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over 3s. 4d. per attendance. The council runs its ownbacteriological laboratory. The new houses erectedduring the year numbered 93, all part of the municipalscheme.

Finchley.-Dr. Wilson Jameson reports a smalloutbreak of enteric fever during the last quarter,affecting 10 persons. No cause was ascertained, andthere was difficulty in finding hospital accommodationfor the cases. The scheme for the joint ownershipof Hornsey Isolation Hospital by the three authoritiesof Hornsey, Wood Green, and Finchley is, however,nearing completion. IHendon.-Dr. T. S. McIntosh reports a severe

outbreak of diphtheria in December. The caseswere of an exceptionally severe type. Of 161 samplesof milk taken, 21 were reported to be adulterated-ahigh percentage. The school report shows thatringworm is troublesome, but that the X ray treat-ment has not yet been adopted. The treatment ofdental defects has not been pushed energetically asyet.

Tottenham.-Dr. David C. Kirkhope mentions thatnotification of tuberculosis is not efficient, and thatthis is not surprising seeing that the sanitary authorityof the district has no administrative control of thisdisease. Of the 319 new houses 318 are part of amunicipal scheme, and one has been erected by privateenterprise.Beckenham.-Dr. J. M. Clements discusses the

Greater London scheme, and expresses the opinionthat there should be one central governing authorityand one local governing authority, and that the estab-lishment of intermediaries is unnecessary and thereforeredundant and wasteful. As elsewhere, the phthisisdeath-rate shows a slight increase as compared withthe last two years. The Beckenham and Penge jointmaternity home admitted 173 cases during the year.The revenue expenditure was £1951, of which £581were received from patients. The cost per head wasabout £11, and the payment per head under £3 10s.Dr. Clements states that there is a real need for morehouses of the smaller type, such as are being erectedby the council at Elmers End, and estimates that 145such houses should be erected in Laurie Park andKent House wards to make the housing accommoda-tion as good as it was in 1911.

Croydon.-Dr. R. Veitch Clark reports the need foran extension of the borough isolation hospital, forbetter and more accommodation at the sick nurseryat 228, London-road, and for the appointment ofadditional sanitary inspectors to cope with the wararrears of defective housing. Dr. Clark states that anursing service largely self-supporting was establishedin 1921, which will in time meet the needs of the wholepopulation. He complains of the time wasted by theprofessional staff in their endeavour to prevent theabuse of the milk allowances to mothers and children.Croydon council, like a few other sanitary authorities,has made a satisfactory arrangement with theguardians for the supervision of foster children.Dr. Clark points out that the staff of the tuberculosisdispensary is inadequate for the examination ofcontacts, the most important function of the dis-pensary. Hospital beds are also needed for diagnosticwork. Among the needs of the school medicalservice are an increase in the dental staff, a schoolfor crippled children, and a greater appreciation ofthe advantages of open-air education.

SCHOOL MEDICAL SERVICE.

A GROUP OF COUNTY AREAS.North Riding of Yorkshire.-Dr. H. P. Newsholme’s

report shows material progress in spite of the presentfinancial stringency. Roughly, one in every four ofthe 13,505 children examined in routine inspectionwas found to have some defect requiring treatment.6-8 per cent. of the children had markedly enlargedtonsils or adenoids. Of 70 children found duringroutine inspection to require supervision or treatmentfor deformities rickets was accountable in 12 cases,

spinal curvature in 3, and in the 55 remaining infantileparalysis was the chief cause. Of 3079 childrenreferred for treatment on account of defective eyesight,26 per cent. were attended to. This is an improve-ment on former years. The distinguishing feature ofthe report, giving it great value, is an inquiry intovisual defect, work often of a tedious character,patiently and carefully done. The testing was doneout of doors to avoid variety in illumination. Infants,too, were tested by a special illiterate card. Thestandards of defect were taken thus :-

(1) Grossly defective vision was 6/12 or less in both eyes,or 6/18 or less in one eye (squint included).

(2) Slightly defective vision-6/9 in one or both eyes or6/12 or less in one.Hence a child with normal vision in practical everydaylife, but having an amblyopic squinting eye, is returnedas having grossly defective vision. The results aregiven under four headings :-

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(A) One child in ten has defective vision, requiringglasses, and one in every other ten has visual defect notbad enough to need glasses.

(B) There are reasonable grounds for concluding that theprevalence of gross visual defects among children increaseswith increasing urbanisation.

(C) The factors producing excessive prevalence in townsare related mainly to unhealthiness shown from mortalityreturns and a low standard of physical measurements.

(D) The illumination in schools seems to bear relation tovisual defect.

It should be added, however, that the methodsadopted for assessing the illumination, either sub-jectively by the doctor or objectively by means of anactinometer, give deceptive results, even when theone is used to correct the other. The only measure-ment of lighting to be trusted is by means of footcandles. The mental’ factor, too, in the lower classesdoes not appear to receive sufficient allowance, andno mention is made of myopia in respect to age.Nevertheless, such an inquiry is of great interest anduse to workers, and brings out much in school hygienethat has had too’ little attention given to it in the past.

Norfolk.-In this county Dr. J. T. C. Nash advo-cates restraint in the case of enlarged tonsils andadenoids where operation is not absolutely urgent atthe moment, and by means of a pamphlet entitled" Adenoids," the parents are appealed to as intelligentcooperators in securing the amelioration of thecondition. The pamphlet contains simple reasonedinstructions, and one of the assistant medical officersstates his opinion that mouth breathing is the rootcause of most of the cases of underweight. Duringthe year over 9 per cent. of 17,000 children examinedin the code groups showed evidence of throat and noseaffection, and 267 were operated on for enlargementof tonsils and adenoids. Dr. Nash reports that manycases of moderately enlarged tonsils and adenoidsimprove with the systematic use of gargles andinsufflations of simple saline solution, and this,accompanied with breathing exercises, ought to domuch to diminish the number- of cases requiringoperative treatment. Rickets is an uncommon causeof crippling here, the majority of the 200 cases beingdue to infantile paralysis. The amalgamation of thenursing and school attendance work appears to bejustifying itself, and it is to be hoped that this closeassociation between the home and public healthdepartment will do something to foster a healthconscience among the people, which is the aim ofall up-to-date endeavour in this field of hygiene.Certainly, this seems to be the case in this county,for in 15 schools all the children were found to beperfectly free both from nits and vermin. Theorganiser of physical training reports that in 90 percent. of the schools visited by him the girls were morealert and energetic than the boys, as proved by com-petitive work under the team system. Is this a

reflection on the efficiency of the male teacher ?Northamptonshire.-The number of routine exam-

inations made in 1921 was 7183, in addition to 1200" specials," and of the 700 cases requiring treatment600 received it. The extent of uncleanliness appears

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considerably greater than in previous years, ancDr. Charles E. Paget is making every effort by meansof nurses and lectures to improve this state of affairsThe definite inclusion of teachers in this effort is ahealthy sign. Their possibilities in any healtl

campaign can hardly be overestimated. The teacheis closer to the child and to the parent than any otherpublic official and is the real link between the homeand the school. Dr. Paget also employs the teacheito supervise breathing exercises in such cases of nasalobstruction as do not require operative interference.There was a diminution in the number of new tuber-culosis cases during the year, 23 as against 72 in theyear 1920. Of these, 5 were definitely diagnosedand 14 were suspected cases of pulmonary tuberculosis.The remaining 4 were non-pulmonary. The totalnumber of cases of external eye disease was small,only 76 altogether. Infectious disease, which lastyear accounted for the closure of 88 schools, this yearwas accountable for exactly half that number. Thenursing scheme outlined in the report for the previousyear is working well, and towards the end of the yearthere was obvious improvement in the cleanliness andgeneral tidiness of the children. The new clinic forminor ailments held in one of the schools in Welling-borough had 2365 attendances during the year.The charge made for treatment is sixpence per child,and this covers all attendances for four weeks fromthe date of payment. The clinic is also used for refrac-tion and dental work.

Rutland.--Dr. Christopher Ilolleston complains ofthe extreme detail required by the chief medicalofficer, and states that it was only by taking no holidaythat he was able to send the figures in by the firstweek of the new year. ‘ It is not, apparent," he says," that these extremely dull compilations, whichconsist of snippets from reports, are of any value toschool medical officers or of any interest to thegeneral public. The apparent object of the medicaldepartment is to make the work as laborious as pos-sible, to kill any interest and initiative, and to makethe school medical officer a recorder of useless data."The last indictment seems true of much of thework. It is interesting to note that the appointmentof a nurse in this county has been so very satisfactory.The total number of examinations under the codegroup was 679. The number of refusals was large. In37 instances letters of refusal were received by thehead teachers, and many children were absent. " Thenurse is frequently asked Is it compulsory ? ’ not ’ Isit for the good of the child ? ’

" It is interesting to notethat since vaccination has been made voluntary theregisters are practically empty. Dr. Rolleston foundnothing to support the theory that enlarged tonsilsand adenoids predispose to dental disease. The reportis full of pithy observations, and makes interestingreading.Kent.-Dr. Greenwood’s report is as on previous

occasions full of interest. Of 32,988 children inspectedduring 1921, 9262 had some defect, the majoritycoming under the heading of nose and throat affec-tions, dental trouble, and defective vision. Tuber-culosis accounted for 73 cases of crippling in thecounty, and of these 59 are in attendance at theordinary elementary school. There is close coöpera-tion in Kent with child welfare centres and women’sinstitutes, who arranged lectures on dental care atvarious centres. Talks with the children on thismatter form a routine measure during school inspection.The total percentage of deiital defect-viz., 67-8—islower than that for the previous year on account ofthe inclusion of the 5-year old group. The number ofchildren requiring treatment was 1836, and of these lessthan half received treatment; lectures to parents shouldremove their apathy. There are four permanent andten temporary clinics in the county. An investi-gation into the causation of the dull and backwardchild revealed improper environment as the greatestfactor. Heredity takes second place and physicaldefect comes third. Attention is drawn to theastounding difference " existing between schools in

adjacent or even contiguous villages in respect tophysical and mental alertness, and it is noted that thecondition reflects the social and sanitary conditionof the villages, concerned. It might be added thatthe aggregate physical and mental condition of thechildren in a village taken with the general atmospherein a village school, is a very good criterion of theability of the head teacher there. The extensiveinvestigation into school furniture begun the previousyear was continued and the character of the seatingaccommodation for 44,379 children is now given.Numbers accommodated in forms without backs.. 12,880

" " " with " .. 4,720" " at dual desks...... 22,859" " with chairs and tables .. 3,920

It is to be hoped that the large number of these oldbackless forms will shortly be reduced. The numberof sanitary conveniences even in the best-equippedschools is considerably below the Board of Educationrequirements. ____

ASYLUM MEDICAL SERVICE.

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In the annual report of ltTurray’s Royal Asylum,Perth, it appears that no less than 41 of the 198

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patients treated during the year were admitted asvoluntary boarders. Gratifying as this proportion

_ may be, the medical superintendent is of the opinionthat certification could have, been dispensed with ina number of other cases, and he urges the advantages

E of voluntary admission whenever possible. Strongt emphasis is laid on the frequent association of, toxaemias with mental disease, and "

unsatisfactoryphysical health " is noted in the majority of patients

, on admission, due in most instances to such conditionsas oral sepsis and intestinal stasis. It is also recordedthat ordinary treatment brought about marked im-provement in these respects. Assuming that, as

Dr. Chalmers Watson believes, these complaints play apart in the production of mental disorder, we submitthat a record of the effects of treating them would beof great interest. The statistical tables given do notprovide this information. In what proportion of therecoveries did mental improvement follow the cure ofa physical disease ? In how many cases and in whattypes of insanity such treatment failed to affect themental condition, does not appear in the tables. Ifa number of mental hospitals collected precise infor-mation along these lines, the causes of recovery inmental disease might lose some of their obscurity.The names of two clinical clerks appear in the list ofofficers to this institution.The annual report of the West Sussex County Mental

Hospital reveals the fact that five wards in thisinstitution are empty, and it is recommended thatsome of these should be devoted solely to the careof idiot and imbecile children. A few such childrenare at present accommodated in the adult wards, anarrangement open to strong objections, and otherswould be admitted if more suitable provision weremade for them. It is also recommended in thecommissioner’s report that patients should havegreater freedom of access to the airing grounds, ratherthan be exercised there only for a stated period oneach fine day. This hospital possesses a consultingstaff of five members, and an account is given of thevaluable work done by them, including a number ofsurgical operations and a large amount of dental work.Some of the larger mental hospitals produce their

own magazines. We have received two numbers ofthe -Tlorningside Mirror, which is a good example ofproductions of this kind. Its features include a

serial story, by whose agency the reader of the Julyissue is left in a state of puzzled suspense, an accountby a " Service patient " of his experiences in AsiaMinor, and entertaining records of the various socialactivities of the institution. We are convinced thatsuch a magazine is a valuable asset to a mental hos-pital, providing both employment and entertainment,and emphasising, as it does, the community of interestbetween staff and patients.