies 11,196 10 Babies' homes 355 5,255 * 44 associations provide a single service and 4 associations provide more than one type of service. Medical examination of staff During the year 15,415 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:— 1938 1937 Entrants 3,377 2,681 Sick staff 9,277 8,214 Casualties, illness, etc., at County Hall 450 538 Visits to staff in their homes or in hospitals 77 136 Recommendations based on investigations by telephone and correspondence 2,234 2,343 Total 15,415 13,912 Of the applicants for appointment to the permanent service, 263 failed to pass the medical examination. As a result of the examinations of the staff, 299 officers were deemed to be permanently unfit to carry out their ordinary duties in the service of the Council. Under the Council's scheme for providing pensions to spouses and dependants of contributors to the superannuation and provident fund, twenty applicants for admission to the scheme were examined during the year, and, of these, three were rejected on the ground that their expectation of life was deemed to be less than normal for their age and sex. Auxiliary Fire Service The Air Raid Precautions Act, 1937, placed upon the Council the duty of preparing and carrying into effect schemes for the defence of London against aerial attack. In the performance of this duty the Council created an emergency fire brigade organisation capable of dealing with large numbers of fires in their incipient stages. To this end, the first essential was the enrolment and training of a large number of auxiliary firemen. These were enrolled into various categories corresponding to the different types of duties to be performed. For those who were to undertake the strenuous obligations of fire fighting duties it was considered necessary to require a standard of physical fitness which was to be determined by medical examination, conducted either by the Council's medical staff or by private practitioners. Standards of fitness were prescribed by the medical officer of health, 34 and the duty of examining the volunteers was undertaken for the most part by the medical staff of the Council's hospitals. This arrangement facilitated the attendance of the candidates who were mostly in employment during the day-time and could only attend for examination after working hours. Those who preferred to undergo an examination by their own doctor were allowed to submit a medical certificate of fitness, which was subjected in case of doubt to the scrutiny of the medical officer of health. The scheme came into operation in April, 1938, and, between that date and the end of the year, 10,833 candidates were examined at the hospitals or at County Hall. Work done in the bacteriological laboratory at County Hall The work in the bacteriological laboratory in connection with the examination of diphtheria swabs, water samples, milk samples, specimens of ringworm and favus, sputum, etc., was carried out in the usual way during the year and there is nothing special to report. Work of the chemical branch The work of the chemical branch, both statutory and otherwise, was carried on as usual during the year at the three laboratories, the total number of samples examined being 23,671. 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. Examples of particular instances in which advice has been sought during the year 1938 are: (a) deterioration of paint work at a housing site, (b) the most suitable metal for use in a situation liable to abnormally corrosive conditions, (c) inflammability of various materials (fire prevention), (d) explosion risks in garages, (e) several hundreds of specifications for paints submitted by tenderers under a revised guarantee scheme, (f) the effect of flame cutting of high tensile steel, (g) air in a trial boring in Battersea Park, (h) preservation of antique plaster panels. Sewage treatment The addition of ferric chloride to the sewage has been continued at both outfalls during the year, and chlorination of the sewage in certain sewers has also been carried out with advantage during the summer months. The load on those units of the activated sludge plant which were in operation was increased with satisfactory results to 40 million gallons per day for the latter part of the year, thus lessening the pollution load of the river. The new sludge digestion plant was put into regular operation in August, and samples of inlet and outlet sludge were thenceforward examined daily. The composition and calorific value of the resulting gas were also determined. HOSPITALS AND ANCILLARY SERVICES General Hospitals Appropriation of institutions On 1st April, 1938, the Council completed its policy of removing its hospitals entirely from the ambit of the Poor Law by the appropriation of the remaining six institutions which accommodated chronic sick patients, and which were within the curtilages of general hospitals, viz.: Fulham, Hackney, St. Alfege's, St. Leonard's, St. Mary Abbots, St. Pancras. It was also decided that these institutions should be called hospitals, and that in order to differentiate them, for costing purposes, from the existing general hospitals of the same name, the figure II should be added to the name and also to the separate blocks of wards at Hammersmith and Lambeth hospitals accommodating chronic sick patients ; while those parts of the hospitals treating acutely sick patients would have the figure I added to the name. Planning and development The undermentioned major works of improvement were completed during the year and, in addition, a number of minor works were executed:— Archway Hospital.—Rebuilding of the sanitary annexes of wards 10, 11 and 12, and additions to Histological Laboratory. Bethnal Green Hospital.—Enlargement and remodelling of mortuary including the installation of cooling plant. 35 Dulwich Hospital.—Erection of dispensary (including a laboratory and office) and dispensary stores; conversion of existing dispensary into a sisters' messroom and a servery. Erection of a messroom and sitting room for female domestic staff; and the extension of waiting room for visitors. Hackney Hospital 11.—Remodelling and complete reconditioning and reequipping of five floors of the female block north to accommodate 218 chronic sick. Hammersmith Hospital.—Adaptation, reconditioning and re-equipment of blocks G, H, and I, formerly used by the able-bodied and the infirm, to provide 189 beds for chronic sick patients, 9 for sick nurses and 53 for children. Lambeth Hospital.—Conversion of the former nurses' home (E block) into accommodation for 58 acute sick and 30 child patients. Paddington Hospital.—Demolition of a part of E block and the erection of a ward block containing 59 maternity beds and 26 beds for general cases, with a dental department on the ground floor. Princess Mary's Convalescent Home, Margate.—Demolition of four single-storey children's blocks and the erection of a block for convalescent women, containing four-bedded dormitories for 192 patients. Adaptation of block A to provide sick ward accommodation for 31 patients and 13 cots, patients' dining rooms, cloakrooms and lavatories, X-ray room, treatment room, minor operating theatre and a dispensary. St. Mary Abbots Hospital.—(a) Demolition of narrow iron bridges connecting three ward blocks, and construction of concrete and glass bridges suitable for open-air treatment of patients and erection of new sanitary annexes at each end of the bridges, (b) Adaptation of two wards as a thoracic surgery unit for 44 patients. St. Mary, Islington, Hospital.—Improvement of male genito-urinary ward, including the formation of 2 single and 2 double-bedded cubicles and the construction of a verandah. St. Matthew's Hospital.—Modernisation of 8 male wards in the front block to accommodate 270 chronic sick patients. St. Nicholas' Hospital.—Formation of new main entrance with gate lodge separate from that to Woolwich institution. Maternity The hope expressed in the 1937 report that the inauguration of a domiciliary midwifery service would lead to a substantial decrease in the pressure on maternity wards has not been wholly justified, though it is likely that, but for the domiciliary service, the pressure on hospital beds would have been even greater. The number of births in the Council's hospitals rose from 19,944 in 1937 to 21,147 in 1938. After the middle of the year normal multiparæ whose home circumstances were found to be satisfactory were asked to make their own arrangements if they did not wish to accept the offer of the services of a domiciliary midwife. As far as possible, hospital admission was restricted to primiparæ, to abnormal cases among multiparas, and to those whose domestic circumstances made a home confinement undesirable. The figures for 1938 are as follows:— Table 45 Births in general hospitals Confinements* Ante-natal clinics Live Still Total Total No. Percentage who had attended Council's clinics No. of clinic sessions held weekly No. of women seen No. of attendances made 20,390 757 21,147 20,859 93.2 102 22,755 148,524 * Patients who died or were discharged during 1938. The number is not the same as that shown in table 47 (a), which is the number of confinements occurring during the year. The number of maternity beds available was increased from an average throughout the year 1937 of 906 beds (958 beds on 31st December, 1937) to an average throughout the year 1938 of 972 beds (1,023 beds on 31st December, 1938). The 36 new maternity block at Paddington Hospital, which contains 59 beds and was opened in October, was the only large addition during the year. It enabled a small ward to be set aside for cases of latent (or other non.infectious) syphilis for whom suitable accommodation had hitherto been difficult to find. Severe over.pressure on maternity beds continues to be felt in South London. Maternal deaths It was hardly to be expected that the very low death rate of 1937 would be maintained, and the total rate for all deaths due to or associated with pregnancy or confinement after the 28th week rose from 2.49 per 1,000 in 1937 to 2.83. However, the rate in the most important group (those who died from truly obstetrical causes after ante.natal care in the Council's clinics) fell from 1.00 in 1937 to .87 in 1938. The rise was confined to the emergency cases, and patients suffering from coincident diseases. The sulphanilamide preparations have probably played an important part in the continued fall in deaths from sepsis. The death.rate from abortion continues to fluctuate in an inexplicable fashion. Table 46 Classification 1934 1935 1936 1937 1938 No. Rate per 1,000 No. Rate per 1,000 No. Rate per 1,000 No. Rate per 1,000 No. Rate per 1,000 A. Deaths of women confined in general hospitals and institutions after the 28th week 66 5.1 64 4.18 63 3.51 49 2.49 59 2.83 (a) Death due to pregnancy or confinement 47* 3.6 42 2.74 45 2.51 31 1.58 35 1.67 (1) Ante.natal care in L.C.C. clinic 24 2.1 21 1.53 25 1.53 18 1.00 17 0.87 (2) Ante.natal care, other sources or nil 23 14.1 21 13.13 20 12.24 13 7.71 18 12.56 (6) Death associated with pregnancy or confinement 19 1.5 22 1.44 18 1.00 18 0.92 24 1.14 (1) Ante.natal care in L.C.C. clinic 7 0.6 14 1.02 7 0.43 12 0.66 14 0.72 (2) Ante.natal care, other sources or nil 12 7.4 8 5.00 11 6.73 6 3.56 10 6.98 B. Confined before admission (after 28th week) 17 - 12 - 5 - 12 - 8 - C. Abortions and moles (cases treated in hospital) 3,417 (1934), 3,607 (1935), 3,713 (1936), 3,870 (1937), 4,316 (1938) 50 - 50 - 19 - 25 - 38 - D. Ectopicgestation(casestreated) 109 (1934), 136 (1935), 122 (1936), 120 (1937), 144 (1938) 9 - 4 - 5 - 5 - 5 - * Includes 1 death from nephritis at 24th week. Dental service The scheme commenced in 1937 for the appointment of dental surgeons for whole.time duty at St. Alfege's and St. Stephen's Hospitals has been continued with success and it has been decided to put it on a permanent basis at these hospitals, and to extend it experimentally to Hammersmith and Paddington Hospitals, beginning in 1939. In the remaining hospitals minor increases in the number of sessions have been made, and particular attention has been given to the extension as far as possible of treatment for ante.natal patients and to the conservation of teeth. Arrangements have now been made for all dental treatment for public assistance cases in London to be undertaken by the hospital dental service. This has resulted in an increase in the amount of dental work carried out at the hospitals and all dentures are now manufactured in the Council's Central Dental Laboratory which was opened in April, 1938. Excellent accommodation and modern equipment has been provided at the laboratory and a high standard of work and economy in production has been achieved. The laboratory now undertakes the whole of the dental work for the Council's establishments, including general, special, and mental hospitals. 37 As vacancies have occurred, dental surgeons wholly employed by the Council have been allocated to hospitals in London in place of part-time staff, and outlying hospitals have been staffed by local part-time officers. The reduction of travelling time will permit of full sessions being given at the outlying hospitals, and increases in the number of sessions at these hospitals, which are mainly for children and tuberculous patients, will enable more conservative treatment to be undertaken. District medical service The number of persons seen by district medical officers during 1938 was 66,451, being slightly larger than in 1937, and the number of domiciliary visits increased by 790 to 73,772. There was a slight fall in the number of attendances by patients at medical relief stations and surgeries to 240,634. District nursinq The following statement shows the number of cases visited, and the number of visits made, under the Council's district nursing scheme, during 1938:— Nature of case No. of cases No. of visits Average no. of visits per case Diabetic for administration of insulin 630 132,528 210 General 2,528 95,428 33 3,158 227,956 72 The number of diabetic cases receiving visits for insulin injections increased from 523 in 1937 to 630 in 1938, with a consequent increase in the number of visits to such patients from 106,462 to 132,528. The number of cases receiving general nursing decreased from 2,742 in 1937 to 2,528 in 1938, while the number of visits decreased from 101,428 to 92,248. Oxygen therapy The Council purchased a few oxygen tents in 1936, but the type proved unsatisfactory, and an arrangement was made in November, 1937, to hire from a firm another type of tent. This company supplies tents at a reasonable daily charge, and every tent is assembled and put into operation by a technical assistant of the company, who also examines it daily to ensure its satisfactory working, and to give any instructions necessary to the staff. A twenty-four hour service is provided, including Sundays and public holidays. From November, 1937, to 31st December, 1938, 37 hospitals used 836 tents, the largest number in use at any one time was 39, and the highest number in use at any one hospital at the same time was 9. The tents have been entirely satisfactory from the therapeutic point of view, particularly with young children suffering from pneumonia and other lung conditions. British Empire Cancer Campaign: clinical research scheme The Clinical Cancer Research Committee, constituted in connection with the British Empire Cancer Campaign, instituted some time ago a research into the progress of the disease in patients suffering from cancer and into the results obtained by the different methods of treatment adopted. Prior to the inception of this research scheme, a complete system of following-up cancer patients had been operated only in certain hospitals and in some cases the number of patients had been limited and the records frequently imperfect. As a result, knowledge of the course of the disease and of the relative value of alternative treatments was incomplete. The Clinical Cancer Research Committee desired to extend their enquiry to cover all patients coming under treatment in the hospitals in London in order that a reliable record might be obtained of the condition of each patient, of the treatment received and of the progress of the patient throughout the remainder of his life. As approximately one-third of the cancer patients coming under treatment in London were admitted to the Council's general hospitals, the Council was asked to co-operate, and agreed to do so. Arrangements were made during the year for a record of each patient to be kept on a standard form and for the patients to be followed-up after discharge. The expenditure involved is being borne by the British Empire Cancer Campaign. 38 39 † Opened 10th June, 1938. * Excluding figures for the hospitals for chronic sick. ‡ Valvo-vaginitis unit (33 cots) temporarily closed pending structural improvements. § Increased to 658 beds (1.11.1938). || Includes infants in maternity cots. General Hospitals Table 47 (a) STATISTICS (excluding cots in mater[???] wards and infants in maternity cots), 1938 Hospital Fixed accommodation at 1.4.1938 Admissions during the year Confinements during the year Discharges during the year Deaths during the year Average percentage of occupation of fixed accommodation Average duration of stay in days Operations performed during the year Xdepartments Massage or physio-therapeutic departments Out-patients Hospital Diagnostic Therapeutic Ante-natal clinics Out-patients (excluding ante-natal clinic cases) Inpatients Outpatients No. of films No. of patients No. of treatments Inpatients Outpatients No. of treatments No. of expectant mothers seen No. of attendances No. of persons seen No. of these who had previously received in-patient treatment No. of attendances Beds Acute— Acute- Archway 564 4,386 1 3,545 758 68.8 32.2 719 2,454 77 3,83??? - - 509 17 6,162 — — 359 157 2,081 Archway. Bethnal Green 650 6,181 715 5,698 565 79.5 35.6 1,375 3,256 2,683 11,23??? - - 317 590 24,127 741 4,644 9,197 3,926 53,037 Bethmal Green. Dulwich 723 7,671 1,130 6,688 982 96.0 33.0 2,049 4,045 754 10,53??? - - 535 245 13,519 1,135 8,743 4,404 1,230 10,018 Dulwich. Fulham I 567 5,260 327 4,608 612 83.2 32.5 1,254 2,099 1,227 9,50??? - - 303 312 15,527 488 3,379 5,839 890 21,008 Fulham I. Hackney I 772 7,753 899 6,895 964 80.5 29.1 2,391 4,659 4,293 12,57??? 45 356 496 956 40,744 962 5,964 16,582 754 110,491 Hackney I. Hammersmith I 458 6,643 1,909 6,363 278 92.4 23.5 3,898 4,648 3,936 17,19??? 2,657 4,772 562 1,333 46,099 1,857 10,547 11,148 2,238 47,091 Hammersmith I. Highgate 545 3,223 2 2,836 380 74.9 46.0 1,175 2,180 450 4,27??? - - 499 55 16,230 — — 314 148 3,091 Highgate. Lambeth I 860 9,043 1,006 7,905 1,167 91.8 36.3 1,553 4,102 1,184 7,43??? 835 18,275 714 338 57,030 1,012 5,743 8,104 609 29,405 Lambeth I. Lewisham 781 8,965 1,443 7,942 1,016 99.7 34.6 3,524 4,599 4,573 15,20??? - - 336 1,129 59,519 1,660 10,880 13,553 4,522 56,883 Lewisham. Mile End 466 6,145 991 5,652 513 75.8 22.7 1,373 2,953 2,198 8,665??? - — 328 676 23,128 930 6,300 17,856 1,390 56,763 Mile End. New End 260 2,701 483 2,471 252 86.2 29.0 1,344 1,546 1,072 4,84??? - - 94 213 5,530 552 2,757 2,023 307 13,012 New End. Paddington 567§ 5,706 724 4,974 686 83.9 30.7 1,154 2,441 2,301 10,046 - - 695 816 22,736 774 5,287 7,766 4,613 37,531 Paddington. St. Alfege's I 622 7,603 872 6,767 848 87.0 26.5 3,385 3,877 4,284 10,979 - - 320 405 19,454 1,051 6,425 7,360 1,393 36,238 St. Alfege's I. St. Andrew's 626 8,291 1,115 7,584 776 86.7 23.4 2,198 3,347 3,062 11,710 - - 630 1,104 45,198 1,099 5,176 10,706 1,979 70,098 St. Andrew's. St. Charles' 752 5,551 1 4,819 805 75.9 37.0 1,245 2,600 1,002 6,610 — — 352 146 19,073 — - 5,045 702 9,889 St. Charles'. St. George-in-the-East 410 4,065 365 3,829 300 68.0 24.3 1,277 2,811 2,643 8,116 - - 687 1,312 28,973 257 1,544 10,632 841 48,700 St. George-in-the-East. St. Giles' 810 9,826 1,175 8,595 1,304 96.4 28.9 2,737 5,194 2,248 14,280 - - 899 232 21,788 1,241 11,671 9,682 1,218 26,226 St. Giles'. St. James' 898 14,324 1,682 12,767 1,488 98.9 22.5 5,815 6,112 3,572 17,465 - - 908 588 32,031 1,997 13,169 6,542 2,074 34,237 St. James'. St. Leonard's I 549 5,411 671 4,775 648 89.6 32.6 1,386 2,957 2,056 9,856 — — 434 673 24,883 709 4,344 7,584 1,088 37,667 St. Leonard's I. St. Luke's, Chelsea 390 3,118 2 2,766 389 83.1 40.7 771 1,824 996 4,281 - - 195 224 8,128 — — 2,373 227 16,086 St. Luke's, Chelsea. St. Mary Abbots I 547 6,849 1,041 6,420 434 77.0 21.6 3,435 5,223 1,196 15,148 - - 1,221 821 50,730 1,185 6,355 4,923 1,513 24,800 St. Mary Abbots I. St. Mary, Islington 838 8,164 1,511 7,454 918 86.0 33.0 1,903 4,214 152 8,751 — — 523 222 17,479 1,703 11,408 3,142 911 10,416 St. Mary, Islington. St. Nicholas' 331 3,967 419 3,521 476 86.4 27.0 2,109 2,370 3,709 9,341 — — 313 755 40,164 798 5,571 6,545 1,043 44,836 St. Nicholas. St. Olave's 688 6,557 949 5,988 631 82.4 31.5 2,075 2,960 3,525 11,359 - - 215 2,991 30,060 1,098 6,396 7,138 509 48,030 St. Olave's. St. Pancras I 380 4,876 886 4,347 492 77.6 21.9 617 2,407 676 5,870 - - 548 238 21,003 977 9,096 1,383 229 9,668 St. Pancras I. St. Peter's 408 4,274 - 3,842 432 79.1 29.7 620 1,734 825 4,149 — — 331 322 17,513 — — 5,665 642 28,008 St. Peter's. St. Stephen's 748 7,243 612 6,460 828 91.4 33.5 1,392 4,434 809 9,628 — - 1,943 968 32,428 529 3,125 3,838 764 11,067 St. Stephen's. Total 16,210 173,796 20,831 155,511 18,942 85.5 29.7 52,774 91,046 55,503 263,391 3,537 23,403 14,907 17,681 735,894 22,755 148,524 189,703 36,917 896,305 Children's— Children's— Norwood 210 1,037 — 1,045 11 79.5 54.3 106 — - — — — 204 - 2,168 - - - - - Norwood. Convalescent— Convalescent— Queen Mary's, Sidcup 530 3,164 3,202 84 83.8 49.2 10 - - - - - 352 — 11,326 - - - - - Queen Mary's, Sideup. Princess Mary's Convalescent Home, 236 1,534 — 1,454 - 64.0 20.3 1 15 - 25 — — 191 - 1,293 - - - - - Princess Mary's valescent Home, Margate Total 766 4,698 - 4,656 84 77.7 40.4 - - - - — — 543 - 12,619 - — — — — Epileptic— Epileptic— St. David's 328 141 - 120 3 - - - - - - - - - — — — — - - St. David's. St. Faith's 427 96 — 87 2 84.8 - - - - - — — — — — — - - - - St. Faith's. Total 755 237 — 207 5 87.9 - - - - - — - - — - - - — — — Vulvo-vaginitis and ophthalmia neonatorum— Vulvo-vaginitis and ophthalmia neonatorum— St. Margaret's 48‡ 458 — 440 11 72.9 28.8 — — — - - — — — — - - - - - St. Margaret's. Grand total 17,989 180,226 20,831 161,859 19,053 85.2 30.1 52,897 91,061 55,503 263,416 3,537 23,403 15,654 17,681 750,681 22,755 148,524 189,703 36,917 896,305 Grand total, 1937 17,936 178,829 19,665 159,184 20,486 86-9|| 30.3 47,928* 86,473* 47,319* 232,728* 964 21,550 14,242* 14,995* 693,585* 21,510 132,270 161,952* 33,551* 764,680* 40 General Hospitals—continued Table 47 (6)—Hospitals for chronic sick—Sick cases, 1938 Hospital Accommodation for sick at 1.4.1938 Admissions during the year Discharges during the year Deaths during the year Average percentage occupation of fixed accommodation Beds Fulham II 104 56 26 13 22.1 Hackney II 394 284 94 145 96.7 Hammersmith II 167 (a) 1,132 791 205 69.6 Lambeth II 253 243 150 42 88.5 St. Alfege's II 345 706 507 200 99.7 St. Benedict's 318 991 868 65 91.2 St. Clement's 429 997 817 175 88.4 St. Francis 602 1,009 775 239 100.2 St. John's* 637 1,233 901 389 90.3 St. Mary Abbots II 246 599 368 189 106.6 St. Matthew's 601 421 163 196 94.2 St. Pancras II 271 1,537 1,316 189 81.7 Total 4,367 9,208 6,776 2,047 91.0 (a) Increased to 251 on 1st July, 1938. * Other statistics— Operations, 61.—X-ray department: 278 in-patients; 142 out-patients; 832 films. Out-patients: Number seen, 968; Number of attendances made, 5,469. Table 48—Mental diseases—Analysis of admissions and discharges during year ended 31 st December, 1938 Classification Public Health Public Assistance Total Corresponding totals for the year 1937 Fulham hospital I St. Alfege's hospital I and II St. Clement's hospital St. Francis' hospital St. John's hospital St. Pancras' hospital II Fulham Road Admitted for observation of mental symptoms— Under the Lunacy Acts Order (sections 20, 21 and 24) 413 768 875 725 582 1,417 383 5,163 5,330 Others 23 66 — 8 102 30 8 237 353 Total 436 834 875 733 684 1,447 391 5,400 5,683 Discharged to mental hospitals— Under the Mental Treatment Act as— Voluntary patients 17 85 88 82 115 129 68 584 521 Temporary patients 7 24 4 — 27 54 7 123 77 Total 24 109 92 82 142 183 75 707 598 Under ihe Lunacy Acts as certified patients 265 277 407 219 287 558 122 2,135 2,482 Total 289 386 499 301 429 741 197 2,842 3,080 Detained in the institution (or hospital) under section 24 (3) of the Lunacy Act, 1890 4 22 35 8 49 3 122 108 Discharged otherwise— To Tooting Bec hospital as uncertified 17 49 3 59 17 38 10 193 150 To care of relatives 79 181 166 179 112 232 93 1,042 1,054 For convalescence or to general hospitals, etc. 40 96 177 107 28 297 93 838 837 Total 136 326 346 345 157 567 196 2,073 2,041 Died 11 108 42 54 93 104 — 412 442 41 Special Hospitals Statistical table Condensed statistics of the patients treated in the special hospitals during the year 1938 are as follows:— Table 49 Unit Remaining on 31st December 1937 Admissions Live Births Discharges Deaths Remaining on 31st December, 1938 Smallpox - 3* - 3* - Other fever 4,250 39,658 1 39,758 883 3,268 Tuberculosis— Pulmonary 1,322 (a) 3,510 — 3,375 115 1,342 Non-pulmonary 641 (a) 653 — 643 29 622 Children's diseases 1,940 8,709 - 8,445 43 2,161 Venereal disease— Sheffield-st. Hospital— Women 75 324 - 336 1 62 Babies 25 19 170 187 10 17 Post-encephalitis lethargica— Northern Hospital 284 (a) 49 — 31 6 296 Total 8,537 52,925 171 52,778 1,087 7,768 (a) Including patients on leave. * Proved after admission not to be smallpox. Planning and development I. Larger building works—The final stage of the reconstruction of the NorthEastern Hospital, comprising the erection of four general ward blocks and a staff changing block, was completed in November. The provision of a new nurses' home at Grove Park Hospital was completed and the adaptation as patients' accommodation of staff blocks C and L commenced. The improvement of the sanitary annexes of the patients' blocks at this hospital was continued. The modernisation of the patients' accommodation at High Wood Hospital for Children was advanced a further stage by the commencement of work on block "Firs 5." The construction of two isolation blocks and staff quarters at the Brook Hospital was well advanced. Work on the provision of two isolation blocks, additional staff accommodation, receiving rooms and operating theatre at Joyce Green Hospital was begun. The scheme of improvements at Queen Mary's Hospital for Children, incorporating the extension of the laundry, the provision of new artisans' workshops and of storage accommodation, was completed. A scheme for the provision of balcony accommodation for patients and of accommodation for sick staff at Colindale Hospital was approved. Plans were approved of a new nurses' home at the Eastern Hospital. A scheme for improving the farm buildings at Joyce Green Hospital was approved. The provision of a waiting room and recreation accommodation at Heatherwood Hospital was commenced. The standard of fighting in staff bedrooms generally was improved. II. Other works—Many other important and minor building and improvement works were dealt with. 42 (A) Fever hospitals Infectious diseases hospitals Condensed statistics of the patients in the infectious hospitals from 1932 to 1938 are as follows:— Table 50 1932 1933 1934 1935 1936§ 1937 § 1938§ On books on 1st January 4,148 4,495 6,205 4,672 3,777 3,456 4,250 Admitted during the year 43,769 49,217 53,413 30,664 43,927 33,685 39,659 Discharged during the year 42,060 46,598 53,462 31,065 42,962 31,923 39,758 Died during the year 1,362 909 1,484 518 1,286 967 883 Remaining on 31 st December 4,495 6,205 4,672 3,753 3,456 4,250 3,268 Lowest number under treatment at any time prior to the seasonal rise. 3,195 (10th Sept.) 3,928 (2nd Sept.) 3,419 (1st Sept.) 2,506 (31st Aug.) 2,646 (12th Sept.) 2,582 (21st Aug.) 2,116 (1st Oct.) Highest number under treatment at any time during the seasonal rise. 4,745 (22nd Nov.) 6,328* (4th Dec.) 4,740 (16th Dec.) 3,753† (31st Dec.) 3,435 (30th Dec.) 4,396† (29th Dec.) 3,389 (13th Deo.) N.B.—Figures of admissions and discharges include transfers between infectious diseases hospitals. * The number subsequently reached 7,621 on 4th April, 1934 (measles epidemic). † The number subsequently reached 6,981 on 6th April, 1936 (measles epidemic). ‡ The number subsequently reached 5,848 on 29th March, 1938 (measles epidemic). § Numbers include sick classified as "patients." Incidence of infectious disease The year 1938 was one of comparatively low incidence of infectious diseases. The number of patients, excluding those suffering from measles, treated at the infectious diseases hospitals during the year was 26,809; the number of measles cases treated was 9,292 (comparative figure for 1936: 12,788); the lowest number of patients under treatment at any one time during the year was 2,116 on 1st October, 1938. This was the lowest figure since September, 1918, and was the result of the international situation in September, when all patients who could safely be discharged were sent home. The highest number of patients under treatment during the year was 5,848 on 29th March, i.e., at the peak of the measles epidemic, when there were 2,375 cases of measles under treatment. The number of patients suffering from scarlet fever treated throughout the year was 6,848, and from diphtheria 6,194. The number of cases of whoopingcough treated was low (1,949), but the number under treatment rose rapidly from the end of September to December. On 1st October a partial notification of measles and whooping-cough, to which reference is made on p. 43, was instituted throughout the county, but it was not possible by the end of the year to determine its influence upon the demand for hospital accommodation for patients suffering from those diseases. During the last two years a noteworthy increase has taken place in the number of patients admitted suffering from enteritis, dysentery, puerperal fever and pyrexia, cerebro-spinal fever, poliomyelitis, chickenpox, mumps and German measles. The statement below shows the rise in admissions of some of these diseases:— Cerebrospinal fever Poliomyelitis Puerperal fever and pyrexia Enteritis Dysentery 1938 94 64 301 1,398 502 1937 104 40 276 1,268 541 1936 52 8 181 701 171 1935 35 21 195 132 74 1934 55 22 200 3 -* * Not available. Similar figures for German measles, mumps, and chickenpox are not available, but those diseases constitute, in the aggregate, by far the greater part of the following figures, giving, for each of the last five years, the number of patients admitted with 43 miscellaneous infectious diseases (i.e., excluding those set out in the table above and scarlet fever, diphtheria, whooping-cough, measles and enteric fevers), viz.:— 1938 9,459 1937 10,951 1936 6,982 1935 6,404 1934 6,430 The measles epidemic reached its peak (albeit the lowest recorded for measles in recent years) on 29th March. The steps set out in the report for 1937 which were taken in anticipation of difficulties arising from the epidemic were, nevertheless, found to have been justified. The arrangement whereby certain patients were admitted only on the application of borough medical officers of health was discontinued on 15th May, as by that date the pressure on accommodation had declined. Joyce Green Hospital (normally in reserve) was opened on 16th February and closed on 11th July. The Lower Southern Hospital was closed for infectious patients on 14th May, and reverted to its use for non-infectious convalescent patients. During the year there has been available at each of the central acute infectious hospitals a mechanical respirator, and as a result of the prevalence of poliomyelitis these were fully used. Measles and whoopingcough : notification In view of the seriousness of measles and whooping-cough as epidemic diseases of children and of the great importance of the availability of early information regarding the incidence of these diseases if measures for the control of the spread of infection and the proper treatment of the patients are to be fully effective, the Council asked the Minister of Health to make regulations to require the notification to metropolitan borough medical officers of health of cases of measles (other than German measles) and whooping-cough in the administrative County of London, except (i) cases occurring in an establishment after a case of the same disease had occurred there within the preceding period of two months and been notified ; and (ii) cases which were being treated in a fever hospital; and to include in such regulations provisions under which the borough medical officer of health is required to send copies of the notifications to the Council, to the head teacher of the patient's school (if a child) and to the head teacher of any school attended by any child who is an inmate of the same house as the patient. The Minister made regulations accordingly and they came into operation on 1st October, 1938. (B) Smallpox hospitals The immunity from smallpox which London has enjoyed since 1934 has continued. Children's hospitals Infantile paralysis and cerebral diplegia The investigation, at Queen Mary's Hospital for Children, of the system of treating poliomyelitis practised by Miss Kenny in Australia, to which reference was made in the Annual Report for 1937 (Vol. IV, Part I, p. 41), came to an end in July, and later in the year a report by an advisory committee who had been appointed to watch the experiment was published in extenso in the medical journals. The unit is being retained, but only certain of the methods are being continued in use, viz., those recommended by the advisory committee, who are continuing their observation of the unit. Convalescence of children Negotiations for the acquisition of land adjoining the site of Millfield Convalescent Hospital, Rustington, to enable that establishment to be enlarged from 98 to about 500 beds, were successfully concluded. Dietaries of patients The results obtained since the introduction of the special ketogenic dietary at White Oak Hospital to which reference was made in the Annual Report for 1937 (Vol. IV, Part I, p. 42) indicated the desirability of the continuance of this dietary for a further year and this has been agreed to. Squint During the year a new department has been opened at White Oak Hospital for the admission of children with squint showing amblyopia in one eye. 44 Tuberculosis hospitals Occupational therapy The arrangements in connection with occupational therapy at tuberculosis hospitals and sanatoria were reviewed, and additional staff was appointed to provide increased facilities for patients at Grove Park, Northern and Colindale Hospitals, King George V and Pinewood Sanatoria. Nurses (ex-patients) The scheme for the employment of tuberculous ex-patients, which is in operation at King George V Sanatorium, was extended to include Pinewood Sanatorium. The conditions of appointment were revised and the title "trainee" abolished. The scheme provides that under certain conditions suitable patients are appointed to the temporary staff and after five years' service are placed on the permanent staff, subject to their medical fitness. The arrangement is working satisfactorily and a considerable proportion of the staff at Pinewood Sanatorium is now recruited in this way. It is hoped, at a later date, to extend similar facilities to Colindale Hospital. Pathological Laboratory Services The number of examinations (including post-mortem examinations) completed in the group laboratories during the two years ended 31st December, 1938, are indicated hereunder:— Group laboratory 1937 1938 Archway 38,594 46,709 Lambeth 47,738 60,280 Lewi sham 44,963 50,796 Mile End 34,298 41,907 North-Western 48,724 52,997 St. Mary Abbots 51,953 52,929 Southern 20,948 27,446 287,218 333,064 The number of post-mortem examinations carried out by the Central Histological Laboratory staff during the year ended 31st December, 1938, was 1,075, compared with 865 during 1937. The number of specimens examined histologically was 23,862 compared with 24,561 for 1937. Among the activities of the pathologists the following may be mentioned:— Work on leptospiral infections of sewer workers; cholesterol metabolism; serological typing of hæmolytic streptococcus in relation to midwives and puerperal fever; preparation of endotoxin used in the diagnosis and treatment of whooping-cough; the bacteriology of gastroenteritis in infants; treatment and diagnosis of asthma and other allergic conditions with mould extracts; demyelinating diseases of the central nervous system; tumours of the kidney; comparison of strains of Listerella with strains of Erysipelothrix; the bacteriology and distribution of the influenza bacillus; types of diphtheria bacillus; bacteriology of secondary infections in measles; special studies as regards pneumococcal infections and pulmonary tuberculosis. The total number of specimens examined in the hospital laboratories, as distinct from the group laboratories, during the year was 316,609 (213,040 in general and 103,569 in special hospitals), an increase of 32,634 over 1937. In addition, 4,766 post-mortem examinations were carried out (4,651 in general and 115 in special hospitals). Belmont Laboratories Diphtheria antitoxin is issued from Belmont Laboratories as a refined and concentrated globulin solution of antitoxin in sealed ampoules. The numbers of ampoules issued were as follows:—8,560 of 20,000 units, 22,095 of 8,000 units and 6,727 of 2,000 units, showing an increase of about 8 per cent. over those of 1937. Streptococcus antitoxin is issued in sealed ampoules of 10 c.cm. and 5 c.cm. Of the former, 13,091 and of the latter, 2,177 ampoules were issued. Reference was made in the annual reports for 1936 and 1937 to the provision of a new antitoxin establishment. The new building is well in hand, and it is anticipated that the premises will be ready early in 1940. 45 LONDON AMBULANCE SERVICE Particulars of the normal ambulance service will be found in the Annual Report of the Council for 1937, Vol. IV, Part I. Owing to the growing political tension during 1938, a considerable development of the service took place during the year. Authority for the temporary installation and maintenance of ten additional exchange lines to the switchboard at the headquarters of the London Ambulance Service has been continued until such time as the installation of a "Turret" system switchboard can be effected. The enlargement of the petrol-charging area at the Western Ambulance Station has been approved. Air raid precautions Recruiting for the London Auxiliary Ambulance Service commenced in March, 1938, following an appeal by the Home Secretary for volunteers for A.R.P. duty. Preliminary arrangements for the training of volunteers were approved by the Council on 5th April, 1938. Prior to the international crisis in September, 1938, 130 volunteers had been enrolled, but during the period of the crisis, 1,250 applications were received and by 31st December the total number had reached 1,964. The training of volunteers included, apart from driving practice with heavy vehicles, instruction in first aid to the injured and anti-gas precautions. For training purposes approval was given to the seconding of fourteen ambulance station officers to act as instructors. The resultant vacancies were filled by the up-grading of fourteen ambulance drivers to the position of ambulance station officer. Staff The following is a statement of the number of stall employed at accident and general section stations as at 31st December, 1938:— Table 51—Accident section Grade Permanent Temporary Total Superintendent 1 - 1 Ambulance station officers 18 - 18 Acting ambulance station officers for A.R.P. purposes (14 positions authorised) 13 - 13 Drivers, Grade H 74 8 82 „ F (i) 2 2 4 „ E (i) - 6 6 Not graded 1 — 1 Attendants, Grade H 64 2 66 „ F (i) 17 3 20 Total 190 21 211 Table 52—General ambulance section Superintendents Senior ambulance clerks (men) Ambulance clerks (men) Operative staff Total Grade Drivers Attendants Drivers temporary Washers & helpers. Not graded H 142 5 8 6 6 23 F (i) 11 11 - 1 249 5 temp. E (i) 4 — 9 Not graded 17 1 - The fixed establishment of operative staff is: 1 superintendent (accident section), 18 ambulance station officers, and 379 drivers and attendants. The Council, on 26th July, 1938, agreed to the award of a silver medal to any officer or employee in the London Ambulance Service when conduct in the execution of his duties is considered to be sufficiently meritorious. Vehicles The number of vehicles in commission is as follows: 153 ambulances, 20 ambulance omnibuses, 2 staff cars, and 1 ambulance tender. 46 Notable accidents during the year The accident section ambulances were called to the following railway accidents in which a number of persons were injured:— (1) Waterloo Station (Underground Railway), 10th March, 1938. Eleven persons were removed to hospital and twenty others were treated for minor injuries and shock. (2) Charing Cross Station (District Railway), 17th May, 1938. Fifty-nine persons were conveyed to hospital; of these, six cases proved fatal. Owing to the adverse weather conditions prevailing during the week ended 24th December, 1938, the accident section of the London Ambulance Service dealt with 1,595 calls, the highest number ever dealt with by the service in one week (including the week of Their Majesties' coronation, 1,566 calls). Also 3,814 patients were removed to hospitals by the general section. 47 INDEX Subject Page Anthrax 6 Appropriation of institutions 34 Bacteriological laboratory 34 Births 3,30 Blind Persons Act 28 British Empire Cancer Campaign 37 Cancer 11, 37 Cerebro-spinal fever 7 Chemical branch 31 Child welfare 33 Children's hospitals 43 Convalescence of children 43 Cowsheds 22 Deaths 4 Dental service 36 Diarrhoea and enteritis 9 Diphtheria 9 District medical service 37 District nursing 37 Encephalitis lethargica 7 Enteric fevers 11 Fire Service, Auxiliary 33 Food poisoning 7 General hospitals 34 Housing 21,28 Infant mortality 5 Infantile paralysis 43 Infectious diseases 6, 42 Infectious diseases hospitals 42 Influenza 11 Ketogenic dietary 43 London Ambulance Service 45 Marriages 3 Maternal mortality 10, 30,36 Maternity 33,35 Subject Page Measles 8,43 Medical examination of staff 33 Mental deficiency 28 Midwives Acts 29 Milk examination 21 Nursing homes 32 Occupational therapy 44 Ophthalmia neonatorum 31 Overcrowding 21 Oxygen therapy 37 Pathological laboratory services 44 Pemphigus neonatorum 32 Planning and development of hospitals 34, 41 Polioencephalitis 7 Poliomyelitis 7 Population 3 Puerperal fever 10, 31 Puerperal pyrexia 10,31 Rheumatic fever 11 Scarlet fever 8 Sewage treatment 34 Smallpox 7 Special hospitals 41 Squint 43 Statistics 15, 29, 38, 41, 42 Street accidents 5 Tuberculosis (care committee work) 25 Tuberculosis (dispensary services) 25 Tuberculosis hospitals 44 Tuberculosis (notifications) 11 Tuberculosis (residential treatment) 26 Typhoid fever 7 Venereal diseases 22 Vital statistics 3 Whooping-cough 8,43 LONDON COUNTY COUNCIL Report of the School Medical Officer for the year 1938 800 (mcc. 40796-6) 29.8.39—643. CONTENTS PAGE Introduction 5 Staff 5 School buildings and equipment 6 Medical inspection 7 The nutritional state of London school children 16 Following-up 20 Medical and dental treatment 22 Co-operation of voluntary bodies 27 Stammering children 27 Rheumatism scheme 28 Personal hygiene scheme 31 Chronic invalidity 32 Sleep of school children 33 Infectious diseases in schools 33 Open-air education 39 Convalescence 41 School journeys 41 Physical education 41 Provision of meals 47 Defective children 51 Stamford House remand home 58 Child guidance 61 Nursery schools and nursery classes 63 Medical inspection at secondary and junior technical schools, training colleges, etc. 64 Hospital schools 65 Special inquiries and reports 65 Wage-earning employment of school children 67 Examination of candidates for the education service and scholars 67 Statistical Tables— I. Medical inspections 68 II. Defects 69 III. Exceptional children 70 IV. Treatment of minor ailments 71 V. Medical inspection—Number of children examined 72 VI. Medical treatment—Number of cases treated 73 VII. Medical inspection of students in higher education institutions 73 Index 74 (3) London County Council REPORT OF THE SCHOOL MEDICAL OFFICER FOR THE YEAR 1938. 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 In the preamble to the report for 1937, attention was drawn to the strides made in improving the health and physical condition of the children. The origin of the school medical service can be traced largely to the amount of preventable physical defect revealed by the recruiting statistics at the time of the South African War. It took some time for the necessary legislation to be carried through, and, at the outbreak of the Great War in 1914, sufficient time had not elapsed to show results, and the country was again alarmed when the recruiting statistics showed the presence of a large proportion of C3 individuals. It is satisfactory to have been able to indicate in the annual reports of the last decade, how each year the physical condition of the children had improved ; and, now that critical times have again come, confirmation of this is forthcoming in preliminary reports on the examination of militiamen, which show that the standard of fitness is high. In the present report, the condition of the children in the schools during 1938 is set out, and references are made to advances in all branches of the service. Especial attention may, however, be drawn to the new arrangements for linking up the school medical service with the National Health Insurance service (p. 14), and the interesting advances in the study of nutritional conditions (p. 16). Pre-occupation of the senior staff with matters relating to civil defence has made it necessary to curtail the size of this report compared with previous years. 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 the deputy medical officer of health and deputy school medical officer (Dr. W. A. Daley), who is assisted by a principal clerk, responsible for the work of the lay administrative and clerical staff. 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 school medical work undertaken in the general public health division 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 ; 10 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 ; 3 assistant medical officers giving six sessions a week ; 58 assistant medical officers giving three sessions a week ; additional temporary medical assistance for 120 sessions a week and 9 medical officers (part-time) at open-air schools. There are 271 part-time doctors, surgeons and anaesthetists 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 * Not including two officers temporarily seconded for work under the Housing Acts (equivalent substitutes authorised). (5) 6 at Lissonia treatment centre, established in the Marylebone Health Centre, No. 2, the Old Ford, the South Hammersmith and the Dog Kennel Hill centres, the medical staff is 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, who now has a whole-time assistant. 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. In connection with the re-organisation of the school dental service during the year, the part-time dental surgeons engaged at treatment centres, numbering 105, were taken over directly by the Council. There are in addition 12 dental surgeons appointed by the authorities of voluntary hospitals with whom the Council has agreements for the treatment of school children. 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, 53 nursing sisters and 385 nurses. School buildings and equipment The three years' programme of development for elementary schools adopted for the years 1935-38, made provision for the erection of new schools and the rebuilding, modernisation or enlargement of existing schools. At the end of the programme period in 1938, nine new schools had been erected and opened, two enlargements had been completed, and eight additional schools had been rebuilt or modernised. A further 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. Sixty-six schools were dealt with in 1935-37, and, at the end of the programme period in 1938, 46 additional schools had been completed or nearly completed under this provision. Progress in the provision of playing fields, gymnasia, and shower-baths is described in the report of the organisers of physical education (p. 41). The new programme for 1938-41 provides for the purchase of sites, the erection and equipment of new schools, the enlargement, rebuilding or modernising of existing schools and the provision of further accommodation to meet housing developments. The position at the end of 1938 shows that work on 18 new schools and enlargements brought forward from the previous programme is in hand, together with five additional proposals under the new programme. Twenty-five schools for rebuilding or modernising, brought forward from the previous programme, are being dealt with ; and consideration of preliminary plans of 18 schools under the new programme has commenced. Lavatory accommodation The Council in 1934, in approving a new standard of accommodation for Council elementary schools, decided that office and lavatory accommodation should continue to be provided on the Board of Education's 1914 scale, with some wash basins placed near the w.c.'s. 7 The provision has been reviewed in the light of pamphlet No. 107 issued by the Board on elementary school buildings. There is general agreement that, so far as London is concerned, where children's homes are generally near to the schools and very few children have to spend the whole day on the premises, the 1914 scale for w.c.'s is sufficient, and the Board of Education have now concurred in the continued application of this standard. In regard to the lavatories it is considered that some improvement on the present standard is desirable. It is therefore proposed that the authorised standard of lavatory accommodation in new, enlarged or remodelled public elementary schools in London shall be in accordance with the following scale :— Old scale Pro-posed new scale Up to 100 children 4 8 „ 200 8 12 „ 300 12 16 „ 400 16 20 In reconditioned schools provision is to be as near to that standard as the circumstances of each case will allow. Replacement of trough closets The policy of modernisation of sanitary offices at old schools in advance of rebuilding or reconditioning is being steadily pursued. There are now only 49 schools with trough closets. Of these, 14 will be dealt with during 1939. There will remain 35 schools, of which 14 may possibly soon be closed, 4 are in the current remodelling programme when the closets will be dealt with, there are another 7 in which early rebuilding or remodelling is probable, and a further 8 in which reorganisation is under consideration. Towels The increase of ablution in the schools, the provision of hot water in lavatories and of spray-baths in connection with gymnasia in all senior schools, has caused attention to be paid to the provision of towels. Experiments in this direction have been described in my recent annual reports. The Council in May, 1938, approved the supply to public elementary schools of individual towels, soap and towel hooks. As a further alternative to the use of the common roller towel, an experiment has been conducted at a few schools in the installation of automatic continuous towel cabinets. The machines contain rolls of towelling 50 yards long by 12 inches wide, which provide for about 200 to 220 washes for each machine. Clean towelling is drawn out in lengths required, and the soiled towelling is returned automatically to the machines, the clean and soiled towelling being separately stored. No specific charge is made for the installation and hire of the machines and towel rolls, but 1s. 9d. is charged for the laundering of each roll. In order to obtain conclusive data as to the cost of the machines if extensively used, it has now been decided to conduct an experiment on a larger scale, for about one year, at certain central schools and elementary and special schools attended by senior pupils. About 130 machines in 40 school departments will be installed, on the understanding that the Council will not be committed to any expenditure subsequently. 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. The arrangements are as described in last year's report. 8 The average roll and average attendance (elementary schools) during the last four years, were as follows :— Year Roll Attendance 1934-5 534,611 471,342 1935-6 507,392 444,349 1936-7 479,974 417,028 1937-8 457,253 397,172 Particulars of examinations at school are set out below :— Routine inspections :— Entrants 47,301 Children aged 7 39,044 „ „ 11 41,576 „ „ 13 and over 42,074 „ in special schools 975 170,970 Special inspections :— (a) Children referred by nurses, head teachers, care committee workers, etc. 149,743 (6) Children inspected in connection with outbreaks of infectious disease 20.939 170,682 Total inspections 341,652 Re-inspections of children found ailing at previous inspections 128,067 Total 469,719 As inspections of all kinds and re-inspections totalled no less than 469,719, it is clear that, although some duplicate inspections are included, very few indeed of the children in school escaped coming under the eye of the doctor in some way or another during the course of the year. Co-operation of parents Parents are invited to be present at all routine inspections, and attended in 78.1 per cent. of the examinations in the three prescribed age groups, compared with 77.3 per cent. in 1937 and 76.9 per cent in 1936. At the inspection of entrants, the proportion was 90.5 per cent., and in the "leaver" group 40.9 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. 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 90.5 per cent. of parents attended at this time. Least satisfactory attendances by parents are at the leaving examinations of boys, when only 33.1 per cent. were present, although 48.6 per cent. attended in the case of girls. The intense dislike 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 1938, the parents of 38 children (10 boys, 28 girls), being 3 less than in 1937, refused to allow them to be examined by one of the Council's assistant medical officers. Two objections were subsequently withdrawn, and in 3 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 found needing or receiving treatment for defects other than malnutrition, uncleanliness and dental disease was 20,244, or 15.6 per cent. 9 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 ohildren 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 specially devoted to a consideration of this and cognate conditions (p. 16). Cleanliness Personal hygiene is the second of three great indices—nutrition, cleanliness, clothing—by which social conditions and their improvement can be assessed. In 1938 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 97.7, compared with 97.4 in the previous two years, and 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, 96.1 in 1937 and 96.5 in 1938, thus establishing a new high record. 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 86 children were found in the statutory age groups to be affected by body vermin in 1938, out of 127,921 examined. Clothing and footwear When the children are undressed by the nurse preparatory to the medical inspection, she enters on the medical record card a note of the condition of the clothing and footwear. The results of this classification for 1937 and 1938 are given below. Table 1—Clothing and footgear—Percentages Age group 1937 1938 Good Fair Bad Good Fair Bad Entrant boys 57.4 42.2 0.4 55.1 44.5 0.4 Entrant girls 58.9 40.8 0.3 56.4 43.3 0.3 Seven-year-old boys 55.4 44.2 0.4 54.4 45.2 0.4 Seven-year-old girls 56.6 43.2 0.2 57.7 42.0 0.3 Eleven-year-old boya 52.8 46.8 0.4 52.3 47.3 0.4 Eleven-year-old girls 55.7 44.0 0.3 55.4 44.3 0.3 Leaver boys 51.3 48.2 0.5 50.5 49.2 0.3 Leaver girls 56.4 43.4 0.2 54.8 45.0 0.2 In earlier years the percentages of children with insufficient clothing and inadequate footgear were much higher. On the whole girls are tidier than boys. 10 Dental decay In 1938, the percentage of children found by the school doctors in the statutory age groups with sound teeth was 68.5 compared with 68.3 in 1937, and 68.5 in 1936. A comparison with former years is shown in the following table:— Table 2 Age group 1927 1932 1937 1938 Sound Serious decay Sound Serious decay Sound Serious decay Sound Serious decay Entrant boys Entrant girls 7 or 8-year-old boys 7 or 8-year-old girls 11 or 12-year-old boys 11 or 12-year-old girls 51.7 50.7 61.1 60.9 70.6 72.3 15.3 15.2 8.1 8.3 2.7 2.3 55.6 54.7 68.8 68.8 75.1 78.0 12.2 12.1 4.7 4.7 1.5 1.1 58.7 57.1 71.1 69.7 77.7 78.7 8.2 8.4 3.5 3.7 1.0 0.9 60.1 59.3 70.1 69.2 76.9 77.8 7.8 7.4 3.9 3.9 1.2 1.0 All above age groups 60.3 9.3 67.4 5.8 68.3 4.5 68.5 4.4 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 and the improvement in this respect of late among entrant infants, who up to 1929 seemed to be getting worse every year, is a striking tribute to the efforts made at child welfare centres to improve the condition of children before school age commences. The subjoined table gives figures for the past twelve years of entrants:— Table 3 Year Boys Girls 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 28,086 561 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 54.8 100 1936 25,439 58.1 8.2 25,069 56.6 8.1 1937 24,637 58.7 8.2 24,052 57.1 8.4 1938 24,048 60.1 7.8 23,253 59.3 7.4 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 1937 and 1938 are given in the table below in percentages :— Table 4 Age group Visual acuity (percentages) Normal Slight defect More serious defect 1937 1938 1937 1938 1937 1938 Seven-year-old boys 64.1 63.8 24.7 25.7 11.2 10.5 Seven-year-old girls 63.6 63.6 25.2 25.2 11.2 11.2 Eleven-year-old boys 70.1 70.8 16.5 15.7 13.4 13.5 Eleven-year-old girls 67.8 67.8 17.8 18.2 14.4 140 Leaver boys 70.8 71.4 14.7 14.4 14.5 14.2 Leaver girls 68.2 68.9 16.7 16.0 15.1 15.1 11 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 1938 show that there is still a heavier incidence upon older girls, although the excess of visual defect in girls is much less than in former years. Much care is taken by the school organisation to ensure ocular hygiene. The lighting of classrooms both natural and artificial receives special attention in order to secure the best results. The type of all class books is closely scrutinised and all doubtful cases are submitted to the school medical officer for his decision. Fine tasks, like sewing, are carried out in good natural light and not under artificial lighting, unless this has been approved by the school medical officer. Much of this care is, however, rendered nugatory by out of school activities. Considerable indignation has recently been expressed by teachers and workers in connection with certain of the popular periodicals which are produced and sold to the children. An appeal has been received from the South African Council for Child Welfare drawing attention to the exceedingly poor pages and the small and indistinct print of most boys' papers, all of which are printed in England. An examination of sample copies of these periodicals fully iustifi.es the criticism which is made. Enlarged tonsils and adenoid growths In the prescribed age groups, 6,579 children were referred for some form of treatment of enlarged tonsils or adenoid growths ; this is 5.2 per cent. of the children examined, compared with 5.4 per cent. in 1937, 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 8.7, girls 7.2; 7-year-old boys 4.48, girls 5.2; 11-year-old boys 1.7, girls 2.5. There has been a fall in recent years in the percentage of children referred for treatment for enlarged tonsils and adenoid growths, though 1937 showed a slight upward tendency. The older the children the fewer there are that suffer from ear, nose and throat defects. 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 44.6 per cent., compared with 45.8 in 1937, 44.4 in 1936, 38 per cent. in 1933 and 1934, and 43 per cent. in 1932. Of the 6,579 children referred for treatment for these defects, 4,423 were referred for enlarged tonsils only, 488 for adenoid growths only, and 1,668 for both enlarged tonsils and adenoid growths. Otorrhcea and hardness of hearing Otorrhcea was noted in 870 children, or .7 per cent. of those examined in the prescribed age groups, the same percentage as in 1936 and 1937, 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 226 children, or only .2 per cent. of those examined, being the same percentage as in 1936 and 1937. 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 15), 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 12 interfering with education, are sometimes the indication for active preventive treatment. Many of these cases are not detected by the ordinary method of medical inspection, in which the test is the forced whisper at 20 feet. Heart defect Heart defect (functional or organic) was reported in 1,742 children in the prescribed groups or 1.4 per cent., being the same proportion as in 1937, 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 (1.6) 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. 28). Anaemia Anaemia was recorded in 590 children, or .5 per cent., the same percentage as in 1937, 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. Lung defects Lung defects were noted in 2,393 children in the prescribed age groups (or 1.9 per cent.), compared with 1.8 per cent. in 1937, an improvement upon 1936 and 1935, in both of which years the percentage was 2.1. The bulk of the cases is provided by the entrants (3.0 per cent.). This is due largely to bronchial catarrh, which is especially prevalent among entrant infants Tuberculosis There were 63 children in the three age groups reported to have symptoms indicative of pulmonary tuberculosis, compared with 56 in the previous year, and 66 in 1936. In addition, 17 children were found with other forms of tuberculosis, compared with 24 in 1937, and 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. Nervous diseases Epilepsy was noted in 41 children, compared with 45 in 1937, 30 in 1936, 28 in 1935, 65 in 1931, and 73 in 1929 ; chorea in 90 children, compared with 76 in 1937, 101 in 1936, 104 in 1935, 158 in 1932, and 170 in 1931 ; paralysis in 44 children, compared with 61 in 1937, 41 in 1936,45 in 1935,55 in 1934, 63 in 1932, and 81 in 1931. Rickets Signs of rickets or the effects of early rickets were noted in 551 children in the prescribed groups. This is .4 per cent., compared with -5 in 1937 and 1936, .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., as in 1937 compared with 1.1 in 1936,1.0 in 1935 and 1934, .7 in 1933, and .9 per cent. in 1932, and infant girls .4 per cent., compared with .5 per cent., in 1936 and 1935, .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-yearold group are noted witli remains of the disease. Deformities Among deformities, spinal curvature accounted, in the prescribed age groups, for 377 children, or .3 per cent. as in 1937 and 1936, compared with -4 per cent, in 1935. Of these, 107 were among the 11-year-old girls, and 94 among the 11-year-old boys. Other deformities, mainly flat foot, were present in 1,321 children (or 1-0 per cent.), compared with .9 in 1937 and 1936, and 1.0 in 1935 and 1934. Vaooination. Records are made of the presence or absence of vaccination marks when children are stripped for medical examination, but no enquiries are made. The following are the results of the doctors' observation of the percentage of children having vaccinal scars: entrants, 43.1; 7-year-olds, 44.5; 11-year-olds, 48.6; and "leavers" (13£), 50.5; compared with, in 1937, entrants, 45.3; 7-year-olds, 47.2; 11-year-olds, 47.9 ; and "leavers" (13½), 54.6. These figures show that the percentage of children with obvious vaccination marks is less than last year at all ages except in the 11-year-old group. A greater percentage of the older children in the schools at present are vaccinated than of the younger children. 13 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 attention received since the children entered school. This year's "leaver" group comprised 21,014 boys and 21,060 girls. In nutrition they were found to be better than the younger groups, only 4.7 per cent. of the boys and 4.2 per cent. girls being classed as subnormal, whereas in the three prescribed ages, 7.3 per cent. were considered subnormal. In personal cleanliness, this group also shows an improvement on the 11-year-old group, 98.6 per cent. boys and 97.1 per cent. girls having perfectly clean heads. The dental condition of this group was found to be slightly inferior to that of the 11-yearold group, for both boys and girls, the percentage with satisfactory mouths being 75.8 in the case of boys, and 74.5 in the case of girls, compared with 76.9 and 77.8 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 • 7 per cent, compared with .5 per cent. at age 11 ; on the other hand, heart defect in the "leaver" girls was 1.5 per cent., compared with 1.6 per cent. 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 1.2 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 re-organisation of the upper classes 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. The school doctor indicates any of these occupational groups for which a child is physically unsuitable. In connection with the Education Act, 1936, and the prospective raising of the school-leaving age to fifteen years in September, 1939, consideration has been given to the question of the leaving examination. The Board of Education, in circular 1457, suggested that, in considering exemptions claimed under the plea of beneficial employment, the local education authority should have before them information in regard to the medical record of the child. This information, in the opinion of the Board, should take the form of a confidential medical report similar to that already described above and based upon contraindications to certain occupational conditions. In view of the doubts at present existing as to the extent to which in London exemptions on account of beneficial employment will be claimed, it has been decided that, at any rate at first, the leaving examination should continue to take place when the children are approaching 14 years of age. The "employment slip" already in use has been suitably altered for the purpose and it has been decided that one shall be issued for every leaving child and not as heretofore, only in cases where some contraindication is found to exist. This arrangement has been brought into force in January, 1939, and will ensure that a medical report in the form suggested by the Board will exist for every leaving child. 14 National Health Insurance (Juvenile Contributors and Young Persons) Act, 1937 In connection with section 6 of the National Health Insurance (Juvenile Contributors and Young Persons) Act, 1937, the Board of Education issued Administrative Memorandum No. 175, dated 9th March, 1938, to local education authorities. A summary of the memorandum is set out below:— (1) The general effect of the Act, which came into force on 4th April, 1938, is to provide medical benefit for boys and girls who leave school and become insurably employed under the age of 16. (2) Section 6 of the Act requires local education authorities to make arrangements to furnish (on the application of a medical practitioner or of an insurance committee on his behalf) such particulars of the school medical record or medical history in their possession of any such young person as the practitioner may deem necessary for the purposes of his functions in relation to the provision of medical benefit for that person. A "young person" means a person under the age of 18 years. (3) Local insurance committees are drawing the attention of practitioners to the facilities afforded. The transmission of school medical records would in many cases be of little or no clinical value to the practitioner, and a form of enquiry has been prepared wherein the practitioner can apply for suitable information as to the conditions noted at the last medical inspection in school and the medical history of the young person. Between 4th April and 31st December, 1938, 1,739 applications from medical practitioners were received in the department. Of these, the records of 288 could not be traced, and reports were forwarded to the practitioners in regard to 1,451 young persons. Of this latter number, 427 were noted as clear of any defect at the last school medical inspection, 860 were reported as showing minor defects (such as visual and dental defects) and 164 with major defects (such as heart disease or orthopaedic conditions). Special examinations The number of children, not in the age groups for routine examinations, submitted to the school doctors as special cases was 149,743, equivalent to three and a half additional age groups. The number of special examinations in 1937 was 133,850 in 1936, 122,963, in 1935, 125,199, and in 1934, 91,880. These figures do not include those who came under inspection in the course of enquiries into outbreaks of infectious diseases and who numbered 20,939 in 1938. The increase in the number of special examinations in the past four 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 six and a half 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 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 5,436 children with scabies were referred for treatment at special inspections, compared with 339 only at routine inspections. In regard to children with chorea, 190 were seen at special inspections, compared with 88 at routine examinations. Five-hundred-and-forty children were classed as " nutrition 4 " at special examinations, while only 100 children were placed in this category at the routine examinations of age groups. 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 101,918, compared with 87,567 in 1937, 78,706 in 1936 and 53,066 in 1935. At the resulting 15 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 49,607 1,881 28,725 18,759 242 Girls 52,311 2,141 30,409 19,463 298 Total 1938 101,918 4,022 59,134 38,222 540 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 Audiometric examination in elementary sohools 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. In connection with the new three years' programme one further unit was established during 1938 in the northern division. 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 70,960 and the total number of individual tests was 81,512. 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 Boys 36,203 2,371 1,633 738 6.5 Girls 34,757 2,286 1,574 712 6.5 Total 70,960 4,657 3,207 1,450 6.5 The subjoined table gives the total number of ears tested in 1938 and shows the results 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 1938 141,920 135,810 1,263 3,646 1,201 Percentage 95.7 0.9 2.6 0.8 16 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 2,267 Old mastoid operation 263 Wax 1,196 Polypus 3 Rhinitis 1,423 Nerve deafness 6 Deflected septum 95 Foreign body 4 Otorrhoea 444 Congenital malformations 8 Sclerosis 1,340 Sinusitis 16 External otitis 1 Stenosis of meatus 1 Tonsils and adenoids 364 Nothing abnormal found 60 Among 4,657 children who failed, 966 were treated by diastolisation treatment, and 507 of these benefited sufficiently to enable them to pass their final test, after the completion of their treatment. The results of 121 were unknown owing to their either having left school or lapsed from treatment. Among the 70,960 children tested by the gramophone audiometer, there were 119 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 88 were found to be suitable for ordinary school, and these should be known as grade I children. Nineteen were able to benefit educationally in the ordinary school with special facilities, such as favourable position in class; these should be known as grade Ha children. Seven needed education in a partially deaf school; these should be known as grade lib children. Five did not attend. The nutritional stale of the London school children Unremitting care and attention continues to be paid by the school medical service to the nutritional state of the children, and, compared with earlier years, there is no doubt that it has vastly improved. The emergence of new knowledge, especially in regard to the accessory factors in diets, has resulted in a revision of standards which is still progressing. Comparisons year by year of the figures returned under these changing conditions need therefore to be received with caution. An increase in the number of children classified as subnormal, so far as London is concerned, most certainly reflects a change in standard and not a deterioration in reality. The high standard of general health, the almost complete disappearance of rickets as a crippling disease in London, the improvement in the death rate, the small incidence of tuberculosis, all deny the existence of any serious amount or degree of malnutrition. Alarmists have caused much apprehension by exaggeration, so that some teachers anxious about the condition of their charges have even questioned whether the children in their schools are generally fit for physical exercises. The spontaneous activity of the children themselves is sufficient refutation of any such notions. Let but a barrel organ appear in the alley, and the latter is at once filled with a happy crowd of vivacious dancing youngsters. Distinguished medical officers from the British Dominions overseas visiting our schools compare the children favourably with the bonny specimens of the race in their own land. Of general deficiency of food there is no evidence. There is, however, as there has always been, and in former years to greater degree than now, partial deficiencies in specific ingredients in the dietaries of the people, which are with difficulty made up, especially during the winter months. It is vitamin hunger due to such deficiencies which causes the city man to take his family annually to the seaside, sets the schoolboy robbing the farmer's orchard, drives the indigenous population of the East End en masse to the hop gardens of Kent, and which sent our Viking ancestors foraging and pillaging in the southlands. Further consideration of this problem of dietetics is given later in this report (p. 47) under the heading of the "Oslo experiment." The Board of Education schedule 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 , 17 to year the fluctuations are minute, and each year each age-group preserves its own distinctive features. Thus the 7-year-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. 1 he analysis with regard to nutrition, of the results of routine medical inspection in the ordinary elementary schools during 1938 is shown in the following table :— Table 8—Assessment of nutrition, 1938 Group Numbers examined Nutrition Excellent 1 Normal 2 Subnormal 3 Bad 4 Entrant bovs 24,048 3,400 18,980 1,649 19 Entrant girls 23,253 3,829 18,037 1,371 16 Seven-year-old boys 19,436 2,169 15,410 1,837 20 Seven-year-old girls 19,608 3,122 14,926 1,542 18 Eleven-year-old boys 20,757 2,787 16,501 1,464 5 Eleven-year-old girls 20,819 3,673 15,807 1,330 9 Leaver boys 21,014 3,878 16,141 987 8 Leaver girls 21,060 4,748 15,428 879 5 Total 169,995 27,606 131,230 11,059 100 Percentage — 16.2 77.2 6.54 .06 Corresponding figures for the previous year are shown in the following table:— Table 9—Assessment of nutrition, 1937 Group Numbers examined Nutrition Excellent 1 Normal 2 Subnormal Bad 3 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 Table 10—Assessment of nutrition in percentages 1937 and 1938 Group Nutrition Excellent 1 Normal 2 Sub-normal (and bad) 3 1937 1938 1937 1938 1937 1938 Entrant boys 14.1 14.1 79.0 78.9 6.9 7.0 Entrant girls 16.5 16.5 77.9 77.5 5.6 6.0 Seven-year-old boys 12.0 11.2 79.0 79.3 9.0 9.5 Seven-year-old girls 15.5 15.9 77.0 76.1 7.5 8.0 Eleven-year-old boys 13.6 13.4 79.7 79.5 6.7 7.1 Eleven-year-old girls 18.1 17.7 75.9 75.9 6.0 6.4 Leaver boys 18.2 18.5 77.6 76.8 4.2 4.7 Leaver girls 23.2 22.5 73.0 73.3 3.8 4.2 The percentage of children examined who were assessed as below normal in nutrition was, 6.6 in 1938, and 6.1 in 1937. The number of children who were found 18 to be seriously ill-nourished was 100 in 1938 while in 1937 it was 107, giving exactly the same proportion. Such close accordance in the two years is remarkable. It is satisfactory to note that it is at the end of school life that the children are best nourished. 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 oi milk twice a day, or codliver 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 Nutrition 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. Two new centres were established during the year, one at Woolwich in June and the other at Townsend Street School, Bermondsey, in December. The total number of centres functioning at the end of the year was 14. Particulars of attendances at nutrition centres during 1938 are shown below Number of appointments made for new cases 820 Attendances: new cases 641 old cases 2,877 3,518 Number discharged : no longer needing supervision 100 leaving school 84 — 184 Number of sessions 450 The usefulness of the centres is shown by the number of additional sessions asked for in order to deal with the number of children who could not be dealt with conveniently at the ordinary sessions. Valuable reports have been submitted by the physicians in charge of the centres. The careful and detailed investigations and the constructive work carried out at the nutrition centres are illustrated in the following abstract of the report of Dr. Elizabeth Gourlay at the Hoxton and Starcross Street centres on new cases:— Table 11—Summary of assessment of incomes (after deducting rent and insurance) Classification. Total Income per head below 10s. a week. Income per head 10a. to 16s. a week. Income per head over 15s. a week. Income per head less than 6s. a week Hoxton nutrition centre— Families of employed men 38 23 13 2 15 Families of unemployed men 22 18 4 11 Families of widows or separated parents 10 6 3 1 4 Starcross Street nutrition centre— Families of employed men 14 3 9 2 2 Families of unemployed men 9 7 2 5 Families of widows or separated parents 2 2 — — 2 19 Table 12—Classification of results of haemoglobin estimations Year. No. of children. Hb. 85 per cent, and below. Hb. below 80 per cent. Hoxton nutrition centre— 1937 68 18 3 1938 75 25 9 Starcross Street nutrition centre— 1937 37 20 7 1938 34 14 8 This year I have raised the standard of the suboptimal haemoglobin level by including those children who had a haemoglobin of 85 per cent. I have done this because I feel that any haemoglobin level below 90 per cent, in a child is unsatisfactory, and that these suboptimal levels are so often found in undernourished children, particularly associated with repeated septic lesions and chronic bronchial catarrh. It is remarkable to find a much larger percentage of both anaemic children and those with a suboptimal haemoglobin level attending the Starcross Street than the Hoxton centre where the families are of a lower social status, but each year it is the same, and also is associated with a higher incidence of old rachitic manifestations. Seven of these children with suboptimal haemoglobin levels from Starcross Street and three children from the Hoxton centre have been sent to Dr. Lucy Wills, in the biochemical department of the Royal Free Hospital for investigation. Their blood investigations and those of twelve old cases from Starcross Street have been done by Dr. Crowley, who has given the following report from the biochemical department of the Royal Free Hospital:— "Of 18 children examined in detail, all were found to be suffering from iron-resistant anaemia. Fifteen had, as well, chemical evidence of latent rickets, of these eight were investigated in detail and treated for some months. One was found to be suffering from chorea. The remainder all recovered from the anaemia on combined treatment with iron and massive doses of vitamin D." A number of these children had failed to respond to simple iron therapy and the low inorganic phosphorus level of the blood and low calcium phosphorus ratio suggested a vitamin D as well as an iron deficiency resulting in chemical rickets. Excellent results were obtained with massive doses of calciferol. Vitamin D therapy. Massive doses of vitamin D (calciferol) 100,000 international units weekly have been tried at the Hoxton and Starcross Street nutrition centres on four types of case:— (1) The cases of anaemia and suboptimal haemoglobin levels treated by vitamin D and large doses of iron (pil. ferr. sulph. i. t.d.s. or Blaud's gr. 45 daily). (2) Cases of chronic bronchial catarrh. (3) Cases with repeated septic sores. (4) Cases failing to gain weight. Up to the present I have only treated four cases of sores, eight cases of bronchial catarrh and 25 cases of anaemia. I think that the chest cases have definitely improved, and all the anaemias except two have responded. The calciferol is given in a dose of 200,000 i.u. in four tablets which are eaten at the centre once a fortnight. This safeguards any waste of expensive drugs or refusal of the child to swallow the tablets when given by the mother. Of all the deficiencies in the diet of these children, that of vitamin D is probably the greatest. In many cases it is probably completely absent as so often they dislike fish, such as herring, the only probable dietetic source. They have not much opportunity to store up vitamin D from sunshine in this climate, particularly in winter, and the amount of garments they wear must result in shutting out such ultra-violet rays as might reach them. I do not think that the vitamin A deficiency is so great a problem as the children get considerable amounts in their milk in school and in vitaminised margarine. Many of the children must depend for their vitamin D supply on their dose of cod-liver oil in school, and the vitamin D content of that is small. Even a halibut-oil capsule containing 485 i.u. of vitamin D makes a weekly dosage of 2,425 i.u. only. This is probably a satisfactory maintenance dose for a healthy child, but I think it is too small to benefit a child with chronic bronchial catarrh or a suboptimal haemoglobin level, which are the conditions for which so many of the children are recommended cod-liver oil or halibut oil in school. Only a few children can have vitamin D therapy at the nutrition centres under supervision, and expensive vitamin preparations given to take home would often be wasted. At the nutrition centre the cases of bronchial catarrh and sores have usually needed three fortnightly doses of vitamin D 200,000 i.u. Many of the anaemias have only needed this, or at the most six doses, so the expense would not in the end be greater than the prolonged dosage with cod-liver oil and malt. 20 Treatment recommended at the Hoxton centre during the year was as follows, the numbers in which the treatment had been obtained by the end of the year being given in brackets: convalescence, 53 (48, one in hand); holidays at camp schools, 19 (16); extra nourishment: dinners, 9 (8, one refused), milk, 5 (4), cod-liver oil, 3 (3); holiday meals, 10 (8, two refused); holiday allowance from U.A.B. or P.A.C., 12 (11, one failed to apply); housing, 6(1, two in hand); ultra-violet rays, 8 (6); remedial drill, 5 (5); dental treatment, 20 (12); spectacles, 2 (2); aural treatment, 9 (7); rheumatism scheme, 2 (2); attendance at special ear department, 3 (3); hospital treatment 11 (10). Arrangements were made for all children to receive milk during the holidays, but the attendances were disappointing. At the Starcross Street centre recommendations were : convalescence, 33 (29, one refused, one made own arrangement, two failed to join the parties); holidays, 8 (4, three in hand, one refused on account of scabies); extra nourishment: dinners, 5 (5), milk, 6 (6); holiday meals, 13 (12, one ill); dental treatment, 14 (9, two in hand); aural treatment, 4 (4); rheumatism, 2 (2); orthopaedic treatment, 1(1); hospital treatment: for anaemia, 20 (19, one refused), for other ailments, 4 (3, one in hand); open-air school, 5 (4, one refused); housing, 2 (2 in hand); ultra-violet rays, 2 (2). Miss H. G. Nussey, principal organiser, in her report for 1938 remarks:— Appreciation of the work of the nutrition centres is general. The care committees appreciate the advice given as to how to deal more effectively with the nutrition cases generally and are particularly interested in this endeavour to get at the cause of some of the cases of subnutrition which are obviously not due to poverty. When children, whose parents are in receipt of public assistance, attend, it is customary for them to get an extra grant in order that the mother may buy the foodstuffs recommended by the doctor—usually in the form of protein and fats, such as milk, cheese and butter. Cod-liver oil and malt is being given more generally in the schools also. The care committees of the five contributory schools have had much to do with the success of the Oslo dinner experiment (see p. 47). They visited parents and explained the scheme, visited again those who did not attend the inaugural parents' meeting, and as a result about 60 children began the meals on 9th May, 1938. Some have enjoyed this type of meal, while others have found it monotonous, and there has been a good deal of change of personnel in spite of the fact that children, for the purposes of the experiment, have remained on the feeding list longer than they would otherwise have done. There is evidence of great keenness on the part of care committees, teachers and doctors for the prevention of malnutrition. The publicity given to the subject has undoubtedly aroused much interest and reports have come to hand that eye diseases due to debility are being cured more rapidly owing to the increased facilities for (1) cod-liver oil and malt and milk in schools ; (2) extra diet provided by public assistance ; (3) use made of " invalid kitchens " ; and (4) advice given at nutrition centres. 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 5,500 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. Re-inspections The returns of the school doctors who re-inspect children found at the inspections in elementary schools to be ailing and in need of treatment make it possible to compile a statistical record of following up. During 1938, 128,067 children were re-inspected for 171,594 defects, 116,486 of which had been referred for treatment and 55,108 for observation. At the first re-inspection, which takes place in the next term but one after primary inspection, 80,051 defects requiring treatment (some children having more than one 21 defect) were reviewed. At the second re-inspection, which takes place after the lapse of a clear term after the first re-inspection, 36,435 cases not cleared up at a first reinspection were again reviewed. By combining the results of both re-inspections it is found that 83.1 per cent. of the children re-inspected were treated or discharged as no longer requiring treatment. This figure compares with 82.0 per cent. in 1937; 83.9 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 85.5 per cent. in 1938, compared with 84.4 per cent. in 1937. Table 13 First re-inspections, 1938 (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 dis- charg'd Dis- charg'd Not dis- charg'd Discharg'd Not dis- charg'd Refraction 13,305 88 50 3,422 1,575 353 175 917 3.255 3,470 0.7 0.4 25.7 11.8 2.6 1.3 6.9 24.5 26.1 Minor ailments 4,661 97 21 1,237 295 216 76 1,385 676 658 2.1 0.5 26.6 6.3 4.6 1.6 29.7 14.5 14.1 Nose and throat 11,144 32 13 3,992 184 640 57 1,047 1,504 3,675 0.3 0.1 35.8 1.7 5.7 0.5 9.4 13.5 33.0 Teeth 42,629 891 196 17,535 891 2,108 103 2,145 922 17,838 2.1 0.5 41.1 2.1 4.9 0.2 5.0 2.2 41.9 Other ailments 8,312 146 53 717 683 725 489 1,853 2,367 1,279 1.8 0.6 8.6 8.2 8.7 5.9 22.3 28.5 15.4 Total 80,051 1,254 333 26,903 3,628 4,042 900 7,347 8,724 26,920 1.6 0.4 33.6 4.5 51 11 9.2 10.9 33.6 Do. (without teeth) 37,422 363 137 9,368 2,737 1,934 191 5,202 7,802 9,082 1.0 0.4 25.0 7.3 5.2 21 13.9 20.8 24.3 Second re-inspections, 1938 Refraction 7,909 32 20 1,456 1,089 172 92 523 2,199 2,326 0.4 0.2 18.4 13.8 2.2 1.2 6.6 27.8 29.4 Minor ailments 1,842 22 3 376 206 70 43 466 317 339 1.2 0.2 20.4 11.2 3.8 2.3 25.3 17.2 18.4 Nose and throat 5,968 9 3 1,617 86 247 34 733 887 2,352 0.2 0.0 27.1 1.4 41 0.6 12.3 14.9 39.4 Teeth 16,567 420 88 5,944 345 808 24 1,137 407 7,394 2.5 0.5 35.9 21 4.9 01 6.9 2.5 44.6 Other ailments 4,149 27 22 284 472 243 269 900 1,328 604 0.7 0.5 6.8 11.4 5.9 6.5 21.7 32.0 14.5 Total 36,435 510 136 9,677 2,198 1,540 462 3,759 5,138 13,015 1.4 0.4 26.6 6.0 4.2 1.3 10.3 14.1 35.7 Do. (without teeth) 19,868 90 48 3,733 1,853 732 438 2,622 4,731 5,621 0.5 0.2 18.8 9.3 1.7 2.2 13.2 23.8 28.3 Cases referred to the N.S.P.C.C. During 1938, 322 children, suffering from 417 defects, were reported to the National Society for the Prevention of Cruelty to Children ; these included 219 dental defects, 69 vision cases, 50 nose and throat affections and 8 cases of ear disease or deafness. 22 Aural disease and the acute infectious 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 634, of whom 57 were referred to Borough Councils or other local authorities. Of the children followed up at school, 220 had two examinations during the year, of whom 178 were free from otorrhœa on both occasions. Of 245 children who were examined once during the year, 34 were found to be suffering from otorrhoea, and of 174 children whose second examination only fell due during the year, 7 were found to have otorrhoea. 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 1938, 25,663 children were prescribed spectacles at the treatment centres and hospitals, and 24,730 or 96.36 per cent. obtained them. Medical and dental treatment The work in connection with the medical and dental treatment of school children has been continued during the year and the attendances of the children have on the whole been very satisfactory. The attendances during the period of the international crisis at the end of September and the beginning of October were naturally reduced in number, and some of the activities of the centres, especially throat operations, were abandoned for about a week. The total numbers of hospitals and centres included in the scheme at the end of the vear were 19 hospitals and 85 centres. The numbers of children treated at all the hospitals and centres under the scheme during 1938 compared with 1937 were:— Ailment 1937 1938 Vision 37,341 37,359 Ear, nose and throat 13,592 12,726 Ringworm 78 103 Minor ailments 125,669 128,819 Teeth 138,437 138,639 Total 315,117 317,646 Eye defects The number of children dealt with in the eye departments of the centres and hospitals during the year was 37,359 compared with 37,341 during 1937. The facilities for the treatment of children suffering from squint have been continued at the following hospitals and centres during the year : Belgrave, Central London Ophthalmic, Evelina, Guy's, King's College, Royal Eye and St. Mary's hospitals, and Kilburn, Paddington, Streatham and Whitechapel centres. Special orthoptic training of suitable cases has been undertaken at the Central London Ophthalmic, Evelina, Guy's, King's College and St. Mary's hospitals and at the Kilburn, Streatham and Whitechapel centres. At each of these the services of a specially trained orthoptist are provided to assist the ophthalmic surgeon in examining the children in order to obtain the proper functioning of the eyes. The number of children treated during 1938 was 292, compared with 243 during the year 1937. The number of children discharged, treatment having been completed, was 166 during 1938, compared with 155 during 1937. Ear, nose and throat The number of children suffering from ear, nose and throat defects dealt with during the year was 12,726, and 8,894 operations for the removal of enlarged tonsils and adenoids were performed, compared with 13,592 and 9,251, respectively, during 23 the year 1937. Of the total number of operations performed (8,894), 7,759 were for both enlarged tonsils and adenoids, 749 for enlarged tonsils only, and 377 for adenoid growth only ; the remaining 9 were operations in which cauterisation was used. As a general rule the children are kept in for two nights after the operation, but when the operation is performed on Friday they are kept in for one night only. In the latter case, arrangements are made for the children to be conveyed to their homes by ambulance. This is done throughout the year, mainly on account of the condition of the children after only one night's rest after the operation. Owing to the risk attendant upon the children in many cases having to wait in the street for trams and buses to reach their homes, arrangements have been made for all children operated upon at the hospitals and centres during the winter months to be taken home by ambulance. The vehicles of the London Ambulance Service are used for this purpose, as well as the ambulances provided for the conveyance of physically defective children. The latter are used as far as possible at the week-ends, throughout the year, to convey the children kept in for one night only after operation. Ringworm There are 5 hospitals and 3 school treatment centres in London where suitable X-ray treatment is available in connection with the treatment of children suffering from ringworm of the scalp. Cases are referred to the most convenient centre or hospital as they arise, but happily the number of cases, though larger than in 1937, is still very small. During the year 1938 the number of children treated was 103, of whom 88 were treated by X-rays, compared with 78 cases (69 X-rays) during the year 1937. Twenty-five years ago the number dealt with annually numbered 10,159. Minor ailments I he number of children dealt with at the various minor ailments centres during the year 1938 was 128,819, including 21,086 seen by the nurses only, compared with 125,669 and 19,304, respectively, during 1937. Under the heading "minor ailments" in table IV at the end of this report are included 14,292 children suffering from scabies and impetigo who were treated at the bathing centres, bringing the total of minor ailments treated (including ringworm) to 143,214. The total number of minor ailments centres at the end of 1938 was 80. Daily nursing treatment is also provided at the Bloomsbury dispensary and at 14 schools where difficulty is experienced in arranging conveniently for the children to attend the centres. Dental treatment As a result of the appointment by the Council of a full-time consulting dental surgeon (Major General J. P. Helliwell, C.B.E., L.D.S., M.R.C.S., L.R.C.P.), it was possible for the first time in the history of the Council's administration for a complete and comprehensive survey to be made of the Council's dental treatment scheme. After consideration of this survey, certain recommendations were made for the improvement of the scheme, the chief among which were:— (1) Reduction in the number of children to be dealt with each session of 2% hoursHitherto 10 new cases had been seen each session in addition to such old cases as were instructed to re-attend. This standard number per session was set many years ago, but as time went on and the general condition of the mouths improved, more conservative treatment was possible, with the result that it became difficult to provide a high standard of conservative treatment in the time available each session. It is proposed that the number of cases to be dealt with each session shall be reduced gradually, and, during the year 1938, where additional sessions have been approved, the number of new cases in addition to old cases has been reduced to 6 a session. It is hoped that a reduction throughout the service will be possible in the future. (2) Provision of alternative accommodation for centres which were unsatisfactory. Proceedings have been initiated in this direction, and during the year 1938 arrangements have been made for the replacement or improvement of 6 centres. (3) Improvement and renewal of dental equipment where necessary. The equipment at some of the centres has been in use for many years and requires a thorough overhaul. This is in hand, and modern equipment will be provided as soon as possible. 24 Orthodontics (4) Appointment directly by the Council of the part-time dental surgeons and anaesthetists instead of appointments being made by the centre committees. This was arranged from 1st October, 1938, so far as the dental surgeons were concerned, and it is expected that the dental anaesthetists will be appointed directly by the Council during the year 1939. (5) Gradual replacement of part-time dental surgeons by whole-time officers. It has been decided that the school and hospital dental services shall be combined, and that the services of the officers shall be interchangeable between school treatment centres and general or special hospitals. The part-time dental surgeons will be replaced gradually as opportunity occurs. The scale of salary approved is £500 a year, with annual increments of £25, to a maximum of £750 a year. (6) The employment of dental attendants. At present the dental surgeons are assisted at the dental inspections in the schools by assistant organisers of care committee work, and at the treatment centres by qualified nurses. It is proposed that one dental attendant, who will be a woman, will be appointed for each whole-time dental surgeon. Her duties will mainly consist of chairside assistance, preparation of the dental surgery, clerical duties and attendance at the dental inspections in the schools. The scale of salary approved is £120 a year, with annual increments of £10, to a maximum of £180 a year. So far as the work at the hospitals and treatment centres included in the Council's scheme during the year 1938 is concerned, the total number of children dealt with was 138,639, compared with 138,437 during the year 1937. Details of the work undertaken will be found in table IV, group IV, at the end of this report. The most notable feature in regard to the work is that, although only slightly more children were attended to in 1938 than in 1937, the amount of conservative treatment carried out in 1938 exceeded that of the former year by about 20,000 fillings. This can be accounted for in two ways: firstly, by the introduction of the inspection and the subsequent treatment of certain children in the "leaver" group and, secondly, by the provision of additional dental sessions in order that a higher standard of conservative treatment, especially of permanent teeth, could be attained. The ratio of fillings in permanent teeth to permanent teeth extracted was 2.54 to 1, compared with 2.31 to 1 in 1937, 2.07 to 1 in 1936, and 2.05 to 1 in 1935. The total number of dental treatment centres at the end of 1938 was 74, including the special centre at Berkshire Road school and the Eastman clinic. Three new centres were opened during the year at Brixton, North Hammersmith (sub-centre) and Northwold (Hackney). The Old Ford centre was transferred in October, 1938, from temporary premises at Monteith Road M.D. School to the first floor of the maternity and child welfare centre built by the Poplar Borough Council in Wendon Street, E.3. The dental inspections in the schools have been carried out by the 83 inspecting dental surgeons, of whom 16 are women. The number of sessions devoted to this work was 2,857, and 292,971 children were examined. Of these, 204,205 were found to require treatment, or 69.7 percent., compared with 68.3 per cent, in 1937. During 1937, the number inspected was 315,016, of whom 215,243 were found to require treatment. The scheme for the orthodontic treatment of school children under the direction of the two orthodontists, Miss L. M. Clinch and Miss E. M. Still, has been continued during the year. Miss Clinch undertakes the treatment at the 6 centres north of the Thames, viz., Chelsea, Hackney, Hammersmith, Notting Dale, Paddington and Whitechapel, and Miss Still the 5 centres south of the river, viz., Bermondsey Medical Mission, Deptford, St. Christopher (Battersea), Stockwell and Woolwich. In addition to the treatment at the centres, the orthodontists undertake the construction of fixed appliances at the workshop, 123, Peckham Road, or in their own laboratories. Specially trained nurses assist both at the centres and in the making of the plaster 25 models at the workshop. In certain instances removable appliances are made at the Council's central dental laboratory, Romilly Road, Islington. The number of new cases seen at the centres during the year was 1,114, and the total number of attendances was 6,867. Fixed appliances were made for 677 of the children, and removable appliances were provided for 146 children. The number of cases in which treatment was completed and the children discharged was 198, and 103 were found to be unsuitable for treatment. The Council maintains 15 special aural centres which are under the direction of Mr. A. G. Wells, F.R.C.S., who is assisted by 12 assistant aurists giving part-time services. Excluding purely deaf children, the number of children attending for the first time at these centres for ear treatment during the year was 1,541. Including old cases, the number of examinations of children during the year was 14,942, and the number of ears examined was 18,639. In addition to the above, there were 1,830 children who attended the first time for examination to determine the cause of hardness of hearing. Special aural centres Particulars of this section of the work are given in the following table:— Table 14—Deaf cases Classification Patients Ears treated Total number of attendances 5,957 8,492 New cases 1,830 2,489 Cases carried over from 1936 271 401 Old cases returned 59 87 Cases cured 1,211 1,638 Cases partially relieved 129 182 Cases unrelieved 16 25 On current file, lapsed, etc. 804 1,132 In addition to the above there were:— Throat cases 60 Nasal cases—New 256 „ Carried over from 1937 37 „ Old cases returned 76 At the St. George's dispensary, Southwark, a special aural centre is maintained where children from the Council's residential schools suffering from otorrhœa are treated, and where also the after-care of children who have returned home from the Downs hospital school after mastoid operations is carried out. The number of "ears" dealt with in children from the residential schools was 157, and the percentage of cure 77.6. The number of children under supervision at the centre who had been discharged from the Downs hospital was 165, including 51 children discharged in 1937. The total number of children attending, including after-care cases, was 548, the number of attendances made was 7,929, and the number of children discharged well was 353. The subjoined table gives a detailed analysis of all cases of otorrhcea treated, showing number of acute conditions, cause of the persistence of discharge in chronic leases, the number cured, the number referred for operation, those lost sight of and the numbers still under treatment on 31st December, 1938. This table includes children suffering from otorrhcea who attended the after-care clinic. After-care clinic, St. George's dispensary Analysis of otorrhœa cases from ear, nose and throat clinics 26 Table 15—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 370 303 8 8 51 Chronic otitis media suppurativa due to (I) Tympanic Conditions (a) Tympanic sepsis (T.S.) 1,250 932 2 61 255 (6) T.S. +granulations 213 130 7 13 63 (c) T.S. +polypi 28 11 3 2 12 (d) T.S. +caries 14 3 2 1 8 (e) T.S. +other conditions 4 3 1 — — (II) Tympanic Conditions with (a) Tonsils and adenoids 202 124 6 13 59 (b) Nose conditions 487 317 2 30 138 (e) Mouth conditions 5 2 — 3 — (III) Tympanic Conditions with (a) Attic disease 47 24 7 2 14 (b) Mastoid disease (no operation yet done) 153 8 124 1 20 (e) Mastoid disease (operation already done) 510 284 20 31 175 (IV) Tympanic Conditions with (a) External otitis 65 48 1 5 11 (b) Stricture of meatus 3 1 1 — 1 External otitis 168 137 1 7 23 Cause undetermined 2 2 — — — Total 3,521 2,329 185 177 830 From these figures it will be seen that the percentage of "cases cured" is 69.6 per cent. Orthopaedic treatment The provision for orthopaedic treatment in London is adequate. As local education authority, the Council has established 27 day schools for the physically defective with accommodation for 3,157 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 10 visiting orthopaedic surgeons employed in connection with the Council's general and special hospitals. There are two main special children's hospitals maintained by the Council to which children suffering from orthopaedic 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 orthopaedic patients. There is no difficulty in finding accommodation immediately for all such 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 1937 was 610, of whom 328 were non-tuberculous and 282 tuberculous. Consultations and after-care examinations of children discharged from hospital are held by the orthopaedic surgeons three times weekly at County Hall. 27 London is a great centre for medical education, and there are many voluntary hospitals, which maintain orthopaedic departments, engaged in the teaching of medical students. These are all eager to undertake the orthopaedic care of children. There are also special voluntary orthopaedic hospitals at which orthopaedic surgeons of the highest repute hold appointments. At some of the hospitals the Council's organisers of children's care work attend in the orthopaedic departments as liaison officers. These include the orthopaedic 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 orthopaedic 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 1938 was 173. 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. 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 Belgrave, Charing Cross, Guy's, the London, the Miller, the Queen's, West London, the London Jewish, and Poplar. Organisers are also attached to the aural, eye and skin departments of Guy's Hospital. In order to effect improvement in the pre-school care of children, particularly of those between one and five years of age, 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 preschool 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. In her annual report for 1938, Miss H. G. Nussey, principal organiser of children's care work, says:— All districts report very close co-operation with the numerous other agencies which exist to help parents and their children, e.g., the Invalid Children's Aid Association, the tuberculosis dispensary, the Charity Organisation Society, the Church Army, the N.S.P.C.C., Children's Country Holidays Fund, invalid kitchens, settlements and juvenile organisations. There is frequently cross-representation. In fact, it may sometimes be said that " one man in his time plays many parts." Requests for care committee reports, apart from those required by the medical services, continue to pour in from almoners, relieving officers, the Charity Organisation Society, Juvenile Advisory Committees, psychiatric social workers at the Council's mental hospitals, etc., and after-care done by one of the care committees of a mentally defective school has resulted in a very close liaison with the supervision section of the mental hospitals department. An interesting new development is the reference of cases to the care committees by the judge at one of the county courts when grants are being administered through the court to children. Stammering children At the ten centres for the treatment of stammerers from elementary schools a total of 403 children attended during the year; of these, 107 were discharged as cured, while 42, many of whom had greatly improved, left for various reasons. Voluntary hospitals Pre-school children : co-operation with Borough Councils Stammering 28 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; 51 pupils attended, of whom 5 were discharged cured and 10 left. At Salter's Hill school, 48 children from residential schools of the Council attended a special centre. Of these, 18 were cured and 4 left. One of the speech therapists, Miss Grace Lloyd, has analysed the histories of 100 consecutive children referred for stammering. Place in family: only child, 6 ; first born, 31; second, 25; third, 16; fourth, 8; fifth, 7; sixth, 6; seventh, 1. In regard to five, the child was one of twins. Stammering in other members of the family was found in 33 families. Fathers stammered in 18, mothers in 7 and brothers and sisters in 12. Squint was present in 6 stammerers. Left-handedness was found in 18 of the 100 stammerers and in 31 near relations of stammerers. The stammer was stated always to have been present in 16 cases, and to have come on at 2 years in 2 ; 3 years in 12 ; 4 years in 14 ; 5 years in 19 ; 6 years in 7 ; 7 years in 3 ; 8 years in 5; nine years in 1; 10 years in 7; 11 years in 6 ; and 12 years in 2. The age of onset was uncertain in 6. Causation was said to have been due to: shock, 31 ; start of school life, 6 ; imitation (other than cases of heredity), 7; after exanthemata, 7; after tonsillectomy, 4; change from left hand to right, 1; heredity, 21; no cause assigned, 23. 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 1938 the smooth working of the rheumatism scheme was to some extent interrupted by the events of the international "crisis" in September. In accordance with the general principle which had been decided upon, a large number of the children in the rheumatism units who were not acutely ill were at this time discharged home. Many children also were removed by their parents in order that the chance of their being evacuated from London might not be missed. Except in a few instances where serious cardiac lesions were present, no great immediate harm appears to have resulted, although it is to be noted that subsequently nominations for re-admission were fairly numerous. The number of applications received, during 1938, for institutional treatment (2,371), showed a slight increase on the figure for the previous year (2,367); but, owing to a somewhat larger number than usual of these applications being withdrawn (mostly due to parental objections), the number remaining to be dealt with fell slightly below that of 1937. In addition to these withdrawals, 109 children were found on examination not to be suffering from rheumatism, thus leaving a total of 1,987 children for whom institutional treatment had to be arranged. The difference between this total and the corresponding totals for the two preceding years is negligible, and it seems evident that there is little change at present in the prevalence of juvenile rheumatism. The nominal accommodation of the rheumatism units remains at 900 beds, of which the average number available during the year was 835. This accommodation is adequate, but only just adequate, to cope with the demands made upon it. At times of pressure a waiting list tends to be built up, but the system of preliminary examination by specialist medical referees ensures the careful grading of cases, and thus only in the less urgent ones is admission delayed. During the year 2,030 children were admitted to the units. Approximately 37 per cent, of these showed signs of cardiac involvement, and it is gratifying to note that this is a decrease of 6 per cent, compared with the preceding year. An analysis of the condition of the children on discharge also shows an improvement in the results of treatment. During 1937, 1,925 children were discharged, of whom 23.7 per cent, had cardiac involvement of a degree necessitating some restriction on their activities. In 1938, only 21.3 per cent, of the 2,037 children who were discharged were so handicapped. Nominations for institutional treatment Rheumatism units 29 Progress has been made in regard to the provision of modern cardiac diagnostic apparatus at the rheumatism units, and a considerable amount of patient investigation in connection with the treatment, diagnosis and pathology of the disease is being carried out. So far as treatment is concerned, no spectacular advance has yet been made and rest under good hygienic conditions still remains the mainstay of treatment. The period necessary naturally varies, but six months may be regarded as a fair average. Absolute recumbency during the whole period is not implied; to quote Dr. Gray Hill, who for many years has supervised the rheumatic unit at Queen Mary's Hospital "a prolonged period of forced recumbency proves a strain on the patient and rest and strain are diametrically opposed; rest must be natural not forced." Accordingly at the rheumatism units the regime is one of gradually increasing physical activity combined with suitably planned education. The results are that the children remain happy and occupied during their stay in hospital—an important factor of successful treatment—and are better able to hold their own educationally on returning to a day school after discharge from a hospital school. At the end of the year, 7,792 rheumatic children were registered as being under supervision. Of these 5,160 were in attendance at rheumatism supervisory centres, and 2,632 were under the supervision of the school doctors. These figures are substantially the same as those for the preceding year. Much administrative work in this connection devolves on the school care committees, who also furnish reports on the home surroundings of the children. Their work cannot be valued too highly, more especially in the matter of the notification of defective conditions in the homes. The number of rheumatism supervisory centres remains still at 20, but an additional centre at Clapham will be available in July, 1939. With the opening of this centre every area in London will be provided for. The centre at Reginald Square, Deptford, has been moved to more convenient premises at Creek Road, Greenwich, and this will enable the work there to be carried out in close co-operation with the Greenwich medical officer of health. In view of the widespread belief that attacks of chorea are related either to mental or physical " shock " and perhaps to the strain of school work, it was thought that it might be instructive to obtain, if possible, definite figures. Accordingly, 296 cases were analysed with this object in view, and it was found that a clear history of fright or physical injury or surgical operation immediately preceding the attack was present in just over 8 per cent, of the cases. It would seem that such factors have a definite influence in an appreciable number of cases. This perhaps should be borne in mind in considering the desirability of operations such as tonsillectomy. In so far as school work is concerned there is no convincing evidence to support the view that it is an important predisposing cause of chorea. Of the 296 cases analysed (all children attending elementary schools), in only four was the attack attributed to this cause. In secondary school children the proportion was somewhat higher, but the small total number of cases found amongst these children suggested that the incidence of chorea in secondary school children was particularly low. Nevertheless it is of interest to note that, in children suffering from recurring attacks of chorea, a transfer to a school for physically defective children very frequently results in the cessation of the attacks. Occasionally, after a period, these children have been retransferred to an elementary school and an immediate relapse has occurred. On the other hand, a steady fall of the prevalence of chorea occurs after the age of nine, and this would seem to negative the suggestion that preparation for examinations plays a considerable part in its occurrence. It is just at this age that the competition for scholarships makes its appearance, and, if preparation for examinations played any significant part, one would expect a rise in the incidence of chorea between the ages of nine and twelve. Probably the important point in the relationship of school work to the incidence of chorea is the presence of an inborn bias towards nervous instability. Supervision Precipitating causes of chorea 30 Table 16 Particulars 1936 1937 1938 Nominations for treatment under the scheme— Number received from the Council's hospitals 678 761 748 „ „ „ voluntary hospitals 619 548 575 „ „ „ rheumatism supervisory centres 576 565 578 „ „ „ school doctors 303 348 338 „ „ „ other sources (chiefly private practitioners and welfare organisations) 221 145 132 Total number received 2,397 2,367 2,371 Subsequently withdrawn 55 69 141 Final total 2,342 2,298 2,230 Examinations by medical referees— Examined and accepted with concurrence of parents 2,013 2,059 1,987 „ „ „ but treatment refused 210 114 122 Examined and found unsuitable for institutional treatment 117 113 109 Awaiting examination, 31st December 2 12 12 Total 2,342 2,298 2,230 Treatment— Admitted to rheumatism units 2,039 2,018 2,030 Died before admission was arranged 1 5 4 Awaiting admission, 31st December 45 69 33 Total 2,085 2,092 2,067 Supervision— Number of children under supervision (31st December) by school doctors. 2,596 2,526 2,632 Number of children under supervision (31st December) at supervisory centres not recorded 5,164 5,160 Total — 7,690 7,792 Number of supervisory centres 20 20 20 Number of sessions at supervisory centres 1,088 1,073 1,090 Number of children attending for first time 1,921 1,920 1,885 Number discharged as no longer needing supervision Not recorded 432 Total number of attendances at centres 15,913 15,552 15,306 Reports by care committees on home conditions 1,664 1,448 1,744 Number of premises reported to borough medical offficer of health re dampness or to valuer re obtaining of better accommodation 442 335 434 Rheumatism Units— Nominal accommodation (i.e., number of beds) 930 900 900 Average number of beds available 889 856 835 Average number of beds occupied 803 798 794 Table 17—Admissions to rheumatism units, 1938 Sex Rheumatism and/or chorea with cardiac involvement Rheumatism and/or chorea with no cardiac involvement Total Number Percentage Number Percentage Boys 363 39.5 556 60.5 919 Girls 383 34.5 728 65.5 1,111 Total 746 36.7 1,284 63.3 2,030 Sex Table 18—Discharges from rheumatism units, 1938 Total Fit for elementary school or any employment Fit for P.D. school or light work only Permanently unfit Number Percentage Number Percentage Number Percentage Boys 716 75.9 189 20.3 26 3.8 931 Girls Total ... 887 80.9 185 16.7 34 2.4 1,106 1,603 78.7 374 18.4 60 2.9 2,037 31 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 1938, 1,463,634 examinations of children were made at these rota visits. In 106,299 cases the child was noted as verminous, i.e., in 7.3 per cent, of the examinations, compared with 7.9 for 1937 and 8.1 for 1936. 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 65,292 (compared with 82,357 in 1937, and 85,300 in 1936), figures which represent all those children who were noted to be infested with live vermin or their ova. About 47 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, 22 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, Finsbury, was opened in December, one head cleansing centre at Downham was closed in July, and an additional head cleansing centre was opened in January in connection with the Hoxton treatment centre. The following particulars for 1937 and 1938 are in respect of the cleansing scheme operated from the Council's and Borough Councils' centres (as distinct from the " head " cleansing centres):— 1937 1938 Number of advice cards issued to parents from bathing centres 82,357 88,240 Number of children attending voluntarily at bathing centres after advice cards 42,899 47,736 Number of statutory notices served in accordance with section 87 of the Education Act, 1921 22,604 22,389 Number attending bathing centres after statutory notices:— (а) voluntarily 4,279 5,047 (б) compulsorily 16,514 15,399 Number of cases in which police court proceedings were taken 250 195 At the head cleansing centres, 22,363 children attended during the year compared with 20,362 in 1937. 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 1938 a total of 63,975 children attended the bathing and head-cleansing centres, compared with 63,451 in 1937 and 66,464 in 1936. 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 1938,11,458 children were conveyed in the ambulances. Children suffering from scabies and impetigo are treated at the bathing centres. The total of such cases was 14,292 for the year, a considerable increase on the number for the previous year (10,962). The co-operation of the local sanitary authorities in respect of simultaneous disinfection of homes is gratefully acknowledged. 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 Scabies and impetigo 32 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 my last report measures taken to diffuse information concerning scabies were given in detail. Further efforts at more intensive propaganda are under way. 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 19 shows the number of children reported to have been out of school for more than three months in November, 1938, and comparative figures for the three preceding years. The number of children (91) absent on account of rheumatism, chorea and heart disease still forms a high proportion (25 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 91, compared with 320 in 1934. Nervous disorders (including 14 cases of epilepsy, and 5 of infantile paralysis) accounted for 26 children. For the first time for many years there was not a single case of encephalitis lethargica. Ringworm, formerly a chief cause of prolonged absence from school, accounted for only 5 cases, compared with 129 in 1919. Since the introduction of X-ray treatment for ringworm, the average length of absence has steadily declined, and consequent upon the shorter period of infectivity, the danger of the spread of the disease has likewise diminished. Tuberculosis was the cause in 26 cases. Among other ailments, respiratory diseases, other than tuberculosis, accounted for 31 cases, and ear disease for 15. The total invalidity among girls was greater during 1938 than among boys (188 to 175). There were 1 boy cripple and 3 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 " is a small number of mentally defective children, who, after ascertainment, at the moment of taking the census had not been placed in special schools, though excluded from elementary school. No blind or deaf child was reported as waiting admission to an appropriate school in November, 1938. Table 19—Census of chronic invalids, November, 1938, and preceding years Ailment Cases Percentage of total 1935 1936 1937 1938 1935 1936 1937 1938 Rheumatism, heart ease and chorea 232 153 114 91 30.9 26.7 22.3 25.1 Nervous disorders 61 58 36 26 8.1 10.0 7.0 7.2 Tuberculosis (all forms) 67 39 22 26 8.9 6.8 4.3 7.2 Anaemia and debility 41 37 30 12 5.5 6.4 5.9 3.3 Ringworm 2 2 6 5 0.3 0.3 1.2 1.4 Skin complaints (excluding ringworm) 35 24 29 20 4.7 4.2 5.6 5.5 Eye disease 9 12 10 7 1.2 2.1 2.0 1.9 Infectious diseases 35 23 29 20 4.7 4.0 5.6 5.5 Other defects 268 225 236 156 35.7 39.5 46.1 42.9 Total 750 573 512 363 100 100 100 100 33 Sleep of school children The General Purposes Sub-Committee of the Consultative Committee of Headmistresses of Girls' Schools asked that consideration should be given to the desirability of issuing to parents a leaflet drawing attention to children's lack of sleep owing to various factors, e.g., summer time, the radio, the cinema. The school medical officer has prepared a leaflet which was printed and distributed through the schools. Included in the leaflet was the advice that essential hours of sleep and times to go to bed are:— 12 hours at 4 years old 6.30 p.m. 11 to 12 hours at 5 to 7 years old 7.0 p.m. 10 to 11 hours at 8 to 11 years old 8.0 p.m. 9 to 10 hours at 12 to 14 years old 8-9.0 p.m. The leaflet received an immediate and widespread response and its influence extended far beyond the London schools through laudatory notices in both the London and provincial press. A Junior Red Cross link, when established in a school, forms a valuable aid to health, as is shown by the following extract from a recent number of the Junior Red Cross Journal:— Link 1074. Senior Girls' School, Walworth—We have tried to keep the health rules, especially in the matter of going to bed early. (This is good news indeed !—Ed.) Infectious diseases in schools Elementary schools The numbers of cases of infectious illness which occurred among children in the day elementary schools during the year, together with comparative figures for the preceding six years. are shown below:— Table 20 Year Diphtheria Scarlet fever Measles and German measles Whoopingcough Chickenpox Mumps Ophthalmia 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 1936 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 1938 3,576 3,988 34,235 4,067 11,018 4,805 342 The figures for ringworm are given later in this section of the report (page 36). The numbers of cases of scabies and impetigo, the treatment of these diseases and the measures taken during 1938 with a view to reducing their incidence, are referred to on page 31. No case of smallpox was notified in London during the year. The last confirmed case occurred in June, 1934. Members of the school medical staff carried out a number of special investigations during the year into the possible causes of infectious diseases in schools, details of which are given hereunder:— Table 21 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. 45 31 4,227 12 11 1,216 N. 30 23 1,882 8 7 646 N.W. 23 15 1,882 8 8 585 S.W. 28 24 2,772 16 15 1,625 S.E. 49 38 4,785 18 18 1,319 Total 175 •131 15,548 62 59 5,391 34 In addition, a special examination was held at one school on account of the prevalence of a skin complaint. The sequel illustrates the value of such epidemiological field work. The condition was found to be molluscum contagiosum, and as a result it was found possible to arrange for the admission of one child to a Council hospital, while others were treated at home by private medical practitioners and at school clinics. Valuable work was done by the school nursing staff in following up the investigations by medical officers shown above, and also in making special visits to schools in connection with the occurrence of infectious disease as indicated below:— Nature of No. of special visits infectious disease by school nurse Diphtheria 173 Scarlet fever 126 Chickenpox 108 Mumps 63 Whooping-cough 33 Sore throats 88 Diphtheria As shown in table 21, school doctors made 175 visits to 131 departments in elementary schools, during the course of which 15,548 children were inspected and swabbingS from the throat and nose of 2,380 selected children were taken. Of this number, 103 (4.3 per cent.) proved positive. In addition, 1,082 children were swabbed at treatment centres or clinics, and bacteriological examination showed that 98 (9.1 per cent.) of them were positive for Bacilli diphtheriœ. As a precautionary measure, swabs were also taken from the throat and nose of 638 children prior to entry to convalescent homes, and 635 of these proved to be negative. It was considered necessary to re-swab children in 62 cases when examination of a primary swab was inconclusive or suspicious. In 27 of these cases, Bacilli diphtherice were found to be present. The systematic swabbing of contacts and of certain other children is of considerable value because it leads to the segregation of possible sources of infection. During the period 1st January to 13th April, 1938, morphological Bacilli diphtherice were isolated and tested for virulence in 70 cases, of which 61 (87 per cent.) proved virulent and 9(13 per cent.) non-virulent. Since April, however, the virulence tests have been largely discontinued and replaced by fermentation tests. 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 were continued throughout 1938, 60 children of school age being referred there by various authorities, hospitals or private doctors. A report has been furnished by the medical officer in charge of each of the clinics, giving details of treatment and the results obtained. The majority of cases were found to have lost their " carrying " propensity by the time they were examined at the clinics. Three cases were removed to hospital as cases of clinical diphtheria, and one with measles. Tonsillectomy was advised for three more cases, and the remainder were given treatment and ultimately discharged as cured. The Corporation of London and the Metropolitan Borough Councils arrange for immunisation against diphtheria to be carried out at infant welfare or special centres, or by arrangement with medical practitioners or voluntary hospitals. As in previous years, 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. Children in the Council's residential establishments are immunised against diphtheria and a summary of the work done during the year appears later in this section of the report. The incidence of scarlet fever among school children was slightly higher than in 1937, 3,988 cases having been reported, compared with 3,903 cases during 1937. The average number of cases for the years 1932-8 was 6,409. Investigations were made on 62 occasions at schools where several cases had occurred. Diphtheria "carriers" out-patient clinics Active immunisation against diphtheria Scarlet fever 35 Active immunisation against scarlet fever was carried out at four of the Council's residential establishments, and a reference to this work is made later in the report At two treatment centres the practice obtains of passively immunising childrer against scarlet fever and diphtheria with a combined antitoxin consisting of streptococcus and diphtheria antitoxins before tonsil and adenoid operations, with a view to preventing the occurrence of those diseases after the operations have been performed. Parental consent is obtained in each case. This procedure has been in force at the Cyril Henry treatment centre, Woolwich, since 1933, and at the Hanover Park treatment centre. Peckham, since 1936. Passive immunisation before tonsil and adenoid operations The following figures relating to this pre-operative immunisation during 1938 have been received from the divisional medical officer:— Cyril Henry treatment centre Hanover Park treatment centre Children attended 1,433 1,295 Operation performed 1,108 1,085 Operation deferred 325 210 Serum given 920 680 Serum not given because of— Recent attack of scarlet fever or diphtheria Recent immunisation or recent reaction after antitoxin 39 216 History of asthma 3 3 Parents refused consent 146 186 Serum rashes, etc., occurring among children passively immunised 351 174 One child at the Cyril Henry treatment centre suffered from scarlet fever after the operation. The parents had consented to immunisation, but this was not done as the child had been immunised a year previously in similar circumstances. The previous high incidence of post-operative scarlet fever and diphtheria at the clinics has disappeared. The biennial epidemic of measles commenced in November, 1937, and for the Measles week ended 18th December, 1937, the number of school children reported to be suffering from the disease was 324. After the Christmas holiday, the number of cases reported in the four school days of the week ended 15th January, 1938, was 999, which number included absentees suspected to be suffering from measles. The Council's scheme of control, which provides for special co-operation between the school nurses, teachers, school attendance officers and borough medical officers of health, in order to bring to the notice of the borough medical officers of health cases of measles in their earliest stage, was put into operation on 12th January, 1938, and continued until the incidence of measles in the schools had decreased sufficiently to justify its suspension during the week ended 16th July, 1938. The following figures indicate the numbers of measles cases reported among the elementary school population during this and the five previous epidemics. The figures relate to the epidemic period of nine months from November to July. Cases reported Average number Attack rate Date from schools on school rolls per 1,000 1927-28 45,343 652,342 69 1929-30 36,634 623,728 59 1931-32 35,705 598,865 60 1933-34 38,949 584,049 67 1935-36 32,690 518,630 63 1937-38 35,292 467,442 75 It will be noted that the number of cases was greater than in the previous epidemic, but less than in the 1933-34 epidemic. The attack rate per 1,000 was higher than in recent epidemics. A detailed report on the epidemic is in course of preparation. Cases of ringworm of the scalp occurring among children in the Council's elementary schools are followed up by the school nurses, and, if any difficulty is experienced in treatment by ointments and lotions, or if this treatment is considered unsatisfactory,the parents are offered X-ray treatment under agreements made by the Council with certain voluntary hospitals and treatment centres. Ringworm and favus 36 The following table shows the number of cases of ringworm of the scalp among the children in the Council's elementary schools reported during 1938 and in previous years:— Table 22 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 1936 190 187 44 67 1937 181 164 61 66 1938 194 206 44 83 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 During the year, 408 specimens of hair from school children were examined for ringworm at the laboratory at County Hall. After microscopical examination fungus was found in 134 of these (116 small spore ringworm, 15 large spore ringworm and 3 favus). As has been the practice in previous years, co-operation has been maintained with the Play Centres Committee, who were notified of all schools where infectious disease 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, and borough medical officers of health have again been asked to co-operate by forwarding information when a case of infectious disease occurs in a home from which a child has proceeded on a school journey. Particulars of the general arrangements made for school journeys during 1938 are set out on page 41. The measures taken in co-operation with the Kent public health authority with a view to preventing the introduction of infectious diseases among workers in the hop-gardens, which have been described in previous annual reports, were continued in 1938. Residential establishments for children There was a recrudescence of body ringworm at Ardale approved school, twentynine cases having been reported during the year. A special visit was paid to the school in May by a medical officer from County Hall who made a thorough examination and proffered suggestions on the method of treatment and disinfection of clothing. The outbreak subsided in October and no further case has been reported since. At Stamford House remand home there occurred during the year a number of cases of scarlet fever, diphtheria and scabies. All necessary steps were taken to prevent the spread of infection but the incidence of infectious disease was not regarded as excessive, bearing in mind the shifting population of the home. One boy was found to be suffering from gonorrhoea on admission. He was admitted to hospital and later discharged as cured. Another boy, who was found to be suffering from gonorrhoea on admission, was discharged by the court before treatment was completed. He was subsequently re-admitted to the remand home, but, as he refused treatment, he was sent by the court to a prison hospital for treatment. Reference to the occurrence of cases of vulvo-vaginitis at this home is made later in this report. Active immunisation against diphtheria was continued during 1938 at all five of the approved schools, and, in addition, active immunisation against scarlet fever was continued at the Mayford school. The numbers of cases of infectious disease at the residential special and open-air schools were not unduly excessive and no special comment is called for. The infectious diseases occurring in the residential schools, children's homes and children's receiving homes in numbers sufficient to warrant special mention were : measles at three institutions, German measles at two, and chickenpox at three. All practicable steps were taken to prevent the dissemination of infectious disease in the establishments, including the removal of patients to appropriate hospitals. 37 Mention has been made in previous annual reports of the arrangements for sending infectious disease "contacts" to Earlsfield House children's receiving home. This procedure has been continued. During the year, 360 children were admitted to the " contact " block at Earlsfield House, and, of these, 13 children developed the disease to which it was stated they had been exposed, and 10 developed other diseases. Schick-testing and immunisation against diphtheria are carried out at the Council's residential establishments for children with certain exceptions, viz., the receiving homes, 3 residential open-air schools and the remand home. At these latter establishments the children do not remain a sufficient length of time for immunisation to be carried out. During the year 1937, 1,066 children were Schicktested, viz., 724 boys and 342 girls, of whom 442 boys (61.0 per cent.) and 163 girls (47.7 per cent.) proved to be Schick negative or naturally immune from diphtheria, while 282 boys (39.0 per cent.) and 179 girls (52.3 per cent.) were found to be Schick positive or susceptible to diphtheria. Active immunisation against diphtheria The percentage proportion in each year of age of Schick negative and positive cases, tabulated according to sex, was as follows:— Table 23 Age Total tested Percentage Male Female Schick negative Schick positive Male Female Male Female 2 years 41 31 22.0 9.7 78.0 90.3 3 „ 42 33 31.0 36.3 69.0 63.7 4 „ 30 31 46.7 35.5 53.3 64.5 5 „ 34 19 44.1 47.4 55.9 52.6 6 „ 33 13 57.6 38.5 42.4 61.5 7 „ 22 28 54.5 42.9 45.5 57.1 8 „ 26 21 73.1 47.6 26.9 52.4 9 „ 30 18 90.0 55.6 10.0 44.4 10 „ 39 16 64.1 50.0 35.9 50.0 11 „ 53 22 71.7 63.6 28.3 36.4 12 „ 90 19 63.3 84.2 36.7 15.8 13 „ 113 36 73.5 63.9 26.5 36.1 14 „ 70 20 52.9 50.0 47.1 50.0 15 „ 51 22 76.5 50.0 23.5 50.0 16 „ 50 13 70.0 69.2 30.0 30.8 724 342 61.0 47.7 39.0 52.3 Age groups of children in above table 2-5 years 147 114 34.7 30.7 65.3 69.3 6-10 „ 150 96 68.0 46.9 32.0 53.1 11-16 „ 427 132 67.7 62.9 32.3 37.1 724 342 61.0 47.7 39.0 523 Of the total of 461 Schick positive cases, 354 proved to be negative after the usual course of immunising injections, and 16 became immune after further injections. The remaining 91 children left school before immunisation was completed. In these cases the appropriate medical officers of health were informed so that they might make arrangements for the immunisation to be completed. The following is a summary of the progress of immunisation during 1938:— Uncompleted cases brought forward from 1937 162 Number tested for susceptibility 1,169 Number found to be immune 705 Number found to be susceptible 464 Completed full immunising course and gave negative reactions on re-test 377 Left school before course of immunising injections had been completed 1ll Outstanding on 31st December, 1938, to be completed in 1939 138 38 During the year, 33 children were removed to hospital from the residential establishments where immunisation against diphtheria is carried out, suffering or suspected to be suffering from diphtheria. As a result of subsequent findings, 7 (21.2 per cent.) proved not to be suffering from diphtheria, 1 (3 per cent.) yielded bacteriological but no clinical evidence of diphtheria, and 25 (75.8 per cent.) were found to be suffering from clinical diphtheria. The following analysis of the 25 clinical cases indicates the number of children who had been subjected to immunisation at the residential establishments and the subsequent diagnosis at the hospital:— Classification Hospital diagnosis Schick negative on preliminary test and therefore not Faucial 3 subjected subsequently to prophylactic injections Nasal 1 — 4* Schick negative after course of prophylactic injections Nasal 1† Course of prophylactic injections not completed Faucial 3 Nasal 3 — 6** Not Schick-tested Faucial 10 Nasal 4 —14 *1—10 months after Schick negative result. 1—11 „ „ „ „ „ 1—7 „ „ „ „ „ 1— 6 years „ „ „ „ tl— 2½ „ „ „ „ „ **1—10 days after second injection of diphtheria prophylactic. 1—10 months „ „ „ „ „ 4—No prophylactic given. Active immunisation against scarlet fever was carried out at four of the Council's residential establishments, viz., Mayford approved school and Shirley, Ongar and Hutton residential schools. During the year 1937, 857 children were Dick-tested, viz., 501 boys and 356 girls, of whom 374 boys (74.7 per cent.) and 251 girls (70.5 per cent.) proved to be Dick negative, while 127 boys (25.3 per cent.) and 105 girls (29.5 per cent.) were Dick positive or susceptible to scarlet fever. The following is an analysis of the number of children Dick-tested and immunised during 1937:— Active immunisation against scarlet fever Table 24 Age Total tested Percentage Male Female Dick negative Dick positive Male Female Male Female 2 years 51 32 31.4 25.0 68.6 75.0 3 „ 45 32 46.6 43.7 53.4 56.3 4 „ 25 21 64.0 57.1 36.0 42.9 5 „ 24 18 66.7 77.8 33.3 22.2 6 „ 17 23 82.4 82.6 17.6 17.4 7 „ 34 25 79.4 84.0 20.6 16.0 8 „ 23 17 91.3 88.2 8.7 11.8 9 „ 33 37 93.9 91.9 6.1 8.1 10 „ 16 20 100.0 85.0 — 15.0 11 „ 43 22 86.0 77.2 14.0 22.8 12 „ 40 32 87.5 68.7 12.5 31.3 13 „ 79 27 81.0 89.0 19.0 11.0 14 „ 65 26 84.6 76.9 15.4 23.1 15 „ 5 22 80.0 54.5 20.0 45.5 16 „ 1 2 100.0 100.0 — — 501 356 74.7 70.5 25.3 29.5 Age groups of children in above table 2-5 years 145 103 47.6 46.6 52.4 53.4 6-10 „ 123 122 88.6 86.9 11.4 13.1 11-16 „ 233 131 84.1 74.0 15.9 26.0 501 356 74.7 70.5 25.3 29.5 39 Of the total of 232 Dick positive cases, 27 left school before immunisation was completed, 202 proved to be negative after the usual course of immunising injections, and 3 became immune after further injections. The following is a summary of the progress of immunisation during 1938:— Uncompleted cases brought forward from 1937 50 Tested for susceptibility 308 Found to be immune 156 Found to be susceptible 152 Completed full immunising course and gave negative reactions on re-test 115 Left school before course of injections had been completed 28 Outstanding on 31st December, 1938, to be completed in 1939 59 During the year, 5 children were removed to hospital from the above-named schools suffering from scarlet fever: 3 had not been Dick-tested, 1 was Dick negative in 1937 (18 months prior to the onset of scarlet fever) and 1 had been immunised and showed a negative reaction on retest (18 months prior to contracting scarlet fever). During the year 18 cases of vulvo-vaginitis were reported among the girls in the residential establishments (excluding the remand home). Every case proved negative for gonococcal infection. There were 104 cases of vulvo-vaginitis reported from the Stamford House remand home, compared with 65 for the previous year. In every case the patient was removed to hospital. Bacteriological or clinical examination revealed evidence of gonococcal infection in 21 of these cases, a marked decrease in positive infection compared with the number (27) for 1937. Open-air education Provision for education in the open air includes nine day open-air schools (non-tuberculosis) with accommodation for 1,460 children, and six day open-air schools (tuberculosis) accommodating 515 children. There are also seven country and seaside convalescent camp schools, accommodating 520 children for periods varying from one to three months, through which 3,824 children passed last year, and 215 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. 1938:— Boys Girls Total Aspen House 71 49 120 Bow Road 106 73 179 Brent Knoll 86 52 138 Charlton Park 93 60 153 Downham 83 62 145 Holly Court 165 116 281 Stowey House 160 119 279 Upton House 82 67 149 Wood Lane 91 65 156 Total 937 663 1,600* *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. The organisation of the two types of day open-air school has been under review during the year, and, as the result, it has been decided that while it is desirable for the present to retain a distinction between the two types of school, the time is opportune for some modification of the difference in regime. Proposals have therefore been adopted which will increase the interchangeability of the accommodation and enable it to be utilised to the best advantage. These changes will come into effect during 1939 and will be dealt with in my next annual report. 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 Vulvovaginitis Provision Open-air scnools for non-tuberculous children Open-air schools for tuberculous children 40 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 598. The number on the roll on 31st December, 1938, was 559, and the average attendance for the year was 476. 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 1938, 189 children were admitted and 199 discharged. Of the latter, 55 were transferred as fit to attend elementary schools, 85 were fit for work on attaining school-leaving age, 37 moved away, 17 were transferred to other special schools, and 5 were discharged for other reasons (e.g., the distance was found to be too great for the children). During the year, 90 children were also transferred to institutions for residential treatment for tuberculosis or admitted to hospitals for various reasons. During 1938, arrangements were made under the ordinary school journey organisation for 362 children on the rolls of open-air schools (type T) to have a holiday out of London for two weeks. A further party of 35 children was accommodated at the Council's Millfield Convalescent Hospital for a fortnight. The numbers of children spending a period of stay at the residential convalescent camp schools during 1938 were: boys, 2,120; girls, 1,704; total, 3,824. Convalescent camp schools In detail the numbers were:— Provided schools:— Boys Girls King's Canadian school, Bushy Park 2,045 — George Rainey, St. Leonards — 543 Wanstead House, Margate — 688 Total 2,045 1,231 Non-provided schools:— Boys Girls Fairfield House, Broadstairs — 80 Russell Cotes school, Bournemouth — 196 St. Vincent's, Hastings — 90 Sandon home, Chelmsford 75 107 Total 75 473 The actual number of children away at these schools at one lime in 1938 was : Bushy Park, 250; St. Leonards, 64; Margate, 87; Broadstairs, 20; Bournemouth, 29; Hastings, 10; Sandon, 20; total, 480. The small home at Sandon accommodates the children needing a country holiday from the various types of special schools. The number of open-air classes held in connection with the elementary schools in 1938 was 215. Of these, 13 were of type A (children selected on medical grounds from a group of schools); 121 were of type B (children selected on medical grounds from the various classes of a single school); 18 were of type C (consisting of a single class from one school, educated continuously at one open-air station); and 63 of type D (consisting in a rotation of classes from one school occupying one open-air station). Fifteen classes are permanent, that is to say they are outside the yearly programme and do not need re-authorisation each year. In addition, 126 of the 215 classes were continued throughout the winter, where the suitability of the sites had been approved by the school medical officer. Of the 215 classes, 77 were held in parks, gardens, playing-fields and other open sites, while 102 were held in school playgrounds, of which 36 were roof playgrounds. Open-air classes in parks and playgrounds 41 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. During the year 4,725 children were discharged from convalescence at the undermentioned hospitals. No. of children discharged from Institution convalescence St. Anne's home 1,331 Goldie Leigh hospital 102 Downs hospital for children 475 Lower Southern hospital 2,392 Millfield convalescent hospital 425 Total 4,725 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 1938 grants in respect of a maximum period of eight weeks' convalescence were authorised for each of 2,638 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 1938, 395 school journeys were arranged. The children taking part were medically examined in all cases before departure. In all, 13,710 children were examined, and of these 76 were excluded as unfit to take part in the journeys for the following reasons: heart disease, 6; tonsillitis, 8; otorrhœa, 4; conjunctivitis, 1; septic wounds, 8; skin disease, 17; raised temperature, 8; dental trouble, 5; infectious disease, 10; other conditions, 9. Several children were provisionally rejected on grounds connected with personal hygiene, but were subsequently passed after visiting a bathing centre. Physical education The following is abstracted from the report of the organisers of physical education (Mr. A. H. A. Gem and Miss Grant S. Clark) for the three years ended September, 1938:— The report covers three years which, from the point of view of physical education, have been highly significant. Progress has been rapid and far-reaching. One of the prominent features has been the large building programme which has been undertaken by the Council. The standard planning has been altered in the case of central and senior schools to include a gymnasium, a showering-drying-changing room, a teacher's changing room, and an apparatus store in each new school. Central and elementary schools 42 The gymnasia in these new schools are light and airy, and have an area of 1,800 sq. ft.; they are equipped with a limited range of apparatus, the floors are specially constructed of non-splintering hard wood, and they are designed in such a manner that they afford a measure of resilience. The floor is perhaps the most important piece of apparatus, as so many exercises are taken in a sitting or lying position, and for this reason cleanliness is a matter of major importance. The design of the gymnasium and changing room is such that the children must enter the changing room first where they change for their lesson before entering the gymnasium. This arrangement does much to ensure the preservation and cleanliness of the gymnasium floor. The purpose of reconditioning is to afford to a school, so far as the limitations of the building permit, facilities which approximate to those which would be provided in a new school. So far as physical education is concerned this treatment has, in the majority of cases, proved most effective. By September, 1938, the following position had been achieved:— New central schools with gymnasium, showers, etc 2 Re-conditioned central schools with hall-gymnasium, showers, etc. 5 *New senior schools with gymnasium, showers, etc. 7 Re-conditioned senior schools with hall-gymnasium, showers, etc. 9 Total 23 *Two of these are without modern changing and showering rooms. Physical education in junior schools has not benefited to the same extent by the building and reconditioning programme. Prior to the re-organisation of schools, physical training was based on the Board of Education Syllabus of Physical Training, 1919. This syllabus was compiled on the basis that schools were "through" schools, and that in any given class there would undoubtedly be a wide age range. Re-organisation, however, led to a much closer grading and after a few years it became evident that this publication did not make adequate provision for the older children in central and senior schools, and a temporary pamphlet was issued to act as a guide for boys' work in central and senior schools, while the girls in central schools received similar help. In 1933 the Board of Education revised the syllabus, and in its new form it is intended to act as a text-book for junior schools and for the first year's work in a central or senior school. It was stated that separate publications would shortly be issued for senior boys and senior girls, but at the time of compiling this report these books have not been published. The need for a definite syllabus for the senior children was meanwhile growing urgent, and during the past year the Council's organisers of physical education have themselves written the necessary books, and these have been published by the Council The decision to introduce this extended range of training has raised two major problems :— (i) The supply of apparatus. The Council has agreed to supply to each senior school, and to each " through " school with a senior section, the following equipment: 6 gymnastic benches, 4 stools, 1 vaulting box, 1 vaulting buck or horse, 1 beating board, 4 gymnastic mats, 1 pair jumping stands and rope, 10 climbing ropes. (ii) The training of the necessary number of teachers to conduct such work. With this end in view the Council recently sanctioned the holding of a series of special six-week half-time courses, the training at which was to be based on the new senior syllabuses. The first course to be held was one in the late autumn of 1937 for young men teachers from the unattached list. The first courses for permanent teachers were held in May, 1938 ; one in the mornings for men, and one in the afternoons for women. As a result of the training given in these courses the equipment in eleven central schools has been brought up to scale, and 53 senior departments have been equipped with portable apparatus. The recruitment to these courses is giving rise to some anxiety. In some cases the only suitable man or woman has now been trained, in others there is no member of the staff suitable for training. The method which has been adopted in recruitment is for members of the organising staff to visit the schools and discuss on the spot the possibility of teachers attending these classes. So far 146 boys' schools have been visited, and of this total 21 departments have no teacher on the staff able to take the training. In a similar manner 90 girls' schools have been visited and 35 have no teacher available for this specialised training. It is apparent that, unless exceptional steps are taken, the introduction of work embracing the use of portable apparatus cannot be ensured in many senior schools. There is a further issue to be faced, namely that in certain departments there is only one teacher suitable for training in this advanced work, and it is neither reasonable nor desirable for that teacher to shoulder the entire responsibility for the physical training of his or her department. In the main, the physical training in senior schools is confined to free standing exercises, activities, games and the simpler agilities, and the general standard of efficiency in this range of work is quite good, and shows every indication of becoming still better. While the main developments have centred round senior departments, attention has also I been paid to the work in junior and unreorganised schools. Steps have been taken to give the teachers concerned a more intimate knowledge of the Board of Education 1933 Syllabus of Physical Training, and the quality of the work has steadily improved. Introduction of apparatus work Junior and unreorganired schools 43 During the period covered by this report special day and evening courses have been organised for teachers working in junior and unreorganised schools. The response has been excellent, and many hundreds of teachers have availed themselves of the facilities provided. While the majority of central schools had been equipped with a good range of portable apparatus prior to the period covered by this report, climbing ropes and certain other items had not been supplied, and it was hoped that this apparatus would be provided during the current three-year programme. The demands of the senior reorganisation, however, make this unlikely, and additional equipment can only be supplied in so far as central schools come within the scope of this scheme. The demand for specially trained physical training teachers is growing throughout the country and, at the present time, the output from the men's training colleges is rapidly absorbed for posts as organisers or tutors in training colleges, or teachers in secondary and technical schools. The result is that the central schools are not at the moment attracting teachers with this qualification, and only four of the boys' central schools have teachers on the staff who have attended a one-year course. While many children bring their own shoes, and great efforts are made to provide separate clothing or to adapt the normal clothing, it has been shown during past years that such provision, in spite of every effort on the part of the teachers, leaves a large number of children unprovided for. It is a matter for regret that no advance can be recorded with regard to the provision of plimsolls and clothing for physical training by the authority. It is necessary to point out that the physical training cannot be really satisfactory until proper footwear is available and suitable clothing is worn by the children. Reference has been made to the extensive provision of shower baths which has been made recently, and one of the problems which has to be solved is how this facility is to be most effectively used. Difficulty arises when a parent flatly refuses to let his or her child have a shower bath. Compulsion is not possible, and the teachers concerned are deserving of the warmest praise for persuading between 70 and 80 per cent, of the children to take part. The most difficult problems which have to be solved are those concerned with the provision, drying and storage of towels. Every effort is made to induce the children to bring their own towels, and, while this method is effective so far as the majority of children are concerned, there are many who fail to bring towels. If these children are to use the facilities provided, towels will have to be supplied by the authority. Assuming that every child has a towel, the problem of drying and storing has still to be faced. It is a comparatively simple matter for those whose physical training lessons take place during the last period of the morning or afternoon, as they can take the towels straight home with them. But if the lesson takes place during the first period of the morning or afternoon, then a wet towel has to be disposed of for the rest of the session. Some practical and cheap method of drying and storing towels must be evolved, and it is urged that experiments should be started immediately to discover the solution of this problem. The shower baths have been planned so as to permit of rapid showering, drying and dressing, and, with this end in view, the space available for this purpose is divided into three sections, one containing the actual showers, one serving as a place in which the children can dry themselves, and one providing the accommodation in which the children dress. It is essential to separate the drying and changing spaces, otherwise the children, returning direct from the showers to the changing room, are apt to get their ordinary clothing wet. It has been shown that a total of ten minutes is sufficient time for changing and showering purposes : three minutes to change into gymnastic clothing at the beginning of the lesson, two minutes to shower, and five minutes to re-dress at the end of the lesson. Of course, if the task is to be carried out in this time method is necessary. Drying and dressing are things which can take a long time ; anyone who has had to deal with children will realise this. The actual showering space has, in each case, been planned in one of two ways. If the showers have to serve both boys and girls they are of the individual type with the side shower, the cubicles being formed by movable rubber curtains. If the showers have to serve boys only, then they are planned on the continuous "walk through " basis with the water projected from two sides simultaneously. By either of these methods 12 children can receive a good shower in 45 seconds, and the whole of an average sized class in two minutes, thus leaving five minutes for drying and dressing. A great experiment has been started which, if wisely and energetically directed, should produce far-reaching results. One of the immediate results of the issue of Circular 1445 by the Board of Education was that the Education Committee decided to circularise all schools for a second time with regard to the amount of time which should be devoted to physical education. The recommendation was couched in the following terms:— " The appropriate Committee wish to direct special attention to one point raised in the Circular, which is set out in the following paragraph:— " There should be a daily period of organised physical activity in every elementary school, the length of these periods as well as their allocation will depend somewhat upon circumstances, but an allowance of three periods weekly to physical exercises, one to swimming, and one to organised games, will often be found suitable ; for girls, dancing may, on occasion, be substituted for games or swimming. Central schools Clothing Shower baths Allocation of time to physical education 44 "The Committee are in agreement with the view herein expressed by the Board as to the desirability of a daily period of organised physical activity in every elementary school . . . The proposal now put forward is that there should be a daily period of organised physical activity on each of the five school days of the week." The results of this circular were broadly, that the majority of schools substantially carried out the recommendations, while a limited number made out a reasonable case for being unable to do so. There are still cases, however, in which the time devoted to this work falls short of the Committee's recommendation, and it is hoped that in the near future a real effort will be made by such schools to provide a daily period of organised physical activity for all children. Facilities for organised games in the London area are provided in the Council's parks and open spaces, in certain Royal parks, in parks and grounds controlled by Borough Councils, on sites under the control of the Education Committee which have been adapted for the purpose, on grounds rented from sports organisations and others, and on a number of playing fields which are provided with special classroom accommodation. It is with regard to the last named that considerable development has taken place. The aim of the Council is to ensure that all pupils throughout their final year in junior schools, and all pupils in a senior department (or its equivalent in an unreorganised school) have at least one hour's games on a playing field each week. The facilities already available, owing to their extent, and more particularly to their distribution, are insufficient to meet such a demand, and the policy of acquiring large playing fields under the control of the Education Committee has therefore been adopted. One of the problems is the inevitable distance from schools to playing fields. The length of time taken to reach a playing field is often out of all proportion to the time available for play, and many head teachers are reluctant to make heavy inroads into the time-table. The solution is to send children to a playing field for the whole day, and in order to make this possible classrooms have been built on some of the fields already purchased, and these are used by the children when they are not actually playing games. These classrooms are adequately heated and are furnished with portable desks and chairs and all necessary storage facilities, in which books, writing materials, etc., can be kept. In addition, cloakrooms, lavatories, changing and showering rooms and staff rooms are provided. The grounds are laid out so as to provide pitches for football and hockey in the winter together with other games such as Rugby touch, netball and skittle-ball. In the summer the major games are cricket, rounders and stoolball, while cricket nets, slip catching cradles, long and high jump pits and minor games pitches are also provided. All equipment for games is stored on the playing fields and the supply is sufficient to allow of mass coaching in all games. Experience has shown that it is essential to have on each field a dry playing area, so that games shall not be missed owing to the grass pitches being unfit for play. One of the many difficult problems which still have to be faced is the lack of suitable footwear and clothing. While parents should be encouraged to provide suitable footwear and clothing for their children, the number capable of so doing is limited, and some form of provision by the Council would appear to be inevitable. The children leave the neighbourhood of their schools at 9.15 a.m., and on an average reach the fields at 10 a.m. There they remain until 3.30 p.m., at which hour they start the homeward journey. During the time spent at the ground every class is allocated at least one hour for games. The children bring their own mid-day meal with them and this is, as a rule, eaten between 12.15 and 1.15 or 1.30 p.m., the luncheon interval being reduced to allow a full afternoon session of two hours before the return journey at about 3.30 p.m. Milk can be obtained, and there are facilities for heating it when the weather is cold. Negotiations are taking place to secure five further playing areas, each of 100 or more acres, and each provided with 50 or more classrooms catering for some 2,000 children daily. The five areas will, therefore, cater for 10,000 children daily or 50,000 each week. A start has been made on a scheme to which the often abused word " gigantic " might reasonably be applied. From the inception of this scheme up to September, 1938, five grounds, comprising in all 55 acres with 19 classrooms, have been purchased, equipped, and are in full operation. Special arrangements have also been made at three further grounds with 12 classrooms. In addition six sites, covering 480 acres, have been purchased with a view to development. While the major effort has been directed towards the purchase of outlying fields and the building of the necessary classrooms thereon, no opportunity has been missed of purchasing local grounds nearer to the schools for the purpose of organised games only. During the period under review, facilities of this type, comprising 13 acres, have been provided in six districts. This report would not be complete without reference being made to the admirable work carried out in London by the many voluntary sports associations. Such activities form an essential part of a comprehensive scheme of physical education, and the Council has recently emphasised its appreciation of this work by giving a measure of financial assistance, such money to be used to help to defray the travelling expenses of children taking part in the various fixtures. These include the London Schools' Athletic Association, the London Schools' Amateur Boxing Association, the London Schools' Cricket Association, the London Schools' Games Association for girls, the London Schools' Football Association, and the London Schools' Swimming Association. The classroom playing-field scheme Voluntary associations 45 The vast amount of work carried out by these admirable associations may be gauged by the results of the activities of the last named, which, during 1935-37, issued 114,783 swimming and 25,351 life-saving certificates. It must be remembered that these voluntary services are performed by a comparatively small number of teachers as the average school has two or at the most three teachers on the staff who are actively concerned with these extra-mural activities, while in some cases the entire responsibility falls on one man or woman. Month after month and year after year they give their Saturday mornings and their evenings to this cause. They perform a great work for the children in their charge and one deserving of high nraise. Play leadership scheme The play leadership scheme has now been in operation for a period of four summers, and it is possible to form some reliable estimate of its value. In 1935, 39 centres were opened and there was an average attendance of 87 children per centre; while in 1938 games were held at 80 centres and the average attendance was 102 children. The success of this evening work was such that the Council decided to extend the scheme to the establishment of centres in parks and playgrounds during the summer holidays of 1938, and this decision was amply justified, particularly in respect of the centres situated in the parks. The following figures illustrate what was aphieved:— Number Average attendance Boys playground centres 27 52 Boys park centres 16 115 Girls playground centres 25 51 Girls park centres 17 130 Total 85 The parks proved more attractive to the children than the playgrounds, and it is suggested that in the summer of 1939 the number of playground centres should be decreased and the number of park centres correspondingly increased. Training of teachers When the Carnegie College was opened, the Council decided to grant a certain number of scholarships to enable teachers to attend the one-year course. The majority of teachers who have t attended the course have done well, and several have obtained posts in training colleges, secondary and technical schools. A course for men, of similar type to that organised at Carnegie College, has been commenced at the Loughborough training college. This course is recognised by the Council, and in the year 1937-38 two teachers were granted scholarships to enable them to attend. For many years the Council has given scholarships to enable girls to attend a three years' course at a physical training college ; these scholarships are tenable at the physical training college at Chelsea Polytechnic, and at the Bergman Osterberg College, Dartford. The growing necessity of training teachers to undertake a measure of specialisation in physical education in senior schools has led to the establishment of a certain number of threemonth courses. The Council, realising the value of such training, has made provision for a certain number of teachers to take advantage of these facilities. Two women have already attended a course, and two are due to attend shortly, and by Easter of 1939 five men will have received similar training. The Council recently agreed to re-introduce the practice of aiding teachers to attend holiday courses, and during the summer of 1938 four men and two women availed themselves of this facilitv. Secondary schools The past three years have been marked by considerable activity so far as building is concerned. In former reports attention was directed to the fact that many secondary schools either had no gymnasium or else one that did not conform to modern standards. During the three years, progress has been rapid and ten schools have been provided with a modern gymnasium, a changing-drying-showering room, an apparatus store and a teacher's changing room. In addition, 13 schools are scheduled to be provided with similar facilities during the current three-year programme. Two new schools are proposed, and preliminary plans have been approved, while two county secondary schools are to be replaced by new buildings. In each case physical training accommodation on the most modern scale will be provided. A further matter which has received careful attention during the period under review has been the provision of adequate changing facilities in those schools which do not already possess them. It is by no means unusual to find that in the years gone by schools were provided with quite an effective gynmasium, but no room in which the children could change. The addition of a changing room is by no means always an easy matter, as it is not unusual to find that owing to the original structure of the building it is either extremely difficult or even impossible to build the changing room adjacent to the existing gymnasium. During the past three years it has, however, proved possible to provide changing rooms, fitted with shower baths, at four schools. It is hoped, moreover, that during the current programme similar facilities will be provided at ten further schools. There is a problem closely allied to the provision of shower baths which has not, as yet, been solved, viz., the provision of drying and storage facilities for towels and gymnastic kit. 46 Assuming that a physical training master or mistress is able to teach for approximately thirty periods a week, it follows that for every ten classes in a school one full-time teacher, or the equivalent, will be required. This figure does not take into account the coaching in games. Similarly, a gymnasium can accommodate only thirty-five groups a week ; thus one gymnasium just affords adequate accommodation for an eleven-class school. It will therefore be appreciated that, quite apart from the curriculum difficulty, there are many serious obstacles to be overcome before the principle of a daily period of organised physical activity becomes an established fact in the secondary schools of London. The work seen during the period under review has been vigorous and purposeful, and effective training is given in the majority of schools. The gymnastic teachers are zealous and interested in their work, and are always ready to avail themselves of opportunities to keep abreast of modern developments. A new and more enlightened attitude towards games has been developing during recent years. The practice, which was at one time general, of allowing boys only to play football and cricket whether or not they were suited to these particular games, is no longer enforced to the same extent. Fives, tennis, boxing, athletics and cross-country running are being more widely introduced, and, although the major school games must be the dominating factor, there are nowadays alternatives for boys who show no aptitude or liking for football or cricket. The main essential is that all shall take some form of exercise with regularity, and to meet this a considerable extension of playing fields has proved necessary. During the period under review ten fields have been acquired and laid out, comprising 61½ acres, while negotiations are proceeding for the purchase of land for four other schools. During the current programme a field of five acres is being provided at Wormwood Scrubs to afford a much needed extension for four schools. Encouragement has been given to boys to play the excellent game of fives. New courts have been provided at three schools. The courts at two have been covered and artificially lighted; while the covering and lighting of the courts at two more are at present under consideration. Further, it is hoped that during the current three-year programme courts will be provided at two additional schools. The games played during school hours are liberally supplemented by class, house and school games which are played after work is over. The teachers give ungrudgingly of their time and energy, and the high quality of the results achieved bears witness to the enthusiasm with which this task is undertaken. There can be little doubt that the post-school population is more actively interested in health than was formerly the case. There are signs that the public is now more appreciative of the fact that inactivity leads to physical deterioration, and in this present highly competitive life no one can afford to deteriorate. London is already making a notable contribution to national fitness, largely through the medium of the evening institutes. The scope of the curriculum, which at one time was apt to be narrow, being confined almost entirely to gymnastics, free standing exercises and dancing, has been steadily widened and a man now has a choice of gymnastics, free standing exercises, boxing, swimming, wrestling, fencing and folk dancing. A woman has a choice of gymnastics, free standing exercises (keep fit work), dancing of various types, swimming or fencing. It is urged that this process of expansion be continued, and that in the near future field games, athletics and cross-country running be added to the curriculum. In the last report it was indicated that after the set back of 1931 a forward movement had again set in, and the number of classes then in existence was 628 for men and boys, and 776 for women and girls. It is most satisfactory to be able to report continued progress, and the latest figures available are as follows:— Total number Total student of classes hours Men and boys 958 515,175 Women and girls 1,209 502,239 Hand-in-hand with the growth of classes has gone a steady development in the quality of the work. It is noticeable that those institutes which expect and demand a high standard of work and behaviour achieve it; those who are content with the second rate in their turn receive it. It is quite clear that the majority of students expect and wish to work hard, and are not prepared to accept a lifeless and dull lesson which fails to extend them adequately. It is inevitable that evening institutes should in the main be housed in school buildings which were never designed with a view to the needs of the adult. The dictates of economic administration, moreover, make it most improbable that this position will alter fundamentally for many years to come. Yet, although change on a wholesale scale is impracticable, nevertheless, a progressive policy has been adopted and, whenever a suitable opportunity presents itself, steps are taken to improve facilities and make them more in keeping with adult requirements. Gymnasia and shower-baths are being provided or are under consideration at many institutes. The foregoing brief account of the physical activities of the evening institutes gives some indication of the part which London is playing in the development of national fitness. There is clearly the will to succeed in this difficult task, and the future is full of promise. Development of secondary school work Games Evening institutes 47 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 (one-third pint each) 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. The numbers of individual children on free "meals" in December in the years 1934 to 1938, inclusive, were as follows:— Table 25 Meal 1934 1935 1936 1937 1938 Dinners 5,725 5,245 5,596 6,251 7,228 Milk 15,691 20,300 24,120 28,800 32,224 Some 2,000-3,000 children received cod-liver oil and malt in school on the doctor's advice; many others obtained it in school on payment by the parents. In view of the changing attitude and beliefs in regard to the nutritional needs of children, and the recognition that the difficulties experienced are no longer those of total insufficiency of nutriment, but are due rather to specific defects in home dietaries, certain experiments are being carried out which are of great interest. Two of these experiments are those concerned with the substitution of halibut-liver oil for cod-liver oil and malt, and the substitution of an "Oslo" meal for the ordinary hot dinner. Difficulties have arisen in certain schools in the provision of cod-liver oil and malt when recommended by the school doctor. These have been due in part to the sticky or messy nature of the mixture. Consideration has therefore been given to the provision of a substitute which can be administered in capsule form. A thousand doses (each a desertspoonful) of cod-liver oil and malt cost 18s. 1d. The equivalent of halibut-liver oil (two capsules to a dose) would cost 18s. 4d. In the distribution of cod-liver oil and malt to about 11,000 children women helpers are employed for a total of about 1,150 hours a week, at an annual cost of about £2,371. There would thus be a saving of about £2,340 if this service could be dispensed with by the substitution of capsules for liquid oil and malt. An experimental trial of capsules has been sanctioned at five schools. Considerable attention has of late been directed to the method of giving school meals to necessitous school children and others in the schools of Norway and other northern countries. This method is generally referred to as " the Oslo breakfast." Not only has it spread far and wide in schools of Norway and neighbouring countries, but it has attracted the attention of dieticians in other countries and has been favourably commented on in the bulletin of the Health Organisation of the League of Nations ; and suggestions have been made that it should be introduced into London schools in substitution for the present provision of hot mid-day meals. Prior to the passing of the Education (Provision of Meals) Act, in 1906, there existed no powers to local education authorities under which money could be expended on the provision of food for hungry or ill-nourished children. Halibut-liver oil The "Oslo" experiment 48 Malnutrition existed among London school children to a much greater extent than now prevails, and the teachers of London, faced with the difficulties of endeavouring to educate children who were obviously suffering from lack of food, undertook extensively to give some nourishment to such children with the aid of voluntary funds. With the collection of these funds the name of Mrs. Burgwin must always be remembered, for she, with the late Mr. G. R. Sims, of the Referee newspaper, was largely associated with the collection and distribution of funds for the purpose. The meals given varied widely, but were restricted in scope and in nutritional value by the inadequacy of the funds contributed to cover the whole of the needs of the schools. Bread and soup given at mid-day were, in many instances, the form in which the supplemental needs were partially met; in other cases a breakfast of cocoa with bread and margarine had to suffice. After the enabling Act of 1906, the Council took over the responsibilities of feeding necessitous children in the schools, and the children's care organisation was set up to carry out the necessary local enquiries and the selection of children to be fed. The nature of the meals to be given was discussed, and it was decided that a substantial mid-day meal should be given on the lines sanctioned by English use and custom and consisting, generally, of two courses, one of meat and vegetables and the other of a substantial pudding. On the advice of the Council's medical officer, the standard adopted was that each meal should give 750 calories and contain at least 25 grammes of protein. At that time the discoveries in relation to vitamins had not been made, and it was considered that, whereas the children obtained at home sufficient, or even possibly an excess of carbo-hydrate food, the more expensive protein element necessary for growth was lacking in the home diets, and it was desirable that a meal rich in protein should, therefore, be provided. The desirability of including more food of a fresh nature was raised on medical grounds, but the arguments which could be used in the state of knowledge which existed at that time were not found to be sufficiently convincing. During the winter of 1910, the school doctor at Wolverley-street school, Bethnal Green, finding so many children in the school at that time suffering from malnutrition, suggested that they should be given milk in school. The head teachers and the care committee of the school took up the suggestion and milk was provided. The results were so excellent that the practice spread, first to neighbouring schools, and eventually to the whole of London, of giving milk to school children on the school doctor's advice. Since the introduction of the Milk Marketing Board's scheme in 1934, the custom of giving milk in school has widely spread beyond the limits formerly observed, and, in addition to the necessitous, a large proportion of children are obtaining milk in school on the payment by the parents of roughly half the economic cost. It should be mentioned that, before the introduction of the scheme of the Milk Marketing Board, many head teachers had organised milk clubs in the schools, through which the children were able to obtain milk on payment, if the parents so desired. Special attention has been paid to the milk question, since the necessity for adequate vitamin content in the food consumed has been at least partially met by this provision. In the case of necessitous children, in whom specific vitamin deficiency has been diagnosed by the school doctor, the provision of cod-liver oil and malt as a school " meal " has also been fairly widely made in London. Until comparatively recently, the same practice in dealing with necessitous school children, was followed in the Scandinavian countries as in London, i.e., the giving of a substantial hot meal in the middle of the day. Since attention has been drawn to the existence of vitamin deficiency, the authorities in these countries have been revising their ideas. Owing to the long period of the winter, there is a special difficulty experienced by the parents in northern countries in providing sufficient food of the protective kinds, e.g., fresh farm and dairy produce, raw salads and fruit. 49 It occurred, therefore, to some of the medical officers of these countries, led by the late Dr. Carl Schiotz of Oslo, to make a comparison between the effects of giving to school children a cold breakfast which consisted practically entirely of protective foods and the effects obtained by means of the usual hot mid-day meal. It is claimed that the results of the cold " protective " breakfast were greatly superior to those of the hot mid-day meal. A description of the Oslo breakfast, the extent to which it has spread, and the results of its substitution for hot dinners is best given in a letter from Dr. Carl Schiotz himself, which was transmitted through Professor Drummond of University College, London, who has studied the methods used abroad of dealing with the problem of feeding school children. This letter runs as follows : Now the Oslo breakfast is adopted at all public schools in Oslo, Bergen, Trondheim, Stavanger, Tromso, Harstad, Hamar, Sarpsborg, Horten, Porsgrunn, lately also in some rural schools in Norway (locally adopted), and, with local adoption, at some schools in Sweden, Finland and Copenhagen. The Oslo breakfast, as it is practised in Norway, is composed as follows: J litre unskimmed milk, a so-called Kneipp-cracker (baked preferably of whole-meal wheat) with margarine and goat's cheese, further so-called Kneipp-bread with margarine and goat's cheese, amount ad. lib. Finally, half-an-orange, half-an-apple or one raw carrot; as regards the vegetables, they are alternated according to the season. Further, it is to be noted that, if oranges are used, the meal begins therewith; if apples or carrots are used, the meal ends therewith (the cleaning of the teeth). The margarine is introduced only for economical reasons. It will now surely in several places be replaced by butter, as the Government has decided that public and municipal institutions can get butter at reduced prices. Experiments for comparing with other forms of breakfast have not been made, but, on the other hand, experiments have been made for comparison with the former school lunch. The results after 6 weeks' test were as follows :—The boys at the breakfast-school gained on an average of 886 g. per individual, at the lunch-school they gained 600 g. The girls at the breakfastschool gained on an average of 1,029 g., at the lunch-school 429 g. That is, with a very closely connected material (the two schools are socially and hygienically very equal) the weight-increase for the breakfast-boys equals that of the lunch-boys plus 48 per cent. ; for the girls, the increase of the breakfast-eaters exceeds that of the lunch-eaters by 140 per cent. There was no other difference introduced between the two schools than the composition of the meals. Particular attention is called to the high vitamin content of the Oslo breakfast as compared with the usual cooked midday meal. It is felt by many that the same considerations which have prevailed in the Scandinavian countries are applicable also in the great cities of this country, particularly in London. Conditions in London are not favourable to the introduction of breakfasts in place of midday dinners, but there is no great point in the time of the day at which the supplementary school meal is given, and it may be held that the Oslo meal would have the same effect if given at midday as if given first thing in the morning. Our people are very tenacious of their habits and customs, particularly those connected with food, and it might well prove that some prejudice would have to be overcome before all would agree to the substitution of a cold meal of protective articles of diet in the middle of the day for the usual solid hot meal of meat followed by pudding. A similar prejudice no doubt had to be met in Norway against the giving up of the hot midday meal, but, according to Professor Drummond, not only is the system applied to necessitous children in Norway, but the opportunity to receive the breakfast has been thrown open to all on payment; and, in 1935, 40 per cent, of the whole population of Oslo was taking advantage of it, and this proportion has since been rapidly rising. It is also, in London, difficult to secure such a close-cut comparison as in Norway between children fed on the Oslo system and those fed on the present system, owing to the practice which has developed here of distributing milk to children in the middle of the morning. The comparison is, therefore, not between Oslo meal and hot dinner but between Oslo meal plus milk and hot dinner plus milk. Nevertheless, it was considered that it would be advantageous to try a controlled experiment under which a relatively small but sufficient number of necessitous 50 children were fed for a time by the Oslo method and compared with a similar number of children, corresponding in other respects as closely as possible, who were being fed as is usual on hot dinners. It was agreed by the Council that an experiment on these lines should be made at the Trafalgar Square dining centre, Mile End, where 40 to 50 children are fed daily. It was decided that wholemeal bread should be substituted for Kneipp crackers and that New Zealand butter could, with advantage, be substituted for margarine. Goats' milk cheese was not considered essential and the substitution was adopted of a bland cheese of one of the lighter varieties, e.g., Caerphilly cheese. It was also decided that the meals should be called " health dinners." The experiment commenced at the above-named centre on 5th May, 1938. Weekly weighings and measurings were carried out, not only of the necessitous children receiving the modified Oslo diet, but also of an equal number of necessitous children receiving ordinary meals at a neighbouring centre. The experiment was supervised on the medical side by Dr. Bertha Sharpe. Apart from the difference in diet the children in the two groups were comparable, so far as could be ascertained, in all respects, including age, sex and social position. Particulars of the two groups are given in the following table:— Period, 9th May to 18th July, 1938 Height per cent. increase per child per week Weight per cent. increase per child per week " Health dinner" children " Control" children " Health dinner' children " Control" children Boys .159 per cent. (36—average age 9.7 years) .093 percent. (47—average age 9.9 years) .311 percent. .171 percent. Girls .155 per cent. (30—average age 9.7 years) .074 per cent. (33—average age 9.7 years) . 270 per cent. .193 per cent. Percentage increase of average " health dinner " child over " control" child, according to number of weeks fed Height Weight Boys 71.0 per cent. 81.9 per cent. Girls 109.5 39.9 Average no. of attendances per child "Health dinner" boys 33 "Control" boys 32 "Health dinner" girls 38 "Control" girls 34 It was inevitable that changes in the actual children attending should take place in both groups owing to withdrawals, removals, illnesses, etc. The statistical method used was, therefore, to take all the full weeks put in by children at both the "Oslo" centre and the ordinary centre, and to obtain from the figures the average percentage increase of height and of body-weight per week of children attending both centres irrespective of whether they remained throughout the period or not. It will be seen that the figures indicate a very significant improvement of those children on the Oslo diet compared with those on ordinary dinners; indeed they are very similar to the striking figures which were reported from Scandinavia before this experiment was started in London. The cost of the foodstuffs for the Oslo experiment during the above period was £65 2s. for 2,754 meals which approximately averages 5.7d. a meal. The Oslo foodstuffs had mostly to be bought in small quantities locally. On the other hand, the experiment during the period under review was carried on during a part of the year in which the food stuffs are cheaper than during the winter. It may be assumed, however, that, if the feeding on Oslo lines were done on a large scale, the cost would be reduced. Most of the children liked the meals, and observers were pleased to find that the children were enjoying the food and attending regularly. 51 As the Oslo diet was introduced to counteract the deficiency in vitamincontaining food from which town children generally suffer, especially during the winter in northern latitudes, it was considered of importance that the experiment should be continued throughout one year, particularly when such encouraging results had been obtained in the first three months, as it is during the winter that shortage of vitamin stuffs is chiefly experienced. The experiment is, therefore, being continued throughout the winter of 1938-9. One of the remarkable results is the striking improvement in the complexions of the children, and the disappearance of minor ailments, particularly of blepharitis. The effect on blepharitis of a somewhat similar diet at the Swanley hospital school supports the view that this disease is a manifestation of specific vitamin deficiency. Milk Marketing Board's scheme, voluntary milk clubs 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 two bottles a dav. Distribution of milk during the holidays 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. The result of the experiment was encouraging and it was decided to provide milk during the holidays for all children having milk on the recommendation of school doctors in term time, if the parents so desired. As on former occasions, all " doctors " cases receiving milk either free, for payment or for part payment, were given the opportunity of having milk. Children having two bottles of milk daily for part-payment in term-time were considered to be "free cases" for the purposes of this distribution, at which one bottle daily was given to each child attending. The distribution was arranged during the Christmas holidays at 162 centres, which included 159 schools in suitable positions, two central kitchens and one dining centre. The number of distribution centres was 160 during the summer holidays, 1938, and 135 at Easter, 1938. The following table shows the number of invitations issued and the total average attendance for all centres, compared with the distributions during the Easter and summer holidays, 1938:— No. of invitations issued Average attendance daily Percentage of average attendance to invitations Free cases— Easter holidays, 1938 40,339 20,831 51.6 Summer holidays, 1938 40,248 17,419 43.2 Christmas holidays, 1938-39 41,675 17,001 40.8 Full paying cases— Easter holidays, 1938 23,887 6,995 29.2 Summer holidays, 1938 22,816 7,382 32.3 Christmas holidays, 1938-39 21,385 5,668 26.5 The attendances, particularly at Christmastide, were considered to be disappointing, and efforts are to be made, by notices and talks to the parents by the school doctors on the importance of milk to growing children, to secure better attendances in forthcoming holidays. The experiment was, however, handicapped owing to the Christmas holiday weather being very severe, particularly on two of the days when there was much thawing snow. Defective children Examinations with a view to the admission of children to special schools were made in 4,425 cases. The following table shows the number of children nominated for examination and the recommendations made:— 52 Table 26 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 629 791 3 3 75 75 249 253 295 455 7 5 — — Deaf school Partially deaf school Boys Giris Boys Girls Aura] 158 144 34 1 23 26 20 97 101 1 — — — P.D. school Day open-air school Residential P.D and hospital school Physically defective Boys Girls Boys Girls Boys Girls 722 521 388 311 53 23 113 58 148 114 20 15 — — M.D. school Mentally defective Boys Girls 778 559 301 232 400 261 36 39 *41 *27 Epileptic colony Boys Girls Epileptic 58 65 18 19 25 28 15 18 — — Total 2,345 2,080 1,260 1,017 965 959 79 77 41 27 4,425 2.277 1,924 156 68 * Of these 30 boys and 17 girls were imbeciles; 2 boys and 2 girls were idiots ; and 9 boys and 8 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 27 Morbid conditions Boys Girls Total Infantile paralysis 26 21 47 Cerebral paralysis 17 10 27 Various paralyses 16 7 23 Tuberculosis of bones and joints 35 20 55 Osteomyelitis 48 15 63 Rickets and resulting deformities 7 3 10 Congenital deformities 15 11 26 Spinal deformities (including scoliosis) 5 5 10 Traumata and amputations 19 14 33 Non-tuberculous arthritis and synovitis 11 14 25 Rheumatism and chorea 13 20 33 Various chest conditions—fibrosis, bronchitis, asthma Heart diseases— 84 35 119 Congenital 21 16 37 Acquired valvular with history of rheumatism 121 138 259 without history of rheumatism 6 6 12 Non-valvular with history of rheumatism 4 6 10 without history of rheumatism 4 — 4 Anaemia 26 16 42 Pseudo-hypertrophic muscular dystrophy 6 — 6 Various nervous conditions, ataxia, etc. 5 4 9 *Other diseases—chiefly medical 12 8 20 Total 501 369 870 * Including 1 boy and 2 girls suffering from nephritis. 53 The following statement gives an analysis of the 297 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:— Children returned to elementary schools or invalided Table 28 Morbid conditions Elementary school ided Infantile paralysis 14 2 Cerebral paralysis 1 4 Various paralyses 5 2 Tuberculosis of bones and joints 10 1 Osteomyelitis 25 — Rickets and resulting deformities 5 — Congenital deformities 14 2 Spinal deformities (including scoliosis) 9 2 Traumata and amputations 8 — Non-tuberculous arthritis and synovitis 14 — Rheumatism and chorea 23 1 Various chest conditions—fibrosis, bronchitis, asthma 35 7 Heart diseases— Congenital 13 2 Acquired valvular— with history of rheumatism 32 4 without history of rheumatism 6 — Non-valvular— with history of rheumatism 2 — without history of rheumatism 6 — Anaemia 14 — Pseudo-hypertrophic muscular dystrophy — 1 Various nervous conditions, ataxia, etc. 1 — Other diseases—chiefly medical 25 7 Total 262 35 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 13,244, and in addition 766 special examinations were made of children already on the rolls of special schools in connection with applications for non-enforcement of attendance and for other reasons. As a result of the rota examinations the following re-classifications took place :— Rota visits to the schools Table 29 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 — 6 — — — — 3 — 1 Mentally defective 1 — 1 — — 1 — 1 9 Partially sighted 2 1 — 8 — — — — 2 Blind — — 1 — — — — — — Deaf — — — — — 1 — — — Partially deaf — — — — — — — — — Epileptic colony — 1 — — — — — — — After trial in a special school, 89 children were excluded (24 as imbecile, 34 as feeble-minded ineducable, 3 as "special circumstances," and 6 as feeble-minded " detrimental," and 22 invalided on medical grounds). 54 There were also 365 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 30 Action taken Special school classification P.D. M.D. Blind Partially sighted Deaf Partially deaf Total Returned, on improvement, to elementary schools 113 8 1 7 — — 129 Over 14 years of age and excluded as no longer certifiable 142 17 — 77 — — 236 Total 255 25 1 84 — — 365 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 :— Decertifica. tion of physically defective children Table 31 Morbid conditions Cases deemed no longer certifiable Cases deemed fit to return to elementary schools Infantile paralysis 5 6 Cerebral paralysis — — Various paralyses 3 — Tuberculosis of bones and joints 11 10 Osteomyelitis 17 8 Rickets and resulting deformities — 3 Congenital deformities 5 6 Spinal deformities (including scoliosis) — — Traumata and amputations 4 7 Non-tuberculous arthritis and synovitis 5 10 Rheumatism and chorea 26 22 Various chest conditions—fibrosis, bronchitis, asthma 4 — Heart diseases— Congenital 6 2 Acquired valvular with history of rheumatism 51 21 without history of rheumatism — 1 Non-valvular with history of rheumatism 2 5 without history of rheumatism — 1 Anaemia — 2 Various nervous conditions—ataxia, etc. — — Other diseases—chiefly medical 3 9 Total 142 113 Deaf children During the year Mr. Wells examined 302 children referred for special examination owing to defective hearing, and the decisions reached are set out on page 52. An analysis of the hearing 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 Ha 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 lib includes children who need educational training in a class for partially deaf children ; and grade III includes those children who can only benefit by education provided in a school for the deaf. 55 Acquired cases—Hearing defect due to:— Post-suppurative otitis media Grade I 35 „ IIa 17 „ IIb 20 „ III 7 — 79 Suppurative otitis media (unknown origin) „ I 12 „ IIa 7 „ IIb 6 „ III 2 — 27 Suppurative otitis media (due to infectious disease) „ I 2 „ IIa 3 „ IIb 10 „ III 1 — 16 Suppurative otitis media (due to other known causes) I 2 „ IIa 2 „ IIb 1 „ III 1 — 6 Middle ear catarrh (due to various causes) „ I 51 „ IIa 10 „ IIb 9 „ III 1 — 71 Suppurative otitis media of one ear and middle-ear catarrh of the other „ I 11 „ IIa 3 „ IIb 3 — 17 Wax „ I 1 Meningitis „ IIb 1 „ III 3 — 4 Nerve deafness due to infectious fevers „ I 1 „ IIa 1 „ IIb 11 „ III 10 — 23 Congenital syphilis „ III 1 Mixed deafness due to infectious disease „ IIb 1 Congenital cases. True hereditary deafness I 1 „ III 9 — 10 Sporadic deaf birth „ III 27 Uncertain origin „ IIb 3 „ III 10 — 13 Aphasia „ III 1 Found to be not defective as regards hearing, but M.D. „ 5 There are 392 children in schools for the deaf, and 135 in those for the partially deaf. During the year Mr. Wells made 676 examinations at these schools. 56 Schools for the blind A classification has been made by Dr. McVail of all children in the two Council schools for the blind in the winter of 1938. She has submitted the following report:— The total number of children concerned was 100, of whom 60 were boys and 40 were girls. Ages ranged from 6 to 16 years. For purposes of comparison, classification has been made under headings similar to those in my report of the spring of 1931, which was included in Vol. III, part II of the Annual Report for that year (p. 66), and which dealt with the 218 children then in the Council's schools for the blind. Defect Number and percentage Congenital and hereditary defects— Albinism 6 49 Nystagmus 8 Microphthalmia 7 Buphthalmia 2 Aniridia 6 Cataract 8 Dislocation of lenses 1 Coloboma 4 Retinitis pigmentosa 1 Others 6 Ophthalmia neonatorum 14 Interstitial keratitis 1 4 probably specific Choroido-retinitis 5 1 possibly specific Other choroiditis 2 1 probably congenital defect 1 cause unknown 2 probably specific 2 hydrocephalus Optic atrophy 9 4 associated with general diseases 1 cause unknown Superficial keratitis 3 Macular disease 1 Myopia 5 Traumatism 4 3 optic atrophy 1 sympathetic Glioma 1 1 irido cyclitis occurred shortly after birth Others 6 (Wasserman negative) 2 associated with measles 1 associated with diphtheria 1 associated with meningitis 1 associated with leontiasis ossium Total 100 Under the heading of congenital and hereditary defects there are 49 cases in the total of 100 blind. To these might be added two or three children in other groups who were almost certainly born with defect. This compares with 38.99 per cent, in the 1931 group of 218 children, and 24.04 per cent, in an analysis of 1,855 blind children of school age given by Mr. Bishop Harman in the report of 1922 of the Departmental Committee on the Causes and Prevention of Blindness. The percentage increase from 1922 to 1931 and from 1931 to 1938, is, of course, relative, and is largely due to a substantial fall in the incidence of blindness due to venereal disease in its several forms. The actual number of children blind from congenital defect has fallen from 85 in 1931 to 49 in 1938. The percentage of cases of ophthalmia neonatorum is 14 compared with 21.1 in 1931 and 19.75 in Mr. Harman's group examined before 1922. The actual number of children in Council schools blind from this disease is 14 in 1938, compared with 45 in 1931, a striking fall. 57 The following is an analysis of the 14 cases of ophthalmia neonatorum in the two schools for the blind in 1938, with reference to their year of birth, together with the corresponding particulars contained in the annual report for 1931:— Year of birth No. of children Year of birth No. of children 1923 4 1915 6 1924 1 1916 5 1925 2 1917 5 1926 2 1918 4 1927 1 1919 6 1928 1 1920 5 1929 1 1921 6* 1930 1 1922 3 1931 0 1923 2 1932 1 1924 1 1925 2* Total 14 Total 45 * Including one doubtful case. Both lists include two children whose history was not obtainable but whose eyes showed evidence of effects of the disease. Grouping cases of interstitial keratitis, optic atrophy and choroiditis, conditions which may be associated with venereal disease, Mr. Harman's percentage in children examined before 1922 is 40.32, compared with 25.69 in the Council's schools in 1931, and 17 in 1938. Of the 17 in 1938, at least 7 have been ascribed to other causes. In that year only one child was blind from interstitial keratitis compared with 13 in 1931. Traumatism is a preventable cause of blindness in which there has been no decrease. In 1931, the number blind from that cause was 3, and in 1938 it was 4. Three of the four were blind from optic atrophy, two from head injuries in street accidents and the third by a fall from a window. One only was blind from traumatism followed by sympathetic ophthalmia. The accident in this case did not occur in London, nor was the child treated in London. It should be noted that most of the figures given relate to children in the Council's schools for the blind, numbers in which vary from month to month. The total number of London children of school age in schools for the blind, whether under the Council or other authorities, as given in official tables, was 216 in December, 1931, and 113 in December, 1938. The total number of children in the Council's elementary schools was 610,101 in 1931 and 469,978 in 1938. In 1931 the ratio of blind children to the elementary school population was thus 3.54 per 10,000 and in 1938 it was 2.40 per 10,000, a fall of approximately a third in the seven years. Mental Deficiency Acts : cases notified to the local authority 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 1938 (the figures in brackets being those for the previous year):— (a) Feeble-minded— Boys Girls (1) Leavers 245 (269) 196 (210) (2) Detrimental 2 (1) — (4) (3) Special circumstances 3 (1) 1 (3) (4) Ineducable 23 (27) 19 (23) (6) Imbeciles 48 (51) 27 (49) (c) Idiots 3 (5) 3 (4) (d) In addition to being mentally defective, were blind or deaf 1 (2) 1 (-) 325 (356) 247 (293) Total 572 (649) After-careers The chief officer of the mental hospitals department has furnished the following return for the year 1938 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 :— 58 Table 32 Classification Male Female Total Grand total under headings (1) Number not exceeding 18 years of age who have loft special schools and who were on the books of the supervision section on 31st December, 1938 524 394 918 918 (2) Number who after trial have proved themselves to be incapable by reason of mental or physical defect of undertaking remunerative employment 26 27 53 53 (3) Number employed as under:— (a) Industrial or manual occupations (i.e., factory work, trade or any part of a trade) 338 289 627 (6) Agricultural or rural occupations 2 — 2 (c) Domestic occupations— M. F. Total (1) Receiving remuneration 5 22 27 (2) Required for work at home 2 19 21 7 41 48 (d) Commercial, shop assistant, or selling behind a counter, office boys or girls 8 — 8 (e) Gone into army, navy or merchant service 1 — 1 (/) Blind alley or other precarious occupations (i.e., vanboys, newsboys, errand boys and girls, selling from a barrow) 83 4 87 773 (4) (a) Number judged to be employable but out of work 34 22 56 (b) Attending polytechnic for further training — 1 1 57 (5) Number whose careers have not been traced:— (a) Not visited and not seen at bureaux 11 3 14 (b) Visited but no information obtainable 14 7 21 35 (6) Cases dealt with in addition to above including those who have since:— (a) died — — — (b) attained the age of 18 years 341 243 584 (c) been dealt with under M.D. Acts 17 7 24 (d) been lost sight of, or have left London 22 18 40 648 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. During the year 2,188 children and young persona were admitted, of whom 1,732 were male and 456 were female. There was a decrease of 143 in the admission rate compared with 1937. The variation in admission rate is shown below:— 1930 1935 1936 1937 1938 Admissions from all areas 785 2,420 2,608 2,331 2,188 „ „ London area 695 1,436 1,881 1,985 1,908 „ „ out-county areas 90 984 727 346 280 The general observations made on the figures for the previous year apply equally to the subjoined records. 59 The various physical and mental illnesses treated are set out below:— Condition No of cases Condition No. of cases Scarlet fever 25 Bronchitis 5 Diphtheria 2 Disease of ear 76 Chickenpox 1 Dental affections 65 Vaginal discharge (97 plus 7 recurrences) 104 Affections of alimentary system 47 Disease of the heart 19 Congenital syphilis 2 Boils, cellulitis and whitlows 121 Gonorrhoea in male 3 Adenitis 16 Rheumatism 11 Debility and anaemia 77 Tubercular mediastinitis 1 Accidents 184 Pediculosis pubis 15 Injuries present on admission 63 Ringworm 2 Pregnancy 2 Scabies 40 Various minor ailments 20 Impetigo 20 — 1,435 Other skin affections 182 Hunger strike 1 Conjunctivitis 3 Hysteral 6 Other eye affections 34 Mania 1 Influenza 13 Schizophrenia 1 Coryza 35 Epilepsy 1 10 Tonsillitis 176 — Quinsy 1 Pharyngitis 69 Total 1,445 Laryngitis 1 With but few exceptions, every case was submitted to a detailed physical examination, and the general findings were similar to those of previous years and do not call for further comment. There was a large increase in the number of cases of vaginal discharge, but a marked decline in the incidence, real and relative, of gonorrhoea. In 104 cases of vaginal discharge, of which 7 were recurrences, there were 21 cases of gonorrhoea. In 1937 there were 65 cases of vaginal discharge, of which 27 proved to be gonorrhceal. As in former years, the great majority of cases other than those awaiting hearing at Court were mentally tested. In those cases in which there was no request for a psychiatric report, and where the opinion expressed by the headmaster of the school attended by the child or young person was that the mental ability was normal, this was quoted in the routine medical report. In the remainder, the general intelligence and mental endowment were estimated by applying standardised mental tests. Aetiological diagnosis and classification were made only in a minority of these cases. Detailed psychiatric examination was confined largely to those cases in which the magistrate requested that full medical and psychological examinations should be made. Such investigations and reports form the main body of the work under review. During the year 579 special reports were furnished, compared with 487 in the preceding year. It was found that the longer the time spent on an individual case the more accurate and precise was the diagnosis. Any attempt to shorten the psychiatric interview is found in general to defeat its own purpose. The economic gain which results from the increased accuracy of diagnosis and remedial measures indicated is very considerable. In my last report I gave some account of the psychological classification employed. In the examination of an individual case certain principles are followed. Any behaviour can be regarded only as a final resultant of various component factors (i.e., it is a reaction of the total personality to the environment). It is always the outcome of interaction between a psychobiological unit and its milieu. This is always a dynamic relationship. Individuals differ from one another quantitatively and qualitatively in their psycho-physical endowment. In the analysis of an individual case the physical and mental state of health is considered both from objective and subjective aspects. In either or both senses the physical state may be an asset or a handicap to which an individual may react in a variety of ways. The particular nature of the temperament and disposition has to be evaluated. The intellectual endowment, general and specific, is measured. The strength and direction of the instinctual drives require careful elucidation. The moral character of the individual can be understood only by a direct study of his social and other attitudes revealed in the history and during the examination. To appreciate accurately the significance of age and the degree of maturity it is necessary to have a systematic knowledge of the mental, bodily and social behaviour, attitudes and interests of normal children at each age level. In order to understand the personality of an individual, these components and their subtle inter-relationships must be recognised and assessed. If they are moulded together in a harmonious pattern orientated towards the general social environment the personality is a healthy one. Where there is disharmony, undercurrents of tension lead to dissatisfaction and frustration which may result in delinquency. That environmental conditions alone cannot account for delinquency is shown clearly bv the great frequency of non-delinquent siblings living under the same conditions as a delinquent. Healy and Bronner find that it is the less tangible and the less obvious emotional factors which are the most important in delinquency, and my experience in general serves to confirm this. 60 The following is a record of admissions during 1938 and the two preceding years:— 1938 1937 1936 City of London 12 32 21 Hampstead 16 21 10 Islington 306 342 341 Lambeth 253 325 295 South wark 291 325 255 Caxton Hall 179 157 169 Stamford House 287 303 308 Toynbee Hall 278 307 334 Buckinghamshire and Berkshire — — 2 East Ham 25 28 30 Essex 38 32 122 Hertfordshire 17 30 30 Kent 55 45 50 Middlesex 77 64 271 Southend 1 7 17 Surrey 16 26 57 West Ham 49 62 78 Woolwich 47 * * Adult Courts 121 132 117 Education Act 17 41 31 Place of safety lodgers 103 52 70 Total 2,188 2,331 2,608 * No court at Woolwich. Subjoined is a record of the charges. In many cases this grouping is misleading, in that so frequently the delinquency is found to be multiple in type. The increase in the frequency of breach of recognizances may appear to imply a failure in the probation system; but equally it may imply increased vigilance and zeal on the part of the probationer officers. 1938 1937 1936 Stealing 912 1,106 1,181 Breaking, entering and stealing 138 116 162 Breaking and entering 100 117 170 Burglary 4 2 13 Carrying firearms without licence — 4 — Embezzlement 20 23 28 Forgery 4 6 7 Demanding money with menaces 1 2 1 False pretences 2 7 6 Travelling without ticket 8 9 11 Suspected person 37 54 102 Trespassing — — 1 Begging 5 2 2 Insulting conduct 7 9 6 Wilful damage 11 7 16 Assault 7 6 6 Malicious wounding 4 6 7 Sex offences 20 26 30 Absconding 7 7 7 Breach of recognizance 153 119 77 Beyond control 195 212 270 Education Act 17 44 31 Place of safety lodgers 103 52 70 Motor offences 82 68 80 Murder 1 1 1 Manslaughter 2 — — Care or protection 340 311 309 Deserting from Army 4 1 — Arson 2 2 — Sacrilege 1 1 1 Drunk and incapable 1 4 - Other offences — 7 13 Total 2,188 2,331 2,608 61 It is a pleasure to acknowledge the unremitting assistance and help of Mr. M. S. T. Jones and also of Mr. A. M. Murray, who has prepared the records set out above. Child Guidance The Council has continued to co-operate with certain organisations responsible for child guidance clinics in various districts of London, by placing at their disposal information regarding school children through the education and school medical services. For the past two years a special grant in aid, of £400 a year, has been paid by the Council for the treatment of school children at the London child guidance clinic, while in the year 1938 small grants have been paid to the Creighton House clinic, East London clinic, Institute of Child Psychology, and the Tavistock clinic. Information with regard to the work has been received from the clinics concerned, and is set out below. Maudsley hospital child guidance clinic. The child guidance clinic attached to the Maudsley mental hospital has continued under the direction of Dr. Mapother, the medical superintendent. Up to the beginning of December work continued in the children's department on the same lines as previously, the clinic being a sub-division of the out-patients' department pending the building of new premises. This new building consists of an independent out-patients' department for children with a separate entrance some distance from the main entrance to the hospital, and a complete hospital unit of 30 beds, together with playgrounds, schoolroom, and research facilities. The out-patients' department was opened early in December, 1938, but the in-patients' section is not yet complete. An additional medical officer has been appointed to the staff and the time given by the physicians to the children's department has been nearly doubled. The department is open daily through the week and all cases are now seen by appointment. Owing to the large number of neurological cases attending for psychiatric reasons, a neuro-psychiatric clinic has been opened on one afternoon a week. Arrangements are being made to take advantage of the new playroom accommodation by expanding the present programme of play activities, and sessions for group play therapy and play observations and remedial teaching by play have been arranged. The increase of staff, iogether with increased voluntary assistance, has enabled greater attention to be given to intensive individual therapy. Much of the work, however, is still of a consultant nature, the number of cases suitable for individual therapy forming a rather small proportion of those attending. Cases treated by adjustment of school and social conditions, placement, etc., still form the bulk of the children kept on after the initial investigation. The number of new cases from London schools was 397, of whom 231 were boys and 166 girls. The age distribution was: under 5 years, 35; 5 to 8 years, 119; 9 to 11 years, 99; 12 to 14 years, 103; over 14 years, 41. The reasons for reference were: difficult and unmanageable, 59; backwardness, 50; nervousness, 40; enuresis and incontinence, 34; intelligence tests, 29; stealing and lying, 25; fits, 22; nervous movements, 23; sex difficulties, 14; temper tantrums, 13; truancy, 12; speech difficulties, 10; night terrors and fears, 10; other reasons, 56. The results obtained were: satisfactorily adjusted, 18; partially adjusted, 33; unadjusted, 27; unsuitable, 65; transferred, 4; consultations and psychological examinations only, 49; still under treatment. 201. The work at the London child guidance clinic is under the direction of Dr. William Moodie, who reports that the number of cases dealt with continues to increase, although no additional staffhas been appointed, while the work and methods used have evolved to a maximum of efficiency and economy. London child guidance clinic The methods employed have not varied greatly from those employed in past years, though increasing experience permits of improvements in technique. The results of treatment, so far as cases can be followed up, appear to remain satisfactory. The clinic will have been open ten years in July, 1939, and it is proposed, as soon as staffing permits, to institute a wider system of following-up of all children treated over a period of years. The increased co-operation with school care committees is evidenced by the greater number of children referred through them. The clinic staff express gratitude to the staff of the Council for the help and co-operation received. The average period of treatment is just over six months. Hence, relatively few of the cases accepted during the year would be completed by the end of the year. Teaching activities continue. Three Fellows in Psychiatry and 23 mental health course students from the London School of Economics undertook courses of training in practical work. The number of new cases from the London schools was 203, of whom 136 were boys and 67 girls. The age distribution was : under 5 years, 11 ; 5 to 8 years, 74; 9 to 11 years, 63; 12 to 14 years, 42; over 14 years, 13. The reasons for reference were: stealing, 32; behaviour difficulties, 24; nervousness, 22; intelligence tests, 21; enuresis, 19; backwardness, 15; unmanageable, 15; speech difficulties, 12; sex difficulties, 10; truancy, 8; night terrors and fears, 5; temper tantrums, 5; fits, 1; other reasons, 14. The results of treatment were: adjusted, 4; improved, 12 ; not improved, 11; unsuitable or not co-operative, 4; special service or placement, 9; consultations only, 54; still under treatment, 107; moved away and treatment incomDlete. 2. East London child guidance clinic The work in connection with the East London child guidance clinic has continued under the direction of Dr. Emanuel Miller. During the year the centre was transferred from the Jews' Free school to premises at 19, Rampart Street, Commercial Road, E.l, where there are a special play room in which all free activities associated with play can be carried out without hindrance, and a suite of rooms for treatment and investigation admirably suited for the team method 62 which is the foundation of the work. The director expresses gratitude to the various care committees, school medical officers and teachers for their co-operation. The number of new cases from London schools was 125, of whom 81 were boys and 44 girls. The age distribution was : under 5 years, 10 ; 5 to 8 years, 54 ; 9 to 11 years, 36 ; 12 to 14 years, 19 ; over 14 years, 0. The reasons for reference were : behaviour difficulties, 15 ; nervousness, 20 ; backwardness, 12 ; stealing, 13 ; enuresis, 19 ; night terrors and fears, 5 ; speech difficulties, 10 ; temper tantrums, 4 ; truancy, 5 ; sex difficulties, 2 ; unmanageable, 16 ; other reasons, 4. The results obtained were: satisfactorily adjusted, 13; improved, 11; not improved, 2; unsuitable or not cooperative, 38 ; placement, 6 ; consultations onlv, 14 ; transferred, 1 ; still under treatment, 40. The child guidance clinic at Guy s hospital, attached to the .Department of Psychological Medicine, has continued under the direction of Dr. R. D. Gillespie. The number of new cases dealt with from London schools was 246, of whom 163 were boys and 83 girls. The age distribution was : under 5 years, 11 ; 5 to 8 years, 89 ; 9 to 11 years, 80 ; 12 to 14 years, 58 ; over 14 years, 8. The reasons for reference were ; nervousness, 48 ; backwardness, 39 ; enuresis, 25 ; stealing, 24 ; unmanageable, 24 ; behaviour difficulties, 16 ; night terrors, 14 ; sex difficulties, 12 ; speech defects, 10 ; temper tantrums, 9 ; truancy, 8 ; movements, 7 ; fits, 6 ; intelligence tests, 4. The results obtained were : adjusted, 32 ; improved, 31 ; not improved, 8 ; unsuitable or not co-operative, 16 ; failed to attend, 28 ; placement, 5 ; consultations only and special tests, 58 ; transferred, 1 ; still under treatment, 67. Guy's hospital child guidance clinic Institute of Child Psychology The work at the Institute of Child Psychology is under the direction of Dr. Margaret Lowenfeld. The number of new cases dealt with from London schools was 99, of whom 62 were boys and 37 girls. The age distribution was : under 5 years, 8 ; 5 to 8 years, 31 ; 9 to 11 years, 29 , 12 to 14 years, 21 ; over 14 years, 10. The reasons for reference were : behaviour difficulties, 19 ; nervousness, 22 ; backwardness, 14 ; stealing, 9 ; enuresis, 3 ; night terrors and fears, 4 ; speech difficulties, 5 ; temper tantrums, 3 ; truancy, 1 ; sex difficulties, 6 ; unmanageable, 10 ; fits, 1 ; other reasons, 2. The results obtained were : adjusted, 13 ; improved, 9 ; not improved, 3 ; unsuitable or not co-operative, 26 ; consultations only, 14 ; transferred, 3 ; still under treatment, 31. North Western child guidance clinic The work at the North Western child guidance clinic has continued under the direction of Dr. W. Paterson Brown. The number of new cases from London schools was 25, of whom 18 were boys and 7 girls. The age distribution was: under 5 years, 5 ; 5 to 8 years, 6 ; 9 to 11 years, 8 ; 12 to 14 years, 5; over 14 years, 1. The reasons for reference were: stealing, 5 ; enuresis, 3 ; unmanageable, 3 ; behaviour difficulties, 2 ; nervousness, 2 ; backwardness, 2 ; night terrors and fears, 2 ; temper tantrums, 2 ; sex difficulties, 1 ; fits, 1 ; intelligence tests, 1 ; other reasons, 1. The results obtained were : adjusted, 4 ; improved, 3 ; unsuitable or not cooperative, 1 ; placement, 1 ; consultations only, 3 ; transferred, 1 ; still under treatment, 12. Tavistock clinic Ihe work at the lavistock clinic (Institute of Medical Psychology) has continued under the direction of Dr. J. R. Rees, and the number of new cases from London schools was 77, of whom 45 were boys and 32 girls. The age distribution was: under 5 years, 1 ; 5 to 8 years, 29 ; 9 to 11 years, 27 ; 12 to 14 years, 16 ; and over 14 years, 4. The reasons for reference were : backwardness, 16 ; stealing, 12 ; night terrors and fears, 12 ; behaviour difficulties, 9 ; nervousness, 6 ; temper tantrums, 6 ; sex difficulties, 4 ; speech difficulties, 3 ; truancy, 3 ; fits, 2 ; enuresis. 2 ; other reasons, 2. The results obtained were : adjusted, 2 ; improved, 9 ; not improved, 1 ; unsuitable or not co-operative, 12 ; placement, 2 ; consultations only, 17 ; transferred, 2 ; still under treatment. 32. West End hospital for nervous diseases Treatment has continued at the West End hospital for nervous diseases under the direction of Dr. Emanuel Miller. The number of new cases from London schools was 75, of whom 41 were boys and 34 girls. The reasons for reference were : behaviour difficulties, 18 , night terrors and fears, 9 ; backwardness, 8 ; enuresis and incontinence, 8 ; nervousness, 7 ; stealing, 7 ; speech difficulties, 6 ; temper tantrums, 3 ; intelligence tests, 3 ; migraine, 2 ; other reasons, 4. The results obtained were : adjusted, 3 ; improved, 5 ; unsuitable or not co-operative, 6 ; placement, 2 ; consultations onlv, 24 ; still under treatment, 35. Summary During the year, 1,247 London school children, of whom 777 were boys and 470 girls, were dealt with at the above-mentioned clinics. The following statement gives details of the cases:— Source of reference Hospitals 209 Care committees or district organisers 294 School doctors 192 Parents and friends 122 Head teachers 154 Private doctors 99 Probation officers 61 Other agencies 116 Total 1,247 Reasons for reference Behaviour difficulties 230 Nervousness 190 Backwardness 156 Stealing 127 Enuresis, etc. 113 Night terrors and fears 61 Intelligence tests 58 Speech difficulties 56 Temper tantrums 45 Truancy 37 Sex difficulties 49 Fits 35 Other reasons 90 Total 1,247 63 Results obtained Adjusted 89 Improved 113 Not improved 52 Unsuitable or not co-operative 198 Placement 25 Consultations only 233 Transferred 12 Still under treatment 525 Total 1,247 Nursery schools and nursery classes The nursery schools provided and aided by the Council now number twenty-two. Nursery The medical oversight of the schools is carried out by Dr. E. M. McVail. schools The nursery schools at the end of the year, 1938, were:— Provided by the 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 Council 1. Balham, Endlesham-road, S.W.12 40 2. Buck Street, Kentish Town, N.W.1 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-street, W.C.I 60 *16. Sherborne, Litcham-street, N.W.5 40 *17. Somers Town, Crowndale-road, N.W.I 40 18. U.G.S. settlement, Peckham, S.E.15 40 19. Women's university settlement, Blackfriars-road, S.E.I 35 Total 894 One of the Council's medical officers is responsible for the medical work at 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. In addition to the schools named above, two nursery schools provided by the Council under the three-year programme, 1935-38, have been erected in Kintore Way, Bermondsey, and at Honor Oak, and these will be opened in the early months of 1939. The three-year programme, 1938-41, contains proposals for 4 new nursery schools for children aged 2 to 5 years, and one school for children aged 2 to 7 years. One school is to be provided in 1938-39, two in 1939-40 and two, including the school for children aged 2 to 7 vears, in 1940-41. Nursery classes The three-year programme 1935-38 provided for the establishment of experimental " nursery classes " in connection with infants' departments. 64 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 and in 1938 two classes have also been formed at Creek Road school, Deptford. 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 is also available for the children. The babies are attended to by the school nurse daily, and all are medically examined once a term. In my report for 1937 full accounts were given of the organisation of nursery schools and nursery classes, and of the effects of the methods upon the health and physique of the infants attending. A visit to one of these schools or classes is always enheartening, and the work done in them is worthy of all praise. Medical inspection at secondary and junior technical schools, training colleges, etc. The arrangements have been as set out in the report for 1937. Excluding students in training colleges, 15,250 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 3,394 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 the case of one pupil only, a girl, was the clothing found to be poor, but in 15 cases (1 boy and 14 girls) infestation with vermin was noted. Dental condition The percentage of children, aged 12, with sound teeth was : boys, 86.5 ; girls, 81.6; but at the age of 15 this percentage had decreased to 82.2 per cent, among boys and to 79.8 per cent, among girls. Of cases of widespread dental decay where 4 or more teeth were affected, the percentage among boys and girls of 12 years old was 1.5 and 1.2, respectively, compared with 1.1 in both boys and girls leaving elementary schools. Vision At the age of 12, 81.5 per cent, of the boys and 76.4 per cent, of the girls were able to pass the vision test with glasses, if any, compared with 71.4 and 68.9 in elementary school leavers. In secondary schools, 17.4 per cent, of both boys and girls were wearing glasses at the age of 12, but at the age of 15 the percentages were 19.2 boys and 21.4 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., 76.2 per cent, among boys and 73.4 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 em phasised by the figures for more serious defect (6-12 or worse) which rises between 12 and 15 from 8.5 to 13.6 per cent, in secondary school boys, and from 11.7 to 13 • 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, 4.9 per cent, being returned as subnormal in secondary schools, as against 4.5 in elementary school leavers. Defects During the year, 3,575 pupils (23.3 per cent.) were referred for treatment for various defects. Heart defect was noted in 1.9 per cent, boys and 2.8 per cent, girls ; defects of nose and throat in 1.1 per cent, boys and 4.8 per cent, girls; ear disease in .5 per cent, boys and .4 per cent, girls; anaemia and debility in 1.2 per cent, boys and 1.9 per cent, girls. 65 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 1.4 percent, of boys at 12 and 1.6 per cent, at 15, but in girls the amount recorded of this defect was much greater, viz., 8.8 per cent, at 12 and 8.9 at 15. Attention must be called again to the increase between ages 12 and 15 in institutions of higher education, of defect of vision and dental caries. Re- inspection The re-inspection of 4,167 pupils in higher education institutions was carried out; 1,889 defects had been satisfactorily treated, 586 were under treatment, 999 had had treatment but needed further treatment, and in 659 cases no treatment had been obtained. Training colleges Of the 866 students examined in training colleges, 3 were found to be suffering from extensive dental caries; 86.5 per cent of the men and 79.0 of the women passed the vision test, but 27.2 per cent, of the men and 37.8 per cent, of the women were wearing glasses. While none of the men was classified as below normal in nutrition, no less than 8.5 per cent, of the women were placed in the subnormal class. Hospital schools The following is a list of the hospital schools with their classification and nominal school accommodation:— Table 33 Hospital school Classification Nominal accommodation Number of children In hospital 31-12-38* On school roll at end of winter term* Downs, Sutton Mastoiditis, otitis media, rheumatism and convalescence 360 342 230 Goldie Leigh, Abbey Wood Skin diseases and convalescence 248 144 108 Heatherwood, Ascot Surgical tuberculosis 244 224 211 High Wood, Brentwood Pulmonary tuberculosis, rheumati m 482 393 345 Millfield, Littlehampton Convalescent tuberculosis and other convalescents 98 88 87 Northern, Winchmore Hill Post-encephalitis lethargica 38 12 12 Norwood children's Severe crippling, rheumatism 210 133 31 Queen Mary's, Carshalton Rheumatism, tuberculosis (nonpulmonary), poliomyelitis, osteomyelitis and congenital malformations 1,284 994 658 St. Anne's home, Heme Bay Convalescence 127 86 96 St. Faith's, Brentwood Epilepsy 30 20 23 White Oak, Swanley Trachoma, interstitial keratitis, and other acute eye diseases 364 219 168 * The above dates are not identical. Of the 2,655 children who were in-patients at the hospital schools at the end of the year, 630 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 Dr. E. M. McYail on the causation of blindness (p. 56); by Dr. C. E. Thornton on rheumatism (p. 28); and by Dr. Elizabeth Gourlay on nutrition (p. 18). The following report has been prepared under the direction of Dr. Thomas on the incidence of plantar warts:— Plantar warts During the past five or six years there have been many enquiries and complaints in connection with the occurrence of plantar warts in school children. These complaints are by no means confined to elementary schools but have been numerous also in secondary schools. 66 The impression was formed that the incidence of plantar warts was greater in girls' schools than in boys' schools, and that in infants' departments it was almost negligible. Such an incidence, if confirmed, would lend support to the suggestion that the trouble is associated with a change in custom, whereby the older children now frequently remove shoes and stockings in connection with physical exercises, bathing and swimming, and frequently walk on moist surfaces in their bare feet, for there is no doubt that the warts are contagious. In order to obtain more accurate knowledge of the extent and distribution of this painful and troublesome condition, the school doctors were asked to make a survey of the schools they visited during a period of the summer term in 1938. The enquiry covered schools containing 231,650 children equally distributed throughout the county. Table 34—Incidence of plantar warts Division Number of children examined Number of children suffering from plantar warts Boys Girls Mixed Boys Girls Mixed North-West 11,947 11,959 14,707 3 28 1 North 14,098 14,019 19,152 21 68 5 North-East 13,736 15,896 18,380 12 48 5 South-East 12,637 12,547 18,136 13 49 4 South-West 18,483 16,076 19,877 11 49 1 Total 70,901 70,497 90,252 60 242 16 In order to discover the differential sex incidence, the schools were divided in the above table into boys' departments, girls' departments and mixed departments (which contained also the infants' departments). Of the 231,650 children brought into the enquiry, 318 were found to be suffering from, or recently to have been treated for, plantar warts, that is an incidence of 1.37 per thousand. Among the 70,901 children in boys' departments, 60 were found suffering, or .8 per thousand. Among the 70,497 children in girls' departments, 242 children were found with plantar warts, an incidence of 3.4 per thousand. This establishes the incidence on girls compared with boys in the ratio of about 4 to 1. In mixed departments containing 90,252 children, only 16 children were found with plantar warts, an incidence of nearly .02 per thousand. As mixed departments are predominantly infants' departments, this result indicated that the incidence in older boys and girls is very much greater than among infants under seven. To get the figures for infants more accurately, the numbers for infants' departments were taken out separately, with the following results:— Number examined Number suffering from plantar warts North-West 10,569 1 North 15,053 3 North-East 14,710 1 South-East 12,635 3 South-West 16,690 1 Total 69,657 9 Among 69,657 children in infants' departments nine were found with plantar warts, an incidence of just over .1 per thousand. Older girls therefore suffer from plantar warts 34 times as often as infants, and older boys 8 times as often. The local character of the complaints that had been received gave the impression that the trouble was not uniformly distributed over the county. The tables therefore were calculated as above for each of the five school medical divisions, with the result that a higher incidence was shown in the east and north of London than in the south and west. The incidence in the five divisions was north-west .8 per thousand, north 1.9 per thousand, north-east 1.3 per thousand south-east 1.5 per thousand, and south-west 1.1 per thousand. In connection with the enquiry, five secondary girls' schools were visited containing 1,669 pupils, among whom 23 had plantar warts. This is a much higher incidence (13.7 per thousand) than was found in the more comprehensive survey of the elementary schools detailed above, but these secondary schools were picked out for investigation on account of the special incidence which had been reported in them. 67 Wage-earning employment of school children In the year 1938, 3,941 applications (3,908 boys and 33 girls) were dealt with under the by-laws for medical certificates in connection with the employment of school children out of school hours. Unconditional certificates were issued in 3,567 instances, which included 30 girls. Conditional certificates were issued in 270 cases, one being a girl. Certificates were withheld in 104 instances, two being girls. In 57 of these the reasons for refusal were non-medical. Medical grounds for refusal The conditions which led to refusal in the other 47 cases were:— Boys Girls Total Rheumatism 9 — 9 Teeth 4 — 4 Vision and eyes 2 1 3 Heart 5 — 5 Anaemia and malnutrition 2 — 2 T.B. glands 1 — 1 Otorrhœa 3 — 3 Personal hygiene 2 — 2 Fatigue signs 2 — 2 General condition 15 — 15 Flat feet 1 — 1 Total 46 1 47 Employment of children in entertainments Two hundred and ninety-five children were medically examined at the County Hall in connection with employment under licence in entertainments, comprising 252 girls and 43 boys. Of these, 131 were referred for treatment, including: refraction error, 17; dental decay, 76; throat affections, 1; skin disease, 11; personal hygiene, 14; discharging ears, 1; anaemia, rheumatism or heart trouble, 5; scoliosis, 2; minor ailments, 4. Six were refused certificates on account of the presence of the following conditions : heart disease, 2; high myopia, 2; osteomyelitis, 1; enuresis, 1. Three hundred and fifty-nine re-examinations were made. Examination of candidates for the education service and scholars The total number of examinations in 1938 was 12,765, compared with 12,044 in 1937 and 12,252 in 1936. During 1938, 10,022 entrants to the education service, and candidates for teaching awards, scholarships, and local special places, presented themselves for examination : of these. 61 had been referred from 1937. The follow table indicates the numbers of candidates and the results of the examinations:— Table 35 Category Number examined Number fit Number rejected Number who withdrew after being referred for remediable defects or were not due for reexamination until 1939 Male Female Male Female Male Female Male Female Education service 297 293 267 288 13 5 17 — Royal Air Force candidates 14 11 3 — — — Teaching awards 113 428 113 406 — 8 — 14 Scholarships 4,542 4,335 4,353 4,160 50 10 139 165 4,966 5,056 4,744 4,854 66 23 156 179 Total 10,022 9,598 † 89 335 † The main causes of rejection were defects of vision, and diseases of the heart and ears. 68 In addition to the candidates referred to above, 367 scholars were examined (154 males, 213 females) with a view to determining their fitness to continue to hold awards, and of these 17 (7 males, 10 females) were found to be unfit. Re-examinations totalling 2,376 were made of entrants, scholars, etc., who were referred at the first examination for treatment for one or more remediable defects. In order to determine the medical fitness of applicants for admission as aircraft apprentices in the Royal Air Force, their medical records are scrutinised at County Hall. Boys whose records appear doubtful are examined. In the course of the year 38 records were submitted, 14 boys were examined, and three were found to be unfit for nomination. Cases specially referred There were also referred to the public health department 3,361 special cases in which medical advice was required. This figure includes 2,719 teachers (636 men, 2,083 women) and 642 schoolkeepers, cleaners, etc. (134 men, 508 women). In regard to recommendations governing sick leave to teachers, 1,927 or 70.87 per cent, were in respect of teachers over 40 years of age. Teachers of physical education During the year, 239 applicants for admission to the Council's course of physical education were examined. Of these, 22 were deemed to be either temporarily or permanently unfit to undergo the training on the following grounds : debility, etc, 8; varicose veins, 2; injury, 2; heart condition, 1; rheumatism, 2; myopia, 3; hernia, 3; lung disease, 1. Medical inspection of scholarship holders The number of scholars medically inspected at County Hall was 945, comprising 252 girls and 693 boys. Re-inspection of scholars referred for treatment was carried out in respect of 36 girls and 45 boys. STATISTICAL TABLES Table 1—Medical inspection, 1938 (a) Routine inspections Group Boye Girls Total Entrants 24,048 23,253 47,301 Age 7 19,436 19,608 39,044 Age 11 20,757 20,819 41,576 Leavers 21,014 21,060 42,074 Total, elementary schools 85,255 84,740 169,995 „ special schools 546 429 975 (b) Other inspections Special inspections 73,726 76,017 149,743 Infectious disease enquiries — — 20,939 Re-inspections — — 128,067 (c) Children found at routine medical inspection to require treatment (excluding nutrition, uncleanliness and dental disease) Age group Inspected Found to require treatment Percentage Defective vision Other conditions in Table II Total Entrants 47,301 — 6,731 6,731 14.2 Age 7 39,044 2,668 4,417 6,811 17.4 Age 11 41,576 4,135 2,802 6,702 16.1 Leavers—age 13¾ 42,074 4,412 2,091 6,303 15.0 Total, elementarv schools 169,995 11,215 16,041 26,547 15.6 „ special schools 975 74 263 337 34.6 69 Table II (a) (1) Defects found at medical inspections of all children in elementary and special schools Disease or defect Routine inspections— Defects Special inspections— Defects Requiring treatment Requiring observation. Requiring treatment Requiring observation Elementary schools Special schools Elementary schools Special schools Malnutrition 1,663 3 663 4 424 — Skin—Ringworm, head 2 — — — 10 1 „ „ body 22 — — — 11 — Scabies 336 1 2 — 5,432 4 Impetigo 99 1 4 — 518 11 Other disease (non-tubercular) 796 5 102 1 735 77 Eye— Blepharitis 562 5 58 — 237 37 Conjunctivitis 100 4 1 1 114 5 Keratitis — — 2 — 4 9 Corneal opacities 5 — 1 — 6 1 Defective vision, excluding squint 11,215 74 5,616 58 2,656 418 Squint 994 4 359 — 322 40 Other conditions 133 2 28 1 215 57 Ear— Defective hearing 153 2 85 1 122 37 Otitis media 638 11 228 1 389 106 Other ear disease or defect 307 3 84 — 226 66 Nose and throat— Chronic tonsillitis 4,784 7 5,054 9 1,120 333 Adenoids 507 3 183 — 156 18 Chronic tonsillitis and adenoids 1,753 2 559 1 626 36 Other conditions 579 2 242 1 446 53 Enlarged cervical glands 248 823 1 108 135 Defective speech 139 — 138 — 108 42 Teeth—Dental disease or defect 48,563 230 1,010 — 4,170 84 Heart and circulation, heart disease— Organic 30 — 47 1 — — Functional 18 — 78 1 5 8 Not stated 165 2 1,357 11 149 442 Anaemia 314 1 207 — 182 75 Lungs—Bronchitis 636 2 668 1 91 34 Other non-tubercular 304 1 354 — 132 81 Tuberculosis— Pulmonary definite 1 — 3 — 1 2 ,, suspected 19 — 48 — 18 30 Glands 3 — 3 — 4 6 Spine — — — — — — Hip 1 — 1 — 4 — Bones and joints 2 — 2 — — — Skin — — 1 — — — Other forms 2 — 1 — — 1 Nervous—Epilepsy 30 — 15 — 30 12 Chorea 50 — 38 — 123 67 Other conditions 195 2 146 — 103 51 Deformities— Rickets 51 — 33 — 9 1 Spinal curvature 368 5 116 4 52 34 Other 772 7 402 3 186 94 Other conditions 2,332 19 840 7 2,539 960 Total 78,891 398 19,602 107 21,783 3,468 70 Table II (continued) (b) 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 47,301 7,229 15.28 37,017 78.26 3,020 6.39 35 0.07 Age 7 years 39,044 5,291 13.55 30,336 77.70 3,379 8.65 38 0.10 „ 11 41,576 6,460 15.54 32,308 77.71 2,794 6.72 14 0.03 „ 13¾ (leavers) 42,074 8,626 20.50 31,569 75.03 1,866 4.44 13 0.03 Total, elementary 169,995 27,606 16.24 131,230 77.20 11,059 6.50 100 0.06 „ special sch. 975 95 9.74 799 81.95 81 8.31 0 0.00 Table III (a) Exceptional children in London in 1938 Classification At certified special schools At public elementary schools At other institutions* At no school or institution Total Blind children 113 — 1 1† 115 Partially sighted children 489 21 — — 510 Deaf children 435 — 4 2‡ 441 Partially deaf children 136 3 4 — 143 Mentally defective children— Feeble-minded children 2,825 — 22 6** 2,853 Epileptic children— Children suffering from severe epilepsy 85 — 6 — 91 Physically defective children— Tuberculous children— Pulmonary 378 — 36 — 414 Non-pulmonary 525 — 15 — 540 Delicate children 2,361 5,721|| 9 — 8,091 Crippled children 1,791†† — 20 — 1,811 Children with heart disease 1,805 — 19 — 1,824 * Undergoing treatment in general hospitals, etc. † Under instruction at home. ‡ under enforceable age and 1 under instruction at home, †† Includes 10 children at Northern Hospital (post-encephalitis lethargica) and also non-cardiac cases of chorea, rheumatism, etc. || Of these 48 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. ** Two under instruction at home and four under enforceable age. Table III (continued) (b) Return of children suffering from more than one defect, 1938 Defect Type of school Day M.D. Residential P.D. Residential deaf Epileptic colony Day P.D. Certified hospital schls. At other institutions Total M.D. and deaf 2 — 24 — — — — 26 M.D. and crippled 26 1 - - 8 1 — 36 M.D. and heart 25 - - - 3 - 1 29 M.D. and epileptic 17 - - 23 - - - 40 M.D. and T.B. — - — — — 1 — 1 M.D., crippled and deaf - - 4 - - - — 4 Deaf and crippled - - 2 - - - - 2 Blind M.D., and crippled — — — — — 1 — 1 Epileptic and crippled - - - 4 - - - 4 Heart and crippled - 1 - - 15 - - 16 Total 70 2 30 27 26 3 1 159 71 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 9,010 — 9,010 Impetigo 5,282 — 5,282 Ringworm, head *103 147 †250 „ 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) 128,819 548 129,367 Miscellaneous (minor injuries, bruises, sores, chilblains, etc.) 143,214 695 143,909 * 88 by X-ray. † 118 by X-ray. (b) Group II—Defective vision and squint (excluding eye defects treated as minor ailments, for which see group I) Disease or defect Defects dealt with Under Council's scheme Otherwise Total Errors of refraction (including squint, but excluding operations for squint) 35,359 982 38,341 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, 25,663; otherwise 713 (estimated). Children who obtained or received glasses—under the Council's scheme, 24,730 = 96.3 per cent.; otherwise 645. * Included in group I minor ailment9. 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 749 574 1,323 3,832 13,761 Adenoids 377 57 434 Tonsils and adenoids 7,759 311 8,070 Other 9 93 102 Total 8,894 1,035 9,929 3,832 13,761 72 (d) Group IV—Dental defects 1. Number of children who were:— (a) Inspected by the dentist—Age groups 5 years and under 27,434 292,971 6 „ 27,044 7 „ 29,664 8 „ 29,133 9 „ 32,285 10 „ 33,909 11 „ 30,104 12 „ 30,014 13 „ 31,089 14 „ and over 22,295 (b) Found to require treatment 204,205 (c) Actually treated 138,639 2. Halt-days devoted to inspection 2,857 26,278 ,, ,, ,, treatment 23,421 3. Attendances by children for treatment 259,404 4. Fillings—permanent teeth 148,921 173,805 „ temporary teeth 24,884 5. Extractions—permanent teeth 58,540 275,565 ,, temporary teeth 217,025 6. Administration of general anaesthetics for extractions 64,950 7. Other operations—permanent teeth 38,774 „ „ temporary teeth (e) Group V.—Uncleanliness and verminous conditions (a) Average number of visits per school made by school nurse during the year 1938 6 (b) Examinations of children in the schools by school nurses 1,463,634 (c) Number of verminous children noted 65,292 (d) Children cleansed under Council's arrangements *63,975 (e) Cases in which legal proceedings were taken under the Education Act, 1921 (section 87) 195 * Includes 15,399 compulsory cleansings. Table V Medical inspection—number of children examined, 1928-1938 Year Routine examinations Special examinations Reinspections Examinations at special enquiries into outbreaks of infectious disease Special ear inspection centre attendances Rheumatism supervisory centre attendances 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 1938 170,970 149,743 128,067 20,939 25,828* 15,306 * Includes after-care clinic attendances : 1936—8,317; 1937—8,108 ; 1938—7,929. 73 Table VI Medical treatment—number of cases treated under the Council's scheme and by other agencies, 1928-1938 Year Minor ailments† Vision Nose and throat Dental Under the Council's scheme Otherwise Under the Council's scheme Otherwise Under the Council's scheme Other. wise Under the Council's scheme Otherwise* . 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 ||130.783 801 39,570 1,006 13,190 966 144,416 5,862 1937 ¶136.707 724 37,341 889 13,592 1,115 138,437 4,281 1938 °143,214 548 37,359 982 12,726 1,035 138,639 4,638 * It is not possible to give complete figures, but those given are the result of following up of medical inspections, inspection. Other children receive dental treatment outside the Council's scheme as a result of dental † Includes skin and head ringworm cases. § Includes 14,537 "nurses' cases." ¶ Includes 19,304 "nurses' cases." ‡ Includes 13,087 " nurses' cases." || Includes 16,548 " nurses' cases.'' ° Includes 21,086 "nurses' cases." Table VII Medical inspection of students in higher education institutions, 1938 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 2 3 45 47 I. Routine detailed examination at— (1) age 12 666 919 1,041 704 110 36 — — 1,817 1,659 (2) age 15 836 1,011 1,210 523 913 1,168 — — 2,959 2,702 II. Examination (not necessarily detailed) at other ages (i.e., specials) 1,295 1,136 1,551 869 712 640 81 785 3,639 3,340 III. Reviewals 478 1,483 639 553 101 140 — 11 — — IV. Re-inspections 692 1,295 671 643 474 392 5 1 1,842 2,331 74 INDEX page After-care clinic 25 After careers 57 Anaemia 12 Approved schools 36 Audiometer 15 Blind, Schools for the 56 Candidates, Examination of 67 Child guidance 61 Children's care committees 20 Chorea 29 Cleanliness 9, 31 Clothing and footwear 9 Convalescence 40, 41 Co-operation of parents 8 Co-operation of voluntary bodies 27 Deaf children 54 Defective children 51 Deformities 12 Delinquency, Juvenile 58 Diphtheria 34, 37 Ears 11, 15, 22, 25 Employment of school children 67 Entertainments, Employment of children in 67 Evening institutes 46 Eyes 10, 22, 64 Favus 35 Games 46 Halibut-liver oil 47 Heart 12 Hop picking 36 Hospital schools 65 Hygiene, Personal 31 Impetigo 31 Infectious diseases 33 Invalidity, Chronic 32 Lavatory accommodation 6 Leaving children 13 Lungs 12 Measles 35 Medical inspection 7, 64 Medical treatment 22 PAGE Mental deficiency 57 Milk distribution during holidays 51 Minor ailments 23 National health insurance 14 Nervous diseases 12 Nursery schools and classes 63 Nutrition 9, 15, 16, 47, 64 Open-air education 39 Orthodontics 24 Orthopaedic treatment 26 Oslo experiment 47 Otorrhœa 11, 25 Personal hygiene 31 Physical education 41 Plantar warts 65 Play centres 36 Play leadership scheme 45 Playing-fields 44 Re-inspection 20, 65 Remand home 58 Residential schools and children's homes 36 Rheumatism 28 Rickets 12 Ringworm 23, 35 Scabies 31 Scarlet fever 34, 38 Scholars, Examination of 67 School buildings and equipment 6 School journeys 36, 41 Secondary and junior technical schools 45, 64 Sleep of school children 33 Spectacles 22 Staff 5 Stammering 27 Teeth 10, 23, 64 Tonsils and adenoids 11 Towels 7 Training colleges 65 Tuberculosis 12, 39 Vaccination 12 Vitamin D therapy 19 Vulvo-vaginitis 39 LCC 47 LONDON COUNTY COUNCIL Report of the School Medical Officer for the year 1938 Published by the LONDON COUNTY COUNCIL and may be purchased, either directly or through any Bookseller, from P. S. KING AND SON, Limited, 14, Great Smith Street, Victoria Street, Westminster, S.W.1, Agents for the sale of the Publications of the London County Council. 1939 No. 3454 Price 1s. 6d. Post Free 1s. 8d. LONDON COUNTY COUNCIL Report of the School Medical Officer for the year 1938 800 (m'c. 40796-6) 29.8.39—643. CONTENTS PAGE Introduction 5 Staff 5 School buildings and equipment 6 Medical inspection 7 The nutritional state of London school children 16 Following-up 20 Medical and dental treatment 22 Co-operation of voluntary bodies 27 Stammering children 27 Rheumatism scheme 28 Personal hygiene scheme 31 Chronic invalidity 32 Sleep of school children 33 Infectious diseases in schools 33 Open-air education 39 Convalescence 41 School journeys 41 Physical education 41 Provision of meals 47 Defective children 51 Stamford House remand home 58 Child guidance 61 Nursery schools and nursery classes 63 Medical inspection at secondary and junior technical schools, training colleges, etc. 64 Hospital schools 65 Special inquiries and reports 65 Wage-earning employment of school children 67 Examination of candidates for the education service and scholars 67 Statistical Tables— I. Medical inspections 68 II. Defects 69 III. Exceptional children 70 IV. Treatment of minor ailments 71 V. Medical inspection—Number of children examined 72 VI. Medical treatment—Number of cases treated 73 VII. Medical inspection of students in higher education institutions 73 Index 74 {3} London County Council REPORT OF THE SCHOOL MEDICAL OFFICER FOR THE YEAR 1938. 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 In the preamble to the report for 1937, attention was drawn to the strides made in improving the health and physical condition of the children. The origin of the school medical service can be traced largely to the amount of preventable physical defect revealed by the recruiting statistics at the time of the South African War. It took some time for the necessary legislation to be carried through, and, at the outbreak of the Great War in 1914, sufficient time had not elapsed to show results, and the country was again alarmed when the recruiting statistics showed the presence of a large proportion of C3 individuals. It is satisfactory to have been able to indicate in the annual reports of the last decade, how each year the physical condition of the children had improved; and, now that critical times have again come, confirmation of this is forthcoming in preliminary reports on the examination of militiamen, which show that the standard of fitness is high. In the present report, the condition of the children in the schools during 1938 is set out, and references are made to advances in all branches of the service. Especial attention may, however, be drawn to the new arrangements for linking up the school medical service with the National Health Insurance service (p. 14), and the interesting advances in the study of nutritional conditions (p. 16). Pre-occupation of the senior staff with matters relating to civil defence has made it necessary to curtail the size of this report compared with previous years. 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 the deputy medical officer of health and deputy school medical officer (Dr. W. A. Daley), who is assisted by a principal clerk, responsible for the work of the lay administrative and clerical staff. 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 school medical work undertaken in the general public health division 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; 10 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; 3 assistant medical officers giving six sessions a week; 58 assistant medical officers giving three sessions a week; additional temporary medical assistance for 120 sessions a week and 9 medical officers (part-time) at open-air schools. There are 271 part-time doctors, surgeons and anaesthetists 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 * Not including two officers temporarily seconded for work under the Housing Acts (equivalent substitutes authorised). (5) 6 at Lissonia treatment centre, established in the Marylebone Health Centre, No. 2, the Old Ford, the South Hammersmith and the Dog Kennel Hill centres, the medical staff is 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, who now has a whole-time assistant. 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. In connection with the re-organisation of the school dental service during the year, the part-time dental surgeons engaged at treatment centres, numbering 105, were taken over directly by the Council. There are in addition 12 dental surgeons appointed by the authorities of voluntary hospitals with whom the Council has agreements for the treatment of school children. 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, 53 nursing sisters and 385 nurses. School buildings and equipment The three years' programme of development for elementary schools adopted for the years 1935-38, made provision for the erection of new schools and the rebuilding, modernisation or enlargement of existing schools. At the end of the programme period in 1938, nine new schools had been erected and opened, two enlargements had been completed, and eight additional schools had been rebuilt or modernised. A further 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. Sixty-six schools were dealt with in 1935-37, and, at the end of the programme period in 1938, 46 additional schools had been completed or nearly completed under this provision. Progress in the provision of playing fields, gymnasia, and shower-baths is described in the report of the organisers of physical education (p. 41). The new programme for 1938-41 provides for the purchase of sites, the erection and equipment of new schools, the enlargement, rebuilding or modernising of existing schools and the provision of further accommodation to meet housing developments. The position at the end of 1938 shows that work on 18 new schools and enlargements brought forward from the previous programme is in hand, together with five additional proposals under the new programme. Twenty-five schools for rebuilding or modernising, brought forward from the previous programme, are being dealt with ; and consideration of preliminary plans of 18 schools under the new programme has commenced. Lavatory accommodation The Council in 1934, in approving a new standard of accommodation for Council elementary schools, decided that office and lavatory accommodation should continue to be provided on the Board of Education's 1914 scale, with some wash basins placed near the w.c.'s. 7 The provision has been reviewed in the light of pamphlet No. 107 issued by the Board on elementary school buildings. There is general agreement that, so far as London is concerned, where children's homes are generally near to the schools and very few children have to spend the whole day on the premises, the 1914 scale for w.c.'s is sufficient, and the Board of Education have now concurred in the continued application of this standard. In regard to the lavatories it is considered that some improvement on the present standard is desirable. It is therefore proposed that the authorised standard of lavatory accommodation in new, enlarged or remodelled public elementary schools in London shall be in accordance with the following scale:— Old scale Proposed new scale Up to 100 children 4 8 „ 200 8 12 „ 300 12 16 „ 400 16 20 In reconditioned schools provision is to be as near to that standard as the circumstances of each case will allow. Replacement of trough closets The policy of modernisation of sanitary offices at old schools in advance of rebuilding or reconditioning is being steadily pursued. There are now only 49 schools with trough closets. Of these, 14 will be dealt with during 1939. There will remain 35 schools, of which 14 may possibly soon be closed, 4 are in the current remodelling programme when the closets will be dealt with, there are another 7 in which early rebuilding or remodelling is probable, and a further 8 in which reorganisation is under consideration. Towels The increase of ablution in the schools, the provision of hot water in lavatories and of spray-baths in connection with gymnasia in all senior schools, has caused attention to be paid to the provision of towels. Experiments in this direction have been described in my recent annual reports. The Council in May, 1938, approved the supply to public elementary schools of individual towels, soap and towel hooks. As a further alternative to the use of the common roller towel, an experiment has been conducted at a few schools in the installation of automatic continuous towel cabinets. The machines contain rolls of towelling 50 yards long by 12 inches wide, which provide for about 200 to 220 washes for each machine. Clean towelling is drawn out in lengths required, and the soiled towelling is returned automatically to the machines, the clean and soiled towelling being separately stored. No specific charge is made for the installation and hire of the machines and towel rolls, but 1s. 9d. is charged for the laundering of each roll. In order to obtain conclusive data as to the cost of the machines if extensively used, it has now been decided to conduct an experiment on a larger scale, for about one year, at certain central schools and elementary and special schools attended by senior pupils. About 130 machines in 40 school departments will be installed, on the understandingthat the Council will not be committed to any expenditure subsequently. 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. The arrangements are as described in last year's report. 8 The average roll and average attendance (elementary schools) during the last four years, were as follows:— Year Roll Attendance 1934-5 534,611 471,342 1935-6 507,392 444,349 1936-7 479,974 417,028 1937-8 457,253 397,172 Particulars of examinations at school are set out below:— Routine inspections:— Entrants 47,301 Children aged 7 39,044 „ 11 41,576 ,, „ 13 and over 42,074 „ in special schools 975 170,970 Special inspections:— (a) Children referred by nurses, head teachers, care committee workers, etc. 149,743 (b) Children inspected in connection with outbreaks of infectious disease 20.939 170,682 Total inspections 341,652 Re-inspections of children found ailing at previous inspections 128,067 Total 469,719 As inspections of all kinds and re-inspections totalled no less than 469,719, it is clear that, although some duplicate inspections are included, very few indeed of the children in school escaped coming under the eye of the doctor in some way or another during the course of the year. Co-operation of parents Parents are invited to be present at all routine inspections, and attended in 78.1 per cent. of the examinations in the three prescribed age groups, compared with 77.3 per cent. in 1937 and 76.9 per cent in 1936. At the inspection of entrants, the proportion was 90.5 per cent., and in the "leaver" group 40.9 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. 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 90.5 per cent. of parents attended at this time. Least satisfactory attendances by parents are at the leaving examinations of boys, when only 33.1 per cent. were present, although 48.6 per cent. attended in the case of girls. The intense dislike 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 1938, the parents of 38 children (10 boys, 28 girls), being 3 less than in 1937, refused to allow them to be examined by one of the Council's assistant medical officers. Two objections were subsequently withdrawn, and in 3 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 found needing or receiving treatment for defects other than malnutrition, uncleanliness and dental disease was 20,244, or 15.6 per cent. 9 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 ohildren 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 specially devoted to a consideration of this and cognate conditions (p. 16). Cleanliness Personal hygiene is the second of three great indices—nutrition, cleanliness, clothing—by which social conditions and their improvement can be assessed. In 1938 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 97.7, compared with 97.4 in the previous two years, and 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, 96.1 in 1937 and 96.5 in 1938, thus establishing a new high record. 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 86 children were found in the statutory age groups to be affected by body vermin in 1938, out of 127,921 examined. Clothing and footwear When the children are undressed by the nurse preparatory to the medical inspection, she enters on the medical record card a note of the condition of the clothing and footwear. The results of this classification for 1937 and 1938 are given below. Table 1—Clothing and footgear—Percentages Age group 1937 1938 Good Fair Bad Good Fair Bad Entrant boys 57.4 42.2 0.4 55.1 44.5 0.4 Entrant girls 58.9 40.8 0.3 56.4 43.3 0.3 Seven-year-old boys 55.4 44.2 0.4 54.4 45.2 0.4 Seven-year-old girls 56.6 43.2 0.2 57.7 42 0 0.3 Eleven-year-old boys 52.8 46.8 0.4 52.3 47.3 0.4 Eleven-year-old girls 55.7 44.0 0.3 55.4 44.3 0.3 Leaver boys 51.3 48.2 0.5 50.5 49.2 0.3 Leaver girls 56.4 43.4 0.2 54.8 45.0 0.2 In earlier years the percentages of children with insufficient clothing and inadequate footgear were much higher. On the whole girls are tidier than boys. 10 Dental decay In 1938, the percentage of children found by the school doctors in the statutory age groups with sound teeth was 68.5 compared with 68.3 in 1937, and 68.5 in 1936. A comparison with former years is shown in the following table:— Table 2 Age group 1927 1932 1937 1938 Sound Serious decay Sound Serious decay Sound Serious decay Sound Serious decay Entrant boys 51.7 15.3 55.6 12.2 58.7 8.2 60.1 7.8 Entrant girls 50.7 15.2 54.7 12.1 57.1 8.4 59.3 7.4 7 or 8-year-old boys 61.1 8.1 68.8 4.7 71.1 3.5 70.1 3.9 7 or 8-year-old girls 60.9 8.3 68.8 4.7 69.7 3.7 69.2 3.9 11 or 12-year-old boys 70.6 2.7 75.1 1.5 77.7 1.0 76.9 1.2 11 or 12-year-old girls 72.3 2.3 78.0 1.1 78.7 0.9 77.8 1.0 All above age groups 60.3 9.3 67.4 5.8 68.3 4.5 68.5 4.4 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 and the improvement in this respect of late among entrant infants, who up to 1929 seemed to be getting worse every year, is a striking tribute to the efforts made at child welfare centres to improve the condition of children before school age commences. The subjoined table gives figures for the past twelve years of entrants:— Table 3 Year Boys Girls Number inspected Percentage with sound teeth Percentage with serious decay Number inspected Percentage with sound teeth Percentage with serious decay 1927 39,199 61.7 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 57.1 8.4 1938 24,048 60.1 7.8 23,253 59.3 7.4 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 1937 and 1938 are given in the table below in percentages:— Table 4 Age group Visual acuity (percentages) Normal Slight defect More serious defect 1937 1938 1937 1938 1937 1938 Seven-year-old boys 64.1 63.8 24.7 25.7 11.2 10.5 Seven-year-old girls 63.6 63.6 25.2 25.2 11.2 11.2 Eleven-year-old boys 70.1 70.8 16.5 15.7 13.4 13.5 Eleven-year-old girls 67.8 67.8 17.8 18.2 14.4 14.0 Leaver boys 70.8 71.4 14.7 14.4 14.5 14.2 Leaver girls 68.2 68.9 16.7 16.0 15.1 15.1 11 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 1938 show that there is still a heavier incidence upon older girls, although the excess of visual defect in girls is much less than in former years. Much care is taken by the school organisation to ensure ocular hygiene. The lighting of classrooms both natural and artificial receives special attention in order to secure the best results. The type of all class books is closely scrutinised and all doubtful cases are submitted to the school medical officer for his decision. Fine tasks, like sewing, are carried out in good natural light and not under artificial lighting, unless this has been approved by the school medical officer. Much of this care is, however, rendered nugatory by out of school activities. Considerable indignation has recently been expressed by teachers and workers in connection with certain of the popular periodicals which are produced and sold to the children. An appeal has been received from the South African Council for Child Welfare drawing attention to the exceedingly poor pages and the small and indistinct print of most boys' papers, all of which are printed in England. An examination of sample conies of these neriodicals fully justifies the criticism which is made. Enlarged tonsils and adenoid growths In the prescribed age groups, 6,579 children were referred for some form of treatment of enlarged tonsils or adenoid growths; this is 5.2 per cent. of the children examined, compared with 5.4 per cent. in 1937, 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 8.7, girls 7.2; 7-year-old boys 4.48, girls 5.2; 11-year-old boys 1.7, girls 2.5. There has been a fall in recent years in the percentage of children referred for treatment for enlarged tonsils and adenoid growths, though 1937 showed a slight upward tendency. The older the children the fewer there are that suffer from ear, nose and throat defects. 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 44.6 per cent., compared with 45.8 in 1937, 44.4 in 1936, 38 per cent. in 1933 and 1934, and 43 per cent. in 1932. Of the 6,579 children referred for treatment for these defects, 4,423 were referred for enlarged tonsils only, 488 for adenoid growths only, and 1,668 for both enlarged tonsils and adenoid growths. Otorrhœa and hardness of hearing Otorrhœa was noted in 870 children, or .7 per cent. of those examined in the prescribed age groups, the same percentage as in 1936 and 1937, 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 226 children, or only .2 per cent. of those examined, being the same percentage as in 1936 and 1937. 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 15), 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 12 interfering with education, are sometimes the indication for active preventive treatment. Many of these cases are not detected by the ordinary method of medical inspection, in which the test is the forced whisper at 20 feet. Heart defect Heart defect (functional or organic) was reported in 1,742 children in the prescribed groups or 1.4 per cent., being the same proportion as in 1937, 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 (1.6) 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. 28). Anæmia Anaemia was recorded in 590 children, or .5 per cent., the same percentage as in 1937, 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. Lung defects Lung defects were noted in 2,393 children in the prescribed age groups (or 1.9 per cent.), compared with 1.8 per cent. in 1937, an improvement upon 1936 and 1935, in both of which years the percentage was 2.1. The bulk of the cases is provided by the entrants (3.0 per cent.). This is due largely to bronchial catarrh, which is especially prevalent among entrant infants Tuberculosis There were 63 children in the three age groups reported to have symptoms indicative of pulmonary tuberculosis, compared with 56 in the previous year, and 66 in 1936. In addition, 17 children were found with other forms of tuberculosis, compared with 24 in 1937, and 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. Nervous diseases Epilepsy was noted in 41 children, compared with 45 in 1937, 30 in 1936, 28 in 1935, 65 in 1931, and 73 in 1929; chorea in 90 children, compared with 76 in 1937, 101 in 1936, 104 in 1935, 158 in 1932, and 170 in 1931; paralysis in 44 children, compared with 61 in 1937, 41 in 1936, 45 in 1935, 55 in 1934, 63 in 1932, and 81 in 1931. Rickets Signs of rickets or the effects of early rickets were noted in 551 children in the prescribed groups. This is .4 per cent., compared with .5 in 1937 and 1936, .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., as in 1937 compared with 1.1 in 1936, 1.0 in 1935 and 1934, .7 in 1933, and .9 per cent. in 1932, and infant girls .4 per cent., compared with .5 per cent., in 1936 and 1935, .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-yearold group are noted with remains of the disease. Deformities Among deformities, spinal curvature accounted, in the prescribed age groups, for 377 children, or .3 per cent. as in 1937 and 1936, compared with .4 per cent. in 1935. Of these, 107 were among the 11-year-old girls, and 94 among the 11-year-old boys. Other deformities, mainly flat foot, were present in 1,321 children (or 1.0 per cent.), compared with .9 in 1937 and 1936. and 1.0 in 1935 and 1934. Vaccination. Records are made of the presence or absence of vaccination marks when children are stripped for medical examination, but no enquiries are made. The following are the results of the doctors' observation of the percentage of children having vaccinal scars: entrants, 43.1; 7-year-olds, 44.5; 11-year-olds, 48.6; and "leavers" (13½), 50.5; compared with, in 1937, entrants, 45.3; 7-year-olds, 47.2; 11-year-olds, 47.9; and "leavers" (13½), 54.6. These figures show that the percentage of children with obvious vaccination marks is less than last year at all ages except in the 11-year-old group. A greater percentage of the older children in the schools at present are vaccinated than of the younger children. 13 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 attention received since the children entered school. This year's "leaver" group comprised 21,014 boys and 21,060 girls. In nutrition they were found to be better than the younger groups, only 4.7 per cent. of the boys and 4.2 per cent. girls being classed as subnormal, whereas in the three prescribed ages, 7.3 per cent. were considered subnormal. In personal cleanliness, this group also shows an improvement on the 11-year-old group, 98.6 per cent. boys and 97.1 per cent. girls having perfectly clean heads. The dental condition of this group was found to be slightly inferior to that of the 11-yearold group, for both boys and girls, the percentage with satisfactory mouths being 75.8 in the case of boys, and 74.5 in the case of girls, compared with 76.9 and 77.8 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 .7 per cent. compared with .5 per cent. at age 11; on the other hand, heart defect in the "leaver" girls was 1.5 per cent., compared with 1.6 per cent. 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 1.2 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 re-organisation of the upper classes 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. The schopl doctor indicates any of these occupational groups for which a child is physically unsuitable. In connection with the Education Act, 1936, and the prospective raising of the school-leaving age to fifteen years in September, 1939, consideration has been given to the question of the leaving examination. The Board of Education, in circular 1457, suggested that, in considering exemptions claimed under the plea of beneficial employment, the local education authority should have before them information in regard to the medical record of the child. This information, in the opinion of the Board, should take the form of a confidential medical report similar to that already described above and based upon contraindications to certain occupational conditions. In view of the doubts at present existing as to the extent to which in London exemptions on account of beneficial employment will be claimed, it has been decided that, at any rate at first, the leaving examination should continue to take place when the children are approaching 14 years of age. The "employment slip" already in use has been suitably altered for the purpose and it has been decided that one shall be issued for every leaving child and not as heretofore, only in cases where some contraindication is found to exist. This arrangement has been brought into force in January, 1939, and will ensure that a medical report in the form suggested by the Board will exist for every leaving child. 14 National Health Insurance (Juvenile Contributors and Young Persons) Act, 1937 In connection with section 6 of the National Health Insurance (Juvenile Contributors and Young Persons) Act, 1937, the Board of Education issued Administrative Memorandum No. 175, dated 9th March, 1938, to local education authorities. A summary of the memorandum is set out below:— (1) The general effect of the Act, which came into force on 4th April, 1938, is to provide medical benefit for boys and girls who leave school and become insurably employed under the age of 16. (2) Section 6 of the Act requires local education authorities to make arrangements to furnish (on the application of a medical practitioner or of an insurance committee on his behalf) such particulars of the school medical record or medical history in their possession of any such young person as the practitioner may deem necessary for the purposes of his functions in relation to the provision of medical benefit for that person. A "young person" means a person under the age of 18 years. (3) Local insurance committees are drawing the attention of practitioners to the facilities afforded. The transmission of school medical records would in many cases be of little or no clinical value to the practitioner, and a form of enquiry has been prepared wherein the practitioner can apply for suitable information as to the conditions noted at the last medical inspection in school and the medical history of the young person. Between 4th April and 31st December, 1938, 1,739 applications from medical practitioners were received in the department. Of these, the records of 288 could not be traced, and reports were forwarded to the practitioners in regard to 1,451 young persons. Of this latter number, 427 were noted as clear of any defect at the last school medical inspection, 860 were reported as showing minor defects (such as visual and dental defects) and 164 with major defects (such as heart disease or orthopaedic conditions). Special examinations The number of children, not in the age groups for routine examinations, submitted to the school doctors as special cases was 149,743, equivalent to three and a half additional age groups. The number of special examinations in 1937 was 133,850 in 1936, 122,963, in 1935, 125,199, and in 1934, 91,880. These figures do not include those who came under inspection in the course of enquiries into outbreaks of infectious diseases and who numbered 20,939 in 1938. The increase in the number of special examinations in the past four 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 six and a half 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 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 5,436 children with scabies were referred for treatment at special inspections, compared with 339 only at routine inspections. In regard to children with chorea, 190 were seen at special inspections, compared with 88 at routine examinations. Five-hundred-and-forty children were classed as "nutrition 4" at special examinations, while only 100 children were placed in this category at the routine examinations of age groups. 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 101,918, compared with 87,567 in 1937, 78,706 in 1936 and 53,066 in 1935. At the resulting 15 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 49,607 1,881 28,725 18,759 242 Girls 52,311 2,141 30,409 19,463 298 Total 1938 101,918 4,022 59,134 38,222 540 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 Audiometric examination in elementary sohools 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. In connection with the new three years' programme one further unit was established during 1938 in the northern division. 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. Audiometric work The work is under the direction of Mr. A. G. Wells, F.R.C.S., who has submitted the following report:— The number of children tested by the gramophone audiometer during the year was 70,960, and the total number of individual testa was 81,512. 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 Boys 36,203 2,371 1,633 738 6.5 Girls Total 34,757 2,286 1,574 712 6.5 70,960 4,657 3,207 1,450 6.5 The subjoined table gives the total number of ears tested in 1938 and shows the results 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 1918 141,920 135,810 1,263 3,646 1,201 Percentage 95.7 0.9 2.6 0.8 16 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 2,267 Wax 1,196 Rhinitis 1,423 Deflected septum 95 Otorrhoea 444 Sclerosis 1,340 External otitis 1 Tonsils and adenoids 364 Old mastoid operation 263 Polypus 3 Nerve deafness 6 Foreign body 4 Congenital malformations 8 Sinusitis 16 Stenosis of meatus 1 Nothing abnormal found 60 Among 4,657 children who failed, 966 were treated by diastolisation treatment, and 507 of these benefited sufficiently to enable them to pass their final test, after the completion of their treatment. The results of 121 were unknown owing to their either having left school or lapsed from treatment. Among the 70,960 children tested by the gramophone audiometer, there were 119 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 88 were found to be suitable for ordinary school, and these should be known as grade I children. Nineteen 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. Seven needed education in a partially deaf school; these should be known as grade IIb children. Five did not attend. The nutritional state of the London school children Unremitting care and attention continues to be paid by the school medical service to the nutritional state of the children, and, compared with earlier years, there is no doubt that it has vastly improved. The emergence of new knowledge, especially in regard to the accessory factors in diets, has resulted in a revision of standards which is still progressing. Comparisons year by year of the figures returned under these changing conditions need therefore to be received with caution. An increase in the number of children classified as subnormal, so far as London is concerned, most certainly reflects a change in standard and not a deterioration in reality. The high standard of general health, the almost complete disappearance of rickets as a crippling disease in London, the improvement in the death rate, the small incidence of tuberculosis, all deny the existence of any serious amount or degree of • malnutrition. Alarmists have caused much apprehension by exaggeration, so that some teachers anxious about the condition of their charges have even questioned whether the children in their schools are generally fit for physical exercises. The spontaneous activity of the children themselves is sufficient refutation of any such notions. Let but a barrel organ appear in the alley, and the latter is at once filled with a happy crowd of vivacious dancing youngsters. Distinguished medical officers from the British Dominions overseas visiting our schools compare the children favourably with the bonny specimens of the race in their own land. Of general deficiency of food there is no evidence. There is, however, as there has always been, and in former years to greater degree than now, partial deficiencies in specific ingredients in the dietaries of the people, which are with difficulty made up, especially during the winter months. It is vitamin hunger due to such deficiencies which causes the city man to take his family annually to the seaside, sets the schoolboy robbing the farmer's orchard, drives the indigenous population of the East End en masse to the hop gardens of Kent, and which sent our Viking ancestors foraging and pillaging in the southlands. Further consideration of this problem of dietetics is given later in this report (p. 47) under the heading of the " Oslo experiment." The Board of Education schedule 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 17 to year the fluctuations are minute, and each year each age-group preserves its own distinctive features. Thus the 7-year-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. Table 8—Assessment of nutrition, 1938 Group Numbers examined Nutrition Excellent Normal Subnormal Bad 1 2 3 4 Entrant boys 24,048 3,400 18,980 1,649 19 Entrant girls 23,253 3,829 18,037 1,371 16 Seven-year-old boys 19,436 2,169 15,410 1,837 20 Seven-year-old girls 19,608 3,122 14,926 1,542 18 Eleven-year-old boys 20,757 2,787 16,501 1,464 5 Eleven-year-old girls 20,819 3,673 15,807 1,330 9 Leaver boys 21,014 3,878 16,141 987 8 Leaver girls 21,060 4,748 15,428 879 5 Total 169,995 27,606 131,230 11,059 100 Percentage — 16.2 77.2 6.54 .06 Corresponding figures for the previous year are shown in the following table :— Table 9—Assessment of nutrition, 1937 Group Numbers examined Nutrition Excellent 1 Normal 2 Subnormal 3 Bad 4 Entrant bovs 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 Table 10—Assessment of nutrition in percentages 1937 and 1938 Group Nutrition Excellent 1 Normal 2 Sub-normal (and bad) 3 1937 1938 1937 1938 1937 1938 Entrant boys 14.1 14.1 79.0 78.9 6.9 7.0 Entrant girls 16.5 16.5 77.9 77.5 5.6 6.0 Seven-year-old boys 120 11.2 79.0 79.3 9.0 9.5 Seven-year-old girls 15.5 15.9 77.0 76.1 7.5 8.0 Eleven.year-old bovs 13.6 13.4 79.7 79.5 6.7 7.1 Eleven-year-old girls 18.1 17.7 75.9 75.9 6.0 6.4 Leaver boys 18.2 18.5 77.6 76.8 4.2 4.7 Leaver girls 23.2 22.5 73.0 73.3 3.8 4.2 The percentage of children examined who were assessed as below normal in nutrition was, 6.6 in 1938, and 6.1 in 1937. The number of children who were found 18 to be seriously ill-nourished was 100 in 1938 while in 1937 it was 107, giving exactly the same proportion. Such close accordance in the two years is remarkable. It is satisfactory to note that it is at the end of school life that the children are best nourished. 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 codliver 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 Nutrition 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. Two new centres were established during the year, one at Woolwich in June and the other at Townsend Street School, Bermondsey, in December. The total number of centres functioning at the end of the year was 14. Particulars of attendances at nutrition centres during 1938 are shown below:— Number of appointments made for new cases 820 Attendances: new cases 641 old cases 2,877 3,518 Number discharged : no longer needing supervision 100 leaving school 84 — 184 Number of sessions 450 The usefulness of the centres is shown by the number of additional sessions asked for in order to deal with the number of children who could not be dealt with conveniently at the ordinary sessions. Valuable reports have been submitted by the physicians in charge of the centres. The careful and detailed investigations and the constructive work carried out at the nutrition centres are illustrated in the following abstract of the report of Dr. Elizabeth Gourlay at the Hoxton and Starcross Street centres on new cases:— Table 11—Summary of assessment of incomes (after deducting rent and insurance) Classification. Total Income per head below 10s. a week. Income per head 10s. to 158. a week. Income per | head over 15s. a week. Income per head less than 5s. a week Hoxton nutrition centre— Families of employed men 38 23 13 2 15 Families of unemployed men 22 18 4 — 11 Families of widows or separated parents 10 6 3 1 4 Starcross Street nutrition centre— Families of employed men 14 3 9 2 2 Families of unemployed men. 9 7 2 — 5 Families of widows or separated parents 2 2 — — 2 19 Table 12—Classification of results of haemoglobin estimations Year. No. of children. Hb. 85 per cent. and below. Hb. below 80 per cent. Hoxton nutrition centre— 1937 68 18 3 1938 75 25 9 Starcross Street nutrition centre— 1937 37 20 7 1938 34 14 8 This year I have raised the standard of the suboptimal haemoglobin level by including those children who had a haemoglobin of 85 per cent. I have done this because I feel that any haemoglobin level below 90 per cent. in a child is unsatisfactory, and that these suboptimal levels are so often found in undernourished children, particularly associated with repeated septic lesions and chronic bronchial catarrh. It is remarkable to find a much larger percentage of both anaemic children and those with a suboptimal haemoglobin level attending the Starcross Street than the Hoxton centre where the families are of a lower social status, but each year it is the same, and also is associated with a higher incidence of old rachitic manifestations. Seven of these children with suboptimal haemoglobin levels from Starcross Street and three children from the Hoxton centre have been sent to Dr. Lucy Wills, in the biochemical department of the Royal Free Hospital for investigation. Their blood investigations and those of twelve old cases from Starcross Street have been done by Dr. Crowley, who has given the following report from the biochemical department of the Royal Free Hospital:— "Of 18 children examined in detail, all were found to be suffering from iron-resistant anaemia. Fifteen had, as well, chemical evidence of latent rickets, of these eight were investigated in detail and treated for some months. One was found to be suffering from chorea. The remainder all recovered from the anaemia on combined treatment with iron and massive doses of vitamin D." A number of these children had failed to respond to simple iron therapy and the low inorganic phosphorus level of the blood and low calcium phosphorus ratio suggested a vitamin D as well as an iron deficiency resulting in chemical rickets. Excellent results were obtained with massive doses of calciferol. Vitamin D therapy. Massive doses of vitamin D (calciferol) 100,000 international units weekly have been tried at the Hoxton and Starcross Street nutrition centres on four types of case:— (1) The cases of anaemia and suboptimal haemoglobin levels treated by vitamin D and large doses of iron (pil. ferr. sulph. i. t.d.s. or Blaud's gr. 45 daily). (2) Cases of chronic bronchial catarrh. (3) Cases with repeated septic sores. (4) Cases failing to gain weight. Up to the present I have only treated four cases of sores, eight cases of bronchial catarrh and 25 cases of anaemia. I think that the chest cases have definitely improved, and all the anaemias except two have responded. The calciferol is given in a dose of 200,000 i.u. in four tablets which are eaten at the centre once a fortnight. This safeguards any waste of expensive drugs or refusal of the child to swallow the tablets when given by the mother. Of all the deficiencies in the diet of these children, that of vitamin D is probably the greatest. In many cases it is probably completely absent as so often they dislike fish, such as herring, the only probable dietetic source. They have not much opportunity to store up vitamin D from sunshine in this climate, particularly in winter, and the amount of garments they wear must result in shutting out such ultra-violet rays as might reach them. I do not think that the vitamin A deficiency is so great a problem as the children get considerable amounts in their milk in school and in vitaminised margarine. Many of the children must depend for their vitamin D supply on their dose of cod-liver oil in school, and the vitamin D content of that is small. Even a halibut-oil capsule containing 485 i.u. of vitamin D makes a weekly dosage of 2,425 i.u. only. This is probably a satisfactory maintenance dose for a healthy child, but I think it is too small to benefit a child with chronic bronchial catarrh or a suboptimal haemoglobin level, which are the conditions for which so many of the children are recommended cod-liver. oil or halibut oil in school. Only a few children can have vitamin D therapy at the nutrition centres under supervision, and expensive vitamin preparations given to take home would often be wasted. At the nutrition centre the cases of bronchial catarrh and sores have usually needed three fortnightly doses of vitamin D 200,000 i.u. Many of the anaemias have only needed this, or at the most six doses, so the expense would not in the end be greater than the prolonged dosage with cod-liver oil and malt. 20 Treatment recommended at the Hoxton centre during the year was as follows, the numbers in which the treatment had been obtained by the end of the year being given in brackets: convalescence, 53 (48, one in hand); holidays at camp schools, 19 (16); extra nourishment: dinners, 9 (8, one refused), milk, 5 (4), cod-liver oil, 3 (3); holiday meals, 10 (8, two refused); holiday allowance from U.A.B. or P.A.C., 12 (11, one failed to apply); housing, 6(1, two in hand); ultra-violet rays, 8 (6); remedial drill, 5 (5); dental treatment, 20 (12); spectacles, 2 (2); aural treatment, 9 (7); rheumatism scheme, 2 (2); attendance at special ear department, 3 (3); hospital treatment 11 (10). Arrangements were made for all children to receive milk during the holidays, but the attendances were disappointing. At the Starcross Street centre recommendations were: convalescence, 33 (29, one refused, one made own arrangement, two failed to join the parties); holidays, 8 (4, three in hand, one refused on account of scabies); extra nourishment: dinners, 5 (5), milk, 6 (6); holiday meals, 13 (12, one ill); dental treatment, 14 (9, two in hand); aural treatment, 4 (4); rheumatism, 2 (2); orthopaedic treatment, 1 (1); hospital treatment: for anaemia, 20 (19, one refused), for other ailments, 4 (3, one in hand); open-air school, 5 (4, one refused); housing, 2 (2 in hand); ultra-violet rays, 2 (2). Miss H. G. Nussey, principal organiser, in her report for 1938 remarks:— Appreciation of the work of the nutrition centres is general. The care committees appreciate the advice given as to how to deal more effectively with the nutrition cases generally and are particularly interested in this endeavour to get at the cause of some of the cases of subnutrition which are obviously not due to poverty. When children, whose parents are in receipt of public assistance, attend, it is customary for them to get an extra grant in order that the mother may buy the foodstuffs recommended by the doctor—usually in the form of protein and fats, such as milk, cheese and butter. Cod-liver oil and malt is being given more generally in the schools also. The care committees of the five contributory schools have had much to do with the success of the Oslo dinner experiment (see p. 47). They visited parents and explained the scheme, visited again those who did not attend the inaugural parents' meeting, and as a result about 60 children began the meals on 9th May, 1938. Some have enjoyed this type of meal, while others have found it monotonous, and there has been a good deal of change of personnel in spite of the fact that children, for the purposes of the experiment, have remained on the feeding list longer than they would otherwise have done. There is evidence of great keenness on the part of care committees, teachers and doctors for the prevention of malnutrition. The publicity given to the subject has undoubtedly aroused much interest and reports have come to hand that eye diseases due to debility are being cured more rapidly owing to the increased facilities for (1) cod-liver oil and malt and milk in schools; (2) extra diet provided by public assistance; (3) use made of "invalid kitchens"; and (4) advice given at nutrition centres. 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 5,500 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. Re-inspections The returns of the school doctors who re-inspect children found at the inspections in elementary schools to be ailing and in need of treatment make it possible to compile a statistical record of following up. During 1938, 128,067 children were re-inspected for 171,594 defects, 116,486 of which had been referred for treatment and 55,108 for observation. At the first re-inspection, which takes place in the next term but one after primary inspection, 80,051 defects requiring treatment (some children having more than one 21 defect) were reviewed. At the second re-inspection, which takes place after the lapse of a clear term after the first re-inspection, 36,435 cases not cleared up at a first reinspection were again reviewed. By combining the results of both re-inspections it is found that 83.1 per cent. of the children re-inspected were treated or discharged as no longer requiring treatment. This figure compares with 82.0 per cent. in 1937; 83.9 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 85.5 per cent. in 1938, compared with 84.4 per cent. in 1937. Table 13 First re-inspections, 1938 (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 charg'd Discharg'd Not discharg'd Refraction 13,305 88 50 3,422 1,575 353 175 917 3.255 3,470 0.7 0.4 25.7 11.8 2.6 1.3 6.9 24.5 26.1 Minor ailments 4,661 97 21 1,237 295 216 76 1,385 676 658 2.1 0.5 26.6 6.3 4.6 1.6 29.7 14.5 14.1 Nose and throat 11,144 32 13 3,992 184 640 57 1,047 1,504 3,675 0.3 01 35.8 1.7 5.7 0.5 9.4 13.5 33.0 Teeth 42,629 891 196 17,535 891 2,108 103 2,145 922 17,838 2.1 0.5 41.1 2.1 4.9 0.2 5.0 2.2 41.9 Other ailments 8,312 146 53 717 683 725 489 1,853 2,367 1,279 1.8 0.6 8.6 8.2 8.7 5.9 22.3 28.5 15.4 Total 80,051 1,254 333 26.903 3,628 4,042 900 7,347 8,724 26,920 1.6 0.4 33.6 4.5 5.1 1.1 9.2 10.9 33.6 Do. (without teeth) 37,422 363 137 9,368 2,737 1,934 797 5,202 7,802 9,082 1.0 0.4 25.0 7.3 5.2 2.1 13.9 20.8 24.3 Second re.inspections, 1938 Refraction 7,909 32 20 1,456 1,089 172 92 523 2,199 2,326 0.4 0.2 18.4 13.8 2.2 1.2 6.6 27.8 29.4 Minor ailments 1,842 22 3 376 206 70 43 466 317 339 1.2 0.2 20.4 11.2 3.8 2.3 25.3 17.2 18.4 Nose and throat 5,968 9 3 1,617 86 247 34 733 887 2,352 0.2 0.0 27.1 1.4 4.1 0.6 12.3 14.9 39.4 Teeth 16,567 420 88 5,944 345 808 24 1,137 407 7,394 2.5 0.5 35.9 2.1 4.9 0.1 6.9 2.5 44.6 Other ailments 4,149 27 22 284 472 243 269 900 1,328 604 0.7 0.5 6.8 11.4 5.9 6.5 21.7 32.0 14.5 Total 36,435 510 136 9,677 2,198 1,540 462 3,759 5,138 13,015 1.4 0.4 26.6 6.0 4.2 1.3 10.3 14.1 35.7 Do. (without teeth) 19,868 90 48 3,733 1,853 732 438 2,622 4,731 5,621 0.5 0.2 18.8 9.3 3.7 2.2 13.2 23.8 28.3 Cases referred to the N.S.P.C.C. During 1938, 322 children, suffering from 417 defects, were reported to the National Society for the Prevention of Cruelty to Children; these included 219 dental defects, 69 vision cases, 50 nose and throat affections and 8 cases of ear disease or deafness. 22 Aural disease and the acute infectious 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 634, of whom 57 were referred to Borough Councils or other local authorities. Of the children followed up at school, 220 had two examinations during the year, of whom 178 were free from otorrhoea on both occasions. Of 245 children who were examined once during the year, 34 were found to be suffering from otorrhoea, and of 174 children whose second examination only fell due during the year, 7 were found to have otorrhoea. 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 1938, 25,663 children were prescribed spectacles at the treatment centres and hospitals, and 24,730 or 96.36 per cent. obtained them. Medical and denial treatment The work in connection with the medical and dental treatment of school children has been continued during the year and the attendances of the children have on the whole been very satisfactory. The attendances during the period of the international crisis at the end of September and the beginning of October were naturally reduced in number, and some of the activities of the centres, especially throat operations, were abandoned for about a week. The total numbers of hospitals and centres included in the scheme at the end of the vear were 19 hospitals and 85 centres. The numbers of children treated at all the hospitals and centres under scheme during 1938 compared with 1937 were :— Ailment 1937 1938 Vision 37,341 37,359 Ear, nose and throat 13,592 12,726 Ringworm 78 103 Minor ailments 125,669 128,819 Teeth 138,437 138,639 Total 315,117 317,646 Eye defects The number of children dealt with in the eye departments of the centres and hospitals during the year was 37,359 compared with 37,341 during 1937. The facilities for the treatment of children suffering from squint have been continued at the following hospitals and centres during the year : Belgrave, Central London Ophthalmic, Evelina, Guy's, King's College, Royal Eye and St. Mary's hospitals, and Kilburn, Paddington, Streatham and Whitechapel centres. Special orthoptic training of suitable cases has been undertaken at the Central London Ophthalmic, Evelina, Guy's, King's College and St. Mary's hospitals and at the Kilburn, Streatham and Whitechapel centres. At each of these the services of a specially trained orthoptist are provided to assist the ophthalmic surgeon in examining the children in order to obtain the proper functioning of the eyes. The number of children treated during 1938 was 292, compared with 243 during the year 1937. The number of children discharged, treatment having been completed, was 166 during 1938, compared with 155 during 1937. Ear, nose and throat The number of children suffering from ear, nose and throat defects dealt with during the year was 12,726, and 8,894 operations for the removal of enlarged tonsils and adenoids were performed, compared with 13,592 and 9,251, respectively, during 23 the year 1937. Of the total number of operations performed (8,894), 7,759 were for both enlarged tonsils and adenoids, 749 for enlarged tonsils only, and 377 for adenoid growth only; the remaining 9 were operations in which cauterisation was used. As a general rule the children are kept in for two nights after the operation, but when the operation is performed on Friday they are kept in for one night only. In the latter case, arrangements are made for the children to be conveyed to their homes by ambulance. This is done throughout the year, mainly on account of the condition of the children after only one night's rest after the operation. Owing to the risk attendant upon the children in many cases having to wait in the street for trams and buses to reach their homes, arrangements have been made for all children operated upon at the hospitals and centres during the winter months to be taken home by ambulance. The vehicles of the London Ambulance Service are used for this purpose, as well as the ambulances provided for the conveyance of physically defective children. The latter are used as far as possible at the week-ends, throughout the year, to convey the children kept in for one night only after operation. Ringworm There are 5 hospitals and 3 school treatment centres in London where suitable X-ray treatment is available in connection with the treatment of children suffering from ringworm of the scalp. Cases are referred to the most convenient centre or hospital as they arise, but happily the number of cases, though larger than in 1937, is still very small. During the year 1938 the number of children treated was 103, of whom 88 were treated by X-rays, compared with 78 cases (69 X-rays) during the year 1937. Twenty-five years ago the number dealt with annually numbered 10,159. Minor ailments The number of children dealt with at the various minor ailments centres during the year 1938 was 128,819, including 21,086 seen by the nurses only, compared with 125,669 and 19,304, respectively, during 1937. Under the heading " minor ailments" in table IV at the end of this report are included 14,292 children suffering from scabies and impetigo who were treated at the bathing centres, bringing the total of minor ailments treated (including ringworm) to 143,214. The total number of minor ailments centres at the end of 1938 was 80. Daily nursing treatment is also provided at the Bloomsbury dispensary and at 14 schools where difficulty is experienced in arranging conveniently for the children to attend the centres. Dental treatment As a result of the appointment by the Council of a full-time consulting dental surgeon (Major General J. P. Helliwell, C.B.E., L.D.S., M.R.C.S., L.R.C.P.), it was possible for the first time in the history of the Council's administration for a complete and comprehensive survey to be made of the Council's dental treatment scheme. After consideration of this survey, certain recommendations were made for the improvement of the scheme, the chief among which were:— (1) Reduction in the number of children to be dealt with each session of 2½ hoursHitherto 10 new cases had been seen each session in addition to such old cases as were instructed to re-attend. This standard number per session was set many years ago, but as time went on and the general condition of the mouths improved, more conservative treatment was possible, with the result that it became difficult to provide a high standard of conservative treatment in the time available each session. It is proposed that the number of cases to be dealt with each session shall be reduced gradually, and, during the year 1938, where additional sessions have been approved, the number of new cases in addition to old cases has been reduced to 6 a session. It is hoped that a reduction throughout the service will be possible in the future. (2) Provision of alternative accommodation for centres which were unsatisfactory. Proceedings have been initiated in this direction, and during the year 1938 arrangements have been made for the replacement or improvement of 6 centres. (3) Improvement and renewal of dental equipment where necessary. The equipment at some of the centres has been in use for many years and requires a thorough overhaul. This is in hand, and modern equipment "will be provided as soon as possible. 24 (4) Appointment directly by the Council of the part-time dental surgeons and ancesthetists instead of appointments being made by the centre committees. This was arranged from 1st October, 1938, so far as the dental surgeons were concerned, and it is expected that the dental anaesthetists will be appointed directly by the Council during the year 1939. (5) Gradual replacement of part-time dental surgeons by whole-time officers. It has been decided that the school and hospital dental services shall be combined, and that the services of the officers shall be interchangeable between school treatment centres and general or special hospitals. The part-time dental surgeons will be replaced gradually as opportunity occurs. The scale of salary approved is £500 a year, with annual increments of £25, to a maximum of £750 a year. (6) The employment of dental attendants. At present the dental surgeons are assisted at the dental inspections in the schools by assistant organisers of care committee work, and at the treatment centres by qualified nurses. It is proposed that one dental attendant, who will be a woman, will be appointed for each whole-time dental surgeon. Her duties will mainly consist of chairside assistance, preparation of the dental surgery, clerical duties and attendance at the dental inspections in the schools. The scale of salary approved is £120 a year, with annual increments of £10, to a maximum of £180 a year. So far as the work at the hospitals and treatment centres included in the Council's scheme during the year 1938 is concerned, the total number of children dealt with was 138,639, compared with 138,437 during the year 1937. Details of the work undertaken will be found in table IV, group IV, at the end of this report. The most notable feature in regard to the work is that, although only slightly more children were attended to in 1938 than in 1937, the amount of conservative treatment carried out in 1938 exceeded that of the former year by about 20,000 fillings. This can be accounted for in two ways : firstly, by the introduction of the inspection and the subsequent treatment of certain children in the " leaver " group and, secondly, by the provision of additional dental sessions in order that a higher standard of conservative treatment, especially of permanent teeth, could be attained. The ratio of fillings in permanent teeth to permanent teeth extracted was 2.54 to 1, compared with 2.31 to 1 in 1937, 2.07 to 1 in 1936, and 2.05 to 1 in 1935. The total number of dental treatment centres at the end of 1938 was 74, including the special centre at Berkshire Road school and the Eastman clinic. Three new centres were opened during the year at Brixton, North Hammersmith (sub-centre) and Northwold (Hackney). The Old Ford centre was transferred in October, 1938, from temporary premises at Monteith Road M.D. School to the first floor of the maternity and child welfare centre built by the Poplar Borough Council in Wendon Street, E.3. The dental inspections in the schools have been carried out by the 83 inspecting dental surgeons, of whom 16 are women. The number of sessions devoted to this work was 2,857, and 292,971 children were examined. Of these, 204,205 were found to require treatment, or 69.7 per cent., compared with 68.3 per cent. in 1937. During 1937, the number inspected was 315,016, of whom 215,243 were found to require treatment. Orthodontics The scheme for the orthodontic treatment of school children under the direction of the two orthodontists, Miss L. M. Clinch and Miss E. M. Still, has been continued during the year. Miss Clinch undertakes the treatment at the 6 centres north of the Thames, viz., Chelsea, Hackney, Hammersmith, Notting Dale, Paddington and Whitechapel, and Miss Still the 5 centres south of the river, viz., Bermondsey Medical Mission, Deptford, St. Christopher (Battersea), Stockwell and Woolwich. In addition to the treatment at the centres, the orthodontists undertake the construction of fixed appliances at the workshop, 123, Peckham Road, or in their own laboratories. Specially trained nurses assist both at the centres and in the making of the plaster 25 models at the workshop. In certain instances removable appliances are made at the Council's central dental laboratory, Romilly Road, Islington. The number of new cases seen at the centres during the year was 1,114, and the total number of attendances was 6,867. Fixed appliances were made for 677 of the children, and removable appliances were provided for 146 children. The number of cases in which treatment was completed and the children discharged was 198, and 103 were found to be unsuitable for treatment. Special aural centres The Council maintains 15 special aural centres which are under the direction of Mr. A. G. Wells, F.R.C.S., who is assisted by 12 assistant aurists giving part-time services. Excluding purely deaf children, the number of children attending for the first time at these centres for ear treatment during the year was 1,541. Including old cases, the number of examinations of children during the year was 14,942, and the number of ears examined was 18,639. In addition to the above, there were 1,830 children who attended the first time for examination to determine the cause of hardness of hearing. Particulars of this section of the work are given in the following table:— Table 14—Deaf cases Classification Patients Ears treated Total number of attendances 5,957 8,492 New cases 1,830 2,489 Cases carried over from 1936 271 401 Old cases returned 59 87 Cases cured 1,211 1,638 Cases partially relieved 129 182 Cases unrelieved 16 25 On current file, lapsed, etc. 804 1,132 In addition to the above there were:— Throat cases 60 Nasal cases—New 256 „ Carried over from 1937 37 „ Old cases returned 76 After-care clinic, St. George's dispensary At the St. George's dispensary, Southwark, a special aural centre is maintained where children from the Council's residential schools suffering from otorrhoea are treated, and where also the after-care of children who have returned home from the Downs hospital school after mastoid operations is carried out. The number of "ears" dealt with in children from the residential schools was 157, and the percentage of cure 77.6. The number of children under supervision at the centre who had been discharged from the Downs hospital was 165, including 51 children discharged in 1937. The total number of children attending, including after-care cases, was 548, the number of attendances made was 7,929, and the number of children discharged well was 353. Analysis of otorrhoea cases from ear, nose and throat clinics The subjoined table gives a detailed analysis of all cases of otorrhoea 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, 1938. This table includes children suffering from otorrhoea who attended the after-care clinic. 26 Table 16—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 370 303 8 8 51 Chronic otitis media suppurativa due to (I) Tympanic Conditions (a) Tympanic sepsis (T.S.) 1,250 932 2 61 255 (b) T.S. + granulations 213 130 7 13 63 (c) T.S. + polypi 28 11 3 2 12 (d) T.S. + caries 14 3 2 1 8 (e) T.S. + other conditions 4 3 1 — — (II) Tympanic Conditions with (a) Tonsils and adenoids 202 124 6 13 59 (b) Nose conditions 487 317 2 30 138 (c) Mouth conditions 5 2 — 3 — (III) Tympanic Conditions with (a) Attic disease 47 24 7 2 14 (b) Mastoid disease (no operation yet done) 153 8 124 1 20 (e) Mastoid disease (operation already done) 510 284 20 31 175 (IV) Tympanic Conditions with (a) External otitis 65 48 1 5 11 (b) Stricture of meatus 3 1 1 — 1 External otitis 168 137 1 7 23 Cause undetermined 2 2 — — — Total 3,521 2,329 185 177 830 From these figures it will be seen that the percentage of "cases cured" is 69.6 per cent. Orthopadie treatment The provision for orthopaedic treatment in London is adequate. As local education authority, the Council has established 27 day schools for the physically defective with accommodation for 3,157 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 10 visiting orthopaedic surgeons employed in connection with the Council's general and special hospitals. There are two main special children's hospitals maintained by the Council to which children suffering from orthopaedic 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 orthopaedic patients. There is no difficulty in finding accommodation immediately for all such 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 1937 was 610, of whom 328 were non-tuberculous and 282 tuberculous. Consultations and after-care examinations of children discharged from hospital are held by the orthopaedic surgeons three times weekly at County Hall. 27 London is a great centre for medical education, and there are many voluntary hospitals, which maintain orthopaedic departments, engaged in the teaching of medical students. These are all eager to undertake the orthopaedic care of children. There are also special voluntary orthopaedic hospitals at which orthopaedic surgeons of the highest repute hold appointments. At some of the hospitals the Council's organisers of children's care work attend in the orthopaedic departments as liaison officers. These include the orthopaedic 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 orthopaedic 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 1938 was 173. 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. 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 Belgrave, Charing Cross, Guy's, the London, the Miller, the Queen's, West London, the London Jewish, and Poplar. Organisers are also attached to the aural, eye and skin departments of Guy's Hospital. 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, 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 preschool 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. In her annual report for 1938, Miss H. G. Nussey, principal organiser of children's care work, says:— All districts report very close co-operation with the numerous other agencies which exist to help parents and their children, e.g., the Invalid Children's Aid Association, the tuberculosis dispensary, the Charity Organisation Society, the Church Army, the N.S.P.C.C., Children's Country Holidays Fund, invalid kitchens, settlements and juvenile organisations. There is frequently cross-representation. In fact, it may sometimes be said that "one man in his time plays many parts." Requests for care committee reports, apart from those required by the medical services, continue to pour in from almoners, relieving officers, the Charity Organisation Society, Juvenile Advisory Committees, psychiatric social workers at the Council's mental hospitals, etc., and after-care done by one of the care committees of a mentally defective school has resulted in a very close liaison with the supervision section of the mental hospitals department. An interesting new development is the reference of cases to the care committees by the judge at one of the county courts when grants are being administered through the court to children. Stammering Stammering children At the ten centres for the treatment of stammerers from elementary schools a total of 403 children attended during the year; of these, 107 were discharged as cured, while 42, many of whom had greatly improved, left for various reasons. 28 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; 51 pupils attended, of whom 5 were discharged cured and 10 left. At Salter's Hill school, 48 children from residential schools of the Council attended a special centre. Of these, 18 were cured and 4 left. One of the speech therapists, Miss Grace Lloyd, has analysed the histories of 100 consecutive children referred for stammering. Place in family: only child, 6; first born, 31; second, 25; third, 16; fourth, 8; fifth, 7; sixth, 6; seventh, 1. In regard to five, the child was one of twins. Stammering in other members of the family was found in 33 families. Fathers stammered in 18, mothers in 7 and brothers and sisters in 12. Squint was present in 6 stammerers. Left-handedness was found in 18 of the 100 stammerers and in 31 near relations of stammerers. The stammer was stated always to have been present in 16 cases, and to have come on at 2 years in 2; 3 years in 12; 4 years in 14; 5 years in 19; 6 years in 7; 7 years in 3; 8 years in 5; nine years in 1; 10 years in 7; 11 years in 6; and 12 years in 2. The age of onset was uncertain in 6. Causation was said to have been due to: shock, 31; start of school life, 6; imitation (other than cases of heredity), 7; after exanthemata, 7; after tonsillectomy, 4; change from left hand to right, 1; heredity, 21; no cause assigned, 23. 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 1938 the smooth working of the rheumatism scheme was to some extent interrupted by the events of the international " crisis " in September. In accordance with the general principle which had been decided upon, a large number of the children in the rheumatism units who were not acutely ill were at this time discharged home. Many children also were removed by their parents in order that the chance of their being evacuated from London might not be missed. Except in a few instances where serious cardiac lesions were present, no great immediate harm appears to have resulted, although it is to be noted that subsequently nominations for re-admission were fairly numerous. Nominations for institutional treatment The number of applications received, during 1938, for institutional treatment (2,371), showed a slight increase on the figure for the previous year (2,367); but, owing to a somewhat larger number than usual of these applications being withdrawn (mostly due to parental objections), the number remaining to be dealt with fell slightly below that of 1937. In addition to these withdrawals, 109 children were found on examination not to be suffering from rheumatism, thus leaving a total of 1,987 children for whom institutional treatment had to be arranged. The difference between this total and the corresponding totals for the two preceding years is negligible, and it seems evident that there is little change at present in the prevalence of juvenile rheumatism. The nominal accommodation of the rheumatism units remains at 900 beds, of which the average number available during the year was 835. This accommodation is adequate, but only just adequate, to cope with the demands made upon it. At times of pressure a waiting list tends to be built up, but the system of preliminary examination by specialist medical referees ensures the careful grading of cases, and thus only in the less urgent ones is admission delayed. Rheumatism units During the year 2,030 children were admitted to the units. Approximately 37 per cent. of these showed signs of cardiac involvement, and it is gratifying to note that this is a decrease of 6 per cent. compared with the preceding year. An analysis of the condition of the children on discharge also shows an improvement in the results of treatment. During 1937, 1,925 children were discharged, of whom 23.7 per cent. had cardiac involvement of a degree necessitating some restriction on their activities. In 1938, only 21.3 per cent. of the 2,037 children who were discharged were so handicapped. 29 Progress has been made in regard to the provision of modern cardiac diagnostic apparatus at the rheumatism units, and a considerable amount of patient investigation in connection with the treatment, diagnosis and pathology of the disease is being carried out. So far as treatment is concerned, no spectacular advance has yet been made and rest under good hygienic conditions still remains the mainstay of treatment. The period necessary naturally varies, but six months may be regarded as a fair average. Absolute recumbency during the whole period is not implied; to quote Dr. Gray Hill, who for many years has supervised the rheumatic unit at Queen Mary's Hospital "a prolonged period of forced recumbency proves a strain on the patient and rest and strain are diametrically opposed; rest must be natural not forced." Accordingly at the rheumatism units the regime is one of gradually increasing physical activity combined with suitably planned education. The results are that the children remain happy and occupied during their stay in hospital—an important factor of successful treatment—and are better able to hold their own educationally on returning to a day school after discharge from a hospital school. Supervision At the end of the year, 7,792 rheumatic children were registered as being under supervision. Of these 5,160 were in attendance at rheumatism supervisory centres, and 2,632 were under the supervision of the school doctors. These figures are substantially the same as those for the preceding year. Much administrative work in this connection devolves on the school care committees, who also furnish reports on the home surroundings of the children. Their work cannot be valued too highly, more especially in the matter of the notification of defective conditions in the homes. The number of rheumatism supervisory centres remains still at 20, but an additional centre at Clapham will be available in July, 1939. With the opening of this centre every area in London will be provided for. The centre at Reginald Square, Deptford, has been moved to more convenient premises at Creek Road, Greenwich, and this will enable the work there to be carried out in close co-operation with the Greenwich medical officer of health. Precipitating causes of chorea In view of the widespread belief that attacks of chorea are related either to mental or physical " shock " and perhaps to the strain of school work, it was thought that it might be instructive to obtain, if possible, definite figures. Accordingly, 296 cases were analysed with this object in view, and it was found that a clear history of fright or physical injury or surgical operation immediately preceding the attack was present in just over 8 per cent. of the cases. It would seem that such factors have a definite influence in an appreciable number of cases. This perhaps should be borne in mind in considering the desirability of operations such as tonsillectomy. In so far as school work is concerned there is no convincing evidence to support the view that it is an important predisposing cause of chorea. Of the 296 cases analysed (all children attending elementary schools), in only four was the attack attributed to this cause. In secondary school children the proportion was somewhat higher, but the small total number of cases found amongst these children suggested that the incidence of chorea in secondary school children was particularly low. Nevertheless it is of interest to note that, in children suffering from recurring attacks of chorea, a transfer to a school for physically defective children very frequently results in the cessation of the attacks. Occasionally, after a period, these children have been retransferred to an elementary school and an immediate relapse has occurred. On the other hand, a steady fall of the prevalence of chorea occurs after the age of nine, and this would seem to negative the suggestion that preparation for examinations plays a considerable part in its occurrence. It is just at this age that the competition for scholarships makes its appearance, and, if preparation for examinations played any significant part, one would expect a rise in the incidence of chorea between the ages of nine and twelve. Probably the important point in the relationship of school work to the incidence of chorea is the presence of an inborn bias towards nervous instability. 30 Table 16 Particulars 1936 1937 1938 Nominations for treatment under the scheme— Number received from the Council's hospitals 678 761 748 „ „ „ voluntary hospitals 619 548 575 „ „ „ rheumatism supervisory centres 576 565 578 „ „ „ school doctors 303 348 338 „ „ „ other sources (chiefly private practitioners and welfare organisations) 221 145 132 Total number received 2,397 2,367 2,371 Subsequently withdrawn 55 69 141 Final total 2,342 2,298 2,230 Examinations by medical referees— Examined and accepted with concurrence of parents 2,013 2,059 1,987 „ ,, „ but treatment refused 210 114 122 Examined and found unsuitable for institutional treatment 117 113 109 Awaiting examination, 31st December 2 12 12 Total 2,342 2,298 2,230 Treatment—• Admitted to rheumatism units 2,039 2,018 2,030 Died before admission was arranged 1 5 4 Awaiting admission, 31st December 45 69 33 Total 2,085 2,092 2,067 Supervision— Number of children under supervision (31st December) by school doctors. 2,596 2,526 2,632 Number of children under supervision (31st December) at not visory centres recorded 5,164 5,160 Total — 7,690 7,792 Number of supervisory centres 20 20 20 Number of sessions at supervisory centres 1,088 1,073 1,090 Number of children attending for first time 1,921 1,920 1,885 Number discharged as no longer needing supervision Not re corded 432 Total number of attendances at centres 15,913 15,552 15,306 Reports by care committees on home conditions 1,664 1,448 1,744 Number of premises reported to borough medical officers of health re dampness or to valuer re obtaining of better accommodation 442 335 434 Rheumatism Units— Nominal accommodation (i.e., number of beds) 930 900 900 Average number of beds available 889 856 835 Average number of beds occupied 803 798 794 Table 17—Admissions to rheumatism units, 1938 Sex Rheumatism and/or chorea with cardiac involvement Rheumatism and/or chorea with no cardiac involvement Total Number Percentage Number Percentage Boys 363 39.5 556 60.5 919 Girls 383 34.5 728 65.5 1,111 Total 746 36.7 1,284 63.3 2,030 Table 18—Discharges from rheumatism units, 1938 Sex Fit for elementary school or any employment Fit for P.D. school or light work only Permanently unfit / Number Percentage Number Percentage Number Percentage Boys 716 7519 189 20.3 26 3.8 931 Girls 887 80.9 185 16.7 34 2.4 1,106 Total 1,603 78.7 374 18.4 60 2.9 2,037 31 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 1938, 1,463,634 examinations of children were made at these rota visits. In 106,299 cases the child was noted as verminous, i.e., in 7.3 per cent. of the examinations, compared with 7.9 for 1937 and 8.1 for 1936. 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 65,292 (compared with 82,357 in 1937, and 85,300 in 1936), figures which represent all those children who were noted to be infested with live vermin or their ova. About 47 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, 22 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, Finsbury, was opened in December, one head cleansing centre at Downham was closed in July, and an additional head cleansing centre was opened in January in connection with the Hoxton treatment centre. The following particulars for 1937 and 1938 are in respect of the cleansing scheme operated from the Council's and Borough Councils' centres (as distinct from the " head " cleansing centres):— 1937 1938 Number of advice cards issued to parents from bathing centres 82,357 88,240 Number of children attending voluntarily at bathing centres after advice cards 42,899 47,730 Number of statutory notices served in accordance with section 87 of the Education Act, 1921 22,604 22,389 Number attending bathing centres after statutory notices:— (а) voluntarily 4,279 5,047 (b) compulsorily 16,514 15,399 Number of cases in which police court proceedings were taken ... 250 195 At the head cleansing centres, 22,363 children attended during the year compared with 20,362 in 1937. 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 1938 a total of 63,975 children attended the bathing and head-cleansing centres, compared with 63,451 in 1937 and 66,464 in 1936. 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 1938, 11,458 children were conveyed in the ambulances. Scabies and impetigo Children suffering trom scabies and impetigo are treated at the bathing centres. The total of such cases was 14,292 for the year, a considerable increase on the number for the previous year (10,962). The co-operation of the local sanitary authorities in respect of simultaneous disinfection of homes is gratefully acknowledged. 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 32 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 my last report measures taken to diffuse information concerning scabies were given in detail. Further efforts at more intensive propaganda are under way. 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 19 shows the number of children reported to have been out of school for more than three months in November, 1938, and comparative figures for the three preceding years. The number of children (91) absent on account of rheumatism, chorea and heart disease still forms a high proportion (25 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 91, compared with 320 in 1934. Nervous disorders (including 14 cases of epilepsy, and 5 of infantile paralysis) accounted for 26 children. For the first time for many years there was not a single case of encephalitis lethargica. Kingworm, formerly a chief cause of prolonged absence from school, accounted for only 5 cases, compared with 129 in 1919. Since the introduction of X-ray treatment for ringworm, the average length of absence has steadily declined, and consequent upon the shorter period of infectivity, the danger of the spread of the disease has likewise diminished. Tuberculosis was the cause in 26 cases. Among other ailments, respiratory diseases, other than tuberculosis, accounted for 31 cases, and ear disease for 15. The total invalidity among girls was greater during 1938 than among boys (188 to 175). There were 1 boy cripple and 3 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" is a small number of mentally defective children, who, after ascertainment, at the moment of taking the census had not been placed in special schools, though excluded from elementary school. No blind or deaf child was reported as waiting admission to an appropriate school in November, 1938. Table 19—Census of chronic invalids, November, 1938. and preceding years Ailment Cases Percentage of total 1935 1936 1937 1938 1935 1936 1937 1938 Rheumatism, heart disease and chorea 232 153 114 91 30.9 26.7 22.3 25.1 Nervous disorders 61 58 36 26 8.1 100 70 7.2 Tuberculosis (all forms) 67 39 22 26 8.9 6.8 4.3 7.2 Anaemia and debility 41 37 30 12 5.5 6.4 5.9 3.3 Ringworm 2 2 6 5 0.3 0.3 1.2 1.4 Skin complaints (excluding ringworm) 35 24 29 20 4.7 4.2 5.6 5.5 Eye disease 9 12 10 7 1.2 2.1 2.0 1.9 Infectious diseases 35 23 29 20 4.7 4.0 5.6 5.5 Other defects 268 225 236 156 35.7 39.5 46.1 42.9 Total 750 573 512 363 100 100 100 100 33 Sleep of school children The General Purposes Sub-Committee of the Consultative Committee of Headmistresses of Girls' Schools asked that consideration should be given to the desirability of issuing to parents a leaflet drawing attention to children's lack of sleep owing to various factors, e.g., summer time, the radio, the cinema. The school medical officer has prepared a leaflet which was printed and distributed through the schools. Included in the leaflet was the advice that essential hours of sleep and times to go to bed are:— 12 hours at 4 years old 6.30 p.m. 11 to 12 hours at 5 to 7 years old 7.0 p.m. 10 to 11 hours at 8 to 11 years old 8.0 p.m. 9 to 10 hours at 12 to 14 years old 8.9.0 p.m. The leaflet received an immediate and widespread response and its influence extended far beyond the London schools through laudatory notices in both the London and provincial press. A Junior Red Cross link, when established in a school, forms a valuable aid to health, as is shown by the following extract from a recent number of the Junior Red Cross Journal:— Link 1074. Senior Girls' School, Walworth—We have tried to keep the health rules, especially in the matter of going to bed early. (This is good news indeed !—Ed.) Infectious diseases in schools Elementary schools The numbers of cases of infectious illness which occurred among children in the day elementary schools during the year, together with comparative figures for the preceding six years, are shown below:— Table 20 Year Diphtheria Scarlet fever Measles and German measles Whoopingcough Chickenpox Mumps Ophthalmia 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 1936 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 1938 3,576 3,988 34,235 4,067 11,018 4,805 342 The figures for ringworm are given later in this section of the report (page 36). The numbers of cases of scabies and impetigo, the treatment of these diseases and the measures taken during 1938 with a view to reducing their incidence, are referred to on page 31. No case of smallpox was notified in London during the year. The last confirmed case occurred in June. 1934. Members of the school medical staff carried out a number of special investigations during the year into the possible causes of infectious diseases in schools, details of which are given hereunder:— Table 21 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. 45 31 4,227 12 11 1,216 N. 30 23 1,882 8 7 646 N.W. 23 15 1,882 8 8 585 S.W. 28 24 2,772 16 15 1,625 S.E. 49 38 4,785 18 18 1,319 Total 175 131 15,548 62 59 5,391 34 In addition, a special examination was held at one school on account of the prevalence of a skin complaint. The sequel illustrates the value of such epidemiological field work. The condition was found to be molluscum contagiosum, and as a result it was found possible to arrange for the admission of one child to a Council hospital, while others were treated at home by private medical practitioners and at school clinics. Valuable work was done by the school nursing staff in following up the investigations by medical officers shown above, and also in making special visits to schools in connection with the occurrence of infectious disease as indicated below:— Nature of No. of special visits infectious disease by school nurse Diphtheria 173 Scarlet fever 126 Chickenpox 108 Mumps 63 Whooping-cough 33 Sore throats 88 Diphtheria As shown in table 21, school doctors made 175 visits to 131 departments in elementary schools, during the course of which 15,548 children were inspected and swabbings from the throat and nose of 2,380 selected children were taken. Of this number, 103 (4.3 per cent.) proved positive. In addition, 1,082 children were swabbed at treatment centres or clinics, and bacteriological examination showed that 98 (9.1 per cent.) of them were positive for Bacilli diphtheriæ. As a precautionary measure, swabs were also taken from the throat and nose of 638 children prior to entry to convalescent homes, and 635 of these proved to be negative. It was considered necessary to re-swab children in 62 cases when examination of a primary swab was inconclusive or suspicious. In 27 of these cases, Bacilli diphtheria were found to be present. The systematic swabbing of contacts and of certain other children is of considerable value because it leads to the segregation of possible sources of infection. During the period 1st January to 13th April, 1938, morphological Bacilli diphtheriæ were isolated and tested for virulence in 70 cases, of which 61 (87 per cent.) proved virulent and 9(13 per cent.) non-virulent. Since April, however, the virulence tests have been largely discontinued and replaced bv fermentation tests. Diphtheria "carriers" out-patient clinics 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 were continued throughout 1938, 60 children of school age being referred there by various authorities, hospitals or private doctors. A report has been furnished by the medical officer in charge of each of the clinics, giving details of treatment and the results obtained. The majority of cases were found to have lost their " carrying " propensity by the time they were examined at the clinics. Three cases were removed to hospital as cases of clinical diphtheria, and one with measles. Tonsillectomy was advised for three more cases, and the remainder were given treatment and ultimately discharged as cured. Active immunisation against diphtheria The Corporation or London and the Metropolitan borough Councils arrange for immunisation against diphtheria to be carried out at infant welfare or special centres, or by arrangement with medical practitioners or voluntary hospitals. As in previous years, 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. Children in the Council's residential establishments are immunised against diphtheria and a summary of the work done during the year appears later in this section of the report. Scarlet fever The incidence of scarlet fever among school children was slightly higher than in 1937, 3,988 cases having been reported, compared with 3,903 cases during 1937. The average number of cases for the years 1932-8 was 6,409. Investigations were made on 62 occasions at schools where several cases had occurred. 35 Passive immunisation before tonsil and adenoid operations Active immunisation against scarlet fever was carried out at four of the Council's residential establishments, and a reference to this work is made later in the report. At two treatment centres the practice obtains 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 preventing the occurrence of those diseases after the operations have been performed. Parental consent is obtained in each case. This procedure has been in force at the Cyril Henry treatment centre, Woolwich, since 1933, and at the Hanover Park treatment centre. Peckham. since 1936. The following figures relating to this pre-operative immunisation during 1938 have been received from the divisional medical officer:— Cyril Henry treatment centre Hanover Park treatment centre Children attended 1,433 1,295 Operation performed 1,108 1,085 Operation deferred 325 210 Serum given 920 680 Serum not given because of— Recent attack of scarlet fever or diphtheria Recent immunisation or recent reaction after antitoxin 39 216 History of asthma 3 3 Parents refused consent 146 186 Serum rashes, etc., occurring among children passively immunised 351 174 One child at the Cyril Henry treatment centre suffered from scarlet fever after the operation. The parents had consented to immunisation, but this was not done as the child had been immunised a year previously in similar circumstances. The previous high incidence of post-operative scarlet fever and diphtheria at the clinics has disappeared. Measles The biennial epidemic of measles commenced in November, 1937, and for the week ended 18th December. 1937, the number of school children reported to be suffering from the disease was 324. After the Christmas holiday, the number of cases reported in the four school days of the week ended 15th January, 1938, was 999, which number included absentees suspected to be suffering from measles. The Council's scheme of control, which provides for special co-operation between the school nurses, teachers, school attendance officers and borough medical officers of health, in order to bring to the notice of the borough medical officers of health cases of measles in their earliest stage, was put into operation on 12th January, 1938, and continued until the incidence of measles in the schools had decreased sufficiently to justify its suspension during the week ended 16th July, 1938. The following figures indicate the numbers of measles cases reported among the elementary school population during this and the five previous epidemics. The figures relate to the epidemic period of nine months from November to July. Date Cases reported from schools Average number on school rolls Attack rate per 1,000 1927-28 45,343 652,342 69 1929-30 36,634 623,728 59 1931-32 35,705 598,865 60 1933-34 38,949 584,049 67 1935-36 32,690 518,630 63 1937-38 35,292 467,442 75 It will be noted that the number of cases was greater than in the previous epidemic, but less than in the 1933-34 epidemic. The attack rate per 1,000 was higher than in recent epidemics. A detailed report on the epidemic is in course of preparation. Ringworm and favus Cases of ringworm of the scalp occurring among children in the Council's elementary schools are followed up by the school nurses, and, if any difficulty is experienced in treatment by ointments and lotions, or if this treatment is considered unsatisfactory,the parents are offered X-ray treatment under agreements made by the Council with certain voluntary hospitals and treatment centres. 36 The following table shows the number of cases of ringworm of the scalp among the children in the Council's elementary schools reported during 1938 and in previous years:— Table 22 Year New cases Cured cases Cases outstanding Percentage of cures at the end of effected by X-ray the year treatment 1926 1,029 1,141 228 76 1931 419 420 107 62 1936 190 187 44 67 1937 181 164 61 66 1938 194 206 44 83 During the year, 408 specimens of hair from school children were examined for ringworm at the laboratory at County Hall. After microscopical examination fungus was found in 134 of these (116 small spore ringworm, 15 large spore ringworm and 3 favus). Play centrcs As has been the practice m previous years, co-operation has been maintained with the Play Centres Committee, who were notified of all schools where infectious disease was prevalent. The Committee have continued the scheme for the distribution of notices warning parents against sending children to the centres if they are unwell or are home contacts of infectious illness. School journeys Special arrangements for the medical examination of children before departure for school journeys were continued, and borough medical officers of health have again been asked to co-operate by forwarding information when a case of infectious disease occurs in a home from which a child has proceeded on a school journey. Particulars of the general arrangements made for school journeys during 1938 are set out on page 41. Hop picking —infectious disease The measures taken in co-operation with the Kent public health authority with a view to preventing the introduction of infectious diseases among workers in the hop-gardens, which have been described in previous annual reports, were continued in 1938. Approved schools and remand home Residential establishments for children There was a recrudescence of body ringworm at Ardale approved school, twentynine cases having been reported during the year. A special visit was paid to the school in May by a medical officer from County Hall who made a thorough examination and proffered suggestions on the method of treatment and disinfection of clothing. The outbreak subsided in October and no further case has been reported since. At Stamford House remand home there occurred during the year a number of cases of scarlet fever, diphtheria and scabies. All necessary steps were taken to prevent the spread of infection but the incidence of infectious disease was not regarded as excessive, bearing in mind the shifting population of the home. One boy was found to be suffering from gonorrhcea on admission. He was admitted to hospital and later discharged as cured. Another boy, who was found to be suffering from gonorrhcea on admission, was discharged by the court before treatment was completed. He was subsequently re-admitted to the remand home, but, as he refused treatment, he was sent by the court to a prison hospital for treatment. Reference to the occurrence of cases of vulvo-vaginitis at this home is made later in this report. Residential special and open-air schools Residential schools, children's homes, and children's receiving homes Active immunisation against diphtheria was continued during 1938 at all five of the approved schools, and, in addition, active immunisation against scarlet fever was continued at the Mayford school. The numbers of cases of infectious disease at the residential special and open-air schools were not unduly excessive and no special comment is called for. The infectious diseases occurring in the residential schools, children's homes and children's receiving homes in numbers sufficient to warrant special mention were : measles at three institutions, German measles at two, and chickenpox at three. All practicable steps were taken to prevent the dissemination of infectious disease in the establishments, including the removal of patients to appropriate hospitals. 37 Mention has been made in previous annual reports of the arrangements for sending infectious disease "contacts" to Earlsfield House children's receiving home. This procedure has been continued. During the year, 360 children were admitted to the "contact" block at Earlsfield House, and, of these, 13 children developed the disease to which it was stated they had been exposed, and 10 developed other diseases. Active immunisation against diphtheria Schick-testing and immunisation against diphtheria are carried out at the Council's residential establishments for children with certain exceptions, viz., the receiving homes, 3 residential open-air schools and the remand home. At these latter establishments the children do not remain a sufficient length of time for immunisation to be carried out. During the year 1937, 1,066 children were Schicktested, viz., 724 boys and 342 girls, of whom 442 boys (61.0 per cent.) and 163 girls (47.7 per cent.) proved to be Schick negative or naturally immune from diphtheria, while 282 boys (39.0 per cent.) and 179 girls (52.3 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 as follows:— Table 23 Age Total tested Percentage Male Female Schick negative Schick positive Male Female Male Female 2 years 41 31 22.0 9.7 78.0 90.3 3 „ 42 33 31.0 36.3 69.0 63.7 4 „ 30 31 46.7 35.5 53.3 64.5 5 „ 34 19 44.1 47.4 55.9 52.6 6 „ 33 13 57.6 38.5 42.4 61.5 7 „ 22 28 54.5 42.9 45.5 57.1 8 „ 26 21 73.1 47.6 26.9 52.4 9 „ 30 18 90.0 55.6 10.0 44.4 10 „ 39 16 64.1 50.0 35.9 50.0 11 „ 53 22 71.7 63.6 28.3 36.4 12 „ 90 19 63.3 84.2 36.7 15.8 13 „ 113 36 73.5 63.9 26.5 36.1 14 „ 70 20 52.9 500 47.1 50.0 15 „ 51 22 76.5 50.0 23.5 50.0 16 „ 50 13 70.0 69.2 30.0 30.8 724 342 61. 0 47.7 39 0 52.3 Age groups of children in above table 2- 5 years 147 114 34.7 30.7 65.3 69.3 6-10 „ 150 96 68.0 46.9 32 0 53.1 11-16 „ 427 132 67.7 62.9 32.3 37.1 724 342 610 47.7 390 52.3 Of the total of 461 Schick positive cases, 354 proved to be negative after the usual course of immunising injections, and 16 became immune after further injections. The remaining 91 children left school before immunisation was completed. In these cases the appropriate medical officers of health were informed so that they might make arrangements for the immunisation to be completed. The following is a summary of the progress of immunisation during 1938 :— Uncompleted cases brought forward from 1937 162 Number tested for susceptibility 1,169 Number found to be immune 705 Number found to be susceptible 464 Completed full immunising course and gave negative reactions on re.test 377 Left school before course of immunising injections had been completed 111 Outstanding on 31st December, 1938, to be completed in 1939 138 38 During the year, 33 children were removed to hospital from the residential establishments where immunisation against diphtheria is carried out, suffering or suspected to be suffering from diphtheria. As a result of subsequent findings, 7 (21.2 per cent.) proved not to be suffering from diphtheria, 1 (3 per cent.) yielded bacteriological but no clinical evidence of diphtheria, and 25 (75.8 per cent.) were found to be suffering from clinical diphtheria. The following analysis of the 25 clinical cases indicates the number of children who had been subjected to immunisation at the residential establishments and the subsequent diagnosis at the hospital:— Classification Hospital diagnosis Schick negative on preliminary test and therefore notl subjected subsequently to prophylactic injections | Paucial 3 Nasal 1 4* Schick negative after course of prophylactic injections Course of prophylactic injections not completed Nasal 1† Faucial 3 Nasal 3 6** Not Schick-tested Faucial 10 Nasal 4 14 *1—10 months after Schick negative result. 1—11 ,, ,, ,, ,, ,, 1—7 „ ,, ,, ,, ,, 1—6 years ,, ,, ,, ,, †l—2½ ,, ,, ,, ,, ,, **1—10 days after second injection of diphtheria prophylactic. 1—10 months ,, ,, ,, ,, ,, 4—No prophylactic given. Active immunisation against scarlet fever Active immunisation against scarlet lever was carried out at tour of the Council's residential establishments, viz., Mayford approved school and Shirley, Ongar and Hutton residential schools. During the year 1937, 857 children were Dick-tested, viz., 501 boys and 356 girls, of whom 374 boys (74.7 per cent.) and 251 girls (70-5 per cent.) proved to be Dick negative, while 127 boys (25.3 per cent.) and 105 girls (29.5 per cent.) were Dick positive or susceptible to scarlet fever. The following is an analysis of the number of children Dick-tested and immunised during 1937:— Table 24 Age Total tested Percentage Male Female Dick negative Dick positive Male Female Male Female 2 years 51 32 31.4 25.0 68.6 75.0 3 „ 45 32 46.6 43.7 53.4 56.3 4 „ 25 21 64.0 57.1 36.0 42.9 5 „ 24 18 66.7 77.8 33.3 22.2 6 „ 17 23 82.4 82.6 17.6 17.4 7 „ 34 25 79.4 84.0 20.6 16.0 8 „ 23 17 91.3 88.2 8.7 11.8 9 „ 33 37 93.9 91.9 61 8.1 10 „ 16 20 100.0 85.0 — 15.0 11 „ 43 22 86'0 77.2 140 22.8 12 „ 40 32 87.5 68.7 12.5 31.3 13 „ 79 27 81.0 89.0 190 11.0 14 „ 65 26 84.6 76.9 15.4 23.1 15 „ 5 22 80.0 54.5 20.0 45.5 16 „ 1 2 100.0 100.0 — — 501 356 74.7 70.5 25.3 29.5 Age groups of children in above table 2—5 years 145 103 47.6 46.6 52.4 53.4 6—10 „ 123 122 88.6 86.9 11.4 13.1 11—16 „ 233 131 84.1 74 0 15.9 26 0 501 356 74.7 70.5 25.3 29.5 39 Of the total of 232 Dick positive cases, 27 left school before immunisation was completed, 202 proved to be negative after the usual course of immunising injections, and 3 became immune after further injections. The following is a summary of the progress of immunisation during 1938:— Uncompleted cases brought forward from 1937 50 Tested for susceptibility 308 Found to be immune 156 Found to be susceptible 152 Completed full immunising course and gave negative reactions on re-test 115 Left school before course of injections had been completed 28 Outstanding on 31st December, 1938, to be completed in 1939 59 During the year, 5 children were removed to hospital from the above-named schools suffering from scarlet fever : 3 had not been Dick-tested, 1 was Dick negative in 1937 (18 months prior to the onset of scarlet fever) and 1 had been immunised and showed a negative reaction on retest (18 months prior to contracting scarlet fever). Vulvovaginitis During the year 18 cases of vulvo-vaginitis were reported among the girls in the residential establishments (excluding the remand home). Every case proved negative for gonococcal infection. There were 104 cases of vulvo-vaginitis reported trom the Stamtord House remand home, compared with 65 for the previous year. In every case the patient was removed to hospital. Bacteriological or clinical examination revealed evidence of gonococcal infection in 21 of these cases, a marked decrease in positive infection compared with the number (27) for 1937. Provision Open-air education Provision for education in the open air includes nine day open-air schools (non-tuberculosis) with accommodation for 1,460 children, and six day open-air schools (tuberculosis) accommodating 515 children. There are also seven country and seaside convalescent camp schools, accommodating 520 children for periods varying from one to three months, through which 3,824 children passed last year, and 215 open-air classes in playgrounds and parks providing for upwards of 6,000 children. Open-air schools for non-tuberculous 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. 1938:— Boys Girls Total Aspen House 71 49 120 Bow Road 106 73 179 Brent Knoll 86 52 138 Charlton Park 93 60 153 Downham 83 62 145 Holly Court 165 116 281 Stowey House 160 119 279 Upton House 82 67 149 Wood Lane 91 65 156 Total 937 663 1,600* *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. The organisation of the two types of day open-air school has been under review during the year, and, as the result, it has been decided that while it is desirable for the present to retain a distinction between the two types of school, the time is opportune for some modification of the difference in regime. Proposals have therefore been adopted which will increase the interchangeability of the accommodation and enable it to be utilised to the best advantage. These changes will come into effect during 1939 and will be dealt with in my next annual report. Open-air schools for tuberculous children 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 40 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 598. The number on the roll on 31st December, 1938, was 559, and the average attendance for the year was 476. 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 1938, 189 children were admitted and 199 discharged. Of the latter, 55 were transferred as fit to attend elementary schools, 85 were fit for work on attaining school-leaving age, 37 moved away, 17 were transferred to other special schools, and 5 were discharged for other reasons (e.g., the distance was found to be too great for the children). During the year, 90 children were also transferred to institutions for residential treatment for tuberculosis or admitted to hospitals for various reasons. During 1938, arrangements were made under the ordinary school journey organisation for 362 children on the rolls of open-air schools (type T) to have a holiday out of London for two weeks. A further party of 35 children was accommodated at the Council's Millfield Convalescent Hospital for a fortnight. Convalescent camp schools The numbers of children spending a period of stay at the residential convalescent camp schools during 1938 were : boys, 2,120 ; girls, 1,704 ; total, 3,824. In detail the numbers were:— Provided schools:— Boys Girls King's Canadian school, Bushy Park 2,045 — George Rainey, St. Leonards — 543 Wanstead House. Margate — 688 Total 2,045 1,231 Non-provided schools:— Boys Girls Fairfield House, Broadstairs — 80 Russell Cotes school, Bournemouth — 196 St. Vincent's, Hastings — 90 Sandon home, Chelmsford 75 107 Total 75 473 The actual number of children away at these schools at one time in 1938 was: Bushy Park, 250; St. Leonards, 64; Margate, 87; Broadstairs, 20; Bournemouth, 29; Hastings, 10 ; Sandon, 20 ; total, 480. The small home at Sandon accommodates the children needing a country holiday from the various types of special schools. The number of open-air classes held in connection with the elementary schools in 1938 was 215. Of these, 13 were of type A (children selected on medical grounds from a group of schools); 121 were of type B (children selected on medical grounds from the various classes of a single school); 18 were of type C (consisting of a single class from one school, educated continuously at one open-air station); and 63 of type D (consisting in a rotation of classes from one school occupying one open-air station). Fifteen classes are permanent, that is to say they are outside the yearly programme and do not need re-authorisation each year. In addition, 126 of the 215 classes were continued throughout the winter, where the suitability of the sites had been approved by the school medical officer. Of the 215 classes, 77 were held in parks, gardens, playing-fields and other open sites, while 102 were held in school playgrounds, of which 36 were roof playgrounds. Open-air classes in parks and playgrounds 41 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. During the year 4,725 children were discharged from convalescence at the undermentioned hospitals. No. of children discharged from Institution convalescence St. Anne's home 1,331 Goldie Leigh hospital 102 Downs hospital for children 475 Lower Southern hospital 2,392 Millfield convalescent hospital 425 Total 4,725 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 1938 grants in respect of a maximum period of eight weeks' convalescence were authorised for each of 2,638 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 1938, 395 school journeys were arranged. The children taking part were medically examined in all cases before departure. In all, 13,710 children were examined, and of these 76 were excluded as unfit to take part in the journeys for the following reasons: heart disease, 6; tonsillitis, 8; otorrhoea, 4; conjunctivitis, 1; septic wounds, 8; skin disease, 17; raised temperature, 8; dental trouble, 5; infectious disease, 10; other conditions, 9. Several children were provisionally rejected on grounds connected with personal hygiene, but were subsequently passed after visiting a bathing centre. Physical education The following is abstracted from the report of the organisers of physical education (Mr. A. H. A. Gem and Miss Grant S. Clark) for the three years ended September, 1938:— The report covers three years which, from the point of view of physical education, have been highly significant. Progress has been rapid and far-reaching. One of the prominent features has been the large building programme which has been undertaken by the Council. 1 The standard planning has been altered in the case of central and senior schools to include 1 a gymnasium, a showering-drying-changing room, a teacher's changing room, and an apparatus store in each new school. Central and ilementary schools 42 The gymnasia in these new schools are light and airy, and have an area of 1,800 sq. ft. ; they are equipped with a limited range of apparatus, the floors are specially constructed of non-splintering hard wood, and they are designed in such a manner that they afford a measure of resilience. The floor is perhaps the most important piece of apparatus, as so many exercises are taken in a sitting or lying position, and for this reason cleanliness is a matter of major importance. The design of the gymnasium and changing room is such that the children must enter the changing room first where they change for their lesson before entering the gymnasium. This arrangement does much to ensure the preservation and cleanliness of the gymnasium floor. The purpose of reconditioning is to afford to a school, so far as the limitations of the building permit, facilities which approximate to those which would be provided in a new school. So far as physical education is concerned this treatment has, in the majority of cases, proved most effective. By September, 1938, the following position had been achieved:— New central schools with gymnasium, showers, etc. 2 Re-conditioned central schools with hall-gymnasium, showers, etc. 5 *New senior schools with gymnasium, showers, etc. 7 Re-conditioned senior schools with hall-gymnasium, showers, etc. 9 Total 23 Introduction of apparatus work *Two of these are without modern changing and showering rooms. Physical education in junior schools has not benefited to the same extent by the building and reconditioning programme. Prior to the re-organisation of schools, physical training was based on the Board of Education Syllabus of Physical Training, 1919. This syllabus was compiled on the basis that schools were "through" schools, and that in any given class there would undoubtedly be a wide age range. Re-organisation, however, led to a much closer grading and after a few years it became evident that this publication did not make adequate provision for the older children in central and senior schools, and a temporary pamphlet was issued to act as a guide for boys' work in central and senior schools, while the girls in central schools received similar help. In 1933 the Board of Education revised the syllabus, and in its new form it is intended to act as a text-book for junior schools and for the first year's work in a central or senior school. It was stated that separate publications would shortly be issued for senior boys and senior girls, but at the time of compiling this report these books have not been published. The need for a definite syllabus for the senior children was meanwhile growing urgent, and during the past year the Council's organisers of physical education have themselves written the necessary books, and these have been published by the Council The decision to introduce this extended range of training has raised two major problems :—- (i) The supply of apparatus. The Council has agreed to supply to each senior school, and to each " through " school with a senior section, the following equipment: 6 gymnastic benches, 4 stools, 1 vaulting box, 1 vaulting buck or horse, 1 beating board, 4 gymnastic mats, 1 pair jumping stands and rope, 10 climbing ropes. (ii) The training of the necessary number of teachers to conduct such work. With this end in view the Council recently sanctioned the holding of a series of special six-week half-time courses, the training at which was to be based on the new senior syllabuses. The first course to be held was one in the late autumn of 1937 for young men teachers from the unattached list. The first courses for permanent teachers were held in May, 1938; one in the mornings for men, and one in the afternoons for women. As a result of the training given in these courses the equipment in eleven central schools has been brought up to scale, and 53 senior departments have been equipped with portable apparatus. The recruitment to these courses is giving rise to some anxiety. In some cases the only suitable man or woman has now been trained, in others there is no member of the staff suitable for training. The method which has been adopted in recruitment is for members of the organising staff to visit the schools and discuss on the spot the possibility of teachers attending these classes. So far 146 boys' schools have been visited, and of this total 21 departments have no teacher on the staff able to take the training. In a similar manner 90 girls' schools have been visited and 35 have no teacher available for this specialised training. It is apparent that, unless exceptional steps are taken, the introduction of work embracing the use of portable apparatus cannot be ensured in many senior schools. There is a further issue to be faced, namely that in certain departments there is only one teacher suitable for training in this advanced work, and it is neither reasonable nor desirable for that teacher to shoulder the entire responsibility for the physical training of his or her department. In the main, the physical training in senior schools is confined to free standing exercises, activities, games and the simpler agilities, and the general standard of efficiency in this range of work is ouite good, and shows everv indication of becoming still better. Junior and unreorganifed schools While the main developments have centred round senior departments, attention has also been paid to the work in junior and unreorganised schools. Steps have been taken to give the teachers concerned a more intimate knowledge of the Board of Education 1933 Syllabus of Physical Training, and the quality of the work has steadily improved. 43 During the period covered by this report special day and evening courses have been organised for teachers working in junior and unreorganised schools. The response has been excellent, and many hundreds of teachers have availed themselves of the facilities provided. While the majority of central schools had been equipped with a good range of portable apparatus prior to the period covered by this report, climbing ropes and certain other items had not been supplied, and it was hoped that this apparatus would be provided during the current three-year programme. The demands of the senior reorganisation, however, make this unlikely, and additional equipment can only be supplied in so far as central schools come within the scope of this scheme. Central schools The demand for specially trained physical training teachers is growing throughout the country and, at the present time, the output from the men's training colleges is rapidly absorbed for posts as organisers or tutors in training colleges, or teachers in secondary and technical schools. The result is that the central schools are not at the moment attracting teachers with this qualification, and only four of the boys' central schools have teachers on the staff who have attended a one-year course. While many children bring their own shoes, and great efforts are made to provide separate clothing or to adapt the normal clothing, it has been shown during past years that such provision, in spite of every effort on the part of the teachers, leaves a large number of children unprovided for. Clothing It is a matter for regret that no advance can be recorded with regard to the provision of plimsolls and clothing for physical training by the authority. It is necessary to point out that the physical training cannot be really satisfactory until proper footwear is available and suitable clothing is worn by the children. Reference has been made to the extensive provision of shower baths which has been made recently, and one of the problems which has to be solved is how this facility is to be most effectively used. Shower baths Difficulty arises when a parent flatly refuses to let his or her child have a shower bath. Compulsion is not possible, and the teachers concerned are deserving of the warmest praise for persuading between 70 and 80 per cent, of the children to take part. The most difficult problems which have to be solved are those concerned with the provision, drying and storage of towels. Every effort is made to induce the children to bring their own towels, and, while this method is effective so far as the majority of children are concerned, there are many who fail to bring towels. If these children are to use the facilities provided, towels will have to be supplied by the authority. Assuming that every child has a towel, the problem of drying and storing has still to be faced. It is a comparatively simple matter for those whose physical training lessons take place during the last period of the morning or afternoon, as they can take the towels straight home with them. But if the lesson takes place during the first period of the morning or afternoon, then a wet towel has to be disposed of for the rest of the session. Some practical and cheap method of drying and storing towels must be evolved, and it is urged that experiments should be started immediately to discover the solution of this problem. The shower baths have been planned so as to permit of rapid showering, drying and dressing, and, with this end in view, the space available for this purpose is divided into three sections, one containing the actual showers, one serving as a place in which the children can dry themselves, and one providing the accommodation in which the children dress. It is essential to separate the drying and changing spaces, otherwise the children, returning direct from the showers to the changing room, are apt to get their ordinary clothing wet. It has been shown that a total of ten minutes is sufficient time for changing and showering purposes: three minutes to change into gymnastic clothing at the beginning of the lesson, two minutes to shower, and five minutes to re-dress at the end of the lesson. Of course, if the task is to be carried out in this time method is necessary. Drying and dressing are things which can take a long time ; anyone who has had to deal with children will realise this. The actual showering space has, in each case, been planned in one of two ways. If the showers have to serve both boys and girls they are of the individual type with the side shower, the cubicles being formed by movable rubber curtains. If the showers have to serve boys only, then they are planned on the continuous "walk through " basis with the water projected from two sides simultaneously. By either of these methods 12 children can receive a good shower in 45 seconds, and the whole of an average sized class in two minutes, thus leaving five minutes for drying and dressing. A great experiment has been started which, if wisely and energetically directed, should produce far-reaching results. Allocation of ime to ihysical ducation One of the immediate results of the issue of Circular 1445 by the Board of Education was that the Education Committee decided to circularise all schools for a second time with regard to the amount of time which should be devoted to physical education. The recommendation was couched in the following terms :— 1 " The appropriate Committee wish to direct special attention to one point raised in the Circular, which is set out in the following paragraph :— " There should be a daily period of organised physical activity in every elementary school, the length of these periods as well as their allocation will depend somewhat upon circumstances, but an allowance of three periods weekly to physical exercises, one to swimming, and one to organised games, will often be found suitable ; for girls, dancing may, on occasion, be substituted for games or swimming. 44 "The Committee are in agreement with the view herein expressed by the Board as to the desirability of a daily period of organised physical activity in every elementary school The proposal now put forward is that there should be a daily period of organised physical activity on each of the five school days of the week." The results of this circular were broadly, that the majority of schools substantially carried out the recommendations, while a limited number made out a reasonable case for being unable to do so. There are still cases, however, in which the time devoted to this work falls short of the Committee's recommendation, and it is hoped that in the near future a real effort will be made by such schools to provide a daily period of organised phvsical activity for all children. The classroom playing-field scheme facilities tor organised games in the London area are provided in the Council s parks and open spaces, in certain Royal parks, in parks and grounds controlled by Borough Councils, on sites under the control of the Education Committee which have been adapted for the purpose, on grounds rented from sports organisations and others, and on a number of playing fields which are provided with special classroom accommodation. It is with regard to the last named that considerable development has taken place. The aim of the Council is to ensure that all pupils throughout their final year in junior schools, and all pupils in a senior department (or its equivalent in an unreorganised school) have at least one hour's games on a playing field each week. The facilities already available, owing to their extent, and more particularly to their distribution, are insufficient to meet such a demand, and the policy of acquiring large playing fields under the control of the Education Committee has therefore been adopted. One of the problems is the inevitable distance from schools to playing fields. The length of time taken to reach a playing field is often out of all proportion to the time available for play, and many head teachers are reluctant to make heavy inroads into the time-table. The solution is to send children to a playing field for the whole day, and in order to make this possible classrooms have been built on some of the fields already purchased, and these are used by the children when they are not actually playing games. These classrooms are adequately heated and are furnished with portable desks and chairs and all necessary storage facilities, in which books, writing materials, etc., can be kept. In addition, cloakrooms, lavatories, changing and showering rooms and staff rooms are provided. The grounds are laid out so as to provide pitches for football and hockey in the winter together with other games such as Rugby touch, netball and skittle-ball. In the summer the major games are cricket, rounders and stoolball, while cricket nets, slip catching cradles, long and high jump pits and minor games pitches are also provided. All equipment for games is stored on the playing fields and the supply is sufficient to allow of mass coaching in all games. Experience has shown that it is essential to have on each field a dry playing area, so that games shall not be missed owing to the grass pitches being unfit for play. One of the many difficult problems which still have to be faced is the lack of suitable footwear and clothing. While parents should be encouraged to provide suitable footwear and clothing for their children, the number capable of so doing is limited, and some form of provision by the Council would appear to be inevitable. The children leave the neighbourhood of their schools at 9.15 a.m., and on an average reach the fields at 10 a.m. There they remain until 3.30 p.m., at which hour they start the homeward journey. During the time spent at the ground every class is allocated at least one hour for games. The children bring their own mid-day meal with them and this is, as a rule, eaten between 12.15 and 1.15 or 1.30 p.m., the luncheon interval being reduced to allow a full afternoon session of two hours before the return journey at about 3.30 p.m. Milk can be obtained, and there are facilities for heating it when the weather is cold. Negotiations are taking place to secure five further playing areas, each of 100 or more acres, and each provided with 50 or more classrooms catering for some 2,000 children daily. The five areas will, therefore, cater for 10,000 children daily or 50,000 each week. A start has been made on a scheme to which the often abused word " gigantic " might reasonably be applied. From the inception of this scheme up to September, 1938, five grounds, comprising in all 55 acres with 19 classrooms, have been purchased, equipped, and are in full operation. Special arrangements have also been made at three further grounds with 12 classrooms. In addition six sites, covering 480 acres, have been purchased with a view to development. While the major effort has been directed towards the purchase of outlying fields and the building of the necessary classrooms thereon, no opportunity has been missed of purchasing local grounds nearer to the schools for the purpose of organised games only. During the period under review, facilities of this type, comprising 13 acres, have been provided in six districts. Voluntary associations This report would not be complete without reference being made to the admirable work carried out in London by the many voluntary sports associations. Such activities form an essential part of a comprehensive scheme of physical education, and the Council has recently emphasised its appreciation of this work by giving a measure of financial assistance, such money to be used to help to defray the travelling expenses of children taking part in the various fixtures. These include the London Schools' Athletic Association, the London Schools' Amateur Boxing Association, the London Schools' Cricket Association, the London Schools' Games Association for girls, the London Schools' Football Association, and the London Schools' Swimming Association. 45 The vast amount of work carried out by these admirable associations may be gauged by the results of the activities of the last named, which, during 1935-37, issued 114,783 swimming and 25,351 life-saving certificates. It must be remembered that these voluntary services are performed by a comparatively small number of teachers as the average school has two or at the most three teachers on the staff who are actively concerned with these extra-mural activities, while in some cases the entire responsibility falls on one man or woman. Month after month and year after year they give their Saturday mornings and their evenings to this cause. They perform a great work for the children in their charge and one deserving of high praise. The play leadership scheme has now been in operation for a period of four summers, and it is possible to form some reliable estimate of its value. In 1935, 39 centres were opened and there was an average attendance of 87 children per centre; while in 1938 games were held at 80 centres and the average attendance was 102 children. Play leadership scheme The success of this evening work was such that the Council decided to extend the scheme to the establishment of centres in parks and playgrounds during the summer holidays of 1938, and this decision was amply justified, particularly in respect of the centres situated in the parks. The following figures illustrate what was achieved :— Number Average attendance Boys playground centres 27 52 Boys park centres 16 115 Girls playground centres 25 51 Girls park centres 17 130 Total 85 The parks proved more attractive to the children than the playgrounds, and it is suggested that in the summer of 1939 the number of playground centres should be decreased and the number of park centres correspondingly increased. When the Carnegie College was opened, the Council decided to grant a certain number of scholarships to enable teachers to attend the one-year course. The majority of teachers who have attended the course have done well, and several have obtained posts in training colleges, secondary and technical schools. Training of teachers A course tor men, ot similar type to that organised at uarnegie ooliege, nas Deen commenced at the Loughborough training college. This course is recognised by the Council, and in the year 1937-38 two teachers were granted scholarships to enable them to attend. For many years the Council has given scholarships to enable girls to attend a three years' course at a physical training college ; these scholarships are tenable at the physical training college at Chelsea Polytechnic, and at the Bergman Osterberg College, Dartford. The growing necessity of training teachers to undertake a measure of specialisation in physical education in senior schools has led to the establishment of a certain number of threemonth courses. The Council, realising the value of such training, has made provision for a certain number of teachers to take advantage of these facilities. Two women have already attended a course, and two are due to attend shortly, and by Easter of 1939 five men will have received similar training. The Council recently agreed to re-introduce the practice of aiding teachers to attend holiday courses, and during the summer of 1938 four men and two women availed themselves of this facility. ±I1C paoi IUICC j cai o nave uccu maiA^u uj wuoiuciauic avvivii/j ov iai ao LsuiiiAjug ID concerned. In former reports attention was directed to the fact that many secondary schools either had no gymnasium or else one that did not conform to modern standards. During the three years, progress has been rapid and ten schools have been provided with a modern gymnasium, a changing-drying-showering room, an apparatus store and a teacher's changing room. In addition, 13 schools are scheduled to be provided with similar facilities during the current three-year programme. Two new schools are proposed, and preliminary plans have been approved, while two county secondary schools are to be replaced by new buildings. In each case physical training accommodation on the most modern scale will be provided. Secondary schools A further matter which has received careful attention during the period under review has been the provision of adequate changing facilities in those schools which do not already possess them. It is by no means unusual to find that in the years gone by schools were provided with quite an effective gynmasium, but no room in which the children could change. The addition of a changing room is by no means always an easy matter, as it is not unusual to find that owing to the original structure of the building it is either extremely difficult or even impossible to build the changing room adjacent to the existing gymnasium. During the past three years it has, however, proved possible to provide changing rooms, fitted with shower baths, at four schools. It is hoped, moreover, that during the current programme similar facilities will be provided at ten further schools. There is a problem closely allied to the provision of shower baths which has not, as yet, been solved, viz., the provision of drying and storage facilities for towels and gymnastic kit. 46 Development of secondary school work Assuming that a physical training master or mistress is able to teach for approximately thirty periods a week, it follows that for every ten classes in a school one full-time teacher, or the equivalent, will be required. This figure does not take into account the coaching in games. Similarly, a gymnasium can accommodate only thirty-five groups a week ; thus one gymnasium just affords adequate accommodation for an eleven-class school. It will therefore be appreciated that, quite apart from the curriculum difficulty, there are many serious obstacles to be overcome before the principle of a daily period of organised physical activity becomes an established fact in the secondary schools of London. The work seen during the period under review has been vigorous and purposeful, and effective training is given in the majority of schools. The gymnastic teachers are zealous and interested in their work, and are always ready to avail themselves of opportunities to keep abreast of modern developments. Games A new and more enlightened attitude towards games has been developing during recent years. The practice, which was at one time general, of allowing boys only to play football and cricket whether or not they were suited to these particular games, is no longer enforced to the same extent. Fives, tennis, boxing, athletics and cross-country running are being more widely introduced, and, although the major school games must be the dominating factor, there are nowadays alternatives for boys who show no aptitude or liking for football or cricket. The main essential is that all shall take some form of exercise with regularity, and to meet this a considerable extension of playing fields has proved necessary. During the period under review ten fields have been acquired and laid out, comprising 61J acres, while negotiations are proceeding for the purchase of land for four other schools. During the current programme a field of five acres is being provided at Wormwood Scrubs to afford a much needed extension for four schools. Encouragement has been given to boys to play the excellent game of fives. New courts have been provided at three schools. The courts at two have been covered and artificially lighted ; while the covering and lighting of the courts at two more are at present under consideration. Further, it is hoped that during the current three-year programme courts will be provided at two additional schools. The games played during school hours are liberally supplemented by class, house and school games which are played after work is over. The teachers give ungrudgingly of their time and energy, and the high quality of the results achieved bears witness to the enthusiasm with which this task is undertaken. Evening institutes There can be little doubt that the post-school population is more actively interested in health than was formerly the case. There are signs that the public is now more appreciative of the fact that inactivity leads to physical deterioration, and in this present highly competitive life no one can afford to deteriorate. London is already making a notable contribution to national fitness, largely through the medium of the evening institutes. The scope of the curriculum, which at one time was apt to be narrow, being confined almost entirely to gymnastics, free standing exercises and dancing, has been steadily widened and a man now has a choice of gymnastics, free standing exercises, boxing, swimming, wrestling, fencing and folk dancing. A woman has a choice of gymnastics, free standing exercises (keep fit work), dancing of various types, swimming or fencing. It is urged that this process of expansion be continued, and that in the near future field games, athletics and cross-country running be added to the curriculum. In the last report it was indicated that after the set back of 1931 a forward movement had again set in, and the number of classes then in existence was 628 for men and boys, and 776 for women and girls. It is most satisfactory to be able to report continued progress, and the latest figures available are as follows:— Total number Total strident of classes hours Men and boys 958 515,175 Women and girls 1,209 502,239 Hand-in-hand with the growth of classes has gone a steady development in the quality of the work. It is noticeable that those institutes which expect and demand a high standard of work and behaviour achieve it; those who are content with the second rate in their turn receive it. It is quite clear that the majority of students expect and wish to work hard, and are not prepared to accept a lifeless and dull lesson which fails to extend them adequately. It is inevitable that evening institutes should in the main be housed in school buildings which were never designed with a view to the needs of the adult. The dictates of economic administration, moreover, make it most improbable that this position will alter fundamentally for many years to come. Yet, although change on a wholesale scale is impracticable, nevertheless, a progressive policy has been adopted and, whenever a suitable opportunity presents itself, steps are taken to improve facilities and make them more in keeping with adult requirements. Gymnasia and shower-baths are being provided or are under consideration at many institutes. The foregoing brief account of the physical activities of the evening institutes gives some indication of the part which London is playing in the development of national fitness. There is clearly the will to succeed in this difficult task, and the future is full of promise. 47 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 (one-third pint each) 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. The numbers of individual children on free "meals" in December in the years 1934 to 1938, inclusive, were as follows :— Table 25 Meal 1934 1935 1936 1937 1938[/##] Dinners 5,725 5,245 5,596 6,251 7,228 Milk 15,691 20,300 24,120 28,800 32,224 Some 2,000-3,000 children received cod-liver oil and malt in school on the doctor's advice; many others obtained it in school on payment by the parents. In view of the changing attitude and beliefs in regard to the nutritional needs of children, and the recognition that the difficulties experienced are no longer those of total insufficiency of nutriment, but are due rather to specific defects in home dietaries, certain experiments are being carried out which are of great interest. Two of these experiments are those concerned with the substitution of halibut-liver oil for cod-liver oil and malt, and the substitution of an " Oslo " meal for the ordinary hot dinner. Difficulties have arisen in certain schools in the provision of cod-liver oil and malt when recommended by the school doctor. These have been due in part to the sticky or messy nature of the mixture. Consideration has therefore been given to the provision of a substitute which can be administered in capsule form. Halibut-liver oil A thousand doses (each a desertspoonful) of cod-liver oil and malt cost 18s. Id. The equivalent of halibut-liver oil (two capsules to a dose) would cost 18s. 4d. In the distribution of cod-liver oil and malt to about 11,000 children women helpers are employed for a total of about 1,150 hours a week, at an annual cost of about £2,371. There would thus be a saving of about £2,340 if this service could be dispensed with by the substitution of capsules for liquid oil and malt. An experimental trial of capsules has been sanctioned at five schools. Considerable attention has of late been directed to the method of giving school meals to necessitous school children and others in the schools of Norway and other northern countries. This method is generally referred to as "the Oslo breakfast." Not only has it spread far and wide in schools of Norway and neighbouring countries, but it has attracted the attention of dieticians in other countries and has been favourably commented on in the bulletin of the Health Organisation of the League of Nations ; and suggestions have been made that it should be introduced into London schools in substitution for the present provision of hot mid-day meals. Prior to the passing of the Education (Provision of Meals) Act, in 1906, there existed no powers to local education authorities under which money could be expended on the provision of food for hungry or ill-nourished children. The " Oslo " experiment 48 Malnutrition existed among London school children to a much greater extent than now prevails, and the teachers of London, faced with the difficulties of endeavouring to educate children who were obviously suffering from lack of food, undertook extensively to give some nourishment to such children with the aid of voluntary funds. With the collection of these funds the name of Mrs. Burgwin must always be remembered, for she, with the late Mr. G. E. Sims, of the Referee newspaper, was largely associated with the collection and distribution of funds for the purpose. The meals given varied widely, but were restricted in scope and in nutritional value by the inadequacy of the funds contributed to cover the whole of the needs of the schools. Bread and soup given at mid-day were, in many instances, the form in which the supplemental needs were partially met; in other cases a breakfast of cocoa with bread and margarine had to suffice. After the enabling Act of 1906, the Council took over the responsibilities of feeding necessitous children in the schools, and the children's care organisation was set up to carry out the necessary local enquiries and the selection of children to be fed. The nature of the meals to be given was discussed, and it was decided that a substantial mid-day meal should be given on the lines sanctioned by English use and custom and consisting, generally, of two courses, one of meat and vegetables and the other of a substantial pudding. On the advice of the Council's medical officer, the standard adopted was that each meal should give 750 calories and contain at least 25 grammes of protein. At that time the discoveries in relation to vitamins had not been made, and it was considered that, whereas the children obtained at home sufficient, or even possibly an excess of carbo-hydrate food, the more expensive protein element necessary for growth was lacking in the home diets, and it was desirable that a meal rich in protein should, therefore, be provided. The desirability of including more food of a fresh nature was raised on medical grounds, but the arguments which could be used in the state of knowledge which existed at that time were not found to be sufficiently convincing. During the winter of 1910, the school doctor at Wolverley-street school, Bethnal Green, finding so many children in the school at that time suffering from malnutrition, suggested that they should be given milk in school. The head teachers and the care committee of the school took up the suggestion and milk was provided. The results were so excellent that the practice spread, first to neighbouring schools, and eventually to the whole of London, of giving milk to school children on the school doctor's advice. Since the introduction of the Milk Marketing Board's scheme in 1934, the custom of giving milk in school has widely spread beyond the limits formerly observed, and, in addition to the necessitous, a large proportion of children are obtaining milk in school on the payment by the parents of roughly half the economic cost. It should be mentioned that, before the introduction of the scheme of the Milk Marketing Board, many head teachers had organised milk clubs in the schools, through which the children were able to obtain milk on payment, if the parents so desired. Special attention has been paid to the milk question, since the necessity for adequate vitamin content in the food consumed has been at least partially met by this provision. In the case of necessitous children, in whom specific vitamin deficiency has been diagnosed by the school doctor, the provision of cod-liver oil and malt as a school " meal " has also been fairly widely made in London. Until comparatively recently, the same practice in dealing with necessitous school children, was followed in the Scandinavian countries as in London, i.e., the giving of a substantial hot meal in the middle of the day. Since attention has been drawn to the existence of vitamin deficiency, the authorities in these countries have been revising their ideas. Owing to the long period of the winter, there is a special difficulty experienced by the parents in northern countries in providing sufficient food of the protective kinds, e.g., fresh farm and dairy produce, raw salads and fruit. 49 It occurred, therefore, to some of the medical officers of these countries, led by the late Dr. Carl Schiotz of Oslo, to make a comparison between the effects of giving to school children a cold breakfast which consisted practically entirely of protective foods and the effects obtained by means of the usual hot mid-day meal. It is claimed that the results of the cold "protective" breakfast were greatly superior to those of the hot mid-day meal. A description of the Oslo breakfast, the extent to which it has spread, and the results of its substitution for hot dinners is best given in a letter from Dr. Carl Schiotz himself, which was transmitted through Professor Drummond of University College, London, who has studied the methods used abroad of dealing with the problem of feeding school children. This letter runs as follows : Now the Oslo breakfast is adopted at all public schools in Oslo, Bergen, Trondheim, Stavanger, Tromso, Harstad, Hamar, Sarpsborg, Horten, Porsgrunn, lately also in some rural schools in Norway (locally adopted), and, with local adoption, at some schools in Sweden, Finland and Copenhagen. The Oslo breakfast, as it is practised in Norway, is composed as follows: J litre unskimmed milk, a so-called Kneipp-cracker (baked preferably of whole-meal wheat) with margarine and goat's cheese, further so-called Kneipp-bread with margarine and goat's cheese, amount ad. lib. Finally, half-an-orange, half-an-apple or one raw carrot; as regards the vegetables, they are alternated according to the season. Further, it is to be noted that, if oranges are used, the meal begins therewith; if apples or carrots are used, the meal ends therewith (the cleaning of the teeth). The margarine is introduced only for economical reasons. It will now surely in several places be replaced by butter, as the Government has decided that public and municipal institutions can get butter at reduced prices. Experiments for comparing with other forms of breakfast have not been made, but, on the other hand, experiments have been made for comparison with the former school lunch. The results after 6 weeks' test were as follows:—The boys at the breakfast-school gained on an average of 886 g. per individual, at the lunch-school they gained 600 g. The girls at the breakfastschool gained on an average of 1,029 g., at the lunch-school 429 g. That is, with a very closely conneoted material (the two schools are socially and hygienically very equal) the weight-increase for the breakfast-boys equals that of the lunch-boys plus 48 per cent. ; for the girls, the increase of the breakfast-eaters exceeds that of the lunch-eaters by 140 per cent. There was no other difference introduced between the two schools than the composition of the meals. Particular attention is called to the high vitamin content of the Oslo breakfast as compared with the usual cooked midday meal. It is felt by many that the same considerations which have prevailed in the Scandinavian countries are applicable also in the great cities of this country, particularly in London. Conditions in London are not favourable to the introduction of breakfasts in place of midday dinners, but there is no great point in the time of the day at which the supplementary school meal is given, and it may be held that the Oslo meal would have the same effect if given at midday as if given first thing in the morning. Our people are very tenacious of their habits and customs, particularly those connected with food, and it might well prove that some prejudice would have to be overcome before all would agree to the substitution of a cold meal of protective articles of diet in the middle of the day for the usual solid hot meal of meat followed by pudding. A similar prejudice no doubt had to be met in Norway against the giving up of the hot midday meal, but, according to Professor Drummond, not only is the system applied to necessitous children in Norway, but the opportunity to receive the breakfast has been thrown open to all on payment; and, in 1935, 40 per cent, of the whole population of Oslo was taking advantage of it, and this proportion has since been rapidly rising. It is also, in London, difficult to secure such a close-cut comparison as in Norway between children fed on the Oslo system and those fed on the present system, owing to the practice which has developed here of distributing milk to children in the middle of the morning. The comparison is, therefore, not between Oslo meal and hot dinner but between Oslo meal plus milk and hot dinner plus milk. Nevertheless, it was considered that it would be advantageous to try a controlled experiment under which a relatively small but sufficient number of necessitous 50 children were fed for a time by the Oslo method and compared with a similar number of children, corresponding in other respects as closely as possible, who were being fed as is usual on hot dinners. It was agreed by the Council that an experiment on these lines should be made at the Trafalgar Square dining centre, Mile End, where 40 to 50 children are fed daily. It was decided that wholemeal bread should be substituted for Kneipp crackers and that New Zealand butter could, with advantage, be substituted for margarine. Goats' milk cheese was not considered essential and the substitution was adopted of a bland cheese of one of the lighter varieties, e.g., Caerphilly cheese. It was also decided that the meals should be called "health dinners." The experiment commenced at the above-named centre on 5th May, 1938. Weekly weighings and measurings were carried out, not only of the necessitous children receiving the modified Oslo diet, but also of an equal number of necessitous children receiving ordinary meals at a neighbouring centre. The experiment was supervised on the medical side by Dr. Bertha Sharpe. Apart from the difference in diet the children in the two groups were comparable, so far as could be ascertained, in all respects, including age, sex and social position. Particulars of the two groups are given in the following table Period, 9th May to 18th July, 1938 Height per cent, increase per child per week Weight per cent, increase per child per week " Health dinner" children " Control" children " Health dinner children Control" children Boys .159percent. .093 per cent. .311 per cent. .171 percent. (36—average age 9-7 years) (47—average age 9. 9 years) Girls .155 per cent. .074 per cent. .270 per cent. .193 per cent. (30—average age 9-7 years) (33—average age 9-7 years) Percentage increase of average "health dinner" child over "control" child, according to number of weeks fed Height weight Boys 71.0 per cent. 81-9 per cent. Girls 109.5 39-9 Average no. of attendances per child " Health dinner" boys 33 " Control" boys 32 " Health dinner" girls 38 " Control" girls 34 It was inevitable that changes in the actual children attending should take place in both groups owing to withdrawals, removals, illnesses, etc. The statistical method used was, therefore, to take all the full weeks put in by children at both the "Oslo" centre and the ordinary centre, and to obtain from the figures the average percentage increase of height and of body-weight per week of children attending both centres irrespective of whether they remained throughout the period or not. It will be seen that the figures indicate a very significant improvement of those children on the Oslo diet compared with those on ordinary dinners ; indeed they are very similar to the striking figures which were reported from Scandinavia before this experiment was started in London. The cost of the foodstuffs for the Oslo experiment during the above period was £65 2s. for 2,754 meals which approximately averages 5-7d. a meal. The Oslo foodstuffs had mostly to be bought in small quantities locally. On the other hand, the experiment during the period under review was carried on during a part of the year in which the food stuffs are cheaper than during the winter. It may be assumed, however, that, if the feeding on Oslo lines were done on a large scale, the cost would be reduced. Most of the children (liked the meals, and observers were pleased to find that the children were enjoying the food and attending regularly. 51 As the Oslo diet was introduced to counteract the deficiency in vitamincontaining food from which town children generally suffer, especially during the winter in northern latitudes, it was considered of importance that the experiment should be continued throughout one year, particularly when such encouraging results had been obtained in the first three months, as it is during the winter that shortage of vitamin stuffs is chiefly experienced. The experiment is, therefore, being continued throughout the winter of 1938-9. One of the remarkable results is the striking improvement in the complexions of the children, and the disappearance of minor ailments, particularly of blepharitis. The effect on blepharitis of a somewhat similar diet at the Swanley hospital school supports the view that this disease is a manifestation of specific vitamin deficiency. 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 two bottles a day. Milk Marketing Board's scheme, voluntary milk clubs 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. Distribution of milk during the holidays The result of the experiment was encouraging and it was decided to provide milk during the holidays for all children having milk on the recommendation of school doctors in term time, if the parents so desired. As on former occasions, all "doctors" cases receiving milk either free, for payment or for part payment, were given the opportunity of having milk. Children having two bottles of milk daily for part-payment in term-time were considered to be "free cases" for the purposes of this distribution, at which one bottle daily was given to each child attending. The distribution was arranged during the Christmas holidays at 162 centres, which included 159 schools in suitable positions, two central kitchens and one dining centre. The number of distribution centres was 160 during the summer holidays, 1938, and 135 at Easter, 1938. The following table shows the number ot invitations issued and the total average attendance for all centres, compared with the distributions during the Easter and summer holidays, 1938:— No. of invitations issued Average attendance daily Percentage of average attendance to invitations Free cases— Easter holidays, 1938 40,339 20,831 51-6 Summer holidays, 1938 40,248 17,419 43-2 Christmas holidays, 1938-39 41,675 17,001 40-8 Full paying cases— Easter holidays, 1938 23,887 6,995 29-2 Summer holidays, 1938 22,816 7,382 32-3 Christmas holidays, 1938-39 21,385 5,668 26-5 The attendances, particularly at Christmastide, were considered to be disappointing, and efforts are to be made, by notices and talks to the parents by the school doctors on the importance of milk to growing children, to secure better attendances in forthcoming holidays. The experiment was, however, handicapped owing to the Christmas holiday weather being very severe, particularly on two of the days when there was much thawing snow. Defective children Examinations with a view to the admission of children to special schools were made in 4,425 cases. The following table shows the number of children nominated for examination and the recommendations made:— 52 Table 26 Defect Number nominated Suitable for admission to Returned to elementary school Invalided as for the time unfit for any school Notified under M.D. Acts Boys Girls Blind school Partially sighted Swanley Boys Girls Boys Girls Boys Girls Boys Girl Boys Girls Boys Girls Ocular 629 791 3 3 75 75 249 253 295 455 7 5 — — Deaf school Partially deaf school Boys Girls Boy s Girls Aural 158 144 34 23 2 6 20 97 101 1 — — — P.D. school Day open-air school Residential P.D and hospital sohool Physically defective Boys Girls Boys Girl£ Boys 1 Girls 722 521 388 311 53 23 113 1 58 148 114 20 15 — — M.D.school Mentally defective Boys Girls 778 559 301 232 400 261 36 39 *41 *27 Epileptic colony 3oys Girls Epileptic 58 65 18 19 25 28 15 18 — — Total 2,345 2,080 1,260 1 ,017 965 959 79 77 41 27 4,425 2,277 1,924 156 68 *Of these 30 boys and 17 girls were imbeciles; 2 boys and 2 girls were idiots; and 9 boys and 8 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 27 Morbid conditions Boys Girls Total Infantile paralysis 26 21 47 Cerebral paralysis 17 10 27 Various paralyses 16 7 23 Tuberculosis of bones and joints 35 20 55 Osteomyelitis 48 15 63 Rickets and resulting deformities 7 3 10 Congenital deformities 15 11 26 Spinal deformities (including scoliosis) 5 5 10 Traumata and amputations 19 14 33 Non-tuberculous arthritis and synovitis 11 14 25 Rheumatism and chorea 13 20 33 Various chest conditions—fibrosis, bronchitis, asthma 84 35 119 Heart diseases— Congenital 21 16 37 Acquired valvular with history of rheumatism 121 138 259 without history of rheumatism 6 6 12 Non-valvular with history of rheumatism 4 6 10 without history of rheumatism ... 4 — 4 Anaemia 26 16 42 Pseudo-hypertrophic muscular dystrophy 6 — 6 Various nervous conditions, ataxia, etc 5 4 9 *Other diseases—chiefly medical 12 8 20 Total 501 369 870 * Including 1 boy and 2 girls suffering from nephritis. 53 The following statement gives an analysis of the 297 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 28 Morbid conditions Elementary school Invalided Infantile paralysis 14 2 Cerebral paralysis 1 4 Various paralyses 5 2 Tuberculosis of bones and joints 10 1 Osteomyelitis 25 — Rickets and resulting deformities 5 — Congenital deformities 14 2 Spinal deformities (including scoliosis) 9 2 Traumata and amputations 8 Non-tuberculous arthritis and synovitis 14 Rheumatism and chorea 23 1 Various chest conditions—fibrosis, bronchitis, asthma 35 7 Heart diseases— Congenital 13 2 Acquired valvular— with history of rheumatism 32 4 without history of rheumatism 6 — Non-valvular— with history of rheumatism 2 — without history of rheumatism 6 — Anaemia 14 — Pseudo-hypertrophic muscular dystrophy — 1 Various nervous conditions, ataxia, etc. 1 Other diseases—chiefly medical 25 7 Total 262 35 Children returned to elementary schools or invalided 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 13,244, and in addition 766 special examinations were made of children already on the rolls of special schools in connection with applications for non-enforcement of attendance and for other reasons. Rota visits to the schools As a result of the rota examinations the following re-classifications took place :— Table 29 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 ospital Physically defective — 6 — — — _ 3 _ 1 Mentally defective 1 — 1 — — 1 — 1 9 Partially sighted. 2 1 — 8 — — — — 2 Blind — — 1 — — — — — — Deaf — _ _ — — 1 — — — Partially deaf — — — — — — — — — Epileptic colony — 1 — — — — — — — After trial in a special school, 89 children were excluded (24 as imbecile, 34 as feeble—minded ineducable, 3 as "special circumstances," and 6 as feeble—minded "detrimental," and 22 invalided on medical grounds). 54 There were also 365 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 30 Action taken Special school classification P.D. M.D. Blind Partially sighted Deaf Partially deaf Total Returned, on improvement, to elementary schools 113 8 1 7 _ — 129 Over 14 years of age and excluded as no longer certifiable 142 17 — 77 _ _ 236 Total 255 25 1 84 — — 365 Decertification of physically defective children The following table classifies the children who improved to such an extent that they were able to return from the schools for physically defective children to the ordinary elementary schools, or were " no longer certifiable " as defective between the ages of 14 and 16 years :— Table 31 Morbid conditions Cases deemed no longer certifiable Cases deemed fit to return to elementary schools Infantile paralysis 5 6 Cerebral paralysis — — Various paralyses 3 — Tuberculosis of bones and joints 11 10 Osteomyelitis 17 8 Rickets and resulting deformities — 3 Congenital deformities 5 6 Spinal deformities (including scoliosis) — — Traumata and amputations 4 7 Non-tuberculous arthritis and synovitis 5 10 Rheumatism and chorea 26 22 Various chest conditions—fibrosis, bronchitis, asthma 4 — Heart diseases— Congenital 6 2 Acquired valvular with history of rheumatism 51 21 without history of rheumatism — 1 Non-valvular (with history of rheumatism 2 5 (without history of rheumatism — 1 Ansemia — 2 Various nervous conditions—ataxia, etc. — — Other diseases—chiefly medical 3 9 Total 142 113 Deaf ohildren During the year Mr. Wells examined 302 children referred for special examination owing to defective hearing, and the decisions reached are set out on page 52. An analysis of the hearing 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 Ha 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 lib includes children who need educational training in a class for partially deaf children; and grade III includes those children who can only benefit by education provided in a school for the deaf. 55 Acquired cases—Hearing defect due to:— Po3t-suppurative otitis media Grade I 35 „ Ia 17 „ IIb 20 „ III 7 — 79 Suppurative otitis media (unknown origin) ... „ I 12 „ IIa 7 „ IIb 6 „ III 2 — 27 Suppurative otitis media (due to infectious disease) „ I 2 „ IIa 3 „ IIb 10 „ III1 — 16 Suppurative otitis media (due to other known causes) „ I 2 „ IIa 2 „ IIb 1 „III 1 — 6 Middle ear catarrh (due to various causes) „ I 51 „ IIa 10 „ IIb 9 „ III1 — 71 Suppurative otitis media of one ear and middle-ear catarrh of the other „ I 11 »IIa 3 „ IIb 3 — 17 Wax „ I 1 Meningitis „ IIb 1 „ III 3 — 4 Nerve deafness due to infectious fevers „ I 1 » IIa 1 „ IIb 11 „ III 10 — 23 Congenital syphilis III 1 Mixed deafness due to infectious diseasa IIb 1 Congenital cases. True hereditary deafness I 1 „ II 9 — 10 Sporadic deaf birth„ III 27 Uncertain origin IIb 3 „ III 10 — 13 Aphasia „ III 1 Found to be not defective as regards hearing, but M.D. „ 5 There are 392 children in schools for the deaf, and 135 in those for the partially deaf. During the year Mr. Wells made 676 examinations at these schools. 56 Schools for the blind A classification has been made by Dr. McVail of all children in the two Council schools for the blind in the winter of 1938. She has submitted the following report:— The total number of children concerned was 100, of whom 60 were boys and 40 were girls. Ages ranged from 6 to 16 years. For purposes of comparison, classification has been made under headings similar to those in my report of the spring of 1931, which was included in Vol. Ill, part II of the Annual Report for that year (p. 66), and which dealt with the 218 children then in the Council's schools for the blind. Defect Number and percentage Congenital and hereditary defects— Albinism 6 49 Nystagmus 8 Microphthalmia 7 Buphthalmia 2 Aniridia 6 Cataract 8 Dislocation of lenses 1 Coloboma 4 Retinitis pigmentosa 1 Others 6 Ophthalmia neonatorum 14 Interstitial keratitis 1 4 probably specific Choroido-retinitis 5 1 possibly specific Other choroiditis 2 1 probably congenital defect 1 cause unknown 2 probably specific 2 r J r hydrocephalus Optic atrophy 9 4 associated with general diseases 1 cause unknown Superficial keratitis 3 Macular disease 1 Myopia 5 Traumatism 4 3 1 Optic atrophy ympathetic Glioma 1 1 irido cyclitis occurred shortly after birth Others 6 (Wasserman negative) 2 associated with measles 1 associated with diphtheria 1 associated with meningitis 1 associated with leontiasis ossium Total 100 Under the heading of congenital and hereditary defects there are 49 cases in the total of 100 blind. To these might be added two or three children in other groups who were almost certainly born with defect. This compares with 38-99 per cent, in the 1931 group of 218 children, and 24-04 per cent, in an analysis of 1,855 blind children of school age given by Mr. Bishop Harman in the report of 1922 of the Departmental Committee on the Causes and Prevention of Blindness. The percentage increase from 1922 to 1931 and from 1931 to 1938, is, of course, relative, and is largely due to a substantial fall in the incidence of blindness due to venereal disease in its several forms. The actual number of children blind from congenital defect has fallen from 85 in 1931 to 49 in 1938. The percentage of cases of ophthalmia neonatorum is 14 compared with 21-1 in 1931 and 19 -75 in Mr. Harman's group examined before 1922. The actual number of children in Council schools blind from this disease is 14 in 1938, compared with 45 in 1931, a striking fall. 57 The following is an analysis of the 14 cases of ophthalmia neonatorum in the two schools for the blind in 1938, with reference to their year of birth, together with the corresponding particulars contained in the annual report for 1931:— Year of birth No. of children Year of birth No. of children 1923 4 1915 6 1924 1 1916 5 1925 2 1917 5 1926 2 1918 4 1927 1 1919 6 1928 1 1920 5 1929 1 1921 6* 1930 1 1922 3 1931 0 1923 2 1932 1 1924 1 1925 2* T otal 14 Total 45 *Including one doubtful case. Both lists include two children whose history was not obtainable but whose eyes showed evidence of effects of the disease. Grouping cases of interstitial keratitis, optic atrophy and choroiditis, conditions which may be associated with venereal disease, Mr. Harman's percentage in children examined before 1922 i s 40.32, compared with 25.69 in the Council's schools in 1931, and 17 in 1938. Of the 17 in 1938, at least 7 have been ascribed to other causes. In that year only one child was blind from interstitial keratitis compared with 13 in 1931. Traumatism is a preventable cause of blindness in which there has been no decrease. In 1931, the number blind from that cause was 3, and in 1938 it was 4. Three of the four were blind from optic atrophy, two from head injuries in street accidents and the third by a fall from a window. One only was blind from traumatism followed by sympathetic ophthalmia. The accident in this case did not occur in London, nor was the child treated in London. It should be noted that most of the figures given relate to children in the Council's schools for the blind, numbers in which vary from month to month. The total number of London children of school age in schools for the blind, whether under the Council or other authorities, as given in official tables, was 216 in December, 1931, and 113 in December, 1938. The total number of children in the Council's elementary schools was 610,101 in 1931 and 469,978 in 1938. In 1931 the ratio of blind children to the elementary school population was thus 3.54 per 10,000 and in 1938 it was 2.40 per 10,000, a fall of approximately a third in the seven years. 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 1938 (the figures in brackets being those for the previous year):— (a) Feeble-minded— Boys Girls (1) Leavers 245 (269) 196 (210) (2) Detrimental 2 (1) — (4) (3) Special circumstances 3 (1) 1 (3) (4) Ineducable 23 (27) 19 (23) (b) Imbeciles 48 (51) 27 (49) (c) Idiots 3 (5) 3 (4) (d) In addition to being mentally defective, were blind or deaf 1 (2) 1 (-) 325 (356) 247 (293) Total 572 (649) Mental Deficiency Acts : cases notified to the local authority The chief officer of the mental hospitals department has furnished the following return for the year 1938 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:— After-careers 58 Table 32 Classification Malo 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, 1938 524 394 918 918 (2) Number who after trial have proved themselves to be incapable by reason of mental or physical defect of undertaking remunerative employment 26 27 53 53 (3) Number employed as under :— (a) Industrial or manual occupations (i.e., factory work, trade or any part of a trade) 338 289 627 (b) Agricultural or rural occupations 2 — 2 (c) Domestic occupations— M. F. Total (1) Receiving remuneration 5 22 27 (2) Required for work at home 2 19 21 7 41 48 (d) Commercial, shop assistant, or selling behind a counter, office boys or girls 8 8 (e) Gone into army, navy or merchant service 1 — 1 (f) Blind alley or other precarious occupations (i.e., vanboys, newsboys, errand boys and girls, selling from a barrow) 83 4 87 773 (4) (a) Number judged to be employable but out of work 34 22 56 (b) Attending polytechnic for further training — 1 1 57 (b) Number whose careers have not been traced :— (a) Not visited and not seen at bureaux 11 3 14 (b) Visited but no information obtainable 14 7 21 35 (6) Cases dealt with in addition to above including those who have since :— (a) died — — — (b) attained the age of 18 years 341 243 584 (c) been dealt with under M.D. Acts 17 7 24 (d) been lost sight of, or have left London 22 18 40 648 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. During the year 2,188 children and young persons were admitted, of whom 1,732 were male and 456 were female. There was a decrease of 143 in the admission rate compared with 1937. The variation in admission rate is shown below:— 1930 1935 1936 1937 1938 Admissions from all areas 785 2,420 2,608 2,331 2,188 " " London area 695 1,436 1,881 1,985 1,908 " ' out-county areas 90 984 727 346 280 The general observations made on the figures for the previous year apply equally to the subjoined records. 59 The various physical and mental illnesses treated are set out below :— Condition No of cases Condition No. of cases Scarlet fever 25 Bronchitis 5 Diphtheria 2 Disease of ear 76 Chickenpox 1 Dental affections 65 Vaginal discharge (97 plus 7 recurrences) 104 Affections of alimentary system 47 Disease of the heart 19 Congenital syphilis 2 Boils, cellulitis and whitlows 121 Gonorrhoea in male 3 Adenitis 16 Rheumatism 11 Debility and amemia 77 Tubercular mediastinitis 1 Accidents 184 Pediculosis pubis 15 Injuries present on admission 63 Ringworm 2 Pregnancy 2 Scabies 40 Various minor ailments 20 Impetigo 20 _ 1,435 Other skin affections 182 Hunger strike 1 Conjunctivitis 3 Hysteral 6 Other eye affections 34 Mania 1 Influenza 13 Schizophrenia 1 Coryza 35 Epilepsy 1 Tonsillitis 176 _ 10 Quinsy 1 Pharyngitis 69 Total 1,445 Laryngitis 1 With but few exceptions, every case was submitted to a detailed physical examination, and the general findings were similar to those of previous years and do not call for further comment. There was a large increase in the number of cases of vaginal discharge, but a marked decline in the incidence, real and relative, of gonorrhoea. In 104 cases of vaginal discharge, of which 7 were recurrences, there were 21 cases of gonorrhoea. In 1937 there were 65 cases of vaginal discharge, of which 27 proved to be gonorrhoeal. As in former years, the great majority of cases other than those awaiting hearing at Court were mentally tested. In those cases in which there was no request for a psychiatric report, and where the opinion expressed by the headmaster of the school attended by the child or young person was that the mental ability was normal, this was quoted in the routine medical report. In the remainder, the general intelligence and mental endowment were estimated by applying standardised mental tests. Aetiological diagnosis and classification were made only in a minority of these cases. Detailed psychiatric examination was confined largely to those cases in which the magistrate requested that full medical and psychological examinations should be made. Such investigations and reports form the main body of the work under review. During the year 579 special reports were furnished, compared with 487 in the preceding year. It was found that the longer the time spent on an individual case the more accurate and precise was the diagnosis. Any attempt to shorten the psychiatric interview is found in general to defeat its own purpose. The economic gain which results from the increased accuracy of diagnosis and remedial measures indicated is very considerable. In my last report I gave some account of the psychological classification employed. In the examination of an individual case certain principles are followed. Any behaviour can be regarded only as a final resultant of various component factors (i.e., it is a reaction of the total personality to the environment). It is always the outcome of interaction between a psychobiological unit and its milieu. This is always a dynamic relationship. Individuals differ from one another quantitatively and qualitatively in their psycho-physical endowment. In the analysis of an individual case the physical and mental state of health is considered both from objective and subjective aspects. In either or both senses the physical state may be an asset or a handicap to which an individual may react in a variety of ways. The particular nature of the temperament and disposition has to be evaluated. The intellectual endowment, general and specific, is measured. The strength and direction of the instinctual drives require careful elucidation. The moral character of the individual can be understood only by a direct study of his social and other attitudes revealed in the history and during the examination. To appreciate accurately the significance of age and the degree of maturity it is necessary to have a systematic knowledge of the mental, bodily and social behaviour, attitudes and interests of normal children at each age level. In order to understand the personality of an individual, these components and their subtle inter-relationships must be recognised and assessed. If they are moulded together in a harmonious pattern orientated towards the general social environment the personality is a healthy one. Where there is disharmony, undercurrents of tension lead to dissatisfaction and frustration which may result in delinquency. That environmental conditions alone cannot account for delinquency is shown clearly by the great frequency of non-delinquent siblings living under the same conditions as a delinquent. Healy and Bronner find that it is the less tangible and the less obvious emotional factors which are the most important in delinquency, and my experience in general serves to confirm this. 60 The following is a record of admissions during 1938 and the two preceding years:— 1938 1937 1936 City of London 12 32 21 Hampstead 16 21 10 Islington 306 342 341 Lambeth 253 325 295 Southwark 291 325 255 Caxton Hal 179 157 169 Stamford House 287 303 308 Toynbee Hall 278 307 334 Buckinghamshire and Berkshire — — 2 East Ham 25 28 30 Essex 38 32 122 Hertfordshire 17 30 30 Kent 55 45 50 Middlesex 77 64 271 Southend 1 7 17 Surrey 16 26 57 West Ham 49 62 78 Woolwich 47 * * Adult Courts 121 132 117 Education Act 17 41 31 Place of safety lodgers 103 52 70 Total 2,188 2,331 2,608 *No court at Woolwich. Subjoined is a record of the charges. In many cases this grouping is misleading, in that so frequently the delinquency is found to be multiple in type. The increase in the frequency of breach of recognizances may appear to imply a failure in the probation system; but equally it may imply increased vigilance and zeal on the part of the probationer officers. 1938 1937 1936 Stealing 912 1,106 1,181 Breaking, entering and stealing 138 116 162 Breaking and entering 100 117 170 Burglary 4 2 13 Carrying firearms without licence — 4 — Embezzlement 20 23 28 Forgery 4 6 7 Demanding money with menaces 1 2 1 False pretences 2 7 6 Travelling without ticket 8 9 11 Suspected person 37 54 102 Trespassing — — 1 Begging 5 2 2 Insulting conduct 7 9 6 Wilful damage 11 7 16 Assault 7 6 6 Malicious wounding 4 6 7 Sex offences 20 26 30 Absconding 7 7 7 Breach of recognizance 153 119 77 Beyond control 195 212 270 Education Act 17 44 31 Place of safety lodgers 103 52 70 Motor offences 82 68 80 Murder 1 1 1 Manslaughter 2 — — Care or protection 340 311 309 Deserting from Army 4 1 — Arson 2 2 — Sacrilege 1 1 1 Drunk and incapable 1 4 13 Other offences — 7 Total 2,188 2,331 2,608 61 It is a pleasure to acknowledge the unremitting assistance and help of Mr. M. S. T. Jones and also of Mr. A. M. Murray, who has prepared the records set out above. Child Guidance The Council has continued to co-operate with certain organisations responsible for child guidance clinics in various districts of London, by placing at their disposal information regarding school children through the education and school medical services. For the past two years a special grant in aid, of £400 a year, has been paid by the Council for the treatment of school children at the London child guidance clinic, while in the year 1938 small grants have been paid to the Creighton House clinic, East London clinic, Institute of Child Psychology, and the Tavistock clinic. Information with regard to the work has been received from the clinics concerned, and is set out below. Maudsley hospital child guidance clinic. The child guidance clinic attached to the Maudsley mental hospital has continued under the direction of Dr. Mapother, the medical superintendent. Up to the beginning of December work continued in the children's department on the same lines as previously, the clinic being a sub-division of the out-patients' department pending the building of new premises. This new building consists of an independent out-patients' department for children with a separate entrance some distance from the main entrance to the hospital, and a complete hospital unit of 30 beds, together with playgrounds, schoolroom, and research facilities. The out-patients' department was opened early in December, 1938, but the in-patients' section is not yet complete. An additional medical officer has been appointed to the staff and the time given by the physicians to the children's department has been nearly doubled. The department is open daily through the week and all cases are now seen by appointment. Owing to the large number of neurological cases attending for psychiatric reasons, a neuro-psychiatric clinic has been opened on one afternoon a week. Arrangements are being made to take advantage of the new playroom accommodation by expanding the present programme of play activities, and sessions for group play therapy and play observations and remedial teaching by play have been arranged. The increase of staff, i ogether with increased voluntary assistance, has enabled greater attention to be given to intensive individual therapy. Much of the work, however, is still of a consultant nature, the number of cases suitable for individual therapy forming a rather small proportion of those attending. Cases treated by adjustment of school and social conditions, placement, etc., stiirform the bulk of the children kept on after the initial investigation. The number of new cases from London schools was 397, of whom 231 were boys and 166 girls. The age distribution was: under 5 years, 35; 5 to 8 years, 119; 9 to 11 years, 99; 12 to 14 years, 103; over 14 years, 41. The reasons for reference were: difficult and unmanageable, 59; backwardness, 50; nervousness, 40; enuresis and incontinence, 34; intelligence tests, 29; stealing and lying, 25; fits, 22; nervous movements, 23; sex difficulties, 14; temper tantrums, 13; truancy, 12; speech difficulties, 10; night terrors and fears, 10; other reasons, 56. The results obtained were: satisfactorily adjusted, 18; partially adjusted, 33; unadjusted, 27; unsuitable, 65; transferred, 4; consultations and psychological examinations only, 49; still under treatment 201. London child guidance clinic The work at the London child guidance clinic is under the direction of Dr. William Moodie, who reports that the number of cases dealt with continues to increase, although no additional staff has been appointed, while the work and methods used have evolved to a maximum of efficiency and economy. The methods employed have not varied greatly from those employed in past years, though increasing experience permits of improvements in technique. The results of treatment, so far as cases can be followed up, appear to remain satisfactory. The clinic will have been open ten years in July, 1939, and it is proposed, as soon as staffing permits, to institute a wider system of following-up of all children treated over a period of years. The increased co-operation with school care committees is evidenced by the greater number of children referred through them. The clinic staff express gratitude to the staff of the Council for the help and co-operation received. The average period of treatment is just over six months. Hence, relatively few of the cases accepted during the year would be completed by the end of the year. Teaching activities continue. Three Fellows in Psychiatry and 23 mental health course students from the London School of Economics undertook courses of training in practical work. The number of new cases from the London schools was 203, of whom 136 were boys and 67 girls. The age distribution was: under 5 years, 11; 5 to 8 years, 74; 9 to 11 years, 63; 12 to 14 years, 42; over 14 years, 13. The reasons for reference were: stealing, 32; behaviour difficulties, 24; nervousness, 22; intelligence tests, 21; enuresis, 19; backwardness, 15; unmanageable, 15; speech difficulties, 12; sex difficulties, 10; truancy, 8; night terrors and fears, 5; temper tantrums, 5; fits, 1; other reasons, 14. The results of treatment were: adjusted, 4; improved, 12; not improved, 11; unsuitable or not co-operative, 4; special service or placement, 9; consultations only, 54; still under treatment, 107; moved away and treatment incomplete. 2. East London child guidance clinic Ihe work in connection with the Last London child guidance clinic has continued under the direction of Dr. Emanuel Miller. During the year the centre was transferred from the Jews' Free school to premises at 19, Rampart Street, Commercial Road, E.l, where there are a special play room in which all free activities associated with play can be carried out without hindrance, and a suite of rooms for treatment and investigation admirably suited for the team method 62 which is the foundation of the work. The director expresses gratitude to the various care committees, school medical officers and teachers for their co-operation. The number of new cases from London schools was 125, of whom 81 were boys and 44 girls. The age distribution was: under 5 years, 10; 5 to 8 years, 54; 9 to 11 years, 36; 12 to 14 years, 19; over 14 years, 6. The reasons for reference were: behaviour difficulties, 15; nervousness, 20; backwardness, 12; stealing, 13; enuresis, 19; night terrors and fears, 5; speech difficulties, 10; temper tantrums, 4; truancy, 5; sex difficulties, 2; unmanageable, 16; other reasons, 4. The results obtained were: satisfactorily adjusted, 13; improved, 11; not improved, 2; unsuitable or not cooperative, 38 ; placement, 6; consultations onlv, 14; transferred, 1; still under treatment, 40. Guy's hospital child guidance clinic The child guidance clinic at Guy s hospital, attached to the Department of Psychological Medicine, has continued under the direction of Dr. R. D. Gillespie. The number of new cases dealt with from London schools was 246, of whom 163 were boys and 83 girls. The age distribution was: under 5 years, 11; 5 to 8 years, 89; 9 to 11 years, 80; 12 to 14 years, 58; over 14 years, 8. The reasons for reference were: nervousness, 48; backwardness, 39; enuresis, 25; stealing, 24; unmanageable, 24; behaviour difficulties, 16; night terrors, 14; sex difficulties, 12; speech defects, 10; temper tantrums, 9; truancy, 8; movements, 7; fits, 6; intelligence tests, 4. The results obtained were: adjusted, 32; improved, 31; not improved, 8; unsuitable or not co-operative, 16; failed to attend, 28; placement, 5; consultations only and special tests, 58; transferred, 1; still under treatment, 67. Institute of Child Psychology The work at the Institute of child Psyetiology is under the direction ot Dr. Margaret Lowenfeld. The number of new cases dealt with from London schools was 99, of whom 62 were boys and 37 girls. The age distribution was: under 5 years, 8; 5 to 8 years, 31; 9 to 11 years, 29, 12 to 14 years, 21; over 14 years, 10. The reasons for reference were: behaviour difficulties, 19; nervousness, 22; backwardness, 14; stealing, 9; enuresis, 3; night terrors and fears, 4; speech difficulties, 5; temper tantrums, 3; truancy, 1; sex difficulties, 6; unmanageable, 10; fits, 1; other reasons, 2. The results obtained were: adjusted, 13; improved, 9; not improved, 3; unsuitable or not co-operative, 26; consultations only, 14; transferred, 3; still under treatment, 31. North Wt stern child guidance clinic Ihe work at the .North Western child guidance clinic has continued under the direction ot Dr. W. Paterson Brown. The number of new cases from London schools was 25, of whom 18 were boys and 7 girls. The age distribution was: under 5 years, 5; 5 to 8 years, 6; 9 to 11 years, 8; 12 to 14 years, 5; over 14 years, 1. The reasons for reference were: stealing, 5; enuresis, 3; unmanageable, 3; behaviour difficulties, 2; nervousness, 2; backwardness, 2; night terrors and fears, 2; temper tantrums, 2; sex difficulties, 1; fits, 1; intelligence tests, 1; other reasons, 1. The results obtained were: adjusted, 4; improved, 3; unsuitable or not cooperative, 1; placement, 1; consultations only, 3; transferred, 1; still under treatment, 12. Tavistock clinic ine worK at tne lavistocK clinic (institute of Medical Psycnoiogyj has continued under the direction of Dr. J. R. Rees, and the number of new cases from London schools was 77, of whom 45 were boys and 32 girls. The age distribution was: under 5 years, 1; 5 to 8 years, 29; 9 to 11 years, 27; 12 to 14 years, 16; and over 14 years, 4. The reasons for reference were: backwardness, 16; stealing, 12; night terrors and fears, 12; behaviour difficulties, 9; nervousness, 6; temper tantrums, 6; sex difficulties, 4; speech difficulties, 3; truancy, 3; fits, 2; enuresis, 2; other reasons, 2. The results obtained were: adjusted, 2; improved, 9; not improved, 1; unsuitable or not co-operative, 12; placement, 2; consultations only, 17; transferred, 2; still under treatment, 32. West End hospital for nervous diseases Treatment has continued at the West Jind hospital tor nervous diseases under the direction of Dr. Emanuel Miller. The number of new cases from London schools was 75, of whom 41 were boys and 34 girls. The reasons for reference were: behaviour difficulties, 18 , night terrors and fears, 9; backwardness, 8; enuresis and incontinence, 8; nervousness, 7; stealing, 7; speech difficulties, 6; temper tantrums, 3; intelligence tests, 3; migraine, 2; other reasons, 4. The results obtained were: adjusted, 3; improved, 5; unsuitable or not co-operative, 6; placement, 2 ; consultations only, 24; still under treatment, 35. Summary During the year, 1,247 London school children, ot whom 777 were boys and 470 girls, were dealt with at the above-mentioned clinics. The following statement gives details of the cases:— source uj rejererice Hospitals 209 Care committees or district organisers 294 School doctors 192 Parents and friends 122 Head teachers151 Private doctors 99 Probation officers 61 Other agencies 116 Total 1,247 neaaurw jur rejerence Behaviour difficulties 230 Nervousness 190 Backwardness 156 Stealing 127 Enuresis, etc. 113 Night terrors and fears 61 Intelligence tests 58 Speech difficulties 56 Temper tantrums 45 Truancy 37 Sex difficulties 49 Pits 35 Other reasons. 90 Total 1,247 63 Results obtained Adjusted 89 Improved 113 Not improved 52 Unsuitable or not co-operative 198 Placement 25 Consultations only 233 Transferred 12 Still under treatment 525 Total 1,247 Nursery schools 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. The nursery schools at the end of the year, 1938, were :— Provided, by the 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 Council 1. Balham, Endlesham-road, S.W.12. 40 2. Buck Street, Kentish Town, N.W 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 *0. 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-street, W.C.I 60 *16. Sherborne, Litcham-street, N.W.5 40 *17. Somers Town, Crowndale-road, N.W.I 40 18. U.G.S. settlement, Peckham, S.E.15 40 19. Women's university settlement, Blackfriars-road, S.E.I 35 Total 894 One of the Council's medical officers is responsible for the medical work at 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. In addition to the schools named above, two nursery schools provided by the Council under the three-year programme, 1935-38, have been erected in Kintore Way, Bermondsey, and at Honor Oak, and these will be opened in the early months of 1939. The three-year programme, 1938-41, contains proposals for 4 new nursery schools for children aged 2 to 5 years, and one school for children aged 2 to 7 years. One school is to be provided in 1938-39, two in 1939-40 and two, including the school for children aged 2 to 7 years, in 1940-41. Nursery classes The three-year programme 1935-38 provided for the establishment of experimental " nursery classes " in connection with infants' departments. 64 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 and in 1938 two classes have also been formed at Creek Road school, Deptford. 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 is also available for the children. The babies are attended to by the school nurse daily, and all are medically examined once a term. In my report for 1937 full accounts were given of the organisation of nursery schools and nursery classes, and of the effects of the methods upon the health and physique of the infants attending. A visit to one of these schools or classes is always enheartening, and the work done in them is worthy of all praise. Medical inspection at secondary and junior technical schools, training colleges, etc. The arrangements have been as set out in the report for 1937. Excluding students in training colleges, 15,250 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 3,394 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 the case of one pupil only, a girl, was the clothing found to be poor, but in 15 cases (1 boy and 14 girls) infestation with vermin was noted. Dental condition The percentage of children, aged 12, with sound teeth was : boys, 86-5 ; girls, 81 '6 ; but at the age of 15 this percentage had decreased to 82-2 per cent, among boys and to 79-8 per cent, among girls. Of cases of widespread dental decay where 4 or more teeth were affected, the percentage among boys and girls of 12 years old was 1.5 and 1.2, respectively, compared with 1.1 in both boys and girls leaving elementary schools. Vision At the age of 12, 81-5 per cent, of the boys and 76-4 per cent, of the girls were able to pass the vision test with glasses, if any, compared with 71-4 and 68.9 in elementary school leavers. In secondary schools, 17.4 per cent, of both boys and girls were wearing glasses at the age of 12, but at the age of 15 the percentages were 19.2 boys and 21-4 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., 76.2 per cent, among boys and 73.4 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 em phasised by the figures for more serious defect (6.12 or worse) which rises between 12 and 15 from 8.5 to 13.6 per cent, in secondary school boys, and from 11.7 to 13.4 per cent, in girls. Nutrition 1 he 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, 4.9 per cent, being returned as subnormal in secondary schools, as against 4.5 in elementary school leavers. Defects During the year, 3,575 pupils (23.3 per cent.) were referred for treatment for various defects. Heart defect was noted in 1.9 per cent, boys and 2.8 per cent, girls; defects of nose and throat in 1.1 per cent, boys and 4.8 per cent, girls; ear disease in .5 per cent, boys and .4 per cent, girls; anaemia and debility in 1.2 per cent, boys and 1.9 per cent, girls. 65 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 1.4 percent. of boys at 12 and 1.6 per cent. at 15, but in girls the amount recorded of this defect was much greater, viz., 8.8 per cent. at 12 and 8.9 at 15. Attention must be called again to the increase between ages 12 and 15 in institutions of higher education, of defect of vision and dental caries. Re- inspection The re-inspection of 4,167 pupils in higher education institutions was carried out; 1,889 defects had been satisfactorily treated, 586 were under treatment, 999 had had treatment but needed further treatment, and in 659 cases no treatment had been obtained. Training colleges Of the 866 students examined in training colleges, 3 were found to be suffering from extensive dental caries; 86.5 per cent of the men and 79.0 of the women passed the vision test, but 27.2 per cent. of the men and 37.8 per cent. of the women were wearing glasses. While none of the men was classified as below normal in nutrition, no less than 8.5 per cent. of the women were placed in the subnormal class. Hospital schools The following is a list of the hospital schools with their classification and nominal school accommodation:— Table 33 Hospital school Classification Nomina) accommodation Number of children In hospital 31-12-38* On school roll at end of winter term* Downs, Sutton Mastoiditis, otitis media, rheumatism and convalescence 360 342 230 Goldie Leigh, Abbey Wood Skin diseases and convalescence 248 144 108 Heatherwood, Ascot Surgical tuberculosis 244 224 211 High Wood, Brentwood Pulmonary tuberculosis, rheumatism 482 393 345 Millfield, Littlehampton Convalescent tuberculosis and other convalescents 98 88 87 Northern, Winchmore Hill Post-encephalitis lethargica 38 12 12 Norwood children's Severe crippling, rheumatism 210 133 31 Queen Mary's, Carshalton Rheumatism, tuberculosis (nonpulmonary), poliomyelitis, osteomyelitis and congenital malformations 1,284 994 658 St. Anne's home, Herne Bay Convalescence 127 86 96 St. Faith's, Brentwood Epilepsy 30 20 23 White Oak, Swanley Trachoma, interstitial keratitis, and other acute eye diseases 364 219 168 * The above dates are not identical. Of the 2,655 children who were in-patients at the hospital schools at the end of the year, 630 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 Dr. E. M. McVail on the causation of blindness (p. 56); by Dr. C. E. Thornton on rheumatism (p. 28); and by Dr. Elizabeth Gourlay on nutrition (p. 18). The following report has been prepared under the direction of Dr. Thomas on the incidence of plantar warts:— During the past five or six years there have been many enquiries and complaints in connection Plantar with the occurrence of plantar warts in school children. These complaints are by no means warts confined to elementary schools but have been numerous also in secondary schools. 66 The impression was formed that the incidence of plantar warts was greater in girls' schools than in boys' schools, and that in infants' departments it was almost negligible. Such an incidence, if confirmed, would lend support to the suggestion that the trouble is associated with a change in custom, whereby the older children now frequently remove shoes and stockings in connection with physical exercises, bathing and swimming, and frequently walk on moist surfaces in their bare feet, for there is no doubt that the warts are contagious. In order to obtain more accurate knowledge of the extent and distribution of this painful and troublesome condition, the school doctors were asked to make a survey of the schools they visited during a period of the summer term in 1938. The enquiry covered schools containing 231,650 children equally distributed throughout the county. Table 34—Incidence of plantar warts Division Number of children examined Number of children suffering from plantar warts Boys Girls Mixed Boys Girls Mixed North-West 11,947 11,959 14,707 3 28 1 North 14,098 14,019 19,152 21 68 5 North-East 13,736 15,896 18,380 12 48 5 South-East 12,637 12,547 18,136 13 49 4 South-West 18,483 16,076 19,877 11 49 1 Total 70,901 70,497 90,252 60 242 16 In order to discover the differential sex incidence, the schools were divided in the above table into boys' departments, girls' departments and mixed departments (which contained also the infants' departments). Of the 231,650 children brought into the enquiry, 318 were found to be suffering from, or recently to have been treated for, plantar warts, that is an incidence of 1-37 per thousand. Among the 70,901 children in boys' departments, 60 were found suffering, or .8 per thousand. Among the 70,497 children in girls' departments, 242 children were found with plantar warts, an incidence of 3.4 per thousand. This establishes the incidence on girls compared with boys in the ratio of about 4 to 1. In mixed departments containing 90,252 children, only 16 children were found with plantar warts, an incidence of nearly .02 per thousand. As mixed departments are predominantly infants' departments, this result indicated that the incidence in older boys and girls is very much greater than among infants under seven. To get the figures for infants more accurately, the numbers for infants' departments were taken out separately, with the following results:— Number examined Number suffering from plantar warts North-West 10,569 1 North 15,053 3 North-East 14,710 1 South-East 12,635 3 South-West 16,690 1 Total 69,657 9 Among 69,657 children in infants' departments nine were found with plantar warts, an incidence of just over .1 per thousand. Older girls therefore suffer from plantar warts 34 times as often as infants, and older boys 8 times as often. The local character of the complaints that had been received gave the impression that the trouble was not uniformly distributed over the county. The tables therefore were calculated as above for each of the five school medical divisions, with the result that a higher incidence was shown in the east and north of London than in the south and west. The incidence in the five divisions was north-west .8 per thousand, north 1.9 per thousand, north-east 1.3 per thousand south-east 1.5 per thousand, and south-west 1.1 per thousand. In connection with the enquiry, five secondary girls' schools were visited containing 1,669 pupils, among whom 23 had plantar warts. This is a much higher incidence (13.7 per thousand) than was found in the more comprehensive survey of the elementary schools detailed above, but these secondary schools were picked out for investigation on account of the special incidence which had been reported in them. 67 Wage-earning employment of school children In the year 1938, 3,941 applications (3,908 boys and 33 girls) were dealt with under the by-laws for medical certificates in connection with the employment of school children out of school hours. Unconditional certificates were issued in 3,567 instances, which included 30 girls. Conditional certificates were issued in 270 cases, one being a girl. Certificates were withheld in 104 instances, two being girls. In 57 of these the reasons for refusal were non-medical. Medical grounds for refusal The conditions which led to refusal in the other 47 cases were:— Boys Girls Total Rheumatism 9 – 9 Teeth 4 – 4 Vision and eyes 2 1 3 Heart 5 – 5 Anæmia and malnutrition 2 – 2 T.B. glands 1 – 1 Otorrhœa 3 – 3 Personal hygiene 2 – 2 Fatigue signs 2 – 2 General condition 15 – 15 Flat feet 1 – 1 Total 46 1 47 Employment of children in entertainments Two hundred and ninety-five children were medically examined at the County Hall in connection with employment under licence in entertainments, comprising 252 girls and 43 boys. Of these, 131 were referred for treatment, including: refraction error, 17; dental decay, 76; throat affections, 1; skin disease, 11; personal hygiene, 14; discharging ears, 1; anæmia, rheumatism or heart trouble, 5; scoliosis, 2 ; minor ailments, 4. Six were refused certificates on account of the presence of the following conditions : heart disease, 2; high myopia, 2; osteomyelitis, 1; enuresis, 1. Three hundred and fifty-nine re-examinations were made. Examination of candidates for the education service and scholars The total number of examinations in 1938 was 12,765, compared with 12,044 in 1937 and 12,252 in 1936. During 1938, 10,022 entrants to the education service, and candidates for teaching awards, scholarships, and local special places, presented themselves for examination; of these, 61 had been referred from 1937. The following table indicates the numbers of candidates and the results of the examinations:— Table 35 Category Number examined Number fit Number rejected Number who withdrew after being referred for remediable defects or were not due for reexamination until 1939 Male Female Male Female Male Female Male Female Education service 297 293 267 288 13 5 17 – Royal Air Force candidates 14 – 11 – 3 – Teaching awards 113 428 113 406 – 8 – 14 Scholarships 4,542 4,335 4,353 4,160 50 10 139 165 Total 4,966 5,056 4,744 4,854 66 23 156 179 10,022 9,598 † 89 335 † The main causes of rejection were defects of vision, and diseases of the heart and ears. 68 In addition to the candidates referred to above, 367 scholars were examined (154 males, 213 females) with a view to determining their fitness to continue to hold awards, and of these 17 (7 males, 10 females) were found to be unfit. He-examinations totalling 2,376 were made of entrants, scholars, etc., who were referred at the first examination for treatment for one or more remediable defects. In order to determine the medical fitness of applicants for admission as aircraft apprentices in the Royal Air Force, their medical records are scrutinised at County Hall. Boys whose records appear doubtful are examined. In the course of the year 38 records were submitted, 14 boys were examined, and three were found to be unfit for nomination. Cases specially referred There were also referred to the public health department 3,361 special cases in which medical advice was required. This figure includes 2,719 teachers (636 men, 2,083 women) and 642 schoolkeepers, cleaners, etc. (134 men, 508 women). In regard to recommendations governing sick leave to teachers, 1,927 or 70.87 per cent, were in respect of teachers over 40 years of age. Teachers of physical education During the year, 239 applicants for admission to the Council's course of physical education were examined. Of these, 22 were deemed to be either temporarily or permanently unfit to undergo the training on the following grounds: debility, etc, 8; varicose veins, 2; injury, 2; heart condition, 1; rheumatism, 2; myopia, 3; hernia, 3 : lune disease. 1. Medical inspection of scholarship holders The number of scholars medically inspected at County Hall was 945, comprising 252 girls and 693 boys. Re-inspection of scholars referred for treatment was carried out in respect of 36 girls and 45 boys. STATISTICAL TABLES Table I —Medical inspection, 1938 (a) Routine inspections Group Boys Girls Total Entrants 24,048 23,253 47,301 Age 7 19,436 19,608 39,044 Age 11 20,757 20,819 41,576 Leavers 21,014 21,060 42,074 Total, elementary schools 85,255 84,740 169,995 „ special schools 546 429 975 (b) Other inspections Special inspections 73,726 76,017 149,743 Infectious disease enquiries – – 20,939 Re-inspections – – 128,067 (c) Children found at routine medical inspection to require treatment (excluding nutrition, uncleanliness and dental disease) Age group Inspected Found to require treatment Percentage Defective vision Other conditions in Table II Total Entrants 47,301 – 6,731 6,731 14.2 Age 7 39,044 2,668 4,417 6,811 1.-4 Age 11 41,576 4,135 2,802 6,702 16.1 Leavers—age 13¾ 42,074 4,412 2,091 6,303 15.0 Total, elementary schools 169,995 11,215 16,041 26,547 15.6 „ special schools 975 74 263 337 34.6 69 Table II (a) (1) Defects found at medical inspections of all children in elementary and special schools Disease or defect Routine inspections— Defects Special inspections— Defects Requiring treatment Requiring observation. Requiring treatment Requiring observation Elementary schools Special schools Elementary schools Special schools Malnutrition 1,663 3 663 4 424 – Skin—Ringworm, head 2 – – – 10 1 „ „ body 22 – – – 11 – Scabies 336 1 2 – 5,432 4 Impetigo 99 1 4 – 518 11 Other disease (non-tubercular) 796 5 102 1 735 77 Eye— Blepharitis 562 5 58 – 237 37 Conjunctivitis 100 4 1 1 114 5 Keratitis – – 2 – 4 9 Corneal opacities 5 – 1 – 6 1 Defective vision, excluding squint 11,215 74 5,616 58 2,656 418 Squint 994 4 359 – 322 40 Other conditions 133 2 28 1 215 57 Ear— Defective hearing 153 2 85 1 122 37 Otitis media 638 11 228 1 389 106 Other ear disease or defect 307 3 84 – 226 66 Nose and throat— Chronic tonsillitis 4,784 7 5,054 9 1,120 333 Adenoids 507 3 183 – 156 18 Chronic tonsillitis and adenoids 1,753 2 559 1 626 36 Other conditions 579 2 242 1 446 53 Enlarged cervical glands 248 – 823 1 108 135 Defective speech 139 – 138 – 108 42 Teeth—Dental disease or defect 48,563 230 1,010 – 4,170 84 Heart and circulation, heart disease— Organic 30 – 47 1 – – Functional 18 – 78 1 5 8 Not stated 165 2 1,357 11 149 442 Anæmia 314 1 207 – 182 75 Lungs—Bronchitis 636 2 668 1 91 34 Other non-tubercular 304 1 354 – 132 81 Tuberculosis— Pulmonary definite 1 – 3 – 1 2 „ suspected 19 – 48 – 18 30 Glands 3 – 3 – 4 6 Spine – – – – – – Hip 1 – 1 – 4 – Bones and joints 2 – 2 – – – Skin – – 1 – – – Other forms 2 – 1 – – 1 Nervous—Epilepsy 30 – 15 – 30 12 Chorea 50 – 38 – 123 67 Other conditions 195 2 146 – 103 51 Deformities— Rickets 51 – 33 – 9 1 Spinal curvature 368 5 116 4 52 34 Other 772 7 402 3 186 94 Other conditions 2,332 19 840 7 2,539 960 Total 78,891 398 19,602 107 21,783 3,468 70 Table II (continued) (b) Classification of the nutrition of children inspected during the year in the routine age groups roup Number of children inspected A (Excellent) B (Normal) C (Slightly subnormal) D (Bad) No. Percentage No. Percentage No. Percentage No. Percentage Entrants 47,301 7,229 15.28 37,017 78.26 3,020 6.39 35 0.07 Age 7 years 39,044 5,291 13.55 30,336 77.70 3,379 8.65 38 0.10 „ 11 41,576 6,460 15.54 32,308 77.71 2,794 6.72 14 0.03 „ 13¾(leavers) 42,074 8,626 20.50 31,569 75.03 1,866 4.44 13 0.03 Total, elementary 169,995 27,606 16.24 131,230 77.20 11,059 6.50 100 0.06 „ special sc. 975 95 9.74 799 81.95 81 8.31 0 0.00 Table III (a) Exceptional children in London in 1938 ification At certified special schools At public elementary schools At other institutions* At no school or institution Total Blind children 113 – 1 1† 115 Partially sighted children 489 21 – – 510 Deaf children 435 – 4 2‡ 441 Partially deaf children 136 3 4 – 143 Mentally defective children— Feeble-minded children 2,825 – 22 6** 2,853 Epileptio children— Children suffering from severe epilepsy 85 – 6 – 91 Physically defective children— Tuberculous children— Pulmonary 378 – 36 – 414 Non-pulmonary 525 – 15 – 540 Delicate children 2,361 5,721|| 9 – 8,091 Crippled children 1,791†† – 20 – 1,811 Children with heart disease 1,805 – 19 – 1,824 * Undergoing treatment in general hospitals, etc. † Under instruction at home. ‡ 1 under enforceable age and 1 under instruction at home, †† Includes 10 children at Northern Hospital (post-encephalitis lethargica) and also non-cardiac cases of chorea, rheumatism, etc. || Of these 48 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. ** Two under instruction at home and four under enforceable age. Table III (continued) (b) Return of children suffering from more than one defect, 1938 Delect Type of school Day M.D. Residential P.D. Residential deaf Epileptic colony Day P.D. Certified hospital schls. At other institutions Total M.D. and deaf 2 – 24 – – – – 26 M.D. and crippled 26 1 – – 8 1 – 36 M.D. and heart 25 – – – 3 – 1 29 M.D. and epileptic 17 – – 23 – – – 40 M.D. and T.B. – – – – – 1 – 1 M.D., crippled and deaf – – 4 – – – – 4 Deaf and crippled – – 2 – – – – 2 Blind M.D., and crippled – – – – – 1 – 1 Epileptic and crippled – – – 4 – – – 4 Heart and crippled – 1 – – 15 – – 16 Total 70 2 30 27 26 3 1 159 71 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 9,010 – 9,010 Impetigo 5,282 – 5,282 Ringworm, head *103 147 †250 body 128,819 548 129,367 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.) 143,214 695 143,909 * 88 by X-ray. † 118 by X-ray. (b) Group II—Defective vision and squint (excluding eye defects treated as minor ailments, for which see group I) Disease or defect Defects dealt with Under Council's scheme Otherwise Total Errors of refraction (including squint, but excluding operations for squint) 35,359 982 38,341 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, 25,663; otherwise 713 (estimated). Children who obtained or received glasses—under the Council's scheme, 24,730 = 96.3 per cent.; otherwise 645. * Included in group I minor ailments. 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 749 574 1,323 | 3,832 13,761 Adenoids 377 57 434 Tonsils and adenoids ... 7,759 311 8,070 Other 9 93 102 Total 8,894 1,035 9,929 3,832 13,761 72 (d) Group IV—Dental defects 1. Number of children who were:— (a) Inspected by the dentist—Age groups 5 years and under 27,434 6 „ 27,044 7 „ 29,664 8 „ 29,133 9 „ 32,285 10 „ 33,909 11 „ 30,104 12 „ 30,014 13 „ 31,089 14 „ and over 22,295 292,971 (b) Found to require treatment 204,205 (c) Actually treated 138,639 2. Half-days devoted to inspection 2,857 „ „ „ treatment 23,421 26,278 3. Attendances by children for treatment 259,404 4. Fillings—permanent teeth 148,921 „ temporary teeth 24,884 173,805 5. Extractions—permanent teeth 58,540 „ temporary teeth 217,025 275,565 6. Administration of general anaesthetics for extractions 64,950 7. Other operations—permanent teeth „ „ temporary teeth 38,774 (e) Group V.—Uncleanliness and verminous conditions (а)Average number of visits per school made by school nurse during the year 1938 6 (b) Examinations of children in the schools by school nurses 1,463,634 (c) Number of verminous children noted 65,292 (d)Children cleansed under Council's arrangements *63,975 (e) Cases in which legal proceedings were taken under the Education Act, 1921 (section 87) 195 * Includes 15,399 compulsory cleansings. Table V Medical inspection—number of children examined, 1928-1938 Year Routine examinations Special examinations Reinspections Examinations at special enquiries into outbreaks of infectious disease Special ear inspection centre attendances Rheumatism supervisory centre attendances 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 1938 170,970 149,743 128,067 20,939 25,828* 15,306 * Includes after-care clinic attendances: 1936—8,317; 1937—8,108; 1938—7,929. 73 Table VI Medical treatment—number of cases treated under the Council's scheme and by other agencies, 1928-1938 Year Minor ailments† Vision Nose and throat Dental Under the Council's scheme Otherwise Under the Council's scheme Otherwise Under the Council's scheme Otherwise Under the Council's scheme Other wise* 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 ||I30,783 801 39,570 1,006 13,190 966 144,416 5,862 1937 ¶136,707 724 37,341 889 13,592 1,115 138,437 4,281 1938 °143,214 548 37,359 982 12,726 1,035 138,639 4,638 * It is not possible to give complete 6gures, 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 19,304 "nurses' cases." ‡ Includes 13,087 "nurses' cases." || Includes 16,548 "nurses' cases." ° Includes 21,086 "nurses' cases." Table VII Medical inspection of students in higher education institutions, 1938 Classification Council secondary schools Other secondary schools Counoil 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 2 3 45 47 I. Routine detailed examination at— (1) age 12 666 919 1,041 704 110 36 – – 1,817 1,659 (2) age 15 836 1,011 1,210 523 913 1,168 – – 2,959 2,702 II. Examination (not necessarily detailed) at other ages (i.e., specials) 1,295 1,136 1,551 869 712 640 81 785 3,639 3,340 III. Reviewals 478 1,483 639 553 101 140 – 11 – – IV. Re-inspections 692 1,295 671 643 474 392 5 1 1,842 2,331 74 INDEX page After-care clinic 25 After careers 57 Anæmia 12 Approved schools 36 Audiometer 15 Blind, Schools for the 56 Candidates, Examination of 67 Child guidance 61 Children's care committees 20 Chorea 29 Cleanliness 9,31 Clothing and footwear 9 Convalescence 40,41 Co-operation of parents 8 Co-operation of voluntary bodies 27 Deaf children 54 Defective children 51 Deformities 12 Delinquency, Juvenile 58 Diphtheria 34,37 Ears 11,15,22,25 Employment of school children 67 Entertainments, Employment of children in 67 Evening institutes 46 Eyes 10, 22,64 Favus 35 Games 46 Halibut-liver oil 47 Heart 12 Hop picking 36 Hospital schools 65 Hygiene, Personal 31 Impetigo 31 Infectious diseases 33 Invalidity, Chronic 32 Lavatory accommodation 6 Leaving children 13 Lungs 12 Measles 35 Medical inspection 7, 64 Medical treatment 22 page Mental deficiency 57 Milk distribution during holidays 51 Minor ailments 23 National health insurance 14 Nervous diseases 12 Nursery schools and classes 63 Nutrition 9, 15, 16, 47, 64 Open-air education 39 Orthodontics 24 Orthopaedic treatment 26 Oslo experiment 47 Otorrhœa 11, 25 Personal hygiene 31 Physical education 41 Plantar warts 65 Play centres 36 Play leadership scheme 45 Playing-fields 44 Re-inspection 20,65 Remand home 58 Residential schools and children's homes 36 Rheumatism 28 Rickets 12 Ringworm 23, 35 Scabies 31 Scarlet fever 34, 38 Scholars, Examination of 67 School buildings and equipment 6 School journeys 36,41 Secondary and junior technical schools 45, 64 Sleep of school children 33 Spectacles 22 Staff 5 Stammering 27 Teeth 10,23,64 Tonsils and adenoids 11 Towels 7 Training colleges 65 Tuberculosis 12,39 Vaccination 12 Vitamin D therapy 19 Vulvo-vaginitis 39