LCC 23 London Counts Council. ANNUAL REPORT OF THE COUNCIL, 1914. VOL. III. PUBLIC HEALTH (INCLUDING THE REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER, MAIN DRAINAGE, HOUSING OF THE WORKING CLASSES). printed for THE LONDON COUNTY COUNCIL by odiiams limited, And may be purchased, either directly 01 through any Bookseller, from P. S. KING AND SON, LTD., 2 and 4, Great Smith-street, Victoria-street, Westminster, S. VV., Agents for the sale of the Publications of the London County Council. 875—14,2.16—27715 O.C. 2590 CONTENTS. Chapter XXIII. page. Public Health Reports—Report of the County Medical Officer of Health and School Medical Officer for the year 1914—Part I. (Vital Statistics and Administration). Introduction A—-Vital Statistics.—Population—Marriages—Births—Deaths—Decline of the marriage, birth and death rates—-Infantile mortality—-Principal epidemic diseases—-Smallpox and vaccination—Measles—Scarlet fever—Diphtheria—Whooping cough—Typhus—Typhoid fever—Diarrhoea and enteritis—Erysipelas—Puerperal fever—Phthisis—Cancer—Influenza, bronchitis and pneumonia—-Cerebro-spinal meningitis—Influenza and cerebro-spinal fever—Poliomyelitis and polio-encephalitis—Anthrax—Glanders—Cholera and plague—Pemphigus neonatorum— Meteorology B—Administration.—Dairies, cowsheds and milkshops—Offensive businesses-—Nuisances—Housing of the Working Classes—Underground rooms—Overcrowding—Houses let in lodgings—Death rates in Council's dwellings—Common lodging houses—Phthisis in common lodging houses—• Seamen's lodging houses—Cleansing of Persons Act, 1897, etc.—Vermin inquiry-—Water supply to tenement houses—Bevenue Act, 1903—Factory and Workshop Act, 1901 —Places where food is prepared for sale—Inspection of food—Fried fish vendors and fish curers—Shelters— Mortuaries—Inspection of theatres, music halls, etc.—Homeless persons—Mental Deficiency Act, 1913—National Insurance Act, 1911 (Treatment of Tuberculosis)—Maternity and child welfare—Midwives Act—Work of the chemical and analytical branch of the Public Health Department 43 Chapter XXIV. Public Health Reports (continued)—Report of the County Medical Officer of Health and School Medical Officer for the year 1914—Part II. (Education). Introductory Note.—Medical inspection and treatment—" Following up "—Government grants— Personal hygiene scheme—Special reports of school doctors ... ... ... ... ... 81 Medical Inspection 85 Medical and Dental Treatment 98 " Following-up "—Organising staff for children's care work 105 Be-Inspection 106 Provision of Meals for Necessitous Children 108 Children Out of School for Long Periods 109 Tuberculosis 110 Open-Air Schools—Birley House—Shooter's Hill 112 Playground Classes 116 School Journeys Undertaken during 1914 118 Bemedial Exercises 118 Personal Hyigene—Inspection—Verminous heads—Verminous persons and clothing—Action taken in the homes by local authorities—Inculcation of habits of cleanliness—Scabies— Children's Country Holiday Fund 119 Examination of Candidates—For the permanent service—Teachers and county scholars 123 Medical Inspection—(Training colleges, secondary and trade schools) 124 Besidential Institutions—Industrial schools—Places of detention 125 Infectious Diseases—Scarlet fever—Diphtheria—Measles—Whooping cough—Elementary schools under observation—School closures—Bingworm and favus—Besidential, industrial and special schools—Places of detention 126 Schools for Defective Children 132 Chapter XXV. Public Health—Powers and duties—Tuberculosis—Milk—Homeless persons—Common Lodging Houses—Seamen's Lodging Houses—-Nuisances—Offensive businessesAppeal Committee—Midwives—Lying-in Homes—Infant Life Protection—Employment of Children—Diseases of Animals 44 27715 A2 ii. Chapter XXVI. page Main Drainage 147 Chapter XXVII. Housing of the Working Classes 149 Chapter XXVIII. Housing Accounts and Statistics.—Memorandum by the Comptroller of the Council (Mr. H. E. Haward)—Memorandum by the Housing Manager (Mr. S. G. Burgess) .. 151 Appendixes. I.—Classification of children as to clothing, nutrition, cleanliness and teeth i. II.—Hospitals and centres at which medical treatment is provided for elementary school children ; and the annual provision made iv. III.—Medical inspection of school children—summary of results v. IV.—Re-inspection (first) 1914 vi. V.—Re-inspection (second) 1914 vii. VI.—Number of candidates examined and the conditions found viii. VII.—Scholars—Defects noted on medical examination and defects remedied ix. VIII.—Average height and Weight of boys in Council's industrial and elementary schools x. Diagrams. facing page Part I. Diagram A.—Marriages, 1851-1914 4 B.—Births, 1851-1914 4 „ C.—Deaths (all causes), 1841-1914 5 „ D.—Infantile Mortality, 1858-1914 6 „ E.—Tuberculous meningitis and tuberculous peritonitis (England and Wales, London and Manchester), 1891-1914 8 „ F.—Smallpox (mortality), 1841-1914 12 „ 6.—Measles (mortality), 1841-1914 14 „ H.—Measles and Whooping-cough (monthly deaths), 1891-1914 14 „ I.—Scarlet Fever (mortality), 1859-1914 14 „ J.—Scarlet Fever (admissions to hospitals of Metropolitan Asylums Board, percent. of total notified cases in London), 1890-1914 14 „ K.—Scarlet Fever (monthly notified cases and case-mortality), 1891-1914 14 „ L.—Diphtheria and Croup (mortality), 1859-1914 16 „ M.—Diphtheria (admissions to hospitals of Metropolitan Asylums Board, per cent, of total notified cases in London), 1890-1914 16 „ N.—Diphtheria (monthly notified cases and case-mortality), 1891-1914 16 „ 0.—Whooping-cough (mortality), 1841-1914 18 „ P.—Typhus (mortality), 1869-1914 18 „ Q.—Enteric Fever (mortality), 1869-1914 18 „ R.—Enteric Fever (weekly notified cases, 1914, and 1890-1914) 18 „ S.—Enteric Fever (monthly notified cases and case-mortality), 1891-1914 18 „ T.—Typhoid fever (map showing distribution of cases during 9 weeks, 21st December, 1913, to 21st February, 1914) 20 ,, U.—Diarrhoea and Enteritis (deaths under 2 years of age per 1,000 births), 1862-1914 25 „ V.—Phthisis (mortality—males and females), 1851-1914 28 „ W.—Cerebro-spinal Fever and Poliomyelitis, notified cases; Influenza, estimated cases; Influenza, deaths; weekly during 1914 and first five months of 1915 35 „ X.—Influenza, deaths ; cerebro-spinal fever and poliomyelitis, notified cases (monthly, 1908-1913) 35 „ Y.—Cerebro-spinal fever and influenza, relationship 36 „ Z.—Vermin (seasonal prevalence of three kinds), 1909-1914 57 iii. Part II. facing page Diagram C.—Scarlet Fever and Diphtheria (weekly notifications), 1914 126 „ D.—Seasonal prevalence of fleas compared with weekly notifications of scarlet fever and diphtheria, 1909-1914 127 „ E.—Age incidence of scarlet fever 128 Maps. A.—Map showing the hospitals and centres at which medical treatment is provided for elementary school children 100 B.—Area served by cleansing stations 121 London County Council. ANNUAL REPORT OF THE COUNCIL, 1914. CHAPTER XXIII. REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH (Dr. W. H. Hamer) for the year 1914. Part I.—General. Introduction. At the time of the census in April, 1911, the area of the administrative County of London was 74,816 acres, and the enumerated population was 4,521,685 persons. The population in the middle of the year 1914, as estimated by the Registrar-General, was 4,518,021 persons. Reference is made in the subsequent report to the question of movement of population, and in particular to its bearing upon the age-constitution of the London community. This influence has undoubtedly appreciably affected the birth, marriage and death rates, and has disturbed somewhat seriously the recorded mortality rates for many chronic diseases. The principal vital statistics of London as a whole and of certain large towns of England and Wales for the year 1914 and preceding periods, are shown in separate tables at the end of this report (Tables I.—III., pages 40-42); the corresponding figures relating to the constituent administrative districts of London are set out in the various sections of the report. The marriage rate, which fell to a minimum (16-9 per 1,000 living) in 1908 and 1909, attained during the year 1914 the comparatively high level of 19'2, a figure which has not been reached since 1876. The exceptional circumstances prevailing during the latter part of the year undoubtedly exercised sonm influence in producing this result, but since 1909, even in normal years, the marriage rate has shown a gradual recovery from the low level reached in 1908. The birth rate, which failed in 1913 for the first time since 1903 to show a decline on the rate of the preceding year, again showed diminution during 1914, being 24'3 per 1,000 persons living, as compared with 245 per 1,000 in 1912 and 1913. The maximum birth rate was attained in 1876, the year preceding the fall in the marriage rate. The death rate (14.4 per 1,000 living) shows a slight increase on the rate for 1913. This rate has fluctuated considerably in the last decennium, reaching as high a figure as 15'8 in 1906, and falling as low as 13.6 in 1912, in which year the rate was the lowest ever recorded for London. The present rate, however, compares very favourably with the rates, exceeding 20'0 per 1,000, in the years preceding 1890. The infant mortality rate (104 per 1,000 births) is slightly lower than in 1913, but exceeds considerably the very low rate of 1912 (91 per 1,000 births). In the earlier year, it is to be observed that the summer temperature Was below the average, whilst the rainfall, especially during the month of August, was above the average. Probably this fact had its effect upon the mortality from diarrhoea, for the deaths were only half as numerous in 1912 as in 1913 or 1914. Comparing the year 1914 with 1913 as regards the principal epidemic diseases, measles shows decreased mortality, though towards the end of 1914 it began to be increasingly prevalent; while scarlet fever and diphtheria display an increase, the latter with a slightly raised case mortality; whooping cough also exhibits increased mortality. The death rate from typhoid fever remains very low, but the case mortality is slightly higher than that usually observed. Having in view the conditions prevailing on the Continent in the latter half of jthe year, and the large number of persons arriving in this country from abroad, the most careful scrutiny was made of all suspected or possible imported cases of epidemic disease. Fortunately, during 1914 there was no development of mischief in London in respect of cholera, plague, small-pox, typhus or typhoid fevers, though reference to the introduction of isolated cases of the three last named diseases from abroad will be found under the appropriate heads. Among the notifiable infectious diseases, scarlet fever, diphtheria, typhoid fever, and erysipelas all showed some increase of prevalence during the year as compared with the preceding years. Reference is made on p. 57 to the subject of possible relationship between prevalence of scarlet fever and of certain kinds of vermin. The circumstances attending an exceptional prevalence of typhoid fever in the early part of 1914 are analysed in some detail (p. 20) and reference to the general question of the origin of cases of typhoid fever in London is also made. As regards pulmonary tuberculosis 16,467 primary notifications were received as compared with 19,218 during eleven months only of 1913. For " other forms of tuberculosis " the respective figures were 3,862 and 6,436. Seventy-three cases of cerebrospinal fever were notified as against 92 in 1913. A discussion of the relationship between influenza and cerebro-spinal fever, as illustrated during the increased incidence of these diseases commencing towards the end of 1914, will be found on page 34. The subject is one of no little interest; indeed, it has occupied the attention of students of epidemic disease for many years past; the recent outbreak has afforded a good [opportunity for making a detailed study of the whole question. It may be stated as the outcome of this investigation that the number of instances in which sufferers from cerebro-spinal fever have been found to have been coincidently affected by influenza, is far higher than would have been anticipated had the association been merely a matter of chance. Poliomyelitis also shows a decline ; some account of a very interesting group of cases of poliomyelitis notified in East London during the summer months is given on p. 37 ; it is especially noteworthy that the majority of these cases were reported from the London Hospital, and there is no doubt that the careful attention given to this disease by the staff of; that hospital accounts for the fact that this prevalence of the disease has not passed without being recorded. 27715 B 2 Annual Report of the London County Council, 1914. The usual tables have been included in the administrative section of the report giving particulars concerning the activities of local authorities in various branches of work. It is gratifying to find that in spite of the war so much has been accomplished, more especially having in view the claims made for special service and the exceptional rises incidental to influx of refugees and wounded from the Continent, which have made it necessary to keep closer watch than ever upon infectious diseases. On the outbreak of hostilities the late county medical officer of health, Sir Shirley Murphy, was attached to the staff of the Deputy-Director of Medical Services of the London military district. The medical officers of health of London sanitary districts also offered their services in connection with the special arrangements necessary for the housing and feeding of aggregations of men, the maintenance of sanitary conditions, and the taking of precautions against disease. These duties were performed under the direction of the military authority, and were additional to the duties performed as officers of the sanitary authority. Several medical officers of health joined the forces of the Crown for active service and substitutes have had to be engaged. Despite these wholly abnormal conditions, a very large amount of work has been done, but the record furnished has necessarily been less complete than in ordinary years, owing to the exceptional demands made upon the sanitary staffs. For these reasons, some curtailment of the administrative part of this report has been found to be necessary ; indeed, the completed reports have not been available in the case of a few of the boroughs. An account is given on page 64 of the form of procedure adopted and the action taken during 1914 under the Mental Deficiency Act (1913). Other subjects referred to are : the treatment of tuberculosis under the provisions of the National Insurance Act, 1911 (p. 70) ; a review of the results of the several enumerations of homeless persons undertaken by the Council during the past ten years (p. 62); the very satisfactory reduction in the extent of prevalence of verminous conditions in certain sections of the London population (p. 55) ; the administration of the Midwives Act. 1902 (p. 73) ; and the year's work of the chemical and analytical branch of the public health department (p. 78). A.—Vital Statistics. Population. The census populations of London boroughs in 1901 and 1911 and the mid-year population in 1914, as estimated by the Registrar-General, are shown in the following table :— Metropolitan borough. Census Population 1st April, 1901. Census Population 3rd April, 1911. Estimated Population (middle of year 1914). Metropolitan borough. Census Population 1st April, 1901. Census Population 3rd April, 1911. Estimated Populatiou (middle of year 1914). Paddington 143,976 142,551 142,193 Shoreditch 118,637 111,390 109,569 Kensington 176,628 172,317 171,234 Bethnal Green 129,680 128,183 127,807 Hammersmith 112,239 121,521 123,853 Stepney 298,600 279,804 275,081 Fulham 137,289 153,284 157,303 Poplar 168,822 162,442 160,839 Chelsea 73,842 66,385 64,511 Southw ark 206,180 191,907 188,321 Westminster, City of 183,011 160,261 154,544 Bermondsey 130,760 125,903 124,683 St. Marylebone 133,301 118,160 114,355 Lambeth 301,895 298,058 297,094 Hampstead 81,942 85,495 86,388 Battersea 168,907 167,743 167,451 St. Pancras 235,317 218,387 214,133 Wandsworth 231,922 311,360 331,321 Islington 334,991 327,403 325,496 Camberwell 259,339 261,328 261,828 Stoke Newington 51,247 50,659 50,511 Deptford 110,398 109,496 109,269 Hackney 219,110 222,533 223,393 Greenwich 95,770 95,968 96,018 Holbom 59,405 49,357 46,832 Lewisham 127,495 160,834 169,211 Finsbury 101,463 87,923 84,521 Woolwich 117,178 121,376 122,431 London, City of 26,923 19,657 17,831 London 4,536,267 4,521,685 4,518,021 Movement of In recent annual reports attention has been especially directed to the great importance in rela- the London tion to vital statistics of the question of movement of the population. In the annual report for 1912, population in (p 110), reference was made in this connection to evidence pointing to the fact that there has been ieeent years. recen£ years a distinct outward movement from registration London of young married persons with their families. The teaching of the figures is borne in upon the minds of those who have direct knowledge of the very great difficulty experienced by poor persons with four or five children in obtaining accommodation in tenements within the County of London. Again, in the annual report for 1913 (p. 2), the importance of local migration was illustrated by instituting comparisons between the age constitution of the male and female populations, firstly, of England andWales and London, and secondly, of London north of the Thames and London south of the Thames, and it was pointed out that London attracts females of the ages 25-35 in greater degree than males. The striking differences shown by the figures given, illustrate the importance of constantly bearing in mind the variations in age constitution which exercise so marked an influence in London; in particular, the effect of these variations upon the birth, marriage, and death-rates must not be forgotten, and to this subject further reference is made on page 5. Comment, moreover, is made later in this report upon the question of changes in infant mortality which have probably been influenced by changing age-constitution of the London population, and the disturbing effect of movement of population upon the phthisis death-rate has been fully discussed elsewhere (Trans. Roy. Soc. Med., 1912-13) ; again, in last year's report (p. 42), a further examination was instituted into the question as to how far tuberculosis mortality is affected by altering nomenclature and changing age constitution. Report of the County Medical Officer—General. 3 The 74th Annual Report of the Registrar General, published in 1913, contains a diagram showing deaths from all causes at different ages in "various classes of area," and in commenting upon the approximation of curves in early adult life, reference is made by the Superintendent of Statistics to "the explanation of this feature in the diagram." "It has," Dr. Stevenson continues, "often been pointed out, that especially in the case of females, the mortality of young adults from phthisis is understated in large towns and overstated in rural areas, owing to the fact that young immigrants to the towns when disabled by the disease return to their homes in the country, and in many cases die there." Unfortunately, as Dr. Stevenson says, "the resulting mis-statement of mortality cannot be fully corrected by any means at present available. He further adds," The diagram suggests that, as indeed might reasonably be expected, this fallacy in the returns is not restricted to phthisis. It probably applies to all diseases of at all a chronic nature. It is natural that it should apply more in the case of females, who probably do not remove so far from their homes as males, and remain in close touch with them. It is also natural that the fallacy should apply more to London and the rural districts than to the other two area groups." Dr. Stevenson further proceeds to remark that, if the explanation of the curves be a true one, "this peculiarity should appear more markedly in a similar diagram relating exclusively to a chronic disease such as phthisis, and should be absent in the case of a disease such as lobar pneumonia, which strikes down its victims suddenly, giving them 110 opportunity of returning to the old home to die there." He finds the anomaly more pronounced in the case of phthisis than in that of deaths from all causes, but, with one curious exception, absent in the case of pneumonia. He says, "We may, therefore, conclude that such transfer of deaths does, in the main, account for the approximation in youth of urban and rural mortality." The curious exception referred to is further discussed on p. Ixxxviii. It appears that, while at most ages the mortality from lobar pneumonia is higher at all periods of life in the county boroughs than in the rural areas, the London death-rate 1906-10 was lower than that of the country generally at ages 5-30 in males and 15-30 in females. Dr. Stevenson says (p. lxxxix.): "The explanation of the similar feature in the case of deaths from all causes, and from phthisis, cannot apply to lobar pneumonia, sufferers from which are struck down too suddenly, as a rule, to return to distant homes before their death." He considers the possibility that the influence of industrial conditions may explain the difference, but finds no proof of this, and he then enquires whether the proportion of deaths occurring in institutions may contribute to the explanation, "if it may be assumed that for persons in the vigour of youth recovery from this disease is largely a matter of careful nursing." He gives a table showing that a larger proportion per cent, of total deaths from lobar pneumonia and "pneumonia" occurs in institutions in London than in the other classes of area, and he says: "The difference between the various classes of area must be assumed to have had some effect upon the mortality, and probably also upon its age distribution." In connection with appendicitis, Dr. Stevenson has something further to say on the same subject. In the Annual Report of the Registrar General for 1913, p. Ixxiii., he Writes, "Comparing urban and rural mortality at different ages it may be noted that the rural excess, pointed out on p. xxx. for the general mortality of young women, is well marked in the case of appendicitis. At all ages from 10.35 the death rates of females are higher in the rural than in the urban districts, though those of males are lower. This is the more interesting, as the explanation put forward to explain the similar facts met with in the case of tuberculosis—that young women infected in the towns, frequently return to their country homes when invalided—cannot Well apply in the case of an acute disease like appendicitis. The phenomenon may be compared with the depression in the mortality curve of pneumonia in London at similar ages." The influence of hospital treatment and careful nursing does, no doubt, as Dr. Stevenson suggests play its part, but it is perhaps deserving of remark that attacks of appendicitis may go on in seme instances for a considerable period of time ; and again, pneumonia may be a terminal event in a chronic disease; moreover, it may supervene in cases of arrested or ameliorated phthisis; and if it be granted that there is a general tendency for young persons developing phthisis in urban districts to return to their homes in rural districts, where conditions are more favourable to recovery, then it is not impossible that the relatively high prevalence at these ages of pneumonia in rural districts may be directly correlated with the similar relative excess in phthisis. It is generally recognised that it is the fact that young women, particularly domestic servants whose homes are in the country, when they become unfit for work tend to return to their homes to a greater extent than young men do, and this view the figures given in the Registrar General's Annual Reports clearly support; though it is, at first sight at any rate, rather surprising, as Dr. Stevenson points out, that the phenomenon should be so marked in the case of pneumonia and appendicitis. It is, moreover, necessary to remember that the population migrating to the towns is to a large extent a selected population, and that a less resistant residue is left in the country villages. The illustrations which have been given furnish further proof than has been already adduced that the movements of population which have so continuously occurred in the last half century have had very far reaching, though not in all instances very obvious, influence upon vital statistics, and study of these influences is especially necessary in dealing with London. In Part I. of the supplement to the 75th Annual Report of the Registrar-General there will be found a life-table for London, calculated by Mr. George King, F.I.A., F.F.A., based 011 the mortality for the two years 1911 and 1912. The system of transferring to London the deaths of Londoners occurring anywhere in England and Wales was brought into operation in 1911, and consequently the life-table is the first to be computed upon the new series of figures. It should be pointed out that while the deaths allocated to London by transfers render the total deaths belonging to London as complete as possible, no addition lias been made to the London Census population in respect of the occupants of institutions outside London chiefly or exclusively occupied by London residents. Were such an addition made, the 27715 B 2 4 Annual Report of the London County Council, 1914. mortality rates would be decreased, and compare even more favourably with the corresponding figures of the second London life-table, relating to the period 1901-1910, contained in the Annual Report of the Council for 1912 (Vol. Ill,, p. 105). The average death-rate in 1901-1910 for both sexes at all ages was 15-7 per 1,000, as compared with 14-3 per 1,000 in the years J911—12 ; but the improvement in healthiness which these figures imply is not, for the reasons stated above, adequately represented in the 1911-12 life-table. The expectations of life at various ages in the periods 1901-10 and 1911-12 are as follows :— Age x Expectation of Life at Ago x. Males. Females. 1901-1910 1911-12 1901-10 1911-12 Years. Years. Years. Years. 25 37.59 38.06 41.32 42.29 35 29.50 29.84 32.87 33.71 45 22.31 22.45 25.21 25.82 55 15.98 15.95 18.19 18.66 65 10.56 10.51 12.03 12.34 75 6.35 6.28 7.17 7.29 85 3.48 3.71 3.90 4.02 Marriage rates — London. Marriages of minors. Birth rates in London sanitary districts. On comparing the values for males it is observed that from age 55 onwards the expectation of life calculated on the mortality in 1901-1910 is greater than on the experience of 1911-12 ; in actual fact, however, if the correction above referred to had been made in calculating the values for 1911-12, the expectation in the latter period would have exceeded that of 1901-1910. The increase in expectation of female lives from 55 upwards in 1911-12 over 1901-10 would also have been greater than appears from the table. Marriages. The number of marriages in the Administrative County of London in 1914, was 43,366 (365 days) giving an annual rate of 19 2 persons married per 1,000 living. The marriage-rate in successivc periods is given in table I, page 40. The accompanying diagram (A) shows the marriage-rate in each year since 1850, in relation to the mean marriage-rate of the period 1851-1914. It will be seen that in recent years the highest marriage-rates were attained in 1882, 1891 and 1898 ; the rate then fell to a minimum of 16 9 in 1908 and 1909 (the point previously touched in 1887 and 1888) and has since shown recovery to 19.2 in 1914 In the year 1914, among males 3 4 per cent, married were under 21 years of age, and among females 11.4 per cent.; the figures for previous years are shown in table I, page 40. It will be seen that the proportion of male and female minors in every 100 marriages has been diminishing for a number of years, but there is some indication of a pause in the decline. Births. The number of births in the Administrative County of London in 1914 (52 weeks) was 109,667, giving a birth-rate of 24.3 per 1,000 persons living per annum. The birth-rate in successive periods is shown in table I, page 40. The diagram (B.) facing this page shows the London birth-rate in each year since 1850, in relation to the mean birth-rate of the period 1851-1914. In connection with this diagram it should be noted that the registration of births was not made compulsory until the beginning of 1875; before that year many births were probably unregistered. From the year 1885 onwards the number of births has been corrected as far as possible by the exclusion of those which occurred in the chief lying-in institutions in cases where the mother resided outside the County of London. The following table shows the birth-rate in the several sanitary districts per 1,000 persons living in the period 1909-18 and in the year 1914 :— Metropolitan borough. Births, 1914 (52 weeks). Birth-rate per 1000 persons living. Metropolitan borough. Births, 1914 (52 weeks). Birth-rate per 1,000 person living. 1909-13. 1914. 1909-13. 1914. Paddington 2,965 21.5 20.9 Shoreditch 3,511 32.1 32.1 Kensington 3,210 19.1 18.8 Bethnal Green 3,786 31.6 29.7 Hammersmith 2,935 24.4 23.8 Stepney 8,058 31.6 29.4 Fulham 4,154 27.6 26.5 Poplar.. 5,073 31.6 31.6 Chelsea 1,299 19.7 20.2 Southwark 5,604 30.3 29.8 Westminster, City of 2,155 15.3 14.0 Bermondsey 3,849 31.4 31.0 St. Marylebone 2,132 20.4 18.7 Lambeth 7,022 24.4 23.7 Hampstead 1,273 15.3 14.8 Battersea 4,303 26.0 25.8 St. Pancras 5,223 25.4 24.5 Wandsworth 6,675 21.8 20.2 Islington 8,171 25.2 25.2 Cambervvell 6,580 25.1 25.2 Stoke Newington 1.045 20.6 20.7 Deptford 3,115 27.6 28.6 Hackney 5,460 24.0 24.5 Greenwich 2,408 25.4 25.1 Holborn 764 18.8 16.4 Lewisham 3,336 21.3 19.8 Finsbury 2,541 30.6 30.1 Woolwich 2,839 23.4 23.3 London, City of 181 11.3 10.2 London 109,667 25.0 24.3 Diagram A . Marriages. (LONDON) Diagram B. Births. (LONDON) Diagram C. Deaths (all Causes) (LONDON) Report of the County Medical Officer—General. 5 It will be seen from the above table that the birth-rates of the several sanitary districts vary greatly, ranging, when the rates for the year 1914 are compared, from 10-2 in the City of London, to 32-1 in Shoreditch. Deaths. The number of deaths in the Administrative County of London in 1914 (52 weeks) was 64,994 giving an annual death rate of 14*4 per 1,000 of the estimated population. The death-rate in successive periods is given in table I, page 40. The death-rate in each year since 1840 in relation to the mean death-rate of the period 1841-1914 is shown in diagram (C). The following table shows the crude death-rates, and the death-rates corrected tor difterences in the age and sex constitution of the population of the several sanitary districts during the year 1914, and for the period 1909-13. Area. Factor for correction for age and sex distribution. Crude death-rate per 1,000 persons living. Corrected deathrate per 1,000 persons living. Corrected comparative mortality figure (London, 1,000). 1909-13. , 1914. 1909-13. 1914. 1909-13. 1914. England and Wales 0.9790 13.9 13.0 13.6 13.7 951 951 London 1.0000 14.3 14.4 14.3 14.4 1,000 1,000 Paddington 0.9941 13.1 13.0 13.0 12.9 909 896 Kensington 0.9957 13.4 13.1 13.3 13.1 930 910 Hammersmith 0.9884 14.1 13.9 13.9 13.7 972 951 Fulham 1.0340 13.3 13.4 13.8 13.8 965 958 Chelsea 0.9513 14.8 13.5 141 12.9 986 896 Westminster, City of 1.0540 12.5 12.6 13.2 13.2 923 917 St. Marvlebone 1.0198 14.3 13.8 14.6 14.1 1,021 979 Hampstead 1.0572 10.0 10.4 10.6 11.0 741 764 St. Pancras 0.9971 15.2 15.6 15.2 15.6 1,063 1,083 Islington 0.9749 14.6 15.2 14.2 14.8 993 1,028 Stoke Newington 0.9512 12.5 13.1 11.9 12.5 832 868 Hackney 1.0066 13.2 13.9 13.3 14.0 930 972 Holborn 1.0034 15.6 16.1 15.7 16.2 1,098 1,125 Finsbury 0.9887 19.2 19.6 19.0 19.4 1,329 1,347 London, City of 1.0419 14.9 13.4 15.5 14.0 1,084 972 Shoreditch 1.0331 18.6 19.0 19.2 19.6 1,343 1,361 Bethnal Green 1.0397 16.4 16.0 171 16 6 1,196 1,153 Stepney 1.0433 15.9 16.5 166 17.3 1,161 1,201 Poplar 0.9898 16.9 17.1 16.7 16.9 1,168 1,174 Soutliwark 1.0060 17.6 17.8 17.7 17.9 1,238 1,243 Bermondsey 0.9976 18.0 17.4 18.0 17.4 1,259 1,208 Lambeth 0.9804 14.3 14.6 14.0 14.3 979 993 Battersea 1.0098 13.5 13.3 13.6 13.4 951 931 Wandsworth 1.0045 10.9 10.9 10.9 11.0 762 764 Camberwell 0.9883 13.7 13.7 13.5 13.6 944 944 Deptford 0.9879 14.8 14.4 14.6 14.3 1,021 993 Greenwich 0.9837 14.0 14.7 13.8 14.5 965 1,007 Lewisham 0.9826 10.6 10.9 10.4 10.7 727 743 Woolwich 1.0249 12.4 13.8 12.7 14.1 888 979 It will be seen from the foregoing table (comparing the corrected death-rates) that in the quinquennium 1909-13, Shoreditch (19.2)had the highest rate and Lewisham (10.4) the lowest, and that in the year 1914 Shoreditch (19.6) also had the highest, and Lewisham (10.7) the lowest. The death-rates in each of the four quarters of the year 1914 were as follows : first quarter 16.1; second quarter, 131; third quarter, 13.3 ; and fourth quarter, 15.3 per 1,000 persons living. The Decline of the Marriage, Birth and Death Rates. An important consideration to be borne in mind with regard to the observed phenomena is, as already noted on page 2, the appreciable effect that is exerted by migration of population upon the marriage, birth and mortality rates. This subject has been referred to in previous reports, but the question may, perhaps, be again illustrated by reference to Diagrams A and B, showing marriages and births in London. Looked at, broadly, it might perchance have been anticipated that the decline in the marriage rate from a high level in the fifties and sixties, to a distinctly lower level in the eighties, nineties and onwards, would have brought about a fall in the birth rate, commencing in the eighties and steadily continuing for thirty or forty years. This is exactly what has happened; for the minor oscillations or ripples in the chart showing the marriage rate could not of course be expected to produce ripples of like magnitude on the declining wave of the birth rate, for the obvious reason that children are not being born exclusively to the newly married. The objection, however, is raised by those who regard the fall of the birth rate as an artificial rather than a natural phenomenon, that, if the birth-rate be calculated on the numbers of married women, and due correction be made for the age Death rates all causes. Death-rates in London boroughs. 6 1>eaths of infants per 1,000 births. I »eaths and death rates of infants in London boroughs. Annual Report of the London Count// Council, 1914. constitution of tlie child-bearing section of the married female population, the decline in the birthrate is still conspicuously manifested. This is true, but obviously in correcting the crude general birthrate by making allowance for the age constitution of the section of the population formed by its potential mothers, only a very partial and incomplete correction is being made. It has been pointed out, for example, that the age constitution of the potential fathers needs also to be considered, and, if allowance be made for this, the corrections are still only quantitative and not qualitative. Some of the qualitative corrections must be regarded, however, as very important, a particularly noteworthy one being that rendered significant bv reason of the migratory character and the increased urbanisation of the population during the last fifty years. For instance, in the case of London, the young women of to-day cannot be fairly compared with the young women of the London of fifty years ago ; and they differ very widely in respect of the extent to which they may be expected to contribute to the London birth rate. An obvious difference in this respect arises owing to the fact that the large unmarried domestic servant class consists of women, who in very many instances, when they marry leave London ; there is, moreover, a distinct selective influence exercised, under modern conditions of London life, which materially affects the constitution, as regards social status, of the young married women transferred from the country to London. Influences such as these have quite unobtrusively transformed the London mothers of a later generation away from any close resemblance to those of an immediately preceding or of a yet earlier generation. The early Victorian married women of childbearing age cannot, therefore, legitimately be compared with the married women of like ages to-day, and failure to recognise this quite obvious fact is apt to cause much misunderstanding. Similar considerations to those just mentioned exercise influence, too, in connection with the observed decline of the death rate, but this subject has already been alluded to on page 2, and has been discussed at some length, more particularly in connection with the phthisis death rite, in the annual report of last year. Injant Mortality. The deaths of children under one year of age in the Administrative County of London during 1914 (52 weeks) numbered 11,395, being in the proportion of 104 per 1,000 births. The proportion in successive periods is given in table I., page 40. The accompanying diagram (D) shows the infant mortality in each year since 1857 in relation to the mean infant mortality of the period 1858-1914, and also the infant mortality in each year after exclusion of the deaths from premature birth, which cause of death Would in all probability be affected in greater degree than the deaths under any other heading by the more complete registration of recent years. The following table shows the deaths of infants under one year of age, and the number of these deaths per 1,000 births in each of the sanitary districts of the County of London for the period 1909-13 and for the year 1914 :— Metropolitan borough. Deaths under one year of ape, 1914 (52 weeks). Deaths under one year of age per 1,000 births. Metropolitan borough. Deaths under one year of age, 1914 (52 weeks). Deaths under one year of age per 1,000 births. 1909-13. 1914. 1909-13. 1914. Paddington 281 104 95 Shoreditch 496 147 141 Kensington 302 111 94 Bethnal Green 518 123 137 Hammersmith 275 112 94 Stepney 997 118 124 Fulham 468 106 113 Poplar 590 125 116 Chelsea 87 95 67 Southwark 693 120 124 Westminster,City of 173 93 80 Bermondsey 482 133 125 St. Marvlebone 208 98 98 Lambeth 728 102 104 Hampstead 102 70 80 Battersea 402 105 93 St. Pancras 481 99 92 Wandsworth 591 90 89 Islington 857 103 105 Camberwell 653 98 99 Stoke Newington 81 80 78 Deptford 308 113 99 Hackney 502 99 92 Greenwich 235 105 98 Holborn 69 101 90 Lewisham 247 81 74 Finsbury 312 132 123 Woolwich 240 83 85 London, City of .. 17 94 94 London 11,395 107 104 It will be seen from the foregoing table that in the period 1909 13, and in the year 1914, Shoreditch (147 and 141 respectively) had the highest infant death-rates, while the lowest death-rate in 190913 was that of Hampstead (70) and in 1914 that of Chelsea (67). The deaths in London under one year of age per 1,000 births, during each of the four quarters of the year were as follows First quarter, 97 ; second quarter, 80 ; third quarter, 129 ; fourth quarter, 111. The reports of Medical Officers of Health of the several sanitary districts of the Administrative County for the year 1914 contain tables prepared in accordance with the instructions of the Local Government Board giving the number of deaths, from all causes and certain specified causes, of infants at different age-periods in the first year of life. From the information thus supplied, the following table has been compiled, showing the figures for London as a whole for the 52 weeks of 1914. It will be seen that the total deaths here shown differ slightly from the total in the preceding table derived from the annual summary of the Registrar-General. Diagram D. Infantile Mortality (Deaths under one year of age per 1,000 birth) (LONDON ) (LON DON) 7 Report of the County Medical Officer—General. Cause of death. lrnder 1 Week. 1-2 Weeks. 2-3 Weeks. 3-4 Weeks. Total under 1 Month. 0-3 Months. 3-6 Months. 6-9 Months. 9-12 Months. Total Deaths under 1 year. Common Infectious Disease ft— Small-pox — — — — — — — — — — Shieken-pox — — — — — — I 3 3 7 Measles — 2 — —. 2 10 20 76 170 276 Spnrlet, Fever — — — — — — 2 6 3 11 Diphtheria and Hrnnn — — 3 —. 3 8 6 22 28 64 Whooping-cough 1 — 3 8 12 78 98 100 127 403 Diarrheal Diseases— Diarrhoea, all forms 1 12 16 13 42 336 460 304 214 1,314 Enteritis (not tuberculous) 8 18 22 20 68 330 412 236 177 1,155 Gastritis, Gastrointestinal Catarrh 3 4 3 G 16 49 27 15 9 100 Wasting Diseases— Premature Birth 1,330 189 117 77 1,722 1,884 43 7 5 1,939 Congenital Malformations 147 59 24 20 250 317 40 11 9 377 Atelectasis 173 13 12 13 211 229 4 — — 233 Injury at Birth 105 4 3 1 113 113 — — 113 Want of Breast-milk Atrophy, Debility, Marasmus 240 117 110 03 530 890 317 103 75 1,385 Tuberculous Diseases— Tuberculous Meningitis — 1 1 14 39 44 52 140 Abdominal Tuberculosis — — — 1 1 24 30 26 16 96 Other Tuberculous Diseases — 1 1 2 17 24 29 39 109 Erysipelas — 2 5 7 17 10 7 3 37 Syphilis 13 21 23 24 81 158 39 18 12 227 Rickets 1 5 9 7 22 Meningitis (not Tuberculous) — 3 1 — 4 20 34 38 26 118 Convulsions 65 44 29 22 160 209 54 44 18 325 Bronchitis 9 19 35 26 89 286 160 112 89 647 Laryngitis — — — 1 1 4 4 1 4 13 Pneumonia 17 20 28 29 94 326 274 291 303 1,194 Suffocation, overlaying 65 8 17 11 101 213 79 12 3 307 Other causes 114 47 47 32 240 370 148 127 103 748 Total (All Causes) 2,300 580 496 374 3.750 5,903 2,330 1,641 1,495 11,369 Causes of death of infants under one year of age. Comparison may be made between the number of deaths from the several causes in 1914 °f and those in antecedent years by reference to the following table •— Cause of death. 1905. 52 weeks. 1906. 52 weeks. 1907. 52 weeks. 190S. 53 weeks. 1909. 62 weeks. 1910. 52 weeks. 1911. 52 weeks. 1912. 52 weeks. 1913. 53 weeks. 1914. 52 weeks. Deaths in 1914 in excess or defect of t lie corrected average for 1905-13. Diminution in 1914. Excess in 1914. Small-pox — — — — — — 1 — — — — — Chicken-pox 3 3 5 3 10 4 5 3 3 7 — 3 Measles 389 420 400 333 503 391 531 371 323 276 103 — Scarlet Fever 34 18 35 24 20 10 6 10 8 11 6 — Diphtheria and Croup 52 59 53 67 60 30 53 49 50 64 — 15 Whooping Cough 623 502 746 469 524 , 602 424 429 336 403 76 — Diarrhoea 3,423 4,468 1,790 2,709 1,849 1,536 4,443 1,230 2,505 2,569 — 106 Enteritis (not tuberculous) Gastritis, Gastro-intestinal Catarrh Premature Birth 2,423 2,208 2,299 2,197 2,122 2,086 1,970 1,976 1,938 1,939 45 — Congenital Malformation Atelectasis 547 613 645 705 667 657 ! 472 \ 175 397 175 421 216 377 233 — 21 Injury at birth 99 113 117 110 113 108 123 112 114 113 — 8 Want of Breast-milk 2,281 2,130 1,922 1,843 1,825 1,682 1,738 1,384 1,480 1,385 290 — Atrophy, Debility, Marasmus Tuberculous Meningitis 273 241 239 259 203 179 211 162 140 149 47 — Abdominal Tuberculosis 192 225 153 168 145 129 99 78 94 96 35 — OtherTuberculousDiseases 284 246 264 255 188 142 148 126 104 109 70 Erysipelas 64 50 52 35 48 32 26 20 30 37 1 Syphilis 271 233 226 229 216 186 172 172 188 227 — 32 Rickets 79 67 58 51 45 54 38 24 31 22 24 — Meningitis (not tnbereulous 300 302 210 246 170 174 183 125 134 118 70 — Convulsions 803 660 603 520 495 475 428 374 422 325 165 — Bronchitis 1,276 1,043 1,284 982 960 843 847 710 840 647 256 Laryngitis 25 23 15 18 15 13 17 13 9 13 2 Pneumonia 1,490 1,335 1,629 1,431 1,334 1,442 1,334 1,186 1,472 1,194 113 — Suffocation, overlaying 462 417 421 417 322 321 261 301 289 307 23 Other causes 1,004 1,009 979 885 852 751 804 693 711 748 43 — Total 16,397 16,385 14,145 13,956 12,686 11,847 14,509 10,120 11,858 11,369 Net diminution 1,182 Number of births 125,939 124,880 121,408 122,898 116,559 115,190 111,738 110,358 112,637 109,667 8 Annual Report of the London County Council, 1914. With a view to comparing the rates of mortality from the several groups of diseases, per 1,000 bom, in the years 1905-14, the following table has been prepared:— Year. All causes. Measles. Whoopingcough. Diarrhceal diseases. Wasting diseases. Tuberculous diseases. Meningitis and convulsions. Bronchitis. Pneumonia. Other causes. 1905 130.2 3.1 4.9 27.2 42.5 6.0 8.8 10.1 11.8 15.8 1906 131.2 3.4 4.0 35.8 40.5 5.7 7.7 8.4 10.7 15.0 1907 116.5 3.3 6.2 14.7 41.0 5'4 6.7 10.6 13.4 15.2 1908 113.6 2.7 3.8 22.0 39.5 5.6 6.2 8.0 11.7 14.1 1909 108.8 4.3 4.5 15.9 40.6 4.6 5.7 8.2 11.4 13.6 1910 102.8 3.4 5.2 13.3 39.4 3.9 5.6 7.3 12.5 12.2 1911 129.8 4.7 3.8 39.7 40.1 4.1 5.5 7.6 11.9 12.4 1912 91.7 3.4 3.9 11.2 36.6 3.3 4.5 6.4 10.8 11.6 1913 105.3 2.9 3.0 22.2 37.0 3.0 4.9 7.5 13.1 11.7 1914 103.7 2.5 3.7 23.4 36.9 3.2 4.1 5.9 10.9 13.1 In the Annual Report for 1909, Sir Shirley Murphv commented upon the decrease in the London death-rate from tubercular diseases in children, a phenomenon which was already apparent at that time (see p. 22 Annual Report, 1909). Examination of the death rates from tuberculous meningitis in London, and in England and Wales, shows a fairly steady decline for the last fifteen years. The rapidity of decline is greater in London than in England and Wales, but the rate for the former, though it has in recent years rather closely approached, still exceeds that of the latter. On turning to tuberculous peritonitis, decline is apparent in both London and England and Wales, and the rapidity of this decline is again rather greater in London; it is particularly noteworthy, however, that for the last fifteen years (with only two exceptions) the rate in London has been lower than that in England and Wales (see Diagram E). The Registrar.General, in his Annual Report for 1913, specially comments upon the fact that there is a low rate of mortality from abdominal tubercle in London, whereas meningeal tubercle causes a heavier mortality in London than in other classes of area. He says : " The London rate, indeed, is less than half that in the county boroughs, though, London apart, the usual rule of increase in mortality with increasing aggregation of population holds good for each of the three years dealt with in the table. Unless, as seems unlikely, exposure of children to infection by means specially liable to implicate the intestine and peritoneum is at a minimum in London, the question must arise whether the extraordinary difference shown by the figures represents the facts. We have seen that the mortality tends to rise in years when fatal diarrhoea is prevalent. The most obvious explanation of this fact would seem to be the return as tuberculous of certain deaths from diarrhoea not of tuberculous origin, unless, indeed, diarrhoea can be held to prepare the ground for local infection with tubercle. If the deaths returned under this heading are not all due to tubercle, this was probably the case still more thirty years ago, which would help to explain the very great reduction in recorded mortality since that time. It might also account for the low mortality in London, where there is much reason to believe that death certification is at its best." It is, of course, conceivable that the action taken with regard to tuberculous milk coming into London may have had some influence in reducing the London mortality from tuberculous meningitis and tuberculous peritonitis. With a view to further examination of such an hypothesis, the rates for Manchester, which are available since 1897, when the present area of the City was determined, have been plotted out on diagram (E). It will be seen that in Manchester, which took action with regard to tuberculous milk in 1899, nine years prior to the date (1908) when action was taken in London, the decline in mortality has been rather less marked than in London, and in neither instance does the extent of the decline greatly differ from that observed in England and Wales. This behaviour of the rates in these three populations tends to confirm Dr. Stevenson's view that the fall in the London rate is in the main due to improved death certification. In the light of this evidence with regard to the influence exerted by improved diagnosis upon the nomenclature of tubercular disease in children, and in view of the fairly steady decline in the rates from tuberculous meningitis and tuberculous peritonitis over a long series of years, it seems clear that it would be premature to ascribe the decline which has occurred in the last few years to the undertaking of special measures for the protection of the milk supply against tubercular infection. The figures in the above table show a marked decline in the infant mortality from all causes during the period covered. This decline is not peculiar to London or even to England and Wales ; in most of the principal European countries a similar fall has, in varying degrees, been experienced. Coincident with this decline in the mortality, there appears to have been a similar, though not proportionate, fall in the birthrate, and it might be suggested that the two phenomena may be in some way correlated, although variations from this rule may be apparent in different localities as well as at different periods of time. The relationship between the decrease in birth-rate and in mortality when large populations are considered, will be seen from the following table, which relates to European DIAGRAMS SHOWING DEATH-RATES PER 1,000,000 LIVING FROM TUBERCULOUS MENINGITIS AND TUBERCULOUS PERITONITIS (INCLUDING TABES MESENTERICA) SINCE 1890 IN ENGLAND AND WALES, LONDON AND MANCHESTER. 9 Report of the County Medical Officer—General. nations having populations of over 20,000,000 in 1911. The countries are arranged in order of the actual decline in the annual average birth-rate in 1906-10 as compared with 1901-5 :— Area. Decrease in annual average birth rate per 1,000 Living. 1901-5 to 1006-10. Decrease in infant mortality per 1,00 i births, 1901-5 to 1906-10. Italy + 0.0 — 3 Hungary —0.8 — 8 France —1.4 —13 United Kingdom —1.7 —18 Austria —2.0 —15 German Empire —2.7 —25 London —2.1 —24 Greater London —2.3 —25 In order to gauge correctly the precise character of the change which the figures relating to the years 1903 to 1914 (shown in the table at the top of page 8), represent, it is desirable to eliminate from them, as far as possible, the causes of death which, while varying greatly in incidence from year to year, do not in the main imply any corresponding periodical changes in the healthiness of the children; the principal causes of death thus eliminated are deaths from infantile diarrhoea or "summer diarrhoea" (which is influenced by the summer temperature), and the common infectious diseases, the incidence of which among infants varies, of course, mainly with the ever-changing prevalence of epidemics among older children. These diseases having been eliminated, the remaining causes of death may be roughly classified into such as can be more immediately attributed to pre-natal (or natal) influences, and those which may rather be regarded as acquired or developed after birth. In the pre-natal group there is comprised premature birth, congenital malformation, atelectasis, syphilis and injury at birth, and also (as probably resulting from unhealthy condition of the mother) want of breast milk, atrophy, debility and marasmus. In the second group, the stated causes of death are tubercular disease, rickets, meningitis, convulsions, bronchitis, pneumonia, suffocation and overlaying; finally there is a group of less important unspecified causes of death. The years covered by the table may be divided into two periods, namely 1905-1908, when the decline in the infant mortality after elimination of the causes of death above referred to was scarcely noticeable, and 1909-1913, when it was very marked*; it will then be found that the causes of death here regarded as mainly pre-natal show a relative increase, being 48 2 per cnt. of the total in the first period, as against 514.per cent, in the second, while other specified causes declined from 42.4 per cent, to 39.7 per cent., and the miscellaneous unspecified causes from 94 per cent, to 8.9 per cent. The figures do not show any very striking differences when the vagueness of some of the terms under which the deaths are certified are borne in mind; yet so far as they gor they seem to indicate that there had, up to 1913 at any rate, been a somewhat greater improvement in the post-natal influences affecting the health of infants, than there had been in the circumstances affecting their condition at birth. A further point relating to the assignation of the cause of death deserving of special notice is the remarkable change in the number of deaths assigned to premature birth which has occurred since 1871. The death-rate from premature births per 1,000 births recorded in London in successive periods of five years has increased from 103 in 1871-1875 to 18.7 in 1906-1910, and the mortality rate from atrophy and debility has almost correspondingly diminished. The question thereupon arises, has there been an increase in prematurity, and has the mortality from this cause risen in consequence, or is the increase shown merely due to gradual change in assignment of the cause of death ? A prematurely born child is undoubtedly very liable to die from atrophy or debility, and a decision as to whether the prematurity of birth or the subsequent atrophy was the initial cause of death must largely be a matter of personal opinion or local practice. In a lesser degree the same doubt may arise in regard to other causes of death which follow prematurity It seems to be a matter of great doubt as to whether premature births are proportionately more frequent new than formerly, or have since 1871 undergone any such change in frequency as might be deduced from the deaths recorded under this heading. Since 1910 two circumstances affecting the statistics relating to infant mortality have, moreover, to be taken into account. Firstly, the adoption in 1911 of the International Code for classification of causes * The year 1914 is omitted, as the European War may in some measure have affected the continuity of the figures. 27716 c 10 Annual Report of the London County Council, 1914. of death—the effect of which upon the infant mortality rates is probably negligible owing to the care which has been taken to secure continuity of the records; and secondly the granting of maternity benefit under the National Insurance Act of 1911. The latter circumstance is likely to exercise a certain amount of influence upon the nomenclature of deaths among infants; and it may be anticipated that among the assigned causes of death specially likely to be affected is that of premature birth. The reason for this is, of course, that with the granting of maternity benefit, greater facilities are placed in the way of a mother obtaining medical assistance both for herself and her child; and as a consequence the practitioner who now certifies the cause of death of a child born prematurely will in an increased number of instances already have attended the mother, and thus be familiar with the circumstances of her case. Since maternity benefit is paid as well to the single as to the married, the effects upon the assignment of cause of death, so far especially as prematurity is concerned, are likely to be greater among the unmarried than the married, as the former previously had less facilities for obtainincr needed medical assistance than the latter. In this connection it is interesting to note for obtaining needed medical assistance than the latter. In this connection it is interesting to note certain changes in the recorded relative incidence of premature birth and atrophy, etc., as the cause of death, among legitimate and illegitimate children, exhibited in the following table:— Area Assigned cause of death. 1911. 1912. 1913. Legitimate births. Illegitimate births. Legitimate births. Illegitimate births. Legitimate births. Illegitimate births. London Premature birth 17.9 30.7 17.6 35.0 17.2 30.1 Atrophy, etc. 121 35.9 9.3 36.8 9.5 30.0 England and Premature birth 19.5 34.2 19.1 309 19.4 33.7 Wales Atrophy, etc. 14.8 40.7 12.0 31.4 12.8 30.3 It will be seen that while in 1911 the death-rate from premature birth among the illegitimate both in London, and in England and Wales was below that from atrophy, etc., in 1913 the portion is reversed. There may be other causes at work to account for this change, but on the face of it, the greater facilities for medical attendance which the provision of maternity benefit has afforded to mothers since the National Insurance Act came into force in July, 1912, must be largely in question. These, it may be said, are comparatively minor considerations, and, in fact, all the difficulties are fully explained, provided regard is paid to changing fashion in nomenclature. But there are more important questions, For example, why, it may be asked, does a comparison of Diagrams C and D show, first, a more or less steady decline throughout a period of some sixty years in the general death rate in contrast with second, a much more recent, although rather more rapid, decline in the infant mortality rate. The great improvement of environmental conditions brought about during the last half-century, it might perhaps be suggested, has steadily and continuously influenced the general death rate, but this factor has only begun to take effect upon the infant mortality in the last ten or fifteen years. There have not been wanting those who have claimed that it was the absence of special attention directed to mothers and babies until the end of the nineteenth century, and its effect upon being introduced during the present century, which have been mainly responsible for the initial tardy and the later more rapid decrease in the infant mortality. Without venturing to dispute that there is some justification for this claim, it may be held that other and perhaps even more potent influences must also have been at work. The steady improvement of hygienic conditions during the last half-century has, among other factors, clearly resulted in the upgrowth of a generation of persons of child-bearing age, which compares favourably in many respects, and particularly in respect of showing a lessened mortality from disease, with the two or three preceding generations. It might, perhaps, be inferred, therefore, that the children of living persons of child-bearing age should now in their turn manifest the cumulative effect of this process of amelioration; and this process might, perhaps, be expected to display in full measure its influence upon later generations only after time has been allowed for earlier generations to attain to child-bearing ages. The fact that the phenomenon of recent decline in infant mortality is widespread and not peculiar to London, or even England and Wales, suggests that its explanation must be looked for not in some merely local cause, but in some such general cause as is here suggested, and one which may be expected to be operative over a wide area. The effect of migration upon change in the social status and physical characteristics (including resistance to disease) of the present-day parents, as compared with the parents of fifty years ago, which has been already referred to, p. 6, must also be regarded as having some influence upon infant mortality. The decline in the rate of that mortality has, then, in part resulted from the definite though apparently somewhat deferred effect of improvement of conditions of environment, and in part also it has resulted from interchange between London and the country generally of certain elements of population; to this latter factor, perhaps, almost as much importance should be attached as to the former. Under the Notification of Births Act, 1907, the London County Council receives particulars of the births which have been notified to the medical officers of health of the several sanitary 11 Report of the County Medical Officer—General. districts in London, and from the information thus received the following table has been prepared:— Metropolitan borough. Total births notified (corrected for institutions). Stillbirths (corrected). Births less still-births (corrected). Births registered (corrected). Excess of registered over notified births (corrected). Paddington 2,991 76 2,915 2,965 + 50 Kensington 3,080 93 2,987 3,210 + 223 Hammersmith 2,556 61 2,495 2,935 + 440 Fulham 3,492 97 3,402 4,154 + 752 Chelsea 1,154 27 1,127 1,299 + 172 Westminster, City of 1,526 31 1,495 2,155 + 660 St. Marylebone 2,244 49 2,195 2,132 — 63 Hampstead 1,286 31 1,255 1,273 + 18 St. Pancras 5,025 156 4,869 5,223 + 354 Islington 7,780 187 7,593 8,171 + 578 Stoke Newington 896 9 887 1,045 + 158 Hackney 5,770 144 5,626 5,460 — 166 Holborn 749 19 730 764 + 34 Finsbury 2,611 36 2,575 2,541 — 34 London, City of 172 6 166 181 + 15 Shoreditch 3,395 40 3,355 3,511 + 156 Bethnal Green 3,652 95 3,557 3.786 + 229 Stepnev 8,518 253 8,265 8,058 — 207 r J Poplar 4,994 116 4,878 5,073 + 195 Southwark 5,856 115 5,741 5,604 — 137 Bermondsey 3,785 36 3,749 3,849 + 100 Lambeth 7,343 169 7,174 7,022 — 152 Battersea 3,708 58 3,650 4,303 + 653 Wandsworth 6,462 104 6,358 6,675 + 317 Camberwell 5,766 123 5,643 6,580 + 937 Deptford 3,020 64 2,956 3,115 + 159 Greenwich 2,495 35 2,460 2,408 — 52 Lewisham 3,495 102 3,393 3,336 — 57 Woolwich 2,565 59 2,506 2.839 + 333 London 106,393 2,391 104,002 109,667 + 5,665 Notification of births. The number and percentage of still-births and of multiple-births notified in 1914 (uncorrected for institutions) is shown in the following table:— Metropolitan borough. Total births notified. still- births. Percentage still born. Multiple-births. Percentage of mothers delivered of more than one child at a biilh. Twins. Triplets. Total born. Cases. Stillborn. Cases. Stillborn. One both. One. Two. |Three Paddington 2,727 70 2-6 38 4 — — — — — 76 1.41 Kensington 2,938 87 30 36 3 — — — — — 72 1.24 Hammersmith 2,474 59 2-4 17 — l — — — — 34 0.69 Fulham 3,410 95 2-8 30 4 — 1 — — — 63 0.94 Chelsea 1,114 27 2-4 12 4 — — — — — 24 1.08 Westminster, City of 1,387 30 21 12 1 — — — — — 24 0.87 St. Marylebone 3,891 106 2-8 42 6 4 1 — — — 87 1.12 Hampstead 1,221 26 2-1 13 2 — — — — — 26 1.07 St. Pancras 4,682 145 31 56 5 1 1 — — — 115 1.23 Islington 7,428 173 2-3 90 12 — — — — — 180 1.22 Stoke Newington 875 9 10 10 1 — — — — — 20 1.14 Hackney 5,684 141 2-5 78 8 2 — — — — 156 1.39 Holborn 6*0 15 2-2 7 1 — — — — — 14 1.04 Finsbury 3,433 60 1-7 39 2 2 — — — — 78 1.10 London, City of 492 33 6-7 3 2 — — — — — 6 0.60 Shoreditch 3,177 31 10 20 2 — — — — — 40 0.60 Bethnal Green 3,613 94 26 38 5 — — — — — 76 1.06 Stepney 8,480 252 30 134 9 5 2 — — — 274 1.62 Poplar 4,983 113 2-3 73 6 — — — — — 146 1.48 Southwark 5,842 115 20 78 5 1 1 — — — 157 1.35 Bermondsey 3,775 35 •9 22 1 — — — — — 44 0.58 Lambeth 7,318 168 23 62 6 — 1 — — — 127 0.86 Battersea 3,692 58 1-6 47 1 — 1 — — — 97 1.30 Wandsworth 6,632 104 1-5 70 6 — 1 — — — 143 1.07 Camberwell 5,749 121 21 59 7 1 1 — — — 121 1.04 Deptford 3,017 64 21 26 2 — 1 — — — 55 0.90 Greenwich 2,492 35 1*4 31 1 — — — — — 62 1.25 Lewisham 3,490 101 20 46 — 2 1 — — — 95 *1.36 Woolwich 2,562 59 2-3 36 — — — — — — 72 1.42 London 107,258 2,426 2 3 1,224 106 19 12 — — — 2,484 1.15 Still-births and multiplebirths in 1914. 27715 0 2 12 Annual Report of the London County Council, 1914. Smallpox. The death-rates from smallpox in successive periods are given in table I, page 40. The smallpox death-rate in each year since 1840 in relation to the mean death-rate during the period 1841-1914 is shown in diagram (F). The cases notified per 1,000 living since 1890 are given in table II, page 41. It was feared that, owing to the abnormal conditions created by the war, there would be danger of the introduction and spread of cases of smallpox in this country. Notwithstanding these exceptional circumstances, only one case of smallpox occurred in London during the year, and this was notified on 19th February. The patient was staying in Newgate-street, E.C., when smallpox developed. He was an engineer on board the s.s. Avon, which arrived at Southampton on 7th February from Pernambuco (Brazil), where smallpox was prevalent. The infection was, therefore, derived from abroad. A surgeon on the s.s. Avon, who had been attending a case of smallpox on board, had been removed to South Wharf several days prior to the engineer referred to above, on suspicion of smallpox, but he was discharged after four days detention as not suffering from the disease. All necessary precautions were taken and information was circulated to the medical officers of health of the metropolitan boroughs. There were no developments. Requests for the services of the Council's staff in consultation were made in 26 doubtful cases; the patients were examined either by Dr. Wanklyn or Dr. Brincker, but only in the case already mentioned were the suspicions of the medical attendant confirmed. Two cases of smallpox were landed in January from vessels arriving in the Port of London, and were removed to the Port Sanitary Authority's hospital at Denton. The patients were members of the respective crews. One of the vessels had come from Smyrna and the other from Barcelona. In one case another member of the crew was removed to Denton Hospital with suspicious symptoms, but was subsequently discharged as not suffering from smallpox. The crews of both vessels Were vaccinated, and remained on board until the vessels re-sailed. The information was circulated, and the medical officers of health of the ports of destination of the ships were also informed. A further case of smallpox was reported on board a vessel arriving in the Port of London in February. The patient had, however, been landed en voyage at Gibraltar. The names and addresses of the passengers and crew, giving London addresses, were forwarded to the local medical officers of health concerned.. During the year the names and addresses of persons proceeding to London from ships which had arrived at Liverpool, Plymouth and Southampton, with cases of smallpox on board, were received from the medical officers of the Port Sanitary Authorities concerned, and arrangements were made for these persons to b3 kept under observation. Special attention was given by the Council's inspectors to persons who proceeded to common lodging-houses. The question of the prompt notification of cases of smallpox to the county medical officer of health by medical officers of health of the metropolitan boroughs and port sanitary authority was recently the subject of correspondence between the Council, the Local Government Board and the metropolitan boroughs. The Council had approached the Local Government Board representing that in view of the steps which experience had shown it was desirable should be taken to safeguard the health of London as a whole, it was a matter of extreme importance that the Port Sanitary Authority, the City Corporation and the metropolitan borough councils should arrange to give the earliest possible notification to the county medical officer of health of the occurrence of smallpox, plague and cholera. As a result, the Local Government Board, in August, 1914, expressed the view that in their opinion each single case of smallpox, plague or cholera should be regarded as an outbreak of dangerous epidemic disease requiring to be notified immediately to the County Council, and in addition to formal notification, there should be an interchange of more detailed information subsequently elicited. The Local Government Board communicated in this sense with the Port of London Sanitary Authority and each metropolitan borough council. In August, 1914, a memorandum was circulated to sanitary authorities by the Local Government Board on the precautions generally to be adopted in the event of smallpox being imported into the country. The memorandum deals in detail with the steps to be taken when a case of smallpox is notified, the provision of hospital accommodation, disinfection, vaccination and re-vaccination of contacts, tracing and surveillance of contacts. With regard to contacts it will be of interest, as bearing upon the correspondence with the Local Government Board referred to above, to quote the paragraphs in the memorandum dealing with the matter. They read as follows — "If any contacts have removed to another area, the medical officer of health of that area should at once be informed. If, for any reason, it is feared that the list of contacts is incomplete, a house to house visitation may be desirable in the neighbourhood in which a case of smallpox has occurred, to make inquiries as to suspicious illness and to advise vaccination or re-vaccination. If further cases are feared, common lodging-houses and other collections of itinerant persons should receive special supervision. In view of the fact that smallpox is now commonly derived from abroad, all notifications from port medical officers of health as to persons arriving in a given area from ships on which cases of smallpox have occurred should receive the same attention as is given to local contacts." A further memorandum applicable to London only was also issued "on the steps specially requisite to be taken in places where smallpox is prevalent," the principal features of which were insistence upon the importance of prompt measures with regard to vaccination being taken by the Board of Guardians, and upon the obligations of local sanitary authorities under the Public Health (London) Act, 1891. Diagram F. Smallpox.- (London) ' • 13 Report of the County Medical Officer—General. The following table shows the proportion of children born in London in each year who were not finally accounted for in respect of vaccination. Year. Children not finally accounted for (incl dingcise.spostpon d pr;r cent, of total births. Year. Children no' tin-illy accounted for (including ca-es postponed) per cent, of tuial births. Year. Children not ft ally Hcceunttd for (including ca espostponed ) per cent, of tot 1 birtus. Year. hildien not finally accoun1 ed for (including cases postponed; percen . of total births. 1872 .. 8-8 1833 .. 6-5 1894 .. 206 1905 .. 189 1873 .. 8-7 1834 .. 68 1895 .. 24-9 1906 .. 21-2 1874 .. 8-8 1885 .. 7-0 1896 .. 26-4 1907 .. 22-7 1875 .. 93 1836 .. 7-8 1897 .. 291 1903 .. 21-5 1876 .. 65 1837 .. 90 1898 .. 330 1909 .. 20-6 1877 .. 71 1833 .. 103 1899 .. 27-7 1910 .. 20-5 1878 .. 71 1839 .. 11-6 1900 .. 25-8 1911 .. 20-8 1879 .. 7-8 1890 .. 13-9 1901 .. 241 1912 .. 20-9 1880 .. 70 1891 .. 16-4 1902 .. 21-3 1881 .. 5-7 1892 .. 18-4 1903 .. 20-7 1882 .. 6-6 1893 .. 18-2 1904 .. 191 Smallpox — Vaccina ion returns. The percentage of children born who were exempted by "conscientious ob;ection " certificate in and since the year 1898 has been as follows :—1898,1 4; 1899, 1 0; 1900,1-0; 1901,11; 1902,08; 1903,1 0; 1901,1-1; 1903,12; 1906,15; 1907,3 1; 1908,7 3; 1909, 10 1; 1910, 13*6; 1911,15-8; 1912, 20-0. During these years the proportion of children exempted by certificate of conscientious objection, together with the proportion of children not finally accounted for, in the several Unions, has been as folioW3: — Metropolian Un on. 1898. 1899. 1900. 1901. 1902. 1903. 19J4. 1905. 1906. 1907. 1908. 19. 9. 191(1. 1911. 1912. Bermondsey 32-5 23-6 21-8 18-0 17-5 16-3 16-6 15-7 17-2 180 181 200 22-3 23-3 25-7 Bethnal GreeD 67-0 48-2 49-2 52-2 441 44-9 42.8 12 0 48-3 55-1 568 E0-6 56-8 66-7 55-9 Camberwell .. 41-2 29-7 230 20-0 21-4 21-8 23-6 23-4 26-8 34 0 37-3 40-5 45-3 48-3 51-6 Chelsea 17-3 14*9 16-0 13*4 14-9 13-9 100 8-9 130 14-3 16-9 19-8 19-3 2C-0 25-9 Fulham 15-4 12-6 137 12-0 11-8 12-7 11-5 10-8 14-6 18-1 19-3 21-8 23-5 25-2 29-5 George's, St., Hanover-sq. 111 9-0 71 5-8 7-5 5-1 4-9 4-4 4-3 7-2 8-4 10-3 11-8 13 2 16-4 George, St., inthe-East 346 350 33-5 30-6 29-7 27-7 15-7 17-3 16-8 17-7 15-6 18*3 19-6 21-2 25-4 Giles, St., and St. George 32-5 33-0 33-6 30-7 27-1 24-9 17-9 20-4 20-8 28-1 26-9 31-5 20*8 29-4 344 Greenwich .. 17-2 14-2 13-8 12-6 111 11-1 10-4 9-7 9-8 13-1 16-5 19-1 21-4 251 31.6 Haclcney 49-0 38-6 40-4 38-5 261 25-5 26-9 28-2 36-8 33-2 34-4 390 43-8 49.1 E66 Hammersmith 13-8 11-7 91 8-3 9-4 7-2 7-4 8-0 101 131 18-8 19-2 221 24-f 335 llampstead .. 15-4 10-3 110 10-0 9-2 9-5 9-2 9-2 10-4 12-3 151 17-0 22-5 25-2 28-4 Holborn 43-8 31-8 28-5 27-6 23-2 20-7 20-4 20-6 24-5 26-7 29-3 31-8 34-2 391 46-5 Islington 311 29-2 26-2 21-6 17-7 17-0 15-9 17-5 18-2 21-2 25-2 27-1 308 34 2 42-9 Kensington .. 13-5 10-2 9-2 9-0 7-2 6-6 6-6 5-5 7-2 8-0 9-4 110 13-8 15-4 19-6 Lambeth 306 25-2 20-6 22-2 20-4 210 16-9 17-3 19-6 23-4 27-8 32-6 34-6 381 43-3 Lewisham 27-8 22-6 20-7 15-7 13-5 15-4 14-0 13-8 16-2 21-4 26-3 29-4 33 9 381 410 London,City ol 254 18-3 14-2 11-3 11-3 11-8 13-0 15-3 16-8 17-5 18-2 18-2 220 33-2 38-8 Marylebone.St. 18-0 20-9 17-7 14-6 12-5 10-8 104 10-8 121 12-7 12-9 14-5 15-7 16-2 17-2 Mile End Old Town 68-9 69-9 68-0 66-1 58-8 59-8 47-3 47-1 48-4 52-3 53-9 51-8 511 53-4 54-8 Paddington .. 147 146 13-5 11-0 101 11-7 12-7 13-3 13-3 15-5 16-2 15-7 20-1 20-2 224 Pancras, St. 36-7 36-1 329 32-8 26-2 25-3 23-1 22-1 26-0 31-1 31-1 36 8 41-9 45-6 47-4 Poplar 63-6 50-1 49-0 491 44-2 46-9 45-4 45-3 49-3 53-9 55-1 53-3 57-6 E6'5 «2-1 Shoreditch .. 68-8 52-4 53-0 447 36-4 36-6 348 36-7 33-3 33-3 39-2 42-4 47-0 48-6 55-8 Southwark .. 326 30-3 27-6 26-8 25-4 24-9 24-3 24-2 28-4 31-1 32-0 34-3 37 0 39-4 46-0 Stepney 48-6 46-9 44-4 44-3 37-2 35-8 329 32-9 32-9 38-1 50-6 51-3 56-6 58-8 641 Strand 25-2 19-7 19-2 161 190 18-6 lb-0 11-8 11-7 14-2 24-9 21-4 26-3 28-7 29-3 Wandsworth 32-2 251 23-0 20-5 19-2 17-2 16-3 14-8 180 22 8 28-2 30-1 34-5 34-0 39-3 Westminster 17-4 14-8 12-2 13-3 134 12-1 11-0 8-2 9-4 10-1 12-5 13-4 17.2 16-5 20-1 Whitechapel 11-8 14-5 131 10-5 9-5 101 9-1 106 11-5 141 171 159 18-8 19-9 20-2 Woolwich 10-2 8-3 7-5 9-8 9-7 71 7-2 6-6 9-3 150 23-2 239 28-8 28-9 32-8 Lcndon 34 4 28 7 26-8 25 2 221 217 20-2 20-1 22 7 25-8 288 30-7 341 36 6 41'0 Nunrilipr oi cliil'lrpn nnnrcounted for as rosards vaccination ppr rpnt. of total births. The above tuble shows increase since 1905 in the proportion of children born who are remaining unvaccinated. Measles. The deaths from measles in the Administrative County of London during 1914 (52 weeks) numbered 1,385, as compared with 1,570 in 1913 (53 weeks). The death-rates from this disease per 1,000 persons living in 1914 and in preceding periods are 14 Annual Report of the London County Council, 1914. given in table I., page 40. Inasmuch as the birth-rate has not been constant during these periods and the proportion of population in the early years of life has probably diminished in recent years, the death-rate of children under five years of age is also shown in the same table. The death-rate in each year since 1840 in relation to the mean death-rate of the period 1841-1914, calculated on the population at all ages, is shown in diagram (G). The monthly deaths from measles in relation to the mean of the period 1891—1914 is shown in diagram (H). The following table shows the deaths from measles, in 1914(52 weeks) and the death-rates in 1909-13 and 1914 in each of the sanitary districts of the County:— Metropolitan borough. Deaths, 1914 (52 weeks). Death-rate per 1.000 persons living. Metropolitan borough. Deaths, 1914 (52 weeks). Death-rate per 1,000 persons living. 1909-13. 1914. 1909-13. 1914. Paddington 4 0.34 0.03 Shoreditch 112 0.92 1.02 Kensington 15 0.37 0.09 Bethnal Green 68 0.66 0.53 Hammersmith 41 0.43 0.33 Stepney 182 0.65 0.66 Fulham 31 0.41 0.20 Poplar 66 0.74 0.41 Chelsea 3 0.34 0.05 Southwark 95 0.75 0.51 Westminster, City of 6 0.16 0.04 Bermondsey 81 0.94 0.65 St. Marylebone 2 0.34 0.02 Lambeth 58 0.36 0.20 Hampstead 2 0.18 0.02 Battersea 50 0.51 0.30 St. Pancras 56 0.45 0.26 Wandsworth 26 0.35 0.08 Islington 97 0.46 0.30 Cambarwell 65 0.38 0.25 Stoke Newington 1 0.26 0.02 Deptford 51 0.50 0.47 Hackney 106 0.32 0.48 Greenwich 47 0.41 0.49 Holborn 11 0.32 0.24 Lewisham 7 0.09 0.04 Finsbury 76 0.89 0.90 Woolwich 25 0.24 0.20 London, City of 1 0.09 0.06 London 1,385 0.45 0.31 Deaths and death-rates from measles in London boroughs. In the distribution of measles mortality throughout the year 1914, the highest death-rate obtained in Shoreditch (l-02) and the lowest in St. Marylebone, Hampstead and Stoke Newington (0.02) For the period 1909-13, Bermondsey (0.94) had the highest measles death-rate, and the City of London and Lewisham (0.09) the lowest. The death-rates from this disease in London in each of the four quarters of the year 1914 were as follows: first quarter, 0.13; second quarter, 0.31; third quarter, 0.37 and fourth quarter, 0 43 per 1,000 persons living. Measles was made compulsorily notifiable during the year in the borough of Paddington. A system of notification to the sanitary authorities through the school organisation has been in existence for many years, and thus during some nine months a double system of notification was in operation in the borough. On the one hand practitioners and parents and on the other teachers and school attendance officers reported the cases, but in addition through the school organisation many cases came to light of children not attending school owing to the fact that older brothers and sisters or children living in the same house were school attendants. A large number of cases thus came to the knowledge of the authorities which were not being attended by a medical practitioner, and it is in these cases that the authority can give advice and adopt precautions of the greatest assistance in saving life. In order to test the relative numerical values of the two systems of notification, an analysis has been made of all the cases in which houses were known to have been invaded by measles during September, October and November of the year 1914. The total number of houses was £5, and 87 per cent, of them contained school children. Seventy-eight per cent, of the houses were reported through the school organisation, and the comparatively small leakage of 9 per cent. could no debutt be further reduced. Of the remaining 13 per cent, of cases in which knowledge could not have been obtained through the school organisation 6 per cent, came from houses in which there were no children of school age, 4 per cent, were above the elementary school class, and in 3 per cent, information could not be obtained. There were two instances in which the primary case in the house was made known through the school organisation, but subsequent cases were known only by compulsory notification. Of the whole 95 houses invaded, 66 per cent, were made known through compulsory notification. These figures show that under a school system, almost all the cases concerning which knowledge is of practical value come under the notice of the sanitary authorities and school authority. This is still more apparent when it is considered that Paddington stands fairly high in the scale of London boroughs as regards social position; in poorer boroughs the proportion of cases in which a doctor is net called in is still higher. In Paddington the measles death-rate in 1914 was 0.03 per 1,000 persons living, while in Finsbury 0.90; in Bermondsey 0-65, and in Shoreditch l.02 per 1,000 persons living. Scarlet Fever. The cases of scarlet fever notified in the Administrative County of London during 1914 (52 weeks) numbered 25,018, compared with 17,552 in 1913 (53 weeks). The number of deaths registered from this cause was 316 in the year 1914 (52 weeks), compared with 188 in 1913 (53 weeks). The scarlet fever death-rates, case-rates and case-mortality for 1914 and preceding periods are given in tables I. and II., pages 40 and 41. The death-rate in each year since 1858 in relation to the mean death-rate of the period 18591914 will be seen on reference to diagram (I). The monthly case-rate and case-mortality in each of the years 1891-1914 in relation to the mean of the whole period is shown in diagram (K). Diagram G. Measles. (london) Diagram H. Measles & Whooping-Cough (Deaths 1891-1914.) (LONDON) ■ Diagram I. Scarlet Fever. (london) Diagram J. Scarlet Fever. Number of admissions to Hospitals of the Metropolitan Asylums Board per cent of total cases notified in London. 1890-1914. Diagram K. Scarlet Fever. (london) 15 Report of the County Medical Officer—General. The following table shows the scarlet fever cases, deaths, case-rates, and death-rates for the year 1914 and the case-rates and death-rates for the period 1909-13 in the several sanitary districts. Metropolitan borough. Notified cases, 1914 (52 weeks). Case-rate per 1,000 persons living. Deaths, 1914 (52 weeks) Death-rate per 1,000 persons living. 1909-13. 1914. 1909-13. 1914. Paddington 743 2.63 5.24 8 0.05 0.06 Kensington 962 2.06 5.63 17 0.02 0.10 Hammersmith 977 3.01 7.91 5 0.06 0.04 Fulham 1,044 3.25 6.66 21 0.04 0.13 Chelsea 272 2.72 4.23 5 0.04 0.08 Westminster, City of 850 2.14 5.52 10 0.05 0.06 St. Marylebone 434 2.84 3.81 9 0.07 0.08 Hampstead 281 1.98 3.26 2 0.03 0.02 St. Pancras 1,210 2.80 5.67 18 0.05 0.08 Islington 1,851 3.02 5.70 24 0.05 0.07 Stoke Newington 264 1.94 5.24 3 0.03 0.06 Hackney 806 2.81 3.62 9 0.04 0.04 Holborn 172 2.16 3.68 2 0.02 0.04 Finsbury 449 2.32 5.33 6 0.07 0.07 London, City of 85 1.66 4.78 1 0.03 0.06 Shoreditch 424 2.34 3.88 5 0.05 0.05 Bethnal Green 654 2.71 5.13 7 0.07 0.05 Stepney 2,090 2.72 7.62 28 0.05 0.10 Poplar 663 3.26 4.13 10 0.07 0.06 Southwark 1,447 2.99 7.70 22 0.05 0.12 Bermondsey 582 3.61 4.68 8 0.07 0.06 Lambeth 1,756 3.24 5.93 16 0.05 0.05 Battersea 996 3.56 5.96 11 0.04 0.07 Wandsworth 1,412 2.78 4.27 13 0.04 0.04 Camberwell 1,541 3.02 5.90 23 0.04 0.09 Deptford 863 3.79 7.92 9 0.06 0.08 Greenwich 555 3.41 5.80 7 0.05 0.07 Lewisham 955 3.67 5.66 8 0.05 0.05 Woolwich 706 5.23 5.78 9 0.08 0.07 Port of London 4 London 25,048 2.96 5.56 316 0.05 0.07 Scarlet Fever in London boroughs. It will be seen from the foregoing table that in the period 1909-13 the scarlet fever death-rate was highest in Woolwich (0 08), and lowest in Kensington and Holborn (0.02); in the year 1914 Fulham (0.13) had the highest death-rate, and Hampstead (0.02) the lowest. The scarlet fever death-rates in London in each of the four quarters of 1914 were as follows: first quarter 0.06; second quarter 0.06; third quarter 0.06; and fourth quarter 0.10. The following table shows the notified cases, deaths, case-rates, death-rates, and fatality of scarlet fever at the several ages and for each sex in London during the year 1914. It will be seen that at "all ages" the case-rate was higher among females, while the fatality was higher among males. In the age-groups adopted for the purposes of this table, the greatest incidence of attack was upon males and females aged 5-10 years; the greatest incidence of death was upon males and females aged 3—4; and the fatality was highest among males and females aged 0-2 years, if ages over 45 years be disregarded, the figures for one year being too small to afford representative rates. Age-period. Males. Females. Notified cases. 52 weeks. Deaths. 365 days. Casemortality per cent. Rates per 100,000 living. Notified cases. 52 weeks. Deaths. 365 days. Casemortality per cent. Rates per 100,000 living. Cases. Deaths. Cases. Deaths. All Ages 11,599 167 1.4 547 8 13,449 152 1.1 563 6 0— 121 7 5.8 247 14 112 4 3.6 233 8 1— 359 21 5.8 800 47 362 13 3.6 815 29 2— 665 22 3.3 1,400 46 606 19 3.1 1,291 40 3— 892 29 3.2 1,911 62 886 22 2.5 1,886 47 4— 1,039 22 2.1 2,274 48 1,073 17 1.6 2,355 37 5— 4,960 30 0.6 2,305 14 5,715 47 0.8 2,634 22 10— 2,152 13 0.6 1,085 7 2,711 11 0.4 1,340 5 15— 701 9 1.3 364 5 793 5 0.6 375 2 20— 298 4 1.3 157 2 512 3 0.6 216 1 25— 294 6 2.0 81 2 513 8 1.6 119 2 35— 96 2 2.1 33 1 132 2 1.5 40 1 45— 19 2 10.5 9 1 25 - - 10 — 55 & upwards 3 - — 1 — 9 1 11.1 3 0 Scarlet fever cases and deaths by age and sex —London. 16 Annual Report of the London County Council, 1914. It will be seen from diagram (J), facing page 14, that the percentage of cases of scarlet fever admitted to the hospitals of the Metropolitan Asylums Board in 1914 somewhat exceeded that of any previous year. Dr. Millson (Southwark) remarks in connection with scarlet fever that in his opinion "the verminous state of houses is the cause of the spread of this and similar disease." In another part of this report (p. 57) reference is made to the possibility of relationship between -vermin prevalence and scarlet fever. Diphtheria. The cases of diphtheria (including membranous croup) notified in the Administrative County of London in 1914 (52 weeks) numbered 9,143, compared with 7,654 in 1913 (53 weeks). The number of deaths was 706 in 1914 (52 weeks), compared with 431 in 1913 (53 weeks). It should be borne in mind that the case- rate and case-mortality may be affected by variations in the extent of use of bacteriological methods of diagnosis, the effect of which is to increase the number of clinically mild cases of the diseases notified. The diphtheria death-rates, case-rates, and case mortality, in 1914 and preceding periods, are given in table I. and II., pages 40 and 41. The death-rate in each year since 1858 in relation to the mean death-rate of the period 1859-1914 is shown for diphtheria and also for diphtheria and croup combined in diagram (L). The monthly case-rate and case-mortality in each of the years 1891-1914 in relation to the mean of the period is shown in diagram (N). Diphtheria cases, deaths and dpathrates in London boroughs. The following table shows the diphtheria cases, deaths, case-rates, and death-rates for the year 1914, and the case-rates and death-rates for the period 1909-13, in the several sanitary districts:— Metropolitan borough. Notified Cases. 1914 (52 weeks). Case-rate per 1,000 persons living. Deaths, 1914 (52 weeks). Death-rate per 1,000 persons living. 1909-13. 1914. 1909-13. 1914. Paddington 295 1.45 2.08 20 0.07 0.14 Kensington 200 1.02 1.17 13 0.08 0.08 Hammersmith 179 1.42 1.45 16 0.16 0.13 Fulham 271 1.81 1.73 22 0.14 0.14 Chelsea 74 1.25 1.15 8 0.09 0.12 Westminster, City of 187 1.09 1.21 15 0.08 0.10 St. Marylebone 235 1.11 2.06 18 0.06 0.16 Hampstead 231 1.26 2.68 10 0.11 0.12 St. Pancras 452 1.83 2.12 30 0.12 0.14 Islington 661 1.57 2.04 43 0.11 0.13 Stoke Newington 98 1.18 1.95 4 0.05 0.08 Hackney 495 1.21 2.22 39 0.06 0.18 Holborn 64 1.33 1.37 4 0.09 0.09 Finsbury 145 1.70 1.72 9 0.17 0.11 London, City of 31 1.12 1.74 2 0.03 0.11 Shoreditch 221 1.47 2.02 20 0.17 0.18 Bethnal Green 376 1.57 2.95 28 0.12 0.22 Stepney 885 1.67 3.23 70 0.11 0.26 Poplar 353 1.56 2.20 34 0.17 0.21 Southwark 340 1.51 1.81 37 0.15 0.20 Bermondsey 216 1.78 1.74 18 0.12 0.14 Lambeth 560 1.24 1.89 50 0.13 0.17 Battersea 267 1.50 1.60 17 0.11 0.10 Wandsworth 537 1.30 1.63 41 0.07 0.12 Camberwell 458 1.31 1.75 39 0.10 0.15 Deptford 252 1.65 2.31 25 0.13 0.23 Greenwich 246 2.44 2.57 16 0.12 0.17 Lewisham 406 2.25 2.41 24 0.16 0.14 Woolwich 412 2.47 3.37 34 0.13 0.28 Port of London 1 — — — — — London 9,148 1.52 2.03 706 0.11 0.16 Diphtheria cases and deaths by age and sex —London. It will be seen from the foregoing table that in the period 1909-13 the diphtheria death-rate was highest in Finsbury, Shoreditch and Poplar (017) and lowest in the City of London (0.03); in the year 1914 Woolwich (0 28) had the highest death-rate, and Kensington and Stoke Newington (0.08) the lowest. The diphtheria death-rates in London in each of the four quarters of the year 1914 were as follows: first quarter 0.14; second quarter 0.13; third quarter 0.12; and fourth quarter 0.23. The following table shows the notified cases, deaths, case-rates, death-rates and fatality of diphtheria at the several ages and for each sex in London during the year 1914. At "all ages" the fatality was higher among males, while the incidence of attack was slightly higher among females. In the age-groups adopted for the purposes of this table the greatest incidence of attack was upon males Diagram L. Diphtheria. (london) Diagram M. Diphtheria. Number of admissions to Hospitals of the Metropolitan Asylums Board per cent of total cases notified in London. I890-I9I4-. Diagram N. Diphtheria. (london) 17 Report of the County Medical 0fficer—General. and females aged 4-5 years. The greatest incidence of death was upon males aged 1-2 years and females aged 4-5 years, and the fatality was greatest among males and females under 1 year of age, if ages 55 and upwards be disregarded, the figures for one year being too small to afford representative rates. Age-period. Males. Females. Notified Cases, 52 weeks. Deaths, 365 days. Case mortality per cent. Bates per 100,000 living. Notified Cases, 52 weeks. Deaths, 365 days. Case mortality per cent. Rates per 100,000 living. Cases. Deaths. Cases. Deaths. All Ages 4,151 359 8.6 196 17 4,997 353 7.0 209 15 0— 112 34 30.3 228 69 70 22 31.3 145 46 1— 243 51 20.9 541 114 230 42 18.2 518 95 2— 371 46 12.4 781 97 295 41 13.9 629 87 3— 422 45 10.6 904 96 365 38 10.4 777 81 4— 431 45 10.4 943 98 438 51 11.6 961 112 5— 1,632 108 6.6 759 50 1,889 122 6.4 871 56 10— 512 14 2.7 258 7 753 23 3.0 372 11 15— 173 3 1.7 90 2 306 3 1.0 145 1 20— 92 4 4.3 48 2 267 2 0.7 113 1 25— 101 6 5.9 28 2 248 2 0.8 58 0 35— 37 1 2.7 13 0 98 3 3.1 30 1 45— 19 2 10.5 9 1 28 — — 12 — 55 & upwards 6 — — 3 — 10 4 39.9 4 1 To enable the variations in diphtheria prevalence in the several sanitary districts to be more clearly appreciated, the following table has been prepared. This table shows the comparative case-rates of each district in each of the years 1891-1914 inclusive, i.e., the case-rates of each district are shown in relation to the London case-rate of the same year, the London rate being taken as 100. The figures for the years 1901-9 differ from those given in previous reports owing to the revision of the population estimates on the basis of the results of the 1911 census. it will be seen from diagram (M) facing page 16 that the percentage of cases of diphtheria admitted to the hospitals of the Metropolitan Asylums Board exceeded that of previous years. Metropolitan borough. Diphtheria.—Comparative case-rate (London case-rate taken as 100). 1891 1892 1893 1894 1895 1896 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 Paddington 104 77 73 117 74 66 91 98 68 44 88 65 61 63 47 72 61 59 87 69 73 114 126 102 Kensington 78 60 68 63 86 70 67 49 51 74 53 54 60 67 52 57 74 78 69 74 78 67 50 58 Hammersmith 195 164 87 72 77 67 49 58 58 85 75 68 85 111 146 134 94 97 108 112 99 91 66 71 Fulham 61 58 78 126 139 99 109 145 135 178 175 130 122 132 139 156 212 152 145 139 125 95 101 85 Chelsea 138 110 83 107 143 184 107 79 61 74 54 77 80 54 51 130 118 117 98 102 77 87 56 57 Westminster, City of 58 91 57 53 61 53 59 67 50 59 52 67 61 52 48 69 44 64 93 76 56 65 73 60 St. Marylebone 70 81 88 78 64 66 53 64 47 59 73 76 103 58 72 63 53 55 63 88 70 82 67 101 Hampstead 105 96 73 53 61 84 47 65 48 74 70 50 61 43 55 67 69 43 38 49 108 119 88 132 St. Pancras 89 95 103 83 90 64 76 78 79 93 149 152 132 95 88 69 80 78 98 99 119 162 121 104 Islington 152 119 86 103 70 106 73 60 68 70 102 112 81 66 74 75 75 91 89 119 111 101 100 100 Stoke Newingt'n 83 113 97 77 70 70 52 59 34 111 105 82 46 75 110 52 120 72 37 86 95 69 98 96 Haokney 131 147 135 108 93 89 122 152 106 107 167 139 145 163 122 99 127 99 81 70 86 72 87 109 Holborn 52 89 79 61 66 61 104 102 46 70 105 86 53 51 58 69 62 54 62 74 106 18 75 67 Finsbury 118 82 130 81 86 112 170 163 93 74 110 101 77 94 103 118 86 105 125 139 124 106 75 85 London, City of 59 130 60 49 51 74 71 60 68 89 95 158 63 102 47 44 65 76 62 82 72 58 99 86 Shoreditoh 124 89 131 95 80 97 103 80 103 111 103 84 77 101 110 71 101 105 112 96 96 80 100 100 Bethnal Green 154 230 181 168 143 114 144 100 89 115 133 105 110 206 165 110 116 122 97 117 96 109 103 145 Stepney 106 132 112 123 157 150 128 93 89 107 106 111 108 176 154 118 135 131 139 118 113 83 101 159 Poplar 191 148 214 159 179 133 141 105 83 141 137 118 149 252 207 85 113 109 88 88 107 100 127 108 Southwark 71 72 116 113 86 106 102 151 207 141 101 111 102 88 106 114 110 78 89 121 94 95 102 89 Bermondsey 68 60 84 126 80 99 97 90 177 133 94 92 79 94 91 147 129 112 105 137 124 111 115 86 Lambeth 88 97 91 83 88 74 83 103 121 104 65 68 67 68 105 79 56 65 86 90 83 72 81 93 Battersea 144 123 132 122 97 81 125 178 116 70 59 74 109 85 80 92 110 123 116 111 81 88 102 79 Wandsworth 74 83 84 79 60 51 100 114 99 74 76 132 125 98 92 114 117 115 84 77 100 85 80 80 Camberwell 69 65 67 112 140 180 154 102 156 130 125 113 82 65 66 77 80 86 97 86 82 77 91 86 Deptford 72 68 86 153 225 113 141 132 121 111 144 103 243 111 94 156 150 107 121 98 92 98 132 114 Greenwich 60 43 84 85 137 189 82 105 122 89 73 81 127 100 107 240 138 132 115 144 203 168 164 127 Lewisham 48 74 82 70 57 122 85 127 170 126 87 129 121 59 77 101 105 176 170 117 130 168 151 119 Woolwich 32 68 66 66 81 96 91 86 100 115 69 91 91 85 161 182 120 173 150 117 119 221 194 166 London 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 2771$ d 18 Annual Report of the London County Council, 1914. Whooping-cough. The deaths from whooping-cough in the Administrative County of London during the year 1914 (52 weeks) numbered 918 as compared with 800 in 1913 (53 weeks). The death-rates from this disease in 1914 and preceding periods per 1,000 living of all ages and per 1,000 aged 0—5 are given in table I., page 40. The death-rate in each year since 1840 in relation to the mean of the period 1841-1914 is shown in diagram (0), while the deaths in each month since 1890 in relation to the mean monthly deaths of the period 1891-1914 are shown in diagram (H) facing page 14. Ihe following table shows the whooping-cough deaths and death-rates for the year 1914 and the death-rates for the period 1909-13 in the several sanitary districts:— Metropolitan borough. Deaths, 1914 (52 weeks). Death-rate per 1,000 persons living. Metropolitan Borough. Deaths, 1914 (52 weeks). Death-rate per 1,000 persons living. 1909-13. 1914. 1909-13. 1914. Paddington 25 0.24 0.18 Shoreditch 55 0.41 0.50 Kensington 7 0.21 0.04 Bethnal Green 48 0.30 0.38 Hammersmith 21 0.28 0.17 Stepney 72 0.25 0.26 Fulham 42 0.27 0.27 Poplar 31 0.39 0.19 Chelsea 6 0.16 0.09 Southwark 59 0.28 0.31 Westminster, City of 21 0.11 0.14 Bermondsey 14 0.37 0.11 St. Marylebone 20 0.21 0.18 Lambeth 40 0.21 0.14 Hampstead 16 0.11 0.19 Battersea 26 0.26 0.16 St. Pancras 51 0.23 0.24 Wandsworth 56 0.19 0.17 Islington 84 0.24 0.26 Camberwell 47 0.21 0.18 Stoke Newington 6 0.19 0.12 Deptford 9 0.37 0.08 Hackney 53 0.20 0.24 Greenwich 6 0.30 0.06 Holborn 9 0.19 0.19 Lewisham 19 0.14 0.11 Finsbury 45 0.39 0.53 Woolwich 27 0.14 0.22 London, City of 3 0.10 0.17 London 918 0.24 0.20 Whooping Cough in London boroughs. It will be seen from the foregoing table that in the period 1909-1913 the highest whooping-cough death-rate was that of Shoreditch (0 41), and the lowest that of the City of London (0.10); in the year 1914, Finsbury (0.53) had the highest death-rate and Kensington (0.04) the lowest. The whoopingcough death-rates in London in each of the four quarters of the year 1914 were as follows: first quarter, 0.25; second quarter, 0.28; third quarter, 018; and fourth quarter, O.11. Whooping cough was made compulsorily notifiable in the Boroughs of Greenwich, Holborn and Lambeth. The notification which was thus made available duplicates the information already obtained through the school organisation; indeed, the latter covers a wider field, particularly in the direction downward in the social scale involving cases in which a doctor is not called in. It is in these cases that the necessity for action is by far the more urgent. An investigation has been made in respect of all the houses known to be invaded by whooping cough in Lambeth in the months of September, October and November, 1914. A total of 180 such houses were known to the sanitary authority either through the school organisation or through compulsory notification. Of these 129 or 72 per cent, were discovered through the schools, and 96, or 53 per cent, through compulsory notification. Thus no fewer than 84 cases or 47 per cent, of the total were cases in which no doctor was called in and they were known through the school alone. Of the 45 cases in which notification overlapped, in 20 cases the school organisation had informed the sanitary authority before the doctor had been called in. Typhus. There were no deaths from typhus in the Administrative County of London during the year 1914. The death-rates from this disease in successive periods since 1870 are given in table I, page 40. The typhus death-rate in each year since 1868 in relation to the mean death-rate of the entire period 1869-1914 is shown in diagram (P). Only one case of typhus fever was notified during 1914, and this did not originate in London. The patient was a Belgian soldier who was taken ill on 22nd October, 1914, and brought over to this country from the trenches in Flanders. He was admitted to No. 2 General Hospital, Chelsea, on 1st November, with a temperature of 105 deg. A rash developed on 4th November, and the patient was removed on 5th November to one of the Metropolitan Asylums Board's hospitals, where the disease was subsequently diagnosed as typhoid fever. Typhoid Fever. The number of cases of typhoid fever notified in the Administrative County of London during 1914 (52 weeks) was 789, compared with 758 in the year 1913 (53 weeks). The deaths from the disease numbered 147 in 1914 (52 weeks) compared with 114 in 1913 (53 weeks). The death-rates, case-rates and case-mortality in 1914 and preceding periods are given in tables I. and II., pages 40 and 41. The death-rate in each year since 1868 in relation to the mean death-rate of the period 1869— 1914 is shown in diagram (Q). The notified cases in each week of 1914 mav be compared with the average weekly notifications of the period 1890-1914 on reference to diagram (it). The monthly caserate and case-mortality in each of the years 1891-1914 in relation to the mean of the whole period is shown in diagram (S). 19 Report of the County Medical Officer—General. The following table shows the typhoid fever cases, deaths, case-rates and death-rates for the year 1914, arid the case-rates and death-rates for the period 1909-13 in the several sanitary districts— Metropolitan borough. Notified cases, 1914 (52 weeks). Case-rate per 1,000 persons living. Deaths, 1914 (52 weeks). Death-rate per 1,000 persons living. 1909-13. 1914. 1909-13. 1914. Paddington 10 0.20 0.07 3 0.03 0.02 Kensington 11 0.18 0.06 1 0.03 0.01 Hammersmith 14 0.16 0.11 5 0.03 0.04 Fulham 40 0.20 0.25 9 0.04 0.06 Chelsea 23 0.16 0.36 3 0.02 0.05 Westminster, City of 49 0.19 0.32 9 0.03 0.06 St. Marylebone 38 0.15 0.33 6 0.03 0.05 Hampstead 17 0.18 0.20 4 0.03 0.05 St. Pancras 44 0.23 0.21 4 0.02 0.02 Islington 75 0.22 0.23 15 0.03 0.05 Stoke Newington 4 0.15 0.08 — 0.02 — Hackney 29 0.21 0.13 8 0.03 0.04 Holborn 15 0.29 0.32 6 0.04 0.13 Finsbury 19 0.33 0.23 2 0.04 0.02 London, City of 5 0.25 0.28 1 0.05 0.06 Shoreditch 19 0.27 0.17 2 0.04 0.02 Bethnal Green 18 0.35 0.14 4 0.05 0.03 Stepney 48 0.28 0.17 8 0.03 0.03 Poplar 34 0.31 0.21 6 0.06 0.04 Southwark 24 0.22 0.13 2 0.03 0.01 Bermondsey 8 0.25 0.06 3 0.03 0.02 Lambeth 50 0.19 0.17 16 0.04 0.05 Battersea 21 0.20 0.13 3 0.03 0.02 Wandsworth 47 0.19 0.14 5 0.02 0.02 Camberwell 29 0.16 0.11 5 0.02 0.02 Deptford 9 0.18 0.08 3 0.03 0.03 Greenwich 17 0.16 0.18 5 0.03 0.05 Lewisham 51 0.18 0.30 6 0.03 0.04 Woolwich 15 0.12 0.12 3 0.01 0.02 Port of London 6 London 789 0.1 0.17 147 0.03 0.03 Typhoid fever in London boroughs. It will be seen that in the period 1909-13 among the several sanitary districts the typhoid fever death-rate was highest in Poplar (0.06), and lowest in Woolwich (O'Ol); in the year 1914 Holborn (0.13) had the highest typhoid fever death-rate, while two districts had a death-rate of 0.0l only and in Stoke Newington no death occurred. The death-rates from typhoid fever in London in each of the four quarters of the year 1914 were as follows: first quarter, 0.04; second quarter, 0.03; third quarter, 0.03; and fourth quarter, 003. The following table shows the notified cases, deaths, case-rates, death-rates and fatality of typhoid fever at the several ages and for each sex in London during the year 1914. The case-rate and deathrate were, at " all ages," higher among males, while the fatality was somewhat higher among females, In the age groups adopted for the purposes of this table, the greatest incidence of attack was upon males aged 20-25 and females aged 10-15 ; the greatest incidence of death was upon males 20.5 and females 15-20; and the fatality was greatest among males and females over 55 years of age. Age-period. Males. Females. Notified Oases. 52 weeks. Deaths. 365 days. Casemor tality per cent. Rates per 100,000 living. Notified Cases. 52 weeks. Deaths. 365 days. Casemor tality per cent. Rates per 100,000 living. Cases. Deaths. Cases. Deaths. All Ages 429 81 18.8 20 4 360 70 19.4 15 3 0— 1 - 1 1 23.5 7 2 1— — - 2 — 2— 1 - — 4 — 5 1 3— 4 — 5 2 4— 4 — 4 - 5— 39 2 5.1 18 1 38 5 13.1 18 2 10— 51 3 5.9 26 2 52 1 1.9 26 0 15— 60 6 10.0 31 3 50 14 27.9 24 7 20— 62 13 20.9 33 7 55 12 21.8 23 5 25— 94 26 27.6 26 7 76 18 23.6 18 4 35— 69 20 28.9 24 7 43 9 20.9 13 3 45— 34 8 23.4 16 4 21 3 14.2 9 1 55 & upwards 10 3 29.9 5 1 8 4 49.9 3 1 Typhoid fever cases and deaths by age and sex, London. 27715 d 2 20 Annual Report of the London County Council, 1914. At the beginning of the year 1914 there was a heightened prevalence of typhoid fever in London. When the cases are arranged according to the week in which the onset of symptoms occurred, and the number of cases developing in each week are set out in the form of a chart, a marked increase is first noticeable in the week ended 27th December, 1913, and this increased prevalence continues for some 9 weeks, during which period 161 persons developed the disease. This is about double the number that might have been expected, having regard to the normal behaviour of typhoid fever at this time of the year, and it is, therefore, probable that some 70 or 80 of the cases occurring in London during the last fortnight of 1913 and the first six or eight weeks of 1914, were due to the operation of a special cause. Typhoid fever prevalence in 1914. My attention was called soon after the development of the outbreak, by Dr. Sandilands, to the fact that several persons working at a particular establishment in Kensington had been attacked by typhoid; Dr. Menzies on behalf of the County Council conferred with Dr. Sandilands, and effort was made to discover the cause of this special incidence of typhoid upon the employees in question. In all ten persons associated in one way or another with the particular establishment were found to have been attacked; the total number of workers was large, but the cases of illness were far in excess of those which would have been expected in a population of the size in question as a matter of mere chance. Various possible sources of infection were enquired into ; the cases commenced, one in the 3rd, one in the 4th, two in the 5th, three in the 6th, two in the 7th, and one in the 9th of the nine weeks above referred to. There were certain facts strongly suggestive of a food origin of the outbreak ; thus one of the patients was steward of a club situated many miles away from the establishment in question ; employees at the establishment went to this club, and some of the sufferers were known to have partaken of food there ; on the other hand the steward sometimes came to the establishment in question ; again, the dining arrangements at the establishment itself involved differentiation of the employees into certain groups, and this fact led to suspicion being especially directed to particular groups, and ultimately to inquiry into the kitchen arrangements generally. As to the way in which, if it were at fault, the food supply became infected, no certain conclusion could be reached, though detailed inquiries were prosecuted in many directions, including investigation of cases of previous illness among workers in the kitchen and bacteriological enquiries concerning a rat poison which was said to have been used on the premises. The outstanding fact elicited, as the result of the fullest enquiry into the history of past illness among employees, was that the number of cases among workers at the establishment only amounted in all to ten, or about 12 per cent, of the excessive number of cases occurring in London as a whole, during the weeks in which the exceptional incidence of the disease was manifested. This fact makes it highly probable that, if food was at fault in the case of the ten persons , it was at fault too in the case of all those who must be regarded as included in the special prevalence of the disease. Such enquiry as had been made with regard to the cases in London generally had shown their wide distribution over the county, though, as reference to the accompanying map, Diagram (T), will demonstrate, there were certain noteworthy groupings of the patients commencing to be ill during the particular nine weeks in question—thus, a group of cases in Fulham and the adjoining boroughs includes most of the 10 cases among employees at the special "establishment"; but in addition there are well marked Wandsworth, Lewisham, North and South Islington, and North West St. Pancras groups; in two at least of these groups (not including the "establishment" group), suspicion strongly attaches to food supplies as the source of origin of the mischief; further, it may be noted that the age-incidence of the cases was not specially remarkable; and speaking generally of cases occurring during the 9 weeks it transpired that in a considerable number of instances the fact that fried fish or shell fish (mussels, oysters or winkles) had come under suspicion was recorded. It was not possible to carry the matter, further, but on the whole the evidence points to the probability that either fish or shell fish was at fault. Attention may especially be directed to the well marked group of about a dozen cases, five in one family, occurring in Lewisham (in instances in which more than one person living in a house was attacked, the additional cases are indicated by concentric circles surrounding a central dot, see map). The part of London in which this group occurred is remote from the "establishment" already referred to; one of the patients was a fishmonger's assistant, and all the patients were associated in one way or another with the shop in which he worked. In addition, in other parts of London a fishmonger and a fish stall keeper were among the persons attacked during the weeks of special incidence. Dr. Menzies continued to make an analysis of the facts to hand as to the cases of typhoid fever which were notified in London throughout the year, as it was thought possible that the same cause which had operated in the early weeks of 1914 might again yield evidence of producing mischief. This expectation was not fulfilled but the returns, which were most courteously made by London Medical Officers of Health, have been carefully studied by Dr. Menzies, and they show that a particular source of infection came under suspicion in the following number of instances. Out of a total number of 789 cases notified, in 1914, information was given in some 400, and the ascribed sources of infection were:— Cases. Cases. Cases. Food Fried fish 72 Water supply 7 Contracted in country 10 Shell fish 88 Drainage 8 „ from relatives or from cases in house s n 40 Other fish 26 Smells 4 Watercress 22 Wearing clothes of previous case Other food 19 1 „ from other persons 20 Contracted abroad 38 21 Report of the County Medical Officer—General. There were furthermore 5 cases (in which information was given) which proved not to be typhoid. There were 30 cases occurring in barracks and camps, a dozen or more cases occurring among Belgian refugees, two cases attributed to bathing in the Thames, five cases occurring among nurses and attributed to the fact that they had been associated with sulierers from typhoid fever, and one case was that of an assistant in e bacteriological laboratory. In addition to the prevalence to which attention was directed by Dr. Sandilands, three other special prevalences are mentioned in Annual Reports of borough medical officers. Dr. Allan (Westminster) mentions that twelve refugees from Antwerp who came over in one party, developed typhoid fever soon after arrival. Examination was made of a number of others in the refuge with a view to detecting other or carrier cases, but it proved negative. Dr. Davies reports the occurrence in Woolwich of a group of 17 cases during December, 1914, and January, 1915. This group was "connected with one dairy," that is to say, if the cases be divided into "primary" and "secondary," the primary cases belonging to 12 affected houses involved consumers of milk obtained from a particular source. It would be interesting to know whether there remained any degree of possibility or probability that this was a mere chance occurrence. In the case of three of the affected houses, the milk was said to be always boiled, but it is not stated whether the "secondary" cases involved consumers of the milk or not. The age distribution was not that usually observed in milk outbreaks, and there was marked irregularity in the grouping of cases around the suspected dairy. Evidence is quoted to show that the milk could not have been infected prior to its reaching Woolwich, so further investigation of the matter was limited to bacteriological inquiry as to the existence of a possible "carrier" there. This inquiry was of a very detailed character and resulted in the "discovery" of a lad who had been employed at the dairy from whom one of the strains of paratyphoid bacilli was isolated. Dr. Davies reports, however, that " the blood sera of several patients, though giving a positive Widal reaction, did not agglutinate the paratyphoid bacilli found in the boy." The investigation was therefore "inconclusive." "No history of illness could be obtained with regard to this boy." It is further added that Gaertner's bacillus was found in the faeces of a servant at the dairy and the fseces and urine of a porter who had been observed to dip a mug into one of the churns at the railway station and help himself to a pint of milk, were examined, it is stated, with a negative result. Dr. Davies adds that the symptoms observed in the sufferers were " characteristic of enteric fever of a moderately severe type, and of the cases examined 8 gave a positive Widal reaction and in only one case was there reason to suspect the accuracy of the diagnosis." Dr. Porter (Marylebone) reports that ten cases occurred in five houses situated within a short distance of one another ; in six of the cases the onset of illness was between the 8th and the 16th of April; three of the remainder were developed after an interval of a few weeks, and in the last case the illness began in July. Dr. Porter states that "when the first three cases came to hand, the conclusion arrived at as to the source of infection was that A. J. P. (the first case) had probably contracted the disease as a result of eating contaminated food, the two most likely articles being shell-fish or fish bought ready cooked." The varying ascription of suspicion to one and another suspected source depends, of course, very much upon the personal equation of the observer who makes the inquiry ; it is only possible to draw conclusions having any considerable degree of probability when groups of cases occur, and when it is therefore possible to test the extent of association of the ascribed cause with the cases of the disease, and to compare the extent of this association with that exhibited in a control group of cases. Again, in the outbreak in the early weeks of 1914 the hypotheses of the rat poison, and of the existence of a carrier case in the kitchen of the establishment, were rendered extremely improbable by reason of the fact that simultaneously with the occurrence of the 10 cases, 60 or 70 other cases, which could have had no association either with the rat poison or with a hypothetical case in the kitchen, were developed as part and parcel of a widespread excessive prevalence throughout London. The facts with regard to this outbreak regarded as a whole are, indeed, exceedingly difficult if not impossible of explanation unless it be inferred that a particular consignment of infected food was at fault, and study which has been made in previous years, in London, of the distribution of the various kinds of food which have from time to time come under question, especially attaches suspicion in the present instance to fish. Just as the making of a comprehensive survey of the cases of a year tends to throw doubt upon the correctness of the aetiology assigned as the result of examinations of the individual cases making up the total number, so a comprehensive survey of the various aetiological hypotheses which have found favour in the course of the last half century tends to cast doubt upon some of the theories which have held the field, at one and another time, during this period. Thus in the sixties, seventies and eighties inquiry was always made in cases of typhoid with regard to exposure to effluvia from excreta, and very great significance was attached to the inhalation of drain and sewer emanations ; explosive outbreaks were in the latter part of this period generally attributed to water, and towards the end of the thirty years in question the water origin of cases of typhoid began to assume very great prominence, any suspicious circumstance with regard to a well was confidently appealed to, and, in the case of public water services, in-suction, intermittency of supply, and so on, were held to be points to be specially investigated ; the first milk outbreak was reported upon by Dr. Michael Taylor in 1857, but it was not until towards the end of the century that shell-fish, fish and various other articles of food fell under suspicion. The discovery of the Eberth Gaffky bacillus in 1882 had meantime,however, introduced very considerable complications—on the one hand, bacilli presenting characters, regarded as those of the specific bacilli, were not as a rule discoverable in the water, milk, shell fish, etc., which were apparently incriminated in particular outbreaks ; on the other hand, as bacteriologists grew more and more insistent that the bacillus was the fons et origo tnali, it became increasingly realised by them that bacteriological theory must be squared with field practice, and the attempt was made to escape 22 Annual Report of the London County Council, 1914. from the difficulties experienced in applying their doctrines to actual cases investigated, by having recourse to new hypotheses resting upon a bacteriological basis, such as that of conveyance by flies, or again, after failing, as a rule, to find any evidence of direct infection from the sick, by the appeal made rather more than ten years ago by the school of Koch to the healthy carrier. There results from scrutiny of the changing fashions of aetiology during the last fifty years a tendency to lay stress on one or other of two types of theory. There is the theory of Koch that the bacillus causes the disease and that its habitat is the human body; and acceptance of this apparently implies need for assuming that the bacilli of healthy carriers vary in their infectivity and that they can by some change which is not understood, from time to time become effective, and then cause mischief either by direct transference from human excreta by means of fingers, etc., or by dispersion through the medium of milk and shellfish; it is especially noteworthy that during the last five or six years the intermediation of infected food materials has been increasingly appealed to by Koch's followers. On the other hand, there is the theory that the bacillus is produced by the diseased conditions set up in typhoid fever, which so influence certain saprophytic germs commonly present in the human intestine, as to cause their mutation into bacillus typhosus or forms closely allied thereto. According to this theory the causa causans of typhoid fever remains still to be discovered, but its main means of obtaining access to the human body are again, generally speaking, those same food materials to which the school of Koch now attaches such great importance. The controversy from a practical preventive point of view may then be said to turn largely upon the question, do the food materials owe their infective properties to their becoming contaminated by typhoid bacilli, or by the as yet unknown causa causans of typhoid fever ? The great importance of correctly answering this question will be realised on examination of two particular cases in point. In Belfast it is claimed that typhoid prevalence has been greatly reduced by preventing consumption of sewage-contaminated cockles; in south-west Germany it is claimed that a similar reduction has been accomplished by dealing stringently and comprehensively with the excreta of healthy carriers. The two schools of hygienists both confidently claim that their particular plan of campaign has triumphed. It is important to note that in the case of both theories there is need for postulating an unknown causa causans. In Koch's theory this is the something which renders the ordinarily ineffective bacilli of the healthy carrier effective; in the other theory the unknown cause is that which infects mollusc or fish in the well, river, or estuary. Again, in the case of both theories the conception that the spread of the disease is maintained by direct infection from the sick to the healthy is seen to be wholly inadequate; Koch's followers appeal to the healthy carrier, those who accept the rival theory assume that the cause of typhoid can develop and multiply outside the human body. There is yet a third phenomenon which has to be reckoned with by exponents of both theories, viz., the tendency for the disease to assume epidemic form when circumstances are favourable owing to the existence of unsuitable methods of excrement disposal, which enable material from typhoid evacuations again to find its way, it may be after undergoing certain changes, back into the human body, through the mediation of contaminated water or food stuffs. On Koch's theory it thus becomes necessary to admit at any rate, a considerable ability on the part of the typhoid bacillus to maintain its existence outside the human body, and it would seem also necessary to assume that, given "effective" typhoid bacilli, the dose need only be infinitesimal; on the rival hypothesis a doctrine of multiplication and development of the causal agency outside the body is appealed to as explaining how it is that, even after the admixture of enormous quantities of diluting material, the specific poison, say in the oyster or cockle, is still capable of producing typhoid fever. There are special difficulties with regard to both theories. Those which arise in the case of Koch's theory are that the bacillus is very rarely found, where according to the theory, its presence would naturally be expected, in the shell fish, milk, or suspected water; and on the other hand, it is especially encountered in unexpected places, bone abscess, gall bladder, healthy carrier, etc., etc.; moreover, recent research has shown great capacity for undergoing mutation in bacilli of the typhoid and coli group, a fact which compels some modification of Koch's original views; and most important of all, the bacillus per se is not, as a rule, effective, its ability to assume pathogenicity from time to time still remains to be explained. The main difficulty as regards the rival theory was, until recently, proof of mutation of bacilli resembling the typhoid bacillus, this difficulty at the present moment appears less formidable than it did a few years ago; the theory, moreover, fits far better than does Koch's theory the facts as to polluted foreshores and gathering grounds; but two main difficulties still remain ; there is the question of direct case to case transference, and there is that of the part played in the transmission of the disease by infected milk, neither of which facts entirely harmonises with an hypothesis of maturation in the ground, or in the well, or on the foreshore. A question which presses for settlement, therefore, is as to whether the fresh evacuations of a typhoid patient are potent for harm—if they are, direct case to case infection may readily occur, and the phenomena of the recorded milk outbreaks become, perhaps, more easy of explanation. This question is, however, by no means easy to settle. According to the opinion of fifty years ago, the fresh stools were harmless, some days in water or earth were needed to develop their potency for mischief ; moreover, Murchison did not believe in direct case to case infection. The bacteriologists have, of course, changed all that, in accordance with the theoretical requirements, but it still remains exceedingly difficult to estimate the extent of risk on the facts. It should be added that there are, in addition to the various problems just referred to, certain outstanding possibilities which need to be very carefully considered ; for example, the relation of typhoid fever to those food poisonings of man which are associated with development in the human body of bacilli allied to typhoid bacilli; and again, the relation of typhoid fever to diseases affecting the bovine animal and the pig, in which development of certain allied forms of bacilli also occurs. Observers in various parts of the world have arrived at very diverse conclusions with regard 23 Report of the County Medical Officer—General. to the aetiology of typhoid fever—in the Spanish-American and South African wars flies were believed to be largely concerned in spreading the disease; in Germany the healthy carrier is held to be allimportant ; in Scotland, milk; in Belfast, cockles; in some of the large English towns, public water services; in other towns, mussels; in London, fish has been held to be a not infrequent source of infection. A survey of the history of London typhoid suggests certain conclusions which may be formulated as follows:— The cases of typhoid fever in London particularly affect that section of the population which buys and eats what Dr. Niven has termed "trash" in the streets; sometimes purchasers of pennyworths and ha'porths of fried fish are apparently especially involved, sometimes eaters of mussels, more rarely eaters of cockles, or consumers of watercress or of ice cream. At times of epidemic prevalence, i.e., when from 10 to 15, up to 100 or more cases suddenly develop within a limited area, more precise study can be made of the various kinds of "trash" consumed, and the question as to the exact origin of the food implicated can be closely investigated. In 1900 it was thus possible to demonstrate that in three simultaneously occurring outbreaks, in widely separated parts of London (120 cases, 50 cases and 30 cases) the only sort of food material of common origin consumed by the sufferers was fish (which in two of the affected areas was purchased already fried); this was eaten by all the persons who could legitimately be regarded as making up the special prevalence in each area, and three single shops, one in each area, supplied the fish, which, it may be noted, was in every case small plaice. In 1903 there were two small outbreaks of 17 cases each, and similar conclusions were formed. In 1908, 1910 and 1911 like results were again reached in connection with three further outbreaks. In addition to the special point established in these outbreaks that an infected fried fish hypothesis, alone of all suggested hypotheses, was capable of explaining the prevalences, certain important subsidiary conclusions were reached. In one of the areas affected in 1900, and in the area affected in 1911, an icecream hypothesis appeared, on a first cursory examination, to afford some likelihood of yielding an adequate explanation of the outbreak, but a closer analysis of the facts clearly showed that ice-cream from the suspected source had not been consumed by quite a considerable percentage of the sufferers. Similarly, in the outbreaks of 1908 and 1910, a mussel hypothesis at first seemed promising, but close analysis excluded it from further consideration. A similar failure to comprehend all the persons attacked was encountered in an outbreak which it was found had been ascribed to watercress in 1903; the difficulty is fully discussed in the report on watercress presented to the Council in 1905. The conclusion is, therefore, forced upon the mind that in the case of these London outbreaks very careful study is needed, if discrimination is to be properly made between the various suspected kinds of food material, and unless the outbreak is of a certain magnitude no great degree of probability can be attached to the conclusion reached. Thus, a common instance is the following: A group of five or six cases occurs, and a particular source of infection seems a possible cause of the trouble; the difficulty then arises as to deciding whether a further case, developing in the near neighbourhood of the group and not associable with the suspected source, ought to be regarded as constituting part and parcel of the special prevalence. If ten or twelve cases present themselves in a group, and all, or nearly all, are associated with a particular source of infection, the probability of association meaning causation may rise somewhat higher. In a recent instance, however, nine cases were reported as probably due to a milk supply, and it was further found that two other patients not obtaining milk from this supply, but who were living close to the nine milk consumers were almost simultaneously attacked. The evidence against the milk was believed to be confirmed by discovery on the farm in the country from which the milk came of a case of typhoid fever, and also of a man who some years before had suffered from typhoid fever, and who, it was suggested, might therefore be a typhoid carrier. Question was raised as to whether the milk supply should be stopped, but as the supposed carrier had left the farm, and his whereabouts remained in doubt, there appeared no reason justifying drastic action with regard to the London retail supply; the decision arrived at in this instance was justified by the event, for, as a matter of fact, no further cases of typhoid occurred in the affected locality. Another case of like difficulty is that of the dairy supplying the houses referred to at the top of page 21. In outbreaks involving ten to twenty persons, and in which a precise analysis can be made of the facts as to food supply, conclusions possessing a high degree of probability can be reached, witness for example, Bulstrode'e very complete analysis of the Winchester and Southampton outbreaks, which were proved to be due to oysters. In Southwark, in 1900, a still larger exceptional prevalence occurred, and the facts analysed in this outbreak made it practically certain that in that case fried fish was at fault. The student of explosive outbreaks ascribed to water, shell fish, or fish, cannot fail to be struck by the remarkable fact that after cessation of the special prevalence typhoid fever resumes its accustomed behaviour in the community attacked. After the Maidstone and Lincoln and Worthing outbreaks typhoid was not exceptionally prevalent in these towns ; after the Southwark outbreak the disease soon assumed its wonted degree of prevalence. Thus the development of large numbers of typhoid bacilli in an affected community and the presumed setting up of the carrier condition in a considerable number of persons are seen to be incapable of causing post-epidemic cases of typhoid. A like phenomenon was observed in this country on the return of many thousands of convalescents after the South African war; again in Belfast disuse of cockles was followed by cessation of typhoid, despite the presumable existence in the city of large numbers of bacillus carriers. The case of London is especially noteworthy, for in 1898, 1899 and 1900 typhoid prevailed in very considerable excess, many hundreds of carriers of typhoid bacilli must have newly appeared upon the scene, and to these were added in 1900 and 1901 appreciable numbers of returned " carriers " from South Africa ; yet, in the succeeding years typhoid fever 24 Annual Report of the London County Council, 1914. steadily declined. Facts of this nature certainly appear wholly irreconcilable with the bacillus carrier thesis. But apart from all this, the practical limitation of typhoid in London, (and the same was true of Belfast) to a particular social class, is incomprehensible on a theory which ascribes great importance to transmission of disease by healthy persons (cooks, waiters, etc.) who handle articles of food consumed by the comparatively well-to-do. Yet, once more, the recurring incidence of the disease in certain special localities (see Annual Report of the Medical Officer of Health, County of London, 1903) with intervals of comparative freedom from the disease; its simultaneous involvement in many instances of two or three members of a family, and its failure then to spread further in that family; its tendency to manifest a special age incidence (loc. cit.) at the times of special prevalence—all these are features a healthy carrier hypothesis is powerless to explain. These considerations with regard to explosive outbreaks illustrate the failure of Koch's theory and the applicability of a food hypothesis to instances of simultaneous occurrence of large numbers of cases. Before passing to the sporadic cases a word may be added with regard to the intermediate instance, that of the more or less sustained prevalence of typhoid in a particular area. Striking examples of this have been observed in London. Several of these are given in the report of 1903 already referred to, but a particularly remarkable one occurred in Shoreditch in 1908. There, in an area including 6 streets with a population of between two and three thousand persons, after the occurrence of certain earlier and smaller prevalences, some 50 to 60 cases were notified in 1908; a large amount of labour was expended in investigating the personal and food histories of the persons attacked; they all belonged to one social class comprising very poor people, and their inter-communications and common use of places of food supply were closely analysed. Given a short incubation period, say, one week to a fortnight, interrelationship between the large majority of those attacked could be demonstrated, and an hypothesis of direct infection from person to person was carefully examined; on the other hand there was common to most of the cases the history of purchasing fish from a coster living in the middle of the area; this man bought the cheapest fish obtainable at Billingsgate and hawked it in the neighbourhood, and his customers and he himself and his family one after another suffered from typhoid. The man died and his family left the neighbourhood, and the special incidence of typhoid thereupon ceased. If allowance be made of an interval of from a few days to three or four weeks for incubation, all the cases admit of explanation as the result of the introduction on a few distinct occasions of infected fish into the area, during the period of some 12 months covered by the exceptional prevalence. It will be seen, therefore, that either on the theory of Koch or on the rival theory, explanation of the special incidence of typhoid fever could be given; but the difficulty presents itself in the case of the former theory, that just when some hundred or more infected persons had been newly introduced into the area the outbreak came to an end, and did not recur; while, on the other hand, these are facts which, if the latter theory be accepted, the disappearance of the coster who hawked the fish would sufficiently account for. Turning now to the sporadic cases, these in quite a large percentage of the total number occur in groups of two, three of more, and two or more members of one family may be simultaneously or almost simultaneously attacked ; the salient feature, however, is involvement of a particular social class, the people who occupy the light blue and purple streets of Sir Charles Booth's classification (see Annual Report Medical Officer of Health, 1911). This behaviour of the disease accords well enough with the food hypothesis, but is very difficult to reconcile with the carrier hypothesis of Koch. In London sporadic cases not affecting the special class referred to are usually imported cases, and they often give a history of eating shell fish, usually oysters; the vast bulk of the cases on the other hand affect fried fish eaters who obtain their fish already cooked at the cheap shops in certain poor neighbourhoods. It is important to note that a considerable amount of painstaking work has been undertaken in London in connection with search for healthy carriers. In comparsion with effort made in Germany, however, comparatively little has been attempted in this direction; and it is interesting, therefore, to find that despite this fact the incidence of the disease has been steadily falling, particularly during the period when bacteriological methods have been extensively employed elsewhere. In the very limited number of cases dealt with in London on bacteriological lines some hostility to the carrying out of these methods has been manifested by sufferers affected; and it is clear that it would not be practicable to put into actual practice the restrictions which some bacteriologists consider should be imposed ; indeed, this would be even more difficult than in the case of cerebro-spinal meningitis, in which disease, in the light of recent experience, a general attempt to isolate healthy carriers cannot be advocated by anyone with experience of the complications which its rigorous employment would introduce. It will be seen then that the available evidence points to infection being brought into London in the large majority of cases by fish and shell fish coming generally speaking from a considerable distance. The great improvements as regards sanitation effected in the last 50 years and particularly in the last 30 years have made London itself an eminently unfavourable field for growth and cultivation of the typhoid poison ; the areas from which infection is derived are no longer near at hand, but are to be found on distant polluted foreshores and in remote estuarial waters. Question was raised on the outbreak of hostilities as to the likelihood of importation of infection into London by soldiers and refugees coming from the seat of war, and during the later months of 1914 there were some alarmist rumours as to spread of the disease by persons who had recently arrived from the continent. The experience acquired subsequent to the South African war and the knowledge gained of the common method of spread of typhoid in London made it clear that these fears were groundless. At the same time disturbance of the operations of the fishing fleet in the North Sea and possible interference with the shell fish industry, brought about 25 Report of the County Medical Officer—General. by the war, afforded reason for especially closely watching the behaviour of typhoid fever. During the first quarter of the year 1914, 224 cases, just about the 5 years' average (230) were notified; in the second quarter there were 153 cases,the 5 years' average being 152; in the third quarter there were only 193 cases, the 5 years' average being 291; and in the fourth quarter there were only 219 cases, the 5 years' average being 288. In the first quarter of 1915 the number of cases was only 179, considerably less than that in the corresponding quarter of 1914 and indeed in two weeks, that ending April 3rd and that ending May 15th, the total number of cases notified in London fell as low as 5. It is specially noteworthy that in 1914, as in the two preceding years and as also in 1909, there was practically an entire absence of the autumnal rise. While the low rate of incidence of typhoid fever in London must be regarded with satisfaction, it should be pointed out that to some small extent at any rate it is probably due to alterations of nomenclature. From the first separate record of typhoid fever deaths down to 1884 there was a fairly steady maintenance of the mortality level; then came a sudden drop to a lower level and the mortality remained again fairly steady at this point until 1900; since that year there has been a further marked decline. It is noteworthy, however, that during the past 14 years, in which deaths from appendicitis have been separately returned, the number of certificates annually dealt with has undergone steady increase, and at the present time the deaths from appendicitis are about three times as numerous as those from typhoid fever. Again the cases of typhoid fever notified each year include a large percentage of illnesses which are not really examples of this disease. The Metropolitan Asylums Board's Annual Reports give the percentage of cases admitted to the Board's hospitals in which an error in diagnosis was found to have been made ; this percentage has never been lower than the limits reached in two years of special prevalence 1899 and 1900, 17 and 18 per cent, respectively; it rises much higher in some years, particularly in those of low prevalence, and indeed during 1909, 1912 and 1913, recent years of specially low prevalence, the percentages were 37.9, 40.5 and 40.4. There can be no question that the extended use of the Widal test (discovered in 1896) has materially influenced the diagnosis finally decided upon in suspected cases of typhoid fever, and on the whole, during the decade 1905-1914 in which this test has been extensively used, the percentage of cases deemed to be instances of "errors in diagnosis" has only three times been less than 30 per cent., whereas in the preceding 15 years 1890-1904 the percentage only exceeded 30 per cent, on three occasions. There can be no doubt, therefore, that there has been considerable alteration of fashion as regards nomenclature in the case of typhoid-like diseases and, indeed, if due allowance be made for this fact, the estimate as to the extent of the decline credited to typhoid fever in London in the last 15 years must be somewhat modified. Diarrhea and Enteritis. The deaths at all ages from diarrhoea and enteritis in the administrative County of London during 1914 (52 weeks) numbered 3,573 as compared with 3,598 in 1913 (53 weeks) Of the total 3,573 deaths, 2,583 occurred during the first year of life and 448 in the second year. In the four quarters the deaths numbered 354, 329, 2,172, and 718 respectively. In diagram (U) the death-rate from diarrhoea and enteritis among infants under two years of age in each year since 1861 is shown in relation to the mean death-rate for the period 1862-1914. The deaths and death-rates from diarrhoea and enteritis among infants under two years of age for the year 1914 in each of the sanitary districts of London, are shown in the following table:— Metropolitan borough. Deaths 1914 (52 weeks). Death-rate per 1,000 births. Metropolitan borough. Deaths 1914 (52 weeks). Death-rate per 1,000 births. Paddington 79 2664 Shoreditch 148 42-15 Kensington 63 19.63 Bethnal Green 174 45.96 Hammersmith 67 22.83 Stepney 268 33.26 Fulham 126 30.33 Poplar 195 38.44 Chelsea 21 16.17 Southwark 207 36.94 Westminster, City of 35 16.24 Bermondsey 140 36.37 St. Marylebone 59 27.67 Lambeth 202 28.77 Hampstead 11 8.64 Battersea 122 28.35 St. Pancras 121 23.17 Wandsworth 148 22.17 Islington 228 27.90 Camberwell 143 21.73 Stoke Newington 16 15.31 Deptford 91 29.21 Hackney 127 23.26 Greenwich 53 2201 Holborn 13 17.02 Lewisham 55 16.49 Finsbury 88 34.63 Woolwich 30 10.57 London, City of 1 5.52 London 3,031 27.64 Diarrhoea deaths in London boroughs. It will be seen from the foregoing table that the death-rate in 1914 from diarrhoea and enteritis per 1,000 births was highest in Bethnal Green (45.96) and lowest in the City of London (5.52). The death-rates in London in each of the four quarters of the year 1914 were as follows; first quarter, 9.5; second quarter, 8.2; third quarter, 70.3; and fourth quarter, 22.7. 27715 E 26 Annual Report of the London County Council, 1914. Erysipelas. The deaths from erysipelas in the Administrative County of London during 19]4 (52 weeks numbered 213, as compared with 131 in 1913 (53 weeks). The age-distribution of these deaths was as follows:— Under 1 Year. 1— 5 — 10— 15— 20— 25-- 35— 45— 55— 65— 75 + All ages 37 5 2 1 7 4 12 21 29 34 39 22 213 Erysipelas Age distribution of deaths, London. The erysipelas death-rate and case-rate in 1914 and preceding periods are given in tables I. and II., pages 40 and 41. The number of cases of erysipelas notified and the case-rate for the year 1914, together with the case-rates for the period 1903-13, in the several sanitary districts are shown in the following table:— Metropolitan borough. Notified Cases 1914 (52 Weeks). Case-rate per 1,000 persons living. Metropolitan borough. Notified Cases, 1914 (52 weeks). Case-rate per 1,000 persons living. 1909-13. 1914. 1909-13. 1914. Paddington 140 0.77 0.99 Bethnal Green 305 1.63 2.39 Kensington 166 0.73 0.97 Stepney 403 1.48 1.47 Hammersmith ] 02 0.72 0.83 Poplar 222 1.18 1.38 Fulham 152 0.75 0.97 Southwark 325 1.37 1.73 Chelsea 34 0.53 0.53 Bermondsey 125 1.14 1.01 Westminster, City of 112 0.52 0.73 Lambeth 237 0.72 0.80 St. Marylebone 67 0.89 0.59 Battersea 157 0.89 0.94 Hampstead 45 0.44 0.52 Wandsworth 238 0.63 0.72 St. Pancras 224 0.87 1.05 Camberwell 270 0.90 1.03 Islington 335 0.69 1.03 Deptford 229 1.69 2.10 Stoke Newington 49 0.66 0.97 Greenwich 125 1.10 1.32 Hackney 296 1.15 1.33 Lewisham 129 0.57 0.76 Holborn 22 0.80 0.47 Woolwich 106 0.71 0.87 Finsbury 157 1.81 1.86 Port of London 2 London, City of 10 0.64 0.56 London 4,983 0.94 1.11 Shoreditch 198 1.33 1.81 Erysipelas case-rates in London boroughs. The following table shows the age and sex distribution of the notified cases of erysipelas in 1914— Sex. Under 1 year. 1- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75 and upwards. All Ages. Males 64 91 83 54 126 81 255 447 449 300 185 46 2,181 Females 100 104 82 105 194 158 324 477 559 385 225 89 2,802 Persons 164 195 165 159 320 239 579 924 1,008 685 410 135 4,983 Erysipelas cases by age and sex, London, The table shows that the number of females exceeds the number of males attacked, and it should be noted that the attack rate among females is higher, even when allowance is made for the excess of females in the total population. The death-rate among males is nevertheless considerably higher than among females. Puerperal Fever. The deaths in the Administrative County of London during the year 1914 (52 weeks) attributed to puerperal fever numbered 184, as compared with 139 in 1913 (53 weeks) and 159 in 1912 (52 weeks). The puerperal fever death-rate per 1,000 living'and the case-rate and death-rate per 1,000 births in 1914 and preceding periods will be found in tables I. and II., pages 40 and 41. The age-distribution of cases notified and of deaths during 1914 was as follows— 16- 20- 25- 35 Total (15-45) Cases notified 7 79 215 92 393 Deaths 5 25 97 57 184 Case mortality per cent. 71 32 45 62 47 27 Re-port of the County Medical Officer—General. The high mortality rate of age-group 15-20 is due to the smallness of the figures upon which it is calculated ; apart from this age-period it will be noticed that the mortality increases with advancing age. The Council as Local Supervising Authority receives information of cases of puerperal fever occurring in the practice of midwives. During the year 1914 one midwife had four cases of puerperal fever, seven had three, and fourteen had two each. Midwife having four cases during the year:— The first case was confined on 7th March, but was not notified as puerperal fever until the 17th day, two days after being sent into the infirmary. On the 13th day of the puerperium there was a rise of temperature and when the midwife heard of this she disinfected. The second case occurred on 28th March (third day of the puerperium), and was immediately removed to infirmary. There was an interval of 16 days between midwife's last visit to former patient and this delivery, during which she attended 24 women, all of whom did well. The midwife was disinfected and was allowed to resume work four days later. The next case occurred on 29th May, and the fourth at the end of September. None of the patients died. Midwives having three cases each during the year :— A attended a case early in January and was disinfected; the patient died. The second case occurred early in April, after which the midwife was again disinfected. The third case occurred six weeks later. B attended a case on 5th February. The midwife ceased attendance on the twelfth day and went away for a few days' holiday. No special disinfection was done as the case was not notified as puerperal fever until some time after the midwife had left. In the second case the birth occurred on 20th February, but the case was not notified as puerperal fever till seven days after the midwife had ceased attending. The midwife did not disinfect but refrained from practising for two weeks. The third case occurred in October, and all three patients recovered. C attended a case on 12th April, which, however, was not notified as puerperal fever till two days after the midwife ceased attending. The temperature having temporarily risen during the puerperium the midwife, on leaving, disinfected as in cases of puerperal fever except as regards her bonnet and cloak which were only exposed to the air. On 22nd April the midwife delivered the second woman, whose temperature became raised on 28th April. In the interval between these two births the midwife had delivered sixteen other cases in none of which was there a rise of temperature. The third case occurred in July. All three patients recovered. D was engaged, as nurse, for a confinement in April and the doctor, under whose directions she was to act, arrived after the birth. This case terminated fatally. In the second instance, the confinement took place on 22nd October, and the case was notified as puerperal fever on 30th October, after which the midwife ceased attending all her other patients and disinfected on 2nd November when she was allowed to resume work. Prior to the notification of this patient the midwife had been nursing a third patient who was, however, not notified as suffering from puerperal fever until 9th November. Neither of these cases proved fatal, and the midwife did not resume work for some weeks. E had a case in June, after which she was disinfected and resumed work. Two other cases occurred in October, there being a rise of temperature in each instance on the same day. All three patients recovered. F had a case in June, and after disinfection resumed work. The second case was notified as puerperal fever on 21st September. After disinfection, work was resumed. The third confinement took place on 14th October, and in this instance the patient was very excited owing to the absence of her husband on war service. All three patients recovered. G had a case in March, after which she was disinfected and resumed work. The second confinement took place on 31st October. As soon as the patient was known to be suffering from puerperal fever (4th November), the midwife notified the Council and, as she had taken all necessary precautions against infection, she was allowed to resume work on the evening of 5th November. In the third case the patient was confined on 6th November. On the third day a doctor was called in, and on the fifth day the patient was notified to be suffering from puerperal fever. Extra precautions against infection were again taken and the midwife attended no cases for six days. No blame was attributable to the midwife, whose cases have since done well. Phthisis. The London deaths from phthisis, including acute miliary tuberculosis, during 1914 (52 weeks) numbered 6,281, as compared with 5,981 in 1913 (53 weeks). The death-rates from this disease in 1914 and preceding periods are given in table I., page 40. Since the year 1910 the deaths from phthisis belonging to the London population have been more completely ascertained than in previous years; and further the deaths from phthisis include deaths from miliary tuberculosis, which previously had been included under general tuberculosis. These two circumstances in conjunction disturb the continuity of the phthisis deathrates shown on page 40, but it is unfortunately not possible to determine with any certainty from the published figures of the Registrar-General whether, or to what extent, the increase in the deathrate in 1911 denotes an actual increase in the mortality in that year over 1910. The more accurate local distribution of deaths would not, however, affect the rate for England and Wales as a whole ; and from the fact that the increase shown in this rate (exclusive of miliary tuberculosis), in 1911 over 1910, in the Annual Report of the Registrar-General for 1911 (see p. 35) amounted to 4'6 per cent., it 27715 E 2 28 Annual Report of the London County Council, 1914. is reasonable to suppose that there was a corresponding actual increase in mortality in London. The increase due to the addition of miliary tuberculosis to phthisis in England and Wales is found from the same source (p. 156) to be 23 per cent. The phthisis death-rate since 1850 (corrected for differences in the age constitution of the population) in relation to the mean death-rate of the period 1851-1914 (males and females) is shown in diagram (V). This diagram shows the marked decline of phthisis mortality in both sexes since about 1865, the greater incidence of such mortality on males than on females, and the fact that until recent years the decline has been more manifest among females than males. The following table shows the crude phthisis death-rates, and the rates corrected for differences in the age and sex constitution of the populations of the various sanitary districts. The factors for correction, also shown in the table, have been calculated by applying the 1911 census population, at each age and for each sex, of each of the London sanitary districts, to the death-rates, at each age and for each sex, obtaining in England and Wales during the decennium 1901-1910:— Metropolitan borough. Factor for correction for age and sex distribution. Crude death-rate. Corrected death-rate. Comparative mortality figure. (London 1,000.) 1909-13. 1914. 1909-13. 1914. 1909-13. 1914. London 0.9628 1.33 1.39 1.28 1.34 1,000 1,000 Paddington 0.9198 1.05 1.02 0.96 0.94 750 701 Kensington 0.9217 0.99 1.10 0.91 1.01 711 754 Hammersmith 0.9510 1.21 1.38 115 1.31 898 978 Fulham 0.9779 1.32 1.31 1.29 1.28 1,008 955 Chelsea 0.9151 1.37 1.35 1.26 1.24 984 925 Westminster, City of 0.8422 1.25 1.33 105 112 820 836 St. Marylebone 0.8932 1.33 1.28 119 1.14 930 851 Hampstead 0.9021 0.63 0.64 0.57 0.58 445 433 St. Pancras 0.9322 1.55 1.77 1.45 1.65 1,133 1,231 Islington 0.9573 1.29 1.45 1.24 1.39 969 1,037 Stoke Newington 0.9329 0.96 1.15 0.90 107 703 799 Hackney 0.9730 1.28 1.36 1.24 1.32 969 985 Holborn 0.8577 2.07 1.97 1.78 1.69 1,391 1,261 Finsbury 0.9976 2.00 1.98 1.99 1.98 1,555 1,478 London, City of 0.8219 1.62 112 1.33 0.92 1,039 687 Shoreditch 1.0270 1.81 214 1.86 2.20 1,453 1,642 Bethnal Green 1.0436 1.58 1.65 1.65 1.72 1,289 1,284 Stepney 1.0282 1.69 1.70 1.74 1.75 1,359 1,306 Poplar 1.0222 1.42 1.67 1.45 1.71 1,133 1,276 Southwark 0.9786 1.86 1.76 1.82 1.72 1,422 1,284 Bermondsey 1.0123 1.74 1.63 1.76 1.65 1,375 1,231 Lambeth 0.9548 1.38 1.42 1.31 1.36 1,023 1,015 Battersea 0.9829 1.23 1.26 1.21 1.24 945 925 Wandsworth 0.9627 0.89 0.90 0.85 0.87 664 649 Camberwell 0.9902 1.27 1.43 1.26 1.42 984 1,060 Deptford 0.9820 1.32 1.38 1.29 1.36 1,008 1,015 Greenwich 1.0040 1.20 1.38 1.21 1.39 945 1,037 Lewisham 0.9693 0.69 0.75 0.67 073 523 545 Woolwich 0.9781 1.27 1.40 1 24 1.37 969 1,022 Phthisis death-rates in London boroughs. It will be seen from the foregoing table (comparing the corrected death-rates) that among the several sanitary districts, in the quinquennium 1909-13 and in the year 1914, Finsbury (1.99 and 198), and Shoreditch (1.86 and 2.20) respectively had the highest phthisis death-rates and Hampstead (0.57 and 0.58 respectively) the lowest. The death-rates from phthisis in London in each of the four quarters of the year 1914 were as follows: first quarter, 1.58; second quarter, 1.28; third quarter, 123; and fourth quarter, 1.48. The figures upon which the above table is based, so far as the years since 1910 are concerned, are those given in the Annual Summaries of the Registrar-General, which represent the deaths of Londoners occurring within the Greater London area. The steps taken in connection with the treatment of phthisis are dealt with on page 70, and reference to the action taken by the Public Health Committee will be found in chapter xxv. During the year 1911 the system of compulsory notification of pulmonary tuberculosis was completed and it was in operation during the whole of 1912. This scheme was begun on the 1st January, 1909, as the outcome of the Public Health (Tuberculosis) Regulations, 1908, issued by the Local Government Board on the 18th December of that year. These regulations provided for the notification of cases of pulmonary tuberculosis by Medical Officers of Poor Law Institutions, District Medical Officers, Superintending Officers of Poor Law Institutions and Relieving Officers. The respective duties of these officers in connection with notification are prescribed in Articles IV to VIII of the Regulations. Further Regulations were made on 22nd March, 1911, extending the system of notification to cases occurring among the in-patients or out-patients at hospitals, or other similar institutions for the Diagram V. - Phthisis Mortality in London- 1851-1914. Annual Death-rate among males and females per 1,000 living. (Corrected for differences in age- constitution of the population) 29 Report of the County Medical Officer—General. treatment of the sick, which are supported wholly or partially otherwise than by the contributions of the patients (or of their relatives or guardians) and otherwise than from rates and taxes. These Regulations are described as the Public Health (Tuberculosis in Hospitals) Regulations, and came into force on 1st May, 1911. A further stage in the development of notification of pulmonary tuberculosis was reached on the issue of the Local Government Board Order of the 15th November, 1911. This Order provided that from the 1st January, 1912, every Medical Practitioner should notify within 48 hours every case of pulmonary tuberculosis occurring in the course of his public or of his private practice, but it relieved the medical practitioner of the duty of notifying a case which had to his knowledge already been notified to the proper authority. The Order was not a consolidating Order but supplemented and to some degree extended the Poor Law and Hospital Regulations. These three orders were consolidated, and extended to apply to all forms of tuberculosis, by a new order of the Local Government Board dated 19th December, 1912, which came into force on 1st February, 1913 Under this order the Council has made the following summary return of cases of tuberculosis notified in the County of London in 1914 (52 weeks). Form of Tuberculosis notified. Sex. Notifications on Form A. (Total of primary notifications received in London boroughs, other than elementary school cases, infra.) 0— 1— 5— 10— 15— 20— 25— 35— 45— 55— 65 + Age not stated. Total. Pulmonary Tuberculosis M. 31 177 486 429 630 891 2,007 2,140 1,581 712 203 10 9,297 F. 25 157 421 500 572 883 1,797 1,378 780 332 200 2 7,047 Other Tuberculosis M. 144 441 520 290 155 92 136 69 58 32 12 - 1,949 F. 121 361 379 275 168 121 145 98 42 19 20 - 1,749 All forms of Tuberculosis M. 175 618 1,006 719 785 983 2,143 2,209 1,639 744 215 10 11,246 F. 146 518 800 775 740 1,004 1,942 1,476 822 351 220 2 8,796 Form of Tuberculosis notified. Sex. Notifications on Form B. (Primary notifications of cases discovered through medical inspection in elementary schools.) Notifications on Form C. (Secondary notifications from institutions receiving cases.) 0— 5— 10— 15 + Total. Poor-law. Other. Pulmonary Tuberculosis M. 3 26 28 — 57 3,183 1,956 F. 2 34 30 — 66 1,250 1,029 Other Tuberculosis M. 4 54 22 1 81 348 83 F. 2 48 32 1 83 203 62 All forms of Tuberculosis M. 7 80 50 1 138 3,531 2,039 F. 4 82 62 1 149 1,453 1,091 In classifying the returns of notifications received from the borough councils for the purpose of this summary, care has been taken to follow as far as possible the International List of Causes of Death, adopted by the Registrar-General in 1911; and the notifications should therefore be comparable with the deaths in London from "pulmonary," and from "other tuberculosis," respectively. Cancer. The deaths from cancer in the Administrative County of London during 1914 (52 weeks), numbered 5,226, as compared with 5,206 for the 53 weeks of 1913. The death-rates from this disease in 1914 and preceding periods are given in table I., page 40. For the purpose of enabling the incidence of caucer on the several populations of the sanitary districts to be more precisely stated, factors have been calculated for correcting the death-rates, as far as possible, for differences in the age and sex constitution of the several populations concerned. 30 Annual Report of the London County Council, 1914. These factors are shown in the following table, together with the death-rates for each sanitary district, corrected by their application. Metropolitan borough. Factor for correction for age and sex distribution. Crude death-rate per 1,000 persons living. Corrected death-rate por 1,000 persons living. Comparative mortality figure (London 1,000). 1909-13. 1914. 1909-13. 1914. 1909-13. 1914. London 0.9634 1.09 1.18 1.05 1.14 1,000 1,000 Paddington 0.8542 1.19 1.48 1.02 1.26 971 1,105 Kensington 0.8117 1.19 1.54 0.97 1.25 924 1,096 Hammersmith 0.9363 1.09 1.20 1.02 1.12 971 982 Fulham 1.0723 1.04 1.09 1.11 1.17 1,057 1,026 Chelsea 0.8018 1.39 1.43 1.11 1.15 1,057 1,009 Westminster, City of 0.8484 1.31 111 1.11 0.94 1,057 825 St. Marylebone 0.8556 1.35 1.29 1.15 1.10 1,095 965 Hampstead 0.8657 1.10 1.35 0.95 1.17 905 1,026 St. Pancras 0.9362 1.24 1.28 1.16 1.20 1,105 1,053 Islington 0.9163 1.14 1.23 1.04 1.13 990 991 Stoke Newington 0.8235 1.26 1.60 1.04 1.32 990 1,158 Hackney 0.9594 1.03 1.17 0.99 1.12 943 982 Holborn 0.8425 1.20 1.41 1.01 1.19 962 1,044 Finsbury 0.9977 0.95 1.23 0.95 1.23 905 1,079 London, City of 0.7883 1.40 1.40 1.10 110 1,048 965 Shoreditch 1.1342 0.81 0.97 0.92 1.10 876 965 Bethnal Green 1.1866 0.97 0.85 1.15 1.01 1,095 886 Stepney 1.2037 0.84 0.91 101 1.10 962 965 Poplar 1.0747 0.97 1.04 1.04 1.12 990 982 Southwark 1.0335 1.07 1.04 111 1.07 1,057 939 Bermondsey 1.0744 1.13 1.11 1.22 1.19 1,162 1,044 Lambeth 0.9193 1.22 1 35 1.12 1.24 1,067 1,088 Battersea 1.0112 1.03 1.21 1.05 1.22 1,000 1,070 Wandsworth 0.9552 1.02 1.20 0.97 115 924 1,009 Camberwell 0.9688 1.05 1.12 1.02 1.01 971 956 Deptford 0.9963 1.07 1.16 1.07 1.16 1,019 1,018 Greenwich 0.9895 1.02 1.10 1.01 1.09 962 956 Lewisham 0.9223 1.09 1.08 1.00 1.00 952 877 Woolwich 1.0321 0.99 1.13 1.02 1.17 971 1,026 Cancer death.rates in London boroughs. It will be seen from the foregoing table (comparing the corrected death.rates) that in the quinquennium 1909.13 among the several sanitary districts, Bermondsey (1.22) had the highest cancer deathrate, and Shoreditch (0.92) the lowest; in the year 1914, Stoke Newington (1.32) had the highest, the lowest obtaining in Westminster (094). In the report for the year 1909 a table was included showing the cancer death-rates in the period 1901-9 in areas presenting different degrees of overcrowding, the object being to compare the deathrates of populations differently circumstanced in respect of "social condition." The figures for 1914 show that there is no relation between cancer mortality and social condition, whether measured by the degree of overcrowding or by the percentage of children scheduled for compulsory education, and in this respect the behaviour of cancer differs altogether from that of phthisis. Dr. Sidney Davies (Woolwich) gives the results of investigations which he has made into the relation of cancer to certain habits (smoking, alcoholic indulgence, etc.). Influenza, Bronchitis and Pneumonia. The deaths attributed to influenza, which in 1913 numbered 863 (53 weeks), fell to 602 in 1914 (52 weeks). The deaths from bronchitis numbered 5,233 in 1914, as compared with 5,792 in 1913. In 1914 there were 5,519 deaths attributed to pneumonia, as compared with 5,887 in 1913. The deaths and death-rates from these diseases since 1889 have been as follows:— Year. Influenza (a) Bronchitis (a) Pneumonia (a) Year. Influenza (a) Bronchitis (a) Pneumonia (a) 1890 0.15 2.93 1.46 1903 0.14 1.15 1.28 1891 0.55 3.12 1.64 1904 0.16 1.40 1.45 1892 0.53 2.63 1.45 1905 0.15 1.33 1.53 1893 0.35 2.42 1.67 1906 0.20 1.18 1.45 1894 017 1.80 1.23 1907 0.21 1.32 1.66 1895 0.49 2.43 1.37 1908 0.29 1.15 1.46 1896 0.11 1.68 1.23 1909 0.27 1.35 1.68 1897 0.15 1.67 1.14 1910 0.16 1.12 1.49 1898 0.29 1.74 1.22 1911 0.11 1.15 1.25 1899 0.41 2.05 1.49 1912 0.12 1.22 1.18 1900 0.43 1.93 1.60 1913 0.19 1.26 1.28 1901 0.15 1.62 1.35 1914 0.13 1.16 1.22 1902 0.23 1.71 1.47 Influenza, bronchitis and pneumonia death-rates, London. (a) See footnote (2) to table I., page 40, 31 Report of the County Medical Officer—General. The distribution of deaths (a) from influenza throughout the year (b) for each of the years 1891 to 1914 is shown in the following table:- No. of weeks. 18911 1892 1893 1891 1895 1896 1897 1898 1899 1900 1901 1902 1903 19041 1903 1906 1907 1908 1909 1910 1911 1912 1913 1914 1— 4 9 1308 52 272 59 37 40 244 66 1016 57 77 141 67 94 56 291 87 61 112 61 56 66 98 5— 8 7 637 96 96 164 58 55 368 259 298 75 224 103 62 119 44 186 276 90 151 77 101 106 81 9—12 8 119 162 69 1343 61 94 193 430 130 134 298 89 74 119 98 104 424 430 98 57 67 183 72 13—16 29 42 180 56 257 50 121 140 302 172 102 89 54 62 75 129 81 209 257 64 51 32 164 62 17—20 770 33 125 32 106 50 96 61 121 105 81 58 46 40 56 105 48 94 85 41 39 46 90 47 21—24 1044 22 72 27 35 33 54 51 82 57 30 35 37 21 38 40 41 36 46 16 15 22 30 35 25—28 242 15 49 19 28 17 26 25 42 16 21 20 25 17 16 21 25 28 34 11 11 9 16 29 29—32 51 7 23 17 14 15 18 27 27 12 18 7 18 5 4 20 14 15 15 9 10 14 8 11 33—36 32 9 23 20 17 10 13 10 11 11 11 16 6 9 11 15 18 12 10 17 6 15 12 16 37—40 13 6 18 14 15 12 19 17 19 15 12 13 17 24 22 18 19 21 15 29 17 16 22 25 41—44 15 20 28 29 22 27 29 46 55 17 23 35 13 92 39 35 42 30 31 25 40 48 32 37 45—48 35 18 152 41 47 56 35 49 61 55 44 65 44 98 44 86 39 45 56 75 46 39 54 33 49—52 81 28 546 58 49 56 71 52 342 46 56 99 51 138 52 228 59 57 86 75 66 70 57 56 Influenza— seasonal distribution. Cerebrospinal Meningitis. The number of cases of cerebro-spinal meningitis notified during 1914, viz., 73 cases (including one in the Port of London), was the lowest recorded since the disease was made notifiable in London (12th March, 1907) as will be seen from the subjoined statement:— Year. Cases notified. Year. Cases notified. 1907 (from 12th March) 135 1911 101 1908 85 1912 105 1909 111 1913 92 1910 115 1914 73 Upon investigation it was found that of the 73 cases notified only 61 could be regarded as definite cases of cerebro-spinal fever or of post-basic meningitis. During the same period 58 deaths were recorded from cerebro-spinal or post-basic meningitis; these included a number of cases which were not certified as cerebro-spinal or post-basic meningitis until after death. The 73 notified cases were classified as follows—cerebro-spinal meningitis, 40 cases; post-basic meningitis, 19 cases; purulent basal meningitis, 2 cases; pneumococcal meningitis, 2 cases; doubtful, 11 cases. The age distribution of the 73 notified cases was as follows *— Under 1 year 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 to 25 25 to 30 40 to 50 33 6 5 7 1 3 1 - 1 3 1 - -1 2 2 1 1 1 - - 1 3 1 In accordance with the agreed procedure, the borough medical officers furnished detailed information for circulation to their colleagues in respect of 61 cases. This information may be summarised as follows.— Symptoms.—The symptoms most commonly associated with the course of illness in the 61 cases recorded were headache, vomiting, muscular rigidity, drowsiness, delirium and coma. A variety of other manifestations, particularly affecting the nervous system, were also noted in certain cases, e.g., Kernig's sign, extensor plantar response, hyperesthesia, retraction of head, photophobia, strabismus, engorgement of retinal vessels and blurring of discs, and optic neuritis. Recent illnesses of patient.—The information procurable with regard to recent illness was not very detailed. In 36 patients no recent indisposition was noted. Eight gave a history of having recently suffered from colds, in 4 cases bronchitis and in 11 instances otorrhæa or rhinorrhœa was present; of the remainder there was a history of illness with no apparent bearing on the attack of cerebro-spinal fever except possibly in one instance, in which the patient was said to have suffered from a prolonged attack of influenza three months previously. The possible association of influenza with cerebro-spinal fever during periods of epidemic prevalence will be referred to later; during the non-epidemic period of 1914 such association was only recorded in a single instance. Health of other inmates of house.—In 44 instances nothing abnormal was observed with regard to the health of other persons occupying the same house as the patient. In 4 cases influenza colds or sore throat were noted ; in the remaining cases, although other persons in the house had been suffering from various ailments, there was nothing to indicate that these bore any relation to the case of cerebrospinal meningitis. Details of housing accommodation.—In 27 cases there were less than two persons per room, in 15 cases from two to three persons, in 10 cases from three to four persons, in four instances there Were from four to five persons per room, and in one family there were more than five persons to a room. (а) See footnote (2) to table I, page 40. (b) The deaths occurring in the 53rd week of the years 1890, 1896, 1902, 1908 and 1913, which are not ihown, numbered 1, 14, 37, 16 and 22 respectively. 32 Annual Report of the London County Council, 1914. With regard to the recorded number of persons in the patient's family, in 40 cases there were six persons or less in family, in 9 cases there were seven in family, in 3 cases eight persons, in 6 cases nine persons, and in 3 instances there were as many as ten persons in the family. Enquiries as to the number of families occupying the patient's house showed that in 44 cases there were either one or two families occupying the premises, six of which were tenement houses. In 9 cases there were three families, and in 5 cases four families in the house. The number of persons occupying each house attacked ranged between 4 and 20, and the average number to each house was 9 persons. Sanitary condition of house.—Only in 6 cases was the condition of the house from a sanitary point of view referred to as "bad"; in 16 cases the sanitary condition was "fair," and in 21 instances the state of the premises was " good." In 9 of the cases enquired into the premises were verminous. Hospital or Institutional treatment.—In 46 of the 61 cases investigated the patient was removed to a hospital or institution for treatment. Duration of illness.—It has been possible to calculate approximately the duration of illness in the cases of 39 of the 61 patients concerning whom particulars were furnished. There appears to have been considerable variation in the length of the periods between the dates of onset and death, which ranged from one day to nearly three months. Bacteriological examinations.—In 29 cases, or nearly 50 per cent, of the total number of those concerning which enquiries were made, bacteriological examinations were stated to have been conducted. In 26 of these examinations Gram negative diplococci were identified, and in another case polymorphonuclear cellswere present, although the cultures Were sterile; in this case post-mortem examination showed diffuse meningitis over the posterior part of the base of brain and pus in both lateral ventricles; the results in the remaining two cases were indefinite. Post-mortem examinations.—Post mortem examinations were recorded in 23 of the fatal cases registered. In 21 cases the post mortem investigations confirmed the original diagnosis of cerebrospinal or post-basic meningitis; one case proved to be tuberculous meningitis and the remaining case was found to be one of meningitis secondary to disease of the middle ear. The attention which was devoted to cerebro-spinal meningitis in London during 1914 may be attributed largely to the fact that for 7 years special enquiry concerning all cases reported had been made. The London County Council first declared the disease notifiable in March, 1907, at the time of an epidemic in Glasgow, 1907-1908, in the course of which some 1,238 cases with 838 deaths occurred, while almost synchronously some 725 cases with 548 deaths were recorded in Belfast during the eighteen months ended June, 1908. The disease was made notifiable in Glasgow on 10th August, 1907, in the early stages of the outbreak. Sporadic cases of cerebro-spinal meningitis appear at certain seasons of each year in all large communities and this endemic form of the disease when occurring amongst young persons is usually referred to as post-basio meningitis; such cases are commonly treated in general hospitals without isolation. The features of this endemic type of the disease in regard to infectivity, severity of attack, symptoms, duration and mortality differ very considerably from those of the epidemic variety. The epidemic prevalence of the disease occurs in waves of varying intensity from time to time and is governed by a complexity of conditions as yet very incompletely understood. This has been largely due to the fact that cases exhibiting the particular group of symptoms may have been frequently confounded with other diseases. The investigations following upon compulsory notification of the disease have been instrumental in directing attention to the great variability of the symptoms in question. Notification has, moreover, led to a wider knowledge of the bacteriology and epidemiology of the disease. During seven years following the introduction of compulsory notification, cerebro-spinal meningitis had not assumed epidemic dimensions, but towards the end of 1914 cases of the disease were reported from various parts of the country, and in the early months of the following year the disease, in comparision with earlier experience of it in London, may be said to have become almost epidemic in character. A full account of the outbreak will appear in the annual report for 1915, but, in view of the importance of the subject, it may be desirable to make a brief analysis in the present report of the earlier manifestations of this prevalence, and in particular the relationship between cerebro-spinal fever and "influenza," colds and sore throat may be considered. The progress of the disease during the first five months of the year 1915 is shown below:— Week ending January. February. March. April. May. 9 16 23 30 6 13 20 27 6 18 20 33 27 3 10 17 24 1 8 15 22 29 Number of Cases 5 7 5 8 8 15 23 18 32 33 33 22 42 43 32 22 33 21 20 12 Evidence of the increasing prevalence of the disease was primarily observed in certain camps, and in particular an outbreak at the Crystal Palace, Royal Naval Division Depot, specially directed attention to the disease. The appearance of cerebro-spinal fever in camps and barracks has always been the subject of comment and is probably due to the fact that "the population at risk" in camps consists largely of young adults who on account of the prevailing conditions must be regarded as especially susceptible persons. This population is exposed to important predisposing causes of the disease among which close aggregation in huts, etc., with accompanying deficient ventilation, should be especially mentioned. 33 Report of the County Medical Officer—General. The age distribution of cases was as follows— 0-1 1-5 5-10 10-15 15-20 20-25 25-35 35-45 45-55 55-65 65& up. 6. 99 76 38 60 49 42 20 14 5 3 It will be observed that the average age of attack during 1915 was higher than in former years; the average age in 1915 being nearly fifteen, as compared with five in 1914. As increase in the incidence of the disease became clearly marked towards the end of February, the Local Government Board on 22nd February circulated a memorandum among sanitary authorities throughout the country recommending that certain administrative and other measures should be taken to prevent the spread of the malady. The memorandum gave advice with regard to bacteriological aids to diagnosis in suspected cases and made reference to the desirability of making arrangements for the swabbing of contacts. In this connection the Council, at the request of the Local Government Board, addressed a circular to the Metropolitan Sanitary Authorities with a view to securing co-operation between the County Medical Officer and the Medical Officers of Health of the several metropolitan boroughs. It was arranged that the services of the Council's medical officers should be available for the purpose of examining suspected cases, by lumbar puncture where necessary or by making postmortem examinations, and in particular arrangements were made for the bacteriological examination of material in the Council's Public Health Laboratory, the investigations being placed in charge of Dr. J. A. H. Brincker, assisted by Dr. J. G. Forbes and Dr. E. H. Ross. During the first three months of the operation of the scheme a considerable amount of work was done and the services of the Council's experts were placed at the disposal of local Medical Officers of Health and medical practitioners. Furthermore, close co-operation was maintained between the Council's Public Health Department and the Army Medical Service when there was known association between military and civil cases. Up to the end of May, 1915, 51 persons who were regarded as possible subjects of cerebro-spinal fever were visited by the Council's medical officers both with a view to assisting in diaguosis and for removing cerebro-spinal fluid or other suitable material for bacteriological examination. In some of these instances the disease had already proved fatal, at the time of the visit, and post-mortem examinations were conducted. Analysis of the 51 suspected cases shows that material was collected for bacteriological examination in 40 cases. In 28 of the 40 specimens the organism commonly associated with the disease, viz., the particular kind of Gram negative diplococcus known as the meningococcus was found; in 12 cases meningococci could not be identified. Throat cultures were also taken from three persons who had been discharged as cured after having suffered from cerebro-spinal meningitis, and two of them were found still to be carrying the meningococci in the throat, although in one case a second culture taken a week later gave a negative result; in the other case, that of a soldier, the second examination proved positive, but a third gave a negative result. In this latter case, the soldier was in the infirmary suffering from cerebro-spinal fever from 3rd March to 1st April; his sister, aged 4 years, was taken ill on 29th March (prior to the soldier's discharge from the infirmary) and died the next day. The child did not see her brother during his illness. The following information is available concerning the twelve cases in which no evidence of meningococci could be detected in the cerebro-spinal fluid or other material examined:— Case No. 1.—Proved to be cerebro-spinal meningitis at post-mortem examination. Case No. 2.—Not cerebro-spinal fever. Patient a soldier with doubtful symptoms; his throat was examined at request of a consultant. Case No. 3.—Notified as cerebro-spinal fever on clinical evidence. Case No. 4.—Pneumococcus identified. Case of pneumococcal meningitis. Case No. 5.—Not cerebro-spinal fever. Died probably as result of shock following upon extensive burns. Case No. G.—Notified as cerebro-spinal fever on clinical evidence. Case No. 7.—Pneumonia certified as cause of death. Case No. 8.—Examination of the cerebro-spinal fluid indicated that case was one of acute poliomyelitis. Case No. 9.—Clinically the case appeared to be one of cerebro-spinal meningitis, but the result of lumbar puncturc indicated that it was probably poliomyelitis. This was subsequently confirmed in hospital. Case No. 10.—Examination of cerebro-spinal fluid showed that there was no meningitis. The child improved and is now quite well, and the conclusion arrived at was that the child suffered from intestinal toxaemia. Case No. 11.—Although the cerebro-spinal fluid was normal, the clinical features of the case justified notification as cerebro-spinal fever. Case No. 12.—Examination of cerebro-spinal fluid during life showed that the case was not one of meningitis. The patient died and the cause of death was certified as " toxaemia from abdominal infection." With regard to the remaining 11 patients, in 8 cases lumbar puncture was not performed ; of these, the patient was too ill to justify an operation being performed in one case, one proved to be a case of poliomyelitis, in six cases no meningeal symptoms were present; of the last-mentioned group three 27715 f 34 Annual Report of the London County Council, 1914. proved to be measles, one was urticaria, one had influenza, whilst one case was diagnosed and notified as scarlet fever. In three instances no fluid could be obtained by means of lumbar puncture; one of these was found to be a case of tuberculous meningitis,one was notified as diphtheria and the otherwas certified as a case of acute meningitis. On six occasions specimens of material for bacteriological examinatiou have been forwarded to the Council's Public Health Laboratory, two of them being obtained postmortem; meningococci were discovered in four of these cases, including the post-mortem cases, and the other two gave negative results. In three instances cultures were made on account of the presenile of suspicious pharyngeal symptoms or other suspicious signs unaccompanied by any indications of meningitis, one of the patients being a soldier. Bacteriological examination of the specimens on all three occasions gave a negative result. Out of a large number of persons who had been in contact with cases of cerebro-spinal fever during the period under review, 329 persons were selected for bacteriological examination by reason of their having been closely associated with the patients. Of the total number of persons examined, 31 (10 per cent.) proved to be carriers of the meningococcus. An attempt has been made to ascertain whether any correlation exists between closeness of association and the presence or absence of the meningococcus among the contacts examined. The enquiry was conducted on the lines of classifying the contacts according to their degree of relationship to the patient. It was thought that this method might show significant differences in the proportion of carriers found in the various groups classified. Thus, in the case of young children attacked by the disease it might be assumed that mothers of these children come into closer association with them than the father, and older sisters than older brothers, and so on. No satisfactory conclusion on the point in question could however be obtained from the figures, which gave inconsistent results. The value of the results was to some extent vitiated by the fact that the contacts examined formed a selected class and included only those persons who had been in intimate contact with the patient, and further than this it is apparent when the contacts selected for examination are classified into groups that the numbers forming the groups are much too small from a statistical point of view to determine the question at issue. In the majority of cases the carriers were re-examined at varying intervals of two to'six weeks, but only on four occasions were positive results obtained on a second examination, and only in one on a third examination. Of these three were kept under observation. In summary of the conclusions arrived at as the result of the inquiries made it may be stated that there was no evidence that any of the carriers, discovered during the course of these investigations, had been responsible for giving rise to cases of cerebro-spinal meningitis, although they retained complete freedom of action. The advice usually given in such cases was to live as much as possible in the fresh air, to avoid close unnecessary contact with other persons, and to use throat gargles and nasal douches. Of the contacts examined, none of the persons found to be carrying the meningococcus showed, at any time, any symptoms of a serious character. The scope of the present inquiry has been somewhat limited, and it would be unwarrantable to draw definite conclusions with regard to influence of " carrier " cases on the spread of cerebro-spinal meningitis without further investigations. Inquiries are still being pursued, but this short resume of the work already done clearly indicates that the facilities for obtaining expert advice have been freely utilised and appreciated. Influenza and cerebrospinal fever. The prevalences of these diseases, which commenced in London at the end of 1914, have afforded further opportunity for study of their inter-relationship. The large amount of attention which has recently been devoted to their bacteriology has dwarfed almost to insignificance the measure of consideration which has been allotted to their epidemiology, and this fact is the more regrettable because the problem of their epidemiological relationship is an old standing one and presses for further investigation. Already in the fifteenth and sixteenth centuries there were records showing that outbreaks of what was then called" sweating sickness "(doubtless the modern "influenza") were apt to occur concurrently with prevalences of diseases described as "hauptkrankheit," "encephalitis," and "febrile cerebritis." (See The Milroy Lectures, 1906). Symes Thompson in his "Influenza, an historical survey " makes several references to cerebral symptoms in cases of influenza outbreaks. Ozanam in his "Histoire des maladies epidemiques "has a chapter on Encephalite, or Fievre cerebrale, which is full of interest in the same connection; he says, for example, speaking of this brain fever, "File se combina en 1557 et 1559 avec l'epidemie catarrhale qui parcourut successivement l'Allemagne, la Hollande, la France, et 1'Espagne; elle fut mortelle pour les enfants"... and, again, he says, "La cephalee se combina encore en 1580 avec l'epidemie catarrhale qui parcourut toute l'Europe"... then he mentions an Army outbreak in 1616 . . . further he refers to a particularly noteworthy outbreak described by Saalmann in Westphalia, in 1788, in which rigidity of the limbs, "eruption pourpree" and "inflammation des meninges et du cerveau" are mentioned. Finally various authors in the nineteenth century have described varieties of influenza in which the nervous system was principally affected. Attention was specially directed to this question in London at the time of the occurence of "An epidemic influenza " in East Herts, in the winter of 1904—5; the outbreak was carefully studied by Drs. R. A. Dunn and M. H. Gordon, and the claim that, epidemiologically considered, the outbreak was one of influenza was made by Dr. Lovell Drage and myself at the time (see The Milroy Lectures, 1906, p, 39). In 1906, cerebro-spinal fever was reported in Belfast and in Glasgow and as a consequence the disease was made notifiable in London. In that year an anomalous "Outbreak simulating influenza" occurred in an institution in Holborn, and was reported upon by Dr. Bond (Trans. Epid. Soc. of London, 1906-7). In a contribution supplied to the discussion on Dr. Bond's paper I ventured the suggestion that in some of the outbreaks which had been described by medical inspectors of the Local Government Diagram W. DIAGRAM SHEWING WEEKLY (a) NOTIFIED CASES OF CEREBRO-SPINAL FEVER AND POLIOMYELITIS (b) ESTIMATED CASES OF INFLUENZA AND (c) REGISTERED DEATHS FROM INFLUENZA IN LONDON DURING THE YEAR 1914 AND THE FIRST FIVE MONTHS OF THE YEAR 1915. Diagram X. DIAGRAM SHEWING THE MONTHLY (4 weeks) DEATHS FROM INFLUENZA AND NOTIFIED CASES OF CEREBRO-SPINAL FEVER AND POLIOMYELITIS IN LONDON DURING EACH OF THE YEARS 1908-1913 INCLUSIVE. 35 Report of the County Medical Officer—General. Board, in those of Drs. Dunn and Bond, and perhaps in Belfast and Glasgow also, it was really influenza with special involvement of the nervous system that was in question. Further reasons for insisting upon the close inter-relationship existing between influenza and cerebro-spinal meningitis were given at the discussion on cerebro-spinal meningitis reported in the Proceedings of the Royal Society of Medicine, March, 1915. Reference was then made to Sydenham's account of the "new fever," as he termed it, of 1685, and the attempt was made to draw a parallel between this disease and the disease prevailing 230 years later in the same city. In both years 1685 and 1915, there was considerable augmentation of the number of deaths in London, but a few only of the patients presented nervous symptoms or eruptions, in many, instances throat and lung troubles predominated, and in the latter year the Registrar General's Returns included excessive numbers of deaths from bronchitis, pneumonia and influenza as well as from cerebrospinal fever. It may be argued, with some reason, therefore, that if reliance be placed exclusively upon bacteriological findings there is apt to be failure to see the wood because of the trees; and that the germs to which such very great importance is attached may be merely after all "associated organisms" or "secondary invaders." If the epidemiology of cerebro-spinal fever were regarded from a broader point of view, it was, indeed, urged that it " would be possible to attain to more philosophical notions with regard to its setiology, to more rational ideas as regards its prevention, and there might, too, be more hope in respect of treatment than can apparently be entertained in the light of popularly accepted theories." The opportunity presented itself on the occurrence of the recent epidemic of putting these suggestions to the test. During the first ten months of 1914, scattered cases only of cerebro-spinal meningitis were reported in London, then at the end of the year came the outbreak of influenza, pneumonia, bronchitis, etc., and close on its heels the prevalence of cerebro-spinal fever. The time relations of the outbreaks are shown on the accompanying diagram (W). It will be seen on referring to diagram (X) that the deaths from influenza reached a maximum in the eighth week of the year 1915, the deaths in the ninth week sharply declined and this was followed by an increase in the deaths of the tenth and eleventh weeks, after which the deaths progressively diminished. The notified cases of cerebro-spinal fever rose in the sixth and seventh weeks of the same year, reached a higher level in the ninth, tenth, eleventh and twelfth weeks, attaining a maximum in the fourteenth and fifteenth weeks, after which the numbers steadily diminished. It will be seen from the diagram that the cases of cerebro-spinal fever reached a notably high level in the week following that showing the maximum mortality from influenaa. Diagram (X) shows the time relationships of the two diseases for the period 1908-13. With a view to throwing further light on the question of possible inter-relationship between these two diseases the information obtained from borough medical officers of health concerning cases of cerebro-spinal fever has been utilised for the purpose of ascertaining the number of cases giving a history of recent attack by or contact with cases of influenza. As a result it appears that of 61 patients notified during the year 1914, concerning whom particulars were obtained, 12 gave a history of having recently suffered from colds; and contact with cases of influenza, cold or sore throat was noted in 4 cases. During the period 1st January to 22nd May of the year 1915, however, when influenza was prevalent, 523 cases of cerebro-spinal fever were reported and among the 462 cases concerning which particulars were obtained there was a history of recent influenza in 37 instances, and in 27 of these the patient was said to be suffering from influenza within 7 days of the onset of symptoms of cerebro-spinal fever. Colds, sore throat, cough and catarrh were noted as having affected 70 patients prior to attack by cerebro-spinal fever and ten patients had recently suffered from pneumonia. Contact with cases of influenza colds, etc., was noted in 66 instances. The number of cases giving a history of recent attack by or contact with cases of influenza is certainly large enough to afford justification for further examination. The main point to be determined is whether the number of cases of cerebro-spinal fever giving a history of (a) recent attack by, and (6) contact with, cases of influenza is greater than might have been expected as a matter of chance. The determination of the probability of the occurrence of (6) would necessitate the use of some hypothetical figure which would represent the average number of persons coming into association with the average Londoner in the course of a week. It is obvious that the use of such a figure in the absence of any reliable data for its determination would detract from the value of conclusions drawn from the results obtained; consideration therefore has been limited to the determination of (a) where the only unknown quantity, in the problem is that denoting the prevalence of influenza. The only record of influenza in the London population is that of the Registrar General relating to registered deaths, and so far as I am aware no casemortality figures for the disease relating to any large population are available. It was felt, however, that some indication of the prevalence of the disease in the general population of London might be afforded by an examination of the staff returns of illness furnished by the various departments of the London County Council to the Establishment Committee. These returns relate to some 3,000 officials on the staff of the London County Council and the influenza case curve which has been constructed from these records is therefore based upon a population which is of a sufficient size for the purpose in view. It cannot be claimed that the population in question is a random sample of the London population inasmuch as it differs materially in age and sex constitution and exhibits more homogeneity with regard to "social condition" than the London population as a whole. The fit of the "case curve" based on these figures with the mortality curve for London based on the return of the Registrar General is. so remarkably close, however, that it appears questionable whether anything would be gained by attempting to correct for the selective nature of the sample population and whether a random sample of the same size would have given any more accurate result. Moreover, an examination of the age distribution of 27715 f 2 36 Annual Report of the London County Council, 1914. the cases of cerebro-spinal fever giving a history of suffering from influenza, within 7 days of onset of symptoms of cerebro-spinal fever, reveals the fact that of 27 such cases all except 5 were within the age period 15—45; it is therefore obvious that any correction which might be made, to eliminate as far as possible sources of error arising from the lack of precise knowledge of the age incidence of attack of influenza, would tend to reduce the "probability" values which it is desired to obtain. The figures shown in column 2 of the following table have therefore been calculated on the assumption that the cases of influenza occurring in the London population were proportionate to those occurring among members of the Council's staff. The table is as follows:— Week ending. Cases of reported influenza among 3,000 of Council's staff. Estimated cases of influenza in London population based on L.C.C. staff returns. Proportion of London population attacked by influenza in each week. No. of cases ol cereoro-spinal fever occurring in each week. No. of cases of cerebro-Bpinal fever giving a history of suffering from influenza within 7 days of onset of cerebrospinal fever. Probability (p) of the occurrence of the number of cases shown in previous column. 1 2 3 4 5 6 7 1915. Jan. 9 16 24,000 1/187 6 — .9683 „ 16 14 21,000 2/214 6 — .9723 „ 23 27 40,500 1/111 6 — .9472 „ 30 21 31,500 1/143 11 — .9257 Feb. 6 24 36,000 1/125 8 2 .0017 „ 13 19 28,500 1/158 14 4 .0000 „ 20 19 28,500 1/158 25 2 .0104 „ 27 26 39,000 1/115 19 2 .0111 Mar. 6 15 22,500 1/200 40 2 .0161 „ 13 17 25,500 1/176 29 4 .0000 „ 20 21 31,500 1/143 34 — .7877 „ 27 20 30,500 1/148 37 1 .1958 April 3 14 21,000 1/214 14 2 .0019 „ 10 14 21,000 1/214 56 4 .0001 „ 17 12 18,000 1/250 43 — .8417 24 8 12,000 1/375 27 1 .0672 May 1 9 13,500 1/333 19 1 .0541 „ 8 6 9,000 1/560 26 1 .0495 „ 15 3 4,500 1/1000 22 — .9782 „ 22 2 3,000 1/1500 20 1 .0132 In explanation of the table, it may be stated that column 2 shows the number of cases of influenza occurring among 3,000 of the Council's staff in each week; column 3 shows the result of applying the figures in column 2 to the London population, and gives the estimated number of cases of influenza in each week which might be expected to have occurred in the London population; column 4 shows the proportion of the London population attacked in each week, based on the figures shown in column 3, the fractions representing this proportion express the probability that a case of cerebro-spinal fever selected at random in the corresponding week will give a history of recent attack by influenza; column 5 shows the number of cases of cerebro-spinal fever occurring in each week and column 6 the number of these cases giving a history of suffering from influenza within 7 days; column 7 shows the probability of each of the occurrences shown in column 6. The facts shown in columns 5 6 and 7 of the table are exhibited graphically in sections I. and II. of diagram (Y). It will be seen from the table that in 13 out of the 20 weeks investigated cases of cerebro-spinal fever occurred giving a history of suffering from influenza within a week of attack by cerebro spinal fever. The probabilities of such occurrences are shown in column 7 and the values of (p) calculated on the data it has been possible to collect are so small as to raise question whether the occurrence of influenza and cerebro spinal fever in the same person within the limited period can be regarded as independent events. If the figures for the whole period under review be taken it will be seen that of 462 eases of cerebrospinal fever 27 gave a history of suffering from influenza within seven days of the onset of this illness. The probability of the occurrence of so large a number of cases assuming attack by influenza and cerebro-spinal fever within the limited period to be independent events works out at a figure which is practically infinitesminal. It will be seen from section 111. of diagram (Y) that the most probable number of cases giving a history of recent attack by influenza is 2, and that the successive probabilities of obtaining 3, 4, 5, etc., cases rapidly decline, the probability of obtaining 7 cases for instance falls as low as .0077; beyond this point it is unuecessary to calculate the ordinates of the probability curve, but the sum of the probabilities of the first 8 ordinates gives a figure of .9964, the probability of obtaining 8 or more cases with an influenza history is therefore the difference between •9964 and unity—viz. '0036. It will thus be seen that the probability of obtaining more than 7 such cases is less than 4 in 1,000, whereas the number of such cases actually recorded reaches the high figure of 27. The facts set out in the preceding paragraph may perhaps be more clearly appreciated if presented as follows: suppose that 462 persons are chosen at random from the London population in groups of from 20 to 30 during each week of the first five months of the year 1915, one would expect, having regard to the prevalence of influenza during these months to find that some 2 or 3 of the 462 persons thus chosen would either be suffering from or recently recovered from an attack of influenza ; turning, Diagram Y. DIAGRAM ILLUSTRATING CERTAIN ASPECTS OF THE RELATIONSHIP BETWEEN CEREBRO-SPINAL FEVER AND INFLUENZA. 37 Report of the County Medical Officer—General. however, to the "selected" group of 462 sufferers from cerebro-spinal fever we find that not 2 or 3, but as many as 27 give a recent history of influenza attack. This latter number (27) compared with the "expected" is so large as to afford strong ground for the belief that some relationship exists between the two diseases. This presumption is materially strengthened when regard is paid to the large number of cases of cerebro-spinal fever giving a history of contact with sufferers from influenza. Polio-myelitis and polio-encephalitis. Acute polio-myelitis has been a notifiable disease in London since 1st September, 1911. Since then the undermentioned numbers of cases have been recorded annually. No. of cases. 1911 (from 1st September) 66 1912 (52 weeks) 132 1913 (53 weeks) 145 1914 (52 weeks) 93 Diagram (W) shows the monthly distribution of cases m London during 1914. Acute polio-myelitis attacks mainly young children, but is by no means unknown among adults. The age distribution during 1914 is shown below:— Ages. Under 1 year 1— 2- 3— 4— 5— 6— 7— 8— 10—20 20-30 No. of cases 12 23 20 14 5 6 7 - 1 3 1 (18 years) 1 The borough medical officers supplied detailed information on special forms in respect of 77 cases during the year. The severity of attack in the cases which came under observation varied considerably. It was noted that pain was a marked feature of the illness in 32 cases ; there was an eruption in 9 cases, and symptoms of meningitis supervened in one case. In only one instance was there any record of two cases in the same house. The increased knowledge, obtained as a result of the wider study of epidemiology of the disease since compulsory notification was introduced in London, indicates that though cases of this malady occur at all seasons of the year, the numbers notified are greatly increased during the late summer and autumn months. A similar increase of yearly prevalence is observed in the case of cerebro-spinal meningitis, but this increase occurs during the winter and spring months. In the case of influenza the seasonal maximum usually occurs in the winter or very early spring; but occasionally epidemics have been recorded in which the maximum has been reached during the summer. There was a noteworthy increase in the number of notified cases of poliomyelitis during the autumn of 1914 more particularly in the East End, and chiefly in Stepney; the local distribution throughout London was as follows:— West East. Paddington 3 Shoreditch 1 Kensington — Bethnal Green 7 Hammersmith 1 Stepney 27 Fulham — Poplar 8 Chelsea — Westminster 1 South. North. St. Marylebone — Southwark 4 Hampstead 3 Bermondsey 1 St. Pancras 3 Lambeth 10 Islington 8 Battersea 1 Stoke Newington — Wandsworth 2 Hackney 5 Camberwell 5 Central. Deptford 1 Ilolborn — Greenwich — Finsbury 1 Lewisham 1 City of London — Woolwich — The period comprising the 18 weeks from 6th June to 26th September 1914, was that in which the disease was prevalent in East London, and it may be stated that information as to 31 cases was received from the boroughs of Stepney (21 cases), Poplar (a cases), and Bethnal Green (5 cases). This incidence is at the rate of 54 per million in East London (including Stepney, Poplar and Bethnal Green) as compared with 5 per million for the rest of London north of the Thames and 7 per million for South London. This exceptional incidence in East End was made the subject of investigation by Dr. Brincker, who instituted inquiries at the various East End hospitals. It was noteworthy that 18 of the 31 cases were notified from the London Hospital during the above-mentioned period. These cases were under treatment at the hospital, and whenever death occurred the diagnosis was confirmed by post-mortem examination. The 18 cases do not include a certain number of patients who were admitted with obscure illnesses, and who were found upon post-mortem examination to have died from acute poliomyelitis. The 38 Annual Report of the London County Council. 1914. hospital authorities also observed that during the period when so many cases of poliomyelitis were under treatment, a number of other patients were found to be suffering from herpes zoster, and it was concluded that there was probably a close relationship between the two diseases ; thus, while in poliomyelitis the brunt of the attack is borne by the motor neurones, in herpes zoster the neurones of the posterior root ganglia are affected. It may be assumed, moreover, that other cases occur in which the injury produced may only be of a temporary or minor character and would not give rise to recognisable symptoms. For these reasons the number of cases actually notified probably does not represent the full extent of the prevalence of the disease. No evidence has been discovered to show that there is any association between the incidence of poliomyelitis and insanitary conditions. The causes which influence the manifestations of the disease are to be looked for in other directions. The experimental work of Dr. Simon Flexner, of New York, and others has demonstrated that both the cause of sickness and its method of spread are at present involved in obscurity; especially as the virus associated with the disease may be demonstrated in the discharges of persons apparently healthy. The following quotation may be made from Dr. Flexner's paper. "We do not possess a generally acceptable theory to account for the epidemic waves of disease. What is required is an adequate explanation of the initial rise, persistence, and the final fall of the wave as represented by the varying number of the affected. That mere presence of the microbic causes of the disease does not suffice to produce epidemics has long been known. It is just the discrepancy between the occurrence of the microbic cause in sporadic cases of potentially epidemic diseases and the absence of true epidemics that has led to the formulation of the hypothesis of concomitant causes of v. Pettenkofer and of Naegeli. While the one supposes a necessary ripening of the microbic agent in the earth as a pre-requisite, the other invokes the co-operation of a second, though unknown, but subsidiary, microorganism. The subject has not been rendered essentially more comprehensible by the discovery of the healthy and chronic carriers of infectious micro-organisms or by the mere ready detection of so-called abortive cases of infection. Indeed these discoveries only add to the perplexity, since they prove that potentially infective micro-organisms capable of starting epidemics are more frequently present in our surroundings than has hitherto been supposed." Anthrax. Anthrax in human beings is of very rare occurrence in London, as will be noted in the subjoined statement, which shows the number of cases which have occurred since the disease was made compulsorily notifiable in London by order of the Council, 6th April, 1909:— 1909 9 1910 6 1911 6 1912 2 1913 3 During 1914 three cases were notified in London; in only two was the diagnosis confirmed. In one case the patient lived in Southwark and was employed as a phosphor bronze moulder. On 9th October he was admitted to Guy's Hospital suffering from a phosphor bronze splinter wound on the eyelid; an operation Was performed on the following day and the patient died on the 14th October. An inquest was held and evidence at the post-mortem examination indicated that the case was one of anthrax. The disease was not traced to the injury to the eye. Investigations into the source of infection were made, and it was ascertained that the patient's wife was a brush-maker working at home, and that white and black hair from Russia and China was used in the manufacture of the brushes; the infection was attributed to this source. In the other case the patient was a pensioned soldier and was employed at the East India Dock. At the end of December, 1913, he was engaged in unloading hides from a steamer. He was then said to have had a pimple on his right cheek, which he scratched. On 31st December, 1913, his face became very swollen and he consulted a doctor, who subsequently advised him to go to hospital. He was admitted on 6th January, 1914, and was thereupon recognised to be suffering from anthrax. The patient eventually recovered. It may be of interest to record a small outbreak of anthrax in the County Borough of Croydon in December, 1914, which concerned London, inasmuch as two of the patients were admitted into Guy's Hospital. On 21st December an inquest was opened in the Southwark Coroner's Court into the circumstances attending the death of a man (C. T.), aged 46 years, who lived at Mitcham and who had been admitted to Guy's Hospital on the 15th December, where he died two days later. At the adjourned inquest on the 7th January, 1915, it was found that death was due to external anthrax. Enquiries were made, and the following facts are available owing to the courtesy of Dr. Veitch Clark, Medical Officer of Health of the County Borough of Croydon. A small outbreak, in which five persons and a horse were infected, was brought to light in connection with a firm of wholesale meat vendors in Croydon. On 12th December, this firm's head slaughterman was found to have a swelling on the jaw. Bacteriological examinations were conducted on 14th and 15th December with negative result. The patient was then removed to Croydon General Hospital, where as a result of further bacteriological examination the bacillus of anthrax.was discovered. The man died on the 15th December. A junior clerk employed by the firm became seriously ill on the 13th December, and wa6 seen by a doctor on the following day, when he was at once removed to Guy's Hospital suffering from anthrax. He was probably infected on the 11th or 12th December. After admission to Guy's Hospital favourable progress was made under treats merit, and the natient, recovered. 39 Report of the County Medical Officer—General. The remaining three human cases arose in two shops, one in Mitcham and the other in Croydon, supplied by the wholesale firm and owned by a local butcher. On the 12th December the manager of the Mitcham shop (C. T., referred to above) noticed a small pustule on his neck ; he had a headache during the day. On the 14th December he became worse, vomited, and his neck became more swollen. After consulting a doctor the patient was removed to Guy's Hospital on the 15th December, where the ulcer was excised and the patient received an injection of serum. Death ensued on the 17th December. As stated previously, an autopsy showed that death was due to anthrax. The fourth person infected was the son of the proprietor of the shop in Mitcham, who supervised the management of the business. He saw the manager (C. T.) during the latter's illness, prior to his removal to hospital, and examined the pustule. A few days later (17th December) the proprietor's son developed a pustule which was found to be due to anthrax ; he fortunately recovered. The fifth human case occurred in the person of one of the employees at another branch of the butcher's shop in Croydon. He developed anthrax on the 17th December and recovered under specific treatment. On the 17th December a horse in the yard behind the wholesale shop in Croydon died from anthrax. The firm to which the animal belonged had engaged to supply horses to remove carcases from the wholesale to the retail shops, and actually did so during the week ended 12th December. Exhaustive enquiries were made by Dr. Veitch Clark, Medical Officer of Health of Croydon, but the cause of the original infection could not be traced. As stated in last year's annual report a Committee, appointed by the Home Secretary, has been enquiring into the dangers of infection from anthrax in connection with sorting, willeying, washing, combing, and carding wool, goat hair and camel hair and in processes incidental thereto. The Committee had not reported at the end of 1914. Glanders. Glanders in human beings was made a notifiable disease under the Public Health (London) Act, 1891, by order of the Council on 6th April, 1909. No cases of human glanders were notified during 1914 and there is nothing to add to the remarks with reference to this disease which appear in the Annual Report for 1913. Plague and Cholera. No cases of plague or cholera have occurred in London in 1914. Pemphigus Neonatorum. It is the practice of the Inspectors under the Midwives Act to visit all cases of this disease brought to their notice as it is now recognised that it is very infectious, and cases may prove fatal if not properly and satisfactorily treated. During the year 29 cases came under notice; of these 3 died. In the majority of cases the onset of the illness occurred within the first week after birth, the duration of the disease being from two to eight weeks. It has not always been possible to obtain material for bacteriological examination, but in the six instances in which this was done gonococci were found in one and staphylococci in five. Meteorology. The tables published in the Annual Summary of the Registrar-General, deduced from observations at Greenwich under the superintendence of the Astronomer Royal, show that the mean temperature of the air in 1914 was 51.5 deg. Fahrenheit, which is 2.0 degrees above the average of the preceding 70 years. The rainfall during the year amounted to 23.85 inches, being 0.27 inches below the average of the preceding 65 years The temperature and rainfall in each month of the year 1911 re shown in the following table:— Month. Temperature of the air. Departure of mean monthly Rain and other forms of precipitation. Departure of mean monthlyrainfall from average of preceding 65 years. Absolute maximum. Absolute minimum. Mean for the mouth. temperature from average of preceding 70 years. Number of days it fell. Amount collected. deg. F. deg. F. deg. F. deg. F. Inches. Inches. January 55 20 38.4 —0.2 10 0.50 —1.38 February 59 29 44.9 +5.4 10 2.46 +0.98 March 65 28 44.2 + 2.4 27 3.91 + 2.39 April 74 32 50.5 +3.4 11 1.11 —0.46 May 83 38 53.7 +0.7 9 1.63 —0.29 June 88 40 60.4 +1.2 11 1.34 — 0.70 July 92 45 64.2 + 1.8 17 1.41 -0.99 August 84 40 64.0 +2.5 11 1.17 —1.17 September 82 34 58.3 + 1.2 9 0.73 —1.42 October 69 35 52.0 + 1.9 11 0.96 —1.82 November 62 29 45.5 +2.0 18 2.67 +0.45 December 56 27 42.1 + 2.1 24 5.96 + 4.13 40 Annual Report of the London County Council, 1914. Table I. COUNTY OF LONDON. Vital statistics for the decennia 1851-1860 to 1901-1910 and for the years 1905 to 1914. (Marriage- birth- and mortality-rates per 1,000 living). Period. Persons married. Births. Deaths. Tnfant Mortality. Small-pox. Measles. Scarlet lever. Diphtheria. Whooping Cough. Typhus. Typhoid Fever. Erysipelas. Puerperal Fever. Phthisis. Cancer. Per 1,000 living. Minors, per cent, of total. Per 1,000 living. Per 1.000 aged 0-5. Per 1,000 living. Per 1000 aged 0-5. Per 1,000 living. Per-1,000 births. Males. Females. 1851-1860 20.6 2.8 11.9 33.6 23.7 155 0.280 0.53 3.89 .. .. 0.88 6.56 .. .. .. .. .. 2.86 0.42 1861-1870 20.3 3.6 14.6 35.4 24.4 162 0.276 0.58 4.18 1.13 0.18 0.88 6.53 .. .. .. .. .. 2.84 0.48 1871-1880 19.1 4.7 16.9 35.4 22.5 158 0.457 0.51 3.65 0.60 0.12 0.81 6.02 0055 0.24 .. .. .. 2.51 0.55 1881-1890 17.6 5.5 18.9 33.2 20.3 152 0.142 0.64 4.74 0.33 0.26 0.69 5.34 0.008 0.19 .. .. .. 2.08 0.68 1891-1900 17.8 4.7 16.5 30.2 19.2 159 0.009 0.58 4.82 0.19 0.49 0.50 4.21 0.001 0.14 0.05 0.05 1.73 1.79 0.85 1901-1910 17.5 3.5 12.7 27.5 15.7 126 0.035 0.44 3.92 0.10 0.17 0.32 2.95 0.000 0.06 0.04 0.04 1.40 1.49 0.98 1905 17.5 3.6 13.0 27.9 15.6 130 0.002 0.38 3.38 0.12 0.12 0.33 3.01 - 0.05 0.05 0.04 1.45 1.45 0.96 1906 17.9 3.5 12.9 27.6 15.8 131 — 0.42 3.83 0.12 0.15 0.27 2.47 - 0.06 0.05 0.04 1.50 1.50 1.01 1907 17.9 3.2 11.8 26.9 15.3 116 — 0.40 3.58 0.14 0.17 0.40 3.64 - 0.04 0.04 0.03 1.25 1.46 0.99 1908 16.9 2.9 11.3 26.7 14.6 113 — 0.33 3.00 0.12 0.16 0.21 2.00 - 0.05 0.03 0.03 1.11 1.39 1.02 1909 16.9 3.1 11.1 25.8 15.0 108 0.000 0.51 4.73 0.08 0.13 0.28 2.56 - 0.03 0.04 0.04 1.54 1.40 1.04 1910 17.3 2.9 10.8 25.5 13.7 103 - 0.44 4.00 0.05 0.10 0.30 2.83 - 0.04 0.03 0.04 1.40 1.25 1.03 1911 17.8 3.1 10.9 24.8 15.0 129 0.002 0.57 5.18 0.04 0.14 0.23 2.15 - 0.03 0.04 0.03 1.27 1.35 1.05 1912 18.6 3.1 11.2 24.5 13.6 91 0.000 0.40 3.68 0.04 0.10 0.21 2.02. - 0.03 0.03 0.04 1.44 1.35 1.11 1913 18.3 3.3 11.8 24.5 14.2 105 — 0.34 3.08 0.04 0.09 0.17 1.63 - 0.02 0.03 0.03 1.23 1.30 1.13 1914 19.2 3.4 11.4 24.3 14.4 104 — 0.31 2.82 0.07 0.16 0.20 1.92 - 0.03 0.05 0.04 1.68 1.39 1.18 Note (1)—The marriage-rates are calculated upon the number of marriages registered in London, irrespective of the locality in which the persons married were usually resident. Note (2)—(a) The birth-rates and death-rates are calculated, so far as concerns the'' years 1011-1914, upon the births and deaths in Greater London, which have been allocated to London by the Registrar-General. (6) From 1891 to 1910, inclusive, this correction was applied only to births and deaths in institutions; and in respect of deaths from measles and whooping cough of children under five years of age, and deaths from erysipelas, puerperal fever, cancer and all causes not shown in this table, the correction was further limited to deaths occurring in administrative institutions, (c) Prior to 1891, no correction was made, the rates shown being calculated upon the births and deaths registered in London. 41 Report of the Count)/ Medical Officer—General. Table II. COUNTY OF LONDON. Incidence of the principal notifiable infectious diseases during the period 1891-1914. (Cases notified per 1,000 living and mortality rates per 100 cases). Period. Small-pox. Cases per 1,000 living. Scarlet Fever. Diphtheria. Typhoid Fevei. Erysipelas. Cases per 1,000 living. Puerperal Fever. Cases per 1,000 births. Cases per 1,000 living. Deaths per 100 cases. Cases per 1,000 living. Deaths per 100 cases. Cases per 1,000 living. Deaths per 100 cases. 1891-1900 0.138 4.8 3.8 2.6 18.8 0.8 17.4 1.39 2.10 1901.1910 0.229 3.9 2.7 1.8 9.3 0.4 15.3 1.02 2.18 1901 0.375 4.1 3.2 2.7 10.9 0.7 15.6 1.02 1.94 1902 1.683 4.0 3.1 2.3 10.8 0.7 15.8 1.20 2.35 1903 0.091 2.8 2.9 1.7 9.6 0.5 15.7 0.97 1.79 1904 0.107 3.0 2.7 1.6 10.0 0.4 15.1 1.09 2.12 1905 0.016 4.3 2.8 1.4 8.4 0.3 15.1 1.10 2.32 1906 0.007 4.5 2.6 1.8 8.6 0.4 16.3 1.11 2.39 1907 0.002 5.7 2.5 1.9 8.9 0.3 13.9 1.00 2.09 1908 0.001 4.8 2.5 1.7 9.0 0.3 16.6 0.91 1.86 1909 0.005 3.8 2.2 1.5 9.1 0.2 14.0 0.93 2.46 1910 0.002 2.3 2.0 1.2 7.9 0.3 15.3 0.88 2.53 1911 0.016 2.3 1.6 1.6 8.3 0.2 14.1 1.07 2.70 1912 0.001 2.5 1.4 1.6 6.4 0.2 16.6 0.91 3.44 1913 0.001 3.8 1.1 1.7 5.6 0.2 15.0 0.90 3.10 1914 0.000 5.6 1.3 2.0 7.7 0.2 18.8 1.11 3.58 42 Annual Report of the London County Council, 1914. Table III. Vital statistics for the County of London in 1909-1913 and 1914, and the corresponding statistics for Greater London and large towns of England and Wales. (Birth- and mortality- rates per 1,000 living.) Town. Births. Deaths. Infant Mortality. Small-pox. Measles. Scarlet Fever. Diphtheria. Whooping-cough. Diarrhea deaths age 0-2 per 1000 births 1914. 1909-13. 1914. 1909-13. 1914. 1909-13. 1914. 1909-13. 1914. 1909-13. 1914. 1909-13. 1914. 1909-13. 1914. 1909-13. 1914. London 25.0 24.3 14.3 14.4 107 104 0.00 — 0.45 0.31 0.05 0.07 0.11 0.16 0.24 0.20 27.64 Greater London 24.6 23.7 13.0 13.0 101 95 0.00 — 0.38 0.23 0.04 0.06 0.11 0.15 0.22 0.19 23.67 Liverpool 30.6 30.4 18.8 19.5 139 139 0.00 — 0.65 0.68 0.17 0.16 0.14 0.14 0.38 0.33 40.62 Manchester 26.6 25.9 16.6 16.7 133 127 0.00 0.51 0.41 0.13 0.22 0.14 0.14 0.31 0.39 26.85 Birmingham 27.7 27.1 15.4 15.0 134 122 0.00 — 0.55 0.36 0.17 0.16 0.14 0.30 0.29 0.35 27.46 Sheffield 28.3 27.5 15.2 16.4 124 132 0.00 — 0.82 0.79 0.09 0.18 0.10 0.14 0.24 0.49 31.55 Leeds 24.0 23.6 15.3 14.9 129 123 — 0.26 0.47 0.07 0.06 0.20 0.12 0.24 0.30 26.61 Bristol 22.6 21.6 13.4 13.4 106 100 0.01 0.27 0.26 0.03 0.06 0.12 0.10 0.21 0.19 15.94 West Ham 30.3 30.4 14.7 14.9 115 106 0.59 0.44 0.08 0.04 0.14 0.17 0.36 0.38 26.30 Bradford 19.3 19.7 14.7 15.6 121 123 — 0.18 0.40 0.04 0.02 0.17 0.12 0.15 0.32 14.55 Hull 28.7 27.7 15.3 15.4 127 121 0.00 — 0.38 0.34 0.03 0.02 0.13 0.17 0.23 0.18 32.29 Newcastle-on-Tyne 27.7 27.9 15.2 17.1 120 136 0.00 — 0.41 0.79 0.09 0.16 0.14 0.09 0.31 0.28 31.46 Nottingham 24.6 23.4 15.2 15.3 137 145 0.00 — 0.36 0.55 0.06 0.05 0.12 0.13 0.21 0.23 29.07 Stoke-on-Trent 32.0 32.0 18.1 17.6 163 144 — 0.59 0.35 0.17 0.00 0.34 0.33 0.36 0.36 4315 Portsmouth 24.9 23.7 13.2 12.7 100 85 0.27 0.16 0.10 0.02 0.35 0.32 0.16 0.20 12.43 Salford 27.6 26.7 16.8 16.6 137 125 0.64 0.48 0.15 0.33 0.24 0.16 0.30 0.33 26.46 Leicester 23.0 22.0 13.3 13.9 123 120 — — 0.28 0.44 0.05 0.02 0.22 0.07 0.18 0.32 21.48 43 Report of the County Medical Officer—General. B—Administration. Dairies, Cowsheds and Milkshops. The Council received during the year 108 applications for cowhouse licences, 164 of which were granted. The numbers of applications for licences received during the last twenty-one years and the numbers granted are shown in the following table. It will be seen that the number of these premises in London is continually decreasing. Year. No. of applications received. No. of premises for which licences were granted. Year. No. of applications received. No. of premises for which licences were granted. 1894 456 446 1905 257 255 1895 427 416 1906 244 240 1890 405 393 1907 234 233 1897 379 374 1908 229 225 1898 357 354 1909 216 214 1899 338 330 1910 203 199 1901 323 321 1911 194 187 1901 306 295 1912 180 180 1902 294 291 1913 174 171 1903 282 277 1914 168 164 1904 266 259 Cowshed premises. In 1903 effort was made, in conjunction with the medical officers of health of metropolitan boroughs, to secure uniform statistical statement of the proceedings of the local authorities in London. Tables showing these proceedings included in this report have therefore, in the main, been compiled from tabular statements in the annual reports of medical officers of health, but in some cases it has been necessary to use figures otherwise appearing in their reports. The following table relating to cowsheds has been thus prepared:— Metropolitan borough. Number of cowshed premises. Number of inspections by the sanitary authority, 1914.- Number of prosecutions by sanitary authoritv, 1914." On register at end of 1913. Added in 1914. Removed in 1914. On register at end of 1914. Battersea 2 — 2 Frequent. — Bermondsey 1 — — 1 5 — Bethnal Green 13 — — 13 60 — Camberwell 9 — — 9 102 — Chelsea 1 — 1 — 6 — Deptford 2 — — 2 33 — Finsbury 3 — 1 2 3 — Greenwich 4 — — 4 22 — Hackney 14 — — 14 198 — Islington 4 — — 4 56 — Kensington 1 — — 1 42 — Lambeth 11 — 1 10 22 — Lewisham 13 — 2 11 142 — Paddington 1 — — 1 4 — Poplar 12 — 1 11 44 — St. Marylebonc 5 — — 5 38 — St. Pancras 5 — — 5 61 — Shoreditch 7 — 1 6 57 — Southwark 3 — — 3 33 — Stepney 31 — — 31 48 — Stoke Newington 1 — — 1 2 — Wandsworth 11 — — 11 45 — Westminster, City of .. 1 — — 1 23 — Woolwich 16 — — 16 35 — Totals for 24 districts 171 — 7 164 — — Inspection of cowshed premises. Section 5 of the London County Council (General Powers) Act, 1908, gives power to local sanitary authorities to remove from the register or to refuse to register the name of any person carrying on or proposing to carry on the trade of a dairyman or purveyor of milk upon premises which are in the opinion of the sanitary authority unsuitable for the purpose. These powers have been much used, with the result that the sale of milk in small general shops has materially decreased in recent years. The following table shows the number of milkshop premises at the end of 1913 and 1914 in the 27715 G 2 Milkshops. 44 Annual Report of the London County Council, 1914. metropolitan boroughs of London, the number of inspections and the proceedings taken. The table has mainly been compiled from information contained in the annual reports: — Metropolitan borough. Number of premises. (a) Number of inspections, 1914. Number of prosecutions, 1914. On register at end of 1913. Added in 1914. Removed in 1914. On register at end of 1914. City of London 640 30 31 639 - - Battersea 162 24 23 163 545 Bermondsey 254 41 62 233 824 — Bethnal Green 244 12 10 246 807 2 Camberwell 620 17 15 622 1,362 — Chelsea 105 11 9 107 150 1 Deptford 214 39 34 219 412 — Finsbury 184 — — 184 189 — Fulham 206 6 25 187 540 — Greenwich 160 5 7 158 208 — Hackney 315 14 11 318 1,580 — Hammersmith 338 22 58 302 726 2 Hampstead 102 — 4 98 395 — Holborn 188 10 9 189 664 — Islington 560 42 17 585 1,198 — Kensington 201 7 7 201 1,089 — Lambeth 198 20 3 215 1,290 — Lewisham 166 1 19 148 292 — Paddington 123 6 10 119 164 3 Poplar 336 6 8 334 1,225 — St. Marylebone 229 11 3 237 580 — St. Pancras 389 40 188 241 984 — Shoreditch 290 23 20 293 2,741 — Southwark 489 75 59 505 1,306 — Stepney 601 27 39 589 1,904 2 Stoke Newington 58 7 2 63 93 — Wandsworth 381 48 32 397 783 — Westminster 456 33 20 469 1,015 — Woolwich 116 6 13 109 174 — Totals 6,633 1,187(a) - - 6,959 (a)l,22l - -- Indirection of milkshop premises. Tuberculosis of the udder in London cows. London County Council (General Powers) Act, 1904(Part V.) Cows kept in London cowsheds have been inspected since February, 1899, by a veterinary inspector appointed by the Council under the Dairies, Cowsheds and Milkshops Order of 1899. Under this order, the use of milk for human consumption from cows certified by a veterinary surgeon to be suffering from tuberculosis of the udder is prohibited. In 1904 this power was supplemented in London by additional • powers, incorporated in the London County Council (General Powers) Act of that year, for the removal of any cow from any dairy, farm or cowshed in the county (elsewhere than in the City), if suspected to i be suffering from tuberculosis of the. udder, and if, upon slaughter, these suspicions were verified, a sum equal to three-quarters of the agreed value of the animal (not exceeding £22 10s.) became payable to the owner by the Council. If the cow proved to be free from tuberculosis of the udder, the full agreed value (not exceeding £30), together with a further sum of £1, became payable by the Council. Further powers were conferred upon the Council by the Tuberculosis Order of 1913, which came into operation on 1st May, 1913. Under this order the Council was required not only to deal with cows affected with tuberculosis of the udder, but also with cows giving tuberculous milk, or suffering from induration or other chronic disease of the udder, and with all bovine animals suffering from tuberculosis with emaciation. The veterinary inspector was empowered, with the owner's consent, to apply the tuberculin test in cases where the evidence of disease obtained by clinical methods was not conclusive. All persons having in their possession or under their charge animals which appeared to come within the purview of the order, including animals exposed for sale in markets or saleyards, and all veterinary surgeons detecting such cases in the course of their practice, were required to notify the cases to the Council, and it was the duty of the Council to arrange for the veterinary examination of such animals, and, if affected with tuberculosis in any of the forms specified in the order, the animal had to be valued on two bases (i.) on the basis that the animal was not affected with tuberculosis, and (ii.) on the basis that it was so affected. The Council had then to slaughter the animal and conduct a post mortem examination. Should the post mortem examination reveal the presence of tuberculosis in an advanced stage, only one quarter of the valuation (as a tuberculous animal) was payable to the owner as compensation ; if the disease was found not advanced, three-quarters of the valuation of the animal (as a tuberculous animal) was payable ; (rt) Figures in italics refer to persons registered. t The milkshou premisos are being re-registered under new regulations. 45 Report of the County Medical Officer—General. if the animal was not affected with tuberculosis in any of the forms specified in the order the owner Was entitled to the full value of the animal plus £1. The carcases and hides became the property of the Council, and any amount realised by their sale was paid into the County Fund. One-half of the compensation, after deducting salvage receipts, was refunded to the Council by the Treasury. Articles were also inserted in the Order dealing with the restriction of the use of milk, and the isolation of suspected animals, together with the disinfection of the cowshed in which the affected animal was discovered. Although the provisions in the L.C.C. (General Powers) Act, 1904, already referred to were not repealed by the Tuberculosis Order of 1913, the Council proceeded in respect of the seizure of animals and compensation under the Tuberculosis Order of 1913. The experience of the working of the Tuberculosis Order of 1913 indicated that there was considerable difficulty in assessing the valuation of the animals on the dual basis provided by the Order, and further than it was desirable that the scope of the Order should be extended so as to include additional forms of tuberculosis. Complaint had also been made as to the expense of administration borne by local authorities, which was not covered by the Government grant. To meet these difficulties the new Order provided (1) that there should be one basis of valuation, viz., the market value of the animal at the time of seizure (2) that the Order should be extended so as to include within its scope animals suffering from chronic cough and showing definite signs of tuberculosis; (3) that local authorities should be refunded three-quarters of the gross compensation instead of one half of the net compensation, i.e., three-quarters of the amount paid without any deduction in respect of the proceeds of the sale of the carcase. Certain other modifications of a minor character which were considered advisable to ensure the smooth working of the Order were made. The Order of 1913 was cancelled by this new Order, but owing to the war the Order of 1914 was suspended as from 6th August, 1914. During the year 1914, there were five inspections of the cows kept in London cowsheds and the results of the examinations of the veterinary inspector at these routine inspections are given in the subjoined table:— Details of Examination. 1st Period. 2nd Period. 3rd Period. 4th Period. 6th Period. 29th Jan., to 20th March. 21st March to 20th June. 2l8t June to 3rd Sept. 4th Sept. to 24th Oct. 25th Oct. to 26th Dec. No. cowsheds visited 170 171 169 171 168 „ revisited 7 10 7 7 7 No. special visits under Tuberculosis Orders of 1913 and 1914 15 42 23 nil* nil* No. of cows examined 2,676 2,713 2,720 2,719 2,696 No. of cows re-examined 263 239 178 249 137 No. with healthy udders 2,613 2,653 2,673 2,676 2,653 No. suffering from tuberculosis of the udder 5 9 3 1 2 suspicious No. suffering from tuberculosis with emaciation 1 1 1 nil nil No. with acute mastitis 6 7 9 9 8 No. with chronic induration or hypertrophy 32 28 15 9 9 No. with atrophy of udder 16 11 19 22 18 No. with injury to, or eruptions on, teats or udders 4 5 1 2 6 From 29th January to the suspension of the Tuberculosis Order of 1914 on 6th August, 1914, 21 animals were seized and slaughtered under the orders, and on post-mortem examination 13 were found to be suffering from tuberculosis in an advanced form, while in the remaining 8 cases the disease was not advanced within the meaning of the Order. Since the suspension of the Order the veterinary inspector has found 3 cases presenting symptoms suspicious of tuberculosis of the udder and 13 cases presenting symptoms of pulmonary tuberculosis. The cows presenting symptoms of tuberculosis of the udder, and 7 of the cows suspected to be suffering from pulmonary tuberculosis were slaughtered by the owners. There was no power to deal with the remaining 6 animals. The services of the veterinary inspector were also utilised for the purpose of ensuring that cows purchased as milch cows for industrial schools were free from tuberculosis. Four cows were purchased for Mayford Industrial school and 3 for Portsladc, in each case after the submission of the animal to a tuberculin test by the veterinary inspector. Part IV. of the London County Council "(General Powers) Act of 1907 empowers the County Medical Officer of Health or other duly authorised person to take, within and without the County, samples of milk produced or sold or intended for sale within the County ; and, having obtained a justice's order, in company with a veterinary surgeon, to enter any dairy from which milk is being sold or suffered to be sold or used within the County, and to inspect the cows kept therein, and if the Medical Officer or such authorised person has reason to suspect that any cow is suffering from tuberculosis of the udder he may take samples of the milk of such cow. If it appears to the Council that tuberculosis is caused, or is likely to be caused, to persons residing in the County from the consumption Tuberculous milk; London County Council (General Powers) Aot, 1907, Part IV. * Order suspended on account of the war. 46 Annual Report of the London County Council, 1914. of milk from any dairy, or from any cow kept therein, the Council may make an order prohibiting the supply of such milk in the County until the order has been withdrawn, and any person contravening the order is liable to a penalty not exceeding £5, and for a continuing offence to a daily penalty not exceeding 40s. Appeal may be made against the Council's order. On 11th February, 1908, the Council delegated to the Public Health Committee the authority conferred by Part IV. of this Act, dealing with tuberculous milk, and fixed the 1st July, 1908, as the date upon which the Act should become operative. The method of procedure adopted is as follows : samples are taken by the Council's inspectors from churns of milk consigned from the country to the various London railway termini, and these are submitted to the Lister Institute for bacteriological examination. In the case of those samples in respect of which the examination proves that there is evidence of the presence of tubercle bacilli, a clinical examination of the cows at the dairy farm from which the milk is consigned is made by a veterinary inspector appointed for the purpose under the Act, and cows found to have tuberculous udders are certified for the purpose of the Dairies and Cowsheds Orders and copies of the certificates are forwarded to the local sanitary authorities concerned. During the year 1914, 2,925 samples of milk were taken. The milk had been sent to London from the following counties: Bedfordshire, Berkshire, Buckinghamshire, Cambridgeshire, Cheshire, Derbyshire, Devonshire, Dorsetshire, Essex, Gloucestershire, Hampshire, Herefordshire, Hertfordshire, Huntingdonshire, Kent, Leicestershire, Lincolnshire, Middlesex, Norfolk, Northamptonshire, Nottinghamshire, Oxfordshire, Rutlandshire, Shropshire, Somersetshire, Staffordshire, Surrey, Sussex, Warwickshire, Wiltshire and Worcestershire, and from Wales; the samples were taken principally from churns at stations of the Great Western, the Great Eastern, the Great Northern, the Great Central, the Midland, the London Brighton and South Coast, the London and North-Western, the London and South-Western and the South-Eastern Chatham and Dover Railway Companies. The following table shows the number of samples taken during the year under review, the counties from which they were despatched, and the results of bacteriological examination at the Lister Institute. County. No. of samples taken from churns for examination. No. of samples found to be tuberculous. No. of samples found not to be tuberculous. No. of samples the examination of which was not completed owing to accident and other causes. Bedfordshire 53 2 51 - Berkshire 196 16 179 1 Buckinghamshire 118 6 109 3 Cambridgeshire 10 — 9 1 Cheshire 17 2 13 2 Derbyshire 308 38 263 7 Devonshire 6 1 5 — Dorsetshire 56 4 50 2 Essex 101 9 92 — Gloucestershire 79 2 76 1 Hampshire 121 12 107 2 Herefordshire 1 1 — — Hertfordshire 55 6 48 1 Huntingdonshire 5 - 4 1 Kent 19 2 17 — Leicestershire 358 22 323 13 Lincolnshire 20 . 20 Middlesex 5 - 5 — Norfolk 1 - 1 — Northamptonshire 224 8 208 8 Nottinghamshire 11 1 11 2 Oxfordshire 123 2 118 3 Rutlandshire 10 - 10 — Shropshire 25 5 20 — Somersetshire 133 13 117 3 Staffordshire 290 38 228. 24 Surrey 38 — 38 — Sussex 132 12 118 2 Wales 1 1 — Warwickshire 82 4 69 9 Wiltshire 321 18 302 1 Worcestershire 2 2 — Not stated 1 — 1 — Total 2,925 224 2,615 86 This table shows that out of 2,839 completed examinations of samples taken from churns consigned to London, 224 proved to be tuberculous, i.e., 7.9 per cent. Some of the samples were 47 Report of the County Medical Officer—General. derived from churns containing milk from more than one farm. The last annual report gave a similar account of 2,779 samples of milk examined during the year 1913, of which 277, or 9.9 per cent., were found to be tuberculous. Farms inspected in English counties. The following table shows the number of farms visited, the number of cows inspected and the results of the inspections:— County. No. of farms inspected. No. of cows inspected. Result of inspection. Bedfordshire 2 54 Berkshire 15 454 7 cows slaughtered under Tuberculosis Orders; 1 cow unhealthy. Buckinghamshire 5 191 — Cambridgeshire 1 25 — Cheshire 2 145 — Derbyshire 51 1,370 9 cows slaughtered; 3 cows tuberculosis of lungs ; 1 cow indurated udder; 3 cows unhealthy.. Devonshire 1 15 1 cow generalised tuberculosis. Dorsetshire 3 95 — Essex 9 372 2 cows slaughtered under Tuberculosis Orders; 1 cow generalised tuberculosis ; 1 cow suspected tuberculosis of lungs. Gloucestershire 2 106 1 cow slaughtered under Tuberculosis Orders. Hampshire 13 570 1 cow tuberculosis with emaciation ; 2 cows with generalisec tuberculosis ; 1 cow indurated udder. Herefordshire 1 18 — Hertfordshire 10 371 1 cow slaughtered under Tuberculosis Orders; 1 cow indurated udder ; 2 cows unhealthy. Kent 2 67 2 cows indurated udder. Leicestershire 25 495 1 cow slaughtered ; 1 cow generalised tuberculosis ; 1 cow indurated udder. Northamptonshire 12 541 1 cow with suspected tuberculosis of udder. Nottinghamshire 1 20 Oxfordshire 2 77 . i Shropshire 2 52 1 cow tuberculosis with emaciation. Somersetshire 47 964 1 cow with generalised tuberculosis. ♦Staffordshire 41 1,173 1 cow slaughtered ; 1 cow tuberculosis with emaciation 4 cows general tuberculosis ; 1 cow suspected tuberculosis of lung; 4 cows' udders deemed to be tuberculous 3 cows with indurated udders ; 2 cows unhealthy. ♦Sussex 13 462 3 cows slaughtered under Tuberculosis Orders ; 2 cows generalised tuberculosis ; 1 cow indurated udder. Warwickshire 2 66 Wiltshire 92 2,406 3 cows slaughtered under Tuberculosis Orders; 1 cow generalised tuberculosis ; 3 cows indurated udders. Total 354 10,109 76 cows with disease or unhealthy conditions. In 34 cases the infected milk could not be detected owing to the names of the farmers not being on the churns ; in 76 cases it was found that cows had been slaughtered, and in one instance had died, in the interval between the taking of the milk sample at the London terminus and the date of the visit to the farm concerned. During the time the Tuberculosis Orders of 1913 and 1914 were in operation it was the practice to notify the county council concerned of all cases presenting symptoms suggestive of tuberculosis in one of the forms specified under the Order, although the clinical signs were insufficient to enable the Council's veterinary inspector definitely to certify the cases. In several instances this action has led to the slaughter of animals suspected of giving tuberculous milk. Owing to the suspension of these orders in consequence of the war the Council has been limited to the exercise of its powers under the General Powers Act of 1907. As a result of the visits made to farms, 28 cows were slaughtered under the Tuberculosis Orders in the first two quarters of the year and 36 were slaughtered voluntarily by the owners in the last two quarters of the year. For some years the question of further legislation in connection with the control of the milk supply has engaged the attention of Parliament, and on 10th August, 1914, the Roval Assent was given to an Act known as the Milk and Dairies Act, 1914, but its effect on the existing powers of the Council will be largely dependent upon orders to be issued by the Local Government Board under section 2 of the Act. Owing, however, to the war the operation of the Act has been suspended and no orders have yet. been issued by the Local Government Board. * In the cases indicated by an asterisk some of the infected milk from farms in these counties was dispatched from a station in an adjoining county. 48 Annual Report of the London County Council, 1914. Slaughter houses. Offensive Businesses. In the year 1914 the County Council received 213 applications for licences for slaughter-houses and granted 210. The following table shows the numbers of applications received and the numbers of slaughter-houses licensed in recent years. It will be seen that the numbers of these premises is continually decreasing •:— Year. No. of applications received. No. of premises for which licences were granted. Year. No. of applications received. No. of premises for which licences were granted. 1892 543 537 1904 338 333 1893 538 529 1905 322 318 1894 518 506 1906 310 308 1895 497 485 1907 301 294 1896 478 470 1908 281 273 1897 460 460 1909 265 264 189S 442 429 1910 257 255 1899 419 411 1911 247 243 1900 405 393 1912 235 234 1901 384 381 1913 226 223 1902 371 362 1914 213 210 1903 350 346 Inspection of slaughter houses, The number of slaughter-houses in each metropolitan borough (other than those under the jurisdiction of the City Corporation) and the frequency with which these slaughter-houses were inspected, is shown in the following table :— Metropolitan borough. Number of slaughter-houses (a). No. of inspections, 1914. No. of notices, 1914. Licensed at end of 1913. Licence lapsed or refused in 1914. Remaining at end of 1914. Battersea 3 — 3 451 Bermondsey 1 — 1 22 Bethnal Green 4 1 3 4 Camberwell 11 1 10 93 — Chelsea 5 1 4 36 Deptford 2 2 23 Finsbury 2 2 5 Fulham 3 1 2 36 Greenwich 4 4 19 Hackney 20 20 323 Hammersmith 8 1 7 143 11 Hampstead 4 — 4 43 — Holborn 1 — 1 10 Islington 28 1 27 1,529 — Kensington 10 — 10 233 1 Lambeth 17 — 17 204 5 Lewisham 13 — 13 167 Paddington 7 — 7 380 Poplar 14 — 14 69 fit. Marylebone 6 2 4 50 St. Pancras 15 2 13 440 ' , X Shoreditch 5 5 30 Southwsrk 6 G 106 3 Stepney 4 4 11 2 Stoke Newington 4 4 15 Wandsworth 14 1. 13 366 1 Woolwich 12 2 10 40 3 . Totals, 27 districts .. 223 13 210 4,848 27 Offensive businesses. The number of authorised offensive businesses, except those in the markets under the jurisdiction of the City Corporation, at the end of the year was as follows :— Fat meltcrs 15 Manure manufacturers 2 Tripe boilers 20 Soap boilers 9 Glue and size manufacturers 5 Tallow melter3 4 Knackers 4 Gut manufacturers 3 Fellmongers 6 — Bone boil. r3 .. 2 70 In several instances more than one offensive business is carried on at the same premises. (a) The seven slaughter-houses under the jurisdiction of the City of London Corporation are not licensed by theLondon County Council. 49 Report of the County Medical Officer—General. Inspection of offensive trade premises. The boroughs in which these premises are situated, the number of premises, and, for most boroughs, the number of inspections, are shown in the following table:— Metropolitan borough. No. on Register at end of 1914. No. of inspections, 1911, Metropolitan borough. No. on Register at end of 1914. No. of inspections 1914. Battersea 2 12 Lambeth 3 72 Bermondsey 12 250 Poplar 6 Bethnal Green 1 1 St. Marylebone 2 45 Camberwell 4 6 St. Pancras 2 2 Deptford 4 23 Shoreditch 1 1 Finsbury 1 10 Southwark 4 54 Greenwich 3 4 Stepney 7 27 Hackney 1 15 Wandsworth 3 91 Isiington 6 95 Nuisances from stable manure. Nuisances. There are few references in any of the reports to nuisance arising from accumulations of stable manure. This fact has been observed every year since 1909. There is little doubt that the more rigid enforcement of the bylaws and the obvious reduction in the number of horse-drawn vehicles have together combined materially to reduce nuisance from this cause. It must not be overlooked, however, that the removal of small accumulations of manure will probably become a matter of increasing difficulty, inasmuch as contractors will not find it sufficiently remunerative to undertake collection. Inasmuch as stable refuse is the natural breeding place of flies, with their associated evils, the question is deserving of the consideration of local authorities who have power to act under section 36 of the Public Health (London) Act, 1891. Smoke nuisances. The following table, which is compiled entirely from information contained in the annual reports, shows the action taken by sanitary authorities in respect of smoke nuisance during the year, so far as this is stated in those reports. Metropolitan borough. Observations and inspections. Nuisances and complaints. No. of | Notices. Summonses. City of London Battersea Constant 23 . 19 1 Bermondsey 147 43 44 1 Bethnal Green 374 40 29 — Camberwell 124 124 35 — Chelsea 1 — — Deptford 67 14 14 — Finsbury Fulham Greenwich 196 485 4 — Hackney 619 46 46 — Hammersmith 130 16 — — Hampstead 38 20 3 — Holborn 108 — 7 — Islington 77 — 10 — Kensington 193 5 2 — Lambeth 26 24 24 — Lewisham 5 2 9 — Paddington 171 5 — Poplar — 65 62 — St. Marylebone 1,267 3 — — St. Pancras 339 38 7 — Shoreditch 17 11 — Southwark — Stepney 79 79 — Stoke Newington 36 » 6 1 — Wandsworth 331 79 49 — Westminster, City of 2,288 42 104 — Woolwich 54 11 — Housing, Town Planning Act. Section 17 Housing of the Working Classes. Article Y. of the regulations made by the Local Government Board in September, 1910, under this Act, requires that the " medical officer of health shall include in his annual report information and particulars in tabular form in regard to the number of dwelling houses inspected under and for the purposes of section 17 of the Act of 1909, the number of dwelling houses which on inspection were considered to be in a state so dangerous or injurious to health as to be unfit for human habitation, the number of representations made to the local authority with a view to the making of closing orders, the number of closing orders made, the number of dwelling houses the defects in which were remedied without the making of closing orders, the number of dwelling houses which, after the making of closing orders, were put into a fit state for human habitation, and the general character of the defects found to exist. He shall also include any other information and particulars which he may consider desirable in regard to the work of inspection under the said section." 27715 h 50 Annual Report of the London County Council, 1914. Information of these proceedings is not given in tabular form in several of the reports, and the following table has been mainly compiled from the information otherwise contained in them:— Metropolitan borough. No. of houses inspected. No. of houses dealt with under Section 15. No. of representations, 1914. No. of closing orders, 1914. No. of houses, defects remedied without closing orders. No. of houses, defects remedied after closing orders. No. of houses demolished. Remarks. (1) (2) (3) (4) (5) m (7) (8) (9) Battersea 2,218 1,960 185 38 147 38 Bermondsey — — — — — 6 36 — Bethnal Green 607 18 31 25 2 2 3 houses still closed, 17 in hand. Camberwell 3 — Chelsea 425 3 3 — 3 — — Deptford 2,490 — 5 5 4 G — Finsbury — Fulham 140 115 Defects not remedied in 25 cases Greenwich 2,231 266 1,140 1,091 — Hackney 69 69 — — — Hammersmith 598 288 37 6 — — — Hampstead 14 9 9 5 5 4 houses empty at end of year. Holborn 15 2 2 10 2 — — Islington 566 4 21 I 2 4 6 6 houses no longer used for habitation. Kensington 536 10 13 3 319 3 — — Lambeth 358 — 7 7 7 7 — Lewisham 433 412 3 — 7 6 3 houses used as lockup shops. Paddington 6 — 5 5 1 4 cases in hand at end of year. Poplar 49 — 10 10 37 2 2 (" 8 demolition orders St. Marylebone 1,693 — 1 628 — 6 . adjourned. [ 1 appeal pending. St. Pancras 2,371 — 37 — 15 — Shoreditch 10 houses still closed at end of year. Southwark — Stepney 85 — 6 6 — 3 — Stoke Newington — Wandsworth 2,396 — — — — — — — Westminster, City of 24 — — — 3 — 11 — Woolwich 4,538 18 9 9 5 7 5 houses demolished were closed in 1913. The reports of the medical officers of health of Bethnal Green and Woolwich contain detailed statements relating to the Brady-street area and the High-street flats area situate in those boroughs. Further reference to these areas will be found in Chapter XXVII. Some of the annual reports make reference to special housing problems arising in connection with accommodation of soldiers and refugees. Underground Rooms. The number of underground rooms dealt with in 1914 in the several metropolitan boroughs is shown in the following table :— Metropolitan borough. No. of room? illegally occupied. No. of rooms closed or illegal occupation discontinued. Metropolitan borough. No. of rooms illegally occupied. No. of rooms closed or illegal occupation discontinued. Battersea 132 108 Kensington 77 77 Bermondsey 1 1 Lambeth 29 — Bethnal Green 5 5 Paddington 115 115 Camberwell 1 1 St. Marylebone 27 27 Chelsea 1 1 St. Pancras — — Deptford — — Shoreditch 12 12 Finsbury — 6 Southwark — — Fulham 4 4 Stepney 38 18 Greenwich 1 1 Stoke Newington ___ Hackney — Wandsworth — Hampstead 80 28 Westminster, City of 17 17 Holborn 14 14 Woolwich — — Islington 30 30 r 51 Report of the County Medical Officer—General. Under Section 17 (7) of the Housing and Town Planning Act, 1909, a room habitually used as a sleeping place, the surface of the floor of which is more than three feet below the surface of the part of the street adjoining or nearest to the room, is deemed to be unfit for human habitation, if it is not on an average at least seven feet in height from floor to ceiling, or does not comply with regulations which the local authority with the consent of the Local Government Board may prescribe. So far as is shown in recent annual reports of medical officers of health, regulations made by fifteen authorities have been approved by the Local Government Board, these authorities being the metropolitan borough councils of Battersea, Deptford, Fulham, Hampstead, Holborn, Kensington, Lambeth, Paddington, Poplar, St. Marylebone, St. Pancras, Shoreditch, Stoke Newington, Wandsworth and Woolwich. Overcrowding. The following table, showing the number of dwelling rooms found overcrowded, according to the standard prescribed by the bylaws relating to houses let in lodgings, in each metropolitan borough, is compiled from information supplied by the medical officers of health, in their annual reports :— Metropolitan borough. No. of dwellingrooms overcrowded. No. remedied. No. of prosecutions. City of London 8 8 — Battersea 33 33 — Bermondsey 44 44 — Bethnal GreeD 156 156 — Camberwell 96 96 — Chelsea 7 7 — Deptford 28 28 — Finsbury 103 103 — Fulham 45 45 — Greenwich 16 16 — Hackney 62 62 — Hammersmith 18 18 — Hampstead 10 10 — Holborn 32 32 — Islington 187 187 — Kensington 77 77 — Lambeth 31 31 — Lewisham 22 22 — Paddington 197 80 1 Poplar 61 61 — St. Marylebone 40 40 — St. Pancras 96 96 — Shoreditch 256 256 — Southwark 295 295 — Stepney 463 463 1 Stoke Newington 9 9 — Wandsworth 81 81 — , Westminster, City of 52 52 — Woolwich 93 93 — Totals 2,618 2,501 2 Houses let in lodgings. The following table has been compiled from the annual reports of medical officers of health, and shows the number of houses let in lodgings on the register, the number of inspections, notices issued and proceedings taken during the year 1914. Metropolitan borough. Number of places. No. of Inspections, 1914. No. of Prosecutions, 1914. On register at end of 1913. Added in 1914. Removed in 1914. On register at end of 1914. City of London 208 Battersea 114 ___ 114 99 — Bermondsey 218 7 2 223 446 — Bethnal Green 253 30 10 273 1,126 —- (Continued on next page.) (a) Including rooms found overcrowded in 1913. 27715 H 2 52 2 Annual Report of the London County Council, 1914. Metropolitan borough. Number of places. No. of inspections, 1914. No. of prosecutions, 1914. On register at end of 1913. Added in 1914. Removed in 1914. On register at end of 1914. Camberwell 292 292 484 Chelsea Nots tat.ed — — — — Deptford 289 — — 289 578 — Finsbury 1,164 — — 1,164 8,802 3 Fulham .. Not stated Greenwich 243 4 247 300 Hackney 469 469 367 Hammersmith 2,517 215 60 2,672 1,336 — Hampstead 369 36 — 405 524 — Holborn 641 12 16 637 1012 Islington (a) (a) 12,990 3 Kensington 2,085 5 19 2,071 8,245 7 Lambeth 372 —. 372 4,464 — Lewisham 5 5 14 — Paddington 1,376 60 11 1,425 8,781 7 Poplar 1,148 10 — 1,158 3,028 — St. Marylebone 1,213 — 6 1,207 7,346 — St. Pancras 2,360 4 — 2,364 618 2 • Shoreditch 280 — — 280 380 — Southwark 1,247 — 1 1,246 7,412 — Stepney 2,509 39 2 2,546 4,878 1 Stoke Newington 220 11 — 231 231 — Wandsworth 292 — — 292 1 ,045 — Westminster 1,300 — 26 1,274 6,006 10 Woolwich 432 8 22 418 612 1 Reference was made in the annual reports for the years 1910-13 to a provision in the Housing, Town Planning, etc., Act, 1909 (section 16) which extends the power of making by-laws as to lodginghouses for the working classes so as to impose duties upon the owner of the premises in addition to or in substitution for any other person. So far as can be gathered from recent annual reports, new by-laws have been adopted in Battersea, Bethnal Green, Hackney, Islington, Kensington, Paddington, Poplar, St. Marylebone, Shoreditch, and Westminster. Death Rates in Council's Dwellings. The following death-rates obtaining among tenants of the Council's buildings relate to dwellings within the county which were occupied during the whole of the year 1914. The population thus dealt with comprised 30,867 persons, and the death-rate at " all ages, ' after correction for age and sex distribution, was 8'8 per 1,000 living, compared with 14 4 for London :— Cause of death. Death-rate per 1,000 living, 1914. Council's dwellings. London. All Causes—All Ages 8-8 144 „ „ age 0—5 205 369 »> >> „ 5 20 21 29 „ ,, ,,20 and upwards 9-1 158 Diarrhoea 0-5 0-8 Principal epidemic diseases (excluding Diarrhoea) 07 08 Phthisis 0-8 1-4 Tubercular diseases other than Phthisis 04 0-3 Bronchitis 0-7 1-2 Pneumonia 08 1-2 (a) No register is now kept, under the Borough of Islington's new by-laws. 53 Report of the Countij Medical Officer—General. Common Lodging-Houses. The administration of the Common.Lodging Houses Acts devolved upon the Council in 1894. By the passing of the London County Council (General Powers) Act, 1902, the Council obtained powers to license common lodging-houses annually. New by-laws for the regulation of common lodginghouses came into force on the 1st October, 1903. In the lollowing table will be seen the number ot houses, the authorised number ot loagers, tne number of convictions, with the penalties inflicted, and other particulars during each year since 1894 Tear. No. of houses on register. Authorised number of lodgers. No. of day visits by inspectors. No. of night visits. No. of prosecutions. No. of convictions. Penalties and costs. No. of cases of infectious disease. £ s. d. 1895 626 29,574 16 12 37 6 0 99 1896 596 29,140 28,331 — 31 30 112 16 0 71 1897 581 28,718 26,121 — 31 30 92 11 0 48 1898 560 28,332 27,658 — 29 29 167 3 0 44 1899 544 28,448 28,229 1,162 25 22 183 9 0 54 1900 528 28,311 28,428 668 16 13 102 15 0 40 1901 514 28,037 35,225 2,133 16 15 96 3 0 166 ' 1902 491 28,970 40,512 1,449 22 21 98 4 0 <584 ■ 1903 470 28,893 33,402 4,790 6 6 26 11 0 53 1904 451 28,896 27,501 2,970 15 14 62 6 0 66 1905 413 27,571 28.158 1,565 21 16 77 3 0 14 1906 402 28,063 30,028 2,349 4 4 11 1 0 22 ' 1907 395 28,651 33,630 2,307 3 3 12 9 0 27 1908 387 28,379 32,297 2,429 1 1 2 2 0 13 1909 383 28,302 29,324 1,286 3 3 22 0 0 19 1910 368 27,914 26,733 1,589 2 2 7 4 0 13? 1911 364 28,000 25,243 2,066 2 2 5 8 0 16 ■ 1912 351 27,110 25,354 1,872 5 5 7 5 0 9" 1913 346 26,562 25,634 1,856 8 7 23 11 6 8 1914 308 26,308 24,210 1,708 5 5 14 10 0 11 The number of cases of notifiable infectious disease reported in common lodging-houses was as follows : Scarlet fever, 5 ; erysipelas, 4 ; diphtheria, 2 ; total 11. Ihe following table shows the total number ot common lodging houses, ana the authorised accommodation for the different classes of lodgers in the several districts other than the City of London on 31st December, 1914 :— Metropolitan boroughs. Number of Houses. Authorised Accommodation. Men. Women. Couples. Total. Battersea 3 99 66 165 Bermondsey 5 1,261 — — 1,261 Bethnal Green 12 599 — — 599 Camberwell 5 466 — — 466 Chelsea 4 236 — — 236 Deptford 8 1,182 49 — 1,231 Finsbury 6 446 58 — 504 Fulham 2 43 51 — 94 Greenwich 3 121 — — 121 Hackney 7 498 — — 498 Hammersmith .. 9 466 — . 4 474 Hampstead — — — — — Holborn 20 1,476 144 — 1,620 Islington 38 1,101 186 18 1,323 Kensington 22 401 272 — 673 Lambeth 6 691 — — 691 Lewisham 1 30 — — 30 Paddington 7 184 37 — 221 Poplar 7 994 994 St. Marylebone 11 1,028 109 1,137 St. Pancras 6 600 36 — 636 Shoreditch 10 752 — — 752 Southwark 37 2,994 449 — 3,443 Stepney 44 5,232 720 180 6,312 Stoke Newington 1 37 — 37 Wandsworth 8 175 5 16 212 Westminster, City of .. 8 2,005 57 — 2,062 Woolwich 18 465 51 — 516 London—excluding the City of London 308 23,582 2,290 218 26,308 54 Annual Report of the London County Council, 1914. Dcntha among inmates of common lodging houses. The following table shows the proportion of deaths from several causes per 1,000 deaths among males in common lodging-houses, the corresponding figures for London being shown for comparative purposes. The deaths of persons removed from common lodging-houses to infirmaries and other like public institutions have been included. The total number of deaths among lodgers (males and females) in common lodging-houses during the year was 882 ; the large majority of these deaths occurred in public institutions. Table showing the number of deaths of males at five age periods from certain causes per 1,000 deaths from all causes in London (1913) and licensed common lodging-houses (1913 and 1914). Cause of death. Age 25 to 35. Age 35 to 45. Age 45 to 55. Age 55 to 65. Age 65 and upwards. London, 1913. C.L.H. 1913. C.L.H, 1014. London. 1913- O.L.H. "l, CL.H. 1014. London, 1013. C.L.H. 1913. C.L.H. 1914 London 1918. C.L.H. 1913. C.L.H. 1914. London. 1913. C.L.H. 1913. C.L.H. 1914. Phthisis ... 395 438 550 321 473 528 193 355 316 97 189 272 24 85 51 Other tubercular diseases 21 — — t 10 18 4 13 5 5 6 1 — 8 Alcoholism (including cirrhosis of the liver) 7 100 21 21 28 35 ■62 26 25 29 33 9 4 U rinary diseases.. 28 62 — 53 42 46 69 90 69 79 130 5S 80 59 58 Violence, suicide 94 84 25 75 21 28 59 45 26 47 43 28 25 15 20 Cancer 27 42 25 45 42 — 118 64 100 159 145 147 109 95 111 Circulatory diseases Nervous diseases 1 >168 1 104 100 214 95 110 254 123 170 303 145 143 311 188 170 Bronchitis 21 62 25 36 74 46 54 97 79 89 137 165 169 249 277 Pneumonia 98 124 125 98 117 74 80 110 130 66 87 74 51 114 76 Other causes 141 84 50 130 105 122 134 71 79 130 95 74 221 195 225 Total (all causes) 1,0(10 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,0(10 1,000 1,000 1,000 1,000 1,000 Phthisis in common lodging-houses. In 1909 the Local Government Board made an Order requiring the notification of phthisis occurring in poor law practices, and in March, 1911, the requirement of notification was extended to hospitals, dispensaries and similar institutions. In November of the same year a further Order was made requiring every medical practitioner, from 1st January, 1912, to notify such cases within forty-eight hours. Thus from the latter date a complete system of notification of the disease has been in force. Under these Orders the metropolitan borough councils are required to send weekly to the County Council a return of the notifications received and from these returns it has been possible to learn, in some degree, the extent of the disease among inmates of common lodging-houses. Since 1909 until the end of the year 1914, a total of 1,138 cases of the disease in the common lodging house population has been notified. Of this total 1,069 were males and 69 females. The age distribution of 1,117 of these cases was as follows:— 5— 10— 15— 20— 25— 35— 45— 55— 65 and up. 2 1 10 26 170 301 361 202 44 It has been possible in 961 cases to interview the patients, and information was obtained as to whether their illness began before or after they had resorted to this mode of living. The results were as follows :— In 344 cases the onset of the disease was stated to have commenced prior to entering on a common lodging house life. In 80 cases it was practically coincident with entry. In 155 cases the disease first manifested itself within three years of such life. In 71 cases in from three to five years. In 141 cases in from five to ten years. In 121 cases in from ten to twenty years. In 49 cases after more than twenty years of common lodging house life. Thus in nearly half the total number the disease must have been already acquired before the common lodging house environment could possibly have had any influence upon its development. The place of birth in 297 of the cases was stated to be outside London. « Seamen's lodging houses. In July, 1901, the London County Council made by-laws under Section 214 of the Merchant Shipping Act, 1894, for the inspection, sanitary condition and well ordering of seamen's lodging houses. In 1909, after experience of their application, the by-laws were amended, a new series was issued and came into force on 1st January, 1910. By an Order in Council dated 19th February, 1910, powers were conferred on the County Council for the licensing of seamen's lodging houses. The first licensing meeting was held in May of that year and since that date all such premises are annually licensed. 55 Report oj the County Medical Officer—General. At the end of the year 1914, the number of seamen's lodging houses under supervision was 35, situated in the following metropolitan boroughs :— Metropolitan borough. Houses. Lodgers. Poplar 10 334 Stepney 25 709 Total 35 1,043 In the following table will be seen the number of houses, the authorised number of lodgers, the number of convictions, with the penalties inflicted, and other particulars, during each year since the supervision of seamen's lodging-houses was undertaken by the Council:— Year. J No. of houses on register. Authorised number of lodgers. No. of dajvisits by inspectors. No. of night visits. No. of prosecutions. No. of convictions. Penalties and costs. No. of cases of infectious disease. £ s. d. 1902 97 1,665 2,842 1903 102 1,748 1,956 4 o 1 1 16 0 7 1904 90 1,585 1,298 10 3 3 11 7 0 10 1905 77 1,509 1,509 15 5 5 9 13 6 1 1906 84 1,551 1,431 38 9 8 43 7 0 2 1907 82 1,550 2,169 70 8 7 38 19 0 5 1908 85 1,571 2,081 78 3 3 24 0 0 6 1909 80 1,524 1,983 84 7 6 15 0 0 — 1910 37 1,157 2,404 197 15 14 90 9 0 — 1911 36 1,173 1,465 204 7 6 52 13 0 — 1912 41 1,066 1,079 210 18 13 81 12 0 — 1913 44 1,120 1,814 237 15 4 29 16 0 — 1914 35 1,043 1,247 174 4 4 59 13 0 — Proceedings before the magistrate were instituted in 4 cases, three iu respect of licensed premises and one for keeping a house without a licence ; in the latter case the person being an old offender was fined £50 and £1 3s. costs. No cases of infectious disease were reported among inmates of seamen's lodging houses during the year. Cleansing of Persons Act, 1897. Cleansing of Persons Act, 1897, etc. I' I The Cleansing of Persons Act, 1897, provides " that any local authority shall have the power when in their discretion they shall see fit, to permit any person who shall apply to the said authority on the ground that he is infested with vermin to have the use, free of charge, of the apparatus (if any) which the authority possesses for cleansing the person and his clothing from vermin." It is also provided that the use of such apparatus shall not be considered to be parochial relief or charitable allowance, and local authorities may expend any reasonable sum on buildings, appliances, etc., required for carrying out the Act. The Act, however, is a permissive one only. For several years the metropolitan borough councils, with some few exceptions, took very little action under the provisions of this Act, and so recently as 1906 except in boroughs like St. Marylebone, St. Pancras and Poplar, there was little progress to record. General Powers Act, 1904, sects. 19,20, 21, 24 It was recognised, however, in dealing with verminous persons and more particularly in the case of children, that the cleansing of the individual could be of little service unless accompanied by the cleansing of the home and the purification of articles of furniture and clothing. The London County Council, therefore, in its General Powers Bill of 1904 inserted clauses empowering local authorities to cleanse, purify, or destroy articles which the medical officer of health certifies are filthy, dangerous, or unwholesome. In addition, power was obtained to compel owners to strip and cleanse any house or part of a house certified by the medical officer of health to be infested with vermin. These clauses became law and have been increasingly used, and articles to the number of many thousands are recorded each year as having been freed from vermin. For some years, moreover, an average number exceeding 10,000 rooms a year received the attention of the borough councils on account of their verminous condition. General Powers Act, 1907, sects. 36-40. A further impetus was given to this work by the passing of the London County Council (General Powers) Act of 1907. This Act contained clauses empowering the Council, as Education Authority, to make arrangements for the cleansing of school children, and as supervising authority, for the cleansing of the inmates of common lodging houses. In both cases power was obtained to detain and convey to suitable premises for the purpose of cleansing, any person failing to comply with a twenty-four hours' notice. Section 38 of the Act expressly provided that the Council might enter into agreements with local authorities possessing suitable stations for the cleansing of school children and inmates of common lodging houses, and incidentally this section has been the means of securing a considerable extension DO ' " _ o throughout London of the facilities for cleansing which were first provided after the passing of the Cleansing of Persons Act, 1897. Children Act, 1908. Sect. 122. Almost immediately following the General Powers Act of 1907, the Children Act, 1908, was passed. This Act also gave power to cleanse when necessary elementary school children, and, 69 Report of the County Medical Officer—General. while on the journey. At present many of the institutions are situated a considerable distance from London, so that in case of delay. meals have had to be Provided for the Patients. One hundred and sixty cases have been placed under supervision, and the Council has, for an experimental period of six months, entrusted this work to the London Association for the Care of the Mentally Defective. The supervision is carried out by visits and inspection of the homes or places occupied by relatives of defectives, and assistance and guidance is given to the relatives for the benefit of the defectives. The visits are made at intervals according to the needs of the case, but in any case each defective is visited at least once in three months. The results of the visits are tabulated and forwarded to the medical officer, who reports to the local authority when further treatment is considered desirable. Supervision. The local authority has no duties in regard to defective children over the age of 7 years and under the age of 16 years,except those whose names and addresses have been notified to them by the education authority under the provisions of the Act. Defectives under the age of 7 years are only to be dealt with, therefore, provided that they are neglected, abandoned, without visible means of support, or cruelly treated ; or are inmates of, or liable to be sent to a certified industrial school. The ordinary age of admission to public elementary schools is, however, 5 years, so that medical officers carrying out school inspection, attendance officers, and others become aware of the existence of certain defectives at an earlier age than 7 years. Should these, for the above-mentioned reasons, be liable to be dealt with under the Act, they are reported to the Committee in the usual manner, but such circumstances are extremely rare. Children who are defective, but capable of benefiting by education, can be sent to special schools, and their attendance can be enforced thereat between the ages of 7 and 16 years, but children who are idiots or imbeciles cannot be sent to special schools. In the past, when the child was returned as an idiot or imbecile, it was not likely to be seen again for a considerable period. When there was no prospect of ultimate educability, such children were noted down as invalid, and therefore unfit for school attendance for such period of time as might be necessary" to bring them up to the age of 7 years, when arrangements were made by the divisional superintendents of the education authority for the cases to be re-nominated for medical examination. This practice is being continued, but cases not liable to be dealt with are not called definitely idiot or imbecile until after the age of 7 years, as otherwise there would be a risk of their being marked off the books of the attendance branch, and so escaping notice at a later period. All cases are re-examined after attaining the age of 7 years. Defectives under seven years of age. It has not been possible to place the work upon a permanent basis, but up to the present the Council has appointed additional medical staff to the equivalent of five sessions a week, and a full time inspector, and has approved the full time medical staff for the purpose of conducting medical examinations, and three inspectors, in addition to the one specially appointed, to convey alleged defectives to places of safety. The following information furnished by the Clerk of the Asylums and Mental Deficiency Committee, shows the number of cases of alleged mental defect dealt with up to the 31st March, 1915, and the action taken. Cases notified and action taken. Information received from various sources of alleged cases of mental defect in 995 cases. Number dealt with by Local Authority 349 Cases not liable to be dealt with by the L.C.C 9 Cases found after inquiry and medical examination not to be subject to be dealt with under the Act 74 Cases referred by the Education Authority 6 Cases not ascertained and no action taken 27 Cases still under the consideration of the Local Authority on 1st April, 1915 530 Information as to cases dealt with was given:— By the Police Authority 17 By the Board of Control (i.e., cases in prison) 47 By the Board of Control (i.e., cases in receipt of poor-law relief) 15 By the Local Education Authority 208 By miscellaneous informants 62 The cases have been disposed of as follows:— Cases sent to institutions:— Under detention orders made by Metropolitan magistrates under section 8 11 Under orders made by other Judicial Authorities on petition under section 5 53 Under orders made by the Secretary of State under section 9 13 — 77 Cases placed under supervision 160 Cases sent to places of safety pending the presentation of a petition 25 Action could not be taken owing to the lack of suitable accommodation 31 Cases discharged from prison before action taken 19 Referred to or dealt with under poor law 19 No action for other reasons 18 70 Annual Report of the London County Council, 1914. National Insurance Act, 1911—Treatment of Tuberculosis. The circumstances which led to the Council making provision for the treatment of tuberculosis in London were fully dealt with in the two preceding annual reports. Briefly stated these were that (a) the results of the investigation of the Departmental Committee on Tuberculosis, which issued two reports in 1912 and 1913 respectively, and (b) the requirement of compulsory notification of sufferers under the Tuberculosis Regulations, 1912, established the necessity for public provision for dealing with the disease. The Council first accepted a grant from the Government under Section 64 of the National Insurance Act, 1911, which enabled it to enter into agreement with the Metropolitan Asylums Board for the treatment of insured persons at Downs Sanatorium, Sutton, and at the Northern Hospital, Winchmore hill. Subsequently an amending Act passed in 1913 repealed the provision in the original Act of 1911, which prevented the London Insurance Committee from making direct arrangements with the Metropolitan Asylums Board for the treatment of insured persons. Under the amending Act such direct arrangements may be made subject to the concurrence of the County Council. The Council concurred and the London Insurance Committee made their own arrangements with the Metropolitan Asylums Board. The Council ceased to have any responsibility in respect of insured persons on 31st March, 1914. With regard to the general community the Local Government Board invited the Metropolitan Borough Councils to prepare schemes for the treatment of sufferers and the examination of suspects and contacts at dispensaries, and they also invited the Council to formulate a complete scheme for London which would embody the work to be done locally through the dispensaries and include the County Council as the Authority for residential treatment. First, as to dispensaries, the Council decided to make grants in aid of the expenditure of borough councils on dispensary schemes to the extent of 25 per cent. of the cost of dealing with uninsured persons, provided the schemes complied with certain regulations which were adopted by the Council in November, 1913. These were set out on page 226 of volume III. of the Annual Report of the Council, 1913, and were subsequently embodied in the Council's Tuberculosis Scheme for London approved by the Council on 26th May, 1914. Shortly stated the principal of these provide (a) that the Scheme shall include treatment of both insured and uninsured persons (b) that the premises and tuberculosis officers shall be approved by the Council; (c) that the dispensary shall be linked to a hospital for the purpose of determining diagnosis in difficult cases; (d) that records, forms and statistics shall be in the form required by the Council; (e) that the Council shall be supplied with reasonable information as to the work of the dispensary; (f) that home visitation and examination of contacts and suspects shall be provided for; (g) that the Scheme shall be conducted with reasonable economy and that the accounts shall distinguish clearly between the cost of insured and uninsured persons; and (h) that the arrangements and expenditure shall be annually submitted to the Council for its approval. At the end of 1913 qualified approval of two dispensary schemes (Southwark and Chelsea) had been given. By the end of the year 1914 schemes had been received from 25 Borough Councils, and 15 had been approved. Of the 25 schemes, 7 had been in operation for varying periods prior to the adoption of the Council's scheme and 6 others were cither fully or partially working at the end of the year. Ten schemes were then still the subject of negotiation and four boroughs had not submitted their proposals. One of the principles governing the policy of the Council in respect of their approval of dispensary schemes and of provision for residential accommodation is that wherever possible existing institutions should be used. In the various boroughs the following dispensary accommodation has been provided or is proposed:- Municipal.-Deptford, Finsbury, Greenwich, Hammersmith, Hampstead, Southwark, Wandsworth. Hospital.—City of London, Chelsea, Hackney, Holborn, Islington, Shoreditch, Stoke Newington, Westminster. Municipal and Hospital.—Lambeth. Voluntary and Hospital.—St. Pancras. Voluntary.—Poplar. Central Fund.—Battersea, Bermondsey, Camberwell, Fulham, Stepney, Woolwich. Central Fund and Hospital or Borough.—Kensington, Paddington, St. Marylebone. With regard to the general scheme for London, attention was directed during 1914 to the arrangements for residential treatment and to the linking up thereto of the local dispensaries so as to secure the smooth transfer of suitable cases from the care of the dispensaries as in-patients to hospitals or to sanatoria and vice versa on completion of the in-patient treatment. On the question of the provision of beds, it will not be possible to estimate with any degree of accuracy the number required until the dispensary schemes have had time to get fully into operation. It might be possible to arrive at a reliable figure if the accommodation needed were dependent only upon the notifications under the Tuberculosis Regulations, 1912, which are dealt with elsewhere in this report, as it is probable that the number of cases notified has now reached a level which provides an annual average of cases coming under notice as a result of medical advice being sought by persons experiencing definite signs of illness. Dispensary schemes, however, provide for the examination of "contacts" of notified sufferers, and it may therefore be expected that later there will be an increase in the number of cases detected in the early stages of the disease, i.e., the type of case most suitable for sanatorium treatment. Having regard to the fact that the Council is only concerned in providing 71 Report of the County Medical Officer General. residential accommodation for uninsured persons, it has been taken that for adults 160 hospital beds and 240 sanatorium beds may be regarded as sufficient initial provision, excluding advanced cases. It has been recognised throughout that these cases present a separate and distinct problem. In dealing with the question of the sanatorium accommodation required for children it has to be borne in mind that the problem of the treatment of tuberculous children presents special features some of which are referred to in the section of this annual report dealing with the work of the school medical officer. The important factors in dealing with children are (1) the question of education; (2) the position of the day school for physically defective children established under the Elementary Education (Defective and Epileptic Children) Act, 1899, more particularly for surgical cases; (3) the question of the open air day school attached to the local dispensary for children in attendance there for treatment, the majority of whom would be pulmonary cases. As to education the Council has decided that children capable of receiving education during their stay in residential institutions shall be sent only to institutions recognised by the Board of Education under the Elementary Education (Defective and Epileptic Children) Act, 1899. Day schools for physically defective children under the Education Act of 1899 have already been extensively established in London, and experience has shown the type of case most suitable for these institutions. The matter is consequently largely one of the selection of suitable cases. The development of the open air day school for medical cases requires special consideration and an attempt is being made to deal with the matter on experimental lines with a view to determining the type of tuberculous child most suitable for treatment at such an institution. Having regard to these considerations it has been suggested that, as an initial provision, 350 beds for surgical cases and 150 beds for pulmonary and gland cases would be sufficient. On the question of the provision of the accommodation required both for adults and children the Council was during the year in negotiation with the Metropolitan Asylums Board; reference to this will be found in chapter xxv., page 145. The negotiations were not completed at the end of 1914, but by the courtesy and co-operation of the London Insurance Committee it was found possible for the Board temporarily to place at the disposal of the Council 15 sanatorium beds for women at the Northern Hospital, Wiuchmore-hill, which had been allotted to the Insurance Committee, and these have been used by the Council since 11th December, 1914, and the Metropolitan Asylums Board were also able to allot to the Council 13 beds for children at Queen Mary's Hospital, Carshalton. In addition to the negotiations with the Metropolitan Asylums Board correspondence was opened With hospitals and sanatoria with a view to ascertaining the extent to which they would be able to meet the additional needs. It was pointed out to them that the Council in seeking accommodation desired to avoid the displacement of patients suffering from any disease including tuberculosis who would otherwise be received under existing arrangements. In other words that the Council wished to supplement existing provision by paying for beds for patients who, under existing conditions, would be unable to secure appropriate treatment. As the result of these negotiations it was found that, under normal conditions, the Council would have been able to obtain all the beds required at hospitals as initial provision, at the rate of 30s. per bed per week and 20s. per bed per week for children. On the outbreak of war, however, the hospitals found themselves unable definitely to allot beds for the sole use of the Council. Many of them expressed themselves willing to take patients from time to time as vacancies occurred, the beds reverting to the hospital on the discharge of the patient concerned. In this way it was possible to arrange at hospitals for the few hospital beds required during the short period of 1914 the Scheme was in operation. Four patients were admitted to hospitals, viz., two adults and two children. Of these two were subsequently sent to sanatoria and two were discharged. As to sanatoria it was found that there was insufficient suitable accommodation within a reasonable distance of London, and it was Only possible at the end of 1914 to contract for 30 beds for adults, viz., 20 at Maltings Farm Sanatorium, Suffolk, and 10 at Fairtight Sanatorium, Hastings, in addition to the 15 beds for women at the Northern Hospital, Winchmore-hill, already mentioned. The number obtained, however, proved to be sufficient for the demands made upon the Council during this period. A considerable number of additional beds has since been obtained and at the time of writing they are all occupied With regard to the children's beds, arrangements were completed with the undermentioned institutions for the specified numbers of beds.— National Children's Home, Harpenden 10 beds. East Anglian Children's Sanatorium, Nayland 50 beds. Alexandra Hospital for Children with Hip Disease 20 beds. Queen Mary's Hospital, Carshalton 13 beds. Fleet Sanatorium, Hampshire 5 beds. Victoria Home for Invalid Children, Margate 5 beds. At the end of 1914 it transpired that 8 men and 33 women and 87 children had been sent to sanatoria by the Council. Of these 10 adults and 18 children had been discharged at the end of the year, leaving (i men, 25 women and 69 children under treatment on 31st December, 1914. Reference has already been made to the question of the provision necessary for advanced cases. In their own interests and on grounds of public health it is desirable that these cases should be removed from their homes, but much hardship would be caused if they were taken to large institutions at considerable distance from their homes so that their friends would be unable to visit them. It is therefore felt that these patients should remain as near as possible to their homes. It is thought that the provision of medical treatment under the National Insurance Act will tend to reduce the number of persons in infirmaries, and it has been suggested that some of the displaced accommodation in infirmaries might be transferred from the Poor Law for this purpose, 72 Annual Report- of the London County Council, 1914 Much attention has been given to the question of linking up the dispensaries with the various local agencies for the relief of sufferers from tuberculosis and with the arrangements for residential treatment. The medical officers of health of the metropolitan boroughs are required under the Tuberculosis Regulations, 1912, to make enquiries into environmental conditions of all notified cases and they have power to arrange for the improvement of unsuitable conditions and for the prevention of the spread of infection. Their enquiries enable them to ascertain whether sufferers are receiving adequate attention, and, where dispensary schemes are in operation, to secure attendance at the dispensary of suitable cases and of contacts and suspects. It is contemplated that in course of time general practitioners will seek the services of the dispensary medical officers for the purpose of consultation. In the case of children the activities of the school care committees, not only lead to the acquisition of much useful information, but afford channels for obtaining appropriate assistance auxiliary to medical treatment. The experience of the last few months has shown the desirability of centralising these various activities, with a view to economy of energy and to the prevention of duplication of visiting and proposals for this purpose were under consideration at the end of the year. In the meantime the services of the borough medical officers of health, the Invalid Children's Aid Association, and the school care committees have been utilised in connection with the arrangements for residential treatment. One of the initial problems which faced the Council in undertaking the provision of residential treatment for uninsured persons was the question of determining the type of case suitable for the various kinds of institution treating sufferers, particularly as to the line of demarcation between "hospital" and "sanatorium" cases, and as to what constitutes an "advanced" case. Another matter of difficulty was the procedure to be adopted for the admission of patients to residential institutions. This was one of the matters referred to the Advisory Board appointed under the Council's scheme; further reference to this will be found in chapter xxv, page 144. Pending the preparation of the standard classification of the Advisory Board and the appointment of dispensary care committees, the following procedure has been adopted for dealing with cases requiring residential treatment:— 1. A clinical report form (known as form A) is filled up by the physician or surgeon recommending the case and referred by him to the medical officer of health of the borough. 2. Form A is forwarded by the borough medical officer of health to the county medical officer of health together with a report (form B) by the borough medical officer of health on environmental conditions. 3. These reports are examined by the county medical officer of health and if the cases are passed for treatment a vacancy is offered to the patient, if an adult, through the borough medical officer of health, who obtains the signed consent of the patient to treatment and "after care." In the case of children, in addition to forms A and B, reports are obtained from the school care committee or Invalid Children's Aid Association, who also obtain the consent of the parents to treatment and an undertaking to submit the child to "after care " on discharge. 4. In the event of the county medical officer of health desiring a further medical opinion before accepting a case for residential treatment arrangements are made for the patient to be seen by a medical referee at the offices of the public health department. The judgment of the referee is not subject to clinical review by the Council. The referee is also to be consulted if there is difficulty in determining the relative urgency of a number of cases awaiting treatment. In 1914 four cases were referred to referees, and two of them were sent to hospitals. The other two were offered treatment in hospital and refused. 5. Due notice is given to the borough medical officer of health of the date of discharge of a patient in order that suitable arrangements may be made for his "after care " and a medical report on the patient's condition on discharge is supplied to the borough medical officer of health. 6. In the case of children notice of discharge is also supplied to the school care committee, and if the case is recommended by the Invalid Children's Aid Association they are also informed. Arrangements are made for the case to be kept under the special observation of the school medical officer. Maternity and Child Welfare. Material aid in promoting the rearing of healthy children is afforded by schools for mothers, infant consultations, health societies, infant welfare associations, etc. The establishment of such institutions has long been undertaken on a voluntary basis but in July, 1914, the Local Government Board announced that it would henceforth be possible to make a State grant in aid in furtherance of schemes of this nature, and local authorities were asked to co-operate. The Board of Education is associated with the Local Government Board in the assessing of the grants to be paid. Owing to the war there had hardly been time for local authorities to make much headway towards the establishment of complete schemes before the end of the year, though in many cases medical officers of health had reported in detail on the circular of the Local Government Board. A considerable amount of voluntary work in association with medical officers of health, women sanitary inspectors, and health visitors has been done for some time, and it may be stated that as many as 45 institutions in London had been recognised by the Board of Education for the purposes of the grant at the end of the financial vear closing on the 31st March, 1914. In some instances, moreover, in spite of the difficulties of the time, appreciable progress has been made. In illustration of this a few examples may be given, 73 Report of the County Medical Officer—General. City of Westminster.—Women are now in training as home helps and a register is kept of women fitted for such work. Expectant mothers are visited. Mothercraft classes and infant consultations are held. A creche has also been established. There are three clinics for children under school age where the children are medically inspected, and a continuous record is kept. Dr. Allan in his report gives details as to physical defects found at these examinations and points out that, in addition to the preventive work done in the direction of diminishing the diseases due to improper feeding, an amount of hospital treatment has been obtained for children with defects. Special attention is also given to children of tuberculous parents and to suspected cases of tuberculosis and the information obtained on these points is passed on to the school doctor when the child reaches school age. St. Marylebone.—The borough council has formulated a scheme for linking up a maternity and general hospital with infant consultation centres and schools for mothers, and with the public health department. At present the women sanitary inspectors and health visitors supervise infant welfare, and attend clinics and schools for mothers. When the scheme is fully in operation it is intended that one of the women sanitary inspectors shall devote her whole time to this work. Paddington.—A voluntary organisation has founded a school for mothers, and an additional woman inspector has been appointed who visits newly born babies. Arrangements are being made for extending help to expectant mothers. Consultations have been established at three centres, weekly in the case of babies, monthly for older children. Cases requiring treatment are referred to hospitals or private doctors. Finsbury and Shoreditch.—In both cases the borough councils have decided to establish centres and premises have already been taken. Holborn.—The Passmore Edwards School for Mothers (Baby Clinic) is open every Monday afternoon, and there is a needlework and instruction class for mothers every Wednesday afternoon. Dinner tickets are given to poor deserving mothers, and modified milk is supplied at 4d. a day, and some parents are assisted to pay this amount. Proposals have been made to establish clinics for expectant mothers in Marylebone and Woolwich. This statement does not cover the whole of the work now being done, but is indicative of the action being taken. A full account is given in a carefully compiled table published in the report of the Medical Officer of Health of Bethnal Green. Infant consultations and baby weighing centres under the control of the medical officer of health assisted by the health visitors and women sanitary inspectors have been generally adopted throughout London. In one or two instances arrangements for the supply of milk have also been made. As regards pre-natal work there is evidence that the subject is receiving careful attention, and it may be expected that when the existing strain on the resources of the country is relaxed, practical steps will be taken to deal with this important question. Midwives Act, 1902. The number of midwives giving addresses in London whose names appear on the Roll of Midwives for 1914 is 4,949. This number includes midwives who may have removed from the County, but, owing to the fact that they are not practising, their present addresses have not been reported to the Central Midwives Board, and consequently appear as London addresses. Of this number. 580 notified their intention to practise during the whole year or for shorter periods. The qualification of the London midwives is as follows:— Qualification of Midwife. Number not giving notice of intention to practise. Number giving notice of intention to practise. Total. (a) Holding certificates from the Central Midwives Board 3,008 352 3,360 (b) Holding a certificate, obtained as the result of an examination prior to the passing of the Midwives Act 1,283 149 1,432 (c) Enrolled by virtue of having been in bona fide practice as midwives a year previous to the passing of the Act 78 79 157 4,369 580 4,949 The midwives in classes (a) and (b) are entitled to use the description "certified midwife by examination." Of those giving notice of their intention to practise, the untrained midwives, class (c) represent 13.6 per cent. The 580 midwives who gave notice of intention to practise cannot be taken as the number actually practising in the County. In some institutions it is the custom for a midwife to act as an assistant for three months or less after she is qualified, and her place is then filled by another newly qualified assistant, who in her turn gives notice of intention to practise. At any given time it may be estimated that some 400 to 450 midwives, or about 10 per cent. of those on the roll are in actual practice in London. The remaining 90 per cent. act for the most part as monthly or general nurses under medical supervision. Of the practising midwives 37 were working entirely within poor-law institutions or lyingin hospitals and were under medical supervision; 76 others were attending patients on behalf of 27715 l 74 Annual Report of the London County Council, 1914. Inspection. charitable, poor-law or other institutions, and were paid either a salary or a fee for each case allotted to them. The remainder practised independently. All practising midwives, except those working in hospitals under medical supervision, are subject to inspection by the Council's officers, for the purpose of ascertaining whether they are complying with the rules of the Central Midwives Board as to cleanliness, the possession of antiseptics and appliances, the keeping of registers and case books and the sending of the required notices to the Local Supervising Authority. The work of inspection was carried out by Miss E. Macrory, M.B., Ch.B., L.M., D.P.H., and Miss M. A. Pilliet, M.B., Ch.B. In addition to the ordinary routine inspection, special visits are paid to the midwife when any case of a septic nature or of persistent high temperature occurs in her practice, and in all cases of inflammation of an infant's eyes. The inspectors also advise midwives on any points of difficulty which may arise in the course of their duties, and in some instances instruct the midwives as to methods of work. On occasion a midwife is accompanied by the inspector either to a confinement or on a subsequent visit to a patient to ascertain whether her methods of work are efficient. This is done where there is any reason to believe that the midwife's work is not up to standard, and also in cases where a midwife has applied to the Central Midwives Board for approval to her supervising the training of pupils for the Board's examination. The inspectors paid 1,214 visits to midwives or institutions employing midwives. In 886 cases the report was satisfactory, in 36 unsatisfactory or presenting some unusual feature, and in 292 the midwife was not seen. Most of the unsatisfactory reports related to cases in which some slight breach of the rules had occurred, and the midwife's attention was called to the matter by the inspector, who was subsequently able to report favourably. In cases of a more serious nature, or where the midwife had a bad record previously, the matter was reported to the Midwives Act Committee of the Council, and a letter of caution was sent to the midwife. Charges of malpractice, negligence or misconduct made against five midwives were investigated during the year, and in three instances prima facie cases of negligence and misconduct were established against the midwives concerned. The Board considered that the charges in one case were not proved, and the Council was requested to furnish further reports with regard to the other two midwives. Fees charged by midwives. The fee a midwife receives lor attending a confinement and for the subsequent 10 days visiting varies in different localities from 7s. 6d. per case upwards, but usually a fee of 10s. to 15s. is expected. The charities employing midwives pay 5s. or 6s. a case, and provide the midwife with registers, forms, antiseptics, etc. It is apparent from the number of cases taken by midwives and the small fees paid that very few can rely solely on their practice as a means of livelihood. Many of them are married women who do not trouble to obtain a large practice; a few keep lying-in homes; others, especially those with a fairly large practice, are approved by the Central Midwives Board to give practical instruction to pupils preparing for the Board's examination. The pupil resides with the midwife and goes with her to cases. The fees for pupils are usually about £1 1s. per week, and this includes board and lodging in addition to the practical instruction given by the midwife. Maternity charities. Many midwives are employed in Poor Law Infirmaries, and a large proportion or the 3,000 confinements in infirmaries are conducted by midwives, and many of the infirmaries are approved as training schools for pupil midwives. Over 5,000 cases are taken annually into the maternity hospitals, and 18,000 to 20,000 women are delivered in their own homes by midwives working either for maternity Hospitals or in connection with one or other of the free maternity charities. Births notified by midwives. From information received under the Notification of Births Act the following figures have been obtained showing the number of births notified by midwives:— 8 midwives reported over 500 cases in the year. 4 „ „ between 400 and 500 cases in the year. 13 „ „ „ 300 and400 14 „ „ „ 250 and 300 „ „ 22 „ „ „ 200 and 250 „ „ 15 „ „ „ 150 and 200 „ „ 47 „ „ „ 100 and 150 „ „ 81 „ „ „ 50 and 100 „ „ 135 „ „ „ "20 and 50 „ ,, Most of the midwives who had 300 cases and upwards have qualified assistants, and many are approved by the Central Midwives Board for supervising the work of pupils. From information received under the Notification of Births Act, it is computed that some 30,000, or 25 per cent. of the total births in London are attended by midwives, excluding the cases attended by midwives in infirmaries. Uncertified women. By Section 1 (2) of the Act it has been illegal since March, 1910, for any woman, unless she be certified under the Act, habitually and for gain to attend women in childbirth except under the direction of a registered medical practitioner. Since the Act became operative enquiries have been made into all cases in which it has come to the knowledge of the Council that a delivery had been conducted by an uncertified woman, and during the year proceedings were instituted in four cases, and fines amounting to £3 5s., with £3 l1s. 6d. costs, were imposed. Most of the other women reported as having conducted cases were found on enquiry to have acted in emergency, or had conducted only one case and, consequently could not be described as practising habitually; these women were informed of the provisions of the Act. and in some cases cautioned by letter. Medical help. The rules of the Central Midwives Board provide that in certain circumstances a midwife must decline to attend alone and must advise in writing that the case requires medical help. The form on which this written advice is given is sent to a medical practitioner, and a copy is forwarded to the local supervising authority. During the year 3,534 of these notices were received from 363 midwives. The figures for the previous years were: 1905,1,113; 1906,2,320; 1907, 2,533; 1908,2,755; 1909, 75 Report of the County Medical Officer—General. 2,894; 1910, 3,020; 1911,3,477; 1912,3,003; 1913,3,070. Midwives in infirmaries and hospitals acting under the direction of a qualified medical practitioner arc not required to comply with this rule. Assuming that 30,000 births arc attended annually by midwives, the above figures show that medical assistance was required in 11.78 per cent. of the cases.; in 6.89 per cent. on behalf of the mother and in 4.89 per cent. on account of the child. During the year, 219 midwives reported having stillbirths in their practice, the number of stillborn children being 655, or 2.18 per cent. of the births; of this number 300 were reported to have been macerated. There were normal presentations in 544 or 83 per cent. of the stillbirths. Still births. The rules of the Central Midwives Board require the midwife to notify to the local supervising authority all cases in which the mother or child dies before the attendance of a registered medical practitioner. In 67 cases midwives notified the deaths of infants, and in one instance the death of a woman was notified. Death of mother or child. By the courtesy of the London coroners, notices are sent of inquests in which midwives are concerned and one of the Council's inspectors attends the court to hear the evidence and learn whether the midwife has complied with the rules of the Board. One hundred and twenty-six inquests were thus reported upon, eighteen being on the bodies of women, and one hundred and eight on the bodies of infants. The medical evidence given at the inquests as to the cause of death was as follows:— Mothers. Infants. Atelectasis 7 Blood poisoning and loss of blood 1 Suffocation at birth 20 Blood poisoning caused by retained placenta 1 Suffocation in bed 20 Hæmorrhage 4 Prematurity and debility 16 Heart disease and nephritis 1 Malnutrition 1 Heart failure 1 Convulsions 10 Septicæmia 6 Bronchitis and pneumonia 2 Murder 1 Want of skilled attention at birth 4 Erysipelas 1 Twist in intestine 1 Peritonitis 1 Rupture of bowel 1 Rupture of uterus 1 Hæmorrhage 2 Syncope 2 Jaundice 2 Congenital heart disease or malformation 11 Congenital kidney disease 1 Hydrocephalus 1 Burns 1 Stillbirth 6 18 108 During the year 1914, 393 cases of puerperal fever were notified in the County, and the Registrar General records 182 deaths from puerperal septic disease during the year. The term puerperal septic disease used by the Registrar General includes puerperal septicæmia, pyæmia and sapræmia, as well as peritonitis and metritis occurring in connection with parturition. A list of deaths is received weekly from the Registrar General and the deaths are compared with the notified cases so that it is possible to ascertain whether the latter terminate fatally. Of the 393 notified cases, 113 proved fatal, a case-mortality of 28.7 per cent. The other deaths, 69 in number, related to cases which were not notified as puerperal fever. Puerperal fever. Early information of notified cases of puerperal fever is received from the Metropolitan Asylums Board or from the borough medical officers, and particulars as to the person by whom the patient was delivered have been supplied by the latter. The following table gives the results of the inquiries relative to these cases notified and unnotified:— Delivery conducted by Cases. Deaths. (a) Medical practitioners (including cases attended by medical students and also cases in which a medical practitioner was in charge of the case, but the birth took place before his arrival) 212 70 (b) Certified midwives (including cases in which birth took place before the arrival of the midwife) 111 24 (c) Medical practitioner and certified midwife, i.e., cases in which a midwife was unable to deliver and called in a medical practitioner 10 1 (d) Hospitals and poor law institutions 68 47 (e) Cases of miscarriage or abortion where no attendant was engaged 53 38 (f) Uncertified persons acting in emergency 6 2 (g) No skilled attendant 2 0 462 182 27715 l 2 76 Annual Report of the London County Council, 1914, The cause of death as stated in the death certificates in the fatal cases occurring in London is shown in the following table:— Cause of death. Notified cases. Unnotified cases. Total. Puerperal septicæmia, toxæmia, and septic absorption 74 30 104 [12] Puerperal peritonitis 4 25 29 [6] Pyæmia 8 2 10 [1] Sapræmia 4 1 5 [1] Puerperal fever (not defined) 18 2 20 [4] Metritis, perimetritis, parametritis and endometritis 2 1 3 Pelvic cellulitis 1 1 2 Salpingitis 0 1 1 [1] Septic pneumonia 1 4 5 [2] Septic tuberculosis 0 1 1 Septic thrombosis 0 1 1 Rheumatic endocarditis 1 0 1 113 69 182 The number of fatal cases of puerperal fever which followed abortion or miscarriage was 27. The classification of these cases is shown by the figures in brackets in the last column of the above table. The age incidence of the 462 cases was as follows:- Total. 15-20 20-25 25-35 35-45 Over 45 Recovery cases 280 6 67 145 62 - Fatal cases 182 6 28 84 64 — In each case where a midwife was concerned the Council's inspector visited her, learnt particulars of the case, made enquiries as to any other patients recently attended, and took steps to ensure that the rules as to disinfection were fully carried out before the midwife resumed her work. The rule which requires that medical help shall be advised when the patient's temperature rises to 100.4 deg. and remains above that figure for 24 hours has proved useful in affording information concerning cases in which there is danger of the development of puerperal fever; 271 notices were received stating that medical assistance had been ad vised for this reason. The inspector learnt from the midwife whether the high temperature was persistent, and in 160 cases it was found that the temperature had fallen, or that no further symptoms of puerperal fever had occurred. In cases of puerperal fever the services of the nurses of the Queen Victoria Jubilee Institute and the Holloway Institute are usually available in the districts which they serve, so that when the midwife ceases to visit, the patient is left in the hands of a skilled nurse to carry out the directions of the medical practitioner called in. In cases where a midwife has pupils or assistants, one of them is sometimes set apart to nurse the septic case, attending no other patients meanwhile. A midwife is thus usually able to carry out disinfection and resume her work with as little delay as is necessary to ensure that she is no longer likely to be a source of infection to other patients. The following table shows the day of the puerperium on which (a) the rise of temperature if noted) occurred, (b) medical aid was obtained, and (c) if fatal the death took place. Day of confinement. 2nd day. 3rd day. 4 th day. 5th day. 6th day. 7th day. 8th day. 9th day. 10th day. After l0th day. Not stated, Total. Rise of temperature— Recovery cases 2 7 13 14 13 9 6 8 1 2 6 6 87 Fatal cases 1 1 4 7 1 2 1 3 1 1 2 0 24 Medical aid obtained— Recovery cases 10 4 9 15 13 7 5 5 1 3 6 9 87 Fatal cases 4 0 1 5 3 2 0 5 2 0 2 0 24 Fatal cases—Day of death 0 0 1 0 1 2 1 0 1 2 14 2 24 Report of the County Medical Officer—General. 77 The parity of women who contracted puerperal fever was ascertained from the midwife to be:— Total. Primipara.. 2 para. 3 para. 4 para. 5 para. 6 para. 7 para. 8 para. 9 para. 10 para. Over 10 para. Not stated. Recovery 87 18 11 5 13 7 5 8 6 2 l 7 4 Fatal 24 6 l 3 4 2 1 3 3 0 0 0 1 The following conditions were noted among the cases of puerperal fever attended by midwives:— Recovery. Fatal. Laceration of perineum 6 2 Retained or adherent placenta 6 2 Ante partum hæmorrhage 1 1 Post partum hæmorrhage 8 1 Prolonged labor 4 2 Domestic trouble after confinement 3 2 Phthisis, tuberculosis, pleurisy, bronchitis 3 2 In seven cases of puerperal fever, birth took place before the arrival of the midwife. It is the duty of a midwife to advise that medical help is required when inflammation of the eyes, however slight, occurs in infants. When a notice is received from a midwife that medical assistance has been sought on this account, the Council's medical inspector at once visits the infant to ascertain that it is receiving the medical assistance which the midwife has advised, and the medical officer of health of the borough in which the patient resides is immediately informed of the condition of the case and whether the infant is being removed to a hospital for treatment. The midwife is also visited to learn particulars as to the case, the antiseptic precautions taken and the disinfection adopted by the midwife after each visit to the case. Moreover, in order that skilled attention should so far as possible be available, the Queen Victoria Jubilee Institute, the Ranyard Nurses Society, the Holloway Nursing Institute, and the Nursing Sisters of St. John the Divine were asked if they would be willing to allow their nurses to undertake, under the direction of the medical practitioner called in, the care of these infants in order to see that the necessary irrigation or swabbing of the eyes was properly done, and at the proper intervals. All the above societies readily consented and during the year their services were made use of in 27 cases. During the year 488 notices were received from midwives, stating that medical assistance had been advised on account of inflammation of the eyes of infants, and, during the year, the results of investigation into 537 cases were reported to the Midwives Act Committee. 456 cases were reported to be completely cured. In 6 cases there was impairment of vision, 20 died while still suffering from the disease, 2 were still under treatment, and in 53 instances the result could not be ascertained owing to the removal of the parents, who could not be traced. The day of the puerperium on which signs of inflammation were first noticed was: day of confinement, 20 cases; second day, 38; third day, 65; fourth day, 60; fifth day, 63; sixth day, 45; seventh day, 52; eighth day, 57; ninth day, 38; tenth day, 50; later than tenth day, 39; not ascertained, 10 cases. A history of vaginal discharge in the mother was obtained in 213 instances, i.e., in 39.7 per cent. of the cases. The antiseptics used for the child's eyes at birth or as soon afterwards as possible were boracic lotion in 160 instances; perchloride of mercury (1 in 4,000 or weaker) in 229; silver nitrate (a 1 or 2 per cent. solution) in 63; protargol in 16; biniodide of mercury in 2; boracic lotion followed by perchloride of mercury in 7; boracic lotion followed by silver nitrate in 12; boracic lotion followed by protargol in 2; perchloride of mercury followed by boracic lotion, 13; perchloride of mercury followed by silver nitrate in 2; protargol followed by perchloride of mercury in 1; cyllin in 1; sterile water in 20; and in the remaining 9 instances no details could be obtained. An interval between the birth and the use of an antiseptic occurred in 94 instances owing to the fact that the infant was born before the arrival of the midwife. The following facts relating to the six cases in which impairment of vision supervened were learnt: (1) No history of vaginal discharge in mother. Boracic lotion used for eyes at birth. On the 5th day a speck of matter was noticed in the corner of one eye, but there was no inflammation. Medical aid was obtained on the following day. Result—Sight of right eye impaired. (2) Vaginal discharge in mother. A two-per-centum solution of silver nitrate used for eyes at birth. Onset on fifth day, only the right eye being affected; medical aid obtained at once. Result.—Small opacities to the outer side of each eye. No nystagmus at present, and child appears to see fairly well. (3) Vaginal discharge in mother. A solution of perchloride of mercury (1 in 4,000) used for eyes at birth; onset on seventh day, only the left eye being affected; medical aid obtained on that day. Result.—Eyesight permanently injured. Ophthalmia Neonatorum 78 Annual Report of the London County Council. 1914. (4) Vaginal discharge in mother during pregnancy. Solution of perchloride of mercury (1 in 6,000) used at birth. Onset on the fifth day, both eyes being affected, and medical aid obtained on that day. Result.—Permanent impairment of the sight of one eye. (5) No history of vaginal discharge in mother. A weak solution of perchloride of mercury (1 in 6,000 to 1 in 8,000) used for the eyes at birth. Onset on 11th day, both eyes being affected. Medical aid was obtained on day of onset. Result.—Sight of left eye normal, but in the internal inferior quarter of the cornea of the right eye there is an opacity causing partial blindness, but does not extend to the central point of the pupil. (6) Definite history of gonorrhoea in both parents. A solution of perchloride of mercury (1 in 6,000) used for eyes at birth. Onset on day of birth, and medical aid obtained on that day, both eyes being affected. Visits to hospital were not continued. Result.—Loss of sight of both eyes. All the midwives who had three or more cases during the year have extensive practices, and it was found that many of the cases reported were very slight and the eyes were normal in a few days. So far as could be ascertained there was no evidence that infection was carried from one case to another. The Council has endeavoured to secure accommodation for the mother and infant so that while the child was being treated it would not be deprived of the advantage of being breast-fed, but only two institutions have at present sufficient accommodation for this purpose. In March, 1911, the Council made an order extending the provisions of section 55 of the Public Health (London) Act, 1891, to ophthalmia neonatorum. Of the 2,898 cases notified from that time until the end of this year, 732 were in the practice of midwives. During the year the Local Government Board issued a series of regulations, known as the Public Health(Ophthalmia Neonatorum)Regulations, which came into operation on 1st April, 1914. By these, notification of cases of the disease is required not only from a medical practitioner, but from a certified midwife if the case had not already been notified, and a fee of one shilling is payable to her in respect of notification. In the regulations, Ophthalmia Neonatorum is defined as a "purulent discharge from the eyes of an infant, commencing within 21 days from the date of its birth."During the nine months ended 31st December, 1914, 127 notifications were received from certified midwives by the medical officers of health of the several metropolitan boroughs. Registration of Lying-in Homes. On 21st October, 1913, the Council decided under the provisions of section 4 of the Borough Funds Act, 1872, as applied by the County Councils (Bills in Parliament) Act, 1903, to promote legislation in the session of Parliament of 1914 to confer upon the Council power to prohibit the use of any premises as lying-in homes or institutions unless they and the person or persons in charge thereof had been licensed by the Council. This decision was subsequently modified by the substitution of registration for licensing, but the proposals have not yet passed into law. Work of the Chemical and Analytical Branch of the Public Health Department. The work conducted at the Central Laboratory at Savoy-hill comprises the examination of samples received under certain statutes administered by the Council; of other materials used by or for the Council in connection with its several undertakings and of materials concerning the nature and properties of which information is desired by Committees or officers of the Council. In addition, advice on matters involving the application of chemistry, or allied sciences has been given when desired and investigations have been made, or are in progress,on various matters of importance to the Council. The samples examined at the Central Laboratory may be classified under four headings, viz:— (i.) Examined in connection with Statutes:— Fertilisers and Feeding Stuffs Act, 1906.—London is not an agricultural county and most of the samples examined by the agricultural analyst were received from the Council's own institutions. The effect of this Act and of the Act of 1893 for which it was substituted, has undoubtedly been to stop the gross adulteration of feeding stuffs with worthless or poisonous materials which was prevalent 20 or 25 years ago, and to ensure that both fertilisers and feeding stuffs with few exceptions are in fair agreement with their guaranteed composition. On the other hand there has been a general downward tendency in the richness of feeding stuffs. The goods supplied are in most cases pure but of poorer quality than they were 10 or 20 years ago. Petroleum Acts.—Most of the samples examined in 1914 under these acts were of ordinary burning oil taken by inspectors of the Public Control Department at petroleum stores and wharves, but samples of quick drying paint, of various varnish and cleansing materials and of paint remover suspected to contain petroleum were submitted for examination and in some cases proved to contain petroleum to which the Acts apply. By an order in Council of 1907 certain parts of the Petroleum Acts are stated to apply to mixtures of petroleum with other substances, as such mixtures present danger similar to those presented by petroleum without admixture. This order confirmed the view which had been successfully maintained by the Council of the meaning of the Acts. The samples other than petroleum were examined in connection with this order. In connection with the granting and renewal of licenses under these Acts several samples of gas from dry cleaning plants were examined to ascertain whether the risk of explosion from the light petroleum used to remove grease and dirt from the materials to be cleaned was reduced to a minimum. Explosions of a serious nature have occurred in such plants when special precautions have not been taken. L.C.C General Powers Act, 1912.—An act regulating the storage of the less easily volatile grades of petroleum and of inflammable oils. In all these cases a somewhat extended examination of the substances stored is necessary in order that their chemical nature and the applicability of the Act to the particular case may be determined. Report of the County Medical Officer—General. 79 London Building Acts.—A number of samples of mortar and other building materials have been submitted under this Act by the Superintending Architect and District Surveyors in order to ascertain whether their composition was in accordance with the bye-laws and in one instance the costs of analysis and attendance at court were recovered by the district surveyor in court. The results obtained from the examination of samples in connection with the statutes referred to are summarised in the following table:— Satisfactory. Unsatisfactory. Total. (1) Fertilisers and Feeding Stuffs Act, 1906 Fertilisers 7 2 9 Feeding stuffs 42 3 45 (2) Petroleum Acts — - 374 (3) L.C.C. General Powers Act, 1912. (Storage of Petroleum.) — - 27 (4) London Building Act - - 10 465 (ii) Examined in connection with works or contracts undertaken by or for the Council:— Building materials 322 80 402 Foods for necessitous children— Meals 49 1 50 Milk 193 25 218 Other articles 58 14 72 The proportion of cases in which milk supplied for feeding necessitous children was defective was high—12.9 per cent. The average percentage adulteration in metropolitan boroughs of samples examined in 1913 under the Food and Drugs Act was 8.7 per cent., and for the whole of England and Wales 9.5 per cent. (iii) Stores supplied to the Council and its Committees:— Satisfactory. Unsatisfactory. Total. Food stuffs 166 26 192 Oils, paints, etc. 463 71 534 Cleansing materials 156 12 168 Disinfectants 31 6 37 Incandescent mantles 176 462 638 Coal - - 467 Miscellaneous - — 1,148 The greater number of unsatisfactory foodstuffs were jams which, although otherwise pure, had been coloured by the addition of artificial dyes. (iv) General.—Several examinations were made at the request of Chief Officers with a view to ascertaining the ground of complaint as to articles supplied, the failure in use of materials and the value of certain patent preparations. Examination of 5,375 specimens of urine has been made. In 598 cases albumen was found, casts were present in 9 and sugar in 2 cases. The Council decided to co-operate with the Committee for the Investigation of Atmospheric Pollution, who are conducting an enquiry on a large scale in London and other centres. The analytical work in connection with this investigation has been undertaken at the central laboratory. Assistance has also been rendered to the Commissioner of Police in connection with the examination of oils, etc., with a view to assisting in carrying out the provisions of the Defence of the Realm Act. A report on the result of an investigation was submitted to the Public Control Committee. River examination.—Ihe usual daily examination of the sewage and effluent and of the water of the river off the outfalls at both states of the tide has been carried out at the laboratories at Barking and Crossness. The number of samples examined is set out below:— Northern Southern Outfall. Outfall. Sewage 350 349 Effluent 349 348 River water 572 574 In addition about 50 duplicate samples of effluent taken by the Port of London Authority, as well as a number of samples of deliveries of lime and protosulphate of iron were chemically examined. Special examination of the tidal waters of the river Thames in connection with the treatment of sewage was continued save during the months of April, May and June. This work involves the examination of specially collected samples of water taken from several points between the Black Deep at the mouth of the Thames, and Teddington lock, the upper limit of the tideway. The inquiry is still proceeding and it is not at present possible to refer to any of the results obtained, except to state that under the present exceptional conditions they possess a special value. The work has been carried out principally by the staff at the Outfall Laboratories which has been temporarily augmented for the purpose. In connection with the above inquiry the various tributaries and canals connected with the Thames have been examined and a certain amount of laboratory investigation on matters relating to the general question of river purification has been undertaken by the Staff at the Central Laboratories. Biological treatment of sewage.—An investigation of a biological method of sewage treatment which presents some new features was started in 1914 and is still proceeding. Sewage precipitation and river examination CHAPTER XXIV RETORT OF THE COUNTY MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER (DR. W. H. HAMER) FOR THE YEAR 1914. Part II.—Education. Introductory Note. The year 1914 is the third completed year since effect was given to the Council's resolution of 25th July, 1911, reorganising the London school medical service. In the report relating to the year 1913 special reference was made to the question of the medical staff, its numerical strength, permanency and duties. During that year the Board of Education had caused inquiry to be made by its medical inspectors into the working of the Council's inspection and treatment schemes, and arising out of this inquiry certain criticisms of detail were made by the Board and embodied in a letter sent to the Council on 24th June, 1913. This letter was set out in full in last year's annual report and suggestions were made with a view to meeting the points raised. These suggestions had not, however, at the time of preparation of that report been in their entirety considered by the Council and it was not until the 2nd July, 1914, that the Council was in a position to reply fully to the Board's letter. The reply is reproduced in full on pages 83-85. Staff considerations As mentioned in last year's annual report, the question of the medical staff was already receiving attention at the time of the receipt of the Board's letter, the outcome of this consideration being the re-arrangement of the duties of the medical assistants engaged in inspection in the schools, so that their services are now utilised in connection with the whole field of school work in the Council's public health department. The other changes summarised in the Council's letter of the 2nd July last, involved more prolonged consideration, many conflicting interests had to be reconciled, and the importance of the questions precluded hasty decisions. The results, however, briefly stated, were as follows—the organising staff was increased and a definite proportion of its members (54 organisers and 12 women clerks) was allocated to the public health department; arrangements were made for the treating doctor at the centre or hospital to be furnished with full information as to the defects of the children referred to him; the facilities for nursing treatment were increased; and several minor matters arising out of inspection, re-inspection and treatment, were dealt with. Owing to conditions arising out of the war, serious hindrance has been felt in carrying into practical effect some of the decisions communicated to the Board. In several of the districts owing to absence of the permanent school doctor, it has been necessary to carry on his work with the aid of temporary assistance. In the treatment centres and hospitals many changes have occurred in personnel, thus causing interference as regards continuity of method. Difficulty has also been experienced owing to the changes in the nursing staff in consequence of the war. It is evident that it would be premature at the present time to express any final opinion on the new methods. Other changes made during the year. During the year 294,026 children were examined by the assistant medical officers, and of these 101,432 were found to require treatment for one or more defects. The parents were present in 68 per cent. of the cases examined. Dr. C. J. Thomas has examined the results, and it has been possible for him to make comparison between the figures for three years of medical inspection, 1912, 1913 and 1914. The comparison thus made indicates a gratifying improvement in many directions. The percentage of children found suffering from enlarged tonsils and adenoid growths requiring operation continues to be lower than was formerly the case. There appears, moreover, to be a steady improvement in neatness and cleanliness of all children which reflects great credit upon the unremitting efforts for amelioration made by school nurses, head teachers and care committee workers. In comparing the incidence of defect upon age and sex it is found that although starting school life on an equality with boys, the girls at the leaving age show an excessive incidence compared with boys in respect to visual defect, deformities, heart defect, anaemia and nervous disease. This excessive incidence suggests that girls as a whole spend a less healthy and hygienic life than boys, and one of the problems of hygiene remaining to be solved is how to give the girls an equal place in the sun with the boys. Medical Inspection. In the Council's letter to the Board of Education reference has been made to the increase of facilities for nursing treatment, but it may be emphasised that at the end of the year provision had been made for the treatment of nearly 20,000 cases as against 12,320 at the end of 1913. Experience moreover shows in the case of nursing treatment that better attendances have been secured as the number of centres has been increased. The average numbers under the agreements during 1913 were 12,082, while the attendances numbered 10,159, a deficiency of nearly 2,000. During 1914, the numbers were respectively 15,183 and 14,634, a shortage of less than 600 upon considerably higher numbers. Except as regards dental treatment, little alteration has been found to be necessary in the arrangements for treatment, though throat and aural defects show a further decrease, 12,961 cases being treated, as against 13,618 in 1913; eye cases, however, show an increase of some 3,000. The most important sphere of usefulness in a treatment scheme is undoubtedly to be found in dental defect. The demand for dental treatment in London is increasing so rapidly that the provision authorised for the year beginning on the 1st April, 1915, is for more than 63,000 cases, or, roughly, three and a half times as many as two years earlier. For all classes of ailments treated under the Council's scheme, the centres, including hospitals, at the end of the year numbered 42, providing for 98,976 children, as against 34 centres providing for 84,359 children at the end of 1913. Medical and Dental Treatment. It must not be forgotten that every material extension in the development of a treatment scheme involves a corresponding increase in the work of "following up." The Council, has fortunately been able to avail itself of the help of a large body of voluntary workers, inasmuch as each school or group 27715 m "Followingup." 82 Annual Report of the London County Council, 1914. of schools has its own care committee. The school care committee organisation is assisted by a staff of paid organisers. The activities of the whole organisation in connection with medical work are many, and they have contributed greatly to the success of the Council's treatment scheme. Attending at the medical inspection, explaining the doctor's recommendations, advising the parent as to how to secure treatment, visiting to ensure that treatment is obtained, and again to see that continuing care is persevered in, arranging for food for the necessitous, for convalescent homes for those needing them, and for the prevention of cruelty; in all these ways it is possible for the care committee to assist the education authority in its oversight of the physical development of the children in its schools. The task of supplying the care committees with such information as they require lies with the staff of trained organisers and it is to their marked ability that much of the success of care committee workis due. Re inspections. 84,500 re-inspections of children found defective were made during the year. The results of re-inspection show that out of every 100 children found defective 50 per cent. had commenced to receive treatment by the end of six months, and, after a further six months, treatment had been commenced in 23 per cent, of the remainder. In the cases of ear, nose and throat defects, and of dental defects, difficulty has been especially experienced, but this difficulty is steadily diminishing. The success of the Council's treatment arrangements is shown by the fact that children are more rapidly and satisfactorily dealt with under the Council's scheme than by other methods of treatment. Special measures for improving the attendance of children for treatment Special reference must be made to two measures adopted during the year which it is hoped will have the effect of removing difficulties previously encountered in persuading parents to obtain treatment for their children. The first measure is referred to in a minute amending article 44 of the Code, which provides that time spent at a treatment centre or hospital included in the medical treatment scheme of a local education authority, as approved by the Board, may be regarded as school attendance. This provision removes a difficulty felt not only by teachers, but by the children and the parents themselves, for many parents are as interested as the teachers in regularity of attendance at school. As a hindrance to treatment, objection on this ground may appear to be trivial, but its influence is real and has been marked by many observers. Some increase in grant is obtained under the new regulation, though not to the extent anticipated owing to the cost of the machinery for registration at the hospitals and centres. The second measure was given effect to by the Council on the recommendation, of the Highways Committee, and permits parents and children visiting or returning from school treatment centres and hospitals co-operating with the Council to travel any distance in a single tramcar for one halfpenny for each each person. This arrangement has been much appreciated by the parents, especially in cases where many visits have to be made for continuing treatment. Government grants. The regulations of the Board of Education issued in August, 1913, provided that grants would be made to local education authorities in respect of medical inspection as well as in respect of medical treatment and work ancillary to treatment. The amount received in 1914 for the year ended 31st July, 1913, was £31,191 1s. 6d. or 48 per cent. of the total expenditure on these services. A letter dated 29th March, 1915, has been received from the Board stating that for the year ended 31st July, 1914, it has been decided to make a grant of £38,149 7s. in respect of the school medical service. The Board's letter continues as follows:— "The Board are glad on this occasion to recognise, by the payment of grant at the maximum rate, the steps taken by the authority to remedy the defects in their school medical service to which attention was drawn as the result of the last inspection of the work by the Board's medical officers. It should, however, be understood that the assessment will be subject to annual revision, and that in fixing the rate of grant in future years the Board will have regard not only to the maintenance of the existing standard of efficiency, but also to the extent to which provision is made for such improvements and developments of the work as may be required in order that the needs of the area may be completely met." Examination of Candidates. The number of candidates for permanent appointments in the school service and candidates for scholarship awards who were medically examined decreased from 6,045 to 6,015. Special reports were made in regard to 1,012 employees who were unable to carry out their duties owing to personal illness, an increase of 214, or 26.8 per cent. In addition, 250 claims for exceptional treatment in respect of illnesses alleged to have been contracted during the course of school duties were investigated. The pupils in the Council's institutions for higher education, and the London County Council scholars in attendance at aided secondary schools, have also been inspected. Open air Schools. The open-air schools at Birley House and Shooters Hill were both kept open throughout the year. The Kensal House School for tuberculous children has been continued. The playground classes have largely increased in numbers and some of them were held in the public parks. Special Schools. 6,963 children were examined with a view to admission to special schools; of these 3,165 were certified as suitable for admission thereto, and the remainder were either returned to the elementary schools or found to be unsuitable for any of the Council's institutions. The results of the periodical re-examination of the children in the schools for the mentally and physically defective are also shown. An analysis of 150 cases of idiocy and imbecility made by Dr. F. C. Shrubsall appears on page 137. Personal hygiene scheme. The council's cleansing schemes have been in operation throughout the year, mere are now 24 stations, at 20 of which treatment has been extended by the inclusion of scabies. 917,582 children were examined, of whom 28,361 were found to be verminous. 14,392 children were cleansed by the parents and 42,557 cleansings were carried out by the Council and borough councils. 589 children suffering from scabies were given a total of 3,212 baths. Proposals are under consideration Report of the County Medical Officer—Education. 83 for bringing within the scope of the scheme verminous children attending schools in outlying districts by means of an ambulance service, and for providing at reduced rates, hot baths for persons under and over school age. In the secondary schools two pupils were proposed for permanent exclusion from the institutions and eight for withdrawal of scholarships owing to unremedied defects in personal hygiene. The depletion of the medical staff owing to war service has interfered with the continuity of work of a special character. Something has, however, been done in connection with open-air methods and detailed reports upon playground classes have been received from several of the assistant medical officers, including Drs. Norman, Cowell, Elizabeth M. McVail, Margaret C. Macdonald and Griffiths (p. 116). Special note should be taken of the reports of Dr. F. T. H. Wood and Dr. O. H. Peters upon the open-air schools at Birley House and Shooter's-hill respectively (pp. 112-G). Dr. J.G.Forbes has made a special examination of tuberculosis contacts and a summary of the results will be found on p. 94. An investigation of the physical condition of children upon the necessitous lists has been carried out by Dr. Elizabeth M. McVail and Dr. G. Chaikin (p. 108). Dr. Leipoldt has communicated the results of his observations in the schools upon conditions associated with the thyroid gland in children (p. 89). Reports upon remedial exercise classes have been sent in by Drs. Mabel Russell, Ruth Proctor and A. E. Wells (p. 118), upon holiday excursions by Drs. Forbes, Peters, Margaret Macdonald, Lea, Davies, Malcolm, Mabel Russell, Palgravc, Kidner, Lewis, Wood, Norman and Hanson (p. 118), and by Dr. A. C. Williams on the mental condition of paralysed children. Special reports, Letter of the Board of Education, 24th June, 1913. In last year's annual report reference was made in some detail to the letter from the Board of Education dated 21th June, 1913, embodying criticisms on the working of the Council's schemes of inspection and treatment. Proposals for meeting these criticisms, were outlined, but at the time of preparation of the report they had not been fully considered by the Council, although an interim reply on minor matters had been sent to the Board on 29th July, 1913. This letter was as follows:— 1. London. 29th July, 1913. 2. School Medical Service. Sir,—With reference to Mr. Davies' letter of the 24th ultimo (M.3303/13), I am directed to state that the Council has given careful consideration to the points raised therein. With regard to that part of the Board's letter relating to "following up," to the arrangements for medical treatment, and to the extension of the functions of the assistant medical officers (paragraphs 5, 8 and 9), I have to say that a further communication will be sent to the Board as soon as possible. With regard to the point raised in paragraph 3 as to certain inspection work being undertaken by nurses instead of by doctors, I am to state that it is necessary, in order that the requisite number of children shall be inspected by the doctor at each of his visits, that some routine work should be done by the nurses in preparation for the inspection. In this connecttion it may be stated that the physical measurements carried out by the nurses during 1911 are in complete agreement with the standards arrived at in former years from measurements made by the medical officers. Arrangements are, however, being made for the school doctors to take the physical measurements both at the inspections and at subsequent re-inspections of those children who are found to be suffering from malnutrition. The school doctors have also been instructed to examine all cases of defective vision reported as a result of the preliminary examination by the nurse, and it has been decided that during the coming educational year the standard of defect for which children are referred for treatment shall be made more stringent. In connection with the examination of defective hearing, it has recently been arranged that the preliminary examination of children for hard-of-hearing classes shall be made jy the school doctor himself, and cases considered suitable are being further specially examined by the Council's otologist. The question of the investigation of absence due to illness, referred to in paragraph 6, is receiving consideration, and modifications of the existing practice are made from time to time in order to meet the exigencies of the situation. Some time must, however, elapse before the information made available can be fully utilised. With regard to paragraph 7 as to the desirability of establishing inspection centres for more detailed examination, I am to state that arrangements have been made whereby the treatment centres have been available for special medical inspections. It has not been found possible to arrange special inspections as frequently as might be desirable, owing to the fact that the statutory inspections and the re-inspection of children in the schools take up practically the whole of the school doctors' time. Moreover, there has been difficulty in securing the attendance of children on Saturday mornings. In view of these circumstances the Council has combined special inspections with the ordinary statutory inspections in the schools themselves. This question will be further dealt with in the later communication to be sent to the Board. I am to add that the Council notices with satisfaction that the Board finds that, as a result of the organisation of the work carried out during the past year, satisfactory arrangements have now been effected, and that the Board expresses its appreciation of the arrangements made for systematic re-inspection. I am, Sir, The Secretary, Your obedient servant, Board of Education, R. Blair, Whitehall, S W. Education Officer. 27715 m 2 84 Annual Report of the London County Council, 1914. The final reply of the Council was sent on 2nd July, 1914, and in conjunction with the previous letter covered all the points raised by the Board. This letter is here reproduced:— 1. London. 2nd July, 1914. 2. School Medical Service. Sir,—The Council has given further consideration to the points raised in paragraphs 5, 8 and 9 of Mr. Davies' letter of 24th June last (M.3303/13), relating to "following-up," to the arrangements for medical treatment, and to the extension of the functions of the assistant medical officers. With regard to the point raised in paragraph 5, as to the arrangements for "following-up and to the suggestion that a proportion of the staff of organisers of Care Committee work should be allocated to the School Medical Officer, I am to state that it has now been decided to place the organising staff on a permanent basis, to enlarge its numbers, and to allocate to the School Medical Officer a certain proportion of the staff based upon the amount of work involved in connection with the school medical service. For the proper organisation of the work of medical inspection and treatment the Council has decided that London shall be divided into five divisions, and that the medical work in each of these divisions shall be placed in charge of a divisional medical officer. In the five divisional offices the administration of the treatment centre work will be focussed, and officers allocated to the public health service will be employed to deal more particularly with the voucher and "following-up" work connected with the treatment centres. Under the reorganisation the staff of organisers is being increased from 74 to 82, and, in addition, 29 women clerks are to be appointed. Fifty-four of the organisers and twelve of the women clerks are being allocated to the public health department, the work of the whole of the organising staff being co-ordinated by the Education Officer and the School Medical Officer through a principal organiser who is an officer attached to both the education service and the school medical service. Certain criticisms of the Board in connection with medical treatment, referred to in paragraph 8, have been given very careful consideration, and in connection therewith, I am directed to state that arrangements have been made for the medical officers of the treatment centres to be furnished with full information as to the nature of the defects of the children referred to them. With regard to the restriction of dental treatment to the 6-8 age group, I am to point out that it is the practice to make appointments for older children only in cases of those urgently needing assistance, and to furnish facilities for treatment at such times as the accommodation at the centre permits. In connection with the statement of the Board that the arrangements in respect of nursing treatment are not considered to be satisfactory, the Board will remember that, since the receipt of their letter, additional facilities have been provided and further schemes will be submitted for the Board's approval as opportunity arises. It is proposed that arrangements shall be made whereby the school doctor shall inspect at the centre children requiring nursing treatment referred by care committee workers, school nurses, teachers and attendance officers with a view to referring immediately to the proper department those cases found to be suitable for treatment under the Council 's arrangements. The organiser of care committee work at the centre will communicate with the care committee in order that the necessary investigation and assessment may be made. With regard to the suggestion of the Board as to the treatment of the cases of discharging ears, I am to point out that the Council's otologist has given careful consideration to this question and has visited many of the centres at which the treatment of discharging ears is carried out. The other duties which it is necessary for him to perform do not admit of the extension of his work in this direction, but in the arrangements now being made provision is included for certain of the school doctors, who have had special experience, to pay special attention to this side of the work. With regard to the extension of the functions of the school doctors, I am to state that the Council has recently approved a scheme whereby it will be possible to introduce into the duties sufficient variety to obviate the danger indicated by the Board. The scheme involves, as before-mentioned, the division of London for the purposes of medical administration into five districts,each placed in charge of a divisional medical officer and, in order to meet the new requirements of the Board, it has been found necessary considerably to augment the medical staff. In each division the staff under the control of the divisional medical officer consists of a nucleus of permanent medical assistants, the remainder of the staff consisting partly of full time temporary medical assistants appointed for a period of three years only, and partly of temporary quarter time school doctors appointed for a period not exceeding two years. With the recently appointed staff, and with the re-distribution of the work, the numbers of the medical staff now engaged in school medical inspection comprise, in addition to the central staff and the five divisional medical officers, 17 permanent full time medical assistants, 20 temporary full time medical assistants and 20 part time school doctors. The work of the last named class of doctors will be practically confined to inspection, and there will thus be additional opportunity to vary the duties of the permanent officers by utilising their services in connection with special schools, secondary schools and higher education institutions, inspections at treatment centres, special investigations and general public health work. It has 85 Report of the County Medical Officer—Education. already been possible to employ the permanent officers on work of this kind. I am desired to point out that the increase in the number of part time school doctors is in the nature of an experiment, which will be reviewed at the expiration of two years, and the number of permanent medical officers that will ultimately be necessary will depend to some extent upon the results which will be found to have been obtained. I am to express the hope that the above arrangements set out will meet with the approval of the Board. I am, Sir, The Secretary, Your obedient servant, Board of Education, R. Blair, Whitehall, S.W. Education Officer. All the arrangements forecasted in these two letters have actually been put into operation, and so far as they relate to the separate branches of work are described under those heads. Unforeseen difficulties connected with the war have somewhat restricted the progress which might otherwise have been expected, and at the end of the year no final conclusion could be drawn as to the efficiency of the measures adopted. There has, for instance, been considerable interference with the staff arrangements, the nucleus of permanent medical assistants has been of necessity considerably reduced, and it has been necessary to employ substitutes. Although these substitutes have worked very well indeed, they have necessarily not had the knowledge, possessed by the permanent staff, of the special conditions obtaining in the schools. In these circumstances the full effect of the new arrangements has not yet been realised, and it will be necessary to wait for the return of normal conditions before any complete and reliable estimate can be formed of the value of the alterations made. Medical Inspection. The examination of children was carried out in accordance with the regulations of the Board of Education and the table appended to this report shows the details of the inspection of the various age groups. The work of inspection during the early part of the year was carried out by a staff of 31 full time and 4 quarter time assistant medical officers working under the direction of 5 divisional medical officers. On the outbreak of the war several members of the staff were called up for military duties and their places were in most instances filled by medical practitioners giving part of their time to this work. This inspecting staff was assisted by 106 members of the nursing staff, who prepare the children for examination and assist in the weighing, measuring and vision testing. Arrangements are made for an examination to be held each term in every school, and in larger schools several times each term, so that any special cases may be brought to the notice of the doctor. The date of the inspections at all schools is notified in the Council's Gazette and the parents of children due for examination are invited to be present. A representative of the Care Committee is also invited to attend at the time of examination in order to make arrangements to secure that the child receives medical treatment where this is necessary. When a child is found to be in need of medical treatment a card is issued to the parent pointing this out and if the parent is not present at the inspection the school nurse visits and delivers the card at the home. The scheme of inspection was as follows:—During the first term leavers were examined. The expression "leaver" being taken to mean a child reaching the age of 12 during the year, i.e., a child born in the year 1902. During the second term the inspection of entrants was carried out. An entrant is a child entering a public elementary school who has not been medically examined either at that or at any previous school. The term "entrant" is limited to children in the infants' department of the school, and the majority of these children are under 6 years of age. The following table shows the ages of the entrants examined during the year 1914. Age 3—4. Age 4-—5. Age 5—G. Age 6—7. Age 7—8. Total. Boys 6,478 15,753 21,231 3,437 743 47,(642 Girls 5,778 14,431 22,302 3,703 837 47,051 Total 12,256 30,184 43,533 7,140 1,580 94,693 12.9% 31.95% 460% 7.5% 1.7% 100% During the third term of the year the remaining leavers were examined and also any children who had in the meantime entered school. The remainder of the inspection during this term was devoted to the examination of an intermediate group, children at age 8. The examination of this group has not hitherto been required, but the Board of Education has decided to make this one of the statutory age groups from 1st April, 1915. The restriction of the inspection to children of one age group in each term was brought about by the necessity for ensuring the complete inspection of the entrant group. Children, as a rule, begin school in the Summer Term, and, as the Board of Education year formerly ended in July, it was necessary to inspect this age group almost exclusively during that term. As three age groups are now included in the Board's requirements for medical inspection, it is proposed to carry out the inspection as the children arrive at school and reach the ages of 8 and 12 years. The fact that the Board of Education year now begins in April makes it possible, while ensuring that practically all entrants are examined 86 Annual Report of the London County Council, 1914. in the education year in which they first come to school, to distribute the work equally over the three terms. It is hoped in consequence that the work of the treatment centres will be more evenly distributed over the year. The infants are not tested for visual acuity, and it formerly resulted that in one term there were very few cases for the treatment centres, while in another term there were more cases than could be conveniently dealt with. Special and urgent cases are examined at any time the doctor is present at the school, or the child may be presented for examination at another school or other convenient centre in the neighbourhood. Total number of children inspected. The number of children inspected in the calendar year was 228,414, made up of 94,723 entrants, 66,540 of the age group 8-9 years, and 67,151 leavers; but counting in addition all urgent cases and special examinations, as well as the physical examination in the age groups of children in the special schools, the grand total of children inspected amounts to 294,026. This total includes some scholarship candidates examined in the schools, particulars concerning whom arc given in a separate portion of the report. Urgent and special examinations. Urgent cases are those of children upon whom a medical opinion is required without delay, and who are therefore presented to the doctor without notice whenever he may be in the neighbourhood. They comprised:— Boys. Girls. Examined at 7,242 8,324 Routine examinations.0 1,044 969 Re-examinations. 220 300 Special examinations at centres. 8,506 9,593 Totals. These cases were referred for examination as indicated in the subjoined table:- Routine. Reinspection. Specials. Referred by Boys. Girls. Boys. Girls. Boys. Girls. 485 560 58 61 31 39 Divisional medical officers. 942 1,319 64 84 88 92 Divisional superintendents. 89 54 16 16 — — School doctors. 2 - - — 1 — Invalid Children's Aid Association. 198 188 11 14 1 — Nurses. 4,315 4,756 708 654 26 34 Teachers. 233 245 30 28 5 7 Care committees. 3 9 — — — 1 Borough medical officers of health. 350 437 19 21 16 5 School medical officer. 272 297 14 24 2 — Parents. 353 459 124 67 50 122 Not reported. 7,242 8,324 1,044 969 220 300 Totals. The special inspections included:— 15,816 boys and 20,068 girls examined at infectious disease investigations; 2,222 boys and 2,818 girls examined at open air schools and classes; 949 boys and 909 girls examined for school journeys and country holidays; and 1,638 boys and 1,454 girls examined at other general inspections. 20,625 25,249 Routine inspection of age groups. The year just completed is the third since entrants and leavers have been examined in accordance with the schedule of the Board of Education. In addition, during each of the three years, an intermediate group of children has been inspected. There are now, therefore, three sets of complete records, and in the following pages a comparison of the results of inspection during the three years is made for the most important conditions met with. The analyses are confined to the routine examinations of the age groups, and all special and urgent cases, etc., are excluded inasmuch as they form a varying and selected class. Presence of parents at inspection. A parent or relative of the child was present at the medical inspection in 154, 927 cases or 68 per cent. The proportion was highest amongst the entrant group where there were 80 per cent.; among the 8—9 and the leaver groups the percentages were 65 and 55 respectively. In all age groups the parents attended more frequently when girls were being examined. Cases of requests for exemption from medical examination by the Council's staff are comparatively rare. In some instances the wish of the mother to learn the doctor's opinion and her inability to attend are reasons for withdrawing a child, but in such cases arrangements are made for an inspection at a later date. The result of the inspection is placed on a record card which is kept at the school. The information entered on the cards is summarised, and a table in the appendix shows the details for the elementary and special schools for the whole county. (Appendix III.) Report of the County Medical Officer—Education. 87 The heights and weights of all children are recorded at the time of their medical inspection, and in individual cases, and invariably in cases of malnutrition; these have been compared with subsequent measurements. With the exception of records in the open-air classes and certain investigations into malnutrition, no special averages of heights or weights, however, have been calculated from the records taken during 1914. Children are classified as to the condition of the clothing, state of nutrition, cleanliness of head and body and condition of teeth. The classification is made into 3 groups "good," "average," "bad," except in the case of nutrition when the grouping is "good," "normal," "below normal and "bad" (i.e., malnutrition). The percentages in each of these groups of the children examined in each borough are shown in the tables in the appendix. The average of nutrition, etc., varies from district to district and even from school to school, and added to this the personal equation of the examining doctor as to what is "normal" is also a varying factor. Conclusions based on these classifications must therefore be used with very great hesitation in making comparisons between district and district. The percentages for boys and girls of each age group assessed as good (1), fair (2) and poor are given in the following table together with the corresponding figures of the two previous years:— Entrants. 8-9. Leavers. 1 2 3 1 2 3 1 2 3 Boys, 1914 56.3 40.4 3.3 47.8 45.9 6.3 52.6 41.9 5.5 „ 1913 53.9 42.5 3.6 47.5 45.4 7.1 49.1 45.4 5.5 „ 1912 48.5 45.5 6.0 46.5 46.3 7.2 44.8 47.l 8.1 Girls, 1914 56.7 40.7 2.6 51.6 45.0 3.4 55.9 40.8 3.3 „ 1913 55.1 42.3 2.6 51.4 43.9 4.7 51.8 44.8 3.4 „ 1912 50.6 44.6 4.8 49.7 45.2 5.1 48.8 45.9 5.3 (3) Clothing and footgear. It is seen that the averages are very consistent. The entrants are distinctly better looked after than the other children, and the girls as a whole are slightly neater and better clad than the boys. The most gratifying feature of the table, however, is the steady improvement during the 3 years in the conditions as regard cleanliness, neatness and sufficiency of clothing. The very great benefits accruing from medical inspection and its concomitants, the work done for the children by the school nurses and care committees, could not be better illustrated than by this steady, gradual improvement in the appearance of the children which is evident to those working in the schools but is not- alwavs suscentible of numerical renresentation. The following tables give the percentages for cleanliness of the head and body respectively, classified as (1) which may be taken as " clean," as (2) "dirty," with, in the case of the head, a few nits, and as (3) verminous. Entrants. 8-9. Leavers. 1 2 3 1 2 3 1 2 3 Boys, 1914 880 116 04 869 126 05 885 112 03 „ 1913 86-6 12-8 0-6 87-1 12-3 0-6 87-3 12-3 0-4 Girls, 1914 735 247 18 663 31 6 21 688 293 19 „ 1913 73-4 24-9 17 67-3 303 2-4 67-2 30-4 2-4 Entrants. 8-9. Leavers. 1 2 3 1 2 3 1 2 3 Boys, 1914 817 173 10 753 229 18 751 230 19 „ 1913 77-7 20-6 1-7 720 251 2-9 731 24-3 2-6 Girls, 1914 81-3 177 10 77-8 208 14 780 207 13 „ 1913 770 213 1-7 73-7 24-2 21 74-8 231 21 Cleanliness of head. Cleanliness of body. It is to be noted that entrants are cleaner than the other groups, but that girls have much more frequently dirty heads than have boys. Thus, while 86 9 per cent of the 8-year old group and 88-5 per cent, of the leavers among bovs are returned as clean, only 60-3 per cent, of the 8-year olds and 68 8 per cent, of the leavers amongst girls are clean. On the other hand, in regard to cleanliness of the body, although entrants are again cleaner than the other groups, the girls are,if anything, cleaner than the boys. The explanation of these figures of course, is that the wearing of long hair by the girls puts them in a very much worse position than the boys, in warding off the attacks of vermin. Unfortunately the figures of 1912 are not. available for strict comparison, owing to the fact that the assessment of the condition of head and body was not separately made during that year. The figures given in the above tables, however, show that there is a slight, but quite definite improvement over the previous year and there can be no doubt that this is part of a general steady improvement which has been going on in the schools for some years, owing largely to the work of the school nurses. 88 Annual Report of the London County Council. 1914. The combined figures for head and body for 1912 were as follows:— Entrants. 8-9. Leavers. 1 2 3 1 2 3 1 2 3 Boys 60.5 34.1 5.4 62.9 31.7 5.4 57.5 36.3 6.2 Girls 60.0 33.5 5.6 63.7 31.0 5.3 58.7 35.2 6.1 The percentages in column 3 are much higher than the combined head and body percentages of the present year. Although it is to be deplored that even now the heads of only 67 per cent. of the girls are completely free from traces of vermin, it must be remembered that the percentages which were found clean in the early days of medical Work in the schools ten to twelve years ago, were very much lower; so that instead of 67 per cent. being clean there were in those days over 67 per cent. verminous. Condition as regards nutrition. In 1912 the condition of children inspected was for two terms classified as good, fair and poor, but in the third term a classification into four groups was adopted in order to conform with the schedule of the Board of Education. In the following table the two groups 3 and 4 have been combined in order to afford a basis of comparison over the three years. Entrants. 8-9. Leavers. Good. Fair. Poor. Good. Fair. Poor. Good. Fair. Poor. Boys, 1914 31.2 60.7 8.1 19.9 70.1 10.0 26.4 61.1 12.5 , 1913 30.7 58.5 10.8 22.0 62.2 15.8 26.4 58.9 14.7 „ 1912 40.9 51.3 7.8 26.6 58.4 15.0 35.6 56.0 8.4 Girls, 1914 32.2 60.6 7.2 22.8 68.2 9.0 29.9 58.6 11.5 „ 1913 32.7 57.5 9.8 25.1 61.4 13.5 30.6 55.1 14.3 „ 1912 43.1 50.3 6.6 30.6 56.5 12.9 39.2 53.2 7.6 It is doubtful, however, how far the comparison will hold as the alteration in classification has probably made a difference to the numbers placed in the fair or average group. It will be seen that in the year 1914, exactly one per cent. more boys than girls were placed in the subnormal group at all three ages. Infants show a better result than either of the other groups, and the intermediate age a better result than the leaver group. A critical examination of the returns of malnutrition for varying age groups and varying districts, produces results which are often perplexing. There are undoubtedly many obscure factors in the production of subnormal nutrition which are not yet fully worked out. There is no doubt a seasonal influence, thus it is known that in the spring, children remain almost stationary in weight while they are increasing in height, and it is therefore probable that any particular group examined in the spring term would show an excessive degree of malnutrition, just as nervous disorders such as chorea are more prevalent at this season of the year. Again, there is an age factor. During certain years growth in height is much more rapid than in the years which precede or follow, and many observers have noted the tendency to loss of energy and tone at these periods of growth. In a study of the causation of malnutrition made last year, it was shown that rapid growth as a cause was confined to the leaver group amongst school children. In the above table the influence of these factors may possibly be discerned in the excessive incidence of subnormal malnutrition upon the leaver group. Not only are many of the children in this group already affected by the "prepubescent increase" in rapidity of growth, but the whole group was examined during the spring term, when malnutrition might be expected to be more prevalent. It will be interesting to see if the distribution of the examination of all the groups over the three school terms which it is proposed to effect in the future, will alter to any extent this heavier incidence upon the older children. Teeth. The teeth are classified on a rough inspection into 3 groups, (1) apparently healthy, (2) a certain amount of caries, (3) a considerable amount of caries with sepsis of the mouth. Entrants. 8-9. Leavers. 1 2 3 1 2 3 1 2 3 Boys, 1914 51.6 33.9 14.5 48.9 39.1 12.0 51.9 38.9 9.2 „ 1913 62.2 27.7 10.1 51.4 36.6 12.0 50.0 40.0 10.0 „ 1912 61.9 27.8 10.3 45.6 37.4 17.0 47.3 39.8 12.9 Girls, 1914 52.0 34.3 13.7 49.1 39.0 11.9 54.1 38.2 7.7 1913 63.0 27.2 9.8 51.6 36.3 12.1 52.4 39.0 8.6 „ 1912 62.6 27.3 10.1 46.5 37.0 16.5 50.6 37.6 11.8 It is seen that there is no great difference in the sexes in regard to teeth, except that older boys have a rather higher percentage of septic mouths (9.2 per cent.) than older girls (7.7 per cent.), due possibly to greater attention to dental hygiene in the girls' schools. It is probable that the numbers classed as healthy (column 1) are somewhat flattering, as a more prolonged inspection, such as is made by the inspecting dentists, reveals a larger amount of dental caries. The tendency to reduction in the percentages of unhealthy mouths at the older ages is possibly due to the greater attention paid to dental disease and the greater facilities now being provided by the Council for dental treatment. 89 Report of the County Medical Officer—Education. The number of cases suffering from skin disease reported was 4,080 or 1.8 per cent., as compared with 1.9 per cent. in 1913. Boys show a higher percentage of skin complaints than girls and the cases are most frequently met with in the entrant group. Skin diseases. An analysis of the cases noted in the 1st term of 1914 was made under the four headings set out below:— Entrants. 8-9. Leavers. Total. Cases found. Cases for treatment. Cases found. Cases for treatment. Cases found. Cases for treatment. Found. For treatment. Impetigo 13 4 - - 87 50 100 54 Scabies 4 4 — — 64 47 68 51 Ringworm of head 2 2 — — 39 19 41 21 Ringworm of body 2 - - - 23 19 25 19 Number of children examined 3,399 600 56,366 60,365 The figures given in the table below are the percentages of those cases of enlarged tonsils and adenoid growths which are producing symptoms of such a character as to necessitate reference of the children to treatment centres for operation. The total number of such cases was 15,526 or 6.8 per cent., compared with 5.8 per cent. in 1913 and 9.07 per cent. in 1912. Entrants. 8-9. Leavers. Boys, 1914 8.8 6.7 4.7 1913 8.3 6.1 5.3 „ 1912 10 .73 8.76 '7.92 Girls, 1914 7.7 6.3 5.4 „ 1913 7.4 6.3 5.8 „ 1912 9.2 8.6 8.68 Adenoids, and enlarged tonsils. These figures are more reliable than percentages based on figures merely representing all degrees of defect, however slight or severe. It has already been pointed out that the proportion of children now found with adenoids and enlarged tonsils is less than it used to be. So much so, that the facilities for treatment, based on former experience, have proved to be slightly in excess of present requirements and have been, in consequence, curtailed. The figures for the present year correspond very closely with those of the previous year, but are much below the 1912 figures. The greater reductions at the older ages lend some force to the contention that the facilities for treatment have played a direct part in improving the health of the children. Other diseases of the nose and throat referred for treatment amounted to 1,476 or 0.6 per cent. Enlarged glands of the neck were reported in 20,293 instances or 8.8 per cent. as compared with 10.5 per cent. in 1913. Of this large number, however, only 1,001 were considered serious enough to require special measures of treatment. Enlarged glands of the nock. Renewed attention has of late been paid to abnormalities of the thyroid gland in children of school age. Hitherto, investigation has been chiefly directed to conditions in which there is a deficiency of thyroid secretion. The profound effects of this deficiency, leading in the worst cases to idiocy and in the milder cases to retardation of mental and physical growth are well understood, and the marvellous results of administration of extract of thyroid gland to the sufferers have been often demonstrated. Of late an attempt has been made to trace the relationship of thyroid deficiency to the condition of rickets, and observations are being made in the schools in this connection. The effects of over-action of the thyroid gland, in adults, in the production of the group of symptoms constituting Graves' disease or exophthalmic goitre are known, but little attention has been paid to the existence of the beginnings of this condition in children of school age. Abnormalities of the thyroid gland. Before leaving the Council's service to take up work as chief school medical officer to the Transvaal Government. Dr. Louis Leipoldt devoted a considerable amount of attention to this question. Out of 5,000 children examined at routine inspections Dr. Leipoldt found 52 cases in which it was possible to detect symptoms of over-action of the thyroid gland. The percentages of enlarged thyroids and of cases showing symptoms of over-action are:— Enlarged Thyroids. Over-Action of the Thyroid. Boys 1.4 per cent. 0.8 per cent. Girls 3.4 per cent. 1.2 per cent. 27715 n 90 Annual Report of the London County Council, 1914. Of the 34 girls showing symptoms, 7 were in the middle age group and 27 in the leaver group of children. All had definite enlargement of the thyroid gland. In 22 cases the enlargement was bilateral and symmetrical, in 8 the left lobe only was involved, in 3 the right lobe and in one case the isthmus was affected. In 18 cases there was tenderness of the gland, showing the presence of some amount of actual inflammation. In all there was some abnormality of the heart or its action; in ten cases the eyeballs were prominent (exophthalmos); in 5 cases, of which one had been mistaken for a case of chorea, tremor was found. In 28 cases nervous and emotional disturbances, including night terrors, sleep walking and enuresis, were present. Amongst boys 18 were found who showed symptoms of thyroidal over-action. In all there was enlargement of the gland, but in no case so marked as in the most pronounced cases of enlargement among the girls; in practically all the cases the outstanding features, were the thyroid enlargement, the tremor and the tumultuous action of the heart. Emotional disturbances were present in 16 of the 18. Of the 52 children no less than 42 presented definite evidences of septic absorption. Carious teeth and oral sepsis were present in 28, septic tonsils in 6, otorrhœa and other septic conditions in the remainder. Dr. Leipoldt is convinced that the conditions he has found are due to inflammation of the thyroid gland set up by septic absorption. He states that the improvement in some of the children consequent on thorough dental treatment has been striking; the thyroid enlargement has disappeared and the palpitation, tremor and nervous symptoms have been much diminished or altogether abated. Dr. Leipoldt's observations are interesting, suggesting as they do that the early stages of Graves' disease are more often to be detected in children than is usually supposed, that they are connected with inflammation of the thyroid gland, and that with continuance of septic absorption from the mouth or other organs, the condition may become established, and lead either to the development in the adult of exophthalmic goitre on the one hand, or of atrophy of the thyroid gland (myxœdema) on the other. These observations go to show that undetected or unheeded septic conditions in childhood may produce far-reaching effects in those predisposed to certain complaints; they form an additional reason, if any were needed, for redoubling the efforts already vigorously being made to induce parents to obtain treatment for all children found defective at medical inspections. Eye diseases. Eye disease includes cases of Blepharitis, Conjunctivitis, Corneal Opacity and Squint. The total number of cases reported was 9,573 or 4 2 per cent, as compared with 41 per cent, in 1913. The cases of each of these complaints among the 56,000 children in the leaver group examined in the first term of the year were, Blepharitis 664 (250 noted for treatment), Conjunctivitis 197 (93 noted for treatment), Corneal opacities 138 (10 noted for treatment), Squint 675 (201 noted for treatment). Corneal opacities 138 (10 noted for treatment), Squint 675 (201 noted for treatment). The percentages for each age group are:— Entrants. 8-9. Leavers. Noted. Referred for treatment. Noted. Referred for treatment. Noted. Referred for treatment. Boys, 1914 5.0 3.0 4.0 1.9 3.3 1.3 Girls, 1914 4.8 2.9 4.1 1.7 3.4 1.3 The above figures give the percentages of children in each age and sex group found with external eye diseases and those referred for treatment. They are practically identical with the figures for 1913. They include, in accordance with the schedule of the Board of Education, both inflammatory conditions and squints. It should be borne in mind that the two classes of conditions depend on totally different causes, and fall on quite different types of children. The figures for 1912 gave each type separately. Vision. The following table gives an analysis of the children at the two age groups in which vision testing is possible. The children are divided into three classes, (i.) normal vision, (ii.) slight defect, (iii.) severe defect:— I. II. III. IV. 6/6 in both eyes. 6/9 in either or both eyes. 6/12 or worse in either or both eyes. Cases for treatment. 8-9 Boys 13,829 12,642 6,074 4,286 42.5% 38.9% 18.6% 13.2% „ Girls 11935 13,467 6,714 4,832 37.1% 42.0% 20.9% 15.0% Leaver Boys 18,233 8,333 6,995 5,333 54.3% 24.8% 20.9% 15.9% „ Girls 15,786 9,717 7,899 6,001 47.3% 29.1% 23.6% 18.0% 91 Report of the County Medical Officer—Education. The following table gives the comparison with the corresponding percentages of the previous year:- Class I. % Class II.% Class III.% 8-9 Boys, 1914 42.5 38 9 18.6 1913 36.7 43.4 19.9 Girls 1914 37.1 42.0 20.9 1913 32.2 46.1 21.7 Leaver Boys, 1914 54.3 24.8 20.9 1913 51.1 26.2 22.7 Girls, 1914 47.3 29.1 23.6 1913 43.8 30.5 25.7 In both years the double influence acting upon children's eyes during school life is seenfirstly, the gradual education of the physical and mental powers, leading to an increase in the acuity of vision and therefore to a larger percentage of children with normal vision at the older age; and, secondly, the deterioration of vision in a minority of children, leading to the curious result that combined with an increase in the number of children with normal vision at the older age there is also an increase in the percentage with severe defect. The special incidence of defect upon girls and especially upon girls of the older age as compared with boys is again to be observed. There can be little doubt that this is due to some fault in the training of girls tending to deterioration of vision. The better results of 1914 compared with 1913 are to be explained by the fact that a larger number of children are now provided with glasses as a result of the larger facilities for treatment and better following up. During the first term of the year, when most of the leavers were examined, records were tabulated of the visual acuity of all the cases in which the vision of either eye was 6/12 or worse and the result is shown in the following table. The results of the vision tests of some 700 children in the schools for mentally defective children during that term are also tabulated. From these tables it will be seen that in about 70 per cent. of the children the vision of both eyes is the same. Leavers in 1st Term. Right Eye. Left Eye. 6 or 9 12 18 24 36 60 Worse than Total. Boys 373 311 159 149 97 53 1,142 6 or 9 Girls 450 347 167 152 81 36 1,233 Boys 421 879 211 72 48 26 6 1,663 12 Girls 389 1,164 285 107 54 22 8 2,029 Boys 305 220 796 126 55 17 8 1,527 18 Girl 258 278 833 135 58 13 8 1,583 Boys 171 61 144 344 59 21 2 802 24 Girls 163 68 176 384 60 12 4 867 Boys 141 42 61 71 273 16 1 595 36 Girls 121 47 52 90 290 23 1 624 Boys 93 25 17 16 21 84 1 257 60 Girls 63 23 21 14 20 80 1 222 Boys Worse 39 10 2 3 7 2 6 69 than Girls 60 32 6 6 4 4 4 14 70 Boys 1,170 1,610 1,532 791 612 263 77 6,055 Total Girls 1,026 2,036 1,720 901 638 235 72 6,628 27715 n 2 92 Annual Report of the London County Council, 1914. Children aged 12. Special Schools (Mentally Defective Children). Right Eye. Left Eye. 6/6 6/9 6/12 6/18 6/24 6/36 6/60 or worse. Total. Boys 6/6 112 10 1 1 - 1 - 125 Girls 87 1 1 - 1 - 1 91 Boys 6/9 9 155 9 1 - 2 3 179 Girls 5 121 8 1 - - 1 136 Boys 6/12 - 8 19 4 - 1 1 33 Girls 2 5 24 3 1 2 2 39 Boys 6/18 1 4 9 16 - - 1 31 Girls 1 3 4 15 2 - - 25 Boys 6/24 1 - 2 1 2 - - 6 Girls 2 - 1 2 3 1 1 10 Boys 6/36 - 1 - - 1 4 - 6 Girls - - 2 2 - 2 - 6 Boys 6/60 or worse 2 1 1 1 1 - 1 7 Girls 2 - 1 - - - - 3 Boys Total 125 179 41 24 4 8 6 387 Girls 99 130 41 23 7 5 5 310 Ears and hearing. The number of children reported with ear diseases, mainly discharging ears, was 5,609 or 2.5 per cent., compared with 2.4 per cent. in 1913 and 23 per cent. in 1912. 3,046 or l.3 per cent. were referred for treatment. Defective hearing was found in 3,414 cases or 1.5 per cent. as compared with 1.7 per cent. in 1913 and 1912. The particulars are shown in the following tables:— Ear Disease. Entrants. 8-9. Leavers. Referred for Referred for Referred for Disease of ears. treatment. Disease of ears. treatment. Disease of ears. treatment. Boys, 1914 27 1.5 2.0 1.1 2.4 1.2 1913 2.6 1.4 2.0 1.0 2.3 1.2 „ 1912 2.47 - 213 - 1.98 - Girls, 1914 27 1.5 2.2 1.2 2.4 1.3 „ 1913 2.6 1.4 2.2 1.1 2.4 1.2 „ 1912 2.46 — 2.65 — 2.03 — Defect of Hearing. Entrants. 8-9. Leavers. Referred for Referred for Referred for Defect. treatment. Defect. treatment. Defect. treatment. Boys, 1914 1.0 0.3 1.3 0.4 2.4 0.8 „ 1913 1.2 0.3 1.9 0.6 2.1 0.8 „ 1912 1.0 — 1.9 — 2.2 — Girls, 1914 1.0 0.3 1.3 0.4 2.4 0.8 „ 1913 1.3 0.35 1.9 0.7 2.4 1.0 „ 1912 1.2 — 2.1 — 2.1 — The foregoing tables show that disease of the ears is commoner among infants than amongst older children, whereas defect of hearing is more evident at the highest ages. It is interesting to note that disease of the ears and defect of hearing is almost the only condition in childhood which has no varying incidence upon the sexes at each age. Amongst urgent cases examined during the year, 1,066 were found suffering from ear diseases, or 5.9 per cent. and of these a very large proportion were referred for treatment. Speech defects. 559 children (or .25 per cent) were reported as stammerers compared with .32 per cent. in 1913 and 1912. Other speech defects were noted in 1,585 cases, or .69 per cent., compared with .98 per cent. in 1913 and .69 per cent. in 1912. 93 Report of the County Medical Officer—Education. The age and sex distribution of speech defects for the three years was as follows :— Entrants. 8—9. Leavers. Stammering. Other defects. Stammering. Other defects. Stammering. Other defects. Boys, 1914 0.2 1.1 0.4 0.76 0.6 0.7 „ 1913 0.24 1.3 0.44 1.10 0.88 0.9 „ 1912 0.26 0.8 0.62 1.26 0.57 0.46 Girls, 1914 0.1 0.6 0.1 0.46 0.22 0.45 „ 1913 0.1 0.9 0.15 0.7 0.24 0.78 1912 0.15 0.6 0.21 0.75 0.18 0.36 The special incidence upon boys as compared with girls, is well marked at all ages. There is to be noted also an increase in stammering during school life. The very small percentage of London school children who are stammerers is very gratifying, and when it is compared with the conditions described in reports of medical inspectors in foreign countries, it suggests that our nation is not the one with the weakest nerves. Heart disease was reported in 6,199 cases, or 2.7 per cent, of cases, compared with 2.2 per cent. Heart disease in 1913 and 2.25 per cent, in 1912. The increase in 1914 is due to a larger proportion of entrants reported as defective. As the numbers referred for treatment did not rise in the same proportion it is probably due to an alteration in standard on the part of the examining doctors. The percentages are here tabulated :— Entrants. 8—9. Leavers. Cases of defect. Referred for treatment. Cases of defect. Referred for treatment. Cases of defect. Referred for treatment. % % % % % % Boys, 1914 24 02 26 018 j 27 0 39 1913 1.5 0.2 2.2 0.2 2.6 0.4 1912 1.85 0.34 2.3 0.3 2.24 0.62 Girls, 1914 2.1 0.2 3.0 0.29 3.7 0.48 1913 1.6 0.2 2.3 0.3 3.5 0.5 1912 1.73 0.35 2.7 0.45 3.0 0.77 A specially heavy incidence of heart defect is to be noted upon the older girls in all three years and is probably associated with the special incidence upon them of anaemia. This in turn, is probably due to the fact that they are less in the open air than are boys. 6,442 children were returned as anaemic or 2.82 per cent, compared with 3.1 per cent, in 1913 and Anaemia. 2.2 per cent, in 1912. Entrant girls are slightly less anaemic than entrant boys, but at other ages the girls are more anaemic and this is especially so at the leaving age. The special and increasing incidence of anaemia on girls, clearly shown in the following table, appears to be due to the less healthy life they live as compared with boys. Entrants. 8—9. Leavers. Cases found. Referred for treatment. Cases found. Referred for treatment. Cases found. Referred for treatment. % % % % % % Boys, 1914 2.8 1.0 2.6 0.76 2.4 0.62 " 1913 2.9 0.7 3.2 0.7 2.7 0.8 " 1912 2. 13 j 0. 93 2.7 0.8 1 .4 0.5 Girls, 1914 2.6 0.8 3.0 1.0 3.4 1.08 1913 2.6 0.7 3.5 0.8 3.7 1.2 1912 1.93 0.8 2.9 1.1 2.2 1.07 Disease of the lungs Diseases of the lungs, other than tuberculosis, were reported in 9,417 instances or 4.12 per cent, of all children examined, as compared with 5 per cent, in 1913 and 3.25 per cent, in 1912. As the following table shows, the incidence is almost double as great upon entrants as upon children of the higher ages, and at each age boys are distinctly more often affected than girls. Entrants. 8—9. Leavers. Cases found. Referred for treatment. Cases found. Referred for treatment. Cases found. Referred for treatment. % % % % % % Boys, 1914 6.1 1.6 3.2 0.87 3.0 0.62 1913 7.8 2 .0 4. 0 0.92 3.9 0.79 1912 4.58 2.01 3.75 1.03 1.55 0.52 Girls, 1914 5.7 1.5 2.6 0.52 2.74 0.51 1913 6-7 2 .0 3.66 0.90 3.60 0.87 1912 4.45 2. 0 3.40 0.96 1.42 0.49 94 Annual Report of the London County Council, 1914. Diseases of nervous system. The percentages of children referred for treatment in successive years shows that there has been some reduction during the past year in the number of serious cases met with. The number of children noted during the year to be suffering from nervous disease was 2,262, that is 0'99 per cent, of all examined, compared with 11 per cent, in 1913 and 0 93 per cent, in 1912. The following table gives the age and sex distribution during the past year. Entrants. 8—9. Leavers. Cases found. Referred for treatment. Cases found. Referred for treatment. Cases found. Referred for treatment. % % % % % % Boys 0.8 0.13 1.05 0.16 1.04 0.17 Girls 0.8 0.09 1.12 0.14 1.27 0.21 Entrant boys and girls show no difference in incidence, but at other ages there is a slightly heavier incidence upon girls ; and while the percentage in the 8-9 group and in the leavers was the same amongst boys, there is a slightly heavier incidence on the leaver girls. The percentages are, however, gratifyingly small and no great stress should probably be laid upon the sex differences, although the slightly higher incidence on leaver girls than on leaver boys has remained persistent during the three years. During the first term cases of epilepsy, chorea and paralysis were separately noted with the following results :— No. examined. Epilepsy. Chorea. Paralysis. Entrants 3,400 3 3 4 Leavers 56,366 49 54 47 Tuberculosis, , 755 children, or 0 33 per cent., were notified as suffering from phthisis and 631, or 0.28 per cent, presented other tuberculous lesions. The corresponding figures for 1913 were 0.4 per cent, and 0.37 per cent., and for 1912 were 0.3 per cent, and 0.24 per cent., respectively. Entrants. 8—9. Leavers. Phthisis. Other forms. Phthisis. Other forms. Phthisis. Other forms. % % % % % % Boys, 1914 0.3 0.3 0.3 0.3 0.43 0.31 1913 0.3 0.3 0.5 0.4 0.5 0.4 1912 0.23 0.24 0.32 0.3 0.36 0.23 Girls, 1914 0.3 0.2 0.29 0.22 0.41 0.27 1913 0.3 0.2 0.5 0.3 0.5 0.3 1912 0.3 0.2 0.36 0.37 0.3 0.15 The percentages of phthisis and other tuberculous diseases remain exceedingly low for children examined in the age groups. There are distinctly more cases, however, found at the leaver age than at the other ages. The differences between the sexes in phthisis are so small as to be negligible, there is, howeVer a distinctly greater incidence on boys in every age group in the case of other tuberculous diseases. It is interesting to note that amongst children examined as urgent cases 571 or 3 per cent, were found to be suffering from phthisis and of the children out of school 917 or 9 per cent, were fortified to be suffering from the same disease. Examination of tuberculosis contacts. Dr. J. G. Forbes, divisional medical officer in the south eastern area, has carefully made records of the medical inspection of 271 children living in contact with tuberculous patients in the boroughs of Bermonrlsev and Greenwich, and the following is a summarv of the results he obtained. The sex incidence among all contacts was 145 males and 127 females; among contacts showing pulmonary defects, it was 25 males and 20 females, and among tuberculous members of the affected families, the incidence was almost equally divided, 71 being male and 68 female—one or both parents were affected in 63 families, brothers and sisters in 65 families. In Bermondsey the majority of affected families occupied two rooms, and in Greenwich three rooms. Overcrowding was generally more evident among Bermondsey than among Greenwich families, but in Greenwich the two-roomed homes were rather more crowded than those in Bermondsey, the average being 3.3 persons per room in the former and 3 persons per room in the latter. The general appearance and state of nutrition of Bermondsey contacts showed a lower standard than those in Greenwich. The state of nutrition of the Greenwich contacts indeed, compares favourably with that of the average of all London children. The influence of the number of occupants per room on the contacts was rather more marked in Bermondsey than in Greenwich, and the numbers of those showing a poor state of nutrition, or being under average weight for age, or exhibiting pulmonary defects were found to be in direct proportion to the amount of crowding, thus:— Bermondsey. Greenwich. 2 occupants per room 13 out of 55 12 out of 46were in a poor state of nutrition. 3 ,, „ 10 ,, 65 1 ,, 14 ,, ,, ,, ,, ,, 4 ,, ,, 7 „ 18 5 „ 17 ,, 5 ,, ,, .. 3 „ 12 — ,, — 2 occupants per room 33 out of 55 28 out of 46 w ere below average weight for age 3 ,, 38 ,, 65 8 „ 14 ,, ,, ,, 4 „ 11 „ 18 10 „ 17 ,, ,, ,, 5 „ „ 8 ,, 12 — ,, — ,, ,, ,, 95 Report of the County Medical Officer—Education. The total pulmonary defects found in Bermondsey affected 2.0 per cent, of the contacts, and there was a strong probability of pulmonary tuberculosis in 2.4 per cent. The proportions of contacts with pulmonary defects to the total number of contacts were found to be as follows :— 2 occupants per room 10 out of 55 with pulmonary defects 3 ., ,, 10 „ 65 ,, ,, 4.....3 „ 15 ,, ,, ,, 5 6 „ 12 In Greenwich the number with pulmonary defects amounted to 10.5 per cent., including a percentage of 2.85 with probable pulmonary tubercle. Of the contacts suffering from pulmonary defects :— Bermondsey. Greenwich. 17 out of 34 were in a poor state 3 out of 11 were in a poor state of of nutrition. nutrition 25 out of 34 were below the average 7 out of 11 were below the average weight for age weight for age The percentage of contacts showing enlarged tonsils and adenoids and enlargement of cervical glands was higher in Bermondsey than in Greenwich, and was also higher in the case of thsoe with pulmonary defects than when no pulmonary signs were present. Further these defects would appear to be more common among tuberculosis contacts than among all London school children. The number of children returned as suffering from rickets was 3,928 or1.72 per cent, as compared Rickets, with 2.1 per cent, in 1913 and 1.69 per cent, in 1912. The following table gives the age and sex distribution of cases of rickets per cent, of children examined for this and the two former years. Entrants. 8—9. Leavers. Boys, 1914 2.8 2.0 1.6 1913 3.6 2.1 2.3 1912 2.77 2.47 1.19 Girls, 1914 1.5 1.16 0.82 1913 2.0 1.2 1.0 1912 1.44 1.37 0.8 At each age the results of rickets are much more often met with in boys than in girls, and, as school life progresses, they become in each sex more difficult to recognise as such. The number of cases of deformities other than those definitely recognised as rickets was 4,297 Deformities, or l-88 per cent, compared with 2.0 per cent, in 1913 and 1.6 per cent, in 1912. The age and sex distribution is given in the following percentages :— Entrants. 8—9. Leavers. Boys, 1914 1.5 2.1 2.5 ,, 1913 2.0 2.1 2.4 ,, 1912 1.35 1.87 1.61 Girls, 1914 0.8 1.82 3.05 ,, 1913 1.3 1.9 2.9 ,, 1912 0.74 1.97 2.32 The gradual increase in non-rickety deformities during school life is here well shown, and also the changing sex incidence from being heaviest in boys at entrance to school, to being heaviest in girls on leaving school. This exceptional incidence in older girls is due to spinal curvature, and is associated with the hygienic defects in the training of girls as compared with boys, producing in the former an excess of severe visual defect, of anaemia and of heart defect as school life proceeds. During the first term out of 56,366 leavers examined, 102 boys and 257 girls were found with lateral curvature of the spine. Malnutrition as a pathological condition was reported in 1,107 cases or 0.48 per cent, compared Malnutrition. with 0.6 per cent, in 1913 and 0.44 per cent, in 1912. All cases in which the doctor finds malnutrition (group " 4 ") are made the subject of a special investigation. The child is again weighed and measured at re-inspection and in the meantime special enquiries are made by the Care Committee into the home circumstances, the suitability of the child's diet, the family history, the amount of sleep, and into anything that may tend to throw light upon the cause of the malnutrition. These enquiries have been narrowed down somewhat during the year under review, being limited to cases in which the poor degree of nutrition amounts to a definite pathological condition. The number of cases noted at ordinary inspection during the year was 225 or just less than 1 case in 1,000 examined. The cases of malnutrition that came under review during the year included many which were noted at inspections during the previous year. Of 330 cases re-inspected during the year the home conditions were said to be very good in 16, good in 96, fair in 60, poor in 79, very poor in 4 ; in the remaining 75 cases the Care Committee did not supply information on this point. 96 Annual Report of the London County Council, 1914. These malnourished children are considerably under the average height and weight for their age. By taking some 150 cases that fall in the age group 7—9 and comparing the actual height and weight of the child with the height and weight of a normal child, of exactly the same age in years and months, it was found that the difference was in one instance as much as 22 centimetres in height and 10 kilograms in weight. The height is not so frequently below normal as the weight, and 40 of these 150 children were above the normal height for their age. Many of the children in this class are overgrown and thin, in fact, this type of child is fairly frequently met with when dealing with ill-nourished children. The average of the divergence of these 150 children from the normal for their individual ages shows them to be 48 centimetres below normal height and 3.9 kilograms below normal weight; the boys are 59 and the girls 3-7 centimetres below normal height, but in weight both groups are 3 9 kilograms below normal. The yearly increase of normal children between 7 and 9 is 4.6 centimetres in height, and in weight for boys 1.7 and for girls 1.9 kilograms, so that this group of 150 children approximated in height to normal children a year younger and weighed less than normal children two years younger than themselves. Some of the most striking cases of these divergences from the normal are as follows :— Actual Age. Height. Age of normal child of this height. Weight. Age of normal child of this weight. Normal. Actual. Normal. J Actual. 8 7/12 120.9 98 4 1/2 23.7 13.2 3 8 2/12 119.1 100 4 10/12 23.0 14.6 3 7/12 8 2/12 119.1 106 5 10/12 23.0 17..0 5 6/12 9 7/12 125.1 114 7 3/12 25.2 17.8 6 4/12 88/12 121.3 115 7 5/12 23.8 17.0 5 6/12 8 2/12 119.1 123 9 23.0 20.0 6 11/12 88/12 121.0 121 88/12 23.2 18.6 6 8/12 The divergence from normal in height and weight of these children graduated in steps of 5 centimetres in height and 1.5 kilograms in weight is as follows :— No. of children. Total. No. of kilograms below normal weight. 1.5 or less. 1.5—3.0. 3.0—4.5. 4.5 or more. Above normal height 40 10 18 11 1 38 4 15 12 7 5—10 cms. below 41 _ 3 12 26 10—15 cms. below 24 _ _ 3 21 More than 15 cms. below 10 10 Total 153 14 36 38 65 It will be seen that while more than half the children were either above normal height or less than 5 centimetres below it,in regard to weight the large majority were over 3 kilograms below the normal. The effect of the treatment received is apparent in the records of the measurements taken at reinspection,and where there is no organic disease and the child is suffering only from lack of proper food, the change to a suitable diet makes a marked difference in both height and weight. The record of the height and weight of some 250 children seen at re-inspection was compared with their height and weight at the inspection, and the increase or decrease in each case was shown as a yearly increase at the same rate. The average yearly increase of all the cases of which there are records of height and weight, both at inspection and re-inspection, works out at 5.5 centimetres in height and 2.5 kilograms in weight, which is slightly over the normal increase in height, and considerably over the normal increase in weight per annum. Among children of the 8—9 age group the increase in weight was at the rate of 3 kilograms a year. The interval between inspection and re-inspection of this group was as a rule about 5 or 6 months. In a general average are included those cases which do not gain in weight and also those which actually lose weight, owing often to organic disease which does not yield to treatment. In individual cases the increase during the period the child was under observation would, if the same rate had continued for a year, have amounted to the growth of a normal child in 4 or 5 years, but it is not safe to assume that a child who makes rapid progress for six months will continue at the same rate in the following six months. The yearly rate of increase must be looked at in connection with the time that elapsed between the two series of measurements. Among all the children fifteen were recorded to have grown at a yearly rate of over 10 centimetres during the interval between the measurements, which, on the average, was a period of just over six months. Twenty-three children were recorded as having increased their weight at the rate of over 5 kilograms a year, i.e., the growth of a normal child in 3 or 4 years. The most striking instances recorded were :— (1) Girl, 8£, in poor, neglected condition, was given milk and the home was visited ; at re-inspection, 9 months later, weight was found to have increased 7.8 kilograms. (2) Boy, 68/12, had early illness, home poor, milk at school; attended tuberculosis dispensary gained 6.6 kilograms in 7 months. 97 Report of the County Medical Officer—Education. (3) Girl, 128/12, home poor, school dinners and milk given, gained 34 kilograms in 5 months. (4) Boy, 109/12, tall, overgrown, good home, working for scholarship ; given milk, cod liver oil, and malt at parent's expense, gained 2.9 kilograms in 3 months. (5) Girl, 87/12 good home, good food, but poor appetite, much below normal height and weight. Cod liver oil and malt given, gained 2.1 kilograms in 3 months. The cases in which there was a marked decrease in weight recorded at re-inspection were :— (1) Boy, 113/4, home condition and feeding good, milk diet given, gained 2 centimetres in height, but lost 0.9 kilograms in 5 months, no cause assigned. (2) Boy, 88/12, home condition and feeding good, poor appetite, suffered from congenital debility due to premature birth; said to have worms. Cod liver oil given and child attended tuberculosis dispensary, gained 4 centimetres in height, but lost 2.3 kilograms in 4 months. (3) Boy, 111/12, overgrown, 9 centimetres above normal height, but 1.6 kilograms below normal weight for his age, home conditions, good. Milk given at school; no increase in height, and lost 2.3 kilograms in 4 months, no cause assigned for malnutrition. Enquiries as to the adequacy of sleep do not as a rule result in reliable information. In almost all cases the child is said to have 11 or 12 hours sleep, but in some few cases there is other evidence that the child is often out late, that a boy does a milk round in the early morning, that the home conditions are such that sleep is impossible before midnight, and in one case a boy of 8 was said to be attending a class in Hebrew until 9 o'clock each night. The causes assigned for the condition of malnutrition in 330 cases were classified as follows :— Poverty 77 Congenital debility 34 Neglect 21 Rickets 12 Tuberculosis (or tubercular tendency) 73 Overgrown 3 Improper feeding 16 Deformity 2 Digestive trouble, worms, etc. 7 Other illnesses 10 Heart disease, anæmia and rheumatism 23 No cause stated 52 330 Poverty and neglect are an important cause of malnutrition and the temporary loss of work by the bread-winner soon makes its effect felt upon the health of the child. Cases of neglect include wilful negligence on the part of the parents, cases of alcoholism and also cases in which the mother goes to work and is unable to provide a proper midday meal for her children. In quite a large number of the instances under review, it is noted that the death or prolonged illness of either parent by throwing the responsibility of the care of the child on the other parent, brings about neglect of this kind. Out of some 250 cases in which the care committees enquired into the circumstances it was found that the father was dead in 15 instances and the mother in 13, while in one case both parents were dead. Criminal neglect could be alleged in nine cases. In three cases the parents were prosecuted, in two instances the National Society for the Prevention of Cruelty to Children had the children put under proper care, and in one case cautioned the parents, while in three instances alcoholism was alleged, but there was not sufficient evidence to prosecute. Tuberculosis in one form or another is a cause of malnutrition in over 25 per cent, of the cases where any cause is assigned, and the parents are urged by the care committee to attend the local tuberculosis dispensary or other institution where treatment can be obtained. Anæmia and heart disease were causes in 8 per cent, of the cases. Congenital debility was noted in 34 cases. Many of these were instances of children prematurely born and in each of 9 cases the child was a twin. Rickets was noted in a few cases and in others the child's condition was attributed to some previous illness. In respect of treatment, cases of malnutrition may be divided into two groups (a) those where feeding and care are needed, and (b) those in which some definite disease is suspected. Of the cases coming under review during the year, 188 received school meals or extra nourishment at home. The following table shows the number of children to whom meals were supplied and indicates whether they were given free, at the parent's expense, or supplied by a charitable agency. Meal. Supplied at. Council's Cost. Parent's Cost. Cost of Institution. Total. Breakfasts 7 _ _ 7 Dinners 46 2 _ 48 Milk 45 32 —. 77 Cod Liver Oil 30 34 22 86 Malt 4 12 10 26 It will be seen from these figures that about one-third of the 188 children were supplied with more than one kind of extra nourishment. The period for which the meals are continued depends upon the necessity of the cases and it comes under review at short intervals. In some cases the child was already on the school feeding list at the time of inspection, and the care committee reports show that this was so in regard to 30 children either at the time of, or just prior to, the case being noted at medical inspection. 27715 9 98 Annual Report of the London County Council, 1914. Hospital treatment was arranged for 24 children, 23 attended tuberculosis dispensaries or infirmaries and 8 were placed under the care of their private doctor; 10 children were recommended for open-air schools, 9 secured admission to convalescent homes or cottage hospitals, and a country holiday was arranged for 16 under the auspices of the Children's Country Holiday Fund, while in certain other cases the assistance of the Invalid Children's Aid Association was secured. In addition to the treatment of the ill nourishment or its cause, the Care Committee were also able to ensure that other defects noted by the doctor received attention and this operated to a certain extent in the direction of improving the nutrition. Four cases died during the period they were under notice. (1) Boy, 55/12 Height 96 c.m., weight, 14 kilograms. Premature child (mother dying at his birth). Fair home conditions. Suffered from ear discharge. After 11 months, height, 100 c.m., weight, 16 kilograms. Died from abscesses in throat. (2.) Girl, 10. Height, 118 c.m. Weight, 17'8 kilograms. Father dead. Home clean. Suffered from anaemia. Became an in-patient of a hospital, where she died. (3) Girl, 9. Noted at inspection to present symptoms of tubercular peritonitis. Died in hospital from tuberculosis. (4.) Girl. Noted to be malnourished and tubercular. Died from phthisis before re-inspection. At the re-inspection the doctor classified the nutrition of the children formerly noted as illnourished, as follows:—good 1, average 27, sub-normal 133 and bad, 113. In the remaining cases no classification was made, so that it would appear that in spite of the cure bestowed upon them, about 40 per cent, remain cases of malnutrition. Medical and dental treatment. In the introduction to this report some mention has already been made of the great increase in the facilities provided for the medical treatment of school children during the last three years. At the end of the year 1914 the scheme included 12 hospitals and 30 medical treatment centres, providing in the aggregate for 98,976 cases. This figure may be contrasted with the 12,000 children for whom provision was made in January, 1910, the first year in which the Council's treatment scheme actually came into operation. Owing chiefly to the great demand for dental treatment, the London treatment scheme has grown to proportions unforeseen five years ago. Thus, for the year beginning 1st April, 1915, provision has been made for the treatment of 125,486 defects, including 63,140 dental cases. Three-fifths of the provided schools and one-half the non-provided schools are included in the dental scheme at present in operation. As regards the treatment scheme as a whole, the attendance of the children has been very good, although, as might be expected, difficulty has been experienced in maintaining an even flow of cases throughout the year owing to the somewhat considerable variation in the number of applications made. To meet this difficulty it was suggested that hospitals and centres should, as far as possible, treat a definite minimum number of cases to be supplied regularly and should deal with any accumulation of cases by means of additional sessions. This suggestion was carried into effect in the arrangements for treatment for the period beginning 1st August, 1914, and a maximum number of additional sessions was allowed in respect of each hospital and centre, to be used when required during the period of the agreement at the discretion of the school medical officer. Special arrangements made with regard to the various classes of ailment treated under the Council's scheme are set out in the following paragraphs. Eye defects.—In last year's annual report it was pointed out that as the result of inquiry into the visual acuity of children in the " middle age " group, it was deemed desirable to refer for further inspection all children whose visual acuity was 6/12 or worse. In view of the lower standard previously adopted, the existing provision at the hospitals and centres was found to be insufficient; indeed, in some instances considerable increase has be made to to cope with the altered conditions. Even with this increased provision, congestion has occurred and in eight months the number of eye cases dealt with was 1,058 in excess of the numbers for which agreement had been made. To meet this difficulty additional sessions were allowed as mentioned in the preceding paragraph. Ear, nose and throat defects.—It has been pointed out in previous reports that the effect of the facilities provided by the Council since 1910, is now being realised in the material reduction in the number of school children suffering from defect of the ear, nose and throat. This reduction has been maintained during the year 1914 and it has thus been possible to effect a corresponding reduction in the provision proposed for 1915. This type of ailment is especially adapted for the exercise of the method of meeting sudden increases in numbers by arranging for additional sessions. During the year question arose as to the steps to be taken in the event of haemorrhage occurring at home after operation at the centre. It was agreed with the centre authorities that the district nurse who visits the home after the operation should be informed of the name of the surgeon conducting the operation, and that, should bleeding occur, the operating surgeon should visit the patient. In some cases, however, the surgeon who operated may not be accessible, and if the services of a local doctor are requisitioned, question arises as to the responsibility for payment of his fee. The centre authorities took the view that they were responsible for treatment at the centre only, and that the Council should be liable for any after treatment. The Council felt, however, that the entire responsibility for treatment should rest with the centre committees. Finally, it was arranged that the local practitioner's fee should be paid by the centre committee, the Council reimbursing the committee the amount of the fee. It was understood that the arrangement 99 Report of the County Medical Officer—Education. would take effect only in very exceptional circumstances, and that the centre committee would accept full responsibility for treatment. In the last five months of the year 1914 it was necessary in only four instances to require the services of a private medical practitioner in this way. Ringworm.—Since 1st August, 1913, additional facilities have been afforded for treatment at the Fulham, Poplar, Tooting and Woolwich centres, and at the St. George's Dispensary. The numbers of cases treated have approximated very closely to those provided for in the agreements. Under the arrangement with the committee of the Wandsworth centre, the treatment of ringworm was carried out at the surgery of a private practitioner in Battersea, This practitioner has recently left the neighbourhood, and the question of the provision for X-ray treatment in this district needs to be considered. It would, however, be well to see the effect of the opening of the new centre at Tooting before further provision is made. In the arrangements for the year 1914-15 additional sessions were allowed at the Norwood and Peckham centres where pressure has occasionally been felt. Nursing treatment. The Board of Education in their letter of 24th June, 1913, stated that the arrangements for nursing treatment were regarded by them as not altogether satisfactory, partly owing to the insufficient supply of facilities, and partly owing to the absence of provision for securing the prompt attendance of children at the centres. In this connection it should be pointed out that, since the date of the Board's report, additional centres for nursing treatment have been opened at Camberwell, Deptford, Finsbury, Greenwich, Nottingdale, Wapping, Woolwich and at the " Redriff " school. In addition, the facilities at the Peckham and South London (Battersea) centres have been increased. With regard to the provision for securing more prompt attendance of children, arrangements are being considered whereby special inspections may be carried out by the school doctors, of children referred by care committee workers, school nurses, teachers and attendance officers an assistant organiser being present to make the necessary investigations in such cases as are recommended by the school doctor for treatment, with a view to referring immediately to the proper department cases suitable for dealing with under the Council's scheme. Since 1st August, 1913, the attendance of children at the centres has been very satisfactory. Until 31st July, 1913, the agreements in respect of nursing treatment provided for the reception of 25 new cases a week. It was found that this number was too large to be conveniently dealt with, and for this reason it was reduced to 15 a week, a number sufficient to keep the staff fully occupied during each session devoted to the work. Additional facilities for treatment are still in contemplation and the map facing page 100, shows, in addition to the centres now open, the new centres under consideration on 1st March, 1915. Dental defects.—In connection with each centre the arrangements for the inspection by the dental surgeons of children in the contributory schools have been continued. Formerly it was the practice for each inspecting dentist to give a short address to the parents, on the subject of the care of the children's teeth, upon the completion of the dental inspection of all the children of 6, 7 and 8 years of age in the school. The plan now generally adopted is for the dental surgeon to address, at each visit, the parents of the particular children just inspected. It is found that the parents are more ready to avail themselves of the Council's facilities for treatment when the defects of their children can be nersonallv discussed with them bv the inspecting dentist. On 31st December, 1914, there were 25 inspecting dentists engaged in the public health department. The following table gives the details of the inspections held during the year. Centro. No. of children examined. No. of children found to require treatment. Percentage of cases requiring treatment. Bermondsey (from 4.11.11) 600 529 80-2 Camberwell (from 4.5.14) 1,491 1,257 84-3 Deptford 4,698 3,456 73*6 Finsbury (from 14.1.14) 2,249 1,907 81-8 Fulham 2,026 1,604 79 2 Greenwich (from 1.9.14) 902 »27 91-7 Hackney 1,98:1 1,602 80-8 Hammersmith 2,548 2,262 88-8 Islington 1,975 1,625 82*3 London Hospital 2,f'17 2,393 91-4 Norwood 2,254 1,787 79-3 Notting Dale (from 12.5.14) 1,58:5 1,316 832 Peckham 2,248 1,654 73 6 Poplar Hospital for Accidents 3,2n7 2,581 79 Queen's Hospital for Children 2,525 2,017 86*7 St. Cecilia's 2,473 2,152 83 6 St. George's Dispensary 4,087 3,451 84-5 St. Marylebone Geneial Dispensary 1.653 1,409 85-2 St. Pancras ... ... ... ... ... ... 1,666 1,404 84-3 South London (Battersea) ... 2,001 1,813 90 6 Stockwell (from 22.10.14) ... . . 574 510 88-9 Tooting (from 8.6.14) 1,159 880 76 Wandsworth 4,834 3,636 75-2 Western Dispensary 2,352 2.179 92-6 Woolwich 2,766 2,039 73-7 Totals 56,491 46,290 81-95 27715 o 2 100 Annual Report of the London County Council, 1914. It was pointed out by the Board of Education in the letter dated 24th June, 1913, that in certain districts the arrangements for dental treatment include a considerable proportion of older children and that in the Board's opinion treatment should be confined to children of 6, 7 and 8 years of age. It has always been the practice to restrict appointments for older children to those most urgently needing assistance, and to give facilities even to them only at times when there is an insufficient number of children of the specified age groups to make full use of the centre. During the past year the inspecting dentists, in addition to examining the children newly arriving at the age of 6 years, have also re-inspected children previously seen. This is the beginning of a system designed to secure that the child receives supervision as regards dental conditions during the whole of its school life. On the 31st July, 1913, provision existed for the treatment ot 24,130 dental cases at 14 centres. From that date until 31st December, 1914, eleven additional centres had been opened and four new centres were then under consideration. The results of dental treatment for the year 1914 are shown in the following table :— Centre. No. of children attended. No. of attendances. No. of teeth or roots extracted. No. of stoppings. No. of other operations, e.g.; scaling, immediate regulation, application of Ag. N03, etc. No. of general anaesthetics. Temporary Permanent Nitrous Oxide. Ethyl Chloride. Other general anæesthetics. Bermondsey (from 9.11.14) 234 273 730 39 217 19 — 32 — Camberwell (from 13.5.14) 806 1,425 4,434 431 017 314 230 11 — Deptford 2,158 3,777 3,917 893 3,027 485 1,119 — — Finsbury (from 19.1.14) 585 1,144 2,194 230 850 119 487 — — Fulham 1,420 1,879 5,380 003 325 1,358 378 — — Greenwich (from 21.9.14) 516 682 2,823 181 313 22 77 —— Hackney 1,576 2,431 5,053 624 983 216 661 22 Hammersmith 1,434 1,817 6,835 671 600 205 — 408 Islington 6 668 1,773 803 564 5 — London Hospital . 1,540 2,013 7,555 613 1,460 223 333 — Norwood 1,535 2,014 5,177 719 3,397 174 318 59 173 Notting Dale (from 18.5.14) 654 884 2,572 150 596 52 — 131 Peckham 201 1,669 3,471 101 2,456 310 295 16 — -Poplar Hospital for Accidents 1,452 1,921 4,807 651 2,146 981 25 306 •— Queen's Hospital for Children 1,798 2,642 6,844 1,297 3,995 162 — 402 St. Cecilia's ... ... ... 1,247 1,830 5,760 570 566 4 480 — St. George's Dispensary ... 2,156 2,834 8,326 1,499 3,084 130 197 512 — St. Marylebone General Dispell- 925 1,024 8,182 1,126 905 86 — 390 — sary St. Pancras 1,695 2,575 9,636 1,287 1,280 — 578 South London (Battersea) ... 1,676 2,405 6,976 554 1,812 186 — 470 — Stockwell (from 2.11.14) .. 227 268 352 8 488 3 — 55 Tooting (from 15.6.14) ... 931 1,244 5,120 247 657 16 187 Wandsworth 2,261 3,394 11,408 1,094 544 8 997 Western Dispensary ... ... 1,432 2,357 5,610 361 1,941 1,265 124 397 — Woolwich ... ' 1,375 1,942 5,164 880 677 110 430 — Totals 132,439 47,156 133,232 15,557 34,709 7,251 7,480 3,331 173 It may be remembered that in last year's report mention was made of the fact that in certain cases, where the centres had been open for some time, variation was made in the amount of the capitation payment, and instead of an allowance of 2s. per case for all the cases treated, this fee was paid in respect of 1,000 cases per annum only, and the capitation fee was reduced to Is. for all cases exceeding this number. Daring 1914 this arrangement was adopted in connection with the Fulham, St. George's dispensary, Wandsworth, and Islington centres. At the Peckham centre, owing to special circumstances involving expenditure in connection with the renewal of the lease of the premises, the application of the new rule was deferred until 1st April, 1915. As a guide to the extent of the use made of the facilities for treatment provided by the Council, the following table is presented. The figures in the first column are the average numbers under agreements at the various centres and hospitals actually at work during the year, and differ from the figures given elsewhere, which are the actual numbers obtaining on 3lst December, 1914 :— Ailments. Average numbers undor agreements during 1914. Numbers treated under these arrangements during 1914. Eyes (refraction and diseases) 22,571 25,052 Ear, nose and throat . 15,328 12,961 Ringworm . 2,116 1,733 Nursing treatment 14,064 Teeth 38,298 32,439 Totals 93,496 86,819 A list of the hospitals and centres, at work on the 31st December last, is given in the appendix to this report (see Appendix II.). The numbers under agreement in respect of each ailment are also Diagram A. 101 Report of the County Medical Officer—Education. shown. The map facing page 100 shows the positions of the existing centres, and an attempt has been made to indicate approximately the sites of new centres now proposed. The topographical distribution of new centres in proximity to the schools from which they draw their material, becomes increasingly difficult as the scheme develops, but it is hoped that the new facilities for cheap fares on the Council's trams (see p. 104) will neutralise any inconvenience caused by the distances to be travelled, so that no school, however remote, will remain outside the sphere of action of some convenient centre. The new arrangement has not been in force long enough to judge finally of the results, but considerable use of the newly granted facilities has been already made. Teaching of school children suffering from defective vision. Ill connection with the Council's treatment scheme, arrangements have been made whereby the surgeons at some of the eye hospitals draw attention to children suffering from grave defects of vision. These children are then seen by the Council's ophthalmologist with a view to measures being taken to secure that their education is carried out without risk to the eyes, and appropriate recommendations are forwarded in each case to the education officer. Much good work has already been done in this direction and many difficulties have been overcome, but owing to the fact that the Council's arrangements are not universally know, uniformity of action has not been possible an ddifficulties have arisen in connection with certain institutions. It was thought that, if a suitable letter were addressed to the authorities, existing impediments might be removed, and with this object the following letter has been sent to the authorities of the special eye hospitals in London :— School Children suffering from Defective Vision, Blindness or Partial Blindness. Dear Sir, For the better assistance of the school children who may attend the treatment of your hospital, I shall be glad if you will kindly bring the following facts to the notice of the medical staff of your institution. The Council under direction of certain Acts of Parliament is bound to provide for the efficient education of all children within certain ages, and if any of these are unable, by reason of defective sight, to attend the ordinary schools, then special provision is made for them. The Council has the following grades of special provision for children suffering from defective vision: , 1.—Schools for the Blind or Partially Blind. There are a number of these scattered over London in convenient districts. These schools are separate from the ordinary schools; the children have their own classrooms, halls and playgrounds. The teachers are specially trained for their work. The curriculum is of the most approved kind and arrangements are made for the teaching of handicraft with a view to training in work such as the blind and partially blind can live by. Happily, most of the children are only partially blind and, where the state of their eyes permits, exemptions in the curriculum are made to suit them. The children are taken to school by guides paid by the Council and, where tram fares are necessary, these are paid. Midday meals are provided and in necessitous cases they are free. The Council's ophthalmologist visits the schools once a quarter, notes the state of each child, and reports thereon to me. Two residential schools are provided for the senior children ; these are essentially trade schools. They are under the charge of experienced matrons in addition to the teaching staff. 2.—The Myope Classes. There are now five of these. They are attached to elementary schools so that no possible stigma can be attached to the children attending. The child is registered at the ordinary school. The curriculum is arranged so that no use of the eyes in close work is allowed. Oral teaching, drills, games and dancing (when these last two are allowed) are taken with the ordinary children. All fine Work and use of the eyes for ordinary reading and writing is entirely prohibited. Literary work is done in the special classroom 011 blackboards, freearm fashion. A great point is made of handicraft, both for " hand and eye training," and for the associated teaching of arithmetic, history, geography, and general natural history by " object lessons " on the things made. The teachers in these classes attend a course of special lectures and demonstrations to prepare them for this work and the classes are small to secure individual attention. Midday meals are provided where necessary. The Council's ophthalmologist visits each class once a quarter, notes the state of the eyes, and reports to me. Attention is drawn to a paragraph in the current annual report of the Chief Medical Officer of the Board of Education. The particular paragraph is written of children suffering from tuberculosis, but it applies even more strongly to children with defective vision, for in these latter it is a matter of particular urgency to begin training early so that their other senses may be best cultivated. " Such children . . . are usually far better in attendance at school, where they spend a part of the day under reasonably good conditions and are subject to discipline, than at home, where the conditions are often unsatisfactory. If excluded it is difficult to maintain supervision over their mode of life, unless they are really ill and they tend either to loaf aimlessly about the house or streets, or they are made to do household drudgery or other unsuitable work." When children are attending school, it is possible to arrange many general advantages that cannot be obtained by absentees. A trained lady visitor keeps in touch with them, sees that they are properly clothed, that their journeys to school are properly arranged and, if necessary, takes them to hospital. The doctor is empowered to order milk and cod-liver oil for weakly children and the dentist regularly attends the schools. 102 Annual Report, of the London County Council, 1914. 3.— "Easy Treatment" or "Oral Teaching only." In cases where the defect is not so great as to necessitate attendance at a myope class, special arrangements are made at the ordinary schools. According to the degree of defect the head teachers are instructed to give the children " easy treatment." in the cases of slight defect, and to allow the children to have " oral teaching only " when the defect is more severe. The instructions given to the parents and to the teachers in these cases are set out in the accompanying circulars. In view of these facts the Council hopes that it may rely on the members of the staff of your institution to help in any way they can the arrangements for the education of these handicapped children. At the outset there is often a prejudice in the minds of the parents against anything in the nature of a separate training for their little ones, since they are not unnaturally unwilling to recognisc that these are different from other children, but so soon as they are acquainted with the work of the schools and classes their prejudice melts away. The hospital ophthalmic surgeon is often able to facilitate this attainment by his considerate comments. I shall always be grateful for reports concerning defective children ; these may be directed to me at the above address—i.e., 2, Savoy-hill, W.C. Yours faithfully, W. H. Hamer. The circulars referred to are as follows:— Notice Regarding the Care of the Eyes.—To Parents or Guardians of Your child suffers from a defect of vision that prevents him (or her) from joining in the ordinary work of the school. If it is impossible for you to obtain admission for the child to a special class for shortsighted children he (or she) may attend an elementary school with a view to gaining the educational advantage of school discipline and such general knowledge as can be given in the oral lessons of the classes. Reading and writing of any kind will not be allowed except blackboard work. You are particularly asked to watch your child at home, to teach games and outdoor play, and to stop all reading and writing. (In the case of a girl, sewing should be completely stopped, but knitting may be learned provided the child does it by feeling the stitches and not by looking at them.) The child should be out of doors as much as possible. W. H. Hamer, School Medical Officer. Teaching of children rcconnnendcd by the Medical Officer for "easy treatment," "oral teachiii"- oulv," or to " sit in the front row." o J ' Visual defects.—Children recommended for " easy treatment."-—These children usually suffer from a defect of one eye only or they have defective vision in both eyes of a moderate degree. With reasonable care school work should not cause strain of the eyes or entail the risk of exaggeration of their visual defect. These children should sit in the front row of the class, sit upright and not be allowed to stoop over any literary work allowed them. Girls must do no sewing, but may learn knitting, provided it be taught by touch and not by sight. Boys and girls should be prohibited the use of books with small print or writing of any sort other than a bold large-lettered hand. They should not join in exercises that involve the reading or writing of masses of numerals or geometrical figures. They may read or write in large type preferably for periods not exceeding 20 minutes without a break. They should not be allowed to stoop over their work, and, if it be possible, the writing should be done free-arm fashion on a blackboard or millboard set up on the desk. So far as school arrangements allow they should attend all the object lessons, demonstrations and oral lessons that are given ill the school. Drill, dancing and games of all kinds may be freely indulged in. Home lessons of any sort should be prohibited. Children recommended for " oral teaching only."—These children suffer from some serious defect of vision such as gradually increasing short sight. When no place can be found for them in a special class, they are admitted to the elementary school with a view to their gaining the educational advantage of school discipline, and such general knowledge as can be given them in the oral lessons of the classes. The use of books, pens, paper, pencils and slates of any kind and for any purpose is to be prohibited, and the child should be reminded at intervals by the teacher in a friendly chat that the prohibition is for his or her own benefit and that they must do at home what they are trained to do at school. If the class arrangements permit they may be allowed to write or draw on the blackboard in large characters free-arm fashion. If a girl shows aptitude for handwork she may learn knitting by touch, but not by sight. Similarly a boy may do the larger kinds of carpentry, but he must not use the rule or draw measured plans. For the most part these children may drill and dance, but they should be warned against using gymnastic apparatus or dumb-bells, for example, in connection with the Children's Happy Evenings Association. They should be cautious in the playground games. General.—The head teacher should, in the course of each year, draw the attention of the school doctor to these children, and give the doctor information as to their educational progress or any difficulties which may have arisen in connection with the cases. W. H. Hamer, School Medical Officer. Provision of spectacles. Assistance in obtaining spectacles is given by the Local Associations of Care Committees under the general guidance and help of the London Central Spectacles Committee. The following statement is taken from the Annual Report of the Central Committee issued May 21st, 1914, and signed by the Chairman, Miss Margaret Frere. Statement on the Work of Local Spectacles Committees for the year ending March 31st, 1914. "In each district a Sub-Committee of the Local Association is responsible for the Spectacles \Y ork of the area, except in St. Marylebone, where there is no Committee, but the Local Association asks for Annual Reports of Spectacle Work from the School Care Committees, and the following four areas where the Spectacles Committee is an independent one, specially formed for the purpose:— Battersea and Wandsworth. Lambeth. Stepney. Shoreditch. 103 Report of the County Medical Officer—Education. "In Hampstead, St. Marylebone, Paddington and Westminster the individual schools are entirely, responsible for their own cases. " In St. Pancras and Holborn there is no local fund, but the Local Spectacles Committees occasionally assist individual schools to maintain a small fund of their own. "In Fulham and Hammersmith the School Attendance Aid Committee undertakes the work of Spectacle supply, an arrangement which appears to be working satisfactorily. "This leaves 17 areas with local funds (as the two Hackney Local Association areas have one joint equipment fund). " I11 most areas grants and loans are given. One or two areas give, in theory at any rate, loans only, and in one area only grants are given. "Many hundreds of loans of amounts varying from 9d. to 3s. 6d., extending over periods ranging from two weeks to many months, have been given. O11 the whole the repayments have been quite satisfactory, notably in St. Pancras, Battersea and Wandsworth and Camberwell, where a considerable proportion of parents have repaid the full cost. It has been found helpful to ask the parents to sign a simple statement, promising to repay in small weekly instalments whatever their share of the cost of the spectacles may be. This amount is marked off weekly 011 one of the pink collecting cards (obtainable from the Local Correspondents), and the parents become quite keen 011 meeting their obligations. In Camberwell the better-off schools sent subscriptions to the Spectacles Fund, and some also got up entertainments to help the poorer schools—an example which might well be followed in other districts. " The returns show what a large number of agencies help in the supply of spectacles. Among these the Hospital Sunday and Saturday Funds hold the first place. It is interesting to learn that through the Head Master of one of the Council Schools an athletic association sent a cheque for £10 to the latter fund because of the help it gives in the supply of spectacles. The figures from six areas show that while 262 pairs of spectacles were supplied by the local fund, 459 pairs were supplied through the local Committee by other agencies. " Great variety in regard to local finance is shown in the reports. One vast area aims at a Reserve Fund of £50 and an annual income of £15, which it estimates would meet its needs; others again estimate that an income of many times this amount will be needed. Though it cannot at present be said that the poorer areas are 011 a permanently satisfactory financial basis, yet it is most encouraging to see how quickly and easily up to the present the children have obtained their glasses and how well the arrangements appear to be working with the approved local opticians, who, in almost all parts of London, attend at the hospitals and treatment centres to measure the children." I11 addition the following leaflet was issued by the Central Committee. Suggestions of Procedure in Connection with Provision of Spectacles. Parents should understand that there is no general fund available for making grants for spectacles, and they should, as far as possible, be encouraged to repay the cost of glasses in instalments. Collecting cards C.C. 1/249 for this purpose may be obtained from the Secretary of the Local Association and accounts with the Opticians should be settled quarterly to allow time for the repayments to be collected. Where Care Committees need assistance in the supply of Spectacles, they should use all available sources (e.g., Church relief funds, private help, Hospital Sunday and Saturday funds, &<c.) [see note] before applying to the local fund. In many cases a successful concert or entertainment in the school has enabled a Care Committee to obtain sufficient funds to meet the needs of their spectacle work for a very considerable period. It is desirable that, wherever the parents do not pay the full cost, Form 41 C. should be filled up in order that their contributions may be fairly assessed. Where application is made to a local fund this should be sent with Form A. to the local spectacle committee. Form B. 1 should be sent to the local committee at the end of each school term, all cases being included, whether or not assistance has been obtained. Form B. is issued simply for the convenience of those committees who desire to keep their records upon it. Forms A., B. and B. 1 may be obtaired from the Secretary of the local association. The following suggestions are made with a view to reducing to a minimum the needs for repairs and obtaining the full benefit from the glasses.— (a) Complaints as to the quality, &c., of the glasses should be reported at once to the local spectacle committee. (6) Where the teachers are willing to give the required assistance, a spectacle roll call should be instituted in each class so that any child ordered spectacles and not wearing them might be rej orted to the Care Committee. Note.—The following information was prepared by the Finsbury Association. 1.—Grants from the Hospital Sunday Fund. These can only be obtained from the Vicars of Parishes or Ministers of the Free Churches. In the first instance it is always necessary to ascertain what Church or Chapel the parents of the child concerned are connected with, or to what Sunday School or Band of Hope or similar organisation, if any, at a Church or Chapel, the child itself belongs. You should then apply to the Vicar or Minister, as the case may be, giving the following particulars :— (o) Name of the child. r (b) Age of child. (c) Address of child. (d) Appliance required (in this case spectacles of course). (e) Name of optician or maker. (f) Estimated cost. (g) Name of Hospital or Doctor ordering spectacles. In .addition, it is well to give particulars of the circumstances of the family as far as you know them "'and to mention how much the parents are paying towards the cost. On receiving your applications, if the Vicar or Minister approves, he will procure a letter from the Hospital Sunday Fund, which will probably be for about half the cost of the spectacles required. This letter is to be given to the optician along with the balance of the cost when yon pay the bill. Fn the case of a child or family not connected in any way with a Church or Chanel, you should apply to the Vicar of the parish in which the family live. 104 Annual Report of the London County Council, 1914. 2.—Grants from the Hospital Saturday Fund. Every workman who subscribes to the Hospital Saturday Fund is entitled to assistance from the Fund towards the cost of surgical appliances for himself and his family, spectacles being included among these. If you wish to get a grant on behalf of a child, your first step is to find out whether its father is a subscriber to the Hospital Saturday Fund, and, if he is, to get him to apply to the Honorary Collector of the Fund at his place of employment for a Letter of Recommendation. When this letter has been procured and handed to you the spectacles should be supplied in the usual way and the bill paid. You have then to send the receipted bill along with the Letter of Recommendation to the Secretary of the Fund, whose address is A. W. Davis, Esq., Secretary, Hospital Saturday Fund, 54, Grays Inn Road, W.C., and the Committee of the Furd will make a grant of about half the cost, which will be sent you bv Postal Order. Special measures for i mproving the attendance of children for treatment. With the growth of the Council's treatment scheme an increasing difficulty has been felt owing to the loss of school attendance marks, since in a very large proportion of cases treatment is given during school hours. Apart from the question of the loss of grant entailed, this loss of marks was felt to be somewhat of an injustice to the child, inasmuch as it interfered with the obtaining of rewards for punctuality of attendance. The Council had in common with other authorities several times approached the Board of Education on this matter, and on the 24th June, 1914, the Board amended Article 44 of the Code by the addition of the following paragraph (i.) :— " (i) Any period during the School hours occupied by the medical treatment of scholars who are not excluded from School under Article 53 (6), provided that such treatment is given under the authority of the Local Education Authority and under the supervision of their School Medical Officer in a place approved by the Board, and in accordance with arrangements sanctioned by the Board under Section 13 (1) (b) of the Education (Administrative Provisions) Act, 1907. The following Article (c) has also been added after Schedule iv., 23 :— " (c) Any scholar marked absent at any meeting of the School who is found on examination of the Special Register kept at an ' approved place ' to have spent so much time in attending the ' approved place' as in itself or with the addition of the time spent in secular instruction at the School would make up the minimum period required for an attendance under article 43 (b) may have the letter T entered inside the mark of absence, thus T and an attendance in respect of that period may be reckoned. All attendances so registered should be added to the total attendances of each child concerned at some time not later than the end of the School year." Prior to the issue of this regulation, an attendance mark was lost on every occasion on which a child failed to complete the prescribed period of secular instruction in consequence of attendance at a hospital or treatment centre. At a very early stage in the development of the Council's medical treatment scheme, this gave rise to considerable difficulty. For administrative reasons, the hours for treatment, both at hospitals and treatment centres, fell within the school hours, except in the case of the nursing treatment of minor ailments. The Council was thus faced with the position that every successive development of its scheme for securing medical treatment for ailing children resulted in a lowering of the number of attendances registered at the school, and a consequent loss of grant. Another difficulty, which may perhaps be mentioned, though not relevant to the question of grant, arose in connection with the teachers and the children. The teachers, whose co-operation is essential to the successful working of any measure of school hygiene, viewed with concern the effect upon the school attendances produced by their efforts to encourage children to obtain treatment. Moreover, the children themselves resented very much the loss of their attendance medals which resulted upon absence from school to obtain treatment, and in this they had the sympathy of their parents. In both cases, the sentiments, though perfectly natural and reasonable, were directly inimical to the working of the Council's medical treatment scheme. So far as the medal question is concerned, the difficulty has been met by the modification of the Council's regulations for the award of medals, but the difficulty as to the lowering of school attendances and loss of grant lay outside the Council's control. Representations were made to the Board of Education, both by the Council and [by other local authorities and the new regulation meets the difficulty to a very considerable extent. This new regulation, however, has brought with it difficulties of interpretation and of administration. As a result of representations made to the Board, the Council has received the following letter with regard to the interpretation of the phrase " Any scholar . . . who is found ... to have spent so much time in attending the approved place. " " ... I am directed to state that, in view of the arrangements made by the Local Education Authority, the Board of Education consent under Article 44 (i.) of the Code to the time spent by a scholar in going to and from the ' approved place' for the purpose of medical treatment being counted towards the minimum time required under Article 43 (b) in order that an attendance may be reckoned for grant." The arrangements referred to in the Board's letter relate to certain measures which have been taken to secure that children return to school whenever possible and as quickly as possible. The Council has been unable to induce the Board to recognise as attendances for grant purposes, sessions or portions of sessions during which a child is " recovering " at home from the results of treatment. It should be mentioned that the machinery, which it has been necessary to set up in order to comply with the Board's regulations for the registration of attendances, involves an amount of clerical work, which considerably reduces the financial value of the regulations to the Council. During the year, a scheme has been put into operation whereby children and parents attending hospitals and treatment centres are granted special facilities for travelling on the Council's tramways. The object of the scheme was to meet a difficulty which had been felt for a long time, owing to the fact that in many cases, parents were prevented from obtaining treatment for their children by the travelling expenses involved, while, in other cases, long distances were travelled on foot on account of the parent's inability to pay the fares. 105 Report of the County Medical Officer—Education. As a result of negotiations between the Education Committee and the Highways Committee, the plan now to be more particularly referred to was put into operation in the middle of November, 1914. The scheme provides for the issue of tickets at the rate of 1/2d. each for a single journey of any distance. Both the child and the parent, or other adult accompanying the child, are entitled to use these tickets. The tickets are available between 9.30 a.m. and 4 p.m., but are not available on Saturday. This limitation was designed to prevent any interference with the normal traffic. Except as regards the initial journey from home, the tickets are issued by the nurse or organiser who is in attendance at the hospital or centre. Tickets for the first journey are issued under special arrangements made by the district organiser. The average course of treatment entails three journeys to and from the hospital. Assuming that the parent accompanies the child on each occasion, the total number of journeys would be twelve, and if the ordinary fare per journey is l1/2d., the total saving to the parent, as a result of the facilities would be Is. It is impossible to judge as yet of the effect of this plan in encouraging parents to obtain treatment for their children, but it may be mentioned that the arrangement made by the Highways Committee has been greatly appreciated by those parents who have already availed themselves of it. Following-up : Organising staff for children's care work. Since the transfer of the work connected with the medical treatment of school children from the Education Department to the Public Health Department, considerable attention has been given to the respective claims of the two departments to the services of the organisers of children's care work. The question was one of some difficulty, inasmuch as both departments were interested in the work of the care committees, and it was essential that no step should be taken which would impair the efficiency of the care committee system. As a temporary measure one half of the time of one of the principal organisers and the whole of the time of one of the district organisers had been placed at the disposal of the public health department, and the whole organising staff performed its duties in connection with medical treatment under the direction of the school medical officer. On the 29th July, 1913, the Council decided— (a) That a staff of organisers sufficient for the organisation and administration of medical inspection and treatment of children, devolving upon the medical officer under the resolution No. 9 (la) of 25th July, 1911 (p. 329), be allocated to the public health department, and be thus placed entirely under the control of the school medical officer. (b) That a staff of organisers sufficient for the work relating to children's care, other than the organisation and administration of medical inspection and treatment of children, be allocated to the education officer's department and be thus placed entirely under the control of the education officer. (c) That, so as to avoid overlapping and duplication of work the work of the organisers referred to in the foregoing resolution (a) and (b) allocated to the education officer's department and the public health department be for a period of one year co-ordinated by the education officer and school medical officer through a principal organiser, who shall be a half time officer in the education officer's department and a half time officer in the public health department, and that the General Purposes Committee do report at the expiration of one year as to the continuation of this arrangement. Various proposals were considered for giving effect to these resolutions. The problem was to divide the staff in such a way as to ensure that the efficiency of the care committee system should be maintained and that duplication of work should be avoided. In the last annual report the work of the care committees in connection with medical treatment was described in detail and it was pointed out that the success of the work depended upon the co-operation of the organisers engaged in the work of " following up " in the treatment centres, with the care committees, and that it was impossible to detach the " following up " work from the general scope and structure of the care committee organisation without imperilling the whole scheme of treatment. It was also stated that this view had been accepted by the Council, who had decided that the organising staff dealing with medical treatment and work ancillary to medical treatment, should be wholly included in the public health department under the supervision of the school medical officer. As, however, the Council's decisions were not arrived at until the 19th May, 1914, it was possible to make brief reference only to them in last year's report, and this year a more complete statement of the arrangements made may be of interest. In their report to the Council on the subject, the Education Committee, after reviewing the position of the care committees and the organising staff, stated that, in view of the recognised place of the care committee system [in the Council's administration, the time had come for placing the staff on a permanent basis. They were of opinion that, so far as the supervising officers were concerned, there should be one principal organiser instead of two, that two principal assistant organisers should be appointed, one of whom should be allocated to the education officer and one to the school medical officer, and that the appointment of a district organiser in each of the twelve educational administrative areas should be continued. With regard to the division of the staff the committee reported as follows :— " The Council has decided that for the proper organisation of the work of medical inspection and treatment London shall be divided into five divisions, and that the medical work in each of these divisions shall be placed in charge of a divisional medical officer. In the five divisional offices the administration of the treatment centre work will be focussed, and each of the five divisions for medical purposes will, therefore, include two or three educational districts. 27715 * 106 Annual Report of the London County Council, 1914. With a view to co-ordinating the arrangements which the Council has now approved for medical work, with the arrangements for education work, it is suggested that the responsible organiser for the district in which the medical divisional office is situated shall in each instance be allocated to the medical officer. Five officers having thus been allocated, the remaining seven officers are allocated to the education officer. Each of the 12 district organisers would in practice deal with the care committees of her district, but seven of them would have nothing to do with purely treatment centre work. As the five district organisers allocated to the public health department will have duties to perform beyond those required of the seven, they will need special help. We therefore propose that in each of the five divisions an assistant organiser shall be appointed in the public health department to deal more particularly with the voucher and following-up work connected with the treatment centres, and be subject to the direction of the district organiser allocated to the medical officer, and also that the principal assistant organiser allocated to the medical officer, in addition to dealing with the medical work of the organisers of the twelve districts, shall devote special attention to the work of the treatment centres in the five medical divisions. This officer and the five officers mentioned in the preceding paragraph should be able to relieve the district organisers of the treatment centre work to such an extent as to obviate any possibility of their efficiency being in any way impaired. With regard to the subordinate officers, the individual members of the staff will be allocated in each division in appropriate numbers to one or other department, and it will be the duty of the principal organiser, working through the twelve district organisers, to make such special arrangements as will enable individual officers to deal with two separate branches of work and, at the same time, to preserve cohesion and prevent overlapping." It will be seen that under these arrangements no portion of the work is divorced from the care committee organisation, the whole of the medical work is dealt with by the same officers, the structure of the organisation is maintained unimpaired and an allocation of the officers is carried out in accordance with the intention of the Council. Suggestions for increasing the staff to meet the growth of the work were submitted, the total staff recommended for the public health department being one principal organiser (half time), one principal assistant organiser, five district organisers, forty-eight assistant organisers and twelve women clerical assistants. At the same time the Council dealt with the question of giving clerical help to care committees in certain districts. In July, 1913, a special experiment had been authorised in the Whitechapel area, whereby a branch office was established as a centre for care committee work. The accommodation provided was fully used by voluntary workers for committee meetings conferences, and office purposes; and the work of twenty-four care committees was concentrated at this branch office. The experiment was fully successful, and the Council agreed to make similar arrange, ments in four other districts. As stated previously the above proposals were adopted on the 19th May, 1914, and the Council in July, 1914, selected the officers to fill the various posts. The new arrangements have not been in operation a sufficient time to enable their full effect to be estimated, but there is evidence that the care committees are at the present time taking a very keen interest in the " followng-up " work connected with medical treatment. Re-inspection. A most important part of the school doctor's duty is the re-inspection of children found defective at medical examinations. This work has now been thoroughly organised in London, and provision has been made for every case reported defective to be re-inspected a few months after the primary inspection, and for each case not discharged as satisfactorily treated at this first re-inspection.to be again re-inspected at a later date. A system of control cards has been introduced which makes it impossible for any children requiring inspection to be missed. During the year 84,500 re-inspections were made, and the results are given in the following tables. Of all children found defective 50 per cent, were found to have been treated by the time the first reinspection was held, an additional 7 per cent, were no longer in need of treatment and 43-1 per cent, had received no treatment though still requiring it. Out of the 50 per cent, in whom treatment had been commenced, in 70 per cent, it had been completed satisfactorily, 19 per cent, were still under treatment and 11 per cent, had discontinued treatment prematurely or from other causes were uncured. Thus after the first re-inspection had been held 4.2 per cent, of the children were discharged as satisfactory, while 58 per cent, were still requiring treatment; after two re-inspections it was found that of children recommended for treatment, 66.6 per cent, were completely cured, while 25 per cent, still requiring treatment had not yet procured it. The remaining 8.6 per cent, had all been under treatment, but half of this number had discontinued treatment before being cured and in half the treatment was still being continued. Of those children suffering from ailments for which the Council had made special provision 62.6 per cent, of the cases which obtained treatment were dealt with under the Council's scheme, the remainder obtaining relief at the hands of other agencies. The largest proportion of cases which obtain treatment are found amongst those suffering from minor ailments of whom in 65-5 per cent, the treatment is completed during the first 6 months, and in 59-2 per cent, of the remainder treatment is completed during the second 6 months ; next come cases of visual defect, of which 57 per cent, are treated in the first 6 months and 52-5 per cent, of the remainder 107 Report of the County Medical Officer—Education. in the second 6 months. There is then a big drop to the ear, nose and throat cases, of which 44 per cent, obtain treatment during the first period and 38-5 per cent, of the remainder in the second period. The reluctance of parents to face the inconvenience and trouble of operation accounts for the difference between the number of these cases and those of defective vision obtaining treatment. Worst of all are the cases of defective teeth. Of these 41 per cent, are found to be treated in the first 6 months and 35 per cent, of the remainder in the second 6 months. But it must be remembered that these figures relate exclusively to the cases found at medical inspections and that the schemes approved by the Board of Education restrict treatment to the age group 6—8. When it is considered that adequate provision does not as yet exist in London for dental treatment of the leaver age group, the results here given may be looked upon as fairly satisfactory. With regard to " other ailments," including all forms of defect for which the Council has made no provision, 54 per cent, were found to have been treated at the end of the first period, and 44.8 per cent, of the remainder at the end of the second period. Table showing percentages of each class of defect treated by the time of the first re-inspection and percentages of the remainder treated by the time of the second re-inspection. Defect. Re-inspection. Treated. No treatment required. Still requiring treatment. Refraction, 1st 2nd 56.9 52.5 2.7 4.2 40.4 43.3 Nursing treatment 1st 2nd 65.5 59.2 16.5 13.7 18.0 27.1 Ear, nose and throat 1st 2nd 44.3 38.5 7.6 9.5 48.1 520 Teeth 1st 2nd 41.0 35.0 4.7 77 54.3 57.3 Other ailments 1st 2nd 54.1 44.8 20.1 17.0 25.8 38.2 Total 1st 2nd 49.7 43.1 7.2 8.7 43.1 48.2 The result of the two re-inspections taken together is shown in the following table giving the numbers cured or still requiring treatment, per 100 cases of each defect referred for treatment. Treated and completely cured. Cured naturally without treatment, or for observation only. Treated but not completely cured. Not treated and still requiring treatment. Refraction 56.1 6.8 12.2 24.9 Cases requiring nursing treatment 57.7 24.5 9.2 8.6 Ear, nose and throat 53.3 17.7 4.4 24.6 Teeth 48.9 10.2 5.9 35.0 Other ailments 38.3 39.2 12.4 10.1 All cases 51.3 15.3 8.6 24.8 If the cases of dental defect, which do not stand on the same footing as the others, be excluded the total for all cases in the last column would be greatly reduced. A comparison during 3 years of the children found to have received or to be in receipt of treatment, by the time the first re-inspection was held, shows a steady increase in the numbers from 43-1 per cent, of the total in 1912 to 49 7 per cent, of the total in 1914. Treatment no Not treated but Treated. longer required. still requiring treatment. 1912 43-1 per cent. ... 12-0 per cent. ... 44-9 per cent. 1913 45-5 per cent. ... 9-2 per cent. 45-3 per cent. 1914 49-7 per cent.. 7-2 per cent. 43-1 per cent. The percentages of total children treated who receive their treatment through centres and hospitals with which the Council has made arrangements show a very considerable increase. Percentages of total children treated under the Council's scheme :— 1912 38-9 per cent. 1913 46-4 per cent. 1914 56-2 per cent. 27715 P 2 108 Annual Report of the London County Council, 1914. The following table gives, in the case of those children obtaining treatment, the percentages who obtained it,—A, by private doctor or dentist; B, under the Council's scheme ; and C, at other hospitals or institutions. A. B. C. By private Under Council's At other hospitals doctors. scheme. or institutions. Refraction.. 3.1 74.3 22.6 Minor ailments 17.6 50.7 31.7 Ear, nose and throat. 7.4 58.9 33.7 Dental defect 21.2 56.1 22.7 Other ailments 27.1 6.2 66.7 Total 13.6 56.2 30.2 The very great percentage, 74.3 per cent, of the whole, who get their refraction done under the Council's scheme shows what a need has been met by the facilities for treatment of visual defect arranged by the Council; very few cases needing refraction (3.1 per cent.) or cases of operation for adenoids and tonsils (7.4 per cent.) are able to arrange for treatment privately. The percentage of cases treated found on primary re-inspection to have completed treatment and to have been satisfactorily cured of their defects is shown for each class of disease and mode of treatment in the appended table. Private Council's Other hospitals doctor or dentist. scheme. or institutions. Refraction 65.8 63.4 65.3 Minor ailments 78.8 64.4 66.2 Ear, nose and throat 66.4 85.9 76.0 Teeth 63.5 90.2 70.9 Other ailments 61.9 38.4 46.3 Total 65.9 74.4 63.6 It is seen that the treatment given through the Council's scheme is considerably more expeditious and satisfactory in the cases of ear, nose and throat disease and of dental defect than through other channels. It is very largely of course a question of " following up " ; while the parents who can afford to pay are more likely to see that continuous attendance is maintained, the better results obtained generally through the Council's scheme (74.4 per cent, satisfactory against 63.6 per cent, at other hospitals and institutions) are due to the work of the organising staff who attend the centres and inform the Care Committees in cases where failure to attend or some other obstacle to continuous treatment arises. Provision of Meals for Necessitous Children. The work under the Education (Provision of Meals) Act, 1906 is co-ordinated with the school medical service in the following ways— 1. Supervision of dietary.—The menus from which the meals are prepared by the Alexandra Trust were drawn up in consultation with the school medical officer, and all questions of alterations and modifications of the menus are referred to him. A large proportion also of the dietaries supplied by local associations and local caterers have been submitted to him, and this is invariably done when any question of suitability or adequacy is raised. In addition to this the assistant medical officers at their periodical inspections of the dining centres pay regard to the character of the meals supplied. Actual samples of meals provided are forwarded to the public health department from time to time for analysis, and the results of analysis are transmitted to the education officer with recommendations as to improvement of the dietary in cases where this appears to be inadequate. Similar provision exists for the taking of samples and for analysis of milk supplied to the schools. Out of 29 samples of meals, 27 were found to be satisfactory, while two were deficient in fats. The number of samples taken of milk intended for use of children at schools during the year was 214, of which 181 were reported as being either " satisfactory " or " fairly satisfactory." Of the 214 samples, 23 were found to contain added water varying between 3 and 30 per cent.(average 121/2 per cent.) svhilst 2 samples were reported as being deficient in fat to the extent of 5 per cent, and 20 per cent, respectively. A few samples were of such quality as to raise suspicion, but in these cases further samples were obtained and examined. Of two samples of milk supplied to special schools and sent by the Chief Officer of Stores, for examination, one was found to be unsatisfactory, containing about 18 per cent, of added water. Dr. Margaret Macdonald has worked out the protein content of the dinner menus and finds that with one exception the menus supply 46 per cent, to 60 per cent, of the daily protein requirements of a child of 10 years. 2. Medical inspection of individual children.—When children are discovered to be undernourished during the routine inspection of age groups, the assistant medical officers make recommendations to the care committees with regard to feeding, and, in the small proportion of cases in which the assessment 4 is placed opposite the nutrition record, a very careful system of following up has been carried out and the physical measurements of the children have been taken at the subsequent re-inspections. In one of the Shoreditch schools Dr. Elizabeth McVail undertook an investigation, primarily to ascertain the effect of feeding upon the children. Out of 73 children examined in September who were selected for feeding on 7 days a week, only 24 had continued to be fed, or had been sufficiently regular in attendance for an estimate to be made of the effect of feeding at the end of twelve weeks. These children were compared with a similar number of children who had been fed at home, and it was found that 19 boys and infants who had been fed constantly for 12 weeks showed an average weekly increase in weight of .082 kilograms, while 19 corresponding children who had not been fed at school and who had been selected as controls, showed during the same time an average weekly increase of 063 kilograms. The remaining five children were girls and were examined for the second time after a lapse of 109 Report of the County Medical Officer—Education. 18 weeks; it was found that their average weekly increase was .036 kilograms as compared with an average weekly increase of .019 in the selected unfed controls. The effect of feeding, therefore, was to increase materially the rate of growth of those children who were constantly fed at school. Dr. Chaikin examined during September a number of children in two Bethnal Green schools; these children he again examined after the lapse of six months. To show to some extent the difference in results which might be expected if physical conditions were taken into consideration in the selection of the children, the following figures, taken from Dr. Chaikin's report, may be given., indicating the increase in weight observed during 6 months at these two schools, referred to as School I. and School II. The groups of children are— A—Those not fed at school. B—Those fed irregularly at school. C—Those fed regularly at school. Average increase of weight in kilograms in 6 months— Group A. Group B. Group C. School I (72) 1.307 (72) 1.158 (26) 2.704 School II (34) 1.305 (33) 1.666 (25) 1.317 The number of children in each group is given in brackets. In School II.,the children fed irregularly, group B, put on more weight in the time than either those fed at home, group A, or those fed constantly at school, group C. At School I., on the other hand, the children fed constantly at school, group C, put on twice as much weight as those fed at home, group A, and more than twice as much as the children fed irregularly, group B. The original examination of the two schools showed that of the children originally selected just after the summer holiday, for extra feeding at School II., only 50 per cent, were below average weight, while at School I. 70 per cent, were below average weight. Better results were obtained on weighing the children after a considerable interval at School I. than at School II., and this fact gives some indication that still further improvement would be apparent if the children in the schools, under-nourished but not on the feeding list, were substituted for those on the feeding list who are well nourished and about whose necessity there is a grave degree of doubt. In giving a statement of the results obtained at these two schools it should be pointed out that the numbers of children investigated are small, and that further extension of the enquiry is desirable before drawing definite conclusions with regard to the London Schools generally. 3. Inspection of feeding centres.—In addition to the foregoing points, it may be mentioned that co-ordination with the school medical service is further ensured by the fact that the dining centres in the districts are visited periodically by the assistant medical officers who report upon the arrangement so far as they affect the health of the children. During the autumn term 209 feeding centres were visited and the attention of the Education Officer was drawn to defects in sanitary accommodation (1), utensils (5), cleanliness (2), lighting (1), waiting-room (1), nature of meals (9), time allowed (2). These defects were investigated and steps taken to remove them. Children out of school for long periods. The attendance branch of the education officer's department submits each month to the school medical officer, medical certificates concerning all children out of school for a period of three months on account of ill-health. A card index of the cases is kept in the public health department. The number of new cases notified during the year was 5,399, but more than one return has been made in the case of many of the children and the figures are, therefore, not strictly comparable with those shown in last year's report. Altogether 9,749 returns have been made. In 2,860 cases medical certificates were supplied. An analysis of the returns gives the causes of absence as follows :— Rheumatic conditions— Acute rheumatism 557 Heart disease 705 Chorea 1,108 2370 24-31 per cent. Nervous conditions— Paralysis 136 Epilepsy 168 Brain disease 68 Other nervous conditions 242 614 = 6.28 per cent. Tuberculous conditions— Lungs 917 Glands 160 Other organs 216 1293 = 13.36 „ Diseases of chest (excluding phthisis) 738 = 7.56 „ Anaemia and debility 1203 — 12-34 ,, Ringworm 178 = 1-83 „ Various 205 = 2*10 „ Infectious diseases 341 — 3-58 „ Diseases of skin 380 = 3-88 „ Diseases of ear, nose and throat 459 4*71 ,t Diseases of eyes 860 = 8-82 „ Diseases of kidneys 103 = 1-05 „ Rickets, etc. 49 .50 „ Scabies 135 = 1-38 „ Surgical conditions 537 = 5-51 „ Diseases of digestion 125 = 1-26 „ Illegible and unsatisfactory certificates 158 = 1-52 ,, Specific disease 1 = 0-01 „ 9,749 10000 „ 110 Annual Report of the London County Council, 1914. It will be seen that the rheumatic group of diseases forms the highest proportion—nearly 25 per cent, of the total—among the causes that produce protracted absences from school. Next comes tuberculosis in various forms, 13 per cent. It is gratifying to find that the number of returns relating to ringworm has fallen from 234 to 178 and not only are the cases fewer, but the average period of absence appears to have been considerably shortened. An analysis is given in the following table of the action taken in cases in which further followingup was considered advisable. Division. New cases. Total returns Referred for examination by divisional medical officer. Divisional medical officer informed. Referred to attendance officer for further enquiry. Referred for examination for special school. Referred for examination by ophthalmologist. Epileptics registered as suitable for residential treatment. Referred to organiser of care committees. Camberwell 278 312 15 40 2 1 M.D., 2 P.D. _ _ 13 Chelsea 261 294 28 33 6 5 P.D. _ 1 13 City and Stepney ... 129 145 8 27 4 1 Bl„ 1 M.D., 1 P.D. 3 20 Greenwich. 471 661 35 46 9 8 P.D. — 5 55 Hackney 130 134 13 19 3 7 P.D. — — 13 Islington 170 222 12 29 1 1 M.D., 1 P.D. 1 2 14 Lambeth 135 151 4 11 2 — — — 11 Paddington 86 115 13 13 3 — — 2 9 Poplar 662 891 61 90 14 1 BI., 3 P.D., 1 M.D. — 5 48 St. Pancras 247 306 21 14 6 1 M.D., 3 P.D. 1 — 18 Southwark 1,933 3,436 68 144 39 17 P.D. 5 10 110 Wandsworth 937 3,265 94 113 54 4 M.D., 1 Bl., 1 Myope. 30 P.D. 2 13 80 Total 5,399 9,932 372 579 143 9 M.D., 77 P.D., 3 Bl.. 1 Myope. 9 41 404 Many of the causes of absence are due to conditions which, while causing great suffering and incapacitating children from attending school, should with proper care and attention be cured in a shorter period than three months. Such conditions are scabies and various external affections of the eyes. A beginning has been made in the direction of notifying such cases to the local care committees with a view to the investigation of the home conditions and the regularity of medical treatment, and in suitable cases to the provision of daily nursing or convalescent treatment, or to securing attendance at the cleansing stations. The particulars of the examination by the Council's own medical staff in 201 cases, as a result of which it was found that two-thirds were fit for school, are as follows :— Fit to return to school Unfit to return to school. Attendance not to be pressed. Physically defective school. Further examination. Camberwell 6 — — — — Chelsea 2 1 — — — City and Stepney 6 — 1 — — Greenwich 7 6 — 1 1 Hackney 1 — — — — Islington 3 — — — — Lambeth 4 2 — — — Paddington 1 2 — — — Poplar 20 12 1 1 — St. Pancras 3 — — — — Southwark 30 18 — — — Wandsworth 47 16 — 9 — Total 130 57 2 11 1 Tuberculosis. Reference was made in the annual report for 1913 (page 156) to the part taken by the school medical service in the detection of tuberculosis among children and in bringing the cases under the notice of the various agencies engaged in securing appropriate treatment. It was then foreshadowed that, while the question of school attendance or certification for residential treatment will remain the function of the school medical officer, the problem of treatment will fall to be dealt with as part of public health administration carried out under the machinery brought into existence by the compulsory notification of tuberculosis under the Local Government Board Tuberculosis Regulations, 1912, by the establishment of dispensaries by borough councils, and by the constitution of the Council as an authority under Section 64 of the National Insurance Act, 1911, for providing institutional treatment for persons suffering from the disease. The work of the school medical service in connection with open-air schools, playground classes, and schools for physically defective children, where provision is made for cases of tuberculosis in early stages of the disease is dealt with elsewhere in this report. As regards the year 1914 it may be of interest here to mention that 755 children or 0-33 per cent, of those examined under the Elementary Education (Administrative Provisions) Act, 1907, were found to be suffering from pulmonary tuberculosis, and further 631 or 0-28 per cent, from other forms of tuberculosis. The boroughs from which the lowest percentages of pulmonary tuberculosis were reported were the City of London and Hampstead, while those with the heaviest percentages were Chelsea, Fulham, Stepney and Poplar. Ill Report of the County Medical Officer—Education. In the report on children out of school for long periods on account of ill-health (p. 109) it is shown that 1,293 were registered as suffering from tuberculosis, viz., lungs 917 cases, glands 160 cases, other organs 216 cases, the total being 13.36 per cent, of the whole number so excluded. In dealing with the problem of children suffering from tuberculosis the need for a combination of hospital and educational systems has to be borne in mind, and the Council decided that children certified to be capable of receiving education shall be sent to institutions recognised by the Board of Education under the Elementary Education (Defective and Epileptic Children) Act, 1899. The classification of cases and the types of institution, day and residential, suitable for the various classes of cases to be dealt with, and the extent to which the sufferers would be capable of receiving education, were discussed in the annual report for 1913 (p. 157) and it was there indicated that at the end of the year negotiations were in progress with a view to securing suitable residential accommodation ; the question of providing day institutions, other than schools for physically defective children which had already been provided, was deferred, mainly owing to the difficulty in London in securing suitable sites for open-air day schools. The following is the accommodation which it has been estimated should be secured. Residential institutions 350 beds for surgical cases. 150 beds—for pulmonary cases (125) — and gland cases (25) 500 Open-Air Day Schools 1,000 places in addition to existing provision of 300 places. During 1914 the Council was successful in securing the specified number of beds in the under mentioned institutions :— East Anglian Children's Sanatorium 50 beds for pulmonary cases. National Children's Home Sanatorium, Harpenden 10 beds for pulmonary cases. Fleet Sanatorium, Hampshire 5 beds for pulmonary cases. Queen Mary's Hospital, Carshalton 30 beds for either pulmonary or sur(Metropolitan Asylums Board) gical cases as required. Alexandra Hospital for Children with hip disease 20 beds for hip cases. Victoria Home for Invalided Children, Margate 5 beds for surgical cases not requir- ing education. The first cases were sent to the East Anglian Children's Sanatorium on 15th June, and admissions to the various institutions were continued as beds became available. At the end of the year 107 children had been distributed among these institutions. Of this number, 18 had been discharged by 31st December. The reports indicated that in 12 of these, who had completed an average stay of 129 days, the disease was quiescent on discharge. The remaining 6 left after varying periods of residence, owing either to the refusal of the parents to allow the children to complete the treatment, or to insubordination. All children discharged are being kept under medical observation at the local dispensaries and by the school medical service, and reports as to their progress are being obtained by the Council at intervals of three months. It is not considered that any useful data would be provided by an analysis in this report of the results of treatment, having regard to the short time the scheme had been in operation at the end of 1914. It is, moreover, in contemplation to issue in a few months' time, a comprehensive report dealing with the administration of the Council's Tuberculosis Scheme. The procedure in regard to the selection of children for admission to this school and the arrangements made for the periodical medical examinations under the Education (Administrative Provisions) Act, 1907, and the Education (Defective and Epileptic Children) Acts, 1899-1914, are set out in the annual report for 1913. The school has been under the regular supervision of Dr. R. S. Walker, who is also the medical officer of the Paddington Tuberculosis Dispensary, from which the children are drawn. The number of children on the roll on 1st January was 96, and on 31st December 92 ; the average for the year was 95. There was no marked variation in the attendance from month to month except in November and December, when the average fell to 69.8 and 67.9 respectively. The highest average attendance (84 9) was in May. During the year 38 children have been referred for dental treatment; 11 for enlarged tonsils and adenoids; 8 for defective vision; 6 for ringworm, scabies, etc.: 1 developed scarlet fever: and 4 were sent to sanatoria. Keneal House Tuberculosis School The following table shows the increases in the stature and weight of the children :— Average Weight in Kilograms. Boys. Girls. Year of 5th 25th 50th Increase during 5th 25th 50th Increase during birth. week. week. week. whole period. week. week. week. whole period. (1) (2) (3) (4) (5) (6) (7) (8) (9) 1908 20.2 20.0 22.2 2.0 1907 23.9 23.8 26.5 2.6 18.2 18.1 — 0.9 1906 — — — — 20.5 21.0 22.7 2.2 1905 22.0 22.0 23.7 1.7 21.4 21.5 23.0 1.6 1904 25.1 25.5 27.3 2.2 26.3 26.7 28.9 2.6 1903 32.1 32.8 34.5 2.4 28.6 29.3 31.4 2.8 1902 27.1 29.0 30.4 3.3 30.8 32.1 35.1 4.3 1901 31.3 32.0 33 .4 2.1 32.1 33.4 35.0 2.9 1900 — — — — 44.7 45.3 46.8 2.1 1899 32.2 31.9 32.9 0.7 38.9 38.2 38.3 _ 112 Annual Report of the London County Council, 1914. Average Height in Centimetres. Boys. Girls. Year of birth. (1) 5th week. (2) 25th week. (3) 50th week. (4) Increase during whole period. (5) 5th week (6) 25th week. (7) 50th week. (8) Increase during whole period. (9) 1908 110.8 113.0 117-0 6.2 1907 125.2 127.1 130-5 5.3 109.4 112.4 115.0 5.6 1906 — — — _ 113.0 118.0 120.8 7.8 1905 120.6 123.0 127.1 6.5 118.6 121.5 123.9 5.3 1904 128.5 130.0 133.4 4.9 123.8 129.5 132.5 8.5 1903 134.1 135.6 140.6 6.5 133.0 135.2 138.2 5.0 1902 129.8 132.7 137.2 7.4 138.2 140.3 147.2 9.0 1901 135.5 135.5 138.9 3.4 140.2 140.4 145.4 5.2 1900 — — — _ 157.4 157.8 159.0 1.6 1899 142.0 144.2 145.0 3.0 140.0 140.5 150.1 101 Of the 56 children (33 boys, 23 girls) who attended the school during the whole year, 5 (1 boy and 4 girls) gained over 5 kilos in weight; 9 (4 boys and 5 girls) over 4 kilos; 11 (7 boys and 4 girls) over 3 kilos; 26 (16 boys and 10 girls) over 2 kilos ; 4 boys over 1 kilo ; and 1 boy less than 1 kilo. Since the school opened, 230 children have been admitted. Of these, 29 were permitted to leave for suitable work ; 15 returned to elementary schools ; 1 to a secondary school; 12 entered convalescent homes or went to live permanently in the country ; 23 left the district; 36 were excluded on medical grounds ; and 1 died. The results of the year's work are distinctly encouraging ; there is a marked improvement, both physically and mentally, in all the children, with perhaps a few exceptions who were more suitable for other institutions and were referred thereto. The joiner's class has been successful, and also the swimming class, which was held out of school hours, the children attending being selected by the medical officer. Special attention has been given to breathing and physical exercises. The dispensary authorities have provided free dinners and other assistance in cases of extreme poverty. Open-Air Schools. The two open-air schools maintained by the Council have been fully described in previous reports. Both have been continued throughout the winter months. The excellent results of previous years have been fully maintained. The increasing efficiency of the organisation for the care of children suffering from tuberculous conditions is beginning to make itself felt very distinctly. Children are now returning from sanatorium treatment who require education for a period under open-air conditions in order to maintain the improvement which has been effected in their physical condition. Other children referred to tuberculosis dispensaries are found not to be suffering from open phthisis,but are considered to be in such a condition as to require day open-air school treatment and are referred to the medical department of the Council for this purpose. Numerous applications are also received from voluntary agencies. Thus need is being experienced for further accommodation in day open-air schools in all quarters of London, and particularly in the districts north of the Thames. Birley House. The Birley House and Shooter's Hill schools were respectively under the medical supervision of Dr. F. T. H. Wood and Dr. O H. Peters, from whose reports the following particulars have been taken. The work at Birley House has been continued on the same lines as in previous years, and with similar good results. In March, 1914, all the children were re-examined, and 48 were returned to their old schools, while 38 were kept for the new school year commencing March 30th, when they were joined by 60 others selected by the medical officer of the school from a long list of suitable children submitted by the school doctors from their routine and special examinations of the previous few months. The conditions presented by the children in the school in April may be classified as follows, some children being included in more than one class:— Anaemia 30 Malnutrition and general poor physique 21 History or signs indicative of phthisis 15 Phthisis 6 Tubercular glands 5 Recent surgical tuberculosis 3 Lupus 2 Fibroid lung 2 Enlargement of glands (non-tubercular) 5 Other conditions 7 The children were regularly re-examined, and at various times during the year 8 were returned as fit for the elementary schools, 6 were invalided, 5 were excluded by the managing committee as not taking full advantage of the benefits of the school, and 3 left at the age of 14 ; their places were filled by others selected as before, and the period ended with 88 scholars on the roll. The usual tabular statements have been prepared from the observations made during the year, and are now submitted as affording some indication of the improved health and vigour of the scholars. 113 Report of the County Medical Officer—Education. The table below, which shows the average weight in kilograms at the commencement of fh<' year compared with the corresponding averages of all London elementary school children, clcarly indicates inferior physique in the case of the selected girls :— Boys. Girls. Age last birthday. (1) No. of children. (2) Average weight on admission. (3) Average weight of all L.C.C. school boys. (4) Age last birthday. (5) No. of children. (6) Average weight on admission. (7) Average weight of all L.C.C. school girls. (8) 7 2 22-10 2200 7 3 20-40 21-20 8 2 23-40 23-47 8 3 20-36 22-92 9 11 24-81 25-46 9 8 25-81 25-00 10 7 28-28 27-59 10 7 24-33 27-16 11 10 29-24 29-25 11 8 26-31 29-87 12 8 31-73 32-46 12 12 30-75 33-32 13 5 37-30 36-40 13 3 33-60 37-71 Table showing the average gain in weight (in kilograms) in each age group during the year, compared with the corresponding averages of all London elementary school children. In the case of the girls at least, less than the normal increase was being made before admission, so that the gains are the more noteworthy :— Boys. Girls. Age lost birthday. (1) No. of children. (2) Average gain in 37 weeks. (3) Average gain in standard boys. (4) Age last birthday. __ (6) No. of children. (0) Average gain in 37 weeks. (7) Average gain in standard girls. (8) 7 2 2.00 1.03 7 3 1.33 1.80 8 2 2.35 1.41 8 3 2.13 1. 48 9 11 2.28 1.71 9 8 2.26 1.53 10 7 2.10 1.68 10 7 2.30 1.93 11 10 2.61 1.78 11 8 2.81 2.28 12 8 2.49 2.81 12 12 4.01 3.31 13 5 2.96 2.01 13 3 4.66 2.91 Table showing the average weekly gain in weight (in kilograms) at various ages, compared with the corresponding average weekly gain of all London elementary school children :— Boys. Girls. Age last birthday. (1) No. of children. (2) Average weekly gain. (») Average weekly gain in standard boys. (0 Age last birthday. (5) No. of children. (6) Average weekly gain. (7) Average weekly gain in standard girls. (8) 7 2 •054 7 3 •036 _ 8 2 •063 •03 8 3 •057 •03 9 11 •002 •04 9 8 •061 •04 10 7 •057 •04 10 7 •062 •u5 11 10 .071 •05 11 8 •076 •06 12 8 .067 •06 12 12 •108 •07 13 5 •080 •06 13 3 •126 •08 Table showing the weekly increase in weight expressed as percentage of body-weight on admission, compared with the corresponding percentage of increases in all London elementary school children : Boys. Girls. Age last birthday. (1) Birley House, 1914. (2) Birley House. 1913. (3) London elementary schools, 1906. (4) Age last birthday. (5) Birley House, 1914. (8) Birley House. 1913. (7) London elementary schools, 1906. (8) 7 .24 .24 _ 7 .18 .24 _ 8 .27 .29 .14 8 .28 .26 .16 9 .25 .23 .16 9 .24 .29 .16 10 .20 .26 .16 10 .25 .24 .17 11 .24 .24 .15 11 .29 .34 .19 12 .21 .21 .18 12 .35 .26 .23 13 .21 .15 .17 13 .37 .38 .22 27715 114 Annual Report of the London County Council, 1914. As was pointed out in last year's report, tlie table above shows more clearly than any other test the benefits obtained by the weakly child when placed under natural conditions, for the proportional gain of the open-air scholar exceeds that of the child in its old environment in varying degree up to 90 per cent. Observations were taken as usual of the haemoglobin content of the blood by Tallquist's scale; a number of children showed a greater degree of anaemia than was found in previous years (eight had only 70 parts of haemoglobin compared with the normal 90-100); and the average figure obtained at entry for the boys was 81'9 and for the girls 81-7 ; these figures had improved by the end of the year to 88*3 and 89-7 respectively. The estimated changes in the haemoglobin content are shown in the following statement:— Boys. Girls. Number showing decrease of 5 points per 100 3 Number stationary 9 8 Increase of 5 points per 100 9 7 Increase of 10 points per 100 3 7 Increase of 15 points per 100 5 5 Increase of 20 points per 100 4 . 3 Regular frequent attention was given to breathing exercises, with good results; the boys who gave an average chest measurement at entry of 23.5 inches (expiration) and 25.2 inches (inspiration) had corresponding figures at discharge of 23.3 and 25.8, while the girls' averages were 22.9 and 24.7 inches respectively at entry and 23.0 and 25.3 on discharge. The notes given below as to the progress made by individual children are taken from the school record cards, and illustrate the improvement obtained in the tubercular child, the increase of weight during stay at the open-air school, and the possibility of educating in the open air a child who has been kept on physical grounds from the ordinary school for prolonged periods. G.S.—M.—aet. 9—invalided for preceding three years by Council's school doctors as suffering from phthisis ; admitted September, 1913, gained 5.5 kilograms in weight, had good general appearance and was returned fit for elementary school in September, 1914. D.S.—F.—aet. 9—phthisis ; had not attended school for previous twelve months ; no abnormal lung signs detected at the end of the year at Birley House ; had gained 4.0 kilograms. F.K.—F.—aet. 11—fibroid lung with considerable resultant deformity of the chest; general condition was improved and the weight increased 2.G kilograms. P.H.—M.—aet. 11—phthisis ; had spent several periods in sanatoria and had not attended school for four years; was admitted in Octobe-r, 1914, and gained weight steadily, increasing 1.0 kilogram in two months. M.C.—F.—aet. 12—anaemia ; mother and former teacher exceedingly pleased with improvement ; gained 6.0 kilograms weight and 15 points per 100 haemoglobin. E.C.—F.—aet. 11—phthisis; developed phlyctenular conjunctivitis during the year; some pulmonary signs at the end, but excellent general condition and an increased weight of 3.4 kilograms. L.L.—F.—aet. 10-—admitted in October, 1914, with tubercular glands and phlyctenular conjunctivitis ; gained 2 kilograms in a month. F.T.—M.—aet. 11—tubercular glands ; during absence in May and June lost weight, but regained it on return : total sain for the nine months, 1.5 kilograms. Shooter's hill School. Or. Peters reports that at ©hooters Hill school, three and a halt hours each day, or a little more, are devoted to actual study, including manual work, and about one and three-quarter hours to sleep— in summer, immediately after dinner. At 9 a.m. a breakfast of bread and milk or porridge is provided. At 12.30 p.m. dinner of meat, pudding, etc., and at 5.30 p.m. a tea of cocoa, milk and bread, and some "extra." The parents are encouraged to supplement this with some trifle before leaving home in the morning, and before going to bed at night. There are two bungalows, but as often as weather permits, classes are held in the open. History, geography and arithmetic are taught in an applied and practical way in the open, as well as physics and woodwork. In accordance with the special war provisions, since early November, the children have been sent home at 4 p.m. The weather conditions for 1914 were as indicated in the following table, which shows the number of fine and wet days, and whether rest was taken out of doors or in the bungalow. Fires are lit in the bungalows when the temperature falls below 40° F. Month. (1) Fine days for time of year. (2) Medium. (3) Wet. (4) Cold for time of year. (5) Mist or fog. (6) Snow. (7) April. 1914 13 8 1 1 — — May, .. 11 8 1 6 — — June, „ 14 6 5 — — — July, 9 10 3 4 — — August, „ 16 5 4 — — — September, „ 15 5 2 2 2 — October, .. 7 8 7 2 1 — November, , 8 1 9 3 3 — December, „ 5 8 11 — _ — January, 1915 8 5 8 3 — — 115 Report of the County Medical Officer-Education. Table showing where rest was taken :— Month. In the wood. In the field. In the bungalow. From wood or field to bungalow on account of rain. Fires. No, of days. (1) (2) (3) (4) (5) (6) April, 1914 10 9 2 - - May. 10 9 2 - - June, „ 18 - 3 - - July, „ 16 3 2 2 - August, ,, 17 1 2 - - September, ,, 10 5 1 - - October, „ 7 9 4 2 - November, „ 4 5 11 1 4 December, „ 2 2 17 - 7 January, 1915 1 3 16 - 12 The school session extends continuously throughout the winter, and the open-air principle is still quite strictly adhered to, the windows being kept widely open, while good fires are maintained in each bungalow. The danger of taking cold in winter is largely dependent upon stuffy rooms, but there seems little risk from differences of temperature when fires are made under strictly open air conditions. In fact, large fires should be encouraged as the natural relief to any physical hardship the fresh-air regime might be supposed to entail in the coldest weather. During rest, the children cover themselves with blankets. This provides also a protection from the sun on hot days. For wet weather each child has a numbered mackintosh, generally stored at the school, and for use in going to and fro to meals, and in other special circumstances. A stock of clogs sufficient to go round the whole school is also kept. The children put them on for gardening, and also on arrival in winter with wet feet or defective boots, when the clogs are worn all daw During the year there was an average attendance of 100 children, drawn from the districts of Greenwich, Westcombe Park, Charlton, Woolwich, Plumstead, Abbey Wood, and in one case from New Cross. At the resumption of work in April, 1914, the places of 20 old pupils who had left the school at the end of March were filled by 32 newcomers. The defects noted amongst newly arrived children and others, at their admission or at any time during the year, were:— Nutrition poor or bad 14 Early phthisis, suspicion of 20 Active phthisis (excluded from school) 2 Chest expansion poor 8 Adenitis of neck (? tubercular) 7 Defective teeth 8 Enlarged tonsils and adenoids 7 Otorrhœa 3 Anaemia 13 Tendency to chorea 1 Blepharitis 4 Asthma 1 Scoliosis (slight) 8 Kyphosis (slight) 3 Defective vision 8 Paralysis (facial) 1 Rickets 6 Rheumatism 1 Malformed toes 1 Deafness 1 Heart Disease (slight) 1 Total 118 Treatment of the throat and eyes and special medical affections were in all cases, with one exception, promptly attended to by the parents. The Council's dentist visited the school and referred all cases of defective teeth to the local centre for treatment. Otorrhoea and blepharitis were given daily attention at the school by the nurse, who also superintended graduated exercises for spinal and chest cases under the doctor's direction. At the end of the year there were 49 children attending the Woolwich, and 5 the Greenwich tuberculosis dispensaries for phthisical or tuberculous tendencies. The practice adopted is for the children to go down to the dispensary, a class at a time, on certain fixed days. No cases of active phthisis were allowed to remain in the school. During the year two were excluded indefinitely after careful re-examination. With regard to the general defects, such as malnutrition and anæmia, from which most of the children may be supposed to have been suffering in some degree on admission, and for which the open-air school is specially provided, there can be no doubt of the great good received. And this, along with 27715 Q 2 116 Annual Report of the London County Council, 1914. the genera] improvement in all cases, indicates how necessary and beneficial is an institution of such a kind, when available for the children of elementary schools. No haemoglobin tests were made, but marks were carefully given at each examination for colour and nutrition, just as in the case of a general inspection in elementary schools ; i.e., marks 1 to 5 for colour and marks 1 to 4 for nutiition. The N. (nutrition) figure is very interesting, and, from observations here and in various playground classes, seems to be very reliable as a comparative standard by the same observer, but it varies with the personal factor where more than one observer is concerned. It is an index mostly of general fitness in the athletic sense, of the elastic and firm condition of the flesh and body generally apart from actual weight or actual amount of flesh. The weight in July may be only equal to that in the preceding April, yet the N. figure may be raised from 3 to 1½, the condition of the flesh in the earlier month being flabby and probably pale. This appears to be a usual occurrence in all these open-air classes. The results yielded by the two series of terminal examinations shows that out of the 49 cases where an alteration occurred, there was an average rise in N. of 19, and in colour of .16, or, roughly, a rise of N. from 2.3 to 2.1, and of colour, from 2.4 to 2.2. The dates of individual records, however, vary, averaging about the middle of June for the first observation, and about the middle of October for the second. But it is satisfactory to note that about half the casss showed this solid improvement in nutrition and colour. Emulsion of cod liver oil is kept at the school, and supplied to suitable cases when they are not receiving it from elsewhere. The heights and weights which showed satisfactory advances, are set out in the following table:- Age. Average weight. Average height. April, 1914. kilograms. January, 1915. kilograms. April, 1914. c.m. January. 1916. c.m. (1) (2) (3) (4) (5) Boys. 8 years 24.3 26.8 120.8 131.3 9 ,, 23.4 26.1 121.9 124.9 10 ,, 23.9 26.3 124.6 128.4 11 ,, 27.3 29.5 131.3 134.7 12 ,, 33.7 36.3 140.0 143.7 13 „ 32.0 34.7 139.9 144.0 14 ,, 30.2 34.5 140.2 144.0 Girls 8 years 19.2 22.0 113.0 114.0 9 „ 23.0 25.4 122.0 126.3 10 ,, 25.7 27.7 125.8 130.1 11 „ 25.3 27.2 125.1 128.3 12 „ 29.1 32.1 133.4 137.1 13 ,, 32.8 35.9 144.1 148.4 14 ,, 32.4 35.0 138.0 142.0 Cases noted with defective chest expansion were given deep-breathing exercises by the nurse The measure of the improvement obtained gives no actual guide to the total expansion of the lung, where the amount of diaphragmatic expansion is not also noted, but improvement appeared to be general in all cases. The school doctor has been present at various meals and has found all arrangements as to cleanliness, quality and quantity of food quite satisfactory. He has also seen the work of the school in every detail that might have some bearing upon the general health. With the services of a nurse constantly available, a high standard of cleanliness of hair, body and clothing has been satisfactorily maintained even amongst children coming from the most unsatisfactory homes. There has been very helpful co-operation between the nurse and teaching staff in all matters, and every assistance has been given to the doctor by the head master of the schoool. The average length of stay at the school, out of more than a hundred children on the roll at the end of the year, was as follows:-18 had been in attendance for 1 term, 4 had been in attendance for 2 terms, 3 had been in attendance for 3 terms, 32 had been in attendance for 4 terms, the remainder in attendance for more than 4 terms. Playground classcs. Since these classes were commenced in 1909 four different types have been tried. These types have been— (1) For specially selected weakly children in various standards:- Type A.-Central classes for various schools and standards. Type 15.—Single classes for one school and various standards. (2) For unselected normal children of the same class in a school:- Type C.—One standard spending all its time in the playground. Type D.—The standards going to the playground in rotation. Report of the County Medical Officer—Education. 117 Classes of Types A and B.—It has been recognised in previous years that a class organised in the playground of the ordinary school does not prove completely satisfactory for the debilitated and delicate children for whom special educational provision is required. In consequence, the number of such classes has been reduced and last year only one class of Type A was reported upon. This class was organised on Hackney-marshes and had eleven boys from each of the three neighbouring schools at Berkshire-road, Sidney-road and Gainsboro'-road. The selection was made on account of want of health and poor ability, and the boys were therefore delicate and dull. Their average age was nine years and ten months, and they were not equal to Standard I. The fact that the class was held on an open space in a suitable position and that the proximity of a Council refreshment house made it possible for boys especially requiring extra nourishment to receive it, probably explains why the results have shown a striking improvement upon those for Type A classes in former years. Weight and height increased in the case of all boys except two who were suffering from tuberculosis. Milk was supplied daily to fourteen. Dr. Cowell sums up his report in the following words: " The Marsh class is adapted to delicate and dull boys, as it is carried on away from the interruptions of a playground class and can be conducted in quiet surroundings sheltered from the wind and dust and free from disturbance such as the noise of the streets or that of other classes." A class of Type B was held in Greenwich-park. The weakliest boys of the Randall-place School formed a class of 29 aged from 9 to 13 years. Three boys had catarrhal lung conditions suggestive of tuberculosis, which cleared up in two cases. It is stated that when they returned to their respective classes not only had the pupils little difficulty in picking up the routine class instruction, but they were beyond their old classmates in general intelligence and alert response. There was, however, no arrangement for the supply of extra nourishment, and the average gain in weight for the six months was disappointing. Classes of Type C.—There was one such class in 1909 and there were 73 in 1914. Of the 44 detailed reports furnished by the assistant medical officers, 4 related to classes held on roof playgrounds, 11 to classes in parks or open spaces, 28 to classes in playgrounds, and 1 (at the Wandle) was partly indoors and partly playground. The temptation to select and include children considered to be specially suitable for these classes is very great and the children admitted were usually the needy, debilitated and backward. Thus Eglinton-road, which was a success, is described as " the duffers' class of the girls' school." Most of the reports speak of the physique on admission as below the average, of poor clothing, want of cleanliness, and bad sleeping arrangements at home. Anaemic, badly nourished and mentally dull, were usual descriptions, and the children were often described as neglected, untidy or dirty. In a few suburban classes (Earlsfield, Gordonbrock, Finlay-street, Hackney Free, Peterborough, Shillington-street) the children are described as well cared for and from good homes, but even then are frequently noted as anæmic and delicate. The children at Commercial-street (Jews') Infants' School where there was an " open air room " are noted as measuring mostly above the average for their age in London, but this may be in part due to racial precocity. Results of the classes.—At the Peterborough. " On the whole the class on admission was below London standards as regards weight and above as regards height; during the summer the deficiency was rather more than made up." As weight is gained slowly in the spring, when height is being rapidly added, this is a correct statement of what is observed with normal children examined at the end of spring when compared with averages derived from the whole annual growth. Thus at Eglinton-road it is noted " weight actually fell between April and the end of May, remaining the same till July, after this a great and satisfactory change." Most of the reports note this arrested weight at first and ascribe it to change of clothing, but as height is rapidly increasing it is more probably a seasonal physiological fluctuation, as has been pointed out by Dr. Kerr. Some doctors record actual ant of gain in physique in the six months (Ben Jonson, Gordonbrock, Finlay-street, Hawley-crescent and Stanhope-street, John Ruskin, Latchmere, Lucas-street, Olga-street, Priory-grove, St. Thomas Colet, Surrey-square, Wandle, Wilberforce). But against this is to be set the universally noted gain in vitality and muscular tone, absence of fatigue, gain in colour and development of animal spirits. There also appears to be a moral gain in comradeship and mental response, even the sullen and morose becoming sociable. " A more liberal supply of fresh air favours the growth of the virtues as well as the framework of the body," writes Dr. Norman. The absence of illness, complete freedom from colds and disappearance of catarrhal conditions is most obvious. In many cases it was evident that social conditions prejudicially affected the success of the classes. Insufficient sleep and out of school work, as well as injudicious or insufficient feeding at home, were frequently mentioned in the reports. Sleeping is an integral part of the ordinary open-air school arrangements, and was last year introduced at the Forster playground class. This year it has been arranged at the Commercial-street infants' open-air room, whilst at Gordonbrock, hot milk was provided in the morning and the children were required to take a short rest after the midday meal. At Hackney Free 13 of 37 boys were employed out of school chiefly delivering newspapers or milk, 6 of these 13 had heart signs, in one fainting attack ceased on stopping work, but commenced on resuming it. These 6 worked 14, 16, 20, 26, 30 and 34 hours weekly. Only 3 out of the 23 who did not work presented any heart symptoms, and 2 of these rapidly improved (Dr. Cowell). Again, more than one-third (11 out of 29) of the boys at Randall-place class got up at 5.30 a.m. to get stale bread cheaply from a baker's shop in the neighbourhood, which thus cleared out old stock. The amount of nourishment they got daily was quite inadequate for growing bovs (Dr. Macdonald). At Canal-road " the majority of the class were under-developed, 12 of 36 had some form of free feeding " Dr. McVail). At Hackney Free "milk appeared to stimulate growth in several delicate boys"; at 118 Annual Report of the London Country Council, 1914. Latchmere "allowances have to be made for want of proper and sufficient clothing and feeding and poor home conditions" (Dr. Griffiths). At St. Thomas Colet" increase of weight was very small, probably due to lack of food at home. A good many were having school meals and milk." General conclusions.—The results of the classes appear to show that the average child gains considerable advantage in health and vitality from education under open-air conditions such as can be given in a suitable school playground. In connection with measures designed to prevent tuberculosis there is necessarily arising a demand for the further provision of facilities for open-air education for debilitated children. Although the ordinary playground class does not well suit the needs of the more delicate child with phthisical tendencies, the result of the Hackney-marsh class appears to show that there is room for the development of classes for such children in open spaces and parks. Such classes should be organised on the lines of the open-air schools and should admit of the giving of extra nourishment to the children and should provide for periods of rest in a reclining position. School Journeys, 1914. The masters and mistresses making themselves responsible for the organisation of these parties, are keenly aware that much of the pleasure and profit to be obtained from the excursions which are organised under article 44 (<j) of the Board of Education Code, may be marred by the inclusion either of children unfitted physically to undergo an average amount of strain, or of those suffering from infectious ailments. The services of the assistant medical officers were therefore again much sought during the summer term in connection with school journeys. Reports have been received from the assistant medical officers in the case of 25 journeys, and it may be noted that the report which the Children's Care Sub-Committee last year instructed should be circulated, undoubtedly proved of considerable assistance to the organisers of the excursions. The results of the journeys from a medical point of view appear to have depended partly upon the duration of the holiday, partly upon the choice of place for the holiday, and partly upon the arrangements made for the housing and feeding of the children. In 10 of the 25 excursions, the seaside was selected, and in these, generally, a greater improvement in health took place than in the 15 cases in which the countiy was chosen. Thus the greatest improvements, as measured by the scales, took place amongst the Rubystreet boys who spent 14 days at Bexhill, and the St. Mary Magdalen boys, who went to Dymchurch. Four schools chose the Isle of Wight, and while the children did not improve to the same extent as those who visited the Kent or Sussex coasts, yet they obtained more benefit from their holiday, than those who visited the country districts remote from the sea. With regard to iength of holiday, it is quite clear from the reports that from the bodily point of view, the proper period of time for such excursions is 14 days ; the amount of gain physically is not merely twice as great in 14 days as in 7 days, but nearer 6 times as great; thus the Ruby-street boys above mentioned, who spent 14 days at Bexhill, increased on an average 42 ounces each, while the Sydenham II ill boys who spent 7 days at Hastings increased their weights by only 7 ounces. With regard to the housing and feeding of the children, better results were obtained in those excu sions in which the children occupied well ventilated farm buildings, hostels or camps, than in those in which the children were accommodated in cottages. In fact, in some of the excursions in which the accommodation was of the latter type, the benefit from the point of view of health was dubious. The advantage of an adequate dietary and especially of attention to the character of the breakfast given, is shown by the observations of Dr. Palgrave upon the excursion of the Fulham Palace-road boys to Chatham. Considerable trouble was caused on at least one journey by the spread of verminous conditions, while a somewhat serious outbreak of diphtheria which caused great anxiety and considerable expense, completely spoilt another excursion. In connection with some other journeys, isolated cases of illness occurred on account of which claims were submitted to the Council, and in almost all these cases no medical examination of the pupils had been made. The Local Government Board issued on the 25th June, 1914, a circular dealing with children's country holidays, in which questions of health particularly in connection with infectious diseases, are dealt with. The circular has in view mainly the country holidays for poor children arranged by various philanthropic agencies, but the questions raised are pertinent in the case of school journeys organised under article 44 (g). The education officer has given directions that the school medical officer shall be informed of all arrangements in connection with school journeys, in order that the local sanitary authorities concerned may be communicated with. It is clear that it is desirable in every instance that a medical inspection should be made of children whom it is proposed to include in a school journey under article 44 (g) of the Code. Remedial Exercises. In the annual report for 1913 reference was made to experimental classes in remedial exercises. Further reports have been made upon seven of the classes which have been continued in the schools. The reports state that very marked general improvement follows the special attention paid to the selected children. Certain deformities, if of slight degree, entirely disappear during the course. On the other hand there are cases in which the deformity, being more advanced, although still reducible by exercises, does not improve owing to the fact that certain groups of muscles cannot be exercised in the absence of a "balancing bench." It is considered that the utility of these classes would be increased 110 Report of the County Medical Officer—Education. if such benches, which might serve other purposes when not in use for remedial exercises, were provided. Thus, Dr. Russell reports in connection with the " Chaucer " (Girls) classes " on the whole the children show improvement in muscular tone and this is also shown by the increase in clearness of the heart sounds ; practically all show increased chest expansion and better air entry. As far as improvement in spinal deformities is concerned the results are very disappointing. Round shoulders due to faulty methods of standing and lack of muscular tone have improved greatly, but on the other hand more marked cases of curvature (though not fixed) show practically little improvement." At Garratt Lane Dr. Griffiths reports that in some cases spinal curvatures were entirely cured and the others had improved. At Johanna Street Dr. Wells found the largest number of improvements in antero-posterior curves and round shoulders. In the 13 cases that exhibited this defect no fewer than 12 showed improvement. In 10 cases with various lateral curvatures of the spine, 7 showed improvement. Dr. Ruth Proctor at Winchester Street reports:—The class has been in existence for over 18 months and from the results appears to be most beneficial to the 24 children of whom it consists. The children chosen for the class were all poorly developed ; some of them suffered also from spinal curvature, some from mouth breathing and some merely from debility. In this last group, where the debility was in all cases marked, there is considerable improvement though they are still rather below the average standard of development. In the case of the children with obstructed breathing the results, which have in one or two cases to be taken in conjunction with an operation for removal of enlarged tonsils and adenoids, are very satisfactory, the breathing being now nasal and quite free. Eleven of the children had at the outset reducible spinal curvatures of various degrees and types. One of these was not present at the examination. In 8 of the remaining 10 children the deformity had entirely disappeared, while in the other 2 it is now very slight. One of these cases had also marked genu valgum with 3 inches separation of the internal malleoli; the legs are now approximately straight with barely f inch separation of the malleoli. In all cases the height has increased to some extent (average 1.8 cm.), but the increase in weight is usually quite out of proportion to the height, in some cases markedly so (average 9.4 kilos). Perhaps the most marked improvement is seen in the chest expansion which in every case shows a good increase —the average increase in expansion being 1 11/20, inches. The results are most encouraging. Personal hygiene. The duties of the school nurses, with regard to cleansing were steadily pursued throughout the year. They consist of a general inspection of the children, and the application of the Council schemes for dealing with children who are found to be (1) verminous in head only; (2) in body and clothing; (3) suffering from scabies. The nurses are required to visit each school according to a rota so arranged as to ensure that, every department is systematically examined. The head-teachers are given three days' notice of the nurses' visits in order that arrangements may be made for the attendance of children in regard to whom advice is desired. At these visits each child in the department mentioned on the rota is individually examined. The nurse separates the hair with a metal comb, which is disinfected after the examination of each child; examines the under-clothing of all cases of suspected venninous body conditions; notes any abnormal conditions as regards throat, suppurating ears and fingers, obvious neglect, &c. ; and notes and reports every case of scalp ringworm detected, and in doubtful cases sends stumps to the head office for microscopical examination. Upon the completion of the examination in one department the nurse visits the other departments, and examines children found unsatisfactory at previous visits, and children about whom the teachers require advice. If necessary she interviews the parents. The nurse also assists the teachers generally by suggesting temporary procedure in cases of suspected outbreak of infectious or contagious disease, affections of the skin, ophthalmia, offensive discharge, &c. ; by referring to the divisional medical officer cases of minor ailments requiring treatment ; by advising in regard to the many small and doubtful points concerning school hygiene that may be submitted to her ; and by drawing the attention of the school care committees and managers to cases in which their help would be valuable. During the last six months of the year, a complete record of the numbers of examinations and the conditions found was made, and in illustration of the magnitude of this branch of the nurses' work the following figures may be quoted:— Number of examinations 1.053,218 Number found clean 766,554 Number found verminous 286,664 Percentage found verminous 27.2 The number found verminous includes all degrees of unsatisfactory condition from the case of a few nits on the hair to cases of head, body, and clothing infested with pediculi. In all schools one of the two cleansing schemes (a) verminous heads only (b) verminous persons and clothing, is applied; the slight cases, forming the great majority, are cleansed as a result of the rota inspections. Figures are given later showing the numbers of instances in which it was necessarv to take further action under each of the two schemes. The scheme for dealing with children suffering from verminous heads involves the exclusion of such children from school after repeated notice has been given to the parents, and prosecution under the attendance by-laws ensues. This scheme is only applied in those schools which, owing to their situation in outlying parts of the county, are not contributory to a cleansing station. The following table shows Verminous heds. 120 Annual Report of the London County Council, 1914. the results of the examination in those schools where the cleansing scheme, as applied to heads, has been put into operation during the year. Department Number Examined Number Clean Number slightly dirty heads Number verminous Number Red Yellow Cards served Number White Cards .served Number Red Cards served Number Proposed for Exclusion Number Excluded for Prosecution (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) Boys 1 1 1 1 1 1 Girls 7,212 5,112 1,152 948 299 950 754 640 522 Mixed 1,547 1,287 179 81 - 81 59 54 45 Infants 2,756 2,326 241 189 118 211 144 121 104 Special 150 94 37 19 33 25 18 17 14 11,066 8,819 1,609 1,2.38 450 1,268 976 833 786 The parents of 99 children were prosecuted and fines varying from 2s. to 10s. fid. with costs, were imposed. The percentage in the schools in which the head scheme has been applied of children verminous amongst children examined was 10.6 in 1914 as compared with 14.1 in 1913. Verminous persons and clothing The procedure for giving effect to Section 122 of the Children Act, 1908, affords opportunities at each stage for parents voluntarily to send their children to a station for cleansing. To each child found verminous was handed in a sealed envelope a card addressed to the parent drawing attention to the condition and to the facilities for bathing. If advantage were taken of the facilities, each child was, if necessary, given three baths, and in the event of a relapse into a verminous state the procedure was repeated. If, however, the child was not sent for voluntary cleansing, or was not adequately treated at home, a statutory notice under the Act was served. Again, opportunities for gratuitous cleansing were offered, and if accepted a series of three baths was given to each child. If the verminous condition complained of remained unremedied, compulsory cleansing became necessary and in order completely to cleanse the head, the hair infected with nits was snipped off. Relapse after voluntary cleansing was followed by the re-issue of the statutory notice, but relapse after compulsory cleansing resulted in police court proceedings. In order to prevent negligent parents, who allow their children to relapse into a dirty condition in the intervals between the nurses' visits, from claiming that they should be exempted from the operation of the scheme, only two series of baths each were permitted at each stage. There are now 24 stations for the cleansing of verminous children, two of which (Paradise-road and Russia-lane) were, however, not opened until September. Of these, six were established by the Council itself, 17 belong to borough councils with whom the Council has entered into agreement, and the other belongs to the Committee of St. Cecilia's House, with whom an agreement has also been concluded. The total number of examinations relating to persons and clothing made by the nurses under the cleansing scheme proper was 917,582, and 28,361 children were found to be verminous to such an extent as to call for action under the scheme; of these 14,392 were cleansed by the parents; the remainder were dealt with at the cleansing stations and the following table shows the number of cleansings relating to these 13,969 children carried out at each station. Council Stations- Central-street 3,039 Finch-street 3,571 Fountain-road 1,526 Paradise-road 651 Russia-lane 1,585 Sedlescombe-road 1,955 12,327 Other Stations— Battersea 1,587 Bermondsey 2,894 Deptford 1,708 Greenwich 461 Hackney 1,507 Hampstead 226 Islington 2,520 Kensington 1,843 City of London 95 Poplar 1,408 St. Cecilia's House 1,605 St. Marylebone 1,773 St. Pancras 4,081 Southwark 3,956 Stoke Newington 373 Westminster 1,076 Woolwich 968 30,230 42,557 Diagram B. THE CITY OF LONDON UTHOCRAPMIC C?,LTP HARP ALLEY, LONDON.E.C. Report of the County Medical Officer—Education. 121 This number is an increase of 1,099, or 2.6 per cent., when compared with the number for last year. Tae increase, in the main, is accounted for by the fact that two additional stations have been opened. Daring the year 378 parents were fined amounts varying from 1s. 6d. to 10s. with 2s. costs. The following table compares the work done in the year under review with that for the year 1913. Number examined. Number clean. Number verminous. Number returned clean. Number of statutory notices served. Number cleansed at stations. (1) (2) (3) (4) (5) (6) Boys- 1913 248,074 238,248 9,826 4,672 2,171 5,154 1914 254,902 246,284 8,618 4,051 1,798 4,567 Increase or decrease + 6,828 + 8,036 -1,208 - 621 - 373 — 587 Girls- 1913 288,729 278,124 10,605 5,012 2,698 5,593 1914 308,255 297,683 10,572 4,985 4,102 5,587 Increase or decrease + 19,526 + 19,559 - 33 27 + 1,404 — 6 Infants- 1913 227,054 220,753 6,301 4,096 2,137 2,205 1914 261,485 255,146 6,339 4,082 2,160 2,257 Increase or decrease + 34,431 + 34,393 + 38 - 14 + 23 +52 Mixed 1913 81,981 79,865 2,116 1,076 632 1,040 1914 80,668 78,639 2,029 975 560 1,054 Increase or decrease - 1,313 -1,226 -87 - 101 — 72 + 14 Special- 1913 12,853 11,798 1,055 385 260 670 : 1914 12,272 11,469 803 299 173 504 Increase or decrease - 581 - 329 -252 - 86 — 87 — 166 Totals- 1913 858.691 828,788 29,903 15,241 7,898 14,662 1914 917,582 889,221 28,361 14,392 8,793 13,969 Increase or decrease + 58,891 + 60,433 - 1,542 -849 + 895 — 693 Although the number of children examined increased by nearly 60,000, or approximately 7 per cent., the number of children found verminous decreased by 1,542, or 5 per cent. The revision of the scheme mentioned in the report for 1913, limiting the opportunities for voluntary cleansings in cases where there was persistent negligence was responsible for the increase in the number of statutory notices. In last year's report it was pointed out that the cleansing stations were not capable of dealing with all the London schools. Facilities have not hitherto been provided in connection with the areas contiguous to the county boundary, where owing to the scattered distribution of schools, the number of children estimated to require cleansing did not appear to justify the expense of establishing a station. The matter has, however, received the consideration of a committee of the Council, and it is now proposed to utilise two ambulances, which have been placed at the disposal of the public health department, to convey children to the nearest cleansing station. The children, when cleansed will return by means of public conveyances to the nearest point to their schools. By this means it is hoped to bring all schools within the scope of the cleansing scheme. In the annexed map B, the areas which it is proposed to deal with by means of the ambulance service are indicated by cross-hatching. At each stage of the scheme a notice indicating the condition in which a child is found, is "sent, to the local sanitary authority in order that action may be taken in the home under the London County Council General Powers Act, Part 4. Action taken in the homes by local authorities. The following table shows the number of notices issued during 1913 and the action taken by the local authority. Analysis of action taken in the homes. Borough. No. of notifications sent. Total number of homes visited. Home visite and no necessity reported to exist for disinfecting rooms or bedoing. Home in which rows or bedding or both were disinfected. Notice served. No action taken. No report. Battersea 743 558 451 38 69 ... 4 Bermondsey 884 659 521 136 ... 2 Bethnal-green 941 700 277 7 293 3 120 Camberwell 1,067 817 727 69 21 ... ... Chelsea 140 112 91 11 10 ... ... City of London 24 12 9 3 ... ... ... Deptford 600 428 401 18 9 ... ... Finsbury 1,145 34 31 1 2 ... ... Fulham 575 442 313 76 36 ... 18 (Continued on next page.) 27715 R 122 Annual Report of the London Couty Council, 1914 . Borough. Analysis of action taken in the homes. No. of notifications sent. Total number of homes visited. Home visited and no necessily repered to exist for disinfecting rooms or bedding. Home in which rooms or beddding or both were disinfected. Notice served. No act on taken. No report. Greenwich 130 99 79 10 ... ... 10 Hackney 1,488 669 532 137 ... ... ... Himmersmith 50 29 13 13 3 ... 1 Himpstead 129 9 ... 9 ... ... ... Holborn 47 28 15 1 5 ... 7 Islington 1,525 728 488 58 182 ... 25 Kensington 20 19 14 4 1 ... ... Lambeth 762 467 4 349 ... 77 37 Lewisham No information available for 1913. Paddington 429 28 18 5 1 ... 4 Poplar 893 494 376 34 4 45 35 St. Marylebone 485 159 113 19 1 ... 26 St. Pancras 1,037 53 51 2 ... ... ... Shoreditch 1,524 995 481 94 304 ... 137 Southwark 1,520 851 162 503 56 125 5 Stepney 2,053 1,664 977 359 40 21 267 Stoke Newington 136 57 15 38 ... ... 4 Wandsworth 281 265 117 127 21 ... 24 Westminster 109 88 8 80 ... ... ... Woolwich 194 150 111 11 17 ... 11 Totals 18,931 10,614 6,394 2,185 1,075 271 737 The inculca- tion of habits of cleanliness It has been found, however, that notwithstanding the efforts of the local sanitary authorities in i the homes, some children are constantly relapsing into verminous conditions. A Section of the Children's ! Care (Central) Sub-Committee, which was appointed to enquire into this problem reported inter alia as follows:— "We are convinced that one of the main difficulties in regard to the effectiveness of the work is the existence of adult members of the families who are in a verminous condition, even when the simultaneous cleansing of the children and the disinfection of the bedding are effected, the fact that the wage-earning and other older members of the family who share the deplorable condition are left untended, is a source of immediate reinfection. Doubtless the trouble and annoyance arising out of the visits of the sanitary inspector and the fear of prosecution have seme effect in the gradual improvement of the personal habits of such families; but we believe that more could be done by direct education through kindly persuasion and direction towards securing more promptly a better state of affairs in many such cases. This, we think, is eminently work for which the members of the care committees are often more especially fitted, and we think that some means should be found whereby the nurses' findings should, in more instances than is now the case, be brought to the notice of the care committees. In order that the habit of cleanliness should be encouraged alike in the children who are bathed at the stations and in the older members of the families, we are of opinion that the Council should arrange with the borough councils for the sale at the stations, at reduced rates (and in necessitous cases for the free distribution) of tickets of admission to the public baths. We gather from the figures published by the borough sanitary authorities that the public facilities provided are by no means utilised to the full, and we attach the utmost importance to this proposal." The proposals outlined in this report are being proceeded with and it is hoped that arrangements will be made whereby the local authorities will agree to the admission of children and adults to a hot bath at a reduced rate during times when the baths are not in great demand. The Medical Officer of Health for Hackney has made careful investigation into the effect of the use of second-hand clothing in reinfecting children who have once been cleansed. He found that there is some reason for believing that the use of second-hand clothing had an influence and he has urged that the matter should receive further attention. Scabies. In addition to dealing with children found to be verminous in the ordinary sense, arrangements have been made for children suffering from scabies to be cleansed at a number of the stations. This disease is responsible for long periods of suffering and absence from school and a considerable loss of grant. Most of the children suffering are having medical treatment, but the parents do not possess the necessary facilities for bathing and the sterilisation of clothing. The hospitals have been informed of the facilities given at the cleansing stations, and with their co-operation much is being done to eradicate the disease from among school children. The children attend the cleansing stations bringing their ointment, on the latter portion of certain days when the station is open. This time is kept exclusively for the attendance of scabies cases, so that they shall not mix with ordinary verminous cases. When a child attends at the station a notification is sent to the local medical officer of health in order that action necessary in the home may be carried out. The bath is thoroughly cleansed and the towels sterilised after each case. All towels and other materials used in connection with the scabies cases are kept apart. Cases attend at the stations twice a week, but if the child is not cured after eight baths the case is reported for special examination by the school doctor, and further baths are not given until 123 Re-part of the County Medical, Officer—Education. definite instructions have been issued. Children suffering from scabies are bathed at tbe Council's stations at Central-street, Finch-street, Fountain-road, Paradise-road, Russia-lane, Sedlescombe-road, the station of the Corporation of the City of London, and the stations of the Borough Councils of Battersea, Camberwell, Greenwich, Hackney, Hampstead, Islington, Kensington, Poplar, Marylebone, St. Pancras, Southwark, Westminster and Woolwich. The Children's Country Holiday Fund. The total number of children suffering from scabies bathed during the year was 589; they received a total of 3,212 baths. The average number of baths required to effect a cure was 5'4. The school nurses again assisted the executive committee of the Children's Country Holiday Fund by examining for the detection of any infectious disease (e.g., ringworm) or any form of uncleanliness, the children whom it was proposed to send to the country as soon as the summer vacation began. The scheme which was set out in the report for 1913 again worked very smoothly and gave general satisfaction. The Executive Committee of the Fund have asked the Council to permit the nurses to assist in the work in the current vear. Secondary schools and kindred institutions— Verminous heads. The personal hygiene scheme which is applied in all the girls' secondary schools except two, in one of the boys' secondary schools, and in several kindred institutions, was varied during the year by the withdrawal of the more stringent regulations applied to candidates for the teaching profession. All pupils found on examination to be defective as regards personal hygiene are now given three opportunities for remedying the unsatisfactory condition, a period of one month elapsing between the first and last of the series of examinations. The preliminary examinations in all cases are carried out by school nurses, and pupils in whom unsatisfactory conditions remain unremedied are seen by an assistant superintendent of nurses, upon whose report official action is taken. In obstinate cases awards are withdrawn from scholarship-holders, and fee-paying pupils are permanently excluded from the institutions. Few cases are unsatisfactory at the second examination, and a still smaller number at the third, but during the year two pupils ware reported for permanent exclusion from the institutions, and eight for withdrawal of scholarships owing to unremedied defects in personal hygiene. The following table shows the conditions found during the year:— Examination, 1914. (1) Number of pupils. Number found verminous Percentage. Boys. (2) Girls. (3) Boys. (4) Girls. (5) Boys. (6) Girls. (7) Spring 165 4,233 - 188 - 4,44 Summer 95 4,736 - 310 - 654 Autumn 90 4,468 - 273 - 6.11 Examination of candidates. Candidates taking up permanent appointments in the school service are examined in the public health department before commencing work. Candidates for scholarships and the teaching profession are also required to be examined before the awards are finally made. The number of candidates examined was 6,015 and Appendix VI. gives particulars of the conditions noted as present. In examining candidates for the teaching profession special regard is paid to vision. Visual conditions which are apparently satisfactory at 15 may produce discomfort by 20, and serious inefficiency by 25 or 30 ; in addition there may be actual deterioration from diseased or debilitated conditions. The circumstances of the student's life during training have to be remembered, as many breakdowns are due to visual strain ; further, the teacher in the elementary school must have good vision or the children's features appear blurred and indistinct, especially when the teacher is facing a light. A candidate for the teaching profession should have full visual acuity, and in order to attain this the wearing of glasses may be necessary, but in certain cases even when full visual acuity is attained, the fatigue produced may be such that the candidates should not be accepted. Only under very rare and exceptional conditions should a candidate for a bursary requiring convex glasses of 5 dioptres or more, or concave glasses of 4 dioptres or more in any meridian, at the age of 16, be accepted. Teachers with an extra dioptre of myopia who are certificated and whose eyes have attained full growth and presumably will not further deteriorate for many years might be accepted, but each case should be considered on its merits. Relaxation of these rules might be permitted in otherwise healthy eyes in the case of teachers of subjects not involving long continued eye work, or much eye strain, viz., cookery, laundry, domestic economy, housewifery, physical exercises, kindergarten, carpentry or shoemaking. Congenital amblyopia in former squinting eyes should not disqualify if the other eye is satisfactory. Other eye diseases such as opacities of the media, old iritis, cyclitis and most cases of keratitis should be made the subject of special consideration. Teaching candidates Vision. Some difficulty arises in dealing with children who have won scholarships and who are found on medical examination to be shortsighted. Many of these children are brilliant, always at the top of the class, and therefore favourites with their teachers. Their place in class is to a large extent the direct result of their short sight. They cannot see so well or so quickly as their normal comrades so that games do not attract them and the time that should be devoted to games and outdoor play is spent at their school work. Their interests become centred on books to the further detriment of their eyes, and sometimes of their health. When the myopia is of low degree the case can usually be dealt with by the provision of satisfactory glasses, the new world that is presented to the child is, to some Scholarship candidatesVision. 27715 R 2 124 Annual Report of the London County Council, 1914. extent, a corrective of the reading habit, and with the inculcation of proper habits of work and a limitation of hours of study, education can be continued. When the short sight is more serious there can be no question that to grant a scholarship for further education of the ordinary type is to do a very real injury to the child. Most of these cases of myopia are progressive, and the rate of progression is at its highest during the years just preceding puberty, the very time when scholarships are awarded. The strain involved in study for competitive examinations can be held accountable in not a few cases for a sudden increase of the degree of myopia, and, if additional work necessary for advanced study be embarked upon, real injury to the eyes is to be feared, apart from the additional general strain involved by continuous close work when vision is defective. In these cases there is a balance of hardship, on the one hand, deprivation of a scholarship won by diligence and capability, on the other danger to the eyes and health. Of the two the latter is the greater hardship. The greatest difficulty is met with in judging the best course to pursue with those children whose degree of myopia at the time at which they are examined for scholarships is what may be termed borderline. They are just so short-s;ghted that an increase of one or two dioptres would without doubt rule out a scholarship of the usual type as being undesirable for them. But at the actual time of examination it is possible that the degree is not so high as to warrant the recommendation that further study would not be advisable. In these cases the examining surgeon has to take the future into consideration. A junior scholarship may lead to a senior, and so on to other spheres of work. It has to be considered whether the additional work involved by the first step is likely to cause such a progression of the myopia as will lead to a worse disappointment when the child is brought up for examination for a senior scholarship, or it may be, after much labour and many years have been spent in training for teaching work. The failure to pass the medical examination at the second or later stages of a career involves more disturbance, and causes a greater feeling of soreness than a stoppage at the initial stage. So far myopia of an uncomplicated type has been referred to, but many of the cases are complicated by astigmatism of greater or less degree, and in these the conditions of strain produced by the continued eye work are all aggravated. Eyes suffering from astigmatism of any degree even when "corrected" by the best and most accurately fitting glasses cannot vie with the natural eye for correctness of focus, and therefore of ease of vision. Many short-sighted children show considerable capacity and more than ordinary intelligence so that the deprivation of advanced study seems, and often is, a particular hardship. It is desirable therefore that some means of dealing with their cases otherwise than by exclusion should be found. Both for the border-line cases, and for those whose short-sight is of such degree that there is no question of their being admitted to the ordinary form of scholarship, some special scheme of scholarship work might be evolved. Trade scholarships are not generally admissible, as fine work is almost always entailed. But cookery and domestic work for girls are admissible. Too much stress, however, should not be laid on the precocity shown by these children. In many cases their standing in the schools to which they belong is not wholly warranted. Their academic attainments are forced. The time that should be given to healthy play, and which is thus occupied by their normal comrades, is spent by them in additional school work. The class advantage thus obtained is in some sense unfair to the normal children, who in later years are likely by reason of their more robust physical equipment and better staying powers to out-distance the myopes. The question, however, is a thomy one. In all cases of doubt the circumstances should be explained to the parents who should assume the responsibility, and periodical re-examinations of the condition of the eyes should be made, so that the scholarship awards may be terminated in the event of deterioration of vision making itself apparent. Urine examinations Examinations of urine have been made during the year. Out ot 4,712 such examinations, albumin was found present in 644, sugar in 4, oxalate crystals in 231, blood cells in 27 and pus cells in 44. In the great majority of cases the presence of albumin was not of serious import; 357 second specimens were examined in 250 cases with a negative result; in 28 cases a third specimen was thought desirable, and of these 15 which had been positive on the two former occasions proved negative. Cases specially referred. In addition to the first examination, 1,012 referred cases were dealt with. These referred cases relate to leave granted to employees absent owing to personal illness; to cases in which questions have arisen in regard to students in institutions for higher education whose health is considered such as to render exceptional attention advisable; to teachers returning to duty after extended leave of absence (a) owing to personal illness (b) for educational purposes, (c) to married women urder No. 31 of the regulations in regard to the education service, and to teachers about to be superannuated. The number of references under review, compared with those for the preceding year, shows an increase of 214, or 26.8 per cent. In addition, 250 cases (an increase of 23.1 per cent.) were medically investigated in which claims were received from teachers and others in the permanent service for exceptional treatment as regards sick pay and re-imbursement of medical and other expenses in respect of illnesses alleged to be due to conditions under which thev were required to carry out their duties. L.C.C. Training Colleges Secondary and Trade Sellouts Medical inspection in training colleges, secondary and trade schools. Since 1908 medical inspection has been carried out in all the Council's training colleges, secondary schools, trade ai.d technical schools. Each student is examined once a year, and each institution visited once in six weeks, so that the doctor can be consulted concerning pupils presenting any symptoms likely to affect their health or work. Every student bus a medical record curd showing at a glance the condition, so that the students are continually under observation and are not permitted to continue at the institution if through illness or other causes they become unfit. Appendix VII (A) shows the delects noted. 125 Non maintained institutions Report of the County Medical Officer—Education. The principals, head masters and head mistresses thoroughly recognise the advantages to be gained not only to the scholar but indirectly to the school, for the efficiency of teaching must largely depend on the receptivity of the pupil and this again on conditions of good health. The advice of the doctor on health questions is sought to an increasing extent and those in authority devote a considerable amount of time and energy to interviewing and writing to parents, with the result that steps are taken to remedy the defects found. This co-operation of principals, parents and students with the doctors brings about a harmonious working of the scheme with most gratifying results. Appendix VII. (B) shows the conditions remedied The Council's scholars in attendance at non-maintained secondary schools, and all scholars attending aided trade and domestic economy schools at which a system of medical inspection has not been adopted have been periodically examined. These examinations began in the year 1912. In many cases the scholars were examined at the institutions at which they were in attendance, but in others the examinations were conducted at the head office in order to meet the wishes of the governors, who preferred such an arrangement on the ground either of lack of accommodation, or the undesirableness of differentiating at the schools between the holders of the Council's scholarships and other pupils. As in the Council's institutions, a medical record card was filled in for each scholar, so that the scholars were continuously under observation and were thus not peimitted to continue at the institution if through illness or other causes they became unfit. The head masters and mistresses exercised vigilance and showed keenness in obtaining prompt treatment of any ailments noted at the medical examinations, and the parents responded to their efforts. The figures given in this year's report show that this work is increasing and that excellent results are being obtained. Residential institutions. During the year there were 9 residential industrial schools and 6 other residential schools (2 blind) 3 deaf and 1 mentally defective), with accommodation for about 1,170 children. To each institution is allocated a medical offcer who, briefly, is required: (1) to attend the school at least once every week and at such other times as may be necessary, and to enter the visits and the names of the patients attended by him in a book kept for the purpose; (2) to examine the children on admission; (3) to attend any cases of illness occurring amongst the children and to make a note on the cards kept for the purpose of all serious cases of illness, their course, duration and treatment prescribed; (4) to furnish reports to the school medical officer on the health of the inmates ; (5) to furnish any other reports or certificates that may be required to the school medical officer; (6) to give immediate notice to the coroner of the district of cases of sudden or violent death, or cases where he does not feel justified in giving a death certificate of any inmate, and to report the circumstances of the case to the school medical officer. Generally, the medical officers are seldom required to make special reports, but a return of sickness is made monthly. A dentist is also allocated to each institution, who is required to visit the school once in each quarter; to perform all necessary extractions, scalings and stoppings; to arrange the work in such a way that every child in the school is kept as far as possible free from such oral sepsis as may be due to unhealthy conditions and to extract teeth and roots that cannot be rendered healthy; to see and, if necessary, treat every child once in each year; to note on the appropriate cards the condition of each child's mouth and the treatment carried out, and enter the names of the children treated in a book provided for the purpose; to make a short annual report on the condition of the children in the school with special reference to oral sepsis; and to co-operate with the superintendent in devising means for maintaining the general cleanliness cf the teeth of the children in the school. During the year the dentists made 95 visits to the schools, conducted 2,121 examinations and treated 843 cases, but some of the children were treated more than once. In many instances conservative treatment was carried out at the private surgery of the dentist. Industrial Scho 1 children— Stature and weight. The heights and weights of boys of all ages in the Council s industrial schools have been tabulatec and the results are shown in Appendix VIII. It appears from the figures that usually the boys in these schools are inferior in height and weight as compared with the standard for boys attending the Council's elementary schools. Generally speaking, the best physique is found among those who have been longest in the industrial schools. The results, however, are not always consistent, a natural outcome of the small number available for the investigation It may probably be concluded that the type of boy entering an industrial school is physically retarded, and that a considerable period of time is required to effect recovery from this retardation. The recovery is more rapid in the case of weight than in stature There is no evidence of progressive retardation. Pinces of detention. The three places of detention maintained by the Council were fully described in previous annual reports. During the year 1914, 2,391 children were admitted as follows : Harrow-road, 798 ; Pentonville-road, 1,047; and Ponton-road, 546. The accommodation and classification of the institutions are stated below:- Harrow-road 40 boys, 13 to 16 years of age. Pentonville-road 51 boys, 7 to 13 years of age. Ponton-road 40 infants under 7 years of age ; 30 girls 7 to 16 years of age. Schools for Mothers. Schools for mothers, which are of comparatively recent origin, have considerably increased in number during the past few years, and there is now one of these institutions in most of the metropolitan boroughs. The chief aim of these schools is the provision of instruction and training for mothers in the care and management of young children with a view to the prevention of infantile mortality and of those 126 Annual Report of the London County Council, 1914. ailments and defects which are likely to retard the development of children. The activities of the school include (a) infant consultations (b) home visiting and meals for mothers ; (c) systematic classes in health, infant care, home nursing, first aid, cookery, and needlew ork. The Council has, under its scheme for supplying teachers to clubs, mothers' meetings and similar institutions, assisted mateiially in the work of these schools. Instruction in health subjects has been given by lecturers chosen from the appropriate panel or by qualified officers of the particular institution concerned, who have been specially approved for the purpose, while the Council's permanent peripatetic staff has been utilised for the lessons in domestic subjects. So far as the education authority is concerned aid is given to those activities of a school which are educational rather than to those which are primarily clinical. In order that there might be continuity of dealing with the whole period from before birth until the time when a child is entered on a school register, an estimate was laid before Parliament during its last Session for a grant, to be distributed in aid of the expenditure of local authorities and voluntary agencies, in respect of institutions or other provisions for maternity and child welfare. The Local Government Board, in the explanatory letter which it issued as to the formulation of schemes or the expansion of work already undertaken in this direction, stated that its grant would normally amount to one-half of the approved expenditure,but might be less if the Board so decided. It also pointed out that any questions of doubt or difficulty as to the work of an institution coming within the scope of the Local Government Board or the Board of Education would be investigated by a joint committee of officers of the two Boards. Infectious Diseases. The subjoined table shows the incidence of scarlet fever, diphtheria and measles during the past nine years ; the figures for whooping cough are furnished for two years as the records of this disease were not kept prior to 1913. The incidence of scarlet fever and diphtheria upon persons of all ages is compared with the number of school cases notified. The accompanying diagram (C) compares the weekly notifications or cases of scarlet tever and diphtheria occurring amongst school children and persons of all ages during 1914. Disease. Total numbers notified. Weekly mean. Year. All ages. Elementary school children. All ages. Elementary school children. Scarlet fever 1906 20,333 8,371 391 161 1907 25,923 12,307 498 237 1908 21,648 10,291 416 198 1909 17,389 7,716 335 148 1910 10,513 4,700 202 90 1911 10,484 4,640 202 89 1912 11,319 5,060 218 97 1913 17,552 7,969 331 150 1914 25,048 11,337 482 218 Diphtheria • 1906 7,934 2,549 153 49 1907 8,597 3,170 167 61 1908 7,671 2,809 148 54 1909 6,617 2,212 127 43 1910 5,391 1,861 104 36 1911 7,268 2.572 140 49 1912 7,009 2,571 135 49 1913 7,654 2,663 144 50 1914 9,056 3,391 174 65 Measles 1906 Nonnotifiable. 18,899 Nonnotifiable. 365 1907 26,179 503 1908 19,385 373 1909 20.145 387 1910 25,677 494 1911 31,905 614 1912 19,809 381 1913 15,142 286 1914 18,585 357 Whooping Cough 1913 Nonnotifiable 9.672 Nonnotifiable 182 1914 9,977 192 • Scarlet Fever.—There was a considerable incidence of scarlet fever in London, during the year, forming port of a general prevalence throughout the country. In fact the London figures in 1914 were the highest experienced since the year 1907. On reference to the Annual Report of 1913 it will be seen that this epidemic prevalence of scarlet fever was first observed in May of that year, that there was a marked increase immediately after the summer holidays, and that it reached its maximum in the latter part of October. The prevalence experienced during 1914 was a continuation of the outbreak of 1913, the incidence remaining high throughout the winter, spring and summer months, and again rising after the summer holidays. The highest number of cases was reached in October. Diagram C. SCARLET FEVER. DIPHTHERIA. THE CITY OF LONDON LITHOGRAPHIC C9,LTD HARP ALLEY, LONDON, E.C. 127 Report of the County Medical Officer—Education. 1914. From that point the incidence gradually fell until it was reduced to the level prevailing at the end of 1913. The disease was mild in character and the mortality remained low tl.ro ighout the two \ears. The number of schools under observation for scarlet fever was 784, and 236 schools were visited by assistant medical officers for the purpose of investigating the outbreaks. The persistence of infection of scarlet fever in individual schools.—As time goes on it is becoming increasingly realised that, from the point of view of prevention, but little can be accomplished by a direct attack upon the micro-organisms associated with some infectious diseases, and that consideration in this regard must be directed not merely to bacteriological inquiry but to all the branches of study concerned in the aetiology of these diseases. In no instance, perhaps, is this more clearly recognised than in the case of scarlet fever, inasmuch as there has been an uudoubted tendency during the last ten years for less significance lo be attached to the part played, by the organisms encountered in the throa', in originating this disease ; it has, indeed, become more and more apparent that in addition to the susceptible individual and the germ or germs (the x and v, as Pettenkofer termed them), there lies hidden in the background an unknown quantity (z) having important influence in the production of scarlct fever. Some of the reasons for entertaining this belief were summarised six years ago.* First, there is the inability of the supposed causal organisms to produce scarlet fever. Second, there is the tendency of scarlet fever to cling to particular premises, and more especially to school classrooms ; the inadequacy of the theory of infective human carriers, which has usually been invoked, to account fully for the phenomena observed, may be inferred from the fact that risk of infection can apparently be obviated when the environment is changed, for example, from the home or school to the isolation hospital ward. Third, there is the response to variations of temperature, and temperature cannot " get at the organisms within the body where the temperatures are notab.y high and constant." Finally, some unknown s is clearly needed to account for the epidemiologv of scarlet fever; its seasonal distribution, its relation to hot years and to years of deficient rainfall; its historical, geographical and racial distribution ; and all these things the healthy carrier hypothesis fails to elucidate. It was tentatively suggested, in 190*5 (see above), that a flet hvp (thesis of causation of scarlet fever was deserving of examin ition. This su» restion was originally prompted by study of the seasonal curve of flies, aud more particularly by the difficulties presented by the titre relations of the curve of fly prevalence and the curves of diseases which the flv has been supposed to transmit. In 1909 a first flea curve was obtained, and it then transpired that the seasonal prevalence of scarlet fever and diphtheria lagged somewhat (three or four weeks) behind that of maximum flea prevalence. It has been pointed outf that " in the case of flies and diarrhoea no such interval is as a rule observed, the curves are practically superimposed one upon another." This peculiarity is a source of some diffijulty as regards flies and diarrhoea, but no similar objection presents itself in the case of fl°as and scarlet fever. Note was further specially made at this time of the marked tendency of scarlet fever to cling to particular classrooms, and reference was made to the phenomena of " return cases" as justifying further examination of a flea hypothesis in relation to scarlet fever causation. In the Annual Report for 1911 (p. 63) more extended reference was made to the same subject and the curves of three years were then available, for study of the time relations of the seasonal curves of fleas and scarlet fever. In each year there was found to be an interval (varying from three to eight weeks) between the maximum for fleas and that for scarlet fever. Attention was no.v more especially directed to the clinging of infection of scirlet fever to particular schools, and the observations made from ten to fifteen years ago, by Dr. Niven in Manchister, were found to be strikingly corroborated by inquiry in the L^nlon schools. The first results of this stu ly were exhioited in a chart facing p. 134 of the Annual Report for 1912. An unexpected outcomi of this investigation was that it was realised that some of the schools specially attacked by scarlet fever were schools not attended by children of the poorest class (to this question further reference will be male shortly). A summary of the observations with regard to time relationship of the flea curves and scarlet fever curves may here be presented. The figures giving the extent to which children in elementarv schools exhibit evidence of being flea marked are now forthcoming for a period of two years, and these, together with the records for the preceding four years relating to beds in common lodging houses, supply a six years' record for study. The curves which represent the seasonal prevalence for the six years are shown on the accompanying diagram (D), and it will be seen that the maximum of the curve relating to fleas precedes in each year, by a period of from some three to eight weeks, the maximum of the curve relating to scarlet fever. The precise interval separating the maxima of the curves is indicated by the width of the shaded area as shown in the diagram for each of the years under review. The method of counting from maximum to maximum is only a rjugh one, and somewhat different intervals would be recorded if the respective curves were "smoothed." Ttie "flea" curve for the year 1912 exhibits two maxima, and the interval between the earlier maximum and the maximum of the corresponding scarlet fever curve, indicated by the shaded area, is eleveu weeks. If the later maximum of the flea curve be taken, the interval is reduced to five weeks. Broadly, however, it is clear that there is a substantial lag (of some three or four weeks, or more) between the maxima in the flea curves and in the scarlet fever curves. During the past year enquiry has been instituted into the extent to which scarlet fever on the one hand and flea marks on the other hand prevail ;n particular schools. Selection, has been made of some 50 schools which may be classed from the point of view of flea prevalence, as "good" schools and some -50 others, which may be classed as " bad " schools. The, at first sight, anomalous result is obtained that children in schools which are "good," when regarded from tbe point of view of flea * Trans. Roy. Soc. Med., Vol. II., p. 83, 1908. + (Annual Report of Medical Officer of Health, 1909.) 128 Annual Report of the London County Council, 1914. prevalence,exhibit a much more marked tendency to suffer from scarlet fever than children in "bad" schools. This result is, at first sight, surprising, for it has long been generally recognised that the correction between scarlet fever and poverty, with its associated dirt and overcrowding, is a close one. The question was investigated some 20 years ago by Sir Shirlpy Murphy and was referred to in the evidence he gave before the Royal Commission on Metropolitan W'lter Supply. He found, taking groups of districts with differing degrees of poverty, that examination of their comparative mortality from typhoid fever, diarrhoea, scarlet fever, measles, diphtheria, whooping cough, and infant mortality showed excessive incidence of disease in the poorest districts, and this excessive incidence was much more distinctly marked in the case of scarlet fever than in that of any of the other causes of death.J The same phenomenon is observed if comparison be instituted between the poorer and the less poor London borouarhs as regards notifications of scarlet fever, the figures relating to which have now been available for more than twenty years, and have bpen published in successive Annual Reports of the Medical Officer of the Council. An exceedingly interesting fact, therefore, emerges from comparison of the "good" and "bid" schools, on the one hand, and the mortality and notification figures for borough areas on the other hand ; for it transpires that while, when the elementary school population alone is considered, the "good" schools are more seriously iuvolved than the "bad" schools, when the entire population is considered the poor boroughs compare unfavourably with the less poor boroughs. The reason for this seeming discrepancy becomes, however, apparent when the populations concerned are dissected out into ages. Thus comparison has been made between a group of poor boroughs and a group of boroughs in which better social conditions obtain (vide diagram E). It will be noted that, in the case of the poorer boroughs, the infants of one to two years of age suffer more than twice as frequently from scarlet fever as those in the less poor boroughs. Infants from two to three suffer in somewhat similar excess, and the same holds for the infants of three to four and four to five. When tho age five tj six is reached the difference is less marked, and from six onwards to ten, the incidence upon the children in the two groups of boroughs becomes practically identical. After thg age of ten the children in the less poor boroughs actually suffer to a greater extent than do those in the poorer boroughs. Tuis analysis makes it clear that the excessive incidence of scarlet fever in the poorer boroughs is, at any rate in large part, accounted for by the fact that the infants and children under school age in these boroughs suffer to a much greater extent from the disease than the corresponding population in the less poor boroughs, and it may be that this difference fully explains the difference in the incidence of scarlet fever in the two groups of boroughs. It still remains necessary, however, to explain how it comes about that, if consideration is limited to the school age, examination of the figures for the child population as a whole (vide diagram) shows that there is little or no difference between the richer and poorer boroughs, and yet examination of the children in elementary schools classed as "good" schools shows a higher incidence of scarlet fever than in schools classed as " bad " schools. This paradoxical result is probably also fully accounted for when it is borne in mind that the total child population consists of a population attending elementary schools and a population not so attending. As a matter of fact it is common knowledge that children not attending elementarv schools suffer to a less extent than elem3ntary school children from scarlet fever, and this fact doubtless explains why equality of incidence of this dissase upon children of school age in the two groups of boroughs is not incompatible with a much greater incidence of disease upon children in the " good " schools than upon children in the " bad " schools. It is, of course, the fact that in the poorest areas the very large majority of the children attend public elemeutary schools ; in the less poor areas the percentage so attending is somewhat lower; and in the least poor areas quite a considerable percentage of children do not attend these schools. It appears, then, that in considering incidence of scarlet fever in areas of differing degrees of poverty in London, attention should be directed to three groups of persons and to three grades of poverty :— Children under school age Children of school age Persons over school age Poorest areas Less poor areas Least poor areas. The facts as to the incidence of disease in these several groups are indicated in the following table, the sign + signifies excessive incidence and the sign — less marked incidence:— Under school age. School age. Over school age. Poorest areas + + + — Less poor areas + + + + Least poor areas — — + + It will be seen that the children under school age suffer markedly in excess in the poorest areas, and that persons over school age suffer markedly in excess in the least poor areas. In turning now to consider the children of school age the fact must be borne in mind that those not in elementary schools suffer comparatively lightly as compared with those in the schools. In the poorest areas the last-named children form the large bulk of the population at school age and they suffer less than the children under school age ; in the less poor areas the percentage of children in elementary schools is still quite considerable, and these children suffer more than the children under school age ; in the least poor areas, in which the percentage of children of school age is comparatively low, the incidence of scarlet fever upon these children is not markedly higher than upon the children under school age. J Table B., p. 222, Appendices Roynl Commission on Metropolitan Water Supply, 1S93. 6 M I 5 y 5 a ■ s E 0 1 8 E 3 I o o £ o w z t- 129 Report of the County Medical Officer—Education. The analysis which has been given indicates that some condition closely associated with poverty determines an earlier incidence of scarlet fever in the poorest area. When, moreover, children attend elementary schools some condition (presumably the same condition) exerts its influence and determines an even higher incidence of scarlet fever upon the comparatively unprotected " less poor," than upon the partially protected "poorest" children. It is quite possible that one of the factors operating in the schools is the presence of vermin, and this is true despite the fact that the incidence of scarlet fever at school ages is appreciably less in schools where the children are badly, than in those where they are less badly, flea bitten. Diphtheria.—Diphtheria, like scarlet fever, was also specially prevalent during 1914. During the year 440 schools were under special observation and 81 schools were visited by assistant medical officers for the purpose of examining suspected cases. During 1914, 2,712 children were bacteriologically examined, of whom 457 were found to be harbouring Klebs-Loeffler bacilli, whilst in 260 further cases organisms not definitely distinguishable from the diphtheria bacillus were identified. Amongst these cases were a certain number of carriers of diphtheria germs, who were away from school for periods varying from three to upwards of six months, in whom successive bacteriological examinations produced positive results. Enucleation of the tonsils was advised in these cases and when this was performed negative results were subsequently obtained, and the children were allowed to return to school. R. C., the industrial school child referred to from time to time in previous reports, has been in one of the Metropolitan Asylums Board's Hospitals since June, 1912. She is still under observation. In spite of use of all the available means of treatment she remains an intermittent carrier ; although, as frequently happens in such cases, she has herself never suffered from the disease. During the autumn of 1914 she had an operation for enucleation, but diphtheria germs were still present in her throat a month after the operation. Measles.—There has been an increase in the incidence of measles, but with the exception of the year 1913, the figures were below those of any of the previous eight years. During 1914, 742 schools were under observation on account of this disease, including 741 infants' departments, 52 senior departments and 4 special schools. The number of occasions on which unprotected children Were excluded from infant classrooms or departments is shown on p 130. The control of measles still constitutes a very serious problem, and varying methods have been suggested from time to time by public health authorities, some of whom advocate compulsory notification. In the metropolitan borough of Paddington measles was made a notifiable disease on 17th March, 1914. So far as school notifications are concerned, early and reliable information of the first case in the department is of supreme importance in the prevention of the spread of infection. This being obtained, effective control would be possible by excluding from school for a limited period children who have been exposed to infection and are liable to develop the disease. Failure to control the spread of the disease in infants' schools is often due to belated information as to the original source. In order to obtain notification of measles early, that is within as short a period as possible from the date of last attendance of the primary case, an experimental scheme was devised in 1913, by which it was sought with the co-operation of attendance officers and head teachers to secure notification of the first case in a school within a week after the sufferer's last day in attendance. The scheme was fully set out in my report for the year 1913 and was applied to the electoral areas of Bermondsey, Walworth and Southwark, W. It has been continued during the past year, in the course of which measles became somewhat prevalent in the selected districts, and it seems justifiable to assume that, in the absence of stringent methods, measles would probably have attained greater dimensions in those particular areas. Furthermore, the districts' selected were thickly populated and the social standard was low, consequently there is no doubt that the efforts made to check the spread of measles in the schools were largely neutralised by the close association of the children in their homes and in the streets. Moreover, in any discussion as to the methods of controlling measles, it must be borne in mind that, in such highly infectious diseases as measles or smallpox, in proportion to the success of preventive measures, the numbers of susceptible persons in the community will accumulate, and the greater the proportion of susceptible material, the more difficult does it become to keep the disease under control. Whooping cough.— There was no appreciable variation in the number of cases of whooping cough reported from the schools in 1914 as compared with the previous year, the figures being 9,977 in 1914 and 9,336 during 1913. Owing to the absence of records prior to 1913 in regard to this disease it is not possible to obtain a clear conception as to its relative prevalence, although there has been a noticeable decline in the death rate in recent years. The number of deaths in 1914 from whooping cough was 918 (uncorrected) as compared with 800 in 1913 and 970 in 1912. Whooping cough was made compulsorily notifiable in the Metropolitan Borough of Holborn on 28th January, 1914. In the Boroughs of Lambeth and Greenwich the disease has been notifiable since 1912. Infectious disease— Elementary schools under observation. The numbers of schools under special observation during the year for diphtheria, scarlet fever and measles are shown in the following table:— Disease. Departments. Total numbers of departments. Total numbers of schools. Boys. Girls. Mixed. Infants. Special. Diphtheria 72 121 47 364 1 605 440 Scarlet fever 359 433 141 666 8 1,607 784 Measles 16 17 19 741 4 797 742 27715 S 130 Annual Report of the London County Council, 1914. School clotures The subjoined table shows the number of closures of departments or classrooms and special exclusions of groups of children which were resorted to during the year for the purpose of preventing the spread of infection. Action taken. Number of occasions on which exclusions or closures were carried out. Measles. Whooping cough. Scarlet fever. Measles, whooping cough and diphtheria, Departments closed - - - - Classrooms closed 2 - 1 1 Exclusion of all children under 5 years of age 13 12 - - Exclusion of all unprotected children under 5 years of age Unprotected children excluded from departments 88 2 - - - Unprotected children excluded from classrooms 1,801 - - - Exclusions by local medical officers of health acting under Article 57 of the Board of Education Code. - Exclusion of all children under 5 years of age 1 - - - Ringworm.—The following table gives the numbers of new cases, cured cases, and those outstanding at the end of each school term :— Terms. New Cases reported. Cured cases. Suffering cases at end of term. No. Treatment by which cures effected. No. Treatment being obtained. Spring Term 1,513 1,617 X-rays 50% Ointments and lotions from hospitals, etc. 29% Ointments, etc., from private doctors 14% Chemists and home remedies 7% 2,130 X-rays 31% Ointments and lotions from hospitals, etc. 36% Ointments, etc., from private doctors 21% Chemists and home remedies 12% No treatment (8 cases). Summer Term 1,448 1,391 X-rays 48% Ointments and lotions from hospitals, etc. 27% Ointments, etc., from private doctors 15% Chemists and home remedies 10% 2,134 X-rays 31% Ointments and lotions from hospitals, etc. ... 35% Ointments, etc., from private doctors 20% Chemists and home remedies 12% No treatment 2% Michaelmas Term ... 1,488 1,896 X-rays 51% Ointments and lotions from hospitals, etc. 22% Ointments, etc., from private doctors 15% Chemists and home remedies 11% 1,638 X-rays 32% Ointments and lotions from hospitals, etc. ... 35% Ointments, etc., from private doctors 19% Chemists and home remedies 13% No treatment 1% The cases in which children were lost sight of owing to removals or had passed out of the Council's jurisdiction are not recorded in the above table. During 1914, 4,449 fresh cases were discovered as compared with 5,573 during the preceding year, and the number of cases in which treatment had not been completed at the end of the year was 1,638 as against 2,277 in 1913—noteworthy reductions. These figures coupled with the figures given in the table of children out of school for long periods on account of ill health (p. 109) lead to the hope that the active measures taken with regard to this disease are beginning not only to reduce its prevalence but to shorten the average period of its duration. During the year 3,557 specimens of hair have been forwarded by assistant medical officers and school nurses for microscopical examination in the laboratory. The subjoined table sets out the results of these examinations, and for purposes of comparison similar figures for preceding years are also shown. It should be noted that the figures in the table relate to the number of specimens examined and do not indicate the number of children affected. 131 Report of the County Medical Officer—Education. Year. Specimens submitted. Ringworm found. Favus found. Fungus not found. Insufficient material. 1905-6 988 597 104 257 30 1906-7 1,578 1,094 84 336 64 1907-8 2,175 1,705 25 347 58 1908 (Mar. to Dec.) 2,751 2,212 32 423 47 1909 3,019 2,343 37 568 45 1910 3,116 2,400 4 709 3 1911 2,926 2,165 4 757 - 1912 2,820 1,991 41 721 67 1913 3,464 1,979 57 1,415 13 1914 3,557 1,894 65 1,583 15 Favus.—The increase of favus noticed during 1913 was not maintained during 1914, only 38 fresh cases having been discovered as compared with 49 during the preceding year. Of these 38 fresh cases, 16 were treated by means of X-rays and the remainder by ointments or lotions at hospitals. At the end of the year there were 29 school children known to be suffering from favus. Industrial schools and residential special schools.—The following table shows the number of cases of infectious diseases reported from industrial schools and residential special schools during 1914. It will be noted that these institutions were singularly free from epidemic illness and communicable diseases generally:— Institution. Accommodation. Age. Scarlet Fever. Dipththeria. Measles. Mumps. Whooping cough. | Chickenpox. Scabies. Impetigo. Infective Conjunctivitis. Ringworm. Industrial Schools. Upton House 150 7-14 1 — 1 (German) — — 1 — — — — Highbury 200 7-14 1 — — — — — — 2 — — Mayford 180 7-14 — — — — — — — — — — Gisburne House 57 Under 14 — — — — — — — — — — Gordon House 70 Under 14 2 — — — — — — — — 5 Portslade 120 7-14 — — — — — — — — — 1 Brixton Hill 84 6-14 — 1 (bacteriological) — — — — — — — — Home for Little Boys 30 Under 7 1 1 2 5 — — — — — 1 Stormont House 30 Under 7 — — 1 — — 2 — — — 2 Drury-lane 200 5-14 — — — — — — — — — — Special Schools. Deaf— Acre Lane 32 13-16 — — — — — — — — — — Oak Lodge Residential 38 13-16 — — — 1 — — — — — Day 38 Homerton Residential 45 over 7 1 — — — — — — — — — Day 35 Anerley Residential 60 13-16 — — — — 1 — — 1 — 3 Day 30 Blind— Linden Lodge Residential 30 13-16 2 — — 1 — 1 — — — Day 10 Elm Court Residential 40 13-16 1 Day 20 Totals 9 2 4 7 1 3 I 3 — 12 Places of detention.—The number of cases of infectious diseases occurring in the places of detention is shown in the table below:— Institution. Accommodation. Age. Diseases. Scarlet fever. Diphtheria. Measles. Mumps. Whooping cough. Chicken-pox. Scabies. Impetigo. Infective Conjunctivitis. Ringworm. Ponton road 40 infants Under 7 21 11 4 2 18 11 2 12 11 30 girls 11-16 (bacteriological) Pentonville 33 boys 7-11 1 3 2 7 — — 14 1 10 8 51 girls (2 bacteriological) Harrow-road 45 boys 11-16 Totals 22 14 6 9 2 18 26 3 22 19 27715 s 2 132 Annual Report of the London County Council, 1914. There was a considerable increase during 1914 in the incidence of infectious diseases in places, of detention, but it will be observed that the greatest number of cases occurred at Ponton-road place of detention, where more than half of the inmates are infants under the age of seven years. It may be of interest to refer to the outbreak of bacteriological diphtheria at Ponton-road. On the 16th March, 1914, a girl named J. M. was discovered to have a discharge from the eye, and material therefrom was examined bacteriologically. In addition specimens were taken from the throat and nose ; these were examined and diphtheria bacilli were identified in the culture. The case was notified and the girl was removed to hospital on the 20th March. All immediate contacts were swabbed on the 23rd March. These included R. II., who was suffering from a discharge from the ears and nose, and R. M., who was also suffering from discharges from the nose, throat and ears. The bacteriological examination of the cultures indicated that the two children referred to were harbouring diphtheria germs. R. H. was notified and removed to hospital, but R.M. had already been sent to the infirmary owing to the unhealthy condition of her throat, nose and ears, and the authorities of the infirmary were informed of the result of the bacteriological examination. On the 24th March the remainder of the contacts were swabbed, and eight of them were found to be harbouring germs of diphtheria and five were sufficiently suspicious to warrant further cultures being examined. The eight children in respect of whom positive results were obtained were removed to hospital and in due course were discharged as free from infection. None of the children could be stated to have suffered clinically from diphtheria. The occurrence of 21 cases of scarlet fever among the children at Ponton-road place of detention is a striking example of the wide prevalence of mild and unrecognised cases of the disease ; no fewer than 9 of the cases were discovered in a condition of desquamation upon admission to the institution before the children had had an opportunity of mixing with other inmates. These cases occurred during the first seven months of the year. In the autumn, i.e. from 5th October to 27th November, 12 cases of scarlet fever occurred, all of which developed after admission to the place of detention. They may be classified in 2 groups with an intermediate isolated case. After careful investigation it appeared extremely probable that the infection of the primary case in each group was contracted in connection with attendance at the police court. Group I.—This group in all comprised four cases, the first of which was notified on 6th October This child attended the police court on 29th September, and as there was no evidence of infection within the institution, it was assumed that the child must have come into contact with an infectious person either at the court or during the journey. Three further cases occurred and were probably infected by this child; one of these was notified on the 7th October, the two others on the 9th October The children who were associated with the patients were kept in quarantine from the date of detection of the first case and no further cases having occurred they were released from quarantine on the 24th October. Isolated case.—On the 31st October a child, who had attended the police court on the 27th October was found to be suffering from scarlet fever. The child was immediately isolated, and on the following day was removed to hospital. It was improbable that there was any focus of infection within the institution. No secondary cases occurred. Group II.—This outbreak included 7 cases of scarlet fever, and once again the child, who constituted the primary case, went to the police court four days before the onset of illness was discovered, i.e., the child attended court on the 10th November and became ill on the 14th November. Six further cases resulted. Defective children. During the year 7 new schools have been opened, 4 for mentally defective, 2 for physically defective, and 1 for deaf children; 1 school for physically defective, and 2 for deaf children have been closed The number of special schools is as follows, the total average roll is about 12,500:— Schools for the mentally defective (M.D.) 96 „ „ physically defective (P.D.) 38 „ deaf (D.) 9 „ „ partially deaf (hard of hearing) 3 „ „ blind (B.) 8 „ „ myopic (My.) 3 Admission examinations In January of this year 4 additional schools for myopic children were opened, but one was closed. During the earlier part of the year the procedure in regard to the special examinations of children with a view to admission to special schools was on the lines set out in the last annual report, but during the latter portion of the year the examinations for admission to special M.D. schools were conducted in accordance with the following scheme, which was prepared for the purpose of carrying out the administration of the Elementary Education (Defective and Epileptic Children) Acts, 1899 to 1914, and the Mental Deficiency Act, 1913. Elementary Education defective and Epileptic Children) Acts, 1899 to 1914, and Mental Deficiency Act, 1913. (1) In every department of a public elementary school within the area of the Council a list of children suggested as fit for schools for mentally defective children is kept by the head teacher. Head teachers are required to present the list to the school doctor on each visit and to the psychologist on his visits. If the school doctor or the psychologist considers that any of the children on this list should be presented to the school medical officer for the statutory examination, the head teacher places their names on the appropriate form and forwards it to the school medical officer with a view to the examination of the children. The other children on the list undergo a period of special observation under the general supervision of the psychologist. It is open to the school doctor or the psychologist to add names to the list. Arrangements are also made by the Education Committee for the examination by a certifying officer of any child at the request of his parents, or, in the case of a child not in attendance at any school, on the nomination of a divisional superintendent. 133 Report of the County Medical Officer—Education. (2) Examinations for the admission of children to schools for the mentally defective are held periodically, and a child may not be admitted to these schools unless it is certified by a certifying officer approved by the Board of Education under section 1 (3) of the Elementary Education (Defective and Epileptic Children) Act, 1899, as a child who not being imbecile and not being merely dull or backward, is defective—that is to say, is incapable, by reason of mental defect, of receiving proper benefit from the instruction in an ordinary public elementary school, but is not incapable by reason of such defect of receiving benefit from instruction in a special school. Every child presented for examination is accompanied either by an adult teacher who is able to explain the case, or by an attendance officer. The parent or some responsible person is also invited to attend. Any child, who has attained the age of seven years, reported for examination to the school medical officer in accordance with these arrangements shall be examined within three months of such report. Before giving a certificate the certifying officer shall, if so directed by the Education Committee, or if he is so requested by the parent of the child, consult the head teacher of the school, if any, which the child has been attending, or such other person as the Education Committee may appoint for the purpose, and a copy of any report made by the head teacher or such other person shall be forwarded to the Committee. (3) In the event of a child being certified as fit for admission to a school for the mentally defective the certificate of a certifying officer is submitted to the Education Committee, who arrange, through the education officer, for the admission of the child to a suitable school. It is the duty of the Education Committee to endeavour to ascertain the wishes of the parents of the child and, as far as possible, to give effect thereto. (4) If a child over the age of seven years is certified by a certifying officer as being incapable, by reason of mental defect, of receiving benefit from instruction in a school for the mentally defective (schedule C of Model Arrangements of Board of Education), or as being incapable of receiving instruction in such a school without detriment to the interests of the other children (schedule E of Model Arrangements), the case is dealt with in accordance with the provisions hereinafter contained. (5) If the child is certified to be fit to attend the ordinary classes of public elementary schools, arrangements are made by the Education Committee, through the education officer, for its admission thereto, if the child is not in attendance at such a school. (6) Arrangements are made by the Education Committee for the examination from time to time by a certifying officer of all mentally defective children who are being educated in special schools or classes maintained by the Council under the Elementary Education (Defective and Epileptic Children) Acts, 1899 to 1914, with a view to ascertaining in each case (1) whether the child can be discharged from the special school or class on the ground that he or she has attained such a mental condition as to be fit to attend the ordinary classes of public elementary schools, in which case the committee will return to the parent of the child any certificate certifying that the child was mentally defective ; (2) whether he or she is incapable of receiving further benefit from instruction in a special school or class (schedule D of Model Arrangements); or (3) whether he or she cannot be instructed in a special school or class without detriment to the interests of the other children (schedule E of Model Arrangements). Such examinations are made at intervals of not more than twelve months, provided that if the parent of any child claims that his child shall be examined and the child has not been examined within six months before the date of such claim a special examination of the child is made. Action is taken by the committee on the receipt of the certificate of the certifying officer as set out in paragraphs No. 5 above or Nos. 11 to 14 below. (7) Arrangements are made by the Education Committee for ascertaining in the case of any mentally defective child sent by the Council to a special school not maintained by the Council, whether the child comes within either of the three categories set out in paragraph No. 6. For this purpose the Committee arranges for certificates and reports on the child to be forwarded to them at intervals of not more than twelve months. These certificates and reports shall be made by a certifying officer, and for this purpose the Committee may approve the medical officer of the school or class at which the children are being educated as certifying officers in respect of those children. Action is taken by the Committee on the receipt of the certificate and report of the certifying officer similar to that set out in paragraphs No. 5 above or Nos. 11 to 14 below. (8) Head teachers and divisional superintendents shall report immediately to the education officer on appropriate forms cases of children between the ages of 7 and 16 years who, in their opinion, come within any of the following definitions of defectives in the Mental Deficiency Act, 1913, and who also come within any of the categories set out in (e) (i.) and (ii.) below:— Definition of defectives— (a) Idiots; that is to say, persons so deeply defective in mind from birth or from an early age as to be unable to guard themselves against common physical dangers. (b) Imbeciles ; that is to say, persons in whose case there exists from birth or from an early age mental defectiveness not amounting to idiocy, yet so pronounced that they are incapable of managing themselves or their affairs, or in the case of children of being taught to do so. (c) Feeble-minded persons ; that is to say, persons in whose case there exists from birth or from an early age mental defectiveness not amounting to imbecility, yet so pronounced that they require care, supervision and control for their own protection or for the protection of others, or, in the case of children, that they, by reason of such defectiveness, appear to be permanently incapable of receiving proper benefit from the instruction in ordinary schools. (d) Moral imbeciles; that is to say, persons who from an early age display some permanent mental defect coupled with strong vicious or criminal propensities on which punishment has had little or no deterrent effect. 134 Annual Report of the London County Council, 1914. Defective children subject to be dealt with under the Act by way of notification— (e) Defective children— (i.) Who have been ascertained to be incapable by reason of mental defect of receiving (1) benefit, or (2) further benefit, in special schools or classes, or (3) who cannot be instructed in a special school or class without detriment to the interests of the other children, or (4) in regard to whom there are special circumstances which render it desirable that they should be dealt with under this Act by way of supervision or guardianship. (ii.) who on or before attaining the age of 16 are about to be withdrawn or discharged from a special school or class, and in whose case it is considered that it would be to their benefit that they should be sent to an institution or placed under guardianship. (9) The education officer shall compile a register of the children reported to him on the appropriate forms, and shall add to the register the names of any children who, in his opinion, or, in the opinion of the school medical officer, should be included therein. The education officer shall forward the forms, and particulars of all children in the register, to the school medical officer, who shall arrange for a medical examination of the children by a certifying officer approved by the Board of Education under section 1 (3) of the Elementary Education (Defective and Epileptic Children) Act, 1899. Any child, who has attained the age of seven years, reported for examination to the school medical officer in accordance with these arrangements, shall be examined within three months of such report. Before giving a certificate the certifying officer shall, if so directed by the Education Committee, or if he is so requested by the parent of the child, consult the head teacher of the school, if any, which the child has been attending, or such other person as the Education Committee may appoint for the purpose, and a copy of any report made by the head teacher or such other person shall be forwarded to the Committee. (10) The school medical officer shall, after the examination of the children, return the forms to the education officer, with his reports on the children, together with, where required by the Mental Deficiency (Notification of Children) Regulations, 1914, the certificates of the certifying officer (schedules B, C, D or E of Model Arrangements of Board of Education), and the medical record cards (particulars required by schedule F of Model Arrangements) in respect of the children. (11) The Education Committee will inform the parent of any child affected by these arrangements of any action proposed to be taken with reference to that child under these arrangements. (12) The names and addresses of the children, together with the reports of the head teachers or divisional superintendents, etc., who nominated the children, the report of the school medical officer, the certificates of the certifying officer, the medical record cards, the observations of the parents and the care or after-care committee concerned, and such other reports as the education officer may consider desirable shall be presented to the Education Committee by the education officer. (13) The names and addresses of the children certified by the certifying officer to be idiot, imbecile or moral imbecile shall be notified on the approved form to the Asylums and Mental Deficiency Committee, and the certificates of the certifying officer (schedules C, D or E of Model Arrangements) and the medical record cards of the children, together with such other reports upon the children as may have been obtained, shall be forwarded with the notification. (14) Copies of the reports of the certifying officer (Board of Education Form 306m) in respect of children certified as being incapable, by reason of mental defect, of receiving benefit or further benefit from instruction in a special school or of being instructed in a special school without detriment to the interests of the other children except those dealt with in paragraph 13, shall be forwarded to the Board of Education, and if after consideration of the reports the Board so require, the Education Committee shall submit to the Board, for determination, the question whether the names and addresses of the children should be notified to the Asylums and Mental Deficiency Committee. In the event of the Board offering no observations in regard to such notification, or determining in favour of notification, the names and addresses of the children shall be notified on the approved form to the Asylums and Mental Deficiency Committee, and the certificates of the certifying officer (schedules C, D or E of Model Arrangements), and the medical record cards of the children, together with such other reports upon the children as may have been obtained, shall be forwarded with the notification. (15) In the case of a child reported by the head teacher of a school for the mentally defective or other reponsible person as requiring supervision or guardianship owing to unfavourable home conditions, or other special circumstances, but who is certified by the certifying officer as being not incapable of receiving benefit from instruction in a special school (schedule B of Model Arrangements), the Education Committee shall consider the reports provided for in paragraph 12 above and shall decide whether the name and address of the child should be notified or arrangements made for the child's admission to a residential school for the mentally defective or that no action be taken. When it is proposed to notify such a case the special circumstances shall be reported to the Board of Education, and if the Board certify that the circumstances render it desirable that the child should be dealt with under the Mental Deficiency Act by way of supervision or guardianship, the name and address of the child shall be notified on the approved form to the Asylums and Mental Deficiency Committee, and the reports which may have been obtained upon the child shall be forwarded with the notification. (1C) In the cases of the children reported by the head teachers of 'he schools for the mentally defective, or other responsible persons, as being about to be withdrawn or discharged from a special school on or before attaining the age of 16, and in whose case it is considered that it would be to their benefit that they should be sent to an institution or placed under guardianship under the provisions of the Mental Deficiency Act, the Education Committee shall consider the reports provided for in paragraph 12 above and shall decide whether or not the names and addresses of the children should be notified. In the event of it being decided to notify such a case, the name and adddress cf the child shall be notified Report of the County Medical Officer—Education. j 135 on the approved form to the Asylums and Mental Deficiency Committee, and the report of the head teacher, and such other reports on the child as may have been obtained, shall be forwarded with the notification. (17) In any case falling under paragraphs 13 and 14 above, where the Education Committee, notwithstanding the certificate of the certifying officer, are of opinion, after due inquiry, that the name of the child should not be notified to the Asylums and Mental Deficiency Committee, or where, after due inquiry, the Education Committee desire to notify a case which has not been certified under paragraphs 13 and 14, and does not come within the scope of paragraphs 15 and 16, or in cases of doubt, the case shall be submitted to the Board of Education for determination whether the name should be notified. In doubtful cases action may be delayed until the children have been under observation for a further period, either in a day or residential school for the mentally defective. (18) In any case where it is proposed to notify to the Asylums and Mental Deficiency Committee under the Act the name of a child who is also blind or deaf within the meaning of section 15 (1) of the Elementary Education (Blind and Deaf Children) Act, 1893, a copy of the report of the certifying officer on the child (Form 306 M.), and, in the case of a child already in attendance at a special school for blind or deaf children, a report of the head teacher of the school on the child's progress while in the school, shall be forwarded to the Board of Education, and if after consideration of the report, or reports, the Board so require, the Education Committee shall submit to the Board for determination the question whether the name and address of the child should be notified. (19) The managers of the schools for the mentally defective, to which the Council sends children, shall report to the Education Committee cases of children sent to their schools for whom the Council contributes, who, in the opinion of the managers and the medical officer of the school, are feeble-minded within the meaning of section 1 of the Mental Deficiency Act, 1913, and who are also about to be withdrawn or discharged from the school on or before attaining the age of 16 and in whose case it is considered that it would be to their benefit that they should be sent to an institution or placed under guardianship under the provisions of the Mental Deficiency Act. These reports should be submitted to the Education Committee upon the child reaching the age of 15½ years, and action will be taken thereon by the Committee similar to that set out in paragraph No. 16. (20) Particulars of cases of defective children brought before a Court shall be laid before the Education Committee, who, if they do not recommend to the Court that the children should be committed to industrial schools for mentally defective children, may suggest that the cases should be referred to the Asylums and Mental Deficiency Committee, in order that the necessary action may be taken under section 8 of the Mental Deficiency Act, 1913. (21) The managers of the industrial and reformatory schools with whom the Council has agreements shall report to the Council cases of children sent to their schools, towards whose maintenance the Council contributes, who, in the opinion of the managers and the medical officer of the school, are defective within the meaning of the Mental Deficiency Act, 1913, and also which of such children are about to be discharged, and need, in the opinion of the managers, owing to mental defect, further care and control. In the case of the Council's industrial schools it shall be the duty of the managing committees to report the cases of such children to the Education Committee. (22) Particulars of the cases reported by the managers under paragraph 21 above shall be laid before the Education Committee together with the observations of the parents and such reports as may seem desirable, for their consideration as to whether the children should be transferred to industrial schools for mentally defective children, or, in the case of children about to be discharged, whether the Asylums and Mental Deficiency Committee shall be consulted with a view to steps being taken to apply to the Secretary of State for an order for the transfer of the child to an institution, or for the child to be placed under guardianship, in accordance with section 9 of the Mental Deficiency Act, 1913. (23) So soon as the Asylums and Mental Deficiency Committee concur in the proposed application for the transfer of a child to an institution, or for a child to be placed under guardianship, in accordance with section 9 of the Act, the application shall, in the case of a child at one of the Council's industrial schools, be made and, in the case of a child at a school with which the Council has an agreement, the managers shall be asked to make the application. When an order has been issued by the Secretary of State the parents or friends of the child shall be informed and steps taken to give effect to the order. The total number of children seen at admission examinations during the year was 6,963, and the following table compares the results with those of the previous year. Classification. (1) 1914. 1913. Boys. (2) Girls. (3) TotaL (4) Total. (5) Elementary School 914 884 1,798 2,286 Invalid 444 526 970 1,354 Industrial School 77 20 97 113 Blind 57 59 116 125 Blind Epileptic 1 — 1 — Myope (Partially Blind) 90 115 205 237 Deaf 67 55 122 148 Partially Deaf 35 25 60 84 Epileptic 34 36 70 77 Physically Defective 538 581 1,119 1,397 Mentally Defective 884 755 1,639 1,949 (Continued on next page.) 136 Annual Report of the London County Council, 1914. Classification. (1) 1914. 1913. Boys. (2) Girls. (3) Total. (4) Total. (5) Mentally and Physically Defective 11 10 21 2 Mentally and Physically Defective and Epileptic — 1 1 — Mentally Defective and Blind 1 2 3 — Mentally Defective and Deaf 3 1 4 5 Mentally Defective and Epileptic — 2 2 — Feeble-minded 23 19 42 — Feeble-minded Epileptic 2 4 6 — Imbecile 280 249 529 146 Imbecile and Epileptic 9 14 23 — Imbecile and Dumb — 1 1 — Imbecile and Physically Defective 9 2 11 — Imbecile, Blind and Physically Defective — 1 1 — Imbecile, Epileptic and Physically Defective 1 1 2 — Idiot 46 44 90 — Idiot and Blind 1 — 1 — Idiot, Deaf and Dumb 1 1 2 — Idiot and Dumb 4 — 4 — Idiot, Dumb and Physically Defective 3 3 6 — Idiot and Physically Defective 1 3 4 — Idiot and Epileptic 5 6 11 — Idiot, Epileptic and Physically Defective 1 1 — Idiot, Epileptic, Physically Defective and Dumb 1 — Totals 3,542 3,421 6,963 7,923 Rota visits. The special schools were visited at least once a quarter, and every child present was seen at least once during the year. The intended visits of the medical officers to the schools for the mentally defective and physically defective were announced in the Council's Gazette at the beginning of each term, and the head teachers were requested to present for examination all children included in the following categories:— (а) Those who had been admitted to the school during the preceding three months. (б) Those who had not been seen for nine months. (c) Those who were applying for exemption or were approaching the age of 14 years. (d) Those whom it was considered desirable to place before the doctor. In the cases of the other special schools at least three days' notice of intended visits of the medical officers was given to the head teachers. The number of medical examinations under this head during the year was 14,026. The number of medical examinations under this head during the year was 14,026. The following table compares the recommendations made as regards re-classification in the case of scholars attending the schools for the mentally and physically defective, with the recommendations for the previous year (1913). Sex. (1) Elementary school. (2) Blind and Myope. (3) Deaf and partially deaf. (4) P.D. to M.D. (5) M.D. to P.D. (6) Excluded Imbecile. (7) Invalid. (8) Exemption recommended. (9) Boys 189 2 8 22 8 16 39 34 Girls 200 4 6 10 5 18 33 72 Totals, 1914 389 6 14 32 13 34 72 106* Totals, 1913 359 7 15 57 10 73 93 293 The following return shows the categories under which exceptional children recorded in the area of the Council, on the 31st December, 1914, have been certified at special examinations:— Blind (including partially blind) Attending Public Elementary Schools 281 Attending Certified Schools for the Blind 470 Not at School 41 - 792 Deal and Dumb (including partially deaf) Attending Public Elementary Schools 55 Attending Certified Schools for the Deaf 714 Not at School 7 - 776 Mentally Deficient (excluding imbeciles and idiots) Attending Public Elementary Schools 155 Attending Certified Schools for Mentally Defective Children 7,747 Not at School 28 - 7,930 Physically Defective Attending Public Elementary Schools 77 Attending Certified Schools for Physically Defective children 3,643 Not at School 205 - 3,925 * In addition to these cases, 270 special examinations were also made in connection with applications for exemption from further school attendance. Report of the Count;/ Medical Officcr—Education. 137 In the annual report for 1913 attention was drawn to the fact that the local authority for the purposes of the Mental Deficiency Act, 1913, on the advice of Dr. F. W. Mott, F.R.S., was endeavouring to ascertain how far insanity in parents was responsible for the mental deficiency of the children in the schools. This work was undertaken with a view to enabling a judgment to be formed regarding the tendency of insane parents to beget congenital imbeciles, and it was stated that arrangements had been made whereby the local authority notified the names and addresses of all persons admitted to asylums who had children of school age, and the School Medical Officer furnished the authority with information regarding such children. This arrangement was authorised for a period of six months, and in view of the success attained it is being continued. Insanity and mental defect. During the year ended 31st December, 1914, twenty-one cases were notified by the education authority to the local authority. Further cases had been examined but were not notified until the present year. Dr. Shrubsall has analysed the data from the records of 150 children, who, by reason of being idiots or imbeciles were unable to be educated in special schools, and whom it was proposed to notify to the Asylums and Mental Deficiency Committee. Mental Deficiency Act, 1913. These data have been compared with those of defectives in the special schools, with epileptics, and with normal children as reported in the annual report for 1912. Type. Number Observed. Size of Fraternity. Number dead when index child was aged 7. Order of Birth. Idiots and Imbeciles 150 5.97 1.7 3.76 Mentally Defectives in Special Schools 1,000 0.32 1.9 4.35 Epileptics 390 6.32 — 3.61 Normals (Scholarship Candidates) 1,000 4.79 .5 2.87 The average number of defectives per family was l.25. The net size of the family will be noted to be about the same for all grades of defectives. The family history of the defectives revealed the following data:— Member of Family Allected. Pathological Condition. Epilepsy. Alcoholism. Insanity. Feeblemindedness. Brothers and Sisters 6 — 1 20 Fathers 4 10 3 3 Mothers 3 3 2 2 Grandparents 5 19 17 2 Collaterals 8 — 19 5 As might have been expected there is a considerable history of constitutional defects, the following percentages being recorded:— Diseases of Childhood. Marked Rickets 12.0 Infantile Convulsions 15.0 Congenital Heart Disease 3.0 Infantile Paralysis 5.0 Hutchinson's Teeth, Scars on Lips, etc. 2.5 Spastic Paralysis 9.0 Squint 3.0 Epilepsy 22.0 Notable Deafness 3.0 Stigmata. The following numbers were noted in the 150 cases, some having two or more stigmata. Cretinoid Development 9 Broad Based Nose 15 Microcephalic 11 Epicanthic Folds 23 Hydrocephalic 3 Definite Mongolism 19 Marked Cranial Asymmetry 7 High Arched Palate 15 Bossed Forehead 5 Cleft Palate 2 Low Forehead 4 Hare Lip 1 Narrow Forehead 13 Webbed Toes 1 Depressed Nose 5 Notable Deformity of Ears 27 A history of miscarriages was obtained in 12 per cent, of the cases and premature birth in 5 per cent, of cases; prolonged parturition in 9 per cent, of cases, while in 17 per cent, there was a history of mental stress or physical disturbance in the mother during pregnancy. 27715 T i38 Annual Report of the London County Council, 1914. The head dimensions are recorded in the accompanying table:— Age. Circumference of head in inches. 17 17½ 18 18½ 19 19½ 20 20½ 21 21½ 22 22½ 7 1 2 3 1 8 1 1 9 1 3 1 1 10 1 1 2 3 11 1 2 3 2 2 1 2 2 12 2 1 2 3 1 13 5 2 6 3 1 2 14 1 1 1 3 2 2 7 2 2 15 1 2 3 2 2 1 Accommodation for children suffering from double defects. The provision of accommodation for mentally defective children suffering also from blindness, deafness, or other physical defects, should be considered from the standpoint of the best interests of the child and of the economical and efficient working of any institution. To secure classification, industrial training and education, employment and the promotion of industry and good behaviour, it is essential that the children should be in the immediate charge of those who have a special acquaintance with the particular defects and the means of communication with the child, or of employing or exercising him without strain. Each type of defect, and indeed each child, requires to be considered individually. It has been found that the educational treatment required by the blind and the deaf, is of so specialised a nature as to demand a separate training for the teachers and manual instructors. A certain number of the deaf and blind appear to be more mentally defective than they really are, since the maximum possible has not been obtained from them. In the case of the deaf the classification within the group is all important; the deaf who can benefit by oral instruction should be kept away from those who cannot, otherwise the mentality of the former suffers, and they tend to lose whatever degree of speech they may have retained or acquired. There is the risk of the defective voice sounds of those deaf children who cannot be taught by the oral method, being imitated by other feeble-minded children, since, Ln many instances, they are hard to instruct in normal articulation without their receiving the detrimental influence of bad vocal examples. Provided opportunity exists for separating these deaf who can communicate with others by the oral method, and that all can be under the charge of those who thoroughly understand their condition and potentialities, there would be little valid objection to deaf feeble-minded children being lodged in special wards or pavilions of a large general institution for the defective. The opportunities for classification, skilled instruction, and control would probably be greater and be obtained at a more economical rate if a sufficient number of defectives of one class were gathered within a single institution. It is understood that the "National Bureau for the Welfare of the Deaf" has approached the Board of Control to urge on that body the advisability of securing special treatment for deaf defectives. On educational grounds, there is less reason for segregation of the blind, provided there are officers who understand and can communicate with them. Children with milder grades of mental deficiency, such as may be found among those blind from injury or surface inflammation of the eye, can often be educated with their normal fellows, while in the deeper grades of defect, such as may accompany deep seated inflammation or maldevelopment of the eyeball, frequently associated with congenital syphilis, there is often little capacity for manual work, and the cases are of a hopeless character. If it were found convenient, such cases could well reside in a special ward of a general institution. Those who are both mentally and physically defective need some consideration. Ordinary crippling lesions may occur among the feeble-minded as among the normal population and need similar treatment in either instance. The most important ailment to consider is tuberculosis. Tuberculous patients are often kept in wards or shelters in the existing institutions for the feeble-minded, and should this custom continue, the question would arise as to separating those suffering from open tuberculosis and securing for them such medical and surgical treatment as their clinical condition may demand. Certain forms of paralysis are especially associated with feeble-mindedness, with or without epilepsy. Many of these cases after a brief period of improvement and educability, deterioiate and ultimately need institutional treatment. There is a stage at which surgical care is required, and later the best can only be got from them by the employment of suitable orthopedic exercises. Provided adequate nursing is available, the only objection to the treatment of these children in a general institution is the depressing influence the sight of cripples might have on the other inmates. 4 In a certain number of cases information was available as to the age at which the children were able to walk and talk ; the result being as follows:— [ Age in years. I 2 3 4 5 G 7 8 Later Nil. Walk 7 29 18 10 16 G 3 1 2 3 Talk 5 24 6 7 11 8 4 4 4 9 Report of the County Medical Officer—Education. 139 The provision of suitable education for epileptic children continues to present difficulties. The voluntary institutions generally restrict their accommodation to children of the less troublesome type, and these are the very children with whom parents and guardians are most unwilling to part. The remainder of the cases for whom provision is more urgently needed have no possibility of educational or colony treatment. These children are placed in the Council's schedule as "invalided," but this term merely denotes that they arc unfit for any existing educational institution. During the year, 70 epileptic children were scheduled as suitable for admission to colonies and at the end of the year, 72 were attending certificated schools for epileptics while 144 epileptic children were invalided (out of school) either awaiting an institution or because their parents were unwilling for them to be sent from home. The above numbers show all the children who require special provision on account of epilepsy. There are, in addition, a considerable number of epileptic children who are attending school regularly, and to whose condition it is inadvisable, for the sake of the children themselves, to draw special attention. Epileptics. D. A. C. Williams has contributed the following analysis from the medical record cards of the 3,631 children who have been in attendance at schools for the physically defective during the year:— (1) Tuberculous Diseases (6) Various Deformities Spine 389 Rickets 114 Hip 441 Septic Osteitis 34 Knee 214 Amputations 101 Ankle and Tarsus 38 Scoliosis and Kyphosis 69 Elbow 20 Coxa Vara 8 Various 43 Malunited Fractures, etc. 13 —1145 Scarring from Burns 5 Achondroplasia 8 (2) Infantile Paralysis 625 Various 42 — 399 (7) Heart Disease 705 (3) Spastic Paralysis Hemiplegia 85 (8) Other Chronic Diseases Paraplegia 48 Chorea 92 Diplegia 37 Alleged Phthisis 26 — 170 Bronchiectasis, Chronic Bronchitis and Asthma 33 (4) Other forms of Paralysis Old Empyema and Pleurisy 10 Pseudohypertrophic and other Severe Anæmia with Leukaemia, etc. 39 gressive Paralyses 18 Nephritis 10 Various Paralyses 36 Epilepsy 6 — 54 Lupus 5 Various 32 (5) Congenital Deformities Delicate, Convalescent, etc. 32 Dislocation of the Hip 74 — 285 Talipes Equinovarus 90 (9) Other Defects 28 Various 56 — 220 3,631 Schools for the physically defective. The actual changes in the percentage distribution in the years 1907, 1908, 1912, and 1914, during which the medical details were collected on a uniform basis were as follows:— Defect. 1907 1908 1912 1914 Tuberculous Disease 45.6 40.3 33.4 31.5 Heart Disease 11.4 12.5 18.3 19.4 Paralysis 17.8 18.6 21.6 23.3 Chronic disease (chorea, epilepsy, phthisis) 5.1 6.6 7.7 6.9 Various deformities (rickets, septic, congenital) 13.0 15.6 15.9 17.0 Other defects (eyes, ears, tracheotomy, etc.) 1.6 1.0 1.0 .7 Delicate, convalescent, and children kept under observation 5.3 5.3 2.4 .8 Dr. Williams has made inquiries into the mental attainments of the children suffering from paralysis who are in attendance at the schools for the physically defective. The children were grouped into four classes according to the estimates of the teachers, viz., those above the average of children in schools for physically defective, those of average attainments, those below the average, and those verv definitelv below the average and on the border line of mental deficiency. Mental condition of paralytics. The results are shown in the following table which indicates that the mental condition is better in the cases of the spinal than of the cerebral paralysis, and of the latter the cases of hemiplegia are better than those of spastic diplegia or paraplegia. Above Average. Average. Below Average. Definitely below average Almost on border lino of mental deficiency. Poliomyelitis 63 (18.2%) 169 (48.7%) 89 (25.6%) 26 (7.5%) Hemiplegia 6 (8.8%) 22 (32.4%) 21 (30.9%) 19 (27.9%) Diplegia and Paraplegia 0 (0.0%) 10 (15.1%) 16 (24.2%) 40 (60.6%) 27715 T2 140 Annual Report of the London County Council, 1914. Conveyance of children who are physically and mentally defective. Difficulties have arisen with regard to children who are so physically and mentally defective as to render it inadvisable to allow them to travel in the school conveyances with the ordinary physically defective children. At present many of the children who are both mentally and physically defective are admitted temporarily to the physically defective schools for purposes of observation. It is highly desirable that arrangements should be made for their transfer to schools for mentally defective, as soon as their mental status has been determined. The number of these children is not likely to diminish, but with such re-arrangement of centres as from time to time occurs, the diminution of the distance which any child has to travel to school may slightly lessen the proportion requiring carriage by ambulance. It will still be necessary to scrutinise each case individually as there is a tendency on the part of the parents when the child has once been to a physically defective school to demand the use of an ambulance as a right regardless of its necessity. The proportion of mentally defectives is higher among children suffering from spastic paralysis, rickets and congenital club foot, but, apart from these, it is probably no higher amongst physically defectives than among the healthier children. Backwardness amounting to mental stagnation is very common, and it is extremely difficult, during the first years of attendance, to determine whether these children arc strictly mentally defective, so that observation for a considerable time is desirable. The cases of greatest difficulty are those of spastic paralysis, many of whom are quite incapable of getting to a mentally defective school although the nature of their affection cripples mental as well as physical activities. As a rule, children with combined defects should be kept in the mentally defective schools, although some form of conveyance would be necessary. There is no objection to physically defectives with ordinary degrees of mental defect travelling in the school ambulance with physically defectives. Cases in which the mental defect is of a more severe nature have to be invalided, although some of them would be suitable for residential institutions, were such available. The degree of benefit derived by children with combined defects is even less than in the case of those crippled in one set of activities only. Stammering 559 (419 boys, 140 girls) children in the age groups have been noted as suffering from stammering. From time to time attention has been drawn to the need for special educational treatment of children suffering from stammering and schemes have been drawn up for the opening of experimental classes, but up to the present none of the schemes have reached maturity. The Council has, however, made arrangements for the students in the training colleges to be trained in the theory and practice of speech, and the authorities of St. Thomas's Hospital have established a " speech clinic " for the treatment of school children suffering from defective speech including stammering, post-adenoid conditions, rcspiratorv defects and general nervous conditions. Classes for the deaf and partially deaf. Children noted by the teachers as partially deaf are examined at the schools or at special centres by the school doctors, and all cases in which there is marked impairment of hearing are referred for special investigation by Mr. Yearsley (the Council's otologist). In his examinations at the Head Office Mr. Yearsley has seen 277 cases, with regard to which the following decisions were arrived at:— Elementary School 20 „ „ front row 29 Partially deaf 60 Deaf 122 Mentally defective 8 Imbecile 2 Invalided 11 Exemption recommended 2 Advice given 23 277 During the past five years (1910-1914), a total of 260 children have been classified as partially deaf. These children are too deaf for ordinary elementarv school instruction, but are not sufficientlv deaf for the special instruction of a deaf school. Since the establishment of the three centres for the partially deaf at Ackmar-road, Stanley-street and Hearnville-road, 121 children have been dealt with, as shown in the following table. Number. (1) Ackmarroad. (Opened 12.9.10.) (2) Stanley street-. (Opened 13.10.13) (3) Hoarnvilloroad. (Opened 20.10.13.) (4) Totals. (5) Admitted 44 54 23 121 Still on Roll 17 41 21 79 Transferred to E.S. 10 7 1 18 Transferred to Deaf 8 - 1 9 Left at age of 14 4 6 — 10 Excluded 2 - — 2 Left District 2 - — 2 Died 1 - 1 27 13 2 42 Report of the County Medical Officer—Education.. 141 Eighteen children, after receiving instruction at these centres, have been transferred to ordinary elementary schools, where they have held their own with their hearing classmates. As a matter of fact, five children can be excluded in calculating these results (of these five, two were excluded, two left the district and one died), making the percentage 48.0, a result highly satisfactory to the Council and reflecting great credit upon the teachers. Of the If) who left at the age of fourteen, all went into occupations of some kind (domestic service, bookbinding, coppersmith, sanitary engineering) and were so proficient in lip-reading as to be quite capable of self-support. Eight cases were found to be suffering from such a degree of deafness as to necessitate their transference to a deaf centre (6 went to Anerley and 2 to Oak Lodge). The standard of lip-reading attained by the children in these centres is very high. Lip-reading appears to be readily acquired by children, and those with most hearing seem to learn it quicker than those with less hearing who require longer teaching and practice to enable them to become thoroughly proficient. This is due to the fact that the former possess a better knowledge of language and, other things being equal, the greater the amount of hearing the greater the command of language. Mr. Yearsley thinks that the amount of hearing required to enable a child to respond well to education in the front desks of a hearing class is much greater than at first sight appears. It is characteristic of middle ear deafness that the power of accommodating the ears to particular sounds is impaired, and that, in consequence, extraneous noises confuse the slightly deaf and hard of hearing child much more than they do the hearing scholar. In every class, especially in large ones, there is an environment of more or less continuous noises; dropping of books, shuffling, coughing, whispering, etc., as well as the more distant hum of life outside the school, accentuated by open windows. Children examined by the voice and whisper tests in a quiet room may deceive one as to the usefulness of the hearing they possess, especially if the child be examined on one of his " good days." The amount of daily variation of hearing, as shown by records kept by the teachers in partially deaf centres, is sometimes astonishing. Lip-reading. In the deaf centres the health of the children has, generally speaking, been highly satisfactory throughout the year. Health of deaf schools. During the past year much attention has been directed to the condition of the blind. The Council now maintains 8 blind schools (6 day and 2 residential) for 350 children. The Council also maintains 83 children at blind schools other than those under its own control. Fifty-three new children have been certified for the blind schools; of these 14 owe their state to ophthalmia neonatorum, 16 to congenital syphilis, 13 were blind or partially blind from congenital and lamellar cataract, the remaining 10 were suffering from a variety of congenital defects, and inflainmatorv conditions. Blind. There are now (January, 1915) six myope classes working in specially arranged premises. Mr. Bishop Harman points out the usefulness of the original curriculum. This falls into three parts: oral teaching, taken for the most part in the normal schools; literary work taken in the special classrooms; handicraft work, also carried out in the special rooms. For the oral teaching the children are taken over to the associate normal school and drafted into the classes corresponding to their attainments, where they sit in the front rows and engage in the ordinary work other than that involving reading or writing. Experience proves that these arrangements can be carried through regularly without interference with the proper working and discipline of the ordinary school and to the advantage of the children, who learn to regard themselves as definitely associated with their normal comrades. Myopes. Work involving reading or writing is given in the myope class by the use of blackboards, or of large printed sheets. Large sheets of white paper are hung up on the walls or blackboards of the room and printed, by the use of rubber-faced type of 2 in. and 1 in. square, with selected extracts from wellknown authors, and lessons in geography, history and the like. The printing of these sheets is liked and has become a prize task for the best of the elder children. Arithmetic is practised on blackboards, teachers and children working together on the wall blackboards and on individual boards. A great point is made of the development of mental arithmetic so as to facilitate the association of ideas of numbers in the mind without the adjuvant written figures, this is an added safeguard against the excessive use of the eyes in near work. The provision of suitable handicraft work is not a simple matter. The limitations necessarily introduced by the facts that the eyes must not be used for any length of time in the stooping posture and that the work must, not be such as to require close application or strained effort prevent the use of some of the most usual varieties of handwork. A scheme is under trial in which the children are classified in three groups, according to age and attainment. Group I., Standards 1 to 2. Ages 7 to 10.—(A) Bead work.—The stringing of large beads is one of the earliest pieces of work to be done, later simple designs are worked, and finally fancy blinds are made for windows. Besides the actual practice of the work there are the associated lessons in arithmetic. Children readily learn to thread the beads with very little examination by the eyes provided the beads are of sufficient size. (B) Paper folding, cutting and modelling.—In this work stiff paper is used ; the children are taught to fold it into certain lines, then to cut out various squares and finally to set up the remaining portion into the form of some common object. The folding and measuring is an aid to the teaching of arithmetic, so is the cutting, and finally the form attained forms the basis of an object lesson. A great number of simple articles are made in this fashion. Paper weaving, for the purpose of making small mats and book-marks, was formerly practised, but it has been stopped, since too much close attention was required of the eves and there was no expressional value in the work, Classification of myopes according to age and attainments. 142 Annual Report of the London County Council, 1914. (C) Modelling in clay and plasticine.—This is a favourite form of work with all children and is capable of unlimited expansion, both as a simple handicraft practice and in expressional work. Further, it is admirably adapted for the cultivation of the individual powers of the children. No eye strain is involved, for the mass of material with which the work is done is largo, there is no impulse to bring it close to the eyes, for the size of the detail is determined by the sight of the child, so stooping is not fostered. It is possible to associate with this work lessons in arithmetic and general history. (D) Toy-making.—With the aid of such simple materials as old match boxes, corks, sticks and wool, a large variety of toys are made. In this fashion the children are able to produce in a material of somewhat more stable a character the work of modelling. The toys are kept by the little ones and taken home, to the interest of the parents. Use is also made of the different forms of prepared wooden strips for the building up of toys, such as the interlocking building blocks. These are of value in dull and cold weather, with them models can be built up easily when the light is poor and hands are cold. (E) Drawing.—With all the foregoing work there is associated drawing on the blackboards, or on large paper sheets in chalks. All is done on a large scale, an ordinary drawing taking a space of 20 in. by 30 in., that is, the full range of the child's arm. No small scale drawing, such as is common in the ordinary school, is permitted. The children readily fall into the habit of drawing in this fashion, and the work is always done standing. The drawing is systematic with a view to the introduction of design, and is preparatory to some of the modelling tasks, and more especially introductory to the bent iron work of the succeeding standards. Free drawing on the boards is encouraged, and some of the children develop considerable skill in picture production. (F) Other handicrafts of purely utilitarian character such as knitting, and crochet work. The work here includes plain knitting, casting on and off, the making of dusters, kettle-holders, babies' hats, reins, whips, and rattles. Care is taken to foster the habit of working without looking at the work ; if a child shows no ability to do this then the work is stopped. String bag making is begun, also cane weaving, and raffia winding in the making of articles such as frames, mats, napkin rings, etc. Silk and linen fraying for the making of book markers was tried, but abandoned, for it required continual attention of the eyes in the selection of fine strands of material. Further it is said that the practice has fostered a tendency to destructiveness in the mentally defective. Group II.—Standards 3 to 6. Ages 10 to 13.—Following the order of work for the previous group marked A to E :— (A) Bead work is practically stopped, for its educational value is small. Some few girls, however, carry on with it for the making of Japanese window screens. The fine bead work for making bags, etc., is necessarily barred. (B) Paper work.—This gives place to cardboard modelling, in association with lessons in arithmetic, language, etc. Similar articles to those made in paper are now made in cardboard. (C) Modelling in clay and plasticine is continued for its expressional value in the teaching of history, geography, etc., and there is a beginning in the use of paper pulp for the production of permanent models. (D) Toy making.—Strip wood work, and simple carpentry is begun and developed. The work is of value in the practice of making objects, and also in association with the teaching of arithmetic. (E) Drawing.—The systematic design drawing expands into bent iron work. This is an excellent form of handicraft for the shortsighted. For the most part it can be done with the eyes looking right forward at the work. With a bench or table of a proper height for the child there is no necessity for stooping, such as is involved in the use of carpentry tools. For the further development of this work, particularly for the boys, more benches and tools will be needed, and the help of instructors of special and wider experience. The variety of this work done is as follows. Formation of C and S curves, joining by means of clamping, and by means of rivets, drilling, and fixing rivets. The elder children proceed to make such articles as watch stands, calendar stands, flower pot holders, letter and key racks, photograph easels, flower glass holders, double photograph frames, oval frames, fire screens. (F) Other handicrafts.—Knitting is continued. Lock knitting is applied to the making of hats, bonnets, muffs, necklets. Plain and purl in various patterns such as ribbing, imitation brioche, dice. Vests, scarves, tea cosies, and jerseys are made. String bag making is developed. Casting on, passing stitches over, counting rounds, taking work off from frame, casting off, making cords for handle, putting on rings, and fastening off ends is taught and practised. The work involves no eye strain in children who show a capability for it. They are not allowed to hold the work in their laps, it must be placed on the flat topped myope desk. Raffia work is continued in association with cardboard work. No raffia weaving or sewing is permitted, these are far too trying to the eyes. Book-binding of an elementary kind is begun. The children are taught to bind into folios the large printed sheets produced with the rubber faced types in class work. Mat making was tried, but stopped. It is a mechanical work of the dullest and most routine kind, and has no immediate or prospective value for children of this type. Group III.—Standard 7. Aged 13 and 14.—It is in this group that the greatest difficulty is found in providing a sufficiency of good handicraft such as can be done by highly myopic children. Carpentry would be ideal, w ere it not for the necessary stooping posture and the use of plan drawing and measuring which prohibits the work for these children in anything like a full development. Comparing their schedule with that of the former groups. (A) Bead work is stopped. (B) Paper folding work is developed on occupational lines, envelope folding, show card making, and box making are taught. To some extent arithmetic lessons can be introduced by calculating the cost of materials and time. (C) Modelling is practically confined to the use of paper pulp ; this has an education value in the teaching of Report of the County Medical Officer—Education. 143 geography, and a utilitarian side, as the elder children may be able to produce permanent models for the use of the younger children, and for the blind schools. (D) Toy making includes all the carpentry these children can undertake; many of them show considerable skill in the work. (E) Drawing and design are developed in the bent iron work. It is proposed to attempt repousse work, and tinsmithing. All these handicrafts for their fullest development will require special instructors and equipment. The advanced bent iron work, and the repousse work have disadvantages in the noise involved in the work, but this could be neglected if there were sufficient room for the separation of the children working at these crafts. Repousse work as ordinarily done would not be permissible for the highly myopic, since the flat bench and the continual stoop over the work would be injurious. It would however be quite practicable for the work to be done on wallbenches sloped at the angle of 30 degrees from the perpendicular, the benches would have a two or three inch ledge on which to support the work and tools, the children would work standing before the wall benches, in very much the attitude of the sculptor. Tinsmith work would provide an additional exercise for the cleverer boys, but, educationally, it is no more than a development of the cardboard modelling. (F) Knitting is continued by the girls. Bag making is stopped, but cane and basket work is continued. Raffia work is stopped since the full development is prohibited for these children. Book binding is developed. The girls learn domestic work and simple cookery. One of the best of the handicrafts for these older children is the printing, to which attention has been drawn. For value in the inculcation of thought, care, exactness, general neatness and cleanliness of work, it is scarcely to be bettered. The materials employed are simple, and the work can be varied to suit the ability of almost every grade of child. The only limitation is the one that confines the use of sticky black pigments to those who can keep themselves clean. In a former account of the myope classes some remark was made on the work of these children after school years. The necessary inquiries made by teachers and care committee members as to suitable occupations for leavers has resulted in the drawing up of lists of suitable occupations for boys and girls. It must be understood that this list relates to London conditions only. Two grades of work are shown, those most suitable and those of secondary suitability. Boys.—First selection.—Nursery gardening. Poultry farming. Messengers. Hawkers and street traders. Assurance agents. Travellers and canvassers. Rent collectors. Shopwork under good conditions. Piano-tuning. Second selection.—Stick and pipe mounting. Basket-making. Some branches of brush making, Girls.—First selection.—Florists' work. Waitresses in tea shops. Dairy shops. Under nursemaids (no sewing). Creche attendants. Helpers at mothers' schools. Helpers at special schools and dining centres. Light warehouse work (packing). Second selection.—Box making. Cork sorting. Envelope folding, cementing and black-bordering. Show-card mounting. Some branches of brush making. Stockroom work. The kinds of work placed in the first and most suitable selection are of the outdoor type, or those that enable the worker to be out and about, standing and moving, and with a minimum of close eye work. These kinds of work are doubly suitable, for the general health is likely to be the better for the freedom of movement enjoyed, and with the improvement in the general health the state of the eyes is likely to be benefitted. Next after these comes the second selection, all these are of light tasks, that do not unduly involve the use of the eyes, but they necessitate sitting and stooping to some extent and therefore are not so good for the body or the eyes. Looked at from the occupational point of view it is evident that the teaching of handicraft in the myope classes is not a direct preparation for life work, such as is understood for the handicrafts of a blind school, rather the work should be regarded as a convenient peg on which to hang general instruction ; the work itself is of value as a training in method and habits of precision,and as cultivating satisfactory habits in the use of the eyes. The work is of value also in that it tends to engage the minds of the children with the possibility of creating things, of fostering thought and observation, and to that extent withdrawing them from the fatal snare of living in a world of reading and book-thinking. The manual work is both a discipline and a distraction. Occupations for myopes. One concluding note should be made regarding the numbers that can be dealt with in these classes. Two circumstances combine to make a strict limit to the numbers any one teacher can deal with at one and the same time, viz.—(1) Only a certain number of these children can see the teacher's blackboard simultaneously. (2) Individual attention is particularly necessary with these children, if only to correct their ingrained habits of peering into their work. Numerous experiments show that twelve is the optimum number, and at the maximum a class should not exceed twenty children. Size of myope classes. The teeth of all children attending the Council's day schools for blind, myope, deaf and hard of hearing children, are examined and attended to by a dentist specially engaged for the purpose by the Council. The dentist visits each day school twice a year and the consent of the parents is obtained in all cases before the children receive treatment. Where accommodation permits, facilities for toothbrush drill are also provided. During the year the dentist made 1,980 examinations and treated 851 cases, but some of the children were treated more than once. Objections to inspection or treatment, or both, were received in 181 cases. In addition to this work the elentist also made 132 examinations in connection with children boarded out from industrial schools, and treated 62 cases. School buildings.—All plans of new buildings or proposed alterations are submitted to the school medical officer at an early stage. Reports are obtained from the assistant medical officers upon existing school buildings scheduled for remodelling or alterations in the various districts. The inspection consists in going over the school premises and inspecting the general arrangement (environment, playground, etc.), general condition of school (window and artificial lighting, heating, ventilation, sanitation, desks, seating, etc.), and any other matters coming under the medical officer's notice in so far Dental inspection and treatment of children in blind, myope deaf and hard of hearing classes. 144 Annual Report of the London County Council, 1914. as they affect the health of tcachers and children, and the physiological development of the latter. A concise report complete in every detail is forwarded to the School Medical Officer immediately after the inspection. Any details arising in course of the inspection that cannot conveniently be condensed are made the subject of a special report. These reports are returned from time to time for the purpose of recording additional notes as to the action taken to remedy defects reported. In addition, the assistant medical officers report all conditions prejudicial to the health of the children or the teachers which come under their notice during ordinary visits to the schools. Between January 1st and December 31st, 1914, 121 school buildings were inspected, and in 51 cases the attention of the Buildings Sub-Committee, or the Education Officer was drawn to certain defects in regard to lighting, ventilation, heating, drinking water, offices, etc. CHAPTER XXV. Public Health. Treatment of tuberculosis. One of the principal matters which engaged the attention of the Council during the year in connection with Public Health was the treatment of tuberculosis. In the last annual report of the Council particulars were given of various decisions at which the Council had arrived on points of principle in connection with the provision of tuberculosis treatment. These were co-ordinated in a general scheme which was approved by the Local Government Board. In accordance with the wishes of the Board the scheme was prepared on the basis that dispensary treatment should be provided by the City Corporation and metropolitan borough councils and that the Council should be responsible for residential treatment. The Council had already decided to accept financial responsibility only for the residential treatment of persons who are not insured under the National Insurance Acts. The treatment of insured persons was placed in the hands of the London Insurance Committee by the National Insurance Act, 1911, and to provide greater facilities to enable that Committee to discharge its obligations in this direction, the Council, under its powers under Section 39 of the National Insurance Act, 1913, gave its consent to direct arrangements being made by the Insurance Committee with the Metropolitan Asylums Board for the treatment of insured persons in the Board's institutions. Until the passing of the latter Act the Insurance Committee had been prohibited from having any direct dealings with the Board because of the latter's position as a Poor Law Authority. The Council, in formulating its scheme for the treatment of tuberculosis throughout the County, was animated by the desire to make the fullest possible use of the many agencies already available for treating the sick, and, in particular, so to frame the scheme as to ensure the co-operation of the great London hospitals. The object of the scheme was to link up existing agencies and others still to be created so that they would act as a complete whole, and to provide that the patient's progress might be adequately supervised from the time he first developed tuberculosis until the treatment applicable to his case had been completed, and even beyond this period by the provision of after-care. The Council desired to avoid the possibility of its funds being utilised simply to supersede those previously contributed through the medium of charitable organisations, and to expend the funds at its disposal, so far as possible, in encouraging the provision of fresh accommodation or in securing the keeping open of accommodation which was otherwise in danger of being withdrawn. It decided that it would not itself purchase, erect, or maintain institutions. The Council's scheme prescribes the machinery by which the comprehensive treatment of tuberculosis is to be secured. Dispensary treatment both for insured and uninsured persons will be provided by the local sanitary authorities, and towards this expenditure the Council will contribute, so far as uninsured persons are concerned, amounts not exceeding 50 per cent, of the cost which would otherwise fall on the funds of the local authority, after taking into account the Government grant of 50 per cent, of the total expenditure incurred. The conditions under which these grants will be given were set out in the last annual report* and are embodied in the scheme. Residential treatment for uninsured adults and for children will be provided by the Council, and for insured persons by the London Insurance Committee. In order to overcome the difficulty which the Council anticipated would arise from the fact that recommendations for provision of residential treatment would be received from a large number of medical men in various parts of the county who would quite conceivably be working to different standards, provision was made for the appointment of an advisory board consisting of representatives of hospitals, dispensaries and sanatoria. The principal functions of this Board arc to assist in securing some uniformity in standard in the selection of patients for the several kinds of residential treatment and to appoint, either from their own number or from outside, a rota of physicians to act as medical referees and to examine all cases referred to them by the county medical officer. The scheme provides that the cost of the appropriate treatment of insured persons shall be borne by insurance funds and that no part of such expenditure shall be defrayed out of the county rate. The cost of the residential treatment of uninsured persons in institutions other * Annual Report of the London County Council, 1913, Vol. III., pp. 226-227. Public Health. 145 than those of the Metropolitan Asylums Board will be borne by the Council, provided that in all cases in which a patient, or the person responsible for the patient, is in receipt of an income of £160 a year or over, and the circumstances of the case appear to justify it, a charge may be made for the treatment received. The Metropolitan Asylums Board has agreed to receive into its institutions and to treat at the cost of its own funds uninsured tuberculous patients sent by the Council. The Local Government Board in approving the Council's scheme expressed its regret that the Council had not agreed to undertake to provide the accommodation required for the needs of the whole population of the county, insured and uninsured. The Board also raised certain minor points with regard to the clauses relating to the payment by patients and the fees to be paid to medical referees. The Council proceeded to secure accommodation for the provision of residential treatment and estimated that 160 hospital beds, 240 beds in sanatoria and 150 beds for children would be required for the current year. These beds were, as far as possible, to be taken in existing accommodation which was not being utilised. At the same time the Metropolitan Asylums Board was asked whether it would place 100 existing beds at the Council's disposal and provide 150 beds as an initial provision in new sanatoria. Great difficulty was experienced in the first instance in obtaining any considerable amount of residential accommodation, and this difficulty was greatly accentuated after the outbreak of war. The number of applications, however, which were received for residential treatment fell below the number which had been anticipated, and, in spite of the scarcity of accommodation, the Council was able in the case of adults to keep pace with the demand, and in the case of children to keep the numbers on the waiting list from becoming considerable. The scheme did not contemplate the provision by the Council of accommodation for advanced and chronic cases. In this connection, the Council was advised that at the time of the approval of the scheme, there were in Poor Law Institutions in London about 2,300 tuberculous persons, most of whom were suffering from the disease in an advanced stage, and of whom about 86 per cent. were not insured under the National Insurance Act. It was obvious that if the Council were to make considerable provision for cases of the type referred to, a large number of persons who could receive or were receiving suitable treatment in infirmaries would be transferred to the new provision made by the Council and that no advantages would accrue, which would be in any way commensurate with the very considerable additional expenditure which would be thrown on the county rate. The Council therefore approached the Metropolitan Asylums Board with a view to ascertaining whether the Board were prepared to accept responsibility for such cases. The Board informed the Council that it proposed to consider the question in conference with the Local Government Board, as it was of opinion that some re-arrangement of accommodation should be possible which should prevent the need for providing new institutions. At the close of the year under review no decision had been arrived at. Several schemes for the provision of dispensary treatment were received during the year, and the Council approved those in respect of the metropolitan boroughs of Chelsea, Deptford, Fulham, Holborn, Kensington, Lambeth, Paddington, Poplar, St. Marylebone, Southwark and Wandsworth. During the year, the Council, under its powers conferred by Part 4 of the London County Council (General Powers) Act, 1907, continued to examine samples of milk forwarded to London from pieces outside the County. The number of samples taken was 2,925. Of these, examinations of 2,839 were completed, of which 224 were found to be tuberculous. 354 farms outside the county were visited and 10,109 cows were examined, of which 52 were found to be tuberculous. The owners of the defective animals undertook that the use, for human consumption, of the milk from the animals should be discontinued immediately. Tuberculous milk At the beginning of the year in review the Tuberculosis Order of 1913 was in force. This order provided for the notification to the Council, as local authority, of any cases in the County (exclusive of the City of London) in which any cow was or appeared to be suffering from any chronic disease of the udder or any bovine animal which was or appeared to be suffering from tuberculosis with emaciation. Provision was made under the Order for seizure and slaughter of animals so affected and for the payment of compensation to the owners of such animals. Under these powers, 19 animals were seized and slaughtered, and sums, amounting to £79 13s. 9d. were paid to the owners as compensation. On 1st July, 1914, however, this Order was superseded by the Tuberculosis Order of 1914, which varied the conditions under which animals were to be valued for compensation purposes and also varied to some extent the conditions under which an animal might be seized, but owing to the war the operation of this Order was suspended as from 6th August, 1914. During the period in which it was in operation four cows were seized and £28 15s. was paid as compensation to the owners. Tuberculosis in cows In 1904, 1905, 1907, and 1909 to 1913, inclusive, censuses were taken by the medical officer of homeless persons in the County of London in order to ascertain the use made of common lodging houses, and the provisions existing for the accommodation of persons 'of the poorest class. A further census was made on a night in February, 1914, and the medical officer submitted a report showing the number of persons found homeless on that night in the street, on staircases or under arches, the number and sex of persons who might reasonably be regarded as homeless on the ground of not being able to pay for a bed, the arrangements made for the shelter of persons of this description, and other information bearing on the question. The total number of homeless persons found was 540, as compared with 649 at the census of 1913. Following the practice adopted in previous years, the report was printed and placed on sale.* Census of homeless persons. During the year 295 licences were granted to keep and use, as common lodging-houses, 286 premises in the County of London, and 5 licensed keepers were fined £12, with £2 10s. costs, for having infringed the Council's by-laws. Common lodging houses, * Report by the Medical Officer, submitting the result of a census of homeless persons taken on ths night of 13th February, 1914. (No. 1671.) Price 2d. 27715 V 146 Annual Report of the London County Council, 1914. The appeal of the Council, against the magistrate's decision in the proceedings against the keeper of certain premises in Crescent-street, Kensington, for keeping common lodging houses without a licence, referred to in last year's report,* came on for hearing during the year. As a result the appeal was dismissed. Seamen's lodging houses, During the year 35 licences to keep seamen's lodging-houses were granted in respect of 34 premises. Legal proceedings were instituted against one person for keeping an unlicensed seamen's lodginghouse. A conviction followed, and a fine of £50, with £l 3s. costs, was imposed. Legal proceedings were also instituted against three licensed seamen's lodging house keepers for infringements of the by-laws, and fines amounting to £6, with £2 10s. costs, were imposed. Slaughterhouses, cowhouses and knackers' yards. The numbers of slaughterhouses, cowhouses and knackers yards licensed during the year were 211 slaughterhouses, 163 cowhouses, and 4 knackers' yards, the actual number of licences issued being 213, 164 and 4 respectively. Complaints. Various complaints were made to the Council under the Public Health (London) Act, 1891, as to insanitary conditions or failures in sanitary administration. The practice adopted is, in the case of signed complaints, to forward the complaint to the sanitary authority, and to take no further action unless the complainant appeals again to the Council. In the case of anonymous complaints the purport of the complaint is sent to the medical officer of the district, and, unless an intimation is received that action has been taken, an inspection is subsequently made, and, if then found necessary, a further communication is sent to the sanitarv authority concerned. Offensive businesses. In pursuance of the authority conferred upon the Council by section 19 of the Public Health (London) Act, 1891, the transfer of certain tripe-boiling premises in Pleasant-grove, Islington, to new occupiers was sanctioned, and the register of offensive businesses was amended accordingly. The Council on 3rd March, 1914, decided to institute legal proceedings against the Bermondsey Metropolitan Borough Council for the recovery of such of the expenses incurred in the prosecution of Freeland and Smiths, Limited, for establishing anew the business of a manure manufacturer at certain railway arches in Almond-road, Bermondsey, as had not been recovered from the company, the Council contending that it had taken action in default of the borough council. The summons came on for hearing at the Tower-bridge police court on 10th June, 1914, when the defendants admitted the facts, but contested the point that they were the authority under the Public Health (London) Act, 1891, to enforce the provisions of section 19 of the Act. The magistrate after reserving his decision delivered judgment dismissing the summons with £10 10s. costs, but agreed to state a case for the opinion of the High Court. As the question was of considerable importance, determining as it would whether it was the duty of the Council or the metropolitan borough council to enforce the provisions as to the establishment anew of offensive businesses in London, the Council gave authority for the necessary steps to be taken to appeal to the High Court. The appeal had not been decided at the close of the year under review. Businesses of fish curer and fried-fish vendor. By-laws relating to the businesses of a fried fish vendor and fish curer, respectively, made by the Council in 1913 under the powers conferred by Section 9 of the London County Council (General Powers) Act, 1908, received the approval of the Home Office on 24th March, 1914, and of the Local Government Board on 28th February, 1914, and are now, therefore, in force. With regard to the by-laws made by the Council on the same date with regard to the business of rag and bone dealer, certain points were raised by the Local Government Board which were still under consideration at the close of the year. Maternity and infant welfare. The Local Government Board on 30th July, 1914, issued a circular addressed to county councils and sanitary authorities in which attention was directed to the desirability of schemes being formulated with the view of securing improved conditions in respect of maternity and infant welfare. The Board stated that an estimate had been laid before Parliament for a grant to be distributed by the Board in aid of expenditure incurred by local authorities and voluntary agencies under such schemes. These grants would normally amount to one-half of the approved expenditure and the first would be in aid of expenditure incurred in the half-year ended 30th September, 1914. The Board at a later date directed attention to the fact that health visitors would be employed in connection with this maternity and infant welfare work, and the question was raised whether the portion of the salaries of such officers which would not be borne by the funds of local sanitary authorities in London should be met out of the Local Government Board's grant referred to above, or should be paid by the Council under the powers conferred upon it by section 6 of the London County Council (General Powers) Act, 1908. Sub-section 3 of the above-mentioned section empowers the Council to pay out of the county fund and charge to the Exchequer Contribution Account contributions towards the salaries of health visitors, not exceeding in the case of any such person one-half of her salary. Grants amounting to £111 were paid under this authority out of the exchequer contributions for the year 1909-10, and £1,328 out of those for 1913-14. No grants were paid in the intervening years, as in those years the exchequer contributions were insufficient to meet the grants under the Local Government Act, 1888, which, the Council is advised, take priority of the voluntary grants under the Act of 1908. The Council, while of opinion that the appointment by London local sanitary authorities of health visitors should be encouraged, realised that under the conditions obtaining these authorities were, for the reasons stated above, always in doubt whether a contribution towards the salaries of these officers would be paid by the Council, and, in these circumstances, came to the conclusion that contribtions towards the salaries of health visitors employed under schemes referred to in the Local Government Board's circular should be paid regularly out of national funds, rather than intermittently by the Council. This, decision does not, however, affect claims for contributions from the Council in respect of the salaries of health visitors for duties other than those included in the above-mentioned schemes. * Annual Report of the London County Council, 1913. Vol. III, p. 228. Public Health. 147 The order to carry out its duties of general supervision under the Midwives Act, 1902, the Council has appointed two women inspectors, who are duly qualified medical practitioners, to pay visits of inspection to midwives practising within the County, as well as to make special investigation into any case of puerperal fever occurring in the practice of a midwife, and to attend if possible any inquest held upon the body of a woman or infant in those cases in which a midwife had been in attendance. During the year 1914 there were 121 cases of puerperal fever in the practice of midwives, 126 inquests were held in which midwives were concerned, 18 being on the bodies of women, and 108 on the the bodies of children. 537 cases of inflammation of the eyes were investigated, and 225 cases of ophthalmia neonatorum occurring in the practice of midwives were notified. The Public Health (Ophthalmia Neonatorum) Regulations, 1914, issued by the Local Government Board which came into operation on 1st April, 1914, require midwives to notify cases of ophthalmia neonatorum occurring in their practice. In compliance with the regulations, 127 notifications of the disease were received by the metropolitan borough councils from midwives up to the end of the year. During the year ended 31st December, 1914, 556 midwives notified the Council of their intention of practising within the County during the year; in addition to these, 6 notices were received from persons who had acted as midwives on specific occasions-, and 18 notices were received from midwives who 3tated that they intended to practise within the County for specific periods shorter than a year. Five charges of malpractice, negligence or misconduct on the part of four midwives were investigated during the year, with the result that the Central Midwives Board was informed that three prima facie cases, two of negligence and misconduct, and one of misconduct, had been established. The charges in the two remaining cases were not sufficiently sustained to establish a prima facie case for reference to the Board and the midwives concerned were censured. The Board announced its decision with regard to the charges established in one of the three prima facie cases, to take no action in the matter, having found the charges not proved. Several cases of infringements of the rules of the Central Midwives Board were also reported during the year and the midwives concerned were censured or cautioned with regard to their conduct. It became necessary during the year 1914 to institute legal proceedings against four women for attending cases of childbirth without being certified under the Act. Convictions resulted in each case, fines amounting to a total of £3 5s., with £3 11s. 6d. costs, being inflicted. The accounts of the Central Midwives Board showed an adverse balance for the year 1913, and the Council was called upon in 1914 to pay, under section 5 of the Act, a sum of £109 2s. 8d. as its proportion of this deficit. Midwives. During the year the Council introduced into its General Powers Bill clauses to give effect to its views with regard to the licensing of lying-in homes, reference to which was made in last year's report.* These clauses had been passed by a Select Committee of the House of Commons, but the outbreak of war and other circumstances prevented any facilities for a debate in the House of Commons being obtained, and the clauses in common with the rest of the Bill were suspended until the next session of Parliament. Lying-in homes. CHAPTER XXVI. MAIN DRAINAGE. The area drained by the metropolitan main drainage system is approximately 149 square miles, including 32 square miles outside the county boundary, and the population of the whole area in 1911 was about 5,334,731. During the year, the quantities of sewage, etc., treated and disposed of were as follows:— Northern outfall. Gallons. Southern outfall. Gallons. Total. Gallons. Sewage treated 59,752,096,000 43,524,804,600 103,277,900,600 Sewage, daily average 163,707,112 Tons. 119,246,040 Tons. 282,953,152 Tons. Sludge sent to sea 1,665,000 1,036,000 2,701,000 Sludge, weekly average 32,019 19,923 51,942 Refuse intercepted at gratings .. 2,724 2,672 5,396 The quantities of chemicals used in precipitation were as follows:— - Tons. Tons. Tons. Lime used 10,611 9,636 20,247 Proto-sulphate of iron used 2,243 2,715 4,958 From the above figures it will be seen that at the Northern outfall one ton of sludge was extracted from an average of 35,889 gallons of sewage treated; or 3 59 per cent, more than in the previous year. At the Southern outfall the average quantity of sewage treated to produce one ton of sludge was 42,012 gallons, which is 131 per cent. less than in the preceding year. The total quantity of sewage treated is shown as about 0.73 per cent. less than in the preceding year. The quantity of sludge sent to sea was, however, 2.74 per cent. more than in 1913. The six sludge vessels made 2,701 trips to the deposit area, the distance travelled being 286,896 miles. * Annual Report of the London County Council, 1913. Vol. III, p. 230. 27715 u 2 148 Annual Report' of the London County Council, 1914. Treatment of sewage. The treatment of sewage without the use of chemicals during the winter months, which was tried for four months beginning in December, 1913, was continued for a similar period from December, 1914. The use of the one acre coke bed at the Northern outfall, which had been in operation for several years, was discontinued during the year. The capacity of the bed had decreased to a very small proportion of the original, and no further results of a useful character could be obtained from its continuance. Certain of the Council's officers inspected the experimental work in connection with the biological treatment of sewage at the Manchester and Salford sewage works, and experiments in this method of treatment are now being undertaken with a view to ascertaining whether this system is applicable to the treatment of London sewage. The special examination of the water of the river Thames, which was undertaken during June, July, and August, 1913, was continued, but in this instance for twelve months, so as to cover all seasons of the year. The work began in July, 1914. Main drainage works in the River Thames The question of the Council's position in connection with the construction of certain main drainage works in and adjoining the river Thames had for some time past been in dispute between the Port of London Authority and the Council. Plans of certain proposed works had been forwarded to the Port Authority for approval under section 28 of the Metropolis Management (Amendment) Act, 1858, but the Port Authority claimed that the powers conferred by this Act were exhausted, and that the Council's application should be dealt with under the Thames Conservancy Act, 1894. The Port Authority expressed its willingness to grant a licence for the works under certain conditions, to some of which the Council could not agree, and proceedings were instituted in the High Court to test the rights of the Council and of the Port Authority in the matter. Judgment was given to the effect that the Council is entitled by virtue of the Metropolis Management Act, 1855, and the Metropolis Management (Amendment) Act, 1858, to construct works in, over or under the river Thames, and that the Port Authority is bound to consider, pursuant to section 28 of the Act of 1858, the plans submitted by the Council, and, if of opinion that the works or any of them will not interfere with the navigation of the river Thames, to approve the plans and give a certificate accordingly. Further, that in respect of any works, the plans for which may be approved and a certificate given, the Council is not bound to obtain any further licence of the Port Authority. Northeastern storm relief sewer. One of the questions at issue with the Port of London Authority was that of the construction of an outlet at Shadwell for the proposed north-eastern storm relief sewer. As the result of the judgment above referred to, plans of this portion of the sewer have been submitted to and approved by the Port Authority. The work of constructing the sewer has, however, been postponed on account of the war. Wandle Valley sewer. The construction, at an estimated cost of £100,000, of the Wandle Valley sewer, which has been designed to relieve floodings in certain districts in Wandsworth, has also been postponed on account of the war. Ventilation of sewers. For a number of years the Greenwich Metropolitan Borough Council has complained of emanations from the Council's sewers in the borough and much correspondence has taken place between the Council and the Borough Council on the subject. The length of main sewers in Greenwich is approximately 12 miles, and provision for ventilation was made at 99 points, nearly all in the highway. Owing to complaints, 61 of these surface ventilators had been closed, 30 had been sealed and connected to ventilating columns, or stack pipes, and 8 only, including 2 at penstock houses belonging to the Council, remained open. Notwithstanding the Council's efforts, the Borough Council persisted in its demands for the closing of surface ventilators. It was then suggested to the Borough Council that, if it would provide convenient sites, the Council would erect ventilating columns. It was intended that these sites should be on the highways, as owing to the size of the sewers in Greenwich, which comprise some of the largest in London, the ventilation pipes, if provided, would require to be of the most ample dimensions, and to be erected in the most favourable positions. The Borough Council, however, refused to provide sites on the highways on the ground of alleged serious obstruction and inconvenience to the public, and suggested positions for the erection of stack pipes against the walls of houses which were unsuitable for the purpose. Ultimately the Borough Council appealed to the Secretary of State for the Home Department, and asked him to inquire into the alleged failure of the Council to comply with its statutory obligations, and he referred the matter to the Council for its observations. The problem of sewer ventilation has proved to be one of extraordinary difficulty and at present there is no scheme which can be considered satisfactory from all points of view. The Council, therefore, decided that there could be no departure from the existing practice of considering each case of complaint upon its merits, and, if possible, to remedy the defect, and this view was conveyed to the Secretary of State. The Main Drainage Committee subsequently met the representatives of the Borough Council with a view to arriving, if possible, at an agreement in the matter. It was then suggested, on behalf of the Borough Council that a ventilating pipe should be erected at the fire station in Tunnel-avenue, and one at Rainton-road, and the work has been put in hand. Floodings. Many complaints have been received of flooding of houses in various districts of London during times of heavy rainfall. In many cases the flooding could be prevented or remedied, and the Council resolved to make application to Parliament in the session of 1915 for an amendment of the existing law in order to provide that the drains of premises shall be constructed so as to prevent flooding when the main sewer, into which the local sewer draining the said premises discharges, is running full or partly so. At the same time, the Council resolved to apply to Parliament for authority to require alterations to the drainage of existing premises liable to flooding, or, if necessary, to fill in the basements of such premises, subject to the payment by the Council of suitable compensation, and for power to enable local authorities to contribute in cases in which flooding may be due, wholly or in part, to the insufficiency of the local sewers. Main Drainage. 149 The extension of the pumping station at Crossness is proceeding. A new engine house to accommodate eight steam engines, and centrifugal pumps, is nearing completion, the contract amount being £63,690. Only one half the machinery will, in the first instance, be installed at an estimated cost of £30,000. Southern outfall. The question of the coal supply at the outfall has received careful attention. It is essential that there should be ample stocks at the main drainage stations to guard against all possible emergencies. Large stocks of coal have been stored at the Southern outfall, in the open, and the Council has decided to erect overhead coal bunkers with a storage capacity of 4,000 tons. The bunkers will be constructed of reinforced concrete, and the estimated cost of the work, including the erection of a gantry and the provision of a crane, amounts to £12,500. A contract amounting to £745 has been entered into with Messrs. Thomas Smith and Sons, Rodley, for the supply of the crane. The Council has decided to enlarge North Woolwich pumping station, and to construct a new 24 in. main from the station to the Northern outfall. The estimated cost of the work, amounts to £51,000. The tender of G. E. Everitt and Sons, Ltd., amounting to £11,615, has been accepted for the erection of the new engine house, etc. The re-arrangement of the existing piping and the provision of some new steam and other piping which must be done without interfering with the running of the station, is being carried out bv direct employment of labour at an estimated cost of £1,000. North Woolwich pumping station. In connection with the construction of the new dock, the Port of London Authority w ill divert the two existing 14 in. mains at North Woolwich between Woolwich Manoiway and the entrance to the Royal Albert Dock. Opportunity has been taken to arrange for the Pert Authoiity to lay at the same time the portion of the proposed new main between these points, at an estimated cost of £5,400. In connection with the proposed enlargement of the Isle of Dogs pumping station, the Council accepted the tender of the Premier Gas Engine Company, Ltd., amounting to £6,584, for the supply, delivery and erection of two gas engines. The total estimated cost of the enlargement of the pumping station amounts to £32,850. Isle of Dogs pumping station. The s.s. Bazalgette, the oldest of the sludge vessels, has been running for about 27 years. The condition of the machinery has become so defective that new machinery, including boilers, must shortly be installed, while the hull of the vessel also requires extensive repairs. The total estimated cost of the work amounts to £10,500. Sludge vessels. Section 69 of the Metropolis Management Act, 1855, provides that no new local sewer shall be made without the previous approval of the Council, and during the year sanction was given for the construction or reconstruction of 55,494 feet, or about 10£ miles of sewrers of various sizes. Local sewers. CHAPTER XXVII. HOUSING OF THE WORKING CLASSES. The powers of the Council with respect to the housing of the working-classes are derived from the Housing of the Working Classes Acts, 1890 to 1909, and questions relating thereto are considered by the Housing of the Working Classes Committee. Powers and duties of the Council. The Council is at present carrying out a large slum clearance scheme under Part I. of the Act of 1890, known as the Tabard-street, Grotto-place and Crosby-row (Southwark and Bermondsey) Scheme 1910, which deals with three distinct areas comprising altogether about 17 acres. The scheme involves the displacement of 4,552 persons of the working classes, and rehousing accommodation has to be provided on the Tabard-street area for not fewer than 2,580 persons. Progress has been made during the year with the acquisition of the various interests in the properties required for the scheme. Terms have been arranged with the vendors in all cases in which it has been possible to effect a settlement by agreement and an arbitrator has been appointed by the Local Government Board to settle the amount of the compensation to be paid by the Council in the disputed cases. During the year under review one additional house, No. 8, Little Hunter-street, was, with the approval of the Local Government Board, included in the scheme. A piece of land, 2,655 square feet in extent, was also added to the Grotto-place area for the purpose of constructing a new road so as to provide direct communication with a road about to be constructed by the Ecclesiastical Commissioners on adjoining land. The provision of the through communication being primarily of local importance, the Southwark Metropolitan Borough Council agreed to defray the cost of paving and sewering the additional piece of road. In connection with the scheme the Council has acquired three fully licensed public houses and one beer house. The Council has decided to retain none of the licences. The first section of the Tabard-street area has been cleared and a new road, 40 feet wide, constructed from Tabard-street to Long-lane. The provision of new dwellings on the cleared site was delayed by the difficulty experienced in designing a building which could be erected at such a cost as would enable the Council to comply with its financial regulations. Progress was further arrested by conflicts in the building trade, but tenders were eventually obtained and were under consideration at the end of the year. The new dwellings are designed to accommodate 620 persons in 310 rooms (exclusive of sculleries) and the cost of the building work, including all incidentals is estimated at £28,582. The valuer's estimate of the housing value of the site is £4,700. Tabardstreet, etc., scheme. 150 Annual Report oj the London County Council, 1914. Brady-street area. During the year correspondence passed between the Council and the Local Government Board as to the manner of dealing with the Brady-street area, Bethnal Green, which had been represented by the medical officer of health of the district as an unhealthy area under Part I. of the Housing of the Working Classes Act, 1890. The matter was still under consideration at the end of the year. High-street, Woolwich, area. On 16th January, 1914, an official representation under Part I. of the Act of 1890, was made by the medical officer of health of Woolwich with regard to an area in High-street, Woolwich, about half an acre in extent, consisting of an island block and a few other houses. Some of the houses were old and showed signs of decay, in some cases the lighting and ventilation were defective and some of the basement rooms were damp. There was nothing, however, in the arrangement or the condition of the area generally which, in the Council's opinion, would justify the making of an improvement or reconstruction scheme under Part I. or Part II. of the Act, and the Council decided therefore to take no action upon the representation. It appeared to the Council that the proper course was for the borough council to deal with the houses in the area by means of closing and demolition orders, and by the service of sanitary notices under the Public Health or Housing Acts. Capital expenditure on clearance. The amount expended on capital account by the late Metropolitan Board of Works and the Council up to 31st March, 1915, in respect of the clearance of insanitary areas (exclusive of the cost of erecting new buildings), amounted to £3,571,319,. while the receipts derived from rents and sales of land, including the amounts charged against the accounts of the dwellings for the housing values of sites appropriated for that purpose, together with the contributions from local authorities towards the cost of carrying out Part II. schemes, amounted to £906,740 thus leaving the net expenditure at £2,664,579. The capital expenditure during the year 1914-15 amounted to £101,417, and was almost wholly for the new Tabard-street, etc., scheme. Displacement of persons of the working classes. The displacement of persons of the working classes by the Council does not always involve the provision of rehousing accommodation, and, in several cases the Local Government Board has, in the exercise of its powers under the Housing of the Working Classes Act, 1903, dispensed with the necessity for a special housing scheme. During the year the Local Government Board released the Council from rehousing obligations as regards 3,230 persons of the working classes to be displaced from properties proposed to be acquired under compulsory powers for purposes of the education service. The Council also decided during the year that special rehousing schemes were not necessary in respect of the displacement of 259 persona involved in the demolition of certain other properties for similar purposes, there being no statutory obligation to rehouse these people. Development of estates, The Council has proceeded during the year with the development of the suburban cottage estates which it has acquired under Part III. of the Housing of the Working Classes Act, 1890. Roads have been constructed on a further portion of the White Hart Lane estate, Tottenham, the amount of the contract being £2,149 8s. 8d. On the site 79 cottages have been erected, the total expenditure involved including all incidentals amounting to approximately £19,500. A11 estate office with a residence for the superintendent in addition to a workshop and stores has been provided on the estate at an estimated cost of £1,615. On 7th July, 1914, the Council agreed to a proposal to exchange a portion of land about 5¾ acres in extent, forming part of the southern portion of the estate, in consideration for two plots of land comprising about 4¼ acres, adjoining the northern (detached) portion of the estate, and a money payment of £1,800. The transaction has been carried out by means of mutual sales, the Council receiving £2,900 for the 5¾ acres and paying £1,100 for the 4¼ acres. A scheme has been prepared under Part III. of the London County Council (General Powers) Act, 1912, for the laying out and development of part of the White Hart-lane estate on the lines of a garden suburb. The scheme provides that the Council may erect and maintain workmen's cottages on 64 acres, and may sell or let on lease 48 acres for the purpose of the erection of houses of a better class. It is proposed to reserve to the Council in connection with any such sale or lease the right to impose conditions and restrictions as to the elevation, size and design of the houses to be erected. Five plots of land are reserved as sites for public buildings and the scheme provides that the Council may sell or let on lease any such plots accordingly as it may think fit. The scheme provides for a number of small open spaces to be maintained by the Council as recreation grounds with facilities for games, etc. The estate is situated in the urban districts of Tottenham and Wood-green, and the by-laws of the two local authorities differ in some respects from each other. The requirements of some of these by-laws are, in the Council's opinion, unduly restrictive in their application to an estate such as this, the effect being to increase unnecessarily the cost of the roads and the building work. The scheme accordingly provides for the by-laws in the respective districts to be relaxed, varied or modified in certain particulars. The scheme has been submitted for the approval of the Local Government Board as required by the Act and the Board still has the matter under consideration. On the Norbury-estate, the erection of 26 further cottages was undertaken during the year. The estimated cost of the work, including incidental expenses, is estimated at £6,854. The construction of roads and sewers on the eastern section of the Old Oak estate was further proceeded with. The work of finishing roads and paving footways on the western section was undertaken by the Hammersmith Metropolitan Borough Council on the basis of actual cost, estimated by the borough council at £3,200. The portion of Ducane-road from Wood-lane to the eastern end of Wormwood-scrubs prison leading to the estate has been made up and taken over by the borough council as a new street, the cost of the work being apportioned amongst the frontagers. As, however, the road will be subject to exceptional traffic in connection with the development of the estate, the Council has Housing of the Working Classes. 151 undertaken to pay to the borough council at the rate of £155 a year in respect of the additional expenditure which will be incurred in maintaining the road while it is being used by the Council or its contractors for the cartage of heavy building materials. A plot of land on the estate about l½ acres in area adjoining Wormwood-scrubs has been allocated for the erection of a permanent school building in place of the temporary structure now in use. Cottages capable of accommodating 191 persons were completed during the year 1914 at an approximate cost for buildings and plans of £7,701. The erection of new cottages designed to accommodate 785 persons and other works incidental to the development of the various estates were undertaken during the year, and the total cost thereof is estimated at £33,641. Dwellings provided by the Council. The Council's dwellings on 31st December, 1914, contained accommodation for 57,387 persons, reckoned on the basis of two persons a room. The total expenditure on capital account on the Council s working-class dwellings and estates up to 31st March, 1915, amounted to £3,056,646. This sum represents the actual expenditure incurred up to that date, and does not include liabilities under contracts for buildings in course of erection. The capital expenditure during the year 1914-15 amounted to £34,733. The financial results of the dwellings are shown in the memorandum by the Comptroller of the Council on the accounts for 1914-15 (Chapter XXVIII). At the request of the Local Government Board the Council arranged for Carrington House, Deptford, to be taken over on 17th October, 1914, for the accommodation of Belgian war refugees, upon the understanding that there should be no profit or loss to the Council. The Board withdrew the refugees from the house on 7th November, 1914, there then being no lack of other accommodation for them. The house being empty the Council arranged, at the request of the military authorities, for the reception of several companies of National reservists who remained in occupation for three weeks, the catering being carried on by the Council. The total payment made by the War Department in respect of the accommodation and food amounted to £1,248 11s. 7½d., from which an allowance of £14 was made in consideration of the assistance given by the soldiers in preparing food and in other directions. The Local Government Board having intimated that it did not desire to re-enter into occupation, the house was opened for the reception of lodgers on 12th December, 1914. Carrington House. Portions of the yards at Boundary-street estate, Bethnal-green, and Herbrand-street dwellings, St. Pancras, have been allocated for use as ambulance stations. Boundarystreet and Herbrand- street estates. With a view to the Council being kept informed as to the provision of working-class accommodation in London and the adjoining districts, a return* is prepared each year showing the amount of new accommodation provided and old accommodation destroyed. The return, which has been prepared for the years 1902 to 1913 inclusive, gives the number of working-class tenements and rooms provided in each borough or district and the rents at which they are let or to be let, and also particulars of the demolitions which have taken place in each district during the year. The return for 1913 shows that the amount of working-class accommodation in the county of London has remained practically stationary for the year. In extra-London, i.e., the area known as Greater London exclusive of the county of London, the number of rooms provided was 11,933 and the number demolished 983, or a net addition of 10,950. The average weekly rents at which the new dwellings were let or to be be let were, during 1913, 3s. 6d. a room in the central districts of London, 2s. 8d. in the outer districts of London and 2s. 3d. in the extra-London districts. New working-class accommodation. A revised account of the Council's housing work up to 31st December, 1912, has been published.‡ History of housing question, CHAPTER XXVIII. ACCOUNTS AND STATISTICS. Working Clas Dwellings Accounts, 1914-15—Memorandum by the Comptroller of the Council, (Mr. H. E. Haward). The following are the results of the year 1914-15, after interest and sinking fund charges have been met. The results for the year 1918-14 are also given for the purpose of comparison. ]1914-15 1913-14 Dwellings— £ s. d. £ s. d. Housing of the Working Classes Act, 1890 Surplus 12,683 6 1 14,176 - 5 Improvement Acts Surplus 3,805 11 6 4,133 9 - Surplus on dwellings 16,488 17 7 18,309 9 5 Estates in Course of Development Deficiency Less—In respect of the utilisation of the £4,411 14 6 4,292 11 2 Acquisition of Lands Fund ... 2,315 13 - 1,860 6 3 2,096 1 6 2,432 4 11 Net surplus on all dwellings and estates 14,392 16 1 15,877 4 6 Summary of results of year. * New working -class accommodation. ‡ Housing of the Working Classes in London, 1855-1912. 152 Annual Report of the London County Council, 1014. The decrease in the surplus as compared with 1913-14 is due chiefly to the increase in rates and to allowances to officers and employees serving with H.M. Forces. The latter amounted during the year to £861 18s. 6d. The decrease is to some extent counterbalanced by improved lettings generally during the year, the decrease in the loss due to empty tenements being £1,373. Housing of the Working Classes Act, 1890. The Council's operations under the Housing Act comprise (a) dwellings erected under Parts I. and II. of the Act to provide rehousing accommodation for persons displaced by schemes for the clearance of insanitary areas, and (b) dwellings erected under Part III. of the Act to provide accommodation for persons of the working classes, apart frcm any displacements. Dwellings erected under Parts I. and II. represent, therefore, compulsory provision for rehousing under statutory obligations, whereas dwellings under Part III. represent housing accommodation voluntarily provided by the Council. In certain instances of compulsory rehousing it has been necessary to erect dwellings on sites, on the working of which, owing to their character or situation, unfavourable financial results were anticipated from the first. The account under Part III. is sub-divided to show the results of the dwellings apart from the debt charges on estates in course of development, which are referred to in a subsequent paragraph. Results of year. The results of the year's working under the Housing of the Working Classes Act, 1890, are as follows:— £ s. d. Fart I. Surplus 7,066 18 6 „ II Surplus 484 1 0 „ III.—Dwellings Surplus 5,132 - 1 Surplus on dwellings 12,683 6 1 Part III.—Estates in course of development Deficiency 2,096 1 6 Net Surplus for Housing Act 10,587 4 7 The surplus on dwellings under Part III. is after allowing for a deficiency of £1,095 15s. 10d. in respect of Carrington House, a lodging-house erected under Part III. but in fulfilment of rehousing obligations in connection with the Mill-lane, Deptford, scheme under Part II. These premises were requisitioned by H.M. Government for accommodating National Reservists, payment being made at the usual billeting rates. The somewhat more favourable result of the working of the lodging-house as compared with the previous year is due in a measure to this cause. The premises were also placed for a short time at the disposal of the Local Government Board for the purpose of housing Belgian refugees, upon terms which provided that the Council should not be placed in a better financial position by reason of such occupation than if the building had continued to be used for the reception of lodgers. Income. The gross rental for the year from dwellings under the Housing Act was £175,603 15s. including £2,121 18s. 9d. in respect of the occupation of Carrington House by the War office and the Local Government Board. In calculating the percentages subsequently quoted this amount has been eliminated. Deducting allowances for empties, caretakers' quarters and amounts irrecoverable, the net rental amounted to £169,469 0s. 11d., exclusive of £542 6s. 11d. for interest on cash balances. The amount of rent irrecoverable was £312 10s. 10d., or only 0.18 per cent. of the gross rental. The total loss of income due to " empties " was £4,662 18s. 1d., or 2.69 per cent. of the gross rental, as against 3.38 per cent. in 1913-14. Of this loss £2,497 (or 38.57 per cent. of gross rental) occurred at Carrington House. The only other case in which the loss exceeded 10 per cent. was Chadworth Buildings (10'72 per cent.), and this was chiefly due to vacant shops. Expenditure. The total expenditure on dwellings was £156,679. 1913-14. Per cent, of gross rental. 1914-15. Per cent. of gross rental. £ Working Expenses— £ 11,014 6.44 Supervision and collection of rent 11,367 6.35 29,882 17.49 Rates and taxes (less tax on interest on debt recovered) 32,413 18.65 8,844 5.18 Lighting, heating, water and insurance 8,781 5.04 207 0.12 Stores and incidentals 994 0.15 17,686 10.35 Repairs and renewals (transfers to fund) 18,136 10.42 67,633 39.58 71,691 40.61 Debt Charges— Interest (gross) Land £12,161 Buildings 57,638 68,045 39.82 69,799 40.14 Sinking Fund— Land 2,619 Buildings 12,570 14,712 8.61 15,189 8.74 150.390 88.01 Total Expenditure 156,679 89.49 7,065 4.14 Net deductions from gross rental (empties, etc.) 6,135 3.54 13,411 7.85 Surplus on dwellings (excluding interest on cash balances and war service allowances) 12,790 6.97 170,866 100.00 Gross rental 175,604 100.00 Housing Accounts and Statistics. 153 The repairs and renewals fund has been established with the view of equalising the charges against revenue under this head between one year and another, as the expenditure in future years will naturally be larger than at present, when many of the buildings are new. The sums charged to revenue account and carried to this fund are based on the estimated cost of all repairs and renewals during the loan period, after deducting interest earned on the accumulations of the fund. The credits to this fund during the year exceeded the expenditure thereout by £2,864 13s. 3d. The amount standing to the credit of the fund on 31st March, 1915, was £46,866 1s. 4d.. of which £43,834 5s. 10d. was invested. Repairs and renewals fund. The charge on the rates in respect of the deficiency under this head for the year 1914-15 was £2,096 1s. 6d., after deducting £2,315 13s. in respect of debt charges on the capital expenditure met out of the special fund for the acquisition of lands under Part III., referred to in a following paragraph. The aggregate amount raised in the rates to 31st March. 1915, is £82,783 8s. 7d. This amount includes the annual instalments of sinking fund to redeem debt. The amount raised in the rates has now been repaid to a considerable extent from the surplus on the completed dwellings Estates in course of development. The Council purchased Millbank Prison site under Part III. of the Act, and when the Council decided, with the sanction of the Home Secretary, to utilise a portion of this land for the purpose of rehousing persons displaced in connection with the Thames Embankment Extension and Improvements at Westminster, carried out under the London County Council (Improvements) Act, 1900, it was arranged that the Westminster Improvement Account should be charged, and the Part III. Account credited with a sum of £50,000, which has, under the statute, to be applied towards " the cost of the acquisition by the Council of other lands for the purposes of Part III. of the Housing of the Working Classes Act, 1890." After defraying certain expenditure on the Millbank site account, the fund amounted, with interest, to £55,324 4s. 9d. In accordance with the powers conferred by the London County Council (General Powers) Act, 1908, the Council decided to utilise these moneys in connection with the development of the Old Oak estate. The whole fund has been so utilised. The sum of £2,315 13s. being an amount equivalent to the debt charges for the year 1914-15 on the expenditure met out of the moneys of the Fund has, in accordance with the Council's decision, been taken in reduction of the amount raised in the rate in respect of the development of estates under Part III. Special fund for the acquisition of lands under Part HI. of the Housing of the Working Classes Act, 1890. The capital expenditure during the year 1914-15 amounted to £34,732 16s. 2d. and the total expenditure on capital account on the dwellings and estates to 31st March, 1915, was £2,313,107 12s. 9d. Capital expenditure and debt on dwellings and estates. With regard to dwellings erected to rehouse persons displaced by clearance schemes under Parts I. and II. of the Act, the Council's practice is to charge the capital account of the dwellings with the value of the site as earmarked for housing purposes, the account of the clearance scheme being credited with this value. The latter account, which is charged with the cost of clearance and laying out (less sales), is thus placed in the same position as it would have been if the Council had disposed of the land for the erection of dwellings. In the case of dwellings erected under Part III. of the Act the total cost of the land and of its development for building is chargeable against the dwellings. As regards sites sold to Dwellings Companies, the aggregate commercial value at the time of disposal is estimated at £472,100, and the aggregate housing value as represented by cash received from Dwellings Companies is £198,915 the difference of £273,185 being charged against the clearance schemes. The aggregate commercial value on the same basis of sites acquired or appropriated by the Council is estimated at £465,804, and the housing value charged to dwellings accounts at £163,361, the difference of £302,443 being charged against the clearance schemes. The net capital expenditure to 31st March, 1915, under Parts I. and II. of the Housing of the Working Classes Act, 1890, for clearance schemes, amounted to £2,664,578 15s. 9d. The capita! expenditure during the year 1914-15, amounted to £101,417 3s. 10d., and was almost wholly in respect of the new Tabard-street, etc., scheme. Capital expenditure on clearance schemes. Dwellings under Improvement Acts. These dwellings were erected in pursuance of statutory obligations to provide rehousing accommodation for persons displaced by improvements, etc., under various Acts of Parliament. Certain dwellings were erected on sites on the working of which, owing to their character or situation, unfavourable financial results were anticipated from the first. The result of the year's working of Dwellings under Improvement Acts is a net surplus of £3.805 11s. 6d., as compared with £4.133 9s. in 1913-14. Results of year. The gross rental for the year from dwellings was £56,553 14s. 5d. Deducting therefrom allowances for empties, caretakers' quarters, and amounts irrecoverable, the net rental amounted to £54,609 2s. 3d., exclusive of £175 13s. 4d. for interest on cash balances. The amount of rent irrecoverable was £72 17s. 9d., or only 013 per cent. of the gross rental. The total loss of income due to "empties" was £1,289 11s. 4d., or 2.28 per cent. of the gross rental, as against 2.77 per cent. in 1913-14. In no case did the loss reach 10 per cent. in 1914-15. 27715 x Incomc. 154 Annual Report of the London County Council, 1914 Expenditure. The total expenditure on dwellings was £50,767. 1918-14. Per cent. of gross rental. 1914-15 Per cent. of gross rental £ Working Expenses— £ 4,594 8.17 Supervision and collection of rent 4,756 8.41 9,096 16.18 Rates and taxes (less tax on interest on debt recovered) 9,602 16.98 2,582 4.59 Lighting, heating, water and insurance 2,586 4.57 102 0.18 Stores and incidentals 82 015 5,286 9.40 Repairs and renewals (transfers to fund) 5,300 9.37 21,660 38.52 22,326 39.48 Debt Charges— Interest (gross)— Land £3,332 Buildings 19,904 23,314 41.46 23,236 4109 Sinking Fund— Land 719 Buildings 4,486 5,207 9.26 5,205 9.20 50,181 89.24 Total Expenditure 50,767 89.77 2,167 3.85 Net deductions from gross rental (empties, etc.) 1,945 3.44 3,886 6.91 Surplus on dwellings (excluding interest on cash balances and war service allowances) 3,842 6.79 56,234 100.00 56,554 100.00 Repairs and renewals fund. The amount standing to the credit of this fund on 31st March, 1915, was £20,161 15s. lid., of which £19,103 4s. 2d. was invested. The credits to this fund during the year exceeded the expenditure thereout by £157 1s. 2d. Capital Expenditure and debt on dwellings. No capital expenditure was incurred during the year 1914—15, and the total expenditure on capital account to 31st March, 1915, in respect of Dwellings under Improvement Acts remains at £743,538 2s. 4d. The practice with regard to charging to the capital account of the dwellings the value of the site is the same as for dwellings erected to rehouse persons displaced by clearance schemes under Parts I. and II. of the Housing Act. As regards sites sold to Dwellings Companies, the aggregate commercial value at the time of disposal is estimated at £255,435, and the aggregate housing value as mainly represented by cash received from Dwellings Companies is £131,007, the difference of £124,428 being charged against the accounts of the improvements. The aggregate commercial value on the same basis of sites acquired or appropriated by the Council is estimated at £416,277, and the housing value charged to dwellings accounts at £108,213, the difference of £308,064 being charged against the accounts of the improvements. Financial Results of all Dwellings and Estates to 31st March, 1915. The total financial results on all dwellings and estates from April, 1394 (the date of the opening of the first block) to the 31st March, 1915, apart from contributions from or to rates, are as follows— Dwellings— Housing of the Working Classes Act, 1890— £ s. d. Part I. surplus 54,882 19 3 Part II surplus 4,429 6 6 Part III. deficiency 15,619 19 2 surplus 43,692 6 6 Estates in course of development deficiency 82,783 8 7 Total under Housing Act deficiency 39,091 2 1 Dwellings— Improvement Acts surplus 19,686 6 10 Net aggregate deficiency 19,404 15 3 Contributions from Tramways Account 1,251 7 1 Net contributions from Rates 18,153 8 2 £19,404 15 3 (The net aggregate deficiency at 31st March, 1914, was £33,797 11s. 4d.) These results are arrived at after (a) charging interest on capital outlay, (b) making full provision for repairs and renewals, and (c) setting aside a sinking fund sufficient to replace the capital outlay on land and buildings and estates in course of development within a period of 60 years. The accumulations of the sinking fund on 31st March, 1915, amounted to £284,134 19s. 1d. (including £17,879 16s. 3d. derived from proceeds of sales). Housing of the Working Classes—Statistics. 155 Housing Statistics—Memorandum by the Housing Manager (Mr. S. G. Burgess). The new buildings completed and opened between 1st April, 1914, and 31st March, 1915, comprise 76 cottages, providing accommodation for 580 persons. Up to 31st March, 1915, a total of 6,420 tenements in block dwellings, and 3,402 cottages, or a total of 9,822 lettings, containing 28,252 rooms; and 1,874 cubicles in lodging houses, affording accommodation altogether for 57,942 persons, had been provided and opened by the Council. The gross rent receivable for the year 1913.14 was £226,294 11s. 3d., and for the year 1914.15, £228,369 8s. 4d., being an increase of £2,074 17s. 1d. The financial result of the year's working of all dwellings in occupation, after providing for interest and sinking fund charges on the capital expended, is a surplus of £12,625 0s. 10d., which, after adding interest on cash balances (£717 19s. 5d.), and also the difference between totals of debt charges on cash and stock basis (£4,007 15s. 10d.), and deducting the cost of war allowances to staff and employees on active service, gives a total net surplus of £16,488 17s. 7d., or 7.10 per cent. of £232,157 9s. 5d., the gross rental for the year. The interest and sinking fund charges amount to 49.22 per cent. of the gross rental. The sinking fund, which will redeem the capital expended on land and buildings within a period of 60 years, has been increased during the year by £27,174 18s. 4d., and the total sum now set aside in this fund in respect of dwellings in occupation amounts to £260,377 11s. 5d. The expenditure for the management of the estates, including repairs, rates and taxes, water, lighting, etc., amounts to 40.33 per cent. of the gross rental. During the year the sum of £23,436 has been transferred to the repairs and renewals account, the unspent accumulations on which, with the interest earned during the year (£1,990 19s. 3d.), now amount to £67,027 17s. 3d. The total addition to the fund was 10.95 per cent. of the gross rental. The loss of rent by empties (including the amounts lost at the opening of the new buildings— 76 lettings) is equivalent to 2.59 per cent. of the gross rental. During the year 2,144 tenants left the dwellings. This is equivalent to 22 per cent. of the total number of tenements, as compared with 22 per cent. in 1913.14. Of the 2,144 tenants who removed, 294 tenants, or 13.71 per cent. of the number, were given notice to quit by the Council, either for non.payment of rent, disorderly conduct, or some other cause. The remaining 1,850 tenants, or 86.29 per cent., gave notice to the Council and left to suit their own convenience. A total of 6,097 applications for accommodation on the Council's estates (excluding lodging houses) were dealt with, and 702 transfers were effected. These transfers are sometimes to a different estate, owing to the tenant having changed his place of work, and sometimes to a larger or smaller tenement on the same estate, owing to the increase or decrease of the tenant's family. Of the 6,097 applications received, 2,199 or 36.06 per cent. were suited with accommodation. A number of tenants who removed from the dwellings and shops were in arrear with their rent, and left without paying the amounts owing. Every effort has been made to recover these arrears on vacation, but the amount of £385 8s. 7d. or .16 per cent. (3s. 2¼d. in each £100) of the gross rental has been included in the accounts as irrecoverable. During the year the Council did not rehouse any persons who had been displaced by improvement, clearance or education schemes. The total number of displaced persons rehoused to 31st March, 1915, is 1,756. The usual annual enumeration of tenants of the Council's dwellings was taken in March, 1915, and showed that the rooms (excluding lodging houses), available for letting, were actually occupied by 35,570 persons, or an average of 1.27 persons per room. The birth rate for the year amounted to 25.22 per 1,000, and the death rate (exclusive of the three men's lodging houses) to 9.53 per 1,000. As in previous years, a careful examination of the enumeration returns was made with a view to the detection of cases of overcrowding. The maximum number of persons to be allowed in any tenement in the Council's dwellings has been fixed at two persons per room, children up to the age of 5 being for this purpose reckoned as nil, and children between the ages of 5 and 10 as half an adult. This year the number of cases not complying with this standard was 16 or .16 per cent. of the total number of occupied tenements. The overcrowding is usually found to be due to one or more children in the tenement having reached the age of 5 or 10 years, and so being counted in accordance with the Council's scale. This overcrowding is usually remedied by the removal of the family to a larger tenement in the dwellings. A sum of £22,400 7s. 1d. (9.64 per cent. of the gross rental) has been spent in repairs to the buildings during the year. These repairs include external painting at 27 blocks of tenements and 985 cottages, whitening the soffits and cleaning or minting walls of 137 staircases, comb graining and varnishing the woodwork of 216 tenements and cottages, and cleansing repairs at 6,600 tenements and cottages. The ground and basement floors of Bruce House, have also been painted internally as well as the framed partitions to the cubicles on the dormitory floors. The whole of these repairs have been executed by direct labour employed in the housing department. During the year 21 small fires occurred in the dwellings. The damage was in every case slight and the total cost of reinstatement, amounting to £17 6s. 6d., was covered by the Council's insurance fund. 27715 x 2 APPENDIX 1. Classification of children as to condition of clothing, nutrition, cleanliness and condition of teeth. Percentage in each class. 1 = good ; 2 = fair ; 3 = poor; 4= malnutrition. Number of children examined. Condition of clothing and foot.gear. Condition as regards nutrition. Cleanliness of head. Cleanliness of body. Condition of teeth. 1 2 3 1 2 3 4 1 2 3 1 2 3 1 2 3 ENTRANTS. BOYS. City of London 139 74.8 24.5 0.7 31.6 58.3 10.1 . 89.9 10.1 . 88.5 11.5 . 69.8 7.9 22.3 Battersea 1,798 62.9 34.1 3.0 31.0 61.2 7.7 0.1 88.6 10.6 0.8 84.2 14.7 1.1 43.1 28.7 28.2 Bermondsey 1,853 59.1 37.9 3.0 32.8 59.5 7.6 0.1 86.7 13.0 0.3 79.3 19.5 1.2 45.3 43.5 11.2 Bethnal Green 1,775 36.5 60.5 3.0 14.4 67.3 18.3 . 90.9 8.8 0.3 83.1 15.9 1.0 55.2 39.5 5.3 Camberwell 2,747 70.0 27.9 2.1 22.1 67.9 9.8 0.2 86.6 12.6 0.8 79.6 18.3 2.1 51.8 34.0 14.2 Chelsea 490 19.2 78.3 2.5 26.5 69.0 4.1 0.4 78.6 21.2 0.2 81.4 18.0 0.6 38.6 43.0 18.4 Deptford 1,247 58.0 38.5 3.5 33.1 64.3 2.4 0.2 90.2 9.5 0.3 88.2 11.6 0.2 47.6 39.8 12.6 Finsbury 1,093 32.9 58.2 8.9 28.9 58.9 12.0 0.2 80.1 19.0 0.9 60.1 38.6 1.3 49.4 40.5 10.1 Fulham 1,824 58.9 39.8 1.3 28.1 59.9 11.9 0.1 85.4 14.3 0.3 77.9 22.0 0.1 44.5 37.5 18.0 Greenwich 980 53.8 44.3 1.9 48.1 45.8 5.7 0.4 77.7 21.8 0.5 72.7 26.6 0.7 53.3 38.5 8.2 Hackney 2,460 45.9 47.9 6.2 42.3 53.7 4.0 — 86.5 13.1 0.4 82.6 16.6 0.8 57.5 34.2 8.3 Hammersmith 1,114 81.7 17.9 0.4 17.6 78.7 3.5 0.2 96.4 3.4 0.2 96.0 3.9 0.1 52.1 34.7 13.2 Hampstead 386 69.4 28.8 1.8 67.6 31.6 0.8 — 97.9 1.8 0.3 95.6 4.4 — 58.0 32.7 9.3 Holborn 351 71.0 25.6 3.4 34.5 53.3 10.8 1.4 86.1 12.0 1.9 72.4 25.3 2.3 57.0 31.3 11.7 Islington 3,399 56.9 39.4 37 25.1 62.7 11.9 0.3 87.5 12.1 0.4 81.2 17.3 1.5 56.9 26.5 16.6 Kensington 1,283 61.0 37.5 1.5 16.0 81.5 2.5 — 84.3 15..4 0.3 92.0 7.5 0.5 49.2 39.9 10.9 Lambeth 2,745 62.4 35.1 2.5 26.0 69.5 4.4 0.1 92.9 6.7 0.4 85.2 13.9 0.9 53.0 21.9 25.1 Lewisham 1,640 82.4 17.4 0.2 32.7 55.5 11.8 — 96.4 3.5 0.1 80.6 18.4 1.0 57.2 32.8 10.0 Paddington 1,228 690 29.6 1.4 30.6 63.7 5.7 — 94.1 5.8 0.1 88.3 11.1 0.6 31.6 61.7 6.7 Poplar 2,028 45.5 51.7 2.8 36.3 56.3 7.3 0.1 83.2 15.8 1.0 86.2 13.1 0.7 66.2 27.4 6.4 St. Marylebone 867 58.4 40.3 1.3 61.3 35.6 2.9 0.2 92.3 7.5 0.2 89.6 10.1 0.3 55.5 33.7 10.8 St. Pancras 2,172 54.3 44.1 1.6 37.6 57.8 4.6 — 82.7 16.6 0.7 81.3 18.4 0.3 48.0 34.7 17.3 Shoreditch 1,208 37.6 49.7 12.7 26.2 65.8 7.9 0.1 82.5 17.0 0.5 74.7 23.9 1.4 69.2 21.7 9.1 Southwark 2,529 34.4 57.3 8.3 20.4 66.7 12.8 0.1 85.5 14.0 0.5 63.7 33.4 2.9 34.2 41.3 24.5 Stepney 4,213 51.4 45.3 3.3 37.5 53.8 8.7 0.0 88.4 11.5 0.1 74.2 24.8 1.0 53.2 33.8 13.0 Stoke Newington 312 60.0 37.1 2.9 42.6 56.1 1.3 — 88.5 10.9 0.6 92.6 7.4 — 74.4 20.2 5.4 Wandsworth 3,475 72.5 25.3 2.2 33.6 61.3 5.1 0.0 90.9 9.1 0.1 92.3 7.4 0.3 47.5 32.3 20.2 Westminster 963 44.0 52.5 3.5 46.3 43.1 10.6 — 94.4 5.4 0.2 91.9 7.6 0.5 49.5 27.0 23.5 Woolwich 1,323 56.8 42.1 1.1 29.6 61.1 9.3 — 87.4 11.9 0.7 88.4 10.9 0.7 68.7 29.6 1.7 London County 47,642 56.3 40.4 3.3 31.2 60.7 8.0 0.1 88.0 11.6 0.4 81.7 17.3 1.0 51.6 33.9 14.5 ENTRANTS. GIRLS. City of London 141 73.8 25.5 0.7 41.1 53.2 5.7 . 73.0 27.0 — 90.8 7.8 1.4 76.6 8.5 14.9 Battersea 1,779 61.6 35.6 2.8 29.4 61.5 9.1 — 72.8 26.6 0.6 82.4 16.8 0.8 41.9 32.4 25.7 Bermondsey 1,814 62.5 35.3 2.2 30.7 57.4 6.8 0.1 72.7 26.1 1.2 78.5 20.5 1.0 44.0 45.7 10.3 Bethnal Green 1,824 35.1 62.7 2.2 16.7 67.9 15.3 0.1 64.7 33.7 1.6 81.6 17.7 0.7 58.7 37.1 4.2 Camberwell 2,754 73.6 25.6 0.8 25.6 66.3 8.0 0.1 72.6 25.8 1.6 77.9 20.0 2.1 51.7 33.9 14.4 Chelsea 539 19.8 78.7 1.5 25.2 70.5 4.3 — 80.2 19.4 0.4 84.0 15.2 0.8 40.4 38.8 20.8 Deptford 1,175 610 36.4 2.6 35.7 62.9 1.4 — 77.5 20.8 1.7 88.6 10.9 0.5 44.8 40.1 15.1 Finsbury 1,012 29.6 64.9 5.5 28.4 57.6 13.7 0.3 61.0 33.1 5.9 61.1 37.9 1.0 47.6 43.5 8.9 Fulham 1,804 58.7 40.6 0.7 29.2 58.6 12.1 0.1 73.3 24.9 1.8 80.0 19.6 0.4 40.1 41.5 18.4 Greenwich 967 54.4 44.7 0.9 57.8 38.7 3.3 0.2 71.5 27.1 1.4 75.8 23.5 0.7 55.4 35.1 9.5 Hackney 2,412 51.6 44.1 4.3 44.7 51.7 3.6 — 65.6 29.1 5.3 83.2 15.8 1.0 58.1 34.7 7.2 Hammersmith 1,219 83.6 16.2 0.2 12.4 81.8 5.7 0.1 88.8 10.7 0.5 95.3 4.5 0.2 55.5 31.4 13.1 Hampstead 387 70.0 29.2 0.8 64.9 33.6 1.5 — 91. 0 8.5 0.5 95.1 4.6 0.3 52.2 36.9 10.9 Holborn 407 73.2 22.4 4.4 38.8 52.8 8.1 0.3 71.0 26.0 3.0 75.4 23.1 1.5 57.5 31.2 11.3 Islington 3,167 56.7 39.9 3.4 26.5 62.0 11.2 0.3 68.7 29.6 1.7 79.5 18.7 1.8 54.6 29.3 16.1 Kensington 1,209 60.0 38.3 1.7 14.0 83.2 2.8 — 69.5 28.9 1.6 88.7 10.6 0.7 49.0 40.3 10.7 Lambeth 2,681 61.5 36.4 2.1 29.0 67.9 3.1 0.0 81.8 16.5 1.7 85.6 14.0 0.4 52.7 24.1 23.2 Lewisham 1,450 84.4 15.5 0.1 27.5 52.1 10.3 0.1 93.3 6.3 0.4 83.4 15.9 0.7 59.1 33.0 7.9 Paddington 1,171 72.1 26.8 1.1 33.9 60.0 6.0 0.1 83.3 15.5 1.2 87.1 12.3 0.6 30.4 63.0 6.6 Poplar 2,106 38.9 59.0 2.1 33.9 59.9 6.0 0.2 74.5 24.0 1.5 86.3 13.3 0.4 65.8 28.4 5.8 St. Marylebone 856 63.4 34.7 1.9 62.6 34.4 3.0 — 83.8 14.2 2.0 88.8 11.0 0.2 53.0 34.5 12.5 St. Pancras 2,056 54.3 44.4 1.3 36.1 59.7 4.1 0.1 66.8 30.5 2.7 80.7 18.6 0.7 48.0 37.3 14.7 Shoreditch 1,385 37.3 51.1 11.6 27.6 66.3 6.0 0.1 56.7 39.8 3.5 72.6 26.1 1.3 74.9 17.7 7.4 Southwark 2,469 33.0 60.6 6.4 18.7 68.1 13.0 0.2 62.1 35.5 2.4 60.2 37.0 2.8 31.4 41.8 26.8 Stepney 4,476 51.0 46.6 2.4 38.8 53.9 7.3 0.0 68.0 30.8 1.2 74.8 23.8 1.1 57.6 31.8 10.6 Stoke Newington 317 65.0 33.8 1.6 45.4 52.7 1.9 — 64.0 34.4 1.6 91.2 8.5 0.3 75.1 20.2 4.7 Wandsworth 3,313 74.0 24.5 1.5 32.7 61.9 5.3 0.1 82.7 16.5 0.8 91.4 7.8 0.8 47.1 34.4 18.5 Westminster 949 44.8 52.3 2.9 41.8 50.4 7.7 0.1 89.9 9.6 0.5 89.7 10.0 0.3 46.9 28.1 25.0 Woolwich 1,242 60.2 38.9 0.9 33.9 61.7 4.3 0.1 84.4 14.3 1.3 91.9 7.6 0.5 73.8 24.8 1.4 London County 47,081 56.7 40.7 2.6 32.2 60.6 7.1 0.1 73.5 24.7 1.8 81.3 17.7 1.0 52.0 34.3 13.7 ii. Annual Report of the London County Council, 1914. APPENDIX 1.—(Contd.) Classification of children as to condition of clothing, nutrition, cleanliness and condition of teeth. Percentage in each class. Number of children examined. Condition of clothing and foot gear. Condition as regards nutrition. Cleanliness of head. Cleanliness of body. Condition of teeth. 1 2 3 1 2 3 4 1 2 3 1 2 3 1 2 3 BOYS BORN IN 1906. City of London 102 52.0 48.0 . 20.6 65.7 13.7 . 97.0 2.0 1.0 86.2 11.8 2.0 72.6 7.8 19.6 Battersea 1,281 48.3 46.5 5.2 25.2 67.3 7.3 02 91.0 8.8 0.2 86.1 130 0.9 34.6 42.3 23.1 Bermondsey 1,100 321 580 9.9 19.6 71.0 9.4 . 87.2 11.9 0.9 71.1 26.0 2.9 26.6 53.8 19.6 Bethnal Green 1,403 25.6 64.8 9.6 9.5 65.7 24.6 0.2 86.1 12.8 1.1 70.4 28.2 1.4 52.9 42.7 4.4 Camberwell 2,197 59.2 35.7 51 15.5 71.2 13.2 0.1 85.4 12.8 1.8 75.8 21.3 2.9 51.0 37.1 11.9 Chelsea 374 13.9 82.6 3.5 13.4 70.3 16.3 — 79.1 20.9 — 81.6 17.6 0.8 35.8 52.2 12.0 Deptford 815 480 48.7 3.3 18.9 76.7 4.3 0.1 89.7 9.4 0.9 83.6 14.7 1.7 37.9 48.9 13.2 Finsbury 820 250 58.3 16.7 19.7 67.7 12.1 0.5 84.4 14.6 1.0 52.2 44.8 3.0 52.3 42.6 5.1 Fulham 1,335 54.2 42.9 2.9 13.1 72.0 14.8 0.1 88.1 11.6 0.3 79.0 20.4 0.6 42.6 44.4 13.0 Greenwich 876 48.4 47.1 4.5 33.9 55.6 10.5 — 72.0 27.4 0.6 59.9 38.8 1.3 38.2 560 5.8 Hackney 1,773 48.2 39.6 12.2 26.9 64.5 8.4 0.2 85.6 14.0 0.4 71.9 26.3 1.8 67.8 24.1 8.1 Hammersmith 866 80.1 18.5 1.4 4.6 88.8 6.6 . 96.3 3.7 — 94.1 5.7 0.2 52.8 38.1 9.1 Hampstead 304 55.9 39.8 4.3 35.2 62.8 2.0 — 91.1 8.6 0.3 83.6 16.4 . 45.7 45.1 9.2 Holborn 248 38.3 54.0 7.7 33.0 58.5 8.5 — 85.5 14.1 0.4 77.0 20.6 2.4 76.6 18.6 4.8 Islington 2,351 47.6 44.0 8.4 20.6 69.4 9.9 0.1 91.3 8.4 0.3 73.1 24.5 2.4 53.6 32.4 14.0 Kensington 763 57.8 41.3 0.9 8.4 88.1 3.5 — 85.4 14.5 0.1 91.1 7.7 1.2 25.7 63.0 11.3 Lambeth 1,894 54.8 41.7 3.5 19.6 75.6 4.8 — 90.3 9.3 0.4 76.9 20.9 2.2 52.2 27.4 20.4 Lewisham 1,031 81.0 18.2 0.8 30.0 53.0 17.0 — 96.6 3.4 — 80.0 18.4 1.6 47.1 46.0 6.9 Paddington 786 56.9 41.1 2.0 21.1 75.3 3.6 — 94.7 5.2 0.1 85.0 14.0 1.0 34.1 52.7 13.2 Poplar 1,553 32.6 60.9 6.5 26.0 64.9 8.8 0.3 87.0 12.7 0.3 72.4 26.0 1.6 59.2 33.9 6.9 St. Marylebone 581 41.7 54.2 4.1 21.5 75.7 2.8 — 80.4 19.5 0.1 78.3 20.5 1.2 48.7 38.9 12.4 St. Pancras 1,410 52.6 43.8 3.6 23.2 70.4 6.4 — 86.6 13.3 0.1 81.3 17.7 1.0 46.1 40.3 13.6 Shoreditch 1,127 27.1 57.0 15.9 16.7 72.2 11.0 0.1 81.5 18.4 0.1 69.0 28.7 2.3 71.7 20.9 7.4 Southwark 1,800 34.6 51.8 13.6 13.8 72.6 13.5 0.1 82.7 16.5 0.8 49.7 44.8 5.5 34.2 47.6 18.2 Stepney 2,810 41.3 54.5 4.2 21.5 66.7 11.8 0.0 83.7 15.9 0.4 64.2 33.8 2.0 50.7 38.6 10.7 Stoke Newington 249 53.4 42.2 4.4 29.3 66.3 4.4 — 96.8 3.2 . 94.4 5.2 0.4 72.3 21.7 6.0 Wandsworth 2,214 60.7 34.5 4.8 17.5 76.1 6.4 — 85.6 14.1 0.3 90.8 8.7 0.5 44.1 40.8 15.1 Westminster 487 38.4 57.7 3.9 34.3 57.7 8.0 — 98.6 1.4 . 93.4 6.6 . 45.8 36.6 17.6 Woolwich 1,085 62.8 35.1 2.1 16.8 74.9 8.2 0.1 83.4 15.9 0.7 83.2 15.4 1.4 67.6 31.4 1.0 London County 33,635 47.8 45.9 6.3 19.9 70.1 9.9 0.1 86.9 12.6 0.5 75.3 22.9 1.8 48.9 39.1 12.0 GIRLS BORN IN 1906. City of London 122 54.9 45.1 — 23.8 67.2 9.0 . 69.7 30.3 . 86.9 12.3 0.8 82.0 6.6 11.4 Battersea 1,322 55.9 41.5 2.6 21.5 69.2 9.2 0.1 69.0 30.4 0.6 87.6 11.9 0.5 33.9 42.9 23.2 Bermondsey 1,157 35.1 58.9 6.0 22.6 69.9 7.5 — 61.7 35.7 2.6 72.3 25.1 2.6 26.0 58.3 15.7 Bethnal Green 1,334 23.4 70.5 6.1 8.0 72.6 19.4 — 48.2 49.1 2.7 74.3 23.7 2.0 53.5 43.6 2.9 Camberwell 2,193 62.2 35.4 2.4 16.1 71.6 12.3 0.0 69.5 28.4 2.1 76.6 20.8 2.6 52.4 36.9 10.7 Chelsea 362 13.0 85.1 1.9 15.2 69.9 14.9 — 86.7 13.3 . 82.6 17.4 . 31.5 55.5 13.0 Deptford 802 47.9 49.2 2.9 24.3 71.8 3.9 — 69.3 28.1 2.6 83.9 15.5 0.6 42.4 45.6 12.0 Finsbury 796 27.2 64.6 8.2 27.8 60.5 11.7 . 50.3 43.7 6.0 54.9 42.3 2.8 51.6 43.1 5.3 Fulham 1,258 56.4 42.5 1.1 11.7 74.8 13.4 0.1 72.8 25.3 1.9 78.4 21.2 0.4 46.9 40.2 12.9 Greenwich 859 46.0 52.8 1.2 37.2 57.5 5.2 0.1 66.0 32.0 2.0 72.2 27.1 0.7 42.1 50.4 7.5 Hackney 1,764 57.2 38.2 4.6 30.0 61.7 8.1 0.2 57.7 37.4 4.9 78.7 20.2 1.1 66.1 25.8 8.1 Hammersmith 804 83.3 16.7 — 8.6 86.9 4.4 0.1 83.6 16.3 0.1 96.6 3.0 0.4 58.3 33.4 8.3 Hampstead 326 56.4 41.1 2.5 37.4 58.9 3.7 . 77.9 21.5 0.6 87.8 11.3 0.9 34.7 57.0 8.3 Holborn 221 56.6 40.2 3.2 39.4 53.8 6.8 — 65.1 32.6 2.3 78.3 18.5 3.2 67.9 26.2 5.9 Islington 2,297 54.9 40.8 4.3 24.8 64.5 10.5 0.2 63.2 35.5 1.3 73.8 24.0 2.2 50.8 33.6 15.6 Kensington 844 64.1 33.9 2.0 12.1 84.5 3.4 — 66.0 32.8 1.2 93.4 5.7 0.9 28.2 61.0 10.8 Lambeth 1,869 57.9 40.3 1.8 17.9 77.8 4.3 . 76.5 21.1 2.4 80.0 19.0 1.0 50.9 29.3 19.8 Lewisham 1,139 82.7 16.8 0.5 34.4 50.8 14.8 — 93.1 6.1 0.8 82.7 16.6 0.7 48.8 46.1 5.1 Paddington 806 56.6 41.5 1.9 26.2 71.3 2.5 — 70.3 27.4 2.3 85.1 14.5 0.4 34.9 52.6 12.5 Poplar 1,355 38.6 58.6 2.8 29.7 62.8 7.5 — 58.2 40.4 1.4 75.1 24.0 0.9 60.2 33.3 6.5 St. Marylebone 559 47.8 513 0.9 29.5 67.3 3.0 0.2 78.2 21.1 0.7 75.2 24.5 0.3 39.5 50.8 9.7 St. Pancras 1,269 52.2 45.7 2.1 20.2 73.5 6.3 — 68.7 28.7 2.6 80.4 19.0 0.6 44.8 41.9 13.3 Shoreditch 1,079 32.5 56.9 10.6 25.0 66.4 8.6 . 47.5 49.1 3.4 70.3 28.7 1.0 76.3 17.2 6.5 Southwark 1,714 37.3 52.8 9.9 13.4 71.4 15.2 . 48.8 471 4.1 52.4 42.6 5.0 30.8 50.4 18.8 Stepney 2,787 47.3 50.1 2.6 30.5 60.4 9.0 0.1 55.9 42.2 1.9 70.5 28.6 0.9 56.9 31.9 11.2 Stoke Newington 249 49.8 48.2 2.0 32.1 65.5 2.4 — 70.3 28.5 1.2 90.4 9.2 0.4 69.1 18.9 12.0 Wandsworth 2,114 66.8 30.9 2.3 20.1 74.1 5.8 0.0 76.7 22.6 0.7 92.9 6.6 0.5 41.9 41.5 16.6 Westminster 554 47.5 50.7 1.8 33.5 56.0 10.5 — 88.2 11.6 0.2 89.0 10.8 0.2 48.2 39.2 12.6 Woolwich 950 53.9 45.3 0.8 26.2 68.1 5.6 0.1 78.9 18.6 2.5 86.9 11.9 1.2 70.9 27.5 1.6 London County 32,905 51.6 45.0 3.4 22.8 68.2 8.9 0.1 66.3 31.6 2.1 77.8 20.8 1.4 49.1 39.0 11.9 Appendix I. iii APPENDIX 1.(Contd.) Classification of children as to condition of clothing, nutrition, cleanliness and condition of teeth. Percentage in each class. Number of children examined. Condition of clothing and foot.gear. Condition as regards nutrition. Cleanliness of head. Cleanliness of body. Condition of teeth. 1 2 3 1 2 3 4 1 2 3 1 2 3 1 2 3 BOYS BORN IN 1902. City of London 135 62.2 35.6 2.2 19.3 74.0 6.7 - 90.4 9.6 - 69.6 30.4 - 80.8 13.3 5.9 Battersea 1,334 52.8 40.0 7.2 18.4 72.0 9.5 0.1 96.5 3.4 0.1 83.4 15.7 0.9 36.9 400 23.1 Bermondsey 1,148 47.3 43.1 9.6 44.9 43.7 11.1 0.3 90.7 9.2 0.1 70.8 24.7 4.5 52.6 35.0 12.4 Bethnal Green 1,180 35.6 52.9 11.5 9.5 45.5 44.9 0.1 79.6 20.1 0.3 50.3 46.4 3.3 44.7 51.8 3.5 Camberwell 2,370 63.7 31.1 5.2 15.7 72.8 11.4 0.1 86.3 12.7 1.0 77.0 19.4 3.6 57.9 30.9 11.2 Chelsea 472 36.9 53.6 9.5 49.2 41.5 9.3 — 66.5 29.5 4.0 66.9 29.9 3.2 66.3 28.0 5.7 Deptford 765 61.3 35.6 3.1 21.8 64.3 13.9 — 85.4 12.9 1.7 80.2 16.5 3.3 57.1 35.2 7.7 Finsbury 738 24.2 61.8 14.0 24.4 65.2 10.4 — 83.6 16.4 - 44.8 50.3 4.9 58.3 36.8 4.9 Fulham 1,181 57.3 40.4 2.3 26.6 49.9 23.3 0.2 93.2 6.4 0.4 83.5 16.0 0.5 59.4 29.3 11.3 Greenwich 865 45.9 51.3 2.8 46.1 47.1 6.2 0.6 67.1 32.7 0.2 56.0 43.1 0.9 230 74.7 2.3 Hackney 1,768 53.6 420 4.4 30.0 60.0 9.8 0.2 94.5 5.4 0.1 86.0 13.0 1.0 65.7 24.4 9.9 Hammersmith 870 87.6 11.8 0.6 10.3 80.8 8.8 0.1 97.4 2.6 — 96.0 3.9 0.1 52.5 35.6 11.9 Hampstead 240 35.4 58.3 6.3 34.2 52.9 12.9 — 98.8 1.2 — 87.5 12.5 — 20.4 63.8 15.8 Holborn 189 55.5 37.6 6.9 19.6 73.0 7.4 — 90.5 9.0 0.5 66.1 31.8 2.1 66.7 21.7 11.6 Islington 2,461 51.7 42.9 5.4 15.7 67.7 16.5 0.1 92.0 7.8 0.2 84.7 13.5 1.8 58.8 311 10.1 Kensington 782 27.6 61.0 11.4 35.4 56.4 8.1 0.1 75.6 24.2 0.2 65.9 29.9 4.2 21.5 73.8 4.7 Lambeth 2,637 61.8 35.8 2.4 23.6 69.1 7.3 — 94.9 5.0 0.1 79.1 19.7 1.2 61.2 28.4 10.4 Lewisham 1,187 85.5 14.1 0.4 26.0 62.3 11.6 0.1 98.1 1.8 0.1 82.0 17.3 0.7 54.4 38.6 7.0 Paddington 841 68.4 29.8 1.8 53.9 42.1 3.8 0.2 99.2 0.8 — 96.8 2.5 0.7 36.5 56.7 6.8 Poplar 1,356 34.4 57.5 8.1 19.8 61.7 17.9 0.6 90.6 9.0 0.4 73.1 26.3 0.6 69.0 29.4 1.6 St. Marylebone 567 75.7 22.7 1.6 77.1 22.2 0.7 — 98.4 1.6 — 96.8 3.0 0.2 56.4 32.1 11.5 St. Pancras 1,337 62.4 34.2 3.4 26.4 64.8 8.7 0.1 92.3 7.6 0.1 78.9 20.3 0.8 41.9 44.0 14.1 Shoreditch 1,053 33.4 55.2 11.4 24.5 65 8 9.7 — 56 3 433 0.4 48.1 49 1 2.8 68.8 26.2 5.0 Southwark 1,751 21.7 63.5 14.8 14.4 67.2 18.3 0.1 87.5 12.2 0.3 46.1 48.0 5.9 40.3 49.6 10.1 Stepney 2,877 48.4 47.7 3.9 27.5 58.4 14.0 0.1 89.6 10.2 0.2 69.0 29.5 1.5 59.2 35.3 5.5 Stoke Newington 264 49.3 47.7 3.0 43.5 54.2 1.9 0.4 95.1 4.9 — 92.0 7.6 0.4 61.7 23.9 14.4 Wandsworth 2,299 72.9 24.6 2.5 25.2 66.1 8.7 0.0 96.2 3.7 0.1 91.0 8.5 0.5 43.6 45.0 11.4 Westminster 531 51.0 43.9 5.1 55.9 36.9 7.2 — 80.6 18.3 1.1 79.9 18.8 1.3 57.1 33.5 9.4 Woolwich 1,057 34.3 63.8 1.9 28.7 66.7 4.4 0.2 71.7 28.1 0.2 72.2 27.2 0.6 23.5 69.0 7.5 London County 33,661 52.6 41.9 5.5 26.4 61.1 12.4 0.1 88.5 11.2 0.3 75.1 23.0 1.9 51.9 38.9 9.2 GIRLS BORN IN 1902. City of London 106 60.4 36.8 2.8 29.2 62.3 8.5 - 50.9 47.2 1.9 61.4 37.7 0.9 77.4 16.0 6.6 Battersea 1,338 58.7 37.3 4.0 21.9 67.0 11.0 0.1 71.8 28.0 0.2 82.0 17.7 0.3 40.9 41.8 17.3 Bermondsey 1,252 51.4 42.0 6.6 40.9 46.6 12.5 — 75.8 24.0 0.2 71.3 25.7 3.0 51.8 36.6 11.6 Bethnal Green 1,238 41.9 54.2 3.9 12.5 53.3 34.2 — 51.4 42.1 6.5 67.6 30.5 1.9 43.3 54.5 2.2 Camberwell 1,997 66.2 31.9 1.9 15.4 74.1 10.3 0.2 67.9 30.6 1.5 75.4 22.0 2.6 62.3 27.8 9.9 Chelsea 374 37.7 54.5 7.8 46.0 46.2 7.8 — 69.2 27.3 3.5 70.6 28.1 1.3 51.8 34.0 14.2 Deptford 871 73.1 25.2 1.7 27.0 58.7 14.3 — 75.5 23.1 1.4 76.1 21.7 2.2 63.5 30.8 5.7 Finsbury 729 34.4 58.6 7.0 34.6 58.4 7.0 — 55.3 41.0 3.7 59.0 39.2 1.8 58.3 37.7 4.0 Fulham 1,241 64.4 34.3 1.3 32.5 47.1 19.8 0.6 78.8 20.5 0.7 92.6 7.4 — 62.4 27.5 10.1 Greenwich 869 42.1 57.7 0.2 48.3 47.5 3.7 0.5 69.6 28.8 1.6 73.9 25.6 0.5 38.0 59.4 2.6 Hackney 1.873 57.7 40.4 1.9 32.4 61.4 6.1 01 78.8 19.8 1.3 86.7 12.9 0.4 66.9 23.8 9.3 Hammersmith 786 89.4 10.2 0.4 18 6 73.8 7.2 0.4 81.3 18.4 0.3 96.1 3.9 — 54.2 36.4 9.4 Hampstead 242 38.4 57.9 3.7 43.8 45.5 10.7 — 80.6 19.4 — 86.0 13.6 0.4 27.7 60.7 11.6 Holborn 254 68.5 28.3 3.2 32.3 64.6 3.1 — 74.0 25.2 0.8 78.0 20.4 1.6 72.5 17.3 10.2 Islington 2,508 55.3 41.7 3.0 22.2 58.5 19.3 0.0 61.1 36.6 2.3 86.2 12.4 1.4 60.3 31.3 8.4 Kensington 830 30.9 62.2 6.9 37.7 55.2 7.1 — 55.1 41.3 3.6 59.8 37.2 3.0 25.7 70.0 4.3 Lambeth 1,954 69.6 29.2 1.2 29.2 63.7 7.0 0.1 81.0 17.7 1.3 85.9 13.4 0.7 62.7 28.9 8.4 Lewisham 1.151 90.3 9.6 0.1 31.4 58.6 10.0 — 94.3 5.0 0.7 88.8 10.9 0.3 51.0 42.1 6.9 Paddington 761 71.3 27.9 0.8 54.3 43.2 2.2 0.3 81.2 18.0 0.8 91.7 7.6 0.7 32.5 62.2 5.3 Poplar 1,472 47.3 46.7 6.0 28.2 58.2 13.1 0.5 61.9 34.6 3.5 84.3 15.2 0.5 71.8 26.8 1.4 St. Marylebone 463 86.0 13.6 0.4 78.9 20.7 0.4 — 91.6 7.3 1.1 94.8 5.0 0.2 61.8 31.1 7.1 St. Pancras 1,381 56.7 41.1 2.2 34.5 57.4 8.1 — 67.9 30.4 1.7 83.8 15.5 0.7 50.3 39.5 10.2 Shoreditch 1,066 33.9 58.5 7.6 27.1 64.4 8.5 — 37.0 59.2 3.8 48.1 50.8 11 64.6 31.2 4.2 Southwark 1,806 25.6 64.3 0.1 17.1 62.2 20.5 0.2 48.8 49.5 1.7 49.1 46.4 4.5 41.1 50.1 8.8 Stepney 2,796 47.9 50.0 2.1 29.4 59.8 10.7 0.1 58.3 40.2 1.5 69.5 29.1 1.4 59.1 36.1 4.8 Stoke Newington 240 48.8 50.0 1.2 42.9 55.4 1.7 — 76.6 21.7 1.7 91.3 8.3 0.4 60.0 23.3 16.7 Wandsworth 2.352 76.0 22.3 1.7 33.1 58.4 8.5 0.0 83.0 16.6 0.4 91.8 7.7 0.5 49.2 43.3 7.5 Westminster 539 44.5 49.2 6.3 51.6 40.6 7.8 — 75.3 23.6 1.1 76.8 21.9 1.3 62.9 27.1 10.0 Woolwich 1,001 38.9 59.8 1.3 26.6 67.4 5.9 0.1 69.4 20.8 9.8 74.2 25.1 0.7 31.2 64.0 4.8 London County 33,490 55.9 40.8 3.3 29.9 58.6 11.4 0.1 68.8 29.3 1.9 78.0 20.7 1.3 54.1 38.2 7.7 iv. Annual Report of the London County Council, 1914. APPENDIX II. Statement showing the various hospitals and centres included in the Council's scheme, and the annual provision made as from the 1st January, 1915, for the treatment of the specified ailments. Hospital or Centre. Eyes. Ear, Nose & Throat. Ringworm. Nursing Treatment. Teeth. Total number provided for in agreement. Belgrave Hospital 500 500 - - - 1,000 *Bermondsey (Rotherhithe) Centre - - - 660 1,540 2,200 *Camberwell Centre — — — 660 1,540 2,200 Charing Cross Hospital 250 500 70 — — 820 *Deptford Centre 660 660 — 1,320 3,520 6,160 *Finsbury Centre — — — 660 1,540 2,200 *Fulham Centre 660 660 176 660 1,540 3,696 *Greenwich Centre 440 440 — 660 1,540 3,080 *Hackney Centre 880 660 — 660 1,540 3,740 *Hammersmith Centre — - — 660 1,540 2,200 *Home and Infirmary, Lower Sydenham 250 250 — — — 500 *Islington Centre 880 880 264 660 1,540 4,224 *London Hospital 3,000 3,000 350 — 1,540 7,890 *Marylebone Centre — — — 660 — 660 Metropolitan Ear, Nose and Throat Hospital — 250 — — — 250 Metropolitan Hospital, Kingsland Road 500 500 — — — 1,000 Miller General Hospital — — 88 — — 88 *Norwood Centre 660 440 176 — 1,540 2,816 *Notting Dale Centre — — — 660 1,540 2,200 *Peckham Centre 660 660 176 1,320 1,540 4,356 *Poplar Centre 880 1,320 176 660 — 3,036 Poplar Hospital for Accidents — — — — 1,760 1,760 *Queen's Hospital for Children — — — — 1,540 1,540 *"Redriff" School Centre — — — 300 — 300 *Royal Eye Hospital 4,000 — — — — 4,000 *Royal London Ophthalmic Hospital 5,000 — — — — 5,000 *St. Cecilia's Centre — — — 440 1,540 1,980 *St. George's Dispensary — 440 176 660 2,640 3,916 *St. George's Mission — — — 660 — 660 *St. Marylebone General Dispensary — — — — 1,100 1,100 St. Mary's Hospital 500 500 176 — — 1,176 St. Mary's (Eltham) School — — 66 — — 66 *St. Pancras Centre 880 440 — 660 1,540 3,520 *Shoreditch Centre — — — 660 — 660 *South London (Battersea) Centre — — — 1,320 1,540 2,860 *Stockwell Centre — — — 660 1,540 2,200 *Tooting Centre — — 176 — 1,540 1,716 *Wandsworth Centre 880 880 — 660 2,200 4,620 *Wapping Centre 60 — — 300 — 360 *Western Dispensary — — — — 1,540 1,540 Women's Hospital for children 500 500 — 660 — 1,660 *Woolwich Centre 660 660 176 990 1,540 4,026 Total 22,700 14,140 2,246 17,870 42,020 98,976 *The Council guarantees payment for a minimum number in these cases. V. APPENDIX III. SUMMARY OP MEDICAL INSPECTION. F—Denotes Defects found, (x)—Signifies Cases referred for treatment. school. Number of children examined. Clothing and footgear. Nutrition. Cleanliness and condition of skin. Teeth. Nose and throat. Eyes. Ears. Speech. Mental Condition. Heart. Lung defects. Diseases of Nervous system. Tuberculosis Rickets. Deformities. Infectious diseases. Malnutrition. Glands (other than throat Other defects. Cards Issued. Parents Presents. Head. Body. Skin. 1. 2. 3. Defects. Tonsils. Adenoids. Tonsils and Adenoids. Other defects. Glands. Eye disease. Vision. Disease. Hearing. Stammering. Other defects. Heart disease. Anaemia. Phthisis. Other forms. 1. 2. 3. 1. 2. 3. 4. 1 2 3 1. 2. 3. Defect. Disease. (x) f. (x) f. f. (x) f. (x) f. (X) f. (x) 1. 2. 3. (X) f. (X) f. ' (X) f. (X) f. (X) 1. 2. 3. 4. M.D. mb. f. (x) f. (X) f. (x) f. (x) f. (x) f. (x) f. (x) f. (x) f. (X) f. (x) F. (x) F. (x) Elementary Schools. Entrants Boys 47,642 26,837 19,237 1,568 14,850 28,939 3,804 49 41,906 5,531 205 38,943 8,232 467 999 1,059 533 24,609 16,129 6,904 22,599 10,240 7,105 4,279 4,189 1,972 379 4,986 287 2,369 1,421 ... ... ... ... 1,278 712 456 127 94 1 511 6 ... ... ... ... ... ... 1,161 106 1,356 457 2,890 752 387 63 137 63 147 59 1,344 113 726 145 150 66 241 132 82 6 1,350 754 17,114 37,384 Girls 47,081 26,704 19,172 1,205 15,150 28,502 3,386 43 34,580 11,662 839 38,279 8,325 477 3,677 904 458 24,468 16,149 6,464 22,348 9,955 6,586 3,663 3,607 1,484 284 4,418 214 2,275 1,352 ... ... ... ... 1,280 707 490 160 30 1 280 6 ... ... ... ... ... ... 1,000 83 1,252 397 2,669 704 373 42 129 62 116 55 717 77 392 102 153 78 240 138 20 8 766 532 16,418 37,727 Children born in 1906— Boys 33,635 16,099 15,426 2,110 6,679 23,591 3,337 28 29,238 4,228 169 25,318 7,697 620 537 659 295 16,449 13,146 4,040 16,590 7,225 4,067 2,140 2,249 1,182 224 3,181 138 1,338 635 13,829 12,642 6,074 4,286 660 365 447 143 127 3 256 3 1,906 28,943 2,428 295 63 ... 889 60 895 256 1,083 191 355 56 109 57 101 23 676 18 695 140 29 12 176 77 13 2 806 332 14,193 20,194 Girls 32,905 16,985 14,801 1,119 7,499 22,459 2,927 20 21,825 10,385 695 25,607 6,852 446 2,917 515 232 16,162 12,844 3,899 16,390 7,341 4,352 1,795 2,083 826 161 2,860 131 1,348 562 11,935 13,467 6,714 4,823 738 397 430 144 37 ... 152 2 2,002 28,303 2,295 245 60 ... 984 96 979 334 843 172 369 46 97 52 74 10 381 7 600 126 47 12 167 87 19 2 838 390 14,237 22,823 Children born in 1902— Boys 33,661 17,690 14,111 1,860 8,862 20,570 4,184 45 29,792 3,756 113 25,273 7,750 638 433 524 226 17,459 13,093 3,109 16,222 6,793 3,031 1,518 1,580 1,404 254 2,483 105 1,120 453 18,233 8,333 6,995 5,333 813 420 803 293 198 3 234 4 4 ,412 25,635 3 ,245 361 8 ... 925 131 810 209 1,014 207 351 58 145 73 103 36 537 11 862 112 23 11 153 83 25 7 656 299 13,742 17,086 Girls 33,490 18,738 13,663 1,089 10,041 19,598 3,811 40 23,048 9,784 658 26,103 6,959 428 3,257 419 175 18,120 12,796 2,574 15,449 6,771 3,752 1,241 1,818 899 174 2,365 126 1,123 439 15,786 9,717 7,899 6,001 840 445 787 282 73 2 152 3 4,224 25,537 3,344 376 9 ... 1,240 162 1,150 363 918 171 427 72 138 66 90 43 273 8 1,022 238 20 9 130 78 57 7 814 372 14,450 19,713 Total, Elementary Schools 228,414 123,053 96,410 8,951 63,081 143,659 21,449 225 180,389 45,346 2,679 179,523 45,815 3,076 11,820 4,080 1,919 117,267 84,157 26,990 109,598 48,325 28,893 14,636 15,526 7,767 1,476 20,293 1,001 9,573 4,862 ... ... ... 20,452 5,609 3,046 3,414 1,149 559 10 1,585 24 ... ... ... ... ... ... 6,199 638 6,442 2,016 9,417 2,197 2,262 337 755 373 631 226 3,928 234 4,297 863 422 188 1,107 595 216 32 5,230 2,679 90,154 154,927 Mentally Defective Schools. 1902 Boys 587 162 334 91 119 359 106 3 440 143 4 323 239 25 18 14 5 268 254 65 297 122 57 48 33 58 16 69 5 44 22 168 229 172 111 14 11 24 8 6 ... 26 ... ... ... ... ... ... ... 24 2 23 8 18 2 28 5 3 ... 2 ... 22 1 32 ... 2 2 ... ... ... ... 11 3 274 270 Girls 455 129 275 51 99 274 81 1 200 232 23 242 199 14 51 9 3 210 195 50 225 93 60 35 42 34 1 53 2 35 9 123 162 153 102 14 13 20 11 ... ... 16 ... ... ... ... ... ... ... 18 ... 14 4 23 5 17 2 7 3 2 ... 7 ... 21 6 1 ... 4 2 ... ... 17 9 206 235 1906 Boys 241 46 165 30 32 138 70 1 188 51 2 144 88 9 7 8 3 121 88 32 118 52 20 20 13 35 5 13 ... 27 12 61 86 51 23 16 10 16 3 ... ... 13 ... ... ... ... ... ... ... 7 ... 10 3 12 1 8 3 1 1 ... ... 18 ... 8 1 ... ... 2 1 1 ... 8 5 95 136 Girls 159 30 99 30 30 93 31 5 63 75 21 77 67 15 28 4 3 71 59 29 71 30 13 16 8 18 3 14 5 13 6 37 56 39 17 6 2 8 1 ... ... 7 1 ... ... ... ... ... ... 5 1 5 3 7 1 2 1 1 1 2 ... 8 ... 5 ... ... ... 3 3 ... ... 5 3 73 86 Schools for Blind. 1902 Boys 24 10 11 3 5 18 1 ... 22 2 ... 13 11 ... 1 ... ... 20 3 1 8 1 ... ... ... 2 ... 2 ... 4 ... ... ... ... ... ... ... 1 ... ... ... 1 ... 1 18 4 1 ... ... ... ... 1 ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... 1 8 Girls 23 16 7 ... 4 16 3 ... 12 11 ... 14 9 ... 6 ... ... 10 11 2 14 4 2 3 3 2 ... 3 ... 2 ... ... ... ... ... 1 ... 1 ... 1 ... ... ... ... 19 3 1 ... ... ... ... ... ... 2 ... 1 1 ... ... ... ... ... ... 2 ... ... ... ... ... ... ... ... ... 7 7 1906 Boys 21 14 6 1 4 13 4 ... 20 1 ... 20 1 ... ... ... ... 18 ... 3 10 3 1 2 1 1 ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... 1 ... ... 17 3 1 ... ... 1 1 2 ... ... ... ... ... ... ... 1 ... 1 ... ... ... ... ... 2 ... ... ... ... ... 3 4 Girls 16 9 7 ... 1 14 1 ... 13 3 ... 13 3 ... 2 ... ... 13 2 1 6 ... 3 1 1 ... ... ... ... 1 ... ... ... ... ... ... ... 1 ... ... ... ... ... ... 13 3 ... ... ... ... ... ... ... ... ... ... ... 2 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 4 School for Deaf. 1902 Boys 28 8 18 2 5 14 8 1 25 2 1 17 9 2 ... ... ... 15 10 3 9 2 1 1 ... 1 ... 4 ... 6 ... 14 5 4 ... 5 4 9 ... ... ... 2 ... 1 19 7 1 ... ... 2 ... 2 1 2 ... ... ... ... ... ... ... 1 ... ... ... ... ... 1 1 ... ... 1 1 9 9 Girls 24 11 13 ... 6 15 3 ... 19 5 ... 19 5 1 ... ... 17 6 1 7 2 1 ... ... 1 ... 5 ... 1 ... 18 1 4 1 3 3 6 ... ... ... 2 ... 2 19 2 1 ... ... 1 ... 2 ... 1 1 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 7 12 1906 Boys 28 7 18 3 9 13 6 ... 25 3 ... 21 7 ... ... 1 ... 10 15 3 9 3 2 2 ... 2 ... 4 ... 3 ... 6 8 4 3 1 ... 3 ... ... ... ... ... 1 21 3 2 1 ... 2 ... 4 ... 2 1 ... ... ... ... ... ... 3 ... 1 ... ... ... ... ... ... ... ... ... 7 14 Girls 33 26 7 ... 24 8 1 ... 24 8 1 32 1 ... 2 1 ... 22 9 2 11 5 2 ... ... ... ... 1 ... 3 ... 3 9 4 2 2 ... 2 ... ... ... 1 ... 2 29 2 ... ... ... ... ... 4 ... 5 2 ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... 10 23 Urgent Cases, Elementary Schools. Boys 8,506 ... ... ... ... ... ... ... ... ... ... ... ... ... ... 717 510 ... ... ... 590 523 444 531 594 338 188 160 72 763 618 ... ... 902 772 560 474 198 149 10 4 33 9 ... ... ... ... 734 3 230 48 253 158 353 136 369 143 279 98 123 58 44 16 119 65 98 41 187 103 8 5 535 298 4,267 ... Girls 9,593 ... ... ... ... ... ... ... ... ... ... ... ... ... ... 714 503 ... ... ... 592 521 555 524 643 323 165 162 85 889 702 ... ... 1,121 925 506 346 177 120 5 ... 16 ... ... ... ... ... 646 1 394 74 392 249 361 116 385 105 292 127 150 60 27 14 145 70 121 50 106 55 16 9 633 339 4,736 ... Special Inspections, Elementary Schools. Boys 20,825 ... ... ... ... ... ... ... ... ... ... ... ... ... ... 106 91 ... ... ... 137 123 118 51 117 61 37 17 12 141 128 ... ... 136 127 90 81 17 15 ... ... 2 ... ... ... ... ... 70 ... 40 7 37 21 41 27 31 14 31 18 14 7 2 2 9 1 14 4 20 9 1 1 73 44 815 ... Girls 25,249 ... ... ... ... ... ... ... ... ... ... ... ... ... ... 84 71 ... ... ... 135 132 151 62 140 78 42 12 4 174 150 ... ... 128 107 74 62 15 14 ... ... 1 ... ... ... ... ... 45 ... 52 7 39 23 34 18 20 12 30 15 13 7 4 2 15 4 12 44 20 27 3 2 70 37 767 ... Total 294,026 ... ... ... ... ... ... ... ... ... ... ... ... ... 11,936 5,737 3,108 ... ... ... 111,837 49,941 30,323 15,932 17,121 8,721 1,933 20,812 1,186 11,680 6,509 ... ... ... 22,642 6,901 4,052 3,912 1,470 581 14 1,706 34 ... ... ... ... ... ... 6,975 778 7,230 2,486 10,278 2,507 3,133 623 1,401 637 938 358 4,067 269 4,654 1,010 670 287 1,476 796 245 49 6,584 3,419 101,432 ... Appendix IV. vi. APPENDIX IV. RETURN SHOWING THE RESULTS OF FIRST RE-INSPECTIONS OF CHILDREN DURING THE YEAR, 1914. Defects found requiring treatment. Number of defects under revision (outstanding from first re. inspection). Form of treatment in cases in which treatment was obtained. Total numbers treated. No treatment received By private doctor or dentist. Under Council's scheme. At other hospitals or Institutions. Completed and satisfactory. (1) Still under treatment. (2) Discontinued treatment before remedied, or from other causes uncured. (3) Total. Completed and satisfactory. (1) Still under treatment. (2) Discontinued treatment before remedied, or from other causes uncured. (3) Total Completed and satisfactory. (1) Still under treatment. (2) Discontinued treatment before remedied, or from other causes uncured. (3) Total. Completed and satisfactory. Still under treatment. Discontinued treatment before remedied, or from other causes uncured Total. Condition irremediable or treatment no longer considered necessary. Still requires treatment. Refraction 16,727 65.8 14.1 20.1 298 63.4 23.7 12.9 7,071 65.3 20.1 14.6 2,153 63.9 22.6 13.5 9,522 451 6,751 196 42 60 4,481 1,676 914 1,407 432 314 6,084 2,150 1,288 3.1 74.3 22.6 56.9 2.7 40.4 Nursing treatment cases 5,200 78.8 15.7 5.5 598 64.4 24.9 10.7 1,727 66.2 22.1 11.7 1,080 67.5 22.4 10.1 3,405 858 937 471 94 33 1,112 430 185 715 239 126 17.6 50.7 31.7 2,298 76.3 344 65.5 16.5 18.0 Ear, nose and throat 8,776 66.4 17.5 16.1 286 85.9 9.3 4.8 2,290 76.0 15.4 8.6 1,309 81.1 12.0 6.9 3 885 663 4,228 190 50 46 1,965 214 111 996 201 112 3,151 465 269 7.4 58.9 33.7 41.3 7.6 48.1 Teeth 21,333 63.5 12.0 24.5 1,855 90.2 5.4 4.4 4,898 70.9 8.6 20.5 1,985 80.2 7.5 12.3 8,738 1,006 11,589 1,179 222 454 4,417 264 217 1,408 171 406 7,004 657 1,077 21.2 56.1 22.7 41.0 4.7 54.3 Other ailments 6,067 61.9 33.9 4.2 891 38.4 57.7 3.9 203 46.3 45.6 8.1 2,189 50.0 43.2 6.8 3,283 1,220 1,504 552 302 37 78 117 8 1,012 999 178 1,642 1,418 223 27.1 6.2 66.7 54.1 20.1 25.8 Total 58,103 65.9 18.1 16.0 3,928 74.4 16.7 8.9 16,189 63.6 23 4 7 30 8 716 70.0 15.9 11.1 28,833 4,198 25,072 2,588 710 630 12,053 2,701 1,435 5,538 2,042 1,136 20,179 5,453 3,201 13.6 56.2 30.2 496 7.2 43.2 27715 vii. Annual Report of the London County Council, 1914. APPENDIX V. RETURN SHOWING THE RESULTS OP SECOND RE-INSPECTIONS OF CHILDREN DURING THE YEAR, 1914. Defects found requiring treatment. Number of defects under revision (outstanding from first re. inspection). Form of treatment in cases in which treatment was obtained. Total numbers treated. No treatment receive. F. O., i.e., cases not requiring treatment but requiring still to be kept under observation. By private doctor or dentist. Under Council's scheme. At other hospitals or institutions. Completed and satisfactory. (1) Still under treatment. (2) Discontinued treatment before remedied, or from other causes uncured. (3) Total. Completed and satisfactory. (1) Still under treatment. (2) Discontinued treatment before remedied, or from other causes uncured. (3) Total. Completed and satisfactory. (1) Still under treatment. (2) Discontinued treatment before remedied, or from other causes uncured. (3) Total. Completed and' satisfactory. (1) Still under treatment. (2) Discontinued treatment before remedied, or from other causes uncured (3) Total. Condition irremediable or treatment no longer considered necessary. Still requires treatment Refraction 7,127 61.0 10.6 28.3 113 62.7 17.3 20.0 2,572 58.8 15.8 25.4 1,053 61.5 16.7 21.8 3,738 298 2,910 181 69 12 32 1,613 445 514 620 166 267 2,302 623 813 3.0 68.8 28.2 52.5 4.2 40.8 2.5 Nursing treatment cases 1,792 66.4 19.5 14.1 128 58.2 25.0 16.8 519 63.7 22.3 14.0 413 61.3 23.3 15.4 1,060 246 387 99 85 25 18 302 130 87 263 92 58 650 241 163 12.1 48.9 39.0 59.2 13.7 21.6 5.5 Ear, nose and throat 4,107 59.0 18.0 23.0 100 83.7 8.1 8.2 841 78.1 11.8 10.1 642 79.9 10.2 9.9 1,583 391 1,785 348 59 18 23 704 68 69 501 76 65 1,264 162 157 6.3 53.1 40.6 38.5 9.5 43.5 8.5 Teeth 9,896 58.6 12.5 28.9 937 86.7 4.2 9.1 1,418 68.1 9.2 22.7 1,108 73.1 8.1 18.8 3,463 764 5,560 109 549 117 271 1,229 60 129 755 102 251 2,533 279 651 27.1 40.9 32.0 35.0 7.7 56.2 1.1 Other ailments 3,475 53.1 43.1 3.8 320 47.5 43.4 9.1 198 45.9 46.5 7.6 1,036 47.6 45.4 7.0 1,554 592 665 664 170 138 12 94 86 18 475 482 79 739 706 109 20.6 12.7 66.7 44.8 17.0 19.1 19.1 Total 26,397 58.3 19.4 22.3 1,598 71.1 14.2 14.7 5,548 61.5 21.6 16.9 4,252 65.7 17.7 16.6 11,398 2,291 11,307 1,401 932 310 356 3,942 789 817 2,614 918 720 7,488 2,017 1,893 14.0 48.6 37.4 43.1 8.7 42.9 5.3 Appendix VI. viii. APPENDIX VI. NUMBER OF CANDIDATES EXAMINED AND THE CONDITIONS FOUND. Status. No. Examined No. of Examinations. No. Fit. Vaccination. Referred back. Rejected. Withdrawn prior to re-examination or not yet reported. Not vaccinated. No marks. Want of cleanliness. Throat. Teeth. Vision. Heart. Vaccination. Sundry. For one defect. For two or more defects. Total. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. Candidates for the permanent service 384 738 535* 921† 379* 689† 2 7 — — — — — 1 107 162 35 75 2 1 2 5 13 16 133 190 13 (2 for 3) 34 146 224 5 3 36 55 Candidates for the teaching profession 186 1237 277* 1781† 172* 1180† 10 28 1 1 - 33 - 6 59 316 22 124 1 - 9 31 23 140 75 402 (1 for 3) 19 (10 for 3) 119 94 521 9 46 7 22 Candidates for scholarships 1499 1971 2385* 3180† 1475* 1885† 82 119 6 3 32 172 29 44 585 745 232 314 — 4 - — 105 170 642 815 (9 for 3) 166 (40 for 3) (4 for 4) 293 808 1108 18 51 8 41 Totals 2069 3946 3197* 5882† 2026* 3754† 94 154 7 4 32 205 29 51 751 1223 289 513 3 5 11 36 141 326 850 1407 . (10 for 3) 198 (52 for 3) (4 for 4) 446 1048 1853 32 100 51 118 *In the case of 40 males (36 for the permanent service, 2 for the teaching profession, and 2 for scholarships) the figures for the first examination were included in the report for 1913. †In the case of 26 females (9 for the permanent service, 11 for the teaching profession, and 6 for scholarships) ,, ,, „ ,, ,, „ ,, ix. Annual Report of the London County Council, 1914. APPENDIX VII. (A). SCHOLARS—DEFECTS NOTED ON MEDICAL EXAMINATION. Institutions. No. examined. Defects. Teeth. Vision. Throat and Nose. Ears. Heart. Lungs. Anaemia. Back. Nutrition. Cleanliness. Various. Defective Signs of Eye Strain. Hearing. Discharge. Round. Curvature. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (i.) L.C.C. Training Colleges, Secondary and Trade Schools. Training Colleges. Males 268 19 35 1 — — — — 1 — 6 1 - - 4 Females 1,246 143 259 11 8 1 1 5 4 34 80 22 18 5 48 Secondary Schools. Males 1,614 894 240 22 41 9 9 20 12 20 37 17 4 — 56 Females 5,508 1,305 944 122 114 19 14 91 14 195 736 176 134 153 343 Trade Schools. Males 712 152 75 5 9 3 1 6 - 6 19 5 - 2 13 Females 557 105 93 11 14 2 - 16 - 22 59 26 9 7 23 (ii.) Secondary and Trade Schools, aided but not maintained by the Council. Secondary Schools. Males 980 217 135 3 19 4 3 15 2 5 14 9 11 35 Females 974 140 115 4 6 — 2 7 2 22 82 29 17 33 36 Trade Schools Males 253 56 40 1 10 6 1 3 — 1 3 2 — 2 11 Females 816 217 128 13 20 4 4 19 5 32 58 31 5 55 46 (B). SCHOLARS—DEFECTS REMEDIED. Institutions. Defects. Teeth. Vision. Ears. Throat and Nose. Anaemia. Various. (i.) L.C.C. Training Colleges, Secondary and Trade Schools. Training Colleges. Males ... ... ... — — — - — — Females ... ... ... 27 8 - 1 6 — Secondary Schools. Males ... ... ... 55 23 — 9 — 5 Females ... ... ... 263 136 3 6 13 67 Trade Schools. Males ... ... •• 32 21 — — 1 8 Females ... ... ... 31 12 - 1 — 2 (ii) Secondary and Trade Schools, aided but not maintained by the Council. Secondary Schools. Males ... ... ... 60 29 1 4 — 13 Females ... ... ... 68 30 3 — 5 16 Trade Schools. Males ... ... ... 16 3 1 — 1 — Females ... ... 25 8 — 1 - 2 Appendix VIII. x. APPENDIX VIII. Table showing the average height and weight of boys in the Council's industrial and elementary schools. Age on admission. School and number of boys weighed and measured. Aged. 1 Aged. 2 Aged. 3 Aged. 4 Aged. 5 Aged. 6 Aged. 7 Aged. 8 Aged. 9 Aged. 10 Aged. 11 Aged. 12 Aged. 13 Aged. 14 Aged . 15 Ht. wt. Ht. Wt. Ht. Wt. Ht. Wt. Ht. Wt. Ht. Wt. Ht. Wt. Ht. Wt. Ht. Wt. Ht. Wt. Ht. Wt. Ht. Ht. Wt. Ht. Wt. Ht. Wt. Stormont House (28). Cm. Kilog. Cm. Kilog. Cm. Kilog. Cm. Kilog. Cm. Kilog. Cm. Kilog. Cm. Kilog. Cm. Kilog Cm. Kilog. Cm. Kilog Cm. Kilog Cm Kilog. Cm. Kilog Cm. Kilog. Cm. Kilog. 1 ... ... ... 69.8 9.4 83.6 10.8 90.2 14.8 104.7 19.6 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2 .... ... ... ... ... 74.2 9.8 82.1 10.8 92.2 13.7. 101.1 17.8 107.8 22.2 ... ... ... ... ... ... ... .... ... ... ... ... ... ... ... ... ... ... 3 ... ... ... ... ... ... ... 85.2 101 92.6 14.0 97.8 16.2 107.2 18.2 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 4 ... ... ... ... ... ... ... ... ... 91.6 13.2 98.6 16.6 106.0 18.9 114.7 221 120.0 25.0 ... ... ... ... ... ... ... ... ... ... ... ... ... ... 5 ... ... ... ... ... ... ... ... ... ... ... 98.2 15.4 103.7 17.7 114.1 21.9 128.0 26.4 ... ... ... ... ... ... ... ... ... ... ... ... ... ... Home for Little Boys (20) 1 ... ... ... ... ... ... ... ... ... 98.9 17.2 103.4 18.8 109.0 20.5 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2 ... ... ... ... ... ... ... 85.7 11.3 92.1 141 101.2 16.8 112.7 20.3 119.6 21.3 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 3 ... ... ... ... ... ... ... 75.3 11.2 96.5 16.3 100.3 17.0 107.6 18.4 111.9 19.9 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 4 ... ... ... ... ... ... ... ... ... 81.4 12.9 100.6 16.2 105.5 18.4 112.1 20.0 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 5 ... ... ... ... ... ... ... ... ... ... ... 90.0 15.1 107.1 17.0 113.2 21.2 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 6 ... ... ... ... ... ... ... ... ... ... ... ... ... 101.1 17.9 110.2 20.9 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Mayford (161). 5 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 112.5 22.1 124.0 241 127.8 26.5 132.0 29.0 138.0 31.2 ... ... ... ... ... ... ... ... 6 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 112.5 18.7 113.5 20.3 117.6 22.1 122.5 24.0 129.3 27.7 134.6 30.7 137.1 32.4 144.5 34.1 ... ... 7 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 115.6 21.0 119.2 22.9 123.8 24.2 126.7 25.8 130.3 28.2 135.5 31.0 142.2 35.6 ... ... 8 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 121.4 23.9 124.8 24.9 128.0 26.1 131.3 28.7 136.0 32.4 142.8 36.0 ... ... 9 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 125.0 23.9 126.5 24.6 134.0 28.0 140.7 32.2 143.1 34.3 ... ... 10 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 128.7 27.2 133.7 29.0 137.6 30.1 ... ... ... ... 11 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 132.0 30.0 134.0 29.4 138.0 30.8 ... ... 12 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 136.2 30.3 137.4 30.5 ... ... 13 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 141.0 34.0 ... ... Upton House (70). 5 ... ... ... ... ... ... ... ... ... ... ... 93.5 11.8 103.0 15.7 112.1 20.4 117.6 25.9 ... ... ... ... ... ... ... ... ... ... ... ... ... ... 6 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 7 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... . . . ... ... ... ... ... ... 8 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 115.0 24.2 120.9 26.5 127.4 29.8 129.6 30.0 132.0 29.8 ... ... .... ... ... ... 9 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 121.8 23.6 127.9 29.4 131.3 32.1 136.3 33.9 141.6 38.2 ... ... ... ... 10 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 126.3 29.4 130.7 31.0 134.7 34.2 139.6 36.7 149.8 42.6 ... ... 11 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 124.8 26.8 129.0 29.7 135.8 33.8 144.0 39.6 ... ... 12 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 132.6 32.4 137.0 35.3 142.4 38.8 151.2 43.5 13 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 137.3 32.6 143.4 38.5 149.0 42.5 Highbury (43). 7 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 119.0 21.5 124.0 24.1 ... ... ... ... . . . ... ... ... ... ... ... ... 8 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 9 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 127.5 26.5 134.5 29.2 ... ... ... ... ... ... ... 10 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 129.6 27.8 ... ... .... ... ... ... ... ... 11 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 133.1 28.4 140.9 33.4 ... ... ... ... 12 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... • • • ... ... ... ... 135.5 30.8 140.9 33.7 ... ... 13 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 143.3 35.5 157.3 45.3 Standard for Council's elementary schools (boys) ... ... ... ... ... ... ... ... ... ... ... ... 116.0 22.0 120.5 23.5 125.2 25.5 129.8 27.6 134.3 30.0 138.7 32.5 143.1 36.4 148.3 39.3 ... ... 27715 z